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

Meniscal Repair Outcome in 3829 Patients With a Minimum Follow-up From 2 Years Up to 5 Years: A Meta-analysis on the Overall Failure Rate and Factors Influencing Failure

BACKGROUND

The importance of meniscal repair is widely accepted because of the association of loss of meniscal tissue with the development of early-onset knee arthritis. Many factors influencing the results of meniscal repair have been reported, but results remain controversial.

PURPOSE

This meta-analysis determines the pooled meniscal repair failure rate of studies with a minimum follow-up of 2 years up to 5 years, with a mean follow-up of 43 months. Moreover, selected failure-influencing factors are analyzed.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

PubMed and Scopus were searched for studies published between January 2000 and November 2021 reporting on meniscal repair outcome with a minimum follow-up of 24 months. The overall pooled failure rate and pooled failure rates for possible predictors were calculated. Random-effect models were used to pool failure rates, and effect estimates in the form of odds ratios with 95% CIs were established.

RESULTS

The initial literature search identified 6519 studies. A total of 51 studies met the inclusion criteria. In total, 3931 menisci were included with an overall failure rate of 14.8%. Subgroup analysis revealed a significantly lower failure rate for meniscal repair with concomitant anterior cruciate ligament (ACL) reconstruction compared with knees without any reported injury to the ACL (8.5% vs 14%; P = .043). The pooled failure rate for lateral meniscal repair was significantly lower than that for medial meniscal repair (6.1% vs 10.8%; P = .031). Pooled failure rates of all-inside and inside-out repair were not significantly different (11.9% vs 10.6%; P > .05).

CONCLUSION

This meta-analysis on close to 4000 patients demonstrates an overall meniscal repair failure rate of 14.8% at a minimum follow-up from 2 years up to 5 years. Meniscal repair remains a procedure with a high failure rate, especially within the first 2 postoperative years. This review and meta-analysis also identified clinically relevant factors associated with favorable outcomes such as concomitant ACL reconstruction or repair of the lateral meniscus. All-inside meniscal repair with the latest-generation devices yields failure rates of <10%. The failure mechanism and the time of failure is poorly documented; further studies are needed for a better understanding of the retear mechanism.

All-Cause Failure Rates Increase With Time Following Meniscal Repair Despite Favorable Outcomes: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this review is to perform a meta-analysis of studies reporting meniscus repair outcomes. Pooled analyses of such studies will provide an accurate estimate of the outcomes that can be expected following meniscal repair at various postoperative time points.

METHODS

A meta-analysis of meniscal repair failure (defined as persistent symptoms, lack of healing on magnetic resonance imaging or revision surgery) and other clinical outcomes was performed following meniscal repair. Patients included had traumatic, nondegenerative meniscal tears, were skeletally mature, and had specific time-points after surgery. Repairs included were performed either in isolation, or with concomitant ACL reconstruction. Because of the inherent heterogeneity of single-arm meta-analyses, pooled analyses were performed using a random-effects model.

RESULTS

Rates of all-cause meniscal repair failure was pooled to be 12% at 0-1 years (95% CI: .09-.16), 15% at 2-3 years (95% CI: .11-.20), and 19% at 4-6 years (95% CI: .13-.24). Sensitivity analysis for studies performing meniscal repair entirely on patients with concomitant ACL reconstruction (ACLR) showed comparable rates of failure at similar time intervals. Development of osteoarthritis, in patients with knees previously free from articular pathologies, was 4% at 2-3 years (95% CI: .02-.07), and 10% at 4-6 years (95% CI: .03-.25).

CONCLUSION

Meniscus repair for traumatic injuries have an all-cause failure rate that increases from 12% to 19% through a time period ranging from 1-6 years following surgery. The failure rates were comparable for patients with meniscal repairs performed with concomitant ACLRs.

LEVEL OF EVIDENCE

IV; Systematic Review of Level II-IV Studies.

Mid-term evaluation of clinical and functional outcomes after arthroscopic medial longitudinal and bucket-handle meniscus repair

OBJECTIVES

The aim of this study was to evaluate clinical and functional outcomes following the arthroscopic medial meniscal repair.

PATIENTS AND METHODS

A total of 50 patients (42 males, 8 females; mean age: 32.9±7.6 years; range, 17 to 48 years) who underwent arthroscopic repair for longitudinal and bucket-handle medial meniscal tears between March 2005 and October 2011 were retrospectively evaluated. The patients were divided into two groups as those having a longitudinal tear (patient group, n=31) and having a bucket-handle tear (control group, n=19). Preoperative and final follow-up functional outcomes were evaluated using the Lysholm Knee Score (LKS), International Knee Documentation Committee (IKDC) score, Tegner Activity Scale (TAS) score, and Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

The mean follow-up was 61.7±22.8 (range, 36 to 110) months. The mean preoperative LKS, IKDC score, TAS, and KOOS scores were significantly improved at the final postoperative follow-up (p<0.05). There was no significant difference in functional outcome scores between longitudinal and bucket-handle repairs (p>0.05), and isolated repairs and concomitant meniscal repair and anterior cruciate ligament reconstruction (p>0.05).

CONCLUSION

Arthroscopic meniscal repair provides similar mid-term functional and clinical outcomes for longitudinal and bucket-handle medial meniscal tears. Concomitant meniscal repair does not seem to affect meniscal healing.

The modified cross-suture technique for unilateral pulled-out anchor during all-inside meniscal repair

Background

Meniscal repair has received increasing attention, but for inexperienced doctors, unilateral suture anchor pulling out may occur during all-inside meniscal repair, and the treatment outcome may be affected. When the errors happened intraoperatively, how to minimize the loss under guaranteeing of treatment effectiveness is a topic worth studying.

Purpose

To explore the practicability and effectiveness of the modified cross-suture method for arthroscopic remediation of unilateral suture anchor pulling out of an all-inside meniscal repair system.

Methods

From May 2014 to May 2017, 28 patients diagnosed with injuries of the meniscus and anterior cruciate ligaments (ACL) from the First Department of Orthopaedics of the Second Affiliated Hospital of Xi’an Jiaotong University were enrolled in the study as the observation group, including 18 males and 10 females with an average age of 25.5 ± 2.3 years (range 18–42 years). All patients underwent ACL reconstruction concurrently. All meniscus injuries were repaired with an all-inside meniscal repair technique, and 1–3 needles of unilateral suture anchor pulling out occurred intraoperatively. The modified cross-suture method was used to remedy the error of anchor pulling out and to eventually complete an effective repair. Another 30 patients who underwent ACL reconstruction and all-inside meniscal concurrently without unilateral suture anchor pulling out, including 20 males and 10 females with an average age of 26.3 ± 1.9 years (range 19–45 years), were enrolled as the control group. During postoperative follow-up, range of motion, Lachman test and pivot shift test were performed during the physical examination. The clinical healing of the meniscus was evaluated according to the Barrett standard. The meniscus healing status was also confirmed with magnetic resonance imaging (MRI). The function of the knee joint was evaluated according to the IKDC, Lysholm and Tegner scores.

Results

Twenty-five patients in the observation group and 28 patients in the control group completed the follow-up, with an average follow-up of 18.4 ± 5.2 months. All operations were performed by the same surgeon. At the follow-up 1 year after the operation, the average knee ROM of the two groups was 125.2 ± 4.3 degrees and 124.7 ± 3.8 degrees, the clinical healing rate of the meniscus of the two groups was 92.0% (23/25) and 92.9% (26/28), the MRI healing rate of the menniscus of the two groups was 72.0% (18/25) and 71.4% (20/28), and the IKDC, Lysholm and Tegner scores of the two groups were 90.52 ± 2.8, 89.17 ± 3.1, and 6.81 ± 1.7 and 91.42 ± 1.9, 90.32 ± 3.4, and 7.02 ± 1.4, respectively. The differences were not statistically significant (P > 0.05).

Conclusions

The modified cross-suture method is practicable and effective for arthroscopic remediation of unilateral suture anchor pulling out in an all-inside meniscal repair system.

Clinical and radiological outcomes following isolated vertical medial meniscal tear repair in patients over 40 years old

PURPOSE

To evaluate the short-term clinical and radiological outcomes with degenerative changes in patients over 40 years old following isolated vertical medial meniscal tear repair.

METHODS

Between 2007 and 2015, 438 patients underwent arthroscopic meniscal repair. Thirty-three patients aged over 40 years with isolated vertical medial meniscal repair (23 males and 10 females, mean age 46.1 ± 7.0; range 40-67) were included in the study. Preoperative and postoperative physical examination findings, Lysholm knee score, the International Knee Documentation Committee score, magnetic resonance imaging findings, and Kellgren-Lawrence osteoarthritis stage were evaluated.

RESULTS

The mean follow-up period was 31.1 months ± 20.1 (range 12-100 months). There was statistically significant improvement in functional scores ( p < 0.05) and physical examination findings. In 22 patients (66.7%), improvement in the clinical and radiological results was detected ( p < 0.05). However, no correlation was found between clinical and radiological outcomes. There was also no significant change in osteoarthritis stages at the last follow-up visit. No significant difference was found between smokers and nonsmokers regarding clinical outcomes.

CONCLUSION

Successful clinical and radiological outcomes can be obtained following isolated vertical medial meniscal tear repair in patients older than 40 years. Age is not the sole criterion for the success of meniscal repair; rather, the functional capacity of the patient, the location of the tear, the grade of knee joint arthritis, and the quality of the meniscal tissue should be taken into consideration.

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.

Repair Augmentation of Unstable, Complete Vertical Meniscal Tears With Bone Marrow Venting Procedure: A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study

PURPOSE

To compare the effectiveness and safety of meniscal repair in 2 groups of patients: meniscal repair with biological augmentation using a bone marrow venting procedure (BMVP) of the intercondylar notch versus meniscal repair only.

METHODS

This single-center, prospective, randomized, double-blind, placebo-controlled, parallel-arm study included 40 patients (21 menisci in control, 23 in BMVP group) with complete vertical meniscus tears. Patients underwent all-inside and outside-in meniscal repair and a concomitant BMVP of the intercondylar notch or meniscal repair alone during an index arthroscopy. The primary endpoint was the rate of meniscus healing in the 2 groups assessed during a second-look arthroscopy (at week 35). The secondary endpoints were changes in the International Knee Documentation Committee score, Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and visual analog scale in the 2 groups at 30 months.

RESULTS

After 36 weeks, the meniscus healing rate was significantly higher in the BMVP-treated group than in the control group (100% vs. 76%, P = .0035). Functional outcomes were significantly better 30 months after treatment than at baseline in both groups. The International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and visual analog scale scores were significantly better in the BMVP-treated group than in the control group. No adverse events were reported during the study period.

CONCLUSIONS

Our blinded, prospective, randomized, controlled trial on the role of BMVP augmentation in meniscus repair, indicates that BMVP augmentation results in a significant improvement in the rate of meniscus healing (100% vs. 76%, P = .0035). The risk of adverse events related to augmentation with BMVP of the arthroscopic meniscal repair is very low.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.