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Anaspure O, Patel S, Baumann AN, Anastasio AT, Walley KC, Kelly JD, Lau BC. Examining the Evidence Regarding Smoking and Patient Outcomes for Isolated Meniscus Pathology: A Comprehensive Systematic Review and Meta-Analysis. Life (Basel) 2024; 14:584. [PMID: 38792605 PMCID: PMC11122235 DOI: 10.3390/life14050584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/19/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
Smoking is a well-known cause of impairment in wound healing and postoperative outcomes; however, its effects on treating meniscus issues remain unclear. This study assesses the relationship between smoking and meniscus treatment outcomes. PubMed, Scopus, Cochrane, and CINAHL were searched from inception to 24 December 2023. Inclusion criteria encompassed studies examining smoking's impact on patient outcomes regarding meniscus pathology. A secondary PubMed search targeted randomized controlled trials (RCTs) in the top ten orthopedic journals focusing on meniscus pathology and smoking as a demographic variable. Meta-analysis of six studies (n = 528) assessed meniscus failure rate based on smoking status. Eighteen observational studies (n = 8353 patients; 53.25% male; mean age: 51.35 ± 11.53 years; follow-up: 184.11 ± 117.34 months) were analyzed, covering meniscus repair, meniscectomy, allograft transplant, conservative care, and arthroscopy. Results showed four studies (36.36%) linked smoking with worse meniscus repair outcomes, while seven studies (63.64%) did not find significant associations. Meta-analysis from six studies showed no significant impact of smoking on repair failure (p = 0.118). Regarding meniscectomy, one study (33.33%) identified a significant association with smoking, but two did not. Only one (3.8%) of the RCTs in leading orthopedic journals included smoking as a factor. The evidence on smoking's effect on meniscus treatment is mixed, necessitating further investigation.
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Affiliation(s)
- Omkar Anaspure
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Shiv Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Anthony N. Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA;
| | - Albert T. Anastasio
- Department of Orthopedic Surgery, Duke University, Durham, NC 27710, USA; (A.T.A.); (B.C.L.)
| | - Kempland C. Walley
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI 48109, USA;
| | - John D. Kelly
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Brian C. Lau
- Department of Orthopedic Surgery, Duke University, Durham, NC 27710, USA; (A.T.A.); (B.C.L.)
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2
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Migliorini F, Asparago G, Oliva F, Bell A, Hildebrand F, Maffulli N. Greater rate of return to play and re-injury following all-inside meniscal repair compared to the inside-out technique: a systematic review. Arch Orthop Trauma Surg 2023; 143:6273-6282. [PMID: 37284879 PMCID: PMC10491517 DOI: 10.1007/s00402-023-04933-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 05/25/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Inside-out and all-inside arthroscopic meniscal repairs are widely performed. However, it remains unclear which method promotes greater clinical outcomes. This study compared inside-out versus all-inside arthroscopic meniscal repair in terms of patient-reported outcome measures (PROMs), failures, return to play, and symptoms. METHODS This systematic review was conducted in accordance with the PRISMA guidelines. Two authors independently performed the literature search by accessing the following databases: PubMed, Google Scholar, and Scopus in February 2023. All clinical studies which investigated the outcomes of all-inside and/or inside-out meniscal repair were considered. RESULTS Data from 39 studies (1848 patients) were retrieved. The mean follow-up was 36.8 (9 to 120) months. The mean age of the patients was 25.8 ± 7.9 years. 28% (521 of 1848 patients) were women. No difference was found in PROMs: Tegner Activity Scale (P = 0.4), Lysholm score (P = 0.2), and International Knee Document Committee score (P = 0.4) among patients undergoing meniscal repair with all inside or inside-out techniques. All-inside repairs showed a greater rate of re-injury (P = 0.009) but also a greater rate of return to play at the pre-injury level (P = 0.0001). No difference was found in failures (P = 0.7), chronic pain (P = 0.05), reoperation (P = 0.1) between the two techniques. No difference was found in the rate of return to play (P = 0.5) and to daily activities (P = 0.1) between the two techniques. CONCLUSION Arthroscopic all-inside meniscal repair may be of special interest in patients with a particular interest in a fast return to sport, while, for less demanding patients, the inside-out suture technique may be recommended. High-quality comparative trials are required to validate these results in a clinical setting. LEVEL OF EVIDENCE Level III, systematic review.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, Simmerath, Germany.
| | - Giovanni Asparago
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, Simmerath, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, ST4 7QB, Stoke On Trent, England
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, E1 4DG, London, England
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Wei W, Zhang Y, Li R, Ni J, Wang D, Zhang S, Shi Z. Efficacy of meniscus suture absorbability on meniscus healing success rate via second-look arthroscopy after meniscal repair: a systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:717. [PMID: 37684657 PMCID: PMC10485939 DOI: 10.1186/s12891-023-06602-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 06/03/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND To preserve the meniscus's function, repairing the torn meniscus has become a common understanding. After which, the search for the ideal suture material is continuous. However, it is still controversial about the efficacy of suture absorbability on meniscus healing. METHODS This review is designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. INCLUSION CRITERIA (1) Studies on meniscus repair; (2) Second-look arthroscopy was performed; (3) The meniscus was repaired by absorbable and non-absorbable sutures; (4) The healing condition of repaired meniscus via second-look arthroscopy was described. EXCLUSION CRITERIA (1) Animal studies, cadaveric studies, or in vitro research; (2) Meniscus transplantation; (3) Open meniscus repair; (4) Reviews, meta-analysis, case reports, letters, and comments; (5) non-English studies. MEDLINE, Embase, and Cochrane Database were searched up to October 2022. Risk of bias and methodology quality of included literature were assessed according to ROBINS-I and the modified Coleman Methodological Scale (MCMS). Descriptive analysis was performed, and meta-analysis was completed by RevMan5.4.1. RESULTS Four studies were included in the systematic review. Among them, three studies were brought into the meta-analysis, including 1 cohort study and 2 case series studies about 130 patients with meniscal tears combined with anterior cruciate ligament injury. Forty-two cases were repaired by absorbable sutures, and 88 were repaired by non-absorbable sutures. Using the fixed effect model, there was a statistical difference in the healing success rate between the absorbable and the non-absorbable groups [RR1.20, 95%CI (1.03, 1.40)]. CONCLUSION In early and limited studies, insufficient evidence supports that non-absorbable sutures in meniscus repair surgery could improve meniscal healing success rate under second-look arthroscopy compared with absorbable sutures. In contrast, available data suggest that absorbable sutures have an advantage in meniscal healing. TRIAL REGISTRATION The review was registered in the PROSPERO System Review International Pre-Registration System (Registration number CRD42021283739).
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Affiliation(s)
- Wang Wei
- The First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an Jiaotong University, Xi'an, China
| | - Yi Zhang
- Department of Orthopaedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ruiying Li
- The First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an Jiaotong University, Xi'an, China
| | - Jianlong Ni
- The First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an Jiaotong University, Xi'an, China
| | - Dongjian Wang
- Second Department of Orthopaedics, Shaanxi Sengong Hospital, Xi'an, China
| | - Sanpeng Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an Jiaotong University, Xi'an, China
| | - Zhibin Shi
- The First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an Jiaotong University, Xi'an, China.
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Robinson JR, Bruce D, Davies H, Porteous AJ, Murray JRD, Howells NR. Single-stage repair of displaced bucket-handle meniscal tears with anterior cruciate ligament reconstruction leads to good meniscal survivorship : a retrospective cohort study. Bone Joint J 2022; 104-B:680-686. [PMID: 35638209 DOI: 10.1302/0301-620x.104b6.bjj-2021-1340.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR. METHODS We reviewed the data for a consecutive series of 88 patients (mean age 27.1 years (15 to 49); 65 male (74%) and 23 female (26%)) who underwent single-stage repair of a displaced BH meniscal tear (67 medial (76%) and 21 lateral (24%)) with concomitant hamstring autograft ACLR. The patient-reported outcome measures (PROMs) EuroQol visual analogue scale (EQ-VAS), EuroQol five-dimension health questionnaire (EQ-5D), Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), and Tegner score were recorded at final follow-up. A Kaplan-Meier survival analysis was performed to estimate meniscal repair survivorship. Analyses were performed with different cut-offs for meniscal and ACL injury-to-surgery time (within three weeks, three to ten weeks, and more than ten weeks). RESULTS Meniscal repair survivorship at a median final follow-up of 55 months (interquartile range (IQR) 24 to 91) was 82% (95% confidence interval 70 to 89). A total of 13 meniscus repairs failed (12 requiring meniscectomy and one requiring a further meniscal repair). At final follow-up, median PROMs were: EQ-VAS 85 (IQR 75 to 90), EQ-5D Index 0.84 (IQR 0.74 to 1.00), KOOS Pain 89 (IQR 80 to 94), KOOS Symptoms 82 (IQR 71 to 93), KOOS Activities of Daily Living 97 (IQR 91 to 100), KOOS Sport and Recreation 80 (IQR 65 to 90), KOOS Quality of Life 69 (IQR 53 to 86), IKDC 82.8 (IQR 67.8 to 90.8), and Tegner 6 (IQR 4 to 7). Two patients underwent revision ACLR following further injuries. One patient had an arthroscopic washout for infection at 11 days post-BH meniscal repair/ACLR. Four patients (4.5%) required a further procedure for stiffness, reduced ROM, and pain, and all were operated on within three weeks of meniscal injury. There was no difference in the interval between meniscal injury and surgery between repairs that failed and those that survived. CONCLUSION These data suggest that concomitant ACLR with repair of displaced BH meniscal tears, even if they have been displaced for some time, appears to afford satisfactory PROMs and good survivorship. Repairs within three weeks of meniscal injury may be associated with higher rates of postoperative reintervention for stiffness. Cite this article: Bone Joint J 2022;104-B(6):680-686.
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Affiliation(s)
| | - David Bruce
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Hywel Davies
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | | | | | - Nick R Howells
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Hou JH, Gong YL, Ma P, Chen X, Dong WT, Liu JJ, Liu BJ, Zhang CM. Comparative clinical outcomes of different therapies for traumatic meniscal tears in adults: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2022; 101:e28557. [PMID: 35029222 PMCID: PMC8757970 DOI: 10.1097/md.0000000000028557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Meniscus tears are usually classified as degenerative or traumatic tears according to their pathogenesis. At present, traumatic meniscal tears are generally believed to have high healing potential. In recent years, multiple treatments have been described for traumatic meniscal tears, such as the inside-out technique, outside-in technique, all-inside technique, biological augmentation of meniscal repair, meniscectomy, and non-surgical treatment. However, the functional recovery of the knee joint and healing of the meniscus after treatment are quite different from the results reported in the literature, which requires more reliable evidence-based medical findings. This study will evaluate evidence from multiple types of research comparing different therapies for traumatic meniscal tears in adults. METHODS We will search the EMBASE, Cochrane Library (the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register), PubMed, Web of Science (Science and Social Science Citation Index), China Knowledge Network, CBM, Wanfang data, and VIP electronic databases from their inception to August 10, 2021, with no language restrictions. We will also manually search Baidu and Google Scholar to identify randomized controlled studies, non-randomized controlled studies, and cohort studies on the treatment of traumatic meniscal tears. Two researchers will independently screen the literature, extract the data, and evaluate the quality of the studies. Software programs, including Microsoft Access, Excel, Stata (Version 15), WinBUGS (Version 1.4.3), and ADDIS (Version 1.16.8), were used to analyze and manipulate the data. RESULTS In this study, the main outcomes were physical function and healing rate, based on the Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm Knee Scoring Scale, Knee Injury and Osteoarthritis Outcome Score, Functional Recovery Scale, and clinical healing rate. The secondary indexes included total cost, cost-effectiveness ratio, incremental cost-effectiveness ratio, Tegner activity scale score, visual analogue scale, numerical rating scale, and meniscal tear complications. CONCLUSIONS This systematic review will provide reliable evidence-based findings for the clinical application of different therapies for traumatic meniscal tears in adults.
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6
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Gousopoulos L, Grob C, Ahrens P, Levy Y, Vieira TD, Sonnery-Cottet B. How to Avoid Iatrogenic Saphenous Nerve Injury During Outside-In or Inside-Out Medial Meniscus Sutures. Arthrosc Tech 2022; 11:e127-e132. [PMID: 35155103 PMCID: PMC8821034 DOI: 10.1016/j.eats.2021.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/29/2021] [Indexed: 02/03/2023] Open
Abstract
Medial meniscal sutures using outside-in or inside-out techniques are very popular. Nevertheless, a saphenous nerve entrapment may occur with these techniques. This Technical Note describes a modified outside-in medial meniscus suture without any additional skin incisions. By dissecting the space between the subcutaneous and the capsule, which is performed by grasping and knotting the sutures through the anteromedial portal, iatrogenic saphenous nerve injury is avoided.
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Affiliation(s)
- Lampros Gousopoulos
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Charles Grob
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | | | - Yoann Levy
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France,Address correspondence to Thais Dutra Vieira, M.D., Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe Ramsay GDS, 69008 Lyon, France.
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
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Chuaychoosakoon C, Wuttimanop W, Tangjatsakow P, Charoenrattanawat S, Parinyakhup W, Boonriong T, Chernchujit B. The Danger Zone for Iatrogenic Neurovascular Injury in All-Inside Lateral Meniscal Repair in Relation to the Popliteal Tendon: An MRI Study. Orthop J Sports Med 2021; 9:23259671211038397. [PMID: 34631905 PMCID: PMC8493316 DOI: 10.1177/23259671211038397] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/19/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Lateral meniscal repair can endanger the nearby neurovascular structure (peroneal nerve or popliteal artery). To our knowledge, there have been no studies to evaluate the danger zone of all-inside meniscal repair through the anteromedial (AM) and anterolateral (AL) portals in relation to the medial and lateral edges of the popliteal tendon (PT). Purpose: To establish the risk of neurovascular injury and the danger zone in repairing the lateral meniscus in relation to the medial and lateral edges of the PT. Study Design: Descriptive laboratory study. Methods: Using axial magnetic resonance imaging (MRI) studies at the level of the lateral meniscus, lines were drawn to simulate a straight, all-inside meniscal repair device, drawn from the AM and AL portals to both the medial and lateral edges of the PT. In cases in which the line passed through the neurovascular structure, a risk of iatrogenic neurovascular injury was deemed, and measurements were made to determine the danger zones of neurovascular injury in relation to the medial or lateral edges of the PT. Results: Axial MRI images of 240 adult patients were reviewed retrospectively. Repairing the body of the lateral meniscus through the AM portal had a greater risk of neurovascular injury than repairs made through the AL portal in relation to the medial edge of the PT (P = .006). The danger zone in repairing the lateral meniscus through the AM portal extended 1.82 ± 1.68 mm laterally from the lateral edge of the PT and 3.13 ± 2.45 mm medially from the medial edge of the PT. Through the AL portal, the danger zone extended 2.81 ± 1.94 mm laterally from the lateral edge of the PT and 1.39 ± 1.53 mm medially from the medial edge of the PT. Conclusion: Repairing the lateral meniscus through either the AM or the AL portals in relation to the PT can endanger the peroneal nerve or popliteal artery. Clinical Relevance: The surgeon can minimize the risk of iatrogenic neurovascular injury in lateral meniscal repair by avoiding using the all-inside meniscal device in the danger zone area as described in this study.
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Affiliation(s)
- Chaiwat Chuaychoosakoon
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Watit Wuttimanop
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Preyanun Tangjatsakow
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Wachiraphan Parinyakhup
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Tanarat Boonriong
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Bancha Chernchujit
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Klarmann GJ, Gaston J, Ho VB. A review of strategies for development of tissue engineered meniscal implants. BIOMATERIALS AND BIOSYSTEMS 2021; 4:100026. [PMID: 36824574 PMCID: PMC9934480 DOI: 10.1016/j.bbiosy.2021.100026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/17/2021] [Accepted: 08/25/2021] [Indexed: 12/09/2022] Open
Abstract
The meniscus is a key stabilizing tissue of the knee that facilitates proper tracking and movement of the knee joint and absorbs stresses related to physical activity. This review article describes the biology, structure, and functions of the human knee meniscus, common tears and repair approaches, and current research and development approaches using modern methods to fabricate a scaffold or tissue engineered meniscal replacement. Meniscal tears are quite common, often resulting from sports or physical training, though injury can result without specific contact during normal physical activity such as bending or squatting. Meniscal injuries often require surgical intervention to repair, restore basic functionality and relieve pain, and severe damage may warrant reconstruction using allograft transplants or commercial implant devices. Ongoing research is attempting to develop alternative scaffold and tissue engineered devices using modern fabrication techniques including three-dimensional (3D) printing which can fabricate a patient-specific meniscus replacement. An ideal meniscal substitute should have mechanical properties that are close to that of natural human meniscus, and also be easily adapted for surgical procedures and fixation. A better understanding of the organization and structure of the meniscus as well as its potential points of failure will lead to improved design approaches to generate a suitable and functional replacement.
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Affiliation(s)
- George J. Klarmann
- 4D Bio³ Center, Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA,The Geneva Foundation, 917 Pacific Ave., Tacoma, WA 98402, USA,Corresponding author at: USU-4D Bio³ Center, 9410 Key West Ave., Rockville, MD 20850, USA.
| | - Joel Gaston
- 4D Bio³ Center, Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA,The Geneva Foundation, 917 Pacific Ave., Tacoma, WA 98402, USA
| | - Vincent B. Ho
- 4D Bio³ Center, Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA
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9
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Meniscus Repair Techniques. Sports Med Arthrosc Rev 2021; 29:e34-e43. [PMID: 34398120 DOI: 10.1097/jsa.0000000000000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The menisci play a vital role in maintaining knee function and protecting the chondral surfaces. Acute and chronic tears are common injuries among both young athletes and older patients with early degenerative changes. The progression of physiological derangement and chondral injury after meniscus injury and meniscectomy have prompted interest in expanding meniscus repair techniques. Recent literature encourages an attempt at repair in tear patterns previously declared irreparable if the tissue quality allows. The orthopedic surgeon should understand the multitude of techniques available to them and be prepared to combine techniques to optimize the quality of their repair construct. While biological augmentation may show some promising early results, the quality of the current data precludes strong recommendations in their favor.
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10
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Vint H, Quartley M, Robinson JR. All-inside versus inside-out meniscal repair: A systematic review and meta-analysis. Knee 2021; 28:326-337. [PMID: 33482623 DOI: 10.1016/j.knee.2020.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/25/2020] [Accepted: 12/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Meniscal repair using all-inside devices has garnered popularity compared to inside-out repair, yet few studies directly compare the two techniques in terms meniscal healing rates, surgical time, patient outcomes and incidence of complications. METHODS A systematic literature review was performed using the Medline, Cochrane and Embase databases. English-language studies comparing all-inside and inside-out arthroscopic meniscal repair techniques directly were included. Randomised controlled trials (RCTs) and observational studies with at least 10 patients in each treatment arm were included. Meta-analyses were performed using a fixed effect (when I2 < 50%) or random effects model (I2 ≥ 50%). RESULTS A total of 1042 studies were identified with seven being sui for inclusion (n = 505 patients). These comprised of one RCT two prospective and four retrospective, comparative, observational studies. Meta-analyses demonstrated that there was a significant reduction in operating time favouring all-inside repair (ratio of means [ROM] 0.62, 95% confidence interval [CI] 0.48-0.79; p = 0.0002) based on 3 studies (n = 208 patients). Based on 5 studies (n = 370 patients), there was no significant difference in meniscal healing rates between the groups (OR 1.26, 95% CI 0.52-3.10; p = 0.61). Nerve injury was more common after inside-out repair. There was a 85% reduction in the odds of nerve injury with the all-inside technique (OR 0.15, 95% CI 0.05-0.47; p = 0.0013). A qualitative data analysis suggested no difference in functional outcomes between the two techniques. CONCLUSIONS All-inside meniscal repair is associated with reduced operative time and a lower odds of nerve injury complications compared to inside-out repair, without compromising meniscal healing or functional results.
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Affiliation(s)
- Helen Vint
- Avon Orthopaedic Centre, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
| | - Megan Quartley
- Smith and Nephew, Department of Evidence Analysis, Smith and Nephew, Croxley Park Building 5, Hatters Lane, Watford, Hertfordshire WD18 8YE, UK
| | - James R Robinson
- Avon Orthopaedic Centre, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK.
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11
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Examining Techniques for Treatment of Medial Meniscal Ramp Lesions During Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2020; 36:2921-2933. [PMID: 32674943 DOI: 10.1016/j.arthro.2020.05.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to systematically review the clinical outcomes and adverse events among different techniques for treatment of medial meniscal ramp lesions performed in conjunction with anterior cruciate ligament (ACL) reconstruction. METHODS A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane Reviews, Web of Science, and Medline databases were searched for studies examining clinical outcomes after surgical treatment of ramp lesions. Studies were selected if they met the following criteria: (1) evaluation of the outcome of surgical repair of meniscal ramp lesions, (2) injuries associated with ACL tears, (3) minimum 6-month follow up, (4) publication in a peer-reviewed journal, and (5) English language or translation readily available. RESULTS Seven studies met inclusion criteria (485 patients; mean age 27.1 years [range 12 to 59]; mean follow-up 26.9 months [range 8 to 40]). Two all-inside techniques (suture-hook and an all-inside meniscus repair device) in addition to abrasion and trephination alone were analyzed. Each technique demonstrated significant increases in postoperative Lysholm and International Knee Documentation Committee (IKDC) scores, reaching the established minimal clinically important difference (MCID) for each patient reported outcome. Incomplete healing was documented in 12.1% to 12.9% of cases in which the tear was not repaired at the time of ACL reconstruction, 2.3% to 11.7% in cases using the suture-hook for repair, and 10.8% to 15% in the all-inside meniscus repair device group. CONCLUSION This systematic review demonstrated that several approaches used to treat medial meniscal ramp lesions associated with ACL tears lead to positive clinical outcomes. Small, stable tears <2 cm in size may be managed with debridement alone. For larger, more unstable lesions, an all-inside approach has demonstrated positive clinical outcomes. Prospective trials are needed to determine the best management for meniscal ramp lesions. Additionally, further research is needed to better understand how to minimize the risk of technique-related complications (e.g., improper implant deployment). LEVEL OF EVIDENCE Level IV, systematic review of level II, III, and IV studies.
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The all-inside all-suture technique demonstrated better biomechanical behaviors in meniscus radial tear repair. Knee Surg Sports Traumatol Arthrosc 2020; 28:3606-3612. [PMID: 32514843 DOI: 10.1007/s00167-020-06078-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of three constructs and techniques for repair of radial tears of the meniscus. METHODS Thirty fresh frozen porcine menisci were divided equally into three groups consisting of (1) inside-out repair group, (2) a commonly used all-inside suture with anchor hybrid repair construct (AISAH) (Meniscal Cinch™), and (3) an all-inside all-suture repair construct (AIAS) (Knee Scorpion™). Radial tears were created and repaired and then the menisci were secured to the materials testing machine. Both cyclic loading and load-to-failure testing were performed. The displacement, stiffness, response to cyclic loading, and mode of failure were recorded and analyzed statistically. RESULTS The displacement after cyclic loading (DACL) of the Cinch repair construct group was significantly higher than that of the inside-out repair construct group (p = 0.000) and AIAS repair construct (p = 0.000). There was not a statistical difference of DACL between inside-out and AIAS groups (n.s.). The inside-out construct failed at a significantly higher load than the AISAH repair construct (p = 0.000) and AIAS construct (p = 0.006). The AIAS construct failed at a significantly higher load than the AISAH repair construct (p = 0.009). The AIAS had a higher stiffness than AISAH (p = 0.047). The AIAS had a higher load at 3 mm protrusion than AISAH (p = 0.034). CONCLUSION The AIAS repair construct had better biomechanical behaviors than AISAH construct and inside-out repair technique. Inside-out sutures and AIAS repair construct had similar biomechanical responses to cyclic loading. The AIAS can be used for meniscus tear surgical repair with less damage to peri-meniscus tissues.
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Lin Y, Zhao J, Qiu H, Huang Y. All-inside versus inside-out suture techniques in arthroscopic meniscus repair: A prospective randomized study protocol. Medicine (Baltimore) 2020; 99:e20688. [PMID: 32629640 PMCID: PMC7337569 DOI: 10.1097/md.0000000000020688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND With advancements in our understanding of meniscal function, treatment options for meniscal injuries have evolved considerably over the past few decades. The aim of the current study was to compare the all-inside and inside-out techniques with regard to retear rate, functional outcomes, and perioperative complications in patients who had undergone arthroscopic meniscus repair. We hypothesized that there was no significant difference between the 2 groups in terms of postoperative outcomes after arthroscopic meniscus repair. METHODS This study was a prospective randomized blinded study, with a parallel design and an allocation ratio of 1:1 for the treatment groups. This study was approved by the Institutional Review Board in our hospital and written informed consent was obtained from all subjects participating in the trial. It was carried out in accordance with the principles of the Helsinki Declaration. A total of 70 patients who meet inclusion criteria are randomized to either all-inside or inside-out group. The primary outcome measure was retear rate. Retear was determined by repeat arthroscopic evaluation of patients with follow-up for symptoms of persistent or new pain, catching, or locking that was possibly related to the meniscal repair. Secondary outcomes included disease-specific quality of life measurement with the Western Ontario Meniscal Evaluation Tool, range of motion, operative time, and adverse events at surgery or throughout the follow-up period. RESULTS This study has limited inclusion and exclusion criteria and a well-controlled intervention. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry5589).
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Rocha de Faria JL, Pavão DM, Villardi AM, de Sousa EB, Guimarães JM, Carmo JMDM, Mozella ADP. Continuous Meniscal Suture Technique of the Knee. Arthrosc Tech 2020; 9:e791-e796. [PMID: 32577353 PMCID: PMC7301274 DOI: 10.1016/j.eats.2020.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/12/2020] [Indexed: 02/03/2023] Open
Abstract
The menisci are fibroelastic structures interposed between the articular surfaces of the femur and tibia. They absorb impact and transmit load. Meniscal injury may compromise function and cause rapid joint degeneration, leading to the development of secondary osteoarthritis. Surgical treatment of meniscal injury is usually performed by arthroscopy, and meniscectomy or meniscal suture may be associated with such treatment. Meniscal suture should be considered when the injury compromises the proper functioning of the meniscus to recover its anatomy and function. Different meniscal suture techniques exist; the most widely used are the inside-out, outside-in, and all-inside techniques. The gold-standard repair technique is the inside-out technique. A drawback of this technique is the need to alternate between intra- and extra-articular structures for every stitch, which makes it even more laborious. We describe the continuous meniscal suture technique, also called "meniscal stitching," for a medial meniscal bucket-handle injury. This technique is performed from the inside out and allows the surgeon to perform multiple stitches with the same thread quickly and effectively. This surgical technique is performed using a single meniscal suture device that was developed by our group, called the "Meniscus 4 A-II" device.
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Affiliation(s)
- José Leonardo Rocha de Faria
- Knee Surgery Center, National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil,Address correspondence to José Leonardo Rocha de Faria, M.D., Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Av Brasil, 500, Rio de Janeiro, Brazil, CEP 20940-070.
| | - Douglas Mello Pavão
- Knee Surgery Center, National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil
| | - Alfredo Marques Villardi
- Knee Surgery Center, National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil
| | - Eduardo Branco de Sousa
- Knee Surgery Center, National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil
| | - João Matheus Guimarães
- Research and Teaching Division, National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil
| | | | - Alan de Paula Mozella
- Knee Surgery Center, National Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil,Orthopedics Discipline, Medical Science Faculty, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Wang Z, Xiong Y, Tang X, Li Q, Zhang Z, Li J, Chen G. An arthroscopic repair technique for meniscal tear using a needle and suture: outside-in transfer all-inside repair. BMC Musculoskelet Disord 2019; 20:614. [PMID: 31870350 PMCID: PMC6929296 DOI: 10.1186/s12891-019-2984-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND At present, most repair techniques for meniscal tears fix the meniscus directly over the capsule. This changes the normal anatomy and biomechanics and limits the activity of the meniscus during motion. We introduce an arthroscopic repair technique by suturing the true meniscus tissue without the capsule and subcutaneous tissue. METHODS After confirmation of a tear, a custom-designed meniscal repair needle first penetrates percutaneously, crossing the capsular portion and the torn meniscus, and exits from the femoral surface of one side of the torn meniscus. Then a No. 2 PDS suture is passed through the needle and retrieved through the arthroscopy portal. Next, the needle is withdrawn to the synovial margin of the meniscus and is reinserted, exiting the femoral surface of the other side of the torn meniscus. The suture is pulled out through the same portal with a grasper. Finally, arthroscopic knotting is performed. RESULTS We had 149 cases of meniscal tears repaired with this outside-in transfer all-inside technique since July 2016. CONCLUSIONS It is a simple, minimally invasive, and economical procedure that is appropriate for most parts of the meniscus except the posterior horn of the lateral meniscus, and it can be used to fix torn meniscus tissue firmly while also preserving the inherent activity of the meniscus.
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Affiliation(s)
- Zhiqiang Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China.,Department of Orthopaedic Surgery, Suining Central Hospital, No. 127, West Desheng Rd., Chuanshan District, Suining, Sichuan, 629000, China
| | - Yan Xiong
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Xin Tang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Qi Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Zhong Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Jian Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China.
| | - Gang Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China.
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Kang DG, Park YJ, Yu JH, Oh JB, Lee DY. A Systematic Review and Meta-Analysis of Arthroscopic Meniscus Repair in Young Patients: Comparison of All-Inside and Inside-Out Suture Techniques. Knee Surg Relat Res 2019; 31:1-11. [PMID: 30497231 PMCID: PMC6425899 DOI: 10.5792/ksrr.17.078] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/15/2018] [Accepted: 02/19/2018] [Indexed: 01/11/2023] Open
Abstract
Purpose The purposes of the present study were to review published studies that investigated arthroscopic meniscus repair to treat meniscus injury in young patients and to compare all-inside and inside-out suture techniques. Methods Various electronic databases were queried for published articles, and this search was updated in August 2017 for evaluating the outcomes of arthroscopic meniscus surgery in young patients. Data search, extraction, analysis, and quality assessment were performed according to the Cochrane Collaboration guidelines, and the clinical outcomes were evaluated using various outcome values in young patients according to suture techniques. Results Three randomized controlled trials and three prospective comparative studies were included in this systematic review and meta-analysis. There were no significant differences in clinical outcomes such as meniscus healing rate (risk ratio [RR], 1.11; 95% confidence interval [CI], 0.90 to 1.37; I2=39%) and perioperative complications (RR, 0.62; 95% CI, 0.23 to 1.72; I2=43%) between all-inside and inside-out techniques for meniscus repair. Conclusions The present study shows favorable results for clinical outcomes such as meniscus healing rate and perioperative complications in young patients. Furthermore, based on our results, both all-inside and inside-out meniscal suture techniques are equally effective in these patients.
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Affiliation(s)
- Dong-Geun Kang
- Department of Orthopaedic Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon
| | - Young-Jin Park
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju
| | - Jae-Ha Yu
- Department of Orthopaedic Surgery, The Armed Forces Daegu Hospital, Gyeongsan, Korea
| | - Jong-Byung Oh
- Department of Orthopaedic Surgery, The Armed Forces Daegu Hospital, Gyeongsan, Korea
| | - Dong-Yeong Lee
- Department of Orthopaedic Surgery, The Armed Forces Daegu Hospital, Gyeongsan, Korea
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Vaquero-Picado A, Rodríguez-Merchán EC. Arthroscopic repair of the meniscus: Surgical management and clinical outcomes. EFORT Open Rev 2018; 3:584-594. [PMID: 30595844 PMCID: PMC6275851 DOI: 10.1302/2058-5241.3.170059] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
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
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All-Inside Meniscus Repair Method for Injury of the Margin of the Anterior Segment of the Meniscus. Arthrosc Tech 2018; 7:e215-e218. [PMID: 29881692 PMCID: PMC5989657 DOI: 10.1016/j.eats.2017.08.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/22/2017] [Indexed: 02/03/2023] Open
Abstract
Although the outside-in method has been used to treat injuries to the anterior segment of the meniscus, this method has drawbacks including the need to make a skin incision and portals for arthroscopy, pain caused by strangulation of the subcutaneous tissue and joint capsule, and protrusion of the knots. To resolve these problems, we present an all-inside method that enables simple suture of injuries to the anterior segment of the meniscus through arthroscopic portals placed only on the anteromedial and lateral sides without using a specific instrument. This simple, low-cost, low-invasive technique may be useful for suturing marginal injuries to the anterior segment of the meniscus.
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Mutsaerts ELAR, van Eck CF, van de Graaf VA, Doornberg JN, van den Bekerom MPJ. Surgical interventions for meniscal tears: a closer look at the evidence. Arch Orthop Trauma Surg 2016; 136:361-70. [PMID: 26497982 DOI: 10.1007/s00402-015-2351-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim of the present study was to compare the outcomes of various surgical treatments for meniscal injuries including (1) total and partial meniscectomy; (2) meniscectomy and meniscal repair; (3) meniscectomy and meniscal transplantation; (4) open and arthroscopic meniscectomy and (5) various different repair techniques. MATERIALS AND METHODS The Bone, Joint and Muscle Trauma Group Register, Cochrane Database, MEDLINE, EMBASE and CINAHL were searched for all (quasi) randomized controlled clinical trials comparing various surgical techniques for meniscal injuries. Primary outcomes of interest included patient-reported outcomes scores, return to pre-injury activity level, level of sports participation and persistence of pain using the visual analogue score. Where possible, data were pooled and a meta-analysis was performed. RESULTS A total of nine studies were included, involving a combined 904 subjects, 330 patients underwent a meniscal repair, 402 meniscectomy and 160 a collagen meniscal implant. The only surgical treatments that were compared in homogeneous fashion across more than one study were the arrow and inside-out technique, which showed no difference for re-tear or complication rate. Strong evidence-based recommendations regarding the other surgical treatments that were compared could not be made. CONCLUSIONS This meta-analysis illustrates the lack of level I evidence to guide the surgical management of meniscal tears. LEVEL OF EVIDENCE Level I meta-analysis.
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Affiliation(s)
- Eduard L A R Mutsaerts
- Department of Orthopaedic Surgery, Joint Research, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Carola F van Eck
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Kaufmann building suite 1011, Pittsburgh, PA, USA.
| | - Victor A van de Graaf
- Department of Orthopaedic Surgery, Joint Research, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Michel P J van den Bekerom
- Department of Orthopaedic Surgery, Joint Research, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Abstract
BACKGROUND Total meniscus resection after meniscus tear usually leads to faster degeneration and osteoarthritis of the knee joint. Preservation and repair of the injured menisci are therefore of great clinical importance. The aim of this study was to evaluate the clinical effects of arthroscopic repair of meniscal injuries using the Fast-Fix device. MATERIALS AND METHODS 96 patients (58 males, 38 females) with mean age of 24.3 years (range 12-46 years)) with a meniscus injury were treated with the Fast-Fix device under arthroscopy between July 2007 and June 2009. The right and left knees were involved in 46 and 50 patients respectively. In 12, 46 and 38 patients, the injury was located in the anterior horn, body and posterior horn respectively. In 38, 45 and 13 patients, it was in the red, red-white, and white regions, respectively. All-inside and outside-in techniques were used for these meniscal injuries. Criteria for successful surgery were no locking pain or swelling and a negative McMurray test. RESULTS The mean followup period was 3.7 years (range 2-5 years). The surgical success rate was 91.7% (n = 88). The mean Lysholm score increased from 47.8 ± 10.4 preoperatively to 85.7 ± 12.8 postoperatively. The mean Tegner activity score was 7.4 ± 1.6 (range 5-9) preinjury, 2.1 ± 0.9 (range 0-4) preoperatively and 7.2 ± 2.2 (range 4-10) postoperatively (P < 0.001). A total of 92 patients (95.8%) returned to full-time work. The International Knee Documentation Committee score increased from 32.7 ± 10.7 (range 10.3-51.7) preoperatively to 82.5 ± 5.1 (range 65.1-91.2) postoperatively (P < 0.001). CONCLUSIONS The Fast-Fix system is an efficient, safe and effective suture technique for meniscal repair.
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Affiliation(s)
- Tang Hengtao
- Department of Orthopeadics, The 1 Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Su Xuntong
- Department of Orthopeadics, The 3 Affiliated Hospital of Nanfang University, Guangzhou, Guangdong Province, China
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Werner BC, Cancienne JM, Miller MD, Gwathmey FW. Incidence of Manipulation Under Anesthesia or Lysis of Adhesions After Arthroscopic Knee Surgery. Am J Sports Med 2015; 43:1656-61. [PMID: 25883170 DOI: 10.1177/0363546515578660] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Arthrofibrosis after knee arthroscopy is a challenging complication. Previous studies reporting incidences of manipulation under anesthesia (MUA) or lysis of adhesions (LOA) after knee arthroscopy are limited by confounders such as small sample size and regional sampling bias. PURPOSE To investigate the incidence of MUA or LOA after common arthroscopic knee procedures. STUDY DESIGN Descriptive epidemiology study. METHODS A national insurance database was retrospectively queried for arthroscopic knee procedures from 2007 to 2011. The incidence of postoperative MUA and LOA within 3 and 6 months postoperatively was determined for each of 13 common arthroscopic knee surgeries, including ligamentous reconstructive procedures, cartilage restoration procedures, and meniscal procedures. RESULTS A total of 330,714 unique patients who underwent knee arthroscopy were included in the study. The overall incidence of MUA was 0.06% to 6.00% by 3 months and 0.11% to 8.00% by 6 months postoperatively. The incidence of LOA was somewhat less, ranging from 0.04% to 4.00% by 3 months and 0.06% to 6.00% by 6 months postoperatively. Isolated arthroscopic partial meniscectomy had the lowest incidence of postoperative MUA and LOA, while multiligament reconstructions and meniscal transplants had the highest incidences. CONCLUSION The overall incidence of MUA and LOA after arthroscopic knee procedures is low but rises significantly as the number of concomitant procedures or complexity of the procedures increases. This information may be useful in counseling patients on the likelihood of MUA or LOA based on the type of arthroscopic knee procedure that is planned.
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Affiliation(s)
- Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Westermann RW, Wright RW, Huston LJ, Wolf BR, Wolf BR. Meniscal repair with concurrent anterior cruciate ligament reconstruction: operative success and patient outcomes at 6-year follow-up. Am J Sports Med 2014; 42:2184-92. [PMID: 25023440 PMCID: PMC4451057 DOI: 10.1177/0363546514536022] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscal repair is commonly performed concurrently with anterior cruciate ligament reconstruction (ACLR) in the acutely injured knee. No large-scale, prospective multicenter studies have evaluated the long-term success and patient-oriented outcomes after combined ACLR and meniscal repair. PURPOSE To define the operative success and patient-oriented outcome scores 6 years after combined meniscal repair and ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All ipsilateral primary ACLR and meniscal repair cases from a multicenter study group between 2002 and 2004 were selected. Validated patient-oriented outcome instruments were completed at 3 time points: preoperatively and then 2 and 6 years after the index procedure. Subsequent ipsilateral knee reoperations were confirmed by operative reports to evaluate for the failure of meniscal repairs. RESULTS In total, 286 patients with 1440 primary ACLRs underwent concurrent meniscal repairs (298 meniscal repairs). Of these, 235 (82.2%) were available for follow-up at 6 years (154 medial, 72 lateral, and 9 both lateral and medial meniscal repairs). Repaired menisci most commonly involved the peripheral one third of the meniscus (84%); patterns were typically longitudinal (84%) or displaced bucket-handle (10%), with a mean length of 16.5 ± 5.8 mm. Overall, the meniscal repair failure rate was 14% (medial: 21/154; lateral: 10/72; both: 2/9) at 6 years. Medial repairs failed earlier than lateral repairs (2.1 vs 3.7 years, respectively; P = .01). Significant improvements in outcome scores were sustained at 6-year follow-up. No differences in the suture number or type were detected between repair failures and successes. The rate of meniscal reoperations was higher in patients who underwent repair compared with those who did not have an identified meniscal injury at the time of ACLR (P < .01. CONCLUSION Concurrent meniscal repair with ACLR is associated with failure rates approximating 14% at 6-year follow-up. Improvements in patient-oriented outcome scores were sustained at 6-year follow-up. Surgeons may expect good clinical outcomes 6 years after combined ACLR and meniscal repair.
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Affiliation(s)
| | - RW Wright
- Washington University at St. Louis, St. Louis, MO
| | - LJ Huston
- Vanderbilt University Medical Center, Nashville, TN
| | | | - BR Wolf
- University of Iowa, Iowa City, IA
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Abstract
The meniscus has several important roles, such as transmission of the load, absorption of the shock in the knee joint, acting as a secondary anteroposterior stabilizer of the knee joint, and contributing to proprioception of the knee joint. Degenerative changes of the knee joint develop in the long-term follow-up even after partial meniscectomy. Thus, there has been growing interest in meniscal repair. In addition, with increased understanding of the important roles of the meniscal root and advancement of diagnostic methods, efforts have been made to ensure preservation of the meniscal roots. In this review article, we will discuss operative techniques and clinical outcomes of arthroscopic repair of the meniscus and the meniscal root and postoperative rehabilitation and complications as well.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Keun Ho Park
- Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea
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Mezhov V, Teichtahl AJ, Strasser R, Wluka AE, Cicuttini FM. Meniscal pathology - the evidence for treatment. Arthritis Res Ther 2014; 16:206. [PMID: 25167471 PMCID: PMC4060175 DOI: 10.1186/ar4515] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Whilst arthroscopic surgery for the treatment of meniscal tears is the most commonly performed orthopaedic surgery, meniscal tears at the knee are frequently identified on magnetic resonance imaging in adults with and without knee pain. The evidence for arthroscopic treatment of meniscal tears is controversial and lacks a supporting evidence base; it may be no more efficacious than conservative therapies. Surgical approaches to the treatment of meniscal pathology can be broadly categorised into those in which partial menisectomy or repair are performed. This review highlights that the major factor determining the choice of operative approach is age: meniscal repair is performed exclusively on younger populations, while older populations are subject to partial menisectomy procedures. This is probably because the meniscus is less amenable to repair in the older population where other degenerative changes co-exist. In middle-aged to older adults, arthroscopic partial menisectomy (APM) may treat the meniscus tear, but does not address the degenerative whole organ disease of knee osteoarthritis. Thus far, there is no convincing evidence that operative approaches are superior to conservative measures as the first-line treatment of older people with knee pain and meniscal tears. However, in two randomised controlled trials (RCTs) approximately one-third of subjects in the exercise groups had persisting knee pain with some evidence of improvement following APM, although the characteristics of this subgroup are unclear. From the available data, a first-line trial of conservative therapy, which includes weight loss, is recommended for the treatment of degenerative meniscal tears in older adults. The exception to this may be when mechanical symptoms, such as knee locking, predominate. Although requiring corroboration by RCTs, there is accumulating evidence from cohort studies and case series that meniscal repair rather than APM may improve function and reduce the long-term risk of knee osteoarthritis in young adults. There is no clear evidence from RCTs that one surgical method of meniscal repair is superior to another.
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Wyatt RWB, Inacio MCS, Liddle KD, Maletis GB. Factors associated with meniscus repair in patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med 2013; 41:2766-71. [PMID: 24029723 DOI: 10.1177/0363546513503287] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscus injuries are common in patients with anterior cruciate ligament (ACL) tears. Patient demographics, surgeon characteristics, and concurrent diagnostic factors affecting the prevalence of meniscus repairs in patients undergoing ACL reconstruction (ACLR) by community-based orthopaedic surgeons have not been fully studied. HYPOTHESIS Patient (age, sex, race, and body mass index [BMI]), surgeon (sports medicine fellowship training status and case volume), and injury characteristics (1 or both menisci injured, injury location, and concurrent cartilage injury) and surgical venue (case volume) are associated with a higher likelihood of meniscus repair. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A cross-sectional study using data from a large community-based ACLR registry was performed. Patients with a meniscus injury and primary ACLR between February 2005 and June 2010 were included in the study. Meniscus repair rates by patient, surgeon, and injury characteristics were described. Associations were evaluated using generalized linear models. RESULTS During the study period, 5712 primary ACLRs with a meniscus tear diagnosis were registered. There was 1 torn meniscus in 4248 (74.4%) patients, and both menisci were torn in 1464 (25.6%) patients. Medial meniscus tears were repaired in 1192 (31.2%) of 3818 cases; the remaining 2626 (68.8%) tears were not repaired, underwent alternative treatment (meniscectomy, trephination, rasped), or were left in situ. Lateral meniscus tears were repaired in 893 (26.6%) of 3358 cases; the remaining 2465 (73.4%) tears underwent alternative treatment or were left in situ. Adjusted models showed that younger patient age (P < .001), lower patient BMI (P < .001), surgeon's sports medicine fellowship training (P < .001), higher surgeon case volume (P < .001), higher surgical venue volume (P = .019), and medial meniscus tears (P < .001) were all associated with a higher likelihood of a meniscus repair. CONCLUSION Younger patient age, lower patient BMI, surgeon's sports medicine fellowship training, higher surgeon case volume, and higher site volume are associated with a higher likelihood of a meniscus repair in patients undergoing primary ACLR in a large cohort from a community-based ACLR registry.
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Affiliation(s)
- Ronald W B Wyatt
- Ronald W.B. Wyatt, Orthopedics Department, Kaiser-Permanente, 1425 South Main Street, Walnut Creek, CA 94596.
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Hagino T, Ochiai S, Watanabe Y, Senga S, Wako M, Ando T, Sato E, Haro H. Clinical results of arthroscopic all-inside lateral meniscal repair using the Meniscal Viper Repair System. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 24:99-104. [DOI: 10.1007/s00590-012-1138-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 11/08/2012] [Indexed: 11/28/2022]
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Abstract
When a meniscus injury occurs, it is generally accepted that preserving the meniscus is important for life-long joint preservation. Traditional suture repair of the meniscus has good results; however, the healing potential of meniscus tissue remains as a biological challenge because it is not a completely vascularized structure. For this reason, investigators have continued to search for adjuncts to improve clinical results. Mechanical adjuncts, local factor enhancement, scaffolds, gene therapy, and cell therapy have all been examined as options for improvement of biology and structure. This study reviews the basic science and clinical application of these modalities and provides an assessment of techniques on the horizon.
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Noyes FR, Barber-Westin SD. Treatment of meniscus tears during anterior cruciate ligament reconstruction. Arthroscopy 2012; 28:123-30. [PMID: 22074619 DOI: 10.1016/j.arthro.2011.08.292] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 08/01/2011] [Accepted: 08/12/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE To define the incidence of meniscectomy, meniscus repair, and meniscus tears left in situ during anterior cruciate ligament (ACL) reconstruction. METHODS A systematic search of PubMed and 7 sports medicine journal databases was performed to determine the treatment of meniscus tears during ACL reconstruction. Inclusion criteria were English language, publication in the last 10 years, clinical trials, all evidence levels, and skeletally mature or immature knees. Exclusion criteria were revision ACL reconstruction, concomitant ligament reconstruction, and studies with exclusion or inclusion criteria regarding meniscus surgery during ACL reconstruction. RESULTS Of 634 articles identified, 159 met the inclusion criteria, encompassing 19,531 patients. There were 11,711 meniscus tears; they were treated by meniscectomy in 65% (7,621 tears), treated by repair in 26% (3,022 tears), or left in situ in 9% (1,068 tears). Only 19 studies analyzed the treatment of meniscus tears according to the tibiofemoral compartment. These reported medial compartment tears were treated by meniscectomy in 63%, treated by repair in 27%, and left in situ in 9%. Lateral compartment tears were treated by meniscectomy in 71%, treated by repair in 14%, and left in situ in 14%. Only 24 studies identified the type of meniscus repair procedure performed. In 33 studies (21%) repair was performed more frequently than meniscectomy. CONCLUSIONS Meniscectomy is performed 2 to 3 times more frequently than meniscus repair during ACL reconstruction. We were unable to analyze the effect of the location and type of meniscus tear, sex, age, or chronicity of injury on the treatment of meniscus tears. The number of potentially repairable meniscus tears that were treated by resection could not be identified. CLINICAL RELEVANCE This study found that meniscectomy was performed in 65% of meniscus tears. This is concerning because studies have shown that, regardless of knee stability obtained after ACL reconstruction, meniscectomy accelerates degenerative joint changes. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.
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Affiliation(s)
- Frank R Noyes
- Cincinnati Sportsmedicine Research and Education Foundation, Cincinnati, Ohio 45242, USA
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Affiliation(s)
- Don Johnson
- Carleton University Sports Medicine Clinic, Ottawa, ON, Canada.
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Affiliation(s)
- Eric D Bava
- Plano Orthopedic Sports Medicine and Spine Center, TX 75093, USA
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Likes RL, Julka A, Aros BC, Pedroza AD, Kaeding CC, Jones GL, Flanigan DC. Meniscal repair with the MaxFire device: a cadaveric study. Orthop Surg 2011; 3:259-64. [PMID: 22021143 DOI: 10.1111/j.1757-7861.2011.00151.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To use a cadaver model to evaluate an all-inside meniscal repair device (MaxFire). METHODS Six fresh-frozen cadaveric knees (ages 30-84 years) without evidence of prior surgery were used for this study. The knees were rigidly mounted and arthroscopy performed using standard anteromedial and anterolateral portals. Four MaxFire devices were placed into the medial and lateral meniscus according to the technique provided by the manufacturer. The devices were placed in a vertical or horizontal mattress fashion systematically from posterior to anterior. Implants were placed from either the ipsilateral- or contralateral-portal at the discretion of each surgeon. Placement into the medial meniscus was performed with the knee in approximately 10° of flexion and into the lateral meniscus in 45° of flexion. RESULTS In all, 54 MaxFire devices were placed. Twenty-six devices were used medially, and 28 laterally. Forty-five (83%) were placed successfully. Of those, 3 (7%) were placed in a "top hat" fashion. The nine failures (17%) were related to final device tensioning. Three of the sutures broke, one suture would not reduce, and three implants pulled out of the meniscus. The devices were successfully removed arthroscopically with a grasper or oscillating shaver. Pulling of implants out of menisci occurred in degenerative knees with degenerative meniscal tissue and did not occur with healthy appearing menisci. CONCLUSION The MaxFire device is easy to use, has a low risk of complications, and can be inserted expeditiously by arthroscopy.
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Affiliation(s)
- Rickland L Likes
- Sports Medicine Center, Department of Orthopaedics, Ohio State University, Columbus, Ohio 43221-3502, USA
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Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy 2011; 27:1275-88. [PMID: 21820843 DOI: 10.1016/j.arthro.2011.03.088] [Citation(s) in RCA: 294] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 03/26/2011] [Accepted: 03/28/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this investigation was to compare reoperation rates and clinical outcomes after meniscal repair and partial meniscectomy. METHODS A systematic literature review was performed to identify outcome studies of arthroscopic meniscal repair (inside-out, outside-in, and all-inside techniques) or partial meniscectomy in patients with traumatic meniscal tears. The studies included patients with no previous injuries or operations. RESULTS At short- and long-term follow-up, partial meniscectomy had a lower reoperation rate (1.4% [2 of 143] and 3.9% [52 of 1,319], respectively) than isolated meniscal repair (16.5% [47 of 284] and 20.7% [30 of 145], respectively). There was a slightly higher reoperation rate after partial lateral meniscectomy compared with partial medial meniscectomy. Repairs of the medial meniscus resulted in higher reoperation rates than repairs of the lateral meniscus. Meniscal repairs at the time of anterior cruciate ligament reconstruction had a lower failure rate than isolated repairs. In the limited number of studies with long-term clinical outcome scores, meniscal repair was associated with higher Lysholm scores and less radiologic degeneration than partial meniscectomy. CONCLUSIONS Whereas meniscal repairs have a higher reoperation rate than partial meniscectomies, they are associated with better long-term outcomes. LEVEL OF EVIDENCE Level IV, systematic review of Level I-IV studies.
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Chen HC, Yang CB, Tsai CF, Ma HL, Liu CL, Huang TF. Management and outcome of discoid meniscus tears. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.fjmd.2011.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Tengrootenhuysen M, Meermans G, Pittoors K, van Riet R, Victor J. Long-term outcome after meniscal repair. Knee Surg Sports Traumatol Arthrosc 2011; 19:236-41. [PMID: 20953762 DOI: 10.1007/s00167-010-1286-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Accepted: 09/16/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE the purpose of this study was to analyse the clinical and radiological results of meniscal repairs and identify factors that correlate with the success of this procedure. METHODS a retrospective review of 119 meniscal repairs was completed. The average follow-up was 70 months. Successful meniscal repairs were observed critically in terms of radiographic changes and clinical outcomes and compared with failed meniscal repairs. RESULTS the overall success rate of meniscal repairs was 74%. Meniscal repairs that were performed within 6 weeks of injury had better results (83%) than late repairs (52%). The best results were obtained with the inside-out technique using #0 PDS suture (80%) compared to all-inside Biofix arrows (70%) and combined repairs (63%). Patients with associated ACL injury had a better chance of a successful outcome, but this was only significant when the ACL was reconstructed at the time of repair (P < 0.05). Those patients who had failed meniscal repair had increased radiographic osteoarthritic changes (81%) on long-term follow-up compared to patients with successful repair (14%). CONCLUSION this retrospective study shows the clinical and radiological importance of meniscal repair. Successful results in this study were associated with younger age and earlier repair using inside-out technique. Furthermore, increased success was seen in meniscal repairs performed in association with ACL reconstruction.
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Affiliation(s)
- Mike Tengrootenhuysen
- Department of Orthopaedic Surgery, University Hospital Antwerp, 2650 Edegem, Belgium.
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Sobhy MH, AbouElsoud MMS, Kamel EM, Desouki AM. Neurovascular safety and clinical outcome of outside-in repair of tears of the posterior horn of the medial meniscus. Arthroscopy 2010; 26:1648-54. [PMID: 20934845 DOI: 10.1016/j.arthro.2010.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 05/09/2010] [Accepted: 05/10/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the safety and clinical outcome of a new posterior approach for the known outside-in technique for repair of tears of the posterior horn of the medial meniscus (PHMM). METHODS First, a cadaveric study was performed on 6 cadaveric knees to assess the safety of a point just lateral to the semitendinosus tendon as an entry point for outside-in repair. Dissection was done to measure the clearance of this point to the nearby popliteal bundle and saphenous nerve. A prospective case series study was then performed to assess the clinical outcome of such an approach. We treated 41 consecutive cases with PHMM tears by the outside-in technique using a shuttle relay method through the same point. Clinical assessments, magnetic resonance imaging findings, Lysholm scores, and International Knee Documentation Committee subjective scores were recorded for all patients. After a minimum postoperative period of 2 years, all cases were re-evaluated and re-scored. RESULTS The cadaveric study showed a mean clearance distance of 2.4 cm for the popliteal bundle and 4.6 cm for the saphenous nerve. The case series study was done on 41 meniscal repairs; 15 of 41 cases (37%) were performed in conjunction with anterior cruciate ligament reconstruction. There were 22 right knees (54%) and 19 left knees (36%). After a mean follow-up period of 27 months, patients showed a clinical success rate of 88% in terms of disappearance of pain, locking, and swelling, together with improved Lysholm scores (from 34 to 88) and International Knee Documentation Committee scores (from 25 to 88). These improvements were statistically significant (P < .05). CONCLUSIONS An outside-in repair technique with a posterior entry central to the semitendinosus tendon was used safely with 88% satisfactory clinical results for treatment of PHMM tears. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Redfern J, Burks R. 2009 survey results: surgeon practice patterns regarding arthroscopic surgery. Arthroscopy 2009; 25:1447-52. [PMID: 19962073 DOI: 10.1016/j.arthro.2009.07.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 07/08/2009] [Indexed: 02/02/2023]
Abstract
A survey was conducted to collect information on the surgical management and practice preferences of the audience members at a recent continuing medical education conference. Participants were polled on a variety of surgical topics, and their responses were recorded using a wireless audience response system. The answers were tabulated and are presented in this report. The majority of respondents preferred an arthroscopic repair for rotator cuff tears (52%) and shoulder instability (71%). Most (50%) perform single-row repair; 33% perform double-row repair. For simple knee arthroscopy, most use preoperative antibiotics (85%), no tourniquet (53%), and no chemical anticoagulation or only compression boots (69%). For cruciate ligament reconstruction, the majority preferred only a preoperative antibiotic (67%), no chemical anticoagulation or only compression boots (56%), and single-bundle reconstruction (88%) using a transtibial femoral tunnel (78%). Most (47%) prefer an all inside suture-based meniscus repair device.
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Affiliation(s)
- John Redfern
- Department of Orthopaedic Surgery, University OrthopaedicCenter, University of Utah, Salt Lake City,UT 84108, USA.
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Choi NH, Kim TH, Victoroff BN. Comparison of arthroscopic medial meniscal suture repair techniques: inside-out versus all-inside repair. Am J Sports Med 2009; 37:2144-50. [PMID: 19684293 DOI: 10.1177/0363546509339010] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are no reports comparing meniscal healing between inside-out and all-inside repairs using sutures. HYPOTHESIS No difference in healing rate exists between meniscal repairs with inside-out and all-inside suture repair in conjunction with anterior cruciate ligament reconstruction with hamstring tendon. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Forty-eight consecutive patients underwent meniscal repairs of longitudinal tears of the posterior horn of the medial meniscus combined with anterior cruciate ligament reconstructions. All-inside repair was attempted when the tears were located in the red-red zone or the ramp area of the meniscus. If a tear that was in the ramp area or red-red zone extended to the midbody of the meniscus, or if there was a tear in red-white zone, the inside-out repair technique was used. Fourteen patients had all-inside meniscal repairs, and 34 patients had inside-out meniscal repairs with absorbable sutures. Identical postoperative rehabilitation protocols were used. Postoperative evaluations included Lysholm knee scoring scale, Tegner activity levels, Lachman and pivot-shift tests, and KT-1000 arthrometer. Assessment of meniscal status was performed using joint line tenderness, McMurray test, and range of motion. Follow-up magnetic resonance imaging scans were obtained on all patients. RESULTS Mean follow-up was 35.7 months. No patient had joint line tenderness or reported pain or clicking on McMurray test. There was no significant difference in range of motion between groups. Follow-up magnetic resonance imaging scans demonstrated that 10 (71.4%) menisci were healed and 4 (28.6%) partially healed in the all-inside group; 24 (70.6%) menisci were healed and 10 (29.4%) partially healed in the inside-out group. There was no significant difference in meniscal healing between groups. There were no differences in Lachman test, KT-1000 arthrometer side-to-side differences measurements, Lysholm scores, and Tegner activity scales. There was a significant difference in pivot-shift test between groups (P = .023). There were 2 complications associated with surgery. In the inside-out group, 1 patient required manipulation, and 2 patients had limited motion at final follow-up. Two patients in the inside-out group experienced transient saphenous nerve injury. CONCLUSION There was no significant difference in meniscal healing between inside-out and all-inside repair techniques in combination with anterior cruciate ligament reconstructions.
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Affiliation(s)
- Nam-Hong Choi
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, Korea.
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Toman C, Spindler KP, Dunn WR, Amendola A, Andrish JT, Bergfeld JA, Flanigan D, Jones M, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Wolcott M, Vidal A, Wolf BR, Huston LJ, Harrell FE, Wright RW. Success of meniscal repair at anterior cruciate ligament reconstruction. Am J Sports Med 2009; 37:1111-5. [PMID: 19465734 PMCID: PMC3692358 DOI: 10.1177/0363546509337010] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscal repair is performed in an attempt to prevent posttraumatic arthritis resulting from meniscal dysfunction after meniscal tears. The socioeconomic implications of premature arthritis are significant in the young patient population. Investigations and techniques focusing on meniscus preservation and healing are now at the forefront of orthopaedic sports medicine. HYPOTHESIS Concomitant meniscal repair with anterior cruciate ligament reconstruction is a durable and successful procedure at 2-year follow-up. STUDY DESIGN Case series; Level of evidence, 4. METHODS All unilateral primary anterior cruciate ligament reconstructions entered in 2002 in a cohort who had meniscal repair at the time of anterior cruciate ligament reconstruction were evaluated. Validated patient-oriented outcome instruments were completed preoperatively and then again at the 2-year postoperative time point. Reoperation after the index procedure was also documented and confirmed by operative reports. RESULTS A total of 437 unilateral primary anterior cruciate ligament reconstructions were performed with 82 concomitant meniscal repairs (54 medial, 28 lateral) in 80 patients during the study period. Patient follow-up was obtained on 94% (77 of 82) of the meniscal repairs, allowing confirmation of meniscal repair success (defined as no repeat arthroscopic procedure) or failure. The overall success rate for meniscal repairs was 96% (74 of 77 patients) at 2-year follow-up. CONCLUSION Meniscal repair is a successful procedure in conjunction with anterior cruciate ligament reconstruction. When confronted with a "repairable" meniscal tear at the time of anterior cruciate ligament reconstruction, orthopaedic surgeons can expect an estimated >90% clinical success rate at 2-year follow-up using a variety of methods as shown in our study.
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Affiliation(s)
- Charles Toman
- Department of Orthopaedic Surgery, Washington University School of Medicine @Barnes-Jewish Hospital, St. Louis, MO
| | - Kurt P. Spindler
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical School, Nashville, TN
| | - Warren R. Dunn
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical School, Nashville, TN
| | - Annunziata Amendola
- Department of Orthopaedic Surgery, University of Iowa School of Medicine, Cleveland, OH
| | - Jack T. Andrish
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - John A. Bergfeld
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - David Flanigan
- Department of Orthopaedic Surgery, The Ohio State University School of Medicine, Columbus, OH
| | - Morgan Jones
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Christopher C. Kaeding
- Department of Orthopaedic Surgery, The Ohio State University School of Medicine, Columbus, OH
| | - Robert G. Marx
- Sports Medicine Division, Hospital for Special Surgery, New York, NY
| | - Matthew J. Matava
- Department of Orthopaedic Surgery, Washington University School of Medicine @Barnes-Jewish Hospital, St. Louis, MO
| | - Eric C. McCarty
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, CO
| | | | - Michelle Wolcott
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, CO
| | - Armando Vidal
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, CO
| | - Brian R. Wolf
- Department of Orthopaedic Surgery, University of Iowa School of Medicine, Cleveland, OH
| | - Laura J. Huston
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical School, Nashville, TN
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University Medical School, Nashville, TN
| | - Rick W. Wright
- Department of Orthopaedic Surgery, Washington University School of Medicine @Barnes-Jewish Hospital, St. Louis, MO
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DeHaan A, Rubinstein RA, Baldwin JL. Evaluation of success of a meniscus repair device for vertical unstable medial meniscus tears in ACL-reconstructed knees. Orthopedics 2009; 32:orthopedics.38346. [PMID: 19388621 DOI: 10.3928/01477447-20090401-02] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We retrospectively reviewed the success of meniscus repair with the FasT-Fix meniscus repair device for vertical unstable medial meniscus tears at the time of anterior cruciate ligament (ACL) reconstruction. A repair failure was defined as patients having medial knee symptoms leading to a subsequent arthroscopy confirming a tear at the repair site. Objective follow-up was obtained on 27 patients at a mean of 3.1 years postoperatively (range, 2-5 years). Two of 22 repairs (9%) in the red-red vascular zone and 4 of 5 repairs (80%) in the red-white vascular zone retore at the repair site at an average of 9 months postoperatively (range, 3-20 months). The results of this study showed a high failure rate (22%) of unstable vertical medial meniscus repairs with ACL reconstruction, especially for repairs done to tears in the red-white vascular zone.
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Affiliation(s)
- Alex DeHaan
- Portland Knee Clinic, Portland, Oregon 97213, USA
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Wilmes P, Lorbach O, Brogard P, Seil R. [Complications with all-inside devices used in reconstructive meniscal surgery]. DER ORTHOPADE 2009; 37:1088-9, 1091-5, 1097-8. [PMID: 18958444 DOI: 10.1007/s00132-008-1307-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
All-inside devices have become increasingly popular in reconstructive meniscal surgery since their introduction at the beginning of the 1990s. Although the latest clinical investigations show better results for conventional suture techniques, meniscal devices are an important alternative because of the low risk of neurovascular injury and the easy handling of the instruments. Over the years, many reports on specific complications related to all-inside devices have been published. Especially chondral injuries, implant loosening, device migration and capsular or neural irritations have been described. Furthermore, some authors reported on foreign body reactions and cystic granulomas after the use of meniscal fixation devices. However, there is no evidence for a higher infection rate or for specific infections after the use of intra-articular techniques. Clinical reports on complications along with biomechanical studies on meniscal repair devices have led to the enhancement of all-inside techniques through substantial modifications of established products as well as to the development of new implants. After reviewing the latest literature, the complication rate seems to be decreasing. In many ways, all-inside devices are an interesting alternative to conventional suture techniques. A precise knowledge of their potential complications and the pitfalls during surgery however is crucial to make a risk evaluation in the choice of the right technique for meniscal reconstruction.
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Affiliation(s)
- P Wilmes
- Service d'Orthopédie et de Traumatologie, Centre de l'Appareil Locomoteur, de Médecine du Sport et de Prévention, Centre Hospitalier de Luxembourg - Clinique d'Eich, Luxembourg, Luxembourg.
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Krych AJ, McIntosh AL, Voll AE, Stuart MJ, Dahm DL. Arthroscopic repair of isolated meniscal tears in patients 18 years and younger. Am J Sports Med 2008; 36:1283-9. [PMID: 18319351 DOI: 10.1177/0363546508314411] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Isolated meniscal tears in the skeletally immature patient are infrequent but well-recognized injuries. Although few studies have evaluated the pediatric and adolescent population, arthroscopic surgical repair remains the standard of care for patients in this age group with unstable meniscal tears. PURPOSE To review our results of arthroscopic repair of isolated meniscal tears in pediatric and adolescent patients to further define future management of these injuries. STUDY DESIGN Case series; Level of evidence, 4. METHODS The records of all patients 18 years old or younger who underwent isolated meniscal repair between 1990 and 2005 were retrospectively reviewed. Forty-four patients (6 girls, 38 boys) with an average age of 15.8 years (range, 9.9-18.7 years) were included in this study, for a total of 45 isolated meniscal tears. Clinical examinations were performed, International Knee Documentation Committee forms were administered, and Tegner scores were determined at an average of 5.8 years (range, 2.5 months-13.8 years) postoperative follow-up. Three patients were lost to follow-up. RESULTS The clinical success rate of arthroscopic meniscal repair was 80% for simple tears, 68% for displaced bucket-handle tears, and 13% for complex tears. Seventeen menisci (38% overall) failed initial repair at a mean of 17 months (range, 3-61 months) postoperatively and underwent repeat arthroscopic surgery (15 partial meniscectomies, 2 rerepair). The average Tegner and International Knee Documentation Committee scores were 8 (range, 5-9) and 89.4 (range, 79-99), respectively, at the time of final follow-up. Risk factors for failure included complex tears and rim width greater than 3 mm. CONCLUSION Clinically successful repair of an isolated meniscal tear in patients 18 years or younger was variable depending on tear type, with complex tears and rim width 3 mm or greater being negative prognostic factors.
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Affiliation(s)
- Aaron J Krych
- Department of Orthopedic Surgery, The Sports Medicine Center, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Bottoni CR, Liddell TR, Trainor TJ, Freccero DM, Lindell KK. Postoperative range of motion following anterior cruciate ligament reconstruction using autograft hamstrings: a prospective, randomized clinical trial of early versus delayed reconstructions. Am J Sports Med 2008; 36:656-62. [PMID: 18212347 DOI: 10.1177/0363546507312164] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a common belief that surgical reconstruction of an acutely torn anterior cruciate ligament (ACL) should be delayed for at least 3 weeks because of the increased incidence of postoperative motion loss (arthrofibrosis) and suboptimal clinical results. HYPOTHESIS There is no difference in postoperative range of motion or stability after ACL reconstructions performed either acutely or delayed. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Patients with an acute ACL tear were prospectively randomized to either early (within 21 days) or delayed (beyond 6 weeks) reconstruction using autograft hamstring tendon. Previous knee surgery on the index extremity and a multiligamentous injury were exclusionary criteria. Surgical technique and postoperative rehabilitation were identical for all patients. Postoperative assessments included range of motion and KT-1000 arthrometer measurements compared with the contralateral knee. Standardized outcome measures were used including single assessment numeric evaluation (SANE), Lysholm, and Tegner Activity Score. RESULTS Seventy consecutive patients were enrolled, and 1 patient was dropped after a postoperative infection. Sixty-nine patients (34 acute, 35 delayed) with an average age of 27 years composed the study cohort. The mean time from injury to surgery was 9 days (range, 2-17 days) for patients in the early group and 85 days (range, 42-192) for those in the delayed group. The average follow-up from surgery was 366 days (range, 185-869). Articular cartilage and meniscal injuries were comparable between the 2 groups. There were no significant differences between the 2 treatment groups in degrees of extension or flexion lost relative to the nonoperative side, operative time, KT-1000 arthrometer differences, or subjective knee evaluations. CONCLUSION Excellent clinical results can be achieved after ACL reconstructions performed soon after injury using autograft hamstrings. Although the authors do not advocate that all reconstructions should be performed acutely, they found that early ACL reconstructions do not result in loss of motion or suboptimal clinical results as long as a rehabilitation protocol emphasizing extension and early range of motion is employed.
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Affiliation(s)
- Craig R Bottoni
- Aspetar Orthopaedic & Sports Medicine Hospital, Doha, Qatar.
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Espejo-Baena A, Figueroa-Mata A, Serrano-Fernández J, de la Torre-Solís F. All-inside suture technique using anterior portals in posterior horn tears of lateral meniscus. Arthroscopy 2008; 24:369.e1-4. [PMID: 18308191 DOI: 10.1016/j.arthro.2007.06.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Revised: 06/14/2007] [Accepted: 06/25/2007] [Indexed: 02/02/2023]
Abstract
Methods for the repair of meniscal tears include inside-out, outside-in, and all-inside techniques. In this article an all-inside technique is proposed for the posterior horn of the lateral meniscus that takes advantage of the capacious posterolateral recess when the knee is flexed. A device consisting of a large needle with a buttonhole in the tip (previously used for inside-out suture of the medial meniscus) is used. This technique uses only anterior portals (anteromedial and anterolateral portals and an accessory lateral or transpatellar tendon portal). The arthroscope is inserted through the accessory portal. Once the tear has been located and its edges refreshed, the suture device is placed anterolaterally. The tip of the needle is loaded with suture and passed through both sides of the tear and into the posterolateral recess of the knee (without exiting the capsule). The suture tail is recovered with the use of a suture retriever through the anteromedial portal. Next, the suture retriever is inserted through the anterolateral portal to once again retrieve and shuttle the tail before completion of an arthroscopic knot. In addition to the ease of the technique, use of this simple, reusable device adds the benefit of low cost when compared with other techniques.
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Affiliation(s)
- Alejandro Espejo-Baena
- Servicio de Cirugia Ortopedica y Traumatologia, Hospital Clinico Universitario Virgen de la Victoria, Málaga, Spain.
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Abstract
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.
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Affiliation(s)
- Jesus Lozano
- University of California, San Francisco School of Medicine, CA 94143, USA
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