All-inside Meniscal Repair Research Articles

Continuous suture all-inside meniscal repair technique produces excellent functional outcomes and return to play rates with a low rate of failure.

The all-inside technique is now the most established treatment for meniscal repair, this usually involves a suture-based repair utilising interrupted sutures. A similar technique using continuous sutures can also be used; however there are no studies in the literature appraising this technique. This study aims to review outcomes for patients undergoing meniscal repair using a continuous suture all-inside technique. We reviewed patients undergoing meniscal repair using a continuous suture all-inside technique over a 5year period. We recorded demographic details, injury type, surgical procedure, incidence of reoperation, functional outcomes (Tegner-Lysholm and International Knee Documentation Committee (IKDC) score) return to sport and failure of repair. Data were collected for 37 patients. Mean age was 25.8years, 81%, were male, median time to theatre was 169days, mean follow-up time was 2.9years. Concurrent ACL ruptures were present in 57%, all underwent ACL reconstruction in the same sitting. The mean Tegner-Lysholm score was 89. Mean IKDC score was 90.2. 78% were able to return to sport. Overall failure rate was 10.81%. Increasing age was associated with a decreased IKDC score (p = 0.02). Tegner-Lysholm score was significantly greater in patients with concurrent ACL injuries (p = 0.03) and patients with lateral meniscal tears (p = 0.04). In the first study to review outcomes following continuous all-inside suture-based meniscal repair we demonstrate excellent clinical outcomes with IKDC, Tegner-Lysholm, return to play and failure rates comparable to other commonly used techniques. We conclude that this is an acceptable and cost-effective technique.

Outcome after Arthroscopic Meniscal Repair

Abstract Objective: The objective of this study was to evaluate the functional outcomes of all-inside meniscal repair using the Fast-Fix suturebased fixation device and its correlation with postoperative MRI findings in serving military personnel with symptomatic torn menisci. Materials and Methods: Thirty patients under 40 years of age with symptomatic meniscal tears were included in the study. Clinical evaluation, arthroscopic assessment, and meniscal repair using the Fast-Fix system were performed. Patients were followed up clinically and with postoperative MRI at one year. Functional outcomes were evaluated using the International Knee Documentation Committee (IKDC) form. Results: At one year postoperative follow-up, 10% of patients had excellent results, 66.6% had good results, 13.4% had fair results, and 10% had poor results according to the IKDC evaluation. MRI evaluation showed overall satisfactory results in 86.7% of patients. The Fast-Fix system demonstrated a success rate of 90% in this short-term follow-up study, with minimal complications. Conclusion: Arthroscopic all-inside meniscal repair using the Fast-Fix system showed promising clinical outcomes in serving military personnel with symptomatic torn menisci. The success rate was comparable to traditional suture techniques. Postoperative MRI provided valuable information for evaluating the physiological state of the repaired meniscus. Long-term followup studies are necessary to assess the structural and functional integrity of the repaired menisci over time.

Superior load-to-failure in an all-suture anchor system for all-inside meniscal repair compared to a PEEK-cage anchor system in an experimental cadaveric test setting.

The purpose of this study was to compare the biomechanical properties of a latest generation all-suture anchor repair device (ASARD) for meniscal repair with that of a latest generation PEEK-cage anchor repair device (PCARD) in an experimental setting using cadaveric menisci. Twenty-six menisci were obtained from the knees of fresh body donors. Artificially created meniscal lesions were treated randomly, using a single stitch with either an ASARD or a PCARD. Cyclic biomechanical testing, utilising a universal material testing machine and following an established protocol, was carried out and load-to-failure (LTF), displacement, stiffness, and mode-of-failure (MOF) reported. Mean LTF was found to be 61% higher in the ASARD group at 107.10 N (standard deviation [SD], 42.34), compared to 65.86 N (SD, 27.42) in the PCARD group with statistical significance (p = 0.022). The ASARD exhibited a trend towards higher stiffness (10.35 N; SD, 3.92 versus 7.78 N; SD; 3.59) and higher displacement at cycles one, 100, and 499 (1.64, 3.27, and 4.17 mm versus 0.93, 2.19, and 2.83 mm) compared to the PCARD. Cheese wiring was the most common mode-of-failure in both groups (76.9%). This study demonstrates that an ASARD shows a higher mean LTF than a PCARD when compared in an experimental biomechanical setting. Level III.

Perspective on Clinical and Functional Outcomes of Arthroscopic All-Inside Meniscal Repair: Insights From a Lower Middle-Income Country.

Background Meniscal tears are a common injury in the adult population. With the advent of newer devices, the adoption of the all-inside repair technique has been expanding substantially because of its feasibility and reduced risk to surrounding neurovascular structures. This study was conducted in a lower middle-income country to assess the functional outcome of the arthroscopic all-inside technique and to identify the potential factors that may affect the functional outcome that will eventually influence the future management of these patients. Method This study is a retrospective case series conducted at the Department of Orthopedic Surgery, Aga Khan University Hospital, Karachi, Pakistan. Patients presenting to the outpatient clinics with meniscal tears who underwent arthroscopic all-inside repair from January 2015 to December 2021 were included in this study. The exclusion criteria included patients who had associated fractures and patients with meniscal tears greater than six months ago. Results A total of 29 patients underwent all-inside meniscal repair for meniscus tears. The mean age of our patients was 26.31 years (SD = 7.11 years), ranging from 17 years to 48 years. Of these patients, 26 were males and three were females, accounting for 89.7% and 10.3%, respectively. The most frequent mechanism of injury was twisting while playing sports, accounting for 51.7%, followed by falling while playing sports and road traffic accidents (RTAs), accounting for 13.8% and 20.7%, respectively. Of the 29 patients, 16 (55.2%) had lateral meniscal injuries, 10 (34.5%) were diagnosed with medial meniscus injuries, and three (10.3%) had injuries to both menisci. The most common type of tear that was observed in our sample size was bucket handle tears, which were found in 14 patients, accounting for a total of 48.3%, followed by complex tears in seven patients (24.1%). The majority of the patients, i.e., 19 out of 29 patients (65.5%), had an acute course of injury, i.e., less than six weeks. For the functional outcome, the Lysholm score was calculated at 12 months and was found to be excellent in 17 patients, good in six patients, and fair in six patients, accounting for 58.6%, 20.7%, and 20.7%, respectively. The mean Lysholm score was 90.03 ± 8.85 points. Of the 29 patients, 27 (93.2%) had no complaints at the regular 12-month follow-up, whereas one patient (3.4%) experienced rotatory instability and one patient (3.4%) experienced stiffness at the knee joint. None of the patients had to undergo a reoperation. The mean Lysholm score in the 25 patients who had an associated anterior cruciate ligament tear was 89.64 ± 9.442 points, whereas the four patients who had an isolated meniscal tear had a mean score of 92.50 ± 2.887 points, which was not significantly different (p-value = 0.831). Conclusion All-inside meniscal repair for treating meniscal tears has become the new treatment paradigm as it not only renders excellent functional outcomes with minimal complications but also prevents damage to the surrounding neurovasculature and the soft tissue envelope as it is a minimally invasive technique.

Biomechanical Characteristics of All-Suture Meniscal Repair Devices Compared With PEEK-Anchored Devices and Inside-Out Suture for Meniscal Repair: A Porcine Study.

Recently, all-suture, all-inside meniscal repair devices-including devices containing flat sutures or tapes-have been introduced. Similar to those in suture anchors, these modifications may have different performance characteristics than conventional sutures and polyether ether ketone (PEEK)-anchored devices. To compare the biomechanical characteristics of all-suture meniscal repair devices with those of a conventional PEEK-anchored device and an inside-out meniscal suture construct. Controlled laboratory study. A total of 48 adult porcine menisci with simulated bucket-handle tears were included. Single-device repairs were performed with the SuperBall Meniscal Repair System, FiberStitch, and FAST-FIX 360 with 2 PEEK anchors, and a vertical mattress inside-out suture repair was performed using a Ti-Cron No. 2-0 braided polyethylene terephthalate suture. All specimens were preloaded (10 N) and cycled 200 times (between 10 and 50 N). Specimens surviving cyclic loading were then destructively tested. Endpoints included maximum failure load, stiffness, cyclic displacement, and failure mode. The goal was 12 successful tests in each group. Metrics between groups were compared using analysis of variance with post hoc tests to control for multiple comparisons. The SuperBall (108.9 N) was significantly stronger than the FAST-FIX 360 (67.3 N) and Ti-Cron (75.2 N), and the FiberStitch (102.8 N) was significantly stronger than the FAST-FIX 360 (P≤ .01 for all). Cyclic stiffness increased during cyclic loading for all constructs (P < .001). The Ti-Cron was significantly stiffer than the SuperBall during 5 to 200 cycles (P < .001). Cyclic displacement significantly increased in all constructs during cycling (P < .001) but did not differ between devices. Failure mode varied by device: the Ti-Cron repairs failed because of suture breakage, the SuperBall and FAST-FIX 360 failed at the anchor, and the FiberStitch showed both failure modes. The all-suture, all-inside meniscal repair devices demonstrated superior strength to the PEEK-anchored device and the classic inside-out suture meniscal repair but no statistically significant difference in cyclic displacement.

Circumferential Cross-Stitch Suture for Longitudinal Lateral Meniscal Tear Around the Popliteal Tendon Hiatus Region

Lateral meniscal repair of the popliteal hiatus is technically demanding. The inside-out technique requires an additional incision and carries the risk of posterolateral soft tissue damage to the knee joint. In addition, the presence of the popliteal tendon limits the route of the suture thread. Within the current trend of the all-inside suture technique, meniscal suture-based all-inside repair demonstrates biomechanical advantages over anchor-based all-inside repair. We introduce a meniscal suture-based all-inside meniscal repair technique for longitudinal lateral meniscal tears.

Biomechanical Comparison of All-Suture, All-Inside Meniscus Repair Devices in a Human Cadaveric Meniscus Model.

Newer all-suture, all-inside meniscus repair devices utilize soft suture anchors. The purpose of this study was to compare the biomechanical performance of 4 meniscus repair devices in human cadaver menisci: the JuggerStitch (all-suture, all-inside), the FiberStitch (all-suture, all-inside), a polyether ether ketone (PEEK) all-inside, and an inside-out device. Forty human cadaver menisci were tested after creating 20 mm longitudinal tears in the posterior meniscus. Each knee was randomized to 1 of 4 meniscus repair groups: JuggerStitch (all-suture, all-inside), FiberStitch (all-suture, all-inside), FAST-FIX 360 (PEEK-based anchor all-inside), and inside-out (with BroadbandTM tape meniscus needles). For each meniscus, 2 devices were used to prepare vertical mattress repair construct. The specimens were tested by pre-conditioning 20 cycles between 5 N and 30 N and then the tear diastasis was measured, followed by distraction to failure phase after imposing a displacement at a rate of 0.5 mm/s. Ten menisci were tested in each of the 4 groups. After pre-conditioning, there was no significant difference in the gap formation among groups (P = 0.212). The average failure load for the JuggerStitch, FiberStitch, PEEK all-inside, and inside-out was 384 N, 311 N, 207 N, and 261 N, respectively, with a significant difference between groups (P = 0.034). Post hoc analysis showed the JuggerStitch failure load was higher than the PEEK all-inside and inside-out (P = 0.005, and P = 0.045, respectively). There was no significant difference between the failure load of the JuggerStitch and FiberStitch (P = 0.225). The JuggerStitch all-suture device, FiberStitch all-suture device, PEEK all-inside, and inside-out devices have similar biomechanical properties for gapping and stiffness. The JuggerStitch all-suture, all-inside device has superior failure load compared with the PEEK all-inside and inside-out repair for longitudinal meniscus tear repair.

Assessing Risk of Iatrogenic Peroneal Nerve Injury in All-Inside Lateral Meniscal Repair Between Standard Vs. Arthroscopic MRI.

Various studies have examined the risk of peroneal nerve injury with use of standard magnetic resonance imaging (MRI) of the knee. However, the position of the knee during standard MRI is different from that during an actual arthroscopic lateral meniscal repair. The purpose of the present study was to evaluate and compare the risk of peroneal nerve injury during simulated all-inside lateral meniscal repairs on the basis of MRI scans made with the knee in both positions. With use of axial MRI scans made with the knee in the standard position (i.e., in 30° of flexion) and in the actual position used during arthroscopic lateral meniscal repair (i.e., in a figure-of-4 position), direct lines were drawn to simulate the passage of a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the popliteus tendon. The distance from the closest passage of each line to the peroneal nerve was measured. If a line touched or passed through the peroneal nerve, a risk of iatrogenic injury was noted and a new line was drawn from the same portal to the outer border of the peroneal nerve. The danger area was measured from the first line to the new line along the joint capsule. In 28 Thai patients, the shortest distances from each line to the peroneal nerve were significantly shorter on the MRI scans made with the knee in the standard position than on those made with the knee in the arthroscopic position (p < 0.05 for all). All danger areas on the MRI scans that were made with the knee in the arthroscopic position were included within the danger areas on the scans that were made with the knee in the standard position. Standard MRI scans of the knee can be used to determine the risk of peroneal nerve injury at the time of arthroscopic lateral meniscal repair, although the risks are slightly overestimated. Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

COMPARING THE RISK ASSESSMENTS OF IATROGENIC PERONEAL NERVE INJURY IN ALL-INSIDE LATERAL MENISCAL REPAIR BETWEEN STANDARD KNEE MRIS AND SIMULATED ACTUAL ARTHROSCOPIC LATERAL MENISCAL REPAIR POSITION MRIS

Several studies have evaluated the risk of peroneal nerve (PN) injuries in all-inside lateral meniscal repair using standard knee magnetic resonance imaging (MRI) with the 30 degrees flexed knee position which is different from the knee position during actual arthroscopic lateral meniscal repair. The point of concern is “Can the risk of PN injury using standard knee MRIs be accurately determined”.To evaluate and compare the risk of PN injury in all-inside lateral meniscal repair in relation to both borders of the popliteus tendon (PT) using MRIs of the two knee positions in the same patients.Using axial MRI studies with standard knee MRIs and figure-of-4 with joint fluid dilatation actual arthroscopic lateral meniscal repair position MRIs, direct lines were drawn simulating a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the PT. The distance from the tip of each line to the PN was measured. If a line touched or passed the PN, a potential risk of iatrogenic injury was noted and a new line was drawn from the same portal to the border of the PN. The danger area was measured from the first line to the new direct line along the joint capsule.In 28 adult patients, the closest distances from each line to the PN in standard knee MRI images were significantly shorter than arthroscopic position MRI images (all p-values &lt; 0.05). All danger areas assessed in the actual arthroscopic position MRIs were included within the danger areas as assessed by the standard knee MRIs.We found that the standard knee MRIs can be used to determine the risk of peroneal nerve injury in arthroscopic lateral meniscal repair, although the risks are slightly overestimated.

Posterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft and Concomitant Meniscal Ramp Repair

Background: Quadriceps autograft, though well established for anterior cruciate ligament reconstruction, is underutilized in posterior cruciate ligament (PCL) reconstruction largely due to slow adoption. All-inside meniscal ramp repair and quadriceps tendon autograft PCL reconstruction have been described in isolation, but not concomitantly in a video journal. Indications: PCL reconstruction is indicated in grade 3 isolated tears with instability that have not improved with nonoperative management and in instances with associated injuries such as meniscal ramp tears, as observed in this 18-year-old division I football player. Graft selection is dependent upon surgeon and patient preference, with quadriceps autograft delivering a viable option with desirable long-term outcomes. Technique Description: A partial-thickness quadriceps tendon autograft was harvested, the remnant PCL stump was debrided, and a reamer was used to drill the all-inside tibial tunnel for traction suture passage. An accessory low anterolateral portal was utilized to drill the femoral tunnel for passage of the femoral traction stitch. Traction sutures were withdrawn, and the graft was passed into the tibia, docked into the femur, fixated with an interference screw, and tensioned over the tibial button. A medial meniscal ramp tear was also identified and repaired in all-inside fashion with a 90° SutureLasso, polydioxanone suture (PDS), and suturetape via standard arthroscopic knot tying. Following the procedure, the patient began a PCL reconstruction rehabilitation protocol with a PCL rebound brace. Due to the meniscal ramp repair, toe touch weightbearing with the knee in extension during ambulation was completed for 6 weeks. Physical therapy (PT) focused on early quadriceps and patellar mobilization as well as active-assisted range of motion exercises. Results: At 6 months postoperation, the patient continued to progress in PT without major concerns. A full recovery and return to sport are expected approximately 9 to 12 months after surgery, as is consistent with the standard protocol. Discussion/Conclusion: This study describes the treatment of chronic PCL with concomitant meniscal ramp tear in a division I athlete. Further adoption of PCL reconstruction utilizing quadriceps autograft, even in the context of concomitant ligamentous or meniscal reconstruction, such as medial meniscal ramp repair, will aid in the widespread treatment of PCL injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

All-inside suture meniscal repair using suture passer.

In recent years, to save the meniscus and prevent the progression of knee osteoarthritis, the indications for meniscus repair have been expanding instead of partial menisectomy. Accordingly, various repair techniques for meniscus tears have been developed. The conventional inside-out and outside-in meniscus repair techniques and all-inside repair technique with an implant/anchor can be classified as trans-capsular (TC) repair from the perspective of suture with penetrating capsule. Recently, new suture passers for all-inside meniscus repair have been developed. To distinguish from conventional all-inside repair with implant/anchors, all-inside repair with only suture using these suture passers was described as all-inside suture (AIS) repair. This AIS repair could achieve meniscus-to-meniscus suture across the tear without interposition of soft tissues including the capsule between suture and meniscus, leading direct gap closing of torn edges. In this respect, AIS repair is considered to be "anatomical meniscus repair". Actually, some reports showed biomechanical and clinical advantages of AIS repair. However, there is still limited evidence in clinical practice. Moreover, there are some disadvantages for AIS repair. Not only further studies but also development of new devices and surgical techniques for AIS should be required. This review describes the current status of AIS repair for each type of tear.

The Risk of Iatrogenic Posterior Neurovascular Injuries in Lateral Meniscal Repair Based on the Standard Arthroscopic Knee Position: A Magnetic Resonance Imaging Study.

Repair of the posterior horn of the lateral meniscus using an all-inside meniscal repair device involves the risk of iatrogenic posterior neurovascular injuries. Previous studies that have evaluated this risk were based on preoperative magnetic resonance imaging (MRI) with the knee in 30° of flexion and used landmarks that are impractical in the actual operative situation. To use an MRI model simulating actual knee arthroscopic conditions to (1) compare the potential risk of injuries related to the lateral border of the posterior lateral meniscus root (LMR) through the anterolateral versus anteromedial portal and (2) establish "safe" and "danger" zones to reduce the possibility of injuries to posterior neurovascular structures when performing lateral meniscal repair in relation to the lateral border of the posterior LMR. Descriptive laboratory study. Using 29 axial MRI scans of knees in the figure-of-4 position with joint fluid dilatation at the level of the lateral meniscus, direct lines were drawn to simulate a straight all-inside meniscal repair device deployed from the anterolateral and anteromedial portals to the lateral border of the posterior LMR, extending 14 mm beyond the joint capsule. If the line passed through or touched a posterior neurovascular structure, a risk of iatrogenic injuries was noted, and measurements were made to determine the safe zone in relation to the lateral border of the posterior LMR. Repairing the lateral meniscus through the anterolateral portal in relation to the lateral border of the posterior LMR resulted in a significantly greater risk of posterior neurovascular injuries compared with repairing through the anteromedial portal, with injury incidences of 68.97% and 10.35%, respectively (P = .001). The safe zones of lateral meniscal repair through the anterolateral and anteromedial portals were 4.15 ± 1.87 and 6.57 ± 0.98 mm, respectively, beyond the lateral border of the posterior LMR. The risk of posterior neurovascular injuries when repairing posterior lateral meniscal tissue was found to be significantly greater through the anterolateral portal compared with the anteromedial portal. Surgeons can use the safe zones as defined in this study to decrease the risk of iatrogenic posterior neurovascular injuries during arthroscopic lateral meniscal repair.

More Is Not Merrier: Increasing Numbers of All-Inside Implants Do Not Correlate with Higher Odds of Revision Surgery.

The purpose of this study was to evaluate the relationship between the number of all-inside meniscal repair implants placed and the risk of repair failure. We hypothesized that the use of higher numbers of all-inside meniscus repair implants would be associated with increased failure risk. A retrospective chart review identified 351 patients who underwent all-inside meniscus repair between 2006 and 2013 by a sports medicine fellowship-trained orthopaedic surgeon at a single institution. Patient demographics (age, body mass index [BMI], sex) and surgical data (number of implants used, concomitant anterior cruciate ligament reconstruction [cACLR], and tear type/size/location) were recorded. Patients who received repairs in both menisci or who had follow-up < 1-year postoperatively were excluded. Repair failure was identified through chart review or patient interviews defined as a revision surgery on the index knee such as partial meniscectomy, total knee arthroplasty, meniscus transplant, or repeat repair. Logistic regression modeling was utilized to evaluate the relationship between the number of implants used and repair failure. A total of 227 all-inside meniscus repairs were included with a mean follow-up of 5.0 ± 3.0 years following surgery. Repair failure was noted in 68 knees (30.3%)-in 28.1% of knees with fewer than four implants and in 35.8% of knees with four or more implants (p = 0.31). No significant increase in failure was observed with increasing number of all-inside medial (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 0.79-1.7; p = 0.46) or lateral (OR: 0.86; 95% CI: 0.47-1.57; p = 0.63) implants after controlling for patient age, BMI, cACLR, tear type, or size. Tears of the lateral meniscus located in the red-white and white-white zones had lower odds of failure (OR: 0.14; 95% CI: 0.02-0.88; p = 0.036) than tears within the red-red zone, and patients with cACLR had lower odds of repair failure (OR: 0.40; 95% CI: 0.18-0.86, p = 0.024) than those without. The number of all-inside implants placed during meniscus tear repair did not affect the likelihood of repair failure leading to reoperation after controlling for BMI, age, tear type, size, location, and cACLR. LEVEL OF EVIDENCE: III.

Poster 145: A Biomechanical Comparison of All-Inside versus Trans-tibial Meniscal Root Repair Techniques

Objectives: To evaluate the biomechanical characteristics of an all-inside meniscal root repair procedure versus transtibial repair Methods: Nine paired cadaveric knees were prepared with pressure mapping sensors and underwent pressure testing to obtain peak pressures, average pressures, and femorotibial contact area in both the medial and lateral compartments. Testing was performed in three states: meniscus intact, meniscal root cut, and following meniscal root repair with all-inside repair technique. Additionally, testing was completed on eight pairs of cadaveric knees to compare stiffness and maximal load to failure between all-inside and transtibial meniscal root repair techniques. Results: In the medial compartment, there were significant increases in both median peak pressures (p=0.017) and median average pressures (p=0.047) in the root cut state compared to the intact state (+636 kilopascal (kPA) [246-1026 95% confidence interval (95%CI)] and +190 kPA [49-330 95%CI] respectively). All-inside meniscal root repair restored median peak pressures and median average pressures to approach that of the intact meniscus (p=0.293; +311 kPA [-79-701 95%CI] and p=0.171; +137 kPA [-3-277 95%CI] respectively). In the lateral compartment, there were also significant increases in both median peak pressures (p=0.025) and median average pressures (p=0.05) in the root cut state compared to the intact state (+718 kPA [246-1191 95%CI] and +203 kPA [51-355 95%CI]) respectively). All-inside meniscal root repair restored median peak pressures and median average pressures to be not significantly different from the intact state (p=0.399; +322 kPA [-150-795 95%CI] and p=0.97; +18 kPA [- 134-171 95%CI] respectively). There was no difference between repair techniques regarding load to failure (p=0.896). Conclusions: All-inside meniscal root repair restores median peak and average pressures that approach that of the native, intact meniscus. Compared to a transtibial meniscal root repair technique, all-inside repair demonstrated equivalent load to failure.

Poster 265: The Risk of Iatrogenic Posterior Neurovascular Injury in Lateral Meniscal Repair Based on Real Arthroscopic Position: An MRI Study

Objectives: Posterior horn of lateral meniscal repair using an all-inside meniscal repair device involves a risk of iatrogenic posterior neurovascular injury. Some studies have evaluating the injury risk in this area but most were based on preoperative MRIs and landmarks which are difficult to clearly see under actual arthroscopic surgery. To our knowledge, there have been no studies to date evaluating the risk of injury based on MRIs with the knee in the standard operational figure-of-4 position with joint dilatation in arthroscopic lateral meniscal repair related to the lateral border of the lateral meniscal root which is easy to identify during surgery. The objective of this study was to evaluate and compare the risk of posterior neurovascular injury and establish the safe and danger zones in repairing the lateral meniscus through the anterolateral and anteromedial portals in relation to the medial and lateral borders of the lateral meniscal root (LMR) using standard operational figure-of-4 position with joint dilatation MRIs. Methods: This study was descriptive laboratory study. Using 29 axial magnetic resonance imaging (MRI) studies of knees in the figure-of-4 position with joint fluid dilatation at the level of the lateral meniscus, direct lines were drawn to simulate a straight all-inside meniscal repair device deployed from the anteromedial and anterolateral portals to the medial and lateral borders of the LMR extending 14 mm beyond the joint capsule. If the line passed through or touched the posterior neurovascular structure, a risk of iatrogenic injury was noted, and measurements were made to determine the safe zones in relation to the medial or lateral border of the LMR. Results: Repairing the lateral meniscus through the anterolateral portal in relation to the lateral border of the LMR had a significantly greater risk of posterior neurovascular injury than repairing through the anteromedial portal, of which the incidences were 68.97% and 10.35%, respectively (p-value = 0.001). The “safe zones” of lateral meniscal repair in relation to the lateral border of the LMR through the anterolateral and anteromedial portals were 4.15 ± 1.87 mm and 6.57 ± 0.98 mm lateral to the lateral border of the LMR, respectively. Conclusions: Our study found a risk of iatrogenic posterior neurovascular injury when repairing the posterior lateral meniscus tissue through both the anterolateral and anteromedial portals in relation to both the lateral and medial borders of the LMR, with repairs through the anterolateral portal having greater risk than through the anteromedial portal. To reduce this risk, the surgeon can use the “safe zones” as described in this study to decrease the potential risk of iatrogenic posterior neurovascular injury during arthroscopic lateral meniscal repair. Clinical Relevance: Iatrogenic injury is always a concern in any surgery, and the results of this study can be a guide to reducing iatrogenic posterior neurovascular injury during posterior horn of lateral meniscal repair.

Incomplete meniscal healing in early second-look arthroscopy does not indicate failure of repair: a case series

PurposeTo assess if incomplete meniscal healing during second-look arthroscopy at six to eight weeks after all-inside suture hook meniscus repair results in longer-term failure of repair in patients with restored knee stability.MethodsFrom 2008 to 2013, 41 patients with post-traumatic, longitudinal, vertical, complete meniscal tears with concomitant ACL injury were treated via a two-stage surgical procedure and prospectively evaluated. In the first stage, all-inside meniscus repair was performed using suture hook passers and non-absorbable sutures. In total, there were 26 medial and 16 lateral meniscus tears. A second-stage ACL reconstruction, performed six to eight weeks later, served as an early second-look arthroscopic evaluation of meniscal healing. Clinical follow-up was performed at a minimum of 24 months.ResultsSecond-look arthroscopy revealed 31 cases (75.6%) of complete and ten cases (24.4%) of incomplete meniscal healing. Two patients were lost prior to follow-up, and three were excluded due to recurrent instability. Therefore, 36 patients were assessed at the final follow-up. All patients with complete meniscal healing during second-look arthroscopy achieved clinical success at follow-up. Six out of nine (66.7%) of patients with incomplete meniscal healing during second-look arthroscopy achieved clinical success at follow-up (p = 0.012). One saphenous neuropathy occurred (2.4%).ConclusionIncomplete meniscal healing during early second-look arthroscopy after all-inside meniscal repair using suture hook passers and non-absorbable sutures did not necessarily result in longer-term failure in patients with restored knee stability. The described method of meniscal repair was associated with a low rate of symptomatic re-tears and complications.

Ten-Year Outcomes of Second-Generation, All-Inside Meniscal Repair in the Setting of ACL Reconstruction.

Meniscal repair is the goal, whenever possible, for the treatment of meniscal injury. The purpose of this study was to evaluate the long-term clinical success of meniscal repair performed with a second-generation, all-inside repair device with a concomitant anterior cruciate ligament (ACL) reconstruction. This was a retrospective review of prospectively collected patients who underwent meniscal repair by a single surgeon using the all-inside FAST-FIX Meniscal Repair System (Smith & Nephew) in conjunction with a concurrent ACL reconstruction. Eighty-one meniscal repairs (81 patients) were identified: 59 medial repairs and 22 lateral repairs. Clinical failure was defined as repeat surgical intervention involving resection or revision repair. Clinical outcomes were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and Marx Activity Rating Scale score. Ten-year follow-up was obtained for 85% (69) of 81 patients. Nine patients (13% of 69) underwent a failed meniscal repair (6 medial, 3 lateral), corresponding to a failure rate of 12% (6 of 50) for medial repairs and 16% (3 of 19) for lateral repairs. The mean time to failure was 2.8 years (range, 1.2 to 5.6 years) for the medial repairs and 5.8 years (range, 4.2 to 7.0 years) for the lateral repairs (p = 0.002). There was no difference in mean patient age, sex, body mass index, graft type, or number of sutures utilized between successful repairs and failures. Postoperative KOOS and IKDC outcome scores significantly improved over baseline scores (p < 0.001). There was no significant difference in patient-reported outcomes at 10 years between the group with successful repairs and those who had a failed repair. This report of long-term follow-up results of primary second-generation, all-inside meniscal repair demonstrates its relative success when it is performed with concurrent ACL reconstruction. After a minimum follow-up of 10 years, 84% to 88% of the patients continued to demonstrate successful repair. Failure of medial meniscal repairs occurred significantly earlier compared with lateral meniscal repairs. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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".

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.

Greater rate of return to play and re-injury following all-inside meniscal repair compared to the inside-out technique: a systematic review.

Inside-out and all-inside arthroscopic meniscal repairs are widely performed. However, it remains unclear which method promotes greater clinical outcomes. This study compared inside-out versus all-inside arthroscopic meniscal repair in terms of patient-reported outcome measures (PROMs), failures, return to play, and symptoms. This systematic review was conducted in accordance with the PRISMA guidelines. Two authors independently performed the literature search by accessing the following databases: PubMed, Google Scholar, and Scopus in February 2023. All clinical studies which investigated the outcomes of all-inside and/or inside-out meniscal repair were considered. Data from 39 studies (1848 patients) were retrieved. The mean follow-up was 36.8 (9 to 120) months. The mean age of the patients was 25.8 ± 7.9years. 28% (521 of 1848 patients) were women. No difference was found in PROMs: Tegner Activity Scale (P = 0.4), Lysholm score (P = 0.2), and International Knee Document Committee score (P = 0.4) among patients undergoing meniscal repair with all inside or inside-out techniques. All-inside repairs showed a greater rate of re-injury (P = 0.009) but also a greater rate of return to play at the pre-injury level (P = 0.0001). No difference was found in failures (P = 0.7), chronic pain (P = 0.05), reoperation (P = 0.1) between the two techniques. No difference was found in the rate of return to play (P = 0.5) and to daily activities (P = 0.1) between the two techniques. Arthroscopic all-inside meniscal repair may be of special interest in patients with a particular interest in a fast return to sport, while, for less demanding patients, the inside-out suture technique may be recommended. High-quality comparative trials are required to validate these results in a clinical setting. Level III, systematic review.

All-Inside Repair of Complex Posterior Horn Meniscus Tears

Background: Due to difficult-to-access location and complex tear patterns, the management of meniscus injuries in isolation and in conjunction with anterior cruciate ligament injury may be challenging. The aim of this video is to present techniques and tips that may help surgeons perform arthroscopic all-inside repair of complex meniscus tears. Indications: Indications for the presented repair techniques are young patients with high activity demands, symptomatic lateral and medial meniscus lesions, ligamentous knee instability, chondral changes grade 2 or less, neutral joint alignment, and body mass index below 35 kg/m2. Technique Description: High anterolateral, low anteromedial, and accessory anterolateral portals are used for the arthroscopic assessment of meniscus tear quality and pattern, and to ensure adequate access to the lesion. Horizontal mattress, vertical mattress, and cerclage sutures are passed using a range of all-inside devices to approximate tear edges with the aim of restoring native hoop stresses along the circumferential meniscus collagen fibers. Tear edges are abraded to enhance healing potential. Two separate cases and complex tear configurations are presented to illustrate these all-inside meniscus repair techniques. Results: Meniscus repair yields superior long-term outcomes compared with partial meniscectomy. Improvements in subjective knee function and lower rates of progression to long-term knee osteoarthritis are reported in patients treated with meniscus repair versus resection. Advantages of all-inside meniscus repair include the reduced risk of iatrogenic neurovascular lesions, decreased operative time, restoration of native contact surfaces, and repair without fixation of the menisci to the surrounding soft tissue. Discussion/Conclusion: Arthroscopic all-inside meniscus repair enables the safe and efficient management of complex meniscus tears in active patients with symptomatic meniscus pathology, and can be performed concurrent with knee ligament surgery. Consequently, all-inside meniscus repair techniques are a versatile addition to the toolkit of complex knee surgeons. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.