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Background: Management of discoid meniscus in pediatric patients requires understanding of the presentation, associated risks, and appropriate techniques. Surgical treatment consists of saucerization, meniscus repair, meniscocapular stabilization, and, periodically, subtotal meniscectomy. The type of meniscal treatment is commonly determined during arthroscopy. Thus, surgeons, patients, and their parents/guardians must be prepared for a variety of surgical options. Hypothesis/Purpose: To compare intraoperative arthroscopic findings and treatment of discoid meniscus across pediatric age groups in a large multicenter quality improvement registry. Methods: A multi-center quality improvement registry (16 institutions, 26 surgeons) monitoring the safety of discoid meniscus surgery was reviewed. Audit processes using CPT codes were designed to ensure that all consecutive cases from 2018-2020 were prospectively entered on patients <19 years old into a HIPAA-compliant electronic platform. Patients were grouped into five groups based on age at time of surgery (<7, 7-10, 11-13, 14-16, >16). Demographic characteristics, discoid type, presence and type of tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Chi-Square or Fisher's exact tests were used for categorical comparisons and a Kruskal-Wallis test for continuous comparisons. Results: 274 patients were identified (mean age 12.4 years, range 3-18; 47.3% females). Complete discoid meniscus and peripheral rim instability were found to be more prevalent in younger age groups (Table 1). Peripheral rim instability was noted in 55.5% of cases, most commonly in the posterior horn (24.8%). While a focal region of instability was most common, the youngest age group was more likely to have either multifocal instability or no instability. Repair was conducted more commonly in the younger cohorts, with a significant decrease in repair percentage (p=0.008) per age group. All-inside was the most common repair technique in all age groups. Partial meniscectomy/debridement beyond saucerization occurred more frequently in older age groups than younger age groups (p=.0002), including 38.4% of cases in the oldest age group (Table 2). Conclusion: Younger patients experienced a greater incidence of complete discoid menisci and meniscus repair in this age group and was more likely to have more than one area of rim instability. However, when meniscal resection beyond a saucerization was required, this was more likely to occur in older patients. Table 1. Age-Related Comparison of Discoid Meniscal Presentation and Treatment Table 2. Incidence of Additional Meniscal Resection Beyond Saucerization [ABSTRACT FROM AUTHOR]

Background: Discoid meniscus is a congenital variant typically affecting the lateral meniscus of the knee. Historically, surgical intervention when symptomatic consisted of total meniscectomy; however, after degenerative changes were observed, current treatments now focus on rim preservation with arthroscopic saucerization and meniscal repair for instability, when indicated. Purpose: The aim of this study was to examine long-term patient-reported outcomes of lateral discoid menisci (LDM) treated with meniscal-preserving techniques. Methods: Ninety-eight patients treated arthroscopically for LDM at a single institution at a minimum of 15 years ago were retrospectively identified and contacted by mailers and telephone to participate. Subjective functional outcomes and patient satisfaction data were collected using a questionnaire that included the validated IKDC Subjective Knee Evaluation Form, Lysholm Score, Marx Activity Rating Scale, Tegner Activity Score, and WOMAC Osteoarthritis Index. Patient and surgical characteristics and patient-reported outcomes were summarized by mean and standard deviation (SD), median and interquartile range (IQR), or frequency and percent, as appropriate. Results: Of the 46 patients contacted (response rate of 46/98 eligible), 25 (54%) completed the questionnaires. The mean (± SD) age at initial surgery was 10.8 (± 3.4) years and 30.3 (± 3.7) years at final follow-up. The mean (± SD) follow-up time from initial surgery was 19.5 (± 2.8) years (range, 16–27). Patient-reported outcomes included: IKDC 77.4 ± 17.2, Lysholm 78.6 ± 21, WOMAC 7.6 ± 11.3, Tegner Activity 7 (out of 10), and Marx Activity Rating Scale 8 (out of 10) (Table 1). Eleven (44%) cases underwent subsequent LDM-related surgery on the ipsilateral knee(s). There were no cases of total knee replacement (Table 2). Conclusions: Overall, patient-reported outcomes were favorable at a minimum of 15-year follow-up after rim-preserving saucerization of lateral discoid meniscus. While two-thirds of patients were satisfied with their surgical outcomes, nearly half of patients underwent revision saucerization with or without meniscal repair. Subsequent long-term follow-up studies with radiographs will be important to determine how meniscus-preserving procedures may curb the development of arthritis. Table 1. Overall Postoperative Outcomes (N=25 patients)a Table 2. Postoperative Outcomes by Discoid Type and Surgery (N=26)a [ABSTRACT FROM AUTHOR]

Background: Paediatric patients undergoing Anterior Cruciate Ligament (ACL) reconstruction often present with a repairable meniscus tear. When a conservative early post-operative rehabilitation protocol is used to protect the meniscus repair, some have wondered whether this has an effect on functional and subjective outcomes, or time required, at return to activity. Purpose: The goal of this study was to compare the quantitative lower limb functional measures and subjective patient reported outcome scores at Return to Activity (RTA) in paediatric patients undergoing ACL reconstruction, with or without meniscus repair. Methods: This study was performed as a retrospective comparative cohort analysis of prospectively collected data in paediatric patients undergoing ACL reconstruction. Inclusion criteria for this study included a full data set and a visit to our biomechanics lab post-operatively, after being cleared for RTA by their attending surgeon. If a repairable meniscus injury was present, it was repaired concurrently with ACL reconstruction. Patients with a meniscus repair were provided rehabilitation guidelines that included partial weightbearing and limited range of motion (ROM) for six weeks, whereas full weightbearing and unrestricted ROM was recommended for the non-meniscal repair group. Postoperative quantitative knee functional outcome variables (drop vertical jump ground reaction forces, isometric knee extension/flexion strength, and hip abduction strength) were expressed as limb symmetry indices (LSIs; reconstructed limb/uninjured limb). Patient reported subjective knee outcome scores (Tegner and HSS Pedi-FABS) were also obtained. Differences in outcome measures were assessed using Mann-Whitney U-test and independent T-tests. Results: Twenty-four paediatric ACL reconstruction patients met criteria for inclusion in this study. Thirteen patients had a meniscus repair (median age 15 (13-17)) and 11 patients did not (median age 15.8 (14-17)). The median days between surgery and follow-up was 267 (168-460) days for the meniscus repair group and 251 (167-435) days for the non-meniscus repair group. There were no differences between the groups for the postoperative drop vertical jump test (p=0.21), knee extension/flexion strength (p=0.88/0.46) and hip abduction strength (p=0.46). Both groups also displayed similar Tegner (6.1/6.2) and Pedi-FABS (12.5/12.8) scores. Conclusion: Despite conservative weight-bearing and range of motion restrictions, repair of the meniscus in combination with ACL reconstruction in pediatric patients does not appear to induce a meaningful strength deficit at the return-to-activity evaluation phase, and is therefore not expected to influence return to activity in comparison with non-meniscus repair patients. This is important guidance for paediatric patients, families, and rehabilitation professionals involved in the care of young athletes. Table 1. Patient characteristics Table 2. Post-operative patient reported outcome scores [ABSTRACT FROM AUTHOR]

Introduction: Meniscal repair techniques (inside-out, all-inside, outside-in) continue to evolve. Assessment of meniscus repair outcomes at a minimum of 5 years postoperatively appears to best represent the true failure rates compared to 1 and 2-year timepoints. In the last decade, the literature on outcomes of meniscus repair has grown significantly. Purpose: To conduct a systematic review and meta-analysis to assess the rate of failure after meniscal repair at a minimum 5 years postoperatively. Methods: We performed a systematic review of studies reporting the outcomes of meniscal repair at a minimum of 5 years postoperatively. A standardized search strategy was utilized with the assistance of a medical librarian. Abstracts and full-text articles were reviewed by two reviewers to identify studies assessing the clinical outcome of meniscus repair, which was most uniformly assessed by reoperation. Outcomes were assessed (when reported) relative to anterior cruciate ligament (ACL) status, sex, age, and postoperative rehabilitation protocol. Pooling of data and meta-analysis with a random-effects model were performed. Results: A total of 28 studies of 1712 patients were included. In the last decade, 15 studies of 1168 patients have been reported, compared to 566 patients in 13 studies in the previous decade. The pooled failure rate of all devices was 22.2% (365/1712) and the failure rates of modern repairs was 17.5% (194/1128). Medial repairs were significantly more likely to fail compared to lateral repairs (26.4% [178/745] v. 13.0% [55/365], p=0.01). Failure rates varied from 16.9% for inside-out (78/501), 16.2% modern all-inside (66/396), 20.2% for outside-in (34/153), and 19.8% for open (22/109). First generation all-inside devices had a significantly higher failure rate (30.3%) compared to modern all-inside devices (16.2%) (p=0.01). There was no significant difference in failure rates between meniscal repair with concomitant ACL reconstruction (19.0%) and isolated meniscal repairs (19.6%, p=0.780). There was also no difference between post-operative rehabilitation protocols, sex, or age (all p>0.05). Conclusions: The outcomes of meniscal repair at a minimum 5 years postoperatively had an overall failure rate of 21.8%. Modern all-inside meniscus repair techniques appear to have improved the success rates compared to first-generation all-inside devices, and now appear similar to those of inside-out meniscus repair. Lateral repairs were significantly more likely to be successful compared to medial repairs. Finally, despite traditional teaching that ACL reconstruction improves rates of meniscus healing, across ˜700 patients, no difference in rates of healing were seen in ACL reconstruction compared to isolated meniscus repair. Figure 1. Scatter Plot of the failure rate reported by the study compared time of follow up completed. Each study is represented by a dot, the size of which represents the indivudual study's sample size. A simple linear regression line of best fit is shown (R2=0.02). Figure 2. Forest plot demonstrating failure rates sorted by the technique of repair used. All inside divices were subdivided into first generation (meniscal arrows) and modern (defined as 2nd generation and newer). Other techniques include inside out, outside in, and open. Es=Estimated significance; 95% CI-95% Confidence interval. [ABSTRACT FROM AUTHOR]

Background: Lateral discoid meniscus (LDM) often present with complex morphology that can be challenging to assess and treat arthroscopically. Preoperative magnetic resonance imaging (MRI) is frequently used for diagnosis and surgical planning, however it is not known whether surgeons are reliable and consistent in their interpretation of MRI findings. Hypothesis/Purpose: We hypothesize that surgeons experienced in treating LDM are able to reliably interpret discoid pathology using MRI, with the exception of evaluating dynamic factors (i.e. instability). Methods: Forty five discoid meniscus MRI selected from a pool of surgical discoid meniscus cases were included in this review. Five reviewers (experienced pediatric sports medicine surgeons) who were not involved in the MRI selection process performed independent review of each MRI to determine discoid meniscus classification. More than 4 weeks later, a second reading was performed by 3 of the 5 reviewers. Interobserver and intraobserver reliability of the primary (width, presence of instability or tear) and secondary (location of instability or tear, tear type) rating factors was assessed using the Fleiss κ coefficient, designed for multiple readers with nominal variables (reliability: fair, 0.21–0.40; moderate, 0.41–0.60; substantial, 0.61–0.80; excellent, 0.81–1.00). Reliability is reported as κ (95% CI). Results: Interobserver reliability of assessment of meniscal width was substantial 0.67 (0.58-0.76), and intraobserver was moderate 0.52 (0.35-0.69). Assessment of presence of peripheral instability had moderate interobserver reliability 0.54 (0.45-0.63) and substantial intraobserver 0.61 (0.44-0.78). Presence of tear had fair interobserver reliability 0.39 (0.29–0.48) and substantial intraobserver 0.68 (0.51-0.85). When identifying location of instability or tear, interobserver reliability was moderate while intraobserver agreement was substantial for assessment of anterior instability (0.47 (0.37-0.56) and 0.68 (0.51-0.85), respectively); posterior instability (0.56 (0.47-0.65) and 0.62 (0.45-0.79), respectively); and posterior tear (0.41 (0.32-0.50) and 0.69 (0.52-0.86), respectively). The exception was identifying anterior tear, with fair interobserver reliability 0.33 (0.23-0.42) and moderate intraobserver 0.56 (0.39-0.73); Interobserver reliability was fair for tear type 0.34 (0.28-0.41) and intraobserver reliability moderate 0.55 (0.43-0.67). Conclusion: Orthopaedic surgeons experienced in the treatment of LDM vary from each other in their classification using MRI, especially with regard to assessment of meniscus tears. MRI evaluation may be helpful to diagnose discoid by width and identify presence of instability, two major factors in the decision to proceed with surgery. However, definitive treatment should be guided by a comprehensive arthroscopic evaluation. [ABSTRACT FROM AUTHOR]

Background/Purpose: The discoid meniscus is a congenital variant that is reported to be present in 3-5% of the United States population. Treatment involves partial meniscectomy and saucerization to obtain a more anatomic-appearing meniscus. The immediate post-operative cross-sectional morphology is often squared due to the inherent thickness of the discoid meniscus at the resection margin. The purpose of this study is to determine if the discoid meniscus can remodel and regain the triangular cross sectional configuration of a normal meniscus after surgical intervention. Methods: A retrospective chart review was performed to identify all patients undergoing partial meniscectomy for symptomatic discoid meniscus within the past 3 years at our institution. Patients were included if they had a subsequent knee magnetic resonance imaging (MRI) study. Each MRI study was evaluated by two orthopaedic surgeons independently. The extent of remodeling was graded on the cross-sectional morphology of the saucerized discoid meniscus on coronal and sagittal T1-weighted images of the corresponding knee mri based on the following scheme: 1) complete for a triangular cross-section, 2) partial for a trapezoidal cross-section, and 3) none for a square cross-section. Descriptive means and statistical analysis for intraclass correlation coefficient (ICC) were performed using Microsoft Excel. Results: A total of 11 patients and 14 knees were included in this study. Average age at time of surgery was 10.85. Average time to the follow-up MRI of the same knee was 540.50 +/- 341.84 days. 2 knees required additional surgical intervention following their index surgery. Complete remodeling was identified in 78.5% (11/14) knees. 1 knee had no remodeling and 2 knees had partial remodeling. Our ICC was 0.87 (95% CI: [0.66,0.96]). Conclusion: Our results indicate that the discoid meniscus has the potential to remodel into a "normal" triangular cross-sectional morphology after partial meniscectomy and saucerization. In our series, 21.4% (3/14) knees did not experience complete remodeling. This may have been due to over resection of the discoid meniscus at the index surgery owing to the extent of an existing tears. The remodeling all occurred within a two-year time frame though the exact time is unknown. This study indicates no additional intervention is required at the central resection margin to thin out the thick edge that often results from the meniscal biter. [ABSTRACT FROM AUTHOR]

Background: The discoid medial meniscus is a rare congenital anomaly of the knee. The literature on discoid medial menisci is limited, with few reported cases in children. Purpose: To report the clinical manifestations and operative treatments of discoid medial menisci in children from multiple centers in North America. Methods: A retrospective review of medical records including operative reports was performed to identify patients diagnosed with a discoid medial meniscus confirmed via direct surgical observation across eight children's hospitals between January 2000 and March 2020. Results: Twenty-one patients (9 female, 12 male) with 22 discoid medial menisci were identified, one with bilateral discoid medial menisci. The mean age at time of diagnosis was 12.7 years (range, 3-18 years). One patient had discoid medial and discoid lateral menisci in the same knee. The most common symptoms and signs of patients with a discoid medial meniscus were locking and/or clunking, present in over 50% of patients. Twelve discoid medial menisci were complete (55%), 8 were incomplete (36%), and two were indeterminate (9%). Tears were present in 13 knees. Of those with tears, 7 were horizontal tears (4 posterior, 1 anterior, and 2 mid-body), 5 were complex (3 posterior, 1 anterior, and 1 mid-body), and 1 was a posterior vertical tear. Five of these discoid medial menisci were unstable (23%). The average time between initial diagnosis and treatment was 13 months (range, 0-121 months). All knees underwent arthroscopic saucerization, and of the 13 torn discoid medial menisci, 7 were repaired (54%). The mean length of clinical follow-up postoperatively was 24 months (range, 1-82 months). Four of these discoid medial menisci underwent re-operation, most commonly for persistent symptoms. All knees which required re-treatment initially presented with a tear, all of which had been repaired. There was a significant association between initial presence of a tear and need for re-operation, [χ2 = 4.1, p = 0.044]. Conclusions: In this multicenter study of patients treated for a discoid medial meniscus, symptoms and signs at presentation and findings at arthroscopy were similar with those commonly seen in patients with a discoid lateral meniscus. Tears were present in more than half of knees, and reoperation was more common in knees identified with tears of their discoid medial menisci than those without tears. Future studies should seek to determine the long-term functional and patient-reported outcomes following treatment of discoid medial menisci. [ABSTRACT FROM AUTHOR]