White on white meniscal tears to fix or not to fix?

doi:10.1016/j.knee.2010.02.016

The Knee

Volume 17, Issue 4, August 2010, Pages 270-273

https://doi.org/10.1016/j.knee.2010.02.016 Get rights and content

Abstract

The mechanical disadvantage to articular cartilage following meniscectomy has been well documented in the literature. Meniscal repair in the avascular (white on white) is controversial and would be deemed inappropriate by many. We have developed criteria for repair in all meniscal tears. These are:

The meniscus

1.
must not be degenerated
2.
must be reducible, without a rolled edge
3.
the fixation must be considered sound.

Between 1999 and 2008 our department prospectively collected data on meniscal repairs as part of a sports database. Four hundred and twenty three patients underwent repair during this time period. We identified 87 patients with no co existent ACL injury or instability. There were 73 males and 14 females with a mean age of 26 years (13–54). All tears were in the non peripheral (white on white) area. The criterion for failure was reoperation on the same meniscus requiring excision or re fixation. The mean follow up was 49 months (10–112). Twenty eight patients required further surgery on their repaired meniscus. There were eight re-repairs and 20 partial menisectomies. This represents a success rate of 68% (59/87). The mean pre operative Lysholm score was 61 (4–88) which rose to 75 (12–100) postoperatively, p = 0.002. The mean pre op Tegner score was 6 (3–10) and this did not change significantly post operatively, mean 6 (0–10) p = 0.4. Isolated white on white avascular meniscal tears can be successfully repaired in the majority of cases with a good clinical and functional result.

Introduction

The mechanical disadvantage and detriment to articular cartilage following meniscectomy have been well documented in the literature [1], [2], [3], [4], [5]. Despite this, the mainstay of treatment for meniscal tears is partial arthroscopic menisectomy. The use of meniscal repair has been advocated for peripheral vascular tears, i.e. those tears within the red on red and red on white areas of the meniscus, with reasonable success rates reported in these tear groups. Meniscal repair in the avascular (white on white zone) is controversial and would be deemed inappropriate by many.

We have developed criteria for meniscal repair in all meniscal tears.

Our hypothesis is that using these criteria a white on white meniscal tear can be repaired with a good clinical result. We reviewed our results of meniscal repair in non peripheral (avascular) tears without concomitant knee pathology.

Section snippets

Methods

Between 1999 and 2008 our department prospectively collected data on all meniscal repairs as part of a sports injury database. Four hundred and twenty three (423) patients underwent meniscal repair at our unit during this time period. Surgery was performed by the senior authors (DR and SNJR) or under their direct supervision.

A review was undertaken of the surgical results along with pre/post operative Lysholm knee scores, pre injury/post operative Tegner activity scores and the need for further

Results

Eighty seven patients were identified as having a repair of meniscal tear in the white on white, avascular area. The mean follow up was 52 months (13–115) with a median of 48 months. No patient was lost to follow up.

Twenty eight patients required further surgery on their repaired meniscus. There were eight re-repairs and twenty partial menisectomies. Of the eight re-repairs only one has gone on to have a further procedure with a meniscectomy. This represents a success rate of 68% (59/87). However

Discussion

We demonstrate good clinical outcomes when repairing meniscal tears in the non peripheral, avascular area. Our success rate achieved is 68% using any further meniscal surgery as an end point.

The primary function of the menisci is to protect the joint surfaces from excessive load by the conversion of axial load to hoop stress and increased conformity of the joint. It has been well demonstrated that removal of part [1], [2], [3], [5] or all [4] of the meniscus leads to increased peak contact

Conflict of interest statement

No author has received external funding which has been used in the course of this research.

Acknowledgments

We would like to acknowledge and thank our specialist physiotherapists Jane Hughes and Andrea Bailey for all their help and expertise with our patients.

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Cited by (30)

Outcomes and morbidity after corticosteroid ultrasound guided infiltration into the meniscal wall in degenerative meniscal lesions
2023, Journal de Traumatologie du Sport
Le traitement des lésions méniscales dégénératives (LMD) a fait l’objet de nombreuses publications récentes. La méniscectomie partielle arthroscopique (MPA) est l’une des procédures orthopédiques les plus pratiquées dans le monde malgré son risque arthrosique connu. Les études récentes ne montrent pas de supériorité de la MPA par rapport au traitement médical. Le concept de préservation méniscale est aujourd’hui validé. L’objectif principal de cette étude était d’évaluer l’efficacité de l’infiltration de corticoïdes dans le mur méniscal sous échographie dans les LMD.
Nous avons donc réalisé un étude rétrospective monocentrique de 2014 à 2017 sur des patients de plus de 40 ans présentant une LMD chronique symptomatique, sans blocage mécanique, documentée par des radiographies et l’IRM et ayant bénéficié d’une infiltration de corticoïdes sous échographie dans le mur méniscal. L’infiltration était considérée comme efficace quand le patient rapportait une sédation totale/partielle de la douleur et reprise totale/partielle des activités de la vie quotidienne (groupe « bons répondeurs »). Les objectifs secondaires étaient d’évaluer l’efficacité à plus long terme, la survenue d’effets indésirables, la satisfaction globale du patient et enfin les facteurs favorisant la bonne réponse à l’infiltration.
Au total, 82 patients ont été analysés, il y avait 38 (46,3 %) hommes et 44 femmes (53,7 %), l’âge moyen était de 59 ans (40–87), l’IMC moyen de 26,3 (18,2–39,2). Au 3^e mois, 70 patients étaient retrouvés dans le groupe « bons répondeurs » (85,4 %) versus 12 dans le groupe « mauvais répondeurs » (14,6 %). À 21 mois de recul moyen, il y avait 64 « bons répondeurs » (78,1 %) versus 18 « mauvais répondeurs » (21,9 %). Cinquante-huit patients (71 %) étaient satisfaits ou très satisfaits de la prise en charge par infiltration. La douleur initiale, le stade d’arthrose initial et le type de lésion méniscale étaient des facteurs influençant des résultats fonctionnels au dernier recul.
La prise en charge des LMD symptomatiques par l’infiltration de corticoïdes sous échographie dans le mur méniscal était efficace et présentait peu d’effets secondaires. Au regard de nos résultats, ce traitement non chirurgical semble être une bonne option dans l’arsenal thérapeutique pour la prise en charge des LMD.
IV, étude rétrospective analytique.
The treatment of degenerative meniscal lesions (DML) has been the subject of numerous recent publications. Arthroscopic partial meniscectomy (APM) is one of the most commonly performed orthopedic procedures worldwide despite its known osteoarthritic risk. Recent studies do not show superiority of APM compared to medical treatment. The concept of meniscal preservation is now validated. The main objective of this study was to evaluate the effectiveness of corticosteroid infiltration into the meniscal wall under ultrasound in DML.
Retrospective single-center study from 2014 to 2017 on patients over 40 years old presenting symptomatic chronic LMD, without mechanical blockage, documented on X-rays and MRI and having undergone infiltration of corticosteroids into the meniscal wall under ultrasound. The infiltration was considered effective when the patient reported total/partial pain relief and total/partial resumption of daily activities (“good responder” group). The secondary objectives were to evaluate longer-term effectiveness, the occurrence of adverse effects, overall patient satisfaction, and finally the factors favoring a good response to the infiltration.
Eighty-two patients were analyzed, there were 38 (46.3%) men and 44 women (53.7%), the average age was 59 years (40–87), the average BMI was 26.3 (18.2–39.2). At the 3rd month, 70 patients were found in the good responder group (85.4%) compared to 12 in the poor responder group (14.6%). At an average follow-up of 21 months, there were 64 correct responses (78.1%) compared to 18 incorrect responses (21.9%). Fifty-eighty patients (71%) were satisfied or very satisfied with the infiltration treatment. Initial pain, initial stage of osteoarthritis and type of meniscal lesion were factors influencing functional results at final follow-up.
The management of symptomatic DML by infiltration of corticosteroids under ultrasound into the meniscal wall was effective and had few side effects. Based on our results, this non-surgical treatment seems to be a good option in the therapeutic armamentarium for the management of DML.
IV, retrospective study.
Postoperative rehabilitation and outcomes following arthroscopic isolated meniscus repairs: A systematic review
2020, Physical Therapy in Sport
Citation Excerpt :
Lind et al., 2013). From pre-surgery to post-surgery, five studies reported Tegner score improvements from 4.6 ± 2.1 to 6.9 ± 1.0 at 5.8 years post-surgery (Ahn et al., 2015; Choi et al., 2010; Hagmeijer et al., 2019; Lucas et al., 2015; Tiftikci & Serbest, 2016), four studies reported Lysholm score improvements from 62.5 ± 7.7 to 86.3 ± 8.4 at 4.3 years post-surgery (Choi et al., 2010; Gallacher et al., 2010; Lucas et al., 2015; Tiftikci & Serbest, 2016), two studies reported IKDC score improvements from 56.9 ± 11.9 to 90.3 ± 0.1 at 9.7 years post-surgery (Hagmeijer et al., 2019; Tiftikci & Serbest, 2016) and one study reported KOOS score improvements from 69.4 to 78.4 at two years post-surgery (Lind et al., 2013). Studies that contributed to this systematic review reported meniscal repair failure rates based on MRI (Choi et al., 2010; Eggli et al., 1995; Kimura et al., 2004; Lind et al., 2013; Lucas et al., 2015; Samuelsen et al., 2018; Tiftikci & Serbest, 2016), weight-bearing radiographs (Majewski et al., 2006; Stein et al., 2010), second-look arthroscopy (Choi et al., 2010; Horibe et al., 1996; Kocabey et al., 2004; Lind et al., 2013; Samuelsen et al., 2018; Solheim et al., 2016), clinical examination (Tsai et al., 2004) or re-operation on the same meniscus requiring excision or re-fixation (Gallacher et al., 2010; Hagmeijer et al., 2019; Perkins et al., 2018; Samuelsen et al., 2018).
The purpose of this study was to review the current literature on rehabilitation protocols following arthroscopic meniscus repair.
A systematic literature review was performed of Medline, Scopus, and Web of Science databases to identify relevant articles from January 1990 to April 2019. Search terms were (meniscus OR meniscal repair) AND (repaired OR repair) AND (rehabilitation OR physiotherapy OR physical therapy). Each study was independently scored for methodological research quality level using the Modified Coleman Methodology Score (MCMS). The following variables were extracted from each study: publication year, study type, evidence level, subject demographics, injury mechanism, meniscus tear type, surgical procedure, rehabilitation program [immobilization, weight bearing, ROM progression, therapeutic exercises, length of follow-up, patient-reported outcome measurements, return to sport timing/criteria and failure rate/criteria.
Eighteen studies met the inclusion criteria. The overall MCMS was moderate 59.5 ± 11.7 (range = 42–90). The average MCMS score for postoperative rehabilitation was 4.7 ± 1.18. Only 1 (5.6%) study was a prospective randomized controlled trial and 14 studies (78%) had retrospective designs. Fourteen (78%) studies suggested that return to sports should occur between 3 and 6 months post-surgery. Early range of motion and immediate weight-bearing had no influence over patient-reported outcomes or failure rates for vertical meniscus tear repairs.
Low MCMS scores, primarily retrospective study designs and poorly described postoperative rehabilitation protocols made it difficult to design an evidence-based therapeutic rehabilitation program for patients following arthroscopic repair of an isolated meniscus tear. An arthroscopic isolated meniscal tear repair rehabilitation protocol is being attempted to present based on a synopsis of existing evidence.
One-Third of Meniscal Tears Are Repairable: An Epidemiological Study Evaluating Meniscal Tear Patterns in Stable and Unstable Knees
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
To analyze, in a long series of patients with knee injuries, the meniscal tear patterns in both stable and unstable knees to ascertain the exact proportion of such injuries that could have been repaired.
A descriptive cross-sectional study was undertaken by reviewing the clinical reports of arthroscopic knee operations carried out in 1 hospital. A total of 2,066 consecutive patients were included in the study. An analysis of clinical and anatomical data of knee lesions, including the shape of the meniscal tears and the surrounding injuries, was performed.
Out of all meniscal tears, 34.9% were found to be repairable, a figure that rose to 55.6% in those tears accompanied by anterior cruciate ligament injuries; 37% of meniscal tears in male patients were repairable, and 28% in their female counterparts; 38.2% of medial meniscal tears were repairable and 30.6% in their lateral counterparts. The most frequently encountered injury was the complex tear (46.9%).
Our study concludes that, according to current standard indications, 34.9% of all meniscal injuries offer the potential for repair. Where the injury is also accompanied by anterior cruciate ligament damage, the proportion of repairable tears rises to 55.6%. This information should increase the interest for meniscal preservation in the future.
Level IV, case series.
Rehabilitation and Return to Play Following Meniscal Repair
2017, Operative Techniques in Sports Medicine
Citation Excerpt :
Kamimura et al86 noted that 60% (6 of 10) of the total number of patients achieved their preinjury score, when the other 40% recovered postoperatively to just 1 level below their preinjury Tegner activity level. Most studies are in accordance with those rates, showing that almost all patients return to the preinjury level of sports and the average postoperative Tegner score is either equal or less than 1 point decreased from the preinjury score77-83 (Table 3). Τhe initial high rate of RTP following meniscal repair or the level of sports activities may over time decrease in the long-term follow-up.
The outcome of meniscal repair has been good to excellent with regard to functional restoration and return to play (RTP). Athletes represent the most demanding subgroup of patients as they have high expectations to return to their preinjury level of activity and in doing so they place maximum stress on any meniscal repair. Physical therapy rehabilitation protocols and RTP decision-making remains controversial in the setting of meniscal repair. Protective protocols had been the mainstay of treatment for many years, however, newer research has shown no harm and quicker RTP for longitudinal and bucket-handle tears located close to the outer vascular zone of the periphery of the meniscus using accelerated rehabilitation. Protective protocols and slower RTP remain the most prudent choice in complex, horizontal and radial tears or those extending into the middle to central third of the more avascular zone of the meniscus. The authors have therefore, with evidence from current publications, developed 2 separate protocols to treat both peripheral and complex tears. One accelerated and one protective protocol is established. During the preoperative planning, it would be helpful for the surgeon, patient, and family to know what can be expected with regard to the surgical success of meniscal repair and the likelihood of RTP in this active population. A literature review on the outcome of meniscal repair related to RTP was performed and revealed that the majority of patients succeed to RTP at the same or similar to their preinjury level, between 4 and 6 months following meniscal repair. Factors that may affect the outcome and RTP along with rehabilitative considerations following meniscal repair are discussed.
Failure of meniscal repair association with late anterior cruciate ligament reconstruction
2016, Journal of Orthopaedics
Meniscus injury is associated with ACL (anterior cruciate ligament) injury. It would be ideal to repair all meniscus tears but failure rate is high.
Our objective was to assess the success of meniscus repair.
All consecutive patients between Jan 2009 to Dec 2013 were retrospectively analysed.
85 meniscus repairs were performed: 64 patients presented after 3 months (Group 1) and 21 patients had meniscus repair within 2 weeks. The failure rate group 1 was 23%–4.8% group 2 at a mean follow up of 11 months.
Early meniscal repair had a higher success rate.
Level III evidence.
Outcomes after repair of chronic bucket-handle tears of medial meniscus
2014, Arthroscopy - Journal of Arthroscopic and Related Surgery
The purpose of this study was to determine the outcomes after repair of chronic bucket-handle medial meniscal tears by use of magnetic resonance imaging, clinical examination, and patient-reported outcomes.
A retrospective review of patients with chronic bucket-handle medial meniscal tears that had been repaired with meniscal sutures was undertaken. The following criteria for inclusion were adopted: minimum tear length of 2 cm and chronic medial meniscal tear identified at the time of arthroscopy. The tears were susceptible to dislocation with probing. Data collected included demographic, clinical, radiologic, and surgical data. Postoperative healing was assessed with the clinical criteria of Barrett et al. The International Knee Documentation Committee rating, Lysholm score, and Tegner activity level were determined, and postoperative magnetic resonance imaging was used to evaluate healing in accordance with the criteria of Henning et al.
Twenty-four patients fulfilled the inclusion criteria. The mean time from injury to surgery was 10 months (range, 2 to 60 months). Sixteen patients underwent anterior cruciate ligament reconstruction, 1 patient underwent posterior cruciate ligament reconstruction, and 6 patients underwent meniscus repair only. A median of 5 sutures (range, 3 to 6 sutures) were used for repair. Four cases (all of which had undergone meniscus repair only) required revision. Complete healing was achieved in 83% of cases according to the criteria of Barrett et al. The mean follow-up time was 48 months (range, 24 to 112 months). An International Knee Documentation Committee rating of A or B was achieved in the 20 patients who did not require revision. The median Lysholm score was 95 (range, 92 to 100). The median Tegner activity level before injury was 7, and it remained unchanged after surgery in all cases.
This study showed that repair of chronic bucket-handle meniscal tears can lead to good clinical outcomes and a relatively low (17%) failure rate. In addition, repairs of isolated meniscal tears had a significantly higher risk of failure than repairs performed in conjunction with anterior cruciate ligament reconstruction.
Level IV, therapeutic case series.

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White on white meniscal tears to fix or not to fix?

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Conflict of interest statement

Acknowledgments

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Osteoarthritis Cartilage

Rate of knee cartilage loss after partial meniscectomy

J Rheumatol

The natural history of the knee following arthroscopic medial meniscectomy

Knee Surg Sports Traumatol Arthrosc

Late results after arthroscopic partial medial meniscectomy

Knee Surg Sports Traumatol Arthrosc

Knee joint changes after meniscectomy

J Bone Joint Surg Am

Arthroscopic medial meniscectomy on stable knees

J Bone Joint Surg Br

Long-term results of arthroscopic partial lateral meniscectomy in knees without associated damage

J Bone Joint Surg Br

Repair of meniscal tears with the absorbable Clearfix screw: results after 1–3 years

Arch Orthop Trauma Surg