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Meniscal repair at the time of primary ACLR does not negatively influence short term knee stability, graft rupture rates, or patient-reported outcome measures: the STABILITY experience

Abstract

Purpose

To assess how meniscal repair and excision impact short term patient-reported outcome measures (PROMs), knee stability, and early graft rupture rates following primary hamstring anterior cruciate ligament reconstruction (ACLR) with or without lateral extra-articular tenodesis (LET) in a group of young active patients where meniscal repair is commonly advocated.

Methods

Six hundred and eighteen patients under 25 years of age at high-risk of graft failure following ACLR were recruited to the Stability 1 study. Multivariable regression models were developed to identify statistically and clinically significant surgical and demographic predictors of Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Subjective Knee Form (IKDC), ACL Quality of Life Questionnaire (ACL-QOL) and Marx Activity Rating Scale (MARS) scores. Chi-Square tests of independence were used to explore the association between meniscal status (torn, not torn), meniscal treatment (excision or repair), graft rupture, and rotatory knee laxity.

Results

Medial meniscus repair was associated with worse outcomes on the KOOS (β = −1.32, 95% CI: −1.57 to −1.10, p = 0.003), IKDC (β = −1.66, 95% CI: −1.53 to −1.02, p = 0.031) and ACL-QOL (β = −1.25, 95% CI: −1.61 to 1.02, p = n.s.). However, these associations indicated small, clinically insignificant changes based on reported measures of clinical relevance. Other important predictors of post-operative PROMs included age, sex, and baseline scores. Medial meniscus excision and lateral meniscus treatment (repair or excision) did not have an important influence on PROMs. There was no significant association between meniscal treatment and graft rupture or rotatory knee laxity.

Conclusion

While repairing the medial meniscus may result in a small reduction in PROM scores at two-year follow-up, these differences are not likely to be important to patients or clinicians. Any surgical morbidity associated with meniscal repair appears negligible in terms of PROMs. Meniscal repair does not affect rotatory laxity or graft failure rates in the short term. Therefore, meniscal repair should likely be maintained as the standard of care for concomitant meniscal tears with ACLR.

Level of evidence

III.

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Abbreviations

PROMs:

Patient reported outcome measures

ACLR:

Anterior cruciate ligament reconstruction

KOOS:

Knee injury and osteoarthritis outcome score

IKDC:

International knee documentation committee subjective knee form

ACL-QOL:

Anterior cruciate ligament quality of life questionnaire

MARS:

Marx activity rating scale

ACL:

Anterior cruciate ligament

MOON:

Multicenter orthopaedic outcomes network

OA:

osteoarthritis

MCID:

Minimal clinically important difference

LET:

lateral extra-articular tenodesis

ICRS:

International Cartilage Repair Society

VIF:

variance inflation factor

CIs:

confidence intervals

ORs:

odds ratios

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Acknowledgements

The authors would like to thank the members of the Stability Study Group who made this data collection possible. The Stability Study was funded by a research award from the International Society for Arthroscopic Knee Surgery and Orthopaedic Sports Medicine (ISAKOS). Stability Study Group: London Health Science Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Ontario: Alan Getgood, Dianne Bryant, Robert Litchfield, Kevin Willits, Trevor Birmingham, Chris Hewison, Stacey Wanlin, Andrew Firth, Ryan Pinto, Ashley Martindale, Lindsey O’Neill, Morgan Jennings, Michal Daniluk. Fraser Orthopaedic Institute, New Westminster, British Columbia: Dory Boyer, Bob McCormack, Mauri Zomar, Karyn Moon, Raely Moon, Brenda Fan, Bindu Mohan. Banff Sport Medicine, Banff, Alberta: Mark Heard, Gregory M. Buchko, Laurie A. Hiemstra, Sarah Kerslake, Jeremy Tynedal. Pan Am Clinic, Winnipeg, Manitoba: Peter MacDonald, Greg Stranges, Sheila Mcrae, LeeAnne Gullett, Holly Brown, Alexandra Legary, Alison Longo, Mat Christian, Celeste Ferguson. University of Calgary, Sport Medicine Centre, Calgary, Alberta: Alex Rezansoff, Nick Mohtadi, Rhamona Barber, Denise Chan, Caitlin Campbell, Alexandra Garven, Karen Pulsifer, Michelle Mayer. McMaster University, Hamilton, Ontario: Devin Peterson, Nicole Simunovic, Andrew Duong, David Robinson, David Levy, Matt Skelly and Ajaykumar Shanmugaraj. Queens University, Kingston, Ontario: Davide Bardana, Fiona Howells, Murray Tough. University Hospitals Coventry Warwickshire NHS Trust, Coventry, United Kingdom: Tim Spalding, Pete Thompson, Andrew Metcalfe, Laura Asplin, Alisen Dube, Louise Clarkson, Jaclyn Brown, Alison Bolsover, Carolyn Bradshaw, Larissa Belgrove, Francis Millan, Sylvia Turner, Sarah Verdugo, Janet Lowe, Debra Dunne, Kerri McGowan, Charlie-Marie Suddens. Antwerp Orthopaedic Center, Ghent, Belgium: Peter Verdonk, Geert Declerq, Kristien Vuylsteke, Mieke Van Haver.

Funding

The Stability 1 study was funded by a research award from the International Society for Arthroscopic Knee Surgery and Orthopaedic Sports Medicine (ISAKOS).

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Contributions

HM conducted the data analysis and wrote the manuscript. AF assisted with study design, data collection, data analysis and writing the manuscript. LB assisted with study design and writing the manuscript. DB assisted with study design, data analysis and manuscript revision. AG assisted with study design and manuscript revision.

Corresponding author

Correspondence to Alan M. J. Getgood.

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Conflict of interest

HM, AF, LB and DB have no conflicts of interest to report. AG reports research support from the International Society for Arthroscopic Knee Surgery and Orthopaedic Sports Medicine (ISAKOS), royalties and consulting fees from Smith & Nephew, and consulting fees from Graymont Inc., Ossur, Olympus, Xiros Inc, and Precision OS.

Ethical Approval

The Stability 1 study obtained ethical approval from the Western University Health Sciences Research Ethics Board. File Number: 104524.

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Informed consent was obtained from all study participants.

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Collaborator under STABILITY Study Group are listed in acknowledgements.

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Marmura, H., Firth, A., Batty, L. et al. Meniscal repair at the time of primary ACLR does not negatively influence short term knee stability, graft rupture rates, or patient-reported outcome measures: the STABILITY experience. Knee Surg Sports Traumatol Arthrosc (2022). https://doi.org/10.1007/s00167-022-06962-z

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Keywords

  • Knee
  • ACL
  • Meniscus
  • ACL reconstruction
  • Meniscal repair
  • Meniscectomy
  • Young patients
  • Athletes
  • Patient reported outcomes
  • Stability