Meniscal Repair Outcome in 3829 Patients With a Minimum Follow-up From 2 Years Up to 5 Years: A Meta-analysis on the Overall Failure Rate and Factors Influencing Failure

All-inside ramp lesion repair via anterior portals and pie-crusting: Excellent outcomes and survivorship at one-year follow-up

Background

Ramp lesions, located in the posterior horn of the medial meniscus, are commonly associated with anterior cruciate ligament (ACL) injuries and contribute to knee instability if untreated. Traditional repair methods use posteromedial portals, but newer approaches, such as the all-inside technique through anterior arthroscopic portals with pie-crusting of the posterior oblique ligament (POL), offer improved access and reduced morbidity. This study aimed to assess the clinical outcomes, return-to-sport rates, and failure rates of this technique compared to established methods.

Materials and methods

A retrospective analysis included 54 patients (mean age: 29.1 years) who underwent ramp lesion repair using the all-inside technique between January 2019 and December 2022. Clinical outcomes were evaluated with the IKDC score, Lysholm score, and Tegner activity scale. Failure was defined as the need for revision surgery.

Results

At a mean follow-up of 30.7 months, patients had a mean IKDC score of 81.5 ± 7.1 and Lysholm score of 94.5 ± 7.4. The Tegner activity scale declined slightly from 7.2 ± 1.2 preoperatively to 6.8 ± 1.3 postoperatively. All patients returned to sport within 9.2 ± 2.5 months, with a failure rate of 12.9 % and an average revision time of 13.1 ± 8.2 months.

Conclusion

The all-inside technique for ramp lesion repair via anterior portals provides excellent clinical outcomes and return-to-sport rates, with failure rates comparable to other methods. This minimally invasive approach offers improved access, reduced morbidity, and a reliable option for managing ramp lesions in ACL-injured patients.

Level of evidence

IV.

Report on Evolving Indications, Technique, and Outcomes of Novel And Surgical Procedures-NUsurface

PURPOSE OF REVIEW

Meniscectomy alters knee function and known to be associated with an increased incidence of knee arthritis. Several methods and materials have been tried to replicate the function of a meniscus. One is a polycarbonate-urethane synthetic medial meniscus implant labeled as NUsurface. It is a non-anchored implant that is meant to replace the native meniscus. This article is intended to give an overview of the NUsurface implant and the experience to date.

RECENT FINDINGS

The NUsurface implant is not intended to be a substitute for arthroplasty but has indications similar to meniscal allografts. It has had both prospective double armed and single armed prospective studies. Follow up at the 2-year mark has shown the implant can be successful in decreasing patients' pain and improving function. However, the reoperation rate has been high with a little over a 1/3 requiring an additional procedure and 30% requiring implant exchanged. With improved surgical technique and knowledge of contributing anatomic variables, the reoperation rate has been decreased by half. The synthetic medial meniscus implant NUsurface is able to improve the quality of life in select patients that are symptomatic after meniscectomy. The reoperation rate is of concern but it is decreasing as we refine the variables contributing to the high rate.

MR imaging of pediatric meniscal retears: pearls and pitfalls - a pictorial review

Differentiating expected pediatric knee MRI post-operative changes and meniscal retear after primary repair or debridement may be challenging. This pictorial essay reviews treatment strategies for meniscal tears with or without underlying discoid morphology. MRI pearls and pitfalls to identify meniscal retears and differentiate them from normal post-treatment findings will be shown, geared toward pediatric musculoskeletal radiologists.

Clinical outcomes of repaired radial meniscal tears: A retrospective study with minimum 2-year follow-up

BACKGROUND

The management of meniscal radial tears has changed significantly in recent years in favor of meniscus repair. However, there is still limited published data on the outcomes and risk factors associated with repair failure. The objective of this study is to evaluate the clinical success rate of repaired meniscal radial tears and identify potential risk factors for failure.

METHODS

Patients who underwent repair of meniscal radial tears between 2016 and 2022 were reviewed retrospectively. The following parameters were collected: demographic data, pre-operative Kellgren-Lawrence grading, history of previous knee surgeries, time from injury to surgery, injury location, number of sutures used, use of transtibial tunnel augmentation, associated procedures, postoperative functional scores, and clinical failure rates.

RESULTS

81 patients were included, with a mean age of 29.9 ± 12.3 years. The mean follow-up time was 36.7 ± 17.0 months. Postoperatively, the mean IKDC was 81 ± 18.1, and the mean Lysholm score was 82 ± 18.4. The clinical failure rate was 19.8%. In the univariate analysis, the factors associated with failure included increased age, female gender, medial meniscus repair, isolated repairs (without ACL reconstruction), a Kellgren-Lawrence scale greater than 0, and repairs without a transtibial tunnel. However, none of these variables were statistically significant in the multivariate analysis adjusted for age and gender.

CONCLUSION

The clinical success rate of repaired meniscal radial tears was about 80% after a minimum 2-year follow-up. Increased age, female gender, repair of medial meniscus, isolated repair without ACL reconstruction, mild preoperative osteoarthritic signs, and repair without a transtibial tunnel augmentation are possible risk factors for failure.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Knee malalignment and laterality influence 2-year meniscus tear repair outcomes: A pilot study

PURPOSE

To analyse biomechanical determinants for radiological and clinical outcomes of posterior horn longitudinal vertical meniscal tear (LVMT) repairs.

METHODS

Patients undergoing primary repair of vascular zone traumatic full-thickness posterior horn LVMT were enroled. We hypothesized four potential factors would influence mid-term outcomes: malalignment (varus/valgus ≥5° for medial/lateral tears), meniscal laterality (medial vs. lateral), concomitant anterior cruciate ligament reconstruction (ACLR) and cartilage damage (Outerbridge grade ≥ II). The primary outcome was posterior horn nonhealing rate 6 months postoperatively (T1), evaluated using computed tomography arthrography (CTA) and Henning's criteria. Secondary outcomes were patient-reported outcomes measures (PROMs) assessed at T1 and ≥24 months postoperatively (T2). Univariate and multivariate logistic regression models estimated the marginal relative risk (MRR) of nonhealing for each determinant, while fractional logit regression assessed determinants' impact on PROMs at T1 and T2.

RESULTS

Seventy-eight patients (median age 29 years, interquartile range [IQR]: [21-37]); 76% male), were followed for ≥2 years (median 2.5 years, IQR: [2.1-3.6]). LVMTs extended to the middle horn in 81% and to the anterior horn in 52%. Posterior horn nonhealing rates (53%) were higher than in the middle (35%, p = 0.013) and anterior horn (7%, p < 0.001). Malalignment was present in 14%, medial meniscal involvement in 77%, ACLR in 55% and cartilage damage in 37%. Malalignment (MRR = 1.48, 95% confidence interval (CI): [0.84, 2.09]) and medial laterality (MRR = 1.7, 95% CI: [0.93, 3.6]) were independently identified as potential nonhealing risk factors. But it is the combination of varus malalignment and medial laterality that significantly increased the risk of nonhealing (MRR = 2.54, 95% CI: [1.09, 6.01], p = 0.033) and negatively impacted all Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales and International Knee Documentation Committee (IKDC) score at T1 and/or T2.

CONCLUSION

Combined varus malalignment and medial meniscus involvement strongly predicted repair nonhealing and poorer outcomes after posterior horn LVMT repair.

STUDY DESIGN

Prospective cohort pilot study.

LEVEL OF EVIDENCE

Level III.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy of platelet-rich plasma in meniscal repair surgery: a systematic review of randomized controlled trials

PURPOSE

This study's primary objective was to evaluate the effectiveness of platelet-rich plasma (PRP) administration for meniscal injuries treated with meniscal repair procedures (sutures), using radiologic measures and clinical scales. The secondary objective was to identify potential bias-inducing elements in the analyzed studies.

METHODS

In December 2023, a systematic search was conducted in PubMed, Cochrane, Embase, and Scopus for randomized controlled trials. This review compares PRP with placebo. Three studies were finally selected. The risk of bias was assessed using Cochrane's Risk of Bias Tool 2. Radiologic evaluation of meniscal healing was measured with magnetic resonance imaging (MRI) and arthroscopic studies, while clinical evaluation was performed using four scales [Knee Injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS), International Knee Documentation Committee Subjective Knee Form (IKDC), and Western Ontario and McMaster Universities Index (WOMAC)] and by recording the incidence of complications.

RESULTS

The three selected studies included 139 patients; of these, 76 (54.7%) were randomly assigned to the intervention group (PRP injection) and 63 (45.3%) to the control group (placebo). The mean age of the intervention group was 37.4 ± 7.5 years, while the mean age of the control group was 36.5 ± 9.2 years. There were 41 female patients (29.5%). The median follow-up duration was 27.58 ± 17.3 months. MRI evaluation did not show a significant improvement in the PRP group in any of the studies (p-value = 0.41-0.54). However, when assessed by the cumulative evaluation of MRI and arthroscopy, the cumulative failure rate was significantly better in the PRP group (p-value = 0.04-0.048). One study that evaluated isolated arthroscopy also showed significant improvement in the PRP group (p = 0.003). Regarding the VAS scale, no study demonstrated a significant difference, except for one study that showed significant improvement after 6 months and in the difference between the 3rd and 6th months. The KOOS scale yielded conflicting results; one study showed no significant difference, while the other two indicated significant improvement. The IKDC and WOMAC scales were evaluated in two studies, showing opposite results. All included studies reported no complications, and one study indicated no increased risk in the treatment group.

CONCLUSIONS

The results of this review indicate the necessity for further studies to make a definitive statement about the effectiveness of PRP administration in meniscal repair processes. Level of evidence Systematic review and meta-analysis of articles of level 1.

Suture Tying Force for Cut-Out during Radial Meniscus Tear Repair: A Biomechanical Evaluation of Failure Loads during the Knot-Tying Process

OBJECTIVE

The purpose of the study was to determine average tensile forces resulting in suture failure while tying a knot during repair of complete radial meniscus tears and to compare the failure tensile force based on meniscus tissue location: the peripheral (red-red) versus inner (white-white).

DESIGN

This study was designed as a cadaveric biomechanical study using 24 menisci harvested from fresh frozen cadaveric knees with midbody radial tears. Tears were repaired using 2-0 nonabsorbable suture in both the inner meniscus and the peripheral meniscus. A force gauge was used to measure the tension of a surgeon's knot until failure of either the suture or the meniscus tissue. Statistical analysis was performed comparing suture failure tensile forces between inner and peripheral sutures using 2-sample t test.

RESULTS

Suture repairs primarily failed due to meniscal tissue cut-out after suture tensioning (96%). There was no statistical difference in failure mode between medial and lateral meniscus for both the inner (100% cut-out) and the peripheral (92% cut-out; P = 0.703) sutures. The peripheral sutures failed as significantly higher loads (54 ± 26 N) than the inner sutures (36 ± 11 N, P = 0.006). The peripheral meniscus tissue tolerated significantly higher tension at failure (36 ± 7 N) than the inner meniscus (26 ± 7 N, P < 0.001).

CONCLUSION

When tying parallel sutures to repair a radial meniscus tear, suture tensile forces above 30 N may tear through meniscus tissue. Surgeons should not use suture tying forces above 30 N when repairing radial meniscus tears with parallel sutures. The peripheral meniscus can withstand higher knot-tying forces than the inner meniscus, so surgeons should consider tying the peripheral suture before the inner suture.

How to Improve Meniscal Repair through Biological Augmentation: A Narrative Review

Since the role of the menisci in knee stability, proprioception, and homeostasis has been well established, significant efforts have been made to repair meniscal tears, resulting in excellent clinical outcomes and a reduction in the progression of knee osteoarthritis (OA). However, varying failure rates have been reported, raising questions regarding the healing potential in cases of complex injuries, poorly vascularized and degenerated areas, and generally in the presence of unfavorable biological characteristics. Therefore, over the last few decades, different strategies have been described to increase the chances of meniscal healing. Biological augmentation of meniscal repair through various techniques represents a safe and effective strategy with proven clinical benefits. This approach could reduce the failure rate and expand the indications for meniscal repair. In the present study, we thoroughly reviewed the available evidence on meniscal repair surgery and summarized the main techniques that can be employed to enhance the biological healing potential of a meniscal lesion. Our aim was to provide an overview of the state of the art on meniscal repair and suggest the best techniques to reduce their failure rate.

Degenerative Meniscus Tears Treated Nonoperatively With Platelet-Rich Plasma Yield Variable Clinical and Imaging Outcomes: A Systematic Review

Purpose

To perform a systematic review on clinical and radiologic outcomes for meniscus tears treated nonoperatively with platelet-rich plasma (PRP).

Methods

A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using keywords and Boolean operators in SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials in April 2023. Inclusion criteria were limited to Level I to IV human studies reporting on outcomes of meniscus tears treated nonoperatively with PRP.

Results

A total of 6 studies, consisting of 184 patients, were identified. There was 1 Level I study and 5 Level IV studies. Mean patient age was 47.8 ± 7.9 years, with 62% (n = 114/184) being female. The medial meniscus was treated in 95.7% (n = 157/164) of patients. Mean follow-up ranged from 75.9 days to 31.9 months. Meniscus tears were generally described as chronic, degenerative, or intrasubstance. In 4 studies, magnetic resonance imaging revealed variable improvement in meniscus grade with complete healing in 0% to 44% of patients and partial healing in 0% to 40% of patients. Four of 5 studies reported significant statistical improvement in pain from baseline to final follow-up. Studies reporting on clinical outcomes showed significant improvements Lysholm score (2 studies), Knee injury and Osteoarthritis Outcome Score total score (2 studies), and Tegner score (1 study). Successful return to sport occurred in 60% to 100% of patients. Two studies reported that most patients were either very satisfied or satisfied following treatment.

Conclusions

The use of PRP injections for the treatment of meniscus tears led to variable results based on postoperative magnetic resonance evaluation and improvements in clinical outcomes, although the clinical significance remains unclear. The heterogeneity of PRP protocols, short-term follow-up, and lack of comparative studies limit findings.

Level of Evidence

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

Outcomes of Meniscal Repair in Patients Aged 40 and Above: A Systematic Review

PURPOSE

Meniscal injuries are increasingly common in older age groups. Age is often cited as a contraindication to undergoing meniscal repair due to concerns regarding failure rates. There has recently, however, been an increasing shift towards repair in older populations. The purpose of this study was to review outcomes of meniscal repair in patients over the age of 40.

METHODS

A systematic search of the following databases was conducted of PubMed, SCOPUS, Web of Science, and Cochrane Library to identify studies reporting failure rates of patients over 40 with meniscal injuries undergoing repair. The definition of meniscus failure was noted for each study evaluated in this systematic review. Further data surrounding clinical and radiological outcomes were recorded and evaluated, when available.

RESULTS

Thirteen studies were included in this review, encompassing a total of 316 meniscal repairs in patients over the age of 40 years. The overall failure rate was found to be 15.5% (49/316) (range 0-33.3%). There was no difference in the failure rate in those over 40 vs. under 40, and the two groups had equivalent functional outcomes.

CONCLUSIONS

Age should not be considered a contra-indication for meniscal repair. Appropriately selected older patients can have acceptably low failure rates with meniscal repair and similar functional outcomes to those under the age of forty. Meniscal repairs in those over 40 achieved better functional outcomes than patients of the same age group who underwent meniscectomy.