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

PURPOSE: All-inside meniscal repair devices have evolved to allow surgeons to undertake complex repairs in a timely and efficient manner. This is advantageous in active patients, where meniscus preservation is critical in preserving joint function and stability. The aim of the study was to evaluate the failure rate of all-inside meniscal repair performed in patients undergoing reconstructive ligament surgery using a particular meniscal repair device. METHODS: Patients were identified using a single-site prospectively maintained patient registry. Primary outcome was failure, defined as return to surgery with documented failure of repair. Complication rates and functional scores were also recorded. Patients in whom meniscal repair failure was identified were further assessed, to identify any common features. RESULTS: Over an 8-year period, 323 patients underwent meniscal repair at the time of ligament reconstruction, compared to 244 meniscectomies. Of these, 286 patients underwent repair using an all-inside suture device. One-hundred and twenty-seven repairs were to the medial meniscus only, 124 were lateral, and in 35 patients both menisci were repaired. Follow-up was to a median of 51.5 months. There were 31 (9.7%) failures reported at a median of 22 months post-operatively (IQR 13.5-41.5). Medial repair failures were seen more frequently than lateral (13.6% versus 5.6% OR 2.62 95% CI 1.17-5.88 p = 0.022). Failure of ACL reconstruction was associated with meniscal repair failure (OR 5.83 95% CI 1.55-21.95 p = 0.0039). Multi-ligament reconstruction was undertaken in 70/286 patients receiving meniscal repair and was not associated with failure (OR 1.3 95% CI 0.57-2.98 p = 0.51). Mode number of all-inside sutures used was 3 in both medial and lateral repairs (Range 1-9 lateral; 1-7 medial). CONCLUSIONS: All-inside repair is a safe and versatile technique which can be used in the majority of meniscal tears encountered during ligament reconstruction with excellent mid-term success. Failure is seen more commonly in medial sided repairs and with failure of ACL reconstruction. LEVEL OF EVIDENCE: IV.

Paediatric physeal sparing posterior cruciate ligament (PCL) reconstruction with parental donation allograft: Rationale and operative approach.

BACKGROUND: Paediatric PCL injuries are rare but constitute a significant management challenge. We describe a novel approach to the surgical management of an 11-year-old boy who presented with persisting symptomatic instability following 18months of failed conservative therapy. METHODS: PCL reconstruction was performed using a physeal sparing, all-inside technique under fluoroscopic control. This avoids the potential for iatrogenic growth injury. A parentally donated hamstrings allograft was used to ensure adequate graft size, and reinforced using a non-elastic two millimetre braided suture. Graft reinforcement safeguards against stretching during the early healing phase, but must be removed thereafter to avoid creating a physeal tether. RESULTS: At three months, clinical examination under anaesthesia showed equivalent PCL laxity in the operated knee compared to the normal contralateral knee. The graft reinforcement tape was incised as planned with no change in laxity assessment. Arthroscopic evaluation demonstrated a quiet joint with a well healed graft and no synovitis. Postoperative long leg radiographs showed no growth deformity against preoperative status. CONCLUSION: In paediatric patients with persisting symptomatic instability despite appropriate conservative management, surgical reconstruction of the PCL should be considered. Standard treatment has higher complication rates and poorer graft survival than in an adult cohort. Specific problems include iatrogenic growth plate injury causing growth arrest or angular deformity, inadequate graft size if using hamstrings autograft, and the additional technical challenge of small patient size. Early results from extra-physeal, all-inside PCL reconstruction using a parentally donated allograft are promising and may provide an alternative solution to traditional surgical management.