Biomaterials and Meniscal Lesions: Current Concepts and Future Perspective

Menisci are crucial structures for knee homeostasis. After a meniscal lesion, the golden rule, now, is to save as much meniscus as possible; only the meniscus tissue that is identified as unrepairable should be excised, and meniscal sutures find more and more indications. Several different methods have been proposed to improve meniscal healing. They include very basic techniques, such as needling, abrasion, trephination and gluing, or more complex methods, such as synovial flaps, meniscal wrapping or the application of fibrin clots. Basic research of meniscal substitutes has also become very active in the last decades. The aim of this literature review is to analyze possible therapeutic and surgical options that go beyond traditional meniscal surgery: from scaffolds, which are made of different kind of polymers, such as natural, synthetic or hydrogel components, to new technologies, such as 3-D printing construct or hybrid biomaterials made of scaffolds and specific cells. These recent advances show that there is great interest in the development of new materials for meniscal reconstruction and that, with the development of new biomaterials, there will be the possibility of better management of meniscal injuries

Can Opioids be Eliminated After Arthroscopic Meniscus Surgery? A Prospective Randomized Controlled Trial (202)

Objectives: To compare a multimodal nonopioid pain protocol to traditional opioid medication in controlling postoperative pain following meniscal surgery. We hypothesized that our nonopioid protocol would show no significant difference in pain and reduced side effects when compared to the standard opioid regimen. Methods: Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The two arms of the study included a multimodal non-opioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for 10 days. Secondary outcomes included patient reported outcomes, complications and patient satisfaction. Randomization was achieve using a random number generator. Patients were not blinded. Data collection was done by a blinded observer. Results: Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen, and 31 randomized to the non-opioid regimen. Patients receiving the nonopioid regimen demonstrated non-inferior VAS scores compared to patients who received opioid pain medication (p>0.05) No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, p = 0.724) nor postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, p = 0.064) PROMIS-PI SF scores. No difference was found in recorded side effects between both groups: constipation (p = 0.124), nausea (p = 0.979), diarrhea (p = 0.464), upset stomach (p = 0.174), and drowsiness (p = 0.572). Conclusions: This study found that multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia.

Articular Cartilage and Meniscus Predictors of Patient-Reported Outcomes 10 Years After Anterior Cruciate Ligament Reconstruction: A Multicenter Cohort Study

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.

In patients eligible for meniscal surgery who first receive physical therapy, multivariable prognostic models cannot predict who will eventually undergo surgery

Purpose Although physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscal tear, 24% still opt for meniscal surgery. The aim was to identify those patients with a degenerative meniscal tear who will undergo surgery following physical therapy. Methods The data for this study were generated in the physical therapy arm of the ESCAPE trial, a randomized clinical trial investigating the effectiveness of surgery versus physical therapy in patients of 45–70 years old, with a degenerative meniscal tear. At 6 and 24 months patients were divided into two groups: those who did not undergo surgery, and those who did undergo surgery. Two multivariable prognostic models were developed using candidate predictors that were selected from the list of the patients’ baseline variables. A multivariable logistic regression analysis was performed with backward Wald selection and a cut-off of p < 0.157. For both models the performance was assessed and corrected for the models’ optimism through an internal validation using bootstrapping technique with 500 repetitions. Results At 6 months, 32/153 patients (20.9%) underwent meniscal surgery following physical therapy. Based on the multivariable regression analysis, patients were more likely to opt for meniscal surgery within 6 months when they had worse knee function, lower education level and a better general physical health status at baseline. At 24 months, 43/153 patients (28.1%) underwent meniscal surgery following physical therapy. Patients were more likely to opt for meniscal surgery within 24 months when they had worse knee function and a lower level of education at baseline at baseline. Both models had a low explained variance (16 and 11%, respectively) and an insufficient predictive accuracy. Conclusion Not all patients with degenerative meniscal tears experience beneficial results following physical therapy. The non-responders to physical therapy could not accurately be predicted by our prognostic models. Level of evidence III.

Recent Trends in Concomitant Meniscal Procedures During Anterior Cruciate Ligament Reconstruction

Background: The chondroprotective effect and secondary stabilizing role of the meniscus has been well-established. Meniscal preservation during anterior cruciate ligament reconstruction (ACLR) has been advocated in the literature and supported by advancements in surgical techniques. Purpose: To examine the recent trends in concomitant partial meniscectomy and meniscal repair procedures with ACLR. Study Design: Descriptive epidemiological study. Methods: Patients who underwent arthroscopic meniscectomy (Current Procedural Terminology [CPT] codes 29880, 29881), meniscal repair (CPT codes 29882, 29883), and ACLR (CPT code 29888) between 2010 and 2018 were identified using the National Surgical Quality Improvement Program database. We calculated the proportion of patients who underwent each surgery type, stratified by year and by patient age and body mass index (BMI) groups. The Cochran-Armitage test for trend was used to analyze yearly proportions of concomitant meniscal surgery types. Results: During the 9-year study period, 22,760 patients underwent either isolated ACLR (n = 10,562) or ACLR with concomitant meniscal surgery (either meniscectomy [n = 8931] or meniscal repair [n = 3267]). There was a gradual decrease in the proportion of meniscectomies (from 80.8% of concomitant procedures in 2010 to 63.8% in 2018), while the proportion of meniscal repairs almost doubled (from 19.2% in 2010 to 36.2% in 2018) (trend, P < .001). ACLR with meniscal repair increased in patients aged 35 to 44 years and 45 to 54 years (trend, P = .027) between 2010 and 2018; at the same time, the proportion of normal weight patients decreased by 17.7%, the proportion of overweight patients increased by 13.2%, and increases were seen in BMI groups corresponding to obesity classes 1 to 3 (trend, P < .001). In 2010, the average BMI of patients undergoing ACLR with meniscectomy versus meniscal repair differed by 2 ( P = .004), but by 2018 the difference was nonsignificant (28.83 ± 5.80 vs 28.53 ± 5.73; P = .113). Conclusion: Between 2010 and 2018, there was an upward trend in the proportion of meniscal repairs performed during ACLR, with notable increases in the proportion of repairs being performed on older, overweight, and obese patients.

Surgical Treatment of Isolated Meniscal Tears in Competitive Male Wrestlers: Reoperations, Outcomes, and Return to Sport

Background: Wrestlers are highly active, young athletes prone to meniscal injuries that often require surgery. However, there is a lack of data evaluating the results of meniscal repair or partial meniscectomy in this cohort. Purpose: To describe the outcomes (subjective function, return to play, complications, reoperation rates, and progression of osteoarthritis) for treatment (meniscectomy or repair) of meniscal injuries in a cohort of competitive wrestlers. Study Design: Case series; Level of evidence, 4. Methods: All competitive wrestlers (high school, collegiate, or professional leagues) with a history of a meniscal injury and isolated meniscal surgery at a single institution between 2001 and 2017 were retrospectively identified. Failure was defined as a reinjury of the operative meniscus by clinical or advanced imaging examination, reoperation, or any additional surgical treatment of the meniscus after the index procedure. All patients were contacted for determination of reinjury rates, current sport status, and International Knee Documentation Committee and Tegner activity scores. Results: Of 85 male wrestlers with isolated meniscal tears, 34% underwent a meniscal repair, and 66% received a partial meniscectomy. Index surgery failed for 9.4% of the cohort. Among wrestlers treated with initial meniscal repair, 21% required a subsequent partial meniscectomy at a mean 2.2 years, and of those treated with partial meniscectomy, 3% underwent a second operation ( P < .001). All secondary operations were revision partial meniscectomies occurring at a mean 3.2 years (95% CI, 0.01-6.4 years) after the index procedure. At final follow-up, 89% of patients were able to return to sport, with 65% returning to wrestling competition. There was significant improvement in the Tegner score from a mean 6.5 (95% CI, 5.9-7.2) preoperatively to 8.3 (95% CI 8.0-8.6) postoperatively ( P < .001). Conclusion: The reoperation rate after meniscal surgery in wrestlers was quite low, but only 65% returned to competitive wrestling. Meniscal repair and partial meniscectomy improved patient-reported outcomes and activity levels at short-term follow-up. However, 21% of wrestlers treated with initial meniscal repair required a subsequent partial meniscectomy at a mean 2.2 years.