Tollefson, Luke V.

Purpose To develop an expert consensus statement on the diagnosis, management, and rehabilitation of medial meniscal root tears (MMRTs) using a modified Delphi technique. Methods A working group developed statements on MMRT diagnosis, nonoperative management, surgical indications, surgical management, alignment, and rehabilitation using modified Delphi techniques. Fifty‐six experts were surveyed over 3 rounds to reach consensus, with agreement measured on a 5‐point Likert scale. Statements were included, revised, or excluded on the basis of predefined thresholds (≥75% agreement, <20% disagreement). Experts suggested revisions or new statements in the first 2 rounds, and final consensus statements were included. Results All 56 experts completed 3 survey rounds. Experts agreed that root tears may occur with no known history of trauma, typically in older patients, and that it should be diagnosed with an magnetic resonance imaging. In symptomatic patients with MMRTs without advanced osteoarthritis should be repaired using an anatomic transtibial pull‐out technique (performing a pie‐crusting technique can be helpful for visualization). Nonoperative management is advised for patients with advanced osteoarthritis. High tibial osteotomy may be considered for significant varus malalignment during MMRT repair. The only statement without consensus was the management of asymptomatic MMRTs with mild medial compartment cartilage wear, indicating ongoing debate. Conclusions Overall, 98% of statements reached consensus. There is agreement that magnetic resonance imaging is the gold standard for diagnosis. Symptomatic MMRTs without advanced osteoarthritis should be repaired early using an anatomic transtibial pull‐out technique. End‐stage knee osteoarthritis warrants nonoperative management of MMRTs, and a structured postoperative protocol with limited weightbearing and range of motion is essential after repair. No agreement was reached on managing asymptomatic MMRTs in patients without significant medial compartment degeneration. Meniscal centralization sutures may help in cases of substantial extrusion, but their routine use is debated. Level of Evidence Level V, consensus of expert opinion.

Objectives: The purpose of this study is to use standing anterior cruciate ligament (ACL) stress radiographs to evaluate how posterior tibial slope (PTS) compared to anterior tibial translation (ATT) in an injured knee. A secondary purpose was to determine how posterior tibial slope (PTS) affects ATT side-to-side difference. Our hypothesis was that anterior tibial translation would be higher in the injured knee compared to the contralateral side and posterior tibial slope will have a positive effect on anterior tibial translation. Methods: A retrospective study of ACL stress radiographs was assessed from patients with primary ACL reconstructions with no concomitant ligamentous injury between January 2023 and August 2023. Institutional Review Board approval was obtained. The bilateral radiographs were long-leg lateral “stress views” which was accomplished by monopodal weight-bearing in 20° flexion and are a part of the initial patient workup. Stress radiographs were utilized to measure the anterior tibial translation (ATT) and posterior tibial slope (PTS) for both knees. Differences in ATT between knees and the correlation between PTS and ATT was assessed via paired t-tests and regression analysis. Results: A final cohort of 39 patients were analyzed using preoperative ACL stress radiographs. The results reported a significant regression with positive correlation between posterior tibial slope (PTS) and anterior tibial translation for the injured knee using both anatomic (Figure 1, P<0.001, R 2 =0.302) and mechanical (Figure 2, P=0.038, R 2 =0.111) PTS measurements. Anatomic PTS measurements are better at predicting ATT for the injured knee compared to mechanical PTS measurements. Conclusions: The findings of this study report a significant regression with a positive correlation between posterior tibial slope (PTS) and anterior tibial translation (ATT) of the injured knee, with anatomic PTS measurements being a better predictor of ATT than mechanical PTS measurements. This indicates an important relationship between PTS and ATT with higher PTRS predicting higher ATT.

Objectives: The purpose of this paper was to compare patient reported outcomes (PROMs) between isolated anterior cruciate ligament (ACLR) and ACLR with concomitant medial meniscus ramp and lateral meniscus root repairs and compare PROMs between different medial meniscus ramp and lateral meniscus root repair techniques. Methods: All patients with isolated (ISO) ACL reconstruction or ACL reconstruction with concomitant medial meniscus ramp and lateral meniscus root repairs with a minimum 2 years of follow-up were retrospectively evaluated. Institutional review board approval was obtained for this study. A final total of 42 ISO-ACL patients were matched based upon age, sex, and body mass index to 40 in the “terrible triad” (TT) cohorts. Outcome measures were obtained from 32 patients in the ISO cohort, and 38 patients in the TT cohort. The PROMs used for this study include the International Knee Documentation Committee (IKDC) Subjective Knee, Cincinnati, Tegner, Lysholm, Veterans RAND 12-Item Health Survey (VR-12), and Knee Injury and Osteoarthritis Outcomes Score (KOOS) questionnaire forms. T tests and chi-square goodness of fit tests were used to compare the above PROMs both pre- and postoperatively within each cohort, and between cohorts and rates of revision or reoperation. Results: The preoperative and postoperative PROMs between patients in the isolated cohort and the triad cohort demonstrated no significant differences, except for the Physical category of the VR-12, in which the triad cohort had significantly higher results (p = 0.04) (Figure 1). Both the isolated cohort and the triad cohort reported significant differences between pre- and postoperative PROMs within their own cohorts. When comparing methods of surgery, including all-inside vs. inside-out for the medial meniscus repairs and tunnel versus no-tunnel for the lateral meniscus root repairs, no significant differences were found between postoperative PROMs. Additionally, no significant difference was found in revision or reoperative rates between the triad and isolated cohorts (p = 0.374) (Figure 2), the all-inside versus inside-out medial meniscus cohorts (p = 0.267), or the tunnel vs. no-tunnel lateral meniscus cohorts (p = 0.781). Conclusions: There was no significant difference in PROMs between isolated ACLR versus ACLR with concomitant medial meniscus ramp and lateral meniscus root repairs. While the complexity of the TT ACLR patients was more involved, PROMs and healing rates were similar and performing concurrent medial ramp and lateral root repairs at the time of ACLR should be considered.

Objectives: The purpose of this study was to radiographically assess changes in 1) patellar height, 2) anterior tibial translation (ATT), and 3) posterior tibial slope following supratubercle ACW-PTO and to compare changes in patellar height to a cohort of medial opening proximal tibial osteotomies (MOW-PTO). Methods: Patients who underwent supratubercle ACW-PTO by a single surgeon from July 2019-February 2023 were included. Institutional Review Board approval was obtained for this study. Radiographic assessment at four time points (preoperative, postoperative day 1, 3 months and 6 months) of patellar height (via the Caton Dechamps and Insall Salvati ratios), posterior tibial slope, and anterior tibial translation of the lateral tibial plateau relative to the lateral femoral condyle was completed. A comparison cohort of patients undergoing MOW-PTO was included for comparison of patellar height. Results: Patellar height averages ( n=16) after ACW-PTO using the Caton-Deschamps ratio (Figure 1) demonstrated a significant increase in patellar height on postoperative day 1 ( p=0.004), but were not significantly different at 3 and 6 months postoperatively (Table 2). Conversely, averages of patellar height after MOW-PTO ( n=28) demonstrated no difference on postoperative day 1, but then was significantly decreased by 6 months postoperatively ( p=0.005) (Table 1). There was a significant difference between the closing and opening-wedge cohorts when comparing the difference in patellar height using the CD ratio between preoperative and 6 months ( p=0.011). Anterior tibial translation in the ACW-PTO cohort was significantly decreased by an average of 9.0 mm from preoperative to postoperative values ( p<<0.001) (Figure 2). Posterior tibial slope in the ACW-PTO cohort was significantly decreased by an average of 11.8° from preoperative to postoperative values ( p<<0.001). Conclusions: Supratubercle ACW-PTO performed for ACL failure in the setting of increased tibial slope did not induce significant changes in patellar height postoperatively. Furthermore, following ACW-PTO there was a significant decrease in anterior tibial translation and posterior tibial slope.