Return-to-Play and Rehabilitation Protocols Following Isolated Meniscal Repair-A Systematic Review

Meniscus Tears in Elite Athletes: Treatment Considerations, Clinical Outcomes, and Return to Play

PURPOSE OF REVIEW

Management of meniscal injuries in the elite athlete is a difficult problem secondary to the high demands of athletic competition, the need for a timely return to sport, and the desire to maximize performance over time. The purpose of this review is to provide an up-to-date summary on the current literature and trends regarding the management of meniscus injuries with a special consideration for elite athletes.

RECENT FINDINGS

Historically, partial meniscectomy has been the primary treatment option for meniscus injuries. However, in recent years there has been an increased emphasis on meniscus preservation due to the increased risk of cartilage degeneration over time. Moreover, while partial meniscectomy still provides a quicker return to sport (RTS), recent literature has demonstrated similar rates of RTS and return to pre-injury levels between partial meniscectomy and meniscus repair. In the setting of symptomatic meniscal deficiency, meniscus allograft transplantation has become an increasingly utilized salvage procedure with promising yet variable outcomes on the ability to withstand elite competition. Currently, there is no uniform approach to treating meniscal injuries in elite athletes. Therefore, an individualized approach is required with consideration of the meniscus tear type, location, concomitant injuries, athlete expectations, rehabilitation timeline, and desire to prevent or delay knee osteoarthritis. In athletes with anatomically repairable tears, meniscus repair should be performed given the ability to restore native anatomy, provide high rates of RTS, and mitigate long-term chondral damage. However, partial meniscectomy can be indicated for unrepairable tears.

Rehabilitation protocol after suturing the medial meniscus of a stable knee, a retrospective series of the Francophone Arthroscopy Society

INTRODUCTION

Surgical meniscal lesions are common and 80% of cases involve the medial meniscus of a stable knee. There is a lack of consensus regarding postoperative rehabilitation protocols and a wide variation between restrictive and accelerated rehabilitation protocols exists. The main objective of this study was to report the functional results and the failure rate of the various rehabilitation protocols of the retrospective series of the French Society of Arthroscopy (SFA) after suturing the medial meniscus of a stable knee, considering whether the tear is stable or unstable.

HYPOTHESIS

Our hypothesis was that accelerated rehabilitation was not associated with an increased risk of failure.

MATERIALS AND METHODS

This retrospective, multicenter study was conducted across 10 centers (6 private hospitals and 4 public hospitals) including all patients tested for a medial meniscus suture in a stable knee between January 1, 2005 and November 31, 2017 for a minimum follow-up of 5years. Demographic, imaging, suturing, rehabilitation protocol, and functional TEGNER and KOOS scores were collected. Failure was defined as performing a secondary meniscectomy.

RESULTS

Three hundred and sixty-seven patients were analyzed with an average follow-up of 82months. Immediate weight bearing was allowed in 85% of cases, the wearing of a brace was present in almost 74% of cases and flexion was limited in 97% of cases. Inter-group comparisons found a higher suture failure rate in the group with immediate weight bearing (35.6% vs. 20%, p=0.011) and in the group with a brace (36.9% vs. 22.4%, p<0.001). There was no difference in the 90° flexion group. The TEGNER score was higher in the non-weight bearing group (6.5 vs. 5.4, p=0.028) and the KOOS QOL score was higher in the group without a brace (82.2 vs. 66.8, p=0.025). According to a multivariate analysis, immediate weight bearing (OR=3.6, [1.62; 7.98], p=0.0016) and wearing a brace (OR=2.83, [1.54; 5.02], p<0.001) were associated with a higher failure rate. In the group of stable lesions, the use of a brace (OR=3.73, [1.62; 8.56], p=0.0019) was associated with a higher failure rate.

CONCLUSION

No consensus regarding rehabilitation protocols has been established to date and the results of this retrospective series of the SFA affirm the great variability of practices at a national level. Although accelerated rehabilitation protocols are presently favored, the resumption of immediate full weight bearing should be considered with caution, being associated with a higher risk of failure in this series. Deferring weight bearing for 1 month can be considered in the event of a large tear or in the event of damage to the circumferential fibers. Wearing a brace does not seem to have any influence, while limited flexion achieved a consensus.

LEVEL OF EVIDENCE

IV, retrospective study.

Return-to-sport criteria after isolated meniscus suture: Scoping review of the literature

BACKGROUND

Follow-up care including rehabilitation therapy after isolated meniscal repair remains to be standardized. Thus, no standard criteria are available for the return-to-running (RTR) or return-to-sport (RTS). The objective of this study was to identify criteria for RTR and RTS after isolated meniscal repair, based on a review of the literature.

HYPOTHESIS

Return-to-sport criteria after isolated meniscal repair have been published.

METHODS

We performed a scoping review of the literature using the methodology developed by Arksey and O'Malley. The terms "menisc*" and "repair" and "return-to-sport" or "return to play" or "return to run" or "rehabilitation" were used to search the PubMed database on 1st March 2021. All relevant studies were included. All RTR and RTS criteria were identified, analyzed, and classified.

RESULTS

We included 20 studies. Mean RTR and RTS times were 12.9 and 20 weeks, respectively. Clinical, strength, and performance criteria were identified. The clinical criteria included full range-of-motion recovery with no pain, quadriceps wasting, or joint effusion. Strength criteria were a quadriceps and hamstring deficit, no greater than 30% and 15% for RTR and RTS, respectively, compared to the normal side. Performance criteria were successful completion of proprioception, balance, and neuromuscular tests. RTS rates ranged from 80.4% to 100%.

CONCLUSION

Patients must meet clinical, strength, and performance criteria before resuming running and sports. The level of evidence is low, due to the heterogeneity and generally arbitrary choice of criteria. Further large-scale studies are therefore needed to validate and standardize RTR and RTS criteria.

LEVEL OF EVIDENCE

IV.

Outside-in repair technique is effective in traumatic tears of the meniscus in active adults: a systematic review

PURPOSE

Meniscal injuries are common. Outside-in meniscal repair is one of the techniques advocated for the management of traumatic meniscal tears. This systematic review investigated the outcomes of the outside-in repair technique for the management of traumatic tears of the menisci. The outcomes of interest were to investigate whether PROMs improved and to evaluate the rate of complications.

METHODS

Following the 2020 PRISMA statement, in May 2023, PubMed, Web of Science, Google Scholar, and Embase were accessed with no time constraints. All the clinical investigations which reported data on meniscal repair using the outside-in technique were considered for inclusion. Only studies which reported data on acute traumatic meniscal tears in adults were considered. Only studies which reported a minimum of 24 months of follow-up were eligible.

RESULTS

Data from 458 patients were extracted. 34% (155 of 458) were women. 65% (297 of 458) of tears involved the medial meniscus. The mean operative time was 52.9 ± 13.6 min. Patients returned to their normal activities at 4.8 ± 0.8 months. At a mean of 67-month follow-up, all PROMs of interest improved: Tegner scale (P = 0.003), Lysholm score (P < 0.0001), International Knee Documentation Committee (P < 0.0001). 5.9% (27 of 458) of repairs were considered failures. Four of 186 (2.2%) patients experienced a re-injury, and 5 of 458 (1.1%) patients required re-operation.

CONCLUSION

Meniscal repair using the outside-in technique can be effectively performed to improve the quality of life and the activity level of patients with acute meniscal tears.

LEVEL OF EVIDENCE

Level IV.

In elite athletes with meniscal injuries, always repair the lateral, think about the medial! A systematic review

PURPOSE

This study aimed to evaluate and compare the time required to return to sports (RTS) after surgery, the rate of revision surgery and the time required for RTS after revision surgery in elite athletes undergoing meniscal repair or partial meniscectomy, particularly analysing the difference between medial and lateral menisci. It was hypothesised that both procedures would entail similar, high rates of RTS, with the lateral meniscus exhibiting higher potential healing postprocedure compared to the medial meniscus.

METHODS

A systematic review was conducted based on the PRISMA guidelines. Quality assessment of the systematic review was performed using the AMSTAR-2 checklist. The following search terms were browsed in the title, abstract and keyword fields: 'meniscus' or 'meniscal' AND 'tear,' 'injury' or 'lesion' AND 'professional,' 'elite' or 'high-level' AND 'athletes,' 'sports,' 'sportsman,' 'soccer,' 'basketball,' 'football' or 'handball'. The resulting measures extracted from the studies were the rate of RTS, level of RTS, complications, revision surgery and subsequent RTS, Tegner, International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS).

RESULTS

In this study, the cohort consisted of 421 patients [415 (98.6%) men and 6 (1.4%) women] with a mean age of 23.0 ± 3.0 years. All patients were elite athletes in wrestling, baseball, soccer, rugby or handball. While 327 (77.7%) patients received partial meniscectomy at a mean age of 23.3 ± 2.6 years, 94 (22.3%) patients received meniscal repair at a mean age of 22.1 ± 4.0 years. After partial meniscectomy, 277 patients (84.7%) returned to their competitive sports activity and 256 (78.3%) returned to their pre-injury activity levels. A total of 12 (3.7%) patients required revision surgery because of persistent pain [5 (1.5%) patients], chondrolysis [2 (0.7%) patients] or both chondrolysis and lateral instability [5 (1.5%) patients]. Ten (83.3%) of the twelve patients had involvement of the lateral meniscus, whereas the location of injury was not specified in the remaining two patients. After revision surgery, all patients (100%) resumed sports activity. However, after meniscal repair, 80 (85.1%) athletes returned to their competitive sports activity and 71 (75.5%) returned to their pre-injury activity levels. A total of 16 (17.0%) patients required partial meniscectomy in cases of persistent pain or suture failure. Of these, 4 (25%) patients involved lateral and medial menisci each and 8 (50%) patients were not specified. After revision surgery, more than 80.0% of the patients (13) resumed sports activity.

CONCLUSIONS

In elite athletes with isolated meniscal injury, partial meniscectomy and meniscal suture exhibited similar rates of RTS and return to pre-injury levels. Nonetheless, athletes required more time for RTS after meniscal repair and exhibited an increased rate of revision surgery associated with a reduced rate of RTS after the subsequent surgery. For lateral meniscus tears, meniscectomy was associated with a high rate of revision surgery and risk of chondrolysis, whereas partial medial meniscectomy allowed for rapid RTS but with the potential risk of developing knee osteoarthritis over the years. The findings of this systematic review suggested a suture on the lateral meniscus in elite athletes because of the high healing potential after the procedure, the reduced risk of developing chondrolysis and the high risk of revision surgery after partial meniscectomy. Furthermore, it is important to evaluate several factors while dealing with the medial meniscus. If rapid RTS activity is needed, a hyperselective meniscectomy is recommended; otherwise, a meniscal suture is recommended to avoid accelerated osteoarthritis.

LEVEL OF EVIDENCE

Level IV.

STUDY REGISTRATION

PROSPERO-CRD42022351979 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=351979 ).

Rehabilitation and return to sports after isolated meniscal repairs: a new evidence-based protocol

PURPOSE

Despite many protocols that have been proposed, there's no consensus in the literature regarding the optimal rehabilitation program and return to sports (RTS) protocol following isolated meniscal repair. The aim of this current concept review is to look at the evidence of rehabilitation and RTS program after isolated meniscal repair, focusing on general and specific protocols per type of injury trying to give some guidelines based on the current state of knowledge.

METHODS

A narrative literature review was performed searching PubMed database to identify relevant articles from January 1985 to October 2021 on rehabilitation and RTS after isolated meniscal repair. Randomized controlled trials (RCTs), prospective and retrospective cohort studies, case series, systematic reviews, meta-analyses, cadaveric studies and basic science studies were included.

RESULTS

When the hoop tensile stress effect is preserved, an accelerated rehabilitation program may be suggested. Hence, partial weight bearing (20 kg) in association with ROM limited to 90° is allowed for the first four weeks, followed by weight bearing as tolerated. In contrast, when circumferential hoop fibers are disrupted, a restricted rehabilitation protocol may be recommended. In this scenario no weight bearing is allowed for the first six weeks after the surgery and range of motion (ROM) is limited to 90°.

CONCLUSION

Biomechanical evidence suggests that tailoring an individualized protocol based upon the type of lesion and meniscus stability is reasonable.

LEVEL OF EVIDENCE

Level V.