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Meniscus Allograft Transplantation: A Comparison of Medial and Lateral Procedures


Kyoung Ho Yoon, Sang Hak Lee, Soo Yeon Park, Hwan Jin Kim and Kee Yun Chung
Am J Sports Med 2014 42: 200 originally published online November 8, 2013
DOI: 10.1177/0363546513509057

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Meniscus Allograft Transplantation
A Comparison of Medial and Lateral Procedures
Kyoung Ho Yoon,* MD, Sang Hak Lee,* MD, Soo Yeon Park,y PhD,
Hwan Jin Kim,* MD, and Kee Yun Chung,*z MD
Investigation performed at Kyung Hee University Hospital, Seoul, Korea

Background: Because of the anatomic and biomechanical differences between the lateral and medial menisci, it is believed that
the indications, combined injuries, techniques, and outcomes of the 2 meniscus allograft transplantation (MAT) procedures may
be different.
Hypothesis: Medial meniscus transplantation (medial group) usually combines concomitant surgeries, such as anterior cruciate
ligament (ACL) reconstruction, so the medial group will have worse clinical results than the lateral group (lateral meniscus
transplantation).
Study Design: Cohort study; Level of evidence, 3.
Methods: A retrospective study was conducted on 91 patients who underwent MAT (lateral group, n = 56; medial group, n = 35).
There were 33 patients with an absence of a concurrent injury (isolated group) and 58 patients with the presence of a concurrent
injury (combined group). The mean follow-up was 40 months (range, 24-125 months). Clinical outcomes for range of motion
(ROM), visual analog scale (VAS) for pain score, International Knee Documentation Committee (IKDC) subjective score, Lysholm
score, and Tegner activity score were evaluated, and an objective evaluation was performed using magnetic resonance imaging
(MRI) and second-look arthroscopic surgery.
Results: At final follow-up, the mean results for ROM, VAS score, IKDC subjective score, Lysholm score, Tegner activity score,
and patient subjective satisfaction were not statistically different between the lateral and medial groups (P . .05). The VAS and
Lysholm scores of the isolated group were significantly better than those of the combined group. Follow-up MRI was performed
on 35 patients (24 in the lateral group and 11 in the medial group). Mean graft extrusion was 1.7 mm in the lateral group and
2.6 mm in the medial group (P = .075). The relative percentage of extrusion was 19.4% in the lateral group and 32.0% in the
medial group (P = .011). Anterior cruciate ligament reconstruction occurred more commonly in the medial group, and cartilage
procedures occurred more commonly in the lateral group.
Conclusion: The clinical results of the lateral group were not different from those of the medial group. More graft extrusion was
found in the medial group on MRI, and second-look arthroscopic surgery results of the lateral group were not as good as those of
the medial group. The VAS and Lysholm scores of the combined group were worse than those of the isolated group. With regard
to concomitant surgery, ACL reconstruction was most common in the medial group and cartilage procedures in the lateral group.
Keywords: knee; meniscus allograft transplantation; lateral vs medial group; isolated vs combined group

The meniscus transmits loading across the knee joints, of the knee joints, but it also has roles in lubrication and
improves articular congruency, and contributes to stability nutrition within the joint.13,15,16,26,29,31 Repair of the
meniscus is the first option if a torn meniscus is found.
z However, in irreparable cases, meniscectomy is usually
Address correspondence to Kee Yun Chung, MD, Department of
Orthopaedic Surgery, School of Medicine, Kyung Hee University, 1 necessary. If the meniscus is removed, then loading of
Hoegi-Dong, Dongdaemoon-Gu, Seoul 130-702, Korea (e-mail: opus73 the articular cartilage is increased, and degenerative
@hanmail.net). changes may consequently be induced.7,20 Meniscectomy
*Department of Orthopaedic Surgery, School of Medicine, Kyung Hee can cause degenerative changes of the knee joint, and the
University, Seoul, Korea.
y
Department of Physical Education, Graduate School of Education,
resected amount is proportional to the degeneration.
Yongin University, Yongin, Korea. Thus, meniscectomy is an important factor in determining
The authors declared that they have no conflicts of interest in the clinical outcomes.6,18,28 As our understanding of the func-
authorship and publication of this contribution. tion of the meniscus has grown, meniscus allograft trans-
plantation (MAT) has become a treatment method for
The American Journal of Sports Medicine, Vol. 42, No. 1
DOI: 10.1177/0363546513509057
symptomatic patients after meniscectomy.5,35 The aim of
2013 The Author(s) MAT is to reconstruct the load transmission system and

200
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Vol. 42, No. 1, 2014 Comparison of Medial and Lateral MAT 201

to restore the normal kinematics of the knee joints. Several


studies have reported that MAT increases the contact area
of the joints and reduces contact stress.22
The function and shape of the medial meniscus are dif-
ferent from those of the lateral meniscus. The medial
meniscus covers 64% of the medial tibial plateau, and it
transmits approximately 50% of the load. The lateral
meniscus covers 84% of the lateral tibial plateau, and it
transmits approximately 70% of the load.29 In addition,
the medial tibial plateau is concave, and the contact area
around the medial femoral condyle is relatively wide; how-
ever, the lateral tibial plateau is convex, and so in the
absence of the lateral meniscus, the load from the lateral
femoral condyle is concentrated in a small area. Clinically,
a defect in the lateral meniscus induces faster degenera-
tive changes and clinical symptoms than a defect in the
medial meniscus.16,25,30
Meniscus allograft transplantation can be performed in
both the medial and lateral menisci. In general, the pri- Figure 1. Flow chart of meniscus allograft transplantation.
mary complaint of patients as an indication for MAT is
pain.1 However, in the medial group, instability is another medial group, for a total of 58 cases. The mean age of
important indication as well as pain.14,21 Some investiga- patients in the lateral group was 33.9 years (range, 18-51
tors have reported that the outcomes of lateral MAT may years), and there were 42 male patients and 14 female
be better than those of medial MAT, but this is still patients in the lateral group. The mean age of patients in
unclear.30 Moreover, some investigators have reported the medial group was 32.9 years (range, 19-46 years),
that lateral MAT may be relatively more advantageous and the group included 29 male patients and 6 female
than medial MAT, and even preventive transplantation patients. The mean interval from meniscectomy to MAT
has been considered.27 was 41.0 months (range, 1-243 months) in the lateral
Our hypothesis was that medial MAT would have worse group, and that of the medial group was 30.3 months
clinical results than lateral MAT because of concomitant (range, 1-194 months). The mean follow-up of the lateral
surgery. Also, patients who underwent MAT only would group was 3.3 years (range, 3-10 years), and that of the
have better results than patients who underwent MAT medial group was 3.5 years (range, 2-10.5 years). The
with other combined procedures for concurrent injuries in demographics of the patients are summarized in Table 1.
the knee joint. Therefore, we compared and analyzed the There were no differences between the groups except for
clinical results of lateral MAT and medial MAT. In addition, the proportion of isolated and combined procedures in
the clinical results according to the presence or absence of each group. In the medial group, combined injuries were
concurrent injuries were compared and analyzed. more common (P = .003).

MATERIALS AND METHODS Preoperative Sizing and Operative Technique

Patients Fresh-frozen meniscus allografts were used in all the


cases. The surgeries were performed by a single surgeon.
A total of 98 patients underwent MAT between March Concerning the surgical methods, the keyhole method in
2000 and February 2010 at our university hospital. Seven the lateral group and the bone plug method in the medial
patients were excluded for the following reasons: lost to group were applied.
follow-up before 24 months postoperatively (5 patients) For sizing the graft, magnetic resonance imaging (MRI)
and underwent revision surgery (2 patients). Patients was performed before surgery. Sizing was performed in the
who had surgery for a concurrent injury were included. axial cut of the tibial plateau, which shows the meniscus.
Accordingly, 91 patients were evaluated retrospectively The width of the lateral tibial plateau from the lateral tib-
(Figure 1). Ethical approval for the study was obtained ial spine to the edge of the tibial condyle was the same as
from the authors institutional review board. the width of the allograft. The length from the anterior
There were 56 cases of lateral MAT (lateral group) and to posterior root of the medial meniscus was the same as
35 cases of medial MAT (medial group). Twenty-seven the length of the allograft. There was 5% of mismatching
patients underwent only MAT (isolated group) in the lat- that was allowed.
eral group, and 6 patients underwent only MAT in the For lateral meniscus transplantation (LMT), prepara-
medial group, and thus, there was a total of 33 patients tion of the remnant was performed arthroscopically. About
who underwent isolated MAT. There were 29 patients 1 to 2 mm of the peripheral rim of the meniscus was pre-
who were treated for concurrent injuries in parallel with served for healing of the graft. After preparation of the
MAT (combined group) in both the lateral group and remnant, mini-arthrotomy for graft insertion was

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202 Yoon et al The American Journal of Sports Medicine

TABLE 1
Patient Demographics

Lateral Group (n = 56) Medial Group (n = 35) P Value

Concurrent injury, isolated:combined, n 27:29 6:29 .003


Sex, male:female, n 42:14 29:6 .443
Age, mean (range), y 33.9 (18-51) 32.9 (19-46) .563
Operative technique Keyhole Bone plug
Follow-up, mean (range), y 3.3 (3-10) 3.5 (2-10.5) .751
Interval from total meniscectomy to meniscus transplantation, mean (range), mo 41.0 (1-243) 30.3 (1-194) .313

performed just beside the patellar tendon and below the Clinical Assessment
anterolateral portal in the fully extended knee. A tibial tun-
nel guide was inserted into the arthrotomy site, and a guide Patients were followed up at 6 weeks, 6 months, and 12
wire was positioned under the C-arm image intensifier. A months after surgery and then annually thereafter. For
bone tunnel with a 10-mm diameter was created using evaluation of the clinical results, ROM, the visual analog
a core reamer. The roof of the bone tunnel was removed scale (VAS) for pain score, the International Knee Docu-
using a rongeur and bur to create a keyhole-shaped tunnel. mentation Committee (IKDC) subjective score, the Lysholm
The tunnel was finally checked by a slot sizer. The joint cap- score, and the Tegner activity score before surgery and at
sule was exposed by a posterolateral approach, and a pass- the time of the last follow-up were compared; subjective sat-
ing wire was inserted from the posterolateral capsule to the isfaction (completely satisfied, mostly satisfied, satisfied,
anterolateral arthrotomized opening. Nonabsorbable lead- mostly unsatisfied, completely unsatisfied) was compared,
ing sutures were anchored to the posterior horn of the graft, and the results of follow-up MRI were also compared.
and the graft was inserted into the slot by a passing wire.
Traditional inside-out sutures for graft fixation using 8 to Objective Assessment
10 double-arm needles were placed.
For medial meniscus transplantation (MMT), preservation Postoperative MRI was performed with the patient in
of the peripheral remnant was performed arthroscopically. a nonweightbearing and supine position. All MRI examina-
An anterior cruciate ligament (ACL) tibial guide was inserted, tions were performed using a 3-T MRI scanner (Philips
and a guide pin was also inserted into the native posterior Intera Achieva 3.0 T, Philips Healthcare, Best, the Nether-
horn of the medial meniscus through the posterolateral, post- lands) or a 1.5-T MRI scanner (GE Optima 1.5 T, GE
eromedial, and transseptal portals. The tunnel was created, Healthcare, Little Chalfont, United Kingdom). Magnetic
and the cartilage fragment was removed for firming fixation resonance imaging was performed at least 1 year after sur-
and good healing of the graft. The anterior tunnel was created gery. Extrusion was measured by absolute extrusion and
in the same way. A passing wire was inserted from the poste- relative extrusion. Absolute extrusion was defined as
rior bone tunnel to the anteromedial portal, and the anterior 3-mm extrusion of the graft. The relative percentage of
portal was enlarged for passing the graft. The graft was pre- graft extrusion was used to define relative extrusion of
pared to create a meniscus with bone plugs. The graft was the graft (Figure 2). Two independent investigators
inserted using a passing wire through the enlarged anterome- (H.J.K. and K.Y.C.) checked the MRI scans. Intraobserver
dial portal. Bone plugs were firmly inserted into the posterior and interobserver reliability was assessed using the intra-
and anterior tunnels. Traditional inside-out sutures for graft class correlation coefficient. In this study, the intraclass
fixation using 8 to 10 double-arm needles were placed. The correlation coefficient of all measurements was .0.810
anterior and posterior bone plug stitches were tied firmly for both intraobserver and interobserver reliability.
together and post-tied with staples.
There were no differences in rehabilitation between the Statistical Analysis
2 groups. A continuous passive motion machine was used
for range of motion (ROM) exercises from 1 day after sur- SPSS software (version 12.0, SPSS Inc, Chicago, Illinois)
gery: 0 to 60 during the first 3 weeks, up to 90 during was used for statistical analysis. Statistics are presented
weeks 4 to 6, up to 120 until 12 weeks, and full flexion as the mean 6 standard deviation. Paired t tests were
after 3 months. used for comparison of the preoperative results and the
Ambulation was started with partial weightbearing results of the last follow-up. Student t tests and Pearson
with the fully extended knee in a brace by 3 weeks after x2 tests were used for comparing the results of the lateral
surgery. Full weightbearing was possible by 4 to 6 weeks. group with those of the medial group as well as comparing
Crutches were used until 6 weeks after surgery. After 6 the results of the isolated group with those of the combined
weeks, full weightbearing and noncrutch ambulation group. The Spearman correlation test was used for check-
were possible with the fully extended joint in a brace. After ing the correlation between the relative percentage of
3 months, ambulation without crutches and a brace was extrusion and clinical scores. P values \.05 were consid-
possible. ered statistically significant.

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Vol. 42, No. 1, 2014 Comparison of Medial and Lateral MAT 203

TABLE 2
Preoperative and Postoperative Clinical
Outcomes in All 91 Patientsa

Preoperative Last Follow-up


Outcome Score Score P Value

ROM, deg 141.0 6 10.7 138.2 6 11.6 .115


VAS 5.0 6 2.4 3.3 6 2.1 \.001
IKDC (subjective) 52.2 6 16.7 67.6 6 17.7 \.001
Lysholm 63.5 6 16.8 76.5 6 14.4 \.001
Tegner 2.4 6 1.0 4.2 6 1.6 \.001

a
Values are expressed as mean 6 standard deviation. IKDC,
International Knee Documentation Committee; ROM, range of
motion; VAS, visual analog scale.

a difference was not seen between the groups. Similarly,


there was a difference in the mean preoperative Tegner
activity score between the groups (lateral, 2.6; medial,
2.1; P = .017). The score of both groups significantly
improved at the last follow-up, but a difference between
the 2 groups was not observed.
With regard to surgery for the treatment of concurrent
Figure 2. Measurement of extrusion. (a) Absolute extrusion. injuries, there were 21 cases of ACL reconstruction, 10
(b) Total length of the graft. Relative percentage of graft cases of autologous chondrocyte implantation, 5 cases of
extrusion (RPE) = (a/b) 3 100. simultaneous autologous chondrocyte implantation and
ACL reconstruction, 2 cases of high tibial osteotomy, and
4 cases of microfracture in the medial group. In the lateral
RESULTS group, there were 11 cases of ACL reconstruction, 2 cases
of posterior cruciate ligament reconstruction, 11 cases of
Overall Results autologous chondrocyte implantation, and 12 cases of
microfracture (Table 4).
The mean ROM was slightly decreased from 141.0 6 10.7
preoperatively to 138.2 6 11.6 postoperatively, but it was
not significantly different (P = .115). The VAS score, IKDC Comparison Between Isolated and Combined Groups
subjective score, Lysholm score, and Tegner activity score
improved, and differences were statistically significant. The results of the isolated group and the combined group
The clinical results before surgery and at the last follow- are summarized in Table 5. The mean ROM at the last
up are summarized in Table 2. follow-up was slightly lower than that before surgery in
both groups, but the difference was not statistically
significant.
Comparison Between Lateral and Medial Groups The mean VAS score significantly decreased in both
groups at the last follow-up. A difference between the
All the values measured before surgery and at the last groups was not seen in the mean preoperative score, but
follow-up of the 2 groups were not significantly different it was significantly different at the last follow-up (isolated,
except the Lysholm and Tegner scores before surgery 2.7; combined, 3.7; P = .039; observed power a = .693). The
(Table 3). The mean ROM at the last follow-up was slightly mean IKDC subjective score significantly improved in the
lower than that before surgery, but the difference was not 2 groups. A significant difference between the 2 groups
statistically significant. The difference in ROM between was seen in the mean preoperative score (isolated, 57.6;
the lateral and medial groups was not statistically differ- combined, 49.1; P = .019; a = .768), but no significant dif-
ent. The mean VAS score at the last follow-up decreased ference was seen at the last follow-up. The mean Lysholm
significantly from the preoperative mean VAS score in score significantly improved in both groups at the last
both groups; nevertheless, a difference between the 2 follow-up. A difference between the groups was not seen
groups was not shown. The mean IKDC subjective score in the mean preoperative score, but it was significantly dif-
improved from preoperatively to postoperatively in both ferent at the last follow-up (isolated, 80.5; combined, 74.2;
groups, but a statistical difference between the groups P = .022; a = .700). The mean Tegner activity score signif-
was not shown. With regard to the mean Lysholm score, icantly improved in the 2 groups. A significant difference
there was a difference between the 2 groups preoperatively between the 2 groups was seen in the mean preoperative
(lateral, 66.9; medial, 58.0; P = .014). The score of score (isolated, 2.8; combined, 2.1; P = .010; a = .89), but
both groups significantly improved after surgery, but no significant difference was seen at the last follow-up.

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204 Yoon et al The American Journal of Sports Medicine

TABLE 3
Comparison of Outcome Scores Between the Lateral Group and Medial Groupa

Preoperative Score Last Follow-up Score

Outcome Lateral Medial P Value Lateral Medial P Value

ROM, deg 140.3 6 10.1 142.3 6 11.7 .386 137.3 6 11.7 139.6 6 11.5 .372
VAS 4.8 6 2.4 5.3 6 2.4 .339 3.1 6 2.0 3.6 6 2.4 .243
IKDC (subjective) 53.2 6 16.0 50.6 6 17.9 .467 69.2 6 18.1 65.1 6 16.9 .273
Lysholm 66.9 6 16.0 58.0 6 17.0 .014 76.6 6 14.3 76.2 6 14.6 .887
Tegner 2.6 6 1.1 2.1 6 0.6 .017 4.1 6 1.6 4.2 6 1.5 .885

a
Values are expressed as mean 6 standard deviation. IKDC, International Knee Documentation Committee; ROM, range of motion; VAS,
visual analog scale.

TABLE 4
Concomitant Proceduresa

ACL PCL ACI Microfracture HTO Isolated MAT

Medial group 21 (60) 0 (0) 10 (28) 4 (11) 2 (6) 6 (17)


Lateral group 11 (20) 2 (3) 11 (20) 12 (21) 0 (0) 27 (48)

a
Values are expressed as n (%). ACI, autologous chondrocyte implantation; ACL, anterior cruciate ligament reconstruction; HTO, high
tibial osteotomy; MAT, meniscus allograft transplantation; PCL, posterior cruciate ligament reconstruction.

TABLE 5
Comparison of Outcome Scores Between the Isolated Group and Combined Groupa

Preoperative Score Last Follow-up Score

Outcome Isolated Combined P Value Isolated Combined P Value

ROM, deg 143.5 6 5.5 139.6 6 12.6 .102 137.4 6 12.7 138.6 6 11.0 .640
VAS 4.2 6 2.3 5.2 6 2.4 .169 2.7 6 1.9 3.7 6 2.3 .039
IKDC (subjective) 57.6 6 16.1 49.1 6 16.5 .019 69.8 6 18.1 66.3 6 17.5 .362
Lysholm 60.2 6 19.6 65.3 6 14.9 .194 80.5 6 9.8 74.2 6 16.0 .022
Tegner 2.8 6 1.3 2.1 6 0.7 .010 4.3 6 1.5 4.2 6 1.6 .736

a
Values are expressed as mean 6 standard deviation. IKDC, International Knee Documentation Committee; ROM, range of motion; VAS,
visual analog scale.

Follow-up MRI in the lateral group and in 4 of 11 cases (36.4%) in the


medial group, but the difference was not statistically sig-
Follow-up MRI was performed between 6 months and 10 nificant (P = .689).
years after surgery in 35 cases (24 cases in the lateral
group and 11 cases in the medial group) (Figure 3). Mean
extrusion of the transplanted allograft was 1.7 mm in the Complications and Second-Look
lateral group and 2.6 mm in the medial group, but it was Arthroscopic Surgery
not statistically different (P = .075). The relative percent-
age of graft extrusion was 32.0% in the medial group and Second-look arthroscopic surgery was performed in 27
19.4% in the lateral group, and it was statistically signifi- cases (14 cases in the lateral group and 13 cases in the
cant (P = .011; a = .807). The correlations between the rel- medial group) between 3 months and 7 years after surgery.
ative percentage of graft extrusion and clinical scores were The indications for second-look arthroscopic surgery were
assessed (Table 6). The Lysholm score was significantly a painful knee with a suspected meniscus tear and removal
correlated in both groups (lateral, 0.445; medial, of the staple for post-tie. In 4 cases that underwent simul-
0.670), and the Tegner activity score was significantly taneous autologous chondrocyte implantation and lateral
correlated in the medial group (0.816). Absolute extrusion MAT, the complex tear could not be repaired, and thus,
(ie, extrusion .3 mm) was present in 6 of 24 cases (25.0%) the transplanted allograft was removed.

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Vol. 42, No. 1, 2014 Comparison of Medial and Lateral MAT 205

Figure 3. Magnetic resonance imaging at follow-up: extrusion (white arrow) of the transplanted (A) lateral meniscus allograft and
(B) medial meniscus allograft.

TABLE 6 symptomatic. In a similar study, Lee et al12 compared


Correlation Between Relative Percentage of the clinical outcomes of extruded and nonextruded menis-
Graft Extrusion and Clinical Scoresa cus allografts. They reported a mean extrusion of 3 mm but
no effect of meniscus extrusion on knee function. The
VAS IKDC Lysholm Tegner degree of meniscus extrusion remained stable after 1
b year. Kim et al11 reported MRI and arthroscopic results
Lateral group 0.354 0.145 0.445 0.029
Medial group 0.033 0.506 0.670b 0.816b
of MAT, and 89% of their patients had fair to satisfactory
results.
a
IKDC, International Knee Documentation Committee; VAS, The difference in the clinical outcomes of lateral and
visual analog scale. medial MAT has not been firmly established. Cole et al5
b
Statistically significant (P \ .05). reported that for 40 cases of MAT that were followed up
for longer than 2 years, when comparing the medial group
with the lateral group, the 2 groups were not statistically
DISCUSSION different; but there was a tendency for the results of the
lateral group to be better. Farr et al8 reported that when
According to observations at a minimum 2-year follow-up, comparing the medial group with the lateral group, the
MAT is an effective method to reduce the pain caused by preoperative Lysholm score of the medial group was lower,
meniscus deficiency and to improve the function of the but the postoperative results were not different. They also
knee joint. The clinical results of lateral MAT and medial reported that the VAS score of the lateral group showed
MAT were equivalent. The follow-up MRI findings of lat- a tendency to be high. Verdonk et al35,36 found a 72% suc-
eral MAT showed less extrusion of the graft than that of cess rate for medial meniscus allografts but a 63% success
the medial graft. The clinical results of the isolated group rate for lateral grafts. However, in this study, significant
were better than those of the combined group. For the inci- differences in the clinical results were not observed
dence of concomitant surgery, ACL reconstructions were between the lateral group and the medial group, but the
more frequent in the medial group, and cartilage proce- lateral group showed a tendency to have a better IKDC
dures were more frequent in the lateral group. subjective score at last follow-up, which is believed to be
Since Milachowski et al17 reported an 86% success rate because the postoperative VAS score was relatively lower
of isolated MAT, good results at 2- to 3-year short-term in the lateral group. Nonetheless, in the medial group,
follow-up have been reported, and particularly, it is known the number of isolated procedures was small, and interpre-
to effect pain relief.4,5,8,19 Cole et al4 have reported notice- tation was difficult because of the difference in the type
able pain relief in 88% of their patients and functional and number of concurrent injuries between the 2 groups.
improvement in 95% of the patients after MAT using In this study, the primary indication of LMT was pain.
fresh-frozen dried allografts at 2 years follow-up. van However, in cases of MMT, instability was also an impor-
Arkel and de Boer34 have also reported an 87% success tant indication (not only pain as in LMT). There were
rate at 2- to 5-year follow-up. almost 2 times the number of ACL reconstructions in the
Magnetic resonance imaging or arthroscopic surgery medial group than in the lateral group. However, cartilage
has been used to evaluate objective results of MAT. Potter procedures were more common in the lateral group than in
et al24 reported meniscus degeneration in 63% of patients. the medial group (Table 4). Instability after meniscectomy
All patients in their series with graft extrusion were has been well defined,9,13,33 and Spang et al32 reported

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206 Yoon et al The American Journal of Sports Medicine

restored kinematics after MMT. Lubowitz et al14 also rec- graft. For the incidence of concomitant surgery, ACL recon-
ommended concomitant ACL reconstruction and MAT for structions were more frequent in the medial group. The clini-
menisectomized ACL-deficient knees. cal results of the isolated group were better than those of the
The operative techniques were different between LMT combined group in terms of VAS and Lysholm scores.
and MMT. In LMT, keyhole methods are usually used, so
it is possible to fix the graft firmly in the tibial plateau.
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