Effectiveness of bioabsorbable arrows compared with inside-out suturing for vertical, reparable meniscal lesions: a randomized clinical trial

Examining the Evidence Regarding Smoking and Patient Outcomes for Isolated Meniscus Pathology: A Comprehensive Systematic Review and Meta-Analysis

Smoking is a well-known cause of impairment in wound healing and postoperative outcomes; however, its effects on treating meniscus issues remain unclear. This study assesses the relationship between smoking and meniscus treatment outcomes. PubMed, Scopus, Cochrane, and CINAHL were searched from inception to 24 December 2023. Inclusion criteria encompassed studies examining smoking's impact on patient outcomes regarding meniscus pathology. A secondary PubMed search targeted randomized controlled trials (RCTs) in the top ten orthopedic journals focusing on meniscus pathology and smoking as a demographic variable. Meta-analysis of six studies (n = 528) assessed meniscus failure rate based on smoking status. Eighteen observational studies (n = 8353 patients; 53.25% male; mean age: 51.35 ± 11.53 years; follow-up: 184.11 ± 117.34 months) were analyzed, covering meniscus repair, meniscectomy, allograft transplant, conservative care, and arthroscopy. Results showed four studies (36.36%) linked smoking with worse meniscus repair outcomes, while seven studies (63.64%) did not find significant associations. Meta-analysis from six studies showed no significant impact of smoking on repair failure (p = 0.118). Regarding meniscectomy, one study (33.33%) identified a significant association with smoking, but two did not. Only one (3.8%) of the RCTs in leading orthopedic journals included smoking as a factor. The evidence on smoking's effect on meniscus treatment is mixed, necessitating further investigation.

Greater rate of return to play and re-injury following all-inside meniscal repair compared to the inside-out technique: a systematic review

INTRODUCTION

Inside-out and all-inside arthroscopic meniscal repairs are widely performed. However, it remains unclear which method promotes greater clinical outcomes. This study compared inside-out versus all-inside arthroscopic meniscal repair in terms of patient-reported outcome measures (PROMs), failures, return to play, and symptoms.

METHODS

This systematic review was conducted in accordance with the PRISMA guidelines. Two authors independently performed the literature search by accessing the following databases: PubMed, Google Scholar, and Scopus in February 2023. All clinical studies which investigated the outcomes of all-inside and/or inside-out meniscal repair were considered.

RESULTS

Data from 39 studies (1848 patients) were retrieved. The mean follow-up was 36.8 (9 to 120) months. The mean age of the patients was 25.8 ± 7.9 years. 28% (521 of 1848 patients) were women. No difference was found in PROMs: Tegner Activity Scale (P = 0.4), Lysholm score (P = 0.2), and International Knee Document Committee score (P = 0.4) among patients undergoing meniscal repair with all inside or inside-out techniques. All-inside repairs showed a greater rate of re-injury (P = 0.009) but also a greater rate of return to play at the pre-injury level (P = 0.0001). No difference was found in failures (P = 0.7), chronic pain (P = 0.05), reoperation (P = 0.1) between the two techniques. No difference was found in the rate of return to play (P = 0.5) and to daily activities (P = 0.1) between the two techniques.

CONCLUSION

Arthroscopic all-inside meniscal repair may be of special interest in patients with a particular interest in a fast return to sport, while, for less demanding patients, the inside-out suture technique may be recommended. High-quality comparative trials are required to validate these results in a clinical setting.

LEVEL OF EVIDENCE

Level III, systematic review.

Repair of a meniscus tear within 3 weeks after trauma significantly reduces the likelihood of a recurrent tear compared with later repairs

PURPOSE

To evaluate the potential benefit of meniscus tear repair within 3 weeks after rupture compared with more than 3 weeks after rupture.

METHODS

Ninety-one patients (95 menisci) underwent repair within 3 weeks after meniscus rupture [Group 1] and 15 patients (17 menisci) [Group 2] underwent repair more than 3 weeks after rupture. The posterior part of the ruptured meniscus was repaired with Contour Arrows^®, using a Crossbow as the insertion instrument, whereas the middle third was repaired by inserting PDS 2.0 stitches using a Meniscus Mender^® outside-in device. The patients were followed-up for a mean(SD) 8.9 years (range: 1-12 years).

RESULTS

Of the 91 patients (95 menisci) in Group 1, 88 (96.7%) healed without complications. One meniscus in one patient did not heal after 11 months, requiring resection. Two other menisci in two other patients showed partially healed tears. This part was removed while preserving most of the meniscus (failure rate: 3/91 patients: 3.3%). The other 88 patients recovered without complaints and participated in sports without restraint. Four menisci in four patients experienced a second sports-related incident, resulting in a renewed tear between 12 months and 3 years. These tears were repaired successfully again. Of the 15 patients in Group 2, 12 (80.0%) healed without complications. The ruptured part of the remaining menisci in the other three patients, (20%) was removed, with all patients remaining symptom-free until the end of follow-up. Rates of treatment failure differed significantly in these two groups (3.3% vs 20.0%, p = 0.04).

CONCLUSIONS

The overall failure rate was significantly lower in patients who underwent meniscus repair within 3 weeks than in those who underwent repair at 3 weeks (or more) after the trauma. Thus, early repair of meniscus tears is beneficial, and can prevent failure of meniscus repair surgery.

LEVEL OF EVIDENCE

III.

Second-Look Arthroscopic Evaluation of Healing Rates After Arthroscopic Repair of Meniscal Tears: A Systematic Review and Meta-analysis

Background:

Evaluation of meniscal healing status after repair is important, as it allows the surgeon to inform patients whether they can increase their activities or return to sports.

Purpose:

To identify the healing rates after arthroscopic repair of meniscal tears via second-look arthroscopic evaluation.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Searches of PubMed, Embase, Scopus, and the Cochrane databases were conducted to identify relevant studies published before June 1, 2020. Studies were eligible for this meta-analysis if they provided data regarding healing status of the meniscus at second-look arthroscopy. Random-effects meta-analyses were generated to provide pooled meniscal healing estimates. We further performed subgroup analysis to investigate the healing rates of the meniscus under different situations.

Results:

A total of 41 studies with 1908 individuals were included in the study. The pooled analysis showed the complete healing rate was 74% (95% confidence interval [CI], 67%-80%), the partial healing rate was 10% (95% CI, 6%-16%), and the failure rate was 12% (95% CI, 10%-15%) for arthroscopic repair of meniscal tears via second-look arthroscopic evaluation. Sensitivity analysis demonstrated that no individual study affected the overall healing rate by >1%. Subgroup analysis found higher meniscal healing rates in patients with the following characteristics: age <40 years, male, body mass index <26, red-red tear location, tear in posterior horn, vertical tear, outside-in technique, repair concomitant with anterior cruciate ligament reconstruction, weight-restricted rehabilitation, and time interval from meniscal repair to second-look arthroscopy >12 months.

Conclusion:

In this systematic review, the complete healing rate was 74%, the partial healing rate was 10%, and the failure rate was 12% for arthroscopic repair of meniscal tears via second-look arthroscopic evaluation.

Effects of and Response to Mechanical Loading on the Knee

Mechanical loading to the knee joint results in a differential response based on the local capacity of the tissues (ligament, tendon, meniscus, cartilage, and bone) and how those tissues subsequently adapt to that load at the molecular and cellular level. Participation in cutting, pivoting, and jumping sports predisposes the knee to the risk of injury. In this narrative review, we describe different mechanisms of loading that can result in excessive loads to the knee, leading to ligamentous, musculotendinous, meniscal, and chondral injuries or maladaptations. Following injury (or surgery) to structures around the knee, the primary goal of rehabilitation is to maximize the patient's response to exercise at the current level of function, while minimizing the risk of re-injury to the healing tissue. Clinicians should have a clear understanding of the specific injured tissue(s), and rehabilitation should be driven by knowledge of tissue-healing constraints, knee complex and lower extremity biomechanics, neuromuscular physiology, task-specific activities involving weight-bearing and non-weight-bearing conditions, and training principles. We provide a practical application for prescribing loading progressions of exercises, functional activities, and mobility tasks based on their mechanical load profile to knee-specific structures during the rehabilitation process. Various loading interventions can be used by clinicians to produce physical stress to address body function, physical impairments, activity limitations, and participation restrictions. By modifying the mechanical load elements, clinicians can alter the tissue adaptations, facilitate motor learning, and resolve corresponding physical impairments. Providing different loads that create variable tensile, compressive, and shear deformation on the tissue through mechanotransduction and specificity can promote the appropriate stress adaptations to increase tissue capacity and injury tolerance. Tools for monitoring rehabilitation training loads to the knee are proposed to assess the reactivity of the knee joint to mechanical loading to monitor excessive mechanical loads and facilitate optimal rehabilitation.

All-inside versus inside-out meniscal repair: A systematic review and meta-analysis

BACKGROUND

Meniscal repair using all-inside devices has garnered popularity compared to inside-out repair, yet few studies directly compare the two techniques in terms meniscal healing rates, surgical time, patient outcomes and incidence of complications.

METHODS

A systematic literature review was performed using the Medline, Cochrane and Embase databases. English-language studies comparing all-inside and inside-out arthroscopic meniscal repair techniques directly were included. Randomised controlled trials (RCTs) and observational studies with at least 10 patients in each treatment arm were included. Meta-analyses were performed using a fixed effect (when I2 < 50%) or random effects model (I2 ≥ 50%).

RESULTS

A total of 1042 studies were identified with seven being sui for inclusion (n = 505 patients). These comprised of one RCT two prospective and four retrospective, comparative, observational studies. Meta-analyses demonstrated that there was a significant reduction in operating time favouring all-inside repair (ratio of means [ROM] 0.62, 95% confidence interval [CI] 0.48-0.79; p = 0.0002) based on 3 studies (n = 208 patients). Based on 5 studies (n = 370 patients), there was no significant difference in meniscal healing rates between the groups (OR 1.26, 95% CI 0.52-3.10; p = 0.61). Nerve injury was more common after inside-out repair. There was a 85% reduction in the odds of nerve injury with the all-inside technique (OR 0.15, 95% CI 0.05-0.47; p = 0.0013). A qualitative data analysis suggested no difference in functional outcomes between the two techniques.

CONCLUSIONS

All-inside meniscal repair is associated with reduced operative time and a lower odds of nerve injury complications compared to inside-out repair, without compromising meniscal healing or functional results.

All-inside versus inside-out suture techniques in arthroscopic meniscus repair: A prospective randomized study protocol

BACKGROUND

With advancements in our understanding of meniscal function, treatment options for meniscal injuries have evolved considerably over the past few decades. The aim of the current study was to compare the all-inside and inside-out techniques with regard to retear rate, functional outcomes, and perioperative complications in patients who had undergone arthroscopic meniscus repair. We hypothesized that there was no significant difference between the 2 groups in terms of postoperative outcomes after arthroscopic meniscus repair.

METHODS

This study was a prospective randomized blinded study, with a parallel design and an allocation ratio of 1:1 for the treatment groups. This study was approved by the Institutional Review Board in our hospital and written informed consent was obtained from all subjects participating in the trial. It was carried out in accordance with the principles of the Helsinki Declaration. A total of 70 patients who meet inclusion criteria are randomized to either all-inside or inside-out group. The primary outcome measure was retear rate. Retear was determined by repeat arthroscopic evaluation of patients with follow-up for symptoms of persistent or new pain, catching, or locking that was possibly related to the meniscal repair. Secondary outcomes included disease-specific quality of life measurement with the Western Ontario Meniscal Evaluation Tool, range of motion, operative time, and adverse events at surgery or throughout the follow-up period.

RESULTS

This study has limited inclusion and exclusion criteria and a well-controlled intervention.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5589).

Magnetic resonance imaging can increase the diagnostic accuracy in symptomatic meniscal repair patients

PURPOSE

The purpose of this study was to evaluate meniscal repair healing in symptomatic patients through combined clinical assessment, magnetic resonance imaging (MRI) and re-arthroscopy. This study investigated the diagnostic accuracy of MRI and clinical assessment in determining failed meniscal repair in symptomatic meniscal repair patients, as verified by re-arthroscopy.

METHODS

Eighty patients were included. All had undergone a primary meniscal repair followed by an MRI and re-arthroscopy due to clinical symptoms of a meniscal lesion. A validated semi-quantitative scoring system was employed for identifying MRI-diagnosed healing failure. The clinical assessment was divided into joint swelling, joint-line tenderness, locking and a positive McMurray's test. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MRI and positive clinical findings were calculated using second-look arthroscopy as a standard.

RESULTS

The MRI results showed healing of 22 (27.5%) of the menisci and 58 (72.5%) unhealed menisci, whereas second-look arthroscopy identified 15 (19%) healed menisci and 65 (81%) unhealed menisci. The isolated MRI findings were 0.85, 0.8, 0.95 and 0.55 for sensitivity, specificity, PPV and NPV, respectively. The PPVs of the clinical assessments were 0.78, 0.85 and 0.94, with one, two and three clinical findings, respectively. A grade 3 MRI combined with joint-line tenderness presented a PPV of 0.98.

CONCLUSION

A supplementary MRI will increase diagnostic accuracy when fewer than three clinical findings are present in a symptomatic meniscal repair patient. The clinical relevance of this finding is that MRI contributes to enhancing the diagnostic accuracy of an unhealed meniscal repair when there are limited clinical signs of meniscal pathology.

LEVEL OF EVIDENCE

III.

Evaluation of Midterm Clinical and Radiographic Outcomes of Arthroscopically Repaired Vertical Longitudinal and Bucket-Handle Lateral Meniscal Tears

Background:

Lateral meniscal tears in the stable knee are rare. There are few comparative studies evaluating functional and radiological outcomes of vertical longitudinal and bucket-handle lateral meniscal tears.

Purpose:

To evaluate the midterm clinical and radiological outcomes of arthroscopically repaired traumatic vertical longitudinal and bucket-handle lateral meniscal tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 43 full-thickness lateral meniscal repairs, including 22 (51.2%) for vertical longitudinal tears and 21 (48.8%) for bucket-handle tears, were evaluated. A clinical assessment was performed according to the Barrett criteria, and patient outcomes were measured with the Lysholm knee score, Tegner activity scale, and overall satisfaction scale. Magnetic resonance imaging was used as the radiological re-examination method preoperatively and at final follow-up. A subgroup analysis examining isolated repair versus repair with concurrent anterior cruciate ligament (ACL) reconstruction was performed.

Results:

The mean follow-up period was 63.2 months (range, 24-86 months). Based on clinical and radiological outcomes, 38 of the 43 repairs (88.3%) were successful, and the remaining 5 (11.6%) cases were considered to be failures. Overall, the combined results for both groups demonstrated an improvement in the Lysholm score, Tegner score, and patient satisfaction. There was no significant difference in the postoperative Lysholm score (91.4 vs 87.0, respectively; P = .223), Tegner score (5.4 vs 5.5, respectively; P = .872), or patient satisfaction (7.2 vs 7.4, respectively; P = .624) between bucket-handle repair and vertical longitudinal repair. The subgroup analysis demonstrated no difference in outcome scores for isolated repair versus repair with concurrent ACL reconstruction. Smoking was identified as a risk factor for repair failure.

Conclusion:

Comparable clinical and radiological outcomes were obtained after vertical longitudinal and bucket-handle lateral meniscal repairs using the all-inside or hybrid suture technique with different suture configurations, regardless of whether ACL reconstruction was performed. Smoking was identified as a risk factor for failure.

A Systematic Review and Meta-Analysis of Arthroscopic Meniscus Repair in Young Patients: Comparison of All-Inside and Inside-Out Suture Techniques

Purpose

The purposes of the present study were to review published studies that investigated arthroscopic meniscus repair to treat meniscus injury in young patients and to compare all-inside and inside-out suture techniques.

Methods

Various electronic databases were queried for published articles, and this search was updated in August 2017 for evaluating the outcomes of arthroscopic meniscus surgery in young patients. Data search, extraction, analysis, and quality assessment were performed according to the Cochrane Collaboration guidelines, and the clinical outcomes were evaluated using various outcome values in young patients according to suture techniques.

Results

Three randomized controlled trials and three prospective comparative studies were included in this systematic review and meta-analysis. There were no significant differences in clinical outcomes such as meniscus healing rate (risk ratio [RR], 1.11; 95% confidence interval [CI], 0.90 to 1.37; I²=39%) and perioperative complications (RR, 0.62; 95% CI, 0.23 to 1.72; I²=43%) between all-inside and inside-out techniques for meniscus repair.

Conclusions

The present study shows favorable results for clinical outcomes such as meniscus healing rate and perioperative complications in young patients. Furthermore, based on our results, both all-inside and inside-out meniscal suture techniques are equally effective in these patients.

Rehabilitation following meniscal repair: a systematic review

Objective

To review existing biomechanical and clinical evidence regarding postoperative weight-bearing and range of motion restrictions for patients following meniscal repair surgery.

Methods and data sources

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, we searched MEDLINE using following search strategy: ((((“Weight-Bearing/physiology”[Mesh]) OR “Range of Motion, Articular”[Mesh]) OR “Rehabilitation”[Mesh])) AND (“Menisci, Tibial”[Mesh]). Additional articles were derived from previous reviews. Eligible studies were published in English and reported a rehabilitation protocol following meniscal repair on human. We summarised rehabilitation protocols and patients’ outcome among original studies.

Results

Seventeen clinical studies were included in this systematic review. There was wide variation in rehabilitation protocols among clinical studies. Biomechanical evidence from small cadaveric studies suggests that higher degrees of knee flexion and weight-bearing may be safe following meniscal repair and may not compromise the repair. An accelerated protocol with immediate weight-bearing at tolerance and early motion to non-weight-bearing with immobilising up to 6 weeks postoperatively is reported. Accelerated rehabilitation protocols are not associated with higher failure rates following meniscal repair.

Conclusions

There is a lack of consensus regarding the optimal postoperative protocol following meniscal repair. Small clinical studies support rehabilitation protocols that allow early motion. Additional studies are needed to better clarify the interplay between tear type, repair method and optimal rehabilitation protocol.

The Urgent Need for Evidence in Arthroscopic Meniscal Surgery

BACKGROUND

Arthroscopic surgery of the knee is one of the most frequently performed orthopaedic procedures. One-third of these procedures are performed for meniscal injuries. It is essential that this commonly performed surgery be supported by robust evidence.

PURPOSE

To compare the effectiveness of arthroscopic surgery for meniscal injuries in all populations.

STUDY DESIGN

Systematic review.

METHODS

An online search was conducted for randomized controlled trials (RCTs) and systematic reviews (SRs) that compared treatment options for meniscal injury. The following databases (inception to April 2015) were included in the search: CENTRAL; MEDLINE; EMBASE; NHS Evidence; National Guideline Clearing House, Database of Abstracts of Reviews of Effects, Health Technology Assessment; ISRCTN; Clinicaltrials.gov ; WHO trials platform. Only studies whose participants were selected on the basis of meniscal injury were included; no restrictions were placed on patient demographics. Two independent reviewers applied AMSTAR (A Measurement Tool to Assess Systematic Reviews) criteria for SRs and the Cochrane Collaboration risk-of-bias tool for RCTs.

RESULTS

Nine RCTs and 8 SRs were included in the review. No difference was found between arthroscopic meniscal debridement compared with nonoperative management as a first-line treatment strategy for patients with knee pain and a degenerative meniscal tear (mean difference: Knee injury and Osteoarthritis Outcome Score, 1.6 [95% CI, -2.2 to 5.2], pain visual analog scale, -0.06 [95% CI, -0.28 to 0.15]). Some evidence was found to indicate that patients with resistant mechanical symptoms who initially fail nonoperative management may benefit from meniscal debridement No studies compared meniscal repair with meniscectomy or nonoperative management. Initial evidence suggested that meniscal transplant might be favorable in certain patient groups.

CONCLUSION

Further evidence is required to determine which patient groups have good outcomes from each intervention. Given the current widespread use of arthroscopic meniscal surgeries, more research is urgently needed to support evidence-based practice in meniscal surgery in order to reduce the numbers of ineffective interventions and support potentially beneficial surgery.

Validity, Reliability, and Responsiveness of the Anterior Cruciate Ligament Quality of Life Measure: A Continuation of Its Overall Validation

OBJECTIVE

The purpose is to provide more validity, reliability, and responsiveness testing of the anterior cruciate ligament-quality of life instrument (ACL-QOL), particularly in light of consensus-based standards for the selection of health status measurement instruments (COSMIN) guidelines.

DESIGN

Prospective case series.

SETTING

An orthopedic surgical practice for consultation.

PATIENTS

A convenience sample of 579 ACL-deficient patients.

INTERVENTION

Anterior cruciate ligament reconstructive surgery.

MAIN OUTCOME MEASURES

Patients completed the ACL-QOL at initial visit and underwent reconstructive surgery. Patients were followed at 6, 12, and 24 months using the ACL-QOL to determine its validity and responsiveness. Cronbach's alpha was used to determine the unidimensionality of the ACL-QOL. A subset of patients took the ACL-QOL twice in a test-retest reliability analysis (intraclass correlation coefficient or ICC 2,k). Another subset of 24-month postsurgical patients measured the success of their surgery using a 7-point global rating scale of improvement as an anchor-based method of responsiveness.

RESULTS

Cronbach's alpha coefficients = 0.93, 0.95, 0.96, and 0.98 at 6, 12, and 24 months, respectively. Intraclass correlation coefficient = 0.60, SEM = 6.16, and confidence interval of 12.1 (CI 95%). Responsiveness was measured by comparing the 4 serial time periods. Patients improved significantly at each time period (P < 0.05, ETA squared 0.61). A 24-month ACL-QOL was significantly correlated (P > 0.05) to being "significantly better" or "somewhat better."

CONCLUSIONS

The results of this study added more validity, reliability, and responsiveness for the ACL-QOL. The ACL-QOL has completed 8 of 9 COSMIN criteria.

Surgical interventions for meniscal tears: a closer look at the evidence

INTRODUCTION

The aim of the present study was to compare the outcomes of various surgical treatments for meniscal injuries including (1) total and partial meniscectomy; (2) meniscectomy and meniscal repair; (3) meniscectomy and meniscal transplantation; (4) open and arthroscopic meniscectomy and (5) various different repair techniques.

MATERIALS AND METHODS

The Bone, Joint and Muscle Trauma Group Register, Cochrane Database, MEDLINE, EMBASE and CINAHL were searched for all (quasi) randomized controlled clinical trials comparing various surgical techniques for meniscal injuries. Primary outcomes of interest included patient-reported outcomes scores, return to pre-injury activity level, level of sports participation and persistence of pain using the visual analogue score. Where possible, data were pooled and a meta-analysis was performed.

RESULTS

A total of nine studies were included, involving a combined 904 subjects, 330 patients underwent a meniscal repair, 402 meniscectomy and 160 a collagen meniscal implant. The only surgical treatments that were compared in homogeneous fashion across more than one study were the arrow and inside-out technique, which showed no difference for re-tear or complication rate. Strong evidence-based recommendations regarding the other surgical treatments that were compared could not be made.

CONCLUSIONS

This meta-analysis illustrates the lack of level I evidence to guide the surgical management of meniscal tears.

LEVEL OF EVIDENCE

Level I meta-analysis.

Meniscal pathology - the evidence for treatment

Whilst arthroscopic surgery for the treatment of meniscal tears is the most commonly performed orthopaedic surgery, meniscal tears at the knee are frequently identified on magnetic resonance imaging in adults with and without knee pain. The evidence for arthroscopic treatment of meniscal tears is controversial and lacks a supporting evidence base; it may be no more efficacious than conservative therapies. Surgical approaches to the treatment of meniscal pathology can be broadly categorised into those in which partial menisectomy or repair are performed. This review highlights that the major factor determining the choice of operative approach is age: meniscal repair is performed exclusively on younger populations, while older populations are subject to partial menisectomy procedures. This is probably because the meniscus is less amenable to repair in the older population where other degenerative changes co-exist. In middle-aged to older adults, arthroscopic partial menisectomy (APM) may treat the meniscus tear, but does not address the degenerative whole organ disease of knee osteoarthritis. Thus far, there is no convincing evidence that operative approaches are superior to conservative measures as the first-line treatment of older people with knee pain and meniscal tears. However, in two randomised controlled trials (RCTs) approximately one-third of subjects in the exercise groups had persisting knee pain with some evidence of improvement following APM, although the characteristics of this subgroup are unclear. From the available data, a first-line trial of conservative therapy, which includes weight loss, is recommended for the treatment of degenerative meniscal tears in older adults. The exception to this may be when mechanical symptoms, such as knee locking, predominate. Although requiring corroboration by RCTs, there is accumulating evidence from cohort studies and case series that meniscal repair rather than APM may improve function and reduce the long-term risk of knee osteoarthritis in young adults. There is no clear evidence from RCTs that one surgical method of meniscal repair is superior to another.

Factors associated with meniscus repair in patients undergoing anterior cruciate ligament reconstruction

BACKGROUND

Meniscus injuries are common in patients with anterior cruciate ligament (ACL) tears. Patient demographics, surgeon characteristics, and concurrent diagnostic factors affecting the prevalence of meniscus repairs in patients undergoing ACL reconstruction (ACLR) by community-based orthopaedic surgeons have not been fully studied.

HYPOTHESIS

Patient (age, sex, race, and body mass index [BMI]), surgeon (sports medicine fellowship training status and case volume), and injury characteristics (1 or both menisci injured, injury location, and concurrent cartilage injury) and surgical venue (case volume) are associated with a higher likelihood of meniscus repair.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A cross-sectional study using data from a large community-based ACLR registry was performed. Patients with a meniscus injury and primary ACLR between February 2005 and June 2010 were included in the study. Meniscus repair rates by patient, surgeon, and injury characteristics were described. Associations were evaluated using generalized linear models.

RESULTS

During the study period, 5712 primary ACLRs with a meniscus tear diagnosis were registered. There was 1 torn meniscus in 4248 (74.4%) patients, and both menisci were torn in 1464 (25.6%) patients. Medial meniscus tears were repaired in 1192 (31.2%) of 3818 cases; the remaining 2626 (68.8%) tears were not repaired, underwent alternative treatment (meniscectomy, trephination, rasped), or were left in situ. Lateral meniscus tears were repaired in 893 (26.6%) of 3358 cases; the remaining 2465 (73.4%) tears underwent alternative treatment or were left in situ. Adjusted models showed that younger patient age (P < .001), lower patient BMI (P < .001), surgeon's sports medicine fellowship training (P < .001), higher surgeon case volume (P < .001), higher surgical venue volume (P = .019), and medial meniscus tears (P < .001) were all associated with a higher likelihood of a meniscus repair.

CONCLUSION

Younger patient age, lower patient BMI, surgeon's sports medicine fellowship training, higher surgeon case volume, and higher site volume are associated with a higher likelihood of a meniscus repair in patients undergoing primary ACLR in a large cohort from a community-based ACLR registry.

Cross-sectional analysis of trends in meniscectomy and meniscus repair

Knee arthroscopy to address meniscus tears is among the most common orthopedic procedures performed, and technical advances in the treatment of meniscus tears have affected the treatment options available to orthopedic surgeons. The purpose of this study was to perform a large cross-sectional analysis of orthopedic patients to investigate trends in arthroscopic meniscectomy and meniscus repair in the United States. Patients who underwent arthroscopic meniscectomy (Current Procedural Terminology codes 29881 and 29880) and arthroscopic meniscus repair (Current Procedural Terminology codes 29882 and 29883) were identified using the PearlDiver Patient Record Database, which is a national database of insurance records. The authors identified 187,607 arthroscopic medial or lateral meniscectomies and repairs performed between 2004 and 2009. Ninety-six percent of patients underwent meniscectomy and 4% underwent repair. No change occurred in the incidence of medial or lateral meniscectomy. The incidence of medial meniscus repair decreased from 5.3 cases per 10,000 patients in 2004 to 3.8 in 2009 (P<.001), although no significant change occurred in the incidence of lateral meniscus repair. Medial meniscectomy was most commonly performed in patients aged 50 to 59 years, whereas lateral meniscectomy demonstrated a bimodal age distribution. Conversely, meniscus repairs were most frequently performed in patients aged 10 to 19 years. Sex differences were more pronounced with meniscus repair (63% male vs 37% female) compared with meniscectomy (53% male vs 47% female). A high frequency of meniscus debridement can be expected in arthroscopic knee surgery. Despite advances in meniscus repair techniques and devices, no increase occurred in the performance of meniscus repair compared with meniscectomy.

Rehabilitation following meniscal repair

It has become increasingly more evident that the meniscus plays an important role in contributing to knee joint longevity. Advances in surgical techniques by orthopaedic surgeons to repair traumatized menisci have led to better long term outcomes, decreasing the incidence of articular cartilage degeneration. Advances have also been made in rehabilitative techniques following meniscal repair. These techniques along with sound rehabilitation principles to include a criteria based progression have contributed to excellent outcomes and earlier return to function and sport. The role of the meniscus, recent advances in surgical repair and the current post-operative rehabilitation techniques employed by sports rehabilitation specialists today are discussed.

Meniscal repair in anterior cruciate ligament reconstruction: a long-term outcome study

PURPOSE

To study the long-term outcome of patients who have undergone inside-out, vertical stacked mattress suture repair of meniscal tears combined with anterior cruciate ligament (ACL) reconstruction.

METHODS

From a database of ACL reconstructed patients, consecutive patients undergoing concomitant meniscal repair and ACL reconstruction between 1991 and 1999 were identified. Patients with previous ACL or meniscal pathology were excluded. Two age- and sex-matched cohorts who had undergone combined ACL reconstruction and menisectomy and who had undergone ACL reconstruction with normal menisci were identified for comparison. Outcome scoring included IKDC and Lysholm scores for the meniscal repair group. Two sample t-tests and chi-square tests were used to compare the IKDC subjective scores, with a minimum level of significance set at 5% (P = 0.05).

RESULTS

Fourty-four patients were identified for analysis with a median follow-up of 10 years (7.7-12.6). Patients undergoing ACL reconstruction combined with meniscal repair had a mean IKDC of 84.2 compared with a mean score of 70.5 (P = 0.008) in patients who had undergone menisectomy and 88.2 (P = 0.005) in patients with intact menisci. 86.2% of patients with ACL reconstruction and meniscal repair had Lysholm score of between 80 and 100%. Sixty-nine percent follow-up was achieved. Survival analysis by life table method shows a best case of 89% 10-years survival.

CONCLUSIONS

This study demonstrates that good long-term outcomes can be obtained in patients up to over 12 years after combined ACL reconstruction and meniscal repair. Improved functional scores can be achieved when compared with ACL reconstruction and menisectomy. The authors advocate repair of meniscal tears during ACL reconstruction unless there is complex tearing, radial tearing or plastic deformation of the remaining meniscus.

LEVEL OF EVIDENCE

III.

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.

Diagnostic values of 3 methods for evaluating meniscal healing status after meniscal repair: comparison among second-look arthroscopy, clinical assessment, and magnetic resonance imaging

BACKGROUND

The main diagnostic methods for evaluating repaired menisci include second-look arthroscopy, clinical assessment, and magnetic resonance imaging (MRI). None of the previous studies applied all 3 methods for each consecutive case nor made any systematic comparison among them.

PURPOSE

This study was undertaken to compare the diagnostic values of the 3 different methods in an attempt to propose suggestions for evaluating meniscal healing results.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Eighty-one patients (89 menisci), with a mean age of 25.4 years (standard deviation [SD], 7.7; range, 15-50 years), underwent arthroscopic meniscal repair, including 65 medial menisci and 24 lateral menisci. Follow-up evaluation for each meniscus included clinical assessment, second-look arthroscopy, and postoperative MRI, with a mean follow-up time of 25.4 months (SD, 6.0; range, 17.4-48.3 months). Defined criteria for unhealed meniscus were any symptoms such as joint-line tenderness, swelling, locking, or positive McMurray test for clinical assessment; cleft or instability on second-look arthroscopy; and grade 3 signal intensity shown at the repaired site on postoperative MRI.

RESULTS

Seventy-seven menisci were confirmed completely healed by second-look arthroscopy, with a total healing rate of 86.5%. Clinical assessment found 63 menisci healed, with a clinical healing rate of 70.8% (sensitivity, 58.3%; specificity, 75.3%; accuracy, 73.0%). By using the second-look arthroscopy as the standard, the sensitivity, specificity, and accuracy, respectively, were calculated for MRI in 5 sequences: sagittal T1: 91.7%, 58.4%, 62.9%; sagittal proton density (PD): 83.3%, 40.3%, 46.1%; sagittal T2: 58.3%, 89.6%, 85.4%; coronal PD: 75.0%, 74.0%, 74.2%; and coronal T2: 41.7%, 98.7%, 91.0%.

CONCLUSION

Second-look arthroscopy was the most dependable way to determine meniscal healing. Clinical assessment had obvious limitations in diagnosing healed menisci. On MRI examination, T2-weighted sequences had obviously higher specificity and accuracy, while PD and T1 had higher sensitivity. The diagnostic value could be improved by a combined application of different sequences.

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.

Repair integrity evaluated by second-look arthroscopy after arthroscopic meniscal repair with the FasT-Fix during anterior cruciate ligament reconstruction

BACKGROUND

Although several devices for meniscal repairs have become available, a successful outcome is ultimately due to a healed meniscus on the clinical findings. The authors assessed the repair integrity after meniscal repair with the FasT-Fix device using second-look arthroscopy.

HYPOTHESIS

Meniscal repair with the FasT-Fix will lead to arthroscopically evident healing, but some menisci will show incomplete healing even in clinically successful cases and have newly formed injuries on the meniscal substance resulting from the path of the implant.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Sixty-five consecutive patients were studied, in whom 84 menisci were subjected to all-inside meniscal repair with the FasT-Fix device in conjunction with anterior cruciate ligament reconstruction. Repair was only performed on longitudinal or double longitudinal tears within the red-red or red-white zone. The repaired menisci were evaluated by second-look arthroscopy at the time of staged hardware removal after anterior cruciate ligament reconstruction.

RESULTS

Sixty-two meniscal tears in 46 patients were available for this study. Eight patients were found to be symptomatic and considered to be clinical failures. The clinical success rate was 83%. At second-look arthroscopy, 46 tears (74%) were healed, 9 (15%) were healed incompletely, and 7 (11%) had failed. In the failed menisci, 1 had meniscal symptoms, while the other 6 were asymptomatic. In the 9 menisci with incomplete healing, 3 were associated with nonspecific knee pain but none showed meniscal symptoms. Newly formed injuries, which occurred in an area different from the original repair site, were confirmed on the surface of 19 menisci (35%) among the healed and incompletely healed menisci. Thirty menisci (48%) displayed successful and complete healing of the original tear site without newly formed tears.

CONCLUSION

Meniscal repair with the FasT-Fix in conjunction with anterior cruciate ligament reconstruction resulted in complete healing in 74% of cases. Eighty-three percent of menisci were symptom-free regardless of meniscal integrity. Even when the menisci repaired are asymptomatic and considered to be a clinical success, however, there may be newly formed injuries.

2009 survey results: surgeon practice patterns regarding arthroscopic surgery

A survey was conducted to collect information on the surgical management and practice preferences of the audience members at a recent continuing medical education conference. Participants were polled on a variety of surgical topics, and their responses were recorded using a wireless audience response system. The answers were tabulated and are presented in this report. The majority of respondents preferred an arthroscopic repair for rotator cuff tears (52%) and shoulder instability (71%). Most (50%) perform single-row repair; 33% perform double-row repair. For simple knee arthroscopy, most use preoperative antibiotics (85%), no tourniquet (53%), and no chemical anticoagulation or only compression boots (69%). For cruciate ligament reconstruction, the majority preferred only a preoperative antibiotic (67%), no chemical anticoagulation or only compression boots (56%), and single-bundle reconstruction (88%) using a transtibial femoral tunnel (78%). Most (47%) prefer an all inside suture-based meniscus repair device.

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.

Success of meniscal repair at anterior cruciate ligament reconstruction

BACKGROUND

Meniscal repair is performed in an attempt to prevent posttraumatic arthritis resulting from meniscal dysfunction after meniscal tears. The socioeconomic implications of premature arthritis are significant in the young patient population. Investigations and techniques focusing on meniscus preservation and healing are now at the forefront of orthopaedic sports medicine.

HYPOTHESIS

Concomitant meniscal repair with anterior cruciate ligament reconstruction is a durable and successful procedure at 2-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All unilateral primary anterior cruciate ligament reconstructions entered in 2002 in a cohort who had meniscal repair at the time of anterior cruciate ligament reconstruction were evaluated. Validated patient-oriented outcome instruments were completed preoperatively and then again at the 2-year postoperative time point. Reoperation after the index procedure was also documented and confirmed by operative reports.

RESULTS

A total of 437 unilateral primary anterior cruciate ligament reconstructions were performed with 82 concomitant meniscal repairs (54 medial, 28 lateral) in 80 patients during the study period. Patient follow-up was obtained on 94% (77 of 82) of the meniscal repairs, allowing confirmation of meniscal repair success (defined as no repeat arthroscopic procedure) or failure. The overall success rate for meniscal repairs was 96% (74 of 77 patients) at 2-year follow-up.

CONCLUSION

Meniscal repair is a successful procedure in conjunction with anterior cruciate ligament reconstruction. When confronted with a "repairable" meniscal tear at the time of anterior cruciate ligament reconstruction, orthopaedic surgeons can expect an estimated >90% clinical success rate at 2-year follow-up using a variety of methods as shown in our study.

Healing of meniscal tissue by cellular fibrin glue: an in vivo study

Menisci represent fundamental structures for the maintenance of knee homeostasis, playing a key role in knee biomechanics. However, their intrinsic regenerative potential is poor. As a consequence, when a lesion occurs and the meniscus is partially removed by surgery, knee mechanics is subject to dramatic changes. These have been demonstrated to lead often to the development of early osteoarthritis. Therefore, menisci should be repaired whenever possible. In the last decades, tissue engineering approaches have been advocated to improve the reparative processes of joint tissues. In this study, the bonding capacity of an articular chondrocytes-fibrin glue hydrogel was tested as a biologic glue to improve the bonding between two swine meniscal slices in a nude mouse model. The composites were wrapped with acellular fibrin glue and implanted in subcutaneous pouches of nude mice for 4 weeks. Upon retrieval, a firm gross bonding was observed in the experimental samples while none of the control samples, prepared with acellular fibrin glue at the interface, presented any sign of bonding. This was consistent with the histological and scanning electron microscope findings. In particular, a fibrocartilaginous tissue was found at the interface between the meniscal slices, partially penetrating the native meniscus tissue. In order to overcome the lack of regenerative properties of the meniscus, the rationale of using cellular fibrin glue is that fibrin provides immediate stability while carrying cells in the site of lesion. Moreover, fibrin gel is recognized as an optimal scaffold for cell embedding and for promoting fibrocartilaginous differentiation of the cells which synthesize matrix having healing property. These results demonstrated the potential of this model for improving the meniscal bonding. However, further orthotopic studies in a large animal model are needed to evaluate its potential for clinical application.

Biomechanical testing of a shape memory alloy suture in a meniscal suture model

PURPOSE

The purpose of this study was to evaluate the biomechanical results of meniscal repair in vitro by a nitinol suture and compare them with Ethibond (Ethicon, Somerville, NJ) and nylon.

METHODS

The 6 testing groups consisted of nitinol, Ethibond, and nylon sutures (No. 2-0 and No. 3-0). Sixty bovine menisci with a vertical longitudinal tear were repaired with 1 horizontal mattress suture and were fully immersed into a water bath, adjusted to a tensile testing machine. All specimens were subjected to tensile testing, and force/displacement curves were obtained. Load to 5-mm gap, load to failure, tensile strength, stiffness, and mode of failure for each suture group were recorded. Statistical analysis included analysis of variance with Bonferroni correction for the post hoc multiple comparisons.

RESULTS

Nylon sutures achieved the lowest scores in all measurements. Nitinol achieved better scores, but not significantly better scores, than Ethibond in load to 5-mm gap and stiffness. The No. 2-0 and No. 3-0 nitinol suture repair showed the highest mean tensile strength and load to failure, with significant differences, being 36% and 45% stronger, respectively, than Ethibond. Modes of failure included pulling through the inner segment of meniscus and rupture of the suture at the knot.

CONCLUSIONS

This study shows the superior load-to-failure and tensile strength characteristics of nitinol. However, in terms of stiffness and gap resistance force, the results were equivalent to those of Ethibond. Nitinol is an interesting and promising suture.

CLINICAL RELEVANCE

Nitinol can be elongated and become soft and flexible for proper suturing at low temperature. At body temperature, it can contract to its original length, providing stronger knots. This may result in more efficient primary stability of meniscal repair, minimizing the chances of loosening during healing and allowing earlier rehabilitation.

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.