Time for a paradigm change in meniscal repair: save the meniscus!

One of the most important clinical achievements highlighted at the third international meeting “The Meniscus: Preserve the future”, held in Porto in early February this year [9], was the improvement made in the field of meniscal repair. The loss of the meniscus can be regarded as a pre-arthritic condition for the knee due to the loss of protective function [2, 3]. However, the tear pattern has a crucial impact on that risk, and it became obvious that the differentiation of tear types and repair techniques has resulted in significant progress over the last few years.

In 2016, numerous advanced techniques for meniscal repair are being performed, regardless of the site of the tear [4, 26]. There is no place in the knee that cannot be reached by the arthroscope. However, some of the repair techniques are in the early stages of development and require further improvement to reach global acceptance [24]. They appear very promising, as many surgeons have adopted them in a short period of time.

Meniscus repair is gaining in popularity among an increasing number of surgeons. A better understanding, more sophisticated devices for meniscus repair and the increasing success rate might be some of the explanations. The increasing popularity of meniscus repair also includes meniscus lesions, which are associated with anterior cruciate ligament (ACL) injuries. At several European centres, meniscal repair procedures are now being performed in up to 40–60 % of all ACL reconstructions. In addition, these repairs are being extended increasingly to an athletic population and even professional athletes and football players. The medial meniscus in particular is becoming the focus of attention. As the main secondary stabiliser in anteroposterior laxity after an ACL injury, it is well known that this structure plays an important role in the long-term development of osteoarthritis and, as shown recently by Robb et al. [21], its absence negatively affects the fate of ACL graft survival. These are the reasons why efforts have recently been made to increase our understanding of medial meniscus tears [27], to rediscover certain types of injury like the meniscosynovial or ramp lesions [1, 5, 8, 19, 23, 25] and to improve long-existing repair techniques [15, 20].

Another new development in meniscal repair relates to root tears, which have moved into focus over the last 5–10 years [6, 7, 1113]. Unknown a decade ago, they are attracting extraordinary attention nowadays, from both a clinical and a research perspective. Lateral meniscus root tears frequently occur in conjunction with ACL injuries. For this reason, much more attention may be paid to the posterior horn of the lateral meniscus during ACL reconstructions nowadays [7]. Root tears at the posterior horn of the medial meniscus are also detrimental. Although they may occur in younger individuals after an acute trauma, the majority of them can be observed after a minor event in patients over the age of 50 and particularly in women. The first meta-analyses show that the clinical results improved after surgery and the progression of osteoarthritis could be prevented in the short term in the majority of patients. Perfect results with complete healing and the reduction in meniscal extrusion were observed in about 60 % of patients [7]. This is undoubtedly lower than what can be expected after meniscal repair in younger patients, but, given the age of the patients and the limited options for biological treatment alternatives, these results may be superior to what can be expected as a result of salvage procedures [14]. In addition to this, two recent studies found an association between medial meniscus root tears and spontaneous aseptic osteonecrosis of the medial femoral condyle [22, 28]. Although the causal effect and the deeper understanding of this association still need to be proven, the occurrence of a sudden biomechanical change in the medial tibiofemoral compartment induced by a posterior meniscal root tear may explain the currently most recognised cause of spontaneous osteonecrosis in elderly patients, which is not osteoporosis [16] but an insufficiency fracture [29]. This would further increase the evidence indicating that spontaneous osteonecrosis of the medial femoral condyle is not induced by arthroscopy [17, 18].

When we were trained as residents in our late 20s and early 30s, meniscal repair was only recommended for patients of our age at that time or younger. Twenty years later, general recommendations for repair extend to patients in their 50s—so still of our age, provided that the type of lesion and the patients’ biological healing potential appear adequate. Although we feel blessed to live in such a lucky period of rapid medical and surgical progress, it is obvious that our scientific community needs stronger evidence to support this trend fully. As not all the drawbacks of these advanced repair techniques may have been reported and as medical evidence is lacking in relation to surgical innovation, it is reasonable to suppose that the spectrum of indications for meniscal repair may have to be revisited in a couple of years. At the same time, improvement of surgical techniques, coupled with a high-quality education, will help us to realise the goal of joint preservation. The aim is to bring an increasing number of patients up to an age from which their life expectancy [10] matches the longevity of joint replacement (Fig. 1) [10].

Fig. 1
figure1

Chart representing disease progression and treatment invasiveness in the long term after knee injury and subsequent degeneration. The goal of meniscal repair and joint preservation techniques should be to bring the patient to an age at which the longevity of knee arthroplasty matches life expectancy

References

  1. 1.

    Ahn JH, Wang JH, Yoo JC (2004) Arthroscopic all-inside suture repair of medial meniscus lesion in anterior cruciate ligament-deficient knees: results of second-look arthroscopies in 39 cases. Arthroscopy 20:936–945

    Article  PubMed  Google Scholar 

  2. 2.

    Badlani JT, Borrero C, Golla S, Harner CD, Irrgang JJ (2013) The effects of meniscus injury on the development of knee osteoarthritis: data from the osteoarthritis initiative. Am J Sports Med 41:1238–1244

    Article  PubMed  Google Scholar 

  3. 3.

    Becker R, Berth A, Nehring M, Awiszus F (2004) Neuromuscular quadriceps dysfunction prior to osteoarthritis of the knee. J Orthop Res 22:768–773

    Article  PubMed  Google Scholar 

  4. 4.

    Bhatia S, Civitarese DM, Turnbull TL, LaPrade CM, Nitri M, Wijdicks CA, LaPrade RF (2016) A novel repair method for radial tears of the medial meniscus: biomechanical comparison of transtibial 2-tunnel and double horizontal mattress suture techniques under cyclic loading. Am J Sports Med. 44:639–645

    Article  PubMed  Google Scholar 

  5. 5.

    Bollen SR (2010) Posteromedial meniscocapsular injury associated with rupture of the anterior cruciate ligament: a previously unrecognised association. J Bone Joint Surg B 92:222–223

    CAS  Article  Google Scholar 

  6. 6.

    Chung KS, Ha JK, Ra HJ, Kim JG (2015) A meta-analysis of clinical and radiographic outcomes of posterior horn medial meniscus root repairs. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3832-0

  7. 7.

    Feucht MJ, Kühle J, Bode G, Mehl J, Schmal H, Südkamp NP, Niemeyer P (2015) Arthroscopic transtibial pullout repair for posterior medial meniscus root tears: a systematic review of clinical. Radiogr Second Look Arthrosc Results Arthrosc 31:1808–1816

    Article  Google Scholar 

  8. 8.

    Hamberg P, Gillquist J, Lysholm J (1983) Suture of new and old peripheral meniscus tears. J Bone Joint Surg Am 65:193–197

    CAS  PubMed  Google Scholar 

  9. 9.

    http://www.the-meniscus.org

  10. 10.

    http://www.who.int/gho/mortality_burden_disease/life_tables/en/

  11. 11.

    LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF (2015) Meniscal root tears: a classification system based on tear morphology. Am J Sports Med 43:363–369

    Article  PubMed  Google Scholar 

  12. 12.

    LaPrade CM, Foad A, Smith SD, Turnbull TL, Dornan GJ, Engebretsen L, Wijdicks CA, LaPrade RF (2015) Biomechanical consequences of a nonanatomic posterior medial meniscal root repair. Am J Sports Med 43:912–920

    Article  PubMed  Google Scholar 

  13. 13.

    LaPrade RF, LaPrade CM, Ellman MB, Turnbull TL, Cerminara AJ, Wijdicks CA (2015) Cyclic displacement after meniscal root repair fixation: a human biomechanical evaluation. Am J Sports Med 43:892–898

    Article  PubMed  Google Scholar 

  14. 14.

    Lubowitz JH (2015) Editorial commentary: meniscal root avulsion repair outcomes are at the level of a salvage procedure. Arthroscopy 31:1817–1818

    Article  PubMed  Google Scholar 

  15. 15.

    Morgan CD (1991) The ‘‘all-inside’’ meniscus repair. Arthroscopy 7:120–125

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Nelson FR, Craig J, Francois H, Azuh O, Oyetakin-White P, King B (2014) Subchondral insufficiency fractures and spontaneous osteonecrosis of the knee may not be related to osteoporosis. Arch Osteoporos 9:194

    Article  PubMed  Google Scholar 

  17. 17.

    Pape D, Seil R, Fritsch E, Rupp S, Kohn D (2002) Prevalence of spontaneous osteonecrosis of the medial femoral condyle in elderly patients. Knee Surg Sports Traumatol Arthrosc 10:233–240

    Article  PubMed  Google Scholar 

  18. 18.

    Pape D, Seil R, Anagnostakos K, Kohn D (2007) Postarthroscopic osteonecrosis of the knee. Arthroscopy 23:428–438

    Article  PubMed  Google Scholar 

  19. 19.

    Peltier A, Lording TD, Lustig S, Servien E, Maubisson L, Neyret P (2015) Posteromedial meniscal tears may be missed during anterior cruciate ligament reconstruction. Arthroscopy 31:691–698

    Article  PubMed  Google Scholar 

  20. 20.

    Piontek T, Ciemniewska-Gorzela K, Szulc A, Słomczykowski M, Jakob R (2012) All-arthroscopic technique of biological meniscal tear therapy with collagen matrix. Pol Orthop Traumatol 77:39–45

    PubMed  Google Scholar 

  21. 21.

    Robb C, Kempshall P, Getgood A, Standell H, Sprowson A, Thompson P, Spalding T (2015) Meniscal integrity predicts laxity of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23:3683–3690

    Article  PubMed  Google Scholar 

  22. 22.

    Robertson DD, Armfield DR, Towers JD, Irrgang JJ, Maloney WJ, Harner CD (2009) Meniscal root injury and spontaneous osteonecrosis of the knee: an observation. J Bone Joint Surg Br 91:190–195

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Seil R, VanGiffen N, Pape D (2009) Thirty years of arthroscopic meniscal repair: what’s left to be done? Orthop Traumatol Surg Res 95S:S85–S96

    Article  Google Scholar 

  24. 24.

    Seil R, Van Heerwaarden R, Lobenhoffer P, Kohn D (2013) The rapid evolution of knee osteotomies. Knee Surg Sports Traumatol Arthrosc 21:1–2

    Article  PubMed  Google Scholar 

  25. 25.

    Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX, Seil R (2014) Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic exploration of the concealed portion of the knee. Am J Sports Med 42:921–926

    Article  PubMed  Google Scholar 

  26. 26.

    Stärke C, Kopf S, Petersen W, Becker R (2009) Meniscal repair. Arthroscopy 25:1033–1044

    Article  PubMed  Google Scholar 

  27. 27.

    Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, Amis AA (2016) Posteromedial meniscocapsular lesions increase tibiofemoral joint laxity with anterior cruciate ligament deficiency, and their repair reduces laxity. Am J Sports Med 44:400–408

    Article  PubMed  Google Scholar 

  28. 28.

    Sung JH, Ha JK, Lee DW, Seo WY, Kim JG (2013) Meniscal extrusion and spontaneous osteonecrosis with root tear of medial meniscus: comparison with horizontal tear. Arthroscopy 29:726–732

    Article  PubMed  Google Scholar 

  29. 29.

    Yamamoto T, Bullough PG (2000) Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg Am 82:858–866

    CAS  Article  PubMed  Google Scholar 

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Seil, R., Becker, R. Time for a paradigm change in meniscal repair: save the meniscus!. Knee Surg Sports Traumatol Arthrosc 24, 1421–1423 (2016). https://doi.org/10.1007/s00167-016-4127-9

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