Concurrent Anterior Cruciate Ligament Research Articles

All-Inside Meniscal Repair Using a New Flexible, Tensionable Device (SS-37)

investigators have demonstrated the crucial role that the meniscus plays in load transmission, shock absorption, joint stability, and improving nutrition to the articular surface. Techniques have evolved from early reports of open meniscal repair by DeHaven to modern all-inside repair. Meniscal repair using suture placed “inside-out” has become the gold standard to which other techniques are compared, with 10-year success rates of approximately 90% when performed with concurrent anterior cruciate ligament reconstruction (ACLR). Numerous all-inside devices have been developed to simplify meniscal repair by avoiding the need for a separate incision and thereby decreasing operative time and the risk of neurovascular injury. Although short-term success rates for one commonly used rigid all-inside device have ranged from 88% to 100%, long-term followup has revealed deteriorating outcomes, with a success rate of only 71%. In addition to lower success rates, the rigid “second generation” all-inside devices have been associated with inflammatory reaction, cyst formation, migration, breakage, and chondral injury. The newer “third generation” all-inside devices use suture to place compression across the tear and provide flexible fixation to help prevent chondral wear. One of these devices, the RapidLoc (Mitek, Westwood, Mass), uses either a 2-0 Ethibond or 2-0 Panacryl suture (DePuy Mitek Inc, Raynham, Mass) between a poly-L-lactic acid All-Inside Meniscal Repair Using a New Flexible, Tensionable Device

Results of All-Inside Meniscal Repair With the FasT-Fix Meniscal Repair System

The goal of this prospective study was to evaluate the results of arthroscopic meniscal repair using the FasT-Fix repair system. Prospective case series. Sixty-one meniscal repairs with the FasT-Fix meniscal repair system in 58 patients with a mean age of 32.6 years were performed between 2001 and 2002. Concurrent anterior cruciate ligament reconstruction was performed in 36 patients (62%). All tears were longitudinal and located in the red/red or red/white zone. Criteria for clinical success included absence of joint-line tenderness, locking, swelling, and a negative McMurray test. Clinical evaluation also included the Tegner and Lysholm knee scores, and KT-1000 arthrometry. In addition, all patients were evaluated preoperatively with magnetic resonance imaging. The average follow-up was 18 months (range, 14 to 28 months). Six of 61 repaired menisci (9.8%) were considered failures according to our criteria. Therefore, the success rate was 90.2%. Time required for meniscal repair averaged 11 minutes. Postoperatively, the majority of the patients had no restrictions in sports activities. The mean Lysholm significantly improved from 43.6 preoperatively to 87.5 postoperatively (P < .001). Fifty-one patients (88%) had an excellent or good result according to the Lysholm knee score. Four patients had a restriction of knee joint motion postoperatively, and an arthroscopic arthrolysis was performed in 1 of them. Analysis showed that age, length of tear, simultaneous anterior cruciate ligament reconstruction, chronicity of injury, and location of tear did not affect the clinical outcome. Our results show that arthroscopic meniscal repair with the FasT-Fix repair system provided a high rate of meniscus healing and appeared to be safe and effective in this group of patients. Level IV, therapeutic study, case series (no control group).

Meniscal repair using the FasT-Fix all-inside meniscal repair device

We performed a prospective study of meniscal repair using a new all-inside suture meniscal repair device to evaluate its clinical efficacy. Prospective case series. The results of 42 meniscal tears in 37 patients who underwent meniscal repair using the FasT-Fix device (Smith & Nephew, Andover, MA) were prospectively evaluated. All cases were performed by 1 surgeon (A.A.S.). Preoperative and follow-up evaluation was performed using the objective and subjective International Knee Documentation Committee (IKDC) criteria as well as Lysholm functional questionnaires. Statistical significance was determined to be P < .05 based on a 2-tailed t test. Relook arthroscopy was performed in 8 patients (9 repairs). Any patient who had a hybrid repair was excluded. The patient population studied, 37 patients comprising 42 meniscal repairs, had an average age of 27 years (range, 13 to 48 years), and an average follow-up of 24.3 months (range, 22 to 27 months). There were 20 male and 18 female patients with 23 medial and 9 lateral repairs; 5 patients had both menisci repaired. All patients had tears in Cooper radial zones 1 and 2 and, thus, had a peripheral meniscal rim of at least 2 mm. All tears were predominantly in the middle and posterior third of the meniscus and 8 tears extended into the posteriormost aspect of the anterior third of the meniscus. An average of 2.8 suture devices was used (range, 1 to 5), predominantly in a vertical or vertical oblique mattress configuration. Forty-two percent were isolated meniscal injuries and 58% had a concurrent anterior cruciate ligament (ACL) reconstruction. Concomitant procedures were ACL reconstruction in 22, excision of loose body in 1, and excision of a large meniscal cyst in 1. Tear length averaged 2.9 cm (range, 1.5 to 4.5 cm). The success rate by objective IKDC score was 86% (73% normal, 13% nearly normal, and 14% abnormal). Of the 5 clinical failures, 3 were in the isolated group (80% success rate), and 2 were in the ACL group (91% success rate). Both the subjective IKDC and the Lysholm scores statistically improved (IKDC average, 59 preoperative and 92 postoperative; Lysholm average, 69 preoperative and 94 postoperative). There were 8 relook arthroscopies; 5 for failures and 3 for other procedures at which time complete healing was noted. In no case was there articular scuffing from the knots. Removal of a device at the time of surgery was necessary in 5 instances for failure of engagement of the T-Fix bar. An additional FasT-Fix device was then inserted without difficulty in each case. No case of postoperative extra-articular or intra-articular complications was encountered. The FasT-Fix suture device affords an all-inside method of meniscal repair using a strong vertical or horizontal mattress suture configuration and appears to be a safe and effective technique for meniscal repair for tears with at least a 2-mm peripheral rim. It has a high success rate and low complication rate and has results comparable to classic suture repair techniques. Level IV.

Arthroscopic all-inside suture repair of medial meniscus lesion in anterior cruciate ligament—deficient knees: Results of second-look arthroscopies in 39 cases

To evaluate by second-look arthroscopy the clinical results of arthroscopic all-inside sutures with hook using 2 posteromedial portals for medial meniscus posterior horn (MMPH) tears in patients who underwent concurrent anterior cruciate ligament (ACL) reconstruction. Case series. From May 1997 to June 2001, 78 knees underwent surgery for MMPH tears with arthroscopic all-inside sutures with hook and concurrent ACL reconstruction. Among them, 39 patients were evaluated with follow-up second-look arthroscopy. All MMPH tears were repaired by arthroscopic all-inside suture technique using 2 posteromedial portals. The second-look arthroscopy was performed, on average, 19 months (range, 6 to 40 months) after the ACL reconstruction and meniscal repair. They were divided into complete healing, incomplete healing, and failure groups. Tear size, type, and location were analyzed. We determined clinical criteria for success in meniscal status as (1) not positive for 4 clinical objective parameters--joint line pain and tenderness, locking or catching, recurrent effusions, and McMurray test; and (2) complete healing of all-inside sutured meniscus during second-look arthroscopy. Among 39 knees assessed by second-look arthroscopy, 32 (82.1%) knees showed complete healing and 6 (15.4%) showed incomplete healing without any positive findings of the clinical symptoms. Furthermore, all cases in the incompletely healed group had complete healing of the posterior horn, which was sutured by an all-inside suture; the incomplete healing was observed between the junction areas of all-inside to inside-out sutures, which was mainly at the posteromedial corner. The success rate was 97.4% (38 of 39 patients) overall for all-inside suture healing. The 1 patient (2.6%) with clinical failure had a retear of the repaired site. The average knee scores improved and all showed less than 2-mm side-to-side difference on KT-2000 testing. Arthroscopic all-inside vertical suture using a suture hook resulted in a high rate of healing even in large and complex vertical tears. This suturing can be one of the optimal treatments for MMPH tears greater than 1 cm during concurrent ACL reconstruction. Level IV, Therapeutic Study, Cases Series (no, or historical, control group).

Results of Arthroscopic All-Inside Sutures in Medial Meniscus with Concomitant Anterior Cruciate Ligament Reconstruction

Purpose: To evaluate the clinical results of arthroscopic all-inside suture using 2 posteromedial portals for medial meniscus posterior horn (MMPH) tears by second-look arthroscopy in patients received concurrent anterior cruciate ligament (ACL) reconstruction. Materials and Methods: From May 1997 to June 2001, 78 MMPH tears were treated with arthroscopic all-inside sutures with concurrent anterior cruciate ligament (ACL) reconstruction. Among these 39 patients were availablefor follow-up evaluation by second-look arthroscopy. All MMPH tears were repaired using the arthroscopic all-inside suture technique using 2 posteromedial portals. Second-look arthroscopy was performed on average 19 months (range 6 to 40 month) after the ACL reconstruction and meniscal repair. Meniscus healing status was defined and classified. According to the Henning classification, they were divided into complete healing, incomplete healing, and failure. Tear size, type and location were analyzed and compared with healing category. We determined clinical criterias for success in meniscal status as; (1) no positive among 4 clinical objective parameters: joint line pain and tenderness, locking or catching, recurrent effusions, and positive McMurry test; and (2) complete healing of all-inside sutured meniscus during second-look arthroscopy. Results: Of 39 knees assessed by second-look arthroscopy, 32 (82.1%) showed complete healing, 6 (15.4%) incomplete healing without any positive findings of clinical symptoms. Furthermore, all in the incompletely healed group showed complete healing of the posterior horn, which was sutured by allinside suture, whereas incomplete healing was observed at the junctional areas between all-inside and inside-out sutures, mainly at the posteromedial corner. So the overall success rate was 97.4% (38/39) for all-inside suture healing. The one (2.6%) patient with clinical failure revealed a retear of the repaired site, and subsequent subtotal menisectomy was performed. KT-2000 arthrometry showed that sagittal knee laxity was less than 2 mm (Average 1.5 mm, SD 0.72) in all reconstructed knees. The average knee scores, Lysholm knee score and HSS score, at final follow up were 95.5 and 96.5, respectively. As expected, small, longitudinal, and more peripheral (red-red zone) tears resulted in a higher healing outcome. Conclusion: Accurate repair with arthroscopic all-inside vertical suture using a suture hook, resulted in a high healing rate even in large and complex vertical tears. Arthroscopic all-inside meniscal suturing may be an optimal treatment for medial meniscus posterior horn tear greater than 1 cm during concurrent anterior cruciate ligament reconstruction.

Outcomes after meniscal repair using the meniscus arrow in knees undergoing concurrent anterior cruciate ligament reconstruction

Purpose: To determine the healing rate of meniscal repair using the Meniscus Arrow (Bionx, Blue Bell, PA) in patients undergoing concurrent anterior cruciate ligament (ACL) reconstruction and to evaluate patient outcomes with the International Knee Documentation Committee (IKDC) form and a visual analog scale (VAS). Type of Study: Case series with outcomes analysis. Methods: We retrospectively analyzed 38 consecutive patients with 39 meniscal tears in knees undergoing concurrent endoscopic ACL reconstruction whose menisci were repaired with the Meniscus Arrow system. All meniscal tears were deemed amenable to repair according to length, stability, morphology, and zone of tear. There were 31 medial and 8 lateral meniscal tears, with an average tear length of 2.1 cm. An average of 2.5 arrows were used to repair each tear. All 39 tears were located in the posterior horn of the meniscus or extending into the body of the meniscus from the posterior horn. Follow-up was assessed by clinical examination, the knee disorders subjective history, VAS, and the IKDC evaluation form. Reconstructed ACL laxity was assessed by KT-2000 arthrometry and clinical evaluation. Results: At an average follow-up of 2.3 years (range, 18-39 months), 32 patients have been surveyed to date. The success rate was 90.6% (29 of 32 patients) with 3 patients going on to arthroscopic partial meniscectomy. KT-2000 arthrometry showed that sagittal knee laxity was less than 3 mm in all reconstructed knees. Clinical criteria for success in the rest of the repaired menisci included (1) the absence of locking, catching, or giving way; (2) no history of recurrent effusions; (3) no joint line tenderness; (4) a negative McMurray test; and (5) no subsequent surgical procedures on the repaired meniscus. Additionally, the VAS showed the ability of these patients to return to a high level of activity, including competitive sports, without symptoms suggestive of a meniscal tear. The IKDC showed normal or nearly normal function of all success knees. Conclusions: The study shows that a high rate of meniscus healing can be achieved by the all-inside, bioabsorbable Meniscus Arrow system in conjunction with ACL reconstruction. Also, patients have excellent function of their knee and are able to return to a high level of activity. Our healing rates are comparable to those previously reported with the inside-out suture techniques without the need for an additional posterior incision that would increase operative time and risk to neurovascular structures.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 6 (July-August), 2002: pp 569–577

Two-year follow-up of meniscal repair using a bioabsorbable arrow

Purpose: The value of meniscal repair is well established. Several all-inside arthroscopic techniques have become available to achieve this goal. One such technique involves the use of a biodegradable polylactic acid tack, which has made repair technically easier to perform. This study evaluates the 2-year results of arthroscopic meniscal repair using this device. Type of Study: Retrospective case series. Methods: We reviewed charts of 38 patients who had undergone 39 meniscal repairs with the bioabsorbable arrow. All procedures were performed by one of 4 fellowship-trained sports medicine orthopaedic surgeons in 1 of 2 affiliated hospitals, with a minimum follow-up of 2 years. Review consisted of evaluation of patient records, interview, and clinical examination by an independent examiner. Lysholm and Tegner knee scores were recorded. Complications and clinical failure, defined as reoperation, were noted. Results: The average age of the patients was 29.9 years. The ratio of medial to lateral meniscal repair was 5:1. Twenty-one patients underwent concurrent anterior cruciate ligament reconstruction, and in this subgroup, there were no clinical failures. In the remaining group, isolated meniscal repairs in stable knees, the clinical failure rate was 7% (2 reoperations). Local soft-tissue complications occurred in 31.6% of patients, including 2 with arrow migration through the skin. These symptoms typically resolve over several months. Conclusions: The availability of sutureless all-inside absorbable techniques for meniscal repair has made the procedure technically easier to perform arthroscopically. In our patients, local complications related to device migration, device prominence, and soft-tissue inflammation associated with absorption of the device were common (31.6%). These complications were usually transient. We emphasize the importance of selecting the correct length of device so as to minimize these effects. As with other meniscal repair techniques, a higher success rate was found in knees undergoing concurrent anterior cruciate ligament reconstruction. Our results show a clinical success rate using an absorbable all-inside technique with an absorbable device comparable to reported results using established inside-out techniques.

Rehabilitation following knee osteotomy

This article provides an overview of the clinical management of common complications following knee osteotomy procedures with or without concurrent anterior cruciate ligament reconstruction.