All-inside meniscal repair using a new flexible, tensionable device

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.

All-Inside Repair of Bucket-Handle Meniscal Tears: Clinical Outcomes and Prognostic Factors

BACKGROUND

There is no consensus on technique of choice for repair of bucket-handle meniscal tears (BHMTs).

PURPOSE

To determine factors that affect patient outcomes and failure rates in patients undergoing all-inside repairs of BHMTs.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of 3 databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. All English-language literature from 1993 to 2019 describing clinical outcomes for patients undergoing all-inside BHMT repair with ≥12-month follow-up was reviewed by 2 independent reviewers. Patient characteristics (patient sex, age), intraoperative factors (laterality, concomitant procedures, surgical technique, implants utilized), and postoperative outcomes (failure rates) were analyzed. Study quality was evaluated with the Modified Coleman Methodology Score (MCMS).

RESULTS

Fifteen studies (1 level 1, 4 level 3, 10 level 4) with 763 total patients (64% male; average age, 26.4 years [range, 9-58 years]; average follow-up, 39.8 months [range, 12-120 months]) including 396 all-inside BHMT repairs were included. Six devices were used for repair including the Meniscal Repair System, FasT-Fix, Meniscus Arrow, Biofix Arrow, RapidLoc device, and PDS II suture, with failure rates of 13.5%, 22.4%, 27.1%, 42.9%, 45.2%, and 0%, respectively. The overall repair failure rate was 29.3% at an average of 13.0 months (range, 5.0-32.4 months), but 19.0% for devices still in use. The RapidLoc and Biofix Arrow had higher failure rates than other devices (P = .0003). Women (31%) were less likely to experience a failure than were men (69%) (P = .03). Longer follow-up duration resulted in higher failure rates (>30 months, 34.4%; <30 months, 23.4%; P = .016). In 4 studies reporting on both all-inside and inside-out repairs, no significant differences in failure rates were observed. No significant differences in failure rates were found between medial and lateral repairs nor repair with and without concurrent anterior cruciate ligament reconstruction (P > .05 for all). The overall average MCMS was 54.4 ± 12.

CONCLUSION

The overall failure rate after all-inside repair of BHMTs is 29.3% at an average of 13.0 months, with no difference in failure rates between medial and lateral meniscal repairs. The variables shown to negatively affect the failure rates were the RapidLoc and Biofix Arrow, male sex, and longer follow-up duration.

Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus

PURPOSE

The importance of meniscus integrity in the prevention of early osteoarthritis is well known, and preservation is accepted as the primary goal. The purpose of the ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) European consensus on traumatic meniscus tears was to provide recommendations for the treatment of meniscus tears based on both scientific evidence and the clinical experience of knee experts.

METHODS

Three groups of surgeons and scientists elaborated and ratified the so-called formal consensus process to define the recommendations for the management of traumatic meniscus tears. A traumatic meniscus tear was defined as a tear with an acute onset of symptoms caused by a sufficient trauma. The expert groups included a steering group of eight European surgeons and scientists, a rating group of another nineteen European surgeons, and a peer review group. The steering group prepared twenty-seven question and answer sets based on the scientific literature. The quality of the answers received grades of A (a high level of scientific support), B (scientific presumption), C (a low level of scientific support) or D (expert opinion). These question and answer sets were then submitted to and evaluated by the rating group. All answers were scored from 1 (= totally inappropriate) to 9 (= totally appropriate) points. Thereafter, the comments of the members of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the finalized question and answer sets were submitted for final review by the peer review group composed of representatives of the ESSKA-affiliated national societies. Eighteen representatives replied.

RESULTS

The review of the literature revealed a rather low scientific quality of studies examining the treatment of traumatic meniscus tears. Of the 27 questions, only one question received a grade of A (a high level of scientific support), and another received a grade of B (scientific presumption). The remaining questions received grades of C and D. The mean rating of all questions by the rating group was 8.2 (95% confidence interval 8.1-8.4). A general agreement that MRI should be performed on a systematic basis was not achieved. However, MRI was recommended when arthroscopy would be considered to identify concomitant pathologies. In this case, the indication for MRI should be determined by a musculoskeletal specialist. Based on our data, stable left in situ lateral meniscus tears appear to show a better prognosis than medial tears. When repair is required, surgery should be performed as early as possible. Evidence that biological enhancement such as needling or the application of platelet-rich plasma would improve healing was not identified. Preservation of the meniscus should be considered as the first line of treatment because of an inferior clinical and radiological long-term outcome after partial meniscectomy compared to meniscus repair.

DISCUSSION

The consensus was generated to present the best possible recommendations for the treatment of traumatic meniscus tears and provides some groundwork for a clinical decision-making process regarding the treatment of meniscus tears. Preservation of the meniscus should be the first line of treatment when possible, because the clinical and radiological long-term outcomes are worse after partial meniscectomy than after meniscus preservation. The consensus clearly states that numerous meniscus tears that were considered irreparable should be repaired, e.g., older tears, tears in obese patients, long tears, etc. LEVEL OF EVIDENCE: II.

Factors Predicting Failure Rates and Patient-Reported Outcome Measures After Arthroscopic Meniscal Repair

PURPOSE

To identify factors that affect patient-reported outcome measures (PROMs) and failure rates after arthroscopic meniscal repair.

METHODS

Embase, Embase Classic, and MEDLINE were searched on August 7, 2015, December 23, 2016, and March 11, 2018, for factors associated with PROMs and failure rates after arthroscopic meniscal repair. We excluded studies that (1) were non-English language, (2) did not use human patients, (3) were nonclinical, (4) did not analyze for factors that predicted PROMs or failure rates, and (5) were below Level IV evidence. Studies were graded into higher and lower quality using the Downs and Black scale.

RESULTS

A total of 34 articles met our criteria, and 32 were graded. We identified 16 articles as higher quality. Among higher-quality studies, factors that significantly predicted reduced failure rates were concurrent anterior cruciate ligament reconstruction (ACLR) (n = 6) and reduced tear complexity (n = 4). Factors that did not significantly impact failure rates were side of repair (n = 8), sex (n = 7), time from injury to surgery (n = 7), age (n = 7), rim width (n = 6), and tear length (n = 5). Factors predicting better PROMs were time from injury to surgery of less than 3 months (n = 1), Outerbridge scores below grade 3 or 4 (n = 2), and reduced varus alignment (n = 2). Factors that did not significantly impact PROMs were equipment used (n = 3) and concurrent ACLR (n = 1).

CONCLUSIONS

Factors affecting failure rates and PROMs after arthroscopic meniscal repair were identified. However, more and higher-quality studies supported concurrent ACLR and less complex tears as predictors of lower failure rates. PROMs were negatively affected by a longer time from injury to surgery, higher Outerbridge scores, and greater varus alignment before surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II to IV studies.

Knee Meniscus Injuries: Common Problems and Solutions

The rates of arthroscopic meniscus repair continue to increase with excellent reported outcomes. Complications, sometimes catastrophic, following meniscus repair may occur. The rate of postoperative complications may be reduced by adequate diagnosis, appropriate patient selection, meniscus repair selection, surgical techniques, and postoperative management. When complications occur, the provider must identify and take steps to rectify as well as prevent further complications from occurring. The purpose of this article is to detail the common diagnostic, technical, and postoperative pitfalls that may result in poor patient outcomes.

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.

Long-term outcome after all-inside meniscal repair using the RapidLoc system

PURPOSE

The purpose of the present study was to evaluate the outcome at a minimum of 7 years following meniscal repair using the RapidLoc (suture anchor) system. It was hypothesized that most patients would have an intact meniscus, as has been reported in several short- and medium-term studies.

METHODS

In the time period from 2002 to 2007, all patients with a vertical longitudinal tear of the meniscus that was judged to be repairable were treated with rasping of the tear area and nearby parameniscal synovium and fixation of the torn part with the use of RapidLoc implants. Using a surgeon-administered form, baseline information about the arthroscopic findings and procedures performed was recorded (at the time of surgery). A median 10-year (range 7-12 years) follow-up was conducted in 2014-2015, and surgical procedures to the knee following the (index) meniscal repair were registered. Treatment failure was defined as a new surgical procedure to the same meniscus.

RESULTS

At the time of follow-up, 39 out of 82 patients (48 %) had undergone further surgery to the repaired meniscus (failures). Nine of these occurred within the first 6 months after surgery, 21 within the first 12 months and 26 within the first 24 months. Thus, the failure rate was 11 % at 6 months, 23 % at 12 months and 28 % at 2 years. One-third (N = 13) of the failures occurred 2 years or later after the (index) meniscal repair.

CONCLUSIONS

Long-term results of meniscal repair using the RapidLoc implants were found to be poor with a high failure rate. In a large proportion of the cases, re-rupture appeared several years after the index surgery, and a commonly used follow-up period of 2 years would therefore fail to detect them. In the day-by-day clinical work, of interest to orthopaedic surgeons is that meniscal repair using an all-inside technique similar to the one used by the authors may not solve the problem in the long run.

LEVEL OF EVIDENCE

IV.

Meniscal repair

The meniscus has several important roles, such as transmission of the load, absorption of the shock in the knee joint, acting as a secondary anteroposterior stabilizer of the knee joint, and contributing to proprioception of the knee joint. Degenerative changes of the knee joint develop in the long-term follow-up even after partial meniscectomy. Thus, there has been growing interest in meniscal repair. In addition, with increased understanding of the important roles of the meniscal root and advancement of diagnostic methods, efforts have been made to ensure preservation of the meniscal roots. In this review article, we will discuss operative techniques and clinical outcomes of arthroscopic repair of the meniscus and the meniscal root and postoperative rehabilitation and complications as well.

Clinical healing rates of meniscus repairs of tears in the central-third (red-white) zone

PURPOSE

To determine the clinical healing rate of repairs of meniscus tears that extend into the central one-third region and the factors that affect the outcome.

METHODS

A systematic search of PubMed was conducted to determine the outcome of meniscus repairs in the red-white (R/W) zone. Inclusion criteria were as follows: English language, clinical trials published from 1996 to 2013, R/W tears analyzed separately from tears in other zones, arthroscopic suture-based repairs, and all evidence levels.

RESULTS

Of 344 articles identified, 23 met the inclusion criteria. There were 1,232 patients who had 1,326 meniscus repairs, of which 767 were in the R/W zone. Concurrent anterior cruciate ligament reconstruction was performed in 955 patients (78%). The mean age was 25 years, and the mean follow-up was 4 years. Evaluation criteria included clinical examination in 22 studies, follow-up arthroscopy in 15, magnetic resonance imaging in 6, weight-bearing radiographs in 3, and the International Knee Documentation Committee subjective score in 1. Overall, 637 (83%) of the repairs were considered clinically healed because no additional surgery was required and no obvious clinical meniscus symptoms were detected. This included 382 of 470 inside-out suture repairs (81%) and 255 of 297 all-inside suture repairs (86%). Twenty-two factors were assessed in 13 studies to determine their influence on the outcome, with varying results. Authors generally found that patient age, chronicity of injury, involved tibiofemoral compartment, gender, and concurrent anterior cruciate ligament reconstruction did not adversely affect the results. Insufficient data existed to assess the healing rates according to the type of meniscus tear except for single longitudinal tears. Complications were reported in 3% of the patients in this review. Long-term assessment of a chondroprotective effect of the repairs was conducted in only 2 studies.

CONCLUSIONS

An acceptable midterm clinical healing rate was found for R/W meniscus repairs, supporting this procedure when appropriately indicated. Long-term studies assessing the chondroprotective effect in the involved tibiofemoral compartment using magnetic resonance imaging and radiographs are needed.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens

BACKGROUND

The optimal rehabilitation program after meniscus repair has not been established. Numerous regimens have been suggested as beneficial for meniscus healing, but no controlled trials exist in the literature.

HYPOTHESIS

The purpose of this prospective randomized trial was to investigate outcome with a free or a restricted rehabilitation regimen after isolated meniscus repair. The hypothesis was that free rehabilitation would result in increased failure of meniscus healing.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

A total of 60 patients were included in this study within 2 to 3 days after meniscus repair. No patients with concomitant ligament reconstruction or cartilage repair surgery were included. Meniscus repair was performed with the all-inside technique; only vertical meniscus lesions close to the capsule were repaired. Patients were randomized to free (n = 32) or restricted (n = 28) rehabilitation. Free rehabilitation consisted of 2 weeks (range of motion [ROM], 0°-90°, no brace) and touch weightbearing, with unrestricted activity and free ROM allowed thereafter. Restricted rehabilitation consisted of 6 weeks of hinged brace use with a gradual increase ROM to 90° and only touch weightbearing during the 6 weeks. Patients were seen for follow-up at 3 months, 1 year, and 2 years. Those patients with joint line pain at the 3-month follow-up underwent MRI scanning to evaluate meniscus healing; a subsequent arthroscopy was performed for final evaluation meniscus healing if the MRI indicated lack of meniscus healing. At follow-up, the Knee Osteoarthritis Outcome Score (KOOS), Tegner function score, pain assessment, and patient satisfaction were used to evaluate outcomes.

RESULTS

Eleven patients were lost to follow-up. Repeat arthroscopy in patients with persistent symptoms demonstrated partial healing or lack of healing in 28% and 36% of patients in the free and the restricted rehabilitation groups, respectively (P = .53, nonsignificant). The KOOS and Tegner function scores were similar between groups at all follow-up times, as was patient satisfaction. Patients who underwent subsequent partial meniscectomy because of meniscus repair failure had lower KOOS score and Tegner function score than did patients without repair failure.

CONCLUSION

Free rehabilitation after meniscus repair is safe and does not entail increased failure rates compared with restricted rehabilitation. Subjective and functional outcomes at 1- and 2-year follow-up were not affected by rehabilitation regimen. Clinical outcomes in patients with repair failure who underwent subsequent partial meniscectomy were poorer than in those with healed meniscus repairs. A concern is the 30% overall lack of healing for patients with isolated meniscus lesions repaired with the all-inside technique.

All-inside meniscal repair devices and techniques

Techniques and devices for meniscal repair are evolving, including for all-inside meniscal repair. The first-generation all-inside meniscal repair devices were simplistic in design, but their technical difficulties and risks led to the development of second-generation devices. These devices employed the suture anchor concept for repair and confirmed the safety of use through standard anterior arthroscopic portals. Third-generation devices introduced the idea of rigid, bioabsorbable materials; unfortunately, these demonstrated higher failure and complication rates compared with other repair techniques. They were also limited in their ability to adjust compression and tension across the repair. Now, fourth-generation devices have been developed that are flexible, suture-based, and allow for variable compression and retensioning across the tear. Each device has its own specifications and technical nuances. With a comprehensive understanding of the current devices available, the industry and surgeons may continue in the development of safer, more successful, user-friendly and cost-effective all-inside devices.

Meniscus repair and transplantation: a comprehensive update

Preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following repair of meniscus tears for both simple longitudinal tears located in the periphery and complex multiplanar tears that extend into the central third avascular region. This operation is usually indicated in active patients who have tibiofemoral joint line pain and are less than 50 years of age. However, not all meniscus tears are repairable, especially if considerable damage has occurred. In select patients, meniscus transplantation may restore partial load-bearing meniscus function, decrease symptoms, and provide chondroprotective effects. The initial postoperative goal after both meniscus repair and transplantation is to prevent excessive weight bearing, as high compressive and shear forces can disrupt healing meniscus repair sites and transplants. Immediate knee motion and muscle strengthening are initiated the day after surgery. Variations are built into the rehabilitation protocol according to the type, location, and size of the meniscus repair, if concomitant procedures are performed, and if articular cartilage damage is present. Meniscus repairs located in the periphery heal rapidly, whereas complex multiplanar repairs tend to heal more slowly and require greater caution. The authors have reported the efficacy of the rehabilitation programs and the results of meniscus repair and transplantation in many studies.

Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes

PURPOSE

The aim of this investigation was to compare reoperation rates and clinical outcomes after meniscal repair and partial meniscectomy.

METHODS

A systematic literature review was performed to identify outcome studies of arthroscopic meniscal repair (inside-out, outside-in, and all-inside techniques) or partial meniscectomy in patients with traumatic meniscal tears. The studies included patients with no previous injuries or operations.

RESULTS

At short- and long-term follow-up, partial meniscectomy had a lower reoperation rate (1.4% [2 of 143] and 3.9% [52 of 1,319], respectively) than isolated meniscal repair (16.5% [47 of 284] and 20.7% [30 of 145], respectively). There was a slightly higher reoperation rate after partial lateral meniscectomy compared with partial medial meniscectomy. Repairs of the medial meniscus resulted in higher reoperation rates than repairs of the lateral meniscus. Meniscal repairs at the time of anterior cruciate ligament reconstruction had a lower failure rate than isolated repairs. In the limited number of studies with long-term clinical outcome scores, meniscal repair was associated with higher Lysholm scores and less radiologic degeneration than partial meniscectomy.

CONCLUSIONS

Whereas meniscal repairs have a higher reoperation rate than partial meniscectomies, they are associated with better long-term outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Amount of meniscal resection after failed meniscal repair

BACKGROUND

The failure rate after arthroscopic meniscal repair ranges from 5% to 43.5% (mean, 15%) in the literature. But little is known about the amount of meniscal tissue removed after failed meniscal repair.

HYPOTHESIS

The volume of subsequent meniscectomy after failed meniscal repair is not increased when compared with the volume of meniscectomy that would have been performed if not initially repaired.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From January 2000 to December 2009, 295 knees underwent arthroscopic meniscal repair for unstable peripheral vertical tears. When present (219 cases), all anterior cruciate ligament (ACL) tears underwent reconstruction. Patients with multiple ligament injuries and posterior cruciate ligament injuries were excluded from the analysis. Thirty-two medial and 5 lateral menisci underwent subsequent meniscectomy after failed repair at a mean of 26 months postoperatively (range, 3-114 months). Five parameters were specifically evaluated: the amount of meniscectomy related to the initial tear, the ACL status, the appearance of chondral lesions, the time from the initial injury to meniscal repair, and the time from repair to meniscectomy.

RESULTS

The posterior segment of the meniscus was involved in all tears and retears. Among failures, resection of the meniscal segments primarily repaired occurred for 17 medial and 2 lateral meniscal tears (52%); the tear extended in 5 cases (all medial menisci), and healing of some repaired segments led to a partial resection of the initial lesion in 35% of cases (10 medial menisci, 3 lateral menisci). The time from injury to meniscal repair was correlated with an increasing volume of meniscus removed (P < .05) and with the presence of stage 2 or 3 chondral lesions at revision (P < .03). All knees with extended tears (5 cases) and/or with significant chondral degeneration (8 cases) occurred in ACL-reconstructed knees. Among them, 50% (6 of 12) of ACL-reconstructed knees were ACL deficient.

CONCLUSION

There are few detrimental effects when repairing a repairable meniscal lesion, even if it fails. The amount of meniscectomy is rarely increased when compared with the initial lesion. This study supports the hypothesis that the meniscus can be partially saved and that a risk of a partial failure should be taken when possible.

Quadriceps muscle activation and radiographic osteoarthritis following ACL revision

PURPOSE

Quadriceps strength and activation may play an important role in the recovery from ACL revision surgery. The purpose of this study was to describe quadriceps strength and central activation ratio (CAR) and correlate with radiographic findings in patients with ACL revision surgery.

METHODS

Twenty-one patients who were on average 47.5 ± 21.1 months [range: 14-85 months] post-revision ACL reconstruction. We performed knee joint physical examination and radiographic evaluation. Quadriceps strength testing consisted of maximal voluntary isometric contractions (MVIC) with the knee bent to 90-degrees bilaterally. We calculated quadriceps central activation ratio using the superimposed burst technique. Radiographs (bilateral standing antero-posterior in knee flexion and lateral in full extension) were evaluated by a fellowship-trained orthopedic surgeon using the International Knee Documentation Committee (IKDC) grading system.

RESULTS

Mean CAR was 83.9 ± 12.0% on the reconstructed limb and 85.5 ± 9.5% on the contralateral limb. Average, normalized MVIC torque was 2.5 ± 1.0 Nm/kg on the reconstructed limb and 2.7 ± 1.0 N m/kg for the contralateral limb. Patient age at the time of follow-up evaluation was related to severity of knee joint degeneration, particularly the medial, anterior and patellofemoral compartments. Younger patients with lower CARs tended to have more severe degeneration in the patellofemoral joint. Older patients with lower normalized MVIC torque values tended to exhibit more severely graded degeneration in the patellofemoral joint.

CONCLUSION

Bilateral quadriceps central activation deficits and radiographic osteoarthritis are evident in patients with revision ACL reconstruction.

Arthroscopic all-inside meniscal repair--Does the meniscus heal? A clinical and radiological follow-up examination to verify meniscal healing using a 3-T MRI

OBJECTIVE

The purpose of this study was to correlate clinical and radiological results using a 3-T MRI to verify meniscal healing after arthroscopic all-inside meniscus repair.

MATERIALS AND METHODS

We selected 27 patients (14 men and 13 women) with an average age of 31 ± 9 years and retrospective clinical examinations and radiological assessments using a 3-T MRI after all-inside arthroscopic meniscal repair were conducted. Repair of the medial meniscus was performed in 19 patients and of the lateral meniscus in eight. In 17 patients (63%), we performed concomitant anterior cruciate ligament reconstruction. The mean follow-up period was 4.5 ± 1.7 years. The Lysholm score and Tegner activity index were used for clinical evaluation. Four grades were used to classify the radiological signal alterations within the meniscus: central globular (grade 1); linear horizontal or band-like (grade 2); intrameniscal alterations and linear signal alterations communicating with the articular surface (grade 3); and complex tears (grade 4).

RESULTS

At follow-up, the average Lysholm score was 76 ± 15 points, with ten of the patients placed in group 6 based on the Tegner activity index. MRI examinations revealed no signal alteration in three patients, grade 1 in 0, grade 2 in five, grade 3 in 13, and grade 4 in six. The MRI findings correlated positively with the clinical scores in 21 patients (78%).

CONCLUSIONS

Correlation of clinical and radiological examination was performed using 3-T MRI. In spite of satisfactory clinical outcomes at follow-up, a radiological signal alteration may still be visible on MRI, which was believed to be scar tissue, but could not be proven definitively. Imaging with a 3-Tesla MRI after meniscal suture surgery provides good but no definitive reliability on meniscus healing and therefore gives no advantage compared to 1.5-T MRI, with good clinical outcome using an all-inside arthroscopic meniscal repair.

CLINICAL RELEVANCE

3T-MRI can not substitute diagnostic arthroscopy in patients with persistent complaints after arthroscopic all-inside meniscal repair.

Articular contact pressures of meniscal repair techniques at various knee flexion angles

Articular cartilage injury can occur after meniscal repair with biodegradable implants. Previous contact pressure analyses of the knee have been based on the tibial side of the meniscus at limited knee flexion angles. We investigated articular contact pressures on the posterior femoral condyle with different knee flexion angles and surgical repair techniques. Medial meniscus tears were repaired in 30 fresh bovine knees. Knees were mounted on a 6-degrees-of-freedom jig and statically loaded to 200 N at 45 degrees, 70 degrees, 90 degrees, and 110 degrees of knee flexion under 3 conditions: intact meniscus, torn meniscus, and meniscus after repair. For each repair, 3 sutures or biodegradable implants were used. A pressure sensor was used to determine the contact area and peak pressure. Peak pressures over each implant position were measured. Peak pressure increased significantly as knee flexion increased in normal, injured, and repaired knees. The change in peak pressure in knees with implant repairs was significantly higher than suture repairs at all knee flexion angles. Articular contact pressure on the posterior femoral condyle increased with knee flexion. Avoidance of deep knee flexion angles postoperatively may limit increases in articular contact pressures and potential chondral injury.

Comparison of arthroscopic medial meniscal suture repair techniques: inside-out versus all-inside repair

BACKGROUND

There are no reports comparing meniscal healing between inside-out and all-inside repairs using sutures.

HYPOTHESIS

No difference in healing rate exists between meniscal repairs with inside-out and all-inside suture repair in conjunction with anterior cruciate ligament reconstruction with hamstring tendon.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Forty-eight consecutive patients underwent meniscal repairs of longitudinal tears of the posterior horn of the medial meniscus combined with anterior cruciate ligament reconstructions. All-inside repair was attempted when the tears were located in the red-red zone or the ramp area of the meniscus. If a tear that was in the ramp area or red-red zone extended to the midbody of the meniscus, or if there was a tear in red-white zone, the inside-out repair technique was used. Fourteen patients had all-inside meniscal repairs, and 34 patients had inside-out meniscal repairs with absorbable sutures. Identical postoperative rehabilitation protocols were used. Postoperative evaluations included Lysholm knee scoring scale, Tegner activity levels, Lachman and pivot-shift tests, and KT-1000 arthrometer. Assessment of meniscal status was performed using joint line tenderness, McMurray test, and range of motion. Follow-up magnetic resonance imaging scans were obtained on all patients.

RESULTS

Mean follow-up was 35.7 months. No patient had joint line tenderness or reported pain or clicking on McMurray test. There was no significant difference in range of motion between groups. Follow-up magnetic resonance imaging scans demonstrated that 10 (71.4%) menisci were healed and 4 (28.6%) partially healed in the all-inside group; 24 (70.6%) menisci were healed and 10 (29.4%) partially healed in the inside-out group. There was no significant difference in meniscal healing between groups. There were no differences in Lachman test, KT-1000 arthrometer side-to-side differences measurements, Lysholm scores, and Tegner activity scales. There was a significant difference in pivot-shift test between groups (P = .023). There were 2 complications associated with surgery. In the inside-out group, 1 patient required manipulation, and 2 patients had limited motion at final follow-up. Two patients in the inside-out group experienced transient saphenous nerve injury.

CONCLUSION

There was no significant difference in meniscal healing between inside-out and all-inside repair techniques in combination with anterior cruciate ligament reconstructions.

Meniscal repair

The meniscus plays an important role in preventing osteoarthritis of the knee. Repair of a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with concurrent anterior cruciate ligament reconstruction, and in younger patients. The probability of healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Age or extension of the tear into the avascular area are not exclusion criteria. Numerous repair techniques are available, and suture repair seems to provide superior biomechanical stability. However, the clinical success rate does not correlate well with the mechanical strength of the repair technique. Biologic factors might be of greater importance to the success of meniscal repair than the surgical technique. Therefore, the decision on the most appropriate repair technique should not rely on biomechanical parameters alone. Contemporary all-inside repair systems have decreased the operating time and the level of surgical skill required. Despite the ease of use, there is a potential for complications because of the close proximity of vessels, nerves, and tendons, of which the surgeon should be aware. There is no clear consensus on postoperative rehabilitation. Weight bearing in extension would most likely not be crucial in typical longitudinal lesions. However, higher degrees of flexion, particularly with weight bearing, give rise to large excursions of the menisci and to shear motions, and should therefore be advised carefully. Long-term studies show a decline in success rates with time. Further studies are needed to clarify the factors relevant to the healing of the menisci. Tissue engineering techniques to enhance the healing in situ are promising but have not yet evolved to a practicable level.

All-inside meniscal repair

All-inside meniscal repair has gained widespread popularity over recent years. The devices and techniques have rapidly evolved, resulting in increased ease of use and reduced surgical times and risk to the neurovascular structures. Despite these advances, inside-out suture repairs remain the current gold standard, with proven long-term results. All-inside techniques must continue to be compared to inside-out meniscal repair.

Evaluation of success of a meniscus repair device for vertical unstable medial meniscus tears in ACL-reconstructed knees

We retrospectively reviewed the success of meniscus repair with the FasT-Fix meniscus repair device for vertical unstable medial meniscus tears at the time of anterior cruciate ligament (ACL) reconstruction. A repair failure was defined as patients having medial knee symptoms leading to a subsequent arthroscopy confirming a tear at the repair site. Objective follow-up was obtained on 27 patients at a mean of 3.1 years postoperatively (range, 2-5 years). Two of 22 repairs (9%) in the red-red vascular zone and 4 of 5 repairs (80%) in the red-white vascular zone retore at the repair site at an average of 9 months postoperatively (range, 3-20 months). The results of this study showed a high failure rate (22%) of unstable vertical medial meniscus repairs with ACL reconstruction, especially for repairs done to tears in the red-white vascular zone.

Retears of postoperative knee meniscus: findings on magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) by using low and high field magnets

PURPOSE

The purpose of this study was to determine the diagnostic performance of magnetic resonance (MR) obtained with intra-articular contrast medium in the evaluation of recurrent meniscal tears using low-field extremity-only and high-field whole-body magnets.

MATERIALS AND METHODS

Postoperative standard MR examinations and MR arthrographies of 95 knees were reviewed. Patients experiencing pain and disability after meniscal repair underwent standard MR and MR arthrography (Gadoterate meglumine 0.0025 mmol/ml) on both a 0.2-T and 1.5-T magnet. In 52 of 95 patients, second-look arthroscopy was performed; in the remaining 43 of 95 patients, clinical follow-up was used as the standard of reference. Sensitivity, specificity, positive and negative predictive values as well as accuracy of MRI/MR arthrographic signs as meniscal morphologic changes and the presence of contrast medium tracking into the tear at T1- and T2-weighted sequences in the detection of recurrent meniscal tears were determined.

RESULTS

All MR and MR arthrograpic signs were sensitive in the detection of recurrent tears (range 80-91%). Abnormal meniscal morphology had low specificity [26% (13/50)] for both the 0.2-T and 1.5-T scanner, whereas accuracy was 55% (52/95) and 57% (54/95), respectively. The presence of contrast medium within the meniscus substance on T2-weighted images had higher value of specificity [84% (42/50)] and accuracy [84% (80/95)] by using low field strength magnet than by using high field strength magnet [74% (37/50) and 81% (77/95), respectively]. Whereas, the increased intrameniscal signal intensity extending to the meniscal surface at T1-weighted sequences after intra-articular contrast medium administration had lower specificity and accuracy on 0.2-T images [84% (42/50) and 82% (78/95), respectively] than on 1.5-T images [90% (45/50) and 88% (84/95), respectively].

CONCLUSION

A diagnosis of recurrent meniscal tear in a previously arthroscopically repaired meniscus can be made both on 0.2-T and 1.5-T magnets on the basis of increased signal on T2-weighted and T1-weighted images in the presence of intra-articular contrast material.

Arthroscopic all inside repair of the lateral meniscus root tear

It has been reported that lateral meniscus tears, including posterior horn tears, stable radial flap tears, or peripheral or posterior third tears that are combined with an Anterior Cruciate Ligament (ACL) injury can be treated with being left in situ. However, our experience has shown that the tear patterns are not so simple. They can show complex configurations and the inner side can be lost in chronic cases. Regarding the repair technique, there has been some controversy concerning the follow up results with repair devices and reduction is difficult using these devices if the inner side is non-viable or lost. If the tear involves whole width of bony insertion, it is believed that the meniscal function would be lost, particularly because the anatomic configuration is different in this area. In cases of chronic inner loss types, the meniscus was repaired using a side to side repair or pull out repair technique. Complete healing was achieved using this technique in some patients. Conclusively, Posterior Lateral Meniscus Root Tear (PLMRT) must be managed with different method with tears of other areas because the tear configuration is complex than simple looking.

Second-look arthroscopic evaluation of bucket-handle meniscus tear repairs with anterior cruciate ligament reconstruction: 67 consecutive cases

PURPOSE

To evaluate arthroscopic second-look bucket-handle meniscus tear (BHMT) repairs using different suturing techniques.

METHODS

Between May 2002 and September 2006, 122 consecutive cases underwent arthroscopic repair surgery, including 40 males and 24 females (63 with concurrent anterior cruciate ligament [ACL] injury and 1 isolated BHMT) having 67 (60 medial and 7 lateral) repairs available for second-look arthroscopy evaluation. Inclusion criteria for reparability included reducible tears involving red-red and red-white zone without obvious additional complex tears and tissue degeneration, and concurrent ACL injury and/or isolated BHMT. Patients were excluded if they had combined ligaments injuries other than ACL. The arthroscopic suturing techniques, classified according to different involvement of meniscus zones, consisted of typical inside-out and all-inside suture repair with suture hook.

RESULTS

In a series of 64 second-look cases with 67 repairs, which showed healing after an average of 26 months (range, 14 to 66 mos), 55 repairs (82.1%) were completely healed (and clinically asymptomatic) in 53 cases; 5 cases (5 repairs; 7.5%) had joint line tenderness (incompletely healed and clinically asymptomatic); and 7 repairs (6 medial, and 1 lateral; 10.4%) failed, with recurrent locking or catching in 4 cases (and clinically asymptomatic in 2 cases). The overall success rate, including completely healed and incompletely healed cases, was 89.6%. Four failures occurred in failed ACL-reconstructed knees.

CONCLUSIONS

For large bucket-handle meniscus tears involving red-red and red-white zones, an arthroscopic hybrid suture technique with ACL reconstruction achieves high anatomic healing results, with an overall meniscal healing rate of 89.6%, including 82.1% completely healed and 7.5% incompletely healed. The failure rate was 10.4% in the average 26-month follow-up period.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Meniscal repair using an all-inside, rapidly absorbing, tensionable device

PURPOSE

The purpose of this study was to evaluate the clinical success rate of all-inside meniscal repairs using a rapidly absorbing device in patients undergoing concurrent anterior cruciate ligament (ACL) reconstructions.

METHODS

Patients with menisci repaired using the polydioxanone Mitek RapidLoc (Depuy Mitek, Raynham, MA) during concurrent ACL reconstruction were evaluated clinically 2 years following index surgery. We performed examinations on 38 meniscal tears in 30 patients using the International Knee Documentation Committee form and the Knee Disorders Subjective History visual analog scale. We also performed physical examinations for an effusion, joint line tenderness, McMurray's testing, and KT-1000 arthrometry (MEDmetric, San Diego, CA).

RESULTS

The clinical success rate for meniscal repair was 86.8% (33 of 38) at a mean follow-up of 30.4 months (range, 21 to 56 months). Univariate analysis revealed sex as the only predictive variable for failure; all failures occurred in male patients. Nonpredictive variables included tear length, type, and configuration; a duration of more than 3 months, compartment, zone, ligament graft choice, age, follow-up, Tegner score, and visual analog scale score.

CONCLUSIONS

The polydioxanone RapidLoc device was found to have a clinical success rate of 86.8%. These data suggest that the more rapidly absorbing polydioxanone device is effective for all-inside meniscal repair during concurrent ACL reconstruction.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Meniscal repair techniques

The human meniscus is important for normal knee function and distributes loads, aids in joint lubrication, congruence, stability, and proprioception. Repair of appropriate meniscal tears is possible and several methods exist to accomplish this including suture repairs and device repairs. Clinical evidence suggests that meniscal repairs can result in acceptable healing rates although adverse events have been reported for some devices. New self-adjusting suture devices have facilitated the accurate and effective repair of the torn meniscus. Technique descriptions for these devices are presented.

All-inside meniscus repair: a systematic review

All-inside meniscus repairs are becoming more common with the invention of meniscal arrows, darts, screws, staples, and other suture devices. With the rising popularity of these new all-inside meniscal repair devices, it is necessary to assess the effectiveness of various all-inside surgical interventions used in the treatment of meniscal tears. We performed an evidence based review of the outcomes of all-inside meniscus repair devices. Seventy-seven percent of identified studies were case series; 10% were retrospective comparative studies; 6.5% were prospective comparative studies; and 6.5% were prospective randomized studies. The failure rates ranged from 0 to 43.5%. We found no substantial differences in the failure rates among various meniscus devices. We also found no substantial differences in failure rates with length of followup. Given the paucity of randomized controlled studies comparing different all-inside meniscal repairs, no definite conclusions can be made regarding the difference in clinical outcomes of various all-inside meniscal repair devices.

Meniscal repair with the RapidLoc meniscal repair device

BACKGROUND

The RapidLoc is an all-inside, self-adjusting, flexible meniscal repair device that combines a suture with an anchor component and, by using a reinforced sliding knot, allows for tightening to compress and hold the repaired meniscal segments. The purpose of this study was to evaluate the clinical success of the RapidLoc device.

METHODS

A prospective consecutive series of meniscal repairs performed with the RapidLoc device was studied. Lysholm, Tegner, Cincinnati, IKDC (International Knee Documentation Committee) activity scores, clinical examination findings, and adverse events were recorded on all patients. Associated procedures were recorded. An accelerated postoperative rehabilitation program was followed, independent of whether anterior cruciate ligament (ACL) surgery was also performed.

RESULTS

A total of 32 patients underwent 32 meniscal repairs, with an average follow-up of 31 months (18 to 48 months). In all, 23 repairs were done in conjunction with ACL reconstruction, and 9 repairs were carried out in stable knees. Repairs were made to 25 medial menisci and 7 lateral menisci. Tears repaired consisted of peripheral longitudinal tears with an average length of 2 cm (range, 15 to 30 mm). Four failures (12.5%) were arthroscopically documented. Clinical success occurred in 87.5% at the time of last follow-up. At follow-up, mean Tegner score was 5.1 (2.8 preoperative), IKDC activity score was 3.1 (1.8 preoperative), Lysholm score was 93.6 (48.4 preoperative), and mean Cincinnati score was 88.1 (43.7 preoperative). The most common adverse event was cutting of the suture during RapidLoc insertion. One patient had excoriation and grooving of the medial femoral condyle associated with failed repair. Another patient developed a postoperative infection.

CONCLUSIONS

The early clinical success rate was 87.5% with the RapidLoc device. Chondral grooving was observed in a single case.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.