Editorial Commentary: Meniscal Tears or Meniscal Aging—That Is the Question

Meniscal tears constitute one of the most common pathologies in sports medicine. Although frequently grouped by shape, location, and size for didactic purposes, considering them according to their cause is probably the single most important factor to predict their behavior and prognosis. For instance, an acute traumatic tear and a degenerative tear of the meniscus are located on opposite ends of the spectrum of the meniscal pathology (which is comparable to focal chondral defects and osteoarthritis). For this reason, surgically addressing a non-obstructive degenerative meniscus does not always address the cause of the problem (inherent catabolic state) or the character of the symptoms (due to concomitant osteoarthritis or overload), and therefore, outcomes have been reported to be unpredictable. Of note, several recent randomized clinical trials allowed for a single-way crossover, which could act as a major confounder related to patient recruitment and expectation bias. Considering these thoughts along with the associated media coverage, there is a global trend to treat degenerative tears with a more conservative approach. Despite this, the most appropriate treatment for patients with symptomatic degenerative tears for which a trial of conservative measures failed is yet to be determined.     

Editorial Commentary: Efforts to Heal Meniscal Radial Tears Are Ongoing

Meniscal radial tears are equivalent to the meniscectomized state. However, successful healing rates by current repair methods for meniscal radial tears are still not satisfactory. Several suture configurations that could approximate the tear gap and stabilize meniscal tissue have been developed to overcome the shortcomings of simple horizontal stitches and cross stitches. The hybrid stitch method, composed of horizontal stitches and vertical stitches, has been introduced. This method can provide stable fixation because the vertical stitches suture the bundle of circumferential fibers, and the vertical stitches act as rip stops for the horizontal stitches. However, it is still challenging to heal meniscal radial tears in avascular areas or complex tears. In treating radial tears, it is important not only to improve suture mechanics but also to promote biologic healing potential.     

Editorial Commentary: Meniscal Repair—Why Bother?

Whether to repair or resect meniscal tears remains a matter of controversy. In theory, partial meniscectomy increases contact pressure, which may result in progressive and early cartilage degeneration and early osteoarthritis. Meniscal preservation is the preferred treatment option, but only a small percentage of meniscal tears are suitable for repair. Two recent registry studies challenge this approach and suggest that partial meniscectomy has similar clinical outcomes in the short term. Whether these findings can be maintained in the long term remains to be seen.     

Editorial Commentary: Arthroscopic Partial Meniscectomy Is Not a First-Line Treatment for Degenerative Meniscus Tear: To Meniscectomize or Not to Meniscectomize?

A painful knee with a degenerative meniscal tear is a quite common problem in the middle-aged patient. Arthroscopic partial meniscectomy is too often used to alleviate pain and seems to work in the short-term. However, arthroscopic partial meniscectomy does not guarantee success, particularly in the long run, particularly in patients with greater grades of osteoarthritis, patients who are older than 60 years, female patients, patients with malalignment, and patients having lateral meniscectomy. There is a need for better science to recommend arthroscopic meniscectomy in those cases.     

Editorial Commentary: Are We Over-treating Meniscal Root Tears?

Meniscal root tears function as a complete meniscectomy, with loss of hoop stress due to the detachment of the meniscus. Root tears have been increasingly recognized recently with improvements in diagnostic imaging and the understanding of meniscal biomechanics. Patients have a high rate of progression of osteoarthritis and subsequent knee replacement after a meniscal root tear. Recent advances in repair techniques, arthroscopic instrumentation, and biological augmentation strategies continue to offer surgeons ways to manage historically “irreparable” meniscal tears. Root repair clinical outcomes are generally favorable, although patients may still experience progressive degenerative changes.     

Editorial Commentary: Meniscal Allografts Can Be for Grandparents Too

Meniscal allografts have come a long way since they were first thought to be a salvage procedure before a knee arthroplasty. The surgical procedure and indications have shown significant change, but the variable of patient age has not. Most clinical series report that patients should be <50-55 years of age to be considered as candidates. While outcomes are better for younger patients, good results can be obtained even when the upper age is extended beyond the current accepted limit.     

Editorial Commentary: Meniscal Root Repairs: Let the Biology Help You!

Meniscal root tears are increasingly being recognized as important entities by the orthopaedic community. This is probably due to the catastrophic consequences of not identifying or addressing a root tear in a timely fashion, leading to the need for a total meniscectomy. The majority of the studies on root tears have been focused on natural history, diagnosis, biomechanical consequences, and fixation techniques. Conversely, rehabilitation concepts have been extrapolated from those applied after other meniscal tears/repairs, even though root tears probably constitute a completely different pathology from biological and biomechanical standpoints. Time zero studies are important to determine the effect of certain loads on the repaired structure without taking into consideration the healing process. This allows for examination of the effects that an accelerated protocol would have in the immediate postoperative phase after a root repair. As with any repaired structure, allowing time for the repaired tissue to heal is vital because failing to do so might lead to unrecoverable failure of the root fixation.     

Editorial Commentary: Women and Men Fare Equally Well After Meniscal Repair

Knee meniscal repair has a success rate of approximately 80% in both men and women, and meniscal repair is a critical procedure for maintaining long-term knee health.     

Editorial Commentary: Polyurethane Meniscal Scaffold: A Perfect Fit or Flop?

The goal of using a synthetic scaffold to establish a biomechanically functioning meniscus or provide an equivalent meniscus substitute is not achieved by the polycaprolactone-polyurethane Actifit scaffold. Recent research, that did not include a control group, shows that the revision rate is significant, and any improvements in patient outcomes could reflect the associated reconstructive surgery. Based on these data and similar published reports, it is premature to conclude that this implant is clinically indicated. The technique is currently more flop than fit.     

Editorial Commentary: Failure With Continuity: Redefining Healing With Meniscal Root Repair

The importance of the medial meniscus posterior root for preserving knee joint kinematics, joint contact pressures, and articular cartilage integrity is well recognized. Medial meniscus root repair generally is associated with favorable clinical outcomes and radiographic changes compared with conservative treatment or subtotal meniscectomy; however, second-look arthroscopy often reveals some laxity at the repair site. Even in this latter situation of “failure with continuity” of the meniscus root repair, there may be benefit in delaying progression of radiographic degeneration changes. Given that the displacement of the repair often occurs with premature rehabilitative loading, it is important to delay the progression of weight-bearing until adequate healing has occurred.     

Editorial Commentary: Overtensioning of Rotator Cuff Tear Repair Predisposes to Failure of Complete Healing

Overtension repair of rotator cuff tear may predispose to the failure of postoperative integrity of the rotator cuff tendon. Surgeons should consider the size of the rotator cuff tear and maintain adequate tension for successful rotator cuff repair. Feel the tension on the tendon: too much can poison the outcome.     

Editorial Commentary: Meniscal Allograft Success—How Do We Get There?

Patients undergoing meniscal allograft transplantation show improvement at 10 years and even 15 years of follow-up. However, it is unclear what factors influence the results, including but not limited to bone plug versus all-suture repair, fresh versus cryopreserved grafts, proper sizing, and rehabilitation.     

Editorial Commentary: The Benefits of Three-Dimensional Computed Tomography Images to Evaluate the Safety of All-Inside Meniscal Repair

All-inside meniscal repair is a useful alternative to inside-out repair, particularly for the posterior horn of the lateral meniscus, because open approach to the complex posterolateral corner can be avoided. However, risk to the neurovascular structures is a major concern, and surgeons must be aware of portal placement, degree of penetration, patient size, and patient positioning. Imaging studies may be misleading, as they are generally obtained with the knee in extension. In the future, advanced imaging by 3-dimensional computed tomography may better allow us to preoperatively plan for a safe approach to the posterior horn of the lateral meniscus using all-inside repair techniques.     

Editorial Commentary: It Takes Two to Tango: The Shared Decision of Return to Sport After Meniscal Transplantation

Despite its overall good results, meniscal allograft transplantation is considered a salvage procedure, and abstention from sport practice is considered a valid solution to preserve the transplanted meniscus as long as possible. However, many patients want to return to sport, and this is often beneficial for them. Therefore, we should know how meniscal allograft transplantation performs in terms of return to sport to better counsel our patients. It is thus of primary importance to discuss general and sport-related expectations with each patient, whom should be informed of the potential short- and long-term risks of strenuous or light sport activities. In particular, the high risk of reoperation, the long recovery time, and the potentially deleterious effect of sporting activity on graft survival should be quite clear to both surgeons and patients because, when it comes to return-to-sport decisions, “It takes two to tango”!     

Editorial Commentary: Moving the Needle: Traditional Inside-Out Meniscal Repair Has Advantages Over All-Inside Repair

Meniscus repairs for vertical, peripheral tears can be troublesome due to poor tissue quality and/or vascularity that can lead to re-rupture and subsequent removal. The gold standard, inside-out repair technique, has been challenged by all-inside devices for the benefit of improved efficiency and less morbidity but for the sake of expense and potential structural inferiority. Successful meniscus repair requires multiple components, only one of which is deciding the repair construct of choice. I feel the most important aspect will always be the indication based on tear configuration while respecting biology, because all fixation will eventually fail if the meniscus does not ultimately heal. While all-inside devices may have biomechanical properties that are similar to inside-out techniques, the burden of proof still lies on showing superiority of these devices in a clinical setting. Clinically, I still use inside-out repair techniques for large tears or for high-demand patients due to its structural integrity and small penetration of the meniscus.     

Meniscal Repair for Anterior Horn Tear of the Lateral Meniscus

This technical note describes all-inside meniscal repair for anterior horn tears of the lateral meniscus. A modified anteromedial portal is created for use in visualizing the anterior horn of the lateral meniscus. A crescent-shaped suture hook loaded with a polydioxanone suture (PDS) is inserted through an anterolateral portal. The hook tip penetrates the meniscal peripheral rim and advances across the tear. The suture hook penetrates the mobile central fragment. A leading limb of the PDS is advanced into the knee joint. Then, the leading limb of the suture is retrieved back to the anterolateral portal. With 2 limbs of PDS, endoscopic knot tying is done. With this simple technique, vertically oriented all-inside meniscal repair of an anterior horn tear of the lateral meniscus with the use of absorbable suture materials is easily performed.     

Editorial Commentary: Knee Meniscus and Hip Labrum: The Dilemma of Degenerative Tears

The dilemma for orthopaedic surgeons attempting to solve the problem of treating a knee meniscal tear in an older patient has always been whether or not a conservative approach is of value and if a surgical approach will provide benefit to the patient. Today, the same might be said of hip labral tears. Physical therapy is a wonderful tool to strengthen muscles, but it does not correct underlying pathology, which is often the source of joint pain. In an older patient with a symptomatic internal derangement, it is important for surgeons and payers to recognize that a simple outpatient surgical procedure often can improve that patient's symptoms.