Professional Documents
Culture Documents
Meniscal Repair
Christian Stärke, M.D., Sebastian Kopf, M.D., Wolf Petersen, M.D., and Roland Becker, M.D.
Abstract: The meniscus plays an important role in preventing osteoarthritis of the knee. Repair of
a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with
concurrent anterior cruciate ligament reconstruction, and in younger patients. The probability of
healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Age
or extension of the tear into the avascular area are not exclusion criteria. Numerous repair techniques
are available, and suture repair seems to provide superior biomechanical stability. However, the
clinical success rate does not correlate well with the mechanical strength of the repair technique.
Biologic factors might be of greater importance to the success of meniscal repair than the surgical
technique. Therefore, the decision on the most appropriate repair technique should not rely on
biomechanical parameters alone. Contemporary all-inside repair systems have decreased the oper-
ating time and the level of surgical skill required. Despite the ease of use, there is a potential for
complications because of the close proximity of vessels, nerves, and tendons, of which the surgeon
should be aware. There is no clear consensus on postoperative rehabilitation. Weight bearing in
extension would most likely not be crucial in typical longitudinal lesions. However, higher degrees
of flexion, particularly with weight bearing, give rise to large excursions of the menisci and to shear
motions, and should therefore be advised carefully. Long-term studies show a decline in success rates
with time. Further studies are needed to clarify the factors relevant to the healing of the menisci.
Tissue engineering techniques to enhance the healing in situ are promising but have not yet evolved
to a practicable level. Key Words: Age—Growth factors—Healing—Meniscus—Rehabilitation—
Repair technique.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 25, No 9 (September), 2009: pp 1033-1044 1033
1034 C. STÄRKE ET AL.
Horizontal cleavage tears are a frequent finding and Medial Versus Lateral Lesions
may exist without clinical symptoms.18 There is little
information on the significance of this type of tear. In a series of 53 patients, no significant difference in
They can give rise to flap tears but are otherwise the healing rate was found by means of computed
mechanically stable. It has not been clarified yet tomographic arthrography for the medial and lateral
meniscus.17 Cannon and Vittori10 found lateral me-
whether patients benefit from the repair of these tears.
nisci to have a better healing rate than medial menisci.
It appears questionable if sutures could neutralize the
Another investigation into ACL-reconstructed knees
shear motion that is thought to be responsible for the
did not find different failure rates for lesions located in
development of these tears. If horizontal tears are
the Cooper zones 1 and 2 of either the medial or lateral
encountered incidentally— during ACL surgery, for
meniscus.26 It is not entirely clear whether or not the
example—they might be left alone. At times, those
healing potential in the medial and lateral meniscus
tears are accompanied by meniscal cysts,19 which are
are different. Yet the potential sequelae of meniscec-
thought to arise from the influx of joint fluid through tomy are more serious in the lateral meniscus than in
meniscal tears. Partial meniscectomy is often carried the medial.2 Therefore, in the decision-making pro-
out to drain the cyst. It has been suggested that aspi- cess, it matters which of the menisci is affected.
ration of the cyst and closure of the tear with sutures
could avoid the need for a meniscectomy.20 Influence of Age
Controversy exists concerning radial tears. They
should be clearly distinguished between complete and It has been observed that meniscal tissue from pa-
partial radial tears. Empirically, partial radial tears tients over 40 years of age has a lesser cellularity and
often affect the central parts while the outer rim re- a decreased healing response than tissue from younger
mains intact. This has important mechanical implica- patients.27 Eggli et al.28 stratified their patients into
groups older and younger than 30 years and found
tions: in partial radial tears, the important circumfer-
retears to be more frequent in older patients. Bach
ential fiber bundles are mostly intact and the function
et al.25 analyzed failures in a series of 300 meniscal
of the meniscus is retained. Further, those tears largely
repairs.25 The average time to failure was 34 months
extend into the avascular area, which limits the chance
in this study. Older patients failed significantly later
of healing.21 Therefore, particularly in small radial
than patients younger than 30 years of age. Other
tears, debridement of loose edges is usually sufficient.
investigators did not find a correlation between the
In cases of a complete trans-section, however, the revision rate and patient age in 113 cases of an all-
effect can be similar to a complete meniscectomy.22 If inside repair using the Meniscus Arrow (Conmed Lin-
left untreated, weight bearing would extrude the me- vatec, Largo, FL).29 In a recent study, the results of
niscus out of the joint space and most likely no func- meniscal repair in patients with reconstructed ACLs
tionally sufficient healing would occur. Although it are reported, and in terms of failures, no difference
has been found that lateral meniscal tears in conjunc- was found between patients older or younger than 35
tion with ACL tears seem to have good prognosis in years of age.9 The rates of clinical success in repair
general,23 some surgeons24 including the authors of procedures, which involve the avascular area, seem
this review, feel that it might be beneficial to approx- not to be worse in older patients (40 to 58 years)
imate and secure the tear margins of a complete tear compared with the younger population.8,30 The out-
with sutures. In those cases, non–weight bearing ex- come of repair in young patients is not generally
ercise is warranted postoperatively because circumfer- favorable, as one might expect.31 By means of ar-
ential stress (so-called “hoop stress”) is induced in the thrography or magnetic resonance imaging, it was
meniscus with tibiofemoral loads, which would dis- shown that healing of repaired tears remained incom-
tract the tear margins. plete in a high fraction of young patients, even in the
The influence of the tear length on the failure rate is absence of symptoms.31 The same negative prognostic
not entirely clear. Although some authors could not factors as in older patients, such as a complex tear
prove an association between the failure rate and the configuration, large distance to the periphery, or lig-
length of the tear,11 others found that failures occurred amentous instability, apply to the younger patients.32
significantly earlier in larger tears.25 In one study, the Obviously, the clinical results in younger patients are
healing rate was in excess of 90% if the length of the in conflict with the better intrinsic healing capability
tear was less than 2 cm, whereas it was only 50% with that the basic science suggests. First, there are no
tears larger than 4 cm.10 randomized controlled studies in which the treatment
1036 C. STÄRKE ET AL.
TABLE 1. Overview of Meniscal Repair Instruments ing time and problems to reach the far posterior re-
and Implants gions of the meniscus. Therefore, implants to be used
Suture Repair without the need for additional incisions (all-inside)
Suture Rigid Implants Systems were developed. The first generation of those all-
inside systems were small rigid implants with barbs or
● Inside-out (generic ● Meniscus Arrow ● FasT-Fix (Smith &
threads, usually made from absorbable polymers. In
flexible needles (Conmed Nephew
and prebent Linvatec) Endoscopy) addition to occasional mechanical complications,
cannulas) ● Meniscal Dart ● MaxFire (Biomet) most of the solid all-inside implants show a consider-
● Outside-in (Arthrex) ● Meniscal Cinch able inferior stiffness and failure load, partially less
(generic ● BioStinger (Arthrex) than 10 N.38,39 In an effort to provide the convenience
intravenous (Conmed ● RapidLoc (DePuy
of the rigid implants while giving the strength of
cannulae) Linvatec) Mitek)
● All-inside ● Meniscal Screw suture repair, combinations of sutures and rigid parts
(Meniscal Viper (Biomet) were developed (Table 1; Figs 3–5). While the FasT-
[Arthrex]) Fix (Smith & Nephew Endoscopy, Andover, MA)
implant was the first of its kind, all major suppliers of
arthroscopic equipment now offer devices with a sim-
ilar design. Table 2 shows the rates of clinical success
allocation is primarily based on patient age. Most for a variety of repair techniques and implants. It
investigators will consider the macroscopic appear- should be noted that partial healing or failure of heal-
ance of the meniscus in their treatment decision and
would not repair tears in grossly degenerated menisci.
This results in a selection bias, which potentially ob-
scures the influence of the patient’s age. Further,
higher demands in sports and occupation in the young
population might compromise the outcome despite a
better intrinsic healing capability. The available data
suggest that age is not a general contraindication to
meniscal repair—it merely increases the likelihood of
encountering a tear that is not suitable for repair.15
NOTE. The criteria for success are heterogenous. Most authors shown in Table 2 define failure as the need for repeat arthroscopy or
symptoms of locking and catching. Table 2 is sorted by length of follow-up time, from the shortest amount of time at the top to the longest
amount of time at the bottom. Whether or not the anterior cruciate ligament was reconstructed is given and, if applicable, the impact on the
outcome. Numbers in parentheses give the outcome for the subgroup with unstable knees. It should be noted that there is a general trend of
increasing failure rates with time. Meniscal repairs in anterior cruciate ligament–reconstructed knees have better results than repairs in
primary stable knees or unstable knees.
Abbreviation: ACLR, anterior cruciate ligament reconstruction.
praxia was described in up to 22% of cases,46 perma- mended. However, Kalliakmanis et al.9 reported no
nent damage was found to occur in 0.4% to 1%.47,48 neurovascular complications in a larger series of re-
An anatomic study that investigated the placement pairs using the T-Fix and FasT-Fix implants.
of the T-Fix (Smith & Nephew Endoscopy) device In the case of solid implants, the depth of penetra-
showed that neurovascular structures seem not to be at tion can usually be controlled by choosing an implant
risk of being pierced with the insertion cannula.49 In a of appropriate length. Nevertheless, cases of nerve
more recent investigation, the authors found that the damage have been described.51,52 A complication that
application cannula of a FasT-Fix device came within is less dramatic than neurovascular damage and may
3 mm of the popliteal artery under certain circum- thus be under-recognized is accidental soft tissue te-
stances, whereas the RapidLoc (DePuy Mitek, Rayn- nodeses. Anatomic studies have shown, for example,
ham, MA), with its shorter cannula, had a greater that the sartorius tendon, the deep medial collateral
distance to that vessel.50 The use of the depth limiter ligament, and the popliteus tendon are at risk of being
that comes with the FasT-Fix is therefore recom- penetrated by the application cannula (Fig 7).45,49 Al-
MENISCAL REPAIR 1039
results in about 90% of cases. Zhang and Arnold66 and with concomitant ACL reconstruction, the main rea-
Zhang et al.67 have shown in animal studies that son for the procedure is instability, and that conclu-
trephination enhances the healing capacity of lesions sively not only symptomatic but also clinically silent
in the avascular zone with and without additional lesions of the meniscus are identified and repaired.
sutures. However, in patients with stable knees, the cause for
the meniscal repair usually is meniscal symptoms,
INFLUENCE OF CONCURRENT INJURIES such as locking or effusion. The possibility of a se-
lection bias must therefore be considered.
An injury to the ACL is the most often described
entity encountered together with a meniscus tear. REHABILITATION
While the classic description of the O’Donoghue triad
comprises a lesion of the medial meniscus together Patients should be informed in advance that menis-
with a rupture of the ACL and medial collateral lig- cal repair is usually accompanied by much longer
ament, Barber68 and Shelbourne and Nitz69 have periods of restricted motion and limitation of the knee
pointed out that lesions of the lateral meniscus are function than after a meniscectomy. It has been shown
much more common in acute injuries. In chronic ACL that the reparability of meniscal tears can be predicted
deficiency, the relation shifts toward the medial me- reasonably well by magnetic resonance imaging stud-
niscus.16,70 It has been shown that an abnormal an- ies,78 which gives both the patient and surgeon the
teroposterior laxity increases the resultant forces in the opportunity to be prepared in advance.
medial meniscus.71 The meniscus becomes a second- A generally valid rehabilitation algorithm has not
ary stabilizer, a purpose for which it is not primarily been established. Rehabilitation plans need to be in-
made. dividually tailored and should take into consideration
Accumulated microdamage explains the increasing the nature of the tear, concurrent injuries and proce-
rates of medial meniscal lesions in the course of dures, and the influence of specific exercises on the
untreated ACL deficiency. Conclusively, meniscal re- repaired tear (Table 3).
pair should result in a better outcome if it is done in There are both mechanical and biologic effects as-
conjunction with a stabilization of the knee. There sociated with postoperative weight bearing and mo-
have been no randomized studies that have investi- tion of the knee. In repaired bucket-handle lesions,
gated the outcome of meniscal repair in relation to the weight bearing reduces the meniscus and stabilizes the
ACL state. Usually, the anteroposterior instability will tear.40 Flexion under tibiofemoral loads of the knee,
be regarded as the primary problem, and randomiza- however, leads to increasing compressive and shear
tion in terms of the ACL reconstruction is not an loads in the posterior horn. It was reported that weight
option. Nevertheless, there are some studies that com- bearing flexion from full extension to 90° increases
prise subgroups of patients with either ligamentous the pressure on the posterior horn by, roughly, a factor
intact, reconstructed, or unstable knees. In the major- of 4.79 The menisci translate dorsally with knee flex-
ity of these studies, it seems that the outcome of a ion. This motion depends not only on the flexion angle
repair is better with concomitant reconstruction than but also on the weight bearing condition.80 The mag-
in knees that remain unstable72-74 or even better than
knees without ACL injury.75-77
The fact that meniscal repair appears to be more TABLE 3. Postoperative Rehabilitation Program for a
successful in combination with an ACL reconstruction Typical Bucket-Handle Lesion
deserves some detailed reflection. The simplest expla- Early Phase Intermediate Phase Late Phase
nation is that, with the stabilization of the knee, the
inciting cause for the repeated microtrauma of the ● Ice and analgesics ● Regain full range
● Crutches as needed of motion
menisci is eliminated, or at least diminished. More-
● Brace to limit ● Strength training
over, marrow elements are introduced into the joint motion ● Aqua jogging ● Consider
cavity with the ACL procedure that, as described ● Partial or full ● Isometric strength modification of
earlier, are thought to modulate the healing response weight bearing training activities if
of meniscal fibrochondrocytes. Another potential ex- ● Non–weight ● Continue brace related to
bearing motion ● No squats for development of
planation for a seemingly improved healing rate with
(60° to 90°) 12⫹ wks tear
concurrent ACL surgery is related to patient selection.
It must be assumed that in the subgroup of patients NOTE. Patients might need an individually tailored program.
MENISCAL REPAIR 1041
nitude of the posterior femoral rollback, and necessar- porary all-inside repair systems have significantly de-
ily the posteriorly directed translation of the menisci, creased the level of technical skills required for a
is substantially increased in the weight-loaded knee successful repair. There is currently no scientifically
compared with the unloaded state. Although this was substantiated reason to believe that the choice of a
not directly proven by the cited study, motion exer- particular repair technique would improve the out-
cises of the knee without weight bearing might there- come. It has not been shown thus far that a high failure
fore be preferable during rehabilitation to limit the load is associated with better clinical results.
stress on the repair. Weight bearing in extension most
likely does not pose a problem to repaired meniscal
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