|Year : 2017 | Volume
| Issue : 1 | Page : 1-5
Arthroscopic outside-in meniscal repair: A short-term clinical experience
Ranti O Babalola FMCS, FWACS, FMC (ORTHO) 1, Emmanuel A Laiyemo1, Shopekhai E Itakpe1, Christian Madubueze2, Olaoluwa M Shodipo1
1 National Orthopaedic Hospital, Lagos, Nigeria
2 National Hospital, Abuja, Nigeria
|Date of Web Publication||5-Jul-2017|
Ranti O Babalola
National Orthopaedic Hospital, PMB 2009, Yaba, Lagos State
Source of Support: None, Conflict of Interest: None
Objective: Meniscal injuries are very common knee injuries that are presented to an orthopaedic surgeon. The goal of our study was to assess the early outcome of outside-in meniscal repair in the management of meniscal tears. Patients and Methods: This study was a prospective case series conducted at the National Orthopaedic Hospital, Lagos. Consecutive cases of patients with meniscal tears who met the inclusion criteria were recruited. Anterior cruciate ligament reconstruction was performed with semitendinosus autograft. Meniscal repair was performed arthroscopically by only two surgeons using the outside-in technique with size 2 polydioxanone suture. The Western Ontario and McMaster University Evaluation Tool (WOMET) score was computed during the pre-operative stage and at least 6-months post-operatively as outcome measure. The visual analogue scale (VAS) and WOMET scores in the pre- and post-operative periods were noted. Results: Five patients with injured menisci underwent meniscal repair. The median duration of follow-up was 14 months (range 8–30 months). Using Barret’s criteria, we determined that a clinically healed meniscus was obtained in only 2 (40%) patients. The WOMET score improved from a mean of 46 (±18) to 20 (±10.7) between the pre- and post-operative stages, and the mean VAS score decreased from 4.6 (±0.5) to 2.5 (±1.3). Discussion: The poor health-seeking behaviour in our environment would explain the delayed presentations of our patients. However, it has been established that chronic tears do heal. Outside-in technique remains at the moment our method of choice for meniscal repair because of the challenges we face for equipment and funding of health care in our environment. Trephination of the meniscus was performed to improve the chances of healing. Using Barret’s criteria, we had a healing rate of 40% (2). Conclusions: The outside-in technique remains an option for the treatment of chronic tears with good clinical improvement in the short term.
Keywords: Early outcome, meniscal injury, meniscal repair
|How to cite this article:|
Babalola RO, Laiyemo EA, Itakpe SE, Madubueze C, Shodipo OM. Arthroscopic outside-in meniscal repair: A short-term clinical experience. Afr J Med Health Sci 2017;16:1-5
|How to cite this URL:|
Babalola RO, Laiyemo EA, Itakpe SE, Madubueze C, Shodipo OM. Arthroscopic outside-in meniscal repair: A short-term clinical experience. Afr J Med Health Sci [serial online] 2017 [cited 2017 Oct 19];16:1-5. Available from: http://www.ajmhs.org/text.asp?2017/16/1/1/209483
| Introduction|| |
The meniscus has been documented to play a major role in distributing axial loads through the knee joint. It is said to also help the synovial fluid in the lubrication of the knee and contribute to improved tibio-femoral joint articular congruity and non-contractile knee joint stabilization., Meniscal injuries are the most common knee injuries. They often result from sports and non-sports-related activities, and these injuries result in pain and functional limitation for the patient. There may also be an associated ligament injury to the knee. It may need to be combined with reconstruction of a torn anterior cruciate ligament, as a meniscal injury may be associated with an Anterior Cruciate Ligament (ACL) rupture. Broadly speaking, meniscal surgery may take the form of either a meniscal repair or meniscectomy. Meniscectomy has been established to have negative effects on the underlying articular cartilage by increasing the contact pressure on the articulating surfaces, accelerating articular cartilage damage and enhancing secondary osteoarthritic changes in the joint. Consequently, there is an increasing trend towards preserving the meniscus as much as possible when the conditions of the tear favour a repair. We are not aware of any published report on outside-in meniscal repair from the West African sub-region. The goal of this study was to evaluate the early outcome of outside-in meniscal repair, alone or in combination with anterior cruciate ligament reconstruction, following traumatic meniscal injury at the National Orthopaedic Hospital, Lagos.
| Patients and Methods|| |
This was a prospective case series of five patients with menisci injuries. They were consecutive patients with traumatic meniscal tears seen between January 2014 and June 2016 and who met the inclusion criteria. The inclusion criteria were age less than 40 years, traumatic knee injury, clinical features of a chronic meniscal tear with or without anterior cruciate ligament injury, not more than grade I osteoarthritis on plain radiograph of the knee and the absence of meniscal degeneration on magnetic resonance imaging (MRI) and arthroscopy. Informed consent was obtained from all patients. All the patients were reviewed in the out-patient department with a detailed history taking and physical examination. A history of trauma to the knee, locking and the presence of joint line tenderness and McMurray sign were suggestive of a meniscal injury. Diagnosis of a meniscal injury was clinical and confirmed by an MRI of the knee. Anterior cruciate ligament injury was assessed clinically with a positive history of the knee giving way, positive Lachman’s test, anterior drawer’s test and pivot shift test; it was confirmed on the same MRI requested for the meniscal injury and by examination under anaesthesia during surgery. Arthroscopic repair was performed under spinal anaesthesia. When necessary, anterior cruciate ligament reconstruction was performed with semitendinosus autograft with bio-absorbable interference screw fixation. Meniscal repair was performed arthroscopically by only two surgeons using the outside-in technique with size 2 polydioxanone suture. The repair was preceded by arthroscopic confirmation of the meniscal injury during diagnostic arthroscopy [Figure 1].
This was followed by debridement of the torn meniscal edge with a shaver. All zones were repaired with the outside-in technique using size 18G spinal needles and polydioxanone size 2 sutures [Figure 2].
Following the passage of the sutures, the subcapsular knots were tied to adequately approximate the edges of the torn meniscus [Figure 3].
The healing of the meniscus was facilitated by the trephination of the meniscus. In the immediate post-operative period, the knee was placed in full extension in a range of motion brace. This was followed by increments of 30° of flexion every week for the next 4 weeks and then full range of flexion. Isometric quadriceps exercise was started in the immediate post-operative period. Patients were allowed partial weight-bearing on bilateral axillary crutches from the 4th week and then full weight-bearing as tolerated from the 8th week.
The visual analogue pain score and Western Ontario and McMaster University Evaluation Tool (WOMET) score were computed in the pre-operative period at the time of review in the out-patient department. The post-operative values were assessed at least 6-months post-operatively as the outcome measure. The Barret’s criterion was used for the post-operative clinical assessment of healing. A meniscal repair was considered healed when none of the following features were present: pain at the inter-articular joint line, presence of joint effusion, presence of joint locking or a positive meniscal test.
Descriptive statistics was used for quantitative variables. The visual analogue scale (VAS) score and Western Ontario Meniscal Evaluation Tool scores in the pre- and post-operative periods were computed.
| Results|| |
A total of 30 meniscal injuries in 28 knees were seen during this period. Five patients with injured menisci underwent arthroscopic meniscal repair during the study period, and they were all included in the study. All patients were male, and the most common cause of traumatic meniscal injury was sporting activities [n = 2 (40%)] and domestic activities [n = 2 (40%)]. The sporting activities related to the onset of pain were playing football in one case and playing basketball in the other case. Domestic activities related to the onset of pain were standing up from a squatting position while carrying a heavy object and descending a flight of stairs. The fifth case presented persistent knee pain from a knee injury following a road traffic injury. Four (80%) of the injuries were on the right knee, and only one (20%) was on the left. The medial meniscus was involved in four cases, with only one of the knees having a lateral meniscus tear. Joint line tenderness, a positive McMurray test and wasting were physical findings observed consistently in all the five cases, with locking present in only two cases (40%). The median time between injury and presentation was 10 months (range 66 months). These were all cases of chronic meniscal injuries, and they involved the red–white zone. All meniscal tears in the study were longitudinal tears. The locations of the lesions were as follows: 2 (40%) tears involved the body and anterior horn, two (40%) tears involved the body and posterior horn and one (20%) tear involved the body only. One of the two patients who had a longitudinal tear (bucket handle tear) involving the anterior horn and body also had a torn ACL; therefore, that patient underwent in addition an autograft anterior cruciate ligament reconstruction with semitendinosus tendon. The median duration of follow-up was 14 months (range 8–30 months). Using Barret’s criteria, we determined that a clinically healed meniscus was obtained in only 2 (40%) patients. The WOMET score improved from a mean of 46 (±18) to 20 (±10.7) between the pre- and post-operative periods, and the mean VAS score decreased from 4.6 to 2.5. Four patients (80 %) could resume their pre-injury levels of activities.
| Discussion|| |
Arthroscopic meniscal repair has been advocated over meniscectomy due to the long-term adverse effects of meniscectomy on the articular cartilage and joint function. The cases in our series were all traumatic meniscal injuries resulting from sporting and domestic activities. The knee injury relating to sporting activities occurred while playing football in two cases. The domestic activities relating to the knee injury occurred while trying to lift up a heavy object from the squatting position in one case and following a missed step while descending a flight of stairs in the second case. The fifth case of meniscal tear was from a knee injury following a road traffic accident. Joint line tenderness and a positive McMurray sign were consistently positive in all cases. These diagnostic tests have been observed to be have a strong positive predictive value in diagnosing meniscal injuries. The involvement of the medial meniscus in 4 (80%) of the cases in our series is related to the fact the medial meniscus is less mobile than the lateral meniscus during knee movements, and hence, it is unable to escape an unusual loading of the knee joint during physiologic knee motions. The poor health-seeking behaviour in our environment would explain the delayed presentations and, thus, the chronicity. Previous research has shown that acute meniscal tears have a better healing potential than chronic tears. However, it has also been established on MRI-arthrography that chronic tears do heal as well, although with a higher rate of partial healing as compared to the acute tears. Similar findings have also been noted in patients who had a second-look arthroscopy following a meniscal repair.
However, a second-look arthroscopy represents an invasive method of evaluating outcome of meniscal repair as compared to a Computerized Tomography (CT)- or MRI-arthrography. A second-look arthroscopy is also considered a more subjective way of assessing outcome when compared to arthrography. A long wait between injury to the meniscus and repair of the meniscus has been correlated with a worse outcome of repair. The chronicity of the tears in our series may have contributed to the lower-than-average healing rate observed in our study.
Although outside-in arthroscopic meniscal repair technique has been reported to place adjacent neurovascular structures at a greater risk of injury, it remains at the moment our method of choice of meniscal repair because of the challenges faced with equipment and funding of health care in our environment. The other forms of arthroscopic-assisted repair that have been described are the all-inside technique and the inside-out repair. The all-inside repair has the benefit of smaller incisions and a reduced risk of neurovascular injury. It, however, is costlier than the other two techniques. The outside-in technique has been noted to be useful for tears in the anterior or body of the medial or lateral meniscus with the advantage of avoidance of placing the neurovascular structures at risk. The outside-in technique allows the knot to be tied outside the joint [Figure 3], which reduces the risk of the knots getting in the way of the articular surfaces of the knee joint. This was our technique in all the cases in our series with trephination of the meniscus to improve the chances of healing. The difficulty we had with this technique, as was also documented by other authors, was the problem of placing sutures vertically for tears adjacent to the site of attachment of the posterior horn. In this region, the risk of neurovascular injuries or cartilage damage increases.
There was an improvement in the mean WOMET and visual analogue pain ratings in this series, which implies an improvement in clinical symptoms. However, using Barret’s criteria, we determined that we had a healing rate of 40% (2) in our series. The 40% healing rate was low compared with that in the series by Morgan and Casscells who evaluated 74 outside-in meniscal repairs with second-look arthroscopy. Sixty-five percent of the repairs in his series healed completely, 16% completely failed and 19% had incomplete healing. Ninety-two percent of the failures were noted to have involved the posterior medial meniscus. The two cases that healed satisfactorily in our series were tears in the anterior horn and body of the meniscus, one of which also had a concurrent ACL reconstruction with the repair. The repair of the meniscus has been shown to be more successful when performed in conjunction with an anterior cruciate ligament reconstruction compared with when performed with no anterior cruciate ligament reconstruction. This is because growth factors are released from the marrow during drilling for the reconstruction and the reconstructed anterior cruciate ligament offers stability to the knee. Our method of enhancing meniscal healing is by trephination, which enables fibrovascular scar proliferation in the damaged meniscal section. Other methods that have been described to enhance healing after meniscal repair include the use of fibrin clot injection to promote healing by haematoma chemotactic factors and synovial abrasions that activate chemotactic factors for healing., The complications observed in our study were recurrent knee pain in two cases, recurrent knee effusion in one and paraesthesia around the knee in another. The limitations we noted in our study include the low number of patients and the lack of a control group. In addition, clinical evaluation alone was used to determine the success rate in our study, and there was no objective measurement such as second-look arthroscopy or post-operative MRI examination to evaluate the adequacy of the healing of the repaired meniscus.
| Conclusion|| |
The outside-in technique of meniscal repair remains an option of treatment for chronic tears with good clinical improvement in the short term.
The authors acknowledge the staff of the physiotherapy department for their contribution in the rehabilitation of the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fithian DC, Kelly MA, Mow VC. Material properties and structure-function relationships in the menisci. Clin Orthop Relat Res 1990;19-31.
Hollis JM, Pearsal AW, Niciforos PG. Change in meniscal strain with anterior cruciate ligament injury and after reconstruction. Am J sports Med 2000;28:700-4.
Xu C, Zhao J. A meta-analysis comparing meniscal repair with meniscectomy in the treatment of meniscal tears; the more meniscus, the better outcome. Knee Surg Sports Traumatol Arthrosc 2010;23:164-70.
Salata MJ, Gibbs AE, Sekiya JK. A systematic review of clinical outcomes in patients undergoing meniscectomy. Am J Sports Med 2010;38:1907-16.
McDermott ID, Amis AA. The consequences of meniscectomy. Bone Jt J 2006;88:1549-55.
Lee BS, Kim JM, Sohn DW, Bin SI. Review of meniscal allograft transplantation focusing on long term results and evaluation methods. Knee Surg Relat Res 2013;25:1-6.
Barrett GR, Field MH, Treacy SH, Ruff CG. Clinical results of meniscus repair in patients 40 years and older. Arthroscopy 1998;14:824-9.
Rockborn P, Messner K. Long-term results of meniscus repair and meniscectomy: 13 year functional and radiographic follow-up study. Knee Surg Sports Traumatol Arthrosc 2000;8:2-10.
Yan R, Wang H, Yang Z, Ji ZH, Guo YM. Predicted probability of meniscus tears: Comparing history and physical examination with MRI. Swiss Med Wkly 2011;141:w13314.
Abdulraheem IS. Health needs assessment and determinants of health seeking behavior among elderly Nigerians: A household survey. Ann Afr Med 2007;6:58-63.
] [Full text]
Shelbourne KD, Carr DR. Meniscal repair compared with meniscectomy for bucket handle medial meniscal tears in anterior cruciate ligament reconstructed knees. Am J Sports Med 2003;31:718-23.
Popescu D, Sastre S, Garcia AI, Tomas X, Reategui D, Caballero M. MR-arthrography assessment after repair of chronic meniscal tears. Knee Surg Sports Traumatol Arthrosc 2015;23:171-7.
Seo HS, Lee SC, Jung KA. Second-look arthroscopic findings after repairs of posterior root tears of the medial meniscus. Am J Sports Med 2011;39:99-107.
Pujol N, Panarella L, Si Selmi TA. Meniscal healing after meniscal trepair. A CT arthrography assessment. Am J Sports Med 2008;36:1489-95.
Rodeo SA. Arthroscopic meniscal repair with use of the outside-in technique. Instr Course Lect 2000;49:195-206.
Barber FA, McGarry JE. Meniscal repair techniques. Sports Med Arthrosc 2007;15:199-207.
Gill SS, Diduch DR. Outcomes after meniscal repair using the meniscus arrow in knees undergoing concurrent anterior cruciate ligament reconstruction. Arthroscopy 2002;18:569-77.
Morgan C, Casscells S. Arthroscopic meniscus repair: A safe approach to the posterior horns. Arthroscopy 1986;2:3-12.
de Girolamo L, Galliera E, Volpi P. Why menisci show higher healing rate when repaired during ACL reconstruction? Growth factors release can be an explanation. Knee Surg Sports Traumatol Arthrosc 2015;23:90-6.
Fox JM, Rintz KG, Ferkel RD. Trephination of incomplete meniscal tears. Arthroscopy 1993;9:451-5.
Ochi M, Uchio Y, Okuda K. Expression of cytokines after meniscal rasping to promote meniscal healing. Arthroscopy 2001;17:724-31.
Ra HJ, Ha JK, Jang SH, Lee DW, Kim JG. Arthroscopic inside-out repair of complete radial tears of the meniscus with a fibrin clot. Knee Surg Sports Traumatol Arthrosc 2012;12:2191-3.
[Figure 1], [Figure 2], [Figure 3]