Aims. The aim of the British Association for Surgery of the Knee (BASK) Meniscal Consensus Project was to develop an evidence-based treatment guideline for patients with meniscal lesions of the knee. Materials and Methods. A formal consensus process was undertaken applying nominal group, Delphi, and appropriateness methods. Consensus was first reached on the terminology relating to the definition, investigation, and classification of meniscal lesions. A series of simulated clinical scenarios was then created and the appropriateness of arthroscopic meniscal surgery or nonoperative treatment in each scenario was rated by the group. The process was informed throughout by the latest published, and previously unpublished, clinical and epidemiological evidence. Scenarios were then grouped together based upon the similarity of clinical features and ratings to form the guideline for treatment. Feedback on the draft guideline was sought from the entire membership of BASK before final revisions and approval by the consensus group. Results. A total of 45 simulated clinical scenarios were refined to five common clinical presentations and six corresponding treatment recommendations. The final guideline stratifies patients based upon a new, standardized classification of symptoms, signs, radiological findings, duration of symptoms, and previous treatment. Conclusion. The 2018 BASK Arthroscopic Meniscal Surgery Treatment Guidance will facilitate the consistent identification and treatment of patients with meniscal lesions. It is hoped that this guidance will be adopted nationally by surgeons and help inform healthcare commissioning guidance. Validation in clinical practice is now required and several areas of uncertainty in relation to treatment should be a priority for future high-quality prospective studies. Cite this article: Bone Joint J 2019;101-B:652–659

We reviewed 5086 patients with a mean age of 30 years (9 to 69) undergoing primary reconstruction of the anterior cruciate ligament (ACL) in order to determine the incidence of secondary pathology with respect to the time between injury and reconstruction. There was an increasing incidence of medial meniscal tears and chondral damage, but not lateral meniscal tears, with increasing intervals before surgery. The chances of requiring medial meniscal surgery was increased by a factor of two if ACL reconstruction was delayed more than five months, and increased by a factor of six if surgery was delayed by > 12 months. The effect of delaying surgery on medial meniscal injury was also pronounced in the patients aged < 17 years, where a delay of five to 12 months doubled the odds of medial meniscal surgery (odds ratio (OR) 2.0, p = 0.001) and a delay of > 12 months quadrupled the odds (OR 4.3, p = 0.001). Increasing age was associated with a greater odds of chondral damage (OR 4.6, p = 0.001) and medial meniscal injury (OR 2.9, p = 0.001), but not lateral meniscal injury. The gender split (3251 men, 1835 women) revealed that males had a greater incidence of both lateral (34% (n = 1114) vs 20% (n = 364), p = 0.001) and medial meniscal tears (28% (n = 924) vs 25% (n = 457), p = 0.006), but not chondral damage (35% (n = 1152) vs 36% (n = 665), p = 0.565). We conclude that ideally, and particularly in younger patients, ACL reconstruction should not be delayed more than five months from injury. Cite this article: Bone Joint J 2013;95-B:59–64

The operative treatment of lesions of the anterior cruciate ligament (ACL) in athletes has been widely advocated and performed. We have investigated the outcome of non-operative management in a lower-demand, general population. We reviewed a consecutive group of 228 patients, which excluded professional and high-level athletes, for two to 12 years after an ACL lesion had been diagnosed by arthroscopy. There was a low incidence of secondary ACL and meniscal surgery, 5.4% and 3.5% respectively, and all these procedures were performed during the first three years after the ACL injury. We studied a subgroup of 109 patients with follow-up of at least five years (mean 8.5 years) and evaluated them using the IKDC score. The general outcome was reasonably satisfactory, with 23% in grade A, 50% in grade B, 21% in grade C and only 6.4% in grade D. We found no statistically significant prognostic effect within this group as regards age, activity levels, or the incidence of associated lesions

Aims

The aim of this study was to investigate the long-term clinical and radiological outcome of patients who suffer recurrent injuries to the anterior cruciate ligament (ACL) after reconstruction and require revision surgery.

Aims

To investigate the risk factors for progression of articular cartilage damage after anatomical anterior cruciate ligament (ACL) reconstruction.

Aims

The purpose of this study was to report the experience of dynamic intraligamentary stabilisation (DIS) using the Ligamys device for the treatment of acute ruptures of the anterior cruciate ligament (ACL).

We reviewed 87 patients who underwent revision reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the interval between failure of the primary graft and revision reconstruction. Patients were divided into two groups: early revision surgery within six months of graft failure, and delayed revision. Degenerative change was scored using the French Society of Arthroscopy system.

There was a significantly higher incidence of articular cartilage degeneration in the delayed group (Mann-Whitney U-test, 53.2% vs 24%, p < 0.01). No patient in the early group had advanced degenerative change, compared to 9.2% of patients in the delayed group. There was no significant difference (Mann-Whitney U-test, p = 0.3) in the incidence of meniscal tears between the two groups.

We conclude that revision reconstruction should be carried out within six months of primary graft failure, in order to minimise the risk of degenerative change.

We evaluated the long-term outcome of isolated endoscopically-assisted posterior cruciate ligament reconstruction in 26 patients using hamstring tendon autografts after failure of conservative management. At ten years after surgery the mean International Knee Documentation Committee subjective knee score was 87 (sd 14) of a possible 100 points. Regular participation in moderate to strenuous activities was possible for only seven patients pre-operatively; this increased to 23 patients post-operatively. The mean Lysholm score improved from 64 (sd 15) to 90 (sd 14) at ten years (p = 0.001).

At ten years endoscopic reconstruction of the posterior cruciate ligament with hamstring tendon autograft is effective in reducing knee symptoms. Of the series, 22 patients underwent radiological assessment for the development of osteoarthritis using the Kellgren-Lawrence grading scale. In four patients, grade 2 changes with loss of joint space was observed and another four patients showed osteophyte formation with moderate joint space narrowing (grade 3). These findings compared favourably with non-operatively managed injuries of the posterior cruciate ligament.

This procedure for symptomatic patients with posterior cruciate ligament laxity who have failed conservative management offers good results.

Pulmonary embolism is a serious complication after arthroscopy of the knee, about which there is limited information. We have identified the incidence and risk factors for symptomatic pulmonary embolism after arthroscopic procedures on outpatients. The New York State Department of Health Statewide Planning and Research Cooperative System database was used to review arthroscopic procedures of the knee performed on outpatients between 1997 and 2006, and identify those admitted within 90 days of surgery with an associated diagnosis of pulmonary embolism. Potential risk factors included age, gender, complexity of surgery, operating time defined as the total time that the patient was actually in the operating room, history of cancer, comorbidities, and the type of anaesthesia. We identified 374 033 patients who underwent 418 323 outpatient arthroscopies of the knee. There were 117 events of pulmonary embolism (2.8 cases for every 10 000 arthroscopies). Logistic regression analysis showed that age and operating time had significant dose-response increases in risk (p < 0.001) for a subsequent admission with a pulmonary embolism. Female gender was associated with a 1.5-fold increase in risk (p = 0.03), and a history of cancer with a threefold increase (p = 0.05).

These risk factors can be used when obtaining informed consent before surgery, to elevate the level of clinical suspicion of pulmonary embolism in patients at risk, and to establish a rationale for prospective studies to test the clinical benefit of thromboprophylaxis in high-risk patients.

We reviewed 183 patients who had undergone reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the timing from injury to surgery. Degenerative change was scored using the French Society of Arthroscopy system. The patients were divided into an early (surgery within 12 months of injury) and a late group (surgery more than 12 months from injury). The late group was also subdivided into four groups of 12-month periods ranging from one year to more than four years after injury.

There was a significantly higher incidence of meniscal tears in patients undergoing reconstruction after 12 months compared with those in the early group (71.2% vs 41.7%; p < 0.001). This was due to a large increase in medial meniscal tears in the late group. An increased incidence of degenerative change was also found in the late group (31.3% vs 10.7%; p < 0.001). Analysis of the subgroups showed that the incidence of meniscal tears and degenerative change did not differ significantly when surgery was performed after 12 months from injury. We conclude that reconstruction of the anterior cruciate ligament should be carried out within 12 months of injury to minimise the risk of meniscal tears and degenerative change.