Ludovico Panarella

Interobserver reliability of the international society of arthroscopy, knee surgery and orthopaedic sports medicine (ISAKOS) classification of meniscal tears

Background: Consistency of arthroscopic evaluation and documentation in meniscal tears between investigators is essential to the validity of multicenter studies. A group of experts developed a classification of meniscal tears that may be used internationally. Hypothesis: The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification of meniscal tears provides sufficient interobserver reliability for pooling of data from international clinical trials designed to evaluate the outcomes of treatment for meniscal tears. Study Design: Cohort study (diagnosis); Level of evidence, 1. Methods: A pilot study was performed by having 8 members of the committee grade 10 arthroscopic videos for classification of tear depth, rim width, location, tear pattern, and quality of the tissue. The results of the pilot study were used to change the instruction sheet and evaluation form. International interobserver reliability was determined by having 8 orthopaedic surgeons who practice in different countries evaluate 37 arthroscopic videos selected to represent different meniscal tear characteristics. The Spearman ρ correlation coefficient was used to compare the area of the meniscus excised, as drawn on the diagram, with the numeric percentage of meniscus excised. Results: There was an 87% agreement for anterior-posterior location of the tear (κ = .65); 79% agreement for tear pattern (κ = .72); 88% agreement for tear depth (κ = .52); 68% agreement for anterior, middle, and posterior location of the tear (κ = .46); and 72% agreement for tissue quality (κ = .47). There was 54% agreement for the rim width (κ = .25) and 67% agreement if the tear was central to the popliteal hiatus (κ = .36). Based on the Landis and Koch criteria for κ coefficients, there was substantial agreement for anterior-posterior location of the tear and tear pattern; moderate agreement for tear depth, anterior, middle, and posterior location of the tear, and tissue quality; and fair agreement for rim width and if the tear was central to the popliteal tear. Interobserver reliability based on the intraclass correlation coefficient (ICC) was good for tear length (ICC = .83) and moderate for percentage of meniscus that was excised (ICC = .65). The mean ρ for all raters was .92 (95% confidence interval [CI], .89-.94) comparing the values for percentage of meniscus excised with the area on the diagrams. Conclusion: The ISAKOS classification of meniscal tears provides sufficient interobserver reliability for pooling of data from international clinical trials designed to evaluate the outcomes of treatment for meniscal tears.

Meniscal Healing After Meniscal Repair A CT Arthrography Assessment

Background Studies evaluating healing of repaired meniscus are rare and primarily retrospective. The aim of this study was to assess whether there were different healing rates for arthroscopic meniscal repair with respect to the different zones of the meniscus. Purpose This study was conducted to assess outcomes and to document anatomic characteristics of the repaired meniscus with postoperative arthrography combined with computed tomography (arthro-CT), particularly the dimensions and healing of the repaired meniscus. Study Design Case series; Level of evidence, 4. Methods Fifty-three arthroscopic meniscal repairs were prospectively evaluated between 2002 and 2004 in 2 orthopaedic departments. There were 36 medial and 17 lateral torn menisci. All ACL tears (n = 31, 58.5%) underwent reconstruction. Patients were preoperatively evaluated by magnetic resonance imaging. Clinical evaluation included International Knee Documentation Committee (IKDC) scores before the operation and 6 and 12 months afterward. Healing criteria were evaluated at 6 months by arthro-CT scan. Three parameters were evaluated—healing in thickness (Henning criteria), overall healing rate, and reduction in the width of the remaining meniscus. Results According to the objective IKDC score, 26 patients were graded A, 20 B, and 4 C (92% good results). The mean subjective IKDC score was 78.9 (standard deviation [SD], 16.2). According to Hennings criteria, 58% of the menisci healed completely, 24% partially, and 18% failed. The overall healing rate was 73.1% (SD, 38.5). Twenty tears located in the posterior part had a healing rate of 59.8% (SD, 46.0). Nineteen tears extending from the posterior to the middle part had a healing rate of 79.2% (SD, 28.2). Isolated tears located in the posterior part had a lower healing rate (P < .05). There was a 9% ± 1.2% reduction in the width of the remaining medial meniscus in the middle and posterior repaired portions (P < .02). There was a 15% ± 14% reduction in the width of the remaining lateral meniscus in the middle repaired portion (P < .01). Complete healing of the posterior segment was associated with reduction in the width of the meniscus (P < .04). Conclusion A modern technique using all-inside fixation or outside-in sutures provided good clinical and anatomic outcomes. No statistically significant effect on ACL reconstruction or laterality (medial vs lateral) on overall healing after meniscal repair was identified. Partial healing occurred often, with a stable tear on a narrowed and painless meniscus. The posterior segment healing rate remained low, suggesting a need for further technical improvements.

Osteochondral Lesions: Medial Versus Lateral, Persistent Pain, Cartilage Restoration Options and Indications

Chronic giving way and ankle dysfunction are common after ankle sprains. In our approach to chronic ankle pain and giving way, one must consider the differential diagnosis before treatment can be directed appropriately. One of the common diagnoses associated with ankle injury is osteochondral lesions of the talus. The advent of MRI has allowed us to make the diagnosis of occult lesions more readily. Arthroscopic and open management of these lesions continues to evolve. This article discusses osteochondral lesions of the talus, treatment options, and resurfacing techniques.

Meniscal Healing After Meniscus Repair: A CT Arthrography Assessment

Background Studies evaluating healing of repaired meniscus are rare and primarily retrospective. The aim of this study was to assess whether there were different healing rates for arthroscopic meniscal repair with respect to the different zones of the meniscus. Purpose This study was conducted to assess outcomes and to document anatomic characteristics of the repaired meniscus with postoperative arthrography combined with computed tomography (arthro-CT), particularly the dimensions and healing of the repaired meniscus. Study Design Case series; Level of evidence, 4. Methods Fifty-three arthroscopic meniscal repairs were prospectively evaluated between 2002 and 2004 in 2 orthopaedic departments. There were 36 medial and 17 lateral torn menisci. All ACL tears (n = 31, 58.5%) underwent reconstruction. Patients were preoperatively evaluated by magnetic resonance imaging. Clinical evaluation included International Knee Documentation Committee (IKDC) scores before the operation and 6 and 12 months afterward. Healing criteria were evaluated at 6 months by arthro-CT scan. Three parameters were evaluated—healing in thickness (Henning criteria), overall healing rate, and reduction in the width of the remaining meniscus. Results According to the objective IKDC score, 26 patients were graded A, 20 B, and 4 C (92% good results). The mean subjective IKDC score was 78.9 (standard deviation [SD], 16.2). According to Hennings criteria, 58% of the menisci healed completely, 24% partially, and 18% failed. The overall healing rate was 73.1% (SD, 38.5). Twenty tears located in the posterior part had a healing rate of 59.8% (SD, 46.0). Nineteen tears extending from the posterior to the middle part had a healing rate of 79.2% (SD, 28.2). Isolated tears located in the posterior part had a lower healing rate (P < .05). There was a 9% ± 1.2% reduction in the width of the remaining medial meniscus in the middle and posterior repaired portions (P < .02). There was a 15% ± 14% reduction in the width of the remaining lateral meniscus in the middle repaired portion (P < .01). Complete healing of the posterior segment was associated with reduction in the width of the meniscus (P < .04). Conclusion A modern technique using all-inside fixation or outside-in sutures provided good clinical and anatomic outcomes. No statistically significant effect on ACL reconstruction or laterality (medial vs lateral) on overall healing after meniscal repair was identified. Partial healing occurred often, with a stable tear on a narrowed and painless meniscus. The posterior segment healing rate remained low, suggesting a need for further technical improvements.

Meniscal Healing after Meniscal Repair

Background Studies evaluating healing of repaired meniscus are rare and primarily retrospective. The aim of this study was to assess whether there were different healing rates for arthroscopic meniscal repair with respect to the different zones of the meniscus. Purpose This study was conducted to assess outcomes and to document anatomic characteristics of the repaired meniscus with postoperative arthrography combined with computed tomography (arthro-CT), particularly the dimensions and healing of the repaired meniscus. Study Design Case series; Level of evidence, 4. Methods Fifty-three arthroscopic meniscal repairs were prospectively evaluated between 2002 and 2004 in 2 orthopaedic departments. There were 36 medial and 17 lateral torn menisci. All ACL tears (n = 31, 58.5%) underwent reconstruction. Patients were preoperatively evaluated by magnetic resonance imaging. Clinical evaluation included International Knee Documentation Committee (IKDC) scores before the operation and 6 and 12 months afterward. Healing criteria were evaluated at 6 months by arthro-CT scan. Three parameters were evaluated—healing in thickness (Henning criteria), overall healing rate, and reduction in the width of the remaining meniscus. Results According to the objective IKDC score, 26 patients were graded A, 20 B, and 4 C (92% good results). The mean subjective IKDC score was 78.9 (standard deviation [SD], 16.2). According to Hennings criteria, 58% of the menisci healed completely, 24% partially, and 18% failed. The overall healing rate was 73.1% (SD, 38.5). Twenty tears located in the posterior part had a healing rate of 59.8% (SD, 46.0). Nineteen tears extending from the posterior to the middle part had a healing rate of 79.2% (SD, 28.2). Isolated tears located in the posterior part had a lower healing rate (P < .05). There was a 9% ± 1.2% reduction in the width of the remaining medial meniscus in the middle and posterior repaired portions (P < .02). There was a 15% ± 14% reduction in the width of the remaining lateral meniscus in the middle repaired portion (P < .01). Complete healing of the posterior segment was associated with reduction in the width of the meniscus (P < .04). Conclusion A modern technique using all-inside fixation or outside-in sutures provided good clinical and anatomic outcomes. No statistically significant effect on ACL reconstruction or laterality (medial vs lateral) on overall healing after meniscal repair was identified. Partial healing occurred often, with a stable tear on a narrowed and painless meniscus. The posterior segment healing rate remained low, suggesting a need for further technical improvements.

Considerations for Osteotomy in the Acl Deficient Knee

The natural history of the isolated ACL deficient knee with or without reconstruction remains unclear. Although multifactorial in nature, evidence demonstrates these knees gradually deteriorate over time. Mechanical overload from knee malalignment has been identified to contribute not only to early failure of ACL reconstruction, but also to more rapid deterioration of the joint. However, assessing limb alignment as a contributing factor still remains largely overlooked in the ligamentously unstable knee, and reconstruction has generally focused on the soft tissue constraints. Therefore, the emphasis of this paper is that mechanical axis deviation in the chronic ACL deficient knee needs to be addressed as a means of treating the instability and protecting the joint. Over time, untreated malalignment can worsen ligamentous laxity and lead to symptomatic chronic instability. On reviewing the literature regarding the ACL deficient knee, some emphasis has been placed on the varus knee in the coronal plane, however little exists on the effect of malalingment, particularly in the sagittal plane. Previous authors have identified the varus component and advocate early intervention for the varus, anterior cruciate deficient knee. Most of these studies examined the effect of a closing wedge osteotomy in the chronically ACL deficient knee. In this review, the authors discuss the indications for realignment and the surgical technique utilizing an opening wedge technique at the time of ACL reconstruction. In addition, the importance of this paper is to discuss coronal and sagittal plane alignment and the need to assess and correct alignment in the unstable ACL deficient knee.

Meniscal Repair: Results

Fairbank [10] was the first to document long-term degenerative changes after subtotal meniscectomy. Since then, meniscus-sparing techniques have been developed, ranging from partial meniscectomy to meniscus repair and replacement. Many studies about meniscus repair have been published, especially since the advent of arthroscopy. The techniques have evolved from open repairs to all-inside arthroscopic repairs, and the indications have been well defined [4, 6, 7]. Seventy to ninety-four percent good clinical results have been reported at the mid-term to long-term follow-up [8, 11, 20–22, 29, 37, 47, 52]. In these studies, subsequent meniscectomy has been performed in 15–24% of cases Studies evaluating anatomical healing of repaired menisci are rare and mainly retrospective. The reported partial and complete healing rate varies from 42 to 75% [1, 4, 6, 7, 17–19, 24, 39, 49], and there is a discrepancy between anatomical and clinical results.