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

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.

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.

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.

Using a Combined All-Inside, Inside-Out, and Outside-In Technique to Repair Bucket-Handle Medial Meniscal Tears Without a Safety Incision

We describe a combined all-inside, inside-out, and outside-in technique for the repair of unstable bucket-handle medial meniscal tears. Notably, a greater incidence of neurovascular complications has been associated with meniscal repair techniques that employ an accessory skin incision, especially when damage involves the body of the medial meniscus. However, with the operative knee in relative extension, passing inside-out needles anteromedial to the posterior horn and posterior to the semitendinosus tendon and saphenous nerve allows for the needles to exit the posteromedial knee through a "safe zone." Therefore, we reduce iatrogenic damage by avoiding the necessity of a large safety incision while still maintaining suture placement versatility and meniscal fragment stabilization. Thus, the objective of this Technical Note is to outline an efficient technique for treating bucket-handle medial meniscal tears that yields a strong, durable repair while avoiding damage to adjacent neurovascular structures and eliminating the need for a posteromedial safety incision.

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.

The meniscal tear outcome (METRO) review: A systematic review summarising the clinical course and outcomes of patients with a meniscal tear

BACKGROUND

Meniscal tears affect 222 per 100,000 of the population and can be managed non-operatively or operatively with an arthroscopic partial meniscectomy (APM), meniscal repair or meniscal transplantation. The purpose of this review is to summarise the outcomes following treatment with a meniscal tear and explore correlations between outcomes.

METHOD

A systematic review was performed of MEDLINE, EMBASE, AMED and the Cochrane Central Register of Controlled Trials to identify prospective studies describing the outcomes of patients with a meniscal tear. Comparisons were made of outcomes between APM and non-operative groups. Outcomes were graphically presented over time for all treatment interventions. Pearson's correlations were calculated between outcome timepoints.

RESULTS

35 studies were included, 28 reported outcomes following APM; four following meniscal repair and three following meniscal transplant. Graphical plots demonstrated a sustained improvement for all treatment interventions. A moderate to very strong correlation was reported between baseline and three-month outcomes. In the medium term, there was small significant difference in outcome between APM and non-operative measures (SMD 0.17; 95 % CI 0.04, 0.29), however, this was not clinically significant.

CONCLUSIONS

Patients with a meniscal tear demonstrated a sustained initial improvement in function scores, which was true of all treatments examined. APM may have little benefit in older people, however, previous trials did not include patients who meet the current indications for surgery as a result the findings should not be generalised to all patients with a meniscal tear. Further trials are required in patients who meet current operative indications.

Long-term follow-up of bucket-handle meniscal repairs: chondroprotective effect outweighs high failure risk

PURPOSE

Outcomes after repair of bucket-handle meniscal tears tend to be satisfying in the short-term follow-up. However, the literature is scarce regarding long-term data following repair of bucket-handle meniscal tears. The aim of this study was to assess long-term follow-up outcomes, focusing on knee osteoarthritis (OA) development and failure rate, and determine risk factors associated with failure.

METHODS

This is a retrospective cohort study, including all patients with bucket-handle tears within 4 mm of the menisco-synovial junction, who underwent meniscal repair, either isolated or combined with anterior cruciate ligament reconstruction (ACLR) between 2004 and 2015. A combination of all-inside, outside-in, and inside-out repair technique was used in all patients. Patients over 40 years old, concomitant multi-ligamentous injuries, and severe cartilage lesions documented intraoperatively were excluded. During the follow-up, a meniscus was considered healed using Barrett's criteria, while knee OA evaluation was performed according to Kellgren-Lawrence (KL) classification using standing knee radiographs. Patients were assessed preoperatively as well as postoperatively in terms of knee function using International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

In total, the inclusion criteria were met by 66 patients. Median age at the time of operation was 21.9 years (13-39). Median follow-up was 114 (62-176) months. Total failure rate was approximately 33% at median time of 19 (6-39) months. Osteoarthritis was statistically significantly more prevalent in patients with failed repairs (mean KL score: 2.09) in comparison to patients with successful repairs (mean KL score: 0.54) p = 0.001. In addition, successful repairs were associated with higher KOOS score as compared with failed repairs (mean ± SD, 89.6 ± 4.6 vs 77.8 ± 4.9 p < 0.001), higher IKDC score (mean ± SD, 88.2 ± 5.1 vs 79.2 ± 5.2 p < 0.001), and Lysholm score (mean ± SD, 90.3 ± 5.3 vs 78.4 ± 7.8 p < 0.001). Patients with medial meniscus repair had 4.8 higher relative likelihood of failure compared to lateral meniscus [p = 0 .014, OR = 4.8 (95% Cl 1.2, 18.6)]. Patients over 16 years old had 5.7 higher relative likelihood of failure [p = 0 .016, OR = 5.7 (95% Cl 0.04, 0.85)]. Concurrent ACLR did not have a significant effect on the postoperative outcomes.

CONCLUSION

A high rate of clinical failure was observed after meniscal repair of bucket-handle tears. However, successful treatment led to lower rates of knee OA development and better knee function, approximately 10 years postoperatively. Meniscal repair of bucket-handle tears is recommended to improve knee function and prevent knee OA in young patients.

LEVEL OF EVIDENCE

III.

Outcomes of pediatric anterior cruciate ligament reconstructions in patients with and without bucket handle meniscus repairs

The purpose of this study was to report the outcomes of concomitant bucket handle meniscal tear (BHMT) repair and anterior cruciate ligament (ACL) reconstruction and to compare the outcomes with those after isolated ACL reconstruction in patients aged ≤16 years. Patients in our database from 2013 to 2017 were retrospectively analyzed. Patients were assigned to one of two treatment groups based on the presence of BHMTs: no meniscal tear group (group A) and BHMT group (group B). All BHMTs were repaired using the combined inside-out with all-inside technique. This study included 64 knees divided into two groups: 47 knees in group A and 17 knees in group B. There was a significant difference in the interval between ACL injury and surgery between groups A and B (69 vs. 150 days, respectively; P < 0.001). Mean postoperative International Knee Documentation Committee and Lysholm scores in group A were slightly, although significantly, improved compared to those in group B (96.5 vs. 92.6, respectively; P < 0.05, and 98 vs. 95, respectively; P < 0.05). There were no significant differences in postoperative anteroposterior laxity and graft failure rate between the groups. In group B, four patients (23.5%) required surgery for incomplete meniscal healing. Postoperative International Knee Documentation Committee and Lysholm scores of patients with BHMTs were significantly lower than those of patients without any meniscal tear, although with significant improvement in the amount of instability. Level of evidence was Level III.

Intra-substance meniscal changes and their clinical significance: a meta-analysis

The degeneration of radial tie fibres of the central meniscal layer, and thinning of its lamellar layer results in increased intensity signals on magnetic resonance imaging, making it difficult to differentiate from true meniscal tear. This study aimed to assess the rate of encountered MRI grades 1 and 2 intrasubstance meniscal changes, and to set guidelines to report these changes based on predicted clinical outcome. A systematic review approach was employed using search engines, libraries, and databases (Google Scholar, ERIC, PubMed, and Medline) to search for scholarly sources on meniscal lesions and their significance in MRI published between 1 January 2000 and 30 June 2019. It retrieved 2750 abstracts, out of which 2738 were excluded and 13 studies meeting inclusion criteria were meta-analysed. It found an association between intrasubstances meniscal changes and outcomes. It resulted that intrasubstance meniscal changes were preservable through the protective functioning of the meniscus. Other than weight gain, no other significant risk factor of developing true meniscal tears later in life was found. It is important to examine intrasubstance meniscal change when patients suffer from mechanical meniscal symptoms especially in old age.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Incidence and Risk Factors for Meniscal Cyst After Meniscal Repair

PURPOSE

To investigate the incidence of magnetic resonance imaging-confirmed cyst formation after meniscal repair and to analyze associated risk factors.

METHODS

This retrospective study included cases repaired arthroscopically with the all-inside (AI) technique (using suture anchors) and/or the inside-out (IO) technique between October 2008 and December 2014. A meniscal cyst was detected on T2 fat-suppressed magnetic resonance images. All cases were divided into 3 groups according to the repair method (AI, IO, and combined technique). The incidence of radiographically confirmed meniscal cyst formation in each group and the associated risk factors (age, sex, AI device, medial meniscus, Tegner activity scale preinjury) were analyzed.

RESULTS

A total of 102 menisci in 96 knees were evaluated. The mean follow-up period was 3.8 (range, 2-8) years. The mean patient age was 21.0 (range, 6-53) years. Thirty cases were in the AI group, 60 in the IO group, and 12 in the combined group. Demographically, there were significant differences among groups regarding the number of medial, lateral, and discoid tears; concomitant anterior cruciate ligament tears; Tegner scale; and suture number. Meniscal cysts developed in 14 of 102 cases. Two of the 14 cysts were symptomatic, requiring open cystectomy. The incidence of meniscal cyst was significantly higher in the AI group (12 of 30, 40%) than in the IO group (1 of 60, 1.7%) or the combined-technique group (1 of 12, 8.3%) (P < .001). Both symptomatic cysts were in the AI group and were in continuity with the anchors. Medial meniscus tear (odds ratio = 6.92) and the use of AI suture anchors (odds ratio = 15.03) significantly increased the risk of cyst formation.

CONCLUSIONS

The incidence of meniscal cysts after arthroscopic meniscal repair was 1.7% to 40.0%, depending on the surgical method. Medial meniscus tears and use of an AI device are suggested as risk factors for cyst formation in this retrospective study.

LEVEL OF EVIDENCE

Level Ⅲ, retrospective comparative study.

One-Third of Meniscal Tears Are Repairable: An Epidemiological Study Evaluating Meniscal Tear Patterns in Stable and Unstable Knees

PURPOSE

To analyze, in a long series of patients with knee injuries, the meniscal tear patterns in both stable and unstable knees to ascertain the exact proportion of such injuries that could have been repaired.

METHODS

A descriptive cross-sectional study was undertaken by reviewing the clinical reports of arthroscopic knee operations carried out in 1 hospital. A total of 2,066 consecutive patients were included in the study. An analysis of clinical and anatomical data of knee lesions, including the shape of the meniscal tears and the surrounding injuries, was performed.

RESULTS

Out of all meniscal tears, 34.9% were found to be repairable, a figure that rose to 55.6% in those tears accompanied by anterior cruciate ligament injuries; 37% of meniscal tears in male patients were repairable, and 28% in their female counterparts; 38.2% of medial meniscal tears were repairable and 30.6% in their lateral counterparts. The most frequently encountered injury was the complex tear (46.9%).

CONCLUSIONS

Our study concludes that, according to current standard indications, 34.9% of all meniscal injuries offer the potential for repair. Where the injury is also accompanied by anterior cruciate ligament damage, the proportion of repairable tears rises to 55.6%. This information should increase the interest for meniscal preservation in the future.

LEVEL OF EVIDENCE

Level IV, case series.

Short-Term Outcomes of Percutaneous Trephination with a Platelet Rich Plasma Intrameniscal Injection for the Repair of Degenerative Meniscal Lesions. A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study

Meniscal tears are the most common orthopaedic injuries, with chronic lesions comprising up to 56% of cases. In these situations, no benefit with surgical treatment is observed. Thus, the purpose of this study was to investigate the effectiveness and safety of percutaneous intrameniscal platelet rich plasma (PRP) application to complement repair of a chronic meniscal lesion. This single centre, prospective, randomized, double-blind, placebo-controlled study included 72 patients. All subjects underwent meniscal trephination with or without concomitant PRP injection. Meniscal non-union observed in magnetic resonance arthrography or arthroscopy were considered as failures. Patient related outcome measures (PROMs) were assessed. The failure rate was significantly higher in the control group than in the PRP augmented group (70% vs. 48%, P = 0.04). Kaplan-Meyer analysis for arthroscopy-free survival showed significant reduction in the number of performed arthroscopies in the PRP augmented group. A notably higher percentage of patients treated with PRP achieved minimal clinically significant difference in visual analogue scale (VAS) and Knee injury and Osteoarthritis Outcome Score (KOOS) symptom scores. Our trial indicates that percutaneous meniscal trephination augmented with PRP results in a significant improvement in the rate of chronic meniscal tear healing and this procedure decreases the necessity for arthroscopy in the future (8% vs. 28%, P = 0.032).

Outcomes After the Operative Treatment of Bucket-Handle Meniscal Tears in Children and Adolescents

Background:

Bucket-handle meniscal tears (BHMTs), which we define as vertical longitudinal tears of the meniscus with displacement of the torn inner fragment toward the intercondylar notch region, are a well-recognized tear pattern. Optimizing the management of BHMTs in younger patients is important, as preserving meniscal tissue may limit future joint degeneration.

Purpose/Hypothesis:

The purpose of this study was to review the patient demographics, clinical presentation, operative details, outcomes, and risk factors for a reoperation associated with operatively treated BHMTs in a pediatric population. We hypothesized that the repair of BHMTs in adolescents would yield a higher reoperation rate than meniscectomy in our population.

Study Design:

Case-series; Level of evidence, 4.

Methods:

A departmental database was queried to identify all patients 19 years or younger who presented with a BHMT and underwent surgery between October 2002 and February 2013. Clinical, radiological, and surgical data were retrospectively collected, and risk factors for a reoperation and persistent pain were assessed in all patients with longer than or equal to 6 months of follow-up.

Results:

A total of 280 BHMTs were treated arthroscopically by 1 of 8 sports medicine fellowship–trained surgeons. The mean age at surgery was 15.5 ± 2.5 years (range, 2.1-19.2 years), and most patients were male (177/280; 63%). Most injuries occurred during sports (203/248; 82%) and involved the medial meniscus (157/280; 56%). Concurrent anterior cruciate ligament (ACL) surgery was performed in 103 cases (37%). Meniscal repair was performed in 181 cases (65%) and was more common in younger patients (P = .01) and for the lateral meniscus (P < .001). Among 185 (66%) cases with longer than or equal to 6 months of adequate follow-up data (which included 126 meniscal repairs [68%]), a meniscus-related reoperation occurred in 45 (24%) cases. A reoperation related to the original BHMT injury or surgery was more common after meniscal repair than after meniscectomy (40/126 [32%] vs 5/59 [8%], respectively) (P = .001) and less common with concurrent ACL surgery (P = .07), although this was not statistically significant. Among patients injured during sports and with adequate follow-up, all but 1 patient (176/177; 99%) returned to sports; a slower rate of return was seen in those undergoing meniscal repair (P = .002) and concurrent ACL surgery (P < .001). At final follow-up, 170 of 185 patients (92%) were pain free. For the 15 patients with persistent pain at final follow-up, no identifiable risk factors for persistent pain were identified.

Conclusion:

Most BHMTs in younger patients occurred in males and during sports and affected the medial meniscus. Concurrent ACL surgery was indicated in approximately one-third of cases and was associated with a lower reoperation rate and slower return to sports. Two-thirds of patients underwent meniscal repair, over two-thirds of whom did not require a reoperation during the study period, despite the high activity levels in this age group.

Caracterização de pinos da blenda poli(L-co-D,L ácido láctico)/poli(caprolactona triol) (PLDLA/PCL-T) e análise das propriedade mecânicas dos pinos durante degradação in vitro

Resumo Os dispositivos de fixação óssea, metálicos convencionais, usados em cirurgia crâniomaxilofacial têm apresentado alguns problemas, tais como, corrosão, inflamação e infecção, além de neoformação de estrutura óssea mecanicamente inferior devido à atrofia gerada pela diferença de módulo elástico entre metal e osso, razões que têm levado ao aumento do interesse por dispositivos poliméricos bioarreabsorvíveis. Os polímeros biorreabsorvíveis mais utilizados nesta aplicação pertencem à família dos poli (α-hidroxi ácidos), que têm como característica degradarem por hidrólise de suas ligações ésteres, tal como copolímero poli (L-ácido láctico-co-D, L ácido láctico), PLDLA. Neste trabalho foram investigados alguns efeitos da adição de poli (caprolactona triol), PCL-T sobre PLDLA. Foram preparados pinos por fusão de blendas nas seguintes composições 100/0, 90/10, 70/30 and 50/50 (m/m), PLDLA/PCL-T. Os pinos foram caracterizados por diferentes técnicas (DSC, MEV e ensaio mecânico). A degradação in vitro dos pinos foi investigada, sendo observado que a adição de PCL-T no PLDLA modificou suas propriedades mecânicas e morfológicas. Tais mudanças podem apresentar potencial para outras aplicações do material, onde a questão da flexibilidade se faça necessária.

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.

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.

Regeneration of knee joint menisci – methods review

At present, there is no need to convince anyone that menisci are crucial structures dealing with a huge number of responsibilities, and its absence in a knee joint results in irretrievable chondral damage. A lot of methods have been recently developed to treat meniscal tears: physical therapy as a first and, for some cases, a last step, bonding by biodegradable sutures, screws, or arrows, collagen and polyurethane scaffolds designed for partial meniscus replacement, and finally allograft transplantation. However, all of them have numerous limitations and can be used in specific conditions only. That is the reason why partial and total meniscectomy is up to this time a common operation in the case of degenerative or complex meniscus tears despite its well-known degenerative consequences. Trials to overcome those limitations are ongoing, and the challenge to invent a long-term successful regeneration method or to design a substitute that well mimics an anatomical meniscus is still in front of us.

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.

Outcomes after repair of chronic bucket-handle tears of medial meniscus

PURPOSE

The purpose of this study was to determine the outcomes after repair of chronic bucket-handle medial meniscal tears by use of magnetic resonance imaging, clinical examination, and patient-reported outcomes.

METHODS

A retrospective review of patients with chronic bucket-handle medial meniscal tears that had been repaired with meniscal sutures was undertaken. The following criteria for inclusion were adopted: minimum tear length of 2 cm and chronic medial meniscal tear identified at the time of arthroscopy. The tears were susceptible to dislocation with probing. Data collected included demographic, clinical, radiologic, and surgical data. Postoperative healing was assessed with the clinical criteria of Barrett et al. The International Knee Documentation Committee rating, Lysholm score, and Tegner activity level were determined, and postoperative magnetic resonance imaging was used to evaluate healing in accordance with the criteria of Henning et al.

RESULTS

Twenty-four patients fulfilled the inclusion criteria. The mean time from injury to surgery was 10 months (range, 2 to 60 months). Sixteen patients underwent anterior cruciate ligament reconstruction, 1 patient underwent posterior cruciate ligament reconstruction, and 6 patients underwent meniscus repair only. A median of 5 sutures (range, 3 to 6 sutures) were used for repair. Four cases (all of which had undergone meniscus repair only) required revision. Complete healing was achieved in 83% of cases according to the criteria of Barrett et al. The mean follow-up time was 48 months (range, 24 to 112 months). An International Knee Documentation Committee rating of A or B was achieved in the 20 patients who did not require revision. The median Lysholm score was 95 (range, 92 to 100). The median Tegner activity level before injury was 7, and it remained unchanged after surgery in all cases.

CONCLUSIONS

This study showed that repair of chronic bucket-handle meniscal tears can lead to good clinical outcomes and a relatively low (17%) failure rate. In addition, repairs of isolated meniscal tears had a significantly higher risk of failure than repairs performed in conjunction with anterior cruciate ligament reconstruction.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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.

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.

Meniscal repair

Historically, treatment of meniscus tears consisted of complete meniscectomy. Over the past few decades, however, the long-term morbidities of meniscal removal, namely the early development of knee osteoarthritis, have become apparent. Thus, management of meniscal tears has trended toward meniscal preservation. Recent technological advances have made repairs of the meniscus easier and stronger. In addition, adjunctive therapies used to enhance the healing process have advanced greatly in the past few years. Today, with increased understanding of the impact of meniscal loss and the principles of meniscal repair and healing, meniscal preservation is viewed as an increasingly realistic and important goal in the management of meniscus tears.

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.

Comparison of inside-out and all-inside techniques for the repair of isolated meniscal tears: a systematic review

BACKGROUND

Arthroscopic meniscal repair techniques are continuing to evolve. Most studies to date comparing the healing rate of inside-out to all-inside meniscal repair techniques are confounded by associated anterior cruciate ligament reconstruction or deficiency.

PURPOSE

This review was conducted to compare the effectiveness and complications of the inside-out repair technique to that of the all-inside repair technique in isolated unstable peripheral longitudinal ("bucket-handle") meniscal tears.

STUDY DESIGN

Systematic review.

METHODS

Computerized keyword searches of MEDLINE, EMBASE, CINAHL, ACP Journal Club, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were performed. Two reviewers independently performed searches and article reduction. Studies that included stratified data for isolated unstable longitudinal meniscal tears in stable knees, repaired with either an inside-out or all-inside repair technique, were selected. Data on clinical failure, subjective outcome measures, and complications were summarized.

RESULTS

Nineteen studies included data specific to isolated meniscal tears. The rate of clinical failure was 17% for inside-out repairs and 19% for all-inside repairs. Lysholm scores and Tegner activity scores were similar between the 2 repair methods (87.8 vs 90.2 and 5.6 vs 5.5, respectively). The prevalence of nerve injury/irritation was higher with the inside-out technique (9% vs 2%). All-inside techniques had a higher rate of local soft tissue irritation, swelling, and implant migration or breakage. The use of older generation, rigid, all-inside implants is associated with chondral injury.

CONCLUSION

There are no differences in clinical failure rate or subjective outcome between inside-out and all-inside meniscus repair techniques. Complications are associated with both techniques. More nerve symptoms are associated with the inside-out repair and more implant-related complications are associated with the all-inside technique.

CLINICAL RELEVANCE

Rates of structural healing and complications are comparable for inside-out and all-inside repair techniques for isolated meniscal injury. Differences in observed healing rates after meniscal repair may be more dependent on tear pattern and associated anterior cruciate ligament reconstruction rather than an inside-out versus all-inside surgical approach.

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.

Proliferation of meniscal fibrochondrocytes cultured on a new polyurethane scaffold is stimulated by TGF-β

The aim of this study was to investigate if newly developed polyurethane (PU) scaffolds are suitable as scaffold for cell-seeded meniscus tissue engineered constructs. Scaffolds were seeded with goat meniscal fibrochondrocytes and cultured to assess changes in biological and mechanical properties. Furthermore, the effect of TGF-β on these properties was investigated. PU scaffolds were made from poly d/l lactide and caprolactone as soft segments and 1,4-butanediisocyanate for the urethane hard segments. The porosity of the scaffolds was 95%. Isolated goat meniscal fibrochondrocytes were seeded on the scaffolds and cultured with or without the addition of 10 ng/mL TGF-β in standard culture medium. After 2, 4, and 6 weeks of culture, scaffolds were analyzed for cell proliferation, matrix synthesis, and mechanical properties. Scanning electron microscopy and histology showed that the scaffolds had an interconnected isotropic pore structure. Without the addition of TGF-β, cells did not proliferate during the culture period and isolated meniscus fibrochondrocytes were more frequently located in the peripheral parts of the scaffold. Fibrochondrocytes supplemented with TGF-β were distributed throughout the construct. Clustered cells were surrounded by matrix which stained slightly positive for glycosaminoglycans (GAGs). Also, collagen production was increased significantly after 4 and 6 weeks of culture compared to cultures without TGF-β and also more GAG staining was found after 4 and 6 weeks in the sections of the TGF-β stimulated cultures. Despite the increase in matrix production, the compressive stiffness of the constructs was not increased during the culture period. Meniscal fibrochondrocytes were able to adhere to the PU scaffold. However, the scaffold itself does not stimulate proliferation and matrix production. The addition of TGF-β resulted in a strong induction of both proliferation and extracellular matrix production.