Deteriorating outcomes after meniscal repair using the Meniscus Arrow in knees undergoing concurrent anterior cruciate ligament reconstruction: increased failure rate with long-term follow-up

Arthroscopic all inside repair of the lateral meniscus root tear

It has been reported that lateral meniscus tears, including posterior horn tears, stable radial flap tears, or peripheral or posterior third tears that are combined with an Anterior Cruciate Ligament (ACL) injury can be treated with being left in situ. However, our experience has shown that the tear patterns are not so simple. They can show complex configurations and the inner side can be lost in chronic cases. Regarding the repair technique, there has been some controversy concerning the follow up results with repair devices and reduction is difficult using these devices if the inner side is non-viable or lost. If the tear involves whole width of bony insertion, it is believed that the meniscal function would be lost, particularly because the anatomic configuration is different in this area. In cases of chronic inner loss types, the meniscus was repaired using a side to side repair or pull out repair technique. Complete healing was achieved using this technique in some patients. Conclusively, Posterior Lateral Meniscus Root Tear (PLMRT) must be managed with different method with tears of other areas because the tear configuration is complex than simple looking.

FasT-Fix meniscal repair: mid-term results

PURPOSE

The purpose of this study was to evaluate the clinical success of the FasT-Fix meniscal repair device (Smith & Nephew Endoscopy, Andover, MA) associated with an accelerated rehabilitation program.

METHODS

A prospectively collected consecutive series of meniscal repairs performed with the FasT-Fix device was studied. The Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee activity scores, along with the clinical examination findings and adverse events, were recorded for all patients. Associated procedures were recorded. An accelerated postoperative rehabilitation program was followed, independent of concurrent anterior cruciate ligament surgery.

RESULTS

Forty-one meniscal repairs were performed, with an average follow-up of 30.7 months (range, 12 to 58 months). Twenty-nine of 41 repairs were performed in conjunction with anterior cruciate ligment reconstruction. The other repairs were in stable knees. There were 26 medial and 15 lateral meniscus repairs. Both menisci were repaired in 5 knees. Repeat arthroscopies were performed for 12 repairs and 7 (17%) were found to have failed. The preoperative and postoperative Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee activity scores were 47.3 and 87.4, 3.4 and 7.2, 38.7 and 82.8, and 2.3 and 3.4, respectively.

CONCLUSIONS

The FasT-Fix meniscal repair associated with an accelerated rehabilitation program resulted in clinically effective meniscal repair in 83% at the time of follow-up. Clinical outcome measures all improved.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Comparison of arthroscopic meniscal repair results using 3 different meniscal repair devices in anterior cruciate ligament reconstruction patients

PURPOSE

The goal of this study was the clinical evaluation of arthroscopic meniscal repair results with the use of 3 different repair devices.

METHODS

From 2001 to 2006, 265 patients underwent 280 meniscal repairs (RapidLoc [DePuy Mitek, Raynham, MA] in 88 patients, T-Fix [Acufex Microsurgical, Mansfield, MA] in 85 patients, and FasT-Fix [Smith & Nephew Endoscopy, Andover, MA] in 92 patients). There were 181 medial and 99 lateral tears; 174 tears were located in Cooper radial zone 1, and 106 tears were in Cooper radial zone 2. All patients had associated anterior cruciate ligament reconstructions. Follow-up assessment included clinical examination, arthrometry (KT-1000; MEDmetric, San Diego, CA), International Knee Documentation Committee scores, and scores on Lysholm functional questionnaires. Clinical criteria for a successful result included the absence of joint line tenderness, swelling, and blocking and the presence of a negative McMurray test.

RESULTS

The mean follow-up was 24.5 months (range, 20 to 26 months). Tear length averaged 3.17 cm (range, 1.4 to 4 cm). A mean of 2.4 suture devices was used. On the basis of our criteria, 28 meniscus repairs were considered to be failures (success rates of 92.4% for FasT-Fix, 87% for T-Fix, and 86.5% for RapidLoc). There were 16 relook arthroscopies for device removal and partial meniscectomy, with 11 patients (68.7%) having failure of the meniscal repair in zone 2. Both the Lysholm and International Knee Documentation Committee scores were significantly improved. Chronicity or location of the tear, length of the tear, and patient age did not affect the clinical outcome.

CONCLUSIONS

The compared meniscal repair systems showed comparable clinical results. These meniscal repair systems appeared to be safe and effective, providing a high rate of meniscal healing both in patients with complex tears and in patients with tears located in Cooper radial zone 2.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective comparative study.

Meniscal repair using an all-inside, rapidly absorbing, tensionable device

PURPOSE

The purpose of this study was to evaluate the clinical success rate of all-inside meniscal repairs using a rapidly absorbing device in patients undergoing concurrent anterior cruciate ligament (ACL) reconstructions.

METHODS

Patients with menisci repaired using the polydioxanone Mitek RapidLoc (Depuy Mitek, Raynham, MA) during concurrent ACL reconstruction were evaluated clinically 2 years following index surgery. We performed examinations on 38 meniscal tears in 30 patients using the International Knee Documentation Committee form and the Knee Disorders Subjective History visual analog scale. We also performed physical examinations for an effusion, joint line tenderness, McMurray's testing, and KT-1000 arthrometry (MEDmetric, San Diego, CA).

RESULTS

The clinical success rate for meniscal repair was 86.8% (33 of 38) at a mean follow-up of 30.4 months (range, 21 to 56 months). Univariate analysis revealed sex as the only predictive variable for failure; all failures occurred in male patients. Nonpredictive variables included tear length, type, and configuration; a duration of more than 3 months, compartment, zone, ligament graft choice, age, follow-up, Tegner score, and visual analog scale score.

CONCLUSIONS

The polydioxanone RapidLoc device was found to have a clinical success rate of 86.8%. These data suggest that the more rapidly absorbing polydioxanone device is effective for all-inside meniscal repair during concurrent ACL reconstruction.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Meniscal repair techniques

The human meniscus is important for normal knee function and distributes loads, aids in joint lubrication, congruence, stability, and proprioception. Repair of appropriate meniscal tears is possible and several methods exist to accomplish this including suture repairs and device repairs. Clinical evidence suggests that meniscal repairs can result in acceptable healing rates although adverse events have been reported for some devices. New self-adjusting suture devices have facilitated the accurate and effective repair of the torn meniscus. Technique descriptions for these devices are presented.

Arthroscopic all-inside repair using the Meniscus Arrow: long-term clinical follow-up of 113 patients

PURPOSE

A clinical trial was carried out to investigate the long-term outcome of Meniscus Arrow (Bionx Implants, Blue Bell, PA) repair.

METHODS

In a case series 113 consecutive patients with an arthroscopic all-inside Meniscus Arrow repair were evaluated. The mean age was 30 years, and the mean length of follow-up was 6 years. Of the patients, 84% were available for follow-up. Repairs were performed in either the medial (81%) or lateral (19%) posterior horn in only the red-red or red-white meniscal zone. Concomitant anterior cruciate ligament reconstruction was performed in 66% of patients.

RESULTS

Of the patients, 28% showed a retear of the meniscus and had to undergo arthroscopic revision with partial meniscectomy. Simultaneous anterior cruciate ligament reconstruction had no significant influence on the revision rate. In patients who did not undergo revision, the mean Lysholm score was 91 points and the mean Cincinnati knee score was 93 points. The International Knee Documentation Committee classification was A or B in 90% of patients and C in 10%. At revision surgery, 2 patients showed distinct femoral cartilage damage caused by the head of the Meniscus Arrow.

CONCLUSIONS

The Meniscus Arrow shows a high clinical failure rate of 28.4%, especially given that the use of the device was restricted to tears in the red-red and red-white zone of the meniscus, which would be expected to have a good healing potential. More than 80% of all failures occurred during the first 3 postoperative years, suggesting that the initial refixation potential of the Meniscus Arrow is low. Device-specific complications required additional operative treatment.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

All-inside meniscus repair: a systematic review

All-inside meniscus repairs are becoming more common with the invention of meniscal arrows, darts, screws, staples, and other suture devices. With the rising popularity of these new all-inside meniscal repair devices, it is necessary to assess the effectiveness of various all-inside surgical interventions used in the treatment of meniscal tears. We performed an evidence based review of the outcomes of all-inside meniscus repair devices. Seventy-seven percent of identified studies were case series; 10% were retrospective comparative studies; 6.5% were prospective comparative studies; and 6.5% were prospective randomized studies. The failure rates ranged from 0 to 43.5%. We found no substantial differences in the failure rates among various meniscus devices. We also found no substantial differences in failure rates with length of followup. Given the paucity of randomized controlled studies comparing different all-inside meniscal repairs, no definite conclusions can be made regarding the difference in clinical outcomes of various all-inside meniscal repair devices.

Clinical results of meniscus repair with the meniscus arrow: a 4- to 8-year follow-up study

The short-term clinical results of meniscus repair with the meniscus arrow were promising. Unfavorable outcomes were reported in two studies, with longer follow-up, raising concerns about the efficacy of this device. We retrospectively reviewed 62 patients (mean age 23.7 years; range 14-37 years) that underwent all-inside meniscus repair, using the meniscus arrow. Seventeen patients had an isolated meniscus tear (ACL intact group) and 45 patients concomitant ACL rupture that was reconstructed at the same time with the meniscus repair (ACL reconstructed group). All patients followed a non-aggressive rehabilitation protocol. Follow-up was assessed by clinical examination, Lysholm and Tegner score, IKDC knee examination form and KT-2000 arthrometry for the anteroposterior laxity of the reconstructed knees. At an average follow-up of 73 months (range 49-96 months) there were three failures (4.8%), one from the ACL intact group and two from the ACL reconstructed group. One patient developed arthrofibrosis (ACL reconstructed group) that resolved conservatively. Soft tissue irritation at the repair site was noted in three patients. In two patients the symptoms were transient. In the third patient the arrow tip was cut off under local anaesthesia due to saphenous infrapatellar branch irritation and the symptoms resolved (inappropriate arrow size). KT-2000 arthrometry showed that sagittal knee laxity was less than 3 mm in all reconstructed knees. The mean Tegner activity score decreased from 6.7 (pretrauma) to 6.2 (postoperatively). The average Lysholm score was 96, with normal or nearly normal function of all success knees, according to the IKDC knee examination form. Our results show a high clinical success rate of meniscus repair with the meniscus arrow. We found this device both safe and effective.

Meniscal repair with biofix arrows: results after 4.7 years' follow-up

BACKGROUND

Absorbable meniscus arrows have, since they were introduced in 1993, become a common all-inside technique in meniscal repair. Potential advantages are conserving the meniscus, simplifying the surgical technique, reducing operating time, and reducing the risk of neurovascular damage. Despite extensive use all over the world, few long-term follow-up studies have been published.

HYPOTHESIS

Meniscus arrows have, based on published material, a rate of success around 80% to 90%.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The Biofix arrow fixation technique was used in 123 patients in need of meniscal repair from January 1997 to December 2002 at our hospital. The patients underwent an interview by phone, mail, or e-mail during autumn 2004 that included questions about reoperation and Lysholm score. In addition, the operative charts were reviewed.

RESULTS

There were 118 patients (96%) available for the questionnaire, and 45 of these (38%) had had reoperations done because of meniscal rerupture during the follow-up period. Another 3 patients were waiting for meniscal reoperations. In addition, the charts of 2 of those unavailable for the study showed that they had been reoperated, resulting in a total of 41% verified failures. The Lysholm score for the whole study group at follow-up was 85 (range, 36-100). The mean Lysholm score for those who had a second operation was 81 (range, 36-100), and it was 88 (range, 55-100) for the others (P = .009). The mean time between primary operation and reoperation was 17 months (range, 1-75 months). Mean postoperative follow-up was 4.7 years (range, 1.8-7.7 years).

CONCLUSION

Meniscal repair with Biofix arrows has an unacceptably low rate of success.

Arthroscopic meniscal repair: a comparative study between three different surgical techniques

The purpose of this prospective study was to evaluate and compare the results of arthroscopic meniscal repair using three different techniques. Between January 2002 and March 2004, 57 patients who met the inclusion criteria underwent an arthroscopic meniscal repair. The outside-in technique was used in 17 patients (group A), the inside-out in 20 patients (group B), while the rest of the 20 patients (group C) were managed by the all-inside technique using the Mitek RapidLoc soft tissue anchor (Mitek Surgical Products, Westwood, MA, USA). Anterior cruciate ligament (ACL) reconstruction was performed in 29 patients (51%). The criteria for clinical success included absence of joint line tenderness, locking, swelling, and a negative McMurray test. The minimum follow-up was one year for all groups. The mean follow-up was 23 months for group A, 22 months for group B, and 22 months for group C. All meniscal repairs were considered healed according to our criteria in group A, while 19 out of 20 repairs (95%) healed in group B. Finally 7 of 20 repairs (35%) were considered failures in group C and this difference was statistically significant in comparison with other groups. The time required for meniscal repair averaged 38.5 min for group A, 18.1 min for group B, and 13.6 min for group C. Operation time for meniscal repair in group A was statistically longer in comparison with other groups. There were no significant differences among the three groups concerning complications. According to our results, arhtroscopic meniscal repair with the inside-out technique seems to be superior in comparison with the other methods because it offers a high rate of meniscus healing without prolonged operation time.

Meniscal repair and transplantation: indications, techniques, rehabilitation, and clinical outcome

The purpose of this paper is to provide current knowledge regarding the indications, operative techniques, rehabilitation programs, and clinical outcomes of meniscus repair and transplantation procedures. Meniscus tears that occur in the periphery may be repaired using a variety of operative procedures with high success rates. Complex multiplanar tears that extend into the central one-third avascular zone can also be successfully repaired using a meticulous vertically divergent suture technique. The outcome of these repairs justifies preservation of meniscal tissue, especially in younger athletic individuals. Meniscal transplantation is a valid treatment option for patients who have undergone meniscectomy and have related tibiofemoral joint pain, or in whom articular cartilage deterioration in the meniscectomized compartment is present. Rehabilitation after these operations includes knee motion and quadriceps-strengthening exercises initiated the first day postoperatively. The initial goal is to prevent excessive weight bearing and joint compressive forces that could disrupt the healing meniscus repair or transplant. The protocol contains modifications according to the type of meniscal tear, if a concomitant procedure is done (such as a ligament reconstruction) or if noteworthy articular cartilage deterioration is present. Patients who have repairs of peripheral meniscus tears are generally progressed more rapidly than those who have repairs of tears extending in the central one-third region or those who undergo meniscal transplantation. The safety and effectiveness of the rehabilitation program has been demonstrated in several clinical studies. We recommend preservation of meniscal tissue, regardless of age, in active patients whenever possible.

Meniscal repair with the RapidLoc meniscal repair device

BACKGROUND

The RapidLoc is an all-inside, self-adjusting, flexible meniscal repair device that combines a suture with an anchor component and, by using a reinforced sliding knot, allows for tightening to compress and hold the repaired meniscal segments. The purpose of this study was to evaluate the clinical success of the RapidLoc device.

METHODS

A prospective consecutive series of meniscal repairs performed with the RapidLoc device was studied. Lysholm, Tegner, Cincinnati, IKDC (International Knee Documentation Committee) activity scores, clinical examination findings, and adverse events were recorded on all patients. Associated procedures were recorded. An accelerated postoperative rehabilitation program was followed, independent of whether anterior cruciate ligament (ACL) surgery was also performed.

RESULTS

A total of 32 patients underwent 32 meniscal repairs, with an average follow-up of 31 months (18 to 48 months). In all, 23 repairs were done in conjunction with ACL reconstruction, and 9 repairs were carried out in stable knees. Repairs were made to 25 medial menisci and 7 lateral menisci. Tears repaired consisted of peripheral longitudinal tears with an average length of 2 cm (range, 15 to 30 mm). Four failures (12.5%) were arthroscopically documented. Clinical success occurred in 87.5% at the time of last follow-up. At follow-up, mean Tegner score was 5.1 (2.8 preoperative), IKDC activity score was 3.1 (1.8 preoperative), Lysholm score was 93.6 (48.4 preoperative), and mean Cincinnati score was 88.1 (43.7 preoperative). The most common adverse event was cutting of the suture during RapidLoc insertion. One patient had excoriation and grooving of the medial femoral condyle associated with failed repair. Another patient developed a postoperative infection.

CONCLUSIONS

The early clinical success rate was 87.5% with the RapidLoc device. Chondral grooving was observed in a single case.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

All-inside meniscal repair using a new flexible, tensionable device

BACKGROUND

A new generation of flexible all-inside meniscal repair devices is available, but clinical studies with these devices are lacking.

HYPOTHESIS

The RapidLoc has an intermediate-term meniscal healing rate that is equivalent to literature reports of inside-out suture technique in patients undergoing concurrent anterior cruciate ligament reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Retrospective analysis was performed for 75 meniscal tears in 66 consecutive patients undergoing anterior cruciate ligament reconstruction who underwent meniscal repair with the RapidLoc. Patients with at least 2 years' follow-up were evaluated for symptoms suggestive of a meniscal tear and were assessed with the International Knee Documentation Committee form and the Knee Disorders Subjective History visual analog scale. Subjects were asked to return for a clinical examination to include evaluation for an effusion and joint line tenderness as well as McMurray test and KT-1000 arthrometry readings. Patients with symptoms consistent with meniscal repair failure underwent magnetic resonance arthrography and repeat arthroscopy.

RESULTS

Twenty patients with 21 meniscal tears were excluded, resulting in 54 meniscal tears in 46 patients. At a mean follow-up of 34.8 months, the clinical success rate for meniscal repair was 90.7% (49/54), with 5 failures requiring meniscectomy. Univariate analysis revealed predictive variables for failure: bucket-handle configuration, multiplanar tears, tear length greater than 2 cm, and chronicity longer than 3 months. Non-predictive variables included compartment, zone, ligament graft choice, gender, age, follow-up, and visual analog scale score. Analysis of healed patients revealed a negative correlation between chronicity of tear and International Knee Documentation Committee score.

CONCLUSIONS

The RapidLoc has an acceptable intermediate-term clinical healing rate in patients undergoing concurrent anterior cruciate ligament reconstruction. Predictive variables for failure should be considered during operative decision making.