Published online Aug 18, 2023. doi: 10.5312/wjo.v14.i8.612
Peer-review started: January 14, 2023
First decision: March 14, 2023
Revised: April 18, 2023
Accepted: June 14, 2023
Article in press: June 14, 2023
Published online: August 18, 2023
One of the most important factors to consider in relation to meniscal repair is the high failure rate reported in the existing literature.
To evaluate failure rates, return to sports (RTS) rate, clinical outcomes and mag
We conducted a retrospective review of meniscal repairs between January 2004 and December 2018. All patients treated for longitudinal tears associated or not with an anterior cruciate ligament reconstruction (ACL-R) were included. Menis
One hundred and nineteen patients were included with a mean follow up of 7 years (SD: 4.08). Overall failure rate was 20.3% at a mean 20.1 mo. No statistically significant differences were found when comparing failure for medial and lateral meniscal repair (22.7% and 15.3%, P = 0.36), BHTs and not BHTs (26% and 17.6%, P = 0.27), isolated or associated with an ACL-R (22.9% and 18%, P = 0.47), or when comparing only BHTs associated with an ACL-R (23% and 27.7%, P = 0.9) or not. When comparing cohorts before and after 2014, we found a significant decrease in the overall failure rate from 26% to 11% (P < 0.03). Isolated lesions presented a decrease from 28% to 6.6% (P = 0.02), BHTs from 34% to 8% (P = 0.09) and those associated with an ACL-R from 25% to 10% (P = 0.09). Mean RTS time was 6.5 mo in isolated lesions and 8.64 mo when associated with an ACL-R. Overall, 56% of patients returned to the same sport activity level. Mean pre and postoperative Lysholm scores were 64 and 85 (P = 0.02), and IKDC 58 and 70 (P = 0.03). Out of 84 asymptomatic patients evaluated with MRI, 39% were classified as “not healed” and 61% as “healed”.
Even though the overall failure rate of our series was 20.3%, we found a statistically significant decrease from 26% to 11%, not only for isolated lesions, but also for BHT’s and those associated with an ACL-R when comparing our series in two different cohorts, most probably due to improvements in surgical technique.
Core Tip: One of the most important factors to consider in relation to meniscal repair is the high failure rate reported in the literature. In this retrospective cohort we observed that new and improved suturing techniques have shown significantly lower failure rates, encouraging the need for meniscal repair whenever possible.
- Citation: Zicaro JP, Garrido N, Garcia-Mansilla I, Yacuzzi C, Costa-Paz M. Failure rate, return-to-sports and magnetic resonance imaging after meniscal repair: 119 patients with 7 years mean follow up. World J Orthop 2023; 14(8): 612-620
- URL: https://www.wjgnet.com/2218-5836/full/v14/i8/612.htm
- DOI: https://dx.doi.org/10.5312/wjo.v14.i8.612
Due to the high rate of osteoarthritis observed after partial or total meniscectomy[1], meniscal repair techniques have been gaining significance over the last decades[2], total meniscectomy being particularly important in young patients and athletes[3]. Moreover in the case of Anterior cruciate ligament reconstruction (ACL-R), meniscal deficiency is frequently associated with residual rotational laxity affecting long term clinical outcomes[4-6]. Consequently, it is mandatory to preserve the meniscus when performing an ACL-R whenever possible.
The rate of meniscus repair has increased over the past few decades, along with the number of revision surgeries due to failed repair[6-8]. All-inside sutures required mainly for posterior horn lesions had historically been associated with higher failure rates and revision surgery[9]. Recent studies have shown that improvement in surgical strategies coupled with the development of more sophisticated suture devices, has led to an improvement in the success rate of meniscal preservation[10,11].
In our institution, the number of meniscal repairs has been growing exponentially since 2010. In addition, techniques have been changing over time. Therefore, the main purpose of our study was to evaluate failure rates after meniscus suture repair. As secondary objectives we analyzed return to sports (RTS) rate, clinical outcomes and magnetic resonance image (MRI) evaluation.
After institutional review board approval, we performed a retrospective review of prospectively collected registry data including all patients treated with meniscal repair at our institution between January 2004 and December 2018. We included patients operated on vertical meniscal tears. Ramp lesions, radial lesions and root tears were excluded, as well as patients with meniscal allograft transplant, associated with multiligament knee injuries and patients with less than a two-year follow-up.
All surgical procedures were performed by the same surgical team, followed by a standard rehabilitation protocol. Variables analyzed included the patient’s gender and age, tear type and surgical technique. Repair was registered as follows: all-inside, inside-out, outside-in. Failure was defined as symptomatic patients who underwent a revision surgery due to re-rupture at the previously treated portion of the meniscus. Historically, higher healing rates have been associated with meniscal repair in the setting of an ACL-R[12], as well as small vertical lesions have been compared to Bucket Handle Tears (BHTs)[9,13]. Hence, we analyze our cohort in different subgroups: Meniscal repairs associated with ACL-R compared to isolated meniscal repairs, and BHTs compared to non BHTs.
In addition, rate and time to RTS, subsequent surgeries, preoperative and postoperative subjective assessment (Lysholm and IKDC scores) were reported, and postoperative complications were recorded and analyzed.
X-rays and MRI were routinely obtained during follow-up in order to evaluate meniscal healing. Results were classified and categorized as: “Not healed”, when a gap greater than 2 mm was present in the repaired meniscus with a hyperintense continuous homogeneous line (Figure 1) and “healed”, when continuity was observed (Figure 2). MRI categorization did not define failure, only a description of the images even in asymptomatic patients.
All inside sutures were indicated for posterior horn lesions. Inside-out technique was usually indicated for lesions of the middle third of the meniscus. In selected cases, anterior horn and posterior horn lesions (using a postero-medial or postero-lateral approach to retrieve the sutures) were also treated with this technique. In the case of inside-out technique, specific cannulas were introduced through the contralateral portal, and long needles with 2-0 Tycron sutures were passed through. Outside-in technique was indicated for the anterior third of the meniscus, using 2-0 Tycron sutures or 0 PDS sutures.
In the case of BHTs, usually, two or three of these techniques were combined. In most cases, all-inside devices were used for the posterior horn in combination with inside-out or outside-in techniques for the rest of the meniscus. When all-inside devices were not available, the inside-out technique was used, retrieving the stitches through a postero-medial or postero-lateral approach.
One of the greatest changes in our surgical approach was to begin to perform multiple vertical stitches spaced every 4 mm using cannulas for the inside-out technique with 2-0 Tycron sutures as compared to most sutures performed prior to 2014 using few horizontal inside-out 0 PDS stitches (Figure 3).
Regarding ACL-R, either using hamstrings graft or bone-patellar tendon-bone, we performed transportal anatomic technique, maintaining the anatomic insertion footprint in both the femur and the tibia.
Two different protocols were used after surgery for three different scenarios: isolated lesions, lesions associated with ACL-R and BHTs.
Isolated lesions, as well as those associated with an ACL-R were allowed for immediate partial weight bearing using a knee brace for three weeks. Flexion was limited to 90° for the first three weeks with progressive mobilization until complete flexion. Non-impact activities were allowed after three weeks. RTS was allowed by the fourth month. When associated with an ACL-R, RTS was determined according to the ACL-R protocol.
BHTs were indicated for non-weight bearing and flexion 0-70° for three weeks, followed by partial weight bearing for three more weeks and progressive flexion to 90°. After that period, progressive flexion and non-impact activities were indicated until complete range of motion. Impact sports activities were allowed from the fifth month onwards or according to the ACL-R protocol.
Descriptive statistics including means, standard deviations, median and quartile ranges were deemed appropriate to assess the available demographic, surgical, physical examination and patient-reported outcome data. Statistical hypothesis testing was performed using the Fisher exact test and Wilcoxon rank-sum test. Chi-square test was performed for categorical data. Analysis was performed with 95%CIs, and P values < 0.05 were considered statistically significant. All statistical analyses were performed using STATA version 15.
A total of 140 patients underwent a meniscal repair during the study period. Ten patients did not meet the inclusion criteria and eleven were lost in follow-up. There were no patients whose meniscus was re-ruptured and declined receiving revision surgery. Therefore, 119 patients were included in the study, 83% (n = 99) males, with a mean age of 27.1 years (SD: 8.02). Mean follow-up was 7 years (SD: 4.08). Table 1 shows the number of meniscal sutures, the distribution for isolated or BHT’s, associated or not with an ACL-R, failure rates and time to failure.
| Overall meniscal sutures | |||
| Total | Failure | Time to failure, months | |
| Total sutures | 119 (100) | 24 (20.3) | 20.1 |
| BHT | 34 (28) | 9 (26.4) | 20.8 |
| Not BHT | 85 (72) | 15 (17.6) | 19.7 |
| Posterior horn | 37 (43) | 7 (18.9) | 19.1 |
| Body | 43 (50) | 8 (18.6) | 20.2 |
| Anterior horn | 5 (7) | 0 (0) | 0 |
| Associated w/ACL-R | 71 (60) | 13 (18.5) | 17 |
| ACL-R + BHT | 17 (23) | 4 (23) | 12.5 |
| ACL-R + Not BHT | 54 (77) | 9 (16.6) | 19.1 |
| Isolated | 48 (40) | 11 (22.9) | 23.8 |
| BHT | 18 (37) | 5 (27.7) | 27.6 |
| Other | 30 (63) | 6 (20) | 20.6 |
Overall failure rate was 20.3% (24/119) at a mean of 20.1 mo (range 11-60 mo). We found no statistically significant differences when comparing BHT’s with not BHT’s (26% and 17.6%, P = 0.27), associated with an ACL-R with isolated repairs (18% and 22.9%, P = 0.47), or BHT’s associated or not with an ACL-R (23% and 27.7%, P = 0.9) (Table 1).
No significant difference was found when comparing overall failure rate for medial vs lateral meniscal repair (22.7% and 15.3%, P = 0.36), though medial meniscus lesions were more frequently associated with an ACL-R than lateral meniscus lesions (70% and 41%) (Table 2).
There was an increase in the number of stitches, from a mean of 1.4 (SD: 1.01) to 3.5 (SD: 2.31) for BHTs and 1.2 (SD: 0.5) to 2.1 (SD: 1.1) for isolated repairs. We found a statistically significant decrease (Table 3) in overall failure rate after meniscal repair from 26% for 67 meniscal repairs in the period between 2004 and 2014 to 11% for 52 repairs after that period (P = 0.03) as for isolated lesions (not associated with an ACL-R) with a decrease from 28% (9/32) to 6.6% (1/15) after 2014 (P = 0.02). Although there was no statistically significant difference, overall BHT’s failure rate decreased from 34% (8/23) to 8% (1/12) (P = 0.09), and meniscal sutures associated with an ACL-R decreased from 25% (9/35) to 10% (4/37) (P = 0.09).
| Period | 2004-2013 | 2014-2018 | P value | ||
| Age yr (range) | 25.94 (16-48) | 28.21 (18-59) | 0.72 | ||
| Gender, female | 13 (19) | 7 (13) | 0.12 | ||
| Total | n | Failure | n | Failure | 0.03 |
| 67 | 18 (26) | 52 | 6 (11) | ||
| Associated w/ACL-R | 35 (52) | 9 (25) | 37 (71) | 4 (10) | 0.09 |
| BHT | 11 (31) | 3 (27) | 5 (14) | 1 (20) | 0.63 |
| Not BHT | 24 (69) | 6 (25) | 32 (86) | 3 (9) | 0.11 |
| Isolated | 32 (48) | 9 (28) | 15(29) | 1 (6.6) | 0.02 |
| BHT | 11 (34) | 5 (45) | 7 (47) | 0 (0) | 0.05 |
| Not BHT | 21 (66) | 4 (19) | 8 (53) | 1 (12) | 0.57 |
| BHT1 | 23 (34) | 8 (34) | 12 (23) | 1 (8) | 0.09 |
Overall mean time to RTS was 7.8 mo (SD: 2.77), 6.55 mo (SD: 2.36) for isolated lesions and 8.64 mo (SD: 2.72) when associated with an ACL-R. At the final follow-up, 67 patients (56%) returned to the same activity level, 28 (24%) reported a lower activity level and 3 patients (2%) decided not to return to sport activities. Twenty-one patients (18%) did not practice any sports at all.
The mean pre and postoperative Lysholm score was 64 (SD: 10.2) and 85 (SD: 14.08) respectively (P = 0.02) and the mean pre and postoperative IKDC score was 58 (SD: 7.51) and 70 (SD: 10.22), respectively (P = 0.03).
Eighty-four asymptomatic patients (71%) were evaluated with X-rays and MRI at a mean 3 years postoperative. X-rays did not reveal arthritic changes during that period. A total of 33 MRI’s (39%) were classified as “not healed” and 51 (61%) as “healed”. It is important to emphasize that these were asymptomatic, active patients.
No intraoperative complications were reported. As to postoperative complications, two cases (1.6%) presented septic arthritis in the setting of an ACL-R and were treated with arthroscopic irrigation and debridement followed by intravenous antibiotics for four weeks, and one (0.8%) patient was operated on for isolated meniscal repair presented a superficial wound infection which was treated with oral antibiotics for 10 d.
The most important finding of our study was that even though the overall failure rate was 20.3% (26% for BHTs, 18% when associated with an ACL-R and 22% for isolated lesions), we found a significant decrease of failure rate when comparing two different cohorts in view of differences in surgical technique from 26% to 11% (P = 0.03). Not only for isolated lesions (from 28% to 6.6% for isolated lesions, P = 0.02), but also BHTs (from 34% to 8%, P = 0.09) and those associated with an ACL-R (from 25% to 10%, P = 0.09). These findings add to a growing body of literature on the importance of surgical technique when analyzing failure rate after meniscal repair[7,9,14,15]
For the last two decades meniscal preservation has become the main goal for treatment of meniscal lesions. In 2013, Abrams et al[16] reported that between 2005 and 2011 the incidence of meniscal repair has doubled in the United States. This tendency has continued to increase up to date, thus becoming the gold standard procedure when deciding the fate of a meniscus repairable lesion nowadays[1-17].
Systematic reviews prior to 2012, reported failure rates of 18% to 23%[7,15,16] after meniscal repair. Fillingham et al[9] in 2017 compared inside-out vs modern all-inside devices techniques and reported similar functional outcomes, with equivalent anatomical and clinical failure rates: 11% and 10% respectively. These results were interestingly lower when compared to 17% and 19% previously reported by Grant et al[14] in 2012. Fillingham et al[9] also found that all-inside repairs had an average of 2 stitches, while inside-out had an average of 3. Therefore, they associated the inside-out technique with more complex lesions.
When we analyzed the overall failure rate for meniscal sutures in our series, we found 20.3% with a mean time to failure of 20.1 mo, which is very similar to prior reports in the literature[7,16,18]. Moreover, an overall failure rate for isolated lesions of 22.9%, (27.7% for BHTs) and 18.5% when associated with an ACL-R (23% for BHTs) was found.
The analysis of the evolution of failure rate during our research yields a significant decrease when comparing our series in two different periods. Even though patients treated after 2014 have a shorter follow up, we consider that it is enough to establish a comparison considering that the overall mean time to failure was 20 mo. There might be multiple factors to explain this decrease in failure rates. Most horizontal mattress sutures (usually no more than 2 stitches) were replaced for vertical sutures (one stitch every 5 to 10 mm), which provides more stability and prevents meniscal cutout[19]. This resulted in an increase in the number of stitches, from a mean of 1.4 (SD: 1.01) to 3.5 (SD: 2.31) for BHTs (Figure 3) and 1.2 (SD: 0.5) to 2.1 (SD: 1.1) for isolated repairs, and it continues to increase up to date. Another important factor might be an improvement in the all-inside devices for meniscal sutures as reported in clinical[9] and biomechanical[20] studies.
Blanchard et al[21] reported an overall RTS rate of 83% after 8.7 mo in 21 studies evaluated after isolated meniscal repair. Other authors reported variable time to RTS from 4.2[22,23], 5.6[24] and 5.5[25] mo. When associated with an ACL-R time to RTS is reported from 8.2 (64 Vanderhave) to 11.8 mo (48 Logan). We found a mean RTS of 6.55 mo (SD: 2.36) for isolated lesions and 8.64 mo (SD: 2.72) when associated with an ACL-R. After a mean of 7 years follow-up, only 56% returned to the same activity level and 24% reported a lower activity level. Though this seems to be a low RTS rate, many authors have reported better outcomes after meniscal repair compared with meniscectomy (2018 KSSTA Phillips, 2014 AJSM Westermann, 2021 OJSM Blanchard).
Regarding the role of MRI as a postoperative control measure, we found that it was not useful in evaluating meniscal repairs. We found that 39% out of the 85 asymptomatic patients that performed a routine MRI presented an image compatible with a “not healed” repair. The report even suggested a “failure” or “rupture” of the repair. All of these patients were asymptomatic and performing regular sport activities. Faunø et al[26] in 2020 reported 72% sensitivity for finding meniscal re-ruptures in 80 symptomatic patients who underwent a revision surgery. Yamasaki et al[27] suggested a T2 mapping to improve the sensitivity for unhealed meniscus after comparing standard and T2 mapping MRI for 26 asymptomatic patients who underwent a second look arthroscopy.
The role of biologics in the setting of meniscal repair in order to increase the chance of healing and reduce failure rate is still controversial and very few clinical studies have been reported. In a recent systematic review, Haunschild et al[28] reported that there was considerable heterogeneity in the reporting and preparation of platelet rich plasma (PRP) used for augmentation, and concluded that there was insufficient evidence to support the use of PRP to improve meniscal healing and reduce failure rate. Controversially, Zaffagnini et al[29] and Sochacki et al[30] reported an improvement in survival rate after isolated meniscal repair augmented with PRP.
The limitations of our study need to be acknowledged. First, the main limitation was the retrospective design, yielding an analysis limited to the data available in the medical record database, with potential for selection bias. Second, the fact that we considered asymptomatic patients and analyzed the results as “healed” or “not healed” for MRI subsequent analysis without a second-look arthroscopy confirmation. And finally, the lack of radiographic evaluations which did not allow us to evaluate any degenerative progression.
Despite these limitations, the large sample size and subgroup analysis, as well as the long term follow-up of 7 years constitute a major strength of our study.
The overall meniscal repair failure rate after a mean follow-up of 7 years was 20.3%, with 26% for BHTs, 18% when associated with an ACL-R and 22% for isolated lesions. Interestingly, when comparing our series in two different cohorts in view of differences in surgical technique, we found a decrease from 26% to 11% (P = 0.03), 28% to 6.6% (P = 0.02) for isolated lesions, 34% to 8% (P = 0.09) for BHT’s, and 25% to 10% (P = 0.09) for meniscal sutures associated with an ACL-R. The mean time for return-to-sports was 6.5 mo for isolated meniscal repairs and 8.6 when associated with an ACL-R. Finally, MRI was not efficient for evaluating the condition of the meniscal repair in asymptomatic patients. It is recommended that care should be taken when considering MRI as a routine control practice after meniscal repair.
We perform a large number of meniscal repairs every year. Our surgical techniques have been improving along the years, and with it, the outcomes achieved.
We observed a great improvement over the years in our patient outcomes. That is why we decided to analyze and report the long-term results of our series.
To analyze the failure rate and compare outcomes in our series of patients operated on for longitudinal meniscal lesions. It is important to understand that improvement in the number of stitches and surgical technique is associated with better outcomes than what is reported in the literature.
We retrospectively analyzed and compared demographic data, surgical details, return to sport and failure rate using specific statistical tools.
In our series we found an important decrease in failure rates by improving our surgical technique and increasing the number of stitches. Even so, there is still a high percentage of patients in whom this type of repair fails. It is very important to continue investigating complementary methods that can help to further reduce this failure rate.
The new theory provided by the paper is that the failure rate may continue to fall even further.
Future work could compare the same type of sutures with biological augmentation such as platelet-rich plasma or stem cells.
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Orthopedics
Country/Territory of origin: Argentina
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P-Reviewer: Ohishi T, Japan; Shalaby MN, Egypt S-Editor: Li L L-Editor: A P-Editor: Yuan YY
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