Meniscal repair

Over the past several decades, scientific evidence has mounted to substantiate the vital role of the meniscus in the function of the knee. Total meniscectomy is rarely indicated and the pendulum of orthopedic popular opinion has swung toward new ways to preserve the injured meniscus. This article reviews the anatomy, blood supply, and function of the meniscus and also discusses the supporting scientific evidence, decision-making processes, and techniques for meniscal repair.     

Meniscal repair using the inside-out technique with cross stitch

The treatment of meniscal tears continues to evolve. A few years ago most tears were treated with total meniscectomy, which evolved to partial meniscectomy and then to meniscal repair. The purpose is to preserve as much of the menisci as possible, to maintain their potential biomechanical properties, and to preserve normal knee function. Different repair techniques have been used many of them involving both vertical and horizontal sutures. We are proposing an inside-out meniscal repair technique with cross-shaped stitches that provides a 4-point fixation construct.     

Meniscal repair: the newest fixators

The surgical techniques and associated devices for meniscus repair have improved over time, spurred in part by the clear recognition of the benefits of meniscal preservation and in part by the introduction of ultra-high-molecular weight polyethylene containing sutures. The desires for more minimally invasive techniques that decrease the risks of neurovascular injury and articular cartilage excoriation have seen 1 device generation after another introduced and improved upon. The current generation of meniscal repair all-inside devices are easier to use, limit the presence of material on the meniscal surface, and are self-adjusting and suture based. Although the speed of meniscus fixation device development places increasingly useful devices in surgeons' hands, clinical evidence of their effectiveness lag behind.     

Meniscal repair using the inside-out suture technique

Operations to treat meniscal injuries rank among the most frequent procedures performed by orthopedic surgeons. Ongoing research into the natural history, basic science, and biomechanics of meniscal injury has highlighted the importance of preserving the meniscus to maintain normal knee biomechanics and function. The arthroscopic inside-out suture repair is currently the gold standard by which other meniscal repair techniques are judged. Although it is difficult to identify meniscal tears amenable to repair preoperatively, an assessment of patient factors and tear characteristics on the basis of magnetic resonance imaging and intraoperative findings will aid the decision to excise or repair. For successful repair the meniscal tear must have appropriate location and characteristics, without evidence of fraying or degeneration. Repair with the arthroscopic inside-out method affords anatomic reduction of the meniscus tear and allows stimulation of circulation, factors which contribute to healing of the repair. Coupled with careful dissection and needle placement, this method minimizes complications associated with meniscus repair.     

Meniscal repair using the FasT-Fix device in patients with chronic meniscal lesions

The aim of this prospective study was to evaluate meniscal suturing using the FasT-Fix device for chronic meniscal tears. This procedure was carried out on 25 patients between 2006 and 2007. Nineteen patients were male and the median age was 31 (14–47) years. The median waiting time to surgery was 27 (6–80) months and the median follow-up was 20 (14–29) months. Eleven patients (44%) required reconstruction of an associated anterior cruciate ligament (ACL) injury. 20 patients (80%) showed medial meniscus tears. All tears were located in the red zone or red–white zone. According to Barett’s criteria, meniscal tear healing was achieved in 21 patients (84%). Lysholm and Tegner scale scores improved from 60 (47–77) preoperatively to 95 (58–100) postoperatively and from 3 (2–6) preoperatively to 6 (3–9) postoperatively, respectively. There were no neurovascular complications. Revision surgery was necessary in one patient, in whom a partial meniscectomy was performed. The results obtained suggest that chronic meniscal tears in the zones described can be healed.     

Meniscal repair following meniscectomy: mechanism and protective effect

Meniscal repair was studied to evaluate the mechanism and its potential protective effects on the articular cartilage in an experimental model consisting of 68 knees of adult dogs on which five different types of medial meniscectomy were performed. The results were assessed by macroscopic, microangiographic, and histological methods, after a sequential follow-up period of 10–450 days. Two different mechanisms of meniscal repair were observed, depending on whether meniscal section had been performed in vascular (total meniscectomy) or avascular (subtotal or partial meniscectomy) zones. It was also observed that the repaired meniscal tissue does not prevent articular cartilage degeneration. This is more closely related to the size of the meniscal fragment preserved at meniscectomy. Due to the biomechanical importance of the meniscus and the lack of functional relevance of the repaired meniscal tissue, the most conservative approach possible to meniscectomy is recommended.     

Meniscal tears: MR and arthrographic findings after arthroscopic repair

Magnetic resonance (MR) imaging was performed on 29 previously repaired menisci and one conservatively treated meniscus (total, 30 menisci). Intermediate- and T1-weighted MR sequences revealed persistent signal intensity extending to an articular surface (grade 3 signal intensity) in 27 of the 30 menisci. On T2-weighted images, seven of the 30 menisci were found to contain unequivocally higher signal intensity, defined by a full-thickness defect (grade 3 signal intensity involving two articular surfaces) increasing in signal intensity to a level equivalent to that of joint fluid. The MR imaging and arthrographic appearances of 23 of the 30 menisci were compared. Arthrographic examination revealed partial or complete healing in 13 menisci and tears in 10. The presence of grade 3 signal intensity on intermediate- and T1-weighted MR images did not reliably predict a tear seen at arthrography. Unequivocally higher signal intensity on T2-weighted images is a useful sign in the prediction of a persistent meniscal tear (sensitivity, 60%; specificity, 92%; P less than .02). Since presence of grade 3 signal intensity on intermediate- and T1-weighted images does not reliably predict a tear and unequivocal T2 increase in intensity has a sensitivity of only 60%, arthrography should be considered for assessment of the symptomatic, previously repaired meniscus.     

Meniscal repair compared with meniscectomy for bucket-handle medial meniscal tears in anterior cruciate ligament-reconstructed knees

BACKGROUND: Repair of meniscal tears is generally preferred over meniscectomy. HYPOTHESIS: Repair of unstable bucket-handle tears of the medial meniscus leads to better outcomes than partial meniscectomy. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: We reviewed the records of 155 patients who had isolated bucket-handle medial meniscal tears and anterior cruciate ligament tears. Fifty-six menisci were repaired; 99 that were degenerative and crushed beyond repair were removed. Patients were evaluated at a mean follow-up of 6 to 8 years after surgery with the International Knee Documentation Committee examination and a modified Noyes questionnaire. RESULTS: The mean subjective scores were similar for patients in both the repair (N = 51) and meniscectomy (N = 87) groups. However, in the repair group, the mean subjective score of 93.9 for nondegenerative menisci was significantly better than the 87.1 for degenerative menisci. Objective grades for 25 patients in the repair group were normal or nearly normal in 22 patients (88%) and for 51 of 56 patients (91%) in the removal group. Radiographic subscores for the repair group were normal or nearly normal in 23 patients in the repair group and 49 in the removal group. CONCLUSION: Outcomes from meniscal repair were not superior to those from partial removal. Patients with repaired degenerative tears had significantly lower subjective scores than those with nondegenerative tears.     

Meniscal repair in anterior cruciate ligament reconstruction: a long-term outcome study

Purpose  

To study the long-term outcome of patients who have undergone inside-out, vertical stacked mattress suture repair of meniscal tears combined with anterior cruciate ligament (ACL) reconstruction.     

Tissue engineering for tendon repair

Tissue engineering aims to induce tissue self-regeneration in vivo or to produce a functional tissue replacement in vitro to be then implanted in the body. To produce a viable and functional tendon, a uniaxially orientated collagen type I matrix has to be generated. Biochemical and physical factors can potentially alter both the production and the organisation of this matrix, and their combination in a dose- and time-dependent manner is probably the key to in vitro engineered tendons. This review discusses the role of these different factors affecting tenocyte growth in a three-dimensional environment in vivo and in vitro, and underlines the future challenge of tendon tissue engineering.