In elite athletes with meniscal injuries, always repair the lateral, think about the medial! A systematic review.

PURPOSE: This study aimed to evaluate and compare the time required to return to sports (RTS) after surgery, the rate of revision surgery and the time required for RTS after revision surgery in elite athletes undergoing meniscal repair or partial meniscectomy, particularly analysing the difference between medial and lateral menisci. It was hypothesised that both procedures would entail similar, high rates of RTS, with the lateral meniscus exhibiting higher potential healing postprocedure compared to the medial meniscus. METHODS: A systematic review was conducted based on the PRISMA guidelines. Quality assessment of the systematic review was performed using the AMSTAR-2 checklist. The following search terms were browsed in the title, abstract and keyword fields: 'meniscus' or 'meniscal' AND 'tear,' 'injury' or 'lesion' AND 'professional,' 'elite' or 'high-level' AND 'athletes,' 'sports,' 'sportsman,' 'soccer,' 'basketball,' 'football' or 'handball'. The resulting measures extracted from the studies were the rate of RTS, level of RTS, complications, revision surgery and subsequent RTS, Tegner, International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS). RESULTS: In this study, the cohort consisted of 421 patients [415 (98.6%) men and 6 (1.4%) women] with a mean age of 23.0 ± 3.0 years. All patients were elite athletes in wrestling, baseball, soccer, rugby or handball. While 327 (77.7%) patients received partial meniscectomy at a mean age of 23.3 ± 2.6 years, 94 (22.3%) patients received meniscal repair at a mean age of 22.1 ± 4.0 years. After partial meniscectomy, 277 patients (84.7%) returned to their competitive sports activity and 256 (78.3%) returned to their pre-injury activity levels. A total of 12 (3.7%) patients required revision surgery because of persistent pain [5 (1.5%) patients], chondrolysis [2 (0.7%) patients] or both chondrolysis and lateral instability [5 (1.5%) patients]. Ten (83.3%) of the twelve patients had involvement of the lateral meniscus, whereas the location of injury was not specified in the remaining two patients. After revision surgery, all patients (100%) resumed sports activity. However, after meniscal repair, 80 (85.1%) athletes returned to their competitive sports activity and 71 (75.5%) returned to their pre-injury activity levels. A total of 16 (17.0%) patients required partial meniscectomy in cases of persistent pain or suture failure. Of these, 4 (25%) patients involved lateral and medial menisci each and 8 (50%) patients were not specified. After revision surgery, more than 80.0% of the patients (13) resumed sports activity. CONCLUSIONS: In elite athletes with isolated meniscal injury, partial meniscectomy and meniscal suture exhibited similar rates of RTS and return to pre-injury levels. Nonetheless, athletes required more time for RTS after meniscal repair and exhibited an increased rate of revision surgery associated with a reduced rate of RTS after the subsequent surgery. For lateral meniscus tears, meniscectomy was associated with a high rate of revision surgery and risk of chondrolysis, whereas partial medial meniscectomy allowed for rapid RTS but with the potential risk of developing knee osteoarthritis over the years. The findings of this systematic review suggested a suture on the lateral meniscus in elite athletes because of the high healing potential after the procedure, the reduced risk of developing chondrolysis and the high risk of revision surgery after partial meniscectomy. Furthermore, it is important to evaluate several factors while dealing with the medial meniscus. If rapid RTS activity is needed, a hyperselective meniscectomy is recommended; otherwise, a meniscal suture is recommended to avoid accelerated osteoarthritis. LEVEL OF EVIDENCE: Level IV. STUDY REGISTRATION: PROSPERO-CRD42022351979 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=351979 ).

All-inside repair of meniscal bucket handle tears: a retrospective study at mean 4-years follow-up evaluation.

Bucket-handle tears represent approximately 10% of all meniscal tears. Despite the common treatment is subtotal meniscectomy, repair is technically feasible although complex, and represents a key strategy to avoid severe meniscal tissue loss that could accelerate joint degeneration over time. The aim of this retrospective study was to determine the outcomes of arthroscopically-assisted bucket-handle tear repair, and to identify factors correlating with clinical results. Fifty-four patients affected by meniscal bucket handle tear were included in the present retrospective analysis and evaluated up to mean 4-years follow-up. All patients were treated by arthroscopic-assisted all-inside repair. The primary outcome was considered the need for a re-operation due to failure of meniscal repair. Patients were also evaluated by the following items: KOOS, Lysholm, Tegner, IKDC-subjective and Quadruple-VAS score. Subgroup analysis was performed to identify whether concurrent ACL reconstruction, side of the lesion, age at surgery and time from injury to repair could influence clinical outcome. Ten out 54 patients (18.5%) were considered failed and needed reoperation, mainly within one year from surgery. Overall, there was a significant increase in all clinical scores considered and patients were able to get back to previous sport activity level. Patients with concurrent ACL reconstruction presented a lower risk of failure (p=0.025). Patients with lateral meniscus repair showed better clinical outcome compared to medial meniscus. Timing from injury and age at surgery did not correlated with clinical outcome. Our series showed fair results in bucket handle repair up to middle term evaluation. Concomitant ACL reconstruction was associated with lower failure rate whereas lateral meniscus involvement was associated with higher functional scores at final follow-up evaluation.

The all-inside meniscal repair technique has less risk of injury to the lateral geniculate artery than the inside-out repair technique when suturing the lateral meniscus.

PURPOSE: To evaluate the risk of injury to the inferior lateral geniculate artery with two different techniques for lateral meniscus repair. METHODS: Eight cadaveric knees were used. Inside-out sutures and an all-inside suture device were placed at the most lateral edge of the popliteal hiatus, and 15 and 30 mm anterior to this point. The minimum distances between the sutures and the inferior lateral geniculate artery were measured through a limited lateral arthrotomy. Artery penetration or collapse due to the sutures was also evaluated. RESULTS: The median distance between the sutures and the artery when inserted at the lateral edge of the popliteal hiatus was 1.5 mm (interquartile range: 1.3) for the inside-out technique and 1.5 mm (1.3) for the all-inside technique (differences not significant, n.s.). When the sutures were inserted 15 mm anterior to the popliteal hiatus the distances were 1.0 mm (1.1) and 1.3 mm (1.0) for the inside-out technique and the all-inside technique, respectively (n.s.). When the sutures were inserted 30 mm anterior to the popliteal hiatus the distances were 1.0 mm (1.0) and 1.5 mm (1.0) for the inside-out technique and the all-inside technique, respectively (n.s.). The artery was punctured with two of the inside-out sutures placed 15 mm from the popliteal hiatus, no puncturing occurred in the all-inside technique (n.s.). Tying of the inside-out sutures resulted in obliteration of the artery in four of eight sutures placed at 15 mm from the popliteal hiatus and three of eight sutures at 30 mm; no obliteration of the artery was found using the all-inside device (significant differences, p = 0.002). CONCLUSIONS: Although both all-inside and inside-out lateral meniscal repair techniques place sutures very close to the lateral geniculate artery, the inside-out technique is riskier as extra-articular knot tying can cause artery obliteration when suturing the part of the meniscus immediately lateral to the popliteal hiatus. Therefore, all-inside meniscal repair technique shows less risk of injury to the major blood supply of the lateral meniscus.

Three single loops enhance the biomechanical behavior of the transtibial pull-out technique for posterior meniscal root repair.

PURPOSE: To investigate the effect of applying an additional suture to enhance the biomechanical behavior of the suture-meniscus construct used during the transtibial pull-out repair technique. METHODS: A total of 20 fresh-frozen porcine tibiae with intact medial menisci were used. In one half of all specimens (N = 10), two non-absorbable sutures were passed directly over the meniscal root from the tibia side of the meniscus to the femoral side (2SS). In other ten specimens, three sutures were passed over the meniscal root (3SS). All specimens were subjected to cyclic loading followed by load-to-failure testing. Displacement of the construct was recorded at 100, 500, and 1000 cycles. Further, stiffness (500-1000 cycles) and ultimate load and modes of failure of the suture-meniscus construct were also recorded. RESULTS: There was no statistically significant difference between the Group 2SS and Group 3SS at the 1st (1.6 ± 0.7 vs 1.4 ± 0.4 mm) and the 100th cycle (2 ± 0.7 vs 1.8 ± 0.4 mm). At 500 and 1000 cycles, the 2SS fixation technique resulted in significantly more displacement than the 3SS fixation technique (2.8 ± 0.6 vs 2.3 ± 0.5 mm; 3.1 ± 0.7 vs 2.5 ± 0.5 mm) (p < 0.05). No differences between two groups were noted concerning ultimate load to failure and stiffness (500-1000 cycles). CONCLUSION: Three single sutures technique provided superior biomechanical properties compared with the two single sutures technique during the conducted fatigue tests. CLINICAL RELEVANCE: Applying three simple stitches during meniscal root repair might be beneficial for healing of the posterior meniscal root, potentially reducing the post-operative immobilization time.

Clinical outcome of iterative meniscal suture after ACL reconstruction at a minimum of 2 years' follow-up.

INTRODUCTION: Failure rates in meniscal suture associated to ACL reconstruction range from 10 to 26.9%, often leading to meniscectomy. In young patients, the wish to conserve the meniscus may lead to iterative suture, if the lesion allows. There are no data available for clinical results of repeat meniscal suture at the same site as the primary lesion in a stabilized knee. The immediate socioeconomic cost, compared to meniscectomy, needs to be taken into account, and benefit needs to be demonstrated. The main aim of the present study was to assess the rate of secondary meniscectomy after iterative meniscal suture in stabilized knees. The study hypothesis was that failure rates are higher in iterative isolated meniscal suture after ligament reconstruction than in primary repair. MATERIAL AND METHODS: This single-center retrospective study analyzed patients receiving iterative meniscal suture on stable knee, between 2009 and 2019, with a minimum 26 months' follow-up. Twenty-three patients were analyzed: 15 male, 8 female; mean age at iterative suture, 28.1±7.9 years (range, 14-49 years); mean BMI, 24.2±2.9kg/m2 (range, 19-31). Mean time to recurrence was 38.9±25.1 months (range, 6-93 months). Initial ACL graft used the patellar ligament in 69.6% of cases (n=16) and the hamstrings in 30.4% (n=7). Mean differential laximetry before iterative suture was 1.7±0.3mm (range, 1.2-2.3mm). Iterative suture was in the medial meniscus in 69.6% of cases (16/23) and in the lateral meniscus in 30.4% (7/23). Risk factors for failure, defined by requirement for meniscectomy, were assessed. Functional results were assessed on Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Tegner score. RESULTS: The failure rate was 48% (11/23), incorporating all lesions together. Bucket-handle tear was most frequently associated with failure (91%; p<0.01). There was significant improvement after iterative suture in subjective IKDC score (51.6±15.2 vs. 81.3±15.6; p<0.001) and KOOS scores: symptoms and stiffness, 66.6±13.7 vs. 91.1±7.53 (p<0.001); pain, 79.2±12.7 vs. 93.4±7.4 (p<0.01); function, 91.3±11.2 vs. 97.9±4.44 (p<0.001); quality of life, 38.1±23.2 vs. 62.3±30.1 (p<0.001). CONCLUSION: The failure rate for iterative meniscal suture on stabilized knee was 48%. Bucket-handle tear was a major risk factor for failure (91%). Despite these high failure rates, functional results systematically improved. LEVEL OF EVIDENCE: IV.

Animal models used in meniscal repair research from ex vivo to in vivo: A systematic review.

This systematic review, registered with Prospero, aims to identify an optimal animal model for meniscus repair research, moving from ex vivo experimentation to in vivo studies. Data sources included PubMed, Medline, all Evidence-Based Medicine Reviews, Web of Science, and Embase searched in March 2023. Studies were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data including animal model, type of experiment, type of tear, surgical techniques, and measured outcomes, were recorded, reviewed, and analyzed by four independent reviewers. The SYstematic Review Centre for Laboratory animal Experimentation (SYRCLE) Rob tool was used for critical appraisal and risk of bias assessment. Out of 11,719 studies, 72 manuscripts were included for data extraction and analysis; 41 ex vivo extra-articular studies, 20 ex vivo intra-articular studies, and only 11 in vivo studies. Six animal models were employed: porcine, bovine, lapine, caprine, canine, and ovine. Longitudinal lesions were the most frequently studied tear pattern and sutures the most common repair technique. Studied outcomes focused mainly on biomechanical assessments and gross observations. This systematic review can guide researchers in their choice of animal model for meniscus repair research; it highlighted the strengths of the porcine, caprine, and bovine models for ex vivo cadaveric studies, while the porcine and caprine models were found to be more suited to in vivo studies due to their similarities with human anatomy. Research teams should familiarize themselves with the advantages and disadvantages of various animal models before initiating protocols to improve standardization in the field.

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.

BACKGROUND: The importance of meniscal repair is widely accepted because of the association of loss of meniscal tissue with the development of early-onset knee arthritis. Many factors influencing the results of meniscal repair have been reported, but results remain controversial. PURPOSE: This meta-analysis determines the pooled meniscal repair failure rate of studies with a minimum follow-up of 2 years up to 5 years, with a mean follow-up of 43 months. Moreover, selected failure-influencing factors are analyzed. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed and Scopus were searched for studies published between January 2000 and November 2021 reporting on meniscal repair outcome with a minimum follow-up of 24 months. The overall pooled failure rate and pooled failure rates for possible predictors were calculated. Random-effect models were used to pool failure rates, and effect estimates in the form of odds ratios with 95% CIs were established. RESULTS: The initial literature search identified 6519 studies. A total of 51 studies met the inclusion criteria. In total, 3931 menisci were included with an overall failure rate of 14.8%. Subgroup analysis revealed a significantly lower failure rate for meniscal repair with concomitant anterior cruciate ligament (ACL) reconstruction compared with knees without any reported injury to the ACL (8.5% vs 14%; P = .043). The pooled failure rate for lateral meniscal repair was significantly lower than that for medial meniscal repair (6.1% vs 10.8%; P = .031). Pooled failure rates of all-inside and inside-out repair were not significantly different (11.9% vs 10.6%; P > .05). CONCLUSION: This meta-analysis on close to 4000 patients demonstrates an overall meniscal repair failure rate of 14.8% at a minimum follow-up from 2 years up to 5 years. Meniscal repair remains a procedure with a high failure rate, especially within the first 2 postoperative years. This review and meta-analysis also identified clinically relevant factors associated with favorable outcomes such as concomitant ACL reconstruction or repair of the lateral meniscus. All-inside meniscal repair with the latest-generation devices yields failure rates of <10%. The failure mechanism and the time of failure is poorly documented; further studies are needed for a better understanding of the retear mechanism.

All-Inside Arthroscopic Meniscus Repair for Patients Over 40 Years of Age: Is Forty the New Twenty?

INTRODUCTION: Meniscal injuries are a common challenge in orthopedic surgery. For decades, partial or total meniscectomy has been the primary surgical treatment for meniscal tears. In recent years, the increased recognition of menisci's biomechanical importance has progressively shifted the paradigm towards meniscus repair. However, meniscus-sparing surgery remains the treatment of choice for selected lesions in young and active patients, especially for young and active patients. In this study, we evaluated the effectiveness of all-inside sutures in treating meniscus tears in patients over 40. METHODS: In our retrospective evaluation, we evaluated the clinical and functional outcomes of cases over 40 years of age with post-traumatic acute meniscus tears that received meniscus repairs using the all-inside technique. The pre-operative and post-operative functionality of treated patients were assessed using the knee injury and osteoarthritis outcome score (KOOS) score. Major complications were recorded. RESULTS: Twenty-three cases met our inclusion criteria. Eight females and fifteen males with a mean age of 44.9 were included in our study. Their mean follow-up was 35.1 months. Before surgery, our patients' mean KOOS score was 55.4 (18-80). At the patients' latest follow-up, the value had risen to 87.4 (63-100). There was no statistical correlation between patients' age and their functional recovery. No surgical failure was recorded at the latest follow-up. CONCLUSION: The all-inside suture technique can represent a suitable and reliable solution for suturable meniscal tears, even for patients over 40. Preserving the meniscus and restoring patients' functionality allows patients to return to their daily activities and promote their quality of life.

Tough gel adhesive is an effective method for meniscal repair in a bovine cadaveric study.

PURPOSE: To test tough gel adhesives to repair meniscus tears under relevant loading conditions and determine if they have adequate biomechanical properties to repair meniscus tears in a bovine cadaveric study. METHODS: Cyclic compression tests on 24 dissected bovine knees were performed. The tough gel adhesive was used either as an adhesive patch or as a coating bonded onto commercially available surgical sutures. Forty-eight menisci were tested in this study; 24 complete radial tears and 24 bucket-handle tears. After preconditioning, the specimens underwent 100 cycles of compression, (800 N/0.5 Hz) on an Instron© machine and the size of the gaps measured. One third of the menisci were repaired with pristine sutures, one third with adhesive patches, and one third with sutures coated in adhesive gel. The size of the gaps was compared after 100 and 500 cycles of compression. RESULTS: The mean gap measured at the tear site without treatment was 6.46 mm (± 1.41 mm) for radial tears and 1.92 mm (± 0.65 mm) for bucket-handle tears. After treatment and 500 cycles of compression, the mean gap was 1.63 mm (± 1.41 mm) for pristine sutures, 1.50 mm (± 1.16 mm) for adhesive sutures and 2.06 mm (± 1.53 mm) for adhesive gel patches. There was no significant difference between treatments regardless of the type of tear. Also, the gaps for radial tears increased significantly with the number of compression cycles applied (p > 0.001). CONCLUSION: From a biomechanical standpoint, the tough adhesive gel patch is as effective as suturing. In addition, it would allow the repair of non-suturable tears and thus broaden the indications for meniscus repair. LEVEL OF EVIDENCE: Controlled laboratory study.

Failure rate, return-to-sports and magnetic resonance imaging after meniscal repair: 119 patients with 7 years mean follow up.

BACKGROUND: One of the most important factors to consider in relation to meniscal repair is the high failure rate reported in the existing literature. AIM: To evaluate failure rates, return to sports (RTS) rate, clinical outcomes and magnetic resonance image (MRI) evaluation after meniscus suture repair for longitudinal tears at a minimum 2-year-follow-up. METHODS: We conducted a retrospective review of meniscal repairs between January 2004 and December 2018. All patients treated for longitudinal tears associated or not with an anterior cruciate ligament reconstruction (ACL-R) were included. Meniscal ramp lesions, radial and root tears, associated with multiligament injuries, tibial fracture and meniscal allograft transplants were excluded. Surgical details and failure rate, defined as symptomatic patients who underwent a revision surgery, were analyzed. As isolated bucket handle tears (BHTs) were usually associated with higher failure rates, we compared BHTs and not BHTs associated or not with an ACL-R. Since 2014, the inside-out technique using cannulas and suture needles with 2-0 Tycron began to predominate. In addition, the number of stitches per repair was increased. In view of differences in surgical technique, we compared two different cohorts: before and after 2014. We recorded the RTS according to the level achieved and the time to RTS. Lysholm and IKDC scores were recorded. Patients were studied with x-rays and MRI as standard postoperative control. RESULTS: One hundred and nineteen patients were included with a mean follow up of 7 years (SD: 4.08). Overall failure rate was 20.3% at a mean 20.1 mo. No statistically significant differences were found when comparing failure for medial and lateral meniscal repair (22.7% and 15.3%, P = 0.36), BHTs and not BHTs (26% and 17.6%, P = 0.27), isolated or associated with an ACL-R (22.9% and 18%, P = 0.47), or when comparing only BHTs associated with an ACL-R (23% and 27.7%, P = 0.9) or not. When comparing cohorts before and after 2014, we found a significant decrease in the overall failure rate from 26% to 11% (P < 0.03). Isolated lesions presented a decrease from 28% to 6.6% (P = 0.02), BHTs from 34% to 8% (P = 0.09) and those associated with an ACL-R from 25% to 10% (P = 0.09). Mean RTS time was 6.5 mo in isolated lesions and 8.64 mo when associated with an ACL-R. Overall, 56% of patients returned to the same sport activity level. Mean pre and postoperative Lysholm scores were 64 and 85 (P = 0.02), and IKDC 58 and 70 (P = 0.03). Out of 84 asymptomatic patients evaluated with MRI, 39% were classified as "not healed" and 61% as "healed". CONCLUSION: Even though the overall failure rate of our series was 20.3%, we found a statistically significant decrease from 26% to 11%, not only for isolated lesions, but also for BHT's and those associated with an ACL-R when comparing our series in two different cohorts, most probably due to improvements in surgical technique.

Rehabilitation and return to sports after isolated meniscal repairs: a new evidence-based protocol.

PURPOSE: Despite many protocols that have been proposed, there's no consensus in the literature regarding the optimal rehabilitation program and return to sports (RTS) protocol following isolated meniscal repair. The aim of this current concept review is to look at the evidence of rehabilitation and RTS program after isolated meniscal repair, focusing on general and specific protocols per type of injury trying to give some guidelines based on the current state of knowledge. METHODS: A narrative literature review was performed searching PubMed database to identify relevant articles from January 1985 to October 2021 on rehabilitation and RTS after isolated meniscal repair. Randomized controlled trials (RCTs), prospective and retrospective cohort studies, case series, systematic reviews, meta-analyses, cadaveric studies and basic science studies were included. RESULTS: When the hoop tensile stress effect is preserved, an accelerated rehabilitation program may be suggested. Hence, partial weight bearing (20 kg) in association with ROM limited to 90° is allowed for the first four weeks, followed by weight bearing as tolerated. In contrast, when circumferential hoop fibers are disrupted, a restricted rehabilitation protocol may be recommended. In this scenario no weight bearing is allowed for the first six weeks after the surgery and range of motion (ROM) is limited to 90°. CONCLUSION: Biomechanical evidence suggests that tailoring an individualized protocol based upon the type of lesion and meniscus stability is reasonable. LEVEL OF EVIDENCE: Level V.

Semimembranosus Tendon Entrapment by an All-Inside Meniscal Suture.

Meniscal suturing has become the gold standard when it comes to meniscal tears in vascularized areas, especially in the younger population. The all-inside meniscal suturing technique has gained popularity in the past year due to decreased operative time as well as decreased risk of adverse events, as compared to other modalities. However, several complications have been reported with the all-inside technique, including soft tissue and neurovascular injury. This is the first case reporting a semimembranosus tendon entrapment following an all-inside medial meniscal suture. Being aware of such complications is crucial in order to avoid them and treat them promptly should they arise.

Biologic Augmentation Reduces the Failure Rate of Meniscal Repair: A Systematic Review and Meta-analysis.

BACKGROUND: Clinical results after isolated meniscal repair are not always satisfactory, with an overall failure rate of around 25%. To improve the success rate of meniscal repair, different biologic augmentation techniques have been introduced in clinical practice, but their real efficacy is still controversial. PURPOSE/HYPOTHESIS: To evaluate the safety, clinical results, and failure rate of biologic augmentation techniques for meniscal repair. The hypothesis was that biologic augmentation would improve the results of meniscal repair. STUDY DESIGN: Systematic review and meta-analysis of comparative studies. METHODS: A systematic review of the literature was performed in March 2020 of 3 electronic databases (PubMed, Scopus, and the Cochrane Library) regarding meniscal repair combined with biologic augmentation techniques. Articles combining biologic augmentation with other surgical procedures besides meniscal suture were excluded. The quality of the included studies was assessed using a modified Coleman Methodology Score, and the risk of bias was evaluated using the ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions) and the RoB 2.0 (Revised Tool for Risk of Bias in Randomized Trials) for nonrandomized and randomized controlled trials, respectively. RESULTS: A total of 11 studies were included in the qualitative analysis: platelet-rich plasma (PRP) augmentation in 6 comparatives studies, fibrin clot augmentation in 2 case series, and mesenchymal stem cells augmentation in 2 case series and 1 case report. One severe adverse event of septic arthritis was reported for PRP 1 month after surgery. The quality of evidence evaluated with the modified Coleman Methodology Score was low overall. Five studies reporting on 286 patients (111 PRP augmentation, 175 control) were included in the quantitative synthesis. A significantly lower risk of failure was documented in the PRP augmentation group as compared with the control group: 9.9% (4.5%-19.1%) versus 25.7% (12.7%-38.7%) (P < .0005). CONCLUSION: The literature on biologic meniscal augmentation is recent and scarce. Only a few comparative trials are available, all focusing on the potential of PRP. The meta-analysis documented that PRP is safe and useful in improving the survival rate, with a 9.9% rate of failure versus 25.7% for the control group. Further high-level studies are needed to confirm these findings and identify the most effective biologic augmentation strategy to improve the outcome of meniscal repair.

A comparison of the transtibial pullout technique and all-inside meniscal repair in medial meniscus posterior root tear: Prognostic factors and midterm clinical outcomes.

INTRODUCTION: There is a paucity of comparative clinical data between arthroscopic all-inside end-to-end meniscal root suture and transtibial pullout technique in medial meniscus posterior root tears (MMPRT). Therefore, this study aimed to compare treatment failure, mid-term clinical and radiological outcomes of all-inside meniscus root repair versus the transtibial pullout technique and to analyze prognostic factors of postoperative clinical and radiological outcomes. MATERIAL AND METHODS: Forty-four patients were included in two therapeutic group: arthroscopic all-inside meniscal suture (MS: 13 knees) and transtibial pullout technique (TP: 31 knees).Primary clinical outcomes at a minimum of 27.2 months postoperatively included Knee injury and Osteoarthritis Outcome Score (KOOS) and Lysholm Knee Questionnare (LKQ). Radiographic assessment of the knee was performed to determine osteoarthritis severity using the Kellgren-Lawrence (KL) grading system.In addition, pre and postoperative MRI scans and intraoperative arthroscopic findings were recorded and the correlations between these findings, as outcome predictors and postoperative patients reported subjective outcome were assessed. RESULTS: No significant differences in postoperative KOOS and LKQ scores were found between the MS and TP group (p = 0.38 and 0.17, respectively).During follow-up one patients (7.7%) in the MS group and two (6.5%) in the TP group underwent total knee arthroplasty. The difference did not reach the statistical significance (p = 0.88).No differences were observed in postoperative MRI findings such as meniscal extrusion, osteochondral defect, chondromalacia patella, and bone morrow edema (p = 0.25, 0.97, 0.97, and 0.88, respectively).A univariate model revealed that the presence of postoperative meniscal extrusion; osteochondral defect; chondromalacia patella; increased BMI; age (>40 years) and longer time lapse between clinical onset to surgery (>6 months) were predictors of poor clinical outcome. The presence of meniscal extrusion, osteochondral defect and chondropatia patella portended worst postoperative outcomes in a multiple linear regression model. CONCLUSIONS: It can be concluded that both techniques can reach good results when performed properly and if the injury pattern allows meniscal suture may be considered a treatment option for the management of MMPRT in well-selected patients.Patients with increased BMI, preoperative meniscal extrusion, chondromalacia patella, and osteochondral defect were at higher risk of poor clinical outcomes.

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

BACKGROUND: Meniscal surgery is one of the most common surgical procedures performed by orthopaedic surgeons. Over the past decade, awareness has increased regarding the importance of meniscal preservation to prevent the development of osteoarthritis in the knee joint. Removal of meniscal tissue can lead to a high risk of cartilage degeneration, and moreover, meniscus-preserving surgery rather than meniscal resection is likely to have better long-term outcomes. Success rates after meniscal repair range from 60% to 95%, but many reports are based on a small number of patients. PURPOSE/HYPOTHESIS: The purpose of this study was to review all meniscal repairs and potential predictors for failure during a 12-year period. We hypothesized that meniscal anchors, lateral repairs, and repairs made in conjunction with an anterior cruciate ligament reconstruction (ACLR) would have fewer failures than meniscal arrows, medial repairs, and isolated repairs. We also hypothesized that younger patients and acute tears would be associated with fewer failures. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study was a dual-center, retrospective analysis on consecutive meniscal repairs. The surgical protocols were reviewed, including type of tear, location, associated injury to the knee, and surgery. The study endpoint was failure of repair, defined as a need for reoperation and secondary partial or total meniscal resection, within 3 years. Kaplan-Meier analysis was performed to assess repair survival, with multivariate Cox regression to adjust for confounders. RESULTS: A total of 954 meniscal repairs were performed on 918 patients (536 male patients [58%]; 382 female patients [42%]) with a mean age of 26 years (range, 12-60 years). The failure rate for the entire cohort was 22.5%. Bioabsorbable arrows had significantly more failures than all-inside sutures with anchors (hazard ratio [HR], 1.8; 95% CI, 1.2-2.5; P = .002). Medial meniscal repairs had a higher failure rate than lateral meniscal repairs (HR, 3.7; 95% CI, 2.3-6.0; P < .001). Simultaneous ACLR resulted in less failure than when no simultaneous ACLR was performed (HR, 0.5; 95% CI, 0.3-0.9; P = .009). Age at repair and acuity of tear did not affect the outcome (P = .6 and .07, respectively). CONCLUSION: The failure rate after meniscal repair was significantly higher on the medial side, especially when using arrows. Meniscal repairs performed concomitantly with an ACLR result in fewer reoperations.

Radial Meniscal Tears Are Best Repaired by a Modified "Cross" Tie-Grip Suture Based on a Biomechanical Comparison of 4 Repair Techniques in a Porcine Model.

BACKGROUND: The tie-grip suture can fix radial tears more rigidly than simple conventional sutures. However, one shortcoming is the residual gap at the central margin of the tear. The tie-grip suture was modified to address this issue and named the "cross tie-grip suture." PURPOSE/HYPOTHESIS: The purpose of this study was to compare the suture stability and strength among 4 suturing techniques: the original tie-grip, cross tie-grip, and 2 conventional sutures (double horizontal and cross). It was hypothesized that the cross tie-grip suture would show the least displacement and resist the greatest maximum load. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 40 fresh-frozen porcine knees were dissected to acquire 80 menisci; 20 menisci were tested in each suture group. A radial tear was created at the middle third of the meniscal body. Repair was performed with the following: original tie-grip, cross tie-grip, double horizontal, and cross sutures. The mechanical strength of sutured menisci was evaluated using a tensile testing machine. All menisci underwent submaximal loading and load to failure. The gap distance and ultimate failure load were compared using analysis of variance. The failure mode was recorded after load-to-failure testing. RESULTS: Displacement after 500 cycles was significantly smaller in the cross tie-grip group (0.4 ± 0.3 mm) compared with the tie-grip (0.9 ± 0.6 mm), double horizontal (1.2 ± 0.7 mm), and cross suture groups (1.4 ± 0.6 mm) (P < .05). The ultimate failure load was significantly greater in the cross tie-grip (154.9 ± 29.0 N) and tie-grip (145.2 ± 39.1 N) groups compared with the double horizontal (81.2 ± 19.9 N) and cross suture groups (87.3 ± 17.7 N) (P < .05). Tissue failure was the most common mode of failure in all groups. CONCLUSION: Upon repair of radial meniscal tears, the cross tie-grip suture showed less displacement compared with that of the tie-grip, double horizontal, and cross sutures and demonstrated equivalent load to failure to that of the tie-grip suture at time zero. CLINICAL RELEVANCE: The cross tie-grip suture provided high resistance to displacement after repair of radial tears and may be advantageous in healing for radial meniscal tears.

Quantitative Evaluation of Dynamic Lateral Meniscal Extrusion After Radial Tear Repair.

BACKGROUND: Radial tears of the lateral meniscus frequently accompany acute anterior cruciate ligament (ACL) injuries and lead to increased joint stress and pathological meniscal extrusion (ME). The dynamic behavior of the lateral meniscus after radial tear repair with respect to ME has not been described. PURPOSE: To quantitatively assess dynamic lateral ME after all-inside radial tear repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent ACL reconstruction and all-inside radial tear repair of the lateral meniscus and had no history of contralateral knee injuries were included. Magnetic resonance imaging scans were acquired in loaded (50% of body weight) and unloaded conditions of both the injured and noninjured knees. A custom-made pneumatically driven knee brace was used for standardized knee positioning in 10° of flexion and with axial load application. Quantitative measures included the absolute lateral ME, meniscal body extrusion ratio, and Δ extrusion. Preoperative and postoperative unloaded extrusion data were compared by paired t tests. For postoperative data, the concomitant influence of the factors "leg" and "condition" were assessed through factorial analyses of variance. RESULTS: A total of 10 patients with a mean follow-up of 47.9 months were enrolled. The intraclass correlation coefficient (ICC) confirmed good interrater reliability (ICC, 0.898) and excellent intrarater reliability (ICC, 0.976). In the unloaded injured leg, all-inside repair reduced ME from 3.15 ± 1.07 mm to 2.13 ± 0.61 mm (-32.4%; P = .033). Overall, load application led to a significant increase in ME (+0.34 mm [+21.8%]; P = .029). Significantly greater ME was observed in the injured knee (+1.10 mm [+93.2%]; P = .001) than in the noninjured knee. The condition × leg interaction was not significant (P = .795), suggesting that the compression-associated increase in ME did not differ significantly between the injured and noninjured knees. CONCLUSION: Lateral ME depends on the knee status and loading condition. All-inside repair of radial meniscal tears led to a reduction of extrusion with no alteration in dynamic lateral ME. Meniscus-preserving therapy is recommended in the case of a radial lateral meniscal tear to preserve its dynamic behavior.

Analysis of the trends in arthroscopic meniscectomy and meniscus repair procedures in France from 2005 to 2017.

INTRODUCTION: In 2008, the French National Authority for Health (HAS) recommended that "conservative" treatments be adopted for meniscal lesions. This recommendation and the lack of superiority of meniscectomy over non-operative treatment for meniscus degeneration have modified the treatment pathway. However, the impact of these findings on French clinical practice is not known. The objective of this study was to evaluate the change over time in the number of alternative surgical procedures (meniscectomy and meniscus repair) and regional variation in France using data from the French agency for information on hospital care (ATIH). HYPOTHESIS: We hypothesized that the number of meniscectomy procedures will decrease, and the number of repair procedures will increase over time at various healthcare facilities. PATIENTS AND METHODS: Between 2005 and 2017, the number of hospitalizations in the Medicine-Surgery-Obstetrics wards for meniscectomy (NFFC003 and NFCC004) or meniscus repair (NFEC001 and NFEC002) was evaluated overall and then based on whether the stay occurred in public or private sector hospitals in France. Data were extracted from the ATIH database and the findings were (1) related to French demographics during the period in question; (2) separated into public or private sector hospitals; (3) distributed into various regions in France and; (4) stratified by patient age. RESULTS: Between 2005 and 2017, 1,564,461 meniscectomy and 63,142 meniscus repair procedures were done in France. Over this period in the entire country, the meniscectomy rate gradually decreased from 19.80/10,000 inhabitants in 2005 to 15.77/10,000 inhabitants in 2017 (21.4% reduction) (p<0.0001) while the meniscus repair rate increased from 0.42/10,000 inhabitants in 2005 to 1.36/10,000 inhabitants in 2017 (320% increase) (p<0.0001). The largest meniscectomy reduction effort occurred in private sector hospitals, going from 15.79 to 12.01/10,000 inhabitants in 12 years; the decrease was smaller in public hospitals (going from 4.01 to 3.77/10,000 inhabitants) (p<0.0001 in both cases). The change in the procedure ratio between private and public hospitals was asymmetric, with the meniscus repair/meniscectomy ratio clearly increasing more in public hospitals (4% to 12.6%) between 2005 and 2017 than in private hospitals (1.6% to 6.6%) (p<0.0001). We found large regional differences: regions in Eastern France had higher meniscectomy rates, while regions in Western France had higher meniscus repair rates. When the analysis of procedures between 2008 and 2017 was stratified by age, a similar increase in repair procedures was found in all age brackets. Conversely, the reduction in meniscectomy was most apparent before 40 years of age, and the number of meniscectomy procedures was stable after 60 years of age. CONCLUSION: These findings suggest there has been a significant shift in the surgical management of meniscal injuries towards more conservative treatments. But the large variations between regions in France is evidence of a continued disparity in clinical practices. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Alternative method of outside-in meniscal repair for anterior horn tears.

Treatment of symptomatic meniscal tears continues to evolve as we improve our understanding of the biomechanical role of the meniscus and its long-term importance to the health of the knee joint. Suture repair of meniscal tears is challenging and continues to rise as we aim to preserve meniscal tissue. Outside-in meniscal suture techniques may involve using expensive equipment that is not readily available for immediate use in most operating rooms. Aware of the different techniques available, the authors describe a fast and reproducible technique that does not require the use of specific material or equipment.

[Clinical research for rehabilitation training combined with modified shu-acupuncture for joint dysfunction after meniscal suture surgery].

OBJECTIVE: To compare the effects on joint dysfunction after meniscal suture surgery between rehabilitation training combined with modified shu-acupuncture and simple rehabilitation training. METHODS: Seventy-one patients with meniscal suture surgery were randomized into an observation group (n=36) and a control group (n=35). Patients in the observation group received modified shu-acupuncture combined with rehabilitation training. Acupuncture for 8 weeks were at Zutonggu (BL 65), Shugu (BL 66), Neiting (ST 44), Xiangu (ST 43), Xiaxi (GB 43), Zulinqi (GB 41), Dadu (SP 2), Taibai (SP 3), Xingjian (LR 2), and Taichong (LR 3), once a day for continuous 6 days with 1 day for rest. Patients in the control group received simple rehabilitation training for continuous 8 weeks. The training included quadriceps femoris, range of knee joint motion and motion and limb walking on the affected side. The effect score for meniscus injury after treatment from Japanese Orthopaedics Association (JOA) and visual analogue scale (VAS) score were recorded before and after treatment. The effects were compared in the two groups. RESULTS: After treatment, the VAS and JOA scores were improved in the two groups (all P<0.05), with better results in the observation group (both P<0.05). The effective rate was 91.7% (33/36) in the observation group, which was better than 80.0% (28/35) in the control group (P<0.05). CONCLUSION: Rehabilitation training combined with shu-acupuncture achieve better effect than simple rehabilitation training for joint dysfunction after meniscal suture surgery.