The effect of a longitudinal tear of the medial meniscus on medial meniscal extrusion in anterior cruciate ligament injury patients

doi:10.1016/j.knee.2019.07.019

The Knee

Volume 26, Issue 6, December 2019, Pages 1292-1298

https://doi.org/10.1016/j.knee.2019.07.019 Get rights and content

Abstract

Purpose

The purpose of this study was to investigate the effect of a longitudinal tear of the medial meniscus (MM) and its meniscal repair on MM extrusion in anterior cruciate ligament (ACL)-injured patients. The hypothesis underlying this study was that a longitudinal tear of the MM is correlated with MM extrusion, and that the extrusion would persist after ACL reconstruction with concomitant MM repair.

Methods

Forty-three ACL-injured patients with a concomitant MM longitudinal tear were included in the MM tear group. Thirty-four solely ACL-injured patients without any meniscal injuries were included in the Control group. Medial meniscus extrusion width (MEW) was measured pre-operatively and three months after surgery on magnetic resonance imaging.

Results

Pre-operative MEW in the MM tear group was significantly larger than that in the Control group (MM tear group: 1.5 mm, Control: 0.3 mm, P < 0.001). The MEW change in the MM tear group was significantly greater than that in the Control group three months after operation (MM tear group: 0.8 mm, Control: − 0.2 mm, P < 0.001). The number of sutures required for repair was correlated with MEW both pre-operatively and postoperatively in the MM tear group (pre-operative: P = 0.005, R = 0.42, postoperative: P < 0.001, R = 0.54).

Conclusion

Longitudinal tear of the MM was correlated with MM extrusion and the MM extrusion persisted after ACL reconstruction with concomitant MM repair in the MM tear group. The initial meniscal tear size was directly correlated with the pre-operative MEW. Therefore, meniscal extrusion after longitudinal tears of the medial meniscus should be taken into careful consideration.

Introduction

Medial meniscus (MM) tears result in the progression of post-traumatic knee osteoarthritis (PTOA) [1], [2], [3]. Different morphologies of MM tears show different severities of PTOA progression. Recently, the morphology of meniscal tears has been considered important to better understand their relevance in the occurrence and progression of PTOA [4]. A longitudinal tear is associated with traumatic injuries in the younger age group; 63% of MM tears in anterior cruciate ligament (ACL)-injured knees are longitudinal tears [5]. Biomechanical studies have shown that longitudinal tears of the MM increase contact pressure on the medial tibial plateau by two-fold and result in cartilage degeneration [6], [7].

Medial meniscus extrusion is defined as medial displacement of the meniscus beyond the outer margin of the tibial plateau and is strongly associated with the progression of knee PTOA [8], [9]. Biomechanical studies have reported that the meniscus converts axial load into circumferential hoop stress and MM extrusion reduces the conversion to circumferential hoop stress [10], [11]. Several factors have been reported to be associated with MM extrusion, including: posterior meniscal root tear, meniscal radial tear, varus malalignment, and cartilage damage [12]. However, because the subjects of those studies were old osteoarthritic (OA) patients, it remains to be clarified whether a meniscal tear with a traumatic injury in young patients is the causal factor for MM extrusion. Therefore, further investigation of the independent causal factors for MM extrusion in traumatic knee injuries is essential and could help to prevent MM extrusion and further progression of PTOA in such patients.

A meta-analysis comparing meniscal repair with meniscectomy in the treatment of meniscal tears reported that meniscal repair has better long-term clinical outcomes than meniscectomy [1]. Conversely, ACL-reconstructed patients with a meniscal repair show more rapid progression of PTOA in comparison with ACL-reconstructed patients without any meniscal injury [13], [14]. A biomechanical study has shown that the contact area of the meniscus after meniscal repair for a longitudinal tear is slightly smaller than the intact state [6]. However, there is limited evidence of residual MM extrusion after MM repair for a longitudinal tear.

The purpose of the present study was to investigate the effect of a longitudinal tear of the MM and its meniscal repair on MM extrusion in ACL-injured patients. The hypothesis underlying this study was that a longitudinal tear of the medial meniscus is correlated with MM extrusion and the extrusion would persist after ACL reconstruction with concomitant MM repair.

Section snippets

Subjects

A retrospective review was undertaken of unilateral primary ACL reconstruction (ACLR) between 2011 and 2015 at Tokyo Medical and Dental University Hospital of Medicine. Patients gave their full written informed consent for participation in this study prior to the operative procedure. Fifty patients were included who underwent only ACLR without any concomitant meniscal treatment. Thirty-four of the 50 solely ACLR patients, who had appropriate magnetic resonance imaging (MRI) scans recorded

Patient characteristics

Age at surgery, sex, height, weight, BMI, and preinjury Tegner scores did not show significant between-group differences (Table 2).

Effects of medial meniscal tear on extrusion

Pre-operative MEW in the MM tear group was significantly greater than that in the Control group (MM tear group: 1.5 mm [1.2–1.8 mm], Control: 0.3 mm [0.0–0.7 mm], P < 0.001; Figure 2). Pre-operative MEW in the MM tear group was significantly correlated with the number of sutures, representing an initial meniscal tear size intraoperatively (P = 0.005, R = 0.42;

Discussion

The most important findings of the current study were that a longitudinal tear of the medial meniscus was correlated with an increased MM extrusion in ACL-injured patients, and the MM extrusion persisted after ACLR with concomitant MM repair in the MM tear group. The initial tear size of the longitudinal meniscal tear was directly correlated with MEW both pre-operatively and postoperatively. Therefore, MM extrusion after longitudinal tear of the medial meniscus should be taken into careful

Conclusions

In conclusion, a longitudinal tear of the medial meniscus correlated with MM extrusion, and MM extrusion persisted after ACLR with concomitant MM repair in the MM tear group. The initial meniscal tear size was directly correlated with the pre-operative MM extrusion width. Therefore, meniscal extrusion after longitudinal tear of the medial meniscus and its meniscal repair should be taken into careful consideration.

Acknowledgements

The authors thank Atsushi Okawa, MD, PhD, for continuous support, and Editage (www.editage.jp) for English language editing.

HK conceived the study, performed all the experiments, and participated in its design. KM participated in its design and performed analysis. YN and KO acquired the data. TO and MS analyzed and calculated the data. IS participated in its design. HK had full access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data

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It remains controversial whether meniscal repair causes meniscal extrusion. This study aimed to investigate the effect of inside-out meniscal repair on meniscal dimensions in patients with meniscal tear of the mid-body–posterior horn.
This retrospective study included 75 patients who underwent meniscal repair followed by MRI within 2 weeks after surgery between 2020 and 2022. Patients with a discoid lateral meniscus, pull-out repair, concomitant osteotomy, all-inside repair only, and revision surgery were excluded. Thirty-three meniscal tear treated using an inside-out arthroscopic repair technique were included in the lateral meniscus (LM, n = 19) and medial meniscus (MM, n = 14) tear groups. Thirty-six participants with intact meniscus were included as controls. Meniscal extrusion and posterior shift were measured on coronal and sagittal MRI pre-operatively and within 2 weeks postoperatively.
Preoperative coronal extrusion was significantly greater in the LM tear group than in the control group (P = 0.001). Coronal extrusion and posterior shift were significantly smaller postoperatively than preoperatively in the LM tear group (P < 0.001 and, P = 0.008, respectively). Pre- and postoperative coronal extrusion in the MM tear group were not significantly different (P = 0.291). Postoperative coronal extrusion in both LM and MM tear groups were not significantly correlated with the number of sutures required for repair (LM: P = 0.765, R = −0.076, MM: P = 0.1, R = 0.497).
The torn meniscus of the mid-body - posterior horn before surgery was extruded and shifted posteriorly in both LM and MM tears, and repair using an inside-out arthroscopic technique was effective in reducing meniscal extrusion and posteriors shift in the LM tear immediately after surgery.
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ME has been recently reported in association with traumatic meniscal tear [5,6]. Katagiri et al. [7] reported association of longitudinal tear with ME in ACL-deficient patients and ME persisted after ACL reconstruction and meniscal repair. These authors did not evaluate in their study the health of MTL.
Medial meniscal extrusion (ME) has been found to be associated to anterior cruciate ligament (ACL) injury. Post-traumatic extrusion is mainly attributed to meniscotibial ligament (MTL) tear. The aim of this retrospective study was to assess the incidence of MTL tear associated with meniscal extrusion, evaluate arthroscopic findings and the associated clinical findings.
The medial meniscal extrusion, when associated to ACL injury, is related to a tear of the MTL.
Patients who underwent to primary or revision ACL reconstruction with associated medial meniscal rise and/or meniscotibial tear or insufficiency were retrospectively identified over a 5-year period (from 2015 to 2019). Twenty-four patients were included in this study with preoperative magnetic resonance imaging (MRI) carried out at our institution Each MRI was evaluated by the senior author for the presence of meniscal extrusion and also for the additional pathology of meniscotibial ligament. Patient medical records were reviewed to obtain demographic information, including age, gender, and arthrometric evaluation of anteroposterior laxity.
All included patients underwent arthroscopic ACL reconstruction using autograft tissue, (19 primary and in 5 revision ACL reconstruction). The mean age was 31.2 years (range: 15–57; SD: 12.3 years) at the time of surgery. ME was identified at MRI in all cases preoperatively and confirmed arthroscopically. No correlation was found between meniscal extrusion and anteroposterior translation (ρ = −0.270; p = 0.202). Neither between having more than 3 mm of extrusion and gender (χ² = 0.80; p = 0.371), acute/chronic lesion (χ² = 0.91; p = 0.341) and primary/revision reconstructions (χ² = 0.83; p = 0.364). In the last three patients, arthroscopic treatment of meniscal extrusion was carried out through outside-in repair of medial meniscus at its capsular junction. Reduction of meniscal extrusion has been verified by MRI, performed at 3-month follow-up.
A high prevalence of ME was found at MRI in patients with ACL injury and MTL tear. Therefore, ME may be associated to acute or chronic ligamentous injury involving the MTL, and its tear can be considered as the main determinant of extrusion. Further research is needed to increase evidence concerning MTL incidence and surgical outcomes.
IV, retrospective case series.
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In addition to the meniscal repair techniques, a capsulodesis was performed using knotless anchors from outside of the joint. Previous reports showed that meniscal repair would induce transposition of the medial meniscus,19,20 and the meniscus extrusion after surgery increased as the number of sutures required for repair increased.21 In this surgical procedure, a number of sutures are necessary for meniscal repair, which has a possibility to induce the meniscal extrusion.
Wrisberg variant discoid lateral meniscus (DLM) is a congenital anatomic variation of the meniscus in the knee joint, which is an uncommon type of the DLM. We present a surgical technique in a case of symptomatic Wrisberg variant DLM. To improve the instability due to the lack of the posterior attachment of meniscotibial ligament, the posterior portion of DLM was attached to the insertion site of normal LM posterior root using pull-out repair technique. In addition, a longitudinal tear from the anterior to the middle portion of DLM was repaired with outside-in and inside-out techniques. Finally, a capsulodesis using knotless anchors was performed from outside of the joint to prevent the meniscus extrusion after the surgery. Knee symptoms such as pain, catching, and ROM restriction disappeared at 3 months after the surgery. Postoperative magnetic resonance imaging showed a slightly sharpened shape of the DLM, and the attachment of the posterior portion of the DLM was observed. Longitudinal tear of the DLM was healed without cleavage. This procedure is useful to improve the symptoms of the knee joint with Wrisberg variant DLM and to preserve the function of the meniscus.
Steep posterior slope of the medial tibial plateau is associated with ramp lesions of the medial meniscus and a concomitant anterior cruciate ligament injury
2021, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology
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The posterior segment of the MM is often deformed and shifted posteriorly in ACL-deficient knees complicated with an MM tear at 90° of knee flexion.35 Although longitudinal tears of the MM are correlated with MM extrusion36 and the anteroposterior length and radial extrusion of the MM increase even after ACLR,37 ACLR can reduce the deformation of the MM posterior segment in the knee-flexed position by reducing abnormal ATT. ACLR also possibly prevents secondary injury to the MM posterior segment and cartilage, which can progress to knee osteoarthritis.35
Medial meniscus (MM) tears are associated with both acute and chronic anterior cruciate ligament (ACL) insufficiency and can lead to degenerative changes in the knee. ACL reconstruction (ACLR) combined with the meniscal repair was reported to result in decreased anterior knee joint laxity with evidence of improved patient-reported outcomes in the long term. However, a subtle tear of the MM posterior segment, also known as a ramp lesion, is difficult to detect on conventional magnetic resonance imaging (MRI) and is frequently missed in ACL-deficient knees. However, there are few studies about the associations between bone geometry and ramp lesion of the MM. This study aimed to compare sagittal medial tibial slope (MTS), medial tibial plateau depth (MTPD), and coronal tibial slope (CTS) between ACL-injured knees with and without ramp lesion of the MM. We hypothesised that patients with ramp lesion of the MM and a concomitant ACL injury have a steeper MTS and shallower MTPD than those without ramp lesion of the MM.
Twenty-seven patients who underwent ACLR (group A), and 15 patients with combined MM repair (group AM) were included in the study. Anterior tibial translation (ATT) was measured under general anaesthesia just before surgery using a knee arthrometer. MRI was performed in the 10°-knee-flexed position. The MTS and MTPD were measured on sagittal view, and the CTS was measured on coronal view. These parameters were compared between the groups. Differences in MRI measurements or patient demographics between the groups were evaluated using the Mann-Whitney U test.
No significant difference was observed in demographic data and post-operative side-to-side difference in ATT between both groups. Pre-operative ATT was significantly higher in group AM than in group A (P < 0.05), whereas post-operative ATT was similar in both groups. Further, Pre-operative ATT was significantly higher in patients with MTS ≥5.0° than in those with MTS <5.0° (P < 0.05). In groups A and AM, the MTS were 3.6° ± 1.8° and 6.2° ± 2.9°, the MTPD were 2.0 ± 0.5 mm and 2.1 ± 0.6 mm, and the CTS were 2.5° ± 1.8° and 2.4° ± 1.6°, respectively. Patients in group AM had a significantly steeper MTS compared to those in group A (P < 0.01), whereas MTPD and CTS were nearly the same in both groups. When the MTS cut-off value was set at 5.0°, the sensitivity and specificity for ACL injury with concomitant ramp lesion of the MM were 0.73 and 0.76, respectively.
A steep posterior slope of the medial tibial plateau is a risk factor for ramp lesion of the MM associated with an ACL injury. Especially in patients with MTS ≥5.0°, an occult MM ramp lesion should be strongly suspected, and surgeons should prepare for MM repair in combination with ACLR.
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The effect of a longitudinal tear of the medial meniscus on medial meniscal extrusion in anterior cruciate ligament injury patients

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Section snippets

Subjects

Patient characteristics

Effects of medial meniscal tear on extrusion

Discussion

Conclusions

Acknowledgements

Knee Surg Sports Traumatol Arthrosc

Osteoarthr Cartil

Arthroscopy

Arthroscopy

Eur J Radiol

Knee

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthrosc Tech

J Orthop Sci

Meniscus status at anterior cruciate ligament reconstruction associated with radiographic signs of osteoarthritis at 5- to 10-year follow-up: a systematic review

J Knee Surg

Incidence and patterns of meniscal tears accompanying the anterior cruciate ligament injury: possible local and generalized risk factors

Int Orthop

Changes in tibiofemoral contact mechanics following radial split and vertical tears of the medial meniscus

an in vitro investigation of the efficacy of arthroscopic repair J Bone Joint Surg Am

Meniscal tear and extrusion are strongly associated with progression of symptomatic knee osteoarthritis as assessed by quantitative magnetic resonance imaging

Ann Rheum Dis