Subjective Knee Function and Risk of Failure Are Equivalent for Men and Women at 5 Years After Meniscus Repair

Rates of subsequent surgeries after meniscus repair with and without concurrent anterior cruciate ligament reconstruction

OBJECTIVES

The purpose of this study was to compare the rates of secondary knee surgery for patients undergoing meniscus repair with or without concurrent anterior cruciate ligament reconstruction (ACLr).

METHODS

Utilizing a large national database, patients with meniscal repair with or without concurrent arthroscopic ACLr were identified. The two cohorts were then queried for secondary surgical procedures of the knee within the following 2 years. Frequency, age distribution, rates of secondary surgery, and type of secondary procedures performed were compared.

RESULTS

In total, 1,585 patients were identified: meniscus repair with ACLr was performed for 1,006 (63.5%) and isolated meniscal repair was performed for 579 (36.5%). Minimum of two year follow up was present for 487 (30.7% of the overall study population). Secondary surgery rates were not significantly different between meniscus repair with concurrent ACLr and isolated meniscus repairs with an overall mean follow up of 13 years (1.5-24 years) (10.6% vs. 13.6%, p = 0.126). For the 2 year follow up cohort, secondary surgery rates were not significantly different (19.3% vs. 25.6%, p = 0.1098). There were no differences in survivorship patterns between the two procedures, both in the larger cohort (p = 0.2016), and the cohort with minimum 2-year follow-up (p = 0.0586).

CONCLUSION

The current study assessed secondary surgery rates in patients undergoing meniscus repair with or without concurrent ACLr in a large patient database. Based on this data, no significant difference in rates of secondary knee surgery was identified.

Increased Time to Surgery After Anterior Cruciate Ligament Tear in Female Patients Results in Greater Risk of Medial Meniscus Tear: A Study of 489 Female Patients

PURPOSE

This study assessed the incidence of meniscal tears in anterior cruciate ligament (ACL)-deficient knees, considering the time between injury and reconstruction in a large sample of female patients. Furthermore, we evaluated whether the rate of meniscal repair or meniscectomy was affected by age and body mass index (BMI).

METHODS

The medical records of 489 patients who underwent ACL-reconstructive surgery between January 2011 and April 2021 were analyzed to collect data on the prevalence of meniscal tears, surgical timing, patient age, and BMI. Logistic regression was performed to estimate the association between the prevalence of meniscal tears and the independent variables of surgical timing, age, and BMI.

RESULTS

Between 24 and 60 months after their injury, female patients showed a statistically significant increase in the presence of associated meniscal lesions when compared with ACL reconstruction performed earlier (odds ratio [OR] of 3.11; 95% 1.06-9.10 confidence interval [CI]), especially for medial meniscal tears, with an OR of 1.94 (95% CI 1.23-3.05, P = .004) between 12 and 24 months. There is a statistically significant difference after 12 months in the rate of meniscal suturing for medial meniscus tears (OR 3.30; CI 1.37-7.91 P = .007). Increasing age was associated with a greater prevalence of meniscal tears up to 30-50 years, but there was no clear association between BMI and associated lesions other than a greater rate of meniscectomies.

CONCLUSIONS

In female patients who experienced an ACL injury, a delay in surgery greater than 12 months is associated with a gradual increase in the risk of nonrepairable medial meniscal tear; this risk becomes statistically significant after 24 months. A high BMI does not seem to have relevance in the onset of associated lesions in women but results in a greater rate of meniscectomies compared with meniscal sutures, whereas age between 30 and 50 years is associated with a greater risk of associated injuries.

LEVEL OF EVIDENCE

III, retrospective comparative prognostic trial.

Predictors of Disparities in Patient-Reported Outcomes before and after Arthroscopic Meniscectomy

The purpose of this study is to identify predictors of disparities in patient-reported outcome measures (PROMs) before and after arthroscopic meniscectomy. Knee injury and Osteoarthritis Outcome Score (KOOS) was used in this study. All patients who underwent single-knee arthroscopic meniscectomy from January 2012 to March 2018 performed by a single surgeon at an academic safety-net hospital were identified. We excluded patients who had undergone ipsilateral previous knee surgery, bilateral meniscectomy, or concomitant ligament, cartilage, or osteotomy procedures, and those with severe radiographic osteoarthritis in the operated knee, missing preoperative data, or military insurance. Data abstracted from medical records included demographics (age, sex, race, insurance type), clinical characteristics (body mass index, Charlson comorbidity index, and Kellgren-Lawrence [KL] grade), procedure codes, and KOOS assessed before and 90 days after surgery. Multivariable analyses investigated the associations between patient characteristics and the KOOS Pain, other Symptoms, and Function in activities of daily living (ADL) subscales. Among 251 eligible patients, most were female (65.5%), half were of nonwhite race (50.2%), and almost one third were insured by Medicaid (28.6%). Medicaid and black race were statistically significant (p < 0.05) predictors of worse preoperative values for all three KOOS subscales. Medicaid insurance also predicted a lower likelihood of successful surgery, defined as meeting the 10-point minimal clinically important difference, for the KOOS symptoms (p < 0.05) and KOOS ADL (p < 0.05) subscales. Compared with patients without definitive evidence of radiographic osteoarthrosis (KL grade 1), those with moderate radiographic osteoarthritis (KL grade 3) were less likely to have a successful surgical outcome (p < 0.05 for all subscales). Worse preoperative KOOS values predicted worse postoperative KOOS values (p < 0.001 for all subscales) and a lower likelihood of surgical success (p < 0.01 for all subscales). Insurance-based disparities in access to orthopaedic care for meniscus tears may explain worse preoperative PROMs and lower success rates of meniscectomy among Medicaid patients. Patients with meniscus tears and radiological and/or magnetic resonance imaging evidence of osteoarthritis should be carefully evaluated to determine the appropriateness of arthroscopic meniscectomy.

The Biomechanical Performance of the Latest All-Inside Meniscal Repair Devices

PURPOSE

To evaluate the biomechanical characteristics of recently introduced meniscal repair devices with a hand-tied, inside-out meniscal suture in a human meniscus model.

METHODS

In detached adult human menisci, vertical longitudinal cuts were created 3 mm from the synovial-meniscal junction, simulating a bucket-handle meniscal tear. Each cut was repaired using a single device. Group 1 received a vertical mattress suture of No. 2-0 OrthoCord; group 2, TrueSpan device with PEEK (polyether ether ketone) anchors containing No. 2-0 OrthoCord suture; group 3, TrueSpan device with biodegradable poly-lactide-co-glycolide (PLGA) anchors containing No. 2-0 OrthoCord suture; group 4, Meniscal Cinch II device; group 5, AIR meniscal repair device; and group 6, FasT-Fix 360 device. All samples were preloaded at 5 N and cycled 200 times between 5 and 20 N. The specimens that survived cyclic loading were destructively tested at 12.5 mm/s. Endpoints included maximum load, displacement, stiffness, and failure mode.

RESULTS

The mean failure loads were as follows: 95.8 N for OrthoCord suture, 87.1 N for TrueSpan with PEEK, 84.6 N for TrueSpan with PLGA, 48.6 N for Meniscal Cinch II, 72.3 N for AIR, and 68.1 N for FasT-Fix 360. Repairs performed with OrthoCord suture (P = .002) and both TrueSpan devices (P < .03) but not the FasT-Fix 360 device or AIR device were statistically significantly stronger than Meniscal Cinch II repairs. Mean cyclic displacement measured 1.1 mm for OrthoCord, 1.5 mm for TrueSpan with PEEK, 1.5 mm for TrueSpan with PLGA, 2.1 mm for Meniscal Cinch II, 1.1 mm for AIR, and 1.4 mm for FasT-Fix 360. The Meniscal Cinch II device showed more displacement than all other devices (P < .05). The FasT-Fix 360, AIR, and Meniscal Cinch II devices failed by anchor pullout from the peripheral meniscus. OrthoCord and both TrueSpan devices failed by suture pulling through the bucket-handle tissue.

CONCLUSIONS

OrthoCord suture is stronger than the AIR, FasT-Fix 360, and Meniscal Cinch II devices. The TrueSpan device with PEEK and TrueSpan device with PLGA are stronger than the Meniscal Cinch II device. The Meniscal Cinch II device failed during cyclic loading with greater cyclic displacement than the AIR device, FasT-Fix 360 device, OrthoCord, and TrueSpan device with PEEK. The Meniscal Cinch II, AIR, and FasT-Fix 360 devices failed by anchor pullout, whereas OrthoCord and both TrueSpan devices failed by suture pull-through.

CLINICAL RELEVANCE

Some newly introduced all-inside meniscal repair devices show inferior failure strength compared with earlier versions that might adversely impact clinical outcomes.

The menisci and articular cartilage: a life-long fascination

The menisci and articular cartilage of the knee have a close embryological, anatomical and functional relationship, which explains why often a pathology of one also affects the other.

Traumatic meniscus tears should be repaired, when possible, to protect the articular cartilage.

Traumatic articular cartilage lesions can be treated with success using biological treatment options such as microfracture or microdrilling, autologous chondrocyte transplantation (ACT), or osteochondral transplantation (OCT) depending on the depth and area of the lesion.

Degenerative cartilage and meniscus lesions often occur together, and osteoarthritis is already present or impending. Most degenerative meniscus lesions should be treated first conservatively and, after failed conservative treatment, should undergo arthroscopic partial meniscus resection. Degenerative cartilage lesions should also be treated conservatively initially and then surgically; thereby treating the cartilage defect itself and also maintaining the axis of the leg if necessary.

Tears of the meniscus roots are devastating injuries to the knee and should be repaired e.g. by transtibial re-fixation.

The clinical role of ‘ramp’ lesions of the meniscus is still under investigation.

Cite this article: EFORT Open Rev 2020;5:652-662. DOI: 10.1302/2058-5241.5.200016

Editorial Commentary: Women and Men Fare Equally Well After Meniscal Repair

Knee meniscal repair has a success rate of approximately 80% in both men and women, and meniscal repair is a critical procedure for maintaining long-term knee health.