Articular Cartilage and Meniscus Risk Factors of Patient-Reported Outcomes 10 Years after ACL Reconstruction: A Multicenter Cohort Study (160)

Objectives: 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. 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 meniscus tears/treatment would be predictors of the IKDC, KOOS (all 5 subscales), and Marx activity level at 10-year follow-up after ACLR. Methods: Between 2002 and 2008, 3273 ACLR subjects were prospectively enrolled and followed longitudinally with the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A logistic regression model was built incorporating variables from patient demographics, surgical technique, articular cartilage injuries, and meniscus tears/treatment to determine the risk factors of IKDC, KOOS, and Marx at 10 years. Results: We completed a minimum follow-up on 77% (2530/3273) of our cohort at 10 years. The cohort was 56% male with a median age of 23 years at the time of enrollment. 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%, trochlear-8%) and meniscal (medial-37%, lateral-46%). Variables that were predictive of 10-year outcomes included articular cartilage damage in the patellofemoral and medial compartments and previous medial meniscus surgery (6% of knees) (Table). Medial and lateral meniscus tears and treatment at the time of ACLR were not associated with 10-year outcomes. Other variables that significantly influenced 10-year outcomes included sex, race, BMI, type of reconstruction (primary vs. revision), baseline outcome scores, and MCL pathology (5.5% of knees). Conclusions: Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscus surgery prior to ACLR are associated with 10-year ACLR outcomes. However, meniscal tears/treatment at the time of ACLR did not predict 10-year outcomes.

Racial, Socioeconomic, and Demographic Disparities in the Management of Meniscal Tears (179)

Objectives: Meniscal surgery, repair or debridement, makes up about a third of all arthroscopic related surgery. In the adult population, there is much debate about which patients should undergo surgical intervention and which should be treated nonoperatively. There seems to be a paucity of literature related to how a patient’s demographics, insurance status, socioeconomic status, and race impact the likelihood of undergoing surgical intervention. In the present study, we sought to determine how these factors influence whether a patient undergoes surgical intervention following a meniscal injury. Methods: From 2009-2018, claims for adult (≥18 years of age) patients who were diagnosed with a primary meniscus injury were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database. SPARCS is a comprehensive all-payer database collecting all inpatient and outpatient pre-adjudicated claims in New York. ICD 9/10 CM codes were used to identify the initial diagnosis for each patient. ICD9/10 PCS and Current Procedural Terminology (CPT) codes were used to identify subsequent meniscus surgery. The procedures identified were linked with the initial diagnosis and patients were noted as either having meniscus surgery, or not having meniscus surgery. After missing data was removed, logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having surgery after a diagnosis of meniscus injury. Results: Of 394,007 adult meniscus injury diagnoses, 84.7% proceeded to undergo surgical intervention. The median age for no surgery was 51 (mean: 49.4) and the median age for surgery was 52 (mean: 50.2) (p<.0001) (Table 1). Females relative to males (OR=0.757, p<.0001), increased social deprivation index (SDI) (OR=0.994, p<.0001), African American compared to white race (OR=0.822, p<.0001), hispanic relative to non-hispanic ethnicity (OR=0.682, p<.0001), federal relative to private insurance (OR=0.459, p<.0001), and self-pay relative to private insurance (OR=0.437, p<.0001) were all associated with decreased odds of undergoing meniscus surgery. Older patients (OR=1.009, p<.0001), worker’s compensation relative to private insurance (OR=1.284, p<.0001) and patients with a charlson comorbidity index (CCI) score ≥1 had increased odds of undergoing surgery (OR=1.129, p<.0001) (Table 2). Conclusions: Multiple demographic, insurance status, socioeconomic status, and race factors influence the decision to manage meniscal tears surgically. Females, those with increased social deprivation index, African-Americans, Hispanics, or those with federal insurance or self-pay (when compared to private insurance) were less likely to undergo surgical intervention for meniscal tears. Those with workers’ compensation, who were of older age and higher CCI were more likely to undergo surgical intervention. Further research is ultimately needed to elicit causes for disparities between demographic groups.

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.

The Meniscus Deficient Knee: Options for Repair and Reconstruction

The preservation of the structure of the meniscus despite a tear has been widely discussed in the literature. However, meniscectomy continues to be the most-performed meniscus surgery. In a percentage of patients, knee pain and swelling, as well as tibial plateau bony edema, follow meniscus resection; this panoply of symptoms is known as “post-meniscectomy syndrome”. The management of this condition requires meniscus transplant in case of total meniscectomy or a meniscus scaffold in the case of a partial resection. This chapter aims to discuss the indication, surgical technique, and outcomes of collagen meniscus implants (CMI) for partial resections and meniscus transplants for full resections.

Taxonomic changes in the gut microbiota are associated with cartilage damage independent of adiposity, high fat diet, and joint injury

Lipodystrophic mice are protected from cartilage damage following joint injury. This protection can be reversed by the implantation of a small adipose tissue graft. The purpose of this study was to evaluate the relationship between the gut microbiota and knee cartilage damage while controlling for adiposity, high fat diet, and joint injury using lipodystrophic (LD) mice. LD and littermate control (WT) mice were fed a high fat diet, chow diet, or were rescued with fat implantation, then challenged with destabilization of the medial meniscus surgery to induce osteoarthritis (OA). 16S rRNA sequencing was conducted on feces. MaAslin2 was used to determine associations between taxonomic relative abundance and OA severity. While serum LPS levels between groups were similar, synovial fluid LPS levels were increased in both limbs of HFD WT mice compared to all groups, except for fat transplanted animals. The Bacteroidetes:Firmicutes ratio of the gut microbiota was significantly reduced in HFD and OA-rescued animals when compared to chow. Nine novel significant associations were found between gut microbiota taxa and OA severity. These findings suggest the presence of causal relationships the gut microbiome and cartilage health, independent of diet or adiposity, providing potential therapeutic targets through manipulation of the microbiome.

Does practice of meniscus surgery change over time? A report of the 2021 ‘THE MENISCUS’ Webinar

Purpose The aim of this paper was to report the results presented in the session “Does practice of meniscus surgery change over time?” of the 2021 MENISCUS webinar held online on January 30th 2021. Method During the 2021 MENISCUS webinar, an evaluation of meniscus surgery practices was performed by analyzing: (1) The presentation of the results of a survey conducted among ESSKA members and assessing their current practices in the field of meniscus surgery, (2) Four reports by national experts analyzing the trends in Arthroscopic Partial Meniscectomy (APM) and meniscus repair procedures in their respective countries (France, Belgium, Germany and Japan). Results (1) ESSKA Survey: Among the 461 respondents, 75% of surgeons claimed to perform more meniscus repairs and 85% less APM than 5 years ago. In ACL-associated meniscus injuries, a majority of surgeons (60%) indicated to perform a meniscal resection in less than 25% of cases. 25% declared to perform meniscus repair in ACL-associated meniscus injuries in less than 25% of cases and 37% in more than 50% of cases. Half of the respondents repair medial or lateral root tears in less than 25% of cases. Less than 20% of respondents were not familiar with the ESSKA consensus. (2) National trends: In France, between 2005 and 2017, the APM rate decreased by 21.4%, while the repair rate increased by 320%. In Belgium, between 2007 and 2017, the APM rate decreased by 28.6%. In Germany, between 2010 and 2017 the number of APM decreased by 30%, while the number of repair procedures increased by 55%. Finally, in Japan, between 2011 and 2016, the APM ratio (APM/meniscus procedures) decreased by 16% from 91 to 75% while the repair ratio increased from 9 to 25%. Conclusion The 2021 ESSKA members' survey as well as statistics from 4 specifically examined countries (Belgium, France, Germany and Japan) suggest there has been a significant shift over the last years in the surgical management of meniscal lesions towards less APM and more conservative treatments.

Knee Joint and Quadriceps Dysfunction in Individuals With Anterior Knee Pain, Anterior Cruciate Ligament Reconstruction, and Meniscus Surgery: A Cross-Sectional Study

Context: While arthrogenous muscle inhibition associated with knee injuries is evident, the relative magnitude of functional deficiency related to each individual knee pathology is unclear. Objective: To compare the knee joint and quadriceps dysfunction among patients with anterior knee pain (AKP) without surgical history and those with surgical history (anterior cruciate ligament reconstruction [ACLR]; meniscus surgery) without current AKP, with matched healthy controls. Design: Cross-sectional study. Setting: Laboratory. Participants: A total of 66 patients with knee pathologies and 30 controls. Main Outcome Measures: Pain perception and lower-extremity functional outcomes were assessed. Knee joint function was measured by replication tests. Quadriceps function was measured by strength, voluntary activation, and torque-generating capacity. Results: Patients with AKP reported greater pain perception compared with the other knee conditions (4.3 vs 0.1 of 10 in Numeric Pain Rating Scale, P < .0001). Compared with the controls: (1) patients with AKP showed a greater error on knee-flexion replications at 75° (2.9° vs 5.4°, P = .002), (2) patients with AKP and ACLR showed less quadriceps strength (AKP: 3.3 vs 2.6 N·m/kg, P = .002; ACLR: 3.3 vs 2.7 N·m/kg, P = .02) and voluntary activation (AKP: 0.982 vs 0.928, P < .0001; ACLR: 0.982 vs 0.946, P = .003), and (3) all knee pathologies reported lower scores on functional outcomes (79 vs 65 of 80 points in Lower-Extremity Functional Scale, P < .0001) and showed less quadriceps torque-generating capacity (10.7 vs 7.8 N·m/s/kg, P < .0001). Among the knee pathologies, patients with AKP showed less quadriceps voluntary activation compared with the patients with meniscus surgery (0.928 vs 0.964, P = .03). Conclusion: As patients with AKP had an additional impairment in knee joint flexion replications and reported a less score in functional outcomes, knee pain may produce a greater impact on functional deficiency.