Meniscal repair with biofix arrows: results after 4.7 years' follow-up

Predictive Factors for Failure of Meniscal Repair: A Retrospective Dual-Center Analysis of 918 Consecutive Cases

Background:

Meniscal surgery is one of the most common surgical procedures performed by orthopaedic surgeons. Over the past decade, awareness has increased regarding the importance of meniscal preservation to prevent the development of osteoarthritis in the knee joint. Removal of meniscal tissue can lead to a high risk of cartilage degeneration, and moreover, meniscus-preserving surgery rather than meniscal resection is likely to have better long-term outcomes. Success rates after meniscal repair range from 60% to 95%, but many reports are based on a small number of patients.

Purpose/Hypothesis:

The purpose of this study was to review all meniscal repairs and potential predictors for failure during a 12-year period. We hypothesized that meniscal anchors, lateral repairs, and repairs made in conjunction with an anterior cruciate ligament reconstruction (ACLR) would have fewer failures than meniscal arrows, medial repairs, and isolated repairs. We also hypothesized that younger patients and acute tears would be associated with fewer failures.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

This study was a dual-center, retrospective analysis on consecutive meniscal repairs. The surgical protocols were reviewed, including type of tear, location, associated injury to the knee, and surgery. The study endpoint was failure of repair, defined as a need for reoperation and secondary partial or total meniscal resection, within 3 years. Kaplan-Meier analysis was performed to assess repair survival, with multivariate Cox regression to adjust for confounders.

Results:

A total of 954 meniscal repairs were performed on 918 patients (536 male patients [58%]; 382 female patients [42%]) with a mean age of 26 years (range, 12-60 years). The failure rate for the entire cohort was 22.5%. Bioabsorbable arrows had significantly more failures than all-inside sutures with anchors (hazard ratio [HR], 1.8; 95% CI, 1.2-2.5; P = .002). Medial meniscal repairs had a higher failure rate than lateral meniscal repairs (HR, 3.7; 95% CI, 2.3-6.0; P < .001). Simultaneous ACLR resulted in less failure than when no simultaneous ACLR was performed (HR, 0.5; 95% CI, 0.3-0.9; P = .009). Age at repair and acuity of tear did not affect the outcome (P = .6 and .07, respectively).

Conclusion:

The failure rate after meniscal repair was significantly higher on the medial side, especially when using arrows. Meniscal repairs performed concomitantly with an ACLR result in fewer reoperations.

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.

All-inside suture device is superior to meniscal arrows in meniscal repair: a prospective randomized multicenter clinical trial with 2-year follow-up

PURPOSE

Multiple techniques and implants are available for all-inside meniscal repair, but the knowledge about their failure rates and functional outcome is still incomplete. The hypothesis was that there might be differences between meniscal arrows and suture devices regarding reoperation rates and functional outcome. Thereby, the aim of this study was to compare clinical results following repair with the Biofix(®) arrows or the FasT-Fix(®) suture devices.

METHODS

In this RCT, 46 patients were treated either by Biofix(®) (n = 21) or FasT-Fix(®) (n = 25). The main outcome was reoperation within 2 years. Knee function and activity level were evaluated by KOOS and Tegner activity scale.

RESULTS

Twelve out of 46 (26%) patients were reoperated within 2 years, nine out of 21 (43%) in the Biofix(®)-group versus three out of 25 (12%) in the FasT-Fix(®)-group (p = 0.018). The relative risk of reoperation was 3.6 times higher for Biofix(®) compared to FasT-Fix(®) (95% confidence interval 1.1-11.5). Both treatment groups had significant increase in all KOOS subscales, but there were no major differences between the groups. The subgroup of reoperated patients differed from the other patients with higher Tegner score preoperatively (median 5 vs. 4) (p = 0.037) and at 3-month follow-up (median 4 vs. 3) (p = 0.010).

CONCLUSIONS

These results indicate that FasT-Fix(®) suture is superior to Biofix(®) arrows with significant lower failure rate. Functional outcome did not depend on repair technique. Higher activity score preoperatively and at 3-month follow-up in the reoperated patients indicates that activity level may influence on the risk of reoperation.

LEVEL OF EVIDENCE

I.

Clinical outcomes and complications of a collagen meniscus implant: a systematic review

PURPOSE

The purpose of this systematic review was to summarise and evaluate the clinical outcomes of the collagen meniscus implant (CMI) and its complication and failure rates. These data were then used to evaluate the results of the CMI at different follow-up time periods and investigate possible differences in the behaviour of lateral and medial CMI.

METHODS

A comprehensive search was performed in PubMed, MEDLINE, CINAHL, Cochrane, EMBASE and Google Scholar databases using various combinations of the following keywords: "collagen meniscus implant" or "collagen meniscal implant". All studies evaluating medial or lateral CMI using the Lysholm score, visual analogue scale (VAS) for pain, Tegner activity scale and subjective or objective International Knee Documentation Committee (IKDC) scores were included in the systematic review.

RESULTS

Eleven studies were included in the systematic review. The pooled number of patients involved in CMI surgery were 396 (90.2 % medial, 9.8 % lateral), with a mean age at surgery of 37.8 years. Concomitant procedures were present in 48.8 % of patients; most of them were anterior cruciate ligament (ACL) reconstruction, high tibial osteotomy (HTO) and microfractures. The Lysholm score and VAS for pain showed an improvement at six months up to ten years. No noticeable differences were present comparing short-term values of Lysholm score between medial and lateral CMI. The Tegner activity level reached its peak at 12 months after surgery and showed a progressive decrease through five and ten years post CMI implantation, however always remaining above the pre-operative level. Only a few knees were rated as "nearly abnormal" or "abnormal" at IKDC grading at all follow-up evaluations.

CONCLUSIONS

The CMI could produce good and stable clinical results, particularly regarding knee function and pain, with low rates of complications and reoperations.

Polyurethane scaffold in lateral meniscus segmental defects: clinical outcomes at 24 months follow-up

BACKGROUND

Segmental tissue loss in the lateral meniscus is associated with pain and increased risk of osteoarthritis even when indications have been carefully considered.

HYPOTHESIS

Repairing the defect using a novel biodegradable scaffold will reduce pain and restore the knee function.

METHODS

In this prospective multicenter study, a total of 54 patients (37 males/17 females; mean age: 28 years [16-50]) were enrolled. All patients presented with postmeniscectomy syndrome and segmental lateral meniscus loss, and were treated with a polyurethane biodegradable scaffold (Actifit(®), Orteq) implanted arthroscopically. Clinical outcomes were assessed at 6, 12 and 24 months using Visual Analogue Scale (VAS), International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

VAS decreased from 5.5 at baseline to 3.6 at 6 months, 3.4 at 12 months and 2.9 at 24 months. IKDC improved from 47.0 at baseline to 60.2, 67.0 and 67.0 at 6, 12 and 24 months. All KOOS subscores improved between baseline and 24 months.

DISCUSSION

Clinical results of this study demonstrate clinically and statistically significant improvements of pain and function scores (VAS, IKDC, and all KOOS subscales except sport), at the 6 months follow-up and on all clinical outcomes at the 2-year follow-up. The Actifit(®) scaffold is safe and effective in treating lateral meniscus defects.

LEVEL OF EVIDENCE IV

continuous prospective multicenter study.

Biological enhancement of meniscus repair and replacement

When a meniscus injury occurs, it is generally accepted that preserving the meniscus is important for life-long joint preservation. Traditional suture repair of the meniscus has good results; however, the healing potential of meniscus tissue remains as a biological challenge because it is not a completely vascularized structure. For this reason, investigators have continued to search for adjuncts to improve clinical results. Mechanical adjuncts, local factor enhancement, scaffolds, gene therapy, and cell therapy have all been examined as options for improvement of biology and structure. This study reviews the basic science and clinical application of these modalities and provides an assessment of techniques on the horizon.

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.

Long-term outcome after meniscal repair

PURPOSE

the purpose of this study was to analyse the clinical and radiological results of meniscal repairs and identify factors that correlate with the success of this procedure.

METHODS

a retrospective review of 119 meniscal repairs was completed. The average follow-up was 70 months. Successful meniscal repairs were observed critically in terms of radiographic changes and clinical outcomes and compared with failed meniscal repairs.

RESULTS

the overall success rate of meniscal repairs was 74%. Meniscal repairs that were performed within 6 weeks of injury had better results (83%) than late repairs (52%). The best results were obtained with the inside-out technique using #0 PDS suture (80%) compared to all-inside Biofix arrows (70%) and combined repairs (63%). Patients with associated ACL injury had a better chance of a successful outcome, but this was only significant when the ACL was reconstructed at the time of repair (P < 0.05). Those patients who had failed meniscal repair had increased radiographic osteoarthritic changes (81%) on long-term follow-up compared to patients with successful repair (14%).

CONCLUSION

this retrospective study shows the clinical and radiological importance of meniscal repair. Successful results in this study were associated with younger age and earlier repair using inside-out technique. Furthermore, increased success was seen in meniscal repairs performed in association with ACL reconstruction.

All-inside meniscal repair with bioabsorbable meniscal screws or with bioabsorbable meniscus arrows: a prospective, randomized clinical study with 2-year results

BACKGROUND

All-inside meniscal repairs have gained popularity in the past few years. However, only a few prospective, randomized clinical studies have been done to compare different all-inside meniscal repair techniques.

HYPOTHESIS

Meniscal repair with bioabsorbable meniscal screws and arrows results in similar clinical outcome on short-term follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Forty-two patients were prospectively randomized to have all-inside meniscal repair either by using bioabsorbable meniscal screws or bioabsorbable meniscus arrows (21 patients, 23 meniscal repairs in each group) for the fixation. The evaluation methods were clinical examination, Lysholm score, the International Knee Documentation Committee (IKDC) knee score, and magnetic resonance arthrography (MRA) evaluation. The average follow-up time was 27 months (standard deviation, 8).

RESULTS

There were no differences between the study groups preoperatively. All 42 patients (100%) were available for the follow-up. However, during the follow-up, 11 patients had clinical failure, confirmed at second-look arthroscopy, of the repair leading to partial meniscal resection. Four failures (all on the medial meniscus) were observed with the use of meniscal screw fixation (17%), and 7 (4 on the medial meniscus, and 3 on the lateral meniscus) with the use of meniscus arrow fixation (30%) (P = .242). Six patients with meniscus arrows (29%) had chondral damage on the femoral condyles evaluated by MRA or at second-look arthroscopy, while none of the patients with the meniscal screws had the same (P = .018). However, the Lysholm and the IKDC scores were similar in both groups at follow-up.

CONCLUSION

All-inside meniscal repair with bioabsorbable meniscal screws and arrows resulted in similar clinical outcome, although significantly more chondral damage was observed when using bioabsorbable meniscus arrows for fixation.

Cyclic testing of 3 all-inside meniscal repair devices: a biomechanical analysis

BACKGROUND

Despite the growing popularity of all-inside meniscal repair devices, concerns remain about their fixation strength. It is also unclear which of these devices have the most ideal biomechanical properties.

PURPOSE

To compare the biomechanical properties of 3 all-inside meniscal repair devices: the Meniscal Cinch, Ultra FAST-FIX, and MaxFire.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-seven human cadaveric menisci (3 groups of 9) were repaired using 3 different meniscal repair devices. The repaired menisci were then subjected to cyclic loading and load-to-failure testing. Gap formation and ultimate load to failure were measured.

RESULTS

Six of the devices failed during cyclic testing, 4 in the MaxFire group (44%), 1 in the Ultra FAST-FIX group (11%), and 1 in the Meniscal Cinch group (11%). After 1 cycle, there was a trend toward larger gap formation in the MaxFire group (3.65 mm) compared with the Meniscal Cinch group (2.12 mm, P = .05). After 100 cycles, group differences were found in gap formation (P = .03), with the MaxFire group exhibiting greater displacement (6.70 mm) than the Ultra FAST-FIX group (3.59 mm). After 500 cycles, group differences in gap formation (Meniscal Cinch, 5.94; Ultra FAST-FIX, 4.74 mm; Max Fire, 7.19 mm) did not reach statistical significance (P = .20). A trend was found toward higher ultimate load to failure in the Ultra FAST-FIX (86.1 N) and Meniscal Cinch (85.3 N) groups compared with the MaxFire group (64.5 N, P = .06). Stiffness was also higher in the Ultra FAST-FIX (25.2 N/mm) and Meniscal Cinch (25.5 N/mm) groups than the MaxFire group (16.3 N/mm, P = .02).

CONCLUSION

The Meniscal Cinch and Ultra FAST-FIX devices have more desirable biomechanical properties than the MaxFire as demonstrated by higher stiffness and a lower failure rate during cyclic testing.

CLINICAL RELEVANCE

The Meniscal Cinch and Ultra FAST-FIX devices may be more desirable implants for use during all-inside meniscal repair as they have superior biomechanical properties when compared with the MaxFire device.

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.

[Complications with all-inside devices used in reconstructive meniscal surgery]

All-inside devices have become increasingly popular in reconstructive meniscal surgery since their introduction at the beginning of the 1990s. Although the latest clinical investigations show better results for conventional suture techniques, meniscal devices are an important alternative because of the low risk of neurovascular injury and the easy handling of the instruments. Over the years, many reports on specific complications related to all-inside devices have been published. Especially chondral injuries, implant loosening, device migration and capsular or neural irritations have been described. Furthermore, some authors reported on foreign body reactions and cystic granulomas after the use of meniscal fixation devices. However, there is no evidence for a higher infection rate or for specific infections after the use of intra-articular techniques. Clinical reports on complications along with biomechanical studies on meniscal repair devices have led to the enhancement of all-inside techniques through substantial modifications of established products as well as to the development of new implants. After reviewing the latest literature, the complication rate seems to be decreasing. In many ways, all-inside devices are an interesting alternative to conventional suture techniques. A precise knowledge of their potential complications and the pitfalls during surgery however is crucial to make a risk evaluation in the choice of the right technique for meniscal reconstruction.

All-inside suture technique using anterior portals in posterior horn tears of lateral meniscus

Methods for the repair of meniscal tears include inside-out, outside-in, and all-inside techniques. In this article an all-inside technique is proposed for the posterior horn of the lateral meniscus that takes advantage of the capacious posterolateral recess when the knee is flexed. A device consisting of a large needle with a buttonhole in the tip (previously used for inside-out suture of the medial meniscus) is used. This technique uses only anterior portals (anteromedial and anterolateral portals and an accessory lateral or transpatellar tendon portal). The arthroscope is inserted through the accessory portal. Once the tear has been located and its edges refreshed, the suture device is placed anterolaterally. The tip of the needle is loaded with suture and passed through both sides of the tear and into the posterolateral recess of the knee (without exiting the capsule). The suture tail is recovered with the use of a suture retriever through the anteromedial portal. Next, the suture retriever is inserted through the anterolateral portal to once again retrieve and shuttle the tail before completion of an arthroscopic knot. In addition to the ease of the technique, use of this simple, reusable device adds the benefit of low cost when compared with other techniques.

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.

The development and validation of a quality of life-measurement tool for patients with meniscal pathology: the Western Ontario Meniscal Evaluation Tool (WOMET)

OBJECTIVE

To develop and validate a disease-specific, health-related quality of life (HRQOL) index for patients with meniscal pathology. Our hypothesis was that the Western Ontario Meniscal Evaluation Tool (WOMET) would provide adequate reliability, validity, and responsiveness in measuring HRQOL in patients with meniscal tears or who have undergone meniscal repair or resection.

STUDY DESIGN

Validation of a measurement tool.

SETTING

A tertiary, university-affiliated, sport medicine clinic.

PARTICIPANTS

A methodological protocol based on that of Guyatt et al was used to develop the Western Ontario Meniscal Evaluation Tool (WOMET). Patients with meniscal symptomology and in whom magnetic resonance imaging had suggested meniscal pathology were selected from referrals to a sport medicine clinic. Using this cohort, the development of the WOMET proceeded through item generation, reduction, and instrument pretesting. A second cohort of postarthroscopy patients with confirmed meniscal pathology was used to assess the reliability of the WOMET and validate the instrument.

RESULTS

The final instrument has 16 items representing the domains of physical symptoms (nine items), sports/recreation/work/lifestyle (four items), and emotions (three items). It demonstrated adequate content and construct validity when compared with other measures. Test-retest reliability was assessed and was found to be high, with an intraclass correlation coefficient of 0.833. The new instrument was also found to be more responsive than other knee measurement tools when assessed in the same cohort.

CONCLUSIONS AND CLINICAL RELEVANCE

The WOMET is a disease-specific tool designed to evaluate HRQOL in patients with meniscal pathology. It is therefore put forth as a validated measurement tool to be used in clinical trials evaluating treatments for meniscal pathology. It could also be used as a prospective outcome measure in research or in clinical practice.