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Mazy D, Lu D, Leclerc S, Laor B, Wang J, Pinvicy A, Moldovan F, Nault ML. Animal models used in meniscal repair research from ex vivo to in vivo: A systematic review. J Orthop 2024; 55:23-31. [PMID: 38638113 PMCID: PMC11021913 DOI: 10.1016/j.jor.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/30/2024] [Indexed: 04/20/2024] Open
Abstract
This systematic review, registered with Prospero, aims to identify an optimal animal model for meniscus repair research, moving from ex vivo experimentation to in vivo studies. Data sources included PubMed, Medline, all Evidence-Based Medicine Reviews, Web of Science, and Embase searched in March 2023. Studies were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data including animal model, type of experiment, type of tear, surgical techniques, and measured outcomes, were recorded, reviewed, and analyzed by four independent reviewers. The SYstematic Review Centre for Laboratory animal Experimentation (SYRCLE) Rob tool was used for critical appraisal and risk of bias assessment. Out of 11,719 studies, 72 manuscripts were included for data extraction and analysis; 41 ex vivo extra-articular studies, 20 ex vivo intra-articular studies, and only 11 in vivo studies. Six animal models were employed: porcine, bovine, lapine, caprine, canine, and ovine. Longitudinal lesions were the most frequently studied tear pattern and sutures the most common repair technique. Studied outcomes focused mainly on biomechanical assessments and gross observations. This systematic review can guide researchers in their choice of animal model for meniscus repair research; it highlighted the strengths of the porcine, caprine, and bovine models for ex vivo cadaveric studies, while the porcine and caprine models were found to be more suited to in vivo studies due to their similarities with human anatomy. Research teams should familiarize themselves with the advantages and disadvantages of various animal models before initiating protocols to improve standardization in the field.
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Affiliation(s)
- David Mazy
- CHU Sainte-Justine, 7905-3175 Côte Ste-Catherine, Montréal, QC, H3T 1C5, Canada
- Department of Surgery, Université de Montréal, 2900 boul. Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada
| | - Daisy Lu
- CHU Sainte-Justine Azrieli Research Center, 7905-3175 Côte Ste-Catherine, Montréal, QC H3T 1C5, Canada
| | - Sebastien Leclerc
- CHU Sainte-Justine Azrieli Research Center, 7905-3175 Côte Ste-Catherine, Montréal, QC H3T 1C5, Canada
| | - Boaz Laor
- Faculty of Medecine, McGill university, 1650 Cedar Ave, Montreal, Quebec, H3G 1A4, Canada
| | - Jessica Wang
- CHU Sainte-Justine Azrieli Research Center, 7905-3175 Côte Ste-Catherine, Montréal, QC H3T 1C5, Canada
| | - Alix Pinvicy
- CHU Sainte-Justine, 7905-3175 Côte Ste-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Florina Moldovan
- CHU Sainte-Justine Azrieli Research Center, 7905-3175 Côte Ste-Catherine, Montréal, QC H3T 1C5, Canada
| | - Marie-Lyne Nault
- CHU Sainte-Justine, 7905-3175 Côte Ste-Catherine, Montréal, QC, H3T 1C5, Canada
- Department of Surgery, Université de Montréal, 2900 boul. Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada
- CIUSSS Hôpital du Sacré-Cœur de Montréal (HSCM), Department of Orthopedic surgery, 5400 boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
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Chen Z, Li A, Shi R, Wang L, Cao Z, Mao N, Luo Z, Tan H. Reconstruction of medial meniscus posterior portion deficiency in pigs with an autologous patellar tendon graft: an experimental study. J Orthop Surg Res 2024; 19:225. [PMID: 38576008 PMCID: PMC10996223 DOI: 10.1186/s13018-024-04684-1] [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: 02/01/2024] [Accepted: 03/16/2024] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVE This study was performed to investigate the effectiveness of two surgical procedures, autologous patellar tendon graft reconstruction and trans-tibial plateau pull-out repair, using a pig model. The primary focus was to assess the repair capability of medial meniscus posterior portion (MMPP) deficiency, the overall structural integrity of the meniscus, and protection of the femoral and tibial cartilage between the two surgical groups. The overall aim was to provide experimental guidelines for clinical research using these findings. METHODS Twelve pigs were selected to establish a model of injury to the MMPP 10 mm from the insertion point of the tibial plateau. They were randomly divided into three groups of four animals each: reconstruction (autologous tendon graft reconstruction of the MMPP), pull-out repair (suture repair of the MMPP via a trans-tibial plateau bone tunnel), and control (use of a normal medial meniscus as the negative control). The animals were euthanized 12 weeks postoperatively for evaluation of the meniscus, assessment of tendon bone healing, and gross observation of knee joint cartilage. The tibial and femoral cartilage injuries were evaluated using the International Society for Cartilage Repair (ICRS) grade and Mankin score. Histological and immunohistochemical staining was conducted on the meniscus-tendon junction area, primary meniscus, and tendons. The Ishida score was used to evaluate the regenerated meniscus in the reconstruction group. Magnetic resonance imaging (MRI) was used to evaluate meniscal healing. RESULTS All 12 pigs recovered well after surgery; all incisions healed without infection, and no obvious complications occurred. Gross observation revealed superior results in the reconstruction and pull-out repair groups compared with the control group. In the tibial cartilage, the reconstruction group had ICRS grade I injury whereas the pull-out repair and control groups had ICRS grade II and III injury, respectively. The Mankin score was significantly different between the reconstruction and control groups; histological staining showed that the structure of the regenerated meniscus in the reconstruction group was similar to that of the original meniscus. Immunohistochemical staining showed that the degree of type I and II collagen staining was similar between the regenerated meniscus and the original meniscus in the reconstruction group. The Ishida score was not significantly different between the regenerated meniscus and the normal primary meniscus in the reconstruction group. MRI showed that the MMPP in the reconstruction and pull-out repair groups had fully healed, whereas that in the control group had not healed. CONCLUSION Autologous patellar tendon graft reconstruction of the MMPP can generate a fibrocartilage-like regenerative meniscus. Both reconstruction and pull-out repair can preserve the structural integrity of the meniscus, promote healing of the MMPP, delay meniscal degeneration, and protect the knee cartilage.
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Affiliation(s)
- Zhian Chen
- Graduate School, Kunming Medical University, Kunming City, Yunnan Province, China
| | - Anxu Li
- Department of Orthopaedics, People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming City, Yunnan Province, China
| | - Rongmao Shi
- Department of Orthopaedics, People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming City, Yunnan Province, China
| | - Ling Wang
- Graduate School, Kunming Medical University, Kunming City, Yunnan Province, China
| | - Zijian Cao
- Graduate School, Kunming Medical University, Kunming City, Yunnan Province, China
| | - Neng Mao
- Graduate School, Kunming Medical University, Kunming City, Yunnan Province, China
| | - Zhihong Luo
- Department of Orthopaedics, People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming City, Yunnan Province, China
| | - Hongbo Tan
- Department of Orthopaedics, People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming City, Yunnan Province, China.
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Oosten JD, DiBartola AC, Wright JC, Cavendish PA, Milliron EM, Magnussen RA, Duerr RA, Kaeding CC, Flanigan DC. More Is Not Merrier: Increasing Numbers of All-Inside Implants Do Not Correlate with Higher Odds of Revision Surgery. J Knee Surg 2024; 37:361-367. [PMID: 37336501 DOI: 10.1055/a-2112-8158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The purpose of this study was to evaluate the relationship between the number of all-inside meniscal repair implants placed and the risk of repair failure. We hypothesized that the use of higher numbers of all-inside meniscus repair implants would be associated with increased failure risk. A retrospective chart review identified 351 patients who underwent all-inside meniscus repair between 2006 and 2013 by a sports medicine fellowship-trained orthopaedic surgeon at a single institution. Patient demographics (age, body mass index [BMI], sex) and surgical data (number of implants used, concomitant anterior cruciate ligament reconstruction [cACLR], and tear type/size/location) were recorded. Patients who received repairs in both menisci or who had follow-up < 1-year postoperatively were excluded. Repair failure was identified through chart review or patient interviews defined as a revision surgery on the index knee such as partial meniscectomy, total knee arthroplasty, meniscus transplant, or repeat repair. Logistic regression modeling was utilized to evaluate the relationship between the number of implants used and repair failure. A total of 227 all-inside meniscus repairs were included with a mean follow-up of 5.0 ± 3.0 years following surgery. Repair failure was noted in 68 knees (30.3%)-in 28.1% of knees with fewer than four implants and in 35.8% of knees with four or more implants (p = 0.31). No significant increase in failure was observed with increasing number of all-inside medial (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 0.79-1.7; p = 0.46) or lateral (OR: 0.86; 95% CI: 0.47-1.57; p = 0.63) implants after controlling for patient age, BMI, cACLR, tear type, or size. Tears of the lateral meniscus located in the red-white and white-white zones had lower odds of failure (OR: 0.14; 95% CI: 0.02-0.88; p = 0.036) than tears within the red-red zone, and patients with cACLR had lower odds of repair failure (OR: 0.40; 95% CI: 0.18-0.86, p = 0.024) than those without. The number of all-inside implants placed during meniscus tear repair did not affect the likelihood of repair failure leading to reoperation after controlling for BMI, age, tear type, size, location, and cACLR. LEVEL OF EVIDENCE: III.
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Affiliation(s)
- James D Oosten
- The Ohio State University College of Medicine, Wexner Medical Center, Columbus, Ohio
| | - Alex C DiBartola
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Jonathan C Wright
- The Ohio State University College of Medicine, Wexner Medical Center, Columbus, Ohio
| | - Parker A Cavendish
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Eric M Milliron
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Robert A Duerr
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Christopher C Kaeding
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
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Oosten J, Yoder R, DiBartola A, Bowler J, Sparks A, Duerr R, Magnussen R, Kaeding C, Flanigan D. Several Techniques Exist With Favorable Biomechanical Outcomes in Radial Meniscus Tear Repair-A Systematic Review. Arthroscopy 2022; 38:2557-2578.e4. [PMID: 35189305 DOI: 10.1016/j.arthro.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE To compare biomechanical properties of various radial tear repair techniques in the medial and lateral menisci. METHODS A search was performed for key words regarding mechanical properties of repair of radial meniscal tears in PubMed, Embase, CINAHL, Scopus, and Cochrane databases, yielding 1791 articles. Articles were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines against inclusion criteria and underwent Methodological Index for Non-Randomized Studies (MINORS) methodologic quality assessment. Repair constructs evaluated were classified based on repair technique, use of a transtibial augmentation, and the number, orientation, and pattern of stitches. Results published across different studies were compared but not subjected to meta-analysis due to variability in testing procedures and heterogeneity of repair methods. RESULTS We identified 20 studies that performed mechanical testing on 21 different radial meniscal tear repair techniques. The greatest reported mean load-to-failure (LtF) were the transtibial 2-tunnel + 4 horizontal inside-out sutures (191.2 N ± 17.3, cadaver) and all-inside double vertical repair (146.3 N ± 36.2, porcine). The transtibial technique improved LtF and displacement of an inside-out (IO) horizontal repair. All-inside vertical repairs demonstrated greater LtF, stiffness, and displacement compared with IO horizontal repairs in 2 studies. Compared with IO double horizontal repairs, all-inside double vertical or IO double horizontal repairs with reinforcing stitches parallel to the tear exhibited greater LtF in 3 studies and stiffness in 2 studies. Two studies reported that parallel reinforcing stitches significantly reduced suture tear-through compared with similar, nonreinforced repairs. Mean MINORS score for all studies analyzed was 19.88 ± 1.47 points. CONCLUSIONS A systematic review demonstrated that there may be alternatives to traditional IO horizontal repairs for radial meniscus tears. Less-invasive all-inside vertical techniques reinforced with suture parallel to the tear instead of standard IO horizontal sutures may improve strength of repair. In addition, transtibial 2-tunnel augmentation may also increase strength of radial meniscus tear repairs. CLINICAL RELEVANCE There may be alternatives to IO horizontal repairs for radial meniscus tears.
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Affiliation(s)
- James Oosten
- College of Medicine, Ohio State University, Columbus, Ohio, U.S.A
| | - Robert Yoder
- College of Medicine, Ohio State University, Columbus, Ohio, U.S.A
| | - Alex DiBartola
- Department of Orthopedics, Wexner Medical Center, Ohio State University, Columbus, Ohio, U.S.A
| | - Josh Bowler
- Department of Orthopedics, Wexner Medical Center, Ohio State University, Columbus, Ohio, U.S.A
| | - Alex Sparks
- College of Medicine, Ohio State University, Columbus, Ohio, U.S.A
| | - Robert Duerr
- Department of Orthopedics, Wexner Medical Center, Ohio State University, Columbus, Ohio, U.S.A
| | - Robert Magnussen
- Department of Orthopedics, Wexner Medical Center, Ohio State University, Columbus, Ohio, U.S.A
| | - Christopher Kaeding
- Department of Orthopedics, Wexner Medical Center, Ohio State University, Columbus, Ohio, U.S.A
| | - David Flanigan
- Department of Orthopedics, Wexner Medical Center, Ohio State University, Columbus, Ohio, U.S.A..
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Wang M, Lee YHD. Repair Technique for Displaced Meniscal Flap Tears Indicated by MRI Comma Sign. Arthrosc Tech 2021; 11:e79-e87. [PMID: 35127432 PMCID: PMC8807861 DOI: 10.1016/j.eats.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/07/2021] [Indexed: 02/03/2023] Open
Abstract
The meniscus comma sign has been described for displaced flap tears of the meniscus. These meniscus tears are displaced into the tibia or femoral recesses and can be often difficult to diagnose intraoperatively. We describe the technique of diagnosis and treatment of a large displaced lateral meniscus flap tear, presenting as a meniscus comma sign. The identification of the meniscus comma sign on consecutive magnetic resonance imaging (MRI) cuts suggest a flap tear of a significant size that indicates reparability. The technique would be to lift the meniscus flap from the meniscotibial recess, reduce it and then repair it with an all-inside meniscus repair or by hybrid meniscus repair techniques.
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Affiliation(s)
- Ming Wang
- Address correspondence to Ming Wang, M.D., F.R.C.S., Department of Orthopaedic Surgery, National University Hospital, 5 Lower Kent Ridge Rd., Singapore 119074.
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Yamakawa S, Mae T, Ogasawara I, Hirose T, Konda S, Nakata K. Placement of sutures for inside-out meniscal repair: both sutures through meniscal tissue reduces displacement on cyclical loading. J Exp Orthop 2021; 8:94. [PMID: 34676462 PMCID: PMC8531164 DOI: 10.1186/s40634-021-00417-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/13/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose The inside-out meniscal repair is widely performed to preserve the function of meniscus. In this technique, the outer suture is passed through the capsule as well as the outer meniscus, while the inner suture is inserted into the meniscus. The aim of this study was to biomechanically compare the suture stability between meniscus-meniscus and meniscus-capsule suture methods for the longitudinal meniscal tear with inside-out technique. Methods Twenty-seven porcine knees were dissected to maintain the femur-medial capsule/meniscus-tibia complex, and the inner meniscus was cut off along the meniscus circumferential fiber with 3 mm width of the peripheral meniscus preserved. After one needle with a 2-0 polyester suture was inserted into the inner portion of the meniscus, the other needle was inserted through 1) the peripheral meniscus (Group A), 2) capsule just above the meniscus (Group B), and 3) capsule at 10 mm apart from the meniscus-capsule junction (Group C) in the inside-out manner. Then, the suture was manually tied on the capsule. The suture gap at the repair site during 300 times of cyclic loading and the ultimate failure load in the load-to-failure test were measured. The statistical significance of the data between two groups in each combination was considered by Bonferroni correction, following a one-way analysis of variance. Results In the cyclic loading test, the suture gap was 0.68 ± 0.26 mm in Group A, 1.08 ± 0.36 mm in Group B, and 1.94 ± 0.57 mm in Group C with a significant difference. In the load-to-failure test, the ultimate failure load was 59.1 ± 13.6 N in Group A, 60.0 ± 7.9 N in Group B, and 57.4 ± 4.7 N in Group C, and there was no significant difference. Conclusion The stitching region in the inside-out technique for longitudinal meniscal tear affected the stability of the tear site, and stitching the mid-substance region of the meniscus provides good stability in response to cyclic tensile loading. In addition, the stitching region did not affect the ultimate failure load. Clinical relevance In the inside-out meniscal repair, the outer suture should be inserted into the remaining peripheral meniscus or the capsule near the meniscus.
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Affiliation(s)
- Satoshi Yamakawa
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Issei Ogasawara
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.,Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takehito Hirose
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shoji Konda
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.,Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ken Nakata
- Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Sochacki KR, Safran MR, Abrams GD, Donahue J, Chu C, Sherman SL. Platelet-Rich Plasma Augmentation for Isolated Arthroscopic Meniscal Repairs Leads to Significantly Lower Failure Rates: A Systematic Review of Comparative Studies. Orthop J Sports Med 2020; 8:2325967120964534. [PMID: 33283008 PMCID: PMC7682240 DOI: 10.1177/2325967120964534] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/08/2020] [Indexed: 01/23/2023] Open
Abstract
Background: Studies have reported relatively high failure rates of isolated meniscal repairs. Platelet-rich plasma (PRP) has been suggested as a way to increase growth factors that enhance healing. Purpose: To compare (1) meniscal repair failures and (2) patient-reported outcomes after isolated arthroscopic meniscal repair augmented with and without PRP. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Multiple databases were searched for studies that compared outcomes of isolated arthroscopic meniscal repair augmented with PRP versus without PRP in human patients. Failures and patient-reported outcome scores were reported for each study and compared between groups. Study heterogeneity was assessed using I2 for each outcome measure before meta-analysis. Study methodological quality was analyzed. Continuous variable data were reported as mean and standard deviation from the mean. Categorical variable data were reported as frequency with percentage. All P values were reported with significance set at P < .05. Results: Five articles were analyzed (274 patients [110 with PRP and 164 without PRP]; 65.8% male; mean age, 29.1 ± 4.6 years; mean follow-up, 29.2 ± 22.1 months). The risk of meniscal repair failure ranged from 4.4% to 26.7% for PRP-augmented repairs and 13.3% to 50.0% for repairs without PRP. Meniscal repairs augmented with PRP had significantly lower failure rates than repairs without PRP (odds ratio, 0.32; 95% CI, 0.12-0.90; P = .03). One of the 5 studies reported significantly higher outcomes in the PRP-augmented group versus the no-PRP group for the International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee injury and Osteoarthritis Outcome Score (KOOS) (P < .05 for all). The remaining 4 studies reported no significant difference between groups with regard to outcomes for the IKDC, Lysholm knee scale, visual analog scale for pain, or Tegner activity level. Conclusion: Although the studies were of mostly of low quality, isolated arthroscopic meniscal repairs augmented with PRP led to significantly lower failure rates (10.8% vs 27.0%; odds ratio, 0.32; P = .03) as compared with repairs without PRP. However, most studies reported no significant differences in patient-reported outcomes.
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Affiliation(s)
- Kyle R Sochacki
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Joseph Donahue
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Constance Chu
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA
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Lin JS, Akers A, Miller TL. Updates and Advances in the Management of Lateral Meniscal Radial Tears: A Critical Analysis Review. JBJS Rev 2020; 8:e2000056. [PMID: 33186207 DOI: 10.2106/jbjs.rvw.20.00056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Because of their increased mobility, lack of resistance to hoop stresses, and decreased blood supply, radial tears of the lateral meniscus are more troublesome to heal than vertical longitudinal tears. Given the success of meniscal root repairs, radial tears of the lateral meniscal body should be given strong consideration for repair because of a more reproducible ability to heal such lesions in young, active patients. Technique options that should be considered for the less common anterior radial tears of the lateral meniscus include outside-in repair, self-capturing suture-passing devices, and orthobiologic treatments to stimulate healing. Although a variety of suture techniques, including the double horizontal mattress and horizontal butterfly patterns, have demonstrated improvements in patient outcomes, evidence is still limited with regard to the ideal suture pattern for radial tears.
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Affiliation(s)
- James S Lin
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Allison Akers
- College of Medicine and Public Health, The Ohio State University, Columbus, Ohio
| | - Timothy L Miller
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio.,Jameson Crane Sports Medicine Institute, Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Hang G, Yew AKS, Chou SM, Wong YR, Tay SC, Lie DTT. Biomechanical comparison of vertical suture techniques for repairing radial meniscus tear. J Exp Orthop 2020; 7:77. [PMID: 33025241 PMCID: PMC7538523 DOI: 10.1186/s40634-020-00296-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/24/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose The aim of this study was to (1) develop suture techniques in repairing radial meniscal tear; (2) to compare the biomechanical properties of the proposed repair techniques with the conventional double horizontal technique. Methods Thirty-six fresh-frozen porcine medial menisci were randomly assigned into four groups and a complete tear was made at the midline of each meniscus. The menisci were subsequently repaired using four different repair techniques: double vertical (DV), double vertical cross (DVX), hybrid composing one vertical and one horizontal stitch, and conventional double horizontal (DH) suture technique with suturing parallel to the tibia plateau. The conventional double horizontal group was the control. The repaired menisci were subjected to cyclic loading followed by the load to failure testing. Gap formation and strength were measured, stiffness was calculated, and mode of failure was recorded. Results Group differences in gap formation were not statistically significant at 100 cycles (p = .42), 300 cycles (p = .68), and 500 cycles (p = .70). A trend was found toward higher load to failure in DVX (276.8 N, p < .001), DV (241.5 N, p < .001), and Hybrid (237.6 N, p < .001) compared with DH (148.5 N). Stiffness was also higher in DVX (60.7 N/mm, p < .001), DV (55.3 N/mm, p < .01), and Hybrid (52.1 N/mm, p < .01), than DH group (30.5 N/mm). Tissue failure was the only failure mode observed in all specimens. Conclusion Our two proposed vertical suture techniques, as well as the double vertical technique, had superior biomechanical properties than the conventional technique as demonstrated by higher stiffness and higher strength.
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Affiliation(s)
- Guanqi Hang
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore.
| | - Andy Khye Soon Yew
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
| | - Siaw Meng Chou
- School of Mechanical & Aerospace Engineering, College of Engineering, Nanyang Technological University, 50 Nanyang Ave, Singapore, 639798, Singapore
| | - Yoke Rung Wong
- Department of Hand Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
| | - Shian Chao Tay
- Department of Hand Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
| | - Denny Tijauw Tjoen Lie
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Singapore, 169865, Singapore
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Matthews JR, Wang J, Zhao J, Kluczynski MA, Bisson LJ. The influence of suture materials on the biomechanical behavior of suture-meniscal specimens: a comparative study in a porcine model. Knee Surg Relat Res 2020; 32:42. [PMID: 32859270 PMCID: PMC7453549 DOI: 10.1186/s43019-020-00053-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background Repair of a meniscal tear is indicated in certain conditions. Despite extensive research on the biomechanics of various repair methods, there has been minimal investigation of whether the suture material influences the meniscal-suture construct. The purpose of this study was to compare the biomechanical properties of nine different suture materials under cyclic and load-to-failure conditions. Methods Ninety porcine menisci were randomly allocated to simple suture placement using either Ultrabraid®, Ultratape®, Magnum Wire®, TigerWire®, TigerTape®, LabralTape®, Orthocord®, 0 FiberWire®, or 2-0 FiberWire®. Each suture-meniscus specimen underwent cyclic loading followed by load-to-failure testing. Elongation, maximum load to failure, stiffness, and mode of failure were recorded and compared between each suture type using non-parametric testing. Mean ± standard deviation was reported and the statistical significance was p < 0.05. Results Elongation during cyclic loading was lowest with 2-0 FiberWire (0.95 ± 0.17 mm); this value was statistically significantly different than the results for all other sutures except 0 FiberWire® (1.09 ± 0.17 mm, p = 0.79), TigerWire® (1.09 ± 0.29 mm, p = 0.85), TigerTape® (1.39 ± 0.29 mm, p = 0.08), and LabralTape® (1.20 ± 0.33 mm, p = 0.41). The highest elongation was seen with Ultrabraid® (1.91 ± 0.34 mm); this value was statistically significantly greater than the results for all other suture materials except Orthocord® (1.59 mm ± 0.31 mm, p = 0.46) and Magnum Wire® (1.43 ± 0.25 mm, p = 0.14). Load to failure was highest for TigerTape® (287.43 ± 41.15 N), and this result was statistically significantly different than the results for all other sutures except LabralTape® (271.34 ± 48.48 N, p = 0.99) and TigerWire® (251.03 ± 25.8 N, p = 0.51). Stiffness was highest for LabralTape® (195.77 ± 49.06 N/mm), and this result was statistically significantly different than the results for all other sutures except TigerWire® (186.49 ± 19.83 N/mm, p = 0.45) and TigerTape® (173.35 ± 15.60 N/mm, p = 0.19). The majority of sutures failed by pullout (n = 46, 51%) or tearing (n = 40, 45%). Conclusion Suture design and material affect the biomechanical behavior of porcine meniscal-suture specimens. LabralTape®, TigerWire®, and TigerTape® demonstrated better overall combinations of low elongation, high maximum load to failure, and high stiffness.
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Affiliation(s)
- John Reza Matthews
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Jiefei Wang
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Jiwei Zhao
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Melissa A Kluczynski
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Leslie J Bisson
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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Nakanishi Y, Hoshino Y, Nagamune K, Yamamoto T, Nagai K, Araki D, Kanzaki N, Matsushita T, Kuroda R. Radial Meniscal Tears Are Best Repaired by a Modified "Cross" Tie-Grip Suture Based on a Biomechanical Comparison of 4 Repair Techniques in a Porcine Model. Orthop J Sports Med 2020; 8:2325967120935810. [PMID: 32728592 PMCID: PMC7366409 DOI: 10.1177/2325967120935810] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 12/23/2019] [Indexed: 11/16/2022] Open
Abstract
Background: The tie-grip suture can fix radial tears more rigidly than simple conventional sutures. However, one shortcoming is the residual gap at the central margin of the tear. The tie-grip suture was modified to address this issue and named the “cross tie-grip suture.” Purpose/Hypothesis: The purpose of this study was to compare the suture stability and strength among 4 suturing techniques: the original tie-grip, cross tie-grip, and 2 conventional sutures (double horizontal and cross). It was hypothesized that the cross tie-grip suture would show the least displacement and resist the greatest maximum load. Study Design: Controlled laboratory study. Methods: A total of 40 fresh-frozen porcine knees were dissected to acquire 80 menisci; 20 menisci were tested in each suture group. A radial tear was created at the middle third of the meniscal body. Repair was performed with the following: original tie-grip, cross tie-grip, double horizontal, and cross sutures. The mechanical strength of sutured menisci was evaluated using a tensile testing machine. All menisci underwent submaximal loading and load to failure. The gap distance and ultimate failure load were compared using analysis of variance. The failure mode was recorded after load-to-failure testing. Results: Displacement after 500 cycles was significantly smaller in the cross tie-grip group (0.4 ± 0.3 mm) compared with the tie-grip (0.9 ± 0.6 mm), double horizontal (1.2 ± 0.7 mm), and cross suture groups (1.4 ± 0.6 mm) (P < .05). The ultimate failure load was significantly greater in the cross tie-grip (154.9 ± 29.0 N) and tie-grip (145.2 ± 39.1 N) groups compared with the double horizontal (81.2 ± 19.9 N) and cross suture groups (87.3 ± 17.7 N) (P < .05). Tissue failure was the most common mode of failure in all groups. Conclusion: Upon repair of radial meniscal tears, the cross tie-grip suture showed less displacement compared with that of the tie-grip, double horizontal, and cross sutures and demonstrated equivalent load to failure to that of the tie-grip suture at time zero. Clinical Relevance: The cross tie-grip suture provided high resistance to displacement after repair of radial tears and may be advantageous in healing for radial meniscal tears.
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Affiliation(s)
- Yuta Nakanishi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kouki Nagamune
- Department of Human and Artificial Intelligent Systems, Graduate School of Engineering, University of Fukui, Fukui, Japan
| | - Tetsuya Yamamoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Araki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Noriyuki Kanzaki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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12
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Massey P, McClary K, Parker D, Barton RS, Solitro G. The rebar repair for radial meniscus tears: a biomechanical comparison of a reinforced suture repair versus parallel and cross-stitch techniques. J Exp Orthop 2019; 6:38. [PMID: 31440855 PMCID: PMC6706491 DOI: 10.1186/s40634-019-0206-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/25/2019] [Indexed: 12/04/2022] Open
Abstract
Background Radial meniscus tears can cause the meniscus to be completely incompetent. This serious type of meniscus tear can be difficult to repair. Techniques have been developed that juxtapose the meniscus tear edges and are able to withstand high loads. The purpose of this study was to determine the load to failure of a reinforced suture bar repair (Rebar Repair) for radial meniscus tear and compare it to the parallel suture technique and cross-stitch technique and to compare mode of failure among all three groups. The hypothesis was that the Rebar Repair will have a higher load to failure than both the parallel technique and the cross-stitch technique and that the Rebar Repair would have a lower rate of suture cutting through the meniscus. Methods Forty-eight menisci were tested from 24 human knee specimens, with 16 menisci in each group evenly distributed between medial and lateral menisci. Radial mid body meniscal tears were recreated and repaired with one of three inside-out techniques: the 2-parallel suture technique, 2 cross-stitch sutures, and the Rebar Repair. The specimens were cycled between 5 N to 30 N and axially loaded to failure perpendicularly across the repair site. Results The average load to failure of the parallel group, cross-stitch group and Rebar Repair was 85.5 N ± 22.0, 76.2 N ± 28.8 and 124.1 N ± 27.1 respectively. The Rebar Repair had a higher load to failure than the parallel group (p < 0.01) and cross-stitch group (p < 0.01). There was no difference in the load to failure between the cross-stitch and parallel group (p = 0.49). The failure mechanism was different when comparing the 3 groups (p < 0.01). The predominant mode of failure for both the parallel and cross-stitch group was suture cutout through the meniscus (88% and 94% respectively). The Rebar Repair failed due to suture rupture in 50% and suture cutout through the meniscus in 50%. Conclusion The Rebar Repair for radial meniscus tear has a higher load to failure and a lower rate of suture cutout through the meniscus than the parallel technique and cross-stitch technique. Clinical relevance Radial meniscus tears lead to decreased hoop stresses of the meniscus and effectively a non-functional meniscus. Newer techniques may have a higher load to failure leading to more successful repairs.
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Affiliation(s)
- Patrick Massey
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center- Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Kaylan McClary
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center- Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - David Parker
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center- Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - R Shane Barton
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center- Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Giovanni Solitro
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center- Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
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13
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Stender ZC, Cracchiolo AM, Walsh MP, Patterson DP, Wilusz MJ, Lemos SE. Radial Tears of the Lateral Meniscus-Two Novel Repair Techniques: A Biomechanical Study. Orthop J Sports Med 2018; 6:2325967118768086. [PMID: 29780840 PMCID: PMC5954321 DOI: 10.1177/2325967118768086] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: A common treatment for radial tears of the meniscus has historically been partial meniscectomy. Owing to the poor outcomes associated with partial meniscectomy, repair of the meniscus is an important treatment option. It is important to evaluate different repair techniques for radial tears of the meniscus. Purpose/Hypothesis: The purpose of this study was to evaluate 2 novel techniques to repair radial tears of the lateral meniscus. The 2 techniques were compared biomechanically with the cross-suture method with an inside-out technique. The authors hypothesized that novel repair techniques would result in less displacement after cyclic loading, increased load required to displace the repair 3 mm, greater load to failure, decreased displacement at load to failure, and increased stiffness of the repair, resulting in a construct that more closely re-creates the function of the intact meniscus. Study Design: Controlled laboratory study. Methods: A total of 36 fresh-frozen cadaveric tibial plateaus containing intact menisci were obtained. The menisci were divided into 3 groups (n = 12 in each group), and each meniscus was repaired simulating an inside-out technique. The 3 repairs completed were the hashtag, crosstag, and cross-suture techniques. Radial tears were created at the midbody of the lateral meniscus and repaired via the 3 techniques. The repaired menisci were attached to an axial loading machine and tested for cyclic and failure loading. Results: After cyclic loading, the cross-suture repair displaced 4.78 ± 1.65 mm; the hashtag, 2.42 ± 1.13 mm; and the crosstag, 3.13 ± 1.77 mm. The hashtag and cross-tag repairs both resulted in significantly less displacement (P = .003 and .024, respectively) as compared with the cross-suture repair. The cross-suture technique had a load to failure of 81.43 ± 14.31 N; the hashtag, 86.08 ± 23.58 N; and the crosstag, 62.50 ± 12.15 N. The cross-suture and hashtag repairs both resulted in a greater load to failure when compared with the crosstag (P = .009 and .009, respectively). There was no difference comparing the load required to displace the cross-suture technique 3 mm versus the hashtag or crosstag technique (P = .564 and .094, respectively). However, when compared with the crosstag technique, the hashtag technique required a significantly greater load to displace the repair 3 mm (P = .015). Conclusion: This study introduced 2 novel repair techniques—hashtag and crosstag—that did not demonstrate superiority in terms of load to failure or stiffness, but both repairs were statistically superior to the cross-suture repair in terms of displacement after cyclic loading. Considerations that may influence the validity of these techniques include cost, surgical time, and increased technical demand. Clinical Relevance: Radial tears of the meniscus are difficult to repair. Further research into more stable constructs is necessary.
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14
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Rothrauff BB, Numpaisal PO, Lauro BB, Alexander PG, Debski RE, Musahl V, Tuan RS. Augmented repair of radial meniscus tear with biomimetic electrospun scaffold: an in vitro mechanical analysis. J Exp Orthop 2016; 3:23. [PMID: 27624439 PMCID: PMC5021645 DOI: 10.1186/s40634-016-0058-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/02/2016] [Indexed: 01/26/2023] Open
Abstract
Background Large radial tears that disrupt the circumferential fibers of the meniscus are associated with reduced meniscal function and increased risk of joint degeneration. Electrospun fibrous scaffolds can mimic the topography and mechanics of fibrocartilaginous tissues and simultaneously serve as carriers of cells and growth factors, yet their incorporation into clinically relevant suture repair techniques for radial meniscus tears is unexplored. The purposes of this study were to (1) evaluate the effect of fiber orientation on the tensile properties and suture-retention strength of multilayered electrospun scaffolds and (2) determine the mechanical effects of scaffold inclusion within a surgical repair of a simulated radial meniscal tear. The experimental hypothesis was that augmentation with a multilayered scaffold would not compromise the strength of the repair. Methods Three multilayered electrospun scaffolds with different fiber orientations were fabricated–aligned, random, and biomimetic. The biomimetic scaffold was comprised of four layers in the following order (deep to superficial)–aligned longitudinal, aligned transverse, aligned longitudinal, and random–respectively corresponding to circumferential, radial, circumferential, and superficial collagen fibers of the native meniscus. Material properties (i.e., ultimate stress, modulus, etc.) of the scaffolds were determined in the parallel and perpendicular directions, as was suture retention strength. Complete radial tears of lateral bovine meniscus explants were repaired with a double horizontal mattress suture technique, with or without inclusion of the biomimetic scaffold sheath. Both repair groups, as well as native controls, were cyclically loaded between 5 and 20 N for 500 cycles and then loaded to failure. Clamp-to-clamp distance (i.e., residual elongation) was measured following various cycles. Ultimate load, ultimate elongation, and stiffness, were also determined. Group differences were evaluated by one-way ANOVA or Student’s t-test where appropriate. Results Aligned scaffolds possessed the most anisotropic mechanical properties, whereas random scaffolds showed uniform properties in the parallel and perpendicular directions. In comparison, the biomimetic scaffold possessed moduli in the parallel (68.7 ± 14.7 MPa) and perpendicular (39.4 ± 11.6 MPa) directions that respectively approximate the reported circumferential and radial tensile properties of native menisci. The ultimate suture retention load of the biomimetic scaffold in the parallel direction (7.2 ± 1.6 N) was significantly higher than all other conditions (p < 0.001). Biomimetic scaffold augmentation did not compromise mechanical properties when compared against suture repair in terms of residual elongation after 500 cycles (scaffold: 5.05 ± 0.89 mm vs. repair: 4.78 ± 1.24 mm), ultimate failure load (137.1 ± 31.0 N vs. 124.4 ± 21.4 N), ultimate elongation (12.09 ± 5.89 mm vs. 10.14 ± 4.61 mm), and stiffness (20.8 ± 3.6 vs. 18.4 ± 4.7 N/mm). Conclusions While multilayered scaffold sheets were successfully fabricated to mimic the ultrastructure and anisotropic tensile properties of native menisci, improvements in suture retention strength or adoption of superior surgical techniques will be needed to further enhance the mechanical strength of repairs of radial meniscal tears.
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Affiliation(s)
- Benjamin B Rothrauff
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 450 Technology Drive, Room 221, Pittsburgh, PA, 15219, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15219, USA
| | - Piya-On Numpaisal
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 450 Technology Drive, Room 221, Pittsburgh, PA, 15219, USA.,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Brian B Lauro
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 450 Technology Drive, Room 221, Pittsburgh, PA, 15219, USA.,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter G Alexander
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 450 Technology Drive, Room 221, Pittsburgh, PA, 15219, USA
| | - Richard E Debski
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, USA.,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15219, USA
| | - Volker Musahl
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, USA.,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rocky S Tuan
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 450 Technology Drive, Room 221, Pittsburgh, PA, 15219, USA. .,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA. .,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15219, USA.
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15
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Milchteim C, Branch EA, Maughon T, Hughey J, Anz AW. Biomechanical Comparison of Parallel and Crossed Suture Repair for Longitudinal Meniscus Tears. Orthop J Sports Med 2016; 4:2325967116640263. [PMID: 27104209 PMCID: PMC4827117 DOI: 10.1177/2325967116640263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Longitudinal meniscus tears are commonly encountered in clinical practice. Meniscus repair devices have been previously tested and presented; however, prior studies have not evaluated repair construct designs head to head. This study compared a new-generation meniscus repair device, SpeedCinch, with a similar established device, Fast-Fix 360, and a parallel repair construct to a crossed construct. Both devices utilize self-adjusting No. 2-0 ultra–high molecular weight polyethylene (UHMWPE) and 2 polyether ether ketone (PEEK) anchors. Hypothesis: Crossed suture repair constructs have higher failure loads and stiffness compared with simple parallel constructs. The newer repair device would exhibit similar performance to an established device. Study Design: Controlled laboratory study. Methods: Sutures were placed in an open fashion into the body and posterior horn regions of the medial and lateral menisci in 16 cadaveric knees. Evaluation of 2 repair devices and 2 repair constructs created 4 groups: 2 parallel vertical sutures created with the Fast-Fix 360 (2PFF), 2 crossed vertical sutures created with the Fast-Fix 360 (2XFF), 2 parallel vertical sutures created with the SpeedCinch (2PSC), and 2 crossed vertical sutures created with the SpeedCinch (2XSC). After open placement of the repair construct, each meniscus was explanted and tested to failure on a uniaxial material testing machine. All data were checked for normality of distribution, and 1-way analysis of variance by ranks was chosen to evaluate for statistical significance of maximum failure load and stiffness between groups. Statistical significance was defined as P < .05. Results: The mean maximum failure loads ± 95% CI (range) were 89.6 ± 16.3 N (125.7-47.8 N) (2PFF), 72.1 ± 11.7 N (103.4-47.6 N) (2XFF), 71.9 ± 15.5 N (109.4-41.3 N) (2PSC), and 79.5 ± 25.4 N (119.1-30.9 N) (2XSC). Interconstruct comparison revealed no statistical difference between all 4 constructs regarding maximum failure loads (P = .49). Stiffness values were also similar, with no statistical difference on comparison (P = .28). Conclusion: Both devices in the current study had similar failure load and stiffness when 2 vertical or 2 crossed sutures were tested in cadaveric human menisci. Clinical Relevance: Simple parallel vertical sutures perform similarly to crossed suture patterns at the time of implantation.
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Affiliation(s)
- Charles Milchteim
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Eric A Branch
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Ty Maughon
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Jay Hughey
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Adam W Anz
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
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16
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Branch EA, Milchteim C, Aspey BS, Liu W, Saliman JD, Anz AW. Biomechanical comparison of arthroscopic repair constructs for radial tears of the meniscus. Am J Sports Med 2015; 43:2270-6. [PMID: 26245325 DOI: 10.1177/0363546515591994] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radial tears of the meniscus represent a challenging clinical scenario because benign neglect and partial meniscectomy have both been shown to have negative biomechanical and long-term clinical consequences. HYPOTHESIS Complex suture repair constructs have higher failure loads and stiffness values compared with simple constructs. STUDY DESIGN Controlled laboratory study. METHODS After radial transection of human cadaveric menisci, simulated tears were repaired arthroscopically by use of 1 of 4 repair constructs: (1) 2 inside-out horizontal sutures, (2) 2 all-inside horizontal sutures, (3) an all-inside Mason-Allen construct consisting of 4 sutures, or (4) an all-inside construct consisting of a figure-of-8 suture plus 1 horizontal suture. Meniscus specimens were harvested and tested to failure on an Instron machine. The Kruskal-Wallis test was used to evaluate for significance of maximal failure load and stiffness between groups. RESULTS The mean maximum failure loads were 64 ± 20 N (inside-out horizontal construct), 75 ± 16 N (all-inside horizontal construct), 86 ± 19 N (Mason-Allen construct), and 113 ± 22 N (figure-of-8 plus horizontal construct). Interconstruct comparison revealed a statistically significant difference between the figure-of-8 plus horizontal construct and all 3 remaining constructs (P < .02) as well as the Mason-Allen construct when compared with the inside-out horizontal construct (P < .01). Statistical significance was not found between the all-inside horizontal construct and the Mason-Allen construct or between the all-inside horizontal construct and the inside-out horizontal construct (P = .2 and .7, respectively). Stiffness values were lower for the inside-out construct compared with the all-inside constructs (P < .05). CONCLUSION Complex all-inside repair constructs had significantly higher failure loads than a conventional, simple inside-out suture repair construct for repair of radial meniscal tears. Stiffness values among the all-inside groups were greater than those for the inside-out group. CLINICAL RELEVANCE Arthroscopic techniques are presented to produce stronger radial meniscal tear repairs.
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Affiliation(s)
- Eric A Branch
- Andrews Research and Education Institute, Gulf Breeze, Florida, USA
| | | | - Bradley S Aspey
- Andrews Research and Education Institute, Gulf Breeze, Florida, USA
| | - Wei Liu
- Department of Kinesiology, College of Education, Auburn University, Auburn, Alabama, USA
| | | | - Adam W Anz
- Andrews Research and Education Institute, Gulf Breeze, Florida, USA
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17
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Biomechanical evaluation of different suture materials for arthroscopic transtibial pull-out repair of posterior meniscus root tears. Knee Surg Sports Traumatol Arthrosc 2015; 23:132-9. [PMID: 23999948 DOI: 10.1007/s00167-013-2656-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 08/24/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the biomechanical properties of four different suture materials for arthroscopic transtibial pull-out repair of posterior meniscus root tears, with special focus on the meniscus-suture interface. METHODS Forty fresh-frozen lateral porcine menisci were used. The posterior meniscus root was sutured in a standardized fashion with a simple stitch using four different suture materials: group A, No. 2 PDS™; group B, No. 2 Ethibond™; group C, No. 2 FiberWire™; and group D, 2-mm Fibertape™. Meniscus-suture constructs were subjected to cyclic loading followed by load-to-failure testing using a servo-hydraulic material testing machine. RESULTS During cyclic loading, group D showed a significantly higher displacement after 100, 500, and 1,000 cycles compared to group A (p < 0.001, p = 0.001, and p = 0.001), and a significantly higher displacement after 100 and 500 cycles compared to group B (p = 0.010 and p = 0.045). Group C showed a significantly higher displacement compared to group A after 100 cycles (p = 0.008). The highest maximum load was observed in group D, with significant differences compared to group A (p = 0.013). Group B showed a significantly higher stiffness compared to group A (p = 0.023), and both group C and group D showed a significantly higher stiffness compared to group A and group B (p < 0.001). CONCLUSION None of the evaluated suture materials provided clearly superior properties over the others during both cyclic loading and load-to-failure testing. Based on the results of this study, FiberWire™ may be the preferred suture material for transtibial pull-out repair of posterior meniscus root tears because of comparably low displacement during cyclic loading and high values for maximum load and stiffness. In the clinical setting, FiberWire™ may improve healing rates and avoid progressive extrusion of the meniscus after transtibial pull-out repair of posterior meniscus root tears.
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Ramappa AJ, Chen A, Hertz B, Wexler M, Grimaldi Bournissaint L, DeAngelis JP, Nazarian A. A biomechanical evaluation of all-inside 2-stitch meniscal repair devices with matched inside-out suture repair. Am J Sports Med 2014; 42:194-9. [PMID: 24114752 DOI: 10.1177/0363546513505190] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many all-inside suture-based devices are currently available, including the Meniscal Cinch, FasT-Fix, Ultra FasT-Fix, RapidLoc, MaxFire, and CrossFix System. These different devices have been compared in various configurations, but to our knowledge, the Sequent meniscal repair device, which applies running sutures, has not been compared with the Ultra FasT-Fix, nor has it been compared with its suture, No. 0 Hi-Fi, using an inside-out repair technique. PURPOSE To assess the quality of the meniscal repair, all new devices should be compared with the gold standard: the inside-out repair. To that end, this study aims to compare the biomechanical characteristics of running sutures delivered by the Sequent meniscal repair device with 2 vertical mattress sutures applied using the Ultra FasT-Fix device and with 2 vertical mattress sutures using an inside-out repair technique with No. 0 Hi-Fi suture. STUDY DESIGN Controlled laboratory study. METHODS Paired (medial and lateral), fresh-frozen porcine menisci were randomly assigned to 1 of 3 groups: Sequent (n = 17), Ultra FasT-Fix (n = 19), and No. 0 Hi-Fi inside-out repair (n = 20). Bucket-handle tears were created in all menisci and were subjected to repair according to their grouping. Once repaired, the specimens were subjected to cyclic loading (100, 300, and 500 cycles), followed by loading to failure. RESULTS The Sequent and Ultra FasT-Fix device repairs and the suture repair exhibited low initial displacements. The Sequent meniscal repair device demonstrated the lowest displacement in response to cyclic loading. No. 0 Hi-Fi suture yielded the highest load to failure. CONCLUSION With the development of the next generation of all-inside meniscal repair devices, surgeons may use these findings to select the method best suited for their patients. CLINICAL RELEVANCE The Sequent meniscal repair device displays the least amount of displacement during cyclic loading but has a similar failure load to other devices.
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Affiliation(s)
- Arun J Ramappa
- Ara Nazarian, Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN115, Boston, MA 02215.
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Feucht MJ, Grande E, Brunhuber J, Rosenstiel N, Burgkart R, Imhoff AB, Braun S. Biomechanical comparison between suture anchor and transtibial pull-out repair for posterior medial meniscus root tears. Am J Sports Med 2014; 42:187-93. [PMID: 24018976 DOI: 10.1177/0363546513502946] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterior medial meniscus root (PMMR) tears have a serious effect on knee joint biomechanics. Currently used techniques for refixation of the PMMR include the transtibial pull-out repair (TP) and suture anchor repair (SA). These techniques have not been compared biomechanically. HYPOTHESIS The SA technique provides superior biomechanical properties compared with the TP technique. STUDY DESIGN Controlled laboratory study. METHODS A total of 24 fresh-frozen porcine tibiae with attached intact medial menisci were used. The specimens were randomly assigned to 3 groups (8 specimens each). A standardized PMMR tear was created in 16 specimens. Refixation of the PMMR was performed by either the TP or SA technique. The native PMMR was left intact in 8 specimens. All specimens were subjected to cyclic loading followed by load-to-failure testing. Displacement after 100, 500, and 1000 cycles; maximum load to failure; stiffness; and displacement at failure were recorded. RESULTS Both repair techniques showed a significantly higher displacement during cyclic loading and a significantly lower maximum load and stiffness during load-to-failure testing compared with the native PMMR (P < .05). The SA technique showed a significantly lower displacement after 100, 500, and 1000 cycles (P < .001) and a significantly higher stiffness (P = .016) compared with the TP technique. Maximum load did not differ significantly between the SA and TP techniques (P = .027, Bonferroni adjustment). No significant difference between the 3 groups was observed for displacement at failure (P > .05). CONCLUSION The SA technique provided superior biomechanical properties compared with the TP technique. Both repair techniques did not reach the strength of the native PMMR. CLINICAL RELEVANCE The favorable biomechanical properties of the SA technique might be beneficial for healing of the repaired PMMR and restoration of meniscus function. Because of inferior time zero stability compared with the native PMMR, slow rehabilitation is recommended after meniscus root repair.
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Affiliation(s)
- Matthias J Feucht
- Andreas B. Imhoff, Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany.
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Breland R, Nyland J, Lee YHD, Culy D, Burden R, Caborn D. Outside-in continuous suturing is superior to interrupted suturing for repairing peripheral meniscus lesions: an in vitro biomechanical study using a porcine model. Arthroscopy 2013; 29:1974-80. [PMID: 24140141 DOI: 10.1016/j.arthro.2013.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE This in vitro biomechanical study using a porcine model compared peripheral longitudinal vertical meniscus lesion (PLVML) outside-in suture repair fixation strength using either interrupted or continuous "N" configuration No. 2-0 braided polyester sutures. METHODS Porcine lateral menisci were randomly assigned to group 1 (continuous) or group 2 (interrupted). Standardized PLVMLs were created in each specimen. Repaired specimens were placed in a specially designed clamp and loaded into a servohydraulic device. Specimens underwent preconditioning for 10 cycles (0.1 Hz, 5 to 20 N) and 500 submaximal loading cycles (0.5 Hz, 5 to 20 N), before load-to-failure testing (12.5 mm/s). A 30-second pause after preconditioning and after 10, 100, and 500 submaximal loading cycles enabled standardized digital photographs to be taken for gapping measurement determination. The failure mode was documented. RESULTS Displacement and gapping during preconditioning and submaximal loading cycles did not differ between groups. Group 1 withstood a greater failure load (mean, 118.3 N; 95% confidence interval [CI], 97.2 to 139.4 N) than group 2 (mean, 63.7 N; 95% CI, 51.2 to 76.2 N) (P < .0001) and displacement during load-to-failure testing (mean, 5.3 mm; 95% CI, 4.2 to 6.5 mm) than group 2 (mean, 3.2 mm; 95% CI, 2.1 to 4.3 mm) (P = .005). Group 1 failed by suture breakage or suture pulling through tissue, whereas group 2 primarily failed by knot slippage (P < .0001). CONCLUSIONS Group displacement and gapping differences were not observed after 500 submaximal loading cycles. PLVMLs repaired with a continuous N configuration, however, withstood greater load at failure and greater displacement before failure than repairs that used interrupted sutures. CLINICAL RELEVANCE Continuous suture in an N configuration may improve PLVML repair fixation strength.
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Affiliation(s)
- Ryan Breland
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, U.S.A
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Feucht MJ, Grande E, Brunhuber J, Burgkart R, Imhoff AB, Braun S. Biomechanical evaluation of different suture techniques for arthroscopic transtibial pull-out repair of posterior medial meniscus root tears. Am J Sports Med 2013; 41:2784-90. [PMID: 24013348 DOI: 10.1177/0363546513502464] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A tear of the posterior medial meniscus root (PMMR) is increasingly recognized as a serious knee joint injury. Several suture techniques for arthroscopic transtibial pull-out repair have been described; however, only limited data about the biomechanical properties of these techniques are currently available. HYPOTHESIS There are significant differences between the tested suture techniques, with more complex suture configurations providing superior biomechanical properties. STUDY DESIGN Controlled laboratory study. METHODS A total of 40 porcine medial menisci were randomly assigned to 1 of 4 groups (10 specimens each) according to suture technique: two simple stitches (TSS), horizontal mattress suture (HMS), modified Mason-Allen suture (MMA), and two modified loop stitches (TLS). Meniscus-suture constructs were subjected to cyclic loading followed by load-to-failure testing in a servohydraulic material testing machine. RESULTS During cyclic loading, the HMS and TLS groups showed a significantly higher displacement after 100, 500, and 1000 cycles compared with the TSS and MMA groups. After 1000 cycles, the highest displacement was found for the TLS group, with significant differences compared with all other groups. During load-to-failure testing, the highest maximum load and yield load were observed for the MMA group, with statistically significant differences compared with the TSS and TLS groups. With regard to stiffness, the TSS and MMA groups showed significantly higher values compared with the HMS and TLS groups. CONCLUSION The MMA technique provided the best biomechanical properties with regard to cyclic loading and load-to-failure testing. The TSS technique seems to be a valuable alternative. Both the HMS and TLS techniques have the disadvantage of lower stiffness and higher displacement during cyclic loading. CLINICAL RELEVANCE Using a MMA technique may improve healing rates and avoid progressive extrusion of the medial meniscus after transtibial pull-out repair of PMMR tears. The TSS technique may be used as an alternative that is easier to perform, but a more careful rehabilitation program is possibly necessary to avoid early failure.
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Affiliation(s)
- Matthias J Feucht
- Andreas B. Imhoff, Department of Orthopaedic Sports Medicine, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany.
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Lee YHD, Nyland J, Burden R, Caborn DNM. Repair of peripheral vertical meniscus lesions in porcine menisci: in vitro biomechanical testing of 3 different meniscus repair devices. Am J Sports Med 2013; 41:1074-81. [PMID: 23475943 DOI: 10.1177/0363546513479775] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND All-inside meniscus repair eliminates the need for an extra incision and decreases neurovascular injury risk. Biomechanical testing can help delineate the efficacy of all-inside device use. HYPOTHESIS There would be no group differences between 4 peripheral meniscus repair techniques and 3 different devices tested. STUDY DESIGN Controlled laboratory study. METHODS Equivalent-sized menisci with attached tibiae were randomly assigned to 1 of 4 test groups (8 specimens each), as follows: group 1, Fast-Fix using No. 0 braided polyester suture; group 2, inside-out repair using 2-0 braided polyester suture; group 3, Sequent using No. 0 ultra-high molecular weight polyethylene (UHMWPE) suture in a continuous "N" configuration; and group 4, Sequent using No. 0 UHMWPE suture in an interrupted configuration. After placement in a clamp, specimens underwent preconditioning from 5 to 20 N for 10 cycles (0.1 Hz), 500 submaximal loading cycles from 5 to 20 N (0.5 Hz), and load-to-failure testing at 12.5 mm/s. A 30-second pause after 10 preconditioning cycles and after 10, 100, and 500 submaximal loading cycles enabled digital photographs to be taken for gapping measurements. Failure mode was recorded. RESULTS Specimens in group 3 withstood greater failure loads than did those in groups 1 and 4 (P ≤ .027), and group 3 specimens were stiffer than those in groups 2 and 4 (P ≤ .048). Displacement during submaximal loading and load-to-failure testing did not differ between groups. Groups 1, 3, and 4 each gapped less than group 2 during submaximal cyclic loading (P ≤ .05). Groups 1 and 2 failed primarily by suture breakage (P < .0001), while groups 3 and 4 failed primarily by the suture pulling free from an implant (P < .0001). CONCLUSION Sequent using No. 0 UHMWPE suture in a continuous "N" configuration displayed superior load at failure compared with repairs using Fast-Fix with No. 0 braided polyester suture and displayed greater stiffness and less gapping than inside-out repair using 2-0 braided polyester suture. The suture pulling free from an implant was the primary failure mode for Sequent using No. 0 UHMWPE suture regardless of whether a continuous "N" or an interrupted configuration was used. Study groups that used No. 0 UHMWPE sutures (groups 3 and 4) had more specimens fail by the suture pulling free from an implant. Compared with the weaker braided polyester suture in the inside-out and Fast-Fix groups, the No. 0 UHMWPE suture used in the Sequent groups likely influenced study results, as this suture has stronger material properties. However, the continuous "N" configuration likely also improved the performance of the Sequent with No. 0 UHMWPE suture, as failure load was significantly less with an interrupted configuration. CLINICAL RELEVANCE All-inside meniscus repair with continuous suture function may translate into improved patient outcomes.
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Affiliation(s)
- Yee Han Dave Lee
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, KY 40202, USA
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