The American Journal of Sports Medicine

http://ajs.sagepub.com/ Longitudinal Tear of the Medial Meniscus Posterior Horn in the Anterior Cruciate LigamentDeficient Knee Significantly Influences Anterior Stability
Jin Hwan Ahn, Tae Soo Bae, Ki-Ser Kang, Soo Yong Kang and Sang Hak Lee Am J Sports Med 2011 39: 2187 originally published online August 9, 2011 DOI: 10.1177/0363546511416597 The online version of this article can be found at: http://ajs.sagepub.com/content/39/10/2187

Published by:
http://www.sagepublications.com

On behalf of:

American Orthopaedic Society for Sports Medicine

Additional services and information for The American Journal of Sports Medicine can be found at: Email Alerts: http://ajs.sagepub.com/cgi/alerts Subscriptions: http://ajs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Oct 6, 2011 Proof - Aug 9, 2011 What is This?

Downloaded from ajs.sagepub.com at HINARI on October 22, 2011

Longitudinal Tear of the Medial Meniscus Posterior Horn in the Anterior Cruciate LigamentDeficient Knee Significantly Influences Anterior Stability
Jin Hwan Ahn,* MD, Tae Soo Bae,y PhD, Ki-Ser Kang,z MD, Soo Yong Kang,z MD, and Sang Hak Lee,|| MD Investigation performed at Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, Seoul, Korea
Background: Longitudinal tears of the medial meniscus posterior horn (MMPH) are commonly associated with a chronic anterior cruciate ligament (ACL) deficiency. Many studies have demonstrated the importance of the medial meniscus in terms of limiting the amount of anterior-posterior tibial translation in response to anterior tibial loads in ACL-deficient knees. Hypothesis: An MMPH tear in an ACL-deficient knee increases the anterior-posterior tibial translation and rotatory instability. In addition, MMPH repair will restore the tibial translation to the level before the tear. Study Design: Controlled laboratory study. Methods: Ten human cadaveric knees were tested sequentially using a custom testing system under 5 conditions: intact, ACL deficient, ACL deficient with an MMPH peripheral longitudinal tear, ACL deficient with an MMPH repair, and ACL deficient with a total medial meniscectomy. The knee kinematics were measured at 0, 15, 30, 60, and 90 of flexion in response to a 134-N anterior and 200-N axial compressive tibial load. The rotatory kinematics were also measured at 15 and 30 of flexion in a combined rotatory load of 5 Nm of internal tibial torque and 10 Nm of valgus torque. Results: Medial meniscus posterior horn longitudinal tears in ACL-deficient knees resulted in a significant increase in anteriorposterior tibial translation at all flexion angles except 90 (P \ .05). An MMPH repair in an ACL-deficient knee showed a significant decrease in anterior-posterior tibial translation at all flexion angles except 60 compared with the ACL-deficient/MMPH tear state (P \ .05). The total anterior-posterior translation of the ACL-deficient/MMPH repaired knee was not significantly increased compared with the ACL (only)deficient knee but was increased compared with the ACLintact knee (P . .05). A total medial meniscectomy in an ACL-deficient knee did not increase the anterior-posterior tibial translation significantly compared with MMPH tears in ACL-deficient knees at all flexion angles (P . .05). In a combined rotatory load, tibial rotation after MMPH tears or a total medial meniscectomy in an ACL-deficient knee were not affected significantly at all flexion angles. Conclusion: This study shows that an MMPH longitudinal tear in an ACL-deficient knee alters the knee kinematics, particularly the anterior-posterior tibial translation. MMPH repair significantly improved anterior-posterior tibial translation in ACL-deficient knees. Clinical Relevance: These findings may help improve the treatment of patients with ACL and MMPH longitudinal tear by suggesting that the medial meniscal repairs should be performed for greater longevity when combined with an ACL reconstruction. Keywords: anterior cruciate ligament; medial meniscus posterior horn tear; meniscal repair

Meniscal injuries associated with acute anterior cruciate ligament (ACL) tears are reported to range from 15% to 40%, and become much higher with a chronic ACL deficiency.13 Several researchers have demonstrated that longitudinal tear of the medial meniscus posterior horn (MMPH) around the meniscocapsular junction is found frequently in knees with chronic deficient ACLs.8,19,25 More

The American Journal of Sports Medicine, Vol. 39, No. 10 DOI: 10.1177/0363546511416597 2011 The Author(s)

than 75% of medial meniscal (MM) tears in ACL-deficient knees occur in the peripheral posterior horn according to a prospective analysis of 575 meniscal tears by Smith and Barrett.23 However, many surgeons overlook this combined tear because of the poor visualization and benign appearance of the posterior meniscocapsular junction of the MM from the anterior portals.1,3 Furthermore, MMPH peripheral rim tears may heal slowly despite the rich vascular supply to the red-red zone because the torn meniscus has some movement proximally against the meniscocapsular junction.2,3,19 A recent clinical study demonstrated that the rate of poor results of repair for MM
2187

Downloaded from ajs.sagepub.com at HINARI on October 22, 2011

2188 Ahn et al

The American Journal of Sports Medicine

tears remains high when nonoperative treatment is used, even though the nonoperative approach is more effective for lateral meniscal tears.19,27 Biomechanical studies have demonstrated the importance of the meniscus, particularly the medial, in stabilizing the knee joint in chronically ACL-deficient knees.5,15,22 Furthermore, many authors have demonstrated the importance of the MM in limiting the anterior tibial translation in response to anterior tibial loads in ACL-deficient knees.4,17 Papageorgiou et al17 reported that the resulting forces on the MM were increased by as much as 200% in response to anterior tibial loads after the ACL had been transected. Furthermore, they demonstrated a 33% to 50% increase in the in situ forces in the ACL replacement graft after a medial meniscectomy. More recently, Seon et al20 confirmed that a subtotal medial meniscectomy in an ACL-deficient knee increased significantly the anterior and lateral tibial translations. These results prompted several authors to recommend that an ACL-deficient knee be reconstructed to protect the menisci.7,18,28 The purpose of this study was to quantify the effects of MMPH longitudinal tears and meniscal repair on ACLdeficient knees. It was hypothesized that an MMPH tear in an ACL-deficient knee would increase the anterior-posterior (A-P) tibial translation and combined rotational laxity. It was also hypothesized that MMPH repair could restore the tibial translation to the level before the meniscal tear.

which is representative of the long axis of the bones. The knees were protected from dehydration by the intermittent applications of physiological saline during preparation and testing periods.

Kinematic Measurements
To measure the kinematics of the knee, each specimen was mounted firmly in an Instron testing machine (Instron 850I, MTS, Minneapolis, Minnesota). A custom knee jig was used to hold the denture acrylic potted bone. The potted bones were then bolted securely within the jigs. The jig allowed rigid fixation of the femur but provided 5 degrees of freedom at the tibia (anteroposterior and proximal-distal translations; and varus-valgus, internal-external rotations, and flexion-extension). The custom testing jig was specifically designed with a pulley system to accommodate the manual application of an anterior and posterior tibial load, as well as a varus and valgus torque. The application of a load was achieved by hanging weights from a cable and pulley system. The experimental setup provided control over various knee flexion angles, which were confirmed using a protractor attached to the jig. The tibial kinematic measurements were obtained to the nearest tenth of a millimeter using electronic calipers. Two optical encoders in the joints recorded the varus-valgus rotational laxity and internal-external rotational laxity of the tibia. Because of the challenges inherent in defining the physiologic neutral position of the cadaveric knee, the laxity measurements were defined as the resultant A-P tibial translation, varus-valgus rotational laxity, and internal-external rotational laxity of the tibia relative to the femur when the appropriate force was applied.

METHODS Specimen Preparation

Ten fresh-frozen, nonpaired human cadaveric knees, ranging in age from 34 to 74 years (mean, 58 years), were used in this study. Six were from male donors, and 4 were from female donors. All knees were macroscopically intact and showed no evidence of prior surgery, structural abnormalities, or arthritic changes according to a clinical examination. The specimens were kept frozen at 20C before the tests and were thawed at room temperature overnight before the experiment. The knees were dissected carefully, removing the skin and soft tissue, and leaving the popliteus muscle, joint capsule, ligamentous structures, and surrounding retinaculum intact. The fibular head was transfixed to the tibia by a 6.5-mm cannulated screw and spiked washer (Jeil Meditec, Daegu, Korea) to maintain its anatomic position and then the distal part was excised. The femur and tibia were then sectioned at approximately 25 cm in length from the joint line and secured in thickwalled aluminum cylinders using denture acryl (Vertex, Dentimex BV, Zeist, The Netherlands). Care was taken to center the long axis of the bone within the cylinder,

Testing Protocol
A custom testing system was sequentially tested under 5 conditions: intact, ACL deficient, ACL deficient with MMPH peripheral longitudinal tear, ACL deficient with an MMPH repair, and ACL deficient with a total medial meniscectomy (Table 1). The knee kinematics were measured at 0, 15, 30, 60, and 90 of flexion, while the positions of the knee, which minimized all external forces and moments applied to the joint throughout the range of flexion from 0 to 90, were recorded. These positions, at which the knee was effectively unloaded, served as starting points for the application of an external load as well as the reference points for the measurements of the knee kinematics throughout each test. The difference between the starting point and the end point position was calculated for each test performed for each sectioned state and flexion angle. The externally applied loading condition in this study combined 2 forces: 134-N anterior and 200-N axial compressive tibial load at full extension and 15,

Address correspondence to Sang Hak Lee, MD, Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Korea (e-mail: sangdory@hanmail.net). *Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea. y Korea Orthopedics & Rehabilitation Engineering Center, Inchon, Korea. z Department of Orthopaedic Surgery, Chung-Ang University, School of Medicine, Seoul, Korea. || Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, Seoul, Korea. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

Downloaded from ajs.sagepub.com at HINARI on October 22, 2011

Vol. 39, No. 10, 2011

Medial Meniscus Posterior Horn Tear and Knee Stability 2189

TABLE 1 Experimental Protocol and Data Acquireda

Protocol I. Intact joint External loading conditions A. 134-N anterior tibial load B. 200-N axial compressive tibial load Combined rotatory load (apply loads A and B) C. 10 Nm of valgus load D. 5 Nm of internal tibial torque II. ACL-deficient joint Transect ACL Apply loads A and B Apply loads A, B, C, and D III. MMPH tear with ACL-deficient joint Make MMPH peripheral longitudinal tear Apply loads A and B Apply loads A, B, C, and D IV. MMPH repair with ACL-deficient joint Repair MMPH tear Apply loads A and B Apply loads A, B, C, and D V. Total medial meniscectomy with ACL-deficient joint Perform total medial meniscectomy Apply loads A and B Apply loads A, B, C, and D
a

Data Acquired

Intact joint kinematics at all flexed angles: (1) anterior tibial translation (2) valgus-varus angle (3) internal-external rotations Intact joint kinematics at 15 and 30 of flexion: (4) internal-external rotations

ACL-deficient joint kinematics at all flexed angles(1), (2), (3) ACL-deficient joint kinematics at 15 and 30 of flexion(4)

ACL-deficient joint kinematics at all flexed angles(1), (2), (3) ACL-deficient joint kinematics at 15 and 30 of flexion(4)

ACL-deficient joint kinematics at all flexed angles(1), (2), (3) ACL-deficient joint kinematics at 15 and 30 of flexion(4)

ACL-deficient joint kinematics at all flexed angles(1), (2), (3) ACL-deficient joint kinematics at 15 and 30 of flexion(4)

ACL, anterior cruciate ligament; MMPH, medial meniscus posterior horn.

30, 60, and 90 of flexion. The combined rotatory kinematics were also measured at 15 and 30 of flexion in a combined rotatory load of 5 Nm of internal tibial torque and 10 Nm of valgus torque (Figure 1). Under each of these loads, the testing system manipulated the knee joint in 4 degrees of freedom (with a constant selected flexion angle) until the applied forces were balanced by the knee. After the kinematics in the intact knee was determined, the ACL was transected to represent an ACL-deficient condition through a 5-cm longitudinal anteromedial arthrotomy. The MMPH peripheral longitudinal tear was made from the posterior horn to the posteromedial corner at the meniscocapsular junction through a 5-cm longitudinal posteromedial arthrotomy (Figure 2). The mean length of the longitudinal tears measured 2.8 cm (range, 2.4-3.3 cm). The root of the MMPH and midbody of the MM were preserved in our experimental protocol. The arthrotomy was repaired in layers by sutures with 2-0 Vicryl suture material. In the next step, the MMPH tear was repaired using absorbable sutures (No. 0 PDS [polydioxanone], Ethicon, Somerville, New Jersey). Every stitch was made with a roughly 4- to 5-mm interval using a vertically oriented repair technique. Thus, the MMPH tear in each specimen was repaired by 4 to 5 stitches. Finally, a total resection of the entire MM, removing the inner portion of the whole body and the posterior horn, was performed through the same posteromedial arthrotomy. The arthrotomy was closed carefully in layers in each step. The external load was then reapplied with each step and the resulting kinematics recorded using the testing system. Each knee was tested 2 times at each flexion angle and the results were averaged.

Figure 1. Schematic illustration of testing systems with a right cadaveric knee specimen. The mean difference between the origin and the end point position was calculated for each test performed for each sectioned state flexion angle.

Statistical Analysis
The knee laxity measurements were repeated for 2 trials and the mean value was used for data analysis. The

Downloaded from ajs.sagepub.com at HINARI on October 22, 2011

2190 Ahn et al

The American Journal of Sports Medicine

Figure 2. Schematic drawings show that a peripheral longitudinal tear of the medial meniscus posterior horn (MMPH) was made from the posterior horn to the posteromedial corner at the meniscocapsular junction (A) and the MMPH tear was repaired using absorbable sutures (B). reliability of measurements was assessed by the intraclass correlation coefficient (ICC), which quantifies the proportion of the variance attributable to variability between measurements. Because all variables were measured within each specimen, statistical analysis of the knee kinematics was performed using a Friedman test with Bonferroni correction or 2-way analysis of variance. All statistical analyses were carried out using SAS version 9.13 software (SAS Institute Inc, Cary, North Carolina). P values \ .05 were considered significant.

Figure 3. Anterior translation of the tibia under anterior and compressive tibial load in 5 different knee conditions. Statistical significances were noted between intact and anterior cruciate ligament (ACL) resect groups, ACL resect and ACL resect 1 meniscus tear groups, and ACL resect 1 meniscus tear and ACL resect 1 meniscus repair groups at most flexion angles. An asterisk represents statistical significance (P \ .05); error bars represent the standard deviation. increase the A-P tibial translation significantly compared with the MMPH peripheral tears in the ACL-deficient knee at all flexion angles, which ranged from 11.3 6 6.3 mm at 90 of flexion to 19.5 6 5.9 mm (P . .05). The coupled varus-valgus and internal-external rotations in response to the combined 134-N anterior and 200-N axial compressive tibial load were also measured and are shown Tables 3 and 4. Both varus-valgus and internal-external rotations in ACL-deficient knees were not affected significantly by the MMPH tears or total medial meniscectomy at all flexion angles (P . .05).

RESULTS
The ICC for test-retest reliability of the measurement was greater than 0.9, ranging from 0.99 to 0.92, for all measurements. This value indicated that all measurements had excellent reproducibility.

Knee Kinematics in Response to 134-N Anterior and 200-N Compressive Tibial Load
When a combined 134-N anterior and 200-N axial compressive tibial load was applied, the A-P tibial translation of the ACL-intact knee ranged from 7.1 6 0.9 mm at full extension to 9.0 6 2.9 mm at 30 of flexion (Figure 3, Table 2). The largest A-P tibial translation of the ACL-intact knee was observed at 15 and 30 of flexion as 8.6 6 2.1 mm and 9.0 6 2.9 mm, respectively. After the ACL was resected, the A-P tibial translation under combined loads in the ACL-deficient knees was significantly larger than in the intact knee at all flexion angles selected (P \ .05). Medial meniscus posterior horn tears in the ACL-deficient knees resulted in an additional increase in A-P tibial translation at all flexion angles except 90 (P \ .05). These increases in A-P tibial translation differed according to the flexion angle, from a minimum of 1.7 6 0.8 mm at 90 of flexion to a maximum of 5.2 6 1.2 mm at 15 of flexion. Medial meniscus posterior horn repair in the ACL-deficient knee reduced A-P tibial translation significantly at all flexion angle except 60 (P \ .05). After MMPH repair in the ACL-deficient knee, the A-P tibial translation was not significantly increased compared with the ACL-onlydeficient knee at all flexion angles (P . .05). Furthermore, a total medial meniscectomy in the ACL-deficient knees did not

Knee Kinematics in Response to a Combined Rotatory Load

The resulting internal-external tibial rotation in response to a 5-Nm internal tibial torque with a 10-Nm valgus torque was increased by each step: the ACL resection, MMPH tear, and total medial meniscectomy at 15 and 30 of knee flexion although there were no significantly differences (P . .05). The resulting tibial rotation was decreased by MMPH repair in the ACL-deficient knee at 15 and 30 of knee flexion. However, no statistically significant differences also could be found at any flexion angle among each step at 15 and 30 of knee flexion (P . .05) (Table 5).

DISCUSSION
The effect of an MMPH longitudinal tear in ACL-deficient knees on the kinematics of the knee has not been reported. This biomechanical study showed that an MMPH

Downloaded from ajs.sagepub.com at HINARI on October 22, 2011

Vol. 39, No. 10, 2011

Medial Meniscus Posterior Horn Tear and Knee Stability 2191

TABLE 2 Mean Values (6Standard Deviation) of Anterior Translation (mm) of the Tibia Under 134-N Anterior and 200-N Compressive Tibial Load in 5 Different Knee Conditionsa
Knee Condition Intact ACL resect ACL resect/MMPHT ACL resect/MMPHR ACL resect/TMM
a

0 6.9 10.1 13.9 12.0 13.6 6 6 6 6 6 0.9 1.9b 2.4c 2.2d 4.1e

15 8.6 14.2 18.7 15.6 18.8 6 6 6 6 6 2.1 3.6b 4.8c 3.7d 6.1e

30 9.0 14.8 16.8 14.8 16.9 6 6 6 6 6 2.9 4.7b 4.8c 4.4d 5.5e

60 7.1 11.8 13.9 12.4 14.6 6 6 6 6 6 1.9 2.2b 3.7c 4.3 5.7e 6.6 8.9 9.8 8.1 9.8

90 6 6 6 6 6 2.0 3.2b 4.1 3.9d 6.2e

ACL, anterior cruciate ligament; MMPHT, medial meniscus posterior horn tear; MMPHR, medial meniscus posterior horn repair; TMM, total medial meniscectomy. b P \ .05 when compared with the intact knee. c P \ .05 when compared with the ACL-resected knee. d P \ .05 when compared with the ACL-resected/MMPHT knee. e P \ .05 when compared with the ACL-resected/MMPHR knee.

TABLE 3 Mean Values (6Standard Deviation) of Valgus-Varus Angle (deg) of the Tibia Under 134-N Anterior and 200-N Compressive Tibial Load in 5 Different Knee Conditionsa
Knee Condition Intact ACL resect ACL resect/MMPHT ACL resect/MMPHR ACL resect/TMM 0.2 1.2 1.5 0.3 0.6 0 6 6 6 6 6 1.1 0.7 2.8 1.8 1.4 15 0.5 1.6 0.5 2.6 0.5 6 6 6 6 6 1.0 2.6 6.3 4.0 2.6 30 0.8 2.7 2.6 3.4 2.5 6 6 6 6 6 1.6 3.7 3.4 4.0 6.8 60 0.6 3.0 3.2 3.4 0.3 6 6 6 6 6 0.9 3.4 4.3 4.6 6.2 90 1.2 2.2 1.7 1.6 1.0 6 6 6 6 6 2.0 2.9 4.2 3.4 6.8

a There were no significant differences between the groups at all selected flexion angles. ACL, anterior cruciate ligament; MMPHT, medial meniscus posterior horn tear; MMPHR, medial meniscus posterior horn repair; TMM, total medial meniscectomy.

TABLE 4 Mean Values (6Standard Deviation) of Internal Rotation Angle (deg) of the Tibia Under 134-N Anterior and 200-N Compressive Tibial Load in 5 Different Knee Conditionsa
Knee Condition Intact ACL resect ACL resect/MMPHT ACL resect/MMPHR ACL resect/TMM 2.3 1.3 1.0 1.6 2.3 0 6 6 6 6 6 2.5 1.4 1.1 2.0 1.3 15 4.9 3.2 1.3 2.9 1.5 6 6 6 6 6 3.9 3.7 3.6 3.8 3.4 30 5.3 1.7 1.0 0.6 0.2 6 6 6 6 6 5.3 3.9 4.0 3.6 6.7 60 3.7 0.7 0.5 0.3 1.2 6 6 6 6 6 3.0 3.2 3.4 5.9 4.7 90 3.3 0.2 0.6 1.9 3.1 6 6 6 6 6 2.9 3.3 4.7 4.5 5.9

a There were no significant differences between the groups at all selected flexion angles. ACL, anterior cruciate ligament; MMPHT, medial meniscus posterior horn tear; MMPHR, medial meniscus posterior horn repair; TMM, total medial meniscectomy.

longitudinal tear in ACL-deficient knees increased the anterior translation of the tibia. Medial meniscus posterior horn repair using an absorbable suture material in an ACL-deficient knee reduced A-P tibial translation significantly at most flexion angles. In addition, no significant difference was observed between the total medial meniscectomy and MMPH longitudinal tear in the A-P tibial translation of the tibia. In this study, an MMPH longitudinal tear in the ACL-deficient knee resulted in similar kinematic changes to that with a total medial meniscectomy under a combined anterior and axial compressive tibial load. The meniscal tear patterns that occur in ACL-deficient knees have been studied widely. Cerabona et al6 reported that in 50 patients, most of the medial meniscal tears were peripheral and posterior. Indelicato and Bittar10 also

demonstrated that most medial meniscal tears in ACL-deficient knees were peripheral posterior horn tears. More recently, Smith and Barrett23 prospectively studied 575 meniscal tears to evaluate the locations of meniscal tears associated with ACL injuries. They found that peripheral posterior horn tears of the medial meniscus were the most common type of tear (230 of 575 [40%]) by a statistically significant amount. These findings are in agreement with most theories suggesting that peripheral posterior horn tears are caused by the recurrent trauma sustained by the MM while acting as a bumper in the ACL-deficient knee. Therefore, this study focused on MMPH tears in ACL-deficient knees. The data conclusively show that MMPH tears in ACL-deficient knees alter the knee kinematics, particularly the anterior translation.

Downloaded from ajs.sagepub.com at HINARI on October 22, 2011

2192 Ahn et al

The American Journal of Sports Medicine

TABLE 5 Mean Values (6Standard Deviation) of Internal Rotation Angle (deg) of the Tibia Under Combined Rotatory Load in 5 Different Knee Conditionsa
Knee Condition Intact ACL resect ACL resect/MMPHT ACL resect/MMPHR ACL resect/TMM 15 7.9 10.2 13.0 9.9 12.8 6 6 6 6 6 4.4 5.1 5.7 4.9 6.8 30 8.8 10.8 12.9 8.8 11.0 6 6 6 6 6 4.6 5.9 7.0 4.0 5.3

a There were no significant differences between the groups at all selected flexion angles. ACL, anterior cruciate ligament; MMPHT, medial meniscus posterior horn tear; MMPHR, medial meniscus posterior horn repair; TMM, total medial meniscectomy.

An anterior tibial load of 134 N was chosen because the ACL is a major restraint to the anterior tibial translation and it simulates clinical tests, such as the Lachman or anterior drawer tests, which are commonly used for diagnosing an ACL injury.15 Another important physical examination of an ACL injury and reconstruction is the pivot-shift test, during which a combined internal and valgus torque is applied to the knee. Kanamori et al11 recommended the application of low internal torque in combination with valgus torque to simulate a pivot-shift test when evaluating ACL-deficient knee joints. Therefore, a 5-Nm internal tibial torque and a 10-Nm valgus torque were used to simulate the pivot-shift test. However, tibial rotation and valgusvarus angle were not significantly changed after MMPH tears or total medial meniscectomy. Furthermore, no significant differences were observed in the internal tibial rotations under compressive tibial loads and combined rotator loads among 5 knee conditions, although our data showed a similar trend in tibial internal rotation after MMPH tear in ACL-deficient knees. These results may suggest that the combined internal and valgus torques are an inefficient loading condition for investigating the rotational laxity in cadaveric specimens.12 Comprehensive loading conditions are required to truly assess the ability of the ACL and MMPH to restrain tibial rotations. To more accurately mimic in vivo loading conditions, larger forces such as those from the quadriceps and hamstring muscles will be needed. Some authors have reported that many acute stable peripheral longitudinal meniscal tears with an acute ACL injury either heal spontaneously or the symptoms resolve without an extension of the tear in 58% to 69% of cases.9,26 Shelbourne and Rask21 reported that of stable peripheral vertical MM tears treated with abrasion and trephination, most (94%) remain asymptomatic without stabilization. However, 2 recent reports described different healing results of medial or lateral meniscal tears left in situ during an ACL reconstruction. Yagishita et al27 reported that the overall healing rate of 41 medial meniscal tears left without repair, including completely and incompletely healed tears, was significantly lower than that of 42 lateral meniscal tears (61% vs 79%). Pujol and Beaufils19 also reported that the high prevalence of failures of medial meniscal tears left in situ during an ACL

reconstruction raises concern, even though a conservative approach is more effective for the lateral meniscus. Previous reports1,3 showed that a torn posterior meniscocapsular structure moved inferiorly against the remaining meniscus, displacing the tear during knee flexion. This motion of the torn MM can partially explain the slow healing observed in MMPH peripheral rim tears despite the rich vascular supply to the red-red zone. Therefore, we recommend that MMPH tears in ACL-deficient knees be treated more aggressively using a vertically oriented suturing technique that was previously reported,1,3 an arthroscopic modified all-inside suture technique of Morgan et al16 using 2 posteromedial portals. Absorbable meniscal fixators are not believed to be sufficient for this type of tear because these tears require secure fixation to the capsule, which cannot be provided by the new bioabsorbable devices. Previous clinical reports reported a clinical success rate of 96.4% (135 of 140) for modified all-inside meniscal repairs with a concomitant ACL reconstruction.2 The present study also demonstrated that vertically oriented MMPH repairs in ACL-deficient knees reduced A-P tibial translation significantly at all flexion angles except 60 to a level not increased significantly, compared to the ACLonlydeficient knee at all flexion angles. Many studies have reported the important stabilizing role of the MM. In 1982, Levy et al14 demonstrated that the posterior horn of the MM as a mechanical block contributed significantly to restraining the primary anterior translation of the knee after sectioning of the ACL. The work by Sullivan et al24 in 1984 supports this concept. As a result, the present belief of many researchers is that the MM is a secondary restraint to an A-P tibial translation that becomes much more important with the loss of ACL function. More recently, Seon et al20 showed the effect of an ACL reconstruction on the kinematics of the knee with a combined ACL deficiency and subtotal meniscectomy under anterior tibial and simulated quadriceps loads. Their study demonstrated that a subtotal medial meniscectomy in ACL-deficient knees increased the A-P tibial translation and lateral shift of the tibia. The present study showed that MMPH longitudinal tears in an ACL-deficient knee resulted in similar kinematic changes with a total medial meniscectomy under a combined anterior and axial compressive tibial load. Therefore, MMPH longitudinal tears should be repaired in the setting of an ACL reconstruction to restore the optimal knee kinematics and function. This study had some limitations. First, the biomechanical test setup was obtained only for time-point zero, without the possibility of taking the influence of muscle function into consideration. And the testing setup is not 6 degrees of freedom load cell with a robotic testing system. However, the ICC for test-retest reliability of the measurement was greater than 0.9, ranging from 0.99 to 0.92, for all measurements. Further research will be directed to evaluate this testing protocol under simulated muscle load and in the in vivo situation. Second, an open technique was used to resect the ACL and perform MMPH tear, MMPH repair, and medial meniscectomy procedures. Although the incision and repair of the arthrotomy were performed carefully to avoid potential bias from changes in capsular tension, the

Downloaded from ajs.sagepub.com at HINARI on October 22, 2011

Vol. 39, No. 10, 2011

Medial Meniscus Posterior Horn Tear and Knee Stability 2193

open technique, particularly a posteromedial arthrotomy, may affect the knee kinematics in rotation and posterior translation. Third, these tests were performed in older cadaveric knee specimens. A different pattern of ligamentous versus bony injury may be seen in younger knees, representing the typical patient population that may sustain these types of injuries. Fourth, this is a cadaveric in vitro, time-zero study; therefore, we are unable to determine the effects of biologic processes on the suture material fixation and meniscal healing in vivo. Furthermore, our design facilitated a repeated-measures analysis of kinematics using the same specimen under different loading conditions. This may be influenced subsequently by the effects of chronic relaxation and stretching of specimen. Finally, the rate of stress testing does not reproduce the rate of loading at the time of the actual injury to the knee. This study shows that an MMPH longitudinal tear in an ACL-deficient knee alters the knee kinematics, particularly the anterior tibial translation. MMPH repair reduces significantly the increased anterior tibial translation in ACL-deficient knees. These findings may help improve the treatment of patients with ACL and MMPH longitudinal tears by suggesting that the MM repairs should be undertaken for greater longevity of results when combined with an ACL reconstruction. REFERENCES
1. Ahn JH, Kim SH, Yoo JC, Wang JH. All-inside suture technique using two posteromedial portals in a medial meniscus posterior horn tear. Arthroscopy. 2004;20:101-108. 2. Ahn JH, Lee YS, Yoo JC, Chang MJ, Koh KH, Kim MH. Clinical and second-look arthroscopic evaluation of repaired medial meniscus in anterior cruciate ligament-reconstructed knees. Am J Sports Med. 2010;38:472-477. 3. Ahn JH, Wang JH, Yoo JC. Arthroscopic all-inside suture repair of medial meniscus lesion in anterior cruciate ligament-deficient knees: results of second-look arthroscopies in 39 cases. Arthroscopy. 2004;20:936-945. 4. Allen CR, Wong EK, Livesay GA, Sakane M, Fu FH, Woo SL. Importance of the medial meniscus in the anterior cruciate ligament-deficient knee. J Orthop Res. 2000;18:109-115. 5. Bonnin M, Carret JP, Dimnet J, Dejour H. The weight-bearing knee after anterior cruciate ligament rupture: an in vitro biomechanical study. Knee Surg Sports Traumatol Arthrosc. 1996;3:245-251. 6. Cerabona F, Sherman MF, Bonamo JR, Sklar J. Patterns of meniscal injury with acute anterior cruciate ligament tears. Am J Sports Med. 1988;16:603-609. 7. Church S, Keating JF. Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Joint Surg Br. 2005;87:1639-1642. 8. Henning CE. Current status of meniscus salvage. Clin Sports Med. 1990;9:567-576. 9. Ihara H, Miwa M, Takayanagi K, Nakayama A. Acute torn meniscus combined with acute cruciate ligament injury: second look arthroscopy after 3-month conservative treatment. Clin Orthop Relat Res. 1994;307:146-154. 10. Indelicato PA, Bittar ES. A perspective of lesions associated with ACL insufficiency of the knee: a review of 100 cases. Clin Orthop Relat Res. 1985;198:77-80.

11. Kanamori A, Zeminski J, Rudy TW, Li G, Fu FH, Woo SL. The effect of axial tibial torque on the function of the anterior cruciate ligament: a biomechanical study of a simulated pivot shift test. Arthroscopy. 2002;18:394-398. 12. Kondo E, Merican AM, Yasuda K, Amis AA. Biomechanical comparisons of knee stability after anterior cruciate ligament reconstruction between 2 clinically available transtibial procedures: anatomic double bundle versus single bundle. Am J Sports Med. 2010;38: 1349-1358. 13. Levy AS, Meier SW. Approach to cartilage injury in the anterior cruciate ligament-deficient knee. Orthop Clin North Am. 2003;34: 149-167. 14. Levy IM, Torzilli PA, Warren RF. The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am. 1982;64:883-888. 15. Markolf KL, Kochan A, Amstutz HC. Measurement of knee stiffness and laxity in patients with documented absence of the anterior cruciate ligament. J Bone Joint Surg Am. 1984;66:242-252. 16. Morgan CD, Wojtys EM, Casscells CD, Casscells SW. Arthroscopic meniscal repair evaluated by second-look arthroscopy. Am J Sports Med. 1991;19:632-637; discussion 637-638. 17. Papageorgiou CD, Gil JE, Kanamori A, Fenwick JA, Woo SL, Fu FH. The biomechanical interdependence between the anterior cruciate ligament replacement graft and the medial meniscus. Am J Sports Med. 2001;29:226-231. 18. Papastergiou SG, Koukoulias NE, Mikalef P, Ziogas E, Voulgaropoulos H. Meniscal tears in the ACL-deficient knee: correlation between meniscal tears and the timing of ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2007;15:1438-1444. 19. Pujol N, Beaufils P. Healing results of meniscal tears left in situ during anterior cruciate ligament reconstruction: a review of clinical studies. Knee Surg Sports Traumatol Arthrosc. 2009;17:396-401. 20. Seon JK, Gadikota HR, Kozanek M, Oh LS, Gill TJ, Li G. 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. 2009;25:123-130. 21. Shelbourne KD, Rask BP. The sequelae of salvaged nondegenerative peripheral vertical medial meniscus tears with anterior cruciate ligament reconstruction. Arthroscopy. 2001;17:270-274. 22. Shoemaker SC, Markolf KL. The role of the meniscus in the anteriorposterior stability of the loaded anterior cruciate-deficient knee: effects of partial versus total excision. J Bone Joint Surg Am. 1986;68:71-79. 23. Smith JP 3rd, Barrett GR. Medial and lateral meniscal tear patterns in anterior cruciate ligament-deficient knees: a prospective analysis of 575 tears. Am J Sports Med. 2001;29:415-419. 24. Sullivan D, Levy IM, Sheskier S, Torzilli PA, Warren RF. Medial restraints to anterior-posterior motion of the knee. J Bone Joint Surg Am. 1984;66:930-936. 25. Warren RF, Marshall JL. Injuries of the anterior cruciate and medial collateral ligaments of the knee: a long-term follow-up of 86 cases part II. Clin Orthop Relat Res. 1978;136:198-211. 26. Weiss CB, Lundberg M, Hamberg P, DeHaven KE, Gillquist J. Nonoperative treatment of meniscal tears. J Bone Joint Surg Am. 1989;71:811-822. 27. Yagishita K, Muneta T, Ogiuchi T, Sekiya I, Shinomiya K. Healing potential of meniscal tears without repair in knees with anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32: 1953-1961. 28. Yoo JC, Ahn JH, Lee SH, Yoon YC. Increasing incidence of medial meniscal tears in nonoperatively treated anterior cruciate ligament insufficiency patients documented by serial magnetic resonance imaging studies. Am J Sports Med. 2009;37:1478-1483.

For reprints and permission queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav

Downloaded from ajs.sagepub.com at HINARI on October 22, 2011