Clinical evaluation of suture materials for transtibial pullout repair of medial meniscus posterior root tear

BACKGROUND

There are no recommendations for specific suture materials in transtibial pullout repair of medial meniscus posterior root tears. This study aimed to evaluate the clinical outcomes of transtibial pullout repair of medial meniscus posterior root tears using ultrahigh-molecular-weight polyethylene sutures and suture tape.

METHODS

We retrospectively reviewed the data of 36 patients (27 women and 9 men, mean age 64.1 years) who had undergone transtibial pullout repair of medial meniscus posterior root tears between November 2018 and December 2019. Two groups of 18 patients each received either two different cord-like sutures or suture tape. Clinical parameters were assessed preoperatively and on second-look arthroscopy (mean postoperative period 12 months). The meniscal healing status was assessed using a previously published scoring system (ranging from 0 to 10), and the incidence rate of suture cut-out was assessed on second-look arthroscopy.

RESULTS

All clinical scores significantly improved in both groups, with no significant between-group differences on second-look arthroscopy. The arthroscopic meniscal healing scores significantly differed between sutures (mean 6.7 points) and suture tape (mean 7.4 points; p = 0.044). No significant between-group difference in the suture cut-out rate was observed.

CONCLUSIONS

This study found no significant differences in the clinical outcomes between ultrahigh-molecular-weight polyethylene sutures and suture tape. Favorable clinical outcomes were obtained using both types of suture; however, the usefulness of suture tape appears to be limited.

Postoperative external tibial rotation is correlated with inferior meniscal healing following pullout repair of a medial meniscus posterior root tear

PURPOSE

The purpose of this study was to evaluate the influence of tibial rotation on the postoperative healing status of the medial meniscus (MM) following pullout repair of the MM posterior root tear (MMPRT).

METHODS

Ninety-one patients (68 women and 23 men; mean age 63.3 ± 8.8 years) who had undergone transtibial pullout repair of MMPRT were enrolled in the study. The tibial external rotation angle (ERA) in each patient was measured postoperatively using computed tomography in the extended knee position. The meniscal healing status following transtibial pullout repair was assessed by second-look arthroscopy (mean postoperative period 12 months) using a previously published scoring system (range 0-10). The association between the ERA and the meniscal healing score was investigated using univariate linear regression models. The ERA cut-off for improved meniscal healing score (≥ 7) was determined using receiver-operating characteristic analysis.

RESULTS

The ERA and the meniscal healing score were significantly associated, confirming that increased ERAs were correlated with worse meniscal healing status (R =  - 0.28; P < 0.001). The optimum ERA cut-off value was 0.5°, with a sensitivity of 68% and a specificity of 63%. The mean meniscal healing scores were 7.3 and 6.2 among patients with ERAs < 0.5° and those with ERAs ≥ 0.5°, respectively (P < 0.001).

CONCLUSION

This study demonstrated that the ERA was significantly correlated with the postoperative meniscal healing status. Postoperative tibial rotation could be one of the factors affecting postoperative outcomes of pullout repair of MMPRT. Controlling the tibial rotation may possibly improve meniscal healing.

LEVEL OF EVIDENCE

III.

Accurate placement of a tibial tunnel significantly improves meniscal healing and clinical outcomes at 1 year after medial meniscus posterior root repair

PURPOSE

A medial meniscus posterior root tear results in the loss of meniscal circumferential hoop stress and causes a pathological posteromedial extrusion of the medial meniscus. Although creating a tibial tunnel in the anatomic place improves postoperative medial meniscus posterior extrusion, no studies have evaluated the relationship between tibial tunnel position and clinical outcomes. This study aimed to evaluate how tibial tunnel positioning of medial meniscus posterior root pullout repair affects meniscal healing status and clinical outcomes.

METHODS

Sixty-two patients with 64 medial meniscus posterior root tears (mean age 62.8 ± 7.9 years) who had undergone pullout repairs and second-look arthroscopies were included. All 62 patients were Lachman test negative. Three-dimensional computed tomography images of the tibial surface were evaluated using a rectangular measurement grid to assess the tibial tunnel centre and medial meniscus posterior root attachment centre. Spearman's rank correlation analysis was undertaken to determine displacement distance from the medial meniscus posterior root attachment centre to the tibial tunnel centre and a meniscal healing score, as well as clinical outcomes at 1 year post-repair.

RESULTS

Tibial tunnel centres were located more anteriorly and medially than the medial meniscus posterior root attachment centre (mean distance 5.0 ± 2.2 mm). The mean meniscal healing score was 6.7 ± 1.8 of 10 possible points. The 1-year postoperative clinical scores showed significant improvement compared with preoperative scores for all the items. There was a significant negative correlation in the absolute distance between the medial meniscus posterior root attachment centre and the tibial tunnel centre with the meniscal healing score (ρ =  - 0.39, p = 0.002). Furthermore, there were significant positive correlations between the distance between the medial meniscus posterior root attachment centre and the tibial tunnel centre in the mediolateral direction and patient-based clinical outcomes (ρ = 0.25-0.43, p < 0.05).

CONCLUSION

Accurate placement of a tibial tunnel, especially in the mediolateral direction, significantly improved meniscal healing and clinical outcomes at 1 year following medial meniscus posterior root repair. Surgeons should create a medial meniscus posterior root tibial tunnel at the anatomic attachment with particular attention to the mediolateral position.

LEVEL OF EVIDENCE

Level IV.

Transtibial pullout repair of medial meniscus posterior root tears: effects on the meniscus healing score and ICRS grade among patients with mild osteoarthritis of the knee

PURPOSE

To assess the effects of transtibial pullout repair for medial meniscus posterior root tears (MMPRTs) among patients with early osteoarthritis of the knee as measured by the meniscus healing score and to determine whether the meniscus healing score correlates with the International Cartilage Repair Society (ICRS) grade progression.

METHODS

Forty-seven patients with mild osteoarthritic knees (Kellgren-Lawrence grade ≤ 2 and varus alignment < 5°) who underwent transtibial pullout repair less than 3 months after MMPRT onset were assessed. The association between meniscus healing scores at 1 year postoperatively and cartilage damage of the medial compartment (medial femoral condyle [MFC] and medial tibial plateau [MTP]) were evaluated. The MFC was divided into six zones (A to F) and the MTP into two zones (G and H). The mean ICRS grade for each zone was compared between the primary surgery and second-look arthroscopy. The correlation between cartilage damage and meniscus healing status at the time of second-look arthroscopy in each zone was analysed.

RESULTS

The mean time interval from injury to surgery was 63 days, and all clinical scores showed significant improvement. There were no significant differences in the extent of cartilage damage in areas B, C, E, or F (n.s.) for MFC or in areas G and H (n.s.) for MTP. The meniscus healing score and cartilage damage were correlated in the loading areas (B, C, E, and H; - 0.53, - 0.45, - 0.33, and - 0.38, respectively; p < 0.05).

CONCLUSION

Transtibial pullout repair of MMPRTs among patients with mild osteoarthritic knees improved the clinical outcomes and showed a negative correlation between high meniscus healing scores and ICRS grades in the medial compartment loading area. This study suggests that early surgery should be undertaken for patients with mild osteoarthritic knee who develop MMPRTs.

LEVEL OF EVIDENCE

Level IV.

The distance between the tibial tunnel aperture and meniscal root attachment is correlated with meniscal healing status following transtibial pullout repair for medial meniscus posterior root tear

BACKGROUND

To investigate the relationship between tibial tunnel aperture location and postoperative meniscal healing.

METHODS

We enrolled 25 patients (20 women and five men, mean age: 62.5 years) who underwent transtibial pullout repair for medial meniscus (MM) posterior root repair. The expected MM posterior root attachment center (AC) and tibial tunnel center (TC) were identified using three-dimensional computed tomography, and the minimum AC-TC distance was calculated. The meniscal healing status following transtibial pullout repair was assessed by second-look arthroscopy (mean postoperative period: 15 months) using a previously reported scoring system (meniscal healing score; range: 0-10). The association between AC-TC distance and meniscal healing score was investigated using univariate linear regression models. The optimal AC-TC distance cut-off for improved MM healing score (≥7) was determined using receiver operating characteristic analysis.

RESULTS

The AC-TC distance and meniscal healing score were significantly associated (y = -0.42x + 9.48, R² = 0.342; P = 0.002), with the optimum AC-TC distance being 5.8 mm. This cut-off had a sensitivity of 100% and specificity of 53%.

CONCLUSIONS

This study demonstrates that AC-TC distance is significantly correlated with postoperative meniscal healing. Anatomical repair within 5.8 mm of the AC may result in improved meniscal healing.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

Pullout repair using modified Mason-Allen suture induces better meniscal healing and superior clinical outcomes: A comparison between two surgical methods

BACKGROUND

Pullout repairs of medial meniscus posterior root tears (MMPRTs) have many surgical options. However, there has been no reliable clinical study conducted to compare the superiority of each pullout repair technique. The current study hypothesized that pullout repairs using a modified Mason-Allen suture with FasT-Fix (F-MMA) would have several advantages in postoperative clinical outcomes and meniscal healing compared with single FasT-Fix. The aim of this study was to investigate the clinical usefulness of these two techniques in treating MMPRTs.

METHODS

Thirty-eight patients who had complete MMPRTs were included. All patients underwent transtibial pullout repairs. To compare the clinical usefulness between pullout repairs using single FasT-Fix and F-MMA techniques, patients were divided into two groups. Second-look arthroscopic evaluations of meniscal healing were performed at one year postoperatively. Clinical outcomes were assessed using: Lysholm and visual analogue scale (VAS) pain scores, and Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Single FasT-Fix and F-MMA pullout repairs improved clinical outcomes in patients with MMPRTs. At second-look arthroscopy, VAS pain, KOOS pain, and arthroscopic meniscal healing scores following F-MMA pullout repairs were superior to those after single FasT-Fix pullout repairs.

CONCLUSIONS

This study demonstrated that F-MMA suture configuration obtained better meniscal healing and superior clinical outcomes compared with single FasT-Fix repairs in patients with MMPRTs. These results suggest that the F-MMA pullout repair may possibly reduce knee pain in arthroscopic treatments of MMPRTs.

Possible reparative effect of low-intensity pulsed ultrasound (LIPUS) on injured meniscus

Menisci are a pair of crescent-shaped fibrocartilages, particularly of which their inner region of meniscus is an avascular tissue. It has characteristics similar to those of articular cartilage, and hence is inferior in healing. We previously reported that low-intensity pulsed ultrasound (LIPUS) treatment stimulates the production of CCN2/CTGF, a protein involved in repairing articular cartilage, and the gene expression of major cartilage matrices such as type II collagen and aggrecan in cultured chondrocytes. Therefore, in this present study, we investigated whether LIPUS has also favorable effect on meniscus cells and tissues. LIPUS applied with a 60 mW/cm² intensity for 20 min stimulated the gene expression and protein production of CCN2 via ERK and p38 signaling pathways, as well as gene expression of SOX9, aggrecan, and collagen type II in human inner meniscus cells in culture, and slightly stimulated the gene expression of CCN2 and promoted the migration in human outer meniscus cells in culture. LIPUS also induced the expression of Ccn2, Sox9, Col2a1, and Vegf in rat intact meniscus. Furthermore, histological evaluations showed that LIPUS treatment for 1 to 4 weeks promoted healing of rat injured lateral meniscus, as evidenced by better and earlier angiogenesis and extracellular matrix synthesis. The data presented indicate that LIPUS treatment might prevent meniscus from degenerative change and exert a reparative effect on injured meniscus via up-regulation of repairing factors such as CCN2 and that it might thus be useful for treatment of an injured meniscus as a non-invasive therapy.

Arthroscopic scoring system of meniscal healing following medial meniscus posterior root repair

PURPOSE

Medial meniscus posterior root tear (MMPRT) leads to a rapid degradation of articular cartilage. In the treatment of MMPRT, transtibial pullout repair demonstrates a high clinical survival rate. However, there is no reliable method to evaluate the meniscal healing after surgery. We propose an arthroscopic scoring system for evaluating the meniscal healing status. The aim of this study was to investigate the correlations between second-look arthroscopic scores and clinical outcomes after transtibial pullout repair.

METHODS

Twenty patients who had MMPRTs underwent transtibial pullout repairs. Clinical outcomes were assessed using the Japanese Knee Injury and Osteoarthritis Outcome Score (KOOS) and pain score evaluated by visual analogue scale at preoperatively and 1 year postoperatively. The healing status of repaired MM was assessed at one year post-operatively using a semi-quantitative arthroscopic scoring system (total, 10 points) composed of three evaluation criteria: (i) anteroposterior width of bridging tissues, (ii) stability of the MM posterior root, and (iii) synovial coverage of the sutures. Linear regression analysis was used to assess the correlation between second-look arthroscopic scores and clinical outcomes.

RESULTS

Transtibial pullout repairs of MMPRTs significantly improved clinical evaluation scores at one year post-operatively. A median of second-look arthroscopic scores was 6.5 (5.75-8). A good correlation was observed between the arthroscopic score and KOOS quality of life (QOL) subscale. A moderate negative correlation between the arthroscopic score and pain score was observed.

CONCLUSIONS

This study demonstrated that our semi-quantitative scoring system of meniscal healing correlated with the KOOS QOL subscale following MMPRT transtibial pullout repair. Our results suggest that the second-look arthroscopic score using this system may be a useful scale to determine and compare the healing status of the MM posterior root.