Arthroscopic meniscal repair with an absorbable screw: results and surgical technique

Comparison of Thessaly Test with Joint Line Tenderness and McMurray Test in the Diagnosis of Meniscal Tears

Introduction:

Meniscus injuries are the most frequent problem of the knee. The aim of this study was to investigate the accuracy of the Thessaly test and comparing it with those of McMurray and Joint-line tenderness tests for diagnosing meniscal tears.

Materials and methods: This study was designed as a prospective observational one done in an outpatient clinic at a university hospital. 106 patients with knee pain and 82 age-matched control were included during study period (from February 2014 to January 2015). Each patient was clinically examined with McMurray, Thessaly, and joint line tenderness tests. Then, the findings were matched by MRI and arthroscopic findings. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated as main outcomes.

Results:

Based on MRI, Thessaly was the most sensitive for medial meniscus tears (56.2%), while McMurray and joint-line tenderness were more specific (89.1% and 88.0%, respectively). For lateral meniscus tears, McMurray was the most sensitive (56.2%) and all were specific (McMurray 89.6%, Thessaly 88.4%, joint-line tenderness 90.2%). With arthroscopy, Thessaly was the most sensitive for medial meniscus (76.6%), while McMurray and joint-line tenderness were more specific (81.0%, and 81.0%). Agreement with arthroscopy was the highest with McMurray (for medial meniscus kappa=0.40, p<0.001, and for lateral meniscus kappa=0.38, p=0.002).

Conclusion:

The Thessaly can be used to screen for medial meniscus tears. McMurray and joint-line tenderness should be used for suspected medial meniscus tears. For lateral meniscus, McMurray is appropriate for screening and all the tests are useful in clinic.

The Effect of Perioperative Ketorolac on the Clinical Failure Rate of Meniscal Repair

Background:

There has been recent interest in the effect of nonsteroidal anti-inflammatory medications on musculoskeletal healing. No studies have yet addressed the effect of these medications on meniscal healing.

Hypothesis:

The administration of ketorolac in the perioperative period will result in higher rates of meniscal repair clinical failure.

Study design:

Cohort study; Level of evidence, 3.

Methods:

A total of 110 consecutive patients underwent meniscal repair at our institution between August 1998 and July 2001. Three patients were lost to follow-up, and the remaining 107 (mean age, 15.9 ± 4.4 years) had a minimum 5-year follow-up (mean follow-up, 5.5 years). Thirty-two patients (30%) received ketorolac perioperatively. The primary outcome measure was reoperation for continued symptoms of meniscal pathology. Asymptomatic patients were evaluated by the International Knee Documentation Committee (IKDC) Subjective Knee Form, Short Form–36 (SF-36) Health Survey, and Knee Outcome Osteoarthritis Score (KOOS).

Results:

Kaplan-Meier survivorship revealed no difference in reoperation rates with and without the administration of perioperative ketorolac (P = .95). There was an overall failure rate of 35% (37/107 patients), with a 34% failure rate in patients receiving ketorolac (11/32 patients). Multivariable Cox regression confirmed that age, duration of symptoms, meniscal tear type, fixation technique, concurrent anterior cruciate ligament repair, and ketorolac usage did not have an impact on the rate of failure (P > .05 for all; ketorolac use, P > .50). Female sex (P = .04) and medial location (P = .01) were predictive of an increased risk for reoperation.

Conclusion:

Failure of meniscal repair was not altered with the administration of perioperative ketorolac. Further work studying the effects of longer term anti-inflammatory use after meniscal repair is necessary before stating that this class of medications has no effect on meniscal healing.

Clinical Relevance:

Results of this study suggest that nonsteroidal anti-inflammatory ketorolac can be administered perioperatively during a meniscal repair procedure to harness its benefits of decreased narcotic requirement, decreased pain, and shorter length of hospital stay without negatively influencing the long-term outcome of the surgery.

Biological enhancement of meniscus repair and replacement

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

Outcome of meniscal repair prior compared with concurrent ACL reconstruction

Meniscal tears are commonly associated with traumatic rupture of the anterior cruciate ligament (ACL). At our centre, if a patient presents with locked knee in conjunction with an ACL injury we perform an initial arthroscopy to remove the cause of locking and schedule ACL reconstruction once a full range of motion has returned. The aim of this study was to assess the outcome of meniscal tears stabilised prior to ACL reconstruction. We identified 24 patients who underwent repair of a torn meniscus before having their ACL reconstruction (group 1). As a comparison group we identified 148 patients who underwent meniscal repair at the time of ACL reconstruction (group 2). Twelve of the patients in group 1 underwent meniscectomy, seven at the time of reconstruction and five subsequently. This gives a success rate of 50% (12/24) in the ACL deficient patients. In comparison forty two of the patients in group 2 went on to have a meniscectomy representing a success of 72% (106/148). The odds ratio for meniscectomy in an ACL deficient meniscal repair is 2.52 (95% CI 1.07-5.97) and there is a relative risk of 1.76 (95% CI 1.05-2.63). The difference in success of the meniscal repair between the groups was significant (Fisher's exact test p=0.05). Meniscal repair and delayed ACL reconstruction is more likely to fail than a combined repair and ACL reconstruction.

Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes

PURPOSE

The aim of this investigation was to compare reoperation rates and clinical outcomes after meniscal repair and partial meniscectomy.

METHODS

A systematic literature review was performed to identify outcome studies of arthroscopic meniscal repair (inside-out, outside-in, and all-inside techniques) or partial meniscectomy in patients with traumatic meniscal tears. The studies included patients with no previous injuries or operations.

RESULTS

At short- and long-term follow-up, partial meniscectomy had a lower reoperation rate (1.4% [2 of 143] and 3.9% [52 of 1,319], respectively) than isolated meniscal repair (16.5% [47 of 284] and 20.7% [30 of 145], respectively). There was a slightly higher reoperation rate after partial lateral meniscectomy compared with partial medial meniscectomy. Repairs of the medial meniscus resulted in higher reoperation rates than repairs of the lateral meniscus. Meniscal repairs at the time of anterior cruciate ligament reconstruction had a lower failure rate than isolated repairs. In the limited number of studies with long-term clinical outcome scores, meniscal repair was associated with higher Lysholm scores and less radiologic degeneration than partial meniscectomy.

CONCLUSIONS

Whereas meniscal repairs have a higher reoperation rate than partial meniscectomies, they are associated with better long-term outcomes.

LEVEL OF EVIDENCE

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

Long-term outcome after meniscal repair

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

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

RESULTS

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

CONCLUSION

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

White on white meniscal tears to fix or not to fix?

The mechanical disadvantage to articular cartilage following meniscectomy has been well documented in the literature. Meniscal repair in the avascular (white on white) is controversial and would be deemed inappropriate by many. We have developed criteria for repair in all meniscal tears. These are: The meniscus 1. must not be degenerated 2. must be reducible, without a rolled edge 3. the fixation must be considered sound. Between 1999 and 2008 our department prospectively collected data on meniscal repairs as part of a sports database. Four hundred and twenty three patients underwent repair during this time period. We identified 87 patients with no co existent ACL injury or instability. There were 73 males and 14 females with a mean age of 26 years (13-54). All tears were in the non peripheral (white on white) area. The criterion for failure was reoperation on the same meniscus requiring excision or re fixation. The mean follow up was 49 months (10-112). Twenty eight patients required further surgery on their repaired meniscus. There were eight re-repairs and 20 partial menisectomies. This represents a success rate of 68% (59/87). The mean pre operative Lysholm score was 61 (4-88) which rose to 75 (12-100) postoperatively, p=0.002. The mean pre op Tegner score was 6 (3-10) and this did not change significantly post operatively, mean 6 (0-10) p=0.4. Isolated white on white avascular meniscal tears can be successfully repaired in the majority of cases with a good clinical and functional result.

MRI signal changes in completely healed meniscus confirmed by second-look arthroscopy after meniscal repair with bioabsorbable arrows

This study evaluated the MRI signal characteristics and MRI diagnostic accuracy in identifying completely healed menisci repaired with bioabsorbable arrows. A total of 34 patients (38 menisci), with a mean age of 26.0 years, underwent arthroscopic meniscal repair with bioabsorbable arrows and concomitant anterior cruciate ligament (ACL) reconstruction. Of the 34 patients, 27 were male and 7 were female. Of the 38 menisci, 27 were medial and 11 were lateral. Second-look arthroscopy was performed for each patient while taking out the hardware for ACL reconstruction of the tibial side to evaluate the healing status of the repaired menisci. Postoperative MRI was done 2 days before or after second-look arthroscopy. Sagittal T1, T2 and PD images and coronal T2 and PD images were used as the main diagnostic serials. Second-look arthroscopy showed that surfaces of the repaired sites of all 38 menici were almost smooth. In all 38 cases the tail ends of meniscus arrows disappeared and in four patients new overlying injury of compartmental cartilage at the repaired side was detected. MRI results revealed that different serials had different diagnostic accuracy. Sagittal: T1 28.9%, PD 34.2%, T2 60.5%. Coronal: PD 36.8%, T2 65.8%. The double sides Grade 3 signal had a higher proportion in saggital T1 and PD serials, 47.4 and 39.5%, respectively, while lower in sagittal and coronal T2 serials, both 5.3%. MRI diagnostic accuracy was correlated positively with the follow-up time (P < 0.05). MRI has its limitation in evaluating the status of menisci repaired with bioabsorbable arrows, especially for PD and T1 serials. T2 serials have higher diagnostic accuracy than other serials. MRI diagnostic accuracy can be improved by prolonging follow-up time and might be improved by further classifying Grade 3 signal in terms of signal intensity and the shape of the signal margin.

FasT-Fix meniscal repair: mid-term results

PURPOSE

The purpose of this study was to evaluate the clinical success of the FasT-Fix meniscal repair device (Smith & Nephew Endoscopy, Andover, MA) associated with an accelerated rehabilitation program.

METHODS

A prospectively collected consecutive series of meniscal repairs performed with the FasT-Fix device was studied. The Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee activity scores, along with the clinical examination findings and adverse events, were recorded for all patients. Associated procedures were recorded. An accelerated postoperative rehabilitation program was followed, independent of concurrent anterior cruciate ligament surgery.

RESULTS

Forty-one meniscal repairs were performed, with an average follow-up of 30.7 months (range, 12 to 58 months). Twenty-nine of 41 repairs were performed in conjunction with anterior cruciate ligment reconstruction. The other repairs were in stable knees. There were 26 medial and 15 lateral meniscus repairs. Both menisci were repaired in 5 knees. Repeat arthroscopies were performed for 12 repairs and 7 (17%) were found to have failed. The preoperative and postoperative Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee activity scores were 47.3 and 87.4, 3.4 and 7.2, 38.7 and 82.8, and 2.3 and 3.4, respectively.

CONCLUSIONS

The FasT-Fix meniscal repair associated with an accelerated rehabilitation program resulted in clinically effective meniscal repair in 83% at the time of follow-up. Clinical outcome measures all improved.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Comparison of arthroscopic meniscal repair results using 3 different meniscal repair devices in anterior cruciate ligament reconstruction patients

PURPOSE

The goal of this study was the clinical evaluation of arthroscopic meniscal repair results with the use of 3 different repair devices.

METHODS

From 2001 to 2006, 265 patients underwent 280 meniscal repairs (RapidLoc [DePuy Mitek, Raynham, MA] in 88 patients, T-Fix [Acufex Microsurgical, Mansfield, MA] in 85 patients, and FasT-Fix [Smith & Nephew Endoscopy, Andover, MA] in 92 patients). There were 181 medial and 99 lateral tears; 174 tears were located in Cooper radial zone 1, and 106 tears were in Cooper radial zone 2. All patients had associated anterior cruciate ligament reconstructions. Follow-up assessment included clinical examination, arthrometry (KT-1000; MEDmetric, San Diego, CA), International Knee Documentation Committee scores, and scores on Lysholm functional questionnaires. Clinical criteria for a successful result included the absence of joint line tenderness, swelling, and blocking and the presence of a negative McMurray test.

RESULTS

The mean follow-up was 24.5 months (range, 20 to 26 months). Tear length averaged 3.17 cm (range, 1.4 to 4 cm). A mean of 2.4 suture devices was used. On the basis of our criteria, 28 meniscus repairs were considered to be failures (success rates of 92.4% for FasT-Fix, 87% for T-Fix, and 86.5% for RapidLoc). There were 16 relook arthroscopies for device removal and partial meniscectomy, with 11 patients (68.7%) having failure of the meniscal repair in zone 2. Both the Lysholm and International Knee Documentation Committee scores were significantly improved. Chronicity or location of the tear, length of the tear, and patient age did not affect the clinical outcome.

CONCLUSIONS

The compared meniscal repair systems showed comparable clinical results. These meniscal repair systems appeared to be safe and effective, providing a high rate of meniscal healing both in patients with complex tears and in patients with tears located in Cooper radial zone 2.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective comparative study.

Meniscal repair techniques

The human meniscus is important for normal knee function and distributes loads, aids in joint lubrication, congruence, stability, and proprioception. Repair of appropriate meniscal tears is possible and several methods exist to accomplish this including suture repairs and device repairs. Clinical evidence suggests that meniscal repairs can result in acceptable healing rates although adverse events have been reported for some devices. New self-adjusting suture devices have facilitated the accurate and effective repair of the torn meniscus. Technique descriptions for these devices are presented.

Pathologic characteristics of the torn human meniscus

BACKGROUND

Acellular meniscus tissue is at a high risk for degeneration and retear. Information that would help surgeons predict, preoperatively, or intraoperatively which torn menisci had few viable cells could be useful in deciding which patients might be at increased risk for retear and failure of surgical repair.

HYPOTHESIS

Patient age, length of time since injury, and tear type are predictors of the cellularity of meniscus tissue.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Gross and histologic evaluation of torn meniscus tissue from 44 patients and 10 control menisci was performed.

RESULTS

The patient factors of age, time since injury, and tear type all had significant effects on the pathologic characteristics of the torn meniscus. Patients older than 40 years had lower cellularity in the torn menisci than did patients younger than 40 years (P < .01). As time since injury increased, so did the rates of DNA fragmentation in the midsubstance of the meniscus and rates of Outerbridge II changes in the adjacent cartilage. Worse meniscal histologic scores were found in menisci with degenerative and radial tear types.

CONCLUSION

Patient age had a significant effect on the cellularity of the torn meniscus, with patients older than 40 years having significantly fewer meniscus cells than did those younger than 40 years. Further studies are needed to define the relative importance of the individual histologic findings in the clinical setting of meniscus tear and repair.

CLINICAL RELEVANCE

In light of their decreased cellularity, menisci from patients older than 40 years may be more vulnerable to degeneration and retear after repair than are menisci of younger patients.

Arthroscopic meniscal repair: a comparative study between three different surgical techniques

The purpose of this prospective study was to evaluate and compare the results of arthroscopic meniscal repair using three different techniques. Between January 2002 and March 2004, 57 patients who met the inclusion criteria underwent an arthroscopic meniscal repair. The outside-in technique was used in 17 patients (group A), the inside-out in 20 patients (group B), while the rest of the 20 patients (group C) were managed by the all-inside technique using the Mitek RapidLoc soft tissue anchor (Mitek Surgical Products, Westwood, MA, USA). Anterior cruciate ligament (ACL) reconstruction was performed in 29 patients (51%). The criteria for clinical success included absence of joint line tenderness, locking, swelling, and a negative McMurray test. The minimum follow-up was one year for all groups. The mean follow-up was 23 months for group A, 22 months for group B, and 22 months for group C. All meniscal repairs were considered healed according to our criteria in group A, while 19 out of 20 repairs (95%) healed in group B. Finally 7 of 20 repairs (35%) were considered failures in group C and this difference was statistically significant in comparison with other groups. The time required for meniscal repair averaged 38.5 min for group A, 18.1 min for group B, and 13.6 min for group C. Operation time for meniscal repair in group A was statistically longer in comparison with other groups. There were no significant differences among the three groups concerning complications. According to our results, arhtroscopic meniscal repair with the inside-out technique seems to be superior in comparison with the other methods because it offers a high rate of meniscus healing without prolonged operation time.

Meniscal repair and transplantation: indications, techniques, rehabilitation, and clinical outcome

The purpose of this paper is to provide current knowledge regarding the indications, operative techniques, rehabilitation programs, and clinical outcomes of meniscus repair and transplantation procedures. Meniscus tears that occur in the periphery may be repaired using a variety of operative procedures with high success rates. Complex multiplanar tears that extend into the central one-third avascular zone can also be successfully repaired using a meticulous vertically divergent suture technique. The outcome of these repairs justifies preservation of meniscal tissue, especially in younger athletic individuals. Meniscal transplantation is a valid treatment option for patients who have undergone meniscectomy and have related tibiofemoral joint pain, or in whom articular cartilage deterioration in the meniscectomized compartment is present. Rehabilitation after these operations includes knee motion and quadriceps-strengthening exercises initiated the first day postoperatively. The initial goal is to prevent excessive weight bearing and joint compressive forces that could disrupt the healing meniscus repair or transplant. The protocol contains modifications according to the type of meniscal tear, if a concomitant procedure is done (such as a ligament reconstruction) or if noteworthy articular cartilage deterioration is present. Patients who have repairs of peripheral meniscus tears are generally progressed more rapidly than those who have repairs of tears extending in the central one-third region or those who undergo meniscal transplantation. The safety and effectiveness of the rehabilitation program has been demonstrated in several clinical studies. We recommend preservation of meniscal tissue, regardless of age, in active patients whenever possible.

Meniscal repair with the RapidLoc meniscal repair device

BACKGROUND

The RapidLoc is an all-inside, self-adjusting, flexible meniscal repair device that combines a suture with an anchor component and, by using a reinforced sliding knot, allows for tightening to compress and hold the repaired meniscal segments. The purpose of this study was to evaluate the clinical success of the RapidLoc device.

METHODS

A prospective consecutive series of meniscal repairs performed with the RapidLoc device was studied. Lysholm, Tegner, Cincinnati, IKDC (International Knee Documentation Committee) activity scores, clinical examination findings, and adverse events were recorded on all patients. Associated procedures were recorded. An accelerated postoperative rehabilitation program was followed, independent of whether anterior cruciate ligament (ACL) surgery was also performed.

RESULTS

A total of 32 patients underwent 32 meniscal repairs, with an average follow-up of 31 months (18 to 48 months). In all, 23 repairs were done in conjunction with ACL reconstruction, and 9 repairs were carried out in stable knees. Repairs were made to 25 medial menisci and 7 lateral menisci. Tears repaired consisted of peripheral longitudinal tears with an average length of 2 cm (range, 15 to 30 mm). Four failures (12.5%) were arthroscopically documented. Clinical success occurred in 87.5% at the time of last follow-up. At follow-up, mean Tegner score was 5.1 (2.8 preoperative), IKDC activity score was 3.1 (1.8 preoperative), Lysholm score was 93.6 (48.4 preoperative), and mean Cincinnati score was 88.1 (43.7 preoperative). The most common adverse event was cutting of the suture during RapidLoc insertion. One patient had excoriation and grooving of the medial femoral condyle associated with failed repair. Another patient developed a postoperative infection.

CONCLUSIONS

The early clinical success rate was 87.5% with the RapidLoc device. Chondral grooving was observed in a single case.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.