Results of all-inside meniscal repair with the FasT-Fix meniscal repair system

Arthroscopic all-inside wrapping repair of lateral meniscus bucket-handle tears: clinical and imaging outcomes

PURPOSE

This study aimed to assess the clinical and radiographic healing rates of the arthroscopic all-inside wrapping repair technique for lateral meniscus bucket-handle tears (LMBHTs).

METHODS

This retrospective study examined patients diagnosed with LMBHTs who underwent all-inside wrapping repair with or without anterior cruciate reconstruction between 2012 and 2021. Patients with previous knee surgeries, multiligamentous knee injuries, or advanced osteoarthritis were excluded. Clinical follow-up was at least 2 years. Clinical healing was defined as no reoperation of LMBHTs following initial repair and the absence of symptoms related to the LMBHT during follow-up. Postoperative clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) score. At 6 months postoperatively, the healing of the repaired meniscus was evaluated using Henning's criteria through magnetic resonance imaging (MRI).

RESULTS

Of the 34 patients included, two required re-operation for a re-tear of the BHT, resulting in a clinical healing rate of 94.1% (95% confidence interval [CI]: 82.9-99.2%) at a mean follow-up of 4.2 years. Among the remaining 32 patients, the mean postoperative IKDC score was 83.7 ± 8.2 (range, 70-95). MRI evaluations at 6 months postoperatively revealed complete healing in 64.7% (22/34; 95% CI: 47.9-79.5%), partial healing in 23.5% (8/34), and failure to heal in 12.5% (4/34, including the two re-tear cases). Subgroup analyses indicated no significant difference in the IKDC scores between patients with complete healing and those with partial healing on MRI (85.5 ± 7.9 vs. 82.3 ± 8.5; p = 0.53). Future studies with larger cohorts and stratified analyses are needed to explore potential predictors of healing outcomes.

CONCLUSIONS

The all-inside wrapping repair technique demonstrated favorable outcomes in patients with lateral BHTs and can be used as a viable alternative.

Early Meniscal Repair Leads to Higher Success Rates Than Delayed Meniscal Repair: A Systematic Review and Meta-analysis

BACKGROUND

There has been an increased interest in meniscus preservation over the last decade. Several risk factors for the failure of meniscal repair have been identified. However, the timing of meniscal repair has not been extensively assessed in the literature, and there is currently no high-quality evidence on the optimal timing of performing meniscal repair after an injury with regard to outcomes.

PURPOSE

To assess the role of the timing of meniscal repair on outcomes in the literature.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

The databases of PubMed, Embase, and the Cochrane Library were searched in October 2023 for studies comparing the outcomes of early versus delayed meniscal repair. Studies were eligible for inclusion if they reported outcomes within and after a time threshold (eg, within and after 3 weeks). Random-effects models were used.

RESULTS

A total of 35 studies with 3556 patients and 3767 menisci were included (mean age, 27.5 years; 66% male; mean follow-up, 4.5 years). Most studies were level 3 or 4 evidence, and the overall quality was low. The failure rates of meniscal repair were 11.3% versus 24.1% within versus after 2 weeks, respectively (7 studies, 511 patients; odds ratio [OR], 0.50 [95% CI, 0.22-1.16]; P = .11); 7.2% versus 15.3% within versus after 3 weeks, respectively (5 studies, 556 patients; OR, 0.28 [95% CI, 0.10-0.79]; P = .02); 15.7% versus 21.3% within versus after 6 weeks, respectively (7 studies, 746 patients; OR, 0.63 [95% CI, 0.33-1.18]; P = .15); and 10.2% versus 18.7% within versus after 8 weeks, respectively (7 studies, 652 patients; OR, 0.47 [95% CI, 0.26-0.87]; P = .02); these were significant for 3 and 8 weeks. No differences were seen for within versus after 3 months (7 studies, 1305 patients; 22.4% vs 18.5%, respectively; OR, 1.04 [95% CI, 0.47-2.33]; P = .92).

CONCLUSION

The timing of meniscal surgery was correlated with the likelihood of success, and meniscal repair should preferably be performed within 8 weeks of the injury, with the earliest benefit at 3 weeks. Clinicians should take this into consideration when recommending operative treatment or initial nonoperative treatment.

Long-term Comparative Outcomes of All-Inside Versus Inside-Out Repair of Bucket-Handle Meniscal Tears: A Cohort Study

Background

Bucket-handle meniscal tears (BHMTs) are a common subtype of meniscal tears that represent a clinical challenge. Arthroscopic inside-out repair has been considered the gold standard in treatment; however, an all-inside approach has gained widespread popularity, with limited long-term evidence.

Purpose/Hypothesis

The purpose of this study was to (1) compare long-term clinical outcomes and rates of failure after surgical repair of BHMTs using the all-inside versus inside-out technique, and 2) identify risk factors for failure at long-term follow-up. It was hypothesized that clinical outcomes and rates of failure would be similar between the 2 techniques.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who had undergone surgical repair of BHMTs between 2003 and 2013 at a single institution were identified. Patient-reported outcome measures (PROMs) were assessed preoperatively and at the latest follow-up using the Tegner scale, International Knee Documentation Committee questionnaire, and visual analog scale pain at rest and with activity. A univariate Cox proportional hazards model was used to identify predictors for repair failure, defined as revision meniscal surgery and/or documented meniscal retear.

Results

In total, 63 patients were included (37 with inside-out repair, 26 with all-inside repair). At a mean follow-up of 11.2 years, the survival rate for BHMT repair was 63% overall, 70% for all-inside repairs, and 60% for inside-out repairs (P = .37). The mean time to failure was 2.6 years for all-inside repairs and 2.5 years for inside-out repairs (P = .98). PROM scores were not significantly different between the 2 repair groups (P > .22). Univariate Cox proportional hazards model for failure demonstrated that increasing age at surgery was associated with lower failure rates (hazard ratio, 0.91 change per 1-year increase in age; 95% CI, 0.84-0.98) and medial meniscus repair was associated with higher failure rates (hazard ratio, 3.12; 95% CI, 1.14-8.77).

Conclusion

Long-term follow-up of BHMT repair demonstrated satisfactory clinical outcomes and failure rates. In appropriately selected patients, the all-inside technique did not compromise outcome as compared with the inside-out repair techniques. For both methods, older age was associated with lower failure rates and medial meniscus repair was associated with increased failure.

All-Inside and Inside-Out Repair Techniques for Bucket-Handle Meniscus Tears Both Result in Improved Patient Outcomes and a Broad Range of Failure Rates: A Systematic Review

PURPOSE

To compare patient-reported outcomes, failure rates, risk factors for failure, and complications in patients with bucket-handle meniscus tears (BHMTs) undergoing repair with inside-out (IO) versus all-inside (AI) techniques.

METHODS

A literature search was performed using the PubMed, Embase, and Scopus databases from database inception to August 2023 according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria consisted of Level I to IV clinical studies published in the past 10 years with greater than 2 years of follow-up that evaluated patient-reported outcome scores and/or the incidence of failure after IO or AI repairs for BHMTs. Clinical studies not reporting outcomes or failure rates, older studies using outdated implants, animal studies, reviews, letters to the editor, case reports, cadaveric studies, and articles not written in the English language or with English-language translation were excluded. Study quality was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria. Outcomes were reported as ranges and qualitatively compared.

RESULTS

A total of 16 studies published from 2013 to 2023, consisting of 1,062 patients with BHMTs, were identified. Thirteen studies (14 cohorts, 649 patients) reported on AI repair (mean age range, 23.7-32 years) and 7 studies (7 cohorts, 413 patients) reported on IO repair (mean age range, 16.7-34.6 years). Both groups had improved postoperative Lysholm and Tegner scores. Decreased range of motion was the most commonly reported complication in the AI group (range, 2.6%-4%), whereas adhesions for arthrofibrosis were the most commonly reported complication in the IO group (n = 12; range, 6%-7.9%). The overall reported failure rate ranged from 6.9% to 20.5% within the AI group and from 0% to 20% within the IO group.

CONCLUSIONS

AI and IO repair techniques for BHMTs both result in improved Lysholm and Tegner scores. However, broad ranges of failure are reported in the literature, with overall failure rates ranging from 6.9% to 20.5% after AI repair and from 0% to 20% after IO repair. Younger age and isolated medial BHMT repair are the most frequently reported risk factors for the AI technique, whereas postoperative stiffness is the most frequently reported complication after both repair techniques.

LEVEL OF EVIDENCE

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

More Is Not Merrier: Increasing Numbers of All-Inside Implants Do Not Correlate with Higher Odds of Revision Surgery

The purpose of this study was to evaluate the relationship between the number of all-inside meniscal repair implants placed and the risk of repair failure. We hypothesized that the use of higher numbers of all-inside meniscus repair implants would be associated with increased failure risk. A retrospective chart review identified 351 patients who underwent all-inside meniscus repair between 2006 and 2013 by a sports medicine fellowship-trained orthopaedic surgeon at a single institution. Patient demographics (age, body mass index [BMI], sex) and surgical data (number of implants used, concomitant anterior cruciate ligament reconstruction [cACLR], and tear type/size/location) were recorded. Patients who received repairs in both menisci or who had follow-up < 1-year postoperatively were excluded. Repair failure was identified through chart review or patient interviews defined as a revision surgery on the index knee such as partial meniscectomy, total knee arthroplasty, meniscus transplant, or repeat repair. Logistic regression modeling was utilized to evaluate the relationship between the number of implants used and repair failure. A total of 227 all-inside meniscus repairs were included with a mean follow-up of 5.0 ± 3.0 years following surgery. Repair failure was noted in 68 knees (30.3%)-in 28.1% of knees with fewer than four implants and in 35.8% of knees with four or more implants (p = 0.31). No significant increase in failure was observed with increasing number of all-inside medial (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 0.79-1.7; p = 0.46) or lateral (OR: 0.86; 95% CI: 0.47-1.57; p = 0.63) implants after controlling for patient age, BMI, cACLR, tear type, or size. Tears of the lateral meniscus located in the red-white and white-white zones had lower odds of failure (OR: 0.14; 95% CI: 0.02-0.88; p = 0.036) than tears within the red-red zone, and patients with cACLR had lower odds of repair failure (OR: 0.40; 95% CI: 0.18-0.86, p = 0.024) than those without. The number of all-inside implants placed during meniscus tear repair did not affect the likelihood of repair failure leading to reoperation after controlling for BMI, age, tear type, size, location, and cACLR. LEVEL OF EVIDENCE:  III.

Is the popliteal tendon sufficient for all-inside suture in lateral meniscus repair? A 22-case cadaver study

INTRODUCTION

Arthroscopic lateral meniscus repair is performed in the "figure-of-4 position" (supine, with the affected knee flexed and the lower leg crossed over the extended contralateral leg), and anchorage is often on the popliteal tendon. Extending the limb at the end of the procedure alters the relations between the popliteal tendon and the repaired meniscus. The present study aimed to assess lateral meniscal suture fixation on the popliteal tendon after a cycle of flexion-extension.

HYPOTHESIS

Extending the knee can induce suture release.

TYPE OF STUDY

Cadaver study.

MATERIALS AND METHODS

Twenty-two fresh adult human cadaver knee specimens were used. Under arthroscopy with all-inside implants, a vertical suture onto the popliteal tendon was performed through the lateral meniscus. Suture status was assessed under arthroscopy after a cycle of flexion-extension, and deemed defective if the suture was sufficiently loose for the arthroscope to be able to be passed through the popliteal hiatus, if the stitch had passed through the meniscus, or if the suture was broken.

RESULTS

Thirteen sutures (59.1%) remained well fixed, and 9 (40.1%) were defective: 4 (18.2%) were loose, in 4 (18.2%) the stitch had passed through the meniscus, and in 1 (4.5%) the suture had broken.

CONCLUSION

In a population of elderly cadaver knee specimens, arthroscopic suture of the lateral meniscus to the popliteal tendon was defective after flexion-extension in 40% of cases. Stress seems to be exerted on the suture when extension is resumed. Thus, a single stitch seems insufficient for stable lateral meniscus repair.

CLINICAL IMPLICATIONS

Suture of the lateral meniscus to the popliteal tendon undergoes stress when extension is resumed, potentially causing failure of lateral meniscus repair.

LEVEL OF EVIDENCE

IV.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, systematic review.

Arthroscopic Meniscal Repair: University Hospital Southampton Experience

Introduction The meniscus plays an integral role in the proper functioning of the knee joint. Located between the articular surfaces of the tibia and femur, the meniscus functions to provide stability to the knee joint, even out axial load, absorb shock, and provide some lubrication to the knee joint. Accordingly, treatment of meniscal injuries aims to preserve as much meniscal tissue as possible to avoid the myriad complications that arise from its removal. This study of the all-inside technique for meniscal repair evaluates the University Hospital Southampton experience by comparing our outcomes with the available literature. Patients and methods This is a retrospective study from January 2016 to December 2020. Records of patients were obtained through the preoperative assessment clinics network and electronic notes. The endpoints of the study were defined as patients who either were discharged, experienced failure of repair, i.e., symptomatic or magnetic resonance imaging (MRI) changes, or were offered re-surgery. Results Eighty-one patients, comprising 51 males and 30 females, were included in the study, and 85 repairs were performed. A steady increase in the number of procedures was observed year on year until the outbreak of COVID-19. The mean age of patients was 24.7 years, with a range of 39 years. The medial meniscus was found to be injured more often than the lateral meniscus. The most commonly observed injury pattern was the bucket handle (BH) type. Anterior cruciate ligament (ACL) injury was found to be associated with meniscal injuries in around half of patients. The reason for this occurrence can be attributed to the ligamentous connection between the medial meniscus and the anterior cruciate ligament in the phenomenon described in the "unhappy triad." On average, three FasT-Fix sutures were required per procedure. Discussion and conclusion After a follow-up of 11 months, 11 (13.6%) treated patients were noted to have failed repair, as defined by the endpoint criteria. Age and acuity were noted to not affect outcomes, and the results suggest that males are at higher risk of failed repair than females (p<0.05).

Comparison of Cases with Anterior Cruciate Ligament Reconstruction Accompanied by Simultaneous Medial Meniscus Bucket Handle Tear Repair and Isolated Medial Meniscus Bucket Handle Tear Repair

The aim of this study was to evaluate the success of the all-inside repair technique for medial bucket-handle meniscus tear (BHMT) and the factors affecting healing. A total of 36 patients with BHMT who were operated between 2012 and 2018 and completed final follow-up examinations were included in the study. Functional evaluation was made with the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score. Healing was evaluated on magnetic resonance imaging (MRI) slices. The patients were evaluated with respect to the effect on healing of factors such as demographic data, body mass index (BMI), smoking status, anterior cruciate ligament tear reconstruction (ACLTR) applied at the same time as BHMT repair, and the tear being chronic or acute. The mean age of the patients was 28.6 ± 8.6 years (range,18-46 years), the mean follow-up period was 25.8 ± 13.9 months (range, 13-59 months), and BMI was mean 25.6 ± 3.5 kg/m² (range, 20.1-30.5 kg/m²). The meniscus tears were acute in 16 (44.4%) patients and chronic in 20 (55.6%). ACLTR was applied together with BHMT repair in 25 patients. The hybrid technique, as the outside-in technique in addition to the all-inside technique, was applied to 12 (33.3%) patients, where there was seen to be extension to the anterior horn. The failure rate was determined as 27.8% according to the postoperative MRI evaluation and the Barrett criteria. No positive or negative statistically significant effect on healing was determined of chronic BHMT or of simultaneous application of ACLTR (p = 1.00 and 0.457, respectively). Cigarette smoking and high BMI were determined to have a statistically significant negative effect on healing (p = 0.026 and 0.007, respectively). In conclusion, it can be seen that the success of the all-inside technique for BHMT remains controversial. Due to the features of the application, it can be used in meniscus tears of the posterior horn only. In the current study, with the success rate of 72.2% of the all-inside technique in meniscus body tears, it was seen that a high success rate could not be achieved.

Comparison of new and old all-inside suture devices in meniscal cyst formation rates after meniscal repair

PURPOSE

We compared the magnetic resonance imaging (MRI)-confirmed cyst formation rate after meniscal tear repair using a new all-inside suture device (N group) versus the older all-inside suture device (O group).

METHODS

Between October 2008 and July 2017, 94 consecutive menisci of 89 patients were diagnosed with meniscal tears and underwent arthroscopic meniscal repair using the all-inside suture device. Five of these patients were lost to follow-up within 12 months and were excluded from the study. The remaining 89 menisci were followed up for at least 12 months and were included in this retrospective cohort study. Older all-inside suture devices (FasT-Fix, Ultra FasT-Fix) were used until December 2012, while the new all-inside suture device (FasT-Fix 360) was used from January 2013 onwards. Meniscal cysts were detected on T2-weighted fat-suppressed MRI at 12 months postoperatively. Multiple logistic regression analysis was used to identify demographic and clinical factors associated with the use of the new all-inside suture device and cyst formation.

RESULTS

In total, 36 and 53 menisci were included in the N and O groups, respectively. The incidence of meniscal cysts was significantly greater in the O group (14 out of 53, 26.4%) than in the N group (two out of 36, 5.56%) (P = 0.012). Two patients in the O group had symptomatic cysts that required removal. Multivariate logistic analyses showed that the cyst formation risk significantly decreased after using the new all-inside suture device than the older all-inside suture devices (odds ratio = 0.139; P = 0.04).

CONCLUSIONS

The MRI-confirmed cyst formation rate after meniscal tear repair was significantly lower using the new than the older all-inside suture devices, indicating that the use of a low-profile device may decrease the cyst formation rate.

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

Background:

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

Purpose:

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

Study Design:

Systematic review; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

The Danger Zone for Iatrogenic Neurovascular Injury in All-Inside Lateral Meniscal Repair in Relation to the Popliteal Tendon: An MRI Study

Background:

Lateral meniscal repair can endanger the nearby neurovascular structure (peroneal nerve or popliteal artery). To our knowledge, there have been no studies to evaluate the danger zone of all-inside meniscal repair through the anteromedial (AM) and anterolateral (AL) portals in relation to the medial and lateral edges of the popliteal tendon (PT).

Purpose:

To establish the risk of neurovascular injury and the danger zone in repairing the lateral meniscus in relation to the medial and lateral edges of the PT.

Study Design:

Descriptive laboratory study.

Methods:

Using axial magnetic resonance imaging (MRI) studies at the level of the lateral meniscus, lines were drawn to simulate a straight, all-inside meniscal repair device, drawn from the AM and AL portals to both the medial and lateral edges of the PT. In cases in which the line passed through the neurovascular structure, a risk of iatrogenic neurovascular injury was deemed, and measurements were made to determine the danger zones of neurovascular injury in relation to the medial or lateral edges of the PT.

Results:

Axial MRI images of 240 adult patients were reviewed retrospectively. Repairing the body of the lateral meniscus through the AM portal had a greater risk of neurovascular injury than repairs made through the AL portal in relation to the medial edge of the PT (P = .006). The danger zone in repairing the lateral meniscus through the AM portal extended 1.82 ± 1.68 mm laterally from the lateral edge of the PT and 3.13 ± 2.45 mm medially from the medial edge of the PT. Through the AL portal, the danger zone extended 2.81 ± 1.94 mm laterally from the lateral edge of the PT and 1.39 ± 1.53 mm medially from the medial edge of the PT.

Conclusion:

Repairing the lateral meniscus through either the AM or the AL portals in relation to the PT can endanger the peroneal nerve or popliteal artery.

Clinical Relevance:

The surgeon can minimize the risk of iatrogenic neurovascular injury in lateral meniscal repair by avoiding using the all-inside meniscal device in the danger zone area as described in this study.

Return-to-Sport Rate and Activity Level Are High Following Arthroscopic All-Inside Meniscal Repair With and Without Concomitant Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To systematically review the literature of return-to-sport outcomes following all-inside meniscus repair and evaluate whether concomitant anterior cruciate ligament reconstruction (ACLR) influenced these outcomes.

METHODS

A systematic review of the MEDLINE, PubMed, Embase, and Cochrane Registry of Systematic Reviews databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers examined all literature pertaining to sport outcomes following all-inside meniscal repair. Studies were included if they had a 12-month minimum follow-up and reported return to sport rate, Tegner, or Knee injury and Osteoarthritis Outcome Score (KOOS) Sport outcomes. Studies with meniscal repair techniques other than the all-inside technique were excluded. Studies were not excluded if they contained patients receiving concomitant ACLR. Study quality was evaluated with the Methodological Index for Nonrandomized Studies.

RESULTS

Nineteen studies comprising 872 patients were included in this investigation. The weighted average patient age was 28.7 (range 14.1-42.1) years, and the weighted average follow-up was 56.0 (range 18.0-155.0) months. The mean Methodological Index for Nonrandomized Studies score was 14.4 ± 3.7. Ten investigations reported both preoperative (range 2.3-3.5) and postoperative (range 4.0-7.3) Tegner outcomes, with scores at final follow-up greater in each of the 10 reporting investigations. KOOS Sport outcomes were examined in 5 investigations, with scores at follow-up ranging from 63.6 to 91. Three studies reported a return to sport rate ranging from 89.6 to 90% at follow-up. Four investigations compared sport-related outcomes between isolated meniscal repair and meniscal repair with concomitant ACLR. Two such studies reported no difference between the 2 cohorts, 1 favored the isolated cohort, and 1 favored the combined cohort.

CONCLUSIONS

This systematic review found a 90% return-to-sport rate and high postoperative activity level following all-inside meniscal repair, as assessed by KOOS Sport and Tegner activity scales. Further, concurrent ACLR did not significantly affect these outcomes.

LEVEL OF EVIDENCE

IV, systematic review of level I-IV studies.

Excellent medium-term survival of an all-inside tensionable knotted suture device justifies repair of most meniscal tears encountered during reconstructive knee ligament surgery

PURPOSE

All-inside meniscal repair devices have evolved to allow surgeons to undertake complex repairs in a timely and efficient manner. This is advantageous in active patients, where meniscus preservation is critical in preserving joint function and stability. The aim of the study was to evaluate the failure rate of all-inside meniscal repair performed in patients undergoing reconstructive ligament surgery using a particular meniscal repair device.

METHODS

Patients were identified using a single-site prospectively maintained patient registry. Primary outcome was failure, defined as return to surgery with documented failure of repair. Complication rates and functional scores were also recorded. Patients in whom meniscal repair failure was identified were further assessed, to identify any common features.

RESULTS

Over an 8-year period, 323 patients underwent meniscal repair at the time of ligament reconstruction, compared to 244 meniscectomies. Of these, 286 patients underwent repair using an all-inside suture device. One-hundred and twenty-seven repairs were to the medial meniscus only, 124 were lateral, and in 35 patients both menisci were repaired. Follow-up was to a median of 51.5 months. There were 31 (9.7%) failures reported at a median of 22 months post-operatively (IQR 13.5-41.5). Medial repair failures were seen more frequently than lateral (13.6% versus 5.6% OR 2.62 95% CI 1.17-5.88 p = 0.022). Failure of ACL reconstruction was associated with meniscal repair failure (OR 5.83 95% CI 1.55-21.95 p = 0.0039). Multi-ligament reconstruction was undertaken in 70/286 patients receiving meniscal repair and was not associated with failure (OR 1.3 95% CI 0.57-2.98 p = 0.51). Mode number of all-inside sutures used was 3 in both medial and lateral repairs (Range 1-9 lateral; 1-7 medial).

CONCLUSIONS

All-inside repair is a safe and versatile technique which can be used in the majority of meniscal tears encountered during ligament reconstruction with excellent mid-term success. Failure is seen more commonly in medial sided repairs and with failure of ACL reconstruction.

LEVEL OF EVIDENCE

IV.

All-Inside Arthroscopic Repair For Longitudinal Meniscal Tears: Clinical and Functional Results

Meniscal injuries are a common challenge in orthopaedic surgery. Depending on their location and the patient's age and functional needs, they can be treated either conservatively or surgically. A surgical approach can consist of arthroscopic meniscectomy or meniscal suture. The latter is the treatment of choice in case of lesions involving the red-red or red-white areas of the meniscus, especially for young high-demanding patients. We report here our experience with the repair of longitudinal meniscal tears using the all-inside technique with the Fast-Fix™ 360 Meniscal Repair System (Smith & Nephew Endoscopy, Andover, MA). We retrospectively evaluated 20 consecutive cases of longitudinal meniscal tears. In 4 cases, concomitant ACL rupture was diagnosed and treated alongside the meniscal repair. All patients underwent periodic clinical evaluations. At the latest check-up, their functional outcomes were rated according to the Tegner-Lysholm Knee and KOOS scoring scales. The mean Tegner-Lysholm Knee score was 84.85 (44-100) and the mean KOOS score was 88.58. No failure or major complications were observed. Furthermore, a negative statistical association was observed between age at surgery and the post-operative Tegner-Lysholm Knee score (coef. = -1.01189 [-1.942073,-0.0817063], p = 0.035). This relation, independent of gender, meniscus involved, eventual associated ACL reconstruction, and chondral injury, suggests that functional outcomes worsen with increasing patient age. Our results suggest that the arthroscopic all-inside suture is both safe and effective in cases of longitudinal meniscal tear, considering the good post-operative functionality and low rates of local complications and surgical failures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical outcomes of meniscus repair and partial meniscectomy: Does tear configuration matter?

PURPOSE

We report our experience with the effect of location and configuration of meniscal tears on clinical outcomes.

METHODS

A retrospective review of patients who underwent partial meniscectomy or meniscal repair between 2008 and 2016 was conducted. One hundred fourteen knees in 106 patients were included, comprising 43 partial meniscectomies and 71 meniscal repairs. Patients were graded pre- and postoperatively with the International Knee Documentation Committee (IKDC) score and Tegner Activity Level Scale. Meniscal tears were classified according to location (anterior horn, body, posterior horn, and others) and type (radial, horizontal, longitudinal, and complex) and subgroups were analyzed for their effect on outcomes.

RESULTS

All tears, whether treated with partial meniscectomy or repair, showed significant improvement in postoperative scores (p < 0.05); 39.47% of tears involved the posterior horn alone, 10.53% involved the body alone, 3.51% involved the anterior horn alone, and 46.49% were complex tears that spanned more than one area. Complex tears treated with repair had significantly better scores (IKDC, p = 0.002; Tegner, p = 0.008) than complex tears treated with meniscectomy. Longitudinal tears showed results suggesting better short-term outcomes with meniscectomy than with repair (IKDC, p = 0.036; Tegner p = 0.018), a potential statistical anomaly. Horizontal and radial tears showed no significant difference in outcomes, regardless of treatment. Tears in different locations (anterior horn, body, posterior horn, and others) showed no significant difference in outcomes, regardless of treatment.

CONCLUSION

Meniscal surgery yields significant improvement in postoperative scores. Complex tears showed significantly better postoperative scores when treated with repair.

Examining Techniques for Treatment of Medial Meniscal Ramp Lesions During Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

The purpose of this study was to systematically review the clinical outcomes and adverse events among different techniques for treatment of medial meniscal ramp lesions performed in conjunction with anterior cruciate ligament (ACL) reconstruction.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane Reviews, Web of Science, and Medline databases were searched for studies examining clinical outcomes after surgical treatment of ramp lesions. Studies were selected if they met the following criteria: (1) evaluation of the outcome of surgical repair of meniscal ramp lesions, (2) injuries associated with ACL tears, (3) minimum 6-month follow up, (4) publication in a peer-reviewed journal, and (5) English language or translation readily available.

RESULTS

Seven studies met inclusion criteria (485 patients; mean age 27.1 years [range 12 to 59]; mean follow-up 26.9 months [range 8 to 40]). Two all-inside techniques (suture-hook and an all-inside meniscus repair device) in addition to abrasion and trephination alone were analyzed. Each technique demonstrated significant increases in postoperative Lysholm and International Knee Documentation Committee (IKDC) scores, reaching the established minimal clinically important difference (MCID) for each patient reported outcome. Incomplete healing was documented in 12.1% to 12.9% of cases in which the tear was not repaired at the time of ACL reconstruction, 2.3% to 11.7% in cases using the suture-hook for repair, and 10.8% to 15% in the all-inside meniscus repair device group.

CONCLUSION

This systematic review demonstrated that several approaches used to treat medial meniscal ramp lesions associated with ACL tears lead to positive clinical outcomes. Small, stable tears <2 cm in size may be managed with debridement alone. For larger, more unstable lesions, an all-inside approach has demonstrated positive clinical outcomes. Prospective trials are needed to determine the best management for meniscal ramp lesions. Additionally, further research is needed to better understand how to minimize the risk of technique-related complications (e.g., improper implant deployment).

LEVEL OF EVIDENCE

Level IV, systematic review of level II, III, and IV studies.

Delayed or neglected meniscus tear repair and meniscectomy in addition to ACL reconstruction have similar clinical outcome

PURPOSE

To compare the clinical outcomes of meniscus repair and meniscus resection with concurrent anterior cruciate ligament (ACL) reconstruction in patients with ACL rupture and neglected or delayed medial meniscus tears.

METHODS

Thirty patients with ACL ruptures and unstable vertical longitudinal medial meniscus tears were included. Patients were divided into two groups. Group I included 15 patients who underwent meniscal repair and Group II included 15 patients who underwent meniscectomy. The knee range of motion, McMurray test, Lachman test, pivot shift test, Lysholm Knee Scoring Scale, International Knee Documentation Committee (IKDC) Questionnaire, Hospital for Special Surgery (HSS) Knee score, and Tegner activity (TA) scale were used to assess all patients.

RESULTS

The median follow-up time was 3.6 (0.5-6.5) years. Median age was 28 (16-36) years. Fourteen patients (93.3%) in Group I and six patients (40%) in Group II returned to their preinjury sport activity level (P = .007). Median maximum knee flexion was 132° (121°-140°) in Group I and 134° (121°-139°) in Group II (n.s.). All patients had full knee extension and negative McMurray test results. Lachman and pivot shift test results were similar between groups. The median IKDC Questionnaire score was 99 (86-100) in Group I and 93 (70-100) in Group II (P = .016). The difference in Lysholm Knee Scoring Scale, HSS knee, and TA scale score between groups were not significant.

CONCLUSION

Clinical outcomes of patients that underwent meniscus repair were better than those that underwent meniscus resection with concurrent ACL reconstruction. The technically complicated and costly meniscus repair may achieve better clinical outcomes than meniscectomy when treating a neglected or delayed meniscal tear with a concurrent ACL tear.

LEVEL OF EVIDENCE

III.

Predictive Factors for Failure of Meniscal Repair: A Retrospective Dual-Center Analysis of 918 Consecutive Cases

Background:

Meniscal surgery is one of the most common surgical procedures performed by orthopaedic surgeons. Over the past decade, awareness has increased regarding the importance of meniscal preservation to prevent the development of osteoarthritis in the knee joint. Removal of meniscal tissue can lead to a high risk of cartilage degeneration, and moreover, meniscus-preserving surgery rather than meniscal resection is likely to have better long-term outcomes. Success rates after meniscal repair range from 60% to 95%, but many reports are based on a small number of patients.

Purpose/Hypothesis:

The purpose of this study was to review all meniscal repairs and potential predictors for failure during a 12-year period. We hypothesized that meniscal anchors, lateral repairs, and repairs made in conjunction with an anterior cruciate ligament reconstruction (ACLR) would have fewer failures than meniscal arrows, medial repairs, and isolated repairs. We also hypothesized that younger patients and acute tears would be associated with fewer failures.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

This study was a dual-center, retrospective analysis on consecutive meniscal repairs. The surgical protocols were reviewed, including type of tear, location, associated injury to the knee, and surgery. The study endpoint was failure of repair, defined as a need for reoperation and secondary partial or total meniscal resection, within 3 years. Kaplan-Meier analysis was performed to assess repair survival, with multivariate Cox regression to adjust for confounders.

Results:

A total of 954 meniscal repairs were performed on 918 patients (536 male patients [58%]; 382 female patients [42%]) with a mean age of 26 years (range, 12-60 years). The failure rate for the entire cohort was 22.5%. Bioabsorbable arrows had significantly more failures than all-inside sutures with anchors (hazard ratio [HR], 1.8; 95% CI, 1.2-2.5; P = .002). Medial meniscal repairs had a higher failure rate than lateral meniscal repairs (HR, 3.7; 95% CI, 2.3-6.0; P < .001). Simultaneous ACLR resulted in less failure than when no simultaneous ACLR was performed (HR, 0.5; 95% CI, 0.3-0.9; P = .009). Age at repair and acuity of tear did not affect the outcome (P = .6 and .07, respectively).

Conclusion:

The failure rate after meniscal repair was significantly higher on the medial side, especially when using arrows. Meniscal repairs performed concomitantly with an ACLR result in fewer reoperations.

Second-look arthroscopic findings and clinical outcomes of meniscal repair with concomitant anterior cruciate ligament reconstruction: comparison of suture and meniscus fixation device

INTRODUCTION

The purpose of this study was to evaluate the healing rate of repaired meniscus and functional outcomes of patients who received all-inside meniscal repair using sutures or devices with concomitant arthroscopic anterior cruciate ligament (ACL) reconstruction.

MATERIALS AND METHODS

Among the patients who have ACL tear and posterior horn tear of medial or lateral meniscus, 61 knees who received all-inside repair using sutures (suture group, n = 28) or meniscal fixation devices (device group, n = 33) with concomitant ACL reconstruction during the period from January 2012 to December 2015, followed by second-look arthroscopy, were retrospectively reviewed. Healing status of the repair site was assessed by second-look arthroscopy. Through the clinical assessment, clinical success (negative medial joint line tenderness, no history of locking or recurrent effusion, and negative McMurray test) rate of the repaired meniscus and functional outcomes (International Knee Documentation Committee subjective score and Lysholm knee score) was evaluated.

RESULTS

In a comparison of healing status of repaired meniscus evaluated by second-look arthroscopy, suture group had 23 cases of complete healing (82.1%), 4 cases of incomplete healing (14.3%), and 1 case of failure (3.6%). Device group had 18 cases of complete healing (54.5%), 4 cases of incomplete healing (24.2%), and 7 cases of failure (21.2%) (p = 0.048). Clinical success rate of the meniscal repair was 89.3% (25 cases) and 81.8% (27 cases) in suture group and device group, respectively (p = 0.488). No significant difference of functional outcomes was observed between the two groups (p > 0.05, both parameters).

CONCLUSIONS

Among the patients who received meniscal repair with concomitant ACL reconstruction, suture group showed better healing status of repaired meniscus based on the second-look arthroscopy than device group. However, no significant between-group difference of clinical success rate and functional outcomes was observed.

Factors Predicting Failure Rates and Patient-Reported Outcome Measures After Arthroscopic Meniscal Repair

PURPOSE

To identify factors that affect patient-reported outcome measures (PROMs) and failure rates after arthroscopic meniscal repair.

METHODS

Embase, Embase Classic, and MEDLINE were searched on August 7, 2015, December 23, 2016, and March 11, 2018, for factors associated with PROMs and failure rates after arthroscopic meniscal repair. We excluded studies that (1) were non-English language, (2) did not use human patients, (3) were nonclinical, (4) did not analyze for factors that predicted PROMs or failure rates, and (5) were below Level IV evidence. Studies were graded into higher and lower quality using the Downs and Black scale.

RESULTS

A total of 34 articles met our criteria, and 32 were graded. We identified 16 articles as higher quality. Among higher-quality studies, factors that significantly predicted reduced failure rates were concurrent anterior cruciate ligament reconstruction (ACLR) (n = 6) and reduced tear complexity (n = 4). Factors that did not significantly impact failure rates were side of repair (n = 8), sex (n = 7), time from injury to surgery (n = 7), age (n = 7), rim width (n = 6), and tear length (n = 5). Factors predicting better PROMs were time from injury to surgery of less than 3 months (n = 1), Outerbridge scores below grade 3 or 4 (n = 2), and reduced varus alignment (n = 2). Factors that did not significantly impact PROMs were equipment used (n = 3) and concurrent ACLR (n = 1).

CONCLUSIONS

Factors affecting failure rates and PROMs after arthroscopic meniscal repair were identified. However, more and higher-quality studies supported concurrent ACLR and less complex tears as predictors of lower failure rates. PROMs were negatively affected by a longer time from injury to surgery, higher Outerbridge scores, and greater varus alignment before surgery.

LEVEL OF EVIDENCE

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

Prevalence, development, and factors associated with cyst formation after meniscal repair with the all-inside suture device

PURPOSE

To investigate the prevalence of cyst formation after using all-inside meniscal repair device and analysed the risk factors associated with it.

METHODS

Between August 2008 and September 2013, 51 menisci of 46 patients were included in the study, 46 menisci of which had concomitant anterior cruciate ligament (ACL) ruptures and had an ACL reconstruction. Magnetic resonance imaging (MRI) of the knee was performed at 3, 6, 12 and 24 months after meniscal surgery. The MRIs were assessed to detect the development of cysts encasing the suture anchors and to evaluate meniscal healing. Statistical analysis was performed using multiple regression analysis.

RESULTS

Out of the 51 menisci examined, MRI revealed cysts in 15 menisci. Cysts were detected in 3 menisci at 6 months, in 9 menisci at 12 months, and in 3 menisci at 24 months after surgery. Only 3 patients (6.5%) were symptomatic, and cystectomy was performed in 2 of these patients and arthroscopic debridement in the other. Compared with using both the suture device and an inside-out suture repair, using the suture device alone was more likely to be associated with cyst development [odds ratio (OR), 12.04]. The medial meniscus was also significantly more likely to develop a cyst compared with the lateral meniscus (OR, 12.48). There was an increased outcome for the number of device use (P = 0.033). Though it was not statistically significant, the patients with anterior knee laxity (side-to-side difference > 3 mm using a knee arthrometer) were more likely to develop cysts than those without anterior knee laxity (P = 0.06). There were no significant differences between the remaining variables.

CONCLUSIONS

The prevalence of cyst formation around the suture implant was 29%, but most cases were not symptomatic. Significant risk factors for cyst formation included the use of a suture device alone, and a location in the medial meniscus.

LEVEL OF EVIDENCE

III.

Proximity of the Neurovascular Bundle During Posterior-Lateral Meniscal Repair: A Comparison of the Transpatellar, Anteromedial, and Anterolateral Portals

PURPOSE

To compare the neurovascular proximity of the transpatellar portal with that of the medial and lateral portals and to determine the safe penetration depth for an all-inside device for use on the posterior horn lateral meniscus.

METHODS

Dissection of the popliteal fossa was performed in 10 cadaveric knees to identify all structures. Arthroscopy was performed using penetration depths of 10, 12, 14, and 16 mm with the all-inside system through the anteromedial, anterolateral, and transpatellar portals. Penetrations were made 5 and 10 mm lateral to the posterior horn root at the meniscocapsular junction. Needle-tip distances were measured from the popliteal artery and vein, tibial nerve, and common peroneal nerve.

RESULTS

Among 240 trials, the average distance to the popliteal neurovascular bundle using the medial, transpatellar, and lateral approaches was 6.9 mm, 6.5 mm, and 3.1 mm, respectively. The transpatellar-portal needle had a larger distance from the neurovascular bundle than the lateral portal (P = .001), with no statistical difference compared with the medial portal (P = .58). Compared with the position at a 10-mm distance from the root, the position at a 5-mm distance from the root was closer to the neurovascular bundle in all approaches (P = .001). The transpatellar approach set to 14 mm had a 5% rate of capsular underpenetration and 10% rate of gastrocnemius penetration. The transpatellar and medial portals had no neurovascular penetrations, whereas the lateral approach had a 14% rate of penetration (P < .05).

CONCLUSIONS

The transpatellar portal and anteromedial portal are in less proximity to the neurovascular bundle compared with the anterolateral portal for all-inside meniscal repair of the posterior horn lateral meniscus. Low rates of neurovascular penetration, gastrocnemius muscle penetration, and capsular underpenetration occurred with a depth setting of 14 mm.

CLINICAL RELEVANCE

This study shows the utility of medial and transpatellar portals when using all-inside devices to repair posterior horn lateral meniscal tears and neurovascular proximity based on penetration depth.

Incidence and Risk Factors for Meniscal Cyst After Meniscal Repair

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level Ⅲ, retrospective comparative study.

Biomechanical Study of Meniscal Repair Using Horizontal Sutures and Vertical Loop Techniques

Background:

Meniscus plays an important role in weight-bearing and energy absorption. Moreover, its function is optimal to maintain joint stability and congruous. Treatments for meniscus damage or meniscus tear include open or arthroscopic repair and meniscectomy. One of the most important factors that influence patients’ recovery outcome is restoration technique. The purpose of this study was to compare the strength of recently new method of meniscus repair, submeniscal horizontal sutures, and single vertical loop suturing techniques in meniscus repair.

Materials and Methods:

An experimental study was conducted to study 12 ruptured medial meniscuses of bulls, which were divided into two groups of six meniscuses equally. In this study, submeniscal horizontal and vertical loop suturing techniques were compared based on their resistance to tensile forces and the stability of repaired gaps.

Results:

In this study, submeniscal horizontal and vertical loop knots were 104.3 ± 12.5 N and 110.7 ± 16.4 N, respectively. No significant difference was found between the two groups. To measure the stability of the gap, 95.4 ± 8.7 N tensile force was applied to submeniscal and 124.6 ± 11.7 N to vertical loop techniques. There was significantly different in gap stability between horizontal and vertical loop techniques in meniscal repair (P = 0.02).

Conclusion:

The results of this study indicate that knot resistance in submeniscal horizontal is similar to vertical loop resistance. The stability of the restored gap in vertical loop technique is more than submeniscal horizontal techniques. Vertical loop causes greater stability against tensile force.

Current concepts in the techniques, indications and outcomes of meniscal repairs

Knee arthroscopy for meniscal tears is one of the most commonly performed orthopaedic procedures. In recent years, there has been an increasing incidence of meniscal repairs, as there are concerns that meniscectomy predisposes patients to early osteoarthritis. Indications for meniscal repair are increasing and can now be performed in older patients who are active, even if the tear is in the avascular zone. Options for meniscal tear management broadly fall into three categories: non-operative management, meniscal repair or meniscectomy. With limited evidence directly comparing each of these options optimal management strategies can be difficult. Decision making requires thorough assessment of patient factors (e.g. age and comorbidities) and tear characteristics (e.g. location and reducibility). The purpose of this paper is, therefore, to review the management options of meniscal tears and summarize the evidence for meniscal tear repair.

Meniscus repairs can be saved in the event of postoperative septic arthritis

PURPOSE

No systematic studies on optimal treatment of postoperative septic arthritis following arthroscopic meniscus repair are available. The purpose of this study was to retrospectively evaluate the fate of repaired menisci in cases of postoperative septic arthritis, with treatment for infection focused on arthroscopic irrigation and debridement (I&D) and intention to maintain the meniscus.

METHODS

Data of two sports orthopedics centers of the last 10 years were pooled (approximately 25,000 arthroscopic procedures of the knee). All cases of septic arthritis following arthroscopic meniscus repair were identified. These cases were retrospectively evaluated with regard to clinical course and management, especially the number of necessary I&Ds, if eradication was achieved, and if the repaired meniscus was retained or a partial resection was necessary ('early failure'). Patients with initially maintained meniscus repairs were contacted if further meniscus surgery was performed in further follow-up ('late failure').

RESULTS

20 patients with 23 repaired menisci were included. In 65% (13 cases), a concomitant anterior cruciate ligament reconstruction was performed. A mean of 2.0 ± 1.0 (1-4) arthroscopic I&Ds were performed in the treatment of septic arthritis. In two cases, additional open surgery was performed (after outside-in sutures). Eradication was achieved in all cases. Four repaired menisci (17.4%) showed loosened fixation or substantial degradation and were consequently partially resected within treatment for septic arthritis (early failures). The follow-up rate for the 19 initially maintained menisci was 94.7% after 3.0 ± 2.2 years (median 2.8, 0.4-7.8). Three of these underwent further partial resection (13.0%). Cumulative 3-year survival rate (Kaplan-Meier method) of all repairs was 70.7% (95% CI 50.3-91.1%), and for the subgroup of initially maintained menisci 85.6% (95% CI 67.0-100.0%), respectively.

CONCLUSION

Septic arthritis following meniscus repair can be successfully treated with (sequential) arthroscopic I&Ds. There is a considerable rate of early failures, however, in a mid-term follow-up the failure rate of initially retained menisci is low and comparable to what we know from the literature for cases without infection. Therefore, it is generally recommended to try to save the repaired menisci in these cases.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Top orthopedic sports medicine procedures

Orthopedic sports medicine is a subspecialty of Orthopedics that focuses on managing pathological conditions of the musculoskeletal system arising from sports practice. When dealing with athletes, timing is the most difficult issue to face. Typically, athletes aim to return to play as soon as possible and at the pre-injury level. This means that management should be optimized to combine the need for prompt return to sport and to the biologic healing time of the musculo-skeletal. This poses a great challenge to sport medicine surgeons, who need to follow with attention to the latest scientific evidence to offer their patients the best available treatment options. We briefly review the most commonly performed orthopedic sports medicine procedures, outlining the presently available scientific evidence on their indications and outcomes.

Comparative Outcomes of All-Inside Versus Inside-Out Repair of Bucket-Handle Meniscal Tears: A Propensity-Matched Analysis

Background:

There are limited data comparing the outcomes of all-inside versus inside-out meniscal repair techniques.

Purpose:

To assess failure rates and clinical outcomes after the surgical repair of bucket-handle meniscal tears utilizing either an all-inside or inside-out technique.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients with bucket-handle meniscal tears undergoing all-inside or inside-out repair at a single institution between 2003 and 2013 were analyzed. A total of 28 mensici repaired utilizing second-generation all-inside suturing devices and 42 menisci repaired using an inside-out technique were eligible for inclusion. Rigorous propensity matching was performed on the basis of age, sex, tear laterality, rim width, and concomitant anterior cruciate ligament reconstruction (ACLR), resulting in a total of 40 patients equally distributed between the 2 repair techniques for comparison. Retear-free survival as well as preoperative and postoperative International Knee Documentation Committee (IKDC) and Tegner scores and physical examination findings were subsequently analyzed.

Results:

Twenty patients who underwent all-inside repair (14 male; mean age, 23.7 ± 6.7 years) were successfully propensity matched to 20 patients who underwent inside-out meniscal repair (15 male; mean age, 22.5 ± 7.6 years), with a mean retear-free follow-up of 4.4 years (range, 2.5-7.4 years). Four (20%) all-inside repairs and 4 (20%) inside-out repairs failed over the course of follow-up (P > .999), with a mean time to failure of 2.7 years (range, 1.3-4.4 years) and 5.0 years (range, 0.8-7.5 years), respectively (P = .25). Increasing patient age trended toward a decreased clinical retear rate, independent of the repair technique (hazard ratio, 0.86; P = .056). There were no significant differences in the Tegner scores, IKDC scores, or range of motion between the groups as a whole or when subcategorizing by age, sex, body mass index, tear complexity, rim width, isolated versus concomitant ACLR, or medial- versus lateral-sided repair. There were no complications in the all-inside group, while there was a 10% rate of minor complications in the inside-out group (P = .49).

Conclusion:

Overall, satisfactory clinical outcomes are achievable at short-term to midterm follow-up with both inside-out and all-inside repair techniques of bucket-handle meniscal tears in rigorously matched patients with similar meniscal tear patterns.

Modern treatment of meniscal tears

The complex ultrastructure of the meniscus determines its vital functions for the knee, the lower extremity, and the body.

The most recent concise, reliable, and valid classification system for meniscal tears is the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Classification, which takes into account the subsequent parameters: tear depth, tear pattern, tear length, tear location/rim width, radial location, location according to the popliteal hiatus, and quality of the meniscal tissue.

It is the orthopaedic surgeon’s responsibility to combine clinical information, radiological images, and clinical experience in an effort to individualize management of meniscal tears, taking into account factors related to the patient and lesion.

Surgeons should strive not to operate in most cases, but to protect, repair or reconstruct, in order to prevent early development of osteoarthritis by restoring the native structure, function, and biomechanics of the meniscus.

Currently, there are three main methods of modern surgical management of meniscus tears: arthroscopic partial meniscectomy; meniscal repair with or without augmentation techniques; and meniscal reconstruction. Meniscus surgery has come a long way from the old slogan, “If it is torn, take it out!” to the currently accepted slogan, “Save the meniscus!” which has guided evolving modern treatment methods for meniscal tears. This last slogan will probably constitute the basis for newer alternative biological treatment methods in the future.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170067.

Long-term outcome after all inside meniscal repair using the FasT-Fix system

Purpose

Meniscal surgery is one of the most performed orthopaedic procedures. Because of its chondroprotective properties, meniscal repair should be attempted whenever possible. Several techniques are described in literature, e.g. all-inside repair using FasT-Fix System from Smith & Nephew. The aim of this study was to evaluate the outcome at a minimum of 12 years following meniscal repair using FasT-Fix System.

Materials and Methods

Patients who underwent meniscal repair using FasT-Fix System in the time from 2001 to 2003 were analyzed. We included isolated meniscal tears and combined tears with a concomitant ACL rupture. A median 12-year follow-up was conducted in 2015. Failure was defined as a new surgical procedure to the same meniscus. Moreover, functional outcome was evaluated using the KOOS and tegner activity score (TAS).

Results

At follow-up 27% had undergone further surgery to the repaired meniscus. There was no significant difference between isolated and combined group (p = 0.582). The failure rate was significantly higher in females (female 48% versus male 15%; p = 0.005). Comparing sports there was a significantly higher failure rate within soccer and indoor sports group (p = 0.002).Comparing isolated and combined injury groups there was no difference in the TAS (p > 0.05). Only 1 item of KOOS showed no significant difference: 95.33 versus 94.48 for daily life activities (p > 0.05). The other items showed significant differences.49 out of 51 patients with combined injuries suffered an additional ACL rupture. There was no significant difference regarding the meniscal repair failure rate when comparing the groups of simultaneous and delayed ACL repair (p = 0.521).

Conclusions

At 12 years' follow-up 73% had a successful surgery. KOOS was significantly better within isolated meniscus tears. Both groups showed no difference in the TAS. There were no differences regarding failure rate in the comparison of simultaneous or delayed ACL-reconstruction.

Knee Meniscus Injuries: Common Problems and Solutions

The rates of arthroscopic meniscus repair continue to increase with excellent reported outcomes. Complications, sometimes catastrophic, following meniscus repair may occur. The rate of postoperative complications may be reduced by adequate diagnosis, appropriate patient selection, meniscus repair selection, surgical techniques, and postoperative management. When complications occur, the provider must identify and take steps to rectify as well as prevent further complications from occurring. The purpose of this article is to detail the common diagnostic, technical, and postoperative pitfalls that may result in poor patient outcomes.

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.

Are Outcomes After Meniscal Repair Age Dependent? A Systematic Review

PURPOSE

To determine if the failure rate and functional outcome after arthroscopic meniscus suture repair are age dependent.

METHODS

A systematic review was conducted using a computerized search of the electronic databases MEDLINE and ScienceDirect in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data from each included study were recorded on a standardized form. Studies were included if they (1) were English-language studies in peer-reviewed journals, (2) used a distinct age cut-off to evaluate outcome of meniscal surgery for those above and below the specified cut-off, and (3) used meniscal repairs using suture based technique with inside-out, outside-in, or all-inside techniques. Review papers, case reports, technique papers, non-English language publications, abstracts, and data on meniscal repairs using meniscal screws, arrows, or darts were excluded.

RESULTS

15 of 305 identified articles met the inclusion/exclusion criteria. There were 1,141 menisci treated in 1,063 patients. Seven and 8 studies met the inclusion/exclusion criteria for analysis for the age thresholds of 25 years and 30 years, respectively, demonstrating no difference in failure rates relative to age threshold. Four of 6 studies that met analysis criteria found no difference in failure rates above or below an age threshold of 35 years. No significant difference in failure in patients younger than 40 than patients older than 40 was found for 4 of the 5 studies in that arm of the review.

CONCLUSIONS

Analysis of the composite data in this systematic review reveals that no significant difference exists when evaluating meniscal repair failure rate as a function of age above or below the given age thresholds.

LEVEL OF EVIDENCE

Level IV, systematic review of level III and IV studies.

Meniscal repair: Technique

Meniscal repair aims to achieve meniscal healing, avoiding the adverse effects of meniscectomy. Longitudinal vertical tears in a vascularized area are the reference indication. The technique generally uses hybrid all-inside implants. The outside-in technique has other indications in more anterior tears. Healing has been demonstrated on CT-arthrography and arthroscopy. Specific techniques have been developed for other pathological situations. Posterior meniscosynovial lesions in a context of chronic anterior laxity are identified by exploration of the posterior compartment, and fixed by all-inside hook suture. Horizontal lesions in young athletes can be treated by open meniscal suture. Radial tears, when deep, can be repaired. Root tears, when traumatic, can be treated by transosseous pullout reinsertion.

Arthroscopic medial meniscal repair with or without concurrent anterior cruciate ligament reconstruction: A subgroup analysis

BACKGROUND

There are few large-scale, long-term studies comparing medial meniscal repairs with or without concurrent anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 140 patients who underwent arthroscopic medial meniscal repair were divided into two groups: Group A, meniscus repair only and Group B, meniscus repair with concurrent ACL reconstruction. Clinical assessments in- cluded physical examination findings, Lysholm score, and the International Knee Documentation Committee (IKDC) form. Barret criteria were used for the clinical assessment of healing status. Magnetic resonance imaging (MRI)was obtained to confirmhealing and failure. Subgroups of participants were compared in terms of suture technique, type of tear, and location of tear. KT-2000 arthrometer testing was used for objective evaluation of anterior-posterior knee movement.

RESULTS

Mean follow-up duration was 61 (34-85) months. Clinical outcomes in both groups were significantly improved compared to baseline (P=0.001 vs. P=0.001); however, there was no significant between-group difference in postoperative Lysholm and IKDC scores (P=0.830). The outcomes of three participants (seven percent) in Group A and 11 (11.3%) in Group B were considered as treatment failures (P=0.55). Red-red zone tears had higher scores. Mean postoperative KT2000 arthrometer values of failed participants in Groups A and B were 4.66mm (range, four to six) and 5.2mm (range, two to seven), respectively.

CONCLUSION

Concurrentmedialmeniscus repair and ACL reconstruction did not have clinical superiority over meniscus repair alone. Repairs in the red-red zone appeared to be associated with better outcomes.

Factors Affecting the Outcomes of Arthroscopically Repaired Traumatic Vertical Longitudinal Medial Meniscal Tears

BACKGROUND

Although numerous studies have assessed arthroscopic medial meniscal repairs, few studies have focused on factors affecting outcomes of vertical longitudinal and bucket-handle repairs.

PURPOSE

To evaluate the factors affecting clinical outcomes of arthroscopically repaired traumatic vertical longitudinal and bucket-handle medial meniscal tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 223 patients underwent arthroscopic repair for medial meniscal tears between 2007 and 2012; 140 patients had isolated tears or concurrent anterior cruciate ligament (ACL) reconstruction, and 80 patients (76 men, 4 women; mean age, 29.1 years; range, 18-49 years) had vertical longitudinal tears and were included in the study. Pre- and postoperative functional status was assessed using physical examinations with Lysholm and International Knee Documentation Committee (IKDC) scores. Barrett criteria were used for clinical assessment of meniscal healing, and magnetic resonance imaging (MRI) was used as the radiologic assessment method. The effects of tear location, length, chronicity, and type; suturing technique; concurrent ACL reconstruction; and patient age, sex, and smoking habits were also investigated.

RESULTS

The mean follow-up period was 51.2 ± 9.4 months (range, 34-85 months). The mean Lysholm and IKDC scores improved at final follow-up (both Ps <.001). According to clinical scores, Barrett criteria, and MRI, failure was noted in 12 patients (15%). There were no significant differences in age, tear length, tear type, concurrent ACL rupture, suturing technique, or location of the meniscal repair between the success and failure groups. Failure rates were higher for red-white zone tears than for red-red zone tears (10/30, 33.3% vs 2/50, 4%; P = .004). Tear chronicity significantly affected failure rates. Early repairs had higher healing rates than late repairs (100% vs 73.4%; P = .008). Failure rates were higher for smokers than for nonsmokers (9/24, 37.5% vs 3/56, 5.3%; P = .008).

CONCLUSION

Peripheral tears and early repairs have better outcomes and patient satisfaction. Smoking adversely affects meniscal healing.

Inside-Out Versus All-Inside Repair of Isolated Meniscal Tears: An Updated Systematic Review

BACKGROUND

Meniscal tears are common in the young, active population. In this group of patients, repair is advised when possible. While inside-out repair remains the standard technique, recent advances in all-inside repair devices have led to a growth in their popularity. Previous reviews on the topic have focused on outdated implants of limited clinical relevance.

PURPOSE

To determine the difference in failure rates, functional outcomes, and complications between inside-out and modern all-inside repairs.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was registered with PROSPERO and performed following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using the MEDLINE, EMBASE, and Cochrane databases. Inclusion criteria were (1) clinical study reporting on all-inside or inside-out repair, (2) evidence levels 1 to 4, and (3) use of modern all-inside implants for all-inside repairs. Exclusion criteria were (1) use of meniscal arrows or screws and (2) concomitant surgical procedures. Study characteristics, subjects, surgical technique, clinical outcomes, and complications were collected and analyzed.

RESULTS

A total of 481 studies were screened and assessed for eligibility, which identified 27 studies for review. Studies defined clinical failure as persistent mechanical symptoms, effusion, or joint line tenderness, while anatomic failure was incomplete or no healing on MRI or second-look arthroscopy. There were no significant differences in clinical or anatomic failure rates between inside-out and all-inside repairs (clinical failure: 11% vs 10%, respectively, P = .58; anatomic failure: 13% vs 16%, respectively, P = .63). Mean ± SD Lysholm and Tegner scores for inside-out repair were 88.0 ± 3.5 and 5.3 ± 1.2, while the respective scores for all-inside repair were 90.4 ± 3.7 and 6.3 ± 1.3. Complications occurred at a rate of 5.1% for inside-out repairs and 4.6% for all-inside repairs.

CONCLUSION

The quality of the evidence comparing inside-out and all-inside meniscal repair remains low, with a majority of the literature being evidence level 4 studies. In this review comparing modern all-inside devices with inside-out repair, no differences were seen in failure rates, functional outcome scores, or complication rates.

Combined outside-in and FasT-Fix sutures for the treatment of serious discoid meniscal tears: A midterm follow-up study

BACKGROUND

The treatment of discoid meniscus is debatable. This study aimed to assess the clinical efficacy of combined outside-in and FasT-Fix sutures for the treatment of serious discoid meniscal tears.

METHODS

This study included 32 consecutive patients who underwent arthroscopic meniscal plasty for serious discoid meniscal tears (full-thickness vertical, longitudinal tears >10mm) between October 2006 and June 2012. A combination of outside-in and FasT-Fix sutures was used to treat serious discoid meniscal tears. Disappearance of clinical symptoms (locked knee, pain, and clicking) and negative results in the McMurray and Apley grind tests were assessed during follow-up (26 to 47months). The Lysholm, IKDC, and Tegner scores were assessed for therapeutic efficacy. Some patients were followed up with MRI.

RESULTS

Symptoms (pain, clicking, and locking) disappeared in all patients. The Lysholm score improved from 39.1±9.2 to 89.6±6.7 at six months, and to 90.1±6.3 at the last follow-up. The same trends were observed for the IKDC score (from 38.0±9.5 to 90±6.3, and to 91.1±6.4) and the Tegner score (from 2.8±0.6 to 5.2±0.6, and to 5.2±0.5). Among all patients, 13 were followed up with MRI. Among these patients, four had an unhealed stitched edge, but they did not complain of any discomfort in the knees.

CONCLUSIONS

The use of a combination of outside-in and FasT-Fix sutures for meniscal plasty had good outcomes for serious discoid meniscal tears and can thus be regarded as a good surgical option.

Repair of Meniscal Ramp Lesions Through a Posteromedial Portal During Anterior Cruciate Ligament Reconstruction: Outcome Study With a Minimum 2-Year Follow-up

PURPOSE

To evaluate the results of arthroscopic all-inside suture repair of medial meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament (ACL) reconstruction.

METHODS

All patients who underwent a suture of the posterior segment of the medial meniscus using a suture hook device through a posteromedial portal during ACL reconstruction with minimum 2 year-follow-up were included in the study. Repair was performed for longitudinal tears within the rim of less than 3 mm (capsulomeniscal junction or red-red zone) or 3 to 5 mm (red-white zone) of an unstable torn meniscus. Patients were assessed pre- and postoperatively with IKDC score and Tegner activity scale. Instrumented knee testing was performed with the Rolimeter arthrometer. Complications including reoperation for failed meniscal repair were also recorded.

RESULTS

One hundred thirty-two patients met the inclusion criteria. The mean follow-up time was 27 months (range, 24 to 29 months). The average subjective IKDC rose from 63.8 ± 13.5 (range, 27 to 92) preoperatively to 85.7 ± 12 (range, 43 to 100) at last follow-up (P < .0001). The Rolimeter test decreased from a side-to-side difference in anterior knee laxity of 7 mm (range, 5 to 14 mm) to a mean value of 0.4 mm (range, -3 to 5 mm) at last follow-up (P < .0001). The Tegner activity scale at the last follow-up (6.9 ± 1.72) was slightly lower than that before surgery (7.2 ± 1.92; P = .0017). Nine patients (6.8%) had failure of the meniscal repair. In 5 cases, recurrent tears were related to a newly formed tear located anterior to the initial tear.

CONCLUSIONS

Our results show that arthroscopic meniscal repair of ramp lesions during ACL reconstruction through a posteromedial portal provided a high rate of meniscus healing at the level of the tear and appeared to be safe and effective in this group of patients.

LEVEL OF EVIDENCE

Level IV, therapeutic study, case series (no control group).

Classification and Surgical Repair of Ramp Lesions of the Medial Meniscus

Ramp lesions of the medial meniscus are commonly associated with anterior cruciate ligament ruptures and consist of longitudinal peripheral tears of the posterior horn of the medial meniscus. Given the frequency of partial-thickness tears, they can be difficult to diagnose arthroscopically from the anterior compartment. We describe a classification of the different types of ramp lesions depending on both tear pattern (partial- or full-thickness tear) and associated meniscotibial ligament disruption. An original technique of arthroscopic suture placement through a single posteromedial portal with a 25° curved suture hook device is described.

What Is the Optimal Minimum Penetration Depth for "All-Inside" Meniscal Repairs?

PURPOSE

To identify desired minimum depth setting for safe, effective placement of the all-inside meniscal suture anchors.

METHODS

Using 16 cadaveric knees and standard arthroscopic techniques, 3-dimensional surfaces of the meniscocapsular junction and posterior capsule were digitized. Using standard anteromedial and anterolateral portals, the distance from the meniscocapsular junction to the posterior capsule outer wall was measured for 3 locations along the posterior half of medial and lateral menisci. Multiple all-inside meniscal repairs were performed on 7 knees to determine an alternate measure of capsular thickness (X2) and compared with the digitized results.

RESULTS

In the digitized group, the distance (X1) from the capsular junction to the posterior capsular wall was averaged in both menisci for 3 regions using anteromedial and anterolateral portals. Mean distances of 6.4 to 8.8 mm were found for the lateral meniscus and 6.5 to 9.1 mm for the medial meniscus. The actual penetration depth was determined in the repair group and labeled X2. It showed a similar pattern to the variation seen in X1 by region, although it exceeded predicted distances an average 1.7 mm in the medial and 1.5 mm in the lateral meniscus owing to visible deformation of the capsule as it pierced.

CONCLUSIONS

Capsular thickness during arthroscopic repair measures approximately 6 to 9 mm (X1), with 1.5 to 2 mm additional depth needed to ensure penetration rather than bulging of the posterior capsule (X2), resulting in 8 to 10 mm minimum penetration depth range. Surgeons can add desired distance away from the meniscocapsular junction (L) at device implantation, finding optimal minimal setting for penetration depth (X2 + L), which for most repairable tears may be as short as 8 mm and not likely to be greater than 16 mm.

CLINICAL RELEVANCE

Minimum depth setting for optimal placement of all-inside meniscal suture anchors when performing all-inside repair of the medial or lateral meniscus reduces risk of harming adjacent structures secondary to overpenetration and underpenetration of the posterior capsule.

COMBINED INSIDE-OUT AND ALL-INSIDE TECHNIQUE IN BUCKET-HANDLE MENISCUS TEARS

OBJECTIVE

To determine the outcomes after combined inside-out and all-inside repair technique of bucket-handle meniscus tears.

METHODS

A retrospective review was made of patients with bucket-handle meniscus tears repaired with combined techniques, using the all-inside technique in posterior meniscal tears and the inside-out technique in the middle part of the meniscal tears. Meniscal healing was assessed clinically using Barrett's criteria and MRI.

RESULTS

The study comprised 52 patients with a mean age of 28.4 years old (range, 19-52 years old). The mean follow-up period was 31.3 months (range, 24-59 months). Two patients had ACL re-rupture, and complete meniscal healing was achieved in all but one patient. Although improved from preoperative status, Tegner and Lysholm scores were lower in the ACL reconstructed patients than in the intact ACL patients.

CONCLUSION

Combined inside-out and all-inside meniscal repair technique is a successful and cost-effective treatment method in bucket-handle meniscus tears. Level of Evidence IV, Therapeutic Study.

Sport and early osteoarthritis: the role of sport in aetiology, progression and treatment of knee osteoarthritis

Sports activities are considered favourable for general health; nevertheless, a possible influence of sports practice on the development of early osteoarthritis (OA) is a cause for concern. A higher incidence of OA in knees and ankles of former high-impact sports players than in those of the normal population has been shown and it is still debatable whether the cause is either to be recognized generically in the higher number of injuries or in a joint overload. The possibility to address knee OA in its early phases may be strictly connected to the modification of specific extrinsic or intrinsic factors, related to the patient in order to save the joint from further disease progression; these include sport practice, equipment and load. Non-surgical therapies such as continuative muscles reinforce and training play a strong role in the care of athletes with early OA, particularly if professional. There is an overall agreement on the need of an early restoring of a proper meniscal, ligament and cartilage integrity in order to protect the knee and resume sports safely, whereas alignment is a point still strongly debatable especially for professional athletes. Remaining questions still to be answered are the risks of different sports in relation to one another, although an actual protective effect of low-impact sports, such as walking, swimming or cycling, has been recognized on the appearance or worsening of OA, the effect of continuing or ceasing to practice a sport on the natural history of early OA, and even following appropriate treatment is still unknown.

Return to play after all-inside meniscal repair in competitive football players: a minimum 5-year follow-up

PURPOSE

The purpose of this study was to report the mid-to-long-term return to sports after all-inside meniscal repair in competitive football players.

METHODS

All football players undergoing all-inside meniscal repair with a minimum Tegner activity score of 9 and minimum follow-up of 5 years were eligible for inclusion. Patients were excluded if: (a) they had ipsilateral or contralateral: meniscectomy, posterior cruciate ligament tear, multi-ligament knee injuries, osteotomies, or meniscal transplant (b) they had meniscal tears in the anterior horn, and (c) they had bucket-handle tears. All patients included were contacted by phone and asked for current sport status or Tegner score. Preoperative Tegner scores were collected from the medical charts.

RESULTS

All patients (n = 29) were men with a median (range) age of 27 (18-37) years and a follow-up of 6 (5-8) years. All meniscal injuries were complete and longitudinal tears. The median preinjury Tegner activity score was 9 (range 9-10). Two patients required revision arthroscopy (6.7 %) with partial meniscectomy before being able to return to competitive football due to suture failure. Twenty-six patients (89.6 %) returned to the same level of competition after recovering from surgery. At the last follow-up, 13 patients (45 %) were able to continue playing football at any level, and 8 (28 %) of them were able to return to the same pre-injury competitive level. The main reasons for the decreased level of activity (from competitive to recreational) or to give up football were job-related or changes in their personal life situation, but were not related to knee or meniscal disorders. Fourteen patients underwent meniscal repair alone, whereas 15 patients had an associated ACL reconstruction procedure. There were no significant differences in the collected variables between both subgroups.

CONCLUSIONS

All-inside meniscal repair allows for excellent results with regard to return-to-play rates in competitive football. However, only half of the patients are still playing football in the mid-to-long-term follow-up, although reasons to give up football are not related to knee or meniscal disorders.

LEVEL OF EVIDENCE

Case series, Level-IV.

Biomechanical Comparison of Parallel and Crossed Suture Repair for Longitudinal Meniscus Tears

Background:

Longitudinal meniscus tears are commonly encountered in clinical practice. Meniscus repair devices have been previously tested and presented; however, prior studies have not evaluated repair construct designs head to head. This study compared a new-generation meniscus repair device, SpeedCinch, with a similar established device, Fast-Fix 360, and a parallel repair construct to a crossed construct. Both devices utilize self-adjusting No. 2-0 ultra–high molecular weight polyethylene (UHMWPE) and 2 polyether ether ketone (PEEK) anchors.

Hypothesis:

Crossed suture repair constructs have higher failure loads and stiffness compared with simple parallel constructs. The newer repair device would exhibit similar performance to an established device.

Study Design:

Controlled laboratory study.

Methods:

Sutures were placed in an open fashion into the body and posterior horn regions of the medial and lateral menisci in 16 cadaveric knees. Evaluation of 2 repair devices and 2 repair constructs created 4 groups: 2 parallel vertical sutures created with the Fast-Fix 360 (2PFF), 2 crossed vertical sutures created with the Fast-Fix 360 (2XFF), 2 parallel vertical sutures created with the SpeedCinch (2PSC), and 2 crossed vertical sutures created with the SpeedCinch (2XSC). After open placement of the repair construct, each meniscus was explanted and tested to failure on a uniaxial material testing machine. All data were checked for normality of distribution, and 1-way analysis of variance by ranks was chosen to evaluate for statistical significance of maximum failure load and stiffness between groups. Statistical significance was defined as P < .05.

Results:

The mean maximum failure loads ± 95% CI (range) were 89.6 ± 16.3 N (125.7-47.8 N) (2PFF), 72.1 ± 11.7 N (103.4-47.6 N) (2XFF), 71.9 ± 15.5 N (109.4-41.3 N) (2PSC), and 79.5 ± 25.4 N (119.1-30.9 N) (2XSC). Interconstruct comparison revealed no statistical difference between all 4 constructs regarding maximum failure loads (P = .49). Stiffness values were also similar, with no statistical difference on comparison (P = .28).

Conclusion:

Both devices in the current study had similar failure load and stiffness when 2 vertical or 2 crossed sutures were tested in cadaveric human menisci.

Clinical Relevance:

Simple parallel vertical sutures perform similarly to crossed suture patterns at the time of implantation.

The Effect of Knee Flexion Angle on the Neurovascular Safety of All-Inside Lateral Meniscus Repair: A Cadaveric Study

PURPOSE

To evaluate if different knee flexion angles can modify the neurovascular injury risk during lateral meniscus repair.

METHODS

Twenty cadaveric knees were studied. An all-inside suture device (FasT-Fix; Smith & Nephew, Andover, MA) was placed at the posterior horn and at the medial and lateral limits of the popliteal hiatus. The minimal distances between the device and the popliteal artery and peroneal nerve were measured with the knee at 90°, 45°, and 0° of flexion through a limited posterolateral arthrotomy.

RESULTS

The distance between the device when inserted at the lateral edge of the popliteal hiatus and the peroneal nerve decreased from a median of 26 mm (interquartile range [IQR], 3.5 mm; range, 19 to 29 mm) at 90° to 21.5 mm (IQR, 4.5 mm; range, 14 to 25 mm) at 45° and 15.5 mm (IQR, 6.5 mm; range, 4 to 20 mm) at 0° (significant differences, P < .001). The distance between the device when inserted at the medial edge of the popliteal hiatus and the peroneal nerve decreased from 16 mm (IQR, 3.3 mm; range, 9 to 21 mm) at 90° to 12 mm (IQR, 4.3 mm; range, 9 to 16 mm) at 45° and 7 mm (IQR, 4.0; range, 4 to 15 mm) at 0° (significant differences, P < .001). The distance between the device when inserted at the medial edge of the popliteal hiatus and the popliteal artery decreased from 21 mm (IQR, 5.0 mm; range, 11 to 27 mm) at 90° to 19 mm (IQR, 5.0 mm; range, 10 to 23 mm) at 45° and 16 mm (IQR, 7.5 mm; range, 10 to 23 mm) at 0° (significant differences, P < .001). The distance between the device when inserted 5 mm lateral to the posterior root of the lateral meniscus and the popliteal artery decreased from 13 mm (IQR, 4.3 mm; range, 7 to 27 mm) at 90° to 10.5 mm (IQR, 4.3 mm; range, 4 to 19 mm) at 45° and 5.5 mm (IQR, 4.0 mm; range, 0 to 14 mm) at 0° (significant differences, P < .001).

CONCLUSIONS

The risk of injury to the popliteal artery or to the peroneal nerve during all-inside repair of the posterior half of the lateral meniscus is lower at 90° of flexion and increases with knee extension to 45° and 0°.

CLINICAL RELEVANCE

All-inside meniscal repair of the lateral meniscus is safer with the knee at 90° of flexion.

Intralaryngeal thyroarytaenoid lateralisation using the Fast-Fix 360 system: a canine cadaveric study

Introduction

Laryngeal paralysis is a condition in which failure of arytaenoid abduction results in a reduced rima glottidis cross-sectional area. The most commonly performed surgical techniques rely on unilateral abduction of the arytaenoid, requiring a lateral or ventral surgical approach to the larynx.

Aims and objectives

The aim of the study was to investigate a novel minimally invasive intralaryngeal thyroarytaenoid lateralisation technique, using the Fast-Fix 360 meniscal repair system.

Materials and methods

Larynges were harvested from large breed canine cadavers. With the aid of Kirschner wires placed between the centre of the vocal process and the centre of an imaginary line between the cranial thyroid fissure and the cricothyroid articulation, the mean insertion angle was calculated.

Results

The Fast-Fix 360 delivery needle inserted intralaryngeally (n=10), according to a simplified insertion angle (70°), resulted in thyroid penetration (>2.5 mm from margin) in all patients. The Fast-Fix was applied unilaterally at 70° with the first toggle fired on the lateral aspect of the thyroid cartilage and inside the laryngeal cavity on retraction. The suture was tightened. Preprocedural (61.06±9.21 mm2) and postprocedural (138.37±26.12 mm2) rima glottidis cross-sectional area was significantly different (P<0.0001). The mean percentage increase in rima glottidis cross-sectional area was 125.96 per cent (±16.54 per cent).

Conclusion

Intralaryngeal thyroarytaenoid laterlisation using the Fast-Fix 360 meniscal repair system ex vivo increased the rima glottidis cross-sectional area significantly.