Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-2960-2
KNEE
Short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction Hakan Sofu • Timur Yildirim • Sarper Gu¨rsu Ahmet Issin • Vedat S¸ ahin
•
Received: 23 February 2013 / Accepted: 19 March 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose This study aims to analyse the short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction surgery. Methods Clinical outcomes of 19 patients who had partial medial meniscectomy and anterior cruciate ligament reconstruction during the same surgery (Group 1) were compared with the outcomes of 25 patients who had also reconstruction but did not have any meniscal lesion (Group 2). Median follow-up time was 29 months (range 12–67 months) in Group 1 and 27 months (range 12–70 months) in Group 2. Feeling of apprehension in sports activities, International Knee Documentation Committee (IKDC) score, KT-2000 ArthrometerÒ measurements and post-operative time to return to sports activity were the criteria for data analysis. Results Eight patients (42 %) in Group 1 and 5 patients (20 %) in Group 2 stated feeling of apprehension in sports activities. IKDC score improved to A in 11 patients (58 %) from Group 1, and 18 patients (72 %) from Group 2. Mean anterior translation according to KT-2000 arthrometer measurements was 5.2 ± 1.3 mm in Group 1, and 4.6 ± 1.3 mm in Group 2. Post-operative time to return to
H. Sofu (&) Amasya Suluova State Hospital, Hu¨rriyet Mahallesi Hastane Caddesi No: 16, Suluova, Amasya, Turkey e-mail: [email protected] T. Yildirim S. Gu¨rsu V. S¸ ahin Baltalimani Bone and Joint Diseases Education and Research Hospital, Baltalimani, Turkey A. Issin Erzincan University Faculty of Medicine, Erzincan, Turkey
sports activity was 8.5 ± 3.0 months in Group 1, and 6.5 ± 2.2 months in Group 2. Conclusion Partial meniscectomy for irreparable medial meniscal tears, applied during the same surgery with anterior cruciate ligament reconstruction, negatively affects the clinical outcomes in the short-term follow-up. This study may be a reference for long-term clinical trials and also future investigations of new methods in the treatment of similar cases. Level of evidence IV. Keywords Meniscectomy Anterior cruciate ligament reconstruction Arthroscopy
Introduction Anterior cruciate ligament (ACL) is the most important biomechanical stabilizer of the knee joint which mainly functions to regulate translation in the sagittal plane. Additionally, it contributes to rotational stability and takes part in proprioception [8, 10]. Menisci have also vital functions such as mechanical support, localized pressure distribution and reducing friction between the joint surfaces [12]. Anterior cruciate ligament rupture is the most common injury leading to an unstable knee joint [11, 28]. Although it may be seen as an isolated injury, the ACL rupture may also be diagnosed as associated with meniscal, chondral or other ligamentous injuries [23, 24]. Meniscal tears concomitant with ACL injuries have been reported by several authors to range from 50 to 70 % in the literature [17, 19]. Treatment options include meniscectomy, repair or meniscal allograft transplantation [14, 16, 17, 21, 22, 25]. In the current clinical orthopaedic practice, preservation of the meniscal functions as much as possible has become the key point in the
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treatment of meniscal tears [14]. Partial meniscectomy is still a valid surgical intervention in patients with irreparable meniscal lesions. However, clinical effects of partial meniscectomy during the same surgery with ACL reconstruction have been controversial. Main hypothesis to be tested in this study was that partial meniscectomy would not affect the clinical outcomes of ACL reconstruction. The purpose of our study was to analyse short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction, which was applied for acute irreparable medial meniscal tears in chronic ACL deficient knees.
Materials and methods Clinical outcomes of the patients who underwent ACL reconstruction surgery in Baltalimani Bone and Joint Diseases Hospital between the year 2005 and 2010 were evaluated retrospectively after having approval from the local ethical research committee. From a database of ACL reconstructed patients, consecutive patients undergoing partial medial meniscectomy and ACL reconstruction during the same surgery were identified. Patients who did not attend regular clinical follow-up visits, who had previous meniscal surgery to the index operation and who had bilateral ACL deficiency or previous ACL surgery were excluded. Two age- and sex-matched groups who had undergone combined ACL reconstruction and partial medial meniscectomy and who had undergone ACL reconstruction with normal menisci were identified for comparison. Clinical data of 19 patients who had partial medial meniscectomy for irreparable medial meniscal tear and ACL reconstruction during the same surgery (Group 1) were compared with the data of 25 patients who had also ligament reconstruction but did not present with any meniscal lesion (Group 2). Median age at the time of surgery was 29 years (range 17–38 years) in Group 1, and 28 years (range 19–43 years) in Group 2. Median followup time was 29 months (range 12–67 months) in Group 1, and 27 months (range 12–70 months) in Group 2. Mean time from injury to ACL reconstruction was 15 ± 12 months in Group 1 and 17 ± 16 months in Group 2. All meniscal tears were acute lesions of medial meniscus, leading to locking symptoms in ACL deficient knees. Arthroscopic examinations were first performed to confirm ligament rupture as well as concomitant intra-articular pathologies. Procedures for meniscal pathologies were completed before the ligament reconstruction. Continuous passive motion (CPM) was started at the first post-operative day and continued for 2 days during hospitalization time. A motion-controlled, medial–lateral stabilized brace was used during 4 weeks following the surgery.
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Subjective feeling of apprehension in sports activities, International Knee Documentation Committee (IKDC) score, KT-2000 ArthrometerÒ (MEDmetric, San Diego, California) measurements and post-operative time to return to sports activities were the criteria for data collection. Instrumented laxity measurements were taken by the same author who had attended a training programme on KT2000 ArthrometerÒ. At the latest follow-up, anterior translation of the operated knee joint, as well as the contralateral non-operated healthy joint, was tested twice and the highest value was noted in millimetres as the data to be used for statistical analysis in all patients. Correlation coefficient of repeated instrumented laxity measurements was 0.90 in Group 1 and 0.88 in Group 2. Statistical analysis Wilcoxon’s signed-rank test was used to compare IKDC score changes between pre-operative and post-operative periods, Mann–Whitney U test to compare differences of the patient groups according to subjective feeling of apprehension in sports activities, instrumented laxity measurements and post-operative time to return to sports activities. The level of significance was set at p B 0.05. Results At the latest follow-up, 8 patients (42 %) from Group 1 stated feeling of apprehension in sports activities, whereas it was 5 patients (20 %) from Group 2 (p \ 0.05). In Group 1, pre-operative IKDC score was category B in 4 patients (21 %) and C in 15 patients (79 %), but post-operatively it improved to category A in 11 patients (58 %) and B in 8 patients (42 %). In Group 2, pre-operative IKDC score was category B in 7 patients (28 %) and C in 18 patients (72 %), but post-operatively it improved to category A in 18 patients (72 %) and B in 7 patients (28 %). Mean anterior translation according to KT-2000 ArthrometerÒ was 5.2 ± 1.3 mm in Group 1, and 4.6 ± 1.3 mm in Group 2 at the latest followup (n.s.). Side-to-side analysis demonstrated that 13 knees (68 %) in Group 1 had less than 3 mm of laxity difference when compared with the contra-lateral healthy side, and it was 19 knees (76 %) in Group 2 (n.s.). Post-operative time to return to sports activities was 8.5 ± 3.0 months in Group 1, and 6.5 ± 2.2 months in Group 2 (p \ 0.05). Discussion The most important findings of the present study were relatively increased subjective feeling of apprehension and post-operative time to return to sports activities following partial meniscectomy and ACL reconstruction at the same
Knee Surg Sports Traumatol Arthrosc
surgery. Meniscal tear concomitant with ACL injury is not a rare finding at arthroscopy during ligament reconstruction surgery [6]. Pujol et al. [19] reported that the conservative approach is clinically more effective for lateral menisci; however, the rate of bad results remains high for the medial meniscus tears left in situ during ACL reconstruction. A systematic review has shown that partial or total meniscectomy was performed in 65 % of meniscus tears diagnosed in ACL reconstruction [17]. Melton et al. [16] advocate repair of meniscal tears during ACL reconstruction unless there is complex tear, radial tear or plastic deformation of the remaining meniscus. Shelbourne et al. [21] concluded that outcomes from meniscal repair were not superior to those from partial removal at a mean of 6–8 years follow-up. We believe that preservation of the meniscal functions is crucial and that is why, in our clinical practice today, we prefer to apply meniscal repair as long as it is possible. However, surgical repair may not be achieved in a specific group of patients with complex irreparable tears. Partial meniscectomy is the only remaining option for these patients. Meniscal replacement may be applicable as the treatment of this type of lesions in the future, but it still needs to be improved with stronger evidence by long-term clinical trials. We do not have much clinical experience on meniscal allograft transplantation. In this study, we aimed to analyse short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction, which was applied for acute irreparable medial meniscal tears in chronic ACL deficient knees. According to a prospective study conducted by Wu et al. [26], patients who had undergone ACL surgery with any degree of meniscal resection presented with significantly more subjective complaints and activity limitations than those with intact menisci. Ardern et al. [3] reported that apprehension was the most common reason cited for a postoperative reduction in or cessation of contact sports participation. In our study, 8 patients (42 %) in Group 1 (ACL reconstruction with partial meniscectomy) stated feeling of apprehension in sports activities, whereas it was 5 patients (20 %) in Group 2 (ACL reconstruction with intact menisci). This difference was statistically significant (p \ 0.05). International Knee Documentation Committee scoring system is a very useful tool in evaluating patient-centred subjective outcome after a surgical intervention. It was reported in different studies that patients who had undergone ACL reconstruction combined with subtotal meniscectomy had lower IKDC score than patients with intact menisci [16, 26]. IKDC score at the latest clinical followup was category A in 11 patients (58 %) from Group 1, and category A in 18 patients (72 %) from Group 2. This difference between the groups was not statistically significant. Several studies report that knee kinematics were altered, and tibial displacement was increased at different angles of
flexion following medial menisectomy in ACL deficient joint [1, 2, 5, 9, 13, 15, 22, 27]. Seon et al. [20] mentioned that ligament reconstruction in cadaveric knees with ACL deficiency and subtotal medial meniscectomy significantly reduced the increased anterior tibial translation, but could not restore anterior translation to the intact level. In another study, Petrigliano et al. [18] reported significantly increased anterior translation during pivot shift test following unicompartmental or bicompartmental meniscectomy in ACL reconstruction. We used KT-2000 ArthrometerÒ as an instrumented objective laxity measurement tool to understand if partial meniscectomy caused any difference in anterior tibial translation between our patient groups. Mean anterior translation of the operated knee joint was 5.2 ± 1.3 mm in Group 1, and 4.6 ± 1.3 mm in Group 2 at the latest follow-up. Side-toside analysis demonstrated that 13 knees (68 %) in Group 1 had \3 mm of laxity difference when compared with the healthy side, and it was 19 knees (76 %) in Group 2. Our findings of instrumented laxity measurements did not reveal any statistically significant difference. Post-operative time to return to sports activities is an important factor for the clinical assessment of patients who had undergone ACL reconstruction surgery. Ardern et al. [4] reported that two-thirds of the patients had not returned to the pre-injury level of competitive sports activity by 12 months following ACL reconstruction surgery. According to Brophy et al. [7], comparing the athletes with meniscectomy or ACL reconstruction to athletes with combined ACL reconstruction and meniscectomy, a history of both surgeries, resulted in a shorter career in games started, games played and years than a history of either surgery alone. In the present study, mean post-operative time to return to sports activities was 8.5 ± 3.0 months in Group 1, and 6.5 ± 2.2 months in Group 2. This difference was statistically significant (p \ 0.05). There are some limitations of the present study. First, it was a retrospective study that evaluates the data of prospectively followed patient groups. Second, the cohort was very limited. Only the patients who attended routine postoperative outpatient clinic visits and could be reached for the latest follow-up were included in our study. Therefore, the group sizes diminished, but at the same time, we could obtain more homogenous data. In conclusion, the present study may be a reference for long-term clinical trials and also future investigations of new methods in the treatment of similar cases.
Conclusion Partial meniscectomy for irreparable medial meniscal tears applied during the same surgery with anterior cruciate
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ligament reconstruction negatively affects the clinical outcomes in the short-term follow-up. Although objective instrumented laxity measurements or IKDC score improvements do not significantly differ with respect to the presence of concomitant partial meniscectomy in ACL reconstruction patients, the negative effect of partial medial meniscectomy on the participation of a person in sports activities after ACL reconstruction surgery is significant. Acknowledgments for this study.
There was not any external source of funding
Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Ahn JH, Bae TS, Kang KS, Kang SY, Lee SH (2011) Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate-deficient knee significantly influences anterior stability. Am J Sports Med 39(10):2187–2193 2. Anderson AF, Snyder RB, Federspiel CF, Lipscomb AB (1992) Instrumented evaluation of knee laxity: a comparison of five arthrometers. Am J Sports Med 20:135–140 3. Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a meta-analysis of the state of play. Br J Sports Med 45(7):596–606 4. Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J Sports Med 39(3):538–543 5. Bolbos RI, Link TM, Ma CB, Majumdar S, Li X (2009) T1p relaxation time of the meniscus and its relationship with T1rp of adjacent cartilage in knees with acute ACL injuries at 3 T. Osteoarthr Cartil 17:12–19 6. Borchers JR, Kaeding CC, Pedroza AD, Huston LJ, Spindler KP, Wright RW (2011) Intra-articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS study groups. Am J Sports Med 39(9):1889–1893 7. Brophy RH, Gill CS, Lyman S, Barnes RP, Rodeo SA, Warren RF (2009) Effect of anterior cruciate ligament reconstruction and meniscectomy length of career in National Football League athletes: case control study. Am J Sports Med 37(11):2102–2107 8. Chabra A, Starman JS, Ferratti M, Vidal AF, Zantop T, Fu FH (2006) Anatomic, radiographic, biomechanical and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am 88(Suppl 4):2–10 9. Cohen M, Amaro JT, Ejnisman B, Carvalho RT, Nakano KK, Peccin MS, Teixeira R, Laurino CF, Abdalla RJ (2007) Anterior cruciate ligament reconstruction after 10 to 15 years: association between meniscectomy and osteoarthrosis. Arthroscopy 23(6): 629–634 10. Denti M, Monteleone M, Berardi A, Panni AS (1994) Anterior cruciate ligament mechanoreceptors. Histologic studies on lesions and reconstruction. Clin Orthop Relat Res 308:29–32 11. Finsterbush A, Frankl U, Mann G (1989) Fat pad adhesion to partially torn anterior cruciate ligament: a cause of knee locking. Am J Sports Med 17:92–95
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12. Jeong HJ, Lee SH, Ko CS (2012) Meniscectomy. Knee Surg Relat Res 24(3):129–136 13. Kessler MA, Behrend H, Henz S, Stutz G, Rukavina A, Kuster MS (2008) Function, osteoarthritis and activity after ACL-rupture: 11 years follow-up results of conservative versus reconstructive treatment. Knee Surg Sports Traumatol Arthrosc 16(5):442–448 14. Lee BS, Kim JM, Sohn DW, Bin SI (2013) Review of meniscal allograft transplantation focusing on long-term results and evaluation methods. Knee Surg Relat Res 25(1):1–6 15. McDaniel WJ Jr, Dameron TB Jr (1980) Untreated ruptures of the enterior cruciate ligament: a follow-up study. J Bone Joint Surg Am 62:696–705 16. Melton JT, Murray JR, Karim A, Pandit H, Wandless F, Thomas NP (2011) Meniscal repair in anterior cruciate ligament reconstruction: a long-term outcome study. Knee Surg Sports Traumatol Arthrosc 19(10):1729–1734 17. Noyes FR, Barber-Westin SD (2012) Treatment of meniscus tears during anterior cruciate ligament reconstruction. Arthroscopy 28(1):123–130 18. Petrigliano FA, Musahl V, Suero EM, Citak M, Pearle AD (2011) Effect of meniscal loss on knee stability after single-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 19(Suppl 1):86–93 19. Pujol N, Beaufils P (2009) Healing results of meniscal tears left in situ during anterior cruciate ligament reconstruction: a review of clinical studies. Knee Surg Sports Traumatol Arthrosc 17(4):396–401 20. Seon JK, Gadikota HR, Kozanek M, Oh LS, Gill TJ, Li G (2009) The effect of anterior cruciate ligament reconstruction on kinematics of the knee with combined anterior cruciate ligament injury and subtotal medial meniscectomy: an in vitro robotic investigation. Arthroscopy 25(2):123–130 21. Shelbourne KD, Carr DR (2003) Meniscal repair compared with meniscectomy for bucket-handle medial meniscal tears in anterior cruciate ligament-reconstructed knees. Am J Sports Med 31(5):718–723 22. Spang JT, Dang AB, Mazzocca A, Rincon L, Obopilwe E, Beynnon B, Arciero RA (2010) The effect of medial meniscectomy and meniscal allograft transplantation on knee and anterior cruciate ligament biomechanics. Arthroscopy 26(2):192–201 23. Tandogan RN, Taser O, Kayaalp A, Taskiran E, Pinar H, Alparslan B, Alturfan A (2004) Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport. Knee Surg Sports Traumatol Arthrosc 12(4):262–270 24. Tzurbakis M, Diamantopoulos A, Xenakis T, Georgoulis A (2006) Surgical treatment of multiple knee ligament injuries in 44 patients: 2–8 years follow-up results. Knee Surg Sports Traumatol Arthrosc 14(8):739–749 25. Verdonk R, Volpi P, Verdonk P, Van der Bracht H, Van Laer M, Almqvist KF, Vander Eecken S, Prospero E, Quaglia A (2013) Indications and limits of meniscal allografts. Injury 44(Suppl 1):21–27 26. Wu WH, Hackett T, Richmond JC (2002) Effects of meniscal and articular surface status on knee stability, function, and symptoms after anterior cruciate ligament reconstruction: a long-term prospective study. Am J Sports Med 30(6):845–850 27. Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH (2006) Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc 14(10):982–992 28. Zantop T, Wellmann M, Fu FH, Petersen W (2008) Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med 36:65–72
KNEE
Short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction Hakan Sofu • Timur Yildirim • Sarper Gu¨rsu Ahmet Issin • Vedat S¸ ahin
•
Received: 23 February 2013 / Accepted: 19 March 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose This study aims to analyse the short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction surgery. Methods Clinical outcomes of 19 patients who had partial medial meniscectomy and anterior cruciate ligament reconstruction during the same surgery (Group 1) were compared with the outcomes of 25 patients who had also reconstruction but did not have any meniscal lesion (Group 2). Median follow-up time was 29 months (range 12–67 months) in Group 1 and 27 months (range 12–70 months) in Group 2. Feeling of apprehension in sports activities, International Knee Documentation Committee (IKDC) score, KT-2000 ArthrometerÒ measurements and post-operative time to return to sports activity were the criteria for data analysis. Results Eight patients (42 %) in Group 1 and 5 patients (20 %) in Group 2 stated feeling of apprehension in sports activities. IKDC score improved to A in 11 patients (58 %) from Group 1, and 18 patients (72 %) from Group 2. Mean anterior translation according to KT-2000 arthrometer measurements was 5.2 ± 1.3 mm in Group 1, and 4.6 ± 1.3 mm in Group 2. Post-operative time to return to
H. Sofu (&) Amasya Suluova State Hospital, Hu¨rriyet Mahallesi Hastane Caddesi No: 16, Suluova, Amasya, Turkey e-mail: [email protected] T. Yildirim S. Gu¨rsu V. S¸ ahin Baltalimani Bone and Joint Diseases Education and Research Hospital, Baltalimani, Turkey A. Issin Erzincan University Faculty of Medicine, Erzincan, Turkey
sports activity was 8.5 ± 3.0 months in Group 1, and 6.5 ± 2.2 months in Group 2. Conclusion Partial meniscectomy for irreparable medial meniscal tears, applied during the same surgery with anterior cruciate ligament reconstruction, negatively affects the clinical outcomes in the short-term follow-up. This study may be a reference for long-term clinical trials and also future investigations of new methods in the treatment of similar cases. Level of evidence IV. Keywords Meniscectomy Anterior cruciate ligament reconstruction Arthroscopy
Introduction Anterior cruciate ligament (ACL) is the most important biomechanical stabilizer of the knee joint which mainly functions to regulate translation in the sagittal plane. Additionally, it contributes to rotational stability and takes part in proprioception [8, 10]. Menisci have also vital functions such as mechanical support, localized pressure distribution and reducing friction between the joint surfaces [12]. Anterior cruciate ligament rupture is the most common injury leading to an unstable knee joint [11, 28]. Although it may be seen as an isolated injury, the ACL rupture may also be diagnosed as associated with meniscal, chondral or other ligamentous injuries [23, 24]. Meniscal tears concomitant with ACL injuries have been reported by several authors to range from 50 to 70 % in the literature [17, 19]. Treatment options include meniscectomy, repair or meniscal allograft transplantation [14, 16, 17, 21, 22, 25]. In the current clinical orthopaedic practice, preservation of the meniscal functions as much as possible has become the key point in the
123
Knee Surg Sports Traumatol Arthrosc
treatment of meniscal tears [14]. Partial meniscectomy is still a valid surgical intervention in patients with irreparable meniscal lesions. However, clinical effects of partial meniscectomy during the same surgery with ACL reconstruction have been controversial. Main hypothesis to be tested in this study was that partial meniscectomy would not affect the clinical outcomes of ACL reconstruction. The purpose of our study was to analyse short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction, which was applied for acute irreparable medial meniscal tears in chronic ACL deficient knees.
Materials and methods Clinical outcomes of the patients who underwent ACL reconstruction surgery in Baltalimani Bone and Joint Diseases Hospital between the year 2005 and 2010 were evaluated retrospectively after having approval from the local ethical research committee. From a database of ACL reconstructed patients, consecutive patients undergoing partial medial meniscectomy and ACL reconstruction during the same surgery were identified. Patients who did not attend regular clinical follow-up visits, who had previous meniscal surgery to the index operation and who had bilateral ACL deficiency or previous ACL surgery were excluded. Two age- and sex-matched groups who had undergone combined ACL reconstruction and partial medial meniscectomy and who had undergone ACL reconstruction with normal menisci were identified for comparison. Clinical data of 19 patients who had partial medial meniscectomy for irreparable medial meniscal tear and ACL reconstruction during the same surgery (Group 1) were compared with the data of 25 patients who had also ligament reconstruction but did not present with any meniscal lesion (Group 2). Median age at the time of surgery was 29 years (range 17–38 years) in Group 1, and 28 years (range 19–43 years) in Group 2. Median followup time was 29 months (range 12–67 months) in Group 1, and 27 months (range 12–70 months) in Group 2. Mean time from injury to ACL reconstruction was 15 ± 12 months in Group 1 and 17 ± 16 months in Group 2. All meniscal tears were acute lesions of medial meniscus, leading to locking symptoms in ACL deficient knees. Arthroscopic examinations were first performed to confirm ligament rupture as well as concomitant intra-articular pathologies. Procedures for meniscal pathologies were completed before the ligament reconstruction. Continuous passive motion (CPM) was started at the first post-operative day and continued for 2 days during hospitalization time. A motion-controlled, medial–lateral stabilized brace was used during 4 weeks following the surgery.
123
Subjective feeling of apprehension in sports activities, International Knee Documentation Committee (IKDC) score, KT-2000 ArthrometerÒ (MEDmetric, San Diego, California) measurements and post-operative time to return to sports activities were the criteria for data collection. Instrumented laxity measurements were taken by the same author who had attended a training programme on KT2000 ArthrometerÒ. At the latest follow-up, anterior translation of the operated knee joint, as well as the contralateral non-operated healthy joint, was tested twice and the highest value was noted in millimetres as the data to be used for statistical analysis in all patients. Correlation coefficient of repeated instrumented laxity measurements was 0.90 in Group 1 and 0.88 in Group 2. Statistical analysis Wilcoxon’s signed-rank test was used to compare IKDC score changes between pre-operative and post-operative periods, Mann–Whitney U test to compare differences of the patient groups according to subjective feeling of apprehension in sports activities, instrumented laxity measurements and post-operative time to return to sports activities. The level of significance was set at p B 0.05. Results At the latest follow-up, 8 patients (42 %) from Group 1 stated feeling of apprehension in sports activities, whereas it was 5 patients (20 %) from Group 2 (p \ 0.05). In Group 1, pre-operative IKDC score was category B in 4 patients (21 %) and C in 15 patients (79 %), but post-operatively it improved to category A in 11 patients (58 %) and B in 8 patients (42 %). In Group 2, pre-operative IKDC score was category B in 7 patients (28 %) and C in 18 patients (72 %), but post-operatively it improved to category A in 18 patients (72 %) and B in 7 patients (28 %). Mean anterior translation according to KT-2000 ArthrometerÒ was 5.2 ± 1.3 mm in Group 1, and 4.6 ± 1.3 mm in Group 2 at the latest followup (n.s.). Side-to-side analysis demonstrated that 13 knees (68 %) in Group 1 had less than 3 mm of laxity difference when compared with the contra-lateral healthy side, and it was 19 knees (76 %) in Group 2 (n.s.). Post-operative time to return to sports activities was 8.5 ± 3.0 months in Group 1, and 6.5 ± 2.2 months in Group 2 (p \ 0.05). Discussion The most important findings of the present study were relatively increased subjective feeling of apprehension and post-operative time to return to sports activities following partial meniscectomy and ACL reconstruction at the same
Knee Surg Sports Traumatol Arthrosc
surgery. Meniscal tear concomitant with ACL injury is not a rare finding at arthroscopy during ligament reconstruction surgery [6]. Pujol et al. [19] reported that the conservative approach is clinically more effective for lateral menisci; however, the rate of bad results remains high for the medial meniscus tears left in situ during ACL reconstruction. A systematic review has shown that partial or total meniscectomy was performed in 65 % of meniscus tears diagnosed in ACL reconstruction [17]. Melton et al. [16] advocate repair of meniscal tears during ACL reconstruction unless there is complex tear, radial tear or plastic deformation of the remaining meniscus. Shelbourne et al. [21] concluded that outcomes from meniscal repair were not superior to those from partial removal at a mean of 6–8 years follow-up. We believe that preservation of the meniscal functions is crucial and that is why, in our clinical practice today, we prefer to apply meniscal repair as long as it is possible. However, surgical repair may not be achieved in a specific group of patients with complex irreparable tears. Partial meniscectomy is the only remaining option for these patients. Meniscal replacement may be applicable as the treatment of this type of lesions in the future, but it still needs to be improved with stronger evidence by long-term clinical trials. We do not have much clinical experience on meniscal allograft transplantation. In this study, we aimed to analyse short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction, which was applied for acute irreparable medial meniscal tears in chronic ACL deficient knees. According to a prospective study conducted by Wu et al. [26], patients who had undergone ACL surgery with any degree of meniscal resection presented with significantly more subjective complaints and activity limitations than those with intact menisci. Ardern et al. [3] reported that apprehension was the most common reason cited for a postoperative reduction in or cessation of contact sports participation. In our study, 8 patients (42 %) in Group 1 (ACL reconstruction with partial meniscectomy) stated feeling of apprehension in sports activities, whereas it was 5 patients (20 %) in Group 2 (ACL reconstruction with intact menisci). This difference was statistically significant (p \ 0.05). International Knee Documentation Committee scoring system is a very useful tool in evaluating patient-centred subjective outcome after a surgical intervention. It was reported in different studies that patients who had undergone ACL reconstruction combined with subtotal meniscectomy had lower IKDC score than patients with intact menisci [16, 26]. IKDC score at the latest clinical followup was category A in 11 patients (58 %) from Group 1, and category A in 18 patients (72 %) from Group 2. This difference between the groups was not statistically significant. Several studies report that knee kinematics were altered, and tibial displacement was increased at different angles of
flexion following medial menisectomy in ACL deficient joint [1, 2, 5, 9, 13, 15, 22, 27]. Seon et al. [20] mentioned that ligament reconstruction in cadaveric knees with ACL deficiency and subtotal medial meniscectomy significantly reduced the increased anterior tibial translation, but could not restore anterior translation to the intact level. In another study, Petrigliano et al. [18] reported significantly increased anterior translation during pivot shift test following unicompartmental or bicompartmental meniscectomy in ACL reconstruction. We used KT-2000 ArthrometerÒ as an instrumented objective laxity measurement tool to understand if partial meniscectomy caused any difference in anterior tibial translation between our patient groups. Mean anterior translation of the operated knee joint was 5.2 ± 1.3 mm in Group 1, and 4.6 ± 1.3 mm in Group 2 at the latest follow-up. Side-toside analysis demonstrated that 13 knees (68 %) in Group 1 had \3 mm of laxity difference when compared with the healthy side, and it was 19 knees (76 %) in Group 2. Our findings of instrumented laxity measurements did not reveal any statistically significant difference. Post-operative time to return to sports activities is an important factor for the clinical assessment of patients who had undergone ACL reconstruction surgery. Ardern et al. [4] reported that two-thirds of the patients had not returned to the pre-injury level of competitive sports activity by 12 months following ACL reconstruction surgery. According to Brophy et al. [7], comparing the athletes with meniscectomy or ACL reconstruction to athletes with combined ACL reconstruction and meniscectomy, a history of both surgeries, resulted in a shorter career in games started, games played and years than a history of either surgery alone. In the present study, mean post-operative time to return to sports activities was 8.5 ± 3.0 months in Group 1, and 6.5 ± 2.2 months in Group 2. This difference was statistically significant (p \ 0.05). There are some limitations of the present study. First, it was a retrospective study that evaluates the data of prospectively followed patient groups. Second, the cohort was very limited. Only the patients who attended routine postoperative outpatient clinic visits and could be reached for the latest follow-up were included in our study. Therefore, the group sizes diminished, but at the same time, we could obtain more homogenous data. In conclusion, the present study may be a reference for long-term clinical trials and also future investigations of new methods in the treatment of similar cases.
Conclusion Partial meniscectomy for irreparable medial meniscal tears applied during the same surgery with anterior cruciate
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Knee Surg Sports Traumatol Arthrosc
ligament reconstruction negatively affects the clinical outcomes in the short-term follow-up. Although objective instrumented laxity measurements or IKDC score improvements do not significantly differ with respect to the presence of concomitant partial meniscectomy in ACL reconstruction patients, the negative effect of partial medial meniscectomy on the participation of a person in sports activities after ACL reconstruction surgery is significant. Acknowledgments for this study.
There was not any external source of funding
Conflict of interest of interest.
The authors declare that they have no conflict
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![[Reconstruction of partial anterior cruciate ligament tears].](/assets/img/hold.png)
