Save the Meniscus: The Meniscal Mantra Remains Durable: Commentary on an article by Rick W. Wright, MD, et al.: "Ten-Year Outcomes of Second-Generation, All-Inside Meniscal Repair in the Setting of ACL Reconstruction".

Abstract

Commentary Save the meniscus. Save the meniscus. Save the meniscus. This is a subconscious orthopaedic mantra that we have all heard and repeated numerous times. Ever since Fairbank’s landmark study in 1948, “Knee Joint Changes After Meniscectomy,” and numerous later studies, we have learned to respect the importance of preserving the meniscus and, in turn, preventing degenerative changes1. In 2023, we may continue to debate over the best repair technique and the best repair augmentation and/or biologics, but we can all agree that we should do what we can to preserve and repair the meniscus. This has been demonstrated to be even more certain in the setting of a concomitant anterior cruciate ligament reconstruction (ACLR). Literature has demonstrated that meniscal tears heal better in the environment of an ACLR and, therefore, we should attempt to repair and preserve the meniscus as much as possible in this setting2,3. Historically, inside-out meniscal repair techniques were considered the gold standard, but as all-inside techniques have become more reliable, user-friendly, and able to mimic the traditional technique, they are more popularly used4. There are few 10-year outcome studies, and not many that examine all-inside meniscal suture devices; therefore, I commend Wright et al. on their current study. The authors performed a Level-IV retrospective review of 81 patients with a meniscal repair and concomitant primary ACLR using the second-generation, all-inside FAST-FIX Meniscal Repair System (Smith & Nephew). Some of these patients were included in their previous study evaluating outcomes of all-inside, second-generation repair at a 5-year follow-up4. In this current study, 69 of the 81 patients had a 10-year follow-up and 9 (13%) of the 69 patients had a failed meniscal repair, which was defined as a repeat surgical intervention involving resection or revision repair. The authors demonstrated that 84% to 88% of patients had a successful repair and all patients, regardless of failure, had favorable patient-reported outcome measures, which included the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee (IKDC) score, and the Marx Activity Rating Scale score, at 10 years. There were 59 medial repairs and 22 lateral repairs, and, of all the repaired tears, there were 13 bucket-handle tears, and the remaining tears were vertical longitudinal tears in the red-red or red-white vascular region. The study did not include radial tears, root tears, or ramp lesions. The mean number of sutures used for repair was only 2. Concerns with regard to the study include the lack of a comparison group, the use of older devices, and the shorter postoperative rehabilitation protocol. There are now third-generation, all-inside repair devices available, and the postoperative rehabilitation after a meniscal repair and ACLR is now ≥8 months. Perhaps this longer rehabilitation time can influence meniscal repair success or failure rates. The authors have demonstrated that the success rate of meniscal repair is 84% to 88% using an all-inside, second-generation technique with a concomitant ACLR. Although this is considered successful, what else can we do to optimize our success rates even more? Should we use better techniques and devices, or orthobiologics? How will this change as we repair different types of tears, including root and ramp tears? Also, how will longer rehabilitation affect meniscal healing and retear rates? If our mantra, save the meniscus, remains true, then I look forward to future data demonstrating what else we can do to improve success rates with all tears (bucket-handle, longitudinal, root, and ramp) with newer techniques and biologics.