The efficacy of the pull-out and all-inside techniques for the treatment of Laprad type II medial meniscus posterior root tear

The efficacy of the pull-out and all-inside techniques for the treatment of Laprad type II medial meniscus posterior root tear | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The efficacy of the pull-out and all-inside techniques for the treatment of Laprad type II medial meniscus posterior root tear Zheyuan Shen, Rong Wu, Dan Cai, Heng Li, Qiaoying Peng, Songhua Guo, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5268194/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To investigate the therapeutic effect of Pull-out technique and All-inside technique on Laprad type II medial meniscus posterior root tear (MMPRT). Methods A total of 95 patients were included in this study. Kellgren Lawrence (K-L) grade was recorded by knee X-ray after surgery, and knee cartilage injury grade, subchondral cyst, subchondral edema, insufficiency fracture, meniscal extrusion and meniscal healing were recorded by MRI. International Knee Literature Committee Knee Assessment Scale (IKDC) score, Lysholm score and VAS score were used to evaluate knee joint function. Results There were no significant differences in K-L grade, knee cartilage injury grade, subchondral cyst, subchondral edema and insufficiency fracture between two groups (p > 0.05). The extrusion rate and degree of medial meniscus in pull-out repair group were 88.68%, 3.43 ± 0.71mm, while those in the all-inside repair group were 90.48%, 3.41 ± 0.80mm, with no statistical difference (p > 0.05). There were no significant differences in postoperative IKDC scores and Lysholm scores (p > 0.05). Conclusion Both pull-out repair and all-inside repair can improve knee joint function in the treatment of Laprad type II PMMRT. Medial meniscus posterior root tear Meniscal repair Pull-out repair All-inside repair Figures Figure 1 Figure 2 Figure 3 Introduction Medial meniscus posterior root tear (MMPRT) refers to radial tear within 1 cm of the medial meniscus root attachment, or complete avulsion of the soft tissue or bone structure of the root attachment. Most of these injuries are degenerative injuries caused by chronic repetitive low-energy movements [ 1 ]. The stress-dispersion ability of the meniscus is impaired due to the failure of the annular fiber structure, which leads to stress osteonecrosis of cartilage and subchondral bone, and the induction of osteoarthritis. Previous studies have shown that conservative treatment often results in poorer functional recovery, more severe osteoarthritis, and a higher rate of arthroplasty [ 2 , 3 ]. Meniscectomy has also been widely used for the treatment of MMPRT, and early studies suggested it was effective in improving the patients’ symptoms [ 4 ]. However, long-term follow-up studies have demonstrated that 35% of patients show radiological progression of osteoarthritis during follow-up [ 5 ], and the final rate of arthroplasty is 36–56% [ 6 , 7 ].Due to the poor results of conservative treatment and meniscectomy, restoring the meniscus stress dispersion by repairing the continuity of the meniscus fibrous loop structure has become a new target in the treatment of MMPRT. Indeed, biomechanical repair can restore the normal contact area and peak pressure of the tibiofemoral joint [ 8 , 9 ]. Compared with meniscectomy, repair surgery is able to slow the progression of arthritis [ 10 , 11 ]. Therefore, once MMPRT is diagnosed, root repair has become the preferred method of treatment. Kim et al. [ 13 ] applied pull-out repair technique to the treatment of MMPRT and achieved satisfactory therapeutic effects. Since then, a large number of biomechanical and clinical observational studies have been conducted around pull-out repair technology [ 14 – 21 ]. With the development of meniscus repair technology, especially the wide application of meniscus suture device, new treatment methods called all-inside techniques are provided [ 22 – 26 ]. So far, there have been few reports on the comparative study of the two repair methods in the treatment of MMPRT. To compare the efficacy of pull-out repair technique and all-inside repair technique in the treatment of MMPRT, we conducted a retrospective study to compare the functional prognosis and imaging progression of osteoarthritis between the two techniques. Material and methods Material This study reviewed the data of patients with MMPRT treated with pull-out repair or all-inside repair in our hospital from June 2018 to June 2022. Inclusion criteria: (1) diagnosis consistent with Laprad type II MMPRT [ 28 ]; (2) clinical symptoms correlating with MRI findings; (3) duration of the disease less than 6 months; (4) age between 18 and 60 years; and (5) a minimum of 2 years of follow-up. Exclusion criteria: (1) congenital knee deformity; (2) concomitant injury of the knee joint (fracture, ligament injury, or other meniscus injury); (3) varus alignment more than 5° before operation; (4) preoperative Outerbridge grade[ 27 ] ≥ 3; and (5) body mass index (BMI) > 30. Methods All surgical procedures were performed by two senior surgeons. A standard anterolateral portal (longitudinal incision) was used for arthroscopic visualization. An anteromedial portal (transverse incision) was used for MMPRT guide. When the medial space of the knee joint was narrow and the root exposure was difficult, the "pie-crusting" technique was used to release the medial collateral ligament to assist the exposure of the medial compartment [ 29 ]. Pull-out repair group The tissue structure of the posterior root attachment of the medial meniscus was carefully identified under the microscope. The residual posterior root tissue at the negative attachment of the posterior root of the meniscus and the degenerative tissue at the free end were thoroughly debrided and freshened with the planer and the meniscus rub. Then, a 2.5-mm-diameter tibial bone tunnel was created with the MMPRT guide. The posterior dense tissue attachment point of the root was used as the intra-articular exit of the bone tunnel, and the anterior medial cortex of the proximal tibia was used as the extra-articular exit of the bone tunnel. The No. 2 nonabsorbable sutures (Smith & Nephew) were inserted into the posterior root of the medial meniscus and fixed in the form of loop stitches. The sutures were drawn out of the joint by lasso through the tibial tunnel. Under continuous arthroscopic observation, the sutures were tightened with the knee bent at 90° and fixed to the anterior medial cortex of the tibia with the help of a button (Smith & Nephew). After the repair was completed, the arthroscope was turned to the medial portal for observation with the knee bent at 120° to observe the tension of the suture site. Figure 1 . All-inside repair group Before repair, we first performed debridement and freshened the posterior root stump. The posterior root was sutured with vertical mattress suture using FasT-Fix (Smith & Nephew). The method was as follows: A needle tip was penetrated into one limb of the meniscus 5 mm from the free edge to deliver the first suture bar anchor. Then, the second penetration was performed across the tear line at the opposite end of the meniscus, also 5 mm from the free edge. The suture was tightened to join the two broken ends. The same procedure was repeated one more time. As a result, two parallel sutures were performed 5 mm away from each tear limb. After the repair was completed, the arthroscope was turned to the medial portal for observation with the knee bent at 120° to observe the tension of the suture site. Figure 2 . Muscle strength exercises were started immediately after surgery. During the first 3 weeks, the affected limb was immobilized in a knee extension brace, and weight-bearing was avoided. Flexion was allowed in the range of 30° from the fourth week after surgery. In weeks 5–6, flexion was increased by 25° per week, and partial weight-bearing was gradually started. In weeks 7–8, the range of flexion increased to 120°, and there was gradual transition to full weight-bearing. Physical exercise was prohibited within 6 months after surgery. Assessment methods Clinical function evaluation The Lysholm Knee Scale [ 30 ] and the International Knee Literature Committee Knee Assessment Scale (IKDC) [ 31 ] were evaluated before surgery and at final follow-up by the same author who was not involved in surgery. Imaging evaluation Radiographic data were evaluated, including plain radiographs and Magnetic resonance imaging (MRI) scans. The Kellgren–Lawrence scoring system [ 32 ] was used to evaluate the status of osteoarthritis. MRI was used for the diagnosis, evaluation of meniscus extrusion, and judgment of posterior root healing [ 28 ]. In accordance with the International Cartilage Repair Society (ICRS) grading scores [ 33 ], focal cartilage lesions of the medial condyle of the femur and the medial plateau of the tibia were graded on MRI images before and after surgery. Subchondral edema, subchondral cysts and insufficiency fractures were ALSO recorded on MRI images [ 34 , 35 ]. Meniscal extrusion was measured from the outer margin of the medial tibial plateau to the outer edge of the medial meniscus on the images showing maximal extrusion [ 36 ]. Meniscal healing was classified as complete-union (continuity in sagittal, coronal, and axial MRI views), partial-union (loss of continuity in any 1 view), and non-union (no continuity in any view) [ 37 ]. 3.Theory and calculation Qualitative data were recorded using absolute values. Chi-square test and Fisher's exact test were used for comparative analysis of qualitative data. The continuous data were first tested for normality. Data conforming to normal distribution were recorded by mean ± standard deviation (SD), and independent-samples t test was used for intergroup comparison, whereas paired t test was used for intragroup comparison. Results A total of 95 patients were included in this study. There were no statistically significant differences between the two groups in terms of age, sex, affected side, BMI, trauma history, course of disease, follow-up time, and Outerbridge grade. Table 1 . Table 1 Demographic and clinical characteristics of patients pull-out group All-inside group p- value Number of patients 53 42 Age(years) 51.91 ± 5.63 53.10 ± 6.08 0.326 Sex (male/female) 14/39 10/32 0.772 Side involved (left/right) 20/33 15/27 0.839 Body mass index (kg/m 2 ) 27.32 ± 5.76 27.13 ± 6.28 0.645 Trauma history (yes/no) 14/39 12/30 0.815 Duration from injury to surgery(weeks) 7.00 ± 3.76 6.69 ± 3.21 0.672 follow-up period (months) 26.25 ± 1.66 26.36 ± 1.68 0.747 Outerbridge grade(0/s/1/2) 8/16/24/5 6/10/19/7 0.722 There were no statistically significant differences in cartilage injury grade, subchondral cysts, subchondral edema, and insufficiency fractures between the two groups at the final follow-up. The ratio of complete healing/partial healing/non-healing was 71.70%/24.53%/3.77% in the pull-out repair group, and 71.43%/21.43%/7.14% in the all-inside repair group ( P = 0.936). We observed no significant differences in the incidence and degree of meniscus extrusion between two groups ( P = 0.770). Table 2 . Table 2 Imaging progression of osteoarthritis between two groups pull-out group All-inside group p- value K–L grade (0/Ⅰ/Ⅱ/Ⅲ/Ⅳ) Preoperatively 18/25/10/0/0 12/26/4/0/0 0.279 Postoperatively 15/27/8/3/0 9/27/4/2/0 0.641 ICRS grade(0/Ⅰ/Ⅱ/Ⅲ/Ⅳ) Preoperatively 16/24/13 11/21/10 0.884 Postoperatively 13/23/14/3 8/22/9/3 0.794 Subchondral cysts Preoperatively 14/39 12/30 0.815 Postoperatively 18/35 16/26 0.676 Subchondral edema Preoperatively 16/37 11/31 0.668 Postoperatively 13/40 8/34 0.523 Insufficiency fractures Preoperatively 7/46 5/37 0.849 Postoperatively 8/45 7/35 0.835 Meniscal healing (Complete / Partial / Nonhealed) 38/13/2 30/9/3 0.740 Extrusion Preoperatively 37/16 29/13 0.936 Postoperatively 47/6 38/4 0.770 Extrusion(mm) Preoperatively 2.63 ± 1.28 2.67 ± 1.20 0.893 Postoperatively 3.43 ± 0.71 3.41 ± 0.80 0.903 IKDC score, Lysholm score showed no statistically significant differences between two groups Table 3 , Fig. 3 . Table 3 IKDC score and Lysholm scores of two groups Group Number of patients IKDC Score Lysholm Score Preoperatively Postoperatively Preoperatively Preoperatively pull-out group 53 38.92 ± 7.54 74.11 ± 7.49 43.42 ± 5.88 43.42 ± 5.88 all-inside group 42 40.49 ± 5.58 74.05 ± 6.77 42.81 ± 4.83 42.81 ± 4.83 p- value 0.265 0.965 0.591 0.591 Discussion The posterior horn of the medial meniscus, which bears most of the stress applied to the medial compartment. Therefore, this area is more prone to traumatic or degenerative rupture [ 38 , 39 ]. Once root injury occurs, the biomechanical changes are the same as after total meniscectomy [ 40 ]. Due to the particularity of living habits, Asian women have a higher risk of damage to the posterior medial meniscus root [ 41 ]. According to the morphology, there are six types of MMPRT, Laprad II refers to complete radial tear within 9 mm of the center of the root attachment, which is the most common type of MMPRT [ 42 ]. The long-term results of conservative treatment and meniscectomy for MMPRT are not satisfactory. Conservative treatment, meniscectomy, and meniscus repair result in osteoarthritis in 95.1%, 99.3%, and 53.0% of the cases, respectively [ 43 ]. Worse functional recovery is associated with female gender, increased BMI, and meniscus extrusion [ 44 ]. The purpose of surgical repair of the posterior root is to restore the continuity of the annular structure of the meniscus, the stability of the patellofemoral joint, and the pressure distribution of the medial compartment. The repair methods include pull-out repair [ 14 – 21 ], all-inside repair [ 22 – 26 ], anchor suture repair [ 45 ]. Pull-out repair is a classic technique, which has been used for more than 20 years [ 12 , 13 ]. Similarly, no obvious progression of cartilage and subchondral bone lesions were observed after repair [ 15 ]. Postoperative root healing is a concern for clinicians, because the healing of the posterior root is closely related to the functional prognosis. Previous studies have found that the healing rate of pull-out repair is 97%, of which 62% is completely healed [ 16 ]. According to the study by Cho et al. [ 17 ], all patients had improved function after repair, but the functional improvement was more obvious in the healing group. In this study, the meniscus healing rate after the pull-out repair was 96.23%, which is basically consistent with previous studies, and the postoperative function of patients improved significantly compared with that before surgery. To ensure the therapeutic effect of pull-out repair, the first step is to fellow the contraindications of surgery [ 16 ]. The judgment of the footprint of the medial meniscus is another keypoint [ 18 ]. The autopsy found that the posterior root of the medial meniscus is connected to the tibial plateau through dense fibers, and the footprint is behind the medial intercondylar ridge of the tibia, outside the inflection point of the articular cartilage of the medial plateau of the tibia, and anterior medial to the attachment point of the posterior cruciate ligament (PCL) of the tibia [ 19 ]. A layer of "shining fibers" behind the dense fibers was not considered to be part of the root attachment. A distinction should be made in determining anatomic stops [ 20 ]. When there is meniscus extrusion, especially when there is adhesion of the posterior joint capsule, the in situ fixation cannot restore the normal mechanical environment of the knee joint [ 21 ], and the release of the root tissue of the posterior meniscus is necessary for anatomical reconstruction. The side-to-side repair technique can theoretically achieve anatomical repair of the posterior tibial root without changing the original physiological characteristics of the meniscus. The main advantages of all-inside meniscus suture are lower invasiveness, reduced technical difficulty, avoiding additional incisions or tibial tunnel drilling, and avoiding interference with the bone tunnel during ligament reconstruction. The all-inside repair method can reduce the peak pressure of the medial compartment of the tibiofemoral joint after MMPRT, and its stiffness and failure load are similar to those of the pull-out repair technique [ 22 – 24 ]. Kyoung et al. [ 24 ] found that the healing rate of all-inside suture was higher than that of pull-out repair (96 vs. 81%), and the functional prognosis of the former was significantly better than that of the latter. Our study confirmed that the healing rates of the all-inside repair and pull-out repair group were 96.23% and 92.86%, respectively, with no significant difference. The clinical observation study conducted by Jason suggesting that FasT-Fix suture could be used as an alternative method to treat MMPRT [ 25 ]. Meniscus extrusion is an important factor that induces knee osteoarthritis [ 46 , 47 ]. Previous studies have shown that although the meniscus extrusion could not be corrected after MMPRT repair, all patients show improvement in knee function after surgery [ 48 , 49 ]. In our study, neither pull-out repair method not all-inside repair were able to reverse meniscus extrusion, and the progression of osteoarthritis could also be observed. It has been suggested that the combined centralization of posterior meniscus root repair can reduce the extrusion of medial meniscus and restore the function of load distribution [ 50 ]. An observational study by Krych et al. [ 12 ] also showed that posterior meniscal root repair combined with centralized surgery resulted in significant improvements in postoperative pain, function, and quality of life, and reported high surgical satisfaction. Therefore, centralization of meniscus during posterior root repair is a problem worthy of further study. This study had several limitations. First, the main limitation of this study is its retrospective nature. Second, the study's follow-up time was insufficient to assess the long-term efficacy of either treatment. Third, only MRI was used to evaluate the healing of the posterior meniscus root without the second postoperative microscopic examination, and the results were not intuitive enough. Declarations Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Medical Ethics Committee of Huzhou First People's Hospital (No 2024KYLL015-02). Consent to participate Informed consent was obtained from all individual participants included in the study. Consent to publish The authors declare that they agree to publish Funding This work was supported by the Zhejiang province public welfare technology application research project [grant numbers LTGD24H060001]; Medical Science and Technology Project of Zhejiang province [grant number 2024KY1649]. Author Contribution Zheyuan Shen wrote the original draft. Rong Wu searched the literature and screened it. Dan Cai and Qiaoying Peng conducted data curation.Heng Li and Songhua Guo are responsible for the supervision of the study. Zhanfeng Zhang reviewed and revised the manuscript. Acknowledgement The authors would like to thank Huanyan Yang and Jinghao Shen. 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Knee Surg Sports Traumatol Arthrosc 24:1455–1468 Perry AK, Lavoie-Gagne O, Knapik DM, Maheshwer B, Hodakowski A, Gursoy S, LaPrade RF, Chahla J (2023) Examining the Efficacy of Medial Meniscus Posterior Root Repair: A Meta-analysis and Systematic Review of Biomechanical and Clinical Outcomes. Am J Sports Med 51:1914–1926 Amano Y, Ozeki N, Matsuda J, Nakamura T, Nakagawa Y, Sekiya I, Koga H (2023) Augmentation of a Nonanatomical Repair of a Medial Meniscus Posterior Root Tear With Centralization Using Three Knotless Anchors May Be Associated With Less Meniscal Extrusion and Better Compressive Load Distribution in Mid-Flexion Compared With Non-Anatomical Root Repair Alone in a Porcine Knee Model. Arthroscopy 39:2487–2498.e4 Additional Declarations No competing interests reported. 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First Affiliated Hospital of Huzhou Normal University，The First People's Hospital of Huzhou","correspondingAuthor":false,"prefix":"","firstName":"Rong","middleName":"","lastName":"Wu","suffix":""},{"id":366732669,"identity":"cb041484-eded-4ee9-b4a9-5cf686073e89","order_by":2,"name":"Dan Cai","email":"","orcid":"","institution":"The First Affiliated Hospital of Huzhou Normal University，The First People's Hospital of Huzhou","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Cai","suffix":""},{"id":366732670,"identity":"d481fbb1-860b-42d2-a37e-69a5a8daa5c3","order_by":3,"name":"Heng Li","email":"","orcid":"","institution":"The First Affiliated Hospital of Huzhou Normal University，The First People's Hospital of Huzhou","correspondingAuthor":false,"prefix":"","firstName":"Heng","middleName":"","lastName":"Li","suffix":""},{"id":366732678,"identity":"2c79a319-bad0-4249-9bcc-cb43f07d85b5","order_by":4,"name":"Qiaoying Peng","email":"","orcid":"","institution":"The First Affiliated Hospital of Huzhou Normal University，The First People's Hospital of Huzhou","correspondingAuthor":false,"prefix":"","firstName":"Qiaoying","middleName":"","lastName":"Peng","suffix":""},{"id":366732683,"identity":"f4ce030b-86d2-4ad3-beb2-67579220dc0a","order_by":5,"name":"Songhua Guo","email":"","orcid":"","institution":"The First Affiliated Hospital of Huzhou Normal University，The First People's Hospital of Huzhou","correspondingAuthor":false,"prefix":"","firstName":"Songhua","middleName":"","lastName":"Guo","suffix":""},{"id":366732688,"identity":"54167709-0b71-4f93-a34d-c3daa7a096be","order_by":6,"name":"Zhang Zhanfeng","email":"","orcid":"","institution":"The First Affiliated Hospital of Huzhou Normal University，The First People's Hospital of Huzhou","correspondingAuthor":false,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Zhanfeng","suffix":""},{"id":366732695,"identity":"4df0ba70-4208-43b6-9174-84acc9ff71f9","order_by":7,"name":"Zhanfeng Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYFCCBAMQaScvf/jgg8Q//+r7idWSbDiDLdngY8MBxpkNRGphbLjBYyY5E6hlwwECGvjbk7d9+PCnjplxdo+xMe+OO8zGx5M3MPyo2IZTi8SZZ8UzZ7Yd5mOXOVb4mPfMMzazM88KGHvO3MZtzY0cY2behgPMjA3Jm4152Jh5zG7kGDAztuHWIg/S8udPHWPDgQQzaaAWCeMZBLQYgLQwsAEtuZEC9H7bYQMDCQJaDIF+YextO5xs2HMs2eDDmbQEoO8KDuLzi9zx5M0MP/7U2cmzNx98kFBhkwAMw40PflTg8T4WkGBwgCT1DLDIHQWjYBSMglEAAwDi7mIZGaJSkAAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Huzhou Normal University，The First People's Hospital of Huzhou","correspondingAuthor":true,"prefix":"","firstName":"Zhanfeng","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-10-15 11:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5268194/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5268194/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67283841,"identity":"cca2be9e-fa51-4047-af19-7f5bf665b7ee","added_by":"auto","created_at":"2024-10-23 09:19:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":464433,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Preoperative MRI (B) pull-out repair techniques (C)Postoperative MRI\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5268194/v1/8bbab5af3c0bfec3ae6da264.png"},{"id":67283842,"identity":"8116bef7-055e-4b5c-b2c9-3b631a6c17e1","added_by":"auto","created_at":"2024-10-23 09:19:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":413707,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Preoperative MRI (B) all-inside repair techniques (C)Postoperative MRI\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5268194/v1/7839ccf0297e8396da8dae1d.png"},{"id":67283840,"identity":"ef1e0c92-53d8-4de5-9fc1-3fdb941ad5c0","added_by":"auto","created_at":"2024-10-23 09:19:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":53078,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLysholm score AND IKDC score of two groups\u003c/strong\u003e No statistically significant differences between the two groups with IKDC score, and Lysholm score.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5268194/v1/8453ca877be9f3e3fc641688.png"},{"id":69041427,"identity":"b8bc90a9-1525-4d32-8af4-e7231733d009","added_by":"auto","created_at":"2024-11-15 01:46:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1993076,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5268194/v1/5f9ab5b6-db78-40f9-b1cf-3a8552c308fb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The efficacy of the pull-out and all-inside techniques for the treatment of Laprad type II medial meniscus posterior root tear","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedial meniscus posterior root tear (MMPRT) refers to radial tear within 1 cm of the medial meniscus root attachment, or complete avulsion of the soft tissue or bone structure of the root attachment. Most of these injuries are degenerative injuries caused by chronic repetitive low-energy movements [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The stress-dispersion ability of the meniscus is impaired due to the failure of the annular fiber structure, which leads to stress osteonecrosis of cartilage and subchondral bone, and the induction of osteoarthritis.\u003c/p\u003e \u003cp\u003ePrevious studies have shown that conservative treatment often results in poorer functional recovery, more severe osteoarthritis, and a higher rate of arthroplasty [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Meniscectomy has also been widely used for the treatment of MMPRT, and early studies suggested it was effective in improving the patients\u0026rsquo; symptoms [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, long-term follow-up studies have demonstrated that 35% of patients show radiological progression of osteoarthritis during follow-up [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and the final rate of arthroplasty is 36\u0026ndash;56% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].Due to the poor results of conservative treatment and meniscectomy, restoring the meniscus stress dispersion by repairing the continuity of the meniscus fibrous loop structure has become a new target in the treatment of MMPRT. Indeed, biomechanical repair can restore the normal contact area and peak pressure of the tibiofemoral joint [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Compared with meniscectomy, repair surgery is able to slow the progression of arthritis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, once MMPRT is diagnosed, root repair has become the preferred method of treatment.\u003c/p\u003e \u003cp\u003eKim et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] applied pull-out repair technique to the treatment of MMPRT and achieved satisfactory therapeutic effects. Since then, a large number of biomechanical and clinical observational studies have been conducted around pull-out repair technology [\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. With the development of meniscus repair technology, especially the wide application of meniscus suture device, new treatment methods called all-inside techniques are provided [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. So far, there have been few reports on the comparative study of the two repair methods in the treatment of MMPRT. To compare the efficacy of pull-out repair technique and all-inside repair technique in the treatment of MMPRT, we conducted a retrospective study to compare the functional prognosis and imaging progression of osteoarthritis between the two techniques.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMaterial\u003c/h2\u003e \u003cp\u003e This study reviewed the data of patients with MMPRT treated with pull-out repair or all-inside repair in our hospital from June 2018 to June 2022.\u003c/p\u003e \u003cp\u003eInclusion criteria: (1) diagnosis consistent with Laprad type II MMPRT [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]; (2) clinical symptoms correlating with MRI findings; (3) duration of the disease less than 6 months; (4) age between 18 and 60 years; and (5) a minimum of 2 years of follow-up.\u003c/p\u003e \u003cp\u003eExclusion criteria: (1) congenital knee deformity; (2) concomitant injury of the knee joint (fracture, ligament injury, or other meniscus injury); (3) varus alignment more than 5\u0026deg; before operation; (4) preoperative Outerbridge grade[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u0026thinsp;\u0026ge;\u0026thinsp;3; and (5) body mass index (BMI)\u0026thinsp;\u0026gt;\u0026thinsp;30.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMethods\u003c/h3\u003e\n\u003cp\u003eAll surgical procedures were performed by two senior surgeons. A standard anterolateral portal (longitudinal incision) was used for arthroscopic visualization. An anteromedial portal (transverse incision) was used for MMPRT guide. When the medial space of the knee joint was narrow and the root exposure was difficult, the \"pie-crusting\" technique was used to release the medial collateral ligament to assist the exposure of the medial compartment [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePull-out repair group\u003c/h3\u003e\n\u003cp\u003eThe tissue structure of the posterior root attachment of the medial meniscus was carefully identified under the microscope. The residual posterior root tissue at the negative attachment of the posterior root of the meniscus and the degenerative tissue at the free end were thoroughly debrided and freshened with the planer and the meniscus rub. Then, a 2.5-mm-diameter tibial bone tunnel was created with the MMPRT guide. The posterior dense tissue attachment point of the root was used as the intra-articular exit of the bone tunnel, and the anterior medial cortex of the proximal tibia was used as the extra-articular exit of the bone tunnel. The No. 2 nonabsorbable sutures (Smith \u0026amp; Nephew) were inserted into the posterior root of the medial meniscus and fixed in the form of loop stitches. The sutures were drawn out of the joint by lasso through the tibial tunnel. Under continuous arthroscopic observation, the sutures were tightened with the knee bent at 90\u0026deg; and fixed to the anterior medial cortex of the tibia with the help of a button (Smith \u0026amp; Nephew). After the repair was completed, the arthroscope was turned to the medial portal for observation with the knee bent at 120\u0026deg; to observe the tension of the suture site. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eAll-inside repair group\u003c/h3\u003e\n\u003cp\u003eBefore repair, we first performed debridement and freshened the posterior root stump. The posterior root was sutured with vertical mattress suture using FasT-Fix (Smith \u0026amp; Nephew). The method was as follows: A needle tip was penetrated into one limb of the meniscus 5 mm from the free edge to deliver the first suture bar anchor. Then, the second penetration was performed across the tear line at the opposite end of the meniscus, also 5 mm from the free edge. The suture was tightened to join the two broken ends. The same procedure was repeated one more time. As a result, two parallel sutures were performed 5 mm away from each tear limb. After the repair was completed, the arthroscope was turned to the medial portal for observation with the knee bent at 120\u0026deg; to observe the tension of the suture site. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMuscle strength exercises were started immediately after surgery. During the first 3 weeks, the affected limb was immobilized in a knee extension brace, and weight-bearing was avoided. Flexion was allowed in the range of 30\u0026deg; from the fourth week after surgery. In weeks 5\u0026ndash;6, flexion was increased by 25\u0026deg; per week, and partial weight-bearing was gradually started. In weeks 7\u0026ndash;8, the range of flexion increased to 120\u0026deg;, and there was gradual transition to full weight-bearing. Physical exercise was prohibited within 6 months after surgery.\u003c/p\u003e\n\u003ch3\u003eAssessment methods\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical function evaluation\u003c/h2\u003e \u003cp\u003eThe Lysholm Knee Scale [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and the International Knee Literature Committee Knee Assessment Scale (IKDC) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] were evaluated before surgery and at final follow-up by the same author who was not involved in surgery.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImaging evaluation\u003c/h3\u003e\n\u003cp\u003eRadiographic data were evaluated, including plain radiographs and Magnetic resonance imaging (MRI) scans. The Kellgren\u0026ndash;Lawrence scoring system [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] was used to evaluate the status of osteoarthritis. MRI was used for the diagnosis, evaluation of meniscus extrusion, and judgment of posterior root healing [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In accordance with the International Cartilage Repair Society (ICRS) grading scores [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], focal cartilage lesions of the medial condyle of the femur and the medial plateau of the tibia were graded on MRI images before and after surgery. Subchondral edema, subchondral cysts and insufficiency fractures were ALSO recorded on MRI images [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Meniscal extrusion was measured from the outer margin of the medial tibial plateau to the outer edge of the medial meniscus on the images showing maximal extrusion [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Meniscal healing was classified as complete-union (continuity in sagittal, coronal, and axial MRI views), partial-union (loss of continuity in any 1 view), and non-union (no continuity in any view) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003e3.Theory and calculation\u003c/h3\u003e\n\u003cp\u003eQualitative data were recorded using absolute values. Chi-square test and Fisher's exact test were used for comparative analysis of qualitative data. The continuous data were first tested for normality. Data conforming to normal distribution were recorded by mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and independent-samples \u003cem\u003et\u003c/em\u003e test was used for intergroup comparison, whereas paired \u003cem\u003et\u003c/em\u003e test was used for intragroup comparison.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 95 patients were included in this study. There were no statistically significant differences between the two groups in terms of age, sex, affected side, BMI, trauma history, course of disease, follow-up time, and Outerbridge grade. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epull-out group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAll-inside group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep- value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge(years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.91\u0026thinsp;\u0026plusmn;\u0026thinsp;5.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.10\u0026thinsp;\u0026plusmn;\u0026thinsp;6.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.326\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex (male/female)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.772\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSide involved (left/right)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.839\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.32\u0026thinsp;\u0026plusmn;\u0026thinsp;5.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.13\u0026thinsp;\u0026plusmn;\u0026thinsp;6.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrauma history (yes/no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.815\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration from injury to surgery(weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003efollow-up period (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOuterbridge grade(0/s/1/2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/16/24/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/10/19/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.722\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere were no statistically significant differences in cartilage injury grade, subchondral cysts, subchondral edema, and insufficiency fractures between the two groups at the final follow-up. The ratio of complete healing/partial healing/non-healing was 71.70%/24.53%/3.77% in the pull-out repair group, and 71.43%/21.43%/7.14% in the all-inside repair group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.936). We observed no significant differences in the incidence and degree of meniscus extrusion between two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.770). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImaging progression of osteoarthritis between two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epull-out group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAll-inside group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep- value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eK\u0026ndash;L grade (0/Ⅰ/Ⅱ/Ⅲ/Ⅳ)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/25/10/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/26/4/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15/27/8/3/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9/27/4/2/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICRS grade(0/Ⅰ/Ⅱ/Ⅲ/Ⅳ)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/24/13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11/21/10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.884\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/23/14/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8/22/9/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubchondral cysts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.815\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16/26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.676\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubchondral edema\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11/31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8/34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.523\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInsufficiency fractures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.849\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.835\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeniscal healing\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Complete / Partial / Nonhealed)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38/13/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30/9/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.740\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExtrusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29/13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.936\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.770\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExtrusion(mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.893\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperatively\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.903\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIKDC score, Lysholm score showed no statistically significant differences between two groups Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIKDC score and Lysholm scores of two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eIKDC Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eLysholm Score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePostoperatively\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePreoperatively\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003epull-out group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.92\u0026thinsp;\u0026plusmn;\u0026thinsp;7.54\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74.11\u0026thinsp;\u0026plusmn;\u0026thinsp;7.49\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43.42\u0026thinsp;\u0026plusmn;\u0026thinsp;5.88\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43.42\u0026thinsp;\u0026plusmn;\u0026thinsp;5.88\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eall-inside group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e42\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e40.49\u0026thinsp;\u0026plusmn;\u0026thinsp;5.58\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e74.05\u0026thinsp;\u0026plusmn;\u0026thinsp;6.77\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e42.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e42.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep- value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.265\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.965\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.591\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.591\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe posterior horn of the medial meniscus, which bears most of the stress applied to the medial compartment. Therefore, this area is more prone to traumatic or degenerative rupture [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Once root injury occurs, the biomechanical changes are the same as after total meniscectomy [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Due to the particularity of living habits, Asian women have a higher risk of damage to the posterior medial meniscus root [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. According to the morphology, there are six types of MMPRT, Laprad II refers to complete radial tear within 9 mm of the center of the root attachment, which is the most common type of MMPRT [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe long-term results of conservative treatment and meniscectomy for MMPRT are not satisfactory. Conservative treatment, meniscectomy, and meniscus repair result in osteoarthritis in 95.1%, 99.3%, and 53.0% of the cases, respectively [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Worse functional recovery is associated with female gender, increased BMI, and meniscus extrusion [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The purpose of surgical repair of the posterior root is to restore the continuity of the annular structure of the meniscus, the stability of the patellofemoral joint, and the pressure distribution of the medial compartment. The repair methods include pull-out repair [\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], all-inside repair [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], anchor suture repair [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePull-out repair is a classic technique, which has been used for more than 20 years [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Similarly, no obvious progression of cartilage and subchondral bone lesions were observed after repair [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Postoperative root healing is a concern for clinicians, because the healing of the posterior root is closely related to the functional prognosis. Previous studies have found that the healing rate of pull-out repair is 97%, of which 62% is completely healed [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. According to the study by Cho et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], all patients had improved function after repair, but the functional improvement was more obvious in the healing group. In this study, the meniscus healing rate after the pull-out repair was 96.23%, which is basically consistent with previous studies, and the postoperative function of patients improved significantly compared with that before surgery.\u003c/p\u003e \u003cp\u003eTo ensure the therapeutic effect of pull-out repair, the first step is to fellow the contraindications of surgery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The judgment of the footprint of the medial meniscus is another keypoint [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The autopsy found that the posterior root of the medial meniscus is connected to the tibial plateau through dense fibers, and the footprint is behind the medial intercondylar ridge of the tibia, outside the inflection point of the articular cartilage of the medial plateau of the tibia, and anterior medial to the attachment point of the posterior cruciate ligament (PCL) of the tibia [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A layer of \"shining fibers\" behind the dense fibers was not considered to be part of the root attachment. A distinction should be made in determining anatomic stops [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. When there is meniscus extrusion, especially when there is adhesion of the posterior joint capsule, the in situ fixation cannot restore the normal mechanical environment of the knee joint [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and the release of the root tissue of the posterior meniscus is necessary for anatomical reconstruction.\u003c/p\u003e \u003cp\u003eThe side-to-side repair technique can theoretically achieve anatomical repair of the posterior tibial root without changing the original physiological characteristics of the meniscus. The main advantages of all-inside meniscus suture are lower invasiveness, reduced technical difficulty, avoiding additional incisions or tibial tunnel drilling, and avoiding interference with the bone tunnel during ligament reconstruction. The all-inside repair method can reduce the peak pressure of the medial compartment of the tibiofemoral joint after MMPRT, and its stiffness and failure load are similar to those of the pull-out repair technique [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Kyoung et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] found that the healing rate of all-inside suture was higher than that of pull-out repair (96 vs. 81%), and the functional prognosis of the former was significantly better than that of the latter. Our study confirmed that the healing rates of the all-inside repair and pull-out repair group were 96.23% and 92.86%, respectively, with no significant difference. The clinical observation study conducted by Jason suggesting that FasT-Fix suture could be used as an alternative method to treat MMPRT [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMeniscus extrusion is an important factor that induces knee osteoarthritis [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Previous studies have shown that although the meniscus extrusion could not be corrected after MMPRT repair, all patients show improvement in knee function after surgery [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. In our study, neither pull-out repair method not all-inside repair were able to reverse meniscus extrusion, and the progression of osteoarthritis could also be observed. It has been suggested that the combined centralization of posterior meniscus root repair can reduce the extrusion of medial meniscus and restore the function of load distribution [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. An observational study by Krych et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] also showed that posterior meniscal root repair combined with centralized surgery resulted in significant improvements in postoperative pain, function, and quality of life, and reported high surgical satisfaction. Therefore, centralization of meniscus during posterior root repair is a problem worthy of further study.\u003c/p\u003e \u003cp\u003eThis study had several limitations. First, the main limitation of this study is its retrospective nature. Second, the study's follow-up time was insufficient to assess the long-term efficacy of either treatment. Third, only MRI was used to evaluate the healing of the posterior meniscus root without the second postoperative microscopic examination, and the results were not intuitive enough.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval\u003c/h2\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Medical Ethics Committee of Huzhou First People\u0026apos;s Hospital (No 2024KYLL015-02).\u003c/p\u003e\n\u003ch2\u003eConsent to participate\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003ch2\u003eConsent to publish\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they agree to publish\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis work was supported by the Zhejiang province public welfare technology application research project [grant numbers LTGD24H060001]; Medical Science and Technology Project of Zhejiang province [grant number 2024KY1649].\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eZheyuan Shen wrote the original draft. Rong Wu searched the literature and screened it. Dan Cai and Qiaoying Peng conducted data curation.Heng Li and Songhua Guo are responsible for the supervision of the study. Zhanfeng Zhang reviewed and revised the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors would like to thank Huanyan Yang and Jinghao Shen.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKrych AJ, Bernard CD, Kennedy NI, Tagliero AJ, Camp CL, Levy BA, Stuart MJ (2020) Medial Versus Lateral Meniscus Root Tears: Is There a Difference in Injury Presentation, Treatment Decisions, and Surgical Repair Outcomes. Arthroscopy 36:1135\u0026ndash;1141\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrych AJ, Reardon PJ, Johnson NR, Mohan R, Peter L, Levy BA, Stuart MJ (2017) Non-operative management of medial meniscus posterior horn root tears is associated with worsening arthritis and poor clinical outcome at 5-year follow-up. Knee Surg Sports Traumatol Arthrosc 25:383\u0026ndash;389\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrych AJ, Lamba A, Wang AS, Boos AM, Camp CL, Levy BA, Stuart MJ, Hevesi M (2023) Nonoperative Management of Degenerative Medial Meniscus Posterior Root Tears: Poor Outcomes at a Minimum 10-Year Follow-up. Am J Sports Med 51:2603\u0026ndash;2607\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicholas SJ, Golant A, Schachter AK, Lee SJ (2009) A new surgical technique for arthroscopic repair of the meniscus root tear. Knee Surg Sports Traumatol Arthrosc 17:1433\u0026ndash;1436\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan SB, Shetty GM, Lee DH, Chae DJ, Seo SS, Wang KH, Yoo SH, Nha KW (2010) Unfavorable results of partial meniscectomy for complete posterior medial meniscus root tear with early osteoarthritis: a 5- to 8-year follow-up study. 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Am J Sports Med 51:1914\u0026ndash;1926\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmano Y, Ozeki N, Matsuda J, Nakamura T, Nakagawa Y, Sekiya I, Koga H (2023) Augmentation of a Nonanatomical Repair of a Medial Meniscus Posterior Root Tear With Centralization Using Three Knotless Anchors May Be Associated With Less Meniscal Extrusion and Better Compressive Load Distribution in Mid-Flexion Compared With Non-Anatomical Root Repair Alone in a Porcine Knee Model. Arthroscopy 39:2487\u0026ndash;2498.e4\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medial meniscus posterior root tear, Meniscal repair, Pull-out repair, All-inside repair","lastPublishedDoi":"10.21203/rs.3.rs-5268194/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5268194/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo investigate the therapeutic effect of Pull-out technique and All-inside technique on Laprad type II medial meniscus posterior root tear (MMPRT).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 95 patients were included in this study. Kellgren Lawrence (K-L) grade was recorded by knee X-ray after surgery, and knee cartilage injury grade, subchondral cyst, subchondral edema, insufficiency fracture, meniscal extrusion and meniscal healing were recorded by MRI. International Knee Literature Committee Knee Assessment Scale (IKDC) score, Lysholm score and VAS score were used to evaluate knee joint function.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThere were no significant differences in K-L grade, knee cartilage injury grade, subchondral cyst, subchondral edema and insufficiency fracture between two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The extrusion rate and degree of medial meniscus in pull-out repair group were 88.68%, 3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71mm, while those in the all-inside repair group were 90.48%, 3.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80mm, with no statistical difference (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). There were no significant differences in postoperative IKDC scores and Lysholm scores (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBoth pull-out repair and all-inside repair can improve knee joint function in the treatment of Laprad type II PMMRT.\u003c/p\u003e","manuscriptTitle":"The efficacy of the pull-out and all-inside techniques for the treatment of Laprad type II medial meniscus posterior root tear","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-23 09:18:59","doi":"10.21203/rs.3.rs-5268194/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c58dc28d-95d0-4b7c-bafa-3fbf6d1bdd14","owner":[],"postedDate":"October 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-15T01:38:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-23 09:18:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5268194","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5268194","identity":"rs-5268194","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}