Longitudinal Tear Research Articles

Suture hook versus all-inside repair for longitudinal tears of the posterior horn of the medial meniscus concomitant to anterior cruciate ligament reconstruction: A matched-pair analysis

Secondary meniscectomy rates after longitudinal tears of the posterior horn of the medial meniscus repair performed concomitantly to ACL reconstruction are as high as 25% with all-inside repair technique. Posteromedial suture hook repair is an emerging technique; however, it is unknown whether it confers a significantly reduced secondary meniscectomy rate. Patients with longitudinal tears of the PHMM who underwent meniscal repair during primary ACLR between January 2011 and December 2015 were eligible for the study. Patients undergoing suture hook repair were propensity matched in a 1:1 ratio to patients who underwent all-inside repair. At the end of the study period, secondary meniscectomy rates were determined. The study population comprised 237 matched pairs. The mean follow-up was 97.7 6 17.3 months. Patients who underwent an all-inside repair had a .2-fold higher failure rate compared with patients who underwent suture hook repair through a posteromedial portal (31.2% vs. 15.6%; p = .0003). Patients in the suture hook repair group undergoing additional ALLR demonstrated a 3-fold higher meniscal repair survival rate compared with all other subgroups ( p = .0014). This association was not seen in the all-inside repair group. The only statistically significant risk factor for meniscal repair failure was the suture repair technique (hazard ratio, 2.133 [95% CI, 1.383–3.292]; p = .0008). Suture hook repair through a posteromedial portal is associated with lower secondary meniscectomy rate when compared with the all-inside repair of longitudinal tears of the PHMM performed at the time of ACLR. Patients in the suture hook repair group who underwent additional ALLR had a significantly better meniscal repair survivorship.

Posterior Horn Lateral Meniscal Oblique Radial Tear in Acute Anterior Cruciate Ligament Reconstruction Incidence and Outcomes After All-Inside Repair: Clinical and Second-Look Arthroscopic Evaluation

Background: The term posterior horn lateral meniscal oblique radial tear (LMORT) has emerged to characterize the tear patterns of the lateral meniscus in many patients with acute anterior cruciate ligament (ACL) injury. There is a lack of data regarding the exact incidence according to the types of LMORT and clinical outcomes. Purposes: (1) To investigate the incidence of LMORT according to type in patients with acute ACL reconstruction (ACLR) and (2) to identify healing status after repair of LMORT via second-look arthroscopy and clinical outcomes. Study Design: Case series; Level of evidence: 4. Methods: Patients who underwent primary ACLR within 6 months of injury were retrospectively reviewed. The LMORT was classified into 4 types based on the severity and distance from the root: type 1 (partial tear <10 mm from the root), type 2 (complete tear <10 mm from the root), type 3 (partial tear >10 mm from the root), type 4a (complete tear >10 mm from the root), and type 4b (type 4a with longitudinal tear at the meniscocapsular junction). Only patients with LMORT were isolated, and the clinical outcomes were compared according to the healing status of LMORT in second-look arthroscopy. Results: Of 635 patients with ACLR, LMORT was identified in 97 patients (15.3%), and type 4 LMORT accounted for the largest proportion (n = 62; 32.6%) of 190 lateral meniscal tears. In 79 patients with LMORT who satisfied the 2-year follow-up period, all patient-reported outcomes (PROs), including the Lysholm (preoperative, 64.1; postoperative, 88.2) and International Knee Documentation Committee subjective (preoperative, 50.5; postoperative, 82.9) scores, were significantly improved (P < .001) 31.8 months postoperatively. Of the 61 patients who underwent second-look arthroscopy, 49 (80.3%) were classified into the complete healing group. There was no significant difference in postoperative PROs between the complete and partial healing groups. Conclusion: The incidence of LMORT was 15.3% in patients with acute ACL injury, and type 4 LMORT was the most common type. Complete healing of LMORT was achieved in 80.3% of patients who underwent second-look arthroscopy, and the PROs were significantly improved postoperatively. Good clinical results can be achieved if the LMORT is repaired as much as possible during ACLR.

All-Inside Meniscal Repair: A Historical View

Background: All-inside meniscal repair first became popularized in the early 2000s. Since that time, there has been a wide variety of all-inside implants on the market with rapid changes and developments in recent years. Indications: Small, peripheral, longitudinal tears are best suited for all-inside repair, but this technique may even be used for large bucket handle tears especially when hybridized with an inside-out repair. Technique Description: A percutaneous release of the medial collateral ligament (MCL) with an 18-g spinal needle is frequently performed when working in the medial compartment to improve visualization and decrease risk of iatrogenic chondral injury. Close familiarity with the characteristics of the chosen all-inside device including device angle, modifiability of device angle, modifiability of needle depth, deployment method, and tensioning technique is important for obtaining reproducible results. Typically, obtaining a vertical mattress stitch configuration is optimal as it captures more circumferential collagen fibers in the repair. Results: Factors to consider when selecting an all-inside meniscal repair device include the ergonomics of the device, implant cost, availability, rigid versus suture-based anchor, core needle diameter, device flexibility, and percent of misfires. Discussion: Complications from use of all-inside meniscus repair devices include device failure, soft tissue entrapment, cyst formation, and injury to the popliteal artery. Outcomes, however, with current devices are good and comparable to inside-out meniscus repair with about a 90% return to sports rate at 12 months postoperatively. 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.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures.

Anatomical and biomechanical characteristics of fibularis longus tendon used for cruciate ligaments reconstruction

Abstract Introduction: Arthroscopic reconstruction of the cruciate ligament of the knee becomes routine with modern techniques and special instruments. However, the source of materials for this procedure has always been an eternal issue that affects the surgeons decision. The two peroneal tendons on the lateral side of the lower leg have the same function of plantar flexion and foot eversion. The fibularis longus tendon has been used for reconstruction such as the lateral collateral ligaments of the ankle or the Achilles tendon. Patients and methods: Descriptive cross-sectional study on twenty fresh cadavers were selected randomly for taking the fibularis longus tendon at the Department of Anatomy of the University of Medicine and Pharmacy, Ho Chi Minh City from January to July, 2022. Specimens with intact leg to lower knee segment were not crushed, well preserved and had never been used in previous studies. Results: Fibularis longus tendon length was 29,25 ± 2,1cm; the distances from fibularis longus tendon to deep fibular nerve and superficial fibular nerve was 71.1±8.63mm respectively, no split (longitudinal tear) was observed, the maximum tensile strength was 1170,4 ±203N, the maximum length of rupture 14,29 ± 3,88 mm. Conclusion: There was no split of fibularis longus tendon. Also no sign of impact on adjacent anatomy structures was found. The maximum tensile strength was equivalent to other grafts, such as the Hamstrings and patellar tendons. Its a potential source for arthroscopic reconstruction of the cruciate ligament Keywords: knee arthroplasty, fibularis longus tendon, grafts, Hamstrings tendon

Lateral Internal Anal Sphincterotomy of Chronic Anal Fissure: An Experience of 165 Cases.

The anal fissure is frequently seen in surgical practice. It is caused by a longitudinal tear in the anoderm distal to the dentate line. The hallmark feature of the disease is severe pain during defecation. Chronic anal fissure (CAF) causes undue stress that leads to poor quality of life. Different options of treatment, whether medical or surgical, are employed to treat this condition. One of these modalities is lateral internal anal sphincterotomy (LIAS). We aimed to assess the safety and efficacy of the LIAS surgical procedure for the treatment of CAF. This retrospective study was conducted at the Al-Muqdadiya General Hospital, Diala, Iraq, for a period from January 2016 to March 2021. The medical records of the patients with CAF who were subjected to LIAS under local anesthesia were reviewed. Data regarding the age, gender, smoking habit, body mass index (BMI), healing time, complications, and outcome for each participant were recorded. Of 165 participants, there were 91 men. The majority of the cases were ≤ 35 years (78.19%), were non-smokers (80%), and had no history of DM(98.79%). There was complete healing with a resolution of the pain at two months postoperatively in 163 subjects. The most common complication in our study was flatus incontinence (n = 5). All of them were found in the age group > 35 years and women. There were statistically significant differences between the age groups, gender, BMI, and the occurrence of flatus incontinence (P-value = 0.000, 0.012, and 0.009 respectively). However, there was no such association between smoking habit and a history of DM (P-value > 0.05). Conclusion: LIAS is safe and effective in the treatment of CAF, with an excellent outcome in resolving pain and a low complication rate. Age, female gender, and high BMI might affect the occurrence of flatus incontinence.

An Atypical Presentation of Penile Fracture with Urethral Injury

Background: Penile fracture is a urological emergency that occurs following a traumatic rupture of the tunica albuginea. Patients experience an audible ‘pop’ and immediate detumescence during sexual activity, followed by pain, swelling and ecchymosis. It is uncommon for patients to present without these typical clinical findings. Case Presentation: This case report describes a 33-year-old male with an atypical penile fracture and associated urethral injury. He reported mild pain as his penis buckled against his partner’s thigh during sexual intercourse and a sudden detumescence. Examination was unremarkable other than gross blood at the external urethral meatus. MRI identified a 4 mm focal capsular defect at the ventral aspect of the left corpora cavernosum. Flexible cystoscopy identified a 2cm longitudinal tear in the distal urethra. The patient underwent successful surgical repair with no long term sequalae. Conclusions: The authors of this report wish to highlight the importance of keeping a high index of suspicion for penile fractures in light of a typical history.

S2591 Fatal Gastrointestinal Hemorrhage Caused by a Two cm Deep Mallory Weiss Tear

Introduction: Mallory-Weiss syndrome (MWS) is one of the common causes of acute upper gastrointestinal bleeding (UGIB). These tears occur primarily at the gastroesophageal junction. We present a case of a 45-year-old man presenting with acute bright red bloody vomiting and diagnosed with a rapid UGIB from a Deep Mallory Weiss Tear. Case Description/Methods: A 45-year-old male with unknown past medical history presented to the Emergency Department with bright red blood in the vomitus, going on for the past two days prior to admission. His hemoglobin on presentation was 9.9, INR was 1.2, and platelets were 46. The patient was alert and oriented × 2 on examination. The patient was started on Protonix intravenous drip and an Octreotide intravenous drip. The decision was made to perform an urgent upper endoscopy (EGD) for the patient. There were no previous baseline labs available for this patient. On EGD, a 2 cm bleeding Deep Mallory Weiss Tear was found with active bleeding at the Gastro-Esophageal junction visible in the retroflexion view on the cardia side of the stomach. The spurting area with a visible vessel was successfully injected with epinephrine, and four hemostatic clips were deployed. For further hemostasis, a single hemostatic spray was deployed. Bright red blood was seen in the cardia and fundus, and about 800 cc of blood was aspirated. Post-procedure, the patient was transferred to critical care unit for further care (Figure 1). Discussion: MWS accounts for 1% to 15% of the causes of upper GI bleeding in adults. The suggested theory is that when the intra-abdominal pressure suddenly and severely increases, the gastric contents rush proximally under pressure into the esophagus. This excess pressure from the gastric contents results in longitudinal mucosal tears, which may reach deep into the submucosal arteries and veins, resulting in upper GI bleeding. Treatment and management consist of performing EGD for the diagnosis and using endoscopic therapies like epinephrine injection, deploying clips, and hemostatic spray to control massive bleeding, as seen in our patient.Figure 1.: Therapeutics done for Deep Mallory Weiss Tear.

Margin Convergence Continuous Lasso-Loop Overlocking Technique for the Repair of Horizontal and Longitudinal Knee Meniscal Tears

Horizontal and longitudinal tears are the most common injuries of the meniscus. The arthroscopic all-inside suture technique using meniscal repair devices involving preloaded sutures and nonabsorbable implants is the most popular technique. The 2 main disadvantages of this technique are the high cost and complications associated with implants. We have adopted some modern shoulder surgery techniques to repair horizontal and longitudinal meniscal tears. Our technique is based on the continuous lasso-loop margin convergence technique for rotator cuff repair (Lafosse’s continuous stitches). The technique is an implant-free, cost-effective procedure, which can be performed using general arthroscopic instruments.

Application of YOLOv4 Algorithm for Foreign Object Detection on a Belt Conveyor in a Low-Illumination Environment

The most common failures of belt conveyors are runout, coal piles and longitudinal tears. The detection methods for longitudinal tearing are currently not particularly effective. A key study area for minimizing longitudinal belt tears with the advancement of machine learning is how to use machine vision technology to detect foreign items on the belt. In this study, the real-time detection of foreign items on belt conveyors is accomplished using a machine vision method. Firstly, the KinD++ low-light image enhancement algorithm is used to improve the quality of the captured low-quality images through feature processing. Then, the GridMask method partially masks the foreign objects in the training images, thus extending the data set. Finally, the YOLOv4 algorithm with optimized anchor boxes is combined to achieve efficient detection of foreign objects in belt conveyors, and the method is verified as effective.

Long-term Natural History of Unrepaired Stable Ramp Lesions: A Retrospective Analysis of 28 Patients With a Minimum Follow-up of 20 Years

Background: There is a lack of consensus about whether stable ramp lesions associated with anterior cruciate ligament (ACL) injuries need to be repaired. Purpose/Hypothesis: The purpose of this study was to evaluate how many stable ramp lesions left in situ during ACL reconstruction (ACLR) have subsequently failed after >20 years of follow-up. We hypothesized that ACL-reconstructed knees with ramp lesions left in situ without repair have a high risk of meniscal failure over the long term. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent arthroscopic ACLR by a single experienced surgeon between January 1998 and December 2000 were evaluated retrospectively. Included were all cases of longitudinal tears in the meniscocapsular junction or the red zone of the posterior horn of the medial meniscus that were left in situ and identified through the anterior portals. Successful anterior probing confirmed a meniscal tear of the posterior segment. A lesion was considered stable if it was ≤2 cm and did not extend beyond the lower pole of the femoral condyle. The following data were collected preoperatively and at the last follow-up: demographics, time to surgery, side-to-side laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner activity scale, and meniscal failure rate. We defined 2 groups based on our findings: medial meniscal failure versus no medial meniscal failure. Results: A total of 716 knees underwent primary ACLR during this period. The 39 (5.4%) stable unrepaired ramp lesions identified were included in the case series. Mean ± standard deviation follow-up was 262.1 ± 10.5 months. Eleven patients (28%) were lost to follow-up. Of the remaining patients, 8 (28.6%) had a medial meniscal failure, of which 6 (21.4%) were bucket-handle tears. The average time elapsed before complications was 87.8 ± 52 months (range, 6-156 months). The medial meniscal survival rate was 93% at 5 years, 75% at 10 years, and 71% at 15 and 20 years. The failure event mainly happened between 96 and 120 months (8 and 10 years) after ACLR. No risk factors for failure were found, but some trends appeared, such as older age, higher body mass index, and preoperative rotational instability. All postoperative scores were significantly improved at the last follow-up (P < .0001); 16 patients (57%) returned to their sport of choice. Conclusion: With nearly one-third of patients developing meniscal complications, including a large share of bucket-handle tears and mostly occurring 8 years after the ACLR, it may not be wise to leave stable ramp lesions unrepaired.

Participation of patients during arthroscopic partial meniscectomy is conducive to postoperative rehabilitation and satisfaction: a single-center retrospective study

PurposeTo evaluate the effect of patient participation in arthroscopic partial meniscectomy (APM) on rehabilitation and patient satisfaction.MethodsA total of 86 patients of traumatic longitudinal vertical meniscus tears, between January 2017 and December 2020 at the First Affiliated Hospital of Zhejiang Chinese Medical University, met the inclusion and exclusion criteria. The patients in the intraoperative participation group (n = 33) were awake and could watch the screen during APM and communicate with the surgeon in the surgery; patients who underwent APM in the traditional mode were classified as the traditional group(n = 53). The differences in exercise adherence, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and satisfaction at follow-up were compared. In the intraoperative participation group, the mean age of the patients was 26.97 ± 5.63 years and the follow-up time was 25.12 ± 6.23 months. In the traditional group, the mean age of the patients was 29.21 ± 5.29 years and the follow-up time was 25.08 ± 6.70 months.ResultsThe intraoperative participation group reported a better result in exercise adherence (78.79% VS 50.94%, p = 0.012). As secondary outcomes, Patients in the intraoperative participation group demonstrated better scores on the KOOS domains of pain (79.80 ± 6.38 VS 76.26 ± 5.33, p = 0.007), Symptoms (59.41 ± 5.27 VS 56.74 ± 5.97, p = 0.038), and QOL (65.91 ± 10.72 VS 60.26 ± 9.34, p = 0.012), as compared to these in the traditional group. There were no significant differences in the KOOS domains of Sport (72.88 ± 8.20 VS 72.64 ± 7.70, P = 0.892), and ADL (89.47 ± 3.50 VS 87.87 ± 4.50 p = 0.085). what’s more, in the intraoperative participation group, the results of satisfaction (96.97% VS 81.13%, p = 0.025) were also significantly better.ConclusionThe mode of participation of patients during APM can improve patients’ exercise adherence, reduce pain, improve symptoms and improve patients’ satisfaction as well as the quality of life. More work is needed to develop this mode further.

Classification, Risk Factors, Diagnoses, and Examination for Six-Type Meniscus Tears

The knee is the connection of the tibia and femur, which are two bones near to knees, and the menisci are in the knee joint shaped in two wedge pieces of fibrocartilage. Meniscus tears are considered the most common knee injuries and happen from acute trauma - like the fibrocartilage of meniscus tears, breaks, cracks, ruptures, or splits - or as the result of degenerative changes that happen over time. This study discussed the classification, risk factors, diagnoses, and examination for meniscus tears. The result shows that there are six common meniscus tears including bucket handle, flap, radial, degenerative, horizontal, and longitudinal meniscus tears. Risk factors of meniscus tears include age, gender, limb alignment, accidents, sports injuries, and osteoarthritis. Physical examinations and imaging examinations are commonly used techniques. Magnetic Resonance Imaging (MRI) is considered the most typical standard of testing meniscus tears. It can identify different types of meniscus tears and detect any associated damage to the ligaments, cartilage, and tendons.

Function, Injury, and Treatment for Meniscus

The meniscus is considered a vital structure for maintaining normal functions and perennial health of the knee joint. This study focuses on the meniscus and discusses its function, injuries and the corresponding treatments. Results show that two menisci are located in the knee joint- medial and lateral meniscus, which are different in shape but work together to provide specific functions. The main functions of the meniscus include load sharing, shock absorption, stability, joint lubrication and nutrition. Meniscal injuries include vertical longitudinal, radial, horizontal (cleavage), degenerative (complex), and bucket-handle tears, all of which can cause serious knee morbidity. There are different symptoms of meniscus damage, and the severity of the damage can be identified from the symptoms. Once the meniscus injury is found, conservative or surgical treatment should be carried out immediately. Conservative treatments generally include massage, acupuncture, and slight movement, as well as drug treatment. Surgical treatments include meniscus suture, partial meniscectomy, and meniscectomy. If it is not treated in time, the meniscus could cause irreversible damage and a series of sequelae.

Early Lateral Internal Sphincterotomy Versus Conservative Treatment; Our Experience in Treatment of Chronic Anal Fissure in Qazi Hussain Ahmed Medical Complex Nowshera Pakistan

Background: A chronic anal fissure is a longitudinal tear in the anorectal area beneath the dentate line contributing to chronic pain and emotional stress during defecation. The present study aimed to assess early surgery versus conservative treatment for managing chronic anal fissures. Methodology: This randomized control trial was carried out on 150 chronic anal fissures patients at the Department of General Surgery, Qazi Hussain Ahmed Medical Complex, Nowshera, Pakistan from March 2020 to September 2021. Patients were divided into two groups; Group-I comprised of patients who were treated conservatively and Group II consisted of patients who underwent surgical intervention. Patients above 15 years of age and fit for surgery were enrolled. A Chi-square test was used for correlating the results using SPSS version 24. Results: Of the total patients, there were 132 (88%) male and 18 (12%) female patients. The overall mean age of Group-I and Group-II was 38.7± 6.5 years and 39.6±3.67 years. The prevalence of posterior and anterior located fissures were 136 (90.7%) and 14 (9.3%) respectively. About 86 patients underwent closed LIS, out of which 77 were male and 9 were female. The patient’s main complaints were anal pain followed by bleeding. The response rate to pain relief treatments was 79% in group-I, I, and I and 97% in group II. Conclusion: Our study found that lateral internal sphincterotomy remains the gold standard for the treatment of chronic anal fissures. To avoid recurrence and obtain the best pain relief, LIS remains the gold standard for the treatment of chronic anal fissures. Keywords: Chronic anal fissure, Conservative treatment, surgical intervention

Pulsed Electromagnetic Field Enhances Healing of a Meniscal Tear and Mitigates Posttraumatic Osteoarthritis in a Rat Model

Background: Meniscal tears in the avascular region are thought to rarely heal and are a considerable challenge to treat. Although the therapeutic effects of a pulsed electromagnetic field (PEMF) have been extensively studied in a variety of orthopaedic disorders, the effect of a PEMF on meniscal healing has not been reported. Hypothesis: PEMF treatment would promote meniscal healing and prevent osteoarthritis progression. Study Design: Controlled laboratory study. Methods: A total of 72 twelve-week-old male Sprague-Dawley rats with full-thickness longitudinal medial meniscal tears in the avascular region were divided into 3 groups: control (Gcon), treatment with a classic signal PEMF (Gclassic), and treatment with a high–slew rate signal PEMF (GHSR). Macroscopic observation and histological analysis of the meniscus and articular cartilage were performed to evaluate the meniscal healing and progression of osteoarthritis. The synovium was harvested for histological and immunofluorescent analysis to evaluate the intra-articular inflammation. Meniscal healing, articular cartilage degeneration, and synovitis were quantitatively evaluated according to their scoring systems. Results: Dramatic degenerative changes of the meniscus and articular cartilage were noticed during gross observation and histological evaluation in Gcon at 8 weeks. However, the menisci in the 2 treatment groups were restored to normal morphology, with a smooth surface and shiny white color. Particularly, the HSR signal remarkably enhanced the fibrochondrogenesis and accelerated the remodeling process of the regenerated tissue. The meniscal healing scores of the PEMF treatment groups were significantly higher than those in Gcon at 8 weeks. Specifically, the HSR signal showed a significantly higher meniscal repair score than did the classic signal at week 8 (P < .01). Additionally, the HSR signal significantly downregulated the secretion levels of interleukin 1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α) in the meniscus and synovium as compared with the control group. When compared with the 2 treatment groups, Gcon had significantly higher degeneration scores (Gcon vs Gclassic, P < .0001; Gcon vs GHSR, P < .0001). The HSR signal also exhibited significantly lower synovitis scores compared with the other two groups (Gcon vs Gclassic, P < .0001; Gclassic vs GHSR, P = .0002). Conclusion: A PEMF promoted the healing of meniscal tears in the avascular region and restored the injured meniscus to its structural integrity in a rat model. As compared with the classic signal, the HSR signal showed increased capability to promote fibrocartilaginous tissue formation and modulate the inflammatory environment, therefore protecting the knee joint from posttraumatic osteoarthritis development. Clinical Relevance: Adjuvant PEMF therapy may offer a new approach for the treatment of meniscal tears attributed to the enhanced meniscal repair and ameliorated osteoarthritis progression.

Primary Fixation and Cyclic Performance of Single-Stitch All-Inside and Inside-Out Meniscal Devices for Repairing Vertical Longitudinal Meniscal Tears

Background: Primary device fixation and the resistance against gap formation during repetitive loading influence the quality of meniscal repair. There are limited biomechanical data comparing primary tensioning and cyclic behavior of all-inside versus inside-out repair. Hypothesis: All-inside devices provide higher initial load on the meniscal repair than inside-out fixation, and stiffer constructs show higher resistance against gap formation during cyclic loading. Study Design: Controlled laboratory study. Methods: In total, 60 longitudinal bucket-handle tears in human cadaveric menisci were created and repaired with a single stitch and randomly assigned to 4 all-inside groups (TrueSpan, FastFix 360, Stryker AIR, FiberStich) and 2 inside-out groups (suture repair [IO-S], suture tape [IO-ST]). Residual load after repair tensioning (50 N) and relief displacement were measured. Constructs underwent cyclic loading between 2 and 20 N over 500 cycles (0.75 Hz) with cyclic stiffness, gap formation, and final peak elongation measured. Ultimate load and stiffness were analyzed during pull to failure (3.15 mm/s). Results: All-inside repair demonstrated significantly higher primary fixation strength than inside-out repair. The significantly highest load (mean ± SD; 20.1 ± 0.9 N; P < .037) and relief displacement (–2.40 ± 0.32 mm; P < .03) were for the knotless soft anchoring FiberStich group. The lowest initial load (9.0 ± 1.5 N; P < .001) and relief displacement (–1.39 ± 0.26 mm; P < .045) were for the IO-S repair group. The final gap formation (500th cycle) of FiberStich (0.75 ± 0.37 mm; P < .02) was significantly smaller than others and that of the IO-S (1.47 ± 0.33 mm; P < .045) significantly larger. The construct stiffness of the FiberStich and IO-ST groups was significantly greater at the end of cyclic testing (16.7 ± 0.80 and 15.5 ± 1.42 N/mm; P < .042, respectively) and ultimate failure testing (23.4 ± 3.6 and 20.6 ± 2.3 N/mm; P < .005). The FastFix 360 (86.4 ± 4.8 N) and Stryker AIR (84.4 ± 4.6 N) groups failed at a significantly lower load than the IO-S group (P < .02) with loss of anchor support. The FiberStich (146.8 ± 23.4 N), TrueSpan (142.0 ± 17.8 N), and IO-ST (139.4 ± 7.3 N) groups failed at significantly higher loads (P < .02) due to suture tearing. Conclusion: Overall, primary fixation strength of inside-out meniscal repair was significantly lower than all-inside repair in this cadaveric tissue model. Although absolute differences among groups were small, meniscal repairs with higher construct stiffness (IO-ST, FiberStich) demonstrated increased resistance against gap formation and failure load. Clinical Relevance: Knotless single-stitch all-inside meniscal repair with a soft anchor resulted in less gapping, but the overall clinical significance on healing rates remains unclear.

Suture Hook Versus All-Inside Repair for Longitudinal Tears of the Posterior Horn of the Medial Meniscus Concomitant to Anterior Cruciate Ligament Reconstruction: A Matched-Pair Analysis From the SANTI Study Group

Background: Secondary meniscectomy rates after repair of longitudinal tears of the posterior horn of the medial meniscus (PHMM) performed concomitantly with anterior cruciate ligament reconstruction (ACLR) are reported to be as high as 25% with an all inside repair technique. Posteromedial portal suture hook repair is an emerging technique; however, it is unknown whether it confers a significantly reduced secondary meniscectomy rate compared with the current gold standard. Purpose/Hypothesis: The primary objective of this study was to compare the secondary meniscectomy rates of suture hook repair and all inside repair for longitudinal tears of the PHMM performed concomitant to ACLR. The secondary outcome was to determine the risk factors associated with the failure of the repair. It was hypothesized that repair with an all inside device would be associated with higher secondary meniscectomy rates when compared with suture hook repair and that concomitant anterolateral ligament reconstruction (ALLR) would confer improved meniscal repair survivorship. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with longitudinal tears of the PHMM who underwent meniscal repair during primary ACLR between January 2011 and December 2015 at our institution were eligible for the study. Patients undergoing suture hook repair were propensity matched in a 1:1 ratio to patients who underwent all inside repair. At the end of the study period, secondary meniscectomy rates were determined. Results: The study population comprised 237 matched pairs. The mean follow up was 97.7 ± 17.3 months. Patients who underwent an all inside repair had a >2-fold higher failure rate compared with patients who underwent suture hook repair through a posteromedial portal (31.2% vs 15.6%; P = .0003). Patients in the suture hook repair group undergoing additional ALLR demonstrated a >3-fold higher meniscal repair survival rate compared with all other subgroups (P = .0014). This association was not seen in the all inside repair group. The only statistically significant risk factor for meniscal repair failure was the suture repair technique (hazard ratio, 2.133 [95% CI, 1.383-3.292]; P = .0008). Conclusion: Suture hook repair through a posteromedial portal is associated with a significantly lower secondary meniscectomy rate when compared with the all inside meniscal repair of longitudinal tears of the PHMM performed at the time of ACLR. Furthermore, patients in the suture hook repair group who underwent an additional ALLR had a significantly better meniscal repair survivorship compared with all other subgroups.

All-Inside Meniscus Repair.

The indications for partial meniscectomy are becoming increasingly limited, and recent evidence suggests that the meniscus should be preserved whenever possible. Because of its many proposed advantages, all-inside meniscus repairs are becoming increasingly common. This review discusses the indications, advantages, disadvantages, and biomechanical and clinical outcomes of all-inside meniscus repair. All-inside meniscus repair demonstrates equal functional outcomes, healing rates, and complications compared to inside-out repair of vertical longitudinal and bucket-handle tears with the advantages of decreased surgical time and faster post-operative recovery. In addition, return-to-sport and activity levels are high following all-inside repair regardless of whether concomitant anterior cruciate ligament reconstruction is performed. Biomechanical studies have demonstrated advantages of all-inside meniscal based repairs on radial and horizontal tears. All-inside meniscus repair compares favorably to inside-out repair of vertical longitudinal and bucket-handle tears and continues to increase in popularity. Both capsular based and meniscal based repairs can be used to repair a variety of tear patterns. While biomechanical results are encouraging, further research on the clinical outcomes of meniscal based repairs is needed to elucidate the role of these techniques in the future.

Surgical Outcomes After Bucket-Handle Meniscal Repairs: Analysis of a Large Contained Cohort

Background: Representing approximately 10% of all meniscal tears, bucket-handle meniscal tears (BHMTs) are large longitudinal vertical tears that have an attached fragment flipped into the intercondylar notch. Meniscectomy often results in significant meniscal loss and increased joint loading. Alternatively, meniscal repair attempts to restore the function of the meniscus and aims to preserve joint mechanics. Purpose: To evaluate the long-term risk of subsequent ipsilateral knee surgery in patients who underwent a bucket-handle meniscal repair (BHMR), and to assess risk factors associated with subsequent knee surgical intervention. Study Design: Case series; Level of evidence, 4. Methods: We performed an electronic health record search for all patients aged 12 to 65 years who underwent arthroscopic knee meniscal repairs for BHMT (2011-2018). We excluded patients who had a previous BHMR, did not have magnetic resonance imaging of the knee within 60 days before BHMR, lacked active membership in Kaiser insurance in the year before and after BHMR, or underwent meniscectomy before BHMR. All patients were followed until December 31, 2019, with censoring at death or membership disenrollment. Primary outcomes included ipsilateral knee procedures overall and by type (ie, repeat meniscal repair and meniscectomy); secondary outcomes included other surgical interventions of the same knee, any contralateral knee surgery, deep surgical-site infection, and deep venous thrombosis or pulmonary embolism. Results: The final cohort included 1359 patients with a median age of 24 years (interquartile range [IQR], 17-34) who underwent BHMR for a BHMT. During the follow-up period (median, 50.2 months [IQR, 32.3-60.6]), 495 subsequent ipsilateral procedures were performed in 274 (20.2%) patients, and the median time to the first procedure was 10.6 months (IQR, 4.1-23.5). An overall 59 (4.3%) patients underwent repeat meniscal repair, and 165 (12.1%) had a subsequent meniscectomy of the same knee. Significant risk factors for subsequent ipsilateral procedures included younger age, 12 to 18 years (adjusted odds ratio [aOR], 5.77 [95% CI, 1.84-18.08]) and 19 to 30 years (aOR, 3.65 [95% CI, 1.17-11.36]), as well as normal and overweight body mass index (aOR, 2.84 [95% CI, 1.29-6.23] and 2.34 [95% CI, 1.06-5.17], respectively). Patients undergoing concomitant anterior cruciate ligament reconstruction (ACLR) at the initial BHMR had a lower risk of undergoing subsequent surgery (aOR, 0.66 [95% CI, 0.49-0.87]) than those without concomitant ACLR. Conclusion: This is the largest reported study on outcomes after BHMR in a contained cohort. One-fifth of patients underwent subsequent ipsilateral surgery during follow-up, with 4.3% receiving a repeat meniscal repair and 12.1% experiencing a meniscectomy. Risk factors for subsequent surgery of the same knee included younger age and normal or overweight body mass index. Concomitant ACLR at time of BHMR reduced the risk of subsequent reoperation.