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

Repair of radial tears of the lateral meniscus on a stable knee: Results at a minimum follow-up of 2 years

INTRODUCTION

In younger patients, meniscal repair is recommended for isolated lateral meniscus tears that are most often due to acute trauma. But there is little published data on the outcomes of repairing this specific type of lesion. The goal of this study was to evaluate the clinical outcomes, report the failure rate of repairing radial tears of the lateral meniscus in stable knees and determine the risk factors for failure.

MATERIALS AND METHODS

All patients who had a stable knee and underwent arthroscopic repair of a radial lateral meniscus tear between April 2013 and December 2019 were reviewed retrospectively. Failure was defined as revision surgery for recurrence of symptoms (pain, locking) with intraoperative confirmation that the meniscus did not heal. The following data were collected: demographics (age, sex, BMI), time to surgery, clinical outcome scores (Tegner, Lysholm, IKDC), surgical details (repair technique, lesion zone, number of sutures).

RESULTS

Thirty patients were included having a mean age of 20.1years (14-31). The follow-up ranged from 24 to 110months (mean 66.8±25.2). An all-inside repair was done in 6 patients (20%); an outside-in technique was done in 17 patients (57%) and a combination of all-inside and outside-in was done in 7 patients (23%). Four patients (13%) had a recurrence of their symptoms later on, while participating in sports. All the recurrences were at the initial tear site. The time to revision surgery was 16, 19, 24 and 37months in these four patients (mean 24±9). All the other patients were able to resume sports at their pre-injury level. Significant improvement in the IKDC, Lysholm and Tegner functional scores were found between the preoperative and postoperative assessments. No statistically significant risk factors for failure were identified.

DISCUSSION

The functional healing rate after repair of a radial lateral meniscus tear in a stable knee was 86% at a mean follow-up of 5years, with the surgical technique having no impact on the long-term result. Most of the failures occurred within 2years of the repair procedure. We recommend repairing these tears as they have considerable healing potential.

LEVEL OF EVIDENCE

IV; retrospective observational cohort study.

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.

[Current approach in the follow-up treatment of joint-preserving operations on the knee joint in German-speaking countries]

INTRODUCTION

Postoperative follow-up after joint-preserving knee surgery involves conventional physiotherapy as well as other approaches and devices such as CPM and CAM splints, TENS devices, BFR exercise, prehabilitation, and digital health applications. The aim of this survey was to investigate current standards, trends and control methods in postoperative care to identify fields of concern and to compare them with the current literature.

MATERIAL AND METHODS

We conducted a structured anonymous online survey of specialists in orthopaedics and trauma surgery listed by the German-speaking Society for Arthroscopy and Joint Surgery (AGA). The questionnaire included 36 closed-ended questions on the follow-up of joint-preserving surgery of the knee joint.

RESULTS

Questionnaires from 528 participants with long-term professional experience (86.6% with more than 10 years) were analysed. Standardised post-treatment schemes are used by 97.2% and their evidence is estimated to be high (59.1%) / very high (14.8%). Problems of rehabilitation are seen in 10-20% of cases by 87.3% (persistent muscular atrophy 30.9%). After reconstructive surgery, CPM splints (70.1%), CAM splints (42.1%), orthoses (85.0%) and TENS devices (40.0%) are prescribed. More potent approaches for the treatment of postoperative muscle deficits are desired by 89.4%. BFR exercise is known by 41.7% and is used regularly by 8%. Communication with treating physiotherapists is infrequent (written: 27.5%). Digital rehabilitation management would be supported by 83.3%; 22.7% are not aware of digital health applications. 87.9% of participants believe that prehabilitation can affect postoperative outcomes.

CONCLUSION

Follow-up of knee joint-preserving surgeries is usually standardised and regularly reviewed for up-to-date evidence. The evidence for recommendations made is considered high. Orthoses are usually used after reconstructive surgery, persistent muscle atrophy is a major problem, BFR training is only known to a limited extent, and there is currently a lack of standardised training protocols. Communication with physiotherapists needs to be improved. Digital rehabilitation management is rarely used but would be supported by the majority of surgeons.

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.

Current Practices for Rehabilitation After Meniscus Repair: A Survey of Members of the American Orthopaedic Society for Sports Medicine

Background

There is no consensus among sports medicine surgeons in North America on postoperative rehabilitation strategy after meniscus repair. Various meniscal tear types may necessitate a unique range of motion (ROM) and weightbearing rehabilitation protocol.

Purpose

To assess the current landscape of how sports medicine practitioners in the American Orthopedic Society for Sports Medicine (AOSSM) rehabilitate patients after the repair of varying meniscal tears.

Study Design

Cross-sectional study.

Methods

A survey was distributed to 2973 AOSSM members by email. Participants reviewed arthroscopic images and brief patient history from 6 deidentified cases of meniscus repair-in cases 1 to 3, the tears retained hoop integrity (more stable repair), and in cases 4 to 6, the tear patterns represented a loss of hoop integrity. Cases were shuffled before the presentation. For each case, providers were asked at what postoperative time point they would permit (1) partial weightbearing (PWB), (2) full weightbearing (FWB), (3) full ROM, and (4) ROM allowed immediately after surgery.

Results

In total, 451 surveys were completed (15.2% response). The times to PWB and FWB in cases 1 to 3 (median, 0 and 4 weeks, respectively) were significantly lower than those in cases 4 to 6 (median, 4 and 6 weeks, respectively) (P < .001). In tears with retained hoop integrity, the median time to PWB was immediately after surgery, whereas in tears without hoop integrity, the median time to PWB was at 4 weeks postoperatively. Similarly, the median time to FWB in each tear with retained hoop integrity was 4 weeks after surgery, while it was 6 weeks in each tear without hoop integrity. However, regardless of tear type, most providers (67.1%) allowed 0° to 90° of ROM immediately after surgery and allowed full ROM at 6 weeks. Most providers (83.3%) braced the knee after repair regardless of hoop integrity and utilized synovial rasping/trephination with notch microfracture-a much lower proportion of providers utilized biologic augmentation (9%).

Conclusion

Sports medicine practitioners in the AOSSM rehabilitated meniscal tears differently based on hoop integrity, with loss of hoop stresses triggering a more conservative approach. A majority braced and utilized in situ adjuncts for biological healing, while a minority added extrinsic biologics.

What Do Patients Encounter When Searching Online About Meniscal Surgery? An Analysis of Internet Trends

Background

Many patients use the internet to learn about their orthopaedic conditions and find answers to their common questions. However, the sources and quality of information available to patients regarding meniscal surgery have not been fully evaluated.

Purpose

To determine the most frequently searched questions associated with meniscal surgery based on question type and topic, as well as to assess the website source type and quality.

Study Design

Cross-sectional study.

Methods

The following search terms were entered into a web search (www.google.com) using a clean-install browser: "meniscal tear,""meniscus repair,""meniscectomy,""knee scope,""meniscus surgery," and "knee arthroscopy." The Rothwell classification system was used to categorize questions and sort them into 1 of 13 topics relevant to meniscal surgery. Websites were also categorized by source into groups. The Journal of the American Medical Association (JAMA) benchmark criteria (medians and interquartile ranges [IQRs]) were used to measure website quality.

Results

A total of 337 unique questions associated with 234 websites were extracted and categorized. The most popular questions were "What is the fastest way to recover from meniscus surgery?" and "What happens if a meniscus tear is left untreated?" Academic websites were associated more commonly with diagnosis questions (41.9%, P < .01). Commercial websites were associated more commonly with cost (71.4%, P = .03) and management (47.6%, P = .02). Government websites addressed a higher proportion of questions regarding timeline of recovery (22.2%, P < .01). Websites associated with medical practices were associated more commonly with risks/complications (43.8%, P = .01) while websites associated with single surgeons were associated more commonly with pain (19.4%, P = .03). Commercial and academic websites had the highest median JAMA benchmark scores (4 [IQR, 3-4] and 3 [IQR, 2-4], respectively) while websites associated with a single surgeon or categorized as "other" had the lowest scores (1 [IQR 1-2] and 1 [IQR 1-1.5], respectively).

Conclusion

Our study found that the most common questions regarding meniscal surgery were associated with diagnosis of meniscal injury, followed by activities and restrictions after meniscal surgery. Academic websites were associated significantly with diagnosis questions. The highest quality websites were commercial and academic websites.

Effectiveness of a digital rehabilitation program based on computer vision and augmented reality for isolated meniscus injury: protocol for a prospective randomized controlled trial

BACKGROUND

The lack of access to physical therapists in developing countries and rural areas poses a significant challenge in supervising postsurgical rehabilitation, potentially impeding desirable outcomes following surgical interventions. For this reason, this study aims to evaluate the feasibility, safety, and effectiveness of utilizing a digital rehabilitation program based on computer vision and augmented reality in comparison with traditional care for patients who will undergo isolated meniscus repair, since to date, there is no literature on this topic.

METHODS

This study intends to enroll two groups of participants, each to be provided with informed consent before undergoing randomization into either the experimental or control group. The experimental group will undergo a digital rehabilitation program utilizing computer vision and augmented reality (AR) technology following their surgical procedure, while the control group will receive conventional care, involving in-clinic physical therapy sessions weekly. Both groups will adhere to a standardized rehabilitation protocol over a six-month duration. Follow-up assessments will be conducted at various intervals, including preoperatively, and at 2 weeks, 6 weeks, 12 weeks, and 24 weeks postoperatively. Imaging assessments and return-to-play evaluations will be conducted during the final follow-up. Clinical functionality will be assessed based on improvements in International Knee Documentation Committee (IKDC) and Visual Analog Scale (VAS) scores.

REGISTRATION NUMBER

ChiCTR2300070582.

Rehabilitation protocol after suturing the medial meniscus of a stable knee, a retrospective series of the Francophone Arthroscopy Society

INTRODUCTION

Surgical meniscal lesions are common and 80% of cases involve the medial meniscus of a stable knee. There is a lack of consensus regarding postoperative rehabilitation protocols and a wide variation between restrictive and accelerated rehabilitation protocols exists. The main objective of this study was to report the functional results and the failure rate of the various rehabilitation protocols of the retrospective series of the French Society of Arthroscopy (SFA) after suturing the medial meniscus of a stable knee, considering whether the tear is stable or unstable.

HYPOTHESIS

Our hypothesis was that accelerated rehabilitation was not associated with an increased risk of failure.

MATERIALS AND METHODS

This retrospective, multicenter study was conducted across 10 centers (6 private hospitals and 4 public hospitals) including all patients tested for a medial meniscus suture in a stable knee between January 1, 2005 and November 31, 2017 for a minimum follow-up of 5years. Demographic, imaging, suturing, rehabilitation protocol, and functional TEGNER and KOOS scores were collected. Failure was defined as performing a secondary meniscectomy.

RESULTS

Three hundred and sixty-seven patients were analyzed with an average follow-up of 82months. Immediate weight bearing was allowed in 85% of cases, the wearing of a brace was present in almost 74% of cases and flexion was limited in 97% of cases. Inter-group comparisons found a higher suture failure rate in the group with immediate weight bearing (35.6% vs. 20%, p=0.011) and in the group with a brace (36.9% vs. 22.4%, p<0.001). There was no difference in the 90° flexion group. The TEGNER score was higher in the non-weight bearing group (6.5 vs. 5.4, p=0.028) and the KOOS QOL score was higher in the group without a brace (82.2 vs. 66.8, p=0.025). According to a multivariate analysis, immediate weight bearing (OR=3.6, [1.62; 7.98], p=0.0016) and wearing a brace (OR=2.83, [1.54; 5.02], p<0.001) were associated with a higher failure rate. In the group of stable lesions, the use of a brace (OR=3.73, [1.62; 8.56], p=0.0019) was associated with a higher failure rate.

CONCLUSION

No consensus regarding rehabilitation protocols has been established to date and the results of this retrospective series of the SFA affirm the great variability of practices at a national level. Although accelerated rehabilitation protocols are presently favored, the resumption of immediate full weight bearing should be considered with caution, being associated with a higher risk of failure in this series. Deferring weight bearing for 1 month can be considered in the event of a large tear or in the event of damage to the circumferential fibers. Wearing a brace does not seem to have any influence, while limited flexion achieved a consensus.

LEVEL OF EVIDENCE

IV, retrospective study.

Rehabilitation after Repair of Medial Meniscus Posterior Root Tears: A Systematic Review of the Literature

Background

There is no consensus established on postoperative rehabilitation after medial meniscus posterior root tear (MMPRT) repair, including when and how physicians can apply range of motion (ROM) exercise, weight-bearing (WB), brace use, and return to sports (RTS). The purpose of this study was to systematically review the literature on postoperative rehabilitation characteristics of MMPRT repair regarding ROM, WB, brace use, and RTS.

Methods

A literature search was performed using the Medline/PubMed, Cochrane Central Register of Controlled Trials, and Embase databases. The inclusion criteria were English language, human clinical studies, and studies describing rehabilitation protocols after MMPRT repair such as ROM, WB, brace use, and RTS. Abstracts, case reports, cohort studies, controlled laboratory studies, human cadaveric or animal studies, systematic reviews, and meta-analyses were excluded.

Results

Thirteen studies were included. Of the 12 ROM studies, ROM was started immediately within 1 or 2 days after operation in 6 studies and after 2 to 3 weeks of knee immobilization in the rest. Of the 13 WB studies, partial weight-bearing was initiated 1 to 4 weeks after operation in 8 studies and 6 weeks in the rest. Of the 9 brace studies, patients were immobilized by a splint for 2 weeks in 3 studies, and in the rest, a brace with full extension was applied for 3 to 6 weeks after several days of splint application. Of the 7 RTS studies, RTS was allowed at 6 months in 6 studies and 5 to 7 months in 1 study.

Conclusions

This systematic review revealed conservative rehabilitation protocols were more widely adapted as ROM and WB were restricted at certain degrees during postoperative periods in most protocols analyzed. However, it is impossible to identify a consensus on rehabilitation protocols as the protocols analyzed in this review were distinct each other and heterogeneous. In the future, a well-designed comparative study among different rehabilitation protocols is essential to establish a consensus.

Return-to-sport criteria after isolated meniscus suture: Scoping review of the literature

BACKGROUND

Follow-up care including rehabilitation therapy after isolated meniscal repair remains to be standardized. Thus, no standard criteria are available for the return-to-running (RTR) or return-to-sport (RTS). The objective of this study was to identify criteria for RTR and RTS after isolated meniscal repair, based on a review of the literature.

HYPOTHESIS

Return-to-sport criteria after isolated meniscal repair have been published.

METHODS

We performed a scoping review of the literature using the methodology developed by Arksey and O'Malley. The terms "menisc*" and "repair" and "return-to-sport" or "return to play" or "return to run" or "rehabilitation" were used to search the PubMed database on 1st March 2021. All relevant studies were included. All RTR and RTS criteria were identified, analyzed, and classified.

RESULTS

We included 20 studies. Mean RTR and RTS times were 12.9 and 20 weeks, respectively. Clinical, strength, and performance criteria were identified. The clinical criteria included full range-of-motion recovery with no pain, quadriceps wasting, or joint effusion. Strength criteria were a quadriceps and hamstring deficit, no greater than 30% and 15% for RTR and RTS, respectively, compared to the normal side. Performance criteria were successful completion of proprioception, balance, and neuromuscular tests. RTS rates ranged from 80.4% to 100%.

CONCLUSION

Patients must meet clinical, strength, and performance criteria before resuming running and sports. The level of evidence is low, due to the heterogeneity and generally arbitrary choice of criteria. Further large-scale studies are therefore needed to validate and standardize RTR and RTS criteria.

LEVEL OF EVIDENCE

IV.

Horizontal Cleavage Meniscus Tears: Biomechanics, Indications, Techniques, and Outcomes

» Accounting for up to 24% of all meniscus tears, horizontal cleavage tears (HCTs) are a common pathology orthopaedic practitioners should be comfortable managing.» Historically, HCTs were treated with partial meniscectomy; however, recent studies have demonstrated that these procedures have an adverse biomechanical effect, while HCT repairs restore the knee's natural biomechanics.» Indications for the surgical repair of HCTs remain disputed, but surgery is generally considered for young, active patients and older patients without significant concomitant osteoarthritis.» Early clinical findings surrounding HCT repair are promising. They suggest that this treatment adequately restores meniscus mechanics, leads to good knee functional outcomes, and results in a high likelihood of return to preinjury activity levels.

Does Accelerated Rehabilitation Provide Better Outcomes Than Restricted Rehabilitation in Postarthroscopic Repair of Meniscal Injury?

CONTEXT

Meniscal injury is a common pathology, and the postoperative rehabilitation program is essential to patients after surgery. However, the optimal rehabilitation plan after meniscus suture is still controversial.

OBJECTIVE

To compare the clinical outcomes between accelerated rehabilitation and restricted programs in patients with meniscus suture (with or without anterior cruciate ligament reconstruction, ACLR).

EVIDENCE ACQUISITION

Four databases, including PubMed, Ovid, Embase, and the Cochrane Library, were searched up to November 2021. This study only included studies comparing the clinical outcomes between accelerated (immediate range of motion and weight-bearing) and restricted rehabilitation (immobilization and progressive weight-bearing) for meniscus suture. All selected studies were divided into 2 subgroups: isolated meniscus suture or combined with ACLR. The Lysholm score, Tegner score, and Knee Injury and Osteoarthritis Outcome Score were evaluated in simple meniscus sutures no less than 1 year. Failure rate was evaluated in both groups, and the tunnel enlargement was additionally evaluated in patients who underwent ACLR.

EVIDENCE SYNTHESIS

Eleven studies with 612 patients were eligible for analysis. The accelerated group included 4 studies with 330 participants, while the restricted group included 7 studies with 282 participants. For the patients after isolated meniscus suture, the accelerated group achieved higher Lysholm scores (mean difference = -4.66; 95% confidence interval, -8.6 to -0.73; P = .02; I2 = 88%) than the restricted group. For the patients after meniscus suture with ACLR, patients undergoing accelerated rehabilitation were associated with a significantly larger tibial tunnel enlargement in the anterior-posterior view (mean difference = -7.08; 95% confidence interval, -10.92 to -3.24; P = .0003; I2 = 0%) and lateral view (mean difference = -10.33; 95% confidence interval, -16.9 to -3.75; P = .002; I2 = 17%).

CONCLUSION

This meta-analysis evaluated the effects of postoperative rehabilitation in either accelerated or restricted programs in patients with meniscus lesions after repair. A significant higher mean self-reported function was discovered at final follow-ups in the accelerated group. However, a significant increase in tibial tunnel enlargement was also found in accelerated group.

Blood flow restriction added to usual care exercise in patients with early weight bearing restrictions after cartilage or meniscus repair in the knee joint: a feasibility study

PURPOSE

Blood flow restriction - low load strength training (BFR-LLST) is theoretically superior to traditional heavy strength training when rehabilitating patients who cannot heavily load tissues following surgery. The main purpose of this study was to examine the feasibility of BFR-LLST added to usual care exercise early after cartilage or meniscus repair in the knee joint.

METHODS

We included 42 patients with cartilage (n = 21) or meniscus repair (n = 21) of the knee joint. They attended 9 weeks of BFR-LLST added to a usual care exercise program at an outpatient rehabilitation center. Outcome measures were assessed at different time points from four (baseline) to 26 weeks postoperatively and included adherence, harms, knee joint and thigh pain, perceived exertion, thigh circumference (muscle size proxy), isometric knee-extension strength, self-reported disability and quality of life.

RESULTS

On average, patients with cartilage or meniscus repair completed > 84% of the total BFR-LLST supervised sessions. Thirty-eight patients reported 146 adverse events of which none were considered serious. No decrease in thigh circumference or exacerbation of knee joint or quadriceps muscle pain of the operated leg was found in either group during the intervention period.

CONCLUSIONS

BFR-LLST added to usual care exercise initiated early after cartilage or meniscus repair seems feasible and may prevent disuse thigh muscle atrophy during a period of weight bearing restrictions. Harms were reported, but no serious adverse events were found. Our findings are promising but need replication using a RCT-design.

TRIAL REGISTRATION

NCT03371901 , preprint (open access):  https://www.medrxiv.org/content/10.1101/2022.03.31.22272398v1.

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.

Rehabilitation and return to sports after isolated meniscal repairs: a new evidence-based protocol

PURPOSE

Despite many protocols that have been proposed, there's no consensus in the literature regarding the optimal rehabilitation program and return to sports (RTS) protocol following isolated meniscal repair. The aim of this current concept review is to look at the evidence of rehabilitation and RTS program after isolated meniscal repair, focusing on general and specific protocols per type of injury trying to give some guidelines based on the current state of knowledge.

METHODS

A narrative literature review was performed searching PubMed database to identify relevant articles from January 1985 to October 2021 on rehabilitation and RTS after isolated meniscal repair. Randomized controlled trials (RCTs), prospective and retrospective cohort studies, case series, systematic reviews, meta-analyses, cadaveric studies and basic science studies were included.

RESULTS

When the hoop tensile stress effect is preserved, an accelerated rehabilitation program may be suggested. Hence, partial weight bearing (20 kg) in association with ROM limited to 90° is allowed for the first four weeks, followed by weight bearing as tolerated. In contrast, when circumferential hoop fibers are disrupted, a restricted rehabilitation protocol may be recommended. In this scenario no weight bearing is allowed for the first six weeks after the surgery and range of motion (ROM) is limited to 90°.

CONCLUSION

Biomechanical evidence suggests that tailoring an individualized protocol based upon the type of lesion and meniscus stability is reasonable.

LEVEL OF EVIDENCE

Level V.

Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus

OBJECTIVE

Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes.

DESIGN

Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

ELIGIBILITY CRITERIA

Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults.

RESULTS

We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion.

CONCLUSION

The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.

Treatment, Return to Play, and Performance Following Meniscus Surgery

PURPOSE OF REVIEW

The standard of care in meniscal tear management is constantly evolving, especially for athletes and high-demand patients. Meniscus repairs, meniscus transplants, and partial meniscectomies are commonly performed, and rehabilitation methods following these operations are becoming more sophisticated. The ultimate goal of these procedures is returning patients to full activity with minimal risks. Return to play should be systematic, pathology dependent, and individualized to an athlete's needs, expectations, and level of play. This article provides a review of the current treatment modalities of meniscus tears, the rehabilitation protocols following each modality, and the return to play criteria that must be met before releasing the player to competition. In addition, it overviews articles that describe performance outcomes of patients that have undergone meniscus surgery.

RECENT FINDINGS

Current research shows high return to play rates for athletes that undergo meniscus surgery and describes effective rehabilitation protocols to facilitate recovery. There is an increased emphasis on meniscus preservation in recent literature. In addition, meniscus allograft transplantation has demonstrated its efficacy as a salvage procedure and has become a stronger consideration in the athlete with meniscus pathology. No standardized return to play protocol can be applied uniformly to all kinds of meniscal surgeries, and two athletes with the same pathology cannot be expected to follow identical paths towards full recovery. A multidisciplinary approach to care should be provided to the patients, and in the case of patients with high levels of athleticism, the road to recovery starts even before the injury itself.

Return to Play and Player Performance After Meniscal Tear Among Elite-Level European Soccer Players: A Matched Cohort Analysis of Injuries From 2006 to 2016

Background:

Meniscal injuries are extremely common in soccer athletes, and little is known about postrecovery performance.

Purpose:

To (1) identify characteristics associated with return to play (RTP) to the same league level and (2) evaluate long-term effects that injury and management approach may have on player performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using publicly available records, we identified athletes who sustained meniscal tears across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2006 and 2016. Injured athletes were matched to controls 1:2 by demographics and performance. Investigations included rate of RTP to the same league level, reinjury, player characteristics associated with RTP within 2 seasons, long-term availability, field time, and performance metrics standardized to 90 minutes of play during the next 4 seasons.

Results:

A total of 250 players sustaining meniscal tears were included, of which 106 (42%) received surgical management. Median absence was 57.5 days (interquartile range [IQR], 35-92) or 7 games (IQR, 4-12). Rate of RTP was 70%, and the reinjury rate 5% if a player could RTP. Age greater than 30 years was a negative predictor for RTP (odds ratio [OR], 0.62; P = .002), whereas higher preinjury goals per game (OR, 2.80; P = .04) and surgical management (OR, 1.38; P = .002) were positive predictors for RTP. Surgical management was associated with higher long-term availability (P < .01). As compared with the control, there were no significant differences in field time or performance metrics after RTP, either overall or by player position. As compared with nonoperative management, defenders undergoing surgery demonstrated decreased field time. Attackers and midfielders demonstrated similar field time and performance regardless of management.

Conclusion:

RTP of elite soccer athletes sustaining meniscal tear is contingent on age, preinjury performance, and management approach. Those who RTP to the same league level can be expected to demonstrate equivalent field time, performance, and long-term availability as noninjured athletes.

The modifying factors that help improve anterior cruciate ligament reconstruction rehabilitation: A narrative review

BACKGROUND

The goal of a rehabilitation programme after anterior cruciate ligament (ACL) reconstruction is to manage a patient's goals and expectations (i.e., returning to physical activities and sports) while minimizing the risk of new injury, particularly a new ACL injury. Although general rehabilitation programmes have been proposed, some factors can lead to adapting each programme to each patient.

OBJECTIVE

To describe how different variables, including surgical techniques, sports participation, psycho-social and contextual factors can modify the rehabilitation programme.

METHODS

We performed a narrative review with input from experts in the field (level of evidence 5).

CONCLUSIONS

Modifying factors of the ACL rehabilitation programme are related to the initial lesion or surgery, to sports, or to psychological or social aspects. Regarding the type of graft, the rehabilitation is mainly different in the early postoperative phase; the other phases are not graft-based but rather goal-based rehabilitation. Depending on the meniscal or cartilage repair, the rehabilitation protocol will initially take priority over the anterior cruciate ligament reconstruction protocol. The ACL reconstruction rehabilitation programme should meet the requirements of the anticipated sports, to optimize the athlete's ability to return to the expected level and minimize the risk of reinjury. Psycho-social and contextual factors must also be considered in rehabilitation care to individualize and optimize each patient's programme.

Rehabilitation and Return to Play Following Meniscus Repair

Injuries to the meniscus, particularly tears, can have significant negative impacts on pain, function, and quality of life. Preservation of the meniscus is favorable, especially in the athletic and active populations. While first line treatment is often nonoperative in nature, recalcitrant, and more complex tears, typically require surgery. Meniscus repair rates have increased significantly during the last 2 decades as surgical techniques and postoperative outcomes have improved. Longer postoperative timeframes are to be expected when compared with menisectomy, however, accelerated programs have demonstrated favorable outcomes. Rehabilitation and return to play guidelines should reflect the intricacies of the tear type and repair procedure. Close communication with the surgeon is a vital component to optimize patient outcomes. Further, the patient's goals and expected level of return to function, or sport, must be taken into account for a rehabilitation program to be fully successful.

Publicly Available Rehabilitation Protocols Designated for Meniscal Repairs Are Highly Variable

Purpose

To compare publicly available rehabilitation protocols designated for meniscal repairs published online to determine the variability in meniscus repair protocols including different types of tears (radial vs nonradial repairs).

Methods

From the Fellowship and Residency Electronic Interactive Database Access System (FREIDA), a list of publicly available academic residency programs and orthopaedic sports medicine fellowships was obtained. With this list, an electronic search using Google was performed looking for meniscal repair rehabilitation protocols. In addition to academic institutions, private practice organizations with published meniscus repair rehabilitation protocols found during the search also were examined.

Results

Of 189 academic institutions, a total of 30 academic institutions had protocols that were included. Another 29 private practice programs were subsequently found and included. In total, 59 rehabilitation protocols fit the inclusion criteria. Six of the 59 specified radial repair and 53 did not. For return to full range of motion, nonradial protocols averaged 6.7 weeks and radial protocols averaged 7.3 weeks. For return to full weight-bearing, nonradial protocols averaged 6.2 weeks and radial protocols averaged 7.5 weeks. For return to sport, nonradial protocols averaged 17.8 weeks and radial protocols averaged 23.3 weeks. For time spent in a brace, nonradial protocols averaged 5.7 weeks and radial protocols averaged 6.7 weeks.

Conclusions

Of publicly available meniscal repair rehabilitation protocols, a small percentage (10.2%) changed their protocol in relation to tear type and there was a wide range of timeframes for each rehabilitation component. Protocols for radial tears tended to brace patients longer, limit their range of motion longer, delay full weight-bearing, and delay return to sport. However, it is recognized that some surgeons could be modifying their protocols in relation to tear type without publishing that information online.

Clinical Relevance

As stated in the purpose, the point of this study was to access only the protocols that would be available to the public. If anything, awareness should be raised for surgeons to look at their existing protocols and update them if they are truly incomplete and outdated. More research needs to be done to structure a rehabilitation protocol that is specific to the meniscal tear type, as the current protocols have a wide range of variance.

Return-to-Play and Rehabilitation Protocols Following Isolated Meniscal Repair-A Systematic Review

Purpose

To systematically review the literature and assess the reported rehabilitation protocols, return-to-play guidelines, and reported rates of return-to-play after meniscal repair.

Methods

MEDLINE, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies on meniscal repair. Studies were included if return-to-play data and/or rehabilitation protocols were reported. The rate and timing of return-to-play was assessed. The rehabilitation protocols were documented, in addition to when to start range of motion (ROM), full ROM, partial weight-bearing (WB), and full WB.

Results

Overall, 88 studies met our inclusion criteria. Thirteen studies, including 507 patients, cited a range of 71.2% to 100% of return-to-play, with 53.9% to 92.6% returning to the same/greater level, ranging between 3.3 and 10 months. There was considerable variability in the reported rehabilitation protocols, but the most frequently reported time to begin ROM exercises was within the first week (78.9%) and full ROM at 6 weeks (33.3%). Partial WB was typically begun during the first week (61.0%), and full WB between the fourth and sixth week (65.6%) postoperatively. Following surgery, time elapsed was the most commonly cited criteria for return-to-play (97.0%), with 6 months being the most common time point applied (46.9%). No study advised against returning to competitive or contact sports after meniscal repair.

Conclusions

In conclusion, there was a high rate of return-to-play following meniscal repair, with 60% of patients returning to the same level of play. However, there was considerable diversity in the reported rehabilitation protocols and insufficient reporting on return-to-play criteria in the literature. This demonstrates the need for further research and formulation of an evidence-based consensus statement for this patient population.

Level of Evidence

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

Arthroscopic repair of horizontal cleavage meniscus tears provides good clinical outcomes in spite of poor meniscus healing

PURPOSE

The purpose of this study was to evaluate the clinical outcomes and meniscus healing after arthroscopic repair of horizontal-cleavage meniscus tears, compared with vertical-longitudinal meniscus tears.

METHODS

This was a retrospective review of a consecutive series of 52 meniscal repairs for horizontal-cleavage tears (n = 27) or vertical-longitudinal tears (n = 25); the groups were compared with respect to clinical symptoms and meniscal healing. Arthroscopic meniscal repair was performed using the inside-out technique with a marrow-stimulating technique. Clinical symptoms were evaluated using the Lysholm score and Knee injury and osteoarthritis outcome score (KOOS). Meniscus healing was evaluated by MRI.

RESULTS

The mean follow-up periods were 35.4 ± 8.9 months in the horizontal-cleavage tear group and 39.8 ± 8.3 months in the vertical-longitudinal tear group. There were no significant differences in Lysholm score and KOOS, including each subscale, between the horizontal-cleavage tear- and vertical-longitudinal tear-groups at the final follow-up. At the final follow-up, MRI meniscus grades 0 and 1 were significantly more frequent in the vertical-longitudinal tear-group than in the horizontal-cleavage tear-group, while grade 3 was significantly more frequent in the horizontal-cleavage tear group than in the vertical-longitudinal tear group (p < 0.0001).

CONCLUSIONS

Although meniscus healing of horizontal-cleavage tears may be poor, arthroscopic repair should be considered for horizontal-cleavage tears because it does provide good clinical outcomes.

LEVEL OF EVIDENCE

IV.

Contact mechanics after mattress suture repair of medial meniscus vertical longitudinal tear: an in vitro study

PURPOSE

Most studies have concentrated on the changes in contact pressure and area on the tibiofemoral joint. This study compared the contact mechanics underneath the medial meniscus of a repaired vertical longitudinal tear with that of the intact or the torn ones.

METHODS

In this controlled laboratory study, a 1000 N compressive axial load was applied to eight fresh-frozen cadaveric knees at four flexion angles and four loading conditions using a custom testing apparatus attached to a material testing machine. Intact knees, knees with a medial meniscus vertical longitudinal tear, and knees after meniscal repair were tested. The peak contact pressure and area underneath the meniscus were measured using Fuji pressure-sensitive film.

RESULTS

A medial meniscus vertical longitudinal tear significantly increased the contact pressure and decreased contact area underneath the meniscus compared with those at the intact meniscus under all tested biomechanical conditions, and repair of the tear can restore the contact pressure and area in most conditions. While the repaired group showed a significantly higher or similar contact pressure compared with the tear group at 90° neutral knee position and at 60°, 90° 5 N·m-external rotation and 134 N-anterior tibial translation, and 5 N·m-internal rotation at all flexion angles. The contact area corresponding to the aberrant result of the contact pressure in the repaired group was lower than in the intact meniscus group.

CONCLUSIONS

The contact mechanics underneath the meniscus of the repaired medial meniscus vertical longitudinal tear were significantly improved compared with the corresponding tear conditions in most cases, while the contact pressure and area at some certain status after repair were not significantly different from those of the corresponding tear conditions.

Postoperative rehabilitation and outcomes following arthroscopic isolated meniscus repairs: A systematic review

OBJECTIVES

The purpose of this study was to review the current literature on rehabilitation protocols following arthroscopic meniscus repair.

METHODS

A systematic literature review was performed of Medline, Scopus, and Web of Science databases to identify relevant articles from January 1990 to April 2019. Search terms were (meniscus OR meniscal repair) AND (repaired OR repair) AND (rehabilitation OR physiotherapy OR physical therapy). Each study was independently scored for methodological research quality level using the Modified Coleman Methodology Score (MCMS). The following variables were extracted from each study: publication year, study type, evidence level, subject demographics, injury mechanism, meniscus tear type, surgical procedure, rehabilitation program [immobilization, weight bearing, ROM progression, therapeutic exercises, length of follow-up, patient-reported outcome measurements, return to sport timing/criteria and failure rate/criteria.

RESULTS

Eighteen studies met the inclusion criteria. The overall MCMS was moderate 59.5 ± 11.7 (range = 42-90). The average MCMS score for postoperative rehabilitation was 4.7 ± 1.18. Only 1 (5.6%) study was a prospective randomized controlled trial and 14 studies (78%) had retrospective designs. Fourteen (78%) studies suggested that return to sports should occur between 3 and 6 months post-surgery. Early range of motion and immediate weight-bearing had no influence over patient-reported outcomes or failure rates for vertical meniscus tear repairs.

CONCLUSION

Low MCMS scores, primarily retrospective study designs and poorly described postoperative rehabilitation protocols made it difficult to design an evidence-based therapeutic rehabilitation program for patients following arthroscopic repair of an isolated meniscus tear. An arthroscopic isolated meniscal tear repair rehabilitation protocol is being attempted to present based on a synopsis of existing evidence.

Early Functional Rehabilitation after Meniscus Surgery: Are Currently Used Orthopedic Rehabilitation Standards Up to Date?

Meniscus therapy is a challenging process. Besides the respective surgical procedure such as partial meniscectomy, meniscus repair, or meniscus replacement, early postoperative rehabilitation is important for meniscus regeneration and return to sport and work as well as long-term outcome. Various recommendations are available. However, the current literature lacks information concerning the actual early rehabilitation in daily routine recommended by orthopedic surgeons. Thus, the purpose of this study was to investigate currently used standard early rehabilitation protocols in the daily routine of orthopedic surgeons. This study investigated the recommendations and concepts for early rehabilitation after meniscus therapy given by German, Austrian, and Swiss orthopedic institutions. Standardized criteria such as weight bearing, range of motion, use of an orthosis, and rehabilitation training were analyzed according to the conducted surgical procedure: partial meniscectomy, meniscus repair, or meniscus replacement. The analysis of standard rehabilitation concepts for partial meniscectomy (n = 15), meniscus repair (n = 54), and meniscus replacement (n = 7) showed significantly earlier functional rehabilitation in all criteria after partial meniscectomy in contrast to meniscus repair techniques (p < 0.001). In addition, significant restrictions were found in full weight bearing, full range of motion, and the use of braces. In summary, a wide range of recommendations for weight bearing, ROM, brace therapy, and mobilization is available, particularly after meniscus repair and meniscus replacement. Most concepts are in accordance with those described in the current literature. Further research is necessary to enhance the scientific evidence on currently used early rehabilitation concepts after meniscus therapy.

Variability of online available physical therapy protocols from academic orthopedic surgery programs for arthroscopic meniscus repair

OBJECTIVES

To evaluate the variability of arthroscopic meniscus repair rehabilitation protocols.

METHODS

Arthroscopic meniscus repair rehabilitation protocols from Accreditation Council for Graduate Medical Education (ACGME) accredited orthopedic surgery programs available online were included for review. Data collection was performed to evaluate recommended weight bearing status and immobilization as well as the presence or absence of recommended therapies, goals for progression of range of motion, functional milestones, and activity initiation time points within each protocol.

RESULTS

Out of 162 institutions available for review, 24 (14.8%) institutions made their protocol available on their website, with 28 total protocols available. Initially following repair, 14 (50%) of the protocols allow for weight bearing as tolerated (WBAT). Of the 14 protocols, which do not allow immediate weightbearing, average time to WBAT was 4.7 ± 1.8 weeks. On average, immobilization was recommended for 6.5 ± 2.1 weeks (range 4-12 weeks). A large majority of protocols gave recommendations for flexion to 90 degrees (24 protocols, range 1-8 weeks), as well as full range of motion (22 protocols, range 6-16 weeks). Active range of motion was recommended to begin at 0-6 weeks (average 3.8 ± 1.9 weeks). Lastly, only 14 protocols (50%) gave an actual return to sport, with an average return recommended at 21.9 ± 3.4 weeks (range 12-24).

CONCLUSION

A minority of ACGME-accredited orthopedic surgery programs make their meniscus repair rehabilitation protocols available online. Furthermore, protocols were found to be highly variable. This discrepancy may lead to confusion among therapists and patients.

Similar failure rate in immediate post-operative weight bearing versus protected weight bearing following meniscal repair on peripheral, vertical meniscal tears

PURPOSE AND HYPOTHESIS

Post-operative weight bearing after meniscal repair is a point of debate among physicians. This study sought to evaluate whether patients adhering to an immediate WBAT rehabilitation programme have a higher failure rate compared to those adhering to a more traditional, protected, NWB status following meniscal repair. The null hypothesis was that there would be no difference in failure between the two groups.

METHODS

A retrospective review of meniscal repair patients greater than 5 years from surgery was performed for patients receiving meniscal repair treatment. Patients were categorized by post-surgical weight-bearing status, either NWB or WBAT, and then analysed for failure of repair. Failure was defined as re-operation on the torn meniscus. The study controlled for variables including age at surgery, sex, height, weight, and BMI, classification of tear type, acuity of the tear, repair location (medial or lateral), repair location within the meniscus, repair technique, and concomitant procedures.

RESULTS

Re-operations were performed in 61 of 157 patients [38.9%]. There was no difference between weight-bearing groups for failure of meniscus repair (n.s.). The tears were acute vertical tears located in the posterior horn and body. For the 61 patients with re-operation, the average time to re-operation was 2.2 years with 10 [16%] > 5 years from surgery, 17 [28%] 2-5 years from surgery, and 34 [56%] < 2 years from surgery. In isolated meniscal repair patients (n = 62), there was no difference between weight-bearing groups for rate of re-operation (n.s.).

CONCLUSION

Weight bearing as tolerated after meniscal repair for peripheral, vertical tears does not result in a higher failure rate than traditional, non-weight bearing over a five-year follow-up period. The clinical relevance is that, based on these data, it may be appropriate to allow weight bearing as tolerated following meniscal repair of peripheral, vertical tears.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

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.

Sport-specific outcomes after isolated meniscal repair: a systematic review

PURPOSE

The purpose of this systematic review was to assess sport-specific outcomes after repair of isolated meniscal tears.

METHODS

A systematic electronic search of the MEDLINE and Cochrane database was performed in May 2016 to identify studies that reported sport-specific outcomes after isolated meniscal repair. Included studies were abstracted regarding study characteristics, patient demographics, surgical technique, rehabilitation, and outcome measures. The methodological quality of the included studies was assessed with the Coleman Methodology Score (CMS).

RESULTS

Twenty-eight studies with a total of 664 patients met the inclusion criteria. The methodological quality of the included studies was moderate, with a mean CMS of 69.7 ± 8.3. The mean patient age was 26 ± 7.2 years and 71% of patients were male. Mean preoperative Tegner score improved from 3.5 ± 0.3 to 6.2 ± 0.8 postoperatively. Comparing preinjury and postoperative Tegner scores, comparable values were observed (6.3 ± 1.1 and 5.7 ± 0.8, respectively). Return to sports on the preinjury level was achieved in 89%. Mixed-level populations returned to their preinjury activity level in 90% and professional athletes in 86%. Mean delay of return to sports varied between 4.3 and 6.5 months, with comparable results between professional and mixed-level athletes. The pooled failure rate was 21%. The failure rate was lower in professional athletes compared to mixed-level athletes (9% vs. 22%).

CONCLUSION

This systematic review suggests that isolated repair of meniscal tears results in good to excellent sport-specific outcomes and a high return to sports rate in both recreational and professional athletes. The failure rate is comparable to systematic reviews not focusing on sportive patients.

LEVEL OF EVIDENCE

Level IV systematic review of Level I to Level IV studies.

Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to meniscus and articular cartilage lesions. J Orthop Sports Phys Ther. 2018;48(2):A1-A50. doi:10.2519/jospt.2018.0301.

Meniscal Preservation is Important for the Knee Joint

Native joint preservation has gained importance in recent years. This is mostly to find solutions for limitations of arthroplasty. In the knee joint, the menisci perform critical functions, adding stability during range of motion and efficiently transferring load across the tibiofemoral articulation while protecting the cartilage. The menisci are the most common injury seen by orthopedicians, especially in the younger active patients. Advances in technology and our knowledge on functioning of the knee joint have made meniscus repair an important mode of treatment. This review summarizes the various techniques of meniscus tear repair and also describes biological enhancements of healing.

Current Concepts and Controversies in Rehabilitation After Surgery for Multiple Ligament Knee Injury

PURPOSE OF REVIEW

The purpose of this manuscript is twofold: (1) to review the literature related to rehabilitation after surgery for multiple ligament knee injury (MLKI) and after isolated surgery for the posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial side of the knee and (2) to present a hierarchy of anatomic structures needing the most protection to guide rehabilitation.

RECENT FINDINGS

MLKIs continue to be a rare but devastating injury. Recent evidence indicates that clinicians may be providing too much protection from early weight bearing and range of motion, but an accelerated approach has not been rigorously tested. Consideration of the nature and quality of surgical procedures (repair and reconstruction) can help clinicians determine the structures needing the most protection during the rehabilitation period. The biomechanical literature and prior clinical experience can aid clinicians to better structure rehabilitation after surgery for MLKI and improve clinical outcome for patients.

Rehabilitation Protocols After Isolated Meniscal Repair: A Systematic Review

BACKGROUND

Current postoperative rehabilitation protocols after isolated meniscal repair vary widely. No consensus exists with regard to the optimal amount of weightbearing, range of motion, or speed at which the patient progresses through the rehabilitation phases. Confounding factors including concomitant ligamentous or cartilaginous injuries have made studying isolated meniscal tears problematic.

PURPOSE

To systematically review and evaluate the influence of range of motion and weightbearing status during the postoperative rehabilitation period after isolated meniscal repair on clinical efficacy and outcome scores.

STUDY DESIGN

Systematic review.

METHODS

A search of PubMed, Scopus, and Cochrane Central Register of Controlled Trials was conducted. The selection criteria for inclusion were English-language in vivo clinical studies reporting on isolated meniscal repairs utilizing an arthroscopically assisted technique that outlined the postoperative rehabilitation protocol and included at least a 2-year follow-up. Titles, abstracts, and articles were reviewed, and data concerning patient demographics, tear type, repair technique, postoperative protocol details, clinical failures, and outcome scores were extracted from the eligible studies. Rehabilitation protocols were divided into "accelerated," "motion restricted," "weight restricted," and "dual restricted" according to the limitations placed on the treatment groups.

RESULTS

Fifteen studies, containing 17 different treatment groups, met the inclusion criteria. The 2 accelerated groups, 2 motion-restricted groups, 4 weight-restricted groups, and 9 dual-restricted groups showed similar efficacy in terms of clinical success and postoperative outcome scores. Early range of motion and weightbearing status showed no influence over clinical outcomes. Of the 17 groups, 13 reported a greater than 70% clinical success rate with significant variation in the tear type, fixation technique, and postoperative restrictions.

CONCLUSION

Early range of motion and immediate postoperative weightbearing appear to have no detrimental effect on the chances for clinical success after isolated meniscal repair. Significant variation exists between postoperative protocols, with no current consensus on the ideal parameters for weightbearing and range of motion. Studies reporting outcomes regarding isolated meniscal repair are limited. Future research should include determining the ideal combination of weightbearing and range of motion for specific tear types.

Return to Play Following Meniscus Surgery

Meniscus tears are commonly encountered in the athletic population and can result in significant loss of playing time. Current treatment methods for acute tears consist of meniscectomy and meniscal repair, whereas meniscal allograft transplant is reserved as a salvage procedure for symptomatic meniscectomized patients who desire a more functional knee. This review describes the postoperative rehabilitation protocol for each procedure and evaluates the outcomes in existing literature as it pertains to the athlete.

Complex Meniscus Tears Treated with Collagen Matrix Wrapping and Bone Marrow Blood Injection: A 2-Year Clinical Follow-Up

OBJECTIVE

To collect and analyze the 2-year follow-up clinical and MRI results of patients treated with an arthroscopic technique of collagen membrane-based meniscus repair.

DESIGN

53 consecutive patients with combined (horizontal and radial or longitudinal component) and complex meniscal tears (tear extended through avascular zones or/and composed with two or more morphological tear pattern) were treated with an "all-inside" arthroscopic suture of meniscus and wrapping with a collagen membrane (Chondro-Gide) technique with bone marrow blood injection. The IKDC 2000 subjective score, IKDC 2000 clinical evaluation score, Lysholm score and Barret clinical criteria of meniscal healing were recorded. All patients were examinated by MRI 2 years postoperatively, using modified WORMS criteria for meniscal integrity.

RESULTS

The 2 year follow-up was achieved in 50 cases. Of these, 2 patients were excluded from the evaluation due to incomplete data and 2 patients underwent partial meniscectomy and were classified as failures. In 46 patients (86.8% of the intended to treat cases), a statistically significant improvement in IKDC 2000 subjective, Lysholm scores and IKDC 2000 clinical assessment between preoperative and the 2-year follow-up time points were obsereved. Barret criteria demonstrated an improved clinical outcome between pre- and post-operative values. MRI revealed a non-homogeneous signal without meniscal tear (WORMS grade 1) in 76% of the operated menisci (13% WORMS grade 2).

CONCLUSIONS

The 2-year follow-up data demonstrate that this technique is safe and can offer an additional tool to save the meniscus in the patients otherwise scheduled for meniscal removal. Level of evidence IV.

Weightbearing Versus Nonweightbearing After Meniscus Repair

CONTEXT

Optimal rehabilitation after meniscal repair remains controversial.

OBJECTIVE

To review the current literature on weightbearing status after meniscal repairs and to provide evidence-based recommendations for postoperative rehabilitation.

DATA SOURCES

MEDLINE (January 1, 1993 to July 1, 2014) and Embase (January 1, 1993 to July 1, 2014) were queried with use of the terms meniscus OR/AND repair AND rehabilitation.

STUDY SELECTION

Included studies were those with levels of evidence 1 through 4, with minimum 2 years follow-up and in an English publication.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Demographics and clinical and radiographic outcomes of meniscus repair at a minimum of 2 years follow-up were extracted.

RESULTS

Successful clinical outcomes ranged from 70% to 94% with conservative rehabilitation. More recent studies using an accelerated rehabilitation protocol with full weightbearing and early range of motion reported 64% to 96% good results.

CONCLUSION

Outcomes after both conservative (restricted weightbearing) protocols and accelerated rehabilitation (immediate weightbearing) yielded similar good to excellent results; however, lack of similar objective criteria and consistency among surgical techniques and existing studies makes direct comparison difficult.