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Barber FA, Davidson PA, Henninger HB. Biomechanical Characteristics of All-Suture Meniscal Repair Devices Compared With PEEK-Anchored Devices and Inside-Out Suture for Meniscal Repair: A Porcine Study. Orthop J Sports Med 2024; 12:23259671241245127. [PMID: 38799548 PMCID: PMC11128174 DOI: 10.1177/23259671241245127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 05/29/2024] Open
Abstract
Background Recently, all-suture, all-inside meniscal repair devices-including devices containing flat sutures or tapes-have been introduced. Similar to those in suture anchors, these modifications may have different performance characteristics than conventional sutures and polyether ether ketone (PEEK)-anchored devices. Purpose To compare the biomechanical characteristics of all-suture meniscal repair devices with those of a conventional PEEK-anchored device and an inside-out meniscal suture construct. Study Design Controlled laboratory study. Methods A total of 48 adult porcine menisci with simulated bucket-handle tears were included. Single-device repairs were performed with the SuperBall Meniscal Repair System, FiberStitch, and FAST-FIX 360 with 2 PEEK anchors, and a vertical mattress inside-out suture repair was performed using a Ti-Cron No. 2-0 braided polyethylene terephthalate suture. All specimens were preloaded (10 N) and cycled 200 times (between 10 and 50 N). Specimens surviving cyclic loading were then destructively tested. Endpoints included maximum failure load, stiffness, cyclic displacement, and failure mode. The goal was 12 successful tests in each group. Metrics between groups were compared using analysis of variance with post hoc tests to control for multiple comparisons. Results The SuperBall (108.9 N) was significantly stronger than the FAST-FIX 360 (67.3 N) and Ti-Cron (75.2 N), and the FiberStitch (102.8 N) was significantly stronger than the FAST-FIX 360 (P≤ .01 for all). Cyclic stiffness increased during cyclic loading for all constructs (P < .001). The Ti-Cron was significantly stiffer than the SuperBall during 5 to 200 cycles (P < .001). Cyclic displacement significantly increased in all constructs during cycling (P < .001) but did not differ between devices. Failure mode varied by device: the Ti-Cron repairs failed because of suture breakage, the SuperBall and FAST-FIX 360 failed at the anchor, and the FiberStitch showed both failure modes. Conclusion The all-suture, all-inside meniscal repair devices demonstrated superior strength to the PEEK-anchored device and the classic inside-out suture meniscal repair but no statistically significant difference in cyclic displacement.
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Affiliation(s)
- F. Alan Barber
- Plano Orthopedic and Sports Medicine Center, Plano, Texas, USA
| | | | - Heath B. Henninger
- Orthopaedic Research Laboratory, University of Utah, Salt Lake City, Utah, USA
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Oosten JD, DiBartola AC, Wright JC, Cavendish PA, Milliron EM, Magnussen RA, Duerr RA, Kaeding CC, Flanigan DC. More Is Not Merrier: Increasing Numbers of All-Inside Implants Do Not Correlate with Higher Odds of Revision Surgery. J Knee Surg 2024; 37:361-367. [PMID: 37336501 DOI: 10.1055/a-2112-8158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
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.
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Affiliation(s)
- James D Oosten
- The Ohio State University College of Medicine, Wexner Medical Center, Columbus, Ohio
| | - Alex C DiBartola
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Jonathan C Wright
- The Ohio State University College of Medicine, Wexner Medical Center, Columbus, Ohio
| | - Parker A Cavendish
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Eric M Milliron
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Robert A Duerr
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Christopher C Kaeding
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
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Bachmaier S, Krych AJ, Smith PA, Feucht MJ, LaPrade RF, Wijdicks CA. Biomechanical Performance of Transtibial Pull-Out Posterior Horn Medial Meniscus Root Repair Is Improved With Knotless Adjustable Suture Anchor-Based Fixation. Orthop J Sports Med 2024; 12:23259671241239575. [PMID: 38584990 PMCID: PMC10998488 DOI: 10.1177/23259671241239575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/01/2023] [Indexed: 04/09/2024] Open
Abstract
Background While posterior medial meniscus root (PMMR) techniques have evolved, there remains a need to both optimize repair strength and improve resistance to cyclic loading. Hypothesis Adjustable tensioning would lead to higher initial repair strength and reduce displacement with cyclic loading compared with previously described transtibial pull-out repair (TPOR) fixation techniques. Study Design Controlled laboratory study. Methods A total of 56 porcine medial menisci were used. Eight intact specimens served as a control for the native meniscus. For the others, PMMR tears were created and repaired with 6 different TPOR techniques (8 in each group). Fixed PMMR repairs were executed using 4 different suture techniques (two No. 2 cinch sutures, two cinch tapes, two No. 2 simple sutures, and two No. 2 sutures in a Mason-Allen configuration) all tied over a cortical button. Adjustable PMMR repairs using Mason-Allen sutures were fixed with an adjustable soft tissue anchor fixation tensioned at either 80 N or 120 N. The initial force, stiffness, and relief displacement of the repairs were measured after fixation. Repair constructs were then cyclically loaded, with cyclic displacement and stiffness measured after 1000 cycles. Finally, the specimens were pulled to failure. Results The PMMR repaired with the 2 cinch sutures fixed technique afforded the lowest (P < .001) initial repair load, stiffness, and relief displacement. The adjustable PMMR repairs achieved a higher initial repair load (P < .001) and relief displacement (P < .001) than all fixed repairs. The 2 cinch sutures fixed technique showed an overall higher cyclic displacement (P < .028) and was completely loose compared with the native meniscus functional zone. Repairs with adjustable intratunnel fixation showed displacement with cyclic loading similar to the native meniscus. With cyclic loading, the Mason-Allen adjustable repair with 120 N of tension showed less displacement (P < .016) than all fixed repairs and a stiffness comparable to the fixed Mason-Allen repair. The fixed Mason-Allen technique demonstrated a higher ultimate load (P < .007) than the adjustable Mason-Allen techniques. All repairs were less stiff, with lower ultimate failure loads, than the native meniscus root attachment (P < .0001). Conclusion Adjustable TPOR led to considerably higher initial repair load and relief displacement than other conventional fixed repairs and restricted cyclic displacement to match the native meniscus function. However, the ultimate failure load of the adjustable devices was lower than that of a Mason-Allen construct tied over a cortical button. All repair techniques had a significantly lower load to failure than the native meniscus root. Clinical Relevance Knotless adjustable PMMR repair based on soft anchor fixation results in higher tissue compression and less displacement, but the overall clinical significance on healing rates remains unclear.
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Affiliation(s)
- Samuel Bachmaier
- Arthrex Department of Orthopedic Research, Munich, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Germany
| | - Aaron J. Krych
- Department of Orthopedic Surgery and Sports Medicine Center, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthias J. Feucht
- Department of Orthopaedic Surgery Paulinenhilfe, Diakonie Klinikum, Stuttgart, Germany
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Bachmaier S, Krych AJ, Smith PA, Herbort M, Ritter D, LaPrade RF, Wijdicks CA. Primary Fixation and Cyclic Performance of Single-Stitch All-Inside and Inside-Out Meniscal Devices for Repairing Vertical Longitudinal Meniscal Tears. Am J Sports Med 2022; 50:2705-2713. [PMID: 35787211 DOI: 10.1177/03635465221107086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Primary device fixation and the resistance against gap formation during repetitive loading influence the quality of meniscal repair. There are limited biomechanical data comparing primary tensioning and cyclic behavior of all-inside versus inside-out repair. HYPOTHESIS All-inside devices provide higher initial load on the meniscal repair than inside-out fixation, and stiffer constructs show higher resistance against gap formation during cyclic loading. STUDY DESIGN Controlled laboratory study. METHODS In total, 60 longitudinal bucket-handle tears in human cadaveric menisci were created and repaired with a single stitch and randomly assigned to 4 all-inside groups (TrueSpan, FastFix 360, Stryker AIR, FiberStich) and 2 inside-out groups (suture repair [IO-S], suture tape [IO-ST]). Residual load after repair tensioning (50 N) and relief displacement were measured. Constructs underwent cyclic loading between 2 and 20 N over 500 cycles (0.75 Hz) with cyclic stiffness, gap formation, and final peak elongation measured. Ultimate load and stiffness were analyzed during pull to failure (3.15 mm/s). RESULTS All-inside repair demonstrated significantly higher primary fixation strength than inside-out repair. The significantly highest load (mean ± SD; 20.1 ± 0.9 N; P < .037) and relief displacement (-2.40 ± 0.32 mm; P < .03) were for the knotless soft anchoring FiberStich group. The lowest initial load (9.0 ± 1.5 N; P < .001) and relief displacement (-1.39 ± 0.26 mm; P < .045) were for the IO-S repair group. The final gap formation (500th cycle) of FiberStich (0.75 ± 0.37 mm; P < .02) was significantly smaller than others and that of the IO-S (1.47 ± 0.33 mm; P < .045) significantly larger. The construct stiffness of the FiberStich and IO-ST groups was significantly greater at the end of cyclic testing (16.7 ± 0.80 and 15.5 ± 1.42 N/mm; P < .042, respectively) and ultimate failure testing (23.4 ± 3.6 and 20.6 ± 2.3 N/mm; P < .005). The FastFix 360 (86.4 ± 4.8 N) and Stryker AIR (84.4 ± 4.6 N) groups failed at a significantly lower load than the IO-S group (P < .02) with loss of anchor support. The FiberStich (146.8 ± 23.4 N), TrueSpan (142.0 ± 17.8 N), and IO-ST (139.4 ± 7.3 N) groups failed at significantly higher loads (P < .02) due to suture tearing. CONCLUSION Overall, primary fixation strength of inside-out meniscal repair was significantly lower than all-inside repair in this cadaveric tissue model. Although absolute differences among groups were small, meniscal repairs with higher construct stiffness (IO-ST, FiberStich) demonstrated increased resistance against gap formation and failure load. CLINICAL RELEVANCE Knotless single-stitch all-inside meniscal repair with a soft anchor resulted in less gapping, but the overall clinical significance on healing rates remains unclear.
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Affiliation(s)
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine Center, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Daniel Ritter
- Department of Orthopedic Research, Arthrex, Munich, Germany
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Müller S, Schwenk T, de Wild M, Dimitriou D, Rosso C. Increased Construct Stiffness With Meniscal Repair Sutures and Devices Increases the Risk of Cheese-Wiring During Biomechanical Load-to-Failure Testing. Orthop J Sports Med 2021; 9:23259671211015674. [PMID: 34189149 PMCID: PMC8209834 DOI: 10.1177/23259671211015674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/14/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Cheese-wiring, the suture that cuts through the meniscus, is a well-known issue in meniscal repair. So far, contributing factors are neither fully understood nor sufficiently studied. Hypothesis/Purpose: To investigate whether the construct stiffness of repair sutures and devices correlates with suture cut-through (cheese-wiring) during load-to-failure testing. Study Design: Controlled laboratory study. Methods: In 131 porcine menisci, longitudinal bucket-handle tears were repaired using either inside-out sutures (n = 66; No. 0 Ultrabraid, 2-0 Orthocord, 2-0 FiberWire, and 2-0 Ethibond) or all-inside devices (n = 65; FastFix360, Omnispan, and Meniscal Cinch). After cyclic loading, load-to-failure testing was performed. The mode of failure and construct stiffness were recorded. A receiver operating characteristic curve analysis was performed to define the optimal stiffness threshold for predicting meniscal repair failure by cheese-wiring. The 2-tailed t test and analysis of variance were used to test significance. Results: Loss of suture fixation was the most common mode of failure in all specimens (58%), except for the Omnispan, which failed most commonly because of anchor pull-through. The Omnispan demonstrated the highest construct stiffness (30.8 ± 3.5 N/mm), whereas the Meniscal Cinch (18.0 ± 8.8 N/mm) and Ethibond (19.4 ± 7.8 N/mm) demonstrated the lowest construct stiffness. The Omnispan showed significantly higher stiffness compared with the Meniscal Cinch (P < .001) and Ethibond (P = .02), whereas the stiffness of the Meniscal Cinch was significantly lower compared with that of the FiberWire (P = .01), Ultrabraid (P = .04), and FastFix360 (P = .03). While meniscal repair with a high construct stiffness more often failed by cheese-wiring, meniscal repair with a lower stiffness failed by loss of suture fixation, knot slippage, or anchor pull-through. Meniscal repair with a stiffness >26.5 N/mm had a 3.6 times higher risk of failure due to cheese-wiring during load-to-failure testing (95% CI, 1.4-8.2; P < .0001). Conclusion: Meniscal repair using inside-out sutures and all-inside devices with a higher construct stiffness (>26.5 N/mm) was more likely to fail through suture cut-through (cheese-wiring) than that with a lower stiffness (≤26.5 N/mm). Clinical Relevance: This is the first study investigating the impact of construct stiffness on meniscal repair failure by suture cut-through (cheese-wiring).
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Affiliation(s)
- Sebastian Müller
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Tanja Schwenk
- University of Basel, Basel, Switzerland.,Department of Medical Oncology, Kantonsspital Aarau, Aarau, Switzerland
| | - Michael de Wild
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Muttenz, Switzerland
| | - Dimitris Dimitriou
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Claudio Rosso
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland.,Shoulder and Elbow Unit, ARTHRO Medics, Basel, Switzerland
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Excellent medium-term survival of an all-inside tensionable knotted suture device justifies repair of most meniscal tears encountered during reconstructive knee ligament surgery. Knee Surg Sports Traumatol Arthrosc 2021; 29:1714-1721. [PMID: 32767078 DOI: 10.1007/s00167-020-06189-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
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.
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Vertullo CJ, Cadman J, Dabirrahmani D, Appleyard R. Biomechanical Comparison of an All-Inside Meniscal Repair Device Construct Versus Pullout Sutures for Arthroscopic Transtibial Repair of Posterior Medial Meniscus Root Tears: A Matched-Pair Cadaveric Study. Orthop J Sports Med 2021; 9:23259671211000464. [PMID: 33997064 PMCID: PMC8072104 DOI: 10.1177/23259671211000464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/29/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Meniscus root repairs are important for restoring knee function after a
complete meniscus root tear. Various suturing patterns have been proposed
for the root repair. The 2-simple-stitches (TSS) method is currently the
preferred technique, as it is simplest to perform and allows the least
displacement of the meniscus root. Purpose: To compare the biomechanical properties of a posterior medial meniscus
transtibial root repair consisting of an all-inside meniscal repair device
(AMRD) construct with the TSS pullout suture pattern. Study Design: Controlled laboratory study. Methods: Ten pairs of cadaveric medial menisci were prepared with 1 of the 2
constructs. The constructs were randomized between pairs. All constructs
were subjected to preloading with 2 N for 10 seconds and then cyclic loading
from 5 N to 20 N for 1000 cycles at a frequency of 0.5 Hz. Subsequently, the
menisci were loaded to failure at a rate of 0.5 mm/s. All loads were applied
in-line with the circumferential meniscal fibers near the posterior medial
meniscal horn. Results: The mean yield load and stiffness were similar for both constructs. The
elongation after cyclic loading was greater for the AMRD. The displacement
at both yield load and ultimate failure were also higher for the AMRD. The
ultimate failure load of the AMRD was also significantly higher. During load
to failure, the mode of failure in the AMRD was heterogeneous. All the TSS
constructs failed by suture cutout. Conclusion: Posterior medial meniscus root repairs using both the AMRD and TSS constructs
have elongation under the biomechanically acceptable threshold of 3 mm. The
stiffness and yield loads indicate similar mechanical properties of the
constructs. However, the significantly higher elongation for the AMRD leaves
the TSS method as the preferred option for transtibial repairs. Despite
this, the AMRD construct may still represent a viable alternative to the TSS
suture pattern, comparable to alternative suture patterns with similar
limitations. Clinical Relevance: The AMRD construct may represent a viable alternative to the TSS suture
pattern.
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Affiliation(s)
- Christopher J Vertullo
- Knee Research Australia and the Centre for Musculoskeletal Research, Menzies Health Institute, Griffith University, Gold Coast, Australia
| | - Joseph Cadman
- Orthopaedic Biomechanics Research Group, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Danè Dabirrahmani
- Orthopaedic Biomechanics Research Group, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Richard Appleyard
- Orthopaedic Biomechanics Research Group, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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Barber FA, Howard MS, Ashraf W, Spenciner DB. The Biomechanical Performance of the Latest All-Inside Meniscal Repair Devices. Arthroscopy 2020; 36:3001-3007. [PMID: 32315765 DOI: 10.1016/j.arthro.2020.03.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/16/2020] [Accepted: 03/25/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the biomechanical characteristics of recently introduced meniscal repair devices with a hand-tied, inside-out meniscal suture in a human meniscus model. METHODS In detached adult human menisci, vertical longitudinal cuts were created 3 mm from the synovial-meniscal junction, simulating a bucket-handle meniscal tear. Each cut was repaired using a single device. Group 1 received a vertical mattress suture of No. 2-0 OrthoCord; group 2, TrueSpan device with PEEK (polyether ether ketone) anchors containing No. 2-0 OrthoCord suture; group 3, TrueSpan device with biodegradable poly-lactide-co-glycolide (PLGA) anchors containing No. 2-0 OrthoCord suture; group 4, Meniscal Cinch II device; group 5, AIR meniscal repair device; and group 6, FasT-Fix 360 device. All samples were preloaded at 5 N and cycled 200 times between 5 and 20 N. The specimens that survived cyclic loading were destructively tested at 12.5 mm/s. Endpoints included maximum load, displacement, stiffness, and failure mode. RESULTS The mean failure loads were as follows: 95.8 N for OrthoCord suture, 87.1 N for TrueSpan with PEEK, 84.6 N for TrueSpan with PLGA, 48.6 N for Meniscal Cinch II, 72.3 N for AIR, and 68.1 N for FasT-Fix 360. Repairs performed with OrthoCord suture (P = .002) and both TrueSpan devices (P < .03) but not the FasT-Fix 360 device or AIR device were statistically significantly stronger than Meniscal Cinch II repairs. Mean cyclic displacement measured 1.1 mm for OrthoCord, 1.5 mm for TrueSpan with PEEK, 1.5 mm for TrueSpan with PLGA, 2.1 mm for Meniscal Cinch II, 1.1 mm for AIR, and 1.4 mm for FasT-Fix 360. The Meniscal Cinch II device showed more displacement than all other devices (P < .05). The FasT-Fix 360, AIR, and Meniscal Cinch II devices failed by anchor pullout from the peripheral meniscus. OrthoCord and both TrueSpan devices failed by suture pulling through the bucket-handle tissue. CONCLUSIONS OrthoCord suture is stronger than the AIR, FasT-Fix 360, and Meniscal Cinch II devices. The TrueSpan device with PEEK and TrueSpan device with PLGA are stronger than the Meniscal Cinch II device. The Meniscal Cinch II device failed during cyclic loading with greater cyclic displacement than the AIR device, FasT-Fix 360 device, OrthoCord, and TrueSpan device with PEEK. The Meniscal Cinch II, AIR, and FasT-Fix 360 devices failed by anchor pullout, whereas OrthoCord and both TrueSpan devices failed by suture pull-through. CLINICAL RELEVANCE Some newly introduced all-inside meniscal repair devices show inferior failure strength compared with earlier versions that might adversely impact clinical outcomes.
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Affiliation(s)
- F Alan Barber
- Plano Orthopedic Sports Medicine Center, Plano, Texas, U.S.A
| | | | - Wasik Ashraf
- Crystal Run Healthcare, New Windsor, New York, U.S.A
| | - David B Spenciner
- DePuy Synthes Mitek Sports Medicine, Raynham, Massachusetts, U.S.A.; Rensselaer Polytechnic Institute, Troy, New York, U.S.A
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Examining Techniques for Treatment of Medial Meniscal Ramp Lesions During Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2020; 36:2921-2933. [PMID: 32674943 DOI: 10.1016/j.arthro.2020.05.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 02/02/2023]
Abstract
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.
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Ni J, Shi Z, Fan L, Guo N, Wang H, Dang X, Li D. The modified cross-suture technique for unilateral pulled-out anchor during all-inside meniscal repair. BMC Musculoskelet Disord 2020; 21:480. [PMID: 32698893 PMCID: PMC7374841 DOI: 10.1186/s12891-020-03502-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 07/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Meniscal repair has received increasing attention, but for inexperienced doctors, unilateral suture anchor pulling out may occur during all-inside meniscal repair, and the treatment outcome may be affected. When the errors happened intraoperatively, how to minimize the loss under guaranteeing of treatment effectiveness is a topic worth studying. Purpose To explore the practicability and effectiveness of the modified cross-suture method for arthroscopic remediation of unilateral suture anchor pulling out of an all-inside meniscal repair system. Methods From May 2014 to May 2017, 28 patients diagnosed with injuries of the meniscus and anterior cruciate ligaments (ACL) from the First Department of Orthopaedics of the Second Affiliated Hospital of Xi’an Jiaotong University were enrolled in the study as the observation group, including 18 males and 10 females with an average age of 25.5 ± 2.3 years (range 18–42 years). All patients underwent ACL reconstruction concurrently. All meniscus injuries were repaired with an all-inside meniscal repair technique, and 1–3 needles of unilateral suture anchor pulling out occurred intraoperatively. The modified cross-suture method was used to remedy the error of anchor pulling out and to eventually complete an effective repair. Another 30 patients who underwent ACL reconstruction and all-inside meniscal concurrently without unilateral suture anchor pulling out, including 20 males and 10 females with an average age of 26.3 ± 1.9 years (range 19–45 years), were enrolled as the control group. During postoperative follow-up, range of motion, Lachman test and pivot shift test were performed during the physical examination. The clinical healing of the meniscus was evaluated according to the Barrett standard. The meniscus healing status was also confirmed with magnetic resonance imaging (MRI). The function of the knee joint was evaluated according to the IKDC, Lysholm and Tegner scores. Results Twenty-five patients in the observation group and 28 patients in the control group completed the follow-up, with an average follow-up of 18.4 ± 5.2 months. All operations were performed by the same surgeon. At the follow-up 1 year after the operation, the average knee ROM of the two groups was 125.2 ± 4.3 degrees and 124.7 ± 3.8 degrees, the clinical healing rate of the meniscus of the two groups was 92.0% (23/25) and 92.9% (26/28), the MRI healing rate of the menniscus of the two groups was 72.0% (18/25) and 71.4% (20/28), and the IKDC, Lysholm and Tegner scores of the two groups were 90.52 ± 2.8, 89.17 ± 3.1, and 6.81 ± 1.7 and 91.42 ± 1.9, 90.32 ± 3.4, and 7.02 ± 1.4, respectively. The differences were not statistically significant (P > 0.05). Conclusions The modified cross-suture method is practicable and effective for arthroscopic remediation of unilateral suture anchor pulling out in an all-inside meniscal repair system.
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Affiliation(s)
- Jianlong Ni
- First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an, 710004, Shaanxi, China
| | - Zhibin Shi
- First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an, 710004, Shaanxi, China
| | - Lihong Fan
- First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an, 710004, Shaanxi, China
| | - Ning Guo
- Department of Anesthesiology and Operation, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Haoyu Wang
- First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an, 710004, Shaanxi, China
| | - Xiaoqian Dang
- First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an, 710004, Shaanxi, China
| | - Dichen Li
- First Department of Orthopaedics, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an, 710004, Shaanxi, China. .,State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China.
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Patterson DC, Cirino CM, Gladstone JN. No safe zone: The anatomy of the saphenous nerve and its posteromedial branches. Knee 2019; 26:660-665. [PMID: 30902515 DOI: 10.1016/j.knee.2019.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/21/2019] [Accepted: 02/17/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Following a case of medial meniscal repair via an inside-out repair, a patient developed acute postoperative electric shock-like paresthesias of the proximal medial calf with any knee flexion beyond 80°. Open saphenous nerve exploration revealed entrapment by suture material of an unnamed branch off the sartorial branch of the saphenous nerve. Symptoms resolved immediately with release. The objective of the study was to perform a cadaveric study to examine the existence and frequency of these previously under-reported branches of the sartorial branch of the saphenous nerve. METHODS In 16 knees from eight fresh, matched whole cadavers, the medial structures of the knee were exposed, reproducible anatomical structures were identified, and previously under-described posteromedial branches of the sartorial nerve were identified and measured in relation to surrounding structures and the joint line. RESULTS The saphenous nerve, its sartorial and infrapatellar branches, and its posteromedial branches were identified in all specimens. The sartorial nerve divided from the saphenous nerve an average of 4.8 cm proximal to the medial femoral epicondyle. Between one and four further posteromedial branches off the sartorial nerve were identified. These branches formed at a range of 5.3 cm proximal to 3.0 cm distal to the joint line. CONCLUSIONS This cadaveric study establishes the consistent presence of a posteromedial branch off the sartorial nerve. It was consistently located near the posteromedial joint line. These branches are at risk for injury during medial meniscus repairs due to entrapment by suture materials, or during other surgical procedures near the posteromedial aspect of the knee.
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Affiliation(s)
- Diana C Patterson
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA.
| | - Carl M Cirino
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA.
| | - James N Gladstone
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA.
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Nishino K, Hashimoto Y, Nishida Y, Terai S, Takahashi S, Yamasaki S, Nakamura H. Incidence and Risk Factors for Meniscal Cyst After Meniscal Repair. Arthroscopy 2019; 35:1222-1229. [PMID: 30871908 DOI: 10.1016/j.arthro.2018.11.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Kazuya Nishino
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Yohei Nishida
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shozaburo Terai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinji Takahashi
- Department of Orthopaedic Surgery, Juso City Hospital, Osaka, Japan
| | - Shinya Yamasaki
- Department of Orthopaedic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Abstract
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.
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Affiliation(s)
- Matthew H Blake
- Department of Orthopaedic Surgery and Sports Medicine, Avera McKennan Hospital and University Health Center, 911 East 20th Street, Suite 300, Sioux Falls, SD 57105, USA.
| | - Darren L Johnson
- Department of Orthopaedic Surgery, University of Kentucky School of Medicine, 740 South Limestone, K403, Lexington, KY 40536-0284, USA
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Yokoi H, Mae T, Iuchi R, Take Y, Tachibana Y, Shimomura K, Ohori T, Shino K, Yoshikawa H, Nakata K. Novel flat and wide meniscal repair material improves the ultimate load of knot breakage in a porcine trans-capsular meniscal repair model. J Exp Orthop 2017; 4:41. [PMID: 29260438 PMCID: PMC5736508 DOI: 10.1186/s40634-017-0114-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/30/2017] [Indexed: 11/10/2022] Open
Abstract
Background In the meniscal repair procedures, a high ultimate load capacity and low cyclic creep at the repair site are favorable and lead to good biological incorporation of the tear site after surgery. Previous biomechanical tensile tests of the meniscal sutures have identified the suture knot as the weakest point. We hypothesized that the strength of a suture knot depends on the suture shape, and therefore, we compared three differently shaped suture materials composed of the same material and quantity per length. The purpose of this study was to determine whether a novel flat and wide repair material (FWRM), which consists of braided multi-threads that are cross-sectionally flat and wide, improves the ultimate load of knot breakage in a biomechanical experiment using a porcine trans-capsular meniscal repair model. Methods Eighteen fresh-frozen porcine knees (n = 6 in each group) were used. A longitudinal tear in the middle segment of the medial meniscus was created and repaired with a trans-capsular inside-out method using the following suture materials: No. 2–0 braided polyester conventional suture, hollow suture, and FWRM. After the separation of the inner segment of the meniscus with leaving, the suture stability of the repaired menisci was biomechanically analyzed with a video camera system for widening after a cyclic load between 5 and 20 N was applied 300 times. Ultimate failure load and stiffness at 5 mm/ min were also analyzed. Results We found no significant difference in suture widening after cyclic load tests [conventional suture, mean 0.51 mm (S.D. 0.39 mm); hollow suture, mean 0.23 mm (S.D. 0.11 mm); and FWRM, mean 0.54 mm (S.D. 0.08 mm)]. The failure mode in all specimens was knot breakage. Compared with those of the other groups, the ultimate failure load of FWRM was statistically significantly higher in the load-to-failure tests (conventional suture, mean 58.8 N [S.D. 8.25 N]; hollow suture, mean 79.4 N [S.D. 10.2 N]; and FWRM, mean 97.4 N [S.D. 3.65 N]; p < 0.05). Conclusion FWRM improves the ultimate load of knot breakage without altering stability. This material may contribute to safe and stable meniscus repair.
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Affiliation(s)
- Hiroyuki Yokoi
- Medicine for Sports and Performing Arts, Department of Health and Sports Science, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ryo Iuchi
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Yasuhiro Take
- Medicine for Sports and Performing Arts, Department of Health and Sports Science, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yuta Tachibana
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Kazunori Shimomura
- Medicine for Sports and Performing Arts, Department of Health and Sports Science, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tomoki Ohori
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Konsei Shino
- Sports Orthopaedic Surgery Center, Yukioka Hospital, 2-2-3, Ukita, Kita-ku, Osaka, Osaka, 530-0021, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ken Nakata
- Medicine for Sports and Performing Arts, Department of Health and Sports Science, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
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15
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A novel technique for modified all-inside repair of bucket-handle meniscus tears using standard arthroscopic portals. J Orthop Surg Res 2017; 12:188. [PMID: 29202765 PMCID: PMC5715506 DOI: 10.1186/s13018-017-0692-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 11/15/2017] [Indexed: 11/12/2022] Open
Abstract
Background Bucket-handle meniscus tears (BHMT) are often displaced and unstable. The inside-out technique of repairing such tears is currently the gold standard. All-inside repair with meniscal fixators is getting increasingly popular. Shortcomings of the inside-out technique include neurovascular complications, especially saphenous nerve palsy, and retention of a non-resorbable suture which can result in discomfort to patient, granuloma formation, and a foci of infection. Hence, the purpose of this project was to innovate a novel all-inside technique to precisely reduce and fix BHMT while avoiding neurovascular complications and retention of a non-resorbable suture. Methods Routine arthroscopic portals were created on a patient’s left knee with a displaced BHMT. Through the anteromedial portal, a conjoint pseudo double lumen cannula was inserted. Two limbs of a reduction suture were passed through the cannula, one over the “femoral” surface of the meniscus, one over the “tibial” surface of the meniscus anterior to the biceps femoris tendon, with the knee flexed at 20° to avoid injury to the saphenous nerve. Suture limbs were passed out percutaneously and tensioned. Results Anatomic reduction was ensured under arthroscopic visualization with ease. All inside repair was performed using the vertical mattress suture configuration. Reduction sutures were subsequently removed by cutting flush to the skin and pulling on one suture limb. The patient was back to full activities with minimal discomfort 8 months post-operatively. Conclusion The technique described is superior to existing techniques for the following reasons: (1) Reduction of the displaced meniscal tear is “extra-meniscal,” avoiding further trauma to a damaged meniscus. (2) Tensioning of the two suture limbs created promotes better control of reduction through tensioning. (3) Risk of discomfort, infection, and neurovascular damage caused by a retained suture is reduced. (4) No additional portals/equipment is required. We encourage this novel technique to be attempted by surgeons.
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16
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Barber FA. Editorial Commentary: Feeling the Pressure! A Biomechanical Analysis of All-Inside and Inside-Out Knee Meniscus Repair. Arthroscopy 2017; 33:1849-1851. [PMID: 28969820 DOI: 10.1016/j.arthro.2017.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/01/2017] [Indexed: 02/02/2023]
Abstract
A biomechanical, time-zero comparison found that both No. 2-0 UltraBraid inside-out sutures and FasT-Fix 360 all-inside devices used to repair a displaced bucket handle knee meniscus tear increased the contact area in deeper flexion angles (at 45°-60°) and reduced the peak contact pressure (at 45°-90°). No significance difference was observed between the inside-out and all-inside repair techniques.
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17
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Marchetti DC, Phelps BM, Dahl KD, Slette EL, Mikula JD, Dornan GJ, Bucci G, Turnbull TL, Singleton SB. A Contact Pressure Analysis Comparing an All-Inside and Inside-Out Surgical Repair Technique for Bucket-Handle Medial Meniscus Tears. Arthroscopy 2017; 33:1840-1848. [PMID: 28754246 DOI: 10.1016/j.arthro.2017.04.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 03/24/2017] [Accepted: 04/03/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To directly compare effectiveness of the inside-out and all-inside medial meniscal repair techniques in restoring native contact area and contact pressure across the medial tibial plateau at multiple knee flexion angles. METHODS Twelve male, nonpaired (n = 12), fresh-frozen human cadaveric knees underwent a series of 5 consecutive states: (1) intact medial meniscus, (2) MCL tear and repair, (3) simulated bucket-handle longitudinal tear of the medial meniscus, (4) inside-out meniscal repair, and (5) all-inside meniscal repair. Knees were loaded with a 1,000-N axial compressive force at 5 knee flexion angles (0°, 30°, 45°, 60°, 90°), and contact area, mean contact pressure, and peak contact pressure were calculated using thin film pressure sensors. RESULTS No significant differences were observed between the inside-out and all-inside repair techniques at any flexion angle for contact area, mean contact pressure, and peak contact pressure (all P > .791). Compared with the torn meniscus state, inside-out and all-inside repair techniques resulted in increased contact area at all flexion angles (all P < .005 and all P < .037, respectively), decreased mean contact pressure at all flexion angles (all P < .007 and all P < .001, respectively) except for 0° (P = .097 and P = .39, respectively), and decreased peak contact pressure at all flexion angles (all P < .001, all P < .001, respectively) except for 0° (P = .080 and P = .544, respectively). However, there were significant differences in contact area and peak contact pressure between the intact state and inside-out technique at angles ≥45° (all P < .014 and all P < .032, respectively). Additionally, there were significant differences between the intact state and all-inside technique in contact area at 60° and 90° and peak contact pressure at 90° (both P < .005 and P = .004, respectively). Median values of intact contact area, mean contact pressure, and peak contact pressure over the tested flexion angles ranged from 498 to 561 mm2, 786 to 997 N/mm2, and 1,990 to 2,215 N/mm2, respectively. CONCLUSIONS Contact area, mean contact pressure, and peak contact pressure were not significantly different between the all-inside and inside-out repair techniques at any tested flexion angle. Both techniques adequately restored native meniscus biomechanics near an intact level. CLINICAL RELEVANCE An all-inside repair technique provided similar, native-state-restoring contact mechanics compared with an inside-out repair technique for the treatment of displaced bucket-handle tears of the medial meniscus. Thus, both techniques may adequately decrease the likelihood of cartilage degeneration.
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Affiliation(s)
| | - Brian M Phelps
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Kimi D Dahl
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Erik L Slette
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jacob D Mikula
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Grant J Dornan
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Gabriella Bucci
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
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Iuchi R, Mae T, Shino K, Matsuo T, Yoshikawa H, Nakata K. Biomechanical testing of transcapsular meniscal repair. J Exp Orthop 2017; 4:2. [PMID: 28124287 PMCID: PMC5267586 DOI: 10.1186/s40634-017-0075-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/13/2017] [Indexed: 11/16/2022] Open
Abstract
Background All of previous biomechanical studies on meniscal repair have examined the meniscus itself without synovial membrane and capsule, although in the clinical setting, the meniscal repair is generally performed including capsule. Therefore, biomechanical properties of transcapsular meniscal repair are unclear. Thus, this study aimed to clarify the biomechanical properties of transcapsular meniscal repair. Methods In 70 porcine femur–medial meniscus–tibia complexes with capsules, longitudinal meniscal tears were repaired using different suture techniques (inside-out or all-inside technique), suture methods (vertical or horizontal methods), and numbers of sutures (single or double). A cyclic loading test between 5 and 20 N for 300 cycles was performed followed by a load-to-failure test. Results Tears repaired by the all-inside technique presented significantly larger widening (0.88 ± 0.38 mm) than those by the inside-out technique (0.51 ± 0.39 mm) during the cyclic loading test (P = 0.035). The horizontal suture presented significantly lower ultimate failure load (62.5 ± 15.5 N) in the all-inside technique than in the vertical suture (79.7 ± 13.0 N; P = 0.018). The stacked suture had a significantly higher failure load (104.6 ± 12.5 N) than the parallel suture (83.3 ± 12.6 N; P = 0.001). Furthermore, the double suture presented significantly higher failure loads (83.3 ± 12.6 N and 104.6 ± 20.4 N) than the single suture with both inside-out (58.8 ± 8.3 N; P = 0.001) and all-inside (79.7 ± 13.0 N; P = 0.022) techniques. Conclusions Upon comparison of the suture techniques, the inside-out technique provided a more stable fixation at the repair site than the all-inside technique during the cyclic test. Among the suture methods, the vertical suture had more desirable biomechanical properties than the horizontal suture as demonstrated by smaller widening during the cyclic test and the larger load to failure. The stacked suture created a stronger fixation than the parallel suture. In terms of the number of sutures, the double suture had superior biomechanical properties compared with the single suture.
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Affiliation(s)
- Ryo Iuchi
- Sports Orthop. Center, Yukioka Hospital, Osaka, Japan.
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Konsei Shino
- Sports Orthop. Center, Yukioka Hospital, Osaka, Japan
| | - Tomohiko Matsuo
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ken Nakata
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Pareek A, O'Malley MP, Levy BA, Stuart MJ, Krych AJ. Inside-Out Repair for Radial Meniscus Tears. Arthrosc Tech 2016; 5:e793-e797. [PMID: 27709039 PMCID: PMC5040169 DOI: 10.1016/j.eats.2016.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 03/16/2016] [Indexed: 02/03/2023] Open
Abstract
Understanding of meniscal function through basic science, natural history, and biomechanics has highlighted the importance of preserving the meniscus to maintain normal knee biomechanics. Tears that may alter these biomechanics can contribute to the progressive nature of degenerative joint disease in the knee. Radial tears result in the disruption of the circumferential fibers causing inability of the native meniscus to resist normal hoop stresses, thereby leading to increased focal areas of pressure that cause complications such as early onset arthrosis. In this technical note, we describe our preferred operative technique to repair radial meniscal tears using an arthroscopic inside-out approach with satisfactory clinical outcomes and healing response.
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Affiliation(s)
| | | | | | | | - Aaron J. Krych
- Address correspondence to Aaron J. Krych, M.D., Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, U.S.A.Department of Orthopedic Surgery and Sports MedicineMayo Clinic200 First Street SWRochesterMN55905U.S.A.
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20
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Abstract
OBJECTIVE the menisci are easily injured and difficult to repair. The aim of this study was to analyze the current state of meniscal surgery aimed at preserving morphology and conserving the biomechanics of the knee to prevent joint degeneration. METHODOLOGY a search of the electronic medical literature database Medline was conducted, from http://www.ncbi.nlm.nih.gov/pubmed. The search was not limited by language. Candidate articles were identified by searching for those that included the keywords meniscus, surgery, suture, implant, allograft. The limits were included for clinical research and clinical trials. Basic research was not included. The studies selected were evaluated and classified in three different categories: basic science, reconstruction (suture and meniscectomy) and implants (scaffolds and allograft). RESULTS the consequences of meniscectomy performed at a young age can lead to a joint cartilage degeneration twenty years later. There are few surgical options for the repair of meniscal injuries in order both to preserve the meniscus and to ensure the long term survival of the knee joint, meniscectomy, repair, suturing the tear, or reconstruction, when a meniscal allograft or synthetic substitute is used to replace the meniscus, but the biomechanical properties of the native meniscus are not reproduced entirely by the scaffolds that exist today. CONCLUSION therapies that successfully repair or replace the meniscus are therefore likely to prevent or delay osteoarthritis progression.
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Affiliation(s)
| | - Francisco Forriol
- Department of Clínica Sciences, University San Pablo - CEU, Boadilla del Monte, Spain
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21
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Milchteim C, Branch EA, Maughon T, Hughey J, Anz AW. Biomechanical Comparison of Parallel and Crossed Suture Repair for Longitudinal Meniscus Tears. Orthop J Sports Med 2016; 4:2325967116640263. [PMID: 27104209 PMCID: PMC4827117 DOI: 10.1177/2325967116640263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Charles Milchteim
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Eric A Branch
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Ty Maughon
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Jay Hughey
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Adam W Anz
- Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
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Zhang AL, Miller SL, Coughlin DG, Lotz JC, Feeley BT. Tibiofemoral contact pressures in radial tears of the meniscus treated with all-inside repair, inside-out repair and partial meniscectomy. Knee 2015; 22:400-4. [PMID: 26081591 DOI: 10.1016/j.knee.2015.05.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 05/16/2015] [Accepted: 05/28/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND To test contact pressures in the knee after treatment of a radial meniscus tear with an all-inside meniscal repair technique and compare the results with inside-out repair and partial meniscectomy. METHODS Six non-paired cadaveric knees were analyzed with intra-compartment pressures measured at loads of 250 N, 500 N and 1000 N at 0°, eight degrees, 15°, and 30° of knee flexion. Compartmental contact pressures were measured for the intact medial meniscus, radial tear in the posterior horn, all-inside repair using the NovoStitch suture passer device (Ceterix Orthopaedics Inc., Menlo Park, CA), inside-out repair method, and partial meniscectomy. One-way ANOVA was used for statistical analysis. RESULTS The greatest differences in peak pressures between treatments were observed under 1000 N load at 30° flexion (0.8± (SD) 0.1 MPa (intact meniscus), 0.8± (SD) 0.1 MPa (all-inside), 0.9± (SD) 0.1 MPa (inside-out) and 1.6± (SD) 0.2 MPa (partial meniscectomy)). Treatment with partial meniscectomy resulted in the highest peak pressures compared to all other states (p<0.0001 at each angle). Repair of the radial tear using the all-inside technique as well as the inside-out technique resulted in significantly decreased compartment pressures compared to partial meniscectomies (p<0.0001 at each angle). There were no significant differences between peak pressures in the intact state and after repair with the all-inside or inside-out techniques. CONCLUSION An all-inside repair technique using the NovoStitch suture passer can decrease contact pressures for a radial meniscus tear similarly to the inside-out repair technique when compared to partial meniscectomy. CLINICAL RELEVANCE This novel arthroscopic suture passer warrants further analysis in the clinical setting as it may be a reliable method for repair of radial meniscal tears through an arthroscopic all-inside technique.
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Affiliation(s)
- Alan L Zhang
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, United States.
| | - Stephanie L Miller
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, United States
| | - Dezba G Coughlin
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, United States
| | - Jeffrey C Lotz
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, United States
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, United States
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The concept of three-dimensional hold of both circumferential and radial collagen fibres of the meniscus. Knee Surg Sports Traumatol Arthrosc 2015; 23:20-5. [PMID: 23404512 DOI: 10.1007/s00167-013-2421-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 01/21/2013] [Indexed: 10/27/2022]
Abstract
Collagen fibres of the meniscus arrange into two main orientations: circumferential fibres parallel to the long axis of the meniscus and radial fibres perpendicular to the long axis of the meniscus. Meniscal sutures are placed either in vertical or in horizontal orientations. Vertical sutures better hold circumferential fibres because it encircles them like a rope holding a bunch of tree branches. In the same manner, horizontal sutures better hold radial fibres. The "Simplified Cruciate Suture" consists of two vertical oblique sutures. Placing two vertical sutures in an oblique orientation captures greater meniscal tissue volume, holds and grasps both circumferential and radial collagen fibres of the meniscus into a three-dimensional plane with eventual high fixation strength of the repaired meniscal tear. Simplified cruciate suture is indicated for the repair of long bucket handle tears where it is placed in the middle of the tear like an anchor, and additional vertical and horizontal sutures are placed anterior and posterior to it as needed. Level of evidence V.
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Meta-analysis on biomechanical properties of meniscus repairs: are devices better than sutures? Knee Surg Sports Traumatol Arthrosc 2015; 23:83-9. [PMID: 24841938 DOI: 10.1007/s00167-014-2966-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 03/19/2014] [Indexed: 01/14/2023]
Abstract
PURPOSE Meniscal repair devices have been extensively tested during the past decades as reported in the literature. Reviewing the different meniscal repair devices and sutures with their respective biomechanical properties. METHODS For this meta-analysis, we conducted a systematic online search using PubMed, EMBASE, CCTR, and CINAHL using the search terms Meniscus OR Meniscal AND Biomechanics AND Repair). Load-to-failure (LtF), stiffness, and cyclic outcome measures were extracted independently and in duplicate. The systematic search revealed 841 manuscripts in total. After exclusion of duplicates and irrelevant publications, 41 studies remained for final analysis. The studies were published in English and German from 1995 to 2013. Due to differing cyclic force protocols, cyclic outcomes had to be excluded. RESULTS Overall, sutures had a higher LtF [suture: 87.7 ± 0.3 N (weighted mean ± standard error), device: 56.3 ± 0.1 N] and stiffness (suture: 8.9 ± 0.04 N/mm, device: 8.6 ± 0.04 N/mm) than devices, both p < 0.05. In LfT testing, PDS 0 Vertical (145.0 ± 8.1 N), OrthoCord 2-0 (143.6 ± 11.3 N), and Ethibond No 0 Vertical (133.4 ± 7.7 N) were the strongest sutures and Meniscal Viper (140.9 ± 5.1 N), MaxFire Vertical (136.2 ± 11.3 N), and FasT-Fix Vertical (115.2 ± 1.6 N) were the strongest devices. Second-generation devices were significantly stronger and stiffer than first-generation devices (p < 0.001). CLINICAL RELEVANCE Suture repair remains the gold standard with a vertically oriented suture configuration showing superior LtF values compared to a horizontal configuration. Nevertheless, some meniscal repair devices have similar biomechanical properties to suture repairs. Both suture repairs and devices have a place in meniscal restoration. LEVEL OF EVIDENCE None, meta-analysis of controlled laboratory studies.
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Erduran M, Hapa O, Şen B, Kocabey Y, Erdemli D, Aksel M, Havitçioğlu H. The effect of inclination angle on the strength of vertical mattress configuration for meniscus repair. Knee Surg Sports Traumatol Arthrosc 2015; 23:41-4. [PMID: 23568388 DOI: 10.1007/s00167-013-2496-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 04/03/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE Vertical mattress configuration is the strongest of all other configurations and the repairing devices of meniscus repair. The purpose was whether increasing the inclination angle between two strands of the vertical mattress configuration by increasing the amount of meniscus tissue captured would enhance the initial strength of the construction. METHODS A 2-cm long anteroposterior vertical longitudinal incision was created in two groups of bovine medial menisci. In the first group, the distance between the two vertical suture strands and the vertical horizontal sutures on the capsular side of the meniscal lesion was 2 mm (Group 1). In the second group, the distance was 5 mm (Group 2). The following repair specimens underwent cyclic loading prior to loading the failure testing. The endpoints included ultimate failure load (N), stiffness (N/mm) and cyclic displacement (mm) after the 100 cycles and the mode of failure. RESULTS Group 1 (2 mm) (90.7 (±19.9) N) had lower ultimate load than Group 2 (5 mm) (120.8 (±24.5)) (P < 0.05). Stiffness and displacements during the cycling were not different between the groups (n.s.). All specimens failed by suture rupture. CONCLUSION Increased inclination angle with increased distance between the two vertical suture strands on the capsular side of the meniscal lesion resulted in higher failure load compared to control group with lower inclination angle and distance on the capsular side.
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Affiliation(s)
- Mehmet Erduran
- Department of Orthopedics and Traumatology, Dokuz Eylül University, İnciraltı, Izmir, Turkey
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Song HS, Bae TY, Park BY, Shim J, In Y. Repair of a radial tear in the posterior horn of the lateral meniscus. Knee 2014; 21:1185-90. [PMID: 25128933 DOI: 10.1016/j.knee.2014.07.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/05/2014] [Accepted: 07/21/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND There have been no studies evaluating the clinical results after repair of a radial tear in the posterior horn of the lateral meniscus (PHLM) using the FasT-Fix system. This study was undertaken to evaluate the clinical outcomes after repair of a radial tear in the PHLM using the FasT-Fix system in conjunction with anterior cruciate ligament (ACL) reconstruction. METHODS Between September 2008 and August 2011, 15 radial tears in the PHLM identified during 132 consecutive ACL reconstructions were repaired using the FasT-Fix meniscal repair system. We classified the radial tears into three types according to the tear patterns: simple radial tear, complex radial tear, and radial tear involving the popliteal hiatus. Postoperative evaluation was performed using the Lysholm knee score and Tegner activity level. Second-look arthroscopy was performed in all cases. RESULTS The mean follow-up period was 24 months. None of the patients had a history of recurrent effusion, joint line tenderness or a positive McMurray test. The meniscal repair was considered to have a 100% clinical success rate. At the final follow-up, the Lysholm knee score and Tegner activity level were significantly improved compared to the preoperative values. On the second-look arthroscopy, repair of radial tears in the PHLM in conjunction with ACL reconstruction using the FasT-Fix device resulted in complete or partial healing in 86.6% of cases. CONCLUSION Clinical results after meniscal repair of a radial tear in the PHLM by using the FasT-Fix system were satisfactory. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Hyun-Seok Song
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Yong Bae
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bum-Yong Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jungin Shim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong In
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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27
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Walter RP, Dhadwal AS, Schranz P, Mandalia V. The outcome of all-inside meniscal repair with relation to previous anterior cruciate ligament reconstruction. Knee 2014; 21:1156-9. [PMID: 25257778 DOI: 10.1016/j.knee.2014.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 07/31/2014] [Accepted: 08/15/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Arthroscopically assisted all-inside meniscal repair has become a popular treatment for meniscal tears. Previous studies have suggested a beneficial effect of concomitant anterior cruciate ligament reconstruction on meniscal repair outcomes. The effect of prior cruciate ligament reconstruction (predating the meniscal injury) on meniscal repair success is unreported. The aim of this study was to assess the success of meniscal repair in our practice. Further aims were to analyze the effect of concomitant- and past-anterior cruciate ligament reconstruction on meniscal repair outcomes. METHODS Retrospective review of all patients undergoing arthroscopic meniscal repair during a 53 month period was performed. Mean followup was 13.5 months (mean 6-50). The primary outcome measure was meniscal reoperation. RESULTS Sixteen of 104 patients required reoperation, giving an overall meniscal repair success rate of 85%. Patients undergoing concomitant anterior cruciate ligament reconstruction enjoyed significantly improved outcomes (91%, p=0.049), while those with a past history of anterior cruciate ligament reconstruction had significantly worse meniscal repair success rates (63%, p=0.016). CONCLUSIONS Arthroscopic meniscal repair in a selected patient group offers good success rates, especially when performed with concomitant anterior cruciate ligament reconstruction. We have identified a subgroup of patients, those with a past history of anterior cruciate ligament reconstruction predating the meniscal injury, who appear to have relatively poor outcomes from meniscal repair. Potential reasons for this finding are discussed. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- R P Walter
- The Department of Trauma and Orthopaedics, Royal Devon and Exeter Hospital, Barrack Road, EX2 5DW, United Kingdom.
| | - A S Dhadwal
- The Department of Trauma and Orthopaedics, Royal Devon and Exeter Hospital, Barrack Road, EX2 5DW, United Kingdom
| | - P Schranz
- The Department of Trauma and Orthopaedics, Royal Devon and Exeter Hospital, Barrack Road, EX2 5DW, United Kingdom
| | - V Mandalia
- The Department of Trauma and Orthopaedics, Royal Devon and Exeter Hospital, Barrack Road, EX2 5DW, United Kingdom
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28
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Anz AW, Branch EA, Saliman JD. Biomechanical comparison of arthroscopic repair constructs for meniscal root tears. Am J Sports Med 2014; 42:2699-706. [PMID: 25225682 DOI: 10.1177/0363546514549445] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Complete meniscal root tears render the meniscus nonfunctional. Repair constructs have been presented and tested; however, prior studies have evaluated suture patterns placed ex vivo without simulating an in vivo surgical setting. This study introduces a new double-locking loop suture pattern and compares its biomechanical properties and execution time with commonly used suture patterns. All constructs were performed using an all-inside arthroscopic technique. HYPOTHESIS Complex suture repair constructs have higher failure loads, stiffness, and execution times compared with simple constructs. STUDY DESIGN Controlled laboratory study. METHODS Sutures were placed arthroscopically into the posterior horn root region of the medial and lateral menisci in 21 cadaveric knees. Four repair constructs were evaluated: 2 simple sutures (2SS), 1 inverted mattress suture (1MS), 1 double-locking loop suture (1DLS), and 2 double-locking loop sutures (2DLS). In total, 40 posterior meniscal roots were tested, with 10 trials for each construct. After arthroscopic placement of the root repair constructs, each meniscus was explanted and tested to failure on a uniaxial materials testing machine. The Kruskal-Wallis test was used to evaluate for the significance of maximum failure loads and stiffness between groups. RESULTS The mean maximum failure loads were 137 ± 49 N (2SS), 126 ± 44 N (1MS), 186 ± 43 N (1DLS), and 368 ± 76 N (2DLS). Interconstruct comparison revealed a statistical difference between 2DLS and all 3 remaining constructs (P < .01) and 1DLS when compared with 2SS and 1MS (P < .01 for both). Statistical significance was not found between 2SS and 1MS (P = .8). The mean times for repair of the 4 fixation techniques were 1.8 ± 0.9 minutes (2SS), 2.4 ± 1.9 minutes (1MS), 4.7 ± 2.0 minutes (1DLS), and 5.4 ± 0.6 minutes (2DLS). CONCLUSION The double-locking loop suture repair technique had significantly higher failure loads compared with the 3 other methods tested. As the complexity of repair constructs increases, failure loads and surgical times increase. CLINICAL RELEVANCE Complex suture patterns can be placed via an all-inside arthroscopic technique delivering higher failure loads for meniscal root repair with little increase in surgical time.
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Affiliation(s)
- Adam W Anz
- Andrews Orthopaedic and Sports Medicine Center, Gulf Breeze, Florida, USA Andrews Research and Education Institute, Gulf Breeze, Florida, USA
| | - Eric A Branch
- Florida State University College of Medicine, Tallahassee, Florida, USA
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Choi NH, Kim BY, Hwang Bo BH, Victoroff BN. Suture versus FasT-Fix all-inside meniscus repair at time of anterior cruciate ligament reconstruction. Arthroscopy 2014; 30:1280-6. [PMID: 25085047 DOI: 10.1016/j.arthro.2014.05.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 04/22/2014] [Accepted: 05/19/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare meniscal healing and functional outcomes after all-inside meniscal repair between sutures and meniscal fixation devices. METHODS Sixty patients with a tear within the red-red or red-white zones of the posterior horn of the medial or lateral meniscus in conjunction with an anterior cruciate ligament (ACL) tear were included in this study. Meniscal repairs were performed with sutures in 35 patients and the FasT-Fix device (Smith & Nephew Endoscopy, Andover, MA) in 25 patients concomitantly with hamstring ACL reconstruction. Postoperative evaluations included Lysholm knee score, Tegner activity scale, Lachman and pivot-shift tests, and KT-1000 arthrometer (MEDmetric, San Diego, CA) testing. Follow-up magnetic resonance imaging (MRI) scans were obtained postoperatively for all patients to evaluate meniscal healing. RESULTS The mean follow-up period was 47.2 months. In the suture group, 31 patients (86.1%) were asymptomatic and 4 (13.9%) were symptomatic. In the FasT-Fix group, 20 patients (80%) were asymptomatic and 5 (20%) were symptomatic. Postoperative functional evaluation and knee stability showed no statistically significant difference between the 2 groups. Follow-up MRI showed that 26 menisci (74.3%) were healed, 3 menisci (8.6%) were partially healed, and 6 menisci (17.1%) were not healed in the suture group. In the FasT-Fix group, 15 menisci (64%) were healed, 7 menisci (24%) were partially healed, and 3 menisci (12%) were not healed. Follow-up MRI showed no statistically significant difference between the 2 groups. In the FasT-Fix group, follow-up MRI showed a newly developed cyst posterior to the medial meniscus in 2 patients. A new tear anterior to the previous tear was found in 1 patient. In the suture group, follow-up MRI showed no cysts or new tears. CONCLUSIONS All-inside meniscal repairs using either sutures or the FasT-Fix device showed satisfactory results in patients with concomitant hamstring ACL reconstruction. There was no statistically significant difference in meniscal healing evaluated by MRI and functional outcomes between the 2 techniques. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Nam-Hong Choi
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, South Korea.
| | - Byeong-Yeon Kim
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, South Korea
| | - Byung-Hun Hwang Bo
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, South Korea
| | - Brian N Victoroff
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio, U.S.A
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30
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Rosso C, Müller S, Buckland DM, Schwenk T, Zimmermann S, de Wild M, Valderrabano V. All-inside meniscal repair devices compared with their matched inside-out vertical mattress suture repair: introducing 10,000 and 100,000 loading cycles. Am J Sports Med 2014; 42:2226-33. [PMID: 24966304 DOI: 10.1177/0363546514538394] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND All-inside arthroscopic meniscal repairs are favored by most clinicians because of their lower complication rate and decreased morbidity compared with inside-out techniques. Until now, only 1000 cycles have been used for biomechanical testing. HYPOTHESIS All-inside meniscal repairs will show inferior biomechanical response to cyclic loading (up to 100,000 cycles) and load-to-failure testing compared with inside-out suture controls. STUDY DESIGN Controlled laboratory study. METHODS Bucket-handle tears in 72 porcine menisci were repaired using the Omnispan and Fast-Fix 360 (all-inside devices) and Orthocord 2-0 and Ultrabraid 2-0 sutures (matched controls). Initial displacement, displacement after cyclic loading (100, 500, 1000, 2000, 5000, 10,000, and 100,000 cycles) between 5 and 20 N, ultimate load to failure, and mode of failure were recorded, as well as stiffness. RESULTS Initial displacement and displacement after cyclic loading were not different between the groups. The Omnispan repair demonstrated the highest load-to-failure force (mean ± SD, 151.3 ± 21.5 N) and was significantly stronger than all the other constructs (Orthocord 2-0, 105.5 ± 20.4 N; Ultrabraid 2-0, 93.4 ± 22.5 N; Fast-Fix 360, 76.6 ± 14.2 N) (P < .0001 for all). The Orthocord vertical inside-out mattress repair was significantly stronger than the Fast-Fix 360 repair (P = .003). The Omnispan (30.8 ± 3.5 N/mm) showed significantly higher stiffness compared with the Ultrabraid 2-0 (22.9 ± 6.9 N/mm, P < .0001) and Fast-Fix 360 (23.7 ± 3.9 N/mm, P = .001). The predominant mode of failure was suture failure. CONCLUSION All-inside meniscal devices show comparable biomechanical properties compared with inside-out suture repair in cyclic loading, even after 100,000 cycles. CLINICAL RELEVANCE Eight to 10 weeks of rehabilitation might not pose a problem for all repairs in this worst-case scenario.
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Affiliation(s)
- Claudio Rosso
- Orthopaedic Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sebastian Müller
- Department of Traumatology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel M Buckland
- Orthopaedic Department, University Hospital Basel, University of Basel, Basel, Switzerland Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tanja Schwenk
- Orthopaedic Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Simon Zimmermann
- School of Life Sciences, Institute for Medical and Analytical Technologies, University of Applied Sciences Northwestern Switzerland, Muttenz, Switzerland
| | - Michael de Wild
- School of Life Sciences, Institute for Medical and Analytical Technologies, University of Applied Sciences Northwestern Switzerland, Muttenz, Switzerland
| | - Victor Valderrabano
- Orthopaedic Department, University Hospital Basel, University of Basel, Basel, Switzerland
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Extra-articular dorsal closing-wedge osteotomy to treat late-stage Freiberg disease using polyblend sutures: technical tips and clinical results. INTERNATIONAL ORTHOPAEDICS 2014; 38:1401-5. [PMID: 24867357 DOI: 10.1007/s00264-014-2381-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 05/11/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical outcomes regarding the dorsal wedge osteotomy fixed using a polyblend suture and describe the usefulness of this fixation method for the treatment of Freiberg disease. METHODS The subjects consisted of 13 feet from 13 cases suffering from Freiberg disease that underwent extra-articular dorsal closing-wedge osteotomy using a polyblend suture. The average age was 31.7 (range 13-72) years. The average follow-up period was 17 (range 14-24) months. Regarding image findings, time to bone union and metatarsal shortening was reviewed. The investigation was carried out using the range of motion (ROM), visual analog scale (VAS), and Japanese Society of the Surgery of Foot lesser toe scale (JSSF score) in the MTP joint before surgery and at the latest follow-up. RESULTS Calluses under the metatarsal head were not observed in any cases. The mean metatarsal shortening was 2.33 ± 2.07 mm at follow-up. The bone union required an average of 8.4 ± 0.8 weeks. The average ROM of dorsal flexion improved from 37.2 ± 5.3° before surgery to 73.6 ± 9.9° at latest follow-up (p < 0.0001). The average ROM of plantar flexion improved from 16.0 ± 10.1° before surgery to 19.5 ± 8.6° at latest follow-up (p = 0.35). The average VAS significantly improved from 75.3 ± 8.5 before surgery to 4.9 ± 4.2 at latest follow-up (p < 0.0001). The average JSSF score significantly improved from 67.3 ± 9.4 points before surgery to 98.8 ± 3.0 points at the latest follow-up (p < 0.0001). CONCLUSION Extra-articular dorsal closing-wedge osteotomy using a polyblend suture was carried out to treat Freiberg disease. The bone union was observed in all cases with improved clinical results. Fixation using a polyblend suture was considered to be useful.
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Ramappa AJ, Chen A, Hertz B, Wexler M, Grimaldi Bournissaint L, DeAngelis JP, Nazarian A. A biomechanical evaluation of all-inside 2-stitch meniscal repair devices with matched inside-out suture repair. Am J Sports Med 2014; 42:194-9. [PMID: 24114752 DOI: 10.1177/0363546513505190] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many all-inside suture-based devices are currently available, including the Meniscal Cinch, FasT-Fix, Ultra FasT-Fix, RapidLoc, MaxFire, and CrossFix System. These different devices have been compared in various configurations, but to our knowledge, the Sequent meniscal repair device, which applies running sutures, has not been compared with the Ultra FasT-Fix, nor has it been compared with its suture, No. 0 Hi-Fi, using an inside-out repair technique. PURPOSE To assess the quality of the meniscal repair, all new devices should be compared with the gold standard: the inside-out repair. To that end, this study aims to compare the biomechanical characteristics of running sutures delivered by the Sequent meniscal repair device with 2 vertical mattress sutures applied using the Ultra FasT-Fix device and with 2 vertical mattress sutures using an inside-out repair technique with No. 0 Hi-Fi suture. STUDY DESIGN Controlled laboratory study. METHODS Paired (medial and lateral), fresh-frozen porcine menisci were randomly assigned to 1 of 3 groups: Sequent (n = 17), Ultra FasT-Fix (n = 19), and No. 0 Hi-Fi inside-out repair (n = 20). Bucket-handle tears were created in all menisci and were subjected to repair according to their grouping. Once repaired, the specimens were subjected to cyclic loading (100, 300, and 500 cycles), followed by loading to failure. RESULTS The Sequent and Ultra FasT-Fix device repairs and the suture repair exhibited low initial displacements. The Sequent meniscal repair device demonstrated the lowest displacement in response to cyclic loading. No. 0 Hi-Fi suture yielded the highest load to failure. CONCLUSION With the development of the next generation of all-inside meniscal repair devices, surgeons may use these findings to select the method best suited for their patients. CLINICAL RELEVANCE The Sequent meniscal repair device displays the least amount of displacement during cyclic loading but has a similar failure load to other devices.
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Affiliation(s)
- Arun J Ramappa
- Ara Nazarian, Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN115, Boston, MA 02215.
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Abstract
Meniscus repair over resection, when feasible, should be strongly considered in an effort to preserve meniscus integrity and function, especially in younger patients. Currently, a number of techniques and implants may be used to achieve a successful result. Although all-inside meniscus repair devices have evolved significantly since their introduction and have become the repair technique of choice for many surgeons, the classic inside-out repair technique is still very useful to have in one's armamentarium. Though less popular because of the ease of current-generation fixators, the inside-out technique can still offer advantages for those surgeons who are proficient. With the versatility to address most tear patterns, the ability to deliver sutures with smaller needle diameters, and proven long-term results, it has been considered the gold standard in meniscus repair. We review the inside-out repair technique for both a medial and lateral meniscus tear with some helpful tips when performing the technique, and we present a video demonstration of the lateral meniscus repair technique.
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Barber FA. Pullout strength of bone-patellar tendon-bone allograft bone plugs: a comparison of cadaver tibia and rigid polyurethane foam. Arthroscopy 2013; 29:1546-51. [PMID: 23910001 DOI: 10.1016/j.arthro.2013.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 06/04/2013] [Accepted: 06/05/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the load-to-failure pullout strength of bone-patellar tendon-bone (BPTB) allografts in human cadaver tibias and rigid polyurethane foam blocks. METHODS Twenty BPTB allografts were trimmed creating 25 mm × 10 mm × 10 mm tibial plugs. Ten-millimeter tunnels were drilled in 10 human cadaver tibias and 10 rigid polyurethane foam blocks. The BPTB anterior cruciate ligament allografts were inserted into these tunnels and secured with metal interference screws, with placement of 10 of each type in each material. After preloading (10 N), cyclic loading (500 cycles, 10 to 150 N at 200 mm/min) and load-to-failure testing (200 mm/min) were performed. The endpoints were ultimate failure load, cyclic loading elongation, and failure mode. RESULTS No difference in ultimate failure load existed between grafts inserted into rigid polyurethane foam blocks (705 N) and those in cadaver tibias (669 N) (P = .69). The mean rigid polyurethane foam block elongation (0.211 mm) was less than that in tibial bone (0.470 mm) (P = .038), with a smaller standard deviation (0.07 mm for foam) than tibial bone (0.34 mm). CONCLUSIONS All BPTB grafts successfully completed 500 cycles. The rigid polyurethane foam block showed less variation in test results than human cadaver tibias. CLINICAL RELEVANCE Rigid polyurethane foam blocks provide an acceptable substitute for human cadaver bone tibia for biomechanical testing of BPTB allografts and offer near-equivalent results.
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Affiliation(s)
- F Alan Barber
- Plano Orthopedic Sports Medicine and Spine Center, Plano, Texas 75093, USA
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Goradia VK. All-inside arthroscopic meniscal repair with meniscal cinch. Arthrosc Tech 2013; 2:e171-4. [PMID: 23875146 PMCID: PMC3716229 DOI: 10.1016/j.eats.2013.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 01/22/2013] [Indexed: 02/03/2023] Open
Abstract
The number of commercially available all-arthroscopic meniscal repair devices has increased in recent years. Although inside-out vertical mattress sutures have been considered the gold standard in the past, recent biomechanical studies have shown that some all-arthroscopic repair devices provide comparable strength. To successfully use these devices, surgeons must understand proper insertion technique. The purpose of this article is to demonstrate this technique for the Meniscal Cinch (Arthrex, Naples, FL).
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Affiliation(s)
- Vipool K. Goradia
- Address correspondence to Vipool K. Goradia, M.D., Go Orthopedics, 13225 Rivers Bend Blvd, Chester, VA 23836, U.S.A.
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Beitzel K, Mazzocca A. Möglichkeiten der biologischen Augmentation von RM-Rekonstruktionen. ARTHROSKOPIE 2012. [DOI: 10.1007/s00142-011-0671-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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