Biodegradable arrows for arthroscopic repair of meniscal tears

Thirty-two meniscal tears in 32 patients were repaired using biodegradable meniscus arrows. The tears were fixed arthroscopically using an all-inside technique. Ten patients had a simultaneous anterior cruciate ligament (ACL) reconstruction. The period of follow-up was an average of 25 (10-40) months. Twenty-six patients were clinically stable and asymptomatic at follow-up. Six patients were considered clinically unstable and all had associated ACL reconstruction and required a repeat arthroscopy. Two meniscal repairs failed to heal, and the broken meniscus arrow was retrieved arthroscopically 6 months after the primary operation. In four cases the meniscal tear healed completely (two cases) or partially. Otherwise, there were no objective signs of complications. The use of meniscus arrows is a simple, safe, and reliable method for repair of properly selected meniscal tears.     

Primary knee ligament repair--revisited

There were 4710 knee sprains resulting from skiing in the four Aspen ski areas between 1976 and 1979. Twenty percent of the patients (942) had complete tears. Of these, 302 elected to remain in Aspen for treatment. All were treated by primary ligament repair without augmentation. These cases were evaluated an average of 42 months after injury. Patients with isolated tears of the medial collateral ligament were found to be doing well; virtually all of them had returned to preinjury activity levels. Thirty-six percent of the isolated anterior cruciate repairs were rated failures, and 43% of the combination ACL-MCL injuries had failed because of anterior cruciate deficiency. Twenty-nine percent of the ACL and ACL-MCL injuries had meniscal tears. Cases that included meniscectomy had a failure rate twice as great as those in which the meniscus was preserved. The results following repair of anterior cruciate tears were not acceptable, and augmentation was indicated. Primary repair of medial collateral ligament tears produced excellent results. Meniscal tears were frequent in association with ligament disruption. Ligament repairs were less satisfactory when meniscectomy was performed at the time of the repair.     

Anterior cruciate ligament tears in skeletally immature patients: meniscal pathology at presentation and after attempted conservative treatment.

We evaluated 12 skeletally immature patients with acute, intrasubstance tears of the anterior cruciate ligament (ACL) and open physes for meniscal pathology. Arthrograms were completed in 10 of 12 patients, and subsequent arthroscopy confirmed 8 meniscal tears (4 medial, 4 lateral) in 6 patients. Four patients with repairable menisci underwent arthroscopic meniscal repair and stabilization. Eight patients received quadriceps and hamstrings rehabilitation and returned to sports with a brace. After return to sports, all braced patients developed instability with multiple episodes of "giving way." Average time from initial injury to first episode of instability was 7 months. Seven patients sustained further meniscal damage an average of 15 months (range 7-27 months) after initial injury. We conclude that meniscal pathology is commonly associated with ACL tears in skeletally immature patients and we recommend arthrography or arthroscopy to evaluate patients with suspected ACL tears. Brace management did not prevent instability or new meniscal tears.     

Meniscal repair: indications and techniques

Meniscal tears are exceedingly common. Because the meniscus serves many vital functions to the knee joint, the preservation of meniscal tissue through meniscal repair is ideal. However, not all meniscal tears are amenable to repair, and each case must be critically assessed for repair suitability. It has been well documented that meniscal healing is enhanced in the setting of concurrent anterior cruciate ligament (ACL) reconstruction. This may influence the indications for repair, as well as the repair technique. Meniscal repair techniques have evolved over time from initial open repairs to inside-out and outside-in suture repairs to newer all-inside repair devices. The current gold standard remains inside-out vertical mattress suture repairs. All-inside repairs are best reserved for special circumstances, such as in the setting of concurrent ACL reconstruction.     

Patient outcomes following T-Fix meniscal repair and a modifiable,progressive rehabilitation program,a retrospective study

INTRODUCTION: This retrospective study presents clinical patient outcomes following meniscal repair using T-Fix devices and a modifiable, progressive rehabilitation program. MATERIALS AND METHODS: Fifty-two patients (35 males and 17 females) with a mean age of 26.7 years (range 13-50 years) representing all of the patients who underwent arthroscopic meniscal repair (43 medial meniscus, 12 lateral meniscus) over a 3-year period by the same surgeon (D.C.) (55 menisci) participated in this study. Thirty-two of the patients (62%) had an associated ACL tear. All patients with an ACL tear underwent reconstruction (tibialis anterior allograft) at the time of meniscal repair. All meniscal tears were located in either the red-red zone (29) or the red-white zone (26). All patients who underwent meniscal repair participated in a modifiable (based on meniscal tear size, type, and location) progressive rehabilitation program. Operative notes and photographs were reviewed to identify the meniscal tear location, tear type, tear length, and the number of T-Fix devices used. Orthopedic clinic and physical therapy reports were also reviewed for postoperative range of motion, knee joint effusion, knee joint pain, McMurray test findings, and single-leg broad-jump test performance (90% bilateral equivalence goal). The average postoperative clinical follow-up period was 10.3 months (range 4-24 months). RESULTS: Most (22/23, 96%) patients who underwent meniscal repair alone displayed excellent results. All patients (32/32, 100%) who underwent combined ACL reconstruction-meniscal repair displayed excellent results. During an acute event such as a sudden directional change while running or contact with another player, 5 of these patients re-injured their meniscus at the repair site in conjunction with tearing the reconstructed ACL at 12+/-3 months following the index surgical procedure. Each of these 1-2 cm meniscal tears had been previously repaired with two T-Fix devices. CONCLUSION: The T-Fix device used in combination with a modifiable progressive rehabilitation program produced excellent clinical patient outcomes among this patient group.     

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

Purpose: The purpose of this study was to prospectively determine the outcome of meniscal repairs for tears that extended into the central one-third zone of the meniscus, or had a rim width of 4 mm or greater, in a case series of patients 40 years of age and older. Type of Study: Prospective case series. Materials and Methods: Thirty meniscal repairs in 29 patients were evaluated by a comprehensive examination (28 repairs) a mean of 34 months postoperatively, by follow-up arthroscopy (6 repairs) a mean of 24 months postoperatively, or both. The mean age of the patients at the time of the meniscal repair was 45 years (range, 40 to 58 years). Twenty-one patients (72%) also had ruptures of the anterior cruciate ligament, which were reconstructed at the time of the meniscal repair with bone–patellar tendon–bone autografts (16 patients) or allografts (5 patients). The Cincinnati Knee Rating System was used to rate symptoms, functional limitations with sports and daily activities, patient perception of the knee condition, and sports and occupational rating levels. Results: At a mean of 33 months postoperatively, 26 meniscal repairs (87%) were asymptomatic for tibiofemoral joint symptoms and had not required subsequent surgery. Three repairs failed to heal, requiring partial meniscectomy, and 1 knee with tibiofemoral symptoms related to the repair was treated conservatively. There was no significant effect of the side of the meniscal repair, chronicity of injury, or condition of the articular cartilage on the presence of tibiofemoral symptoms or meniscal resection. Concomitant anterior cruciate ligament reconstruction appeared to increase the rate of asymptomatic meniscal repairs. The patient rating of overall knee condition was normal/very good in 76%, good in 12%, and fair/poor in 12%. Conclusions: In athletically active patients, we recommend the preservation of meniscal tissue wherever possible regardless of age, basing indications for the procedure on current and future activity levels.     

Arthroscopic meniscal repair evaluated with repeat arthroscopy

Arthroscopic meniscal repair is a technically feasible approach to the treatment of meniscal tears in young active individuals. To evaluate this premise, we repaired 29 minisci in 27 patients and then arthroscoped their knees 3 months later. Repairs were limited to displaceable longitudinal tears. In 16 patients ligaments were intact. Eleven patients were anterior cruciate ligament deficient, six of whom underwent concomitant ACL reconstructions. In two patients, bicompartmental tears were encountered. Under arthroscopic control, using curved cannulae, horizontal mattress sutures of absorbable monofilament were placed across the tear, out through the capsule, and tied over the fascia, deep to the skin. No arthrotomies were performed, and all portions of the menisci could be reached with this method. Twenty-four of 29 repairs healed completely; 5 healed partially (30 to 50% healing). Four of the five failed repairs occurred in unstable anterior cruciate ligament deficient knees.     

Arthroscopic meniscus repair with bioabsorbable arrows

Purpose: The clinical results of a single surgeon’s experience with Meniscus Arrows (Bionx, Blue Bell, PA) for meniscal repair are reviewed and reported to determine the safety and efficacy of this device. Type of Study: Consecutive sample. Methods: Over a 3-year period, the senior author has used only Meniscus Arrows for all meniscal repairs. All patients who underwent meniscal repair with at least 12 months of follow-up were evaluated for this study. Thirty patients had a meniscal repair, and 29 were available for follow-up. The average age at surgery was 29 years (range, 15 to 45 years) and there were 24 male and 5 female patients; 25 patients had an anterior cruciate ligament (ACL) reconstruction with the meniscal repair, 2 repairs were performed in ACL-deficient knees, and 2 repairs were performed in ACL stable knees. The average follow-up was 24 months (range, 12 to 42 months). Results: The average Lysholm knee scores for ACL reconstruction, ACL-intact, and ACL-deficient knees improved from 47, 6, and 35, respectively, to 91, 96, and 81 postoperatively. Tegner activity scores improved from 2.7, 0, and 1.5, respectively, to 7.4, 6.5, and 4.5 after surgery. There were no surgical complications, no infections, and no neurovascular injuries. Five patients had mild subcutaneous irritation caused by the Arrow tips, but in each case this resolved within 3 to 7 months. There were 2 failures (7%) that required later arthroscopy and partial meniscectomy. One failure was in an ACL-deficient knee, and the other was in an ACL-reconstructed knee. Conclusions: Although the data presented in this report are based on short-term clinical follow-up, the preliminary results of the Meniscal Arrow repair are encouraging.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 246–253     

The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults

The results of nonoperative treatment of 72 patients with complete anterior cruciate ligament (ACL) tears, documented by examination under anesthesia and arthroscopy, were evaluated. All patients had an acute injury with hemarthrosis in a previously normal knee. Patients having meniscal repair were excluded as were those with collateral or posterior cruciate ligament tears or associated fractures. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. A detailed rating of symptoms and function was performed at an average of 38 months postinjury (range, eight to 84 months). Overall results were 11% excellent, 20% good, 15% fair, and 54% poor. Thirty-five percent had ACL reconstruction during the follow-up period. Results indicate that young adults who return to a vocation requiring strenuous physical activity frequently can expect unsatisfactory results after nonoperative treatment of an acute complete tear of the ACL.     

Arthroscopic meniscal repair with fibrin glue

Since 1984 we have arthroscopically repaired 40 meniscal tears in 32 patients using fibrin glue in our operative technique. This technique was reported initially in 1985 (Ishimura M, Samma M, Habata T, Fujisawa Y. The use of fibrin glue for fresh knee injury. Cent Jpn Orthop Traumat 1985; 28:1404-8), with a more detailed study published in 1987 [Ishimura M, Samma M, Fujisawa Y, et al. Arthroscopic repair of the meniscus tears with fibrin glue. Arthroscopy (Jpn) 1987;12:31-6]. During the follow-up period, which ranged from 10 months to 6 years and 7 months (mean: 3 years and 8 months), only two patients complained of meniscal symptoms and underwent arthroscopic partial meniscectomy. Twenty patients with 25 repairs underwent repeat arthroscopy at an average of 5.7 months (range: 2 months-1 year and 2 months) after the initial repair. Twenty repairs were rated as good, four as fair, and one as poor by arthroscopic evaluation criteria. At present, the most appropriate use of this arthroscopic meniscal gluing technique is in tears in the posterior segment, which are difficult to suture without arthrotomy. Even a long tear with a stable reduced position can be expected to show good healing. When reduction of the tear is not stable, additional sutures should be used.     

Clinical and MRI evaluation of meniscal tears repaired with bioabsorbable arrows.

BACKGROUND AND AIMS: Excision of meniscal tissue has been shown to increase the risk of degenerative changes of the knee joint. Whenever possible, meniscus repair has become the procedure of choice for treatment of meniscal tears. MATERIALS AND METHODS: The present retrospective study evaluated the healing results of 77 meniscal ruptures treated with the an all-inside technique (Biofix meniscus arrow). The study group consisted of 73 patients with 77 longitudinal, vertical meniscal ruptures treated at Helsinki University Hospital between the beginning of January 1997 and the end of March 2001. The patients who had not received secondary surgery for failed repair during the follow-up period were examined clinically and with MRI. RESULTS: Fifty-one out of 77 meniscal ruptures (66%) healed clinically. In repairs performed in conjunction with ligament reconstruction the healing rate was higher (79%) than in the isolated tears (56%). The poorest results were seen in the very long vertical tears with luxation of the meniscus (38% healing rate). CONCLUSIONS: Bioabsorbable arrows offer a good alternative for treatment of meniscal ruptures, but the arrows alone do not seem to be sufficient to provide a reliable long-lasting result in the repair of very unstable meniscal ruptures.     

Nonoperative treatment of partial-thickness meniscal tears identified during anterior cruciate ligament reconstruction

The reported incidence and treatment of partial-thickness meniscal tears seen at anterior cruciate ligament (ACL) reconstruction varies widely. The success of nonoperative treatment of partial meniscal tears identified during ACL reconstruction at our institution was reviewed. All incomplete meniscal tears were treated with observation, all full-thickness tears were treated with repair or partial meniscectomy. Partial tears of the lateral meniscus were noted three times more commonly than in the medial meniscus and were seen more acutely after ACL injury than full-thickness tears. At 2-year follow-up, excellent knee function was noted when these tears were treated nonoperatively.     

Arthroscopic review of meniscal repair: assessment of healing parameters

The purpose of this study was to demonstrate what can be learned by repeat arthroscopy of meniscal repairs with regard to documenting healing, determining reasons for failure to heal, and discovering the fate of nonabsorbable suture material. The study involved 14 patients with 16 repairs who had repeat arthroscopy an average of 7.5 months after repair. Nonabsorbable suture was used in 14 of the repairs. Eleven repairs were done arthroscopically, and five were open. Charts and videotapes of both procedures were reviewed. Results showed 56% of repairs had healed, 25% had partially healed, and 13% had not healed. This is unusually slanted toward bad results for meniscal repair because the knees were usually rearthroscoped due to continued or recurrent problems. Most of the approximately 200 original patients were not symptomatic enough to warrant or submit to rearthroscopy. No damage to articular surfaces was found due to use of nonabsorbable sutures. These sutures become completely or partially incorporated into the meniscus. Meniscal repairs at risk for healing problems were set apart by an analysis of those cases with healing problems, including repairs of multiple longitudinal tears, tears greater than 40 mm in length, and tears in unstable knees. It should be emphasized that these conclusions only suggest a trend. Numbers are too few for statistical significance.     

Return of motion after simultaneous repair of displaced bucket-handle meniscal tears and anterior cruciate ligament reconstruction.

Patients with displaced bucket-handle (DBH) meniscal tears in anterior cruciate ligament (ACL)-deficient knees are prone to flexion contracture following meniscal repair and simultaneous ACL reconstruction. It has been suggested that ACL reconstruction be delayed until full range of motion has returned after the meniscal repair. A retrospective analysis was performed comparing the return of extension in patients undergoing simultaneous ACL reconstruction and repair of DBH tears (group A) versus a control group of patients with non-DBH tears (group B). Age, sex, body mass index, duration of time from injury to surgery, and preoperative extension were also compared between groups and evaluated for their significance as risk factors. Patients in group A achieved recovery to -5 degrees and 0 degrees of extension 22% and 35% more slowly, respectively, when compared with group B. These differences were not statistically significant. Female patients tended to heal more rapidly in both groups. We conclude that a one-stage procedure is sufficient in allowing patients with DBH tears in ACL-deficient knees to regain a functional knee to within 5 degrees of full extension.     

Associated injuries in pediatric and adolescent anterior cruciate ligament tears: Does a delay in treatment increase the risk of meniscal tear?

Purpose: To evaluate the incidence of associated injuries and meniscal tears in children and adolescents with anterior cruciate ligament (ACL) tears, we performed a retrospective review of patients, age 14 and younger, who were treated surgically at our institution. Type of Study: Retrospective review. Methods: We reviewed 39 patients (30 girls, 9 boys) with an average age of 13.6 years (range, 10 to 14 years) who underwent surgical treatment of the ACL; 24 right knees and 15 left knees were treated. Of the injuries treated, 24 occurred by a twisting mechanism, 10 were the result of contact, and 5 occurred from hyperextension. Thirty-five injuries occurred during sports activities, and 2 were sustained in motor vehicle accidents. The mean duration from injury to operative treatment was 101 days (range, 7 to 696 days). Injuries were classified as acute (n = 17) if surgery was performed within 6 weeks of injury and chronic (n = 22) if surgery was performed after 6 weeks from injury. Relationships between medial and lateral meniscal injuries and the time from injury to surgery were analyzed, and the 2 groups, acute and chronic, were compared. Finally, the patterns of meniscal injury were compared. Results: Twenty-six patients had associated injuries (10 medial meniscal tears, 15 lateral meniscal tears, 3 medial collateral ligament tears, and 1 fractured femur). The association between medial meniscal tears and time from injury to surgery was highly statistically significant (P = .0223). There was no statistical significance between the incidence of lateral meniscal tears and time. Medial meniscal tears were more common in the chronic group (36%) than in the acute group (11%), whereas lateral meniscal tears were found with equal frequency. Medial meniscal tears that required surgical treatment (either partial excision or repair) were more common in the chronic group, and lateral meniscal tear patterns were equally distributed. Conclusions: Evidence from this study supports the contention that associated injuries are common in young individuals with ACL tears. Furthermore, the data also show that a delay in surgical treatment was associated with a higher incidence of medial meniscal tears.     

Meniscus repair: results of an arthroscopic technique

A prospective study of arthroscopically repaired peripheral meniscal tears in 24 patients (19 men and five women) was initiated in 1983. Two patients were lost to follow-up. Seventeen medial and five lateral tears were followed an average of 29 months (15-42 months) with 17 having clinically apparent healing (77%). Sixteen had ACL tears, 10 of which were stabilized. Thirteen of 16 stable knees healed their menisci (81%), whereas only 4 of 6 unstable knees had healed menisci (67%). Fifteen were acute tears repaired within 2 weeks of injury, and 7 were chronic tears. Four acutely repaired menisci failed. One lateral meniscus tore in the previously sutured site 12 months later, whereas 1 medial meniscus tore 24 months after repair in a new area associated with significant trauma. Repair of a longitudinal peripheral meniscal tear permits salvage of this structure in a high percentage of cases. No serious complications such as peroneal nerve or popliteal vascular damage occurred. Transient saphenous neuropraxia (22%) and posterior portal adhesions (9%) were temporary problems. The procedure is recommended only for the advanced arthroscopist, who is advised first to establish the anatomical relationships clearly by cadaver dissections.     

Results of isolated meniscal repair evaluated by second-look arthroscopy

Thirty-six isolated torn menisci in 35 patients (average age, 24 years) which had been repaired arthroscopically using an inside-out technique were evaluated by second-look arthroscopy. The time from meniscal repair to second-look arthroscopy ranged from 2 to 10 months with a mean of 5 months. The indications for meniscal repair were a longitudinal or oblique tear located at the outer half of the meniscus. Twenty (56%) were graded as excellent, 10 (28%) as good, and 6 (16%) were graded as poor. Neither age nor length of time between injury and repair affected meniscal healing. The medial meniscal repairs showed better results than the lateral repairs (rate of excellent results: medial, 82%; lateral, 44%; P < .01, χ-squared tes). The rate of excellent results for those with normal meniscal bodies at the time of repair was 79%, which was significantly higher than that seen in the cases with deformed and/or superficial damage to the meniscal body (36%; P < .05, χ-squared test).     

Meniscal repair and transplantation: indications, techniques, rehabilitation, and clinical outcome

The purpose of this paper is to provide current knowledge regarding the indications, operative techniques, rehabilitation programs, and clinical outcomes of meniscus repair and transplantation procedures. Meniscus tears that occur in the periphery may be repaired using a variety of operative procedures with high success rates. Complex multiplanar tears that extend into the central one-third avascular zone can also be successfully repaired using a meticulous vertically divergent suture technique. The outcome of these repairs justifies preservation of meniscal tissue, especially in younger athletic individuals. Meniscal transplantation is a valid treatment option for patients who have undergone meniscectomy and have related tibiofemoral joint pain, or in whom articular cartilage deterioration in the meniscectomized compartment is present. Rehabilitation after these operations includes knee motion and quadriceps-strengthening exercises initiated the first day postoperatively. The initial goal is to prevent excessive weight bearing and joint compressive forces that could disrupt the healing meniscus repair or transplant. The protocol contains modifications according to the type of meniscal tear, if a concomitant procedure is done (such as a ligament reconstruction) or if noteworthy articular cartilage deterioration is present. Patients who have repairs of peripheral meniscus tears are generally progressed more rapidly than those who have repairs of tears extending in the central one-third region or those who undergo meniscal transplantation. The safety and effectiveness of the rehabilitation program has been demonstrated in several clinical studies. We recommend preservation of meniscal tissue, regardless of age, in active patients whenever possible.     

All-inside meniscal repair surgery: factors affecting the outcome

BackgroundMeniscal injury is currently a well-recognized source of knee dysfunction. While it would be ideal to repair all meniscus tears, the failure rate is significantly high, although it may be reduced by careful selection of the patients. Our objective was to assess the outcome of meniscal repair surgery and the role of simultaneous reconstruction of the anterior cruciate ligament (ACL).Results136 Meniscal repairs were performed in 122 patients with a mean age of 26.8 years. Mean follow-up duration was 9 months. 63 % of the patients underwent medial and 37 % underwent lateral meniscal repair, with failure rates of 19 % for medial and 12 % for lateral menisci. Ligament injuries were found in 61 % of the patients (n = 83). Failure of meniscal repair occurred in 14.5 % (n = 12) of the patients who had early ACL reconstruction and in 27 % (n = 22) of the patients who had delayed ACL reconstruction (p = 0.0006). The failure rate was found to be 13 % in patients who were younger than 25 years (61 %) and 15 % in patients who were older than 25 years (39 %).ConclusionThe success rate of meniscal repair was found to be significantly better when ACL reconstruction was performed simultaneously with meniscal repair.

Level of evidence

Level IV.