2025 ISAKOS Congress in Munich, Germany

2025 ISAKOS Biennial Congress Paper


Meniscal Leaflet Resection Decreases Meniscal Loading and Increases Peak Contact Stress After Horizontal Cleavage Tear in Simulated Gait

Heath Patrick Gould, MD, New York, NY UNITED STATES
Kalle Chastain, M.S., New York, NY UNITED STATES
Sean Charles Letendre, B.S., New York, NY UNITED STATES
Joshua Wright-Chisem, MD, New York, NY UNITED STATES
Stephanie S Buza, MD, Long Island City, New York UNITED STATES
Suzanne A. Maher, PhD, New York, NY UNITED STATES
Anil S. Ranawat, MD, New York, NY UNITED STATES

Hospital for Special Surgery, New York, NY, UNITED STATES

FDA Status Cleared

Summary

For horizontal cleavage meniscal tears, resection of the inferior and/or superior leaflet was associated with decreased percent meniscal loading and increased peak contact stress during simulated gait, whereas meniscal repair with vertical mattress sutures maintained native joint biomechanics and contact force distribution across the tibial plateau.

Abstract

Introduction

Horizontal cleavage tears represent a challenging meniscal injury pattern that may be encountered in the acute or degenerative setting. Surgical treatment of these injuries has traditionally comprised either isolated inferior leaflet resection (while maintaining the superior leaflet in situ) or partial meniscectomy (defined here as resection of both the superior and inferior leaflets). In recent years, meniscal repair with placement of vertical mattress sutures has also grown in popularity with the advent of all-inside repair devices. The goal of this study was to compare the effects of isolated inferior leaflet resection, partial meniscectomy, and meniscal repair on joint biomechanics and contact force distribution across the tibial plateau of human knees during simulated gait. We hypothesized that meniscal repair would restore peak contact stress, contact area, and meniscal loading closer to the intact state in comparison to leaflet resection or partial meniscectomy.

Methods

Six human cadaveric knees were denuded of skin, subcutaneous fat, muscle, and the patella, while preserving the cruciate ligaments, collateral ligaments, and capsule. Using a custom fixture, the knees were cemented and mounted on a multi-axis robotic test system [VIVO, AMTI] programmed to apply dynamic forces, moments, and flexion angles that mimic level-ground walking. An electronic, intra-articular pressure sensor [Model 4011, Tekscan] was calibrated and attached across the medial tibial plateau of each knee and programmed to quantify contact forces throughout testing. 12 cycles of multidirectional and dynamic standard gait input waveforms, from ISO standard #142430-1, normalized to specimen specific bodyweight, applied at 0.2 Hz, were applied to the following states: medial meniscus intact, horizontal cleavage tear of the posterior horn, meniscal repair, isolated inferior leaflet resection, partial meniscectomy with resection of superior and inferior leaflets. Isolated superior leaflet resection could not be tested in this experimental setup, as the inferior leaflet had already been resected. Peak contact stress, contact area, and the percentage of compartment force through the medial meniscus (percent meniscal loading) were recorded throughout stance phase of simulated gait for all meniscal testing states. Percent meniscal loading is a calculated ratio of the force transmitted through the medial meniscus compared to the force transmitted through the remainder of the medial compartment (i.e. tibial cartilage). Higher percent meniscal loading indicates a more meniscus-dominant loading pattern, whereas lower percent meniscal loading indicates a more cartilage-dominant loading pattern. The differences between the intact state and meniscal repair, inferior leaflet resection, and partial meniscectomy were calculated for each metric, then the averages and 95th percentile confidence intervals were computed.

Results

No significant differences in peak contact stress, contact area, or percent meniscal loading were observed between the intact meniscus and meniscal repair states. Inferior leaflet resection resulted in a statistically significant decrease in contact area and percent meniscal loading, which corresponded to a significant increase in peak contact stress that was most notable during the stance phase of the gait cycle. This deleterious effect on meniscal loading, contact area, and peak contact stress was further exacerbated after the partial meniscectomy was completed (with resection of both superior and inferior leaflets).

Conclusion

We accept our hypothesis as there was no significant difference observed between the intact meniscus and meniscal repair testing states. Resection of the inferior and/or superior leaflet was associated with decreased percent meniscal loading and increased peak contact stress during simulated gait, whereas meniscal repair with vertical mattress sutures appeared to maintain native joint biomechanics and contact force distribution across the tibial plateau. Taken together, these results support meniscal preservation as an alternative to partial meniscectomy in the management of horizontal cleavage meniscus tears.