ABSTRACT The meniscus plays an important role in preventing osteoarthritis of the knee. Repair of a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with concurrent anterior cruciate ligament reconstruction, and in younger patients. The probability of healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Age or extension of the tear into the avascular area are not exclusion criteria. Numerous repair techniques are available, and suture repair seems to provide superior biomechanical stability. However, the clinical success rate does not correlate well with the mechanical strength of the repair technique. Biologic factors might be of greater importance to the success of meniscal repair than the surgical technique. Therefore, the decision on the most appropriate repair technique should not rely on biomechanical parameters alone. Contemporary all-inside repair systems have decreased the operating time and the level of surgical skill required. Despite the ease of use, there is a potential for complications because of the close proximity of vessels, nerves, and tendons, of which the surgeon should be aware. There is no clear consensus on postoperative rehabilitation. Weight bearing in extension would most likely not be crucial in typical longitudinal lesions. However, higher degrees of flexion, particularly with weight bearing, give rise to large excursions of the menisci and to shear motions, and should therefore be advised carefully. Long-term studies show a decline in success rates with time. Further studies are needed to clarify the factors relevant to the healing of the menisci. Tissue engineering techniques to enhance the healing in situ are promising but have not yet evolved to a practicable level.
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ABSTRACT: The number of commercially available all-arthroscopic meniscal repair devices has increased in recent years. Although inside-out vertical mattress sutures have been considered the gold standard in the past, recent biomechanical studies have shown that some all-arthroscopic repair devices provide comparable strength. To successfully use these devices, surgeons must understand proper insertion technique. The purpose of this article is to demonstrate this technique for the Meniscal Cinch (Arthrex, Naples, FL).Arthroscopy techniques. 05/2013; 2(2):e171-4.
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ABSTRACT: Meniscal tears may cause knee pain and functional impairment. Bilateral bucket-handle meniscal tears is an uncommon condition. This report presents the case of a 35-year-old male patient with bilateral bucket handle medial meniscal tears that occurred nonsimultaneously. The lesions were treated arthroscopically with partial resection in one knee and meniscal suture in the other. Bucket handle meniscal tear of meniscus without underlying meniscal, ligamentous pathology or lower limb deformity is a rare condition. To our knowledge, bilateral bucket handle medial meniscal tears without underlying meniscal anomalies have been reported in only two cases before, and our case is the third one.International journal of surgery case reports. 07/2013; 4(10):926-928.
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ABSTRACT: Healing rate of meniscus repair is higher when the suture is associated with anterior cruciate ligament reconstruction. A possible explanation can be a different pattern of release of growth factors between anterior cruciate ligament reconstruction and isolated meniscus surgery. Hypothesis of this study is that the concentrations of bFGF, TGF-β and platelet-derived growth factor (PDGF) in joint fluid, immediately after single-bundle anterior cruciate ligament reconstruction and arthroscopic partial meniscectomy, can be different. Twenty consecutive patients underwent partial medial meniscectomy and twenty consecutive patients underwent single-bundle anterior cruciate ligament reconstruction with hamstring grafts were enrolled in the study. Thirty minutes after the end of the surgical procedure, a sample of joint fluid, as well of venous blood, was collected from all the patients. Concentrations of growth factors were determined by enzyme-linked immunosorbent assay. The peripheral blood concentration of TGF-β, bFGF and PDGF was comparable between partial meniscectomy and anterior cruciate ligament reconstruction groups. No differences between the two surgical techniques were also found in term of TGF-β and bFGF joint fluid concentration, whereas joint PDGF concentration of anterior cruciate ligament reconstruction patients was significantly higher than the one found in partial meniscectomy patients. A significant growth factors release was detected in the knee joint during arthroscopic surgery. PDGF concentration was significantly higher in anterior cruciate ligament reconstructed knee than in the meniscectomy group. PDGF can play an important role enhancing the healing response of meniscus suture and can be one of the biological reasons of the higher meniscal healing rate in anterior cruciate ligament reconstructed knee.Knee Surgery Sports Traumatology Arthroscopy 10/2013; · 2.68 Impact Factor
Christian Stärke, M.D., Sebastian Kopf, M.D., Wolf Petersen, M.D., and Roland Becker, M.D.
Abstract: The meniscus plays an important role in preventing osteoarthritis of the knee. Repair of
a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with
concurrent anterior cruciate ligament reconstruction, and in younger patients. The probability of
healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Age
or extension of the tear into the avascular area are not exclusion criteria. Numerous repair techniques
are available, and suture repair seems to provide superior biomechanical stability. However, the
clinical success rate does not correlate well with the mechanical strength of the repair technique.
Biologic factors might be of greater importance to the success of meniscal repair than the surgical
technique. Therefore, the decision on the most appropriate repair technique should not rely on
biomechanical parameters alone. Contemporary all-inside repair systems have decreased the oper-
ating time and the level of surgical skill required. Despite the ease of use, there is a potential for
complications because of the close proximity of vessels, nerves, and tendons, of which the surgeon
should be aware. There is no clear consensus on postoperative rehabilitation. Weight bearing in
extension would most likely not be crucial in typical longitudinal lesions. However, higher degrees
of flexion, particularly with weight bearing, give rise to large excursions of the menisci and to shear
motions, and should therefore be advised carefully. Long-term studies show a decline in success rates
with time. Further studies are needed to clarify the factors relevant to the healing of the menisci.
Tissue engineering techniques to enhance the healing in situ are promising but have not yet evolved
to a practicable level. Key Words: Age—Growth factors—Healing—Meniscus—Rehabilitation—
men. Meniscectomy increases the risk of developing
osteoarthritis (OA) of the knee significantly after more
than 20 years.1The extent of resection relates to the
linical evidence supports the hypothesis that
meniscectomy leads to cartilage degeneration in
degree of radiologic OA.2These arguments suggest
that meniscal repair should lead to an improved clin-
ical outcome compared with meniscectomy. However,
the results found in the literature are equivocal. Some
authors have reported fewer radiologic symptoms of
OA in patients who had their meniscus repaired com-
pared with patients who underwent meniscectomy.3
Others failed to prove a substantial clinical benefit to
repairing a meniscus.4A number of case series re-
ported high rates of clinical success of meniscal re-
pair, but investigations with a strong study design are
rare. The available data indicate that meniscal repair
cannot reliably prevent the progression of degenera-
tive changes and clinical symptoms. A potential ex-
planation is that both meniscal lesions and cartilage
damage occur as different features of the same entity,
which is not cured by repairing the meniscus. Indeed,
there is evidence that meniscal pathology occurs not
From the Departments of Orthopaedic Surgery at Otto-von-
Guericke University Magdeburg (C.S.), Magdeburg, Germany, and
Pittsburgh University Medical Center (S.K.), Pittsburgh, Pennsyl-
vania, U.S.A.; the Department of Trauma Surgery, Martin Luther
Hospital (W.P.), Berlin, Germany; and the Department for Ortho-
paedic and Trauma Surgery, City Hospital Brandenburg (R.B.),
The authors report no conflict of interest.
Address correspondence and reprint requests to Roland Becker,
M.D., Department for Orthopaedic and Trauma Surgery, City
Hospital Brandenburg, Hochstrasse 29, 14776 Brandenburg an
der Havel, Germany. E-mail: email@example.com
© 2009 by the Arthroscopy Association of North America
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 25, No 9 (September), 2009: pp 1033-1044
only as a cause but also as a symptom of OA of the
knee.5It seems possible that the fate of a repaired
meniscal lesion depends largely on its nature: namely,
whether it is degenerative or traumatic in origin.
Nonetheless, meniscectomy is an irreversible proce-
dure. Neither replacement nor regeneration of the me-
niscus have yet evolved to a satisfactory level. It is
therefore reasonable to prefer repairing the meniscus
to removing it.
BLOOD SUPPLY AND TEAR LOCATION
In adults, only the peripheral 10% to 25% of the
meniscus is vascularized (Fig 1).6In normal tissue
repair, local bleeding provides cellular elements and
biochemical mediators that are essential for the repair
response. It is therefore generally believed that it is the
missing vascular supply that limits the healing capa-
bility of the central zones. However, it was shown in
animal explant culture models that meniscal tissue is
capable of a repair response in the absence of vascu-
larity.7In a clinical study of 198 meniscal repairs that
extended into the avascular zone, 80% remained
asymptomatic at follow-up.8Kalliakmanis et al.9did
not find a significant difference between tears located
in the red–red zone and tears in the red–white zone.9
Cannon and Vittori10found a substantial drop in the
healing rates if the rim width exceeded 4 mm in stable
knees. Tears located mainly in the central zone have
an inferior healing capability.11
So far, it has not been established if the locally
different healing response is solely a matter of the
vascular supply. Mechanical stress, for instance, may
influence the behavior of cells populating the menis-
cus. The chance of healing is increased if the tear
either is located in the vascularized area or if access to
blood elements is created. Therefore, most surgeons
limit repair to lesions located in the Cooper zones121
and 2 (Fig 2). Nevertheless, an extension of the tear
into the avascular area is not an exclusion criterion. In
select patients, such as young athletes, the chance of
healing probably outweighs the potential risks of the
Tear Pattern and Shape
Meniscal lesions are generally more common in
males.14Metcalf and Barrett15investigated tear pat-
terns in a large number of patients with stable
knees; 39% were peripheral tears (Cooper zone 1 or
2). The majority of tears occurred in the posterior
horns, with 73% being isolated medial tears and
19% isolated lateral tears. Horizontal tears were
most common in this study, followed by complex
and flap tears. Longitudinal and bucket-handle tears
were found in 19% of cases. In a similar study that
investigated patients with an anterior cruciate liga-
ment (ACL) rupture, the portion of lateral meniscal
tears increased to 50% in acute cases.16Again, most
tears were located in the posterior horns. Peripheral
tears (Cooper zones 1 and 2) were found in more
than 60% of cases. The probability of encountering
tears suitable for repair is substantially decreased in
stable knees compared with ligament injured knees.
If repaired, double longitudinal or complex tears
have a higher probability for failure.8Tears that
involve only the posterior segment seem to have an
inferior healing rate compared with lesions extend-
ing into the middle segments.17
the peripheral 10% to 25% of the meniscus is vascularized from the
Blood supply of an adult’s meniscus. Note that only
Zones 0 and 1 are considered peripheral and are associated with a
better healing capability.
Menisci with circumferential and radial Cooper zones.
C. STA¨RKE ET AL.
Horizontal cleavage tears are a frequent finding and
may exist without clinical symptoms.18There is little
information on the significance of this type of tear.
They can give rise to flap tears but are otherwise
mechanically stable. It has not been clarified yet
whether patients benefit from the repair of these tears.
It appears questionable if sutures could neutralize the
shear motion that is thought to be responsible for the
development of these tears. If horizontal tears are
encountered incidentally—during ACL surgery, for
example—they might be left alone. At times, those
tears are accompanied by meniscal cysts,19which are
thought to arise from the influx of joint fluid through
meniscal tears. Partial meniscectomy is often carried
out to drain the cyst. It has been suggested that aspi-
ration of the cyst and closure of the tear with sutures
could avoid the need for a meniscectomy.20
Controversy exists concerning radial tears. They
should be clearly distinguished between complete and
partial radial tears. Empirically, partial radial tears
often affect the central parts while the outer rim re-
mains intact. This has important mechanical implica-
tions: in partial radial tears, the important circumfer-
ential fiber bundles are mostly intact and the function
of the meniscus is retained. Further, those tears largely
extend into the avascular area, which limits the chance
of healing.21Therefore, particularly in small radial
tears, debridement of loose edges is usually sufficient.
In cases of a complete trans-section, however, the
effect can be similar to a complete meniscectomy.22If
left untreated, weight bearing would extrude the me-
niscus out of the joint space and most likely no func-
tionally sufficient healing would occur. Although it
has been found that lateral meniscal tears in conjunc-
tion with ACL tears seem to have good prognosis in
general,23some surgeons24including the authors of
this review, feel that it might be beneficial to approx-
imate and secure the tear margins of a complete tear
with sutures. In those cases, non–weight bearing ex-
ercise is warranted postoperatively because circumfer-
ential stress (so-called “hoop stress”) is induced in the
meniscus with tibiofemoral loads, which would dis-
tract the tear margins.
The influence of the tear length on the failure rate is
not entirely clear. Although some authors could not
prove an association between the failure rate and the
length of the tear,11others found that failures occurred
significantly earlier in larger tears.25In one study, the
healing rate was in excess of 90% if the length of the
tear was less than 2 cm, whereas it was only 50% with
tears larger than 4 cm.10
Medial Versus Lateral Lesions
In a series of 53 patients, no significant difference in
the healing rate was found by means of computed
tomographic arthrography for the medial and lateral
meniscus.17Cannon and Vittori10found lateral me-
nisci to have a better healing rate than medial menisci.
Another investigation into ACL-reconstructed knees
did not find different failure rates for lesions located in
the Cooper zones 1 and 2 of either the medial or lateral
meniscus.26It is not entirely clear whether or not the
healing potential in the medial and lateral meniscus
are different. Yet the potential sequelae of meniscec-
tomy are more serious in the lateral meniscus than in
the medial.2Therefore, in the decision-making pro-
cess, it matters which of the menisci is affected.
Influence of Age
It has been observed that meniscal tissue from pa-
tients over 40 years of age has a lesser cellularity and
a decreased healing response than tissue from younger
patients.27Eggli et al.28stratified their patients into
groups older and younger than 30 years and found
retears to be more frequent in older patients. Bach
et al.25analyzed failures in a series of 300 meniscal
repairs.25The average time to failure was 34 months
in this study. Older patients failed significantly later
than patients younger than 30 years of age. Other
investigators did not find a correlation between the
revision rate and patient age in 113 cases of an all-
inside repair using the Meniscus Arrow (Conmed Lin-
vatec, Largo, FL).29In a recent study, the results of
meniscal repair in patients with reconstructed ACLs
are reported, and in terms of failures, no difference
was found between patients older or younger than 35
years of age.9The rates of clinical success in repair
procedures, which involve the avascular area, seem
not to be worse in older patients (40 to 58 years)
compared with the younger population.8,30The out-
come of repair in young patients is not generally
favorable, as one might expect.31By means of ar-
thrography or magnetic resonance imaging, it was
shown that healing of repaired tears remained incom-
plete in a high fraction of young patients, even in the
absence of symptoms.31The same negative prognostic
factors as in older patients, such as a complex tear
configuration, large distance to the periphery, or lig-
amentous instability, apply to the younger patients.32
Obviously, the clinical results in younger patients are
in conflict with the better intrinsic healing capability
that the basic science suggests. First, there are no
randomized controlled studies in which the treatment
allocation is primarily based on patient age. Most
investigators will consider the macroscopic appear-
ance of the meniscus in their treatment decision and
would not repair tears in grossly degenerated menisci.
This results in a selection bias, which potentially ob-
scures the influence of the patient’s age. Further,
higher demands in sports and occupation in the young
population might compromise the outcome despite a
better intrinsic healing capability. The available data
suggest that age is not a general contraindication to
meniscal repair—it merely increases the likelihood of
encountering a tear that is not suitable for repair.15
CHOICE OF THE REPAIR TECHNIQUE
A central question for the surgeon is whether the
healing response and long-term outcome depends on
the technique that is used. Horizontal sutures usually
yield a lower failure load because they lie in between
the circumferential fiber bundles and are pulled
through those as they are loaded.33Vertical sutures are
commonly considered the gold standard in regard to
the strength, which was found to be in a range from
about 60 N to more than 200 N, depending on the
investigated model.34,35In the case of vertical sutures,
failure occurs mainly by rupture of the suture because
the strong circumferential fiber bundles of the menis-
cus are contained within the suture loop. Here, the
choice of the suture material determines the failure
load.36In general, vertical sutures are preferred to
horizontal stitches; the techniques are very similar, but
vertical sutures result in stiffer repairs. Variations,
with the limbs of the suture crossing each other,
further increase the failure load.37Conventional suture
techniques are afflicted with a relatively long operat-
ing time and problems to reach the far posterior re-
gions of the meniscus. Therefore, implants to be used
without the need for additional incisions (all-inside)
were developed. The first generation of those all-
inside systems were small rigid implants with barbs or
threads, usually made from absorbable polymers. In
addition to occasional mechanical complications,
most of the solid all-inside implants show a consider-
able inferior stiffness and failure load, partially less
than 10 N.38,39In an effort to provide the convenience
of the rigid implants while giving the strength of
suture repair, combinations of sutures and rigid parts
were developed (Table 1; Figs 3–5). While the FasT-
Fix (Smith & Nephew Endoscopy, Andover, MA)
implant was the first of its kind, all major suppliers of
arthroscopic equipment now offer devices with a sim-
ilar design. Table 2 shows the rates of clinical success
for a variety of repair techniques and implants. It
should be noted that partial healing or failure of heal-
Linvatec). (B) Meniscal Dart (Arthrex). (C) BioStinger (Conmed
Bioresorbable implants. (A) Meniscus Arrow (Conmed
Overview of Meniscal Repair Instruments
Suture Rigid Implants
● Inside-out (generic
● Meniscus Arrow
● Meniscal Dart
● Meniscal Screw
● FasT-Fix (Smith &
● MaxFire (Biomet)
● Meniscal Cinch
● RapidLoc (DePuy
C. STA¨RKE ET AL.
ing does not necessarily cause clinical symptoms.8
Therefore, rates of so-called clinical healing do not
exactly reflect the healing status in a structural sense.
Further, the clinical success rates do not correspond
closely to the magnitudes of the mechanical strength
that is found for the different repair techniques38(Ta-
ble 2). The available data do not support the assump-
tion that stronger repair techniques are accompanied
by better outcomes. It must be acknowledged that
mechanical testing is usually done in the axis of in-
sertion, although it has not been shown conclusively
that substantial distraction forces do occur on repaired
lesions.40,41Shear forces might be more relevant but
are not addressed in most studies investigating the
stability of repair systems.
The success rates for the Meniscus Arrow and con-
ventional sutures seem to drop with time (Table 2).
Because there are no long-term studies for the newer
implants, the false impression might arise that those
are more successful than sutures or the Arrow. It is
possible that the same decline in the healing rate will
take effect with a longer follow-up of those systems.
COMPLICATIONS AND PITFALLS OF
Bleeding or pseudoaneurysms descending from
popliteal vessels are described with arthroscopic me-
niscal surgery. But those reports almost exclusively
pertain to the resection of the posterior horns,42,43not
meniscal repair. In a cadaver study, it was found that
the lateral genicular artery is at risk of being pene-
trated by the needle with inside-out and outside-in
sutures of the lateral meniscus (Fig 6). However, it has
not yet been established whether a laceration of this
vessel has detrimental effects on the healing meniscus.
Capture of branches of the peroneal nerve is possi-
ble when lateral meniscal lesions are sutured, but
seems to be rather seldom. Proper use of retractors can
largely avoid this complication.44In the case of medial
meniscal repair, the saphenous vein and nerve are at
risk of being affected.45Although transient neuro-
(Arthrex). (B) Prebent cannula, nitinol needle (Arthrex).
Instruments for suture repair. (A) Meniscal Viper
& Nephew Endoscopy). (B) MaxFire (Biomet). (C) Meniscal
Cinch (Arthrex). (D) RapidLoc (DePuy Mitek).
All-inside suture repair systems. (A) FasT-Fix (Smith
praxia was described in up to 22% of cases,46perma-
nent damage was found to occur in 0.4% to 1%.47,48
An anatomic study that investigated the placement
of the T-Fix (Smith & Nephew Endoscopy) device
showed that neurovascular structures seem not to be at
risk of being pierced with the insertion cannula.49In a
more recent investigation, the authors found that the
application cannula of a FasT-Fix device came within
3 mm of the popliteal artery under certain circum-
stances, whereas the RapidLoc (DePuy Mitek, Rayn-
ham, MA), with its shorter cannula, had a greater
distance to that vessel.50The use of the depth limiter
that comes with the FasT-Fix is therefore recom-
mended. However, Kalliakmanis et al.9reported no
neurovascular complications in a larger series of re-
pairs using the T-Fix and FasT-Fix implants.
In the case of solid implants, the depth of penetra-
tion can usually be controlled by choosing an implant
of appropriate length. Nevertheless, cases of nerve
damage have been described.51,52A complication that
is less dramatic than neurovascular damage and may
thus be under-recognized is accidental soft tissue te-
nodeses. Anatomic studies have shown, for example,
that the sartorius tendon, the deep medial collateral
ligament, and the popliteus tendon are at risk of being
penetrated by the application cannula (Fig 7).45,49Al-
Summary of Outcomes for Different Repair Techniques and Systems
Screw T-Fix FasT-Fix RapidLoc BioStingerSuture
Albrecht-Olsen et al.51
Pujol et al.17
Cannon and Vittori10
Kocabey et al.77
Barrett et al.87
Marinescu et al.88
Hürel et al.89
Kotsovolos et al.90
Frosch et al.76
Venkatachalam et al.91
Petsche et al.92
Haas et al.93
Tsai et al.94
Kalliakmanis et al.9
Barber et al.95
Gill and Diduch96
Spindler et al.97
Billante et al.98
Barber et al.99
Ellermann et al.100
Quinby et al.101
Barber and Coons102
Rubman et al.8
Kurzweil et al.103
Kurosaka et al.104
Gifstad et al.105
Koukoulias et al.106
Lee and Diduch107
Eggli et al.28
Majewski et al.108
NOTE. The criteria for success are heterogenous. Most authors shown in Table 2 define failure as the need for repeat arthroscopy or
symptoms of locking and catching. Table 2 is sorted by length of follow-up time, from the shortest amount of time at the top to the longest
amount of time at the bottom. Whether or not the anterior cruciate ligament was reconstructed is given and, if applicable, the impact on the
outcome. Numbers in parentheses give the outcome for the subgroup with unstable knees. It should be noted that there is a general trend of
increasing failure rates with time. Meniscal repairs in anterior cruciate ligament–reconstructed knees have better results than repairs in
primary stable knees or unstable knees.
Abbreviation: ACLR, anterior cruciate ligament reconstruction.
C. STA¨RKE ET AL.
though the results are not as severe as lacerations of
the nerves or vessels, increased postoperative pain
may compromise and slow down rehabilitation.
Complications specific to solid repair devices are
migration or breakage of the implant.53Parts of the
implants that surmount the surface of the meniscus
can also wear down the cartilage in the contact zones
and cause chronic synovitis.54Although this has been
addressed by changes in the design and resorption
time of the implants, it seems that these problems are
not fully eliminated.55
ENHANCEMENT OF THE HEALING
Biologic factors might be of greater importance to
the success of meniscal repair than the choice of the
surgical technique. The healing potential apparently
coincides with the vascular supply of the meniscal
tissue.56However, the local application of vascular
endothelial growth factor did not lead to improved
healing in a sheep model.57Exogenous fibrin clots
seem to improve the healing in animal models58and in
humans.59It is postulated that the clot serves as a
chemotactic and mitogenous stimulus. Some investi-
gators succeeded in enhancing the healing of meniscal
lesions with the application of mesenchymal stem
cells.60It is not clear whether this is a direct action of
the progenitor cells or is rather mediated by secretion
of certain stimulating factors. The behavior of menis-
cal fibrochondrocytes can be modulated when the cells
are exposed to certain growth factors.61The response
to mitogenic stimuli, however, seems not to be nec-
essarily the same for all regions.62Human menisci are
populated by cells of different phenotypes that might
respond differently to extrinsic stimuli, as was re-
ported by Verdonk et al.63
There are study findings showing that trephination
or rasping alone without suturing the meniscus might
be a reasonable option in stable tears. Shelbourne and
Heinrich23and Shelbourne and Rask64published clin-
ical studies investigating the fate of stable lesions in
the medial and lateral meniscus that were either left
alone or treated by rasping and trephination in con-
junction with an ACL reconstruction. They found that
only a minor proportion of their patients required
subsequent surgery for their meniscus. Fox et al.65
reported on a similar procedure with good or excellent
at the height of the tibiofemoral joint space. Structures potentially
at risk of being penetrated by a cannula or being caught by a suture
are shown. (LCL, lateral collateral ligament; MCL, medial collat-
Transverse magnetic resonance imaging slice of a knee
the close anatomic relationship of the inferior lateral genicular
artery (ILGA) and the lateral meniscus. The vessel is at risk when
passing needles/sutures inside-out or outside-in. (LCL, lateral col-
Coronal magnetic resonance imaging slice illustrating
results in about 90% of cases. Zhang and Arnold66and
Zhang et al.67have shown in animal studies that
trephination enhances the healing capacity of lesions
in the avascular zone with and without additional
INFLUENCE OF CONCURRENT INJURIES
An injury to the ACL is the most often described
entity encountered together with a meniscus tear.
While the classic description of the O’Donoghue triad
comprises a lesion of the medial meniscus together
with a rupture of the ACL and medial collateral lig-
ament, Barber68and Shelbourne and Nitz69have
pointed out that lesions of the lateral meniscus are
much more common in acute injuries. In chronic ACL
deficiency, the relation shifts toward the medial me-
niscus.16,70It has been shown that an abnormal an-
teroposterior laxity increases the resultant forces in the
medial meniscus.71The meniscus becomes a second-
ary stabilizer, a purpose for which it is not primarily
Accumulated microdamage explains the increasing
rates of medial meniscal lesions in the course of
untreated ACL deficiency. Conclusively, meniscal re-
pair should result in a better outcome if it is done in
conjunction with a stabilization of the knee. There
have been no randomized studies that have investi-
gated the outcome of meniscal repair in relation to the
ACL state. Usually, the anteroposterior instability will
be regarded as the primary problem, and randomiza-
tion in terms of the ACL reconstruction is not an
option. Nevertheless, there are some studies that com-
prise subgroups of patients with either ligamentous
intact, reconstructed, or unstable knees. In the major-
ity of these studies, it seems that the outcome of a
repair is better with concomitant reconstruction than
in knees that remain unstable72-74or even better than
knees without ACL injury.75-77
The fact that meniscal repair appears to be more
successful in combination with an ACL reconstruction
deserves some detailed reflection. The simplest expla-
nation is that, with the stabilization of the knee, the
inciting cause for the repeated microtrauma of the
menisci is eliminated, or at least diminished. More-
over, marrow elements are introduced into the joint
cavity with the ACL procedure that, as described
earlier, are thought to modulate the healing response
of meniscal fibrochondrocytes. Another potential ex-
planation for a seemingly improved healing rate with
concurrent ACL surgery is related to patient selection.
It must be assumed that in the subgroup of patients
with concomitant ACL reconstruction, the main rea-
son for the procedure is instability, and that conclu-
sively not only symptomatic but also clinically silent
lesions of the meniscus are identified and repaired.
However, in patients with stable knees, the cause for
the meniscal repair usually is meniscal symptoms,
such as locking or effusion. The possibility of a se-
lection bias must therefore be considered.
Patients should be informed in advance that menis-
cal repair is usually accompanied by much longer
periods of restricted motion and limitation of the knee
function than after a meniscectomy. It has been shown
that the reparability of meniscal tears can be predicted
reasonably well by magnetic resonance imaging stud-
ies,78which gives both the patient and surgeon the
opportunity to be prepared in advance.
A generally valid rehabilitation algorithm has not
been established. Rehabilitation plans need to be in-
dividually tailored and should take into consideration
the nature of the tear, concurrent injuries and proce-
dures, and the influence of specific exercises on the
repaired tear (Table 3).
There are both mechanical and biologic effects as-
sociated with postoperative weight bearing and mo-
tion of the knee. In repaired bucket-handle lesions,
weight bearing reduces the meniscus and stabilizes the
tear.40Flexion under tibiofemoral loads of the knee,
however, leads to increasing compressive and shear
loads in the posterior horn. It was reported that weight
bearing flexion from full extension to 90° increases
the pressure on the posterior horn by, roughly, a factor
of 4.79The menisci translate dorsally with knee flex-
ion. This motion depends not only on the flexion angle
but also on the weight bearing condition.80The mag-
Postoperative Rehabilitation Program for a
Typical Bucket-Handle Lesion
Early Phase Intermediate PhaseLate Phase
● Ice and analgesics
● Crutches as needed
● Brace to limit
● Partial or full
(60° to 90°)
● Aqua jogging
● Isometric strength
● Continue brace
● No squats for
● Regain full range
● Strength training
NOTE. Patients might need an individually tailored program.
C. STA¨RKE ET AL.
nitude of the posterior femoral rollback, and necessar-
ily the posteriorly directed translation of the menisci,
is substantially increased in the weight-loaded knee
compared with the unloaded state. Although this was
not directly proven by the cited study, motion exer-
cises of the knee without weight bearing might there-
fore be preferable during rehabilitation to limit the
stress on the repair. Weight bearing in extension most
likely does not pose a problem to repaired meniscal
lesions. An exception to this is complete transections
of circumferential fiber bundles of the meniscus, such
as radial tears that comprise the whole cross-section or
posterior root tears. In those cases, weight bearing
would be deleterious because the hoop stress distracts
the tear margins and healing is prevented.81
Tibial rotation causes large excursions of the me-
niscus within the first 30° of flexion.82Terminal flex-
ion is accompanied by a large dorsal translation of the
condyles and causes increased compressive stress of
the meniscus.79,80Therefore, deep squats and tibial
rotation should be avoided for at least 12 weeks.
Although the magnitude of the posterior translation
of the medial and lateral meniscus is different, no
significant difference in the pressure that arises on the
medial and lateral posterior horns was found by
Becker et al.79at up to 90° of flexion. So far, it is not
clear if medial and lateral meniscal repairs deserve
different rehabilitation protocols. Most investigations
about the biologic effects of immobilization found that
it impaired the healing of repaired menisci.83Limited
motion and weight bearing in full extension might
have stimulating effects on the healing response.84
There have been some clinical investigations re-
garding the effect of a more aggressive rehabilitation
of meniscal repair patients. Barber and Click46and
Barber85did not find any evidence that an accelerated
program compromises the result of the repair. Simi-
larly, Mariani et al.86failed to show deleterious effects
when patients with concomitant ACL surgery were
subjected to an accelerated rehabilitation program.
However, the design and case number of those studies
do not allow one to infer in general that restrictions
after meniscal repair are not necessary.
Meniscal preservation has gained a high level of
awareness in the recent years. The surgeon must con-
sider the nature of the tear in his decision of whether
or not to repair or resect. The prognosis of a meniscal
repair is better if it is possible to identify and treat an
underlying problem like an ACL deficiency. Contem-
porary all-inside repair systems have significantly de-
creased the level of technical skills required for a
successful repair. There is currently no scientifically
substantiated reason to believe that the choice of a
particular repair technique would improve the out-
come. It has not been shown thus far that a high failure
load is associated with better clinical results.
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