What Kinds Of Meniscus Repair Strategy Are There? For What Kind Of Injuries? (~50 Words)

Eur J Orthop Surg Traumatol. 2019; 29(3): 509–520.

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

Monil Karia

¹Musculoskeletal Lab, Regal Higher London, London, Great britain

Youssef Ghaly

¹Musculoskeletal Lab, Royal College London, London, United Kingdom

Nawfal Al-Hadithy

²Orthopaedic Section, Hillingdon Hospital, London, U.k.

Simon Mordecai

^twoOrthopaedic Section, Hillingdon Hospital, London, Britain

Chinmay Gupte

ⁱMusculoskeletal Lab, Imperial Higher London, London, United Kingdom

Received 2018 Jun nineteen; Accepted 2018 Sep 18.

Abstract

Knee joint arthroscopy for meniscal tears is one of the near ordinarily performed orthopaedic procedures. In recent years, there has been an increasing incidence of meniscal repairs, as there are concerns that meniscectomy predisposes patients to early osteoarthritis. Indications for meniscal repair are increasing and can at present be performed in older patients who are active, even if the tear is in the avascular zone. Options for meniscal tear management broadly autumn into three categories: not-operative management, meniscal repair or meniscectomy. With limited evidence direct comparing each of these options optimal direction strategies can be difficult. Determination making requires thorough assessment of patient factors (due east.g. age and comorbidities) and tear characteristics (due east.g. location and reducibility). The purpose of this paper is, therefore, to review the management options of meniscal tears and summarize the evidence for meniscal tear repair.

Keywords: Meniscal repair, Trauma, Management, Arthroscopy, Knee

Introduction

Meniscal tears are one of the most common knee injuries and often necessitate surgery due to hurting or mechanical symptoms. Historically, menisci were considered vestigial remnants and were commonly resected. In 1948 Fairbank [1] suggested that meniscectomy predisposed the knee to early degenerative changes, and in that location accept since been several studies confirming poor long-term function and early degenerative changes in patients mail service meniscectomy. In more recent years various important roles of menisci including load sharing, shock absorbers, secondary stabilizers, proprioception and lubrication have all been confirmed [ii].

The first meniscal repair was performed by Annandale in 1885 with an open procedure and despite development of diverse arthroscopic techniques in the subsequent years; it is only recently that meniscal preservation has received a high level of awareness. In 2013, a review of arthroscopic procedures institute a doubling in the number of meniscal repairs performed in the past five years, without a concomitant increment in meniscectomies [three]. It is now accepted that knees where in that location has been a meniscal repair accept lower rates of radiographic degenerative changes compared with meniscectomy. Concluding year, a systematic review of various repair techniques and implants was performed and found no difference in outcomes, however focused on outcomes greater than five years, which therefore excluded many of the newer all-within repair techniques [4].

There is nonetheless controversy and uncertainty as to the ideal management of meniscal tears, including which meniscal tears should be repaired, methods of cess mail repair, and the effect of damage to the anterior cruciate ligament (ACL). Lastly a summary of the clinical outcomes for various techniques and devices is presented.

Blood supply

Blood vessels arise from the lateral, middle and medial geniculate arteries and penetrate through the articulation sheathing to form a perimeniscal capillary plexus, where radial branches enter the menisci and supply the peripheral quarter of the menisci (red zone). In cadaveric studies, Arnoczky et al. [5] and Day et al. [6] found that radial branches penetrate the menisci to a depth of two–3 mm (Fig.1), with the about consistent blood supply occurring at the inductive and posterior horns. Both studies found that the posterolateral aspect of the lateral meniscus, adjacent to the popliteus tendon was avascular as was the inner seventy–75% of the menisci (white zone). Cooper described these zones by dividing the meniscus into iii radial sections (Zone A, B and C) from posterior to inductive and the width into 3 from peripheral to central (Fig.2).

Radial branches penetrating the peripheral ¼ of the lateral meniscus

Cooper zones of the meniscus

In addition, the blood supply to the menisci varies with age. Petersen and Tillmann [seven] reviewed cadaveric specimens of 20 human menisci ranging in age from birth to 80 years old and found that at birth the whole meniscus was vascularized. By the second year, they had an avascular area on the inner circumference. By the age of xx, blood vessels were but nowadays in the peripheral tertiary, which farther regressed to a quarter at the age of 50.

Some authors have investigated the effects of osteoarthritis on the vascularity of menisci. Previously it was found that increased angiogenesis was present in OA synovium. More recently, Ashraf et al. [8] used antibodies to localize blood vessels past histochemistry and found an increased density of blood vessels near the fibrocartilage junction in patients with high tibiofemoral chondropathy. They suggested this, in addition to an increment in the number of perivascular sensory fibres, may exist possible mechanisms contributing to knee joint pain in OA. This suggests why meniscal surgery may alleviate pain.

Meniscal tear patterns

Meniscal tears may be classified according to anatomic location and therefore proximity to blood supply and also tear morphology (Fig.3). The tear characteristics vary depending on many factors including stability and sporting activity.

Diagram to illustrate the types of meniscal tears

The pattern of meniscal injuries in the ACL-deficient knee is like in both children and adults, with a higher simply non-progressive incidence of lateral meniscal tears occurring acutely, and a lower merely increasing rate of medial tears correlating with chronicity. Baker et al. [9] reviewed meniscal injuries according to specific sports and constitute medial tears were more common than lateral (81% vs. 19%) and were consistently more common in football, basketball, skiing and baseball game, whereas lateral meniscal tears were equal to medial tears in wrestling. Terzidis et al. [10] evaluated 378 athletes with stable knees, and found 77.5% were vertical (cf 22.5% horizontal).

Vertical tears are the well-nigh common to exist repaired. They are often full thickness and may exist unstable (saucepan handle). They usually occur in traumatic injuries and are associated with ACL ruptures. They are often extensive, and resection would equate to a subtotal excision. If the displaced fragment is not degenerative, which may be the case in chronic injuries, information technology should be assessed for reducibility and considered if repairable. Near of the reported clinical outcomes related to vertical tears.

The furnishings of radial tears depend on whether they are incomplete or consummate. Incomplete tears start centrally and extend to only do non achieve the intact peripheral rim; the circumferential collagen fibres of the meniscus remain intact and stability remains. Small incomplete radial tears, which are in the white–white zone, are ofttimes treated with partial meniscectomy with successful outcomes. This contrasts with complete radial tears which traverse the circumferential collagen fibres resulting in extrusion of the meniscus and abnormal load transmission which is equivalent to total meniscectomy. Ode et al. [11] performed serial sectioning and repairs of lateral meniscal radial tears in 5 cadaveric homo knees and plant significantly reduced contact area and increase in contact pressures in complete radial tears, which approached similar values seen in total meniscectomy. No difference was seen in lesser degrees of tears (< 75%) as compared with an intact meniscus. Although repairs of consummate tears significantly improved biomechanics, it was still reduced compared with the intact meniscus. Bedi et al. [12] also constitute big medial meniscal radial tears (< 90%) had reduced tibiofemoral contact pressures if repaired rather than resected in their cadaveric study.

Horizontal cleavage (intrasubstance) tears extend parallel to the tibial plateau, dividing the meniscus longitudinally, and are stable. They tend to occur as part of a degenerative process and may be accompanied by a meniscal cyst and may be without clinical symptoms [13]; due to this they tend to be resected. Biedert [14] evaluated 4 treatment options for 41 horizontal tears; conservative, repair, trephination and repair with a fibrin clot and fractional meniscectomy. The all-time short-term outcomes (26.5 yard) were with partial meniscectomy. Pujol et al. [xv] suggested at that place is a subgroup of younger agile patients who take horizontal tears due to overuse and trauma rather than as part of a degenerative process who would benefit from repair. They performed open repairs in 21 patients with a hateful age of 25 and found that 20 patients were able to return to sports at 40 months follow-up. Although 4 patients (19%) required secondary meniscectomy, they suggested this outweighed the progression of degenerative changes associated with meniscectomy.

Extent of tear

It is generally accepted that the blood supply to the meniscus is, among other factors, a key factor that determines the result of meniscal repairs. It had previously been thought that meniscal repairs were only successful in vascularized zones (Crimson–Red or Red–White). Nonetheless, Rubman et al. [16] published their series of 198 repairs that extended into the avascular zone, and 80% were clinical successful with twenty% requiring re-operation at 42 months. Gallacher et al. [17] performed all-inside meniscal repairs in the white on white zone and had a 68% success rate with meaning gains in Lysholm scores; withal, follow-upward was limited at 12 months and success was determined on re-operations rate only. Twenty-eight patients required further surgery (8 re-repair, 20 meniscectomy). In a serial with the longest follow-upward of 16.8 years, Noyes et al. [xviii] also had successful outcomes in their series of 29 meniscal repairs in patients with meniscal tears extending into the key avascular region. They had 11 (38%) failures, with vi patients requiring meniscectomies, 2 developing early onset osteoarthritis and 3 patients although asymptomatic had failed repairs on MRI evaluation. Some authors experience that unhealed menisci which remain reduced with acceptable fixation contribute to load transmission and therefore protect articular cartilage. This data are summarized in Table1.

Table 1

Repairs in avascular zones

Authors	No. of patients	Mean age (years)	Mean FU	ACL	Zone	MM/LM	Time from injury to repair	Technique	Evaluation method	Outcome
Rubman [16]	177	28	42 months (18 months arthroscopically)	128 ACL rupture (126 reconstruction)	R–W	106 MM 92 LM		Inside-out	161 clinical exam 91 Arthroscopy	20% required repeat arthroscopy Of 91 arthroscopy 58% farther meniscal surgery
Noyes [18]	29	xvi.8 (10.1–21.nine)	xvi.8 year	24 ACL reconstruction	R–W	11 MM 18 LM	31 weeks	Inside-out vertical divergent sutures		six meniscectomies ii early on onset OA 3 failed on MRI
Gallacher [17]	87 73 Grand 14 F	26 (13–54)	12 months (13–115)	Intact	W–W	50 MM 37 LM iii PT 84 FTT 69 BHT fourteen PHT	8 months (i week–x years)	All-inside Clear prepare (72) FasT-prepare sutures (xiii) Both (2)		Lysholm 61 → 75 Tegner 6 → 6 8 re-repairs 20 meniscectomies LM = MM outcomes
Noyes [21]	29 23 Chiliad vi F	45	33 months	21 ACL reconstruction	R–West iv mm RW	19 MM 11 LM	10 < ten weeks from injury xix > 10 weeks from injury	Inside-out suture repair		3 fractional meniscectomy

West–Westward White white, MM medial meniscus, Lm lateral meniscus, PT fractional tear, FTT full-thickness tear, BH bucket-handle tears, PHT posterior horn tears, RW rim width

Patients age

Several studies have found that menisci with few or no intrinsic cells are more than prone to acute or degenerative tears and that the presence of viable "normal" meniscal cells is an important factor for determining meniscal survival. Mesiha et al. [xix] reviewed histological characteristics of 44 meniscal tears and found decreased intrinsic and perimeniscal cellularity in patients greater than xl years sometime compared with the control group. Despite this, some authors have reported successful outcomes of repairs in older patients; Barrett et al. [20] had a high early clinical success rate (86.5%) at 26.5 months in patients anile 44 years (north= 37). Five patients had recurrence of clinical symptoms, and further arthroscopies were offered. Noyes et al. [21] evaluated repair outcomes in patients with a hateful age of 45 who underwent meniscal repair with or without a concomitant ACL reconstruction (72%) and had very good/skilful outcomes in 88% of patients, with iii requiring a meniscectomy at 33-month follow-upward and suggested meniscal repair should be considered in active patients regardless of historic period.

Chronicity

It has been idea that early on meniscal repair provides better outcomes. Nishida et al. [22] evaluated the cell count and morphology of iatrogenic saucepan-handle tears in dogs at 2, 4, 12, 24 and 48 weeks. They found that the cell count and morphology remained consistent until 12 weeks, nevertheless progressively deteriorated afterwards and suggested that repair may be more than successful if performed before 12 weeks. Other authors have constitute a straight correlation between time since injury and meniscal Deoxyribonucleic acid fragmentation and side by side cartilage degeneration. In agreement, Pujol et al. [23] found a stiff human relationship between time from injury and extent of tear and subsequent meniscectomy book and suggested symptomatic meniscal tears should be operated on as early on as possible. It has been well established that there is a significantly lower take chances of meniscal repair equally fourth dimension from injury progresses.

Associated ACL injury

It has traditionally been thought that meniscal repair was more than likely to be successful if a simultaneous ACL reconstruction was performed compared with ACL-deficient and ACL-intact knees [24], due to the iatrogenic haemarthrosis caused past the drilling of the tunnels. However, this decision was based largely on small-scale and brusk-term studies. Last twelvemonth, Nepple et al. [4] performed a systematic review of mid- and long-term studies (northward= 8) of meniscal repairs in ACL-reconstructed knees and did not find an clan with more successful outcomes. Notwithstanding, information technology is of import to note that of the viii studies, only three directly compared outcomes, and the studies may have been underpowered to detect a divergence. Recently, Wasserstein et al. [25] compared 1332 patients who underwent meniscal repair with and without ACLR at a mean age of 25.5 years using a variety of repair techniques. They found meniscal repairs performed in conjunction with ACLR had a 7% accented and 42% relative run a risk reduction of re-operation at 2 years. Whilst their data are the largest published serial and may be a representative of the true population, it did not account for tear location, characteristics, surgical technique and rehabilitation protocols.

Indications and contraindications

The surgeon must have into diverse patient factors and tear characteristics when deciding whether to repair or resect a meniscal tear (Table2).

Table two

Indications for repair

Patient factors	Tear characteristics
Younger (< twoscore), active patient	Reddish–blood-red/ruddy–white—platonic just not mandatory
No significant comorbidities	Unproblematic tear pattern
BMI < 30	< 3 months erstwhile
Willingness to comply with post-operative rehabilitation regime	Associated ACL reconstruction
	Reducible without excess tension
	Lower threshold for consummate radial tears

Contraindications to repair include: the presence of course 3–four osteoarthritis in ipsilateral compartment, irreducibility of the tear as the meniscus would be under besides loftier tension and a central radial tear < 25%

Surgical repair

Meniscal repair was initially performed open, until in 1969 when Ikeuchi [26] performed the first arthroscopic repair, and since then arthroscopic techniques have evolved which include inside-out, exterior-in or all-inside repairs. As the awareness for meniscal preservation has risen, and so too have the number of devices that permit for an all-inside procedure to be performed which avoids the need for further incisions, reduces the take chances of neurovascular injury and faster operating times.

Open

Open up meniscal repair is now less commonly used, merely may still be indicated in extremely tight medial compartments to facilitate access to a complex posterior horn tear. Information technology is performed through an incision posterior to the collateral ligaments, through the sheathing and synovium to allow directly exposure to the torn meniscus. There take been various long-term studies which have had satisfactory results, albeit with small patient numbers, and evidence re-tear rates between 11–29% [27]. In a report with the longest follow-up, Rockborn and Gillquist [27] had a clinical failure rate of 29% at 13 years in their serial of 31 patients. In that location was a significantly reduced incidence of degenerative changes compared with their series of meniscectomies; in addition fourscore% of their patients had normal function during daily activities, with a Lysholm score of > 84. They besides noted an equal decline in sporting activities in their meniscal repair group equally compared with their command group with unaffected knees. These information are summarized in Table3.

Table 3

Summary of open meniscal repairs with long-term follow-upward

Authors	No. of patients	Mean age (years)	Mean FU (years)	ACL	Zone	MM/LM	Time from injury to repair	Evaluation method	Consequence
DeHaven [52]	30	18.nine	10.nine	15 ACLR	R–R	23 MM 10 LM		Clinical	21% re-tear
Muellner [38]	22	32.2	12.9	7 ACLR		eighteen MM 5 LM	8.7 days	Radiographs MRI	nine% re-tear 27% degenerative changes
Rockborn [27]	31	25	13	All intact		17 MM xiv LM	13.5 weeks	Clinical Radiographs	29% re-tear

Arthroscopic-assisted inside-out and exterior-in techniques

Many surgeons all the same consider the within-out technique to exist the gold standard of meniscal repair as it allows more a more consequent suture placement, perpendicular to the tear. After introduction of the arthroscopic for intra-articular evaluation, accessory posteromedial or posterolateral incisions are required for suture retrieval. In inside-out the sutures are introduced from within the genu, with them beingness knotted onto the capsule. Tears of the posterior and centre thirds of the meniscus are suitable for this technique. Outside-in techniques are more than suitable for repair of the anterior and heart thirds of the meniscus. Once the tear is identified using arthroscopy, the skin is transilluminated to localize the tear. A vertical mattress suture can then be fashioned to repair the torn meniscus.

These allow for safe suture tying and aim to reduce the take chances of neurovascular injury. The structures at risk depend on location of the meniscal tear; lateral meniscal repairs risk lateral genicular avenue and branches of peroneal nerve. With medial meniscal repairs, the saphenous vein and nervus are at risk.

All-inside

Various all-inside devices have been used with early generations consisting of a rigid device and newer devices being suture based. One of the first all-inside arthroscopic meniscal repair device was the Meniscus Arrow (Bionx Implants, Blue Bell, PA) which consists of a rigid degradable poly-lactic acrid arrow and was initially introduced in 1993 and past 1998 had 34.iv% of the Usa marketplace share [28]. In an early report, Gill et al. [29] had first-class results in their series of 32 patients undergoing meniscal repair with just iii patients (9.4%) requiring further meniscal surgery. Still, in their follow-upwardly study [30], they plant their success rate had deteriorated to 71.4% at 6.6 years with a hateful fourth dimension of recurrence of symptoms of 43 months mail service-repair and attributed information technology to incomplete meniscal healing due to degradation of the fixation device. Arnoczky et al. [31] reviewed the biomechanical forcefulness of rigid absorbable implants and found that devices fabricated from polydioxanone including the Mitek meniscus refixation device and Surgical Dynamics S.D.sorb staple were found to undergo hydrolysis which significantly reduced their failure force at 12 and 24 weeks. Other rigid devices have also been introduced with similar results; however complications including chondral injuries, synovitis, implant migration and four fragmentation, and soft tissue irritation have caused concerns, causing some surgeons to abandon it from their practice.

In an endeavour to avoid the complications associated with rigid devices and to permit more controlled tensioning, suture-based implants have been adult which consist of an anchor component and a sliding knot, which allows compression of the torn meniscal segments together examples of which are shown in Fig.4. The FasT-Prepare (Smith and Nephew Endoscopy, Andover, MA) is 1 such instance consisting of two anchors, connected past a preloaded, pre-tied self-sliding and cocky-locking knot. Kotsovolos et al. [32] published their early results of 36 repairs at eighteen-calendar month follow-up and had meaning improvements in Lysholm scores (43.6–87.5) and had a failure charge per unit of 12%, which was due to stiffness rather than re-tear. In a study with longer follow-upwards, Barber et al. [33] evaluated 41 meniscal repairs at xxx.7-month follow-upwards and had a clinically effective meniscal repair in 83% of patients. Repeat arthroscopies were performed in 12 repairs; however, failures were merely plant in 7 (17%). The most mutual adverse event encountered was toggling and pullout of the anchors during the insertion process. In one of the few studies which evaluated the repair with a second-look arthroscopy, Tachibana et al. [34] establish a clinical success rate of 83% in their series of 46 patients undergoing 65 meniscal repairs at 14 months. During arthroscopy 11 had failed and 9 had incompletely healed. In that location were six complications for improper deployment which needed repeat procedures.

Examples of all-inside suture repair devices

Barber and Herbert [35] evaluated the mechanical fixation of various meniscal devices. They found that suture-based devices had a greater pullout forcefulness than rigid devices, and others have found they approach the strength of current suture techniques. These data are summarized in Table4.

Table iv

Summary of outcomes of all-inside meniscal repairs

Authors	No. of patients	Mean age (years)	Hateful FU	ACL	Zone	MM/LM	Time from injury to repair	Implant	Evaluation method	Consequence
Jones [28]	38	29.ix	29.seven months	22 ACLR	R–R 77% R–Westward xix.four% Due west–W two.8%	33 MM 6 LM	5.9 months	Meniscus Arrow	Phone questionnaire	2 fractional meniscectomy 31.6% local irritative symptoms two removal of fragments
Gill [29]	32		2.3 years				sixteen astute < 6 weeks 23 chronic > 6 weeks	Meniscus Arrow	Clinical	ix.four% failure rate 3 fractional meniscectomy
Lee [xxx]	32		6.half-dozen years	32 ACLR				Meniscus Arrow		28.half dozen% failure rate
Siebold [53]	95	xxx	half dozen years	63 ACLR	RR R–W	77 MM 18 LM	iii months	Meniscus Arrow	Clinical	28% meniscectomy ACL had no event Lysholm 64 → xc.5
Kurzweil [54]	57	27	54 months	42 ACLR				Meniscus Pointer	2nd await arthroscopy and MRI	28% failure charge per unit
Kotsovolos [32]	58 37 Thou 21 F	32.half dozen	18 months	36 ACLR	RR 36% R–W 64%	34 MM 27 LM	76 days	FasT-Fix	Clinical	9.viii% failure Lysholm 43.vi → 87.5 4 potent knee
Barber [55]	41 25 One thousand 11 F	28	xxx.seven months	29 ACLR	R–R 37% R–W 63%	26 MM fifteen LM	xiii weeks	FasT-Ready	Clinical	Lysholm 47.3 → 87.4 17% meniscectomy
Tachibana [34]	46 20 Grand 26 W	26.5	14 months	46 ACLR	R–R 34 R–W 28	28 MM 34 LM	37 months	FasT-Set up	2nd Wait arthroscopy
Konan [51]	288	32	eighteen months	138 ACLR		171 LM 141 MM		54 Meniscus Arrow 258 FasT-Prepare	Clinical ± MRI if clinical doubt	22.2% failure rate Meniscus Pointer 10.three% failure rate FasT-Fix 3 painful capsular sutures requiring removal

Assessment of repair

One reason for the heterogeneity in reported outcomes is the difficulty in assessing if the repair has healed or not. Commonly used outcome measures include history and clinical exam, imaging ranging from plain radiographs (progression of tibiofemoral osteoarthritis), MR imaging or arthrogram and second-look arthroscopy. Estimations of when complete meniscal healing occurs varies between iii and 6 months [36].

Clinical signs of an unhealed meniscal repair were described by including the presence of swelling, joint line tenderness, locking symptoms, and a positive McMurray exam. Still, the absence of clinical symptoms does not indicate meniscal healing, as upwards to 10% of patients evaluated with a second-look arthroscopy who had incompletely healed menisci were asymptomatic. The most commonly used scoring scale is the Lysholm Scale, and although during its validation process had a group of patients with meniscal pathologies, it was initially intended for multi-ligament injuries. Although Briggs et al. [37] found it to exist acceptable in their evaluation into its reliability and validity, they suggested the Western Ontario Meniscal Evaluation Tool (WOMET) to exist superior.

MRI is the virtually mutual radiological tool used. Although this has excellent sensitivity and specificity (~ ninety%) for primary meniscal tears, some authors discover its role in assessment of meniscal repairs of express value due to the high dissonance–signal ratio, which tin remain every bit high as 5.5 × the normal value even at 12 months post-operatively. Furthermore oedema and scar of the repaired site elicits a high signal and may confuse cess; furthermore it may be present in up to 50% of cases even equally long every bit 12.9 years mail service-operatively [38].

Arthroscopy remains the aureate standard in evaluating meniscal repairs, every bit information technology allows the opportunity to define the length of the healed segment and probe undisplaced segments for stability of repair. Henning [39] defined incomplete healing as the persistence of a cleft at the site of the meniscal tear measuring 10–fifty% of the meniscal thickness. A cleft more than 50% represented an unhealed repair. Second-wait arthroscopy is more often than not limited to assessing and treating failed repairs. Due to its high cost and invasiveness, information technology is rarely used. Miao et al. [40] recently compared clinical assessment, magnetic resonance imaging and 2d-wait arthroscopy and although clinical assessment was probable to under-guess the healing rate (63 confirmed healed cf 77 arthroscopy), they suggested that when combined with MR, may be sufficient to exclude a re-tear.

More recently, at that place has been interest in MR arthrographic cess. Magee et al. [41] plant that 16 patients who underwent meniscal repair, had equivocal findings on MRI, and underwent MR-arthrography which confirmed 10/16 re-tear rate which was confirmed on second-wait arthroscopy.

Rehabilitation regimes

There are various rehabilitation regimes that range from non-weight bearing immobilization to full-weight bearing and full range of motion. The choice of rehabilitation may exist influenced by meniscal tear pattern, location, repair technique and patient's compliance. Early reports of meniscal repairs involving open procedures tended to have a greater caste of brake with patients oftentimes kept in plaster immobilization and not-weight bearing for 4–6 weeks with a gradual increase in range of motion in the subsequent months. In more recent studies surgeons accept been more than ambitious with the rehabilitation and allow partial weight bearing with some degree of motion early. There has been no prove to support any post-operative regime; all the same given the similar failure rates, the senior author advocates early partial weight bearing and early passive range of movement exercises to aid ease of recovery. As previously discussed, meniscal healing tin can accept 4–vi months, so patients should exist advised to avert touch loading, deep articulatio genus flexion or pivoting which may increment the chance of a re-tear.

Augmentation

To farther aid the healing of meniscal repairs, several studies have evaluated various techniques that act to augment the repair. Shelbourne and Heinrich [42] reviewed 332 patients who underwent ACL reconstructions with stable lateral meniscal tears which were either neglected or rasped/trephined and had a low re-operation rate (2.4%) and suggested that the increased blood menses aided healing of the meniscus. Supervised fail of stable medial meniscal tears too led to them remaining asymptomatic if just trephined/rasped during concomitant ACL reconstruction. Assessment of the repaired menisci was not performed and was accounted satisfactory if functional outcomes, radiographs were normal and if farther surgery was avoided.

There have since been further studies which aim to promote healing including applying exogenous fibrin clots, stem cells, rasping and trephination or performing an ACL reconstruction which increases claret flow [43]. Most studies are used as a means to certificate technique rather than objectively assessing outcomes.

Summary of outcomes

Despite there being a contempo increment in the number of published series evaluating meniscal repairs, there is no consensus on the ideal technique. Grant et al. [44] performed a systematic review of 19 studies, to compare the outcomes of all-within and inside-out techniques in isolated medial meniscal tears in the presence of an intact ACL at a mean follow-up of 38.ane months. They plant a not-significant difference in clinical failure rate of 17% for within-out repairs compared with nineteen% for pooled all-within techniques. Although in that location were similar functional scores, there was a significantly higher rate of neurological injury in the within-out repairs. It should be noted that there was a higher complexity rate in the older generation of all-inside repairs which utilized rigid devices compared with the newer suture-based techniques. Nepple et al. [4] noted the increase failure rate from early to long-term, and performed a systematic review on meniscal repair outcomes with a minimum follow-up of 5 years (mean 7.4 years). They found, in their review of 13 studies, that there was a pooled failure rate of 23.1% with no significant difference between the different techniques. At that place was a small non-significant departure in failure rates for medial and lateral meniscal tears (24.2% and 20.2%, respectively). This may be because the medial side is more tightly attached to the tibial plateau and has to transmit college loads; however noted that the studies that found a difference were heterogenous in patient and tear characteristics. As they expected, they found 30% of the failures occurred afterward 2 years. Whilst the trend in increasing failure rates were seen in all techniques, conclusions cannot be firmly drawn on newer suture-based all-inside techniques every bit there have been no long-term studies published yet. Additionally, in all studies there was big heterogeneity including tear pattern, location, patient demographics, and the authors stated that not-significant differences may be due to underpowered studies.

Trends and factors associated with repair

In 2013, Abrams et al. [3] published their review in the trends of knee joint arthroscopic procedures performed between 2005 and 2011 using a national database compiled from a collection of private insurance records. At that place were 387,833 meniscectomies and 23,640 meniscal repairs performed. Whilst at that place was no increase institute in the number of meniscectomies performed, there was a doubling of meniscal repairs performed (p= 0.01) over that time, suggesting that it is only now that meniscal repairs are preferentially performed over meniscectomies. Wyatt et al. [45] reviewed a large cohort (n= 5712) of patients with meniscal tears undergoing ACL reconstruction, and found significant factors which adamant if the meniscus was repaired. These included younger patient age, lower BMI, higher surgical volume, and if the surgeon was sports fellowship trained. Patients aged fourteen–17 had the highest chance of meniscal repair, and for every twelvemonth increase, there was a 4% decreased risk of meniscal repair. In their series, they constitute that the surgeons who had undergone sports fellowships were 33.6% likely to repair a meniscus compared with those who had not gone on a fellowship (19.8%).

Partial meniscectomy versus repair

Although in recent years there has been a trend towards meniscal preservation and repair, at that place is very limited data that directly compare the two procedures, and there are no randomized controlled trials comparing them. Current studies suggest that meniscectomy predisposes patients to early onset degenerative changes and also that patients with a meniscal repair accept a higher functional outcomes. Evaluating long-term outcomes of meniscal repair [26, 39, 40], degenerative changes are seen ranging from 14 to 28% at a pooled follow-upward of 12.5 years; however, it is important to note that patients with failed repairs were ofttimes excluded from further evaluation, and in those patients degenerative changes can be seen in as many as 56–57% of patients [39, 40]. Piffling and Lubowitz [46] performed a systematic review of 5 studies and found a significantly higher rate of degenerative changes in patients undergoing partial meniscectomy (up to 53%) compared with the contralateral uninjured knee; however clinical symptoms of osteoarthritis were not observed at follow-upwards ranging from 8 to 16 years.

Stein et al. [47] evaluated long-term functional outcomes in athletes and found that although at that place was no difference at midterm (three.43 years) follow-up with regard to return to sports, patients undergoing fractional meniscectomy had significantly worse outcomes at long-term follow-upward. They found that but 50% in the partial meniscectomy grouping were able to render to sports compared with 96.xv% in the repair grouping at 8.8-year follow-up. Information technology is important to notation that patients in the partial meniscectomy group were iii years older (34.8 cf 31.5 years) and this may have partly deemed for this difference. Furthermore, despite these gains in functional outcomes, many studies exclude failed repairs from their evaluations. Paxton et al. [48] found in their systematic review of re-operation rates that patients undergoing meniscal repair were much more likely to have further procedures compared with patients undergoing meniscectomy at early and long-term follow-up (1.4% vs. sixteen.5% and 3.nine% vs. xx.7%, respectively). Fortunately, it appears that the amount of meniscectomy is rarely increased when compared to the initial lesion afterwards a failed repair [23].

Whilst at that place is undeniable evidence that the menisci aids in femoral contact area and load distribution the amount of required meniscal tissue is all the same debated. Although Lee et al. [49] found large decreases in contact area and increases in tibiofemoral stresses when the amount of meniscal resection increased from l% to segmental/total, in that location were fiddling changes when the amount of meniscal resection is small (20–30%) [fifty]. Furthermore, as meniscal repair tends to have a much longer rehabilitation menstruation compared with meniscectomy, a failed repair would have cause more disturbance to a sporting season. Patients should therefore exist counseled well-nigh the high re-operation rate.

Conclusions

In summary, the number of meniscal repairs has been increasing in recent years due to the increasing awareness of the importance of meniscal preservation and associated early degenerative changes associated with meniscectomy. Accompanying this, the indications for meniscal repair have now expanded and include patients of any age provided they are active, and may be amenable even if the tear extends to the avascular zone. There is no difference in failure rates for any technique; nonetheless there are currently no long-term published studies on the newer suture-based all-inside devices. Patients should be counseled on the high rate of re-operation. There is very limited bear witness that straight compares meniscectomy to meniscal repair, which may exist due to the variability in tear characteristics, patient factors and rehabilitation regimes.

Compliance with ethical standards

Conflict of involvement

On behalf of the all authors, the corresponding author states that there is no disharmonize of interest.

References

1. Fairbank TJ. Knee joint articulation changes after meniscectomy. J Bone Jt Surg Br. 1948;30B(4):664–670. doi: 10.1302/0301-620X.30B4.664. [PubMed] [CrossRef] [Google Scholar]

2. McDermott ID, Amis AA. The outcome of meniscectomy. J Bone Jt Surg Br. 2006;88-B:1549–1556. doi: 10.1302/0301-620X.88B12.18140. [PubMed] [CrossRef] [Google Scholar]

3. Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and menisectomy in the U.s.a., 2005–2011. Am J Sports Med. 2013;41(10):2333–2339. doi: ten.1177/0363546513495641. [PubMed] [CrossRef] [Google Scholar]

4. Nepple JJ, Dunn WR, Wright RW. Meniscal repair outcomes at greater than five years: a systematic literature review and meta-analysis. J Bone Jt Surg Am. 2012;94(24):2222–2227. doi: x.2106/JBJS.K.01584. [PMC free commodity] [PubMed] [CrossRef] [Google Scholar]

v. Arnoczky SP, Warren RF. Microvasculature of the homo meniscus. Am J Sports Med. 1982;10(2):90–95. doi: 10.1177/036354658201000205. [PubMed] [CrossRef] [Google Scholar]

half-dozen. Day B, Mackenzie WG, Shim SS, Leung G. The vascular and nerve supply of the man meniscus. Arthroscopy. 1985;1(1):58–62. doi: ten.1016/S0749-8063(85)80080-3. [PubMed] [CrossRef] [Google Scholar]

seven. Petersen Westward, Tillmann B. Historic period-related blood and lymph supply of the knee menisci. A cadaver study. Acta Orthop Scand. 1995;66(4):308–312. doi: 10.3109/17453679508995550. [PubMed] [CrossRef] [Google Scholar]

8. Ashraf Southward, Wibberley H, Mapp PI, Hill R, Wilson D, Walsh DA. Increased vascular penetration and nervus growth in the meniscus: a potential source of pain in osteoarthritis. Ann Rheum Dis. 2011;70:523–529. doi: 10.1136/ard.2010.137844. [PubMed] [CrossRef] [Google Scholar]

9. Baker Be, Peckam Air conditioning, Pupparo F, Sanborn JC. Review of meniscal injury and associated sports. Am J Sports Med. 1985;13:1–four. doi: 10.1177/036354658501300101. [PubMed] [CrossRef] [Google Scholar]

10. Terzidis IP, Christodoulou A, Ploumis A, Givissis P, Natsis One thousand, Koimtzis G. Meniscal tear characteristics in young athletes with a stable knee: arthroscopic evaluation. Am J Sports Med. 2006;34(7):1170–1175. doi: x.1177/0363546506287939. [PubMed] [CrossRef] [Google Scholar]

11. Ode GE, Van Thiel GS, McArthur SA, Dishkin-Paset J, Leurgans SE, Shewman EF, Wang VM, Cole BJ. Furnishings of serial sectioning and repair of radial tears in the lateral meniscus. Am J Sports Med. 2012;40(8):1863–1870. doi: 10.1177/0363546512453291. [PubMed] [CrossRef] [Google Scholar]

12. Bedi A, Kelly NH, Baad M, Fox AJ, Brophy RH, Warren RF, Maher SA. Dynamic contact mechanics of the medial meniscus as a part of radial tear, repair and partial meniscectomy. J Os Jt Surg Am. 2010;92(half-dozen):1398–1408. doi: ten.2106/JBJS.I.00539. [PubMed] [CrossRef] [Google Scholar]

xiii. Noble J. Lesions of the menisci. Autopsy incidence in adults less than fifty-five years old. J Bone Jt Surg Am. 1997;59:480–483. doi: 10.2106/00004623-197759040-00008. [PubMed] [CrossRef] [Google Scholar]

14. Biedert RM. Treatment of intrasubstance meniscal lesions: a randomized prospective study of four different methods. Knee Surg Sports Traumatol Arthrosc. 2000;viii:104–108. doi: x.1007/s001670050195. [PubMed] [CrossRef] [Google Scholar]

fifteen. Pujol Northward, Bohu Y, Boisrenoult P, Macdes A, Beaufils P. Clinical outcomes of open up meniscal repair of horizontal meniscal tears in young patients. Human knee Surg Sports Traumatol Arthrosc. 2013;21(1530):1533. [PubMed] [Google Scholar]

16. Rubman MH, Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears that extend into the avascular zone. A review of 198 single and complex tears. Am J Sports Med. 1998;26(1):87–95. doi: ten.1177/03635465980260013301. [PubMed] [CrossRef] [Google Scholar]

17. Gallacher PD, Gilbert RE, Kanes Thou, Roberts SNJ, Rees D. White on white meniscal tears to fix or not to fix? Knee. 2010;17(4):270–273. doi: x.1016/j.knee.2010.02.016. [PubMed] [CrossRef] [Google Scholar]

18. Noyes FR, Chen RC, Barber-Westin SD, Potter HG. Greater than 10-twelvemonth results of cherry-white longitudinal meniscal repairs in patients 20 years of historic period or younger. Am J Sports Med. 2011;39:1008–1017. doi: ten.1177/0363546510392014. [PubMed] [CrossRef] [Google Scholar]

xix. Mesiha M, Zurakowski D, Soriano J, Nielson JH, Zarins B, Murray MM. Pathologic characteristics of the torn human being meniscus. Am J Sports Med. 2007;35(ane):103–112. doi: ten.1177/0363546506293700. [PubMed] [CrossRef] [Google Scholar]

xx. Barrett GR, Field MH, Treacy SH, Ruff CG. Clinical results of meniscus repair in patients xl years and older. Arthroscopy. 1998;14(8):824–829. doi: 10.1016/S0749-8063(98)70018-0. [PubMed] [CrossRef] [Google Scholar]

21. Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscus tears extending into the avascular zone with or without anterior cruciate ligament reconstruction in patients 40 years of age and older. Arthroscopy. 2000;sixteen(viii):822–829. doi: 10.1053/jars.2000.19434. [PubMed] [CrossRef] [Google Scholar]

22. Nishida M, Higuchi H, Kobayashi Y, Takagishi M. Histological and biochemical changes of experimental meniscus tear in the dog knee. J Orthop Sci. 2005;ten(four):406–413. doi: 10.1007/s00776-005-0916-half-dozen. [PubMed] [CrossRef] [Google Scholar]

23. Pujol N, Barbier O, Boisrenoult P, Beaufils P. Corporeality of meniscal resection after failed meniscal repair. Am J Sports Med. 2011;39(viii):1648–1652. doi: x.1177/0363546511402661. [PubMed] [CrossRef] [Google Scholar]

24. Morgan CD, Em Wojtys, Casscells CD, Casscells SW. Arthroscopic meniscal repair evaluated by second-look arthroscopy. Am J Sports Med. 1991;19(6):632–637. doi: ten.1177/036354659101900614. [PubMed] [CrossRef] [Google Scholar]

25. Wasserstein D, Dwyer T, Gandhi R, Austin PC, Mohomed N, Ogilvie-Harris D. A matched-cohort population written report of reoperation subsequently meniscal repair with and without concomitant anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(2):349–355. doi: 10.1177/0363546512471134. [PubMed] [CrossRef] [Google Scholar]

26. Ikeuchi H (1975) Surgery under arthroscopic control. In: Proceedings of the Societe Internationale d'Arthrscopie. Rheumatology XX:57–62

27. Rockborn P, Gillquist J. Results of open meniscus repair. Long-term follow-up written report with a matched uninjured control group. J Bone Jt Surg Br. 2000;82-B:494–498. doi: ten.1302/0301-620X.82B4.0820494. [PubMed] [CrossRef] [Google Scholar]

28. Jones HP, Lemos MJ, Wilk RM, Smiley PM, Gutierrez R, Schepsis AA. Two-twelvemonth follow-upwards of meniscal repair using a bioabsorbable arrow. Arthroscopy. 2002;xviii:64–69. doi: 10.1053/jars.2002.25343. [PubMed] [CrossRef] [Google Scholar]

29. Gill SS, Diduch DR. Outcomes later meniscal repair using the meniscus pointer in knees undergoing concurrent anterior cruciate ligament reconstruction. Arthroscopy. 2002;xviii(6):569–577. doi: x.1053/jars.2002.29897. [PubMed] [CrossRef] [Google Scholar]

thirty. Lee GP, Diduch DR. Deteriorating outcomes after meniscal repair using the meniscus pointer in knees undergoing concurrent inductive cruciate ligament reconstruction: increased failure rate with long-term follow-up. Am J Sports Med. 2005;33(8):1138–1141. doi: 10.1177/0363546505275348. [PubMed] [CrossRef] [Google Scholar]

31. Arnoczky SP, Lavagnino Yard. Tensile fixation strengths of absorbale meniscal repair devices as a function of hydrolysis time. An in vitro experimental study. Am J Sports Med. 2001;29(2):118–123. doi: 10.1177/03635465010290020201. [PubMed] [CrossRef] [Google Scholar]

32. Kotsovolos ES, Hantes ME, Mastrokalos DS, Lorbach O, Paessler HH. Results of all-inside meniscal repair with the FasT-Prepare meniscal repair system. Arthrscopy. 2006;22(one):three–nine. doi: 10.1016/j.arthro.2005.ten.017. [PubMed] [CrossRef] [Google Scholar]

33. Barber FA, Schroeder FA, Oro FB, Beavis RC. FasT-Ready meniscal repair: mid-term results. Arthroscopy. 2008;24(12):1342–1348. doi: 10.1016/j.arthro.2008.08.001. [PubMed] [CrossRef] [Google Scholar]

34. Tachibana Y, Sakaguchi Yard, Goto T, Oda H, Yamazaki K, Lida S. Repair integrity evaluated by second-look arthroscopy afterwards arthroscopic meniscal repair with the FasT-Fix during anterior cruciate ligament reconstruction. Am J Sports Med. 2010;38:965–971. doi: 10.1177/0363546509356977. [PubMed] [CrossRef] [Google Scholar]

35. Barber FA, Herbert MA. Meniscal repair devices. Arthroscopy. 2000;16(6):613–618. doi: x.1053/jars.2000.4819. [PubMed] [CrossRef] [Google Scholar]

36. Henning CE, Clark JR, Lynch MA, Stallbaumer R, Yearout KM, Vequist SW. Arthroscopic meniscus repair with a posterior incision. Instr Course Lect. 1988;37:209–221. [PubMed] [Google Scholar]

37. Briggs KK, Kocher MS, Rodkey WG, Steadman JR. Reliability, validity, and responsiveness of the Lysholm knee score and Tegner activity scale for patients with meniscal injury of the Knee. J Bone Jt Surg Am. 2006;88(4):698–705. [PubMed] [Google Scholar]

38. Muellner T, Egkher A, Nikolic A, Funovics M, Metz V. Open up meniscal repair: clinical and magnetic resonance imaging findings after twelve years. Am J Sports Med. 1999;27(one):16–xx. doi: 10.1177/03635465990270011001. [PubMed] [CrossRef] [Google Scholar]

39. Henning CE. Arthroscopic repair of meniscus tears. Orthopedics. 1983;half dozen:1130–1132. doi: ten.3928/0147-7447-19830901-08. [PubMed] [CrossRef] [Google Scholar]

forty. Miao Y, Yu JK, Ao YF, Zheng ZZ, Gong X, Leung KK. Diagnostic values of 3 methods for evaluating meniscal healing condition subsequently meniscal repair: comparison amid second-look arthroscopy, clinical assessment, and magnetic resonance imaging. Am J Sports Med. 2011;39(4):735–742. doi: 10.1177/0363546510388930. [PubMed] [CrossRef] [Google Scholar]

41. Magee T, Shapiro M, Rodriguez J, Williams D. MR arthrography of postoperative knee: For which patients is it useful? Radiology. 2003;229(one):159–163. doi: x.1148/radiol.2291020988. [PubMed] [CrossRef] [Google Scholar]

42. Shelbourne KD, Heinrich J. The long-term evaluation of lateral meniscus tears left in situ at the time of inductive cruciate ligament reconstruction. Arthroscopy. 2004;20(4):346–351. doi: ten.1016/j.arthro.2004.01.029. [PubMed] [CrossRef] [Google Scholar]

43. Shelbourne KD, Heinrich J. The long-term evaluation of lateral meniscus tears left in situ at the time of inductive cruciate ligament reconstruction. Arthroscopy. 2004;20:346–351. doi: x.1016/j.arthro.2004.01.029. [PubMed] [CrossRef] [Google Scholar]

44. Grant JA, Wilde J, Miller BS, Bedi A. Comparison of inside-out and all-inside techniques for the repair of isolated meniscal tears: a systematic review. Am J Sports Med. 2010;40(2):459–468. doi: ten.1177/0363546511411701. [PubMed] [CrossRef] [Google Scholar]

45. Wyatt RW, Inacio MC, Liddle KD, Maletis GB. Factors associated with meniscus repair in patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:2766–2771. doi: 10.1177/0363546513503287. [PubMed] [CrossRef] [Google Scholar]

46. Trivial CA, Lubowitz JH. Does arthroscopic partial meniscectomy result in articulatio genus osteoarthritis? A systematic review with a minimum of viii years follow-up. Arthroscopy. 2011;27(three):419–424. doi: ten.1016/j.arthro.2010.08.016. [PubMed] [CrossRef] [Google Scholar]

47. Stein T, Mehling AP, Welsch F, von Eisenhart-Rothe R, Jager A. Long-term issue later arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med. 2010;38(8):1542–1548. doi: ten.1177/0363546510364052. [PubMed] [CrossRef] [Google Scholar]

48. Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy. 2011;27(9):1275–1288. doi: 10.1016/j.arthro.2011.03.088. [PubMed] [CrossRef] [Google Scholar]

49. Lee SJ, Aadalen KJ, Malaviya P, Lorenz EP, Hayden JK, Farr J, Kang RW, Cole BJ. Tibiofemoral contact mechanics later series medial menisectomies in the homo cadaveric knee. Am J Sports Med. 2006;34(8):1334–1344. doi: 10.1177/0363546506286786. [PubMed] [CrossRef] [Google Scholar]

50. Vadher SP, Nayeb-Hashemi H, Canavan PK, Warner GM. Finite element modelling post-obit meniscectomy: effect of various size of resection. Conf Proc IEEE Eng Med Biol Soc. 2006;1:2098–2101. doi: ten.1109/IEMBS.2006.259378. [PubMed] [CrossRef] [Google Scholar]

51. Konan Due south, Haddad FS. Outcomes of meniscal preservation using all-inside meniscus repair devices. Clin Orthop Relat Res. 2010;468:1209–1213. doi: 10.1007/s11999-009-1184-0. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

52. DeHaven KE, Lohrer WA, Lovelock JE. Long-term results of open meniscal repair. Am J Sports Med. 2016;23:524–530. doi: 10.1177/036354659502300502. [PubMed] [CrossRef] [Google Scholar]

53. Siebold R, Dehler C, Boes L, Ellermann A. Arthroscopic all-within repair using the meniscus arrow: long-term clinical follow-up of 113 patients. Arthroscopy: J Arthroscopic & Relat Surg. 2007;23:394–399. doi: 10.1016/j.arthro.2006.11.027. [PubMed] [CrossRef] [Google Scholar]

54. Kurzweil PR, Tifford CD, Ignacio EM. Unsatisfactory clinical results of meniscal repair using the meniscus arrow. Arthroscopy: J Arthroscopic & Relat Surg. 2005;21:905.e1–905.e7. doi: 10.1016/j.arthro.2005.06.002. [PubMed] [CrossRef] [Google Scholar]

55. Barber FA, Johnson DH, Halbrecht JL. Arthroscopic meniscal repair using the bioStinger. Arthroscopy: J Arthroscopic & Relat Surg. 2005;21:744–750. doi: ten.1016/j.arthro.2005.03.002. [PubMed] [CrossRef] [Google Scholar]

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6423358/

Posted by: kennywity1942.blogspot.com

Share this post