Comparison of inside-out and all-inside techniques for the repair of isolated meniscal tears: a systematic review

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Background:

A large number of systematic reviews and meta-analyses regarding the meniscus have been published.

Purpose:

To provide a qualitative summary of the published systematic reviews and meta-analyses regarding the meniscus.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of all meta-analyses and systematic reviews regarding the meniscus and published between July 2009 and July 2019 was performed with PubMed, CINAHL, EMBASE, and the Cochrane database. Published abstracts, narrative reviews, articles not written in English, commentaries, study protocols, and topics that were not focused on the meniscus were excluded. The most pertinent results were extracted and summarized from each study.

Results:

A total of 332 articles were found, of which 142 were included. Included articles were summarized and divided into 16 topics: epidemiology, diagnosis, histology, biomechanics, comorbid pathology, animal models, arthroscopic partial meniscectomy (APM), meniscal repair, meniscal root repairs, meniscal allograft transplantation (MAT), meniscal implants and scaffolds, mesenchymal stem cells and growth factors, postoperative rehabilitation, postoperative imaging assessment, patient-reported outcome measures, and cost-effectiveness. The majority of articles focused on APM (20%), MAT (18%), and meniscal repair (17%).

Conclusion:

This summary of systematic reviews and meta-analyses delivers surgeons a single source of the current evidence regarding the meniscus.

Arthroscopic procedure for revision of failed isolated bucket-handle meniscal tear repair

Surgery failure rates average 20% following bucket-handle meniscal tears (BHMT) repairs in the literature. Achieving the healing of BHMT is difficult, how much more in revision cases. Some authors have reported higher failure rates especially in the early postoperative period and in younger patients. Multiple techniques and augmentations to enhance biologic healing and reduce failure rate have been described. We describe an arthroscopic technique for successfully revising a failed BHMT repair using the technique of percutaneously releasing the posterior fibers of the medial collateral ligament to provide adequate space for arthroscopy, refreshing of the torn surfaces, bed trephination before reduction and repair. We concluded that a combined double-level inside out vertical sutures with horizontal reinforcement and all-inside technique using fast fix give anatomic reduction, stable fixation, surface contact, and increased potential for biologic healing in failed BHMT repairs. Coupled with adequate rehabilitation programs, this technique has reduced the failure rate in revision cases and enhances early return to sport.

Lower donor-site morbidity using QT autografts for ACL reconstruction

PURPOSE

Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction.

METHODS

Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS.

RESULTS

Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm² vs. 88.2 ± 57 cm²; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm² vs. 8.7 ± 5.1 cm²; p < 0.0001).

CONCLUSION

Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions.

LEVEL OF EVIDENCE

III.

Predictive Factors for Failure of Meniscal Repair: A Retrospective Dual-Center Analysis of 918 Consecutive Cases

Background:

Meniscal surgery is one of the most common surgical procedures performed by orthopaedic surgeons. Over the past decade, awareness has increased regarding the importance of meniscal preservation to prevent the development of osteoarthritis in the knee joint. Removal of meniscal tissue can lead to a high risk of cartilage degeneration, and moreover, meniscus-preserving surgery rather than meniscal resection is likely to have better long-term outcomes. Success rates after meniscal repair range from 60% to 95%, but many reports are based on a small number of patients.

Purpose/Hypothesis:

The purpose of this study was to review all meniscal repairs and potential predictors for failure during a 12-year period. We hypothesized that meniscal anchors, lateral repairs, and repairs made in conjunction with an anterior cruciate ligament reconstruction (ACLR) would have fewer failures than meniscal arrows, medial repairs, and isolated repairs. We also hypothesized that younger patients and acute tears would be associated with fewer failures.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

This study was a dual-center, retrospective analysis on consecutive meniscal repairs. The surgical protocols were reviewed, including type of tear, location, associated injury to the knee, and surgery. The study endpoint was failure of repair, defined as a need for reoperation and secondary partial or total meniscal resection, within 3 years. Kaplan-Meier analysis was performed to assess repair survival, with multivariate Cox regression to adjust for confounders.

Results:

A total of 954 meniscal repairs were performed on 918 patients (536 male patients [58%]; 382 female patients [42%]) with a mean age of 26 years (range, 12-60 years). The failure rate for the entire cohort was 22.5%. Bioabsorbable arrows had significantly more failures than all-inside sutures with anchors (hazard ratio [HR], 1.8; 95% CI, 1.2-2.5; P = .002). Medial meniscal repairs had a higher failure rate than lateral meniscal repairs (HR, 3.7; 95% CI, 2.3-6.0; P < .001). Simultaneous ACLR resulted in less failure than when no simultaneous ACLR was performed (HR, 0.5; 95% CI, 0.3-0.9; P = .009). Age at repair and acuity of tear did not affect the outcome (P = .6 and .07, respectively).

Conclusion:

The failure rate after meniscal repair was significantly higher on the medial side, especially when using arrows. Meniscal repairs performed concomitantly with an ACLR result in fewer reoperations.

Inside-Out Bucket-Handle Meniscus Repair With a Single-Handed Self-Advancing Zone-Specific Meniscus Repair Device

Meniscus tears are among the most common knee injuries in the general population and often are treated arthroscopically with a meniscus repair. Of the various meniscus repair techniques available, the inside-out meniscus tear is considered the gold standard due to its versatility and good clinical outcomes. The purpose of this Technical Note and accompanying video is to describe an inside-out bucket-handle meniscus repair using a single handed, self-advancing meniscus repair device with an interchangeable zone-specific multicannula system to decrease the technical difficulty and operative time of the repair.

Clinical Outcomes of Inside-Out Meniscal Repair According to Anatomic Zone of the Meniscal Tear

Background

There is significant discrepancy in the reported vascularity within the meniscus, and a progressively diminishing blood supply may indicate a differential healing capacity of tears that is dependent on the affected meniscal zone.

Purpose

To examine the outcomes after inside-out meniscal repair in all 3 meniscal vascularity zones.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients were included if they underwent inside-out meniscal repair by a single surgeon between 2010 and 2014 and had a minimum 2-year follow-up. Patients were divided into 3 groups based on the meniscal tear location (red-red, red-white, and white-white zones) as determined during an intraoperative assessment. Patient-reported outcome scores were obtained at final follow-up.

Results

A total of 173 patients (mean age, 33.6 ± 14.3 years) were included, with a mean follow-up of 2.9 ± 0.9 years. All patients demonstrated significant improvements with inside-out meniscal repair from preoperatively to postoperatively, regardless of the meniscal tear location. Patients who underwent meniscal repair in the red-red and red-white zones had significantly increased postoperative Tegner, Lysholm, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores compared with patients who underwent meniscal repair in the white-white zone (P < .05). Patients who underwent acute repair (≤6 weeks) demonstrated significantly higher improvements on the Tegner activity scale (acute: 5.8 ± 2.2; chronic: 4.6 ± 2.2; P = .001) and Lysholm score (acute: 85.6 ± 13.3; chronic: 80.8 ± 13.5; P = .025) compared with patients treated beyond 6 weeks from injury, regardless of the meniscal tear zone. Patients with grade IV femoral condyle chondral lesions at the time of surgery had significantly inferior outcomes compared with patients with grade I through III chondral lesions, regardless of the meniscal tear zone. Three patients (1.7%) subsequently underwent revision inside-out repair, and 3 (1.7%) underwent partial meniscectomy.

Conclusion

Patients who underwent inside-out meniscal repair demonstrated significant improvements on subjective outcome measures at a minimum 2-year follow-up, regardless of the meniscal tear zone. Inside-out meniscal repair is recommended for potentially reparable meniscal tears in all 3 vascular zones; however, improved outcomes can be achieved when performed acutely, in the absence of full-thickness femoral condyle chondral injuries, and in the red-red and red-white zones.

No safe zone: The anatomy of the saphenous nerve and its posteromedial branches

BACKGROUND

Following a case of medial meniscal repair via an inside-out repair, a patient developed acute postoperative electric shock-like paresthesias of the proximal medial calf with any knee flexion beyond 80°. Open saphenous nerve exploration revealed entrapment by suture material of an unnamed branch off the sartorial branch of the saphenous nerve. Symptoms resolved immediately with release. The objective of the study was to perform a cadaveric study to examine the existence and frequency of these previously under-reported branches of the sartorial branch of the saphenous nerve.

METHODS

In 16 knees from eight fresh, matched whole cadavers, the medial structures of the knee were exposed, reproducible anatomical structures were identified, and previously under-described posteromedial branches of the sartorial nerve were identified and measured in relation to surrounding structures and the joint line.

RESULTS

The saphenous nerve, its sartorial and infrapatellar branches, and its posteromedial branches were identified in all specimens. The sartorial nerve divided from the saphenous nerve an average of 4.8 cm proximal to the medial femoral epicondyle. Between one and four further posteromedial branches off the sartorial nerve were identified. These branches formed at a range of 5.3 cm proximal to 3.0 cm distal to the joint line.

CONCLUSIONS

This cadaveric study establishes the consistent presence of a posteromedial branch off the sartorial nerve. It was consistently located near the posteromedial joint line. These branches are at risk for injury during medial meniscus repairs due to entrapment by suture materials, or during other surgical procedures near the posteromedial aspect of the knee.

Evaluation of Midterm Clinical and Radiographic Outcomes of Arthroscopically Repaired Vertical Longitudinal and Bucket-Handle Lateral Meniscal Tears

Background:

Lateral meniscal tears in the stable knee are rare. There are few comparative studies evaluating functional and radiological outcomes of vertical longitudinal and bucket-handle lateral meniscal tears.

Purpose:

To evaluate the midterm clinical and radiological outcomes of arthroscopically repaired traumatic vertical longitudinal and bucket-handle lateral meniscal tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 43 full-thickness lateral meniscal repairs, including 22 (51.2%) for vertical longitudinal tears and 21 (48.8%) for bucket-handle tears, were evaluated. A clinical assessment was performed according to the Barrett criteria, and patient outcomes were measured with the Lysholm knee score, Tegner activity scale, and overall satisfaction scale. Magnetic resonance imaging was used as the radiological re-examination method preoperatively and at final follow-up. A subgroup analysis examining isolated repair versus repair with concurrent anterior cruciate ligament (ACL) reconstruction was performed.

Results:

The mean follow-up period was 63.2 months (range, 24-86 months). Based on clinical and radiological outcomes, 38 of the 43 repairs (88.3%) were successful, and the remaining 5 (11.6%) cases were considered to be failures. Overall, the combined results for both groups demonstrated an improvement in the Lysholm score, Tegner score, and patient satisfaction. There was no significant difference in the postoperative Lysholm score (91.4 vs 87.0, respectively; P = .223), Tegner score (5.4 vs 5.5, respectively; P = .872), or patient satisfaction (7.2 vs 7.4, respectively; P = .624) between bucket-handle repair and vertical longitudinal repair. The subgroup analysis demonstrated no difference in outcome scores for isolated repair versus repair with concurrent ACL reconstruction. Smoking was identified as a risk factor for repair failure.

Conclusion:

Comparable clinical and radiological outcomes were obtained after vertical longitudinal and bucket-handle lateral meniscal repairs using the all-inside or hybrid suture technique with different suture configurations, regardless of whether ACL reconstruction was performed. Smoking was identified as a risk factor for failure.

Arthroscopic Repair of Double Radial Tears of the Lateral Meniscus

Double radial tears of the lateral meniscus are rare injuries that typically occur in the setting of an acute anterior cruciate ligament rupture. Full-thickness radial tears of the meniscus body and root render the meniscus nonfunctional from a loss of hoop stress resistance. Repair of these tears can normalize contact pressures in the lateral compartment and delay arthritic changes. We describe our technique for repairing a lateral meniscus body radial tear and concomitant posterior root tear, via inside-out suture repair and transtibial suture repair, respectively. This investigation was performed at Mayo Clinic.

Proximity of the Neurovascular Bundle During Posterior-Lateral Meniscal Repair: A Comparison of the Transpatellar, Anteromedial, and Anterolateral Portals

PURPOSE

To compare the neurovascular proximity of the transpatellar portal with that of the medial and lateral portals and to determine the safe penetration depth for an all-inside device for use on the posterior horn lateral meniscus.

METHODS

Dissection of the popliteal fossa was performed in 10 cadaveric knees to identify all structures. Arthroscopy was performed using penetration depths of 10, 12, 14, and 16 mm with the all-inside system through the anteromedial, anterolateral, and transpatellar portals. Penetrations were made 5 and 10 mm lateral to the posterior horn root at the meniscocapsular junction. Needle-tip distances were measured from the popliteal artery and vein, tibial nerve, and common peroneal nerve.

RESULTS

Among 240 trials, the average distance to the popliteal neurovascular bundle using the medial, transpatellar, and lateral approaches was 6.9 mm, 6.5 mm, and 3.1 mm, respectively. The transpatellar-portal needle had a larger distance from the neurovascular bundle than the lateral portal (P = .001), with no statistical difference compared with the medial portal (P = .58). Compared with the position at a 10-mm distance from the root, the position at a 5-mm distance from the root was closer to the neurovascular bundle in all approaches (P = .001). The transpatellar approach set to 14 mm had a 5% rate of capsular underpenetration and 10% rate of gastrocnemius penetration. The transpatellar and medial portals had no neurovascular penetrations, whereas the lateral approach had a 14% rate of penetration (P < .05).

CONCLUSIONS

The transpatellar portal and anteromedial portal are in less proximity to the neurovascular bundle compared with the anterolateral portal for all-inside meniscal repair of the posterior horn lateral meniscus. Low rates of neurovascular penetration, gastrocnemius muscle penetration, and capsular underpenetration occurred with a depth setting of 14 mm.

CLINICAL RELEVANCE

This study shows the utility of medial and transpatellar portals when using all-inside devices to repair posterior horn lateral meniscal tears and neurovascular proximity based on penetration depth.

Incidence and Risk Factors for Meniscal Cyst After Meniscal Repair

PURPOSE

To investigate the incidence of magnetic resonance imaging-confirmed cyst formation after meniscal repair and to analyze associated risk factors.

METHODS

This retrospective study included cases repaired arthroscopically with the all-inside (AI) technique (using suture anchors) and/or the inside-out (IO) technique between October 2008 and December 2014. A meniscal cyst was detected on T2 fat-suppressed magnetic resonance images. All cases were divided into 3 groups according to the repair method (AI, IO, and combined technique). The incidence of radiographically confirmed meniscal cyst formation in each group and the associated risk factors (age, sex, AI device, medial meniscus, Tegner activity scale preinjury) were analyzed.

RESULTS

A total of 102 menisci in 96 knees were evaluated. The mean follow-up period was 3.8 (range, 2-8) years. The mean patient age was 21.0 (range, 6-53) years. Thirty cases were in the AI group, 60 in the IO group, and 12 in the combined group. Demographically, there were significant differences among groups regarding the number of medial, lateral, and discoid tears; concomitant anterior cruciate ligament tears; Tegner scale; and suture number. Meniscal cysts developed in 14 of 102 cases. Two of the 14 cysts were symptomatic, requiring open cystectomy. The incidence of meniscal cyst was significantly higher in the AI group (12 of 30, 40%) than in the IO group (1 of 60, 1.7%) or the combined-technique group (1 of 12, 8.3%) (P < .001). Both symptomatic cysts were in the AI group and were in continuity with the anchors. Medial meniscus tear (odds ratio = 6.92) and the use of AI suture anchors (odds ratio = 15.03) significantly increased the risk of cyst formation.

CONCLUSIONS

The incidence of meniscal cysts after arthroscopic meniscal repair was 1.7% to 40.0%, depending on the surgical method. Medial meniscus tears and use of an AI device are suggested as risk factors for cyst formation in this retrospective study.

LEVEL OF EVIDENCE

Level Ⅲ, retrospective comparative study.

Tips and Pearls for All-Inside Medial Meniscus Repair

The medial meniscus is one of the most commonly injured structures in the knee. When the importance of its proper function is well understood, an adequate management in meniscus tear is a key issue for whole knee joint well-being. Although it has been proven that meniscal repairs have better long-term results than meniscectomy, there is still no consensus as to which suturing technique is the best. An all-inside technique seems to allow for the most anatomic repairs with the greatest preservation of surrounding soft tissues. Our aim is to show that there are no technical limits for all-inside meniscal repairs with nonabsorbable sutures. We describe the technique and some tricks for medial meniscus repair in this Technical Note.

Outcomes After the Operative Treatment of Bucket-Handle Meniscal Tears in Children and Adolescents

Background:

Bucket-handle meniscal tears (BHMTs), which we define as vertical longitudinal tears of the meniscus with displacement of the torn inner fragment toward the intercondylar notch region, are a well-recognized tear pattern. Optimizing the management of BHMTs in younger patients is important, as preserving meniscal tissue may limit future joint degeneration.

Purpose/Hypothesis:

The purpose of this study was to review the patient demographics, clinical presentation, operative details, outcomes, and risk factors for a reoperation associated with operatively treated BHMTs in a pediatric population. We hypothesized that the repair of BHMTs in adolescents would yield a higher reoperation rate than meniscectomy in our population.

Study Design:

Case-series; Level of evidence, 4.

Methods:

A departmental database was queried to identify all patients 19 years or younger who presented with a BHMT and underwent surgery between October 2002 and February 2013. Clinical, radiological, and surgical data were retrospectively collected, and risk factors for a reoperation and persistent pain were assessed in all patients with longer than or equal to 6 months of follow-up.

Results:

A total of 280 BHMTs were treated arthroscopically by 1 of 8 sports medicine fellowship–trained surgeons. The mean age at surgery was 15.5 ± 2.5 years (range, 2.1-19.2 years), and most patients were male (177/280; 63%). Most injuries occurred during sports (203/248; 82%) and involved the medial meniscus (157/280; 56%). Concurrent anterior cruciate ligament (ACL) surgery was performed in 103 cases (37%). Meniscal repair was performed in 181 cases (65%) and was more common in younger patients (P = .01) and for the lateral meniscus (P < .001). Among 185 (66%) cases with longer than or equal to 6 months of adequate follow-up data (which included 126 meniscal repairs [68%]), a meniscus-related reoperation occurred in 45 (24%) cases. A reoperation related to the original BHMT injury or surgery was more common after meniscal repair than after meniscectomy (40/126 [32%] vs 5/59 [8%], respectively) (P = .001) and less common with concurrent ACL surgery (P = .07), although this was not statistically significant. Among patients injured during sports and with adequate follow-up, all but 1 patient (176/177; 99%) returned to sports; a slower rate of return was seen in those undergoing meniscal repair (P = .002) and concurrent ACL surgery (P < .001). At final follow-up, 170 of 185 patients (92%) were pain free. For the 15 patients with persistent pain at final follow-up, no identifiable risk factors for persistent pain were identified.

Conclusion:

Most BHMTs in younger patients occurred in males and during sports and affected the medial meniscus. Concurrent ACL surgery was indicated in approximately one-third of cases and was associated with a lower reoperation rate and slower return to sports. Two-thirds of patients underwent meniscal repair, over two-thirds of whom did not require a reoperation during the study period, despite the high activity levels in this age group.

Popliteal neurovascular bundle is safe during inside-out repair of medial meniscus without a safety incision

PURPOSE

There is a theoretical risk of injury to neurovascular structures during inside-out meniscal repair without a safety incision, although there are limited studies assessing this risk. This simulation study on archival MRI films was performed to assess the risk for the popliteal neurovascular bundle and the peroneal nerve during passage of needles for inside-out meniscus repair without a "safety incision", thereby defining a "safe zone" of the menisci that can be safely repaired using this technique.

METHODS

Archival MRI scans (n = 50) were retrieved and axial sections through the menisci were used for simulation. The needle passage was simulated for different points on the posterior horn and body of lateral and medial menisci at "half-hour" intervals using clock method (15° intervals) with three different portals and two different needle cannulas, resulting in six different scenarios of needle passage for each point on the meniscus. The distance of the needle in each scenario was measured from popliteal vessels (n = 50) and peroneal nerve (n = 10). The value "mean-3SD" was calculated for positive means and "Mean + 3SD" was calculated if the mean was negative. An additional 2 mm was defined as "safe distance". Thus, simulation models in which the mean - 3SD was less than 2 mm (or mean + 3SD was greater than - 2 mm for negative means) were labelled as "unsafe".

RESULTS

Needle passage through medial meniscus at and medial to 1 o'clock position for a right knee (or 11 o'clock position for a left knee) was safe, irrespective of the portal and needle type. For the lateral meniscus, only the equatorial region was found to be safe with this method.

CONCLUSIONS

The popliteal neurovascular bundle is safe during the inside-out medial meniscal repair without a safety incision. For the terminal-most part of the posterior horn, the AM portal and the straight cannula should be avoided. However, this method without safety incision cannot be recommended for lateral meniscus because of the risk to the popliteal vessels and the peroneal nerve. Instead, the inside-out method with a safety incision, or an all-inside method should be used for lateral meniscus.

LEVEL OF EVIDENCE

III.

Isolated revision meniscal repair - failure rates, clinical outcome, and patient satisfaction

Background

Failure of isolated primary meniscal repair must be expected in approximately 10–25% of cases. Patients requiring revision surgery may benefit from revision meniscal repair, however, the results of this procedure remain underreported. The purpose of this study was therefore to evaluate the outcome and failure rates of isolated revision meniscal repair in patients with re-tears or failed healing after previous meniscal repair in stable knee joints.

Methods

A chart review was performed to identify all patients undergoing revision meniscal repair between 08/2010 and 02/2016. Only patients without concomitant procedures, without ligamentous insufficiency, and a minimum follow-up of 24 months were included. The records of all patients were reviewed to collect patient demographics, injury patterns of the meniscus, and details about primary and revision surgery. Follow-up evaluation included failure rates, clinical outcome scores (Lysholm Score, KOOS Score), sporting activity (Tegner scale), and patient satisfaction.

Results

A total of 12 patients with a mean age of 22 ± 5 years were included. The mean time between primary repair and revision repair was 27 ± 21 months. Reasons for failed primary repairs were traumatic re-tears in 10 patients (83%) and failed healing in two patients (17%). The mean follow-up period after revision meniscal repair was 43 (± 23.4) months. Failure of revision meniscal repair occurred in 3 patients (25%). In two of these patients, successful re-revision repair was performed. At final follow-up, the mean Lysholm Score was 95.2 (± 4.2) with a range of 90–100, representing a good to excellent result in all patients. The final assessment of the KOOS subscores also showed good to excellent results. The mean Tegner scale was 6.8 ± 1.8, indicating a relatively high level of sports participation. Ten patients (83%) were either satisfied or very satisfied with the outcome.

Conclusion

In patients with re-tears or failed healing after previous isolated meniscal repair, revision meniscal repair results in good to excellent knee function, high level of sports participation, and high patient satisfaction. The failure rate is slightly higher compared to isolated primary meniscal repair, but still acceptable. Therefore, revision meniscal repair is worthwhile in selected cases in order to save as much meniscal tissue as possible.

Arthroscopic repair of the meniscus: Surgical management and clinical outcomes

From the biomechanical and biological points of view, an arthroscopic meniscal repair (AMR) should always be considered as an option. However, AMR has a higher reoperation rate compared with arthroscopic partial meniscectomy, so it should be carefully indicated.

Compared with meniscectomy, AMR outcomes are better and the incidence of osteoarthritis is lower when it is well indicated.

Factors influencing healing and satisfactory results must be carefully evaluated before indicating an AMR.

Tears in the peripheral third are more likely to heal than those in the inner thirds.

Vertical peripheral longitudinal tears are the best scenario in terms of success when facing an AMR.

‘Inside-out’ techniques were considered as the gold standard for large repairs on mid-body and posterior parts of the meniscus. However, recent studies do not demonstrate differences regarding failure rate, functional outcomes and complications, when compared with the ‘all-inside’ techniques.

Some biological therapies try to enhance meniscal repair success but their efficacy needs further research. These are: mechanical stimulation, supplemental bone marrow stimulation, platelet rich plasma, stem cell therapy, and scaffolds and membranes.

Meniscal root tear/avulsion dramatically compromises meniscal stability, accelerating cartilage degeneration. Several options for reattachment have been proposed, but no differences between them have been established. However, repair of these lesions is actually the reference of the treatment.

Meniscal ramp lesions consist of disruption of the peripheral attachment of the meniscus. In contrast, with meniscal root tears, the treatment of reference has not yet been well established.

Cite this article: EFORT Open Rev 2018;3:584-594. DOI: 10.1302/2058-5241.3.170059

Current concepts in the techniques, indications and outcomes of meniscal repairs

Knee arthroscopy for meniscal tears is one of the most commonly performed orthopaedic procedures. In recent years, there has been an increasing incidence of meniscal repairs, as there are concerns that meniscectomy predisposes patients to early osteoarthritis. Indications for meniscal repair are increasing and can now be performed in older patients who are active, even if the tear is in the avascular zone. Options for meniscal tear management broadly fall into three categories: non-operative management, meniscal repair or meniscectomy. With limited evidence directly comparing each of these options optimal management strategies can be difficult. Decision making requires thorough assessment of patient factors (e.g. age and comorbidities) and tear characteristics (e.g. location and reducibility). The purpose of this paper is, therefore, to review the management options of meniscal tears and summarize the evidence for meniscal tear repair.

What are the factors to affect outcome and healing of meniscus bucket handle tears?

INTRODUCTION

The purpose of this study is to identify patient, meniscus rupture and surgical characteristics that influence the outcome and clinical healing following operative repair of bucket handle tears.

METHODS

Between 02/2006 and 10/2012, a total of 38 patients (14 women, 24 men) with bucket handle tears underwent surgical meniscus repair. There were 27 isolated repairs and 11 with concomitant anterior cruciate ligament (ACL) replacement. Patients were analyzed on an average of 44.4 months (range 15-96 months) after surgery by the use of standardized subjective scoring instruments [Lysholm, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Tegner Activity Scale (TAS)]. To identify factors affecting the outcome and suture survival, patient-specific, trauma-specific as well as meniscus- and surgery-specific factors were collected. Patients were divided in two groups with healed menisci (group 1) and re-rupture subjects (group 2). Meniscus re-rupture was defined as a clinical failure.

RESULTS

There were 25 patients with healed menisci and 13 (34.2%) that sustained re-rupture and underwent either partial meniscectomy (n = 8) or re-suture (n = 5). Group 1 achieved slightly higher outcome compared to group 2 [Lysholm: 87.8 vs. 84.3 (p = 0.35), IKDC: 86.9 vs. 85.7 (p = 0.67), KOOS: 91.3 vs. 90.5 (p = 0.74)]. TAS was better for group 2 [5.9 vs. 6.8 (p = 0.36)]. Strong impact to result in a significantly increased outcome was identified for higher age, subjective knee joint stability, high preoperative Lysholm Score, short trauma-to-repair time, previous ACL reconstruction and a smaller number of sutures to fulfill meniscus repair. Lower patient age, male gender and higher activity level had the strongest impact to provoke re-rupture.

CONCLUSION

Clinical outcome after meniscus bucket handle suture is satisfying. Re-rupture rate among this collective was 34.2%. Clear risk factors were identified for diminished clinical healing and outcome.

Patient- and Procedure-Specific Variables Driving Total Direct Costs of Outpatient Anterior Cruciate Ligament Reconstruction

Background:

Few studies have investigated the influence of patient-specific variables or procedure-specific factors on the overall cost of anterior cruciate ligament reconstruction (ACLR) in an ambulatory surgery setting.

Purpose:

To determine patient- and procedure-specific factors influencing the overall direct cost of outpatient arthroscopic ACLR utilizing a unique value-driven outcomes (VDO) tool.

Study Design:

Cohort study (economic and decision analysis); Level of evidence, 3.

Methods:

All ACLRs performed by 4 surgeons over 2 years were retrospectively reviewed. Cost data were derived from the VDO tool. Patient-specific variables included age, body mass index, comorbidities, American Society of Anesthesiologists (ASA) classification, smoking status, preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Testing (PF-CAT) score, and preoperative Single Assessment Numeric Evaluation (SANE) score. Procedure-specific variables included graft type, revision status, associated injuries and procedures, time from injury to ACLR, surgeon, and operating room (OR) time. Multivariate analysis determined patient- and procedure-related predictors of total direct costs.

Results:

There were 293 autograft reconstructions, 110 allograft reconstructions, and 31 hybrid reconstructions analyzed. Patient-specific factors did not significantly influence the ACLR cost. The mean OR time was shorter for allograft reconstruction (P < .001). Predictors of an increased direct cost included the use of an allograft or hybrid graft (44.5% and 33.1% increase, respectively; P < .001), increased OR time (0.3% increase per minute; P < .001), surgeon 3 or 4 (9.1% or 5.9% increase, respectively; P < .001 or P = .001, respectively), and concomitant meniscus repair (24.4% increase; P < .001). Within the meniscus repair cohort, all-inside, root, and combined repairs correlated with a 15.5%, 31.4%, and 53.2% increased mean direct cost, respectively, compared with inside-out repairs (P < .001).

Conclusion:

This study failed to identify modifiable patient-specific factors influencing direct costs of ACLR. Allografts and hybrid grafts were associated with an increased total direct cost. Meniscus repair independently predicted an increased direct cost, with all-inside, root, and combined repairs being costlier than inside-out repairs. The time-saving potential of all-inside meniscus repair was not realized in this study, making implant use a significant factor in the overall cost of ACLR with meniscus repair.

It is safe and effective to use all inside meniscal repair devices for posteromedial meniscal 'ramp' lesions

PURPOSE

Recently, it has been recognized that meniscocapsular ('ramp') lesions of the posterior one-third of the medial meniscus frequently occur during injuries causing ACL rupture, and that these lesions are easily missed at arthroscopy. Furthermore, it is clear that these lesions are biomechanically significant, adding to the deficits caused by ACL rupture, and that their repair can reverse this. The efficacy of an all inside repair technique has been questioned by some authors and by those who advocate a suture shuttle technique via an accessory posteromedial portal. The use of Ultra FastFix and FastFix 360 meniscal repair devices to repair posteromedial meniscocapsular separations was investigated in terms of safe deployment and the effectiveness.

METHODS

Twenty cadaveric fresh frozen knees were used-ten in each of two groups. A ramp lesion was created using a Beaver knife. The lesion was then repaired with either 4 Ultra FastFix (Smith and Nephew) or 4 FastFix 360 (Smith and Nephew) meniscal repair devices. The knees were put through a standardized loading cycle consisting of 10 Lachman's tests and ten maximum loading manual anterior drawer tests at 90° of flexion. Each knee was then flexed and extended fully ten times. The specimens were sectioned just proximal to the menisci and each suture anchor identified and its position recorded and photographed.

RESULTS

In the Ultra FastFix group, a single anchor was found to be in an intra-articular position-a failure rate of 2.5%. In the FastFix 360 group, 5 anchors failed-a 12.5% failure rate. In all cases, the anchors were attached to their suture and so not truly loose within the joint.

CONCLUSIONS

This study confirms the safe and effective deployment of an all inside repair device for repair of medial meniscal 'ramp' lesions, and therefore its use is advocated in treating these difficult lesions. Ultra FastFix had the lower failure rate of 2.5%, which the authors believe is acceptable, and makes this device preferable to the FastFix360.

Similar failure rate in immediate post-operative weight bearing versus protected weight bearing following meniscal repair on peripheral, vertical meniscal tears

PURPOSE AND HYPOTHESIS

Post-operative weight bearing after meniscal repair is a point of debate among physicians. This study sought to evaluate whether patients adhering to an immediate WBAT rehabilitation programme have a higher failure rate compared to those adhering to a more traditional, protected, NWB status following meniscal repair. The null hypothesis was that there would be no difference in failure between the two groups.

METHODS

A retrospective review of meniscal repair patients greater than 5 years from surgery was performed for patients receiving meniscal repair treatment. Patients were categorized by post-surgical weight-bearing status, either NWB or WBAT, and then analysed for failure of repair. Failure was defined as re-operation on the torn meniscus. The study controlled for variables including age at surgery, sex, height, weight, and BMI, classification of tear type, acuity of the tear, repair location (medial or lateral), repair location within the meniscus, repair technique, and concomitant procedures.

RESULTS

Re-operations were performed in 61 of 157 patients [38.9%]. There was no difference between weight-bearing groups for failure of meniscus repair (n.s.). The tears were acute vertical tears located in the posterior horn and body. For the 61 patients with re-operation, the average time to re-operation was 2.2 years with 10 [16%] > 5 years from surgery, 17 [28%] 2-5 years from surgery, and 34 [56%] < 2 years from surgery. In isolated meniscal repair patients (n = 62), there was no difference between weight-bearing groups for rate of re-operation (n.s.).

CONCLUSION

Weight bearing as tolerated after meniscal repair for peripheral, vertical tears does not result in a higher failure rate than traditional, non-weight bearing over a five-year follow-up period. The clinical relevance is that, based on these data, it may be appropriate to allow weight bearing as tolerated following meniscal repair of peripheral, vertical tears.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Comparative Outcomes of All-Inside Versus Inside-Out Repair of Bucket-Handle Meniscal Tears: A Propensity-Matched Analysis

Background:

There are limited data comparing the outcomes of all-inside versus inside-out meniscal repair techniques.

Purpose:

To assess failure rates and clinical outcomes after the surgical repair of bucket-handle meniscal tears utilizing either an all-inside or inside-out technique.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients with bucket-handle meniscal tears undergoing all-inside or inside-out repair at a single institution between 2003 and 2013 were analyzed. A total of 28 mensici repaired utilizing second-generation all-inside suturing devices and 42 menisci repaired using an inside-out technique were eligible for inclusion. Rigorous propensity matching was performed on the basis of age, sex, tear laterality, rim width, and concomitant anterior cruciate ligament reconstruction (ACLR), resulting in a total of 40 patients equally distributed between the 2 repair techniques for comparison. Retear-free survival as well as preoperative and postoperative International Knee Documentation Committee (IKDC) and Tegner scores and physical examination findings were subsequently analyzed.

Results:

Twenty patients who underwent all-inside repair (14 male; mean age, 23.7 ± 6.7 years) were successfully propensity matched to 20 patients who underwent inside-out meniscal repair (15 male; mean age, 22.5 ± 7.6 years), with a mean retear-free follow-up of 4.4 years (range, 2.5-7.4 years). Four (20%) all-inside repairs and 4 (20%) inside-out repairs failed over the course of follow-up (P > .999), with a mean time to failure of 2.7 years (range, 1.3-4.4 years) and 5.0 years (range, 0.8-7.5 years), respectively (P = .25). Increasing patient age trended toward a decreased clinical retear rate, independent of the repair technique (hazard ratio, 0.86; P = .056). There were no significant differences in the Tegner scores, IKDC scores, or range of motion between the groups as a whole or when subcategorizing by age, sex, body mass index, tear complexity, rim width, isolated versus concomitant ACLR, or medial- versus lateral-sided repair. There were no complications in the all-inside group, while there was a 10% rate of minor complications in the inside-out group (P = .49).

Conclusion:

Overall, satisfactory clinical outcomes are achievable at short-term to midterm follow-up with both inside-out and all-inside repair techniques of bucket-handle meniscal tears in rigorously matched patients with similar meniscal tear patterns.

Rehabilitation following meniscal repair: a systematic review

Objective

To review existing biomechanical and clinical evidence regarding postoperative weight-bearing and range of motion restrictions for patients following meniscal repair surgery.

Methods and data sources

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, we searched MEDLINE using following search strategy: ((((“Weight-Bearing/physiology”[Mesh]) OR “Range of Motion, Articular”[Mesh]) OR “Rehabilitation”[Mesh])) AND (“Menisci, Tibial”[Mesh]). Additional articles were derived from previous reviews. Eligible studies were published in English and reported a rehabilitation protocol following meniscal repair on human. We summarised rehabilitation protocols and patients’ outcome among original studies.

Results

Seventeen clinical studies were included in this systematic review. There was wide variation in rehabilitation protocols among clinical studies. Biomechanical evidence from small cadaveric studies suggests that higher degrees of knee flexion and weight-bearing may be safe following meniscal repair and may not compromise the repair. An accelerated protocol with immediate weight-bearing at tolerance and early motion to non-weight-bearing with immobilising up to 6 weeks postoperatively is reported. Accelerated rehabilitation protocols are not associated with higher failure rates following meniscal repair.

Conclusions

There is a lack of consensus regarding the optimal postoperative protocol following meniscal repair. Small clinical studies support rehabilitation protocols that allow early motion. Additional studies are needed to better clarify the interplay between tear type, repair method and optimal rehabilitation protocol.

Comparison of Tibiofemoral Contact Mechanics After Various Transtibial and All-Inside Fixation Techniques for Medial Meniscus Posterior Root Radial Tears in a Porcine Model

PURPOSE

To compare tibiofemoral contact mechanics after fixation for medial meniscus posterior root radial tears (MMPRTs).

METHODS

Seven fresh knees from mature pigs were used. Each knee was tested under 5 conditions: normal knee, MMPRT, pullout fixation with simple sutures, fixation with modified Mason-Allen sutures, and all-inside fixation using Fastfix 360. The peak contact pressure and contact surface area were evaluated using a capacitive sensor positioned between the meniscus and tibial plateau, under a 1,000-N compression force, at different flexion angles (0°, 30°, 60°, and 90°).

RESULTS

The peak contact pressure was significantly higher in MMPRTs than in normal knees (P = .018). Although the peak contact pressure decreased significantly after fixation at all flexion angles (P = .031), it never recovered to the values noted in the normal meniscus. No difference was observed among fixation groups (P = .054). The contact surface area was significantly lower in MMPRTs than in the normal meniscus (P = .018) and increased significantly after fixation at all flexion angles (P = .018) but did not recover to within normal limits. For all flexion angles except 60°, the contact surface area was significantly higher for fixation with Mason-Allen sutures than for fixation with simple sutures or all-inside fixation (P = .027). At 90° of flexion, the contact surface area was significantly better for fixation with simple sutures than for all-inside fixation (P = .031).

CONCLUSIONS

The peak contact pressure and contact surface area improved significantly after fixation, regardless of the fixation method, but did not recover to the levels noted in the normal meniscus after any type of fixation. Among the fixation methods evaluated in this time 0 study, fixation using modified Mason-Allen sutures provided a superior contact surface area compared with that noted after fixation using simple sutures or all-inside fixation, except at 60° of flexion. However, this study had insufficient power to accurately detect the differences between the outcomes of various fixation methods.

CLINICAL RELEVANCE

Our results in a porcine model suggest that fixation can restore tibiofemoral contact mechanics in MMPRT and that fixation with a locking mechanism leads to superior biomechanical properties.

Meniscal allograft transplantation using a novel all-arthroscopic technique with specifically designed instrumentation

The present study describes a novel all-arthroscopic technique for medial and lateral meniscal allograft transplantation (MAT). Surgical instruments were specifically designed to assist in the all-arthroscopic approach for MAT. The bone plug attachment technique, either the arthroscopic-assisted or all-arthroscopic approach, attaches bone plugs to the anterior and posterior horns. In the present study, two sets of surgical implements were designed: One to produce bone plugs of predefined sizes in the anterior and posterior horns of the allograft meniscus (bone plug implements) and a second to create bone tunnels in the receptor tibial plateau to hold the bone plugs (bone tunnel implements). The present study demonstrated that an all-arthroscopic approach to MAT was feasible. Furthermore, the specifically designed surgical instruments allowed for consistent preparation of grafts and recipient tissues, contributing to a standardized approach to MAT. The present findings indicate that an all-arthroscopic approach to MAT may be achievable. They also provide the incentive for future clinical studies to directly compare the outcomes and to initiate the standardization of the procedure to optimize MAT and maximize patient outcomes and quality of life.

Meniscal repair and regeneration: Current strategies and future perspectives

The management of meniscal injuries remains difficult and challenging. Although several clinical options exist for the treatment of such injuries, complete regeneration of the damaged meniscus has proved difficult due to the limited healing capacity of the tissue. With the advancements in tissue engineering and cell-based technologies, new therapeutic options for patients with currently incurable meniscal lesions now potentially exist. This review will discuss basic anatomy, current repair techniques and treatment options for loss of meniscal integrity. Specifically, we focus on the possibility and feasibility of the latest tissue engineering approaches, including 3D printing technologies. Therefore, this discussion will facilitate a better understanding of the latest trends in meniscal repair and regeneration, and contribute to the future application of such clinical therapies for patients with meniscal injuries.

A novel technique for modified all-inside repair of bucket-handle meniscus tears using standard arthroscopic portals

Background

Bucket-handle meniscus tears (BHMT) are often displaced and unstable. The inside-out technique of repairing such tears is currently the gold standard. All-inside repair with meniscal fixators is getting increasingly popular. Shortcomings of the inside-out technique include neurovascular complications, especially saphenous nerve palsy, and retention of a non-resorbable suture which can result in discomfort to patient, granuloma formation, and a foci of infection. Hence, the purpose of this project was to innovate a novel all-inside technique to precisely reduce and fix BHMT while avoiding neurovascular complications and retention of a non-resorbable suture.

Methods

Routine arthroscopic portals were created on a patient’s left knee with a displaced BHMT. Through the anteromedial portal, a conjoint pseudo double lumen cannula was inserted. Two limbs of a reduction suture were passed through the cannula, one over the “femoral” surface of the meniscus, one over the “tibial” surface of the meniscus anterior to the biceps femoris tendon, with the knee flexed at 20° to avoid injury to the saphenous nerve. Suture limbs were passed out percutaneously and tensioned.

Results

Anatomic reduction was ensured under arthroscopic visualization with ease. All inside repair was performed using the vertical mattress suture configuration. Reduction sutures were subsequently removed by cutting flush to the skin and pulling on one suture limb. The patient was back to full activities with minimal discomfort 8 months post-operatively.

Conclusion

The technique described is superior to existing techniques for the following reasons: (1) Reduction of the displaced meniscal tear is “extra-meniscal,” avoiding further trauma to a damaged meniscus. (2) Tensioning of the two suture limbs created promotes better control of reduction through tensioning. (3) Risk of discomfort, infection, and neurovascular damage caused by a retained suture is reduced. (4) No additional portals/equipment is required. We encourage this novel technique to be attempted by surgeons.

Editorial Commentary: Feeling the Pressure! A Biomechanical Analysis of All-Inside and Inside-Out Knee Meniscus Repair

A biomechanical, time-zero comparison found that both No. 2-0 UltraBraid inside-out sutures and FasT-Fix 360 all-inside devices used to repair a displaced bucket handle knee meniscus tear increased the contact area in deeper flexion angles (at 45°-60°) and reduced the peak contact pressure (at 45°-90°). No significance difference was observed between the inside-out and all-inside repair techniques.

A Contact Pressure Analysis Comparing an All-Inside and Inside-Out Surgical Repair Technique for Bucket-Handle Medial Meniscus Tears

PURPOSE

To directly compare effectiveness of the inside-out and all-inside medial meniscal repair techniques in restoring native contact area and contact pressure across the medial tibial plateau at multiple knee flexion angles.

METHODS

Twelve male, nonpaired (n = 12), fresh-frozen human cadaveric knees underwent a series of 5 consecutive states: (1) intact medial meniscus, (2) MCL tear and repair, (3) simulated bucket-handle longitudinal tear of the medial meniscus, (4) inside-out meniscal repair, and (5) all-inside meniscal repair. Knees were loaded with a 1,000-N axial compressive force at 5 knee flexion angles (0°, 30°, 45°, 60°, 90°), and contact area, mean contact pressure, and peak contact pressure were calculated using thin film pressure sensors.

RESULTS

No significant differences were observed between the inside-out and all-inside repair techniques at any flexion angle for contact area, mean contact pressure, and peak contact pressure (all P > .791). Compared with the torn meniscus state, inside-out and all-inside repair techniques resulted in increased contact area at all flexion angles (all P < .005 and all P < .037, respectively), decreased mean contact pressure at all flexion angles (all P < .007 and all P < .001, respectively) except for 0° (P = .097 and P = .39, respectively), and decreased peak contact pressure at all flexion angles (all P < .001, all P < .001, respectively) except for 0° (P = .080 and P = .544, respectively). However, there were significant differences in contact area and peak contact pressure between the intact state and inside-out technique at angles ≥45° (all P < .014 and all P < .032, respectively). Additionally, there were significant differences between the intact state and all-inside technique in contact area at 60° and 90° and peak contact pressure at 90° (both P < .005 and P = .004, respectively). Median values of intact contact area, mean contact pressure, and peak contact pressure over the tested flexion angles ranged from 498 to 561 mm², 786 to 997 N/mm², and 1,990 to 2,215 N/mm², respectively.

CONCLUSIONS

Contact area, mean contact pressure, and peak contact pressure were not significantly different between the all-inside and inside-out repair techniques at any tested flexion angle. Both techniques adequately restored native meniscus biomechanics near an intact level.

CLINICAL RELEVANCE

An all-inside repair technique provided similar, native-state-restoring contact mechanics compared with an inside-out repair technique for the treatment of displaced bucket-handle tears of the medial meniscus. Thus, both techniques may adequately decrease the likelihood of cartilage degeneration.

Meniscal Preservation is Important for the Knee Joint

Native joint preservation has gained importance in recent years. This is mostly to find solutions for limitations of arthroplasty. In the knee joint, the menisci perform critical functions, adding stability during range of motion and efficiently transferring load across the tibiofemoral articulation while protecting the cartilage. The menisci are the most common injury seen by orthopedicians, especially in the younger active patients. Advances in technology and our knowledge on functioning of the knee joint have made meniscus repair an important mode of treatment. This review summarizes the various techniques of meniscus tear repair and also describes biological enhancements of healing.

Clinical outcomes following surgically repaired bucket-handle meniscus tears

OBJECTIVES

Meniscus tears are one of the most common knee injuries. Our goal is to investigate the failure rate for surgically repaired bucket-handle meniscus tears and compare clinical outcomes of repairs that failed versus those that did not, at a minimum 2-year follow-up interval.

METHODS

51 patients were identified in this retrospective cohort study who experienced bucket-handle meniscus tears that were isolated or with concomitant ACL injury. Inclusion criteria included age range from 13-55 years, confirmed bucket-handle meniscus tear by MRI and intraoperatively, and at least two-years of post-operative follow-up following index repair. Demographic data and outcome surveys were collected at a minimum of two-years follow-up after repair.

RESULTS

Of the 51 patients that had a bucket-handle meniscal repair, 12 (23.5%) were defined as failures (return of symptoms alongside re-tear in the same zone of the repaired meniscus within two years of surgery). No demographic variables (age, sex, and BMI smoking status, location of tear, or concomitant ACL tear) significantly correlated with failure. The mean of the Sports and Recreation KOOS was significantly lower between the non-failure (87 ± 14.4) and failure (70 ± 17.2) cohorts (p = 0.0072). The Quality of Life subscale was significantly lower between the non-failure (76 ± 15.8) and failure (57 ± 18.2) groups (p = 0.0058). There was a significant difference in the post-operative Lysholm scores (p = 0.0039) with a mean of 90 ± 9.1 for the entire cohort and means of 92 ± 8.4 and 83 ± 8.6, for non-failure and failure groups, respectively.

CONCLUSIONS

We found a higher failure rate (23.5%) for bucket-handle meniscus repairs at two-year follow up than has been cited in the literature, which is typically less than 20%, with significantly lower KOOS Quality of Life and Sports and Recreation subscales and Lysholm scores for the failure cohort. This is the first study to report these outcome scores solely for bucket-handle meniscus repairs, shedding light on the post-operative quality of life of patients with repair success or failure.

Inside-Out Repair of Meniscal Ramp Lesions

Meniscal ramp lesions have been reported to be present in 9% to 17% of patients undergoing anterior cruciate ligament reconstruction. Detection at the time of arthroscopy can be accomplished based upon clinical suspicion and careful evaluation without the use of an accessory posteromedial portal. Options for surgical treatment include arthroscopic repair using an all-inside or inside-out technique. The purpose of this Technical Note is to detail our arthroscopic inside-out repair technique for meniscal ramp lesions.

Horizontal Cleavage Meniscus Tear Treated With All-inside Circumferential Compression Stitches

Horizontal cleavage meniscus tears are a common orthopedic injury often treated with partial or total meniscectomy versus repair. This Technical Note presents a technique for all-inside repair with uniform compression of the superior and inferior leaflets by placement of multiple circumferential compression stitches using an all-inside self-retrieving suture passing device. The currently described technique provides several advantages for all-inside repair of a horizontal cleavage tear: (1) eliminates the need for a posterior incision, (2) minimizes the risk of neurovascular injury, (3) uses standard arthroscopy portals (or small modifications), and (4) requires only a single suture deployment with a self-retrieving device for each circumferential compression stitch. The resulting circumferential stitch provides uniform compression to the superior and inferior leaflets, promoting meniscal healing. This configuration has been shown to have the highest load to failure of all repair patterns.

Arthroscopic Inside-Out Repair of a Meniscus Bucket-Handle Tear Augmented With Bone Marrow Aspirate Concentrate

Bucket-handle tears of the meniscus comprise nearly 10% of all meniscus tears and commonly affect the young male population. Displacement of the free segment can lead to significant pain and disability, necessitating reduction and surgical treatment. General contraindications include malalignment, severe arthritis, significant comorbidities, or chronic asymptomatic tears, but otherwise repair should almost always be performed. Options for surgical treatment include partial meniscectomy and arthroscopic repair using an all-inside, outside-in, or inside-out technique. The purpose of this Technical Note is to detail our arthroscopic inside-out repair technique augmented with bone marrow aspirate concentrate.

Outcomes of Inside-out Meniscal Repair in the Setting of Multiligament Reconstruction in the Knee

BACKGROUND

Limited evidence exists for meniscal repair outcomes in a multiligament reconstruction setting. Purpose/Hypothesis: The purpose of this study was to assess outcomes and failure rates of meniscal repair in patients who underwent multiligament reconstruction compared with patients who underwent multiligament reconstruction but lacked meniscal tears. The authors hypothesized that the outcomes of meniscal repair associated with concomitant multiligament reconstruction would significantly improve from preoperatively to postoperatively at a minimum of 2 years after the index surgery. Secondarily, they hypothesized that this cohort would demonstrate similar outcomes and failure rates compared with the cohort that did not have meniscal lesions at the time of multiligament reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Inclusion criteria for the study included radiographically confirmed skeletally mature patients of at least 16 years of age who underwent multiligamentous reconstruction of the knee without previous ipsilateral osteotomy, intra-articular infections, or intra-articular fractures. Patients were included in the experimental group if they underwent inside-out meniscal suture repair with concurrent multiligament reconstruction. Those included in the control group (multiligament reconstruction without a meniscal tear) underwent multiligament reconstruction but did not undergo any type of meniscal surgery. Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-12 physical component summary and mental component summary, Tegner activity scale, and patient satisfaction scores were recorded preoperatively and postoperatively. The failure of meniscal repair was defined as a retear of the meniscus that was confirmed arthroscopically.

RESULTS

There were 43 patients (16 female, 27 male) in the meniscal repair group and 62 patients (25 female, 37 male) in the control group. Follow-up was obtained in 93% of patients with a mean of 3.0 years (range, 2.0-4.7 years). There was a significant improvement between all preoperative and postoperative outcome scores ( P < .05) for both groups. The meniscal repair group had significantly lower preoperative Lysholm and Tegner scores ( P = .009 and P = .02, respectively). There were no significant differences between any other outcome scores preoperatively. The failure rate of the meniscal repair group was 2.7%, consisting of 1 symptomatic meniscal retear. There was no significant difference in any postoperative outcome score at a minimum 2-year follow-up between the 2 groups.

CONCLUSION

Good to excellent patient-reported outcomes were reported for both groups with no significant differences in outcomes between the cohorts. Additionally, the failure rate for inside-out meniscal repair with concomitant multiligament reconstruction was low, regardless of meniscus laterality and tear characteristics. The use of multiple vertical mattress sutures and the biological augmentation resulting from intra-articular cruciate ligament reconstruction tunnel reaming may be partially responsible for the stability of the meniscal repair construct and thereby contribute to the overall improved outcomes and the low failure rate of meniscal repair, despite lower preoperative Lysholm and Tegner scores in the meniscal repair group.

Rehabilitation Protocols After Isolated Meniscal Repair: A Systematic Review

BACKGROUND

Current postoperative rehabilitation protocols after isolated meniscal repair vary widely. No consensus exists with regard to the optimal amount of weightbearing, range of motion, or speed at which the patient progresses through the rehabilitation phases. Confounding factors including concomitant ligamentous or cartilaginous injuries have made studying isolated meniscal tears problematic.

PURPOSE

To systematically review and evaluate the influence of range of motion and weightbearing status during the postoperative rehabilitation period after isolated meniscal repair on clinical efficacy and outcome scores.

STUDY DESIGN

Systematic review.

METHODS

A search of PubMed, Scopus, and Cochrane Central Register of Controlled Trials was conducted. The selection criteria for inclusion were English-language in vivo clinical studies reporting on isolated meniscal repairs utilizing an arthroscopically assisted technique that outlined the postoperative rehabilitation protocol and included at least a 2-year follow-up. Titles, abstracts, and articles were reviewed, and data concerning patient demographics, tear type, repair technique, postoperative protocol details, clinical failures, and outcome scores were extracted from the eligible studies. Rehabilitation protocols were divided into "accelerated," "motion restricted," "weight restricted," and "dual restricted" according to the limitations placed on the treatment groups.

RESULTS

Fifteen studies, containing 17 different treatment groups, met the inclusion criteria. The 2 accelerated groups, 2 motion-restricted groups, 4 weight-restricted groups, and 9 dual-restricted groups showed similar efficacy in terms of clinical success and postoperative outcome scores. Early range of motion and weightbearing status showed no influence over clinical outcomes. Of the 17 groups, 13 reported a greater than 70% clinical success rate with significant variation in the tear type, fixation technique, and postoperative restrictions.

CONCLUSION

Early range of motion and immediate postoperative weightbearing appear to have no detrimental effect on the chances for clinical success after isolated meniscal repair. Significant variation exists between postoperative protocols, with no current consensus on the ideal parameters for weightbearing and range of motion. Studies reporting outcomes regarding isolated meniscal repair are limited. Future research should include determining the ideal combination of weightbearing and range of motion for specific tear types.

Centralization of extruded medial meniscus delays cartilage degeneration in rats

BACKGROUND

Meniscus extrusion often observed in knee osteoarthritis has a strong correlation with the progression of cartilage degeneration and symptom in the patients. We recently reported a novel procedure "arthroscopic centralization" in which the capsule was sutured to the edge of the tibial plateau to reduce meniscus extrusion in the human knee. However, there is no animal model to study the efficacy of this procedure. The purposes of this study were [1] to establish a model of centralization for the extruded medial meniscus in a rat model; and [2] to investigate the chondroprotective effect of this procedure.

METHODS

Medial meniscus extrusion was induced by the release of the anterior synovial capsule and the transection of the meniscotibial ligament. Centralization was performed by the pulled-out suture technique. Alternatively, control rats had only the medial meniscus extrusion surgery. Medial meniscus extrusion was evaluated by micro-CT and macroscopic findings. Cartilage degeneration of the medial tibial plateau was evaluated macroscopically and histologically.

RESULTS

By micro-CT analysis, the medial meniscus extrusion was significantly improved in the centralization group in comparison to the extrusion group throughout the study. Both macroscopically and histologically, the cartilage lesion of the medial tibial plateau was prevented in the centralization group but was apparent in the control group.

CONCLUSIONS

We developed medial meniscus extrusion in a rat model, and centralization of the extruded medial meniscus by the pull-out suture technique improved the medial meniscus extrusion and delayed cartilage degeneration, though the effect was limited. Centralization is a promising treatment to prevent the progression of osteoarthritis.

All-Inside Versus Inside-Out Meniscal Repair With Concurrent Anterior Cruciate Ligament Reconstruction: A Meta-regression Analysis

BACKGROUND

Meniscal tears are frequently repaired during anterior cruciate ligament reconstruction (ACLR).

PURPOSE

To systematically evaluate differences in clinical failures between all-inside and inside-out meniscal repairs performed during ACLR.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review was perfomed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases queried included MEDLINE, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials. All English-language studies reporting failure rates after meniscal repair with either the all-inside or inside-out technique performed in conjunction with ACLR were identified between 1980 and 2015. Studies with a minimum 2-year follow-up were included. Reported outcomes, clinical meniscal repair failures, and complications were assessed. Studies were weighted according to the size of the clinical series and mean follow-up length. Inverse-variance-weighted mixed models were used to evaluate whether there was a significant difference in pooled reoperation rates between repair techniques.

RESULTS

In total, 21 studies met inclusion criteria. Of these, 13 studies reported outcomes after all-inside repair, and 10 studies reported outcomes after inside-out repair (2 studies reported both). A total of 1126 patients were included in the analysis. The mean (±SD) follow-up for all-inside repair was 58.64 ± 22.24 months versus 76.25 ± 31.69 months for inside-out repair ( P = .13). The clinical failure rate for all-inside meniscal repair performed concurrently with ACLR was 16% (121/744) compared with 10% (39/382) for inside-out repair, and this was found to be significant ( P = .016). Implant irritation and device migration were the most common complications reported for all-inside repair; complication rates did not differ between the groups.

CONCLUSION

There may be fewer early clinical failures when the inside-out technique is utilized for meniscal repair at the time of concomitant ACLR. Additional long-term studies will be useful to determine the operative success of these repairs over time.

The Urgent Need for Evidence in Arthroscopic Meniscal Surgery

BACKGROUND

Arthroscopic surgery of the knee is one of the most frequently performed orthopaedic procedures. One-third of these procedures are performed for meniscal injuries. It is essential that this commonly performed surgery be supported by robust evidence.

PURPOSE

To compare the effectiveness of arthroscopic surgery for meniscal injuries in all populations.

STUDY DESIGN

Systematic review.

METHODS

An online search was conducted for randomized controlled trials (RCTs) and systematic reviews (SRs) that compared treatment options for meniscal injury. The following databases (inception to April 2015) were included in the search: CENTRAL; MEDLINE; EMBASE; NHS Evidence; National Guideline Clearing House, Database of Abstracts of Reviews of Effects, Health Technology Assessment; ISRCTN; Clinicaltrials.gov ; WHO trials platform. Only studies whose participants were selected on the basis of meniscal injury were included; no restrictions were placed on patient demographics. Two independent reviewers applied AMSTAR (A Measurement Tool to Assess Systematic Reviews) criteria for SRs and the Cochrane Collaboration risk-of-bias tool for RCTs.

RESULTS

Nine RCTs and 8 SRs were included in the review. No difference was found between arthroscopic meniscal debridement compared with nonoperative management as a first-line treatment strategy for patients with knee pain and a degenerative meniscal tear (mean difference: Knee injury and Osteoarthritis Outcome Score, 1.6 [95% CI, -2.2 to 5.2], pain visual analog scale, -0.06 [95% CI, -0.28 to 0.15]). Some evidence was found to indicate that patients with resistant mechanical symptoms who initially fail nonoperative management may benefit from meniscal debridement No studies compared meniscal repair with meniscectomy or nonoperative management. Initial evidence suggested that meniscal transplant might be favorable in certain patient groups.

CONCLUSION

Further evidence is required to determine which patient groups have good outcomes from each intervention. Given the current widespread use of arthroscopic meniscal surgeries, more research is urgently needed to support evidence-based practice in meniscal surgery in order to reduce the numbers of ineffective interventions and support potentially beneficial surgery.

Inside-Out Versus All-Inside Repair of Isolated Meniscal Tears: An Updated Systematic Review

BACKGROUND

Meniscal tears are common in the young, active population. In this group of patients, repair is advised when possible. While inside-out repair remains the standard technique, recent advances in all-inside repair devices have led to a growth in their popularity. Previous reviews on the topic have focused on outdated implants of limited clinical relevance.

PURPOSE

To determine the difference in failure rates, functional outcomes, and complications between inside-out and modern all-inside repairs.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was registered with PROSPERO and performed following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using the MEDLINE, EMBASE, and Cochrane databases. Inclusion criteria were (1) clinical study reporting on all-inside or inside-out repair, (2) evidence levels 1 to 4, and (3) use of modern all-inside implants for all-inside repairs. Exclusion criteria were (1) use of meniscal arrows or screws and (2) concomitant surgical procedures. Study characteristics, subjects, surgical technique, clinical outcomes, and complications were collected and analyzed.

RESULTS

A total of 481 studies were screened and assessed for eligibility, which identified 27 studies for review. Studies defined clinical failure as persistent mechanical symptoms, effusion, or joint line tenderness, while anatomic failure was incomplete or no healing on MRI or second-look arthroscopy. There were no significant differences in clinical or anatomic failure rates between inside-out and all-inside repairs (clinical failure: 11% vs 10%, respectively, P = .58; anatomic failure: 13% vs 16%, respectively, P = .63). Mean ± SD Lysholm and Tegner scores for inside-out repair were 88.0 ± 3.5 and 5.3 ± 1.2, while the respective scores for all-inside repair were 90.4 ± 3.7 and 6.3 ± 1.3. Complications occurred at a rate of 5.1% for inside-out repairs and 4.6% for all-inside repairs.

CONCLUSION

The quality of the evidence comparing inside-out and all-inside meniscal repair remains low, with a majority of the literature being evidence level 4 studies. In this review comparing modern all-inside devices with inside-out repair, no differences were seen in failure rates, functional outcome scores, or complication rates.

Effects of suture site or penetration depth on anchor location in all-inside meniscal repair

BACKGROUND

To evaluate the effects of suture site or penetration depth on anchor location in all-inside meniscal repair.

METHODS

Eight fresh-frozen cadaveric knees were evaluated after meniscal repair using eight FasT-Fix360 (FF360) devices (Smith & Nephew Endoscopy, Andover, MA) (16 anchors) for each knee. The penetration depth was 14mm, the distance same from the periphery to insertion point, in four knees (Group A) and that in the remaining four knees (Group B) was 18mm. The anchor location in two groups was evaluated after attentive dissection.

RESULTS

Of 32 anchors for the medial meniscus, 94% were on the capsule, including the superficial medial collateral ligament (sMCL) in both groups. For the lateral meniscus, 47% anchors in Group A and 44% anchors in Group B were on the capsule. Total three anchors were over the lateral collateral ligament (LCL), whereas 15 anchors were behind the popliteus tendon (POP). Although all three anchors settled in the subcutaneous fat were in Group B, no significant difference was observed in anchor location between two groups.

CONCLUSIONS

Secure fixation to thin membranous tissue can be achieved for the medial meniscal repair using FF360, while some were located in/on bunchy LCL or POP in lateral meniscal repair. Only anchors with additional four-millimeter penetration depth were in the subcutaneous fat, although there was no effect of the penetration depth to anchor location. Clinically, for lateral meniscal repair, penetrating toward POP/LCL should be avoided and four-millimeter deeper penetration depth might be a risk for the subcutaneous irritation.

New Complication Associated With All-Inside Meniscal Repair Device: Ultrasound-Aided Diagnosis and Operative Localization of Foreign Body Reaction

Background:

The importance of meniscal preservation has become widely accepted, and meniscal repair techniques have evolved over recent years. With new techniques come new complications, which are critical to recognize.

Purpose:

To describe a new complication of foreign body reaction from a nonabsorbable suture anchor associated with improper placement of the all-inside meniscal device.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study was a retrospective review of 3 patients who developed pain associated with a foreign body reaction from a misplaced all-inside meniscal device.

Results:

All patients had a delayed diagnosis (6 months to 8 years) and negative magnetic resonance imaging (MRI). Diagnostic ultrasound identified the misplaced suture with foreign body reaction and was used to guide a diagnostic injection of local anesthetic prior to surgical intervention. Intraoperative ultrasound guidance was utilized to precisely localize and excise the suture material and associated reactive tissue.

Conclusion:

Foreign body reaction from a misplaced all-inside meniscal device is a previously unreported complication. Diagnosis is challenging as MRI and arthroscopy can be unrevealing. Diagnostic ultrasound was able to identify the foreign body reaction, confirm the diagnosis by facilitating diagnostic local anesthetic injection, and guide surgical excision. Sonographic evaluation should be considered in patients presenting with ongoing knee pain after all-inside meniscus repair.