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Background: Treatment strategies for meniscal tears range from nonoperative management to surgical intervention. However, national trends in cost-related outcomes and patient factors related to the failure of nonoperative management remain poorly understood. Purpose: To describe the costs associated with nonoperative versus operative management of meniscal tears in the 2 years after diagnosis and examine the relationship between patient characteristics and timing of surgery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This study was conducted using the MarketScan databases. Patients diagnosed with a meniscal tear without concomitant knee osteoarthritis between January 1 and December 31, 2017, were included. The primary outcome was the total cost of meniscal tear-related procedures—including insurance deductibles, coinsurance, and net insurance payments—in the 2 years after diagnosis. Procedures included were as follows: (1) surgery—including meniscectomy or meniscal repair; (2) physical therapy; (3) medication—including nonsteroidal anti-inflammatories, opioids, and acetaminophen; (4) intra-articular injections—including professional fee, hyaluronic acid, and corticosteroids; (5) imaging; and (6) clinic visits to orthopaedic specialists. Patients were grouped as having undergone early surgery (ES) (≤3 months of diagnosis), late surgery (LS) (>3 months after diagnosis), or no surgery (NS). Multivariate logistic regression was performed to determine the likelihood of undergoing surgery early and failing nonoperative treatment. Results: The study population included 29,924 patients with a mean age of 43.9 ± 12.9 years (ES: n = 9507 (31.8%); LS: n = 2021 (6.8%); NS: n = 18,396 (61.5%)). Complex (36.6%) and medial (58.8%) meniscal tears were the most common type and location of injuries, respectively. The mean cost of management per patient was $3835 ± $4795. Costs were lower in the NS group ($1905 ± $3175) compared with the ES group ($6759 ± $5155), while the highest costs were observed in the LS group ($7649 ± $5913) (P <.001). Patients who were men, >40 years, and with a bucket-handle or lateral meniscal tear were more likely to undergo surgery early. Patients who were men, <30 years, and with a complex tear or tear to the lateral meniscus were more likely to fail nonoperative management. Conclusion: Nonoperative management had the lowest cost burden and should be recommended for patients with appropriate indications. However, if surgery is necessary, it should be performed earlier. [ABSTRACT FROM AUTHOR]

Background: Preoperative risk factors contributing to poor outcomes after arthroscopic partial meniscectomy (APM) have not yet been consolidated and codified into an index scoring system used to predict APM success. Purpose: To create an index score using available preoperative factors to predict the likelihood of favorable postoperative outcomes after APM. Study Design: Case-control study; Level of evidence, 3. Methods: A consecutive cohort of patients undergoing primary APM were enrolled in this study. Patients completed pre- and postoperative patient-reported outcome measure (PROM) questionnaires that included the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, Veterans RAND 12-Item Health Survey (VR-12 Physical and Mental), and Marx Activity Rating Scale (MARS). Multivariable logistic regression models were performed to evaluate independent predictors of KOOS Pain, Symptoms, and Activities of Daily Living scores and achievement of the minimal clinically important difference (MCID) and substantial clinical benefit (SCB). The authors assigned points to each variable proportional to its odds ratio, rounded to the nearest integer, to generate the index score. Results: In total, 468 patients (mean age, 49 years [SD, 10.4 years; range, 19-81 years]) were included in this study. In the univariate analysis, shorter symptom duration, lower Kellgren-Lawrence (KL) grade, lower preoperative KOOS Pain value, and lower VR-12 Physical score were associated with a higher likelihood of clinical improvement at 1 year. In the multivariable model for clinical improvement with MCID, symptom duration (<3 months: OR, 3.00 [95% CI, 1.45-6.19]; 3-6 months: OR, 2.03 [95% CI, 1.10-3.72], compared with >6 months), KL grade (grade 0: OR, 3.54 [95% CI, 1.66-7.54]; grade 1: OR, 3.04 [95% CI, 1.48-6.26]; grade 2: OR, 2.31 [95% CI, 1.02-5.27], compared with grade 3), and preoperative KOOS Pain value (score <45: OR, 3.00 [95% CI, 1.57-5.76]; score of 45-60: OR, 2.80 [95% CI, 1.47-5.35], compared with score >60) were independent significant predictors for clinical improvement. The scoring algorithm demonstrated that a higher total score predicted a higher likelihood of achieving the MCID: 0 = 40%, 1 = 68%, 2 = 80%, 3 = 89%, and 4 = 96%. Conclusion: Using this model, the authors developed an index score that, using preoperative factors, can help identify which patients will achieve clinical improvement after APM. Longer symptom duration and higher KL grade were associated with a decreased likelihood of clinical improvement as measured by KOOS Pain at 1 year postoperatively. [ABSTRACT FROM AUTHOR]

Background: Meniscal repair for a traumatic meniscal tear is increasingly used to preserve the meniscus. Interpreting postoperative magnetic resonance imaging (MRI) scans remains challenging, especially in symptomatic patients. There is a lack of reliable MRI criteria to affirm the healed character of a traumatic meniscal injury repair. Purpose: To identify relevant MRI criteria for meniscal healing after meniscal repair. Study Design: Case series; Level of evidence, 4. Methods: We prospectively included all patients with a traumatic meniscal injury who underwent either an isolated meniscal repair or a repair during a concomitant anterior cruciate ligament reconstruction. A standardized preoperative and postoperative clinical evaluation was performed, along with collection of functional scores—Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee, Lysholm Score, and 36-Item Short Form Health Survey. An MRI scan was performed 1 year postoperatively and compared with the preoperative MRI scan. The following MRI aspects were analyzed: variation of morphology and fat-saturated (FS) T2 intensity signal and pre- and postoperative tear diastasis measurement. Results: Fifty patients (age, mean ± SD, 28.7 ± 8.5 years [range, 16-45 years]) who were 1 year postoperative were included. All patients were considered clinically healed had the same MRI characteristics. A signal change (FS T2) was observed from a high signal intensity fluid to a nonfluid moderate signal intensity. The morphology of the lesion was more complex: from the initial lesion, line ramifications appeared, creating the appearance of tree branches. The tear diastasis decreased (from 2.3 ± 0.5 mm [range, 1.3-3.5] to 1.1 ± 0.28 mm [range, 0.5-1.5]). Conclusion: MRI criteria confirming meniscal healing after traumatic meniscal repair at 1 year were identified: a change in the intrameniscal signal becoming nonfluid and moderate in intensity; a reduction in tear diastasis to <1.5 mm; and a change in the signal morphology of the repaired meniscus. [ABSTRACT FROM AUTHOR]

Background: Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy. Purpose: To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete). Results: In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P <.001), peripheral rim instability (P =.005), and longitudinal tears (P =.015) and require a meniscal repair (P <.001). Patients ≥14 years of age were more likely to have a radial/oblique tear (P =.015) and require additional debridement beyond the physiologic rim (P =.003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair. Conclusion: To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years. [ABSTRACT FROM AUTHOR]

Background: Studies have shown that meniscal and chondral lesions are more common at the time of revision anterior cruciate ligament reconstruction (ACLR) compared with primary surgery; however, few have evaluated the same patients through both primary and revision surgery. Purpose: To describe the prevalence of meniscal and chondral lesions at the time of primary and subsequent revision ACLR and to determine the effect of age and femoral tunnel drilling technique on the development of intra-articular pathology over time. Study Design: Case series; Level of evidence, 4. Methods: All patients who had primary and subsequent revision ACLR in the same knee between 1997 and 2022 were identified from a prospectively collated database. The grading of chondral surfaces in each compartment, the presence of any meniscal tears, and treatment performed were recorded. Patients were grouped according to age and femoral tunnel drilling technique to allow subgroup analysis. Results: Overall, 262 patients were included. Median age at primary surgery was 20.2 years. Lateral meniscal tears were more prevalent than medial tears at both primary (34.7% vs 28.2%; P =.11) and revision surgery (44.3% vs 40.8%; P =.43). Chondral lesions were most frequently found on the patella (8.8%) and the medial femoral condyle (MFC; 8.0%) at primary surgery. Between surgeries, new lesions developed most commonly on the MFC (13.0%) and the lateral femoral condyle (LFC; 11.1%). It was significantly more common for lateral meniscal tears treated with repair or left in situ at primary surgery to be healed at the time of revision surgery than medial tears (P =.01). Significantly more patients who had transtibial drilling of the femoral tunnel had a new meniscal tear at revision surgery (P =.001). Age did not have a significant influence on the prevalence of meniscal pathology. Conclusion: The prevalence of intra-articular pathology increased between primary and revision ACLR. Lateral meniscal tears were more prevalent than medial tears at both surgeries. At revision surgery, new chondral lesions were more commonly found on the MFC than the LFC. The higher incidence of new meniscal tears observed in the transtibial group may reflect the more vertical graft orientation with this technique and its inferior ability to control rotation. [ABSTRACT FROM AUTHOR]

Background: Lateral discoid meniscus accounts for most meniscal tears in children 10 years of age and younger. The role of bony morphology in discoid meniscus has been previously studied in a limited capacity using radiographs. Purpose: To use magnetic resonance imaging to measure features of the femoral condyles and tibial plateaus in patients with discoid meniscus to assess potential determinants of symptoms and subsequent surgery and to compare with matched controls to investigate age-related changes in bony features. Study Design: Cross-sectional study; Level of evidence, 3. Methods: After institutional review board approval, detailed morphology of the femoral condyles and tibial plateau was measured in 177 patients (3-18 years of age; 56% female) with confirmed lateral discoid meniscus. Measurements from 269 participants (3-18 years of age; 55% female) with asymptomatic knees were used as controls. Two-way analysis of variance with Holm-Šídák post hoc was used to compare measurements between discoid menisci and matched controls. Independent t tests were used to compare aspects of bony morphology within the discoid meniscus cohort. Results: Compared with controls, patients with a lateral discoid meniscus had a larger bicondylar width and notch width (7- to 10-year-old and 15- to 18-year-old age groups; P <.05), larger tibial plateau width (11- to 14-year-old and 15- to 18-year-old age groups; P <.001), and smaller lateral (P <.02) and coronal (P <.02) tibial slopes across all age groups. Among patients with a discoid meniscus, larger bicondylar width, larger tibial plateau width, larger notch width, and a flatter lateral femoral condyle were associated with pain (P <.005) and lateral meniscal tears (P <.02). Larger notch width and notch width index were also associated with subsequent surgery (P <.05). Conclusion: There are clinically significant abnormalities in bony morphology in patients with a discoid meniscus, including larger femoral condyles and tibial plateaus and a flatter tibial plateau. Additionally, femoral size, femoral curvature, and tibial plateau size may influence the likelihood of knee pain, meniscal tear, and need for surgery. These findings highlight the importance of bony morphology in discoid meniscus pathophysiology in children and adolescents. Such measurements may also aid radiographic detection of discoid meniscus and guide decisions regarding the timing of potential surgical intervention. [ABSTRACT FROM AUTHOR]

Background: Delayed anterior cruciate ligament (ACL) reconstruction has been associated with an increased risk of meniscal tears. However, studies comparing early versus delayed ACL reconstruction have not clearly demonstrated that meniscal tears diagnosed arthroscopically are new injuries as opposed to concomitant injuries sustained during ACL rupture. Purpose: To determine whether and how delay of ACL reconstruction is associated with risk of "new" meniscal tears (defined as those visualized arthroscopically that had not been detected on magnetic resonance imaging [MRI]) in adult and pediatric patients. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively identified patients who underwent primary ACL reconstruction between 2013 and 2022 at our institution. To ensure that MRI reflected initial intra-articular pathology, we included only patients who had an MRI scan within 3 weeks after injury (173 pediatric and 369 adult patients). Multivariate Poisson regression was performed to calculate the adjusted relative risk (ARR) of new meniscal tears after delayed (≥8 weeks from injury) operative treatment. Results: The mean (± SD) time from injury to MRI was 1.0 ± 0.8 weeks for pediatric patients and 1.1 ± 0.7 weeks for adults. Less than half of the meniscal tears observed arthroscopically had been absent on initial MRI. New medial meniscal tears occurred in 15% of pediatric patients and 16% of adults. New lateral meniscal tears occurred in 48% of pediatric patients and 34% of adults. Among pediatric patients, delayed ACL reconstruction was associated with higher risk of new medial tears (ARR, 3.9; 95% CI, 1.5-10) but not lateral tears (ARR, 0.8; 95% CI, 0.4-1.5). In contrast, adults had no significant increase in risk of meniscal tears associated with operative delay. Conclusion: Delayed ACL reconstruction may be acceptable in adults, who may be less active and less injury-prone than children and adolescents. [ABSTRACT FROM AUTHOR]

Background: Medial meniscus posterior root tears (MMPRTs) cause pain and dysfunction and are associated with poor clinical outcomes with nonoperative management at short-term follow-up. However, little is known about the long-term natural history of these tears. Purpose: The purpose of this study was to (1) provide an update to a previous minimum 2-year study on the natural progression of these tears and (2) evaluate long-term patient-reported and radiographic outcomes. Study Design: Case series (prognosis); Level of evidence, 4. Methods: A retrospective review was performed on a cohort of patients with untreated MMPRTs, diagnosed between 2005 and 2013, who were followed clinically using International Knee Documentation Committee (IKDC), visual analog scale for pain, and Tegner activity scores as well as radiographically at a minimum 10-year follow-up. Failure was defined as conversion to arthroplasty or a severely abnormal subjective IKDC score <75.4. Results: Overall, 5 (10%) of the original 52 patients with minimum 2-year outcomes were subsequently lost to follow-up. The remaining 47 patients (21 male, 26 female) were followed for a mean of 14 ± 2 years (range, 11-18 years). At final follow-up, 25 patients (53%) had progressed to total knee arthroplasty, 8 (17%) were deceased, and 14 (30%) had not progressed to total knee arthroplasty. The mean IKDC and Tegner activity scores for the 14 patients with remaining MMPRTs were 51.6 ± 22.2 and 3.1 ± 1.1, respectively, and the mean visual analog scale score was 4.4 ± 3.0. Radiographically, the mean Kellgren-Lawrence grade progressed from 1.2 ± 0.7 at baseline to 2.6 ± 0.5 at final follow-up (P <.001). At a minimum 10-year follow-up, 37 of 39 living patients (95%) had failed nonoperative treatment. Conclusion: Poor clinical and radiographic outcomes were associated with the nonoperative treatment of degenerative MMPRTs at long-term follow-up. This study provides a valuable update on the natural history and long-term prognosis of nonoperatively treated MMPRTs. [ABSTRACT FROM AUTHOR]

Background: Platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) have gained popularity in recent years as biologic approaches to potentially augment healing after meniscus repair. There have been few studies comparing outcomes in patients undergoing meniscus repair with versus without biologic augmentation and, furthermore, little clarity on the role of biologic augmentation for meniscus repairs performed with concomitant anterior cruciate ligament reconstruction (ACLR). Purpose: To determine the association of BMAC or PRP augmentation with revision surgery after both isolated meniscus repair and meniscus repair performed concomitantly with ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner dataset was queried to identify all patients who underwent primary meniscus repair, both with and without concomitant ACLR, and who received ipsilateral BMAC or PRP at the time of surgery. Patients who underwent similar surgery but without BMAC or PRP augmentation were then identified and matched in a 5:1 ratio according to age, sex, body mass index, and various comorbidities to 3 separate BMAC/PRP augmentation groups: overall cohort (with and without ACLR), repair with concomitant ACLR, and isolated repair. The primary outcome was revision meniscus surgery (meniscectomy or revision meniscus repair). Results: Overall, 3420 patients (570 with BMAC/PRP augmentation; 2850 matched controls without augmentation) were included. There were no significant differences in the reported demographics or comorbidities between any of the BMAC/PRP groups and their respective matched controls (P >.05 for all comparisons). There was no difference in revision rate between BMAC/PRP-augmented isolated meniscus repairs and matched controls (P =.235). Patients who underwent BMAC/PRP-augmented meniscus repair with concomitant ACLR experienced a significantly lower incidence of revision surgery compared with matched controls without BMAC/PRP augmentation (5.2% vs 7.9% respectively; odds ratio, 0.41; 95% CI, 0.27-0.63; P <.001), but the number of revisions was relatively small. Conclusion: There was no association between BMAC or PRP augmentation and the incidence of revision surgery after isolated primary meniscus repair. There was a statistically significant decrease in the rate of revision meniscus surgery when BMAC or PRP was used to augment meniscus repairs in the setting of concurrent ACLR; however, the overall revision rates were small. [ABSTRACT FROM AUTHOR]

Background: The role of meniscal lesions and repair in combination with anterior cruciate ligament (ACL) injury and reconstruction has not been extensively investigated in vivo and under weightbearing conditions. Purpose: The purposes of this study were to (1) compare the in vivo knee kinematics between patients with ACL tear and those with combined ACL and medial meniscal tears and (2) investigate kinematic differences between isolated ACL reconstruction and ACL reconstruction plus medial meniscal repair (MR). It was hypothesized that concomitant posterior horn medial meniscal tear and ACL deficiency would affect knee internal-external rotation and anterior-posterior translation but MR would restore these parameters. Study Design: Controlled laboratory study. Methods: Nineteen patients who underwent ACL reconstruction were included: 10 had intact menisci (IM group) and 9 had a medial meniscal injury that was repaired during ACL reconstruction using an all-inside technique (MR group). Preoperatively and 18 months postoperatively, active knee kinematics under weightbearing conditions was evaluated during a single-leg squat using a dynamic biplane x-ray imaging system. The general linear model was used to investigate the differences between group (IM vs MR) and time (preoperative vs follow-up) and their interactions. Results: Tibial internal rotation was higher in the MR group than the IM group both before and after surgery (P =.007). Knee valgus rotation was higher in the MR group preoperatively (P <.001), while no differences were found postoperatively because of an increase of valgus rotation in the IM group, which was significant in the descendant phase (P <.001). Preoperatively, the IM group showed a more medial tibial translation compared with the MR group in the descendant phase (P =.006). Conclusion: When performing a single-leg squat, patients with ACL-deficient knees and a medial meniscal tear demonstrated a more valgus rotation, tibial internal rotation, and lateral tibial translation versus those with intact menisci. After ACL reconstruction and MR, these patients demonstrated significantly higher tibial internal rotation when compared with patients who underwent isolated ACL reconstruction. Clinical Relevance: Surgeons should be aware that MR does not fully restore knee kinematics in vivo and under weightbearing conditions in the context of ACL reconstruction. [ABSTRACT FROM AUTHOR]

Background: High-grade knee laxity and excessive anterior tibial subluxation (ATS) are correlated with poor clinical outcomes in patients with anterior cruciate ligament (ACL) deficiency and share similar risk factors; however, the association between excessive ATS and high-grade knee laxity remains unclear. Purpose: To identify the association between excessive ATS and high-grade knee laxity in patients with ACL deficiency and determine the possibility that ATS can predict high-grade knee laxity. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 226 patients who underwent ACL reconstruction between May 2018 and March 2022 were analyzed in the present study; the high-grade group consisted of 113 patients who had a grade 3 result on the preoperative anterior drawer test, Lachman test, or pivot-shift test while under anesthesia, and the low-grade group consisted of 113 matched patients. The ATS values for medial and lateral compartments (ATSMC and ATSLC) were measured on magnetic resonance imaging while patients relaxed the quadriceps in the supine position under no anesthesia. The optimal cutoff values of ATSMC and ATSLC for high-grade knee laxity were determined using receiver operating characteristic curves. Univariate and multivariate logistic regression analyses with stratification were performed to identify the association between excessive ATS and high-grade knee laxity. Results: Compared with the low-grade group, the high-grade group had a longer time from injury to surgery; higher rates of medial meniscus posterior horn tear (MMPHT), lateral meniscus posterior horn tear (LMPHT), and anterolateral ligament (ALL) abnormality; and larger lateral tibial slope, ATSMC, and ATSLC. The optimal cutoff value was 2.6 mm (sensitivity, 52.2%; specificity, 76.1%) for ATSMC and 4.5 mm (sensitivity, 67.3%; specificity, 64.6%) for ATSLC in predicting high-grade knee laxity. After adjustment for covariates, ATSLC ≥4.5 mm (odds ratio [OR], 2.94; 95% CI, 1.56-5.55; P =.001), MMPHT (OR, 2.62; 95% CI, 1.35-5.08; P =.004), LMPHT (OR, 2.39; 95% CI, 1.20-4.78; P =.014), and ALL abnormality (OR, 2.09; 95% CI, 1.13-3.89; P =.019) were associated with high-grade knee laxity. The association between excessive ATSLC and high-grade knee laxity was validated in patients with acute ACL injury as well as those with chronic ACL injury. Conclusion: Excessive ATSLC was associated with high-grade knee laxity in patients who had ACL deficiency, with a predictive cutoff value of 4.5 mm. This study may help surgeons estimate the degree of knee instability more accurately before anesthesia and may facilitate preliminary surgical decision-making, such as appropriate graft choices and consideration of extra-articular augmentation. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) tears are a high-frequency injury requiring a lengthy recovery in professional American football players. Concomitant pathology associated with ACL tears as identified on magnetic resonance imaging (MRI) is not well understood in these athletes. Purpose: To describe the MRI findings of concomitant injuries associated with ACL tears among athletes in the National Football League (NFL). Study Design: Cross-sectional study; Level of evidence, 3. Methods: Of 314 ACL injuries in NFL athletes from 2015 through 2019, 191 complete MRI scans from the time of primary ACL injury were identified and reviewed by 2 fellowship-trained musculoskeletal radiologists. Data were collected on ACL tear type and location, as well as presence and location of bone bruises, meniscal tears, articular cartilage pathology, and concomitant ligament pathology. Mechanism data from video review were linked with imaging data to assess association between injury mechanism (contact vs noncontact) and presence of concomitant pathology. Results: Bone bruises were evident in 94.8% of ACL tears in this cohort, most often in the lateral tibial plateau (81%). Meniscal, additional ligamentous, and/or cartilage injury was present in 89% of these knees. Meniscal tears were present in 70% of knees, lateral (59%) more than medial (41%). Additional ligamentous injury was present in 71% of all MRI scans, more often a grade 1/2 sprain (67%) rather than a grade 3 tear (33%), and most often involving the medial collateral ligament (MCL) (57%) and least often the posterior cruciate ligament (10%). Chondral damage was evident in 49% of all MRI scans, with ≥1 full-thickness defect in 25% of all MRI scans, most often lateral. Most (79%) ACL tears did not involve direct contact to the injured lower extremity. Direct contact injuries (21%) were more likely to have a concomitant MCL tear and/or medial patellofemoral ligament injury and less likely to have a medial meniscal tear. Conclusion: ACL tears were rarely isolated injuries in this cohort of professional American football athletes. Bone bruises were almost always present, and additional meniscal, ligamentous, and chondral injuries were also common. MRI findings varied by injury mechanism. [ABSTRACT FROM AUTHOR]

Background: Delayed anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with an increased risk of meniscal injury. Limited data are available regarding the relationship between surgical delay and meniscal repairability in the setting of ACLR in young patients. Purpose: To determine whether time from ACL injury to primary ACLR was associated with the incidence of medial and/or lateral meniscal repair in young athletes who underwent meniscal treatment at the time of ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: Records were retrospectively reviewed for patients aged 13 to 25 years who underwent primary ACLR between January 2017 and June 2020 by surgeons from a single academic orthopaedic surgery department. Demographic data were collected, and operative reports were reviewed to document all concomitant pathologies and procedures. Univariable and multivariable logistic regression analyses were used to determine factors associated with meniscal repair, including time elapsed from ACL injury to surgery. Results: Concomitant meniscal tears were identified and treated in 243 of 427 patients; their mean age was 17.9 ± 3.3 years, and approximately half (47.7%) of patients were female. There were 144 (59.3%) medial tears treated and 164 (67.5%) lateral tears treated; 65 (26.7%) patients had both medial and lateral tears treated. Median time from ACL injury to ACLR was 2.4 months (interquartile range, 1.4-4.7 months). Adjusted univariate analysis showed a statistically significant correlation between medial meniscal repair and time to surgery, with a 7% decreased incidence of medial meniscal repair per month elapsed between injury and surgery (odds ratio, 0.93 per month; 95% CI, 0.89-0.98; P =.006). No similar relationship was found between lateral meniscal repair and time to surgery (odds ratio, 1.02; 95% CI, 0.99-1.06; P =.24). Conclusion: In the setting of concomitant ACL and meniscal injuries, surgical delay decreased the incidence of medial meniscal repair in young athletes by 7% per month from time of injury. [ABSTRACT FROM AUTHOR]

Background: Peripheral tears of the posterior horn of the medial meniscus, known as "ramp lesions," are commonly found in anterior cruciate ligament (ACL)–deficient knees but are frequently missed on routine evaluation. Purpose: To predict the presence of ramp lesions in ACL-deficient knees using machine learning methods with associated risk factors. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: This study included 362 patients who underwent ACL reconstruction between June 2010 and March 2019. The exclusion criteria were combined fractures and multiple ligament injuries, except for medial collateral ligament injuries. Patients were grouped according to the presence of ramp lesions on arthroscopic surgery. Binary logistic regression was used to analyze risk factors including age, sex, body mass index, time from injury to surgery (≥3 or <3 months), mechanism of injury (contact or noncontact), side-to-side laxity, pivot-shift grade, medial and lateral tibial/meniscal slope, location of bone contusion, mechanical axis angle, and lateral femoral condyle (LFC) ratio. The receiver operating characteristic curve and area under the curve were also evaluated. Results: Ramp lesions were identified in 112 patients (30.9%). The risk for ramp lesions increased with steeper medial tibial and meniscal slopes, higher knee laxity, and an increased LFC ratio. Comparing the final performance of all models, the random forest model yielded the best performance (area under the curve: 0.944), although there were no significant differences among the models (P >.05). The cut-off values for the presence of ramp lesions on receiver operating characteristic analysis were as follows: medial tibial slope >5.5° (P <.001), medial meniscal slope >5.0° (P <.001), and LFC ratio >71.3% (P =.033). Conclusion: Steep medial tibial and meniscal slopes, an increased LFC ratio, and higher knee rotatory laxity were observed risk factors for ramp lesions in patients with an ACL injury. The prediction model of this study could be used as a supplementary diagnostic tool for ramp lesions in ACL-injured knees. In general, care should be taken in patients with ramp lesions and its risk factors during ACL reconstruction. [ABSTRACT FROM AUTHOR]

Background: The prevalence of meniscal tears in patients with anterior cruciate ligament (ACL) injury increases with extended time between injury and ACL reconstruction. Purpose/Hypothesis: The purpose of this study was to determine if there is a relationship between time from magnetic resonance imaging (MRI) to ACL reconstruction and the predictive value of MRI to diagnose meniscal tears in the young active population. It was hypothesized that increased time between MRI and ACL reconstruction would lead to a decrease in the negative predictive value of MRI in diagnosing meniscal tears, as more injuries may accrue over time in the ACL-deficient knee. Study Design: Case series; Level of evidence, 4. Methods: Included were patients aged 13 to 25 years at the authors' institution who underwent primary ACL reconstruction from January 2017 to June 2020. Time from MRI to surgery as well as descriptions of medial and lateral meniscal tears on both MRI and operative reports were documented. Time from MRI to surgery was divided into 4 intervals: 0 to 6 weeks, >6 weeks to 3 months, >3 to 6 months, and beyond 6 months. Multivariable analysis was used to determine the positive and negative predictive values of MRI in diagnosing a meniscal tear as compared with arthroscopic findings. Results: A total of 432 patients were included with a mean age of 17.9 ± 3.4 years. The mean time from MRI to surgery was 70.5 ± 98 days. There was a significant decrease in the negative predictive value of MRI to identify a medial meniscal tear in patients who underwent ACL reconstruction >6 months after imaging (odds ratio, 0.16 [95% CI, 0.05-0.53]; P =.003). This same relationship was not shown for lateral meniscal tears, nor was any other predictor significant. Conclusion: The utility of MRI to rule out a medial meniscal tear significantly diminished in the young athletic population when >6 months passed between MRI and ACL reconstruction. These data suggest these tears occur between the time of the MRI and surgery and that the medial meniscus is more susceptible than the lateral meniscus to new injury once the ACL has torn. [ABSTRACT FROM AUTHOR]

Background: Professional baseball pitchers sustain 75% of knee injuries while at the pitcher's mound, yet no pitching motion has been associated directly with such injuries. Stride width is a potential, modifiable risk factor worth investigating. Hypothesis: Increased stride width in both the positive and negative directions (deviations from neutral stride width) would correlate with increased incidence of knee injury in pitchers. Study Design: Descriptive laboratory. Level of Evidence: Level 5. Methods: Professional pitchers (n = 199) were evaluated with motion capture (480 Hz) while pitching. Injury history over 10 years was recorded at face-to-face interviews with pitchers. Players were subsequently grouped into stride width tertiles, compared for previous injury incidence of the lower extremities. Regressions were performed to observe performance benefits of stride width with ball velocity, accuracy, or consistency in pitch location as secondary outcomes. Results: Of the 40 lower extremity injuries reported, meniscal injury (27.5%) was the most common, followed by foot stress fracture (20.0%). Significant differences in injury incidence were noted between the least and most positive stride width tertiles: lower extremity (10.4% vs 25.8%, respectively; P = 0.03), knee (3.0% vs 15.2%, respectively; P = 0.02), and meniscal (0.0% vs 12.1%; P = 0.00). Stride width of pitchers with meniscal injury in the lead (32.6 ± 7.1 cm, n = 5; P = 0.02) and stance leg (33.5 ± 10.6 cm, n = 5; P = 0.03) was significantly more positive than that of uninjured pitchers (21.1 ± 11.5 cm, n = 164). No significant relationships were established between stride width and ball velocity (P = 0.54) or pitch location metrics (P > 0.05). Conclusion: Pitchers with increased positive, stride width had significantly higher incidence of lower extremity injury (knee and meniscus). Wider, positive stride width may increase the degree of external rotation on the lead knee in a loaded state, which can place the medial side of the knee (and meniscus) at higher risk of injury. Clinical Relevance: Decreasing stride width may be beneficial for professional pitchers to reduce the rate of lower extremity injury, while also preserving performance metric outcomes. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) tears are associated with posttraumatic osteoarthritis, but the early biological changes that initiate joint degeneration after this injury are not well characterized. ACL tears typically result in effusion in the knee, which may provide insight into the initial response of the joint to injuries. Hypothesis: Patient- and injury-specific factors are associated with the proteomics of synovial fluid in knees with ACL tears. Study Design: Descriptive laboratory study. Methods: Synovial fluid was collected from 105 patients (38 male, 67 female) with an acute traumatic ACL tear. Patient- and injury-specific factors such as age, sex, body mass index, time from injury, presence/absence of concomitant meniscal tears, and location of concomitant bone bruises (if present) were recorded. The protein concentration of synovial fluid was measured, followed by benchmarking of samples for multi-affinity high-abundance protein depletion. An isotropically labeled high-resolution nano-liquid chromatography with tandem mass spectrometry–based proteomic approach was used to determine the synovial fluid protein profile. Data were processed, quality controlled, and analyzed computationally for each patient and injury factor. Results: The proteomics of synovial fluid from ACL tears was associated with patient sex, injury pattern, and location of bone bruises but not with patient age, body mass index, or time from injury. Knees with an isolated ACL tear had higher glutathione peroxidase 1 (GPX1) and plastin 3 levels than knees with an ACL tear and meniscal tear. A bone bruise on the lateral femoral condyle was associated with elevated leptin and glucose-6-phosphate dehydrogenase (G6PD) levels. A bone bruise on the lateral tibial plateau was associated with decreased GPX1 levels. Male patients had higher matrix metalloproteinase 9 and lower G6PD levels than female patients. Conclusion: Patient sex, injury pattern, and bone bruise location were important determinants of the proteomic profile of effusion resulting from ACL tears. Clinical Relevance: Longitudinal follow-ups to see if and how proteomic differences relate to clinical outcomes and mechanistic studies to assess the role that specific proteins play in the joint are warranted. Ultimately, these investigations could lead to better approaches to predict clinical outcomes and identify possible interventions to optimize outcomes in these patients. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether race- or insurance-based disparities in health care exist regarding baseline knee pain, knee function, complete meniscal tear, or articular cartilage damage in patients who undergo anterior cruciate ligament reconstruction (ACLR). Hypothesis: Black patients and patients with Medicaid evaluated for ACLR would have worse baseline knee pain, worse knee function, and greater odds of having a complete meniscal tear. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of patients (N = 1463; 81% White, 14% Black, 5% Other race; median age, 22 years) who underwent ACLR between February 2015 and December 2018 was selected from an institutional database. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, KOOS Function subscale, and intraoperatively assessed complete meniscal tear (tear that extended through both the superior and the inferior meniscal surfaces) were determined via multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS). Results: The 3 factors most strongly associated with worse KOOS Pain and KOOS Function were lower VR-12 MCS score, increased BMI, and increased age. Except for age, the other two factors had an unequal distribution between Black and White patients. Univariate analysis demonstrated equal baseline median KOOS Pain scores (Black, 72.2; White, 72.2) and KOOS Function scores (Black, 68.2; White, 68.2). After adjusting for confounding variables, there was no significant difference between Black and White patients in KOOS Pain, KOOS Function, or complete meniscal tears. Insurance status was not a significant predictor of KOOS Pain, KOOS Function, or complete meniscal tear. Conclusion: There were clinically significant differences between Black and White patients evaluated for ACLR. After accounting for confounding factors, no difference was observed between Black and White patients in knee pain, knee function, or complete meniscal tear. Insurance was not a clinically significant predictor of knee pain, knee function, or complete meniscal tear. [ABSTRACT FROM AUTHOR]

Background: Little is known about the benefits and outcomes of meniscal repair in patients older than 60 years. Purpose: To (1) report the clinical and radiographic outcomes of meniscal repair in patients aged ≥60 years and compare them with matched patients who underwent meniscectomy and (2) identify procedural failures. Study Design: Cohort study; Level of evidence, 2. Methods: We included 32 knees in 32 patients aged ≥60 years (20 female, 12 male; mean age, 64.5 ± 4.6 years) who underwent meniscal repair surgery at a single medical institution between 2010 and 2020. Patients were matched according to age, sex, body mass index, and meniscal tear type with a comparison cohort who underwent meniscectomy (n = 49 patients [49 knees]; 32 female, 17 male). For all patients, demographic information, clinical history, physical examination findings, treatment details, and radiographic images were reviewed and analyzed. At final follow-up (mean, 42.2 months; range, 13-128 months), patients completed the 2000 International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score. Clinical failure was defined as revision surgery and/or progression to total knee arthroplasty (TKA). A matched-pairs t test was used to analyze differences between the 2 treatment groups, and Kaplan-Meier analysis was used to determine the rates of knee osteoarthritis and progression to TKA. Results: The majority of patients had a medial meniscal tear (72.8%), whereas the lateral meniscus was torn in 27.2% of cases. Most tears were located in the meniscal root (56.8%), followed by the posterior horn (34.6%) and midbody (8.6%). At final follow-up, all outcome scores were higher in the repair group compared with the meniscectomy group (IKDC, 78.9 ± 13.4 vs 56.0 ± 15.4; KOOS, 86.6 ± 11.9 vs 61.7 ± 16.2; Lysholm, 88.3 ± 13.3 vs 68.7 ± 15.2, respectively; P <.001 for all). Clinical failure was observed in 22% of patients in the repair group. Conclusion: All clinical outcome scores were higher in the meniscal repair group compared with the matched meniscectomy group at final follow-up. The clinical failure rate of the repair group was 22%. These findings support meniscal repair in selected patients aged ≥60 years. [ABSTRACT FROM AUTHOR]

Background: Representing approximately 10% of all meniscal tears, bucket-handle meniscal tears (BHMTs) are large longitudinal vertical tears that have an attached fragment flipped into the intercondylar notch. Meniscectomy often results in significant meniscal loss and increased joint loading. Alternatively, meniscal repair attempts to restore the function of the meniscus and aims to preserve joint mechanics. Purpose: To evaluate the long-term risk of subsequent ipsilateral knee surgery in patients who underwent a bucket-handle meniscal repair (BHMR), and to assess risk factors associated with subsequent knee surgical intervention. Study Design: Case series; Level of evidence, 4. Methods: We performed an electronic health record search for all patients aged 12 to 65 years who underwent arthroscopic knee meniscal repairs for BHMT (2011-2018). We excluded patients who had a previous BHMR, did not have magnetic resonance imaging of the knee within 60 days before BHMR, lacked active membership in Kaiser insurance in the year before and after BHMR, or underwent meniscectomy before BHMR. All patients were followed until December 31, 2019, with censoring at death or membership disenrollment. Primary outcomes included ipsilateral knee procedures overall and by type (ie, repeat meniscal repair and meniscectomy); secondary outcomes included other surgical interventions of the same knee, any contralateral knee surgery, deep surgical-site infection, and deep venous thrombosis or pulmonary embolism. Results: The final cohort included 1359 patients with a median age of 24 years (interquartile range [IQR], 17-34) who underwent BHMR for a BHMT. During the follow-up period (median, 50.2 months [IQR, 32.3-60.6]), 495 subsequent ipsilateral procedures were performed in 274 (20.2%) patients, and the median time to the first procedure was 10.6 months (IQR, 4.1-23.5). An overall 59 (4.3%) patients underwent repeat meniscal repair, and 165 (12.1%) had a subsequent meniscectomy of the same knee. Significant risk factors for subsequent ipsilateral procedures included younger age, 12 to 18 years (adjusted odds ratio [aOR], 5.77 [95% CI, 1.84-18.08]) and 19 to 30 years (aOR, 3.65 [95% CI, 1.17-11.36]), as well as normal and overweight body mass index (aOR, 2.84 [95% CI, 1.29-6.23] and 2.34 [95% CI, 1.06-5.17], respectively). Patients undergoing concomitant anterior cruciate ligament reconstruction (ACLR) at the initial BHMR had a lower risk of undergoing subsequent surgery (aOR, 0.66 [95% CI, 0.49-0.87]) than those without concomitant ACLR. Conclusion: This is the largest reported study on outcomes after BHMR in a contained cohort. One-fifth of patients underwent subsequent ipsilateral surgery during follow-up, with 4.3% receiving a repeat meniscal repair and 12.1% experiencing a meniscectomy. Risk factors for subsequent surgery of the same knee included younger age and normal or overweight body mass index. Concomitant ACLR at time of BHMR reduced the risk of subsequent reoperation. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament reconstruction (ACLR) provides functional stability to an injured knee. While multiple techniques can be used to drill the femoral tunnel during ACLR, a single technique has yet to be proven as clinically superior. One marker of postoperative functional stability is subsequent meniscal tears; a lower risk of subsequent meniscal surgery could be expected with improved knee stability. Purpose: To determine if there is a meniscal protective effect when using an anteromedial portal (AMP) femoral tunnel drilling technique versus transtibial (TT) drilling. Study Design: Cohort study; Level of evidence, 2. Methods: Data from Kaiser Permanente's ACLR registry were used to identify patients who had a primary isolated ACLR between 2009 and 2018; those with previous surgery in the index knee and meniscal pathology at the time of ACLR were excluded. The exposure of interest was TT (n = 2711) versus AMP (n = 5172) drilling. Multivariable Cox proportional hazard regression was used to evaluate the risk of a subsequent ipsilateral meniscal reoperation with adjustment for age, sex, femoral fixation, and graft choice. We observed a shift in surgeon practice from the TT to AMP over the study time frame; therefore, the relationship between technique and surgeon experience on meniscal reoperation was evaluated using an interaction term in the model. Results: At the 9-year follow-up, the crude cumulative meniscal reoperation probability for AMP procedures was 7.76%, while for TT it was 5.88%. After adjustment for covariates, we observed a higher risk for meniscal reoperation with AMP compared with TT (hazard ratio [HR], 1.53; 95% CI, 1.05-2.23). When stratifying by surgeon experience, this adverse association was observed for patients who had their procedure performed by surgeons with less AMP experience (no previous AMP ACLR: HR, 1.26; 95% CI, 0.84-1.91) while a protective association was observed for patients who had their procedure with more experienced surgeons (40 previous AMP ACLRs: HR, 0.34; 95% CI, 0.13-0.92). Conclusion: Drilling the femoral tunnel via the AMP was associated with a higher risk of subsequent meniscal surgery compared with TT drilling. However, when AMP drilling was used by surgeons experienced with the technique, a meniscal protective effect was observed. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic partial meniscectomy (APM) is widely performed and remains an important therapeutic option for patients with a meniscal tear. However, it is debated whether or not APM accelerates the progression of osteoarthritis (OA) in the long term. Purpose/Hypothesis: The purpose was to compare the progression of OA measured by the change in tibiofemoral joint space width (JSW)—a quantitative measure of OA radiographic severity—across 3 groups with a midterm follow-up: (1) patients undergoing APM; (2) those with a meniscal tear treated nonoperatively; and (3) those without a tear. We hypothesized that the reduction in JSW would be greatest in patients undergoing APM and least in those patients without a tear. Study Design: Cohort study; Level of evidence, 3. Methods: Using the Osteoarthritis Initiative cohort, a total of 144 patients were identified that underwent APM with at least 12 months of follow up and without previous knee surgery. Those with a meniscal tear who did not have APM (n = 144) and those without a tear (n = 144) were matched to patients who had APM by sex, age, Kellgren-Lawrence (KL) grade, and follow up time. Participants underwent magnetic resonance imaging at baseline. Knee radiographs to assess JSW were collected annually or biannually. The change in minimum medial compartment JSW was calculated using a validated automated method. A piecewise linear mixed effects model was constructed to examine the relationship between JSW decline over time and treatment group—adjusting for age, body mass index, smoking status, KL grade, and baseline JSW. Results: All groups had comparable baseline JSW—ranging from 4.33 mm to 4.38 mm. The APM group had a rate of JSW decline of −0.083 mm/mo in the first 12 months and −0.014 mm/mo between 12 and 72 months. The rate of JSW decline in the APM group was approximately 27 times greater in the first 12 months than that in the nonsurgical group (−0.003 mm/mo) and 5 times greater than that in the no tear group (−0.015 mm/mo); however, there was no significant difference between groups for 12 to 72 months (nonsurgical group: −0.009 mm/mo; no tear group: −0.010 mm/mo). The adjusted JSW in the APM group was 4.38 mm at baseline and decreased to 2.57 mm at 72 months; the JSW in the nonsurgical group declined from 4.31 mm to 3.73 mm, and in the no tear group it declined from 4.33 mm to 3.54 mm. There was a statistically significant difference in JSW change between baseline and 72 months for the APM group compared with the other groups (P <.001), but not between the nonsurgical and no tear groups (P =.12). Conclusion: In the first postoperative year, APM results in a faster rate of joint space narrowing compared with knees undergoing nonsurgical management of meniscal tears. Thereafter, there are comparable rates of OA progression regardless of the chosen management. APM results in a persistent decrease in JSW over at least 72 months. An untreated meniscal tear does not contribute to radiographic progression—assessed by JSW—as compared with an intact meniscus. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown a higher prevalence of meniscal and chondral lesions at the time of revision anterior cruciate ligament reconstruction (R-ACLR) compared with primary ACLR procedures. However, studies that follow the development of meniscal and chondral status through primary and subsequent R-ACLR are scarce. Purpose: To compare the prevalence of meniscal and chondral injuries in patients undergoing primary ACLR and subsequent R-ACLR. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent ACLR and subsequently needed R-ACLR between January 2009 and February 2018 in a single center were included. A retrospective analysis of prospectively collected data was conducted. Results: A total of 213 patients were included, with a mean follow-up of 59.7 months. The mean age was 22 years at primary ACLR and 26.1 years at the time of revision. The proportion of meniscal tears was higher at the time of R-ACLR compared with the time of primary reconstruction (70.0% vs 44.6%, respectively; P <.001). Similarly, the prevalence of chondral lesions was significantly higher at the time of revision versus the primary reconstruction (15.5% vs 7.0%, respectively; P =.003). Conclusion: R-ACLR is associated with a higher rate of concomitant meniscal and chondral lesions than primary ACLR. [ABSTRACT FROM AUTHOR]

Background: The discoid lateral meniscus (DLM) is one of the most common congenital anomalies of the knee. The pathomorphology of DLM varies. Current classification systems are inadequate to describe the spectrum of abnormality. Purpose: A study group of pediatric orthopaedic surgeons from 20 academic North American institutions developed and tested the reliability of a new DLM classification system. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: After reviewing existing classifications, we developed a comprehensive DLM classification system. Four DLM features were evaluated: meniscal width, meniscal height, peripheral stability, and meniscal tear. Stepwise arthroscopic examination using anteromedial and anterolateral viewing portals was established for evaluating these features. Three senior authors who were not observers selected 50 of 119 submitted videos with the best clarity and stepwise examination for reading. Five observers performed assessments using the new classification system to assess interobserver reliability, and a second reading was performed by 3 of the 5 observers to assess intraobserver reliability using the Fleiss κ coefficient (fair, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00). Results: Interobserver reliability was substantial for most rating factors: meniscal width, meniscal height, peripheral stability, tear presence, and tear type. Interobserver reliability was moderate for tear location. Intraobserver reliability was substantial for meniscal width and meniscal height and excellent for peripheral stability. Intraobserver agreement was moderate for tear presence, type, and location. Conclusion: This new arthroscopic DLM classification system demonstrated moderate to substantial agreement in most diagnostic categories analyzed. [ABSTRACT FROM AUTHOR]

Background: Tissue adhesives (TAs) represent a promising alternative or augmentation method to conventional tissue repair techniques. In sports medicine, TA use has been suggested and implemented in the treatment of meniscal tears. The aim of this review was to present and discuss the current evidence and base of knowledge regarding the clinical usage of TAs for meniscal repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases for studies reporting on clinical outcomes of TA usage for meniscal repair in humans in the English language published before January 2020. Results: Ten studies were eligible for review and included 352 meniscal repairs: 94 (27%) were TA-based repairs and 258 (73%) were combined suture and TA repairs. Concomitant anterior cruciate ligament reconstruction was performed in 224 repairs (64%). All included studies utilized fibrin-based TA. Of the 10 studies, 9 were evidence level 4 (case series), and 8 reported on a cohort of ≤40 meniscal repairs. Rates of meniscal healing were evaluated in 9 of 10 studies, with repair failure seen in 39 repairs (11%). Conclusion: The use of TAs, specifically fibrin-based TAs, for meniscal repair shows good results as either an augmentation or primary repair of various configurations of meniscal tears. However, this review reveals an absence of comparative high-quality evidence supporting the routine use of TAs for meniscal repair and emphasizes the lack of an ideal TA designed for that purpose. Further high-quality research, basic science and clinical, will facilitate the development of new materials and enable testing their suitability for use in meniscal repair. [ABSTRACT FROM AUTHOR]

Background: Prospective evaluation of clinical outcomes after posterior meniscal root repair utilizing a transtibial pullout technique is limited, and factors that may contribute to outcomes are unclear. Hypothesis: It was hypothesized that there would be an overall significant improvement in outcomes after root repair and that differences in clinical outcomes would correlate with age, body mass index (BMI), sex, and meniscal extrusion. Study Design: Case-control study; Level of evidence, 3. Methods: Consecutive patients undergoing transtibial medial or lateral meniscal root repair were enrolled prospectively at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) were obtained to assess for meniscal healing, quantification of extrusion, articular cartilage grade, and subchondral bone changes. Patient-reported outcomes including International Knee Documentation Committee (IKDC) scores, Tegner activity scale, and visual analog scale (VAS) for pain were collected preoperatively and 2 years postoperatively. Patients were then subdivided by clinical and demographic characteristics to determine factors associated with clinical outcomes. Results: Included were 45 patients (29 female, 16 male; mean age, 42.3 ± 12.9 years; mean BMI, 31.6 kg/m2) who underwent 47 meniscal root repairs (29 medial and 16 lateral; 2 had both). Significant improvements at 2-year follow-up were seen in IKDC score (41.1 vs 78.4; P <.001), Tegner activity level (3 vs 4; P <.001), and VAS pain (2.8 vs 0.7; P <.001). BMI, preoperative malalignment, cartilage status, and progressive meniscus extrusion (Δ = 0.7 mm) did not have a negative impact on IKDC and Tegner scores 2 years postoperatively. Age greater than or equal to 50 years and extrusion pre- and postoperatively were associated with decreased Tegner scores. Progressive meniscal extrusion was associated with a decreased overall improvement in Tegner scores. Conclusion: Transtibial root repair for medial and lateral posterior meniscal root tears demonstrated significantly improved clinical outcomes at 2 years postoperatively. Increased age, increased BMI, cartilage status, and meniscal extrusion did not have a negative impact on short-term functional outcomes (IKDC), but age greater than or equal to 50 years and extrusion negatively influenced patient activity level (Tegner). Registration: NCT03037242 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Background: Meniscal injuries are extremely common in soccer athletes, and little is known about postrecovery performance. Purpose: To (1) identify characteristics associated with return to play (RTP) to the same league level and (2) evaluate long-term effects that injury and management approach may have on player performance. Study Design: Cohort study; Level of evidence, 3. Methods: Using publicly available records, we identified athletes who sustained meniscal tears across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2006 and 2016. Injured athletes were matched to controls 1:2 by demographics and performance. Investigations included rate of RTP to the same league level, reinjury, player characteristics associated with RTP within 2 seasons, long-term availability, field time, and performance metrics standardized to 90 minutes of play during the next 4 seasons. Results: A total of 250 players sustaining meniscal tears were included, of which 106 (42%) received surgical management. Median absence was 57.5 days (interquartile range [IQR], 35-92) or 7 games (IQR, 4-12). Rate of RTP was 70%, and the reinjury rate 5% if a player could RTP. Age greater than 30 years was a negative predictor for RTP (odds ratio [OR], 0.62; P =.002), whereas higher preinjury goals per game (OR, 2.80; P =.04) and surgical management (OR, 1.38; P =.002) were positive predictors for RTP. Surgical management was associated with higher long-term availability (P <.01). As compared with the control, there were no significant differences in field time or performance metrics after RTP, either overall or by player position. As compared with nonoperative management, defenders undergoing surgery demonstrated decreased field time. Attackers and midfielders demonstrated similar field time and performance regardless of management. Conclusion: RTP of elite soccer athletes sustaining meniscal tear is contingent on age, preinjury performance, and management approach. Those who RTP to the same league level can be expected to demonstrate equivalent field time, performance, and long-term availability as noninjured athletes. [ABSTRACT FROM AUTHOR]

Background: Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. Purpose/Hypothesis: The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non–English language manuscripts, multiligamentous injuries, and nonclinical studies. Results: A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P =.006) and irreparable meniscal tear (odds ratio, 0.31; P =.001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences (P =.413) or proportion with difference ≥3 mm (P =.181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. Conclusion: Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports. [ABSTRACT FROM AUTHOR]

Background: The effect of concomitant meniscal tears, and their associated treatment, on strength and functional recovery after anterior cruciate ligament reconstruction (ACLR) has not been adequately investigated in young populations. Hypothesis: Concomitant meniscal tears, treated with or without repair, would not adversely affect strength, balance, or functional hop test performance at 6 months postoperatively. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively analyzed return-to-sports (RTS) assessments prospectively collected 6 months after ACLR with hamstring autograft in 165 patients ≤25 years of age. Descriptive, surgical, and RTS testing data were analyzed, and subgroups were compared using analysis of covariance models designed to assess the effects of sex, meniscal tear, and meniscal repair on RTS performance. Results: Included were 115 female (70%) and 50 male (30%) patients with a mean age of 16.4 years (range, 12.3-25 years). Of these patients, 58% had concomitant meniscal tears (59% lateral, 27% medial, 14% lateral + medial), comprising 53% of the female and 70% of the male patients. The authors treated 61% of the tears with repair, with range of motion (ROM) and weightbearing limitations imposed within the first 6 weeks postoperatively, whereas 39% were treated with partial meniscectomy, rasping, or trephination (no ROM or weightbearing restrictions). The mean deficit in hamstring strength at 6 months postoperatively was significantly greater in the meniscal tear group than in those without a tear (32.3% vs 24.6%; P =.028). The meniscal repair group had greater hamstring strength deficits than the group with meniscectomy, rasping or trephination (34.3% vs 26.2%; P =.023). Performance on dynamic balance and functional hop tests was similar among all meniscus subgroups. There were no sex-based effects on any subgroup comparisons. Conclusion: At 6 months postoperatively, both young male and young female patients who underwent ACLR with hamstring autograft demonstrated significant hamstring strength deficits compared with their nonoperative leg. The presence of a meniscal tear and subsequent repair, or its related rehabilitation restrictions, appears to have adverse effects on the postoperative recovery of hamstring strength. [ABSTRACT FROM AUTHOR]

Background: Articular cartilage and meniscal damage are commonly encountered and often treated at the time of anterior cruciate ligament reconstruction (ACLR). Our understanding of how these injuries and their treatment relate to outcomes of ACLR is still evolving. Hypothesis/Purpose: The purpose of this study was to assess whether articular cartilage and meniscal variables are predictive of 10-year outcomes after ACLR. We hypothesized that articular cartilage lesions and meniscal tears and treatment would be predictors of the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level outcomes at 10-year follow-up after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2008, individuals with ACLR were prospectively enrolled and followed longitudinally using the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A proportional odds logistic regression model was built incorporating variables from patient characteristics, surgical technique, articular cartilage injuries, and meniscal tears and treatment to determine the predictors (risk factors) of IKDC, KOOS, and Marx outcomes at 10 years. Results: A total of 3273 patients were enrolled (56% male; median age, 23 years at time of enrollment). Ten-year follow-up was obtained on 79% (2575/3273) of the cohort. Incidence of concomitant pathology at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 22%; lateral femoral condyle [LFC], 15%; medial tibial plateau [MTP], 4%; lateral tibial plateau [LTP], 11%; patella, 18%; trochlea, 8%) and meniscal pathology (medial, 37%; lateral, 46%). Variables that were predictive of poorer 10-year outcomes included articular cartilage damage in the patellofemoral (P <.01) and medial (P <.05) compartments and previous medial meniscal surgery (7% of knees; P <.04). Compared with no meniscal tear, a meniscal injury was not associated with 10-year outcomes. Medial meniscal repair at the time of ACLR was associated with worse 10-year outcomes for 2 of 5 KOOS subscales, while a medial meniscal repair in knees with grade 2 MFC chondrosis was associated with better outcomes on 2 KOOS subscales. Conclusion: Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscal surgery before ACLR were associated with poorer 10-year ACLR patient-reported outcomes, but meniscal injury present at the time of ACLR was not. There was limited and conflicting association of medial meniscal repair with these outcomes. [ABSTRACT FROM AUTHOR]

Background: Prospective studies evaluating second-look imaging of meniscus root repair using a transtibial pull-out technique are limited; therefore, optimal surgical indications and the technique for meniscus root repair remain uncertain. Hypothesis: It was hypothesized that there would be a high rate of healing, improvement in meniscal extrusion, and prevention of articular cartilage degeneration and subchondral bone abnormalities after meniscus root repair. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients undergoing transtibial root repair were prospectively enrolled at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) scans were reviewed by a musculoskeletal radiologist in a blinded fashion for meniscal healing, quantification of extrusion, articular cartilage grade, subchondral bone changes, and coronary/meniscotibial ligament abnormalities. Given persistent extrusion observed on postoperative MRI scans, an additional 10 patients gave consent and were enrolled for immediate (before weightbearing) postoperative MRI scans. Results: A total of 45 patients (16 male, 29 female; mean ± standard deviation age, 42.3 ± 12.9 years; body mass index, 31.6) were prospectively enrolled in the study; there were 47 meniscus root repairs: 29 medial and 18 lateral (2 with both). Postoperative MRI was obtained at an average of 6.3 months (range, 5.1-8 months); 98% of meniscal repairs had evidence of healing. Mean extrusion increased significantly, from 1.9 ± 1.5 mm preoperatively to 2.6 ± 1.4 mm postoperatively (P =.03). There was no significant progression of chondromalacia grade, subchondral edema, insufficiency fracture, subchondral cysts, or subchondral collapse. In the additional 10-patient cohort, the mean preoperative extrusion (1.6 ± 1.2 mm) was not significantly different from that immediately postoperatively (2.0 ± 1.0 mm; P =.23). Conclusion: Prospective MRI analysis of transtibial meniscus root repair confirmed a high rate of meniscal healing and no observable progression of cartilage degeneration or subchondral bone abnormalities at the short-term follow-up. However, meniscal extrusion worsened in the first 6 months after surgery. Registration: NCT03037242 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Background: Residual rotatory knee laxity at midterm follow-up after isolated anterior cruciate ligament reconstruction (ACLR) versus ACLR with lateral extra-articular tenodesis (LET) remains an issue. Purpose/Hypothesis: To evaluate the outcomes of ACLR with or without additional LET at a minimum 2-year follow-up in patients with preoperative high-grade pivot shift (PS). Our hypothesis was that the addition of LET would decrease the risk of secondary meniscal injury and the presence of residual high-grade PS at follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis performed at 3 sports medicine centers identified 266 study patients; all had a high-grade PS (grade 2 or 3) preoperatively and underwent isolated ACLR with or without LET. Four different ACLR techniques were used: single-strand quadrupled semitendinosus (ST4) ACLR without LET (ST4 group; n = 55), ST4 with anatomic LET (ST4+LET group; n = 77), bone–patellar tendon and modified Lemaire LET (BTB+LET group; n = 43), and quadriceps tendon and modified Lemaire LET (QT+LET group; n = 91). At follow-up, we evaluated for the presence of high-grade (grade ≥2) PS. Preoperative meniscal tears and their treatment were recorded. Results: Overall, 185 (69.5%) patients had at least 1 meniscal tear at index surgery. The mean follow-up period was 44.3 months; 47 (17.7%) patients had a new meniscal tear and 64 (24%) patients had a high-grade PS at follow-up. Compared with meniscal repair, significant predictors for high-grade PS at follow-up were meniscectomy (odds ratio [OR] = 2.65 [95% CI, 1.19-5.63]; P =.02) and nonrepair of preoperative meniscal tear (OR = 3.26 [95% CI, 1.27-9.43]; P =.007). The appearance of a new symptomatic meniscal tear was the strongest significant predictor of high-grade PS at follow-up (OR = 4.31 [95% CI, 2.31-8.06]; P <.001). No significant correlation was observed between the addition of LET and the presence of high-grade PS at follow-up. Conclusion: In the current study, 1 in 4 patients with high-grade PS before ACLR with or without LET was at risk of residual rotatory knee laxity at mean 44-month follow-up, regardless of the technique used. Repairing a pre-existing meniscal lesion was more effective than performing LET to decrease the presence of a high-grade PS at follow-up. [ABSTRACT FROM AUTHOR]

Background: Meniscal injuries are among the most common orthopaedic injuries, with a significant volume of published literature. Purpose: To perform a comprehensive bibliometric analysis that appropriately evaluates the 50 most cited articles in meniscal research. Study Design: Cross-sectional study. Methods: We performed a keyword search of the ISIWeb of Knowledge database and then pared the results down to the 50 most cited articles using specific inclusion and exclusion criteria. Data extracted included title, first author, citation count, year of publication, topic, journal, article type, country of origin, and level of evidence. Correlation coefficients were calculated between publication date and citation density and between publication date and raw citation count. Results: The 50 most cited articles were published from 1975 to 2013. The mean number of citations was 258.24 (range, 163-926; median, 225). The majority of articles were published in The American Journal of Sports Medicine (19%), the Journal of Bone and Joint Surgery (12%), and Arthritis & Rheumatology (14%). Most articles focused on either the anatomy and biomechanics of meniscal injury or on prevention and physical rehabilitation (12 papers each). Conclusion: The most popular fields of meniscal research involved anatomy/biomechanics and prevention/rehabilitation, and both are areas that will likely increase the probability of an article's being highly cited in the future. This study provided a quality selection of the most cited articles on meniscal injury and may provide a foundation for both beginner and senior clinician readers for further discussion and research. [ABSTRACT FROM AUTHOR]

Background: One of the goals of anterior cruciate ligament (ACL) reconstruction is a meniscal protective effect on the knee. Despite the advancement of ACL reconstruction techniques, subsequent meniscal tears after ACL reconstruction remain a problem, and the risk factors for recurring lesions are still unclear. Purpose: To investigate the incidence of subsequent meniscal surgery after primary ACL reconstruction without revision ACL surgery and to determine the risk factors associated with this reoperation. Study Design: Case series; Level of evidence, 4. Methods: Overall, 518 patients who underwent primary ACL reconstruction between 2004 and 2012 at one instution participated in this study. Data on body mass index, graft type and femoral tunnel-drilling technique of ACL reconstruction, and location and type of meniscal injury and its treatment at ACL reconstruction were collected from medical records. Clinical outcomes were investigated, including side-to-side difference of anterior laxity, pivot-shift grade, and subsequent meniscal surgery without ACL insufficiency (at minimum 2-year follow-up). Results: The prevalence of tears to the medial meniscus (MM) at the primary ACL reconstruction was 43.6% (226/518), 140 of which were repaired; on the contrary, tears of the lateral meniscus (LM) had a prevalence of 55.8% (289/518), 42 of which were repaired. At a mean 30.3 months (range, 8-124 months) after ACL reconstruction, 20 patients (3.9%; 14 MM tears, 3 LM tears, 3 MM + LM tears) required meniscal surgery without ACL reinjury or recurrence of instability. Of these, 14 MMs and 3 LMs had been repaired at primary ACL reconstruction. The failure rates of repaired MM and LM were 10.0% (14/140) and 7.1% (3/42), respectively. The failure rate of MM repair using the all-inside technique (6/36) was significantly higher compared with no treatment, inside-out repair, or partial resection (P =.045). In multiple regression analysis, the presence of MM injury at the time of ACL reconstruction (odds ratio [OR], 7.81; P =.003), the side-to-side difference of postoperative anterior tibial translation (OR, 1.91; P =.032), and follow-up period after ACL reconstruction (OR, 1.02; P =.003) were risk factors of subsequent meniscal surgery after ACL reconstruction. Conclusion: Incidence of subsequent meniscal surgery after successful ACL reconstruction was <5%. Presence of MM tear at the time of ACL reconsturuction, small amount of increased anterior laxity, and long-term period after ACL reconstruction were predictive of subsequent meniscal surgery. [ABSTRACT FROM AUTHOR]

Background: Meniscal tears are traditionally classified into traumatic versus degenerative tears. Although this classification plays a major role in clinical decision making, no consensus exists on the exact definition of a traumatic or degenerative tear, and the histopathological basis for this classification is unclear. Purpose: To assess the histological degree of meniscal degeneration in patients with a traumatic meniscal tear, as compared with intact meniscal tissue and osteoarthritic meniscal tissue. Study Design: Descriptive laboratory study. Methods: Traumatically torn meniscal tissue was collected during arthroscopic partial meniscectomy. As a control group, intact meniscal tissue was used from transfemoral amputations or direct postmortem dissections. Meniscal tissue from osteoarthritic knees was obtained during total knee replacement surgery. Meniscal tissue was processed, stained, and histologically analyzed with the Pauli scoring system (range, 0-18), comprising the subdomains surface integrity, cellularity, collagen organization, and matrix staining. Scoring was performed by 2 independent observers, blinded to condition, region, and patient data of the meniscus. Results: The traumatic meniscal tear group contained 43 patients (34 men; median age, 29 years; median body mass index [BMI], 24 kg/m2); the intact meniscal tissue group, 8 patients (3 men; median age, 58 years; median BMI, 30 kg/m2); and the osteoarthritic group, 14 patients (4 men; median age, 66 years; median BMI, 28 kg/m2). After adjustment for sex, age, and BMI, patients with a traumatic meniscal tear had a significantly higher histological score than patients with intact meniscal tissue (2.7-point difference; P =.035). Histological score between the traumatic and osteoarthritic groups was not different. Conclusion: Traumatically torn menisci possess a higher degree of degeneration than intact menisci. Our results suggest that patients with a traumatic meniscal tear may already have had a certain degree of meniscal degeneration. These findings potentially challenge the classic view of traumatic versus degenerative meniscal tears. Clinical Relevance: Our findings provide a better understanding of the tissue condition of a torn meniscus. This knowledge may help clinicians decide on choice of treatment and may lead to new perspectives to prevent knee osteoarthritis in patients with a torn meniscus. [ABSTRACT FROM AUTHOR]

Background: While the medial meniscal posterior horn (MMPH) is reported to bear a considerable portion of overall load on the knee joint, including compressive and shear forces, no study has yet investigated the relationship between the MMPH and posterior tibial slope (PTS), which is a geometric factor associated with the shear force component in the presence of a compressive load in the knee joint. Hypothesis/Purpose: The purpose was to investigate the relationship between the PTS and MMPH tears in patients without ligamentous injury. It was hypothesized that the PTS is greater in patients with MMPH tears as compared with those without. Study Design: Cohort study; Level of evidence, 3. Methods: From March 2015 to December 2018, 159 patients with isolated MMPH tears and 60 patients without any pathologic findings on magnetic resonance imaging (control group) were included in this study. The PTS in the affected and contralateral knees was compared between the groups, which were statistically matched according to baseline characteristics (ie, age, sex, body mass index, radiographic osteoarthritis grade according to the Kellgren-Lawrence scale, and hip-knee-ankle angle) via the inverse probability of treatment weighting method. Furthermore, the MMPH tear group was subdivided according to meniscal tear patterns; these subgroups were then compared with the control group. Results: The mean PTS was significantly greater in the MMPH tear group than in the control group (affected knee: MMPH tear group, 7.0°± 3.4° [mean ± SD]; control group, 5.2°± 2.1°, P <.001; contralateral knee: MMPH tear group, 6.7°± 3.3°; control group, 4.7°± 2.2°, P <.001). The mean PTS in each subgroup also tended to be greater than that in the control group. In the receiver operating characteristic curve analysis, the cutoff point of the PTS discriminating between the MMPH tear and control groups was 6.6° for the affected knee (sensitivity, 55.3%; specificity, 75.0%) and 5.5° for the contralateral knee (sensitivity, 61.0%; specificity, 76.7%). Conclusion: An increased PTS is strongly associated with an increased incidence of MMPH tears and less affected by the meniscal tear patterns. [ABSTRACT FROM AUTHOR]

Background: There is limited insight into the mechanisms of knee injuries in rock climbing and bouldering in noncompetitive and competitive athletes. Purpose: To examine the traumatic mechanisms of injury, demographics, distribution, and severity of knee injuries in affected athletes. Study Design: Case series; Level of evidence, 4. Methods: During a 4-year period, we performed a retrospective multicenter analysis of acute knee injuries in competitive and noncompetitive climbing athletes. Traumatic mechanisms were inquired and severity levels, therapies, and outcomes recorded with visual analog scale, Tegner, Lysholm, and climbing-specific outcome scores. Results: Within the observation period, 71 patients (35% competitive athletes, 65% noncompetitive athletes) with 77 independent acute knee injuries were recorded. Four trauma mechanisms were identified: high step (20.8%), drop knee (16.9%), heel hook (40.3%), and (ground) fall (22.1%). The leading structural damage was a medial meniscal tear (28.6%), found significantly more often in the noncompetitive group. A specific climbing injury is iliotibial band strain during the heel hook position. Most injuries resulted from indoor bouldering (46.8%). Surgical procedures were predominantly necessary in noncompetitive climbers. One year after the injury, the Tegner score was 5.9 ± 0.8 (mean ± SD; range, 3-7); the Lysholm score was 97 ± 4.8 (range, 74-100); and the climbing-specific outcome score was 4.8 ± 0.6 (range, 2-5). Conclusion: Increased attention should be placed on the climber's knee, especially given the worldwide rise of indoor bouldering. Sport-specific awareness and training programs for noncompetitive and competitive climbing athletes to reduce knee injuries should be developed, and sports medical supervision is mandatory. [ABSTRACT FROM AUTHOR]

Background: The treatment of meniscal tears in the avascular region remains a clinical challenge. Extracorporeal shockwave therapy (ESWT) is a minimally invasive, safe, and effective therapy for various orthopaedic disorders. However, the therapeutic effect of ESWT on meniscal tears has not been reported. Purpose: To evaluate the therapeutic effect of ESWT in the treatment of meniscal tears. Study Design: Controlled laboratory study. Methods: Twelve-week-old male Wistar rats were divided into 3 groups (normal, ESWT–, and ESWT+). The authors made a full-thickness 2-mm longitudinal tear in the avascular region of the anterior horn in the latter 2 groups. At 1 week after surgery, the ESWT+ group received 800 impulses of shockwave at 0.22-mJ/mm2 energy flux density in a single session. The authors performed a histological examination to evaluate meniscal healing (n = 10 for each group) and immunohistochemistry to analyze the expression of bromodeoxyuridine (BrdU; n = 5 for each group) and CCN family member 2/connective tissue growth factor (CCN2/CTGF; n = 5 for each group) at 2, 4, and 8 weeks after ESWT. The mRNA levels of CCN2, SOX 9, VEGF-a, aggrecan, Col1a2, and Col2a1 at the site of the meniscal tear at 4 weeks after ESWT were quantitatively evaluated by a real-time polymerase chain reaction (n = 5 for each group). Results: The meniscus healing scores in the ESWT+ group were significantly higher than those in the ESWT– group at 4 weeks and 8 weeks. The ratio of BrdU-positive cells was the highest in the ESWT+ group at all observation periods. The ratio of CCN2-positive cells was highest in the ESWT+ group at 4 and 8 weeks. In the ESWT+ group, real-time polymerase chain reaction revealed that the levels of CCN2, SOX9, aggrecan, and Col2a1 were upregulated (All significant data were P <.05). Conclusion: ESWT promoted the healing of meniscal tears in the avascular area. ESWT stimulated proliferation of meniscal cells and the upregulation of cartilage-repairing factors such as CCN2, with the upregulation of cartilage-specific extracellular matrix expression. Clinical Relevance: ESWT may be an effective therapeutic option that promotes meniscal healing in the avascular region. [ABSTRACT FROM AUTHOR]

Background: The time required to develop a secondary cartilage or meniscal injury in the medial compartment after anterior cruciate ligament (ACL) injury is not well understood. Purpose: To determine the association between time delay until ACL reconstruction and the presence of medial compartment Outerbridge grade 3 or 4 chondral injury or medial meniscal tear requiring treatment. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 609 patients underwent primary ACL reconstruction at a single institution at a median 46 days between injury and surgery (61.4% male; mean age, 26.5 years [SD, 11.1]). Chondral status was graded according to Outerbridge criteria at the time of surgery. Multivariate regression analysis was used to assess the relationship between time delay until surgery and medial compartment chondral injury or meniscal injury requiring treatment. Adjustment was performed as needed for patient demographics, sporting activity, and prior knee injuries. Time until surgery had a nonlinear association with medial compartment health and was more effectively described in discrete intervals rather than as a continuous variable. The optimal time intervals to predict medial compartment health were determined by comparison of Bayes information criterion values between fully adjusted regression models. Results: After controlling for relevant confounders, delay of surgery >8 weeks had an increased likelihood of a medial meniscal tear requiring partial meniscectomy (adjusted odds ratio [aOR], 2.30; 95% CI, 1.04-5.12; P = .04) and a decreased likelihood of a meniscal tear requiring repair (aOR, 0.50; 95% CI, 0.32-0.76; P = .001). Delay of surgery >5 months had an increased likelihood of a medial Outerbridge grade ≥3 chondral defect (aOR, 3.11; 95% CI, 1.64-5.87; P = .001) or a grade 4 defect (aOR, 3.84; 95% CI, 1.75-8.45; P = .001). Conclusion: From the time of ACL injury, risk of an irreparable medial meniscal tear found at the time of ACL reconstruction is significantly increased by 8 weeks, and risk of high-grade medial chondral damage is increased by 5 months. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) tears in the pediatric and young adult ACL-deficient knee are often associated with meniscal or chondral injury with delayed time to surgery. The incidence of ACL reconstruction performed in patients aged ≥40 years is rising, and it is unclear if delayed surgery in this cohort similarly affects the health of the meniscus and cartilage. Purpose: To evaluate whether delayed reconstruction in a cohort of patients aged ≥40 years is associated with an increased risk of meniscal or chondral injury. Study Design: Cohort study; Level of evidence, 3. Methods: Records of patients aged ≥40 years who underwent primary arthroscopic ACL reconstruction between 2012 and 2016 at an academic hospital were retrospectively reviewed. Patient characteristic data and time to surgery were recorded. Operative reports were analyzed for meniscal and chondral injuries as well as treatment. Patients were grouped according to time to surgery, defined as early (<90 days) or delayed (≥90 days). Logistic regression modeling was used to form associations between elapsed time to surgery and patient characteristics to meniscal and chondral damage. Additionally, risks for meniscal and chondral injury were analyzed at time points of 180 days and 1 year from injury to surgery. Results: A total of 227 patients met the study criteria: 106 patients underwent early surgery, and 121 underwent delayed surgery. The authors identified 127 medial meniscal tears and 106 lateral meniscal tears. Medial, lateral, and patellofemoral compartment chondral injury was reported in 127, 82, and 130 patients, respectively. Delayed surgery (≥90 days) was not associated with increased risk of medial or lateral meniscal tears or any chondral injury at 90 days. Each year of increased age was associated with an increased odds ratio: 1.09 (P = .001) for medial meniscal tears, 1.06 (P = .014) for lateral meniscal tears, 1.10 (P = .001) for medial compartment chondral injuries, and 1.07 (P = .007) for patellofemoral compartment chondral injuries. Additionally, each unit of increased body mass index was associated with an increased odds ratio: 1.09 (P = .039) for medial meniscal tears and 1.14 (P = .003) for medial compartment cartilage injury. Analysis of 180-day and 1-year time points revealed an increased risk (odds ratio, 3.47; 95% CI, 1.55-7.77; P = .002) for medial meniscal injury when surgery was delayed for >1 year. Conclusion: Delayed ACL reconstruction (≥90 days) among patients aged ≥40 years was not associated with an increased risk of meniscal or chondral injury. Increasing age and body mass index were associated with higher risks of meniscal and chondral injuries in this cohort. Delay in surgery for >1 year was associated with increased risk of medial meniscal tear. [ABSTRACT FROM AUTHOR]

Background: Although several studies were conducted to put forth the biomechanical function of anterior intermeniscal ligament (AIML) on the stability of meniscal structures, there are few data on the etiology of the early degeneration of discoid type compared to the normal shaped ones.Purpose: To determine the AIML subtypes and accompanying meniscal pathologies in discoid lateral menisci (DLM) on knee MRI exams.Material and Methods: Knee MRI exams of 171 individuals with DLM were reviewed. DLMs and AIMLs were typed according to Watanabe's classification and Nelson-Laprade classification, respectively. Medial and lateral menisci were evaluated for tear and menisco-capsular pathology. Pearson's correlation test was used for statistical analysis.Results: DLM was type I in 83 (48.5%) individuals and type II in 88 (51.5%) individuals. AIML was absent in 90 (52.6%) participants; type I AIML was seen in 38 out 81 (22.2%), type II in 31 out of 81(18.1%), and type III in 12 out of 81 (7%). Meniscal pathology was observed in 56 (32.7%) individuals as follows: menisco-capsular strain/separation in 25 (14.6%); medial meniscal tear in 22 (12.8%); and lateral meniscal tear in nine (5.2%); Of these 56 cases, 26 (46%) had no AIML, 15 cases (27%) had type I, nine cases (16%) had type II, and six cases (11%) had type III AIML.Conclusion: No statistically significant correlation was found between the type of DLM and type of AIML ( P = 0.855), between the type of DLM and meniscal pathology ( P = 0.791), or between the type of AIML and meniscal pathology ( P = 0.282). [ABSTRACT FROM AUTHOR]

Background: Limited in vivo kinematic information exists on managing meniscal injury during anterior cruciate ligament reconstruction (ACLR). Hypothesis: Isolated anatomic ACLR restores knee kinematics, whereas ACLR in the presence of medial meniscal injury is associated with altered long-term knee kinematics. Study Design: Cohort study; Level of evidence, 3. Methods: From March 2011 to December 2012, 49 of 57 participants in a clinical trial underwent anatomic ACLR with successful kinematic testing at 24 months after ACLR. Twenty-five patients had associated meniscal tears: medial (n = 11), lateral (n = 9), or bilateral (n = 5). With a dynamic stereo radiography system with superimposed high-resolution computed tomography scans of patient knees, kinematics were measured during downhill running. The initial single-support phase of the gait cycle (0%-10%) was analyzed. Results: Anterior tibial translation (ATT) was the only kinematic outcome between patients’ ACLR and contralateral knees that had significant interactions among meniscal groups (P = .007). There was significant difference in ATT between patients with intact menisci and medial tears (P = .036) and with medial tears and lateral tears (P = .025). Patients with intact menisci had no difference in ATT, with a negligible effect size between the ACLR and contralateral knees (mean ± SEM: 13.1 ± 0.7 mm vs 12.6 ± 0.5 mm, P = .24, Cohen d = 0.15, n = 24), while patients with medial meniscal tears had an increase in ATT, with a medium effect size between the ACLR and contralateral knees (15.4 ± 1.0 mm vs 13.2 ± 1.0 mm, P = .024, Cohen d = 0.66, n = 11). Conclusion: Associated medial meniscal injury in the setting of ACLR leads to increased ATT at 24-month follow-up. Furthermore, isolated anatomic ACLR in the absence of meniscal injury demonstrated no significant difference from native knee kinematics at 24-month follow-up during rigorous “high demand” knee activity with the current sample size. Patients undergoing anatomic ACLR in the presence of medial meniscal injury remained at a higher likelihood of sustaining altered long-term knee kinematics. [ABSTRACT FROM AUTHOR]

All sports come with a risk of injury, and in general, the more contact involved in the sports, the higher the risk of a more significant or traumatic injury. The most frequent types of sports injuries are sprains (ligament injuries), strains (muscle injuries), and stress fractures (bone injuries). In sports medicine, a catastrophic injury is defined as severe trauma to the human head, spine, or brain. Concussions in sports became a major issue in the 2000s as evidence connected repeated concussions and subconcussive hits with chronic traumatic encephalopathy and increased suicide risk. Overuse and repetitive stress injury problems associated with sports include jumper's knee, tennis elbow, and tendinosis. In this review article, we have made an attempt to describe the head to toe spectrum of sports-related injuries including traumatic injuries of the head and face, extremity injuries, soft-tissue injuries, and contact sports-related injuries. [ABSTRACT FROM AUTHOR]

Background: A goal of anterior cruciate ligament (ACL) reconstruction is to provide a meniscal protective effect for the knee. Purpose: (1) To evaluate whether there was a different likelihood of subsequent meniscal surgery in the ACL-reconstructed knee or in the normal contralateral knee and (2) to compare the risk factors associated with subsequent meniscal surgery in the ACL-reconstructed knee and contralateral knee. Study Design: Cohort study; Level of evidence, 3. Methods: Using an integrated health care system’s ACL reconstruction registry, patients undergoing primary ACL reconstruction, with no meniscal injury at the time of index surgery and a normal contralateral knee, were evaluated. Subsequent meniscal tears associated with ACL graft revision were excluded. Subsequent meniscal surgery in either knee was the outcome of interest. Sex, age, and graft type were assessed as potential risk factors. Survival analysis was used to compare meniscal surgery–free survival rates and to assess risk factors of subsequent meniscal surgery. Results: Of 4087 patients, there were 32 (0.78%) patients who underwent subsequent meniscal surgery in the index knee and 9 (0.22%) in the contralateral knee. The meniscal surgery–free survival rate at 4 years was 99.08% (95% CI, 98.64%-99.37%) in the index knee and 99.65% (95% CI, 99.31%-99.82%) in the contralateral knee. There was a 3.73 (95% CI, 1.73-8.04; P < .001) higher risk of subsequent meniscal surgery in the index knee compared with the contralateral knee, or a 0.57% absolute risk difference. After adjustments, allografts (hazard ratio [HR], 5.06; 95% CI, 1.80-14.23; P = .002) and hamstring autografts (HR, 3.11; 95% CI, 1.06-9.10; P = .038) were risk factors for subsequent meniscal surgery in the index knee compared with bone–patellar tendon–bone (BPTB) autografts. Conclusion: After ACL reconstruction, the overall risk of subsequent meniscal surgery was low. However, the relative risk of subsequent meniscal surgery in the ACL-reconstructed knee was higher compared with the contralateral knee. Only graft type was found to be a risk factor for subsequent meniscal surgery in the ACL-reconstructed knee, with a higher risk for allografts and hamstring autografts compared with BPTB autografts. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic surgery of the knee is one of the most frequently performed orthopaedic procedures. One-third of these procedures are performed for meniscal injuries. It is essential that this commonly performed surgery be supported by robust evidence. Purpose: To compare the effectiveness of arthroscopic surgery for meniscal injuries in all populations. Study Design: Systematic review. Methods: An online search was conducted for randomized controlled trials (RCTs) and systematic reviews (SRs) that compared treatment options for meniscal injury. The following databases (inception to April 2015) were included in the search: CENTRAL; MEDLINE; EMBASE; NHS Evidence; National Guideline Clearing House, Database of Abstracts of Reviews of Effects, Health Technology Assessment; ISRCTN; Clinicaltrials.gov; WHO trials platform. Only studies whose participants were selected on the basis of meniscal injury were included; no restrictions were placed on patient demographics. Two independent reviewers applied AMSTAR (A Measurement Tool to Assess Systematic Reviews) criteria for SRs and the Cochrane Collaboration risk-of-bias tool for RCTs. Results: Nine RCTs and 8 SRs were included in the review. No difference was found between arthroscopic meniscal debridement compared with nonoperative management as a first-line treatment strategy for patients with knee pain and a degenerative meniscal tear (mean difference: Knee injury and Osteoarthritis Outcome Score, 1.6 [95% CI, −2.2 to 5.2], pain visual analog scale, −0.06 [95% CI, −0.28 to 0.15]). Some evidence was found to indicate that patients with resistant mechanical symptoms who initially fail nonoperative management may benefit from meniscal debridement No studies compared meniscal repair with meniscectomy or nonoperative management. Initial evidence suggested that meniscal transplant might be favorable in certain patient groups. Conclusion: Further evidence is required to determine which patient groups have good outcomes from each intervention. Given the current widespread use of arthroscopic meniscal surgeries, more research is urgently needed to support evidence-based practice in meniscal surgery in order to reduce the numbers of ineffective interventions and support potentially beneficial surgery. [ABSTRACT FROM AUTHOR]

Background: Reconstruction of anterior cruciate ligament (ACL) tears may potentially prevent the development of secondary meniscal injuries and arthritis. Purpose/Hypothesis: The purpose of this study was to (1) evaluate the protective benefit of ACL reconstruction (ACLR) in preventing subsequent meniscal tears or arthritis, (2) determine if earlier ACLR (<1 year after injury) offers greater protective benefits than delayed reconstruction (≥1 year after injury), and (3) evaluate factors predictive of long-term sequelae after ACLR. The hypothesis was that the incidence of secondary meniscal tears, arthritis, and total knee arthroplasty (TKA) would be higher in patients treated nonoperatively after ACL tears than patients treated with surgical reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective study included a population-based incidence cohort of 964 patients with new-onset, isolated ACL tears between 1990 and 2000 as well as an age- and sex-matched cohort of 964 patients without ACL tears. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. A total of 509 patients were treated with early ACLR, 91 with delayed ACLR, and 364 nonoperatively. All patients were retrospectively followed (range, 2 months to 25 years) to determine the development of subsequent meniscal tears, arthritis, or TKA. Results: At a mean follow-up of 13.7 years, patients treated nonoperatively after ACL tears had a significantly higher likelihood of developing a secondary meniscal tear (hazard ratio [HR], 5.4; 95% CI, 3.8-7.6), being diagnosed with arthritis (HR, 6.0; 95% CI, 4.3-8.4), and undergoing TKA (HR, 16.7; 95% CI, 5.0-55.2) compared with patients treated with ACLR. Similarly, patients treated with delayed ACLR had a higher likelihood of developing a secondary meniscal tear (HR, 3.9; 95% CI, 2.2-6.9) and being diagnosed with arthritis (HR, 6.2; 95% CI, 3.4-11.4) compared with patients treated with early ACLR. Age >21 years at the time of injury, articular cartilage damage, and medial/lateral meniscal tears were predictive of arthritis after ACLR. Conclusion: Patients treated with ACLR have a significantly lower risk of secondary meniscal tears, symptomatic arthritis, and TKA when compared with patients treated nonoperatively after ACL tears. Similarly, early ACLR significantly reduces the risk of subsequent meniscal tears and arthritis compared with delayed ACLR. [ABSTRACT FROM AUTHOR]

Background: Posterior medial meniscal root tears have been reported to extrude with the meniscus becoming adhered posteromedially along the posterior capsule. While anatomic repair has been reported to restore tibiofemoral contact mechanics, it is unknown whether nonanatomic positioning of a meniscal root repair to a posteromedial location would restore the loading profile of the knee joint. Purpose/Hypothesis: The purpose of this study was to compare the tibiofemoral contact mechanics of a nonanatomic posterior medial meniscal tear with that of the intact knee or anatomic repair. It was hypothesized that a nonanatomic root repair would not restore the tibiofemoral contact pressures and areas to that of the intact or anatomic repair state. Study Design: Controlled laboratory study. Methods: Tibiofemoral contact mechanics were recorded in 6 male human cadaveric knee specimens (average age, 45.8 years) using pressure sensors. Each knee underwent 5 testing conditions for the posterior medial meniscal root: (1) intact knee; (2) root tear; (3) anatomic transtibial pull-out repair; (4) nonanatomic transtibial pull-out repair, placed 5 mm posteromedially along the edge of the articular cartilage; and (5) root tear concomitant with an ACL tear. Knees were loaded with a 1000-N axial compressive force at 4 flexion angles (0° , 30° , 60° , 90° ), and contact area, mean contact pressure, and peak contact pressure were calculated. Results: Contact area was significantly lower after nonanatomic repair than for the intact knee at all flexion angles (mean = 44% reduction) and significantly higher for anatomic versus nonanatomic repair at all flexion angles (mean = 27% increase). At 0° and 90° , and when averaged across flexion angles, the nonanatomic repair significantly increased mean contact pressures in comparison to the intact knee or anatomic repair. When averaged across flexion angles, the peak contact pressures after nonanatomic repair were significantly higher than the intact knee but not the anatomic repair. In contrast, when averaged across all flexion angles, the anatomic repair resulted in a 17% reduction in contact area and corresponding increases in mean and peak contact pressures of 13% and 26%, respectively, compared with the intact knee. Conclusion: For most testing conditions, the nonanatomic repair did not restore the contact area or mean contact pressures to that of the intact knee or anatomic repair. However, the anatomic repair produced near-intact contact area and resulted in relatively minimal increases in mean and peak contact pressures compared with the intact knee. Clinical Relevance: Results emphasize the importance of ensuring an anatomic posterior medial meniscal root repair by releasing the extruded menisci from adhesions and the posteromedial capsule. Similar caution toward preventing displacement of the meniscal root repair construct should be emphasized. [ABSTRACT FROM AUTHOR]

Meniscal root tears, less common than meniscal body tears and frequently unrecognized, are a subset of meniscal injuries that often result in significant knee joint disorders. The meniscus root attachment aids meniscal function by securing the meniscus in place and allowing for optimal shock-absorbing function in the knee. With root tears, meniscal extrusion often occurs, and the transmission of circumferential hoop stresses is impaired. This alters knee biomechanics and kinematics and significantly increases tibiofemoral contact pressure. In recent years, meniscal root tears, which by definition include direct avulsions off the tibial plateau or radial tears adjacent to the root itself, have attracted attention because of concerns that significant meniscal extrusion dramatically inhibits normal meniscal function, leading to a condition biomechanically similar to a total meniscectomy. Recent literature has highlighted the importance of early diagnosis and treatment; fortunately, these processes have been vastly improved by advances in magnetic resonance imaging and arthroscopy. This article presents a review of the clinically relevant anatomic, biomechanical, and functional descriptions of the meniscus root attachments, as well as current strategies for accurate diagnosis and treatment of common injuries to these meniscus root attachments. [ABSTRACT FROM PUBLISHER]

The article discusses a study reviewing 15 cases of tibial plateau fractures treated with arthroscopically assisted reduction and internal fixation (ARIF), to determine the repair of meniscal tears. Findings from the mean (SD) Rasmussen score, the mean (SD) Lysholm score, and the mean (SD) IKDC score, suggests that Meniscal repair of tears associated with tibial plateau fractures had effective outcomes.

Background: Meniscal tears have been associated with meniscal cysts and fullness of the knee joint line on physical examination.Hypothesis: Joint line fullness is an accurate, sensitive, and specific test to detect meniscal tears.Study Design: Prospective cohort study.Methods: One hundred consecutive patients undergoing knee arthroscopy were included. All had physical examinations documenting the presence of joint line fullness, joint line tenderness, and the McMurray sign. Arthroscopy was the gold standard for tears. Accuracy, sensitivity, and specificity were calculated and correlated with type of tear. Sixty-one patients had a magnetic resonance imaging preoperatively (the gold standard for determining the presence of a cyst).Results: Meniscal tears were found in 67 patients at arthroscopy. The accuracy, sensitivity, and specificity of joint line fullness were, respectively, 73%, 70%, and 82% in detecting meniscal tears; 68%, 87%, and 30% for joint line tenderness; and 47%, 32%, and 78% for the McMurray sign. The highest positive predictive value for detecting a tear was 88% for joint line fullness, compared with 77% for joint line tenderness and 76% for the McMurray sign. However, joint line fullness did not correlate well with the presence of a cyst, with a low positive predictive value (29%). Of those patients with joint line fullness on physical examination, 89% had a horizontal cleavage component of their tear at arthroscopy.Conclusion: Joint line fullness is an accurate, sensitive, and specific test to detect meniscal tears.Clinical Relevance: The findings support the routine use of joint line fullness during physical examination along with other common tests to improve the accuracy of clinically diagnosing meniscal tears. [ABSTRACT FROM AUTHOR]