Meniscus tears treatment:The good,the bad and the ugly-patterns classification and practical guide

Over the years,several studies demonstrated the crucial role of knee menisci in joint biomechanics.As a result,save the meniscus has become the new imperative nowadays,and more and more studies addressed this topic.The huge amount of data on this topic may create confusion in those who want to approach this surgery.The aim of this review is to provide a practical guide for treatment of meniscus tears,including an overview of technical aspects,outcomes in the literature and personal tips.Taking inspiration from a famous movie directed by Sergio Leone in 1966,the authors classified meniscus tears in three categories:The good,the bad and the ugly lesions.The inclusion in each group was determined by the lesion pattern,its biomechanical effects on knee joint,the technical challenge,and prognosis.This classification is not intended to substitute the currently proposed classifications on meniscus tears but aims at offering a readerfriendly narrative review of an otherwise difficult topic.Furthermore,the authors provide a concise premise to deal with some aspects of menisci phylogeny,anatomy and biomechanics.

An Improved Transosseous Pullout Suture Technique for Arthroscopic Repair of a Meniscus Root Tear

Objective:This study aimed to explore the clinical efficiency of an improved transosseous pullout suture technique for arthroscopic repair of a meniscus root tear.Methods:From January 2017 to January 2021,53 patients with posterior meniscus root tears combined with anterior cruciate ligament(ACL)and/or posterior cruciate ligament(PCL)tears were collected.Totally,in 29 patients(group A),the 2.0 mm modified pullout tunnel method was used to suture the posterior meniscus root,while 24 patients(group B)were treated with the traditional 4.5 mm pullout tunnel method.In group A,20 patients had lateral meniscus posterior root(LMPR)combined with ACL tears,5 patients had LMPR combined with ACL and PCL tears,and 4 patients had medial meniscus posterior root(MMPR)combined with ACL tears.In group B,19 patients had LMPR combined with ACL tears,3 patients had LMPR combined with ACL and PCL tears,and 2 patients had MMPR combined with ACL tears.The improvement of the Lysholm and VAS scores and the incidence of complications in group A and group B before the operation,1 month and 3 months after the operation,and after the final follow-up were compared.Results:Preoperative Lysholm score was 26.0±5.6 in group A and 26.7±5.8 in group B(P>0.05).One-month postoperative Lysholm score was 66.5±5.7 in group A and 54.3±2.4 in group B(P<0.001).Three-month postoperative Lysholm score was 81.1±7.2 in group A and 73.2±9.7 in group B(P<0.05).Lysholm scores after the final follow-up was 90.3±5.6 in group A and 90.0±5.0 in group B(P>0.05).Preoperative VAS score was 6.3±1.4 in group A and 6.3±1.2 in group B(P>0.05).One-month postoperative VAS score was 1.8±0.7 in group A and 2.4±0.9 in group B(P<0.05).Three-month postoperative VAS score was 0.7±0.6 in group A and 0.8±0.6 in group B(P>0.05).VAS score after the final follow-up was 0.2±0.4 in group A and 0.3±0.5 in group B(P>0.05).Conclusion:The improved transosseous pullout suture technique using a smaller 2.0 mm bone tunnel can virtually eliminate the risk of conflict with other bone tunnels and facilitate the management of bone tunnels in multiple ligament injuries,while also diminishing suture abrasion caused by the windshield wiper effect.The technique achieves good clinical efficacy.

Dynamic tear meniscus parameters in complete blinking:insights into dry eye assessment

AIM:To investigate the relationship between dynamic tear meniscus parameters and dry eye using an automated tear meniscus segmentation method.METHODS:The analysis of tear meniscus videos captured within 5s after a complete blink includes data from 38 participates.By processing video data,several key parameters including the average height of the tear meniscus at different lengths,the curvature of the tear meniscus’s upper boundary,and the total area of the tear meniscus in each frame were calculated.The effective values of these dynamic parameters were then linearly fitted to explore the relationship between their changing trends and dry eye disease.RESULTS:In 94.74%of the samples,the average height of central tear meniscus increased over time.Moreover,97.37%of the samples exhibited an increase in the overall tear meniscus height(TMH)and area from the nasal to temporal side.Notably,the central TMH increased at a faster rate compared to the nasal side with the temporal side showing the slowest ascent.Statistical analysis indicates that the upper boundary curvature of the whole tear meniscus as well as the tear meniscus of the nasal side(2,3,and 4 mm)aid in identifying the presence of dry eye and assessing its severity.CONCLUSION:This study contributes to the understanding of tear meniscus dynamics as potential markers for dry eye,utilizing an automated and non-invasive approach that has implications for clinical assessment.

Assessment of tear film parameters post-treatment with commercial eyelid cleaning wipes:a pilot study

AIM:To investigate the short-term effects of commercially available eyelid-cleaning wipes on film parameters.METHODS:This study enrolled 48 healthy participants aged 20-35y(both males and females).Clinical assessment included the Ocular Surface Disease Index(OSDI)questionnaire,non-invasive tear break-up time(NITBUT),tear meniscus height(TMH),and lipid layer pattern(LLP).Based on these initial results,participants were categorized as either non-dry eye or dry eye.Participants in each group were randomly allocated to either Blephaclean■or Systane■treatments.Changes in NITBUT,TMH,and LLP levels before and after lid wipe treatment were assessed.RESULTS:The dry eye group exhibited significantly higher OSDI scores and lower NITBUT and TMH levels than in the non-dry eye group(P<0.001).Following the application of eyelid wipes(Systane■wipes),dry eye subjects experienced a significant improvement in NITBUT levels(P=0.0014)compared to the non-dry eye individuals.Although the remaining participants showed a marginal increase in TMH and NITBUT levels,these changes did not achieve statistical significance(P>0.05).Similarly,the LLP levels were significantly improved with Systane■(P<0.001)post-treatment compared to individuals in the non-dry eye group.However,the dry eye subjects showed higher posttreatment LLP levels than the untreated group(P<0.02).CONCLUSION:The short-term effects of Systane®eyelid wipes on tear film parameters suggest their effectiveness in dry eye disease.Nonetheless,further exploration of their long-term impact is essential to justify their cost effectiveness and efficacy in treating both aqueous deficiency and evaporative dryness.

Lipid layer thickness and tear meniscus height measurements for the differential diagnosis of evaporative dry eye subtypes

AIM： To explore a new diagnostic index for differentiating the evaporative dry eye（EDE） subtypes by analysis of their respective clinical characteristics. METHODS： A cross-sectional study of 139 patients（139 eyes） with EDE who were enrolled and classified as obstructive meibomian gland dysfunction（MGD）（n=81） and non-obstructive MGD（n=58） EDE. All patients completed a Standard Patient Evaluation of Eye Dryness（SPEED） questionnaire and were evaluated for average lipid layer thickness（LLT）, tear meniscus height measurements（TMH）, tear break-up time（TBUT）, ocular surface staining score, Schirmer I test（SIT）, lid margin abnormalities, and meibomian gland function and morphology. RESULTS： Age, average LLT, TMH, scores of lid margin abnormalities, meibum quality, meibomian gland loss（MGL）（all P≤0.001）, and TBUT（P=0.03） were all significantly different between obstructive MGD EDE patients and nonobstructive MGD EDE patients. Average LLT in obstructive MGD EDE was correlated with meibomian expressibility（r=-0.541, P≤0.001）, lid margin abnormalities were marginally not significant（r=0.197, P=0.077）, and TMH was correlated with MGL（total MGL： r=0.552, P≤0.001; upper MGL： r=0.438, P≤0.001; lower MGL： r=0.407, P≤0.001）. Average LLT in non-obstructive MGD EDE, was correlated with meibomian expressibility and Oxford staining（r=-0.396, P=0.002; r=-0.461, P≤0.001）. The efficiency of combining average LLT and TMH was optimal, with a sensitivity of 80.2% and a specificity of 74.1%. Obstructive MGD EDE patients had an average LLT≥69 nm and TMH≥0.25 mm, while non-obstructive MGD EDE patients had an average LLT〈69 nm and TMH〈0.25 mm.CONCLUSION： Obstructive MGD EDE and nonobstructive MGD EDE have significantly different clinical characteristics. Combining average LLT and TMH measurements enhanced their reliability for differentiating these two subtypes and provided guidance for offering more precise treatments for EDE subtypes.

Failure rate,return-to-sports and magnetic resonance imaging after meniscal repair:119 patients with 7 years mean follow up

BACKGROUND One of the most important factors to consider in relation to meniscal repair is the high failure rate reported in the existing literature.AIM To evaluate failure rates,return to sports(RTS)rate,clinical outcomes and magnetic resonance image(MRI)evaluation after meniscus suture repair for longitudinal tears at a minimum 2-year-follow-up.METHODS We conducted a retrospective review of meniscal repairs between January 2004 and December 2018.All patients treated for longitudinal tears associated or not with an anterior cruciate ligament reconstruction(ACL-R)were included.Meniscal ramp lesions,radial and root tears,associated with multiligament injuries,tibial fracture and meniscal allograft transplants were excluded.Surgical details and failure rate,defined as symptomatic patients who underwent a revision surgery,were analyzed.As isolated bucket handle tears(BHTs)were usually associated with higher failure rates,we compared BHTs and not BHTs associated or not with an ACL-R.Since 2014,the inside-out technique using cannulas and suture needles with 2-0 Tycron began to predominate.In addition,the number of stitches per repair was increased.In view of differences in surgical technique,we compared two different cohorts:before and after 2014.We recorded the RTS according to the level achieved and the time to RTS.Lysholm and IKDC scores were recorded.Patients were studied with x-rays and MRI as standard postoperative control.RESULTS One hundred and nineteen patients were included with a mean follow up of 7 years(SD:4.08).Overall failure rate was 20.3%at a mean 20.1 mo.No statistically significant differences were found when comparing failure for medial and lateral meniscal repair(22.7%and 15.3%,P=0.36),BHTs and not BHTs(26%and 17.6%,P=0.27),isolated or associated with an ACL-R(22.9%and 18%,P=0.47),or when comparing only BHTs associated with an ACL-R(23%and 27.7%,P=0.9)or not.When comparing cohorts before and after 2014,we found a significant decrease in the overall failure rate from 26%to 11%(P<0.03).Isolated lesions presented a decrease from 28%to 6.6%(P=0.02),BHTs from 34%to 8%(P=0.09)and those associated with an ACL-R from 25%to 10%(P=0.09).Mean RTS time was 6.5 mo in isolated lesions and 8.64 mo when associated with an ACL-R.Overall,56%of patients returned to the same sport activity level.Mean pre and postoperative Lysholm scores were 64 and 85(P=0.02),and IKDC 58 and 70(P=0.03).Out of 84 asymptomatic patients evaluated with MRI,39%were classified as“not healed”and 61%as“healed”.CONCLUSION Even though the overall failure rate of our series was 20.3%,we found a statistically significant decrease from 26%to 11%,not only for isolated lesions,but also for BHT’s and those associated with an ACL-R when comparing our series in two different cohorts,most probably due to improvements in surgical technique.

Torn discoid lateral meniscus treated with arthroscopic meniscectomy:observations in 62 knees

Background Discoid lateral meniscus of the knee is common in Chinese population. There has been considerable debate about the best treatment for discoid lateral meniscus tears. The purpose of this study was to observe the effect of arthroscopic meniscectomy for the treatment of discoid lateral meniscus tears. Methods Between July 1999 and December 2004, arthroscopic meniscectomy was performed on 62 menisci of 57 patients with discoid lateral meniscus tears （52 unilateral, 5 bilateral）. 41 menisci were ＂complete discoid meniscus＂, 21 =incomplete＂. According to the extent of the meniscus tears, partial meniscectomy was performed on 52 knees, total meniscectomy on 7 knees, and partial meniscectomy combined with meniscus suture on 3 knees through an arthroscope After the operations, early rehabilitation training programs, including straight-leg-raising and range-of-motion exercises, were carried out. 51 patients were followed up for 1 year 2 months to 6 years 5 months （mean, 3 years 3 months）, 6 patients were lost. Lysholm-Ⅱ scoring system was used to assess the function of the knee joints before the operation and during the follow-up. Results The operations on all the 62 knees were successful without complications. The patients could walk normally after completing the 2-week postoperation rehabilitation program. After 3-4 weeks they could lead a normal life and participate in a moderate amount of sports or other physical activities. The mean Lysholm-Ⅱ score was 89 （60--100） during the follow-up, which was significantly higher than that before the operation （50, range 34-74; P〈0.01）. 88% of the patients achieved excellent or good clinical results. Conclusions Arthroscopic meniscectomy is an alternative for treatment of discoid lateral meniscus tears with minimal traumatic effects. It can achieve early mobilization and a low complication rate, as well as the preservation of the meniscus structure and functions to the largest extent. In combination with proper rehabilitation training, the operation can lead to good or excellent results.

Intra-and interobserver reliability of ocular surface analyzer LacryDiag

AIM:To invastigate intra-and interobserver reliability of interferometry,tear meniscus height(TMH)measurement and meibography(MBG)of an ocular surface analyzer,LacryDiag(Quantel Medical,France).METHODS:Five consecutive measurements and subsequent analysis of interferometry,TMH,and MBG were recorded by two examiners using the LacryDiag.To assess intra-and interobserver reliability,we used Cohen’s kappa for categorical variables(interferometry),or intraclass correlation coefficient for continuous variables(TMH,MBG).RESULTS:Thirty eyes of 30 examinees were included.For both observers,there was excellent intraobserver reliability for MBG(0.955 and 0.970 for observer 1 and 2,respectively).Intraobserver reliability for observer 1 was substantial for interferometry(0.799),and excellent for TMH(0.863).Reliability for observer 2 was moderate for interferometry(0.535)and fair to good for TMH(0.431).Interobserver reliability was poor for interferometry(0.074)and fair to good for TMH(0.680)and MBG(0.414).CONCLUSION:LacryDiag ocular surface analyzer in our study proves to be a reliable noninvasive tool for the evaluation of TMH and MBG.As for interferometry,poor interobserver reliability,fair to good intraobserver reliability for observer 1,and moderate for observer 2,leave room for improvement.

Evaluation of dry eye disease in newly diagnosed anxiety and depression patients using anterior segment optical coherence tomography

Background:We aimed to evaluate dry eye diseases(DED)in patients with newly diagnosed depression and anxiety patients.Methods:Forty newly diagnosed depression,35 anxiety patients,and 37 controls without any history of taking psychiatric drugs(or before the beginning of psychiatric medication)and topical ophthalmic drop use,were included in the study.All depression and anxiety diagnoses were performed by an experienced psychiatrist.Beck depression and anxiety tests were used to measure disease severity.Tear film break up time(TBUT),Schirmer’s test,Oxford scores and ocular surface disease index(OSDI)were admiinistered to participants.Anterior segment optical coherence tomography was used to measure tear meniscus heights(TMH),tear meniscus depths(TMD)and tear meniscus areas(TMA).Results:In anxiety and depression groups,Schirmer’s test(mm)(7.24±6.02,6.58±4.9 and 18.79±4.9 respectively,p<0.05)and TBUT(s)(5.62±3.1,5.6±3.5 and 13.37±1.7 respectively,p<0.05)were significantly lower than control group.In addition,OSDI and Oxford scores were significantly higher than controls.OSDI scores were 28.01±19,30.43±18.49,14.38±8.14 respectively(p=0.002)and Oxford scores were 1.9±0.7,2.1±0.6 and 0.7±0.4 respectively(p=0.001).TMD,TMH and TMA values were significantly lower in anxiety and depression groups compared with control groups.Correlations between disease inventory scores and dry eye tests were detected.Conclusions:This study showed a relation between DED and newly diagnosed anxiety and depression patients with no history of psychiatric drug use.The presence of correlation between dry eye tests and disease inventory scores strengthens this association.This is an important knowledge that need to be evaluated in these patients before starting psychiatric medication.

Comparison of Hasner valvulotomy outcomes in pediatric and adult patients: does age matter?

Background:Hasner valve incision has been recently introduced as a new treatment for ophthalmic patients with epiphora symptoms. The aim of this study was to examine whether surgical outcomes of Hasner valve incision for inferior nasolacrimal duct obstruction were different between pediatric and adult patients.Methods:A total of 53 eyes of 52 patients who underwent Hasner valve incision in the Beijing Tongren Hospital from October 2016 to November 2019 were retrospectively observed. Patients were divided into two groups, including pediatric group (23 eyes of 22 patients, <18 years old) and adult group (30 eyes of 30 patients, ≥18 years old). Success rate of surgery was determined by both subjective measure (complete resolution of epiphora) and objective measure (lacrimal passage irrigation and tear meniscus height). Fisher exact test was conducted.Results:By conducting Fisher exact test and comparing complete resolution of epiphora ( P = 0.627), lacrimal passage irrigation ( P = 0.663), measurement of Tear Meniscus Height ( P = 0.561), and appearance of complication ( P = 0.339), there was no statistically significant difference of surgical outcomes between pediatric and adult patients ( P > 0.05). Conclusion:Hasner valve incision was effective for both adult and children with inferior nasolacrimal duct obstruction, with no difference in surgical outcomes between the two groups.