Treatment of meniscal tears: An evidence based approach

Treatment options for meniscal tears fall into three broad categories; non-operative, meniscectomy or meniscal repair. Selecting the most appropriate treatment for a given patient involves both patient factors (e.g., age, co-morbidities and compliance) and tear characteristics (e.g., location of tear/age/reducibility of tear). There is evidence suggesting that degenerative tears in older patients without mechanical symptoms can be effectively treated non-operatively with a structured physical therapy programme as a first line. Even if these patients later require meniscectomy they will still achieve similar functional outcomes than if they had initially been treated surgically. Partial meniscectomy is suitable for symptomatic tears not amenable to repair, and can still preserve meniscal function especially when the peripheral meniscal rim is intact. Meniscal repair shows 80% success at 2 years and is more suitable in younger patients with reducible tears that are peripheral (e.g., nearer the capsular attachment) and horizontal or longitudinal in nature. However, careful patient selection and repair technique is required with good compliance to post-operative rehabilitation, which often consists of bracing and non-weight bearing for 4-6 wk.     

Techniques for meniscal refixation

Surgical Principles Midline approach for arthroscopy [7]. Palpation of the joint line of the involved compartment from outside. A needle armed with a suture is passed through skin, fat tissue, capsule, peripheral, and central meniscal fragment. A second armed needle is placed 1 cm beside the first in identical fashion. With the probe which is introduced by an anteromedial or lateral portal, the suture of the first needle is brought back outside the joint. Depending on needle location sutures can be placed in horizontal or vertical fashion. After preparation of the necessary number of sutures, the sutures are tightened one by one under direct arthroscopic vision of the meniscal tear. A far posteriorly located part of a rupture is thereafter treated via a short posteromedial or -lateral arthrotomy with the knee flexed at 90°. The capsular ring is transected vertically to get access to the central meniscal fragment. Vertical sutures are placed starting from the most posterior aspect of the tear, and then one by one the sutures are tightened. The capsular ring is sutured. The vertical sutures with the open technique usually show a better initial fixation strength than the arthroscopic sutures [17]. The work was supported by grants from the Swedish Medical Research Council (Nr. 10396) and the Swedish Centre for Research in Sports.     

Arthroscopic suture of peripheral meniscal tears

Summary Twenty-nine patients underwent meniscal repair using an inside-to-out technique and instruments developed in our department. The tears were more than 1.5 cm in length, vertical, and located in the outer third of the meniscus. The torn segment was mobile, the remainder of the meniscus stable. After six months, fourteen out of sixteen patients achieved a good or excellent Lysholm knee score. We conclude that the technique is safe and reliable and allows better access than an arthrotomy. Care must be taken to avoid neurovascular injury.

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Résumé Vingt-neuf malades ont bénéficié d'une réinsertion méniscale arthroscopique selon une technique et avec l'aide d'instruments mis au point dans notre service. Les déchirures n'avaient pas plus de 1,5 cm de longueur, étaient verticales et situées dans le tiers périphérique du ménisque. Le segment déchiré était mobile et le reste du ménisque stable. Au sixième mois quatorze des seize opérés présentaient un bon ou un excellent résultat (selon la cotation du genou de Lysholm). Nous en concluons que cette technique est sûre et que'elle est mieux réalisable que par arthrotomie. Il faut prendre soin d'éviter tout traumatisme neuro-vasculaire.

     

膝关节镜Clearfix与FasT-Fix半月板修复系统修复半月板损伤的比较

目的比较膝关节镜Clearfix与FasT—Fix半月板修复系统修复半月板损伤的临床愈合率。方法1998年11月-2001年6月，膝关节镜下采用Clearfix系统修复半月板损伤50例；2001年6月～2002年12月，关节镜下采用FasT—Fix系统修复半月板损伤61例。比较2组半月板损伤的临床愈合率。判断半月板损伤临床愈合的标准包括关节无交锁、无肿胀、关节间隙无压痛以及McMurray试验阴性。结果Clearfix组平均随访19个月（12—48个月），根据临床标准12例半月板修复术失败，临床愈合率为75．O％（36／48）；FasT—Fix组平均随访18个月（14—28个月），5例半月板修复术失败，临床愈合率为91．4％（53／58）。Fast-Fix组半月板临床愈合率显著高于Clearfix组（Z=-2．277，P=0．023）。结论与Clearfix系统相比，FasT—Fix系统修复半月板损伤可获得较高的临床愈合率。     

Arthroscopic repair of the meniscal injury using meniscal repair device

Background:

Total meniscus resection after meniscus tear usually leads to faster degeneration and osteoarthritis of the knee joint. Preservation and repair of the injured menisci are therefore of great clinical importance. The aim of this study was to evaluate the clinical effects of arthroscopic repair of meniscal injuries using the Fast-Fix device.

Materials and Methods:

96 patients (58 males, 38 females) with mean age of 24.3 years (range 12–46 years)) with a meniscus injury were treated with the Fast-Fix device under arthroscopy between July 2007 and June 2009. The right and left knees were involved in 46 and 50 patients respectively. In 12, 46 and 38 patients, the injury was located in the anterior horn, body and posterior horn respectively. In 38, 45 and 13 patients, it was in the red, red-white, and white regions, respectively. All-inside and outside-in techniques were used for these meniscal injuries. Criteria for successful surgery were no locking pain or swelling and a negative McMurray test.

Results:

The mean followup period was 3.7 years (range 2–5 years). The surgical success rate was 91.7% (n = 88). The mean Lysholm score increased from 47.8 ± 10.4 preoperatively to 85.7 ± 12.8 postoperatively. The mean Tegner activity score was 7.4 ± 1.6 (range 5–9) preinjury, 2.1 ± 0.9 (range 0–4) preoperatively and 7.2 ± 2.2 (range 4–10) postoperatively (P < 0.001). A total of 92 patients (95.8%) returned to full-time work. The International Knee Documentation Committee score increased from 32.7 ± 10.7 (range 10.3–51.7) preoperatively to 82.5 ± 5.1 (range 65.1–91.2) postoperatively (P < 0.001).

Conclusions:

The Fast-Fix system is an efficient, safe and effective suture technique for meniscal repair.     

Magnetic Resonance Imaging is not suitable for interpretation of meniscal status ten years after arthroscopic repair

Purpose

The purpose of this study was to assess the MRI features of the all-inside repaired meniscus in the long-term.

Methods

Among 27 consecutive all-inside arthroscopic meniscal repairs, 23 patients aged 25 ± 5 years at the time of surgery were reviewed at a median follow-up of 10 ± 1 years. Retrospective clinical examinations and imaging assessments using a 1.5-T MRI after all-inside arthroscopic meniscal repair were conducted.

Results

At follow-up, Lysholm and IKDC averaged 89 ± 11 and 95 ± 8, respectively. MRI examinations revealed no meniscal signal alteration in three patients (13 %), a vertical signal located in the previously torn area in seven (30 %), a horizontal grade 3 in nine (39 %), and a complex tear (grade 4) in four (17.5 %). There were no differences between medial and lateral menisci (p = 0.15), stable and stabilised knees (p = 0.56).

Conclusions

Several abnormal vertical and/or horizontal hypersignals are still present on MRI examination ten years after arthroscopic all-inside meniscal repair. The appearance of early signs of osteoarthritis is rare, suggesting a chondroprotective effect of the repaired meniscus.     

Arthroscopic and open repair of the TFCC

Injury to the triangular fibrocartilage complex is the most common cause of ulnar-sided wrist pain. This functionally related complex of anatomic structures can be a source of pain secondary to acute injury or chronic degeneration. Strategies for the treatment of these injuries involve determining the anatomic location of the tear, the presence of associated distal radioulnar joint instability, and the presence of associated degenerative changes. Surgical management with open and arthroscopic techniques have been described, both with successful results.     

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.     

Failure of arthroscopic meniscal repair following septic arthritis

Three cases are described in which failure of arthroscopic meniscal repair performed with an inside-out technique occurred following postoperative septic arthritis. Confirmation of septic arthritis was made by bacterial culture of joint fluid aspirates. The treatment consisted of arthroscopic lavage and intravenous antibiotics. In all cases, diagnostic arthroscopy at the time of lavage showed an intact repair site. However, further follow-up arthroscopy revealed disruption at the repair site with no signs of healing.     

Trephination and suturing of avascular meniscal tears: A clinical study of the trephination procedure

On the basis of animal studies, an arthroscopic surgical system and procedure of trephination plus suturing were designed for clinical practice. The system consists of a trephine with a tooth-like tip, a guide, and an ordinary arthroscopic power handle. The guide introduces the trephine to the tear without abrading articular cartilage and controls the depth of the trephination. The power handle connected to a suction system provides an inside-out cut core of meniscal tissue. Thirty-six patients with meniscal tears underwent arthroscopic trephination plus suturing (group TS) and 28 patients had suturing alone (group S). The follow-up was 25 to 78 months. Two symptomatic retears have occurred in group TS and 7 symptomatic retears in group S. The symptomatic retear rate of group TS was significantly smaller than group S (P < .01). It is indicated that the patients treated with trephination have fewer symptoms and lower clinical failure rate. Arthroscopic trephination is a safe and easy procedure.     

Outcome analysis of arthroscopic treatment of partial thickness rotator cuff tears

Background:

Partial thickness rotator cuff tears occupy an important position in the spectrum of rotator cuff disease. The development of a more comprehensive classification has been sought to address both the tear location and extent, which may influence clinical results. The purpose of this study is to classify partial thickness rotator cuff tears according to the arthroscopic findings and to evaluate the clinical outcomes after arthroscopic repair of partial thickness tears.

Materials and Methods:

One hundred and two patients had arthroscopic treatment of partial thickness rotator cuff tears. The inclusion criterion for the study was a partially torn supraspinatus tendon involving articular or bursal side, verified by direct arthroscopic visualization. Outcome analysis was exclusively applied to patients who underwent transtendon repair, using the shoulder index of American Shoulder and Elbow Society and the University of California Los Angeles (UCLA) rating system.

Results:

Partial thickness rotator cuff tears were divided into five groups according to arthroscopic findings. There was significant improvement after surgery in all parameters of clinical evaluation in the tears that warranted repair. Arthroscopic repair in situ (transtendon technique) may be the preferred option in unstable partial thickness tear.

Conclusion:

The proposed classification system may assist decision making in the treatment of partial thickness rotator cuff tears.     

Arthroscopic surgery for traumatic triangular fibrocartilage complex injury

Clinical characteristics, diagnostic imaging, arthroscopic findings, and surgical results of arthroscopic treatment are reported in 62 hands with traumatic triangular fibrocartilage complex (TFCC) injury treated between 1995 and 2002. This retrospective study also describes and compares the results of a novel arthroscopic suture technique for repairing tears with Palmers class 1B and 1D tears. According to Palmers classification, there were 10 class 1A, 27 1B, 8 1C, and 17 1D injuries. The arthroscopic suture and débridement treatments were done under brachial plexus block as a 1-day in-hospital procedure. Class 1D tears required transradial fixation to anchor the TFCC. Surgical results of suture groups according to Minamis criteria were excellent in 16 hands, good in 15 hands, fair in 1 hand, and poor in 1 hand. The results of the débridement group were excellent in 16 hands, good in 10 hands, fair in 2 hands, and poor in 1 hand. The results of the current study indicate that the novel suture technique were easy to perform, provided strong, tight repair for class 1D injuries, and was applicable for class 1B injuries in this small case series.     

Arthroscopic repair of full-thicknessrotator cuff tears: Operative technique

Arthroscopic repair of full-thickness rotator cuff tears is currently performed by a number of surgeons. The goals, indications, and postoperative rehabilitation are identical to traditional open repair. The principles of the operative technique are also identical to open repair, with the differences occurring in the manner in which the tendon is repaired to bone. This article describes in detail the operative technique for the repair of a full-thickness rotator cuff tear.     

Arthroscopic repair of peripheral triangular fibrocartilage complex tears with suture welding: a technical report

This report presents a method of arthroscopic repair of the peripheral triangular fibrocartilage complex tears that replaces traditional suture knots with ultrasonic welding of sutures. This will help eliminate potential causes of ulnar-sided wrist discomfort during the postoperative period.     

Modified arthroscopic double row repair of partial thickness tear of the rotator Cuff involving articular and bursal side

Partial thickness of rotator cuff tears is considered as a common cause of shoulder disability. Various techniques for arthroscopic repair of partial thickness tear of rotator cuff have been reported in the literature. These techniques have addressed the articular side partial thickness cuff tear. We present an arthroscopic repair of partial thickness tear of rotator cuff involving both articular and bursal surfaces without converting into a full thickness tear. Each side of the tear was repaired with suture anchors separately.