What factors associate with medial meniscal extrusion after anterior cruciate ligament reconstruction: An analytical observational study

doi:10.21203/rs.3.rs-3598772/v1

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What factors associate with medial meniscal extrusion after anterior cruciate ligament reconstruction: An analytical observational study

https://doi.org/10.21203/rs.3.rs-3598772/v1

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Background

Medial meniscal extrusion (MME) is a valuable clinical sign for early detection of osteoarthritis (OA). Thus, post-anterior cruciate ligament reconstruction (ACLR) MME is a potential predictor of postoperative OA. We aimed to examine MME variations before and after ACLR including the influence of suture medial meniscus (MM) injuries.

Methods

We analysed 92 knees from 92 patients who underwent anatomic ACLR. Multiple linear regression analysis was conducted using 1-year post-operative MME as the dependent variable, and age, sex, body mass index, preoperative MME, and MM treatment as independent variables. MM treatment was categorised into three groups: no MM injury and no suture [N/N], MM injury but no suture [I/N], and MM injury and suture [I/S]. A paired t-test was performed on the three groups and all patients to compare the pre- and 1-year post-operative MME.

Results

The factors significantly affecting post-operative MME were preoperative MME (P = 0.004) and I/S (P < 0.001). Additionally, the paired t-test showed no significant differences between the pre- and post-operative MME in all groups. Pre- and post-operative MME in the N/N group were 1.89 ± 0.85 and 1.71 ± 0.49 mm (P = 0.17), respectively; in the I/N group, 1.87 ± 0.91 and 1.84 ± 0.73 mm (P = 0.91) respectively; and in the I/S group, 2.40 ± 1.14 and 2.80 ± 0.77 mm (P = 0.12), respectively.

Conclusions

Preoperative MME and I/S were significantly associated with greater MME after ACLR. The evaluation of post-ACLR outcomes using MME should consider preoperative MME and MM injuries that require suture.

anterior cruciate ligament reconstruction

medial meniscal extrusion

osteoarthritis of the knee

medial meniscus suture

Medial meniscal extrusion (MME) is closely linked to the development of knee osteoarthritis (OA) (1–3). With an increase in the MME degree, the ability of the meniscus to distribute load stress on the knee joint is compromised, leading to increased cartilage loss and bone marrow lesions and ultimately resulting in OA(4–7). Therefore, the MME has gained significant attention as an initial biomarker of OA.

Several studies have reported that 50–90% of knees with anterior cruciate ligament (ACL) injuries develop OA owing to joint instability(8–10). A high risk of OA development remains even after ACL reconstruction (ACLR) (8, 11, 12). Furthermore, meniscal injury, another factor that leads to OA development, is often observed in ACL injuries (13, 14). Thus, meniscal procedures are frequently performed along with ACLR.

In the evaluation of post-ACLR outcomes, MME has been suggested as an early biomarker for predicting the development of OA several decades later. Narazaki et al. observed an increase in MME from 1.2 ± 1.1 mm before ACLR to 1.8 ± 0.9 mm after ACLR. However, their analysis excluded patients who had undergone meniscal suture (15); thus, the impact of meniscal suture remains unknown. Among ACLR patients with longitudinal tears in the medial meniscus (MM), the preoperative MME was significantly greater than that in patients without meniscal injury, and the preoperative MME did not improve even after MM suture(16). Moreover, no significant difference in MME was observed between the preoperative and 12-month post-operative evaluations after horizontal or cross-suture using an all-inside device for radial or oblique tears(17).

The impact of meniscal procedure during ACLR on MME is not yet fully understood. Knee surgeons are concerned about whether MM suture may increase MME or if the inability to repair the MM may accelerate OA. We hypothesised that MM injuries, even after suture, are closely linked to MME after ACLR and can predict post-ACLR OA. This study aimed to analyse the variations in MME before and after ACLR and determine whether MM injury and suture influence post-ACLR MME. We believe that when evaluating ACLR using MME, we need to take into account the influence of MM suture, and understanding the extent of this influence is crucial for future clinical research.

This retrospective observational study was conducted at a single hospital. Medical records were collected anonymously and retrospectively reviewed. Owing to the anonymous nature of the data and no new intervention was performed for data collection, individual informed consent was not required. The research protocol was approved by our Institutional Review Board. The study was conducted following the Strengthening of the Reporting of Observational Studies in the Epidemiology (STROBE) statement(18). Approval was obtained in September 2022 and data collection was completed by October 2022.

2.1. Participants

This study included patients who underwent anatomic double-bundle ACLR between January 2016 and July 2021 and could be followed up for one year post-operatively. Patients with complex ligament injuries who underwent reoperation and those who did not undergo pre- or post-operative magnetic resonance imaging (MRI) scans were excluded from the study.

2.2. Data collection

Medical records were reviewed to collect information on patient’s age, sex, and body mass index (BMI). Surgical records were reviewed to collect the ACLR procedure details, site of meniscal injury, and methods used to treat any meniscal injury. MRI was used to assess the MME.

2.3. Surgical Procedure

Anteromedial and anterolateral portals were created, and a 30° arthroscope was used to confirm the presence of a meniscal injury. The type of meniscal procedure (suture, meniscectomy, or repair) was determined based on the degree of the injury. Anatomical ACL reconstruction was performed using hamstring tendon autografts, and femoral and tibial tunnels were created using the outside-in technique. An ACL TightRope (Arthrex, Naples, FL, USA) or EndoButton CL (Smith & Nephew, Andover, MA, USA) was used for femoral graft fixation, whereas TensionLoc (Arthrex) or ACL TightRope ABS (Arthrex) was used for tibial graft fixation. During graft fixation, the anteromedial bundle was fixed in 20° of knee flexion with 40 N traction, whereas the posterolateral bundle was fixed in knee extension with 40 N traction.

2.4. Treatment of meniscal injuries

Knees with no MM injuries were assigned to the N/N group. Those with MM injury in the red-white or red zone without instability upon probing, for which suture were not performed, or those with a small flap injury in the white zone, for which a partial meniscectomy was performed, were assigned to the I/N group. Patients with MM injury with instability, for whom suture was performed, were assigned to the I/S group.

2.5. Post-operative treatment

Patients who underwent meniscal suture had a range of motion limited to 90° of knee joint flexion for four weeks following the operation. However, in cases where the meniscus was left untreated or meniscectomy was performed, no limitation in the range of motion was noticed. Patients were advised to partial weight-bearing for two weeks after the operation; complete weight-bearing was initiated three weeks post-operatively.

2.6. Measurement of MME

Retrospective measurements of MME using pre- and post-operative MRI were conducted by an experienced orthopaedic surgeon who had performed orthopaedic surgeries for over five years. The post-operative MME was measured by MRI one year after surgery. Pre- and post-operative MME were determined by measuring the distance from the innermost edge of the MM to the medial border of the tibia, excluding the osteophyte, in the coronal slice where the intercondylar ridge was the greatest (Fig. 1). To evaluate the reliability of the measurements, two of the aforementioned orthopaedic surgeons re-measured the same 20 cases at intervals of more than two months.

2.7. Statistical analysis

The primary analysis aimed to identify factors influencing MME after ACLR. We particularly expected that the presence of MM injury and suture might impact MME. As a secondary analysis, we examined whether MME changed before and after ACLR and whether there was any variation in MME measurements.

In the event of missing data, only corresponding analyses were excluded. Although this retrospective study had a fixed number of cases, we aimed to evaluate six items for multivariate analysis and set a target of at least 90 cases. A multiple linear regression analysis was used, after confirming normality with histograms, to investigate the factors influencing post-operative MME. The dependent variable was post-operative MME, whereas the independent variables were age, sex, BMI, preoperative MME, and MM treatment. The MM treatment was classified into three groups: N/N, I/N, and I/S. Age was measured in years, BMI in kg/m², and preoperative MME in mm. Sex was coded as 1 = male or 0 = female; I/N as 1 = yes or 0 = no; and I/S as 1 = yes or 0 = no.

Additionally, a paired t-test was conducted to compare the preoperative and post-operative MME. Furthermore, reproducibility of the measurements was verified by examining the intraclass correlation coefficient (ICC) (1, 2) and interclass correlation coefficient (ICC) (2, 1),(3, 1). All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (R Foundation for Statistical Computing, Vienna, Austria). (19). A P-value of < 0.05 was considered statistically significant.

The study included 133 knees of 133 patients. However, 10 patients with complex ligament injuries, eight with reoperation, and 23 without pre- or post-operative MRI were excluded from the analysis. As a result, 92 knees of 92 patients were analysed (Fig. 2).

Thirty-eight male and fifty-four female patients were included in the study. The age at the time of surgery ranged from 12 to 58 years (mean: 27.8 ± 11.5 years). The time between the injury and surgery ranged from 1 month to 25 years (median: 4 months). Among these patients, 41, 27, and 24 were classified into the N/N, I/N, and I/S groups, respectively (Table 1).

Table 1

Demographics of the participants
Characteristic	Value	Range
Case(n)	92	−
Sex, male/female	38/54	−
Mean age (years)	27.8	12–58
BMI (kg/m²)	23.2	17.2–38.3
Months-to-surgery	4	1–300
N/N (n)	41	-
I/N (n)	27	-
I/S (n)	24	-
N, number of knees; BMI, body mass index; N/N, no MM injury and no suture; I/N, MM injury but no suture; I/S, MM injury and suture

3.1. Factors affecting post-operative MME

We found that preoperative MME (P = 0.004) and MM injury requiring suture (P < 0.001) were significant factors affecting post-operative MME (Table 2). The absence of multicollinearity was confirmed by a variance inflation factor (VIF) of < 1.6 among the independent variables. In addition, the normality of the residuals was confirmed. The regression equation was significant (P < 0.001), with an R² value of 0.38. Based on the results, the participants’ predicted post-operative MME was equal to 1.161 − 0.002 (for age), + 0.014 (BMI), + 0.212 (preoperative MME), − 0.263 (sex), + 0.149(I/N), and + 0.971(I/S).

Table 2

Significant factors affecting post-operative MME
		Parameter estimate (B)		95% CI of (B)		P-value
		Parameter estimate (B)		Lower limit	Upper limit
Age	-0.002		-0.014		0.010	0.72
BMI		0.014		-0.027	0.054	0.50
Preoperative MME		0.212		0.071	0.353	0.004^*
Sex		-0.263		-0.541	0.015	0.063
I/N		0.149		-0.160	0.458	0.34
I/S		0.971		0.642	1.300	< 0.001*
BMI, body mass index; MME, medial meniscal extrusion; CI, confidence interval; I/N, MM injury but no suture; I/S, MM injury and suture
* Significant difference.

3.2. Comparison of MME before and after ACLR

The pre- and post-operative MME were 2.02 ± 0.97 mm and 2.03 ± 0.78 mm, respectively, revealing no significant difference (P = 0.89). In the N/N, I/N, and I/S groups, no significant differences were observed between pre- and post-operative MME in either case (Table 3).

Table 3

Comparison of MME before and after ACLR
	Pre-operative (mm) (Mean MME ± SD)	Post-operative (mm) (Mean MME ± SD)	P value
All cases	2.02 ± 0.97	2.03 ± 0.78	0.89
N/N	1.89 ± 0.85	1.71 ± 0.49	0.17
I/N	1.87 ± 0.91	1.84 ± 0.73	0.91
I/S	2.40 ± 1.14	2.80 ± 0.77	0.12
MME, medial meniscal extrusion; ACLR, anterior cruciate ligament reconstruction; SD, standard deviation; N/N, no MM
injury and no suture; I/N, MM injury but no suture; I/S, MM injury and suture

3.3. Reproducibility of MME measurements

Both ICC (1, 2) and ICC (2, 1),(3, 1) were good, with values of 0.82 and 0.80,0.89, respectively.

The most important finding of the present study was that preoperative MME and MM injury requiring suture significantly influenced post-operative MME. Additionally, no significant difference in pre- and post-operative MME was noted, regardless of the MM suture.

To the best of our knowledge, this is the first study to explore the impact of MM injury on post-ACLR MME using a multivariate analysis. we observed that the post-operative MME remained large in knees with MM injuries that required suture. This finding is consistent with a previous report which indicated no MME improvement after suture of longitudinal MM tears in ACLR, suggesting that preoperative MME does not improve even with suture of MM tears (13). Another study reported that suture using the FAST-FIX all-inside suture device (Smith & Nephew, Andover, MA, USA) in patients with radial or oblique posterior MM tears did not improve the MME(17). However, the study differs from ours in that it included patients with isolated MM injuries without ACLR. Nevertheless, the finding that MME did not improve with suture was consistent with the findings of our study.

In this study, we observed that a greater preoperative MME was associated with a greater post-operative MME, suggesting that a meniscus with significant displacement before surgery may continue to displace even after ACLR. A previous study demonstrated that large displacements (> 3 mm) are frequently associated with radial or posterior root tears (20–22), indicating that a large preoperative MME may be indicative of these types of injuries. Thus, the persistence of a large post-operative MME suggests the presence of significant meniscal tears.

A study by Narazaki et al. showed that MME increased from 1.2 mm preoperatively to 1.8 mm at an average of 11 months post-operatively in ACLR cases without meniscal injury(15). The study excluded the effect of meniscal injury on post-operative MME. Although our study included patients with meniscal injury, no significant differences were found in any of the three groups. The shorter interval from injury to surgery in the study compared to the present study, and other confounding factors might affect these results. Moreover, since ACLR is a technique with significant variations, considering the effect of meniscal status and ACLR surgical procedures, such as bone tunnel locations, number of bundles, and graft type, might be crucial for better evaluation.

Previous studies have shown that meniscectomy is a risk factor for OA progression (23–26). Meniscal repair is expected to delay the progression of OA more than meniscectomy(14, 27). However, whether meniscal repair actually delays the progression of OA compared with meniscectomy has not yet been reported. The results of the present study suggest that MM injury requiring suture is a risk factor for OA, and that meniscal suture does not delay OA. However, since meniscal suture leaves more meniscal tissue than meniscectomy, and if preservation of meniscal tissue is a more important factor than MME value for OA development, some benefits may be expected. This should be explored in future high-quality studies.

This study had some limitations. First, this study had a relatively small sample size, although it was considered sufficient to examine the factors that typically affect MME. Second, the follow-up period was short. Third, the effects of the meniscal injury type and suture method were not considered. Finally, the influence of ACLR techniques, such as the bone tunnel location and graft type, were not considered. However, the uniformity of the devices used in this study minimised the effects of variations in ACLR procedures performed at a single institution. We are considering conducting further research to examine the effects of the surgical techniques for ACLR on MME by increasing the number of cases and extending the follow-up period.

Preoperative MME and MM injuries requiring suture were significantly associated with greater MME after ACLR. If preoperative MME is large and there is an MM injury requiring suture, the larger MME after ACLR should be considered.

MME

medial meniscal extrusion

osteoarthritis

ACL

anterior cruciate ligament

ACLR

anterior cruciate ligament reconstruction

medial meniscus

STROBE

Strengthening of the Reporting of Observational Studies in the Epidemiology

MRI

magnetic resonance imaging

BMI

body mass index

ICC

intraclass correlation coefficient

Ethics approval and consent to participate

Waiver of informed consent was granted by the Ethics Review Committee of the Graduate School of Medicine, Chiba University owing to the anonymous nature of the data and not publicly available data. The research protocol was approved by the Ethics Review Committee of the Graduate School of Medicine, Chiba University (M10436).

Ethics approval

The name of the ethics committee is the Ethics Review Committee of the Graduate School of Medicine, Chiba University. The committee’s reference number is M10436. An additional PDF file shows this in more detail [see Additional file 1].

Retrospective ethics approval

Not applicable

New clinical tools and procedures

Not applicable

Consent for publication

Not applicable

Availability of data and materials

Not applicable

Competing interests

The authors declare that they have no competing interests

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of data and materials

The datasets used and analysed during the current study available from the corresponding author on reasonable request.

Authors' contributions

RI and SW contributed to the study's conception and design. RI collected and analysed the data. RI wrote the first draft of the manuscript, and SW and TS revised it. All authors provided constructive comments and approved the final manuscript.

Acknowledgements

We would like to thank Editage (www.editage.com) for the English language editing.

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No competing interests reported.

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What factors associate with medial meniscal extrusion after anterior cruciate ligament reconstruction: An analytical observational study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

1. Introduction

2. Methods

2.1. Participants

2.2. Data collection

2.3. Surgical Procedure

2.4. Treatment of meniscal injuries

2.5. Post-operative treatment

2.6. Measurement of MME

2.7. Statistical analysis

3. Results

3.1. Factors affecting post-operative MME

3.2. Comparison of MME before and after ACLR

3.3. Reproducibility of MME measurements

4. Discussion

5. Conclusion

Abbreviations

Declarations

References

Additional Declarations

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