Treatment of Partial Meniscal Tears Identified During Anterior Cruciate Ligament Reconstruction With Limited Synovial Abrasion

doi:10.1016/S0749-8063(00)90120-8

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 16, Issue 1, January–February 2000, Pages 6-10

https://doi.org/10.1016/S0749-8063(00)90120-8 Get rights and content

Abstract

Summary: This is a retrospective review of the results of 40 patients with 44 partial stable meniscal tears who were treated with parameniscal synovial abrasion at the time of anterior cruciate ligament reconstruction. There were 19 medial meniscal (MM) tears and 25 lateral meniscal (LM) tears. Meniscal tear morphology included 33 single longitudinal tears (18 MM, 15 LM), 10 double longitudinal tears (1 MM, 9 LM), and 1 radial tear (LM). All 44 tears were located in the posterior horn or posterior junction of the meniscus. Rim width was ≤3 mm in 29 and >3 mm in 15 tears. In this study, failure was defined as a symptomatic meniscal tear requiring subsequent surgery. The overall failure rate at an average follow-up of 3.3 years was 11% (5 of 44). Four failures occurred in the MM (21% of total MM tears) and 1 failure occurred in the LM (4% of total LM tears). The median time to failure was 12 months with 3 of 5 failures occurring secondary to a significant reinjury. We looked at the effect of 8 factors on overall failure rate. Although statistical validity was not established in this small patient population, we did observe a higher failure rate for stable MM tears. Our study supports the small amount of literature that shows a high clinical success rate with observation of stable LM tears identified at the time of anterior cruciate ligament reconstruction. However, the much higher failure rate of stable MM tears raises concern. This difference is explained by biomechanical and clinical studies showing that the MM develops higher stresses than the LM with loading. Based on this work, we believe that stable longitudinal MM tears have a higher propensity to fail over time by propagation of the tear and are better managed with meniscal repair.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 1 (January-February), 2000: pp 6–10

Section snippets

MATERIALS AND METHODS

We retrospectively reviewed the charts of 40 patients (44 knees) with stable partial meniscal tears identified at the time of ACL reconstruction that were left unrepaired. Only patients with a minimum of 2 years follow-up were included in the study. There were 20 male and 20 female patients. The average age of patients at surgery was 21.9 years, ranging from 13 to 49 years. The average follow-up was 3.3 years, ranging from 2.0 to 6.5 years. There were 25 lateral meniscal (LM) tears and 19

RESULTS

The results of our study are based on the follow-up of 44 knees after an average of 3.3 years. In this study, failure was defined as a symptomatic meniscal tear requiring subsequent surgery. All 4 patients with MM failures reported symptoms such as pain in the affected compartment, locking, and persistent effusions. Our failure rate was 11% (5 of 44). The median time to failure was 12 months, ranging from 9 to 24 months. Three of the 5 patients who presented with a symptomatic meniscal tear

DISCUSSION

The perimeniscal capillary plexus provides blood supply to the peripheral 10% to 30% of the adult meniscus.1, 7, 15 This zone is larger in younger people and decreases with age.⁷ Injury to the peripheral vascular zone can stimulate the meniscus to generate a reparative response similar to that generated by other connective tissues.¹ Several investigators have documented the healing potential of stable longitudinal tears in the peripheral vascular zone of the meniscus without surgical

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Cited by (27)

Meniscus Repair of the Anterior Third: The Outside-In Option
2018, Operative Techniques in Sports Medicine
Citation Excerpt :
With a displaced bucket-handle tear, tear edges are often easier to abrade prior to reduction. The parameniscal synovium should also be abraded but not ablated adjacent to the tear as this has been shown to improve healing rates in tears with marginal vascularity.11-13 Nonabsorbable suture has become the suture of choice for the various meniscus repair techniques, including the outside-in technique.
Outside-in meniscal repair is an effective and often most optimal technique for addressing tears involving the anterior one-third of the meniscus. It can be performed without an assistant with standard arthroscopy instrumentation. Although the technique may be used for tears in the anterior two-thirds of both the lateral and medial meniscus, it is most commonly utilized for anterior one-third tears, which are not often accessible with other techniques. Knowledge of the anatomy of the saphenous and peroneal nerves in relation to flexion of the knee is paramount to avoiding iatrogenic injury. The technique involves passing sutures through spinal needles that are placed percutaneously from outside-in across the meniscal tear. There are various modifications of the basic technique that may be performed depending on available instrumentation and surgeon preference. Although repairable anterior one-third tears are not as common as posterior horn tears, proficiency with the outside-in technique can be quite valuable and often ideal in this setting. Multiple authors have reported excellent healing rates. With proper attention to needle placement, complications are rare.
Meniscus Repair Enhancement Options
2018, Operative Techniques in Sports Medicine
Citation Excerpt :
Several authors have evaluated the clinical effects of mechanical rasping and parameniscal synovial abrasion techniques without meniscal suture repair.30-32 Talley et al reviewed 40 patients (44 knees) with stable, partial-thickness longitudinal meniscal tears who underwent parameniscal synovial mechanical abrasion without meniscal repair at the time of ACLR.32 With failure defined as a symptomatic meniscal tear requiring reoperation, they determined an overall failure rate of 11% (5/44 knees) at a mean follow-up of 3.3 years.
Meniscal tears are one of the most common pathologies of the knee. They can be managed with observation, partial meniscectomy, or repair. The limited vascularity of the meniscus central to the periphery limits the healing potential of meniscal tissue; however, recent development of biologic augments and surgical techniques have expanded the capability for meniscus repair; potentially avoiding partial meniscectomy in selected cases. The procedures and adjuncts include mechanical stimulation of the healing response, fibrin augmentation, bone marrow aspirate concentrate, mesenchymal stem cells, platelet-rich plasma, scaffolds, and others in development used either in isolation or combination. It is important for surgeons to become familiar with evolving biologic augmentation options to improve meniscal repair healing in an attempt to optimize the long-term health of the knee joint.
Evaluation of peripheral vertical nondegenerative medial meniscus tears treated with trephination alone at the time of anterior cruciate ligament reconstruction
2015, Arthroscopy - Journal of Arthroscopic and Related Surgery
To determine (1) subjective results and incidence of symptomatic medial meniscus tears (MMTs) in patients treated with trephination alone compared with a control group without meniscus tears and (2) if trephination treatment resulted in a higher incidence of knee arthritis compared with controls with intact menisci.
Between 1997 and 2010, 419 patients met the inclusion criteria of having an isolated anterior cruciate ligament (ACL) tear, peripheral vertical nondegenerative MMT treated with trephination alone, no lateral meniscus tears, normal radiographs before surgery, and no bilateral knee involvement. A control group of 462 patients included patients who met the same criteria but without MMT. Objective data included International Knee Documentation Committee (IKDC) objective evaluation. Subjective data included IKDC and Cincinnati Knee Rating System (CKRS) scores.
Objective follow-up was obtained for 191 patients in the study group and 200 patients in the control group (mean, 5.6 and 5.9 years, respectively; range, 2 to 16 years). Subjective survey follow-up was obtained for 312 patients in the study group and 343 patients in the control group (mean, 7.0 and 7.1 years, respectively). The mean CKRS score was 91.8 ± 13.3 for the study group and 92.3 ± 10.9 for the control group (P = .27). The mean IKDC score was 86.5 ± 15.8 for the study group and 86.7 ± 16.3 for the control group (P = .81). Subsequent MMTs occurred in 51 patients (16.3%) in the study group and 20 patients (5.8%) in the control group (P < .0001). IKDC radiographic ratings were normal for 95% of the study group and 92% of the control group (P = .18).
Patients with peripheral nondegenerative MMTs treated with trephination alone had a 16.3% rate of subsequent symptomatic MMTs compared with 6% in patients with intact menisci. However, no statistically significant differences were found between groups for radiographic and subjective results.
Level III, therapeutic case control study.
Parameniscal cyst formation in the knee is associated with meniscal tear size: An MRI study
2013, Knee
Citation Excerpt :
One large prospective cohort study demonstrated that meniscal damage was not directly linked to the development of knee symptoms in middle-aged patients [12]. In addition, some surgeons choose conservative management, instead of partial menisectomy, for meniscal tears during anterior cruciate ligament reconstruction [13–16]. Under these circumstances, even if the meniscal tear is asymptomatic, the assessment of the likelihood of cyst formation has an important impact on treatment for patients with meniscal tears that extend to the meniscocapsular junction.
The relationship between meniscal tears and parameniscal cyst formation is contentious. We investigated whether the development of a parameniscal cyst is related to the size of the meniscal tear by using magnetic resonance imaging (MRI).
On the basis of a retrospective review of an MRI database, we identified parameniscal cysts in 34 patients with adjacent meniscal tears extending to the meniscocapsular junction. The size of the meniscal tear was measured by dividing the length of the tear along two axes: circumferential and radial. We compared parameters, such as the size of the meniscal tear, the location of the tear, the pattern of each tear, and any associated ligamentous injury and intra-articular lesion, between the 34 patients and the 30 control patients who only had meniscal tears with torn components extending to the meniscocapsular junction.
Compared with the controls, patients with parameniscal cysts had significantly larger meniscal tears along the circumferential axis (P < 0.001). A critical size of the meniscal tear along the circumferential axis of 12 mm was associated with the formation of a parameniscal cyst.
A larger meniscal tear extending into the meniscocapsular junction is more likely to be associated with the occurrence of a parameniscal cyst. The critical size of the meniscal tear, 12 mm along the circumferential axis as identified using MRI, is a discrimination value for parameniscal cyst formation. Level of Evidence: Level III
Meniscal Repair Using the Inside-Out Suture Technique
2012, Clinics in Sports Medicine
Citation Excerpt :
Stable tears include those that do not displace when probed, are less than 10 mm long, are in the posterior horn of the medial or lateral meniscus, and have been found to be asymptomatic despite conservative treatment26,27 or after trephination.28,29 However, stable longitudinal medial meniscal tears have been shown to have a higher propensity to propagate and fail over time and may be better managed with meniscal repair.30 The ideal candidate for meniscal repair is a young patient with a 2-cm vertical longitudinal tear in the peripheral 3 mm of the red-red or red-white zone and is undergoing concomitant ACL reconstruction.
Outcomes after meniscal repair using the Meniscus Arrow in knees undergoing concurrent anterior cruciate ligament reconstruction
2002, Arthroscopy
Citation Excerpt :
Total meniscectomy was also found to cause a 2- to 3-fold increase in contact stress across the knee,19 and removal of as little as 16% of the meniscus increased the articular contact forces by 350%.20 Furthermore, the need to be more aggressive in repairing medial menisci has been shown by Fitzgibbons and Shelbourne13 and also by Talley and Grana.21 Both cite the decreased ability of the medial meniscus to heal spontaneously or remain asymptomatic and the higher propensity for a medial meniscus tear to propagate.
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

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^*: Address correspondence and reprint requests to M. Chris Talley, M.D., Duke Orthopaedics of Person County, 601 Ridge Rd, Roxboro, NC 27573, U.S.A.

^**: 0749-8063/00/1601-2084$3.00/0

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Treatment of Partial Meniscal Tears Identified During Anterior Cruciate Ligament Reconstruction With Limited Synovial Abrasion*,**

Abstract

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Oper Tech Sports Med

Arthroscopy

Arthroscopy

Arthroscopy

Clin Sports Med

The microvasculature of the meniscus and its response to injury

Am J Sports Med

Patterns of meniscal injury in the anterior cruciate ligament deficient knee: A literature review

Am J Orthop

Meniscal tears: The effect of menisectomy and repair on intra-articular contact areas and stress in the human knee

Am J Sports Med

Meniscal tears: Treatment in the stable and unstable knee

J Am Acad Orthop Surg

Arthroscopic menisectomy in patients over the age of 40

Am J Sports Med

A biomechanical study of partial and total medial menisectomy

Trans Orthop Res Soc

Knee joint changes after menisectomy

J Bone Joint Surg Br

Arthroscopic partial menisectomy. A long-term follow-up

Arthroscopy