Abstract
Background
Horizontal cleavage tears (HCTs) of the lateral meniscus are common injuries that can significantly affect knee biomechanics and increase stress on the anterior cruciate ligament (ACL). Understanding these changes is crucial for effective clinical management, as they can lead to joint instability and an increased risk of further injury. Finite element analysis (FEA) enables a detailed and non-invasive examination of these complex interactions.
Hypothesis/Purpose
The purpose of this study is to assess how partial HCTs of the lateral meniscus influence ACL stress. Using a validated finite element model, we aim to compare the mechanical implications of intact knees, knees with partial tears, knees with complete tears, and post-meniscus transplantation. We hypothesize that HCTs will increase contact pressures and decrease knee joint stability, thereby increasing stress on the ACL.
Methods
A detailed three-dimensional FEA model of the knee was developed, based on cadaveric CT anatomy. We analyzed four scenarios: intact knees, partial HCTs, complete tears, and meniscus transplantation under various axial loads (200 N, 400 N, 600N, 800 N) at both 0° and 30° of knee flexion. Key metrics evaluated included lateral meniscus contact pressures and von Mises stress in both the ACL and menisci, with careful extraction and analysis of stress distributions.
Results
Our findings indicated that complete lateral meniscus tears resulted in increased stress on the lateral meniscus and decreased contact pressure at the ACL, particularly under the highest load (800 N). While meniscus transplantation reduced some of the stress compared to the torn state, it did not fully restore biomechanical function to baseline levels. Notably, stress increases were more significant and pronounced with lateral tears than with cruciate injuries, highlighting the unique implications of lateral pathology.
Conclusion
This study confirms that lateral meniscus HCTs alter ACL stress, highlighting the importance of clinical awareness of these biomechanical implications in injury management. The results suggest that treatment strategies for lateral HCTs should prioritize preserving meniscal integrity to maintain knee joint function and stability.
Keywords: Horizontal cleavage tear, Lateral meniscus, Finite element analysis, Biomechanics
Background
Meniscal tears are among the most frequently encountered intra-articular knee injuries and are often categorized by their orientation, chronicity, and location [1]. Horizontal cleavage tears (HCTs), characterized by a longitudinal separation of the superior and inferior meniscal leaflets, are prevalent in middle-aged and older patients but are increasingly recognized in younger, active populations [2]. These tears frequently occur in the lateral meniscus, which plays a crucial role in maintaining knee joint stability, distributing load, and preserving cartilage health [1, 3–6].
Unlike radial or root tears, which often result in complete biomechanical failure due to hoop stress, HCTs present a more complex and variable pattern of dysfunction [2, 5]. They may initially spare contact mechanics but, when extensive or symptomatic, can alter load transmission and affect tibiofemoral congruency [7, 8]. Treatment options range from nonoperative management to surgical repair or partial meniscectomy, each carrying varying implications for joint kinematics and long-term outcomes [9–11].
The interplay between meniscal integrity and biomechanical knee stability has been studied, with prior work demonstrating that meniscus injuries can increase anterolateral rotational instability and induce changes in contact pressure in the medial and lateral compartments, especially in an anterior cruciate ligament (ACL)-deficient knee [12–18]. Similarly, prolonged delay to ACL reconstruction increases the risk of secondary meniscal injury, and graft choice, such as peroneus longus autograft and extra-articular procedures, can influence knee kinematics, bone content, and stability [18–22]. However, ACL repair may increase the risk of osteoarthritis, and one study showed that additional meniscal repair during ACL reconstruction did not affect muscle strength recovery, suggesting the need for further understanding of meniscus-ACL interactions [23–25]. While the impact of medial meniscus pathology on ACL mechanics has been explored in finite element models [26], the biomechanical consequences of lateral HCTs on ACL stress remain less well understood. Understanding these interactions is crucial for informed decision-making for preoperative planning and postoperative rehabilitation. For example, rehabilitation strategies such as aquatic and dry-land therapy, postural control, and neuromuscular strengthening play key roles in restoring musculature post ACL injury and meniscal repair [27–29].
Finite element analysis (FEA) simulates complex tissue interactions under controlled loading conditions [13, 30]. By adapting a previously validated cadaveric mesh to incorporate HCTs in the lateral meniscus, this study seeks to clarify how such injuries influence ACL stress.
Methods
A three-dimensional FE model of a human knee joint was developed and modeled from a cadaveric knee joint previously utilized in medial meniscus FE simulations using Ansys software (version 2022, Ansys, Inc., Canonsburg, PA, USA) [26]. The cadaveric knee was scanned using micro-computed tomography (Micro-CT). The bones’ surfaces were reconstructed and transformed into a surface mesh using Mimics software (version 24.0, Materialise, Leuven, Belgium). Accurate modeling of soft tissues requires high-resolution magnetic resonance imaging (MRI) to obtain an adequate number of slices for cartilage representation. However, cartilage surfaces were established with SpaceClaim software (version 2022, ANSYS, Inc., Canonsburg, PA, USA) by extending a layer from the bone surface using the skin surface feature. The generated cartilage layers were mesh-processed and integrated into the model. The mesh was refined to achieve appropriate element aspect ratios and sizing, resulting in a final model comprising approximately 101,000 elements. Convergence testing was conducted to validate the accuracy and stability of the simulation results.
The experimental conditions of the FE model were intact, partial HCT, complete meniscus tear, and partial transplantation of the lateral meniscus. A 2 cm long horizontal tear was made in the body of the lateral meniscus, covering 80% of its width. The complete tear was extended from the partial tear. To address this, a partial meniscectomy was performed to excise the damaged portion of the meniscus. A meniscal transplant condition was created by modifying the torn model to re-establish continuity and simulate the contact mechanics of a reconstructed meniscus, albeit with altered material properties. It utilized a meniscus allograft with varying material properties, primarily altered stiffness. All the bodies are linear isotropic, and these specific material properties are listed in Table 1 [26].
Table 1.
Material properties for the lateral meniscus FE model
All other boundary conditions were consistent with those employed in the experiment, including tibial fixation and loading conditions, across the four scenarios examined. Simulations were run in ABAQUS/Standard using static general steps. The contact between the meniscus and the tibia cartilage is frictional, with a coefficient of 0.04. Simulations were conducted at 0° and 30° flexion under axial compressive loads of 200 N, 400 N, 600 N, and 800 N, as shown in Fig. 1. An axial compressive load of 800 N was chosen based on research indicating knee joint contact forces during walking and stair activities can reach approximately 2–3 times body weight, which, for a 70–80 kg adult, corresponds to roughly 700–900 N [33]. Mechanical output variables included von Mises stress, mean contact pressure, strain, total deformation, and stress contour mapping at 0° and 30°, and peak contact stress at 0°.
Fig. 1.
Simulation model showing the knee at full extension (0°) and 30° degrees of flexion
Results
At 800 N axial load and 0° flexion, peak contact stress in the lateral meniscus increased from 1.397 MPa in the intact condition to 2.700 MPa in the partial HCT state and 2.835 MPa in the complete tear state. Meniscal transplantation reduced peak contact stress to 2.056 MPa, but this remained above intact values. Similar patterns were observed for contact pressure and strain. Total deformation was most significant in the partial tear and transplant conditions (0.154 mm and 0.163 mm, respectively), compared with intact and complete tear states (Table 2). At 30° of flexion, overall contact pressures in the lateral compartment were lower, but the relative behavior mimicked the pathology seen in 0° with highest pressures being in the complete tear (1.577 MPa). Total strain and deformation show the opposite pattern, with the intact meniscus deforming the most (0.36892 mm) and the complete tear having minimum deformation (0.0059 mm) despite the highest pressure (Table 3).
Table 2.
Lateral meniscus mechanical testing at 0° at load condition 800 N
| Condition | Peak contact stress (MPa) | Contact pressure (MPa) | Strain (mm/mm) | Total deformation (mm) |
|---|---|---|---|---|
| Intact | 1.397 | 1.4201 | 0.020234 | 0.060234 |
| Partial Tear | 2.7 | 2.214 | 0.022679 | 0.15357 |
| Complete Tear | 2.8351 | 2.134 | 0.023911 | 0.059047 |
| Transplant | 2.056 | 2.004 | 0.033213 | 0.16256 |
Table 3.
Lateral meniscus mechanical testing at 30° at load condition 800 N
| Condition | Contact pressure (MPa) | Strain (mm/mm) | Total deformation (mm) |
|---|---|---|---|
| Intact | 0.244 | 0.33185 | 0.36892 |
| Partial Tear | 0.539 | 0.026 | 0.153 |
| Complete Tear | 1.577 | 0.0023 | 0.0059 |
| Transplant | 0.458 | 0.033 | 0.162 |
ACL peak contact stress at 800 N and 0° flexion decreased from 2.053 MPa in the intact knee to 1.103 MPa in the partial tear state and 1.629 MPa in the complete tear state. The complete tear condition also exhibited the highest ACL contact pressure (2.344 MPa). Meniscus transplantation reduced ACL stress and deformation compared to the torn state, with a peak contact stress of 0.922 MPa (Table 4 and Fig. 2). Complete tears increased strain on the ACL from 0.0059915 to 0.06388 mm/mm, indicating a significant alteration in biomechanics.
Table 4.
ACL mechanical testing at load condition 800 N
| Condition | Peak contact stress (MPa) | Contact pressure (MPa) | Strain (mm/mm) | Total deformation (mm) |
|---|---|---|---|---|
| Intact | 2.0529 | 2.2635 | 0.0059915 | 0.057767 |
| Partial Tear | 1.1034 | 1.0453 | 0.0030713 | 0.04432 |
| Complete Tear | 1.629 | 2.3444 | 0.06388 | 0.056688 |
| Transplant | 0.92197 | 0.95312 | 0.0025706 | 0.040064 |
Fig. 2.
FEA stress mapping of the ACL under the four testing conditions (intact, horizontal cleavage tear (HCT), partial meniscectomy, and partial transplantation) at 0° knee flexion
Lateral meniscus von Mises stress at 0° flexion increased with load for all conditions. At 800 N, complete tears had the highest stresses (3.164 MPa), followed by intact (3.020 MPa), transplant (2.777 MPa), and partial tear (1.300 MPa). Lower loads (200–600 N) followed similar trends but with reduced magnitudes (Table 5 and Fig. 3). Across all loads at 30°, complete tears consistently have the highest von Mises stresses in the lateral meniscus, showing high stresses (1.846 MPa) while intact states stay close to 0 (0.045 MPa) at 200 N. This difference decreases with increased loading but is still present. The transplant has the lowest stresses at each load, especially at 200–400 N, (Table 6). Stress contour mapping of the lateral meniscus showed similar trends, including at 30º of knee flexion, where transplantation restored stress patterns (Fig. 4).
Table 5.
The lateral meniscus’ Von Mises maximum stress at 0° from Finite Element Analysis (MPa)
| Force | Intact | Partial tear | Complete tear | Transplant |
|---|---|---|---|---|
| 200 N | 2.85 | 2.6115 | 0.38842 | 3.1292 |
| 400 N | 2.535 | 2.409 | 0.3 | 2.8161 |
| 600 N | 2.7521 | 2.5689 | 0.88 | 2.8757 |
| 800 N | 3.02 | 3.1641 | 1.3 | 2.7774 |
Fig. 3.
FEA stress mapping of the lateral meniscus under the four testing conditions (intact, horizontal cleavage tear (HCT), partial meniscectomy, and partial transplantation) at 0° knee flexion
Table 6.
The lateral meniscus’ Von Mises maximum stress at 30° from Finite Element Analysis (MPa)
| Force | Intact | Partial tear | Complete tear | Transplant |
|---|---|---|---|---|
| 200 N | 0.045 | 0.015 | 1.846 | 0.0019 |
| 400 N | 0.272 | 0.13 | 2.425 | 0.0043 |
| 600 N | 0.887 | 0.45 | 2.607 | 0.26 |
| 800 N | 2.2713 | 1.086 | 2.723 | 0.83 |
Fig. 4.
Stress contour mapping of the meniscus across the four testing conditions (intact, horizontal cleavage tear (HCT), partial meniscectomy, and partial transplantation) at 0 (a–d) and 30 degrees (e–h) of knee flexion at 800 N applied force. The four conditions for 0 and 30 degrees are labelled
When examining the effects on the medial and lateral menisci, it was observed that the von Mises maximum stress in the lateral meniscus was generally higher than that in the medial meniscus for both intact and partial-tear conditions across various load levels. At a load of 800 N, the intact lateral meniscus exhibited a stress of 3.02 MPa, compared to 1.376 MPa for the medial meniscus. In cases of partial tears, the lateral meniscus demonstrated a stress of 3.164 MPa, while the medial meniscus showed a stress of 3.126 MPa. In contrast, medial complete tears resulted in slightly higher stress values than lateral tears, with measurements of 1.50 MPa versus 1.30 MPa, respectively. Additionally, medial transplant stresses were greater than those of the lateral meniscus at 800 N, measuring 3.37 MPa compared to 2.777 MPa (Table 7).
Table 7.
Comparison of medial and lateral meniscus’ Von Mises maximum stress at 0° from Finite Element Analysis (MPa)
| Force | Lateral | Medial | ||||||
|---|---|---|---|---|---|---|---|---|
| intact | Partial tear | Complete tear | Transplant | intact | Partial tear | Complete tear | Transplant | |
| 200 N | 2.85 | 2.6115 | 0.38842 | 3.1292 | 0.0012 | 0.15332 | 0.179 | 0.667 |
| 400 N | 2.535 | 2.409 | 0.3 | 2.8161 | 0.1633 | 0.8808 | 1.07 | 0.76497 |
| 600 N | 2.7521 | 2.5689 | 0.88 | 2.8757 | 0.625 | 1.9593 | 1.3 | 0.87174 |
| 800 N | 3.02 | 3.1641 | 1.3 | 2.7774 | 1.376 | 3.1256 | 1.5 | 3.37 |
Lateral tears demonstrated lower ACL peak contact stress than medial tears in both the torn and transplanted states, with intact values identical across compartments (Table 8).
Table 8.
Comparison of medial and lateral ACL peak contact stress at 0° in 800 N loading conditions
| Lateral | Medial | |
|---|---|---|
| Intact | 2.0529 | 2.0529 |
| Partial Tear | 1.1034 | 2.0634 |
| Complete Tear | 1.629 | 2.5776 |
| Transplant | 0.92197 | 1.76258 |
Discussion
This finite element analysis (FEA) demonstrates that lateral meniscus horizontal channel tears (HCTs) significantly alter the biomechanics of both the meniscus and the anterior cruciate ligament (ACL), with complete tears resulting in the most pronounced deviations from the mechanics of an intact knee. Consistent with previous studies on medial meniscus models [26], the disruption of the lateral meniscus resulted in elevated stresses, particularly under conditions of increased axial loads. The mobility of the lateral meniscus, along with its role in resisting anterior tibial translation, likely accounts for the observed changes in ACL stress, corroborating in vitro findings [12, 34].
Meniscus transplantation has been observed to reduce stresses in both the meniscus and the ACL compared to the states characterized by tears. This finding indicates a partial restoration of load distribution. However, the values obtained after transplantation did not reach those observed in intact tissues, suggesting that transplantation does not fully replicate the properties of native tissue. For example, in partial tears, native tissue can still carry load through remaining intact fibers. In transplantation, the mechanical behavior may be reset but not fully restored to a natural joint, affecting ACL stress. Also, the allograft’s altered material properties, geometry, and fixation may result in non-physiologic load distribution. This observation aligns with previously reported limitations concerning allograft stiffness and geometry [10, 35]. Notably, partial tears do not consistently yield intermediate outcomes relative to intact and complete tear states. In certain instances, such as total deformation, partial tears showed greater changes than complete tears, potentially reflecting altered load-sharing dynamics between undamaged and damaged meniscal tissues.
At 30° knee flexion, the posterior horn of the lateral meniscus translates posteriorly with loading, so pathology may be more evident [36]. The results indicate that complete HCTs concentrate load into a small, stiff segment of tissue, producing high contact pressure and Von Mises stress with minimal deformation at 30°. This is biomechanically unfavorable and suggests an increased risk of local tissue fatigue and cartilage overload during activities performed in flexion, such as squatting, pivoting, and stairs, which should be considered clinically. Transplantation may mitigate, but does not fully eliminate these abnormalities, as seen in the 0° results.
Interestingly, peak contact stresses in the ACL decreased with lateral meniscus HCTs but increased with medial meniscus HCTs. Conversely, the lateral meniscus saw a greater increase in von Mises stresses compared to the medial meniscus. These findings suggest that, under pure axial compression at full extension, medial tears may transmit relatively greater load to the ACL, while lateral tears concentrate more stress within the lateral meniscus tissue itself. This indicates that management priorities may differ by compartment: medial HCTs may pose a greater risk of ACL overload during compressive extension and may warrant strategies that specifically limit ACL load transfer, whereas lateral tears may require attention to restoring meniscal load-sharing to reduce local tissue stress.
Overall, these findings support early recognition and repair of symptomatic lateral HCTs, particularly in athletes and patients with ACL deficiency. Untreated or resected tears may increase the loading on the anterior cruciate ligament (ACL) and the meniscus, thereby potentially compromising the integrity of the ligament or adversely affecting the outcomes of reconstruction procedures. Given the significant prevalence of concomitant meniscal and ACL injuries [3, 9], these biomechanical interactions are directly pertinent to the planning of surgical interventions and the development of rehabilitation protocols. Conservative management has remained the first-line approach for many years; however, when instability or mechanical symptoms persist, surgical decisions should consider their impact on ACL loading [1, 2, 18, 37].
This study provides a valuable foundation for understanding knee joint mechanics, though it has limitations. Using a generic FE model derived from cadaveric geometry does not capture the specific anatomical variations found in individual patients. Additionally, the loading conditions were restricted to static axial compression at two selected flexion angles, omitting rotational forces and varus/valgus, which would have provided a more comprehensive analysis. However, the stress patterns identified in this study are consistent with previous in vitro and computational research, suggesting a strong correlation. Moving forward, incorporating patient-specific geometries, simulating dynamic activities, and exploring the long-term effects of graft remodeling would significantly enhance our understanding of these complex interactions and contribute to more personalized approaches in clinical practice.
Conclusions
The study investigates the biomechanical implications of HCTs in the lateral meniscus and their effects on ACL stress levels. The primary hypothesis is that partial HCTs will reduce stress on the ACL by altering joint mechanics.
Using a validated FE model, we evaluated four scenarios: intact knees, partial HCTs, complete tears, and after meniscus transplantation. This model was analyzed under different axial loads (200 N, 400 N, 600 N, and 800 N) at both 0° and 30° of knee flexion, allowing for a comprehensive understanding of the stress distribution throughout the knee.
The results indicated that complete tears of the lateral meniscus resulted in heightened stress on the meniscus itself and reduced contact pressure at the ACL. Meniscus transplantation provided some stress relief compared to the torn meniscus but did not fully restore the biomechanical function to baseline levels. Interestingly, the study found that lateral meniscus injuries increased meniscal contact pressure but had the opposite effect on ACL stress compared with medial meniscus injuries, highlighting the unique challenges posed by lateral pathologies.
Ultimately, the study concludes that HCTs in the lateral meniscus alter ACL stress, with implications for clinical management and treatment strategies. Preservation of meniscal integrity is crucial for maintaining knee stability and function, thereby informing rehabilitation protocols and surgical decisions for patients with these injuries.
Acknowledgements
Not applicable.
Abbreviations
- HCT
Horizontal cleavage tear
- ACL
Anterior cruciate ligament
- FEA
Finite element analysis
Author contributions
FA contributed to the conceptualization, FEA analysis, and manuscript writing. KE contributed to the study and writing of the manuscript. AH contributed to the analysis of the manuscript. JK contributed to the conceptualization and writing of the manuscript. All authors read and approved the final manuscript.
Funding
This project received no funding.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Hevesi M, Krych AJ, Kurzweil PR. Meniscus tear management: indications, technique, and outcomes. Arthroscopy J Arthrosc Relat Surg. 2019;35:2542–4. [DOI] [PubMed] [Google Scholar]
- 2.Lee JK, Lee MC, Kim JI, Lim S. Prognostic factors for the treatment of meniscus horizontal tear. Sci Rep. 2022;12:17293. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hoshino Y, Miyaji N, Nishida K, Nishizawa Y, Araki D, Kanzaki N, et al. The concomitant lateral meniscus injury increased the pivot shift in the anterior cruciate ligament-injured knee. Knee Surg Sports Traumatol Arthrosc. 2019;27:646–51. [DOI] [PubMed] [Google Scholar]
- 4.van der Wal WA, Meijer DT, Hoogeslag RAG, LaPrade RF. Meniscal tears, posterolateral and posteromedial corner injuries, increased coronal plane, and increased sagittal plane tibial slope all influence anterior cruciate ligament–related knee kinematics and increase forces on the native and reconstructed anterior cruciate ligament: a systematic review of cadaveric studies. Arthrosc J Arthrosc Relat Surg. 2022;38(5):1664-1688.e1. [DOI] [PubMed] [Google Scholar]
- 5.Forkel P, Herbort M, Schulze M, Rosenbaum D, Kirstein L, Raschke M, et al. Biomechanical consequences of a posterior root tear of the lateral meniscus: stabilizing effect of the meniscofemoral ligament. Arch Orthop Trauma Surg. 2013;133:621–6. [DOI] [PubMed] [Google Scholar]
- 6.Feucht MJ, Salzmann GM, Bode G, Pestka J, Kühle J, Südkamp NP, et al. Posterior root tears of the lateral meniscus. Knee Surg Sports Traumatol Arthrosc. 2015;23:119–25. [DOI] [PubMed] [Google Scholar]
- 7.Koh JL, Zimmerman TA, Patel S, Ren Y, Xu D, Zhang LQ. Tibiofemoral contact mechanics with horizontal cleavage tears and treatment of the lateral meniscus in the human knee: an in vitro cadaver study. Clin Orthop Relat Res. 2018;476(11):2262–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Koh J, Diaz RL, Tafur JC, Lin Y, Echenique DB, Amirouche F. Small chondral defects affect tibiofemoral contact area and stress: should a lower threshold be used for intervention? Orthop J Sports Med. 2022;10(11):23259671221129308. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Duong V, Oo WM, Ding C, Culvenor AG, Hunter DJ. Evaluation and treatment of knee pain: a review. JAMA. 2023;330(16):1568–80. [DOI] [PubMed] [Google Scholar]
- 10.Beamer BS, Walley KC, Okajima S, Manoukian OS, Perez-Viloria M, DeAngelis JP, et al. Changes in contact area in meniscus horizontal cleavage tears subjected to repair and resection. Arthrosc J Arthrosc Relat Surg. 2017;33:617–24. [DOI] [PubMed] [Google Scholar]
- 11.Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral meniscectomy on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med. 2010;38(8):1591–7. [DOI] [PubMed] [Google Scholar]
- 12.Willinger L, Athwal KK, Holthof S, Imhoff AB, Williams A, Amis AA. Role of the anterior cruciate ligament, anterolateral complex, and lateral meniscus posterior root in anterolateral rotatory knee instability: a biomechanical study. Am J Sports Med. 2023;51(5):1136–45. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Bao HRC, Zhu D, Gong H, Gu GS. The effect of complete radial lateral meniscus posterior root tear on the knee contact mechanics: a finite element analysis. J Orthop Sci. 2013;18(2):256–63. [DOI] [PubMed] [Google Scholar]
- 14.Shybut TB, Vega CE, Haddad J, Alexander JW, Gold JE, Noble PC, et al. Effect of lateral meniscal root tear on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med. 2015;43:905–11. [DOI] [PubMed] [Google Scholar]
- 15.Sihvonen R, Englund M, Turkiewicz A, Järvinen TLN. Mechanical symptoms and arthroscopic partial meniscectomy in patients with degenerative meniscus tear. Ann Intern Med. 2016;164(7):449–55. [DOI] [PubMed] [Google Scholar]
- 16.Smith PA, Bezold WA, Cook CR, Krych AJ, Stuart MJ, Wijdicks C, et al. Kinematic analysis of lateral meniscal oblique radial tears in the anterior cruciate ligament-deficient knee. Am J Sports Med. 2021;49:3898–905. [DOI] [PubMed] [Google Scholar]
- 17.Lemos T, Albarello JCS, Silva SC, Mozella AP. Quadriceps force fluctuation during maximal isometric contraction is altered in ACL injury and is associated with lower limb functional performance: a cross-sectional study with athletes. Muscles Ligaments Tendons J (MLTJ). 2024;14(3):499–506. [Google Scholar]
- 18.Maffulli N, Osti L. ACL stability, function, and arthritis: what have we been missing? Orthopedics. 2013;36(2):90–2. [DOI] [PubMed] [Google Scholar]
- 19.Giordano L, Maffulli N, Carimati G, Morenghi E, Volpi P. Increased time to surgery after anterior cruciate ligament tear in female patients results in greater risk of medial meniscus tear: a study of 489 female patients. Arthrosc J Arthrosc Relat Surg. 2023;39(3):613–22. [DOI] [PubMed] [Google Scholar]
- 20.Agrawal S, Atmananda SH, Seetharama Rao B, Mane PP, Shetty CB, Khanna V, et al. Peroneus longus tendon autograft for primary arthroscopic reconstruction of the anterior cruciate ligament. Muscles Ligaments Tendons J (MLTJ). 2023;13(2):252–8.
- 21.Migliorini F, Lucenti L, Mok YR, Bardazzi T, D’Ambrosi R, De Carli A, et al. Anterior cruciate ligament reconstruction using lateral extra-articular procedures: a systematic review. Medicina. 2025;61:294. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Rittweger J, Maffulli N, Maganaris CN, Narici MV. Reconstruction of the anterior cruciate ligament with a patella-tendon-bone graft may lead to a permanent loss of bone mineral content due to decreased patellar tendon stiffness. Med Hypotheses. 2005;64(6):1166–9. [DOI] [PubMed] [Google Scholar]
- 23.Maffulli N. The early versus late anterior cruciate ligament reconstruction debate: history teaches us that we cannot use reason and evidence to fight and win against conviction. Arthroscopy. 2018;34(9):2524–5. [DOI] [PubMed] [Google Scholar]
- 24.Ramjug S, Ghosh S, Walley G, Maffulli N. Isolated anterior cruciate ligament deficiency, knee scores and function. Acta Orthop Belg. 2008;74(5):643–51. [PubMed] [Google Scholar]
- 25.dos Santos Albarello JC, Torres Laett C, Soares de Palma AM, Mandarino M, Cavalcante da Silva S, Goes RA, et al. Associated ACL reconstruction and meniscal repair do not affect the evolution of isokinetic parameters in professional athletes: a prospective study with a one-year follow-up. Muscles Ligaments Tendons J (MLTJ). 2024;14(3):450–7.
- 26.Hussain A, Madraswala M, Koh J, Amirouche F. Anterior cruciate ligament mechanical response to load in the setting of changes to the medial meniscus. Bioengineering. 2025;12(1):74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Pipino G, Tomasi E, Mardones R, Tedesco A, Vaccarisi DC, Via AG, et al. Rehabilitation after anterior cruciate ligament reconstruction: dry land vs aquatic rehabilitation. Muscles, Ligaments Tendons J (MLTJ). 2023;13(3):421–9. [Google Scholar]
- 28.Papalia R, Franceschi F, Tecame A, D’Adamio S, Maffulli N, Denaro V. Anterior cruciate ligament reconstruction and return to sport activity: postural control as the key to success. Int Orthop (SICOT). 2015;39(3):527–34. [DOI] [PubMed] [Google Scholar]
- 29.Piedade SR, Leite Arruda BP, de Vasconcelos RA, Parker DA, Maffulli N. Rehabilitation following surgical reconstruction for anterior cruciate ligament insufficiency: what has changed since the 1960s?-State of the art. J ISAKOS. 2023;8(3):153–62. [DOI] [PubMed] [Google Scholar]
- 30.Liu W, Sun X, Liu W, Liu H, Zhai H, Zhang D, et al. Finite element study of a partial meniscectomy of a complete discoid lateral meniscus in adults. Med Eng Phys. 2022;107:103855. [DOI] [PubMed] [Google Scholar]
- 31.Morgan EF, Unnikrisnan GU, Hussein AI. Bone mechanical properties in healthy and diseased states. Annu Rev Biomed Eng. 2018;20:119–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Kim S, Koh J, Bedi A, Amirouche F. Lesion size location dependency on maximum pressure in osteochondral defects: experiments and finite-element analysis. Orthop J Sports Med. 2024;12(10):23259671241281735. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Sasaki K, Neptune RR. Individual muscle contributions to the axial knee joint contact force during normal walking. J Biomech. 2010;43(14):2780–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Lording T, Corbo G, Bryant D, Burkhart TA, Getgood A. Rotational laxity control by the anterolateral ligament and the lateral meniscus is dependent on knee flexion angle: a cadaveric biomechanical study. Clin Orthop Relat Res. 2017;475(10):2401–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Pérez-Blanca A, Espejo-Baena A, Amat Trujillo D, Prado Nóvoa M, Espejo-Reina A, Quintero López C, et al. Comparative biomechanical study on contact alterations after lateral meniscus posterior root avulsion, transosseous reinsertion, and total meniscectomy. Arthrosc J Arthrosc Relat Surg. 2016;32(4):624–33. [DOI] [PubMed] [Google Scholar]
- 36.Farivar D, Knapik DM, Vadhera AS, Condron NB, Hevesi M, Shewman EF, et al. Isolated posterior lateral meniscofemoral ligament tears show greater meniscal extrusion in knee extension, and isolated posterior lateral meniscal root tears show greater meniscal extrusion at 30° using ultrasound: a cadaveric study. Arthroscopy. 2023;39(8):1827-1837.e2. [DOI] [PubMed] [Google Scholar]
- 37.Petersen W, Karpinski K, Bierke S, Müller Rath R, Häner M. A systematic review about long-term results after meniscus repair. Arch Orthop Trauma Surg. 2022;142(5):835–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.