FasT-Fix meniscal repair: mid-term results

All-arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears using the FasT-Fix device

PURPOSE

The FasT-Fix device (Smith and Nephew Endoscopy, Andover, MA), initially developed for knee meniscal tears, is described for all-arthroscopic triangular fibrocartilage complex (TFCC) repairs. Potential benefits of this technique are ease of use, the lack of prominent suture knots, and strength of repair. This case series evaluates the early clinical outcomes of this technique.

METHODS

We conducted a retrospective review of patients with TFCC Palmer type 1B injuries treated by 1 hand surgeon from 2005 to 2009. The patients' charts were reviewed for postoperative complications, range of motion, grip strength (percentage of contralateral), and return to full activity. In addition, each patient completed Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires.

RESULTS

Twelve patients had all-arthroscopic peripheral (1B) TFCC repairs using the FasT-Fix suture device. The mean follow-up period was 17.5 months (range, 11-27). Mean supination was 78° (± 14°), and mean grip strength was 64% (±16%) of the nonsurgical extremity by 3 months after surgery. All other range of motion was full. The mean QuickDASH score was 11 (±12), and the mean PRWE score was 19 (±14). Average time to full activity was 5 months. There were no surgical complications of the procedure. One patient complained of persistent ulnar-sided wrist pain 12 months after surgery and had an ulnar shortening osteotomy. Arthroscopy at the time of the osteotomy revealed that the TFCC was stable.

CONCLUSIONS

At mean 1-year follow-up, 11 out of 12 patients achieved excellent subjective outcomes based on QuickDASH and PRWE questionnaires. Although range of motion and grip strength were slightly decreased compared to prior case series reports, the short-term results indicate that the FasT-Fix all-arthroscopic, all-inside technique is a safe and effective technique for repair of Palmer type 1B TFCC tears.

Arthroscopic all-inside meniscal repair--Does the meniscus heal? A clinical and radiological follow-up examination to verify meniscal healing using a 3-T MRI

OBJECTIVE

The purpose of this study was to correlate clinical and radiological results using a 3-T MRI to verify meniscal healing after arthroscopic all-inside meniscus repair.

MATERIALS AND METHODS

We selected 27 patients (14 men and 13 women) with an average age of 31 ± 9 years and retrospective clinical examinations and radiological assessments using a 3-T MRI after all-inside arthroscopic meniscal repair were conducted. Repair of the medial meniscus was performed in 19 patients and of the lateral meniscus in eight. In 17 patients (63%), we performed concomitant anterior cruciate ligament reconstruction. The mean follow-up period was 4.5 ± 1.7 years. The Lysholm score and Tegner activity index were used for clinical evaluation. Four grades were used to classify the radiological signal alterations within the meniscus: central globular (grade 1); linear horizontal or band-like (grade 2); intrameniscal alterations and linear signal alterations communicating with the articular surface (grade 3); and complex tears (grade 4).

RESULTS

At follow-up, the average Lysholm score was 76 ± 15 points, with ten of the patients placed in group 6 based on the Tegner activity index. MRI examinations revealed no signal alteration in three patients, grade 1 in 0, grade 2 in five, grade 3 in 13, and grade 4 in six. The MRI findings correlated positively with the clinical scores in 21 patients (78%).

CONCLUSIONS

Correlation of clinical and radiological examination was performed using 3-T MRI. In spite of satisfactory clinical outcomes at follow-up, a radiological signal alteration may still be visible on MRI, which was believed to be scar tissue, but could not be proven definitively. Imaging with a 3-Tesla MRI after meniscal suture surgery provides good but no definitive reliability on meniscus healing and therefore gives no advantage compared to 1.5-T MRI, with good clinical outcome using an all-inside arthroscopic meniscal repair.

CLINICAL RELEVANCE

3T-MRI can not substitute diagnostic arthroscopy in patients with persistent complaints after arthroscopic all-inside meniscal repair.

Neurovascular safety and clinical outcome of outside-in repair of tears of the posterior horn of the medial meniscus

PURPOSE

The purpose of this study was to evaluate the safety and clinical outcome of a new posterior approach for the known outside-in technique for repair of tears of the posterior horn of the medial meniscus (PHMM).

METHODS

First, a cadaveric study was performed on 6 cadaveric knees to assess the safety of a point just lateral to the semitendinosus tendon as an entry point for outside-in repair. Dissection was done to measure the clearance of this point to the nearby popliteal bundle and saphenous nerve. A prospective case series study was then performed to assess the clinical outcome of such an approach. We treated 41 consecutive cases with PHMM tears by the outside-in technique using a shuttle relay method through the same point. Clinical assessments, magnetic resonance imaging findings, Lysholm scores, and International Knee Documentation Committee subjective scores were recorded for all patients. After a minimum postoperative period of 2 years, all cases were re-evaluated and re-scored.

RESULTS

The cadaveric study showed a mean clearance distance of 2.4 cm for the popliteal bundle and 4.6 cm for the saphenous nerve. The case series study was done on 41 meniscal repairs; 15 of 41 cases (37%) were performed in conjunction with anterior cruciate ligament reconstruction. There were 22 right knees (54%) and 19 left knees (36%). After a mean follow-up period of 27 months, patients showed a clinical success rate of 88% in terms of disappearance of pain, locking, and swelling, together with improved Lysholm scores (from 34 to 88) and International Knee Documentation Committee scores (from 25 to 88). These improvements were statistically significant (P < .05).

CONCLUSIONS

An outside-in repair technique with a posterior entry central to the semitendinosus tendon was used safely with 88% satisfactory clinical results for treatment of PHMM tears.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Outcomes of meniscal preservation using all-inside meniscus repair devices

BACKGROUND

The thrust of meniscal surgery has now moved toward meniscal preservation. Repair is particularly indicated on the lateral side where the sequelae of resection are severe even in an older patient population.

QUESTIONS/PURPOSES

The aim of this study was to analyze the success of all-inside meniscus repairs in a carefully selected patient population.

METHODS

Three hundred twelve repairs were performed in 288 patients with a mean age of 32 years (range, 17-46 years). One hundred seventy-one lateral menisci and 141 medial menisci were repaired. The minimum followup was 12 months (mean, 18 months; range, 12-55 months). Medicolegal cases, major trauma, and knee dislocations were excluded. Failure was defined as persistent meniscal symptoms beyond 16 weeks, an MRI diagnosis of a nonhealed meniscal tear beyond 52 weeks, reoperation for the meniscal tear, and failure to return to the patient's previous functional level.

RESULTS

There were three painful capsular sutures that required removal, two cases of complex regional pain syndrome, and two deep venous thromboses. The repair failed in 6% of cases with associated ACL reconstruction and 14.1% of cases without ACL reconstruction. Repeat surgery was typically performed at a mean of 16 months (range, 1-44 months).

CONCLUSIONS

At short-term followup, all-inside meniscus repairs have good outcomes in the majority of highly selected cases, although this was a very selected cohort with a large number of associated ACL reconstructions.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Practice patterns for combined anterior cruciate ligament and meniscal surgery in the United States

PURPOSE

The purpose of the study was to compare frequency of meniscal repair to partial meniscectomy in patients undergoing anterior cruciate ligament reconstruction using the American Board of Orthopaedic Surgeons (ABOS) database.

HYPOTHESES

(1) Practice patterns are similar with respect to geographic region. (2) Surgeons with fellowship training perform more meniscal repairs compared with general orthopaedic practitioners. (3) Younger patients are more likely to be treated with meniscal repair at the time of anterior cruciate ligament reconstruction. (4) The frequency of meniscal repair in conjunction with anterior cruciate ligament reconstruction has increased over time.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Information was extracted from the ABOS database from 2002 orthopaedic surgeons who sat for the part II examination from 2003 to 2007. The database was queried for all patients who underwent anterior cruciate ligament reconstruction (Current Procedural Terminology [CPT] code 29888) without or with meniscectomy (CPT 29881) or meniscal repair (CPT 29882). Factors affecting meniscal surgery that were investigated included patient age, geographic region of practice, fellowship training, and declared subspecialty of the surgeon.

RESULTS

On average there were 52,000 cases per year registered in the ABOS database, approximately 1700 of whom underwent anterior cruciate ligament reconstruction. Meniscal repair was most frequently performed in the Southwest region (18.6%, P < .001) and least frequently in the Northwest region (11.3%, P < .001). Combined anterior cruciate ligament reconstruction and meniscal repair was performed significantly more often by fellowship-trained surgeons (17%) than by surgeons with other fellowship training (12%) or no fellowship training (12%, P < .001) and in patients younger than age 25 years (19%) compared with those age 40 years and older (8%, P <.001). Meniscal repair was performed in 13.9% of anterior cruciate ligament reconstructions in 2003 and in 16.4% of anterior cruciate ligament reconstructions in 2007 (P > .05).

CONCLUSION

Combined anterior cruciate ligament reconstruction with meniscal repair was more frequent for younger patients and by surgeons with sports fellowship training. Concomitant meniscal repair is performed by fellowship-trained surgeons in this study in only 18% of anterior cruciate ligament reconstructions.

Repair integrity evaluated by second-look arthroscopy after arthroscopic meniscal repair with the FasT-Fix during anterior cruciate ligament reconstruction

BACKGROUND

Although several devices for meniscal repairs have become available, a successful outcome is ultimately due to a healed meniscus on the clinical findings. The authors assessed the repair integrity after meniscal repair with the FasT-Fix device using second-look arthroscopy.

HYPOTHESIS

Meniscal repair with the FasT-Fix will lead to arthroscopically evident healing, but some menisci will show incomplete healing even in clinically successful cases and have newly formed injuries on the meniscal substance resulting from the path of the implant.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Sixty-five consecutive patients were studied, in whom 84 menisci were subjected to all-inside meniscal repair with the FasT-Fix device in conjunction with anterior cruciate ligament reconstruction. Repair was only performed on longitudinal or double longitudinal tears within the red-red or red-white zone. The repaired menisci were evaluated by second-look arthroscopy at the time of staged hardware removal after anterior cruciate ligament reconstruction.

RESULTS

Sixty-two meniscal tears in 46 patients were available for this study. Eight patients were found to be symptomatic and considered to be clinical failures. The clinical success rate was 83%. At second-look arthroscopy, 46 tears (74%) were healed, 9 (15%) were healed incompletely, and 7 (11%) had failed. In the failed menisci, 1 had meniscal symptoms, while the other 6 were asymptomatic. In the 9 menisci with incomplete healing, 3 were associated with nonspecific knee pain but none showed meniscal symptoms. Newly formed injuries, which occurred in an area different from the original repair site, were confirmed on the surface of 19 menisci (35%) among the healed and incompletely healed menisci. Thirty menisci (48%) displayed successful and complete healing of the original tear site without newly formed tears.

CONCLUSION

Meniscal repair with the FasT-Fix in conjunction with anterior cruciate ligament reconstruction resulted in complete healing in 74% of cases. Eighty-three percent of menisci were symptom-free regardless of meniscal integrity. Even when the menisci repaired are asymptomatic and considered to be a clinical success, however, there may be newly formed injuries.

Meniscal repair using the FasT-Fix device in patients with chronic meniscal lesions

The aim of this prospective study was to evaluate meniscal suturing using the FasT-Fix device for chronic meniscal tears. This procedure was carried out on 25 patients between 2006 and 2007. Nineteen patients were male and the median age was 31 (14-47) years. The median waiting time to surgery was 27 (6-80) months and the median follow-up was 20 (14-29) months. Eleven patients (44%) required reconstruction of an associated anterior cruciate ligament (ACL) injury. 20 patients (80%) showed medial meniscus tears. All tears were located in the red zone or red-white zone. According to Barett's criteria, meniscal tear healing was achieved in 21 patients (84%). Lysholm and Tegner scale scores improved from 60 (47-77) preoperatively to 95 (58-100) postoperatively and from 3 (2-6) preoperatively to 6 (3-9) postoperatively, respectively. There were no neurovascular complications. Revision surgery was necessary in one patient, in whom a partial meniscectomy was performed. The results obtained suggest that chronic meniscal tears in the zones described can be healed.

Biomechanical testing of new meniscal repair techniques containing ultra high-molecular weight polyethylene suture

PURPOSE

To evaluate the biomechanical characteristics of current meniscal repair techniques containing ultra high-molecular weight polyethylene (UHMWPE) suture with and without cyclic loading.

METHODS

Vertical longitudinal cuts made in porcine menisci were secured with a single repair device. Noncycled and cycled (500 cycles) biomechanical tests were performed on the following groups: group 1, No. 2-0 Mersilene vertical suture (Ethicon, Somerville, NJ); group 2, No. 2-0 Orthocord vertical suture (DePuy Mitek, Westwood, MA); group 3, No. 0 Ultrabraid vertical suture (Smith & Nephew Endoscopy, Andover, MA); group 4, No. 2-0 FiberWire vertical suture (Arthrex, Naples, FL); group 5, vertically oriented mattress suture by use of an Ultra FasT-Fix device (Smith & Nephew Endoscopy) with No. 0 Ultrabraid; group 6, vertically oriented mattress suture by use of a RapidLoc A2 device (DePuy Mitek) with No. 2-0 Orthocord suture; group 7, vertically oriented stitch by use of a MaxFire device with MaxBraid PE suture (Biomet Sports Medicine, Warsaw, IN); and group 8, an obliquely oriented stitch of No. 0 UHMWPE suture inserted by use of a CrossFix device (Cayenne Medical, Scottsdale, AZ). Endpoints were failure loads, failure modes, stiffness, and cyclic displacement.

RESULTS

Mean single-pull loads were calculated for Ultra FasT-Fix (121 N), FiberWire (110 N), MaxFire (130 N), Mersilene (84 N), Orthocord (124 N), RapidLoc A2 (86 N), CrossFix (77 N), and Ultrabraid (109 N). After 500 cyclic loads, the Orthocord (222 N) repair was stronger than the others: Ultra FasT-Fix (110 N), FiberWire (117 N), MaxFire (132 N), Mersilene (89 N), RapidLoc A2 (108 N), CrossFix (95 N), and Ultrabraid (126 N) (P < .05). Ultrabraid suture showed significantly more elongation over 500 cycles than the other repairs (P < .05). The principal failure mode associated with the single destructive pull (suture breakage) changed to pulling through the meniscus after cyclic loading for most devices. Knot slippage or device failure was seldom observed as the failure mode with these techniques.

CONCLUSIONS

Self-adjusting, UHMWPE suture-containing meniscal repair devices (Ultra FasT-Fix, RapidLoc A2, and MaxFire) were comparable to the isolated UHMWPE-containing suture repairs on single-failure load testing. UHMWPE-containing suture repairs are stronger than braided polyester suture repairs, but pure UHMWPE suture (Ultrabraid) elongated more during cycling. Orthocord suture is significantly stronger than the other meniscal repair techniques after cyclic loading (P < .05).

CLINICAL RELEVANCE

Meniscal repair techniques using UHMWPE containing sutures provide greater strength than earlier generations of meniscal repair techniques.