Delphi Expert Consensus studies are increasingly common in orthopaedic literature and provide clinical guidance on many new and controversial topics. Although meta-analyses and randomized controlled trials remain the gold standard of evidence, they are not always feasible, not always definitive, and not always needed. Delphi Consensus Statements currently play a unique role in our research armamentarium to add insight to the many unanswered questions in arthroscopic surgery and sports medicine that other higher levels of evidence studies have not yet fully answered. Arthroscopy has been intentional in the past decade with our published Delphi articles that have offered compelling guidance in the diagnosis, imaging, and management of multiple pathologies in the knee, shoulder, hip, and elbow and in many sports medicine topics.
PURPOSE:To evaluate cadaveric hip biomechanics in the intact, torn, and repaired labral states. METHODS:Eight fresh-frozen cadaveric hips underwent 250 N of axial load on a material testing load frame. Contact pressures and areas were measured with a Tekscan sensor inserted into the acetabular wall. Measurements were divided into anterior (3 o'clock), superior (1 o'clock), and posterior (9 o'clock) acetabular regions. A motion capture system tracked the 3-dimensional hip motion. Peak contact stress, contact area, and dynamic motion were compared across conditions: (1) intact, (2) simulated labral tear from 11 to 2 o'clock, and (3) labral repair with 5 suture anchors, using repeated measures 2-factor analysis of variance. RESULTS:Labral condition significantly influenced joint mechanics. Tears increased superior peak contact stress by 27%, whereas repair reduced it by 45% compared with intact (P < .05). The total contact area decreased by 21% with tear and was restored within 10% of intact values after repair. Regional differences were also observed, with superior contact area increasing from 42% to 53% of the total contact area after tear (P = .03) and decreasing to 46% after repair. Dynamic analysis showed a 20% decrease in relative abduction with tear (0.96° vs 1.20°), which returned to 98% of intact (1.17°) after repair. CONCLUSIONS:Labral tears result in a proportional increase in contact pressure distribution and contact area in the superior acetabulum, correlating with a decreased femoral head abduction moment under a simulated axial load. Labral repair normalizes these biomechanics toward the intact state, which may more evenly distribute force across the acetabulum and restore dynamic hip motion. CLINICAL RELEVANCE:Restoration of labral integrity may re-establish native biomechanics, supporting improved joint function after repair.
PURPOSE:To report the return-to-sport rate of competitive athletes with hip dysplasia, in relation to their preoperative level of competition, who underwent hip arthroscopy with concomitant periacetabular osteotomy (HA + PAO). METHODS:Patients participating in competitive sports who underwent HA + PAO for the correction of hip dysplasia between January 2016 and December 2023 by a single orthopaedic surgeon were retrospectively reviewed. Patients who underwent periacetabular osteotomy-alone or were classified as participating in recreational sports were excluded. Patients without documentation of attempted RTS or interest in RTS were also excluded. Pre- and postoperative level and type of sport were assessed. Sport level was categorized as high school, competitive club (regional, national, or international competition), college, and/or professional level. The level of RTS was classified as lower, same, or higher than preoperative status. A minimum 2-year follow-up was attempted for all patients. RESULTS:Forty-eight patients (56 hips) were identified. Four patients were lost to follow-up. Forty-four patients (37 women, 7 men) and 52 hips were included in the analysis. Eight patients underwent bilateral HA + PAO. Athletes from high school (n = 16), high school and competitive club (n = 6), competitive club (n = 12), college (n = 9), and professional (n = 1) levels were included. Of the 44, 41 returned (93.18%) to sport and 3 did not (6.82%). Of the 41 athletes who returned to sport, 33 (80.49%) returned to their preoperative level, 5 (12.19%) returned to a higher level of competition, and 3 (7.32%) returned to a lower level of competition. Data on subsequent surgeries after HA + PAO were available for 88.63% (39/44) of patients, with a minimum 2-year follow-up and a mean follow-up duration of 47.78 months (range = 24-120 months). Three patients sustained complications that required a return to the operating room. CONCLUSIONS:This study reported an overall RTS rate of 93.1% in competitive athletes who underwent an HA + PAO, with an 86.36% (38/44) rate of return to the same or higher level of competition. LEVEL OF EVIDENCE:Level IV, retrospective case series.
PURPOSE:To investigate the impact of the correction angle on changes in patellofemoral joint (PFJ) alignment in the coronal plane before and after medial open-wedge high tibial osteotomy and its effect on postoperative patient-reported outcome measures and PFJ cartilage damage. METHODS:Patients who underwent medial open-wedge high tibial osteotomy between 2019 and 2022 and had pre- and postoperative whole-leg computed tomography were included. Coronal PFJ alignment was investigated using angles of the patellar ridge, femoral trochlear groove, quadriceps femoris, and patellar tendon. All coronal angular measurements were formed along the x-axis. Knee Injury and Osteoarthritis Outcome Score obtained preoperatively and before implant removal and International Cartilage Repair Society grades of the PFJ based on primary and second-look arthroscopic findings were evaluated. The minimal clinically important difference was defined as half the standard deviation of the score changes. RESULTS:Forty-five knees of 39 patients were analyzed. Mean coronal correction angle on postoperative computed tomography was 9.3°. Changes in PFJ alignment indicators were significantly smaller than the correction angle, with the patellar ridge being less affected than the quadriceps femoris (3.0° vs 6.8°, P < .001). Only the Knee Injury and Osteoarthritis Outcome Score for activities of daily living decreased as the patellar tendon angle increased (r = -0.333). More than 70% of patients achieved an improvement greater than the minimal clinically important difference for the Knee Injury and Osteoarthritis Outcome Score subscales. The difference in the pre- and postoperative International Cartilage Repair Society grades of the patellar cartilage worsened slightly (P = .004). No significant correlations were found between changes in the International Cartilage Repair Society grade and any clinical scores before and after medial open-wedge high tibial osteotomy. CONCLUSIONS:Changes in PFJ alignment indicators were significantly smaller than those in the coronal correction angle, particularly for bony indicators. The correlations between clinical scores or PFJ cartilage damage and changes in PFJ alignment indicators were negligible in the coronal plane. LEVEL OF EVIDENCE:Level IV, retrospective case series.
Abstract Meniscus surgery remains one of the most common orthopedic procedures worldwide. Successful meniscus repair requires A natomic reduction, B iologic preparation and augmentation, C ircumferential compression (ABCs), and an optimized rehabilitation protocol. Rehabilitation after surgery is critical for optimizing outcomes, yet the ideal approach remains controversial. A recent international European Union‐United States consensus task force developed recommendations for rehabilitation meniscal surgery. The group concluded that rehabilitation after meniscal repair and reconstruction should progress according to both time‐ and criterion‐based milestones. In practice, 2 rehabilitation pathways are utilized after meniscal repair: a standard protocol for biomechanically stable repairs that tolerate some weight‐bearing in full extension and a complex protocol for repairs requiring greater protection. Standard meniscal repairs (i.e., vertical longitudinal) are biomechanically stable and treated with moderate protection. During the first 4 weeks, patients are restricted to 0° to 90° of knee range of motion, partial weight‐bearing with crutches, and full knee extension during ambulation. Between weeks 4 and 8, patients progress to weight‐bearing as tolerated while avoiding loaded knee flexion beyond 90° until week 16, with emphasis on gait normalization and strengthening. From weeks 8 to 16, aerobic conditioning and strengthening continue. Pending surgeon clearance, return to running begins at week 12, plyometric exercises at week 14, and return to sport at 4 to 8 months. Complex meniscal repairs (e.g., radial or root tears) require a protective rehabilitation approach. During weeks 0 to 6, range of motion is restricted to 0° to 90° with toe‐touch weight‐bearing and full knee extension during ambulation. Range of motion and weight‐bearing progress from weeks 6 to 12, while loaded flexion beyond 90° remains restricted until week 16. Between weeks 12 and 18, aerobic conditioning and strengthening continue. Pending surgeon clearance, running begins at week 14, plyometrics at week 16, and return to sport typically occurs at 6 to 9 months.
PURPOSE:To evaluate the patient-reported outcome recovery trajectories of generalized ligamentous laxity (GLL) patients undergoing hip arthroplasty for femoroacetabular impingement and labral tears from preoperative to short- to mid-term follow-up and to compare these results to a propensity-matched control group without GLL. METHODS:Patients from a single-institution database who underwent primary hip arthroplasty for femoroacetabular impingement syndrome and labral tears between October 2012 and August 2022 were retrospectively reviewed. Included patients had preoperative and minimum 2-year follow-up patient-reported outcomes, including modified Harris Hip Score, Nonarthritic Hip Score, International Hip Outcome Tool-12, Hip Outcome Score-Sport Scale, and Visual Analogue Scale for pain. Patients with Beighton score ≥4 were propensity-matched to patients with Beighton score <4. A subanalysis was conducted comparing individuals with high Beighton (HB) scores of 8 or 9 to a non-GLL control group. Rates of achieving clinically relevant outcome thresholds including the patient acceptable symptomatic state (PASS) and minimum clinically important difference were collected. RESULTS:Three hundred forty-five GLL patients were successfully matched to 345 control patients. There were no differences in patient-reported outcomes at any time point. There were no differences in reoperation rates and a high percentage of minimum clinically important difference and PASS threshold achievement across both groups. Subanalysis comparing the HB and non-GLL groups showed a slower recovery for the HB group, with significantly higher pain scores at the 3-month (2.83 ± 2.15 vs 1.53 ± 1.37; P = .02) and 1-year (2.95 ± 1.99 vs 1.75 ± 2.50; P = .03) time points but reaching similar long-term outcomes. Patients in the HB group also had lower rates of PASS threshold achievement at 3 months (52.2% vs 76.0%; P = .02) compared with the control group but had comparable long-term outcomes. CONCLUSIONS:Hip arthroplasty in patients with GLL yielded significant improvements at short- to mid-term follow-up, with a recovery trajectory comparable to that of patients without GLL. However, patients with higher Beighton scores of 8 or 9 exhibited a slower recovery curve with higher pain levels and lower rates of PASS threshold achievement, which then normalized in the mid-term. LEVEL OF EVIDENCE:Level III, retrospective comparative control study.
PURPOSE:To develop and externally validate KneeFusionNet, a multimodal deep learning model for detecting anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) injuries on knee magnetic resonance imaging (MRI), and to assess the impact of multimodal fusion and artificial intelligence (AI) assistance on diagnostic performance. METHODS:This 3-center retrospective study was conducted between April 2020 and August 2025. The injury group included patients who underwent knee MRI within 1 month before arthroscopy and had surgically confirmed ACL, PCL, MCL, or LCL injuries; controls had unremarkable MRI and physical examination findings. Two centers formed the development set, and the remaining center served as the external test set. DenseNet-based KneeFusionNet was developed and compared with 3 deep learning models. Diagnostic performance was assessed using the area under the receiver operating characteristic curve, and a reader study evaluated AI-assisted diagnostic performance. RESULTS:Overall, 919 patients were included: 759 in the development set and 160 in the external test set. Multimodal fusion outperformed single-modality approaches for all ligaments (all P < .05). On internal validation, KneeFusionNet achieved area under the receiver operating characteristic curves of 0.971 for ACL, 0.906 for PCL, 0.919 for MCL, and 0.924 for LCL. Corresponding external area under the receiver operating characteristic curves were 0.888, 0.867, 0.862, and 0.874. Sex-stratified analyses showed no consistent sex-related decrease in model performance. KneeFusionNet outperformed all comparison models on internal validation (all P < .05). AI assistance improved mean diagnostic accuracy for junior surgeons from 0.818 to 0.900 and reduced mean interpretation time by 14.73 seconds across all surgeons (all P < .05). CONCLUSIONS:KneeFusionNet detected ACL, PCL, MCL, and LCL injuries on MRI with high diagnostic performance and outperformed comparison models. AI assistance improved diagnostic accuracy for junior surgeons and reduced interpretation time for all surgeons. LEVEL OF EVIDENCE:Level III, retrospective case-control study.
PURPOSE:To evaluate midterm outcomes of structural allograft reconstruction in patients with chronic proximal hamstring avulsion injuries. METHODS:This was a retrospective cohort study (minimum 2-year follow-up) including patients who underwent allograft surgical reconstruction for proximal hamstring avulsion injuries between 2016 and 2023. The primary outcome was the Parisian Hamstring Avulsion Score (PHAS). Secondary outcomes included the Tegner Activity Scale, University of California, Los Angeles Activity Scale, return to sport rates, postoperative patient satisfaction, and complication rates. A cohort-specific minimal clinically important difference analysis was performed using the distribution-based method (½ standard deviation of the change in PHAS score). In addition, substantial clinical benefit and patient acceptable symptom state thresholds were determined using anchor-based methods. RESULTS:A total of 42 patients were included, with 39 having complete functional follow-up (mean follow-up: 3.4 ± 1.6 years). The PHAS score improved significantly from a median of 56.3 (interquartile range [IQR]: 49.0-64.0) preoperatively to 84.5 (IQR: 73.8-94.8) at the final follow-up (P < .001). The Tegner score increased from 2.0 (IQR: 1.0-3.0) to 3.0 (IQR: 3.0-5.0) and the University of California, Los Angeles from 4.0 (IQR: 3.0-5.0) to 6.0 (IQR: 5.0-9.0) (both P < .001). Compared with preinjury levels, both scores remained significantly lower (P = .005 and P = .007, respectively). Regarding return to sport, 48.7% returned to sport, but only 15.4% resumed at the same or higher level. The overall complication rate was 16.7%, including 5 reruptures (11.9%), occurring at a median of 40 days (IQR: 35.0-73.0). The minimal clinically important difference for PHAS was reached by 97.4% of patients, the substantial clinical benefit by 43.6%, and the patient acceptable symptom state threshold (PHAS > 82.3) by 56.4%. CONCLUSIONS:Allograft reconstruction is a viable option for chronic proximal hamstring avulsion injuries when direct repair is not feasible, yielding significant functional gains and acceptable satisfaction. LEVEL OF EVIDENCE:Level IV, retrospective case series.
Most studies evaluating medial opening wedge high tibial osteotomy (MOWHTO) and medial meniscal tears and extrusion focus on the benefit of MOWHTO on meniscal healing. However, correcting medial meniscal extrusion with centralization or other techniques to augment meniscal repair may be necessary to maintain correction of MOWHTO. MOWHTO patients without MME >3 mm have more than 3 times higher chance of medial compartment International Cartilage Regeneration Society score improvement. This supports the idea that preserved meniscal function, and not MOWHTO alone, promotes cartilage healing and contributes to the long-term maintenance of alignment correction.
Allograft bone block reconstruction for glenoid bone loss has become increasingly used, with favorable clinical outcomes. Among the available donor grafts, the distal tibia allograft remains the most used. Current evidence evaluating alternative grafts, particularly the distal radius, is largely limited to cadaveric, biomechanical, and radiologic studies. Important characteristics, including bone mineral density, radius of curvature, and graft dimensions, have indicated that the distal radius is a promising alternative donor source for glenoid reconstruction. Prospective comparative clinical studies are required before routine clinical adoption can be recommended.
Radial meniscal tears pose a particularly difficult challenge, in terms of both management options and surgical techniques. A recent literature has sought to establish a consensus on risk factors, diagnosis, nonsurgical and surgical treatment options, rehabilitation, and outcomes on radial meniscal tears. A Level V expert opinion study came to ≥80% consensus on 42 statements, 7 of which had 100% agreement from the panelists. We agree that, for degenerative tears, tissue quality, limb alignment, and degree of osteoarthritis need to be factored into decision-making. Furthermore, for acute traumatic complete radial tears (medial or lateral), meticulous surgical planning is necessary, and surgeons need to be familiar with all the different suturing techniques required to anatomically repair these challenging tears.
PURPOSE:To elucidate Mistral-NeMo's proficiency as a novel artificial intelligence assistant to verify coding accuracy and improve efficiency in manual medical coding practices in orthopaedic surgery. METHODS:This study tested Mistral-NeMo on 1000 operative notes labeled with the Current Procedural Terminology (CPT) codes from 177 providers. In total, there were 46 unique CPT codes; the most common were 29881 (knee arthroscopy with meniscectomy for both medial and lateral menisci), 29880 (knee arthroscopy with meniscectomy for 1 meniscus), and 29888 (ACL repair/reconstruction). Each model prompt included an operative note with either the true CPT code associated with the note or a randomly selected incorrect CPT code to serve as positive or negative controls. Trials asked the model for either a binary "Yes/No" response or a confidence score (0-100). RESULTS:The results from the binary-response trials showed that the Mistral-NeMo model correctly identified 90% (n = 1000) of the correct CPT codes for each operative note and rejected 99.80% (n = 1000) of incorrect codes (P < .001). The model achieved a precision of 99.80% and a recall of 90% under the testing framework. The model's performance was subanalyzed for the most common CPT codes, 29881, 29880, and 29888, accounting for 747 of the total operative notes. The model labeled the notes with these CPT codes with accuracy of 95.60% (n = 430), 95.50% (n = 160), and 82.50% (n = 157), respectively (P < .001). Among the confidence score trials, Mistral-NeMo showed an area under the operating curve of 0.96 and 0.97, indicating high classification ability. CONCLUSIONS:The Mistral-NeMo language model showed high accuracy in classifying CPT codes for femur- and knee-related surgical operative notes when CPT billing descriptions were provided. In contrast, model performance was insignificant in the absence of billing descriptions, indicating dependence on contextual information for accurate classification. CLINICAL RELEVANCE:This study assesses the performance of artificial intelligence, specifically the Mistral-NeMo language model, in the role of assisting in automating the billing process. Incidental coding error, along with the overall demands of billing, place a significant burden on both clinicians and administrative staff that divert their attention away from patient care. Investigation of artificial intelligence-based techniques enables automated validation of billing codes. Reducing coding errors has the potential to enhance clinical workflow and decrease the administrative burden on surgical practices.
"Repetition is the key to adult learning" is a critical aphorism that underpins many aspects of surgical training. However, the aphorism is silent on a potentially key aspect of surgical skill acquisition: spacing. Many students have the experience of cramming for a final examination, only to have forgotten the material the next week. This common knowledge acquisition experience likely has parallels in surgical skill acquisition as well. Spacing of practice sessions of the target skill can be modified to optimize long-term retention of the skill. Optimal spacing may be on the order of days, not hours. This finding potentially has important implications for the design of surgical training programs and workshops.
PURPOSE:To perform a systematic review comparing outcomes of segmental and circumferential hip labral reconstructions for irreparable labral tears. METHODS:A systematic search was conducted across PubMed, Embase, and CINAHL. The search terms used were "(hip OR hip arthroscopy) AND (labral reconstruction OR labrum reconstruction)." We included clinical studies reporting outcomes after primary segmental or circumferential hip labral reconstruction in nondysplastic hips and a minimum follow-up of 24 months. A qualitative analysis was performed given the encountered heterogeneity between cohorts. RESULTS:A total of 9 studies (13 cohorts, 371 hips) were included in the analysis, comprising 192 hips that underwent segmental labral reconstruction and 179 circumferential. Only 1 study reported comparative outcomes of segmental and circumferential reconstructions. At the study level, postoperative modified Harris Hip Score in the segmental and circumferential groups ranged from 75.6 to 89.0 and from 83.6 to 87.8, respectively. International Hip Outcome Tool-12 scores in the segmental and circumferential groups ranged from 63.9 to 76.7 and from 73.6 to 79.5, respectively, across studies. Hip Outcome Score-Activities of Daily Living in the segmental and circumferential groups ranged from 86.7 to 92.6 and averaged 88.4 in the single circumferential cohort reporting this outcome. Revision and total hip arthroplasty rates ranged from 0% to 20% in the segmental cohorts and 0% to 5.4% in the circumferential cohorts. At the study level, for International Hip Outcome Tool-12 and/or modified Harris Hip Score, patient acceptable symptom state achievement ranged from 53.8% to 100% after segmental reconstruction and 58.8% to 80% after circumferential reconstruction, whereas minimal clinically important difference achievement ranged from 55.6% to 100% and 64.7% to 100%, respectively. CONCLUSIONS:Primary labral reconstructions of the hip using segmental or circumferential techniques are both effective in improving patient-reported outcomes with high rates of clinically significant improvement; however, there is a current paucity of directly comparative outcomes studies between the 2 approaches. LEVEL OF EVIDENCE:Level IV, systematic review of Level II to IV studies.
Early retear is a devastating complication following arthroscopic rotator cuff repair. The ability to predict early retear in patients undergoing rotator cuff repair may allow for interventions targeted at mitigating the risk of this complication, thereby improving surgical outcomes. Transfer learning, wherein labeled datasets are used to repurpose pretrained convolutional neural networks, represents an important approach for potentially improving the accuracy of these predictions through using artificial intelligence and deep learning. Leveraging deep learning provides an alternative approach to using tabular data for predictions by extracting important and subtle data from imaging (such as arthroscopic photographs) to provide insight into how the appearance of a surgical construct may predict outcomes. However, the value of such pipelines depends highly on preprocessing and generalizability of the training datasets. When labeling datasets, characteristics such as tendon integrity may be partially subjective, so surgeon-versus-surgeon (interrater) reliability or surgeon-versus-model analysis is crucial towards reducing bias. Clinical adoption of these pipelines requires generalizability of models, and convolutional neural networks trained on single surgeon datasets introduces bias variability. Clinical adoption requires trust and fairness as well as governance by artificial intelligence regulatory committees or "umpires;" and, if we are to trust DL models to call balls and strikes with respect to rotator cuff integrity in the real-world, it is important to have a clearly defined strike-zone.
PURPOSE:To compare tibial tubercle-trochlear groove (TT-TG) and tibial tubercle-posterior cruciate ligament (TT-PCL) distances across grades of trochlear dysplasia (TD) in patients with patellofemoral instability, to evaluate their relations with knee rotation angle (KRA) and patellar lateralization, measured as patellar tendon-lateral trochlear ridge (PTLTR), and to determine its influence on surgical indications for realignment procedures. METHODS:Patients with patellofemoral instability treated between 2017 and 2024 were retrospectively reviewed. Magnetic resonance imaging measurements included TT-TG, TT-PCL, TTdiff (TT-TG - TT-PCL), KRA, and PTLTR. TD was graded by Dejour classification and grouped as normal/low grade (normal-A) or high grade (B-D). Pathologic thresholds were defined as TT-TG ≥ 15 mm, TT-PCL ≥ 24 mm, and PTLTR ≥ 5.6 mm. Independent-samples t-tests, Mann-Whitney U tests, Pearson correlation coefficients, Fisher's exact tests, and receiver operating characteristic curve analysis were used as appropriate. RESULTS:A total of 153 patients were included. Mean TT-TG and TT-PCL were 17.3 ± 5.6 and 21.7 ± 4.1 mm, respectively. High-grade TD showed significantly greater TT-TG (18.7 ± 6.3 vs 16.0 ± 5.6 mm, P = .002), KRA (4.4 ± 6.8° vs 1.9 ± 8.0°, P < .001), and PTLTR (18.2 ± 8.5 vs 12.6 ± 8.1 mm, P < .001), whereas TT-PCL did not differ between groups (P = .387). TT-TG correlated positively with KRA (r = 0.47, P < .001), whereas TT-PCL showed a weak inverse correlation (r = -0.18, P = .027); TTdiff showed the strongest association (r = 0.56, P < .001). PTLTR correlated with TT-TG (P < .001) but not TT-PCL. Threshold analysis revealed discordance: 39.2% of normal/low-grade and 44.6% of high-grade TD patients were pathologic by TT-TG despite normal TT-PCL, whereas only 26.8% met TT-PCL criteria overall (P = .004). CONCLUSIONS:TT-PCL underestimates functional patellar lateralization and surgical candidacy for realignment, particularly in high-grade TD where rotational malalignment is prominent. TT-TG shows stronger associations with rotational alignment and patellar engagement. LEVEL OF EVIDENCE:Level III, retrospective cohort study.
PURPOSE:To establish consensus statements on risk factors, diagnosis, nonoperative management, surgical indications and techniques, rehabilitation strategies, and clinical and functional outcomes of meniscus radial tears (MRT). METHODS:A working group of fellowship-trained sports medicine surgeons developed original statements based on a review of the current literature on MRT. A panel of 45 international orthopaedic surgeons was surveyed. Agreement with each statement was assessed using a 5-point Likert scale, and statements were retained, revised, or excluded according to predefined thresholds (≥80% agreement and <20% disagreement). Expert-suggested revisions and additional statements generated during the first 2 rounds were further reviewed and voted on in the final round 3. RESULTS:The expert panel achieved consensus on repair for isolated acute traumatic MRTs and those associated with acute cruciate ligament injuries, whereas repair in chronic degenerative tears should be based on meniscal tissue quality and degree of osteoarthritis. Although partial meniscectomy may provide short-term relief, its long-term detrimental effects should not be underestimated. Increased age alone was not considered a risk factor for MRT repair. Successful healing requires addressing peripheral extension and gapping, with anatomic restoration prioritized over surgical technique or suture choice. Given limited evidence on early weightbearing and unrestricted motion, a conservative postoperative protocol is advised. No repair technique has proven superior with choice guided by surgeon preference. CONCLUSIONS:Expert consensus supports repair of acute traumatic and acute cruciate ligament-associated MRTs, whereas indications for chronic degenerative tears depend on tissue quality and joint status. Increased age alone was not considered a contraindication to MRT repair. Anatomic restoration is essential for a successful outcome, irrespective of surgical technique. An initial nonweight-bearing rehabilitation protocol is recommended. LEVEL OF EVIDENCE:Level V, expert opinion, modified Delphi consensus.
PURPOSE:To determine if medial meniscus extrusion (MME) impacts postoperative alignment and varus correction loss after medial opening-wedge high tibial osteotomy. METHODS:We retrospectively reviewed patients who underwent medial opening-wedge high tibial osteotomy for medial compartment osteoarthritis with ≥5 years of follow-up. Patients were categorized using a 3-mm cutoff for preoperative MME on magnetic resonance imaging (≥3 mm defined pathological). Serial standing radiographs were obtained preoperatively and at 3 months, 1 year, and ≥5 years postoperatively, and the weight-bearing line (WBL) ratio, hip-knee-ankle angle, mechanical lateral distal femoral angle, medial proximal tibial angle, and joint line convergence angle were evaluated by an independent blinded observer. Alignment changes were analyzed using repeated-measures analysis of variance. Varus correction loss was defined as a final WBL ratio <50%, and predictors were identified using multivariate logistic regression including demographic and radiographic variables. Knee Injury and Osteoarthritis Outcome Score values (mean ± standard deviation) were evaluated preoperatively and at the final follow-up. Minimal clinically important difference achievement rates (defined as one-half of the standard deviation of the pre-to-post change) were compared between groups using Fisher's exact tests. RESULTS:Fifty-five knees (44 patients; mean age, 59.3 years; mean follow-up, 6.9 [5.0-10.4] years) were included. Forty knees (72.7%) showed pathological MME. The pathological group had a significantly lower final WBL ratio (55.8% vs 65.7%, P = .008) and hip-knee-ankle (1.9° vs 3.9°, P = .025), whereas mechanical lateral distal femoral angle and medial proximal tibial angle did not differ. MME ≥3 mm (P = .004), lower 3-month WBL ratio (P < .001), and greater preoperative mechanical lateral distal femoral angle (P = .005) independently predicted varus correction loss. Knee Injury and Osteoarthritis Outcome Score significantly improved from preoperative to final follow-up in both groups (all P < .001). At final follow-up, there were no significant differences between the groups (MME ≥3 mm vs <3 mm): pain, 70.3 ± 24.3 vs 73.7 ± 25.4 (P = .667); symptoms, 70.9 ± 22.3 vs 80.7 ± 12.3 (P = .139); activities of daily living, 76.8 ± 22.8 vs 76.7 ± 20.4 (P = .992); sports, 45.3 ± 27.4 vs 53.8 ± 21.4 (P = .313); and quality of life, 53.2 ± 25.8 vs 55.8 ± 22.2 (P = .751). Minimal clinically important difference achievement rates were lower in the pathological group (57.5%-65.0% vs 80.0%-86.7%), although not statistically significant. CONCLUSIONS:Pathological MME was associated with greater varus correction loss despite stable bony alignment and tended to show lower minimal clinically important difference achievement rates. LEVEL OF EVIDENCE:Level III, retrospective comparative case series.
Medial meniscus posterior root repair improves symptoms and function, but repair alone does not normalize gait. In the referenced study, patients who underwent repair achieved an acceptable symptom state more often than those with an unrepaired tear (71.4%-81.0% vs 10.5%-26.3%). Gait mechanics moved toward normal but did not reach it: compared with controls, the tear group differed significantly in midstance knee extension and terminal-stance knee adduction moment, with the repair group falling at an intermediate level. Varus thrust and reduced internal rotation persisted in both groups despite only modest differences in static mechanical alignment. This underscores that dynamic gait assessment, not a static radiograph, is beneficial to fully assess the effect of root repair. Restoration of full extension and objectively confirmed quadriceps recovery may be essential to closing this gap and to long-term chondroprotection. This raises a rehabilitation paradox: prolonged protection safeguards healing but may potentiate quadriceps inhibition and persistent gait dysfunction. Earlier controlled weightbearing, potentially supported by meniscal centralization with multiple fixation points, warrants a prospective study. Root preservation should extend beyond fixation alone to include gait restoration, extrusion control, and long-term joint protection.
