The arthroscopic meniscal repair. Techniques and clinical experience

Conservative meniscal repair should limit resection to only pathologic portions of the meniscus. The periphery of the meniscus is well vascularized, enabling healing of longitudinal tears. Sutures that perforate the meniscus vertically usually lead to stable healing. In arthroscopic meniscal surgery, isolated tears are sutured from within the joint, usually using techniques related to specially developed instrumentation. Our system uses three curved cannulas of various radii and a specific needle of 1.2 mm thickness, and can be operated by one hand while the joint is distracted with an AO/ASIF femoral distractor. In our series of 54 arthroscopic meniscal repairs, 42 (78%) healed without reinjury. Retears occurred in 12 patients, and were refixed again using the same techniques. Our experience has led us to conclude that the type of meniscal tear most suitable for arthroscopic repair is a vertical longitudinal lesion that involves the vascularized zone; abrading the synovial surfaces is helpful, as is positioning the sutures tightly together; the repair should be checked at 4 months by arthroscopy or by arthrogram; and a combination of nonabsorbable and resorbable sutures is most satisfactory. We believe that with experience arthroscopic meniscal repair becomes a less involved procedure than open repair, and that in the future such repair will be successfully extended to the more centrally located lesions.     

Clinical results of arthroscopic meniscal repair using biodegradable screws

This study was performed to assess the clinical results of meniscus refixation using biodegradable Clearfix meniscal screws. Between July 1999 and June 2001 this technique was performed on 65 patients, of whom 60 (27 women, 33 men; 92%) were followed up by clinical examination after an average of 18 months (range 8–34). The average age of the patients at the time of surgery was 30 years (15–58). Two patients had already undergone a partial meniscectomy at the time of follow up; three patients had had a recurrence of typical clinical signs of a meniscal tear. The other 55 patients rated the overall clinical result as "excellent" (n =21), "good" (n =31) or "satisfactory" (n =3). The average Lysholm score [20] at the time of examination was 93 (49–100) points. The Tegner-Lysholm activity grade [29] preinjury was 5.6 (3–9), compared to a grade of 5.1 (3–9) at the follow-up examination. As a result of our study, biodegradable screws can be recommended as fixation devices with a high rate of good and excellent clinical results.     

Modified cruciate suture technique for arthroscopic meniscal repair: a technical note

Arthroscopic meniscal repair is the procedure of choice whenever a reparable tear is diagnosed. The cruciate suture for arthroscopic meniscal repair is a type of the outside-in technique. It has advantages like: (1) its ultimate tension load (UTL) is 1.6 times higher than the UTL of the vertical suture (gold standard), (2) it holds the circumferential collagen fibers of the meniscus in a three-dimensional plane compared to the vertical and horizontal sutures which hold the circumferential fibers of the meniscus in a two-dimensional plane, (3) simple instrumentation, (4) could withstand not only distraction forces on the repaired meniscal tear but also, shear forces because of the oblique orientation of the cruciate suture limbs. It has disadvantages like: being difficult to perform and time-consuming. A modified technique is presented in this study which has the following advantages; (1) less time-consuming, (2) performed through a smaller skin incision, (3) a sliding knot is used to tie the cruciate suture.     

Pull-out and shear failure strengths of arthroscopic meniscal repair systems

Meniscal repair is common and recommended in young patients. Suture techniques and fixation devices were developed for stronger, more facile repairs. Three devices (T-Fix, Meniscal Staple, Meniscus Arrow) were biomechanically compared to horizontal PDS suture. Peripheral tears were created in porcine menisci and repaired using the manufacturer's technique. An Instron was used to distract the menisci at 50 mm/min in axial-pullout and longitudinal shear loads. Load to failure curves and peak failure loads were noted. Load to failure in axially loaded pull-out mode was: Staple, 4.195+/-3.70 N; Arrow, 39.755+/-11.37 N; T-Fix, 45.892+/-13.99 N; Suture, 107.65+/-22.37 N. Analysis of variance with post hoc testing revealed Staple failure at lower load than all devices and Suture failure at higher loads than all devices; Arrow and T-Fix were similar. The data varied significantly from that obtained in shear. Shear loads to failure were: Staple, 8.39+/-8.62 N; Arrow, 27.67+/-14.33 N; T-Fix, 57.47+/-17.05 N; Suture, 64.15+/-17.05 N. Analysis of variance, power analysis, and pair-wise multiple comparisons revealed significant differences between: Suture and Staple, Suture and Arrow, and T-Fix and Staple. No differences were noted between Suture and T-Fix, T-Fix and Arrow, or Arrow and Staple. In pullout, Suture and T-Fix maintained better apposition at low loads. As load increased, the menisci separated until device failure. Arrows allowed low load separation but held tissue until failure. Staples failed at low load. For shear, the menisci attempted to reorient parallel to the force. The devices failed in a pull-slide pattern. Suture failed by pull-through. Meniscal repair devices are easy to use and may provide resistance to shear and pull out. The resistance to pullout loads was very different than the resistance to longitudinal shear loads.     

Parameniscal cyst formation after arthroscopic meniscal repair with biodegradable meniscal arrow: a case report

A 22-year-old male underwent an arthroscopic meniscal repair, using meniscal arrows, due to bucket-handle medial meniscus tear. Magnetic resonance images (MRI) at 3 years revealed a large parameniscal cyst protruding into the extra-capsular popliteal space. Arthroscopic partial cystectomy, removing only the intra-articular portion of the cyst was performed, leaving the extra-articular part of the cyst. Sixteen months postoperatively MRI revealed no cyst remnants, and the patient was free of symptoms.     

A novel technique for arthroscopic reduction and repair of a bucket-handle meniscal tear

We present a new technique designed for the reduction and repair of bucket-handle meniscal tears. After assessing the rotation of the displaced tear fragment of the meniscus, the centrally displaced portion of the tear is vertically pierced with a suture hook enabling passage of a No. 0 PDS suture, both limbs of which are retrieved out of the joint. Next, using a spinal needle and a shuttle relay system, both ends of the No. 0 PDS on the femoral and tibial surfaces of the meniscus are extricated outside the joint capsule. In the final step, reduction of the displaced fragment is achieved by pulling on the PDS suture and the same suture is used for repair too, after which additional sutures are applied. This is a useful technique, which affords the benefit of rotational reduction of a bucket-handle meniscal tear using a single suture, as well as improved maneuverability for freshening of the tear margins prior to repair and additional suturing, and finally for repair as a full-thickness vertical suture.     

Prospective comparison of arthroscopic medial meniscal repair technique: inside-out suture versus entirely arthroscopic arrows

BACKGROUND: Medial meniscal repairs are commonly performed with inside-out sutures and entirely arthroscopic with arrows, but few comparative evaluations on failures have been performed. HYPOTHESIS: No differences in failure rates exist between medial meniscal repairs performed with inside-out suture or entirely arthroscopic at the time of anterior cruciate ligament reconstruction. STUDY DESIGN: Prospective cohort study. MATERIALS: A single surgeon performed 47 consecutive inside-out suture repairs from August 1991 to June 1996 and 98 consecutive entirely arthroscopic repairs with arrows from June 1996 to December 1999. All data were derived from a prospective database and rehabilitation was held constant (nonweightbearing 5 weeks). Clinical success was defined as no reoperation for failed medial meniscal repair. Statistical evaluation was by Kaplan-Meier curves and Cox proportional hazards model. RESULTS: The inside-out suture group had 85% follow-up (40 of 47) with a median 68 months and the entirely arthroscopic group had 87% follow-up (85 of 98) with a median 27 months. There were seven failures in each group. Both Kaplan-Meier curves and the Cox proportional hazards model showed no difference in time to reoperation between techniques (P = 0.85). Three-year success rates (proportions with no reoperations) were 88% for sutures versus 89% for arrows. CONCLUSIONS: Repairs of the longitudinal posterior horn of the medial meniscus during an anterior cruciate ligament reconstruction with nonweightbearing for 5 weeks can be performed with an equivalent high degree of clinical success for both repair techniques.     

Peripheral meniscal tears: MR findings after conservative treatment or arthroscopic repair

Follow-up knee magnetic resonance (MR) examinations were performed on 17 patients (18 menisci) with arthroscopically proved tears of the outer third of the meniscus who were treated either conservatively (six patients) or with surgical repair (11 patients). All patients satisfied accepted clinical orthopedic criteria for meniscal healing. MR examinations obtained 3-27 months after injury revealed persistent signal intensity (grade 3), unchanged from that seen on the preoperative study, in all 15 patients in whom both pre- and postoperative studies were obtained and in three of four menisci that were proved to be healed at second-look arthroscopy. It appears that grade 3 signal from both conservatively treated and repaired menisci may persist long after the tear has become asymptomatic and has presumably healed. The presence of such signal should not be interpreted as necessarily indicating meniscal retear in these patients. Persistent signal intensity at the site of previous injuries may account for some reported cases of disagreement between MR and arthroscopic findings.     

Osteolysis of the tibial plateau after meniscal repair with hybrid suture anchor

Preservation of the meniscus and consideration for repair is important when treating meniscal tears. Many techniques for repair have been described. At present, all-inside, suture anchor-based meniscal repair systems are widely used. Arthroscopic all-inside hybrid meniscal suturing has been shown to have a low complication rate as the suture anchors remain outside the capsule leaving only the suture material inside the joint. Complications such as chondrolysis or arthrolysis have not been reported with these devices until now. The purpose of our study is to highlight the risks of osteochondral damage if these devices persist intra-articularly. Level of evidence IV.     

Complications in arthroscopic meniscal surgery

Arthroscopic meniscal procedures as a whole have an acceptably low complication rate. The rate is no higher than the average for all arthroscopic procedures. In the hands of experienced arthroscopic surgeons the complication rate for meniscal repair is slightly lower than that for arthroscopic partial meniscectomy. Attention to anatomic detail, knee positioning, and proper surgical technique has resulted in a significant decrease in the incidence of major neurovascular injuries. The complication rate for outside-in meniscal repair is no lower than that for inside-out meniscal repair. Further refinements in surgical technique, suture materials, and instrumentation should result in an even lower complication rate. Ongoing studies to determine when the repaired meniscus has achieved clinical stability may allow earlier range of motion and further lessen postoperative stiffness.     

Multirater agreement of arthroscopic meniscal lesions

BACKGROUND: Establishing the validity of classification schemes is a crucial preparatory step that should precede multicenter studies. There are no studies investigating the reproducibility of arthroscopic classification of meniscal pathology among multiple surgeons at different institutions. HYPOTHESIS: Arthroscopic classification of meniscal pathology is reliable and reproducible and suitable for multicenter studies that involve multiple surgeons. STUDY DESIGN: Multirater agreement study. METHODS: Seven surgeons reviewed a video of 18 meniscal tears and completed a meniscal classification questionnaire. Multirater agreement was calculated based on the proportion of agreement, the kappa coefficient, and the intraclass correlation coefficient. RESULTS: There was a 46% agreement on the central/peripheral location of tears (kappa = 0.30), an 80% agreement on the depth of tears (kappa = 0.46), a 72% agreement on the presence of a degenerative component (kappa = 0.44), a 71% agreement on whether lateral tears were central to the popliteal hiatus (kappa = 0.42), a 73% agreement on the type of tear (kappa = 0.63), an 87% agreement on the location of the tear (kappa = 0.61), and an 84% agreement on the treatment of tears (kappa = 0.66). There was considerable agreement among surgeons on length, with an intraclass correlation coefficient of 0.78, 95% confidence interval of 0.57 to 0.92, and P < .001. CONCLUSIONS: Arthroscopic grading of meniscal pathology is reliable and reproducible. CLINICAL RELEVANCE: Surgeons can reliably classify meniscal pathology and agree on treatment, which is important for multicenter trials.     

Lateral meniscal cyst: arthroscopic management

Thirty-six patients underwent arthroscopic cystectomy and partial meniscectomy for a lateral meniscal cyst. In two other patients, an open cystectomy was performed following a diagnostic arthroscopy. The patients were reviewed at an average of 39 months (range 8-82) after the operation, and recurrence was found in four cases. Five patients, all keen sportsmen, were dissatisfied with the operation. Four patients, with arthroscopic signs of early degenerative arthritis, were still experiencing some pain, but were able to lead a normal working and social life. Arthroscopy is safe, giving low morbidity and recurrence. In the cases treated by arthroscopy, a horizontal meniscal tear was always found. The question whether this tear and the resulting meniscal changes are traumatic or degenerative in origin still remains; and, to some extent, neither hypothesis can be readily discarded. This study supports the use of arthroscopy alone in the treatment of lateral meniscal cysts.     

Arthroscopic meniscal repair

The advent of arthroscopy and advanced arthroscopic techniques has made meniscal repair the preferred approach for many meniscal tears. This article reviews the blood supply of the meniscus and discusses the supporting scientific evidence, decision making, and techniques for meniscal repair.     

Arthroscopic meniscal repair

Arthroscopic meniscal repair is a promising new technique for treating peripheral meniscal tears. With proper attention to surgical technique, the repair can be safely performed by any surgeon with moderate arthroscopic skills. We recommend that in all cases the capsule be exposed through a small incision to identify and protect the neurovascular structures. When an associated ACL tear is present, ligamentous reconstruction is also recommended. Although we currently limit our repairs to peripheral tears, newer techniques may expand indications for this procedure.     

Biomechanical comparison of the FasT-Fix meniscal repair suture system with vertical mattress sutures and meniscus arrows

BACKGROUND: A meniscal repair technique that combines the strength of vertical mattress sutures and the decreased tissue morbidity of an all-inside technique would be advantageous. HYPOTHESIS: The FasT-Fix Meniscal Repair Suture System will provide load at failure, stiffness, and displacement equivalent to that of vertical mattress sutures and superior to that of Meniscus Arrows. STUDY DESIGN: In vitro biomechanical study. METHODS: After repair of a 2-cm vertical longitudinal medial meniscal lesion, three groups of six human cadaveric knees were biomechanically tested in a random order on a servohydraulic device, and three groups of five specimens underwent cyclic loading. RESULTS: Specimens repaired with Meniscus Arrows had reduced load at failure, stiffness, and displacement, but there were no differences between the FasT-Fix and vertical mattress suture methods. During cyclic loading, specimens repaired with two Meniscus Arrows failed before test completion, whereas specimens repaired with two vertical mattress sutures (6.0 +/- 3.7 mm) or with two FasT-Fix implants (5.1 +/- 1.4 mm) maintained fixation with comparable displacements. CONCLUSIONS: The FasT-Fix provided load at failure, stiffness, and displacement comparable with that of vertical mattress sutures. Clinical Relevance: The results suggest that the FasT-Fix may be preferable to Meniscus Arrows for meniscal repair with minimal associated tissue morbidity.     

Neuraland vascular complications of arthroscopic meniscal surgery

Injuries to vessels and nerves are very rare complications of arthroscopic meniscal surgery. The clinical development and diagnosis of such complications are described and illustrated by cases described in the literature and by two of our own cases. Typical patterns of injury are simulated by dissection of cadaver knees. To avoid neural complications in suturing the menisci, on the medial side the joint capsule has to be prepared when using the inside-out orthe outside-in technique. On the lateral side the outside-in technique can be performed by small suture incisions in this area when the lateral knee structures can be palpated. When using the inside-out technique the peroneal nerve must be dissected free. When resecting the posterior horn of the medial meniscus forced external rotation of the knee should be avoided because in this position the popliteal artery and the medial inferior genicular artery lie close to the posterior horn.