Meniscal Repair Devices Research Articles

Meniscal Repair with ArthroZheal® an Autologous Bioactive Fibrin Scaffold. A New Technique and Treatment Option.

Injuries of the meniscus often lead to changes in joint biomechanics, which affect the load distribution and contact stresses. The menisci consist of a peripheral vascular region (red zone) and an inner avascular region (white zone). The blood supply plays an important role in the healing of meniscal tears. Surgical treatment of such lesions includes meniscectomy/meniscoplasty and repair, depending on the type of injury, where "meniscoplasty" refers to the treatment modality that occurs under coblation. The application of Autologous Bioactive Matrix (ABM) has been shown to promote healing in such lesions. In addition, a special type of PRF (ArthroZheal®, Vivostat A/S, Allerød, Denmark) has been demonstrated to have healing effects in extracellular matrix synthesis and cell proliferation, as well as regenerative and remodeling effects. This autologous product can be applied directly at the meniscal repair site. We performed a prospective study on meniscus repair with ArthroZheal® alone (plus meniscoplasty) and ArthroZheal® together with an all-inside suturing technique using the STAR AccurFix Meniscal Repair Device system (STAR Sports Medicine, Beijing, China), depending on the type and the site of the lesion. One hundred twenty knees (110 patients) were identified through the use of clinical examination and MRI scan. The study took place between January 2023 and August 2023. Two groups were created: GROUP A was treated only with ArthroZheal®(plus meniscoplasty) and GROUP B was treated with a combination of ArthroZheal® and an all-inside suturing technique (STAR AccurFix). Pre- and postoperative grading was performed with the International Knee Documentation Committee (IKDC) score and the Tegner Activity Level Scale (Tegner Score). The results with both treatment methods were excellent and meniscus restoration has been documented on MRIs conducted 6 months post-op. In 15 patients, 2nd-look arthroscopy was performed through a nanoscope on an outpatient basis, and showed meniscal healing and remodeling. Tegner scores and IKDC scores in both groups showed significant improvement. Meniscal repair should be performed at all costs to maintain meniscal integrity and prevent long-term degenerative changes. New treatment methods include orthobiologics and all-inside suturing techniques. The main idea is to apply an autologous biological scaffold which is able to carry cells into the meniscal lesion and to allow their differentiation, proliferation, and extracellular matrix synthesis to produce a meniscal-like tissue. Our results suggest that the application of autologous ABM (ArthroZheal®) for the treatment of such lesions by means of dry arthroscopy results in better MRI, pain management and functional results at 3 months post-op, and these improvements can persist for up to 6 months.

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.

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.

Methods for Testing Meniscal Repair Using a 3D-Printed Meniscus

Torn and damaged menisci resulting from trauma are very common knee injuries, which can cause pain and mobility limitations and lead to osteoarthritis. Meniscal injuries can require surgery to repair the tissue damage and restore mobility. Here we describe the biomechanical testing of a 3D-printed meniscus to illustrate methods to determine if it has the strength and durability to effectively repair meniscal tears and restore knee biomechanics. This work was designed to demonstrate the steps needed to test novel meniscus repair devices prior to moving toward animal testing. The first testing step determined the ability of the 3D-printed meniscus to withstand surgical fixation by measuring the suture pull-out force. We show that vertical 2/0 silk or Fiberwire sutures need an average of 1.4 or 1.8 N, respectively, to pull through the meniscus, while horizontal sutures need only 0.7 and 1.2 N, respectively. The next step measured the compressive strength of normal, damaged, and repaired porcine meniscus tissue. Here, we show that meniscectomy decreased the stiffness of meniscus tissue from 26.7 ± 0.85 N to 7.43 ± 0.81 N at 25% strain. Menisci repaired with the 3D-printed tissue restored 66% of the measured force at 25% strain. The final step measured the contact pressures and areas in an ex vivo porcine knee before and after meniscal repair was made with the 3D-printed meniscus tissue. The example 3D-printed meniscus was successfully sutured into the porcine knee joint but failed to restore normal knee contact pressures. This work demonstrates the need for an iterative biomechanical testing process of biomaterial development, 3D-printing optimization, and knee kinematics to develop a durable and functional meniscus repair device. In summary, the methods described here serve as a guide for the functional evaluation of novel meniscus repair devices.

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.

Poster 262: The risk factors associated with failure results after arthroscopic repair for bucket handle meniscal tear. A multi-center study

Objectives: Meniscal tears are one of the common knee injuries. Large size of longitudinal-vertical tear is called bucket handle tear, and easily displaced and locked in the knee joint cavity. This type of injury is usually required arthroscopic intervention due to pain or dysfunction such as loss of range of motion of the knee. Recently, the arthroscopic meniscal repair technique and devices have been developed and reported good results. The inside-out technique, outside-in technique, and all-inside technique are well known. However, 20 to 34.2% of failure cases after primary meniscal repair were reported. The purpose of this study is to identify the risk factors to associate with the postoperative failure of bucket handle meniscal tear under multi-center study. Methods: Patients The present study was conducted in 2021, involving patient who was diagnosed and performed primary arthroscopic meniscal repair surgery for bucket handle meniscal tear at four orthopaedic centers. The study followed retrospective observational design including data collected from Jan 2000 to Aug 2021. The experimental design was reviewed and approved (Accession No. 0-0956) by the Ethics Committee of our institute. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Inclusion criteria were the cases of knee bucket handle meniscal tears which were diagnosed clinically and by MRI testing. Exclusion criteria were following; postoperative observation period was less than 12 months cases, meniscal posterior root tear cases, could not obtain full surgical and clinical information cases, infection and inflammatory disease cases, and meniscal resection cases. Senior orthopaedic surgeons were diagnosed and performed arthroscopic surgery in each center. Surgical and clinical information were obtained from four orthopaedic centers. Total 95 bucket handle tear cases were enrolled in this study. Patients were analyzed on an average of 27.14 ± 24.8 months after surgery by the use of Marx score (MS) and Tegner Activity Scale (TAS). To identify factors associated with postoperative failure, we obtained the following information; age, body mass index (BMI), height, weight, injury to surgery duration, postoperative immobilization period, postoperative non-weight bearing period, timing of full-weight bearing, timing of running, presence of knee ligament rupture, medial or lateral meniscus, total number of sutures. Moreover, the number of each suture technique such as inside-out, outside-in, and all-inside method were analyzed. Location of injury such as white-white (WW) zone, red-white (RW) zone, and red-red (RR) zone was also analyzed. Statistical comparisons between the two groups were performed using the 2x2 chi-squared test, t-test, the Mann Whitney U-test. Risk factors of postoperative failure case were determined with multiple logistic regression analysis. The level of significance was set at P &lt; 0.05. Results: There were 69 patients (male: 32, female:37) with healed and 26 (27.4%, male: 12, female: 14) that sustained failure after primary meniscal repair. There were no significantly difference between healing group and failure group in injury to surgery duration (39.7 vs 22.4 days, p=0.65), height (165.2 vs 163.8 cm, p= 0.52), weight (67.2 vs 60.1 kg, p=0.09), postoperative immobilization period (2.0 vs 1.95 weeks, p=0.56), postoperative non-weight bearing period (2.89 vs 2.67 weeks, p=0.34), timing of full- weight bearing (5.60 vs 5.62 weeks, p=0.69), timing of running (3.4 vs 4.75 months, p=0.41), preoperative TAS (5.48 vs 6.08, p=0.33), postoperative TAS (4.50 vs 5.33, p=0.34), postoperative Marx score (6.36 vs 9.17, p=0.59). In the healing group, MM/LM was 48/21 and 21/5 in the failure group (p=0.28). Location of tear in the hearing group was following; RR / RW / WW as 29 / 27 / 3, and failure group was 11 / 9 /2 (p=0.78). Combined knee ligament injury was observed 50 cases in the healing group, and 20 cases in the failure group (p=0.48). Total number of sutures was 4.66 vs 3.85 (p=0.24). The numbers of each suture technique were 2.91 vs 2.88 (p=0.67) in all-inside method, 2.33 vs 2.00 (p=0.8) in outside-in method. On the other hand, the number of inside-out method in the healing group was significantly higher than that of failure group (3.56 vs 2.33, p=0.02, number of inside-out method. OR: 0.339, 95%CI; 0.132-0.873, p=0.02). Additionally, BMI of healing group was higher than failure group with significance (24.39 vs 22.32, p=0.05). Age of healing group was also significantly higher than failure group (26.0 vs 22.3, p=0.05). Conclusions: Failure rate of primary repair for bucket handle tear was 27.4% in this multi-center study. Lower numbers of inside-out suture technique and low value of BMI and age were significantly associated with postoperative failure. [Table: see text][Table: see text]

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.

Paper 21: All-Inside Soft Suture Anchor Meniscus Repair Devices vs. PEEK Anchor Devices: A Biomechanical Analysis

Objectives: To evaluate the load to failure and meniscus gapping of longitudinal meniscus repairs with Soft Suture Based all-inside devices and compare them to a polyether ether ketone (PEEK) anchored device and inside-out repair. Methods: After IRB review 12 human cadaver knees were dissected leaving only the tibia, the posterior capsule and the medial and lateral menisci with roots still attached to the tibia. This yielded 24 menisci total (12 medial, 12 lateral). Posterior horn longitudinal full thickness meniscus tears were simulated with a scapel and 5mm Mersiline tapes were used to load the repair site. Each knee was randomized to one of 4 meniscus repair groups: Fiberstitch, Juggerstitch, FAST-FIX 360(PEEK), and inside-out with Broadband tape meniscus needles. For each meniscus, 2 longitudinal repairs were performed. The specimens were tested with an Instron imposing 20 cycles between 10N and 30N then the tear gap was measured, followed by a distraction to failure phase after imposing a displacement at a rate of 0.5mm/sec. Results: There There were 6 menisci tested in each of the 4 groups. After low-load cyclical loading, the gaps measured were .63mm, 1.1mm, 1.7mm, and 1.2mm for the Juggerstitch, Fiberstitch, FAST-FIX 360, and Inside-out Groups respectively (see figure 2). The failure load was 352N, 301N, 167N, and 189N for the Juggerstitch, Fiberstitch, FAST-FIX 360, and Inside-out (see figure 3). There was less gap formation and higher load to failure for the Juggerstitch over the FAST-FIX 360 (p=.014 and p=.03, respectively). When comparing all other groups there was no significant difference between groups with respect to gapping or failure load. Conclusions: The Juggerstitch had less gapping at the repair site and a higher failure load than the FAST-FIX 360. The soft suture based All-Inside meniscus repair devices have gapping and failure load comparable or better than traditional repair devices.

A Comparison of All-inside and Inside-out Meniscal Repair in Elite Athletes

Background: The popularization of all-inside (AI) meniscal repair devices has led to a shift away from the historical gold standard of inside-out (IO) meniscal repair without comparative studies to support the change. Purpose: To compare the failure rate and time to failure of AI and IO meniscal repair performed in elite athletes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed of all professional and national- and international-level amateur athletes who underwent meniscal repair, with a minimum of 2-year follow-up between January 2013 and September 2019. Meniscal repair was classified as AI or IO depending on the surgical technique performed. Treatment failure was defined as patients having to undergo subsequent surgery to address a persistent meniscal tear after repair. Cox proportional hazards modeling was used to determine if meniscal repair failure rates differed by the location and technique of meniscal repair. Models were controlled for known risk factors such as age, sex, sport, and concurrent cruciate ligament reconstruction. Results: A total of 192 (135 lateral and 57 medial) meniscal repairs were performed in elite athletes during the study period. Overall, 41 (21%) meniscal repairs met the criteria for failure. Medial meniscal tears repaired with the AI technique failed at a significantly higher rate (18/31 [58%]) than medial meniscal tears repaired with the IO technique (6/26 [23%]) or lateral meniscal tears repaired with the AI (9/76 [12%]) or IO (8/59 [14%]) technique (P < .001). Cox proportional hazards modeling revealed that a medial meniscal tear repaired with the AI technique had an almost 8 times greater hazard of failure than a lateral meniscal tear repaired with the AI technique (P < .001). At 1 year postoperatively, 8% of lateral meniscal repairs had failed (regardless of technique), while medial meniscal tears failed at a rate of 16% with the IO technique and 42% with the AI technique. By 2 years, 53% of medial meniscal tears repaired with the AI technique had failed, and by 5 years, 63% had failed. Conclusion: AI repair of medial meniscal tears led to a higher rate of failure than IO repair of medial or lateral meniscal tears in elite athletes. Medial meniscal repair failed at a higher rate than lateral meniscal repair.

Effectivity of the Outside-In Pie-Crusting Technique and an All-Inside Meniscal Repair Device in the Repair of Ramp Lesions

Ramp lesions are characteristic medial meniscus injuries seen in anterior cruciate ligament–injured knees. Anterior cruciate ligament injuries combined with ramp lesions increase the amount of anterior tibial translation and tibial external rotation. Therefore, the diagnosis and treatment of ramp lesions have received increasing attention. However, ramp lesions can be difficult to diagnose on preoperative magnetic resonance imaging. Additionally, ramp lesions are difficult to observe and treat intraoperatively in the posteromedial compartment. Although good results have been reported with the use of a suture hook through the posteromedial portal in the treatment of ramp lesions, the complexity and difficulty of the technique are further problems. The outside-in pie-crusting technique is a simple procedure that can enlarge the medial compartment and facilitate the observation and repair of ramp lesions. After this technique, ramp lesions can be properly sutured, using an all-inside meniscal repair device, without damaging the surrounding cartilage. A combination of the outside-in pie-crusting technique and an all-inside meniscal repair device (with only anterior portals) is effective in the repair of ramp lesions. This Technical Note aims to report in detail the flow of a series of techniques, including our diagnostic and therapeutic methods.

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.

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.

Inside-Out Meniscal Repair: Still a Useful Technique

Background: New generation of all-inside meniscal repair devices are now the preferred repairing method for most orthopedic surgeons. The economic considerations in low-income countries make routine use of these devices very difficult. The inside-out technique described by Charles Henning in the 1980s, which is considered as the gold standard by many expert surgeons, can solve this problem with equal results. Indications: Indications are large and unstable tears localized in the middle and posterior thirds of both menisci. Surgical Technique: We introduced a slight modification to the original technique, allowing the use of a resorbable suture thread. After a good exposition of the lesion and debridement of the margins, a canulated needle with curved tip (Menghini needle) is introduced through the opposite portal to the repaired meniscus. The first passage of the needle is done on the peripheric side of the tear to protect neurovascular structures; posteromedial or posterolateral security approaches are made to control the capsular exit of the needle. A popliteal retractor is placed to keep the articular capsule exposed. A polydioxanone (PDS) suture thread is passed through the needle and retrieved by the assistant. The needle is then pulled out in the joint and reintroduced on the inner part of the tears producing a vertical mattress suture. The second limb of the PDS is retrieved by the assistant, and a knot is tied on the capsular side of the knee. Sutures are placed on the femoral and the tibial side of the meniscus to produce a good reduction and a stable fixation of the lesion. Full range of motion of the knee is allowed at 6 weeks postoperatively. Results: Between January 2017 and June 2020, 33 bucket-handle meniscal tears were repaired. Associated anterior cruciate ligament reconstruction was done in 17 cases. The average International Knee Documentation Committee (IKDC) score jumped from 49.6 to 86.2. We had a short-term success rate of 91%. Recent literature review showed equivalent results with new all-inside repairing devices. Conclusion: Despite some disadvantages as being time-consuming, the need of security approaches, and the need of a trained assistant, inside-out meniscal repair remains a reliable technique offering good results.

Novel Posterior Anchoring Method Associated With Medial Meniscus Posterior Root Repair

Introduction: Transtibial pullout repair is the gold standard surgical treatment for medial meniscus (MM) posterior root tear. However, posteromedial extrusion of the MM during knee flexion may remain a problem postoperatively. Materials and Methods: We used a novel posterior anchoring technique to help reduce posteromedial extrusion, applying two cinch sutures (TCSs) to the MM posterior horn and creating a bone tunnel at the center of the posterior root attachment to pullout the suture. Another bone tunnel was created at the posterior corner of the medial tibial plateau in the externally rotated knee flexion. The first anchor of an all-inside meniscal repair device was inserted through the inferior surface of the MM posterior horn with tensioning TCS and the second anchor into the bone tunnel. Tibial fixation of pullout sutures was performed using a bioabsorbable screw in 30 degrees knee flexion. Conclusions: Our posterior anchoring method, combined with conventional pullout repair with TCS, helped reduce posteromedial extrusion in patients with a MM posterior root tear.

Clinical outcomes of medial meniscus posterior root repair: A midterm follow-up study

BackgroundTranstibial pullout repair of medial meniscus posterior root tears (MMPRTs) cannot prevent the progression of knee osteoarthritis. Conversions of knee arthroplasties are occasionally required following MMPRT repair. However, other knee-related surgical treatments following MMPRT repair are unclear. This study was aimed at investigating the midterm clinical outcomes and knee-related surgical events following MMPRT repair. MethodsPatients with MMPRT underwent pullout repair using FasT-Fix modified Mason-Allen (F-MMA) suturing with an all-inside meniscal repair device. Thirty-two patients with follow-up duration >2 years were enrolled. We assessed the clinical outcomes and postoperative surgical treatment of both knees. ResultsF-MMA pullout repair improved all clinical evaluation scores in patients with MMPRT at a mean follow-up of 36.1 months. Postoperative arthroscopic debridement was required for one patient. An additional MMPRT repair was performed in one patient on second-look arthroscopy. None of the patients required ipsilateral knee arthroplasty. In the contralateral knees, one pullout repair of a newly developed MMPRT and two knee arthroplasties were performed. ConclusionsThis study demonstrated that F-MMA pullout repair yielded satisfactory clinical outcomes. However, subsequent knee-related surgeries were observed in 6.3% of the pullout-repaired knees and 9.4% of the contralateral knees. Our results suggest that surgeons should be aware of the worsening and/or occurrence of contralateral knee joint disease, even when the postoperative clinical outcomes are satisfactory following MMPRT repair.Level of evidence: IV.

Smaller Iatrogenic Defects Created by Inside-Out Compared With All-Inside Meniscus Repair Devices in Human Cadaveric Model

(1) To investigate the pattern and diameter of the iatrogenic defect that meniscal repair devices impose on meniscal tissue and (2) to determine whether repair-induced defect patterns or diameters differ across devices. Sixty-one fresh frozen human cadaveric menisci were used (n= 9; eliminated). All-inside devices (n= 9) included ULTRA FAST-FIX, FAST-FIX 360, Depuy Mitek 0° and 12° TRUESPAN, ConMed Sequent, Zimmer Biomet JuggerStitch, Stryker IvyAIR, Arthrex FiberStitch and Meniscal Cinch II. Inside-out needles (n= 4) included ConMed HiFi, Depuy Mitek ORTHOCORD, Arthrex-2-0 FiberWire, and Stryker SharpShooter. Following India Ink staining, implant devices were inserted into cadaveric menisci. Samples were fixed in formalin solution and imaged with a high-resolution camera. Defects were classified by qualitative evaluation. Defect and needle diameter were quantified with software assistance. Statistical analysis was performed using analysis of variance testing. We analyzed 644 iatrogenic defects with mean defect diameter of 1.96 mm (standard deviation 0.86). For all-inside devices, defect patterns (n= 436) were 15.6% linear, 38.1% semilunar, 46.3% stellate, while inside-out devices (n= 208) were 95.7% stellate, 4.3% linear, and 0.0% semilunar. All-inside devices had mean defect diameter of 2.46 mm, while inside-out meniscus needles had mean 0.90 mm defect diameter (P < .001). FasT-FIX 360, ULTRA-FAST-FIX, and Arthrex Meniscal Cinch II induced smaller diameter defects than other all-inside devices (F= 20.2, P < .05). Strong positive correlation was found comparing outer needle diameter and mean defect diameters across all devices (R2= 0.9447). Needles utilized in meniscal implant systems produce the following basic defect patterns: stellate (62.3%), semilunar (25.8%), and linear (11.9%). A strong positive correlation was found between mean defect size and outer needle diameter across all devices. Inside-out double-armed flexible needles produced significantly smaller defects than all-inside devices. Of the all-inside devices, ULTRA FAST-FIX, FAST-FIX 360, and Arthrex Meniscal Cinch II produced smaller defects on average. While the true clinical impact of these findings cannot be drawn from the present study, this investigation provides necessary context to better understand reported similarities and differences in healing rates and outcomes between inside-out and all-inside repair techniques.

Paper 32: All-inside meniscus repair leads to higher rate of failure compared to inside-out meniscus repair in elite athletes

Objectives:The popularization of ‘all-inside’ meniscal repair devices has led to a paradigm shift away from the historical gold standard of ‘inside-out’ meniscus repair but without comparative studies to support the change. The purpose of this study was to compare the failure rate of ‘all-inside’ and ‘inside-out’ meniscus repair performed in elite athletes.Methods:A retrospective review was performed of all professional or national/international level amateur athletes who underwent meniscal repair between January 1, 2013 and December 31, 2018, with a minimum of two year follow-up. Repairs were classified as ‘all-inside’ or ‘inside-out’ depending on the type of repair performed. Failure was defined as undergoing a subsequent surgery to address a persistent meniscal tear following repair.Results:158 (106 lateral and 52 medial) meniscal repairs were performed on elite athletes during this time period. Overall, 38 out of 158 (24.1%) underwent subsequent meniscectomy or revision meniscal repair. 27 of 88 (30.7%) of ‘all-inside’ meniscal repairs failed versus 11 of 70 (15.7%) of ‘inside-out’ meniscal repairs (p=0.029). For medial meniscus repairs, ‘all-inside’ failed at a higher rate than ‘inside-out’ medial meniscus repairs (58.6% vs 26.1%. p=0.019) but no statistical difference was found in lateral meniscus repairs (16.9% vs 10.6%, p=0.354). Overall 23 out of 52 (44.2%) of medial meniscus repairs failed compared to 15 of 106 (14.2%) of lateral meniscus repairs (p=0.00003)Cruciate ligament reconstruction was performed at the same time with 27 of 29 ‘all-inside’ medial meniscus repairs, 21 of 23 ‘inside-out’ medial meniscus repairs, 45 of 59 ‘all-inside’ lateral meniscus repairs but only 18 of 47 ‘inside-out’ lateral meniscal repairs.Conclusions:‘All-inside’ meniscal repair led to a higher rate of failure compared to ‘inside-out’ meniscus repair in elite athletes. Medial meniscus repairs failed at a high rate than lateral meniscal repairs. This difference is even more noteworthy considering that only a minority of inside out lateral meniscal repairs were done in conjunction with a cruciate ligament reconstruction versus the majority of the other three groups studied. Due to the increased knee loading in elite sports, clinically relevant differences between the medial and lateral meniscus as well as repair strategies were elucidated that may not be in the general population.UPLOAD-https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/fb465a3d-3b0f-451f-8fad-0d1332b8b428/1/Meniscal_repair_chart.docx NoneNoneNone

The Risk of Iatrogenic Peroneal Nerve Injury in Lateral Meniscal Repair and Safe Zone to Minimize the Risk Based on Actual Arthroscopic Position: An MRI Study

Background: Lateral meniscal repair using an all–inside meniscal repair device involves a risk of iatrogenic peroneal nerve injury. To our knowledge, there have been no previous studies evaluating the risk of injury with the knee in the standard operational figure-of-4 position with joint dilatation in arthroscopic lateral meniscal repair. Purpose: To evaluate and compare the risk of peroneal nerve injury and establish the safe and danger zones in repairing the lateral meniscus through the anteromedial, anterolateral, or transpatellar portal in relation to the medial and lateral borders of the popliteal tendon (PT). Study Design: Descriptive laboratory study. Methods: Using 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, we drew direct lines to simulate a straight all–inside meniscal repair device deployed from the anteromedial, anterolateral, and transpatellar portals to the medial and lateral borders of the PT. If the line passed through or touched the peroneal nerve, a risk of iatrogenic peroneal nerve injury was noted, and measurements were made to determine the safe and danger zones for peroneal nerve injury in relation to the medial or lateral border of the PT. Results: Axial MRI images of 29 adult patients were reviewed. Repairing the lateral meniscus through the anteromedial portal in relation to the lateral border of the PT and through the anterolateral portal in relation to the medial border of the PT had a 0% risk of peroneal nerve injury. The “safe zone” in relation to the medial border of the PT through the anterolateral portal was between the medial border of the PT and 9.62 ± 4.60 mm medially from the same border. Conclusion: It is safe to repair the body of the lateral meniscus through the anteromedial portal in the area lateral to the lateral border of the PT or through the anterolateral portal in the area medial to the medial border of the PT. Clinical Relevance: There is a risk of iatrogenic peroneal nerve injury during lateral meniscal repair. Thus, we recommend repairing the lateral meniscal tissue through the anteromedial portal in the area lateral to the lateral border of the PT and using the anterolateral portal in the area medial to the medial border of the PT, as neither of these approaches resulted in peroneal nerve injury. Additionally, the surgeon can decrease this risk by repairing the meniscal tissue using the all–inside meniscal device in the safe zone area.

Inside-Out Approach to Meniscus Repair: Still the Gold Standard?

The purpose of this review is to provide an up-to-date summary on the current literature and trends regarding use of the inside-out approach to meniscus repair. Additionally, the paper describes the authors preferred techniques for inside-out meniscus repair utilizing posteromedial and posterolateral exposures. There has been a substantial increase in recent publications regarding meniscus repair. However, comparisons regarding the optimal repair technique have not been conclusive. Despite the recent increase in use of all-inside devices, multiple investigations with short-to-mid-term follow-up have demonstrated similar rates of meniscus healing between inside-out and all-inside repair techniques. Similarly, current literature describes comparable failure rates of around 20%. There are variations in the profile of complications, with all-inside devices having more implant-related complications and inside-out techniques with higher neurovascular injuries. Inside-out meniscus repair is a versatile, cost-effective technique that remains the gold standard for management of most meniscus tear patterns. Through a thoughtful approach, efficient suture retrieval and repair can be performed while protecting critical neurovascular structures. All-inside meniscus repair devices have increased in popularity and surgeon access, but this technique is not without limitations and comparisons to inside-out meniscus repair demonstrates equivocal outcomes.

Microinvasive Meniscal Suture with Disposable Needle.

The first meniscal suture was performed in 1885 and took about a century to become popular. Currently, all-inside meniscal repair devices are widely used. However, this technique presents the disadvantage of being a method dependent on specific devices, presenting a higher cost than other techniques. This high cost limits the use of such a technique in many locations. The objective of the present technical note is to describe a microinvasive meniscal suture technique as a modification of the all-inside technique, using a disposable 40 × 12 mm procedure needle. The authors believe that the proposed modification to the technique can make it more popular, enabling the use of the microinvasive technique in places with limited resources.