Relationship of Medial Meniscus Posterior Root Tears with Proximal Tibial Morphology and Knee Osteoarthritis

doi:10.21203/rs.3.rs-4943752/v1

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Relationship of Medial Meniscus Posterior Root Tears with Proximal Tibial Morphology and Knee Osteoarthritis

https://doi.org/10.21203/rs.3.rs-4943752/v1

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Purpose: To investigate the relationship between proximal tibial morphology (PTM) and medial meniscus posterior root tears (MMPRT), and to evaluate the association between medial meniscal extrusion amount (MMEA) and osteoarthritis (OA) in patients with MMPRT.

Material and method: This retrospective study analyzed knee MRIs of 100 patients with MMPRT and 100 age, gender, side paired controls. Medial posterior tibial slope angle (MPTSA), mediolateral length (MLL), medial anteroposteiror width (MAW), lateral anteroposteiror width (LAW), were used to evaluate PTM . MMEA and tear gap (TG) correlation and their relationship with knee OA severity was assessed.

Results: MPTSA was significantly higher in MMPRT group compared to controls (p<0.001). Moderate positive correlation was found between MMEA and OA severity (R²=0.445, p<0.001). Cartilage loss was observed when MMEA exceeded 4 mm (sensitivity: 80.68%; specificity: 83.33%). MMEA increased by 1.10 mm for each 1 mm increase in TG.

Conclusion: This groundbreaking study reveals that steeper medial tibial plateau is a significant risk factor for MMPRT. Strikingly, MMEA exceeding 4 mm serves as a critical threshold for cartilage loss, potentially revolutionizing treatment decisions. These findings not only enhance our understanding of MMPRT pathomechanics but also provide crucial insights for early intervention strategies, potentially altering the course of OA progression in patients with MMPRT.

Meniscus

root

tear

morphology

osteoarthritis

tibia

The meniscus plays crucial role in maintaining the function of the knee by contributing to load transmission, shock absorption, joint stability and lubrication, proprioception, and nutrient supply. Of these functions, the most important function for the prevention of arthritis is the maintenance of hoop tension that allows correct intraarticular load transmission for which the medial meniscus is approximately 90% responsible and the lateral meniscus is approximately 70% responsible. Medial meniscus posterior root tear (MMPRT) causes to the loss of hoop tension and, consequently, the meniscus's load transmission capability. As a result, the increased contact pressure on the weight-bearing surface accelerates joint degeneration[1].

Risk factors for meniscal tears include age, sex, lower limb alignment, obesity[2]. Recent studies also highlight that proximal tibial morphology (PTM) could be a risk factor for meniscal and ligament injuries^8,9,13. PTM describes the geometric structure of tibia near the knee joint and tibial plateau. Various morphological measurements have been defined to assess PTM, including mediolateral length (MLL), medial anteroposterior width (MAW), lateral anteroposterior width (LAW), central-lateral length, central-medial length, tibial plateau surface area, medial posterior tibial slope angle (MPTSA), and lateral posterior tibial slope angle[3, 4]. MPTSA has the most significant impact on knee biomechanics among these measurements[4]. There are just few studies associating MPTSA to MMPRT and this relationship has not yet been clearly elucidated[5].

Magnetic resonance imaging (MRI) is the gold standard non-invasive methods for diagnosing medial meniscus root tears and detecting accompanying knee pathologies [6].

The aim of this study is to investigate the effect of PTM on MMRTs and to determine the relationship between medial meniscal extrusion amount (MMEA) observed in root tears and osteoarthritis (OA).

Patients who underwent knee MRI at our hospital between January 2020 and July 2022 were retrospectively evaluated. MRIs were obtained in the supine position with the knee in extension, using an extremity coil with a 1.5 Tesla MRI (Optima; GE Medical System, Milwaukee, Wisconsin, USA). A standardized MRI examination protocol was used (Table 1).

Table 1

Sequences and parameters used in image acquasition in the study
Sequences	TR / TE (ms)	Matriks	Field of view ( cm)	Slice thickness ( mm )
Sagittal T1W FSE	300–500/ 5–10	288 x 224	18 x 18	3
Sagittal 3D Cube FSE T2	1500 / 124,4	224 x 224	20 x 20	1
Sagittal Fatsat Proton Density FSE	2300–2800 / 20–40	256 x 192	18x18	3
Coronal Fatsat Proton Density FSE	2300–2800 / 20–40	288 x 224	20 x 20	3
Axial Fatsat Proton Density FSE	2300–2800 / 20–40	288 x 224	18 x 18	3

Patient images were anonymized and evaluated independently at different times by a radiology specialist with 5 years of experience and an associate professor of radiology with 10 years of experience in musculoskeletal radiology. The portion of the posterior horn of the medial meniscus 10 mm from posterior meniscal insertion to the tibial plateau was determined as posterior meniscal root. Patients with three main MRI findings were considered as MMRT:

A linear high signal intensity perpendicular to the meniscus root in the axial plane.
A vertical linear defect associated with > 3 mm medial meniscus extrusion at meniscus root.
Reappearance of the disappearing meniscus on consecutive sagittal sequences, known as “ghost meniscus” sign (Fig. 1).

Total of 141 patients with MMRT were evaluated. Patients with a history of surgery (9 patients) or trauma (12 patients), those with a secondary tear accompanying the root tear in the medial meniscus (5 patients), patients with mass lesions in the knee joint (2 patients), and those whose evaluation was not possible due to image quality or protocol issues (13 patients) were excluded from the study. Total of 100 patients were included as MMPRT group in the study. Control group was created with 100 patients matched for age, sex, and side, who had no meniscus or ligament pathology (Fig. 1).

The distance between the most medial point of the extruded part of the medial meniscus and the medial corner of the medial tibial plateau in mid-coronal plane, was recorded as the “MMEA”[7]. Osteophytes at the level of the medial tibial plateau were not included in the measurement area (Fig. 2).

The distance between the perpendicular line drawn from the ACL attachment and the torn meniscus root in coronal plane, was defined as the "tear gap" (TG)[8] (Fig. 3).

Cartilage changes were evaluated and classified according to Modified Outerbridge classification for staging osteoarthritis at the knee joint[9]^,[10](Table 2).

Table 2

Modified Outerbridge Classification
Grade	Description
0	Normal cartilage
1	T2 signal increase in morphologically normal cartilage
2	Superficial partial cartilage defect involving less than 50% of total joint surface thickness
3	Deep partial cartilage defect involving more than 50% of total joint surface thickness
4	Full-thickness cartilage defect

MLL, MAW, LAW, and MPTSA were used to evaluate PTM. For MLL, MAW, and LAW measurements, a line perpendicular to the medial tibial plateau extending 10 mm caudally was drawn in coronal plane. The lower end of this line was determined as the target point, and using reference lines in axial plane, MLL measurement was performed at this level on the x-axis. In the same section, MAW was measured at the point with the maximum anteroposterior width of the medial plateau on the y-axis, and LAW was measured at the point with the maximum anteroposterior width of the lateral plateau[11] (Fig. 4).

MPTSA (the angle between the vertical line drawn to the tibial axis and the line passing from the anterior and posterior cortical points of medial tibial plateau in sagittal plane) was measured as described by Hudek et al.[12] (Figs. 5a, 5b, 5c).

Datas were evaluated using IBM SPSS Statistics Standard Concurrent User V 26 (IBM Corp., Armonk, New York, USA). Descriptive statistics were given as unit number (n), mean ± standard deviation, median (M), minimum (min), and maximum (max) values. The normal distribution of numerical variables was assessed with the Shapiro-Wilk normality test. The Mann-Whitney U test was used for comparisons of variables between two categories. The effect of independent variables was evaluated by linear regression analysis. The "Roc Curve" analysis method was used to compare the diagnostic performance of two or more diagnostic or measurement values. Two-way analysis of variance was used to evaluate dependent continuous variables with two or more independent categorical variables. Pearson and Fisher exact tests were used for comparisons between categorical variables. The effect of the MMEA variable on the tear gap and OA stage was evaluated by linear regression analysis. Differences in MLL, MAW, LAW, and MPTSA according to gender in the study groups were analyzed by two-way analysis of variance. Intra- and inter-observer agreement was evaluated with the Wilcoxon test for PTM measurements in both groups. P value < 0.05 was considered statistically significant.

The demographic features of the MMRT and control groups are shown in Table 3. There was no statistically significant difference between the two groups in terms of age, gender, and side (p > 0.05).

Table 3

Comparison of gender, age and side between groups
	Groups		Test statistics
	MMRT group (n = 100)	Control group (n = 100)	p value >0,999 0,993 > 0,999
Gender, n (%) Male Female	47 (%47,0) 53 (%53,0)	47 (%47,0) 53 (%53,0)
Age Mean ± sd Median (min-max)	54,54 ± 8,46 54 (40–79)	54,46 ± 6,37 51 (47–69)
Side Right Left	46 54	46 54

The average of medial meniscal extrusion amount (MMEA) was 5.20 ± 1.74 mm, and TG was 5.54 ± 3.14 mm. In the linear regression analysis between the tear gap and MMEA, for every 1 mm increase in the tear gap, the extrusion amount increased by 1.10 mm.

Knee OA was more severe in MMRT group (p < 0.001). OA was more severe in women than men in both groups (p = 0.026; p < 0.001). There was moderate positive correlation between MMEA and knee OA(p < 0.001, R² = 0,445)(Table 4, 5). When MMEA exceeded 4 mm, cartilage loss was observed (sensitivity: 80.68%; specificity: 83.33%, AUC: 0.876, Fig. 6).

Table 4

Comparison of OA grades according to gender
	Male	Female	p value
	OA grade	OA grade
MMRT group	2 (1–4)	3 (1–4)	0,026
Control group	0 (0–3)	1 (0–3)	< 0,001

Table 5

Linear regression analysis of OA grade and MMEA
	β	se	zβ	t	P value
OA grade
MMEA (mm)	0,399	0,045	0,667	8,860	< 0,001
F = 78,505; p < 0,001; R² = 0,445 Durbin-Watson = 1,594

MLL, MAW, and LAW were smaller in women compared to men in both groups but There was no statistically significant difference between the two groups in terms of these PTM measurements (Table 6).

Table 6

Comparison of MLL, LAW and MAW between groups
	Groups		Test statistics
	MMRT group (n = 100)	Control group (n = 100)	p value
MLL (cm)
Male	7,51 ± 0,41	7,75 ± 0,43	0,202 0,304
Female	6,52 ± 0,29	6,74 ± 0,35	0,202 0,304
LAW (cm)
Male	4,45 ± 0,33	4,68 ± 0,38	0,321 0,361
Female	3,85 ± 0,33	3,93 ± 0,30	0,321 0,361
MAW (cm)
Male	5,27 ± 0,34	5,53 ± 0,26	0,272 0,295
Female	4,31 ± 0,34	4,62 ± 0,26	0,272 0,295

MPTSA was higher in women than in men in both groups, but this was not statistically significant (p > 0.05). MPTSA was significantly higher in the MMRT group compared to the control group for both genders (p < 0.001)(Table 7).

Table 7

Comparison of MPTSA between groups
	Groups
	MMRT group (n = 100)	Control group (n = 100)	p value
MPTSA (degree)
Male	6,67 ± 1,78	4,96 ± 2,10	< 0,001 < 0,001
Female	6,81 ± 2,03	5,15 ± 1,83	< 0,001 < 0,001

Intraobserver and interobserver agreement was present for PTM measurements (p > 0.05).

The first case of MMPRT was reported in 1991 by Pagnani et al[13]. MMPRT is meniscal tear, located within 10 mm of the posterior root insertion of the meniscus, they are usually degenerative and occur in middle-aged women and may represent 21.5% MMPRTs[14]. Similar to the literature 53% of patients with MMPRT were female, with a mean age above 50 years in our study[15–17].

Medial meniscus, a crescent-shaped fibrocartilaginous structure, maintains its anatomical position during weight-bearing stress, with the anchoring horns and circumferential fiber bundles of the medial meniscus providing tensile strength. Radial meniscus tears can lead to medial meniscus extrusion due to the disruption of these root attachments or circumferential fiber bundles. Medial meniscus extrusion is defined as the significant medial displacement of the medial meniscus relative to the central edge of medial tibial plateau. Lerer et al. considered MMEA abnormal if it was 3 mm or more[18] .The average MMEA patitent with MMPRT was 5.2 mm in our study and this result is consistent with the literature.

The first sign of OA is cartilage loss. Studies has shown the relationship between medial tibiofemoral cartilage loss and MMPRTs based on MR imaging and arthroscopic findings[19–23]. Guermazi et al. reported that the likelihood of onset and progression of medial tibiofemoral cartilage degeneration is higher in isolated MMPRTs compared to other types of meniscal tears[24]. Similar to this study, knee OA was more severe in MMPRT group compared to the control group in our study.

It is known that patients with MMPRT have higher MMEA compared to those with other types of meniscal tears[25]. Studies indicate that increased MMEA accelerates the development of OA, and as MMEA increases, the presence and severity of OA also increase[24, 26]. We found that increased extrusion amount was associated with increased cartilage loss, the first sign of OA. Cartilage degeneration and loss were higher in women than in men. The mechanical disruption caused by meniscus tear or extrusion can alter the weight-bearing capacities of the tibiofemoral compartments, leading to damage to the joint cartilage and subchondral bone, thereby contributing to the development and progression of knee osteoarthritis[27]. Additionally, we revealed that cartilage loss begins when MMEA exceeds 4 mm, adding to the literature. Recent studies that compare the repair of MMPRT to total or partial meniscectomy and non-surgical treatment, showing superior outcomes with repair and lower rates of progression to knee OA and lower reoperation rate[28, 29]. Our finding contribute the literature in this regard and suggests that repair of meniscus may give better results in patients with MMEA less than 4 mm, that is, in patients who have not yet started cartilage loss-knee OA. Therefore, patients with MMEA less than 4 mm may be candidates for repair. Nevertheless, clinically correlated new studies are needed.

PTM and biomechanics of knee joint are associated with ACL and meniscal tears. The geometry of the tibial plateau directly affects the biomechanics of the tibiofemoral joint. The MPTSA is the most commonly used measurement for evaluating this geometry[30–32]. Kodama et al. identified steeper MPTSA as a risk factor for MMPRTs in young patients[32]. However, Altınayak et al. found no difference in MPTSA when comparing patients with MMPRTs to control group[31]. We found that the MPTSA was statistically significantly higher in the group with MMPRTs compared to the control group, supporting the findings of Kodama et al. Steeper tibial pleatua is associated with the magnitude of shear force on the tibial plateau and affects the biomechanics of the tibiofemoral joint by increasing the anterior translational force acting on the posterior root of the medial meniscus, which may increase the risk of meniscal injury in adults[30, 33].

There is no study to our knowledge in the literature evaluating the relationship between MMPRT and MLL, MAW, and LAW measurements. This study is unique in the context in that it is the first study to evaluate these measurements. We found no difference in these tibial measurements between two groups. Zhang et al. reported that MLL, MAW and LAW were smaller in women than men in their study [34]. Similarly, we found that these measurements were smaller in women than in men.

This study has few limitations. Arthroscopic correlation could not be performed for the included patients. Body mass index could not be evaluated due to the lack of height and weight information. Standard sequences were used to evaluate cartilage degeneration as specific sequences were not taken. Additionally, since our study was retrospective, clinical correlation with OA stage and MMPRT could not be performed.

In conclusion, as MMEA increases in patients with MMPRT, cartilage degeneration and loss increase. Cartilage loss accompanies when MMEA exceeds 4 mm. MMPRT is associated with PTM. Steeper medial tibial plateau is a risk factor for MMPRT.

Data availability: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to their containing information that could compromise the privacy of patients.

Conflict of interest: The authors declare that this study was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest. The content of the publication is entirely the authors’ responsibility, and the authors examined and edited it as necessary. Each author states that the submitted article, either in full or in part, has not been previously published or is not being assessed for publication as an original article in either printed form or as digital media.

Ethics Committee Approval: Ethics committee approval was received for this study from Ankara Bilkent City Hospital Ethics Committee 1, Faculty of Medicine, Health Sciences University (Ethics Committee Approval Number: E1-23-3233).

Funding: No funding was received for this study.

Author Contribution Statement

Eren Çamur: Conceptualization, Data collection and analysis, Methodology, Manuscript writing&editing

Semra Duran: Methodology, Manuscript review&editing

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No competing interests reported.

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Relationship of Medial Meniscus Posterior Root Tears with Proximal Tibial Morphology and Knee Osteoarthritis

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