Suture versus FasT-Fix all-inside meniscus repair at time of anterior cruciate ligament reconstruction

Biomechanical Comparison of All-Suture, All-Inside Meniscus Repair Devices in a Human Cadaveric Meniscus Model

OBJECTIVE

Newer all-suture, all-inside meniscus repair devices utilize soft suture anchors. The purpose of this study was to compare the biomechanical performance of 4 meniscus repair devices in human cadaver menisci: the JuggerStitch (all-suture, all-inside), the FiberStitch (all-suture, all-inside), a polyether ether ketone (PEEK) all-inside, and an inside-out device.

DESIGN

Forty human cadaver menisci were tested after creating 20 mm longitudinal tears in the posterior meniscus. Each knee was randomized to 1 of 4 meniscus repair groups: JuggerStitch (all-suture, all-inside), FiberStitch (all-suture, all-inside), FAST-FIX 360 (PEEK-based anchor all-inside), and inside-out (with BroadbandTM tape meniscus needles). For each meniscus, 2 devices were used to prepare vertical mattress repair construct. The specimens were tested by pre-conditioning 20 cycles between 5 N and 30 N and then the tear diastasis was measured, followed by distraction to failure phase after imposing a displacement at a rate of 0.5 mm/s.

RESULTS

Ten menisci were tested in each of the 4 groups. After pre-conditioning, there was no significant difference in the gap formation among groups (P = 0.212). The average failure load for the JuggerStitch, FiberStitch, PEEK all-inside, and inside-out was 384 N, 311 N, 207 N, and 261 N, respectively, with a significant difference between groups (P = 0.034). Post hoc analysis showed the JuggerStitch failure load was higher than the PEEK all-inside and inside-out (P = 0.005, and P = 0.045, respectively). There was no significant difference between the failure load of the JuggerStitch and FiberStitch (P = 0.225).

CONCLUSION

The JuggerStitch all-suture device, FiberStitch all-suture device, PEEK all-inside, and inside-out devices have similar biomechanical properties for gapping and stiffness. The JuggerStitch all-suture, all-inside device has superior failure load compared with the PEEK all-inside and inside-out repair for longitudinal meniscus tear repair.

MRI Criteria for Healing at 1 Year After Repair of a Traumatic Meniscal Tear

BACKGROUND

Meniscal repair for a traumatic meniscal tear is increasingly used to preserve the meniscus. Interpreting postoperative magnetic resonance imaging (MRI) scans remains challenging, especially in symptomatic patients. There is a lack of reliable MRI criteria to affirm the healed character of a traumatic meniscal injury repair.

PURPOSE

To identify relevant MRI criteria for meniscal healing after meniscal repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We prospectively included all patients with a traumatic meniscal injury who underwent either an isolated meniscal repair or a repair during a concomitant anterior cruciate ligament reconstruction. A standardized preoperative and postoperative clinical evaluation was performed, along with collection of functional scores-Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee, Lysholm Score, and 36-Item Short Form Health Survey. An MRI scan was performed 1 year postoperatively and compared with the preoperative MRI scan. The following MRI aspects were analyzed: variation of morphology and fat-saturated (FS) T2 intensity signal and pre- and postoperative tear diastasis measurement.

RESULTS

Fifty patients (age, mean ± SD, 28.7 ± 8.5 years [range, 16-45 years]) who were 1 year postoperative were included. All patients were considered clinically healed had the same MRI characteristics. A signal change (FS T2) was observed from a high signal intensity fluid to a nonfluid moderate signal intensity. The morphology of the lesion was more complex: from the initial lesion, line ramifications appeared, creating the appearance of tree branches. The tear diastasis decreased (from 2.3 ± 0.5 mm [range, 1.3-3.5] to 1.1 ± 0.28 mm [range, 0.5-1.5]).

CONCLUSION

MRI criteria confirming meniscal healing after traumatic meniscal repair at 1 year were identified: a change in the intrameniscal signal becoming nonfluid and moderate in intensity; a reduction in tear diastasis to <1.5 mm; and a change in the signal morphology of the repaired meniscus.

Clinical outcomes, healing rate, and presence of peri-meniscal cysts after all-inside meniscal repair in combination with anterior cruciate ligament reconstruction: a prospective comparative study with magnetic resonance imaging assessment

PURPOSE

Meniscal repairs are the most common associated procedures during ACL reconstruction, but they present challenging indications and possible risks of complications or failures. The aim of the present study is to assess the clinical outcomes of all-inside meniscal repairs in the setting of ACL reconstruction.

METHODS

Twenty patients with ACL reconstruction and all-inside meniscal repair were compared to 20 patients with isolated ACL reconstruction. All patients were prospectively evaluated pre-operatively, at four month, and 18-month follow-up with KT-1000, Kira accelerometer for pivot-shift, KOOS, Marx score, and SF-36. Meniscal healing and presence of peri-meniscal cysts were assessed on standardized 1.5-T MRIs performed at 18 months.

RESULTS

Twenty-one meniscal repairs were performed in 20 patients (81% medial, 19% lateral). At 18 months, 48% had complete healing, 38% had incomplete healing, and 14% had no healing. Peri-meniscal cysts were present in 33% of cases. Worst pre-operative KOOS pain (p = 0.0435) and ADL (p = 0 .0201) were present in patients with meniscal lesion, while no differences were present at four months and 18 months between patients with or without meniscal repair (p > 0.05). No significant differences were noted stratifying patients according to meniscal healing or cyst presence, except of a lower Qol KOOS subscale in patients with peri-meniscal cysts (p = 0.0430).

CONCLUSIONS

Meniscal repairs produced good short-term results when performed in combination to ACL reconstruction. Full or partial healing at MRI was present in 86% of cases. One patient out of three developed peri-meniscal cysts.

Comparison of new and old all-inside suture devices in meniscal cyst formation rates after meniscal repair

PURPOSE

We compared the magnetic resonance imaging (MRI)-confirmed cyst formation rate after meniscal tear repair using a new all-inside suture device (N group) versus the older all-inside suture device (O group).

METHODS

Between October 2008 and July 2017, 94 consecutive menisci of 89 patients were diagnosed with meniscal tears and underwent arthroscopic meniscal repair using the all-inside suture device. Five of these patients were lost to follow-up within 12 months and were excluded from the study. The remaining 89 menisci were followed up for at least 12 months and were included in this retrospective cohort study. Older all-inside suture devices (FasT-Fix, Ultra FasT-Fix) were used until December 2012, while the new all-inside suture device (FasT-Fix 360) was used from January 2013 onwards. Meniscal cysts were detected on T2-weighted fat-suppressed MRI at 12 months postoperatively. Multiple logistic regression analysis was used to identify demographic and clinical factors associated with the use of the new all-inside suture device and cyst formation.

RESULTS

In total, 36 and 53 menisci were included in the N and O groups, respectively. The incidence of meniscal cysts was significantly greater in the O group (14 out of 53, 26.4%) than in the N group (two out of 36, 5.56%) (P = 0.012). Two patients in the O group had symptomatic cysts that required removal. Multivariate logistic analyses showed that the cyst formation risk significantly decreased after using the new all-inside suture device than the older all-inside suture devices (odds ratio = 0.139; P = 0.04).

CONCLUSIONS

The MRI-confirmed cyst formation rate after meniscal tear repair was significantly lower using the new than the older all-inside suture devices, indicating that the use of a low-profile device may decrease the cyst formation rate.

Return-to-Sport Rate and Activity Level Are High Following Arthroscopic All-Inside Meniscal Repair With and Without Concomitant Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To systematically review the literature of return-to-sport outcomes following all-inside meniscus repair and evaluate whether concomitant anterior cruciate ligament reconstruction (ACLR) influenced these outcomes.

METHODS

A systematic review of the MEDLINE, PubMed, Embase, and Cochrane Registry of Systematic Reviews databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers examined all literature pertaining to sport outcomes following all-inside meniscal repair. Studies were included if they had a 12-month minimum follow-up and reported return to sport rate, Tegner, or Knee injury and Osteoarthritis Outcome Score (KOOS) Sport outcomes. Studies with meniscal repair techniques other than the all-inside technique were excluded. Studies were not excluded if they contained patients receiving concomitant ACLR. Study quality was evaluated with the Methodological Index for Nonrandomized Studies.

RESULTS

Nineteen studies comprising 872 patients were included in this investigation. The weighted average patient age was 28.7 (range 14.1-42.1) years, and the weighted average follow-up was 56.0 (range 18.0-155.0) months. The mean Methodological Index for Nonrandomized Studies score was 14.4 ± 3.7. Ten investigations reported both preoperative (range 2.3-3.5) and postoperative (range 4.0-7.3) Tegner outcomes, with scores at final follow-up greater in each of the 10 reporting investigations. KOOS Sport outcomes were examined in 5 investigations, with scores at follow-up ranging from 63.6 to 91. Three studies reported a return to sport rate ranging from 89.6 to 90% at follow-up. Four investigations compared sport-related outcomes between isolated meniscal repair and meniscal repair with concomitant ACLR. Two such studies reported no difference between the 2 cohorts, 1 favored the isolated cohort, and 1 favored the combined cohort.

CONCLUSIONS

This systematic review found a 90% return-to-sport rate and high postoperative activity level following all-inside meniscal repair, as assessed by KOOS Sport and Tegner activity scales. Further, concurrent ACLR did not significantly affect these outcomes.

LEVEL OF EVIDENCE

IV, systematic review of level I-IV studies.

Bucket handle meniscus tears in low-resource settings can be successfully treated with a cost-effective technique

PURPOSE

In regions of the world where resources can limit medical care (limited-resource settings, LRS), most meniscal tears are often treated with meniscectomy. A simple, low-cost option for meniscal repair has been developed. We sought to evaluate patient reported outcomes (PROMs) and clinical failure rates of bucket handle meniscus tears (BHTs) treated with meniscal repair in a LRS.

METHODS

We prospectively enrolled patients over 18 who were treated for BHT with meniscal repair in a LRS. Meniscal repair was primarily accomplished using an outside-in technique. Pre-injury and final follow-up PROMs were recorded. Clinical failure was defined as the need for re-operation or symptoms that prevented the patient from returning to recreational activities or work responsibilities.

RESULTS

Nineteen patients with a mean age of 25.4 years were eligible. Two patients sustained a clinical failure (10.5%). At mean follow-up of 40.6 months, there was significant improvement in all PROMs from baseline. Subgroup analysis revealed no significant difference in the failure group compared to the success group in number of knots used, pre-injury Tegner score, number of devices used, suture type, or technique.

CONCLUSION

Bucket-handle meniscal tears can be repaired using a low-cost technique resulting in satisfactory healing rates and excellent outcomes.

Meniscal Ramp Lesions Repair: An Under-Meniscus All-Inside Suture in Cases of Isolated Meniscotibial Ligament Tears

Anterior cruciate ligament ruptures are commonly associated with ramp lesions of the medial meniscus. These posterior longitudinal peripheral tears induce medial meniscus instability and increase the anteroposterior and rotational knee laxity. We divided ramp lesions in 3 types: meniscocapsular ligament tears, meniscotibial ligament tears, and a combination of both lesions. The conventional surgical technique for treating meniscal ramp lesions is to use a suture hook device through a posteromedial approach, which is a complex process requiring a learning curve and extensive surgical time. An anterior approach often is criticized as underestimating the true incidence of ramp lesion and to offer insufficient operating space. The purpose of this technical note is to describe our arthroscopic repair technique in cases of isolated meniscotibial ligament tears. The suture is performed by an under-meniscus anterior approach with a percutaneous medial collateral ligament release to create an additional opening of the medial compartment. This simple procedure allows for accurate diagnoses of the meniscotibial lesions and enables repair of the lesions with an all-inside suture device without the usual drawbacks of a posteromedial approach.

Biomechanical Comparison of an All-Inside Meniscal Repair Device Construct Versus Pullout Sutures for Arthroscopic Transtibial Repair of Posterior Medial Meniscus Root Tears: A Matched-Pair Cadaveric Study

Background:

Meniscus root repairs are important for restoring knee function after a complete meniscus root tear. Various suturing patterns have been proposed for the root repair. The 2-simple-stitches (TSS) method is currently the preferred technique, as it is simplest to perform and allows the least displacement of the meniscus root.

Purpose:

To compare the biomechanical properties of a posterior medial meniscus transtibial root repair consisting of an all-inside meniscal repair device (AMRD) construct with the TSS pullout suture pattern.

Study Design:

Controlled laboratory study.

Methods:

Ten pairs of cadaveric medial menisci were prepared with 1 of the 2 constructs. The constructs were randomized between pairs. All constructs were subjected to preloading with 2 N for 10 seconds and then cyclic loading from 5 N to 20 N for 1000 cycles at a frequency of 0.5 Hz. Subsequently, the menisci were loaded to failure at a rate of 0.5 mm/s. All loads were applied in-line with the circumferential meniscal fibers near the posterior medial meniscal horn.

Results:

The mean yield load and stiffness were similar for both constructs. The elongation after cyclic loading was greater for the AMRD. The displacement at both yield load and ultimate failure were also higher for the AMRD. The ultimate failure load of the AMRD was also significantly higher. During load to failure, the mode of failure in the AMRD was heterogeneous. All the TSS constructs failed by suture cutout.

Conclusion:

Posterior medial meniscus root repairs using both the AMRD and TSS constructs have elongation under the biomechanically acceptable threshold of 3 mm. The stiffness and yield loads indicate similar mechanical properties of the constructs. However, the significantly higher elongation for the AMRD leaves the TSS method as the preferred option for transtibial repairs. Despite this, the AMRD construct may still represent a viable alternative to the TSS suture pattern, comparable to alternative suture patterns with similar limitations.

Clinical Relevance:

The AMRD construct may represent a viable alternative to the TSS suture pattern.

Examining Techniques for Treatment of Medial Meniscal Ramp Lesions During Anterior Cruciate Ligament Reconstruction: A Systematic Review

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.

Second-look arthroscopic findings and clinical outcomes of meniscal repair with concomitant anterior cruciate ligament reconstruction: comparison of suture and meniscus fixation device

INTRODUCTION

The purpose of this study was to evaluate the healing rate of repaired meniscus and functional outcomes of patients who received all-inside meniscal repair using sutures or devices with concomitant arthroscopic anterior cruciate ligament (ACL) reconstruction.

MATERIALS AND METHODS

Among the patients who have ACL tear and posterior horn tear of medial or lateral meniscus, 61 knees who received all-inside repair using sutures (suture group, n = 28) or meniscal fixation devices (device group, n = 33) with concomitant ACL reconstruction during the period from January 2012 to December 2015, followed by second-look arthroscopy, were retrospectively reviewed. Healing status of the repair site was assessed by second-look arthroscopy. Through the clinical assessment, clinical success (negative medial joint line tenderness, no history of locking or recurrent effusion, and negative McMurray test) rate of the repaired meniscus and functional outcomes (International Knee Documentation Committee subjective score and Lysholm knee score) was evaluated.

RESULTS

In a comparison of healing status of repaired meniscus evaluated by second-look arthroscopy, suture group had 23 cases of complete healing (82.1%), 4 cases of incomplete healing (14.3%), and 1 case of failure (3.6%). Device group had 18 cases of complete healing (54.5%), 4 cases of incomplete healing (24.2%), and 7 cases of failure (21.2%) (p = 0.048). Clinical success rate of the meniscal repair was 89.3% (25 cases) and 81.8% (27 cases) in suture group and device group, respectively (p = 0.488). No significant difference of functional outcomes was observed between the two groups (p > 0.05, both parameters).

CONCLUSIONS

Among the patients who received meniscal repair with concomitant ACL reconstruction, suture group showed better healing status of repaired meniscus based on the second-look arthroscopy than device group. However, no significant between-group difference of clinical success rate and functional outcomes was observed.

An arthroscopic repair technique for meniscal tear using a needle and suture: outside-in transfer all-inside repair

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.

Anterior cruciate ligament reconstruction with concomitant meniscal surgery: a systematic review and meta-analysis of outcomes

PURPOSE

The aim of this review was to compare the clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with either meniscal repair or meniscectomy for concomitant meniscal injury. The primary hypothesis was that short-term clinical outcomes (≤ 2-year follow-up) for ACLR concomitant with either meniscal repair or resection would be similar. The secondary hypothesis was that ACLR with meniscal repair would result in better longer term outcomes compared with meniscal resection.

METHODS

The authors searched two online databases (EMBASE and MEDLINE) from inception until March 2018 for the literature on ACLR and concurrent meniscal surgery. Two reviewers systematically screened studies in duplicate, independently, and based on a priori criteria. Quality assessment was also performed in duplicate. The Knee injury and Osteoarthritis Outcome Score (KOOS) sub-scale scores at 2 years post-operatively were combined in a meta-analysis of proportions using a random-effects model.

RESULTS

Of 2566 initial studies, 25 studies satisfied full-text inclusion criteria. Mean follow-up was 2.09 years, with a total sample of 37,087 subjects including controls. The meta-analysis demonstrated equivocal results at 2 years, except for KOOS symptom scores which favoured meniscal resection over repair. Mean KT-1000 side-to-side difference (SSD) scores were 1.51 ± 0.60 mm for meniscal repair, 1.96 ± 0.36 mm for meniscal resection, and 1.58 ± 0.20 for control patients (isolated ACLR). Medial meniscal repair showed decreased anterior knee joint laxity compared to medial meniscal resection (P < 0.001). Patients with meniscal repair had higher rates of re-operation (13.3% vs 0.8% for meniscal resection, P < 0.001).

CONCLUSION

Patients with ACLR combined with meniscal resection demonstrate better symptoms at 2-year follow-up compared to patients with ACLR combined with meniscal repair. ACLR combined with meniscal repair results in decreased anterior knee joint laxity with evidence of improved patient-reported outcomes in the long term, but also higher re-operation rates.

LEVEL OF EVIDENCE

III.

Prevalence, development, and factors associated with cyst formation after meniscal repair with the all-inside suture device

PURPOSE

To investigate the prevalence of cyst formation after using all-inside meniscal repair device and analysed the risk factors associated with it.

METHODS

Between August 2008 and September 2013, 51 menisci of 46 patients were included in the study, 46 menisci of which had concomitant anterior cruciate ligament (ACL) ruptures and had an ACL reconstruction. Magnetic resonance imaging (MRI) of the knee was performed at 3, 6, 12 and 24 months after meniscal surgery. The MRIs were assessed to detect the development of cysts encasing the suture anchors and to evaluate meniscal healing. Statistical analysis was performed using multiple regression analysis.

RESULTS

Out of the 51 menisci examined, MRI revealed cysts in 15 menisci. Cysts were detected in 3 menisci at 6 months, in 9 menisci at 12 months, and in 3 menisci at 24 months after surgery. Only 3 patients (6.5%) were symptomatic, and cystectomy was performed in 2 of these patients and arthroscopic debridement in the other. Compared with using both the suture device and an inside-out suture repair, using the suture device alone was more likely to be associated with cyst development [odds ratio (OR), 12.04]. The medial meniscus was also significantly more likely to develop a cyst compared with the lateral meniscus (OR, 12.48). There was an increased outcome for the number of device use (P = 0.033). Though it was not statistically significant, the patients with anterior knee laxity (side-to-side difference > 3 mm using a knee arthrometer) were more likely to develop cysts than those without anterior knee laxity (P = 0.06). There were no significant differences between the remaining variables.

CONCLUSIONS

The prevalence of cyst formation around the suture implant was 29%, but most cases were not symptomatic. Significant risk factors for cyst formation included the use of a suture device alone, and a location in the medial meniscus.

LEVEL OF EVIDENCE

III.

Incidence and Risk Factors for Meniscal Cyst After Meniscal Repair

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level Ⅲ, retrospective comparative study.

High short-term return to sports rate despite an ongoing healing process after acute meniscus repair in young athletes

PURPOSE

Acute meniscus repair in young athletes is always a challenge due to the long rehabilitation process and time to return to sport (RTS). The purpose was to investigate signal alterations in short-term follow-up after acute meniscus repair on specific magnetic resonance imaging (MRI) scan sequences. It was hypothesized that (1) MRI signal changes over the first postoperative healing phase and represent a continuous healing process and (2) meniscus healing properties correlates with clinical outcomes and RTS.

METHODS

Young athletes with traumatic meniscus lesion and arthroscopic meniscus repair within 6 weeks and available preoperative MRI were enrolled. Clinical examination, outcome scores (IKDC, KOOS, Lysholm Score, Tegner activity score) and RTS were surveyed preoperatively and 6 and 12 weeks and 6 months after surgery. Radiological follow-up examinations were performed 2, 4, 6, 12 weeks and 6 months after operation using a 3T-MRI. Evaluation was based on ISAKOS meniscus classification system, meniscus healing were classified according to Henning's criteria.

RESULTS

At final follow-up (FU) 30 patients (28 month, 2 week) with a total of 35 meniscus tears (19 medial, 16 lateral) were included. Clinical scores improved significantly after surgery: IKDC Score (preOP: 39.4 ± 18.5, final FU: 78.8 ± 15.3) KOOS (preOP: 45.7 ± 22.1, final FU: 82.7 ± 12.5) and Lysholm Score (preOP: 42.8 ± 23.7, final FU: 84.4 ± 13.8) (p < 0.01). Tegner activity score showed a steadily increase to 4 (range 3-9) at 6 months but did not reached the pre-injury level of 6 (range 3-9). RTS rate was 100% whereof 44.8% reached their pre-injury level. MRI examination revealed a continuous healing process and menisci were classified as 55.9% healed, 35.3% partially healed and 8.8% non-healed at final FU.

CONCLUSION

This study showed that MRI signal alterations of the meniscus steadily occur within the first 6 months postoperatively. MRI reveals an ongoing healing process at final FU that have to be carefully considered when RTS is discussed with high demanding patients. However, young athletes provide good clinical results and RTS rate even though MRI alterations are still present.

LEVEL OF EVIDENCE

Therapeutic study, prospective case series, Level IV.

Top orthopedic sports medicine procedures

Orthopedic sports medicine is a subspecialty of Orthopedics that focuses on managing pathological conditions of the musculoskeletal system arising from sports practice. When dealing with athletes, timing is the most difficult issue to face. Typically, athletes aim to return to play as soon as possible and at the pre-injury level. This means that management should be optimized to combine the need for prompt return to sport and to the biologic healing time of the musculo-skeletal. This poses a great challenge to sport medicine surgeons, who need to follow with attention to the latest scientific evidence to offer their patients the best available treatment options. We briefly review the most commonly performed orthopedic sports medicine procedures, outlining the presently available scientific evidence on their indications and outcomes.

Biomechanical performance of the Actifit® scaffold is significantly improved by selection of irrigation fluid

PURPOSE

Clinical reports on meniscal scaffolds seem promising, albeit relatively paucity exists regarding their biomechanical behavior. The aim of the study is to delineate the impact of differing suture materials and the type as well as the temperature of the irrigation fluid on the pull-out strength of a polyurethane meniscal scaffold (Actifit^®).

MATERIALS AND METHODS

128 specimens were utilized with horizontal sutures and uniaxial load-to-failure testing was performed. We compared two different suture materials-polydioxanone (PDS) and non-absorbable, braided polyester sutures (NABP)-as well as two common irrigation fluids-lactated Ringer's and electrolyte-free, hypotonic Mannitol-Sorbitol. All specimens were further evaluated according to two different temperatures [room temperature (20 °C) and near-core body temperature (37 °C)].

RESULTS

Mean load-to-failure was 53.3 ± 6.5 N. There was no significant difference between the NABP and the PDS group. Ringer group showed a significantly higher load-to-failure compared to Purisole (P = .0002). This was equivalent for both PDS (P = .0008) and NABP sutures (P = .0008). Significantly higher failure loads could be established for the 37° group (P = .041); yet, this difference was neither confirmed for the PDS or in in the NABP subgroup. Only the subgroup using Purisole at 37° showed significantly higher failure loads compared to 20° (P = .017).

CONCLUSIONS

This study underlines the potential to improve pull-out strength during implantation of an Actifit^® scaffold by alteration of the type of irrigation fluid. Lactated Ringer solution provided the highest construct stability in regard to load-to-failure testing and should be considered whenever implantation of a polyurethane meniscal scaffold is conducted.

Arthroscopic medial meniscal repair with or without concurrent anterior cruciate ligament reconstruction: A subgroup analysis

BACKGROUND

There are few large-scale, long-term studies comparing medial meniscal repairs with or without concurrent anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 140 patients who underwent arthroscopic medial meniscal repair were divided into two groups: Group A, meniscus repair only and Group B, meniscus repair with concurrent ACL reconstruction. Clinical assessments in- cluded physical examination findings, Lysholm score, and the International Knee Documentation Committee (IKDC) form. Barret criteria were used for the clinical assessment of healing status. Magnetic resonance imaging (MRI)was obtained to confirmhealing and failure. Subgroups of participants were compared in terms of suture technique, type of tear, and location of tear. KT-2000 arthrometer testing was used for objective evaluation of anterior-posterior knee movement.

RESULTS

Mean follow-up duration was 61 (34-85) months. Clinical outcomes in both groups were significantly improved compared to baseline (P=0.001 vs. P=0.001); however, there was no significant between-group difference in postoperative Lysholm and IKDC scores (P=0.830). The outcomes of three participants (seven percent) in Group A and 11 (11.3%) in Group B were considered as treatment failures (P=0.55). Red-red zone tears had higher scores. Mean postoperative KT2000 arthrometer values of failed participants in Groups A and B were 4.66mm (range, four to six) and 5.2mm (range, two to seven), respectively.

CONCLUSION

Concurrentmedialmeniscus repair and ACL reconstruction did not have clinical superiority over meniscus repair alone. Repairs in the red-red zone appeared to be associated with better outcomes.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Biomechanical performance of a collagen meniscus implant with regard to suture material and irrigation fluid

BACKGROUND

The role of meniscus scaffolds remains controversial as failure rates remain high. The aim of this study was to evaluate the pullout strength of different suture materials used for fixation of the Collagen Meniscus Implant (CMI) regarding different suture materials, and type or temperature of irrigation fluid.

METHODS

One-hundred and twelve specimens were utilized with horizontal sutures and mounted to a dedicated test device. Loads were applied perpendicular to the CMI, until failure. Two differing suture materials - polydioxanone (PDS) and non-absorbable, braided polyester sutures (NABP) - were evaluated. Additionally, two common irrigation fluids - lactated Ringer's and electrolyte-free, hypotonic Mannitol-Sorbitol solution - were evaluated. Specimens were further evaluated according to different temperatures of the irrigation fluid. Half of the constructs were tested at room temperature (20°C) and half were evaluated at near-core body temperature (37°C).

RESULTS

PDS sutures showed a significantly higher load-to-failure compared to NABP sutures (P=0.0008). Regarding the type of irrigation fluid, the electrolyte-free Mannitol-Sorbitol solution showed a significantly higher load-to-failure compared to the overall Ringer group (P b 0.0001). This was equivalent for both the PDS (P=0.015) and for the NABP sutures (P b 0.0001). The temperature of the irrigation fluid did not significantly influence load-to-failure.

CONCLUSIONS

PDS sutures and electrolyte-free Mannitol-Sorbitol irrigation fluid provided the best biomechanical properties regarding load-to-failure testing. This study underlines the potential to improve construct stability for the CMI by alteration of the suture material and the type of irrigation fluid, which should be considered whenever scaffold fixation is conducted.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Complications in posteromedial arthroscopic suture of the medial meniscus

INTRODUCTION

All-inside posteromedial suture for lesions of the posterior horn of the medial meniscus in anterior cruciate ligament (ACL) repair provides effective freshening and good healing.

HYPOTHESIS

The posteromedial portal provides satisfactory healing rates without increasing morbidity or complications rates.

MATERIAL AND METHODS

Intra- and postoperative complications were collected for a consecutive single-center series of 132 patients undergoing posteromedial hook suture of the medial meniscus in ACL repair. Meniscal healing was assessed as the rate of recurrence of symptomatic medial meniscus lesions (Barret criteria) and on revision surgery, if any, in terms of the aspect and extent of the iterative lesion. The severity of any sensory disorder was assessed by questionnaire.

RESULTS

The intraoperative complications rate was 1.5% (2 saphenous vein punctures). At a mean 31months (range, 28-35months), there was no loss to follow-up. Twelve patients (9%) showed symptomatic recurrence of the medial meniscus lesion, requiring 10 repeat surgeries. In 6 cases (4.5%), the iterative lesion involved a smaller, more central part of the meniscus anterior to the sutures, of "postage-stamp" effect, possibly implicating the suture hook and/or non-absorbable sutures. There were no cases of infection or fistula. Postoperative hematoma occurred in 7% of patients. In total, 1.8% reported dysesthesia areas equal to or greater than the size of a credit card (45cm²).

DISCUSSION

Some retears, or "partial failures", may implicate a new lesion caused by the suture hook and possibly prolonged by non-resorbable sutures. Hematoma and sensory disorder rates were comparable to those reported in isolated ACL repair without posteromedial portal.

CONCLUSION

The present results show that posteromedial arthroscopic hook suture in posterior medial meniscus tear provides good healing rates without increased morbidity due to the supplementary portal.

LEVEL OF EVIDENCE

IV.

Results with all-inside meniscal suture in pediatrics

INTRODUCTION

Incidence of meniscal lesions is increasing in the pediatric population. Given the harmful impact of meniscectomy, meniscal repair is attempted whenever possible. The present study sought to assess the efficacy of FasT-Fix (Smith and Nephew) all-inside arthroscopic meniscal repair devices in childhood meniscal lesions. The study hypothesis was that functional results would be equivalent to those of other suture techniques.

MATERIAL AND METHODS

Nineteen patients were assessed following arthroscopic meniscal repair, at a mean 6 years (range: 3-9 years). Mean age was 14.8 years. There was associated ACL tear in 31% of cases. Functional assessment used Lysholm, subjective IKDC, Tegner activity level and KOOS scores. Anatomic assessment of healing used MRI, arthroscopy or CT-arthrography.

RESULTS

At last follow-up, the meniscal survival rate was 89.5% (n=17/19). Functional results were good: Lysholm: 95.7/100; subjective IKDC: 90.7/100; Tegner: 7.64. Imaging found systematic healing.

DISCUSSION

All-inside arthroscopic meniscal suture is increasingly used in adults, and can also be implemented in children or adolescents in pediatrics. FasT-Fix (Smith and Nephew) implants, although not always easy to use, ensure a perfectly functional knee and conserve long-term meniscal chondroprotection with a low risk of complications.

LEVEL OF EVIDENCE

IV, retrospective study.

A Technique of Improved Medial Meniscus Visualization by Anterior Cruciate Ligament Graft Placement in Chronic Anterior Cruciate Deficient Knees

It is customary to perform medial meniscus repair before anterior cruciate ligament (ACL) graft placement when undertaken as a combined procedure. However, in chronic ACL-deficient knees, intraoperative anterior tibiofemoral translation can cause the medial meniscus repair to be more technically challenging. Intraoperative anterior tibiofemoral translation can both reduce the visualization of the medial meniscus and make its reduction unstable. An operative sequence alteration of ACL graft placement and tensioning before medial meniscal repair improves medial meniscus visualization in chronically ACL-deficient knees by using the ACL graft's ability to prevent anterior tibiofemoral translation. The technique sequence is as follows: (a) the medial meniscus is reduced, (b) ACL reconstruction is undertaken using a hamstring graft without final tibia fixation,