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Meniscus Tear Management: Indications, Technique, and Outcomes
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Meniscus Tear Management: Indications, Technique, and Outcomes Mario Hevesi, M.D., Aaron J. Krych, M.D., and Peter R. Kurzweil, M.D.
Abstract: Meniscus tears are commonly encountered in the clinical and operative setting and vary in presentation, including bucket-handle, radial, and horizontal cleavage tears. Historically, tears were treated with benign neglect or partial meniscectomy. However, a great deal of subsequent research has highlighted the biomechanical consequences of tears and meniscectomy, including increased peak local contact forces, progressive postmeniscectomy arthritis, and subsequent arthroplasty. With the advent and evolution of repair devices, increasing attention is being turned to the ideal restorative treatment of meniscus tears. Successful meniscus repair is centered about the ABCs of repair: Anatomic reduction, Biologic preparation and augmentation, and Circumferential compression. Recent advances in repair techniques have included microfracture of the intercondylar notch to provide healing factors and marrow cells for augmented healing, all-inside suture devices enabling the reduction and fixation tears without the need for additional assistants and the morbidity of inside-out exposure, and circumferential compression combined with clot augmentation to reduce and fix horizontal cleavage tears and recreate biomechanics to within 15% of baseline contact forces. Clinical outcomes of meniscus repair using modern techniques have been promising, with reapproximation of native joint biomechanics, substantial improvements in patient subjective outcome scores, and satisfactory reoperation rates. With implementation of the ABCs of meniscus repair as well as the continued expansion of the orthopedic surgeons’ meniscus repair toolbox, restoration and preservation of the meniscus are increasingly possible across the spectrum of tear types.
Bibliography Beamer BS, Walley KC, Okajima S, et al. Changes in contact area in meniscus horizontal cleavage tears subjected to repair and resection. Arthroscopy 2017;33:617-624. Bedi A, Kelly N, Baad M, et al. Dynamic contact mechanics of radial tears of the lateral meniscus: Implications for treatment. Arthroscopy 2012;28:372-381. Dean CS, Chahla J, Matheny LM, Mitchell JJ, LaPrade RF. Outcomes after biologically augmented isolated meniscal repair with marrow venting are comparable with those after meniscal repair with concomitant anterior cruciate ligament reconstruction. Am J Sports Med 2017;45:1341-1348.
From the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A. (M.H., A.J.K.); and Memorial Orthopaedic Surgical Group, Long Beach, California, U.S.A. (P.R.K.). The authors report the following potential conflicts of interest or sources of funding: M.H. has nothing to disclose. A.J.K. reports personal fees from Arthrex, personal fees from Vericel, and personal fees from JRF Ortho outside the submitted work. P.R.K. reports research support from NuSurface, stock or stock options from Parcus Medical, and personal fees and research support from Smith & Nephew outside the submitted work. Full ICMJE author
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Kamimura T, Kimura M. Meniscal repair of degenerative horizontal cleavage tears using fibrin clots: Clinical and arthroscopic outcomes in 10 cases. Orthop J Sports Med 2014;2:2325967114555678. Kurzweil PR. Treatment of horizontal cleavage tears e Resection to repair. Oper Techniques Sports Med 2018;26:271-278. Kurzweil PR, Cannon WD, DeHaven KE. Meniscus repair and replacement. Sports Med Arthrosc Rev 2018;26:160-164. Kurzweil PR, Lynch NM, Coleman S, Kearney B. Repair of horizontal meniscus tears: A systematic review. Arthroscopy 2014;30:1513-1519.
disclosure forms are available for this article online, as supplementary material. Received July 16, 2019; accepted July 16, 2019. Address correspondence to Peter R. Kurzweil, M.D., Memorial Orthopaedic Surgical Group, 2760 Atlantic Avenue, Long Beach, CA 90806, U.S.A. E-mail: [email protected] Ó 2019 by the Arthroscopy Association of North America 0749-8063/19896/$36.00 https://doi.org/10.1016/j.arthro.2019.07.013
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 9 (September), 2019: pp 2542-2544
INFOGRAPHIC
Samuelsen BT, Johnson NR, Hevesi M, et al. Comparative outcomes of all-inside versus inside-out repair of bucket-handle meniscal tears: A propensity-matched analysis. Orthop J Sports Med 2018;6:232596 7118779045. Shakespeare DT, Rigby HS. The bucket-handle tear of the meniscus. A clinical and arthrographic study. J Bone Joint Surg Br 1983;65:383-387. Wasserstein D, Dwyer T, Gandhi R, Austin PC, Mahomed N, Ogilvie-Harris D. A matched-cohort population study of reoperation after meniscal repair with and
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without concomitant anterior cruciate ligament reconstruction. Am J Sports Med 2013;41:349-355. Wu IT, Hevesi M, Desai VS, et al. Comparative outcomes of radial and bucket-handle meniscal tear repair: A propensity-matched analysis. Am J Sports Med 2018;46:2653-2660. Woodmass JM, Johnson JD, Wu IT, Saris DBF, Stuart MJ, Krych AJ. Horizontal cleavage meniscus tear treated with all-inside circumferential compression stitches. Arthrosc Techniques 2017;6:e1329e1333.
Meniscus Tear Management: Indications, Technique, and Outcomes Mario Hevesi, M.D., Aaron J. Krych, M.D., and Peter R. Kurzweil, M.D.
Abstract: Meniscus tears are commonly encountered in the clinical and operative setting and vary in presentation, including bucket-handle, radial, and horizontal cleavage tears. Historically, tears were treated with benign neglect or partial meniscectomy. However, a great deal of subsequent research has highlighted the biomechanical consequences of tears and meniscectomy, including increased peak local contact forces, progressive postmeniscectomy arthritis, and subsequent arthroplasty. With the advent and evolution of repair devices, increasing attention is being turned to the ideal restorative treatment of meniscus tears. Successful meniscus repair is centered about the ABCs of repair: Anatomic reduction, Biologic preparation and augmentation, and Circumferential compression. Recent advances in repair techniques have included microfracture of the intercondylar notch to provide healing factors and marrow cells for augmented healing, all-inside suture devices enabling the reduction and fixation tears without the need for additional assistants and the morbidity of inside-out exposure, and circumferential compression combined with clot augmentation to reduce and fix horizontal cleavage tears and recreate biomechanics to within 15% of baseline contact forces. Clinical outcomes of meniscus repair using modern techniques have been promising, with reapproximation of native joint biomechanics, substantial improvements in patient subjective outcome scores, and satisfactory reoperation rates. With implementation of the ABCs of meniscus repair as well as the continued expansion of the orthopedic surgeons’ meniscus repair toolbox, restoration and preservation of the meniscus are increasingly possible across the spectrum of tear types.
Bibliography Beamer BS, Walley KC, Okajima S, et al. Changes in contact area in meniscus horizontal cleavage tears subjected to repair and resection. Arthroscopy 2017;33:617-624. Bedi A, Kelly N, Baad M, et al. Dynamic contact mechanics of radial tears of the lateral meniscus: Implications for treatment. Arthroscopy 2012;28:372-381. Dean CS, Chahla J, Matheny LM, Mitchell JJ, LaPrade RF. Outcomes after biologically augmented isolated meniscal repair with marrow venting are comparable with those after meniscal repair with concomitant anterior cruciate ligament reconstruction. Am J Sports Med 2017;45:1341-1348.
From the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A. (M.H., A.J.K.); and Memorial Orthopaedic Surgical Group, Long Beach, California, U.S.A. (P.R.K.). The authors report the following potential conflicts of interest or sources of funding: M.H. has nothing to disclose. A.J.K. reports personal fees from Arthrex, personal fees from Vericel, and personal fees from JRF Ortho outside the submitted work. P.R.K. reports research support from NuSurface, stock or stock options from Parcus Medical, and personal fees and research support from Smith & Nephew outside the submitted work. Full ICMJE author
2542
Kamimura T, Kimura M. Meniscal repair of degenerative horizontal cleavage tears using fibrin clots: Clinical and arthroscopic outcomes in 10 cases. Orthop J Sports Med 2014;2:2325967114555678. Kurzweil PR. Treatment of horizontal cleavage tears e Resection to repair. Oper Techniques Sports Med 2018;26:271-278. Kurzweil PR, Cannon WD, DeHaven KE. Meniscus repair and replacement. Sports Med Arthrosc Rev 2018;26:160-164. Kurzweil PR, Lynch NM, Coleman S, Kearney B. Repair of horizontal meniscus tears: A systematic review. Arthroscopy 2014;30:1513-1519.
disclosure forms are available for this article online, as supplementary material. Received July 16, 2019; accepted July 16, 2019. Address correspondence to Peter R. Kurzweil, M.D., Memorial Orthopaedic Surgical Group, 2760 Atlantic Avenue, Long Beach, CA 90806, U.S.A. E-mail: [email protected] Ó 2019 by the Arthroscopy Association of North America 0749-8063/19896/$36.00 https://doi.org/10.1016/j.arthro.2019.07.013
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 9 (September), 2019: pp 2542-2544
INFOGRAPHIC
Samuelsen BT, Johnson NR, Hevesi M, et al. Comparative outcomes of all-inside versus inside-out repair of bucket-handle meniscal tears: A propensity-matched analysis. Orthop J Sports Med 2018;6:232596 7118779045. Shakespeare DT, Rigby HS. The bucket-handle tear of the meniscus. A clinical and arthrographic study. J Bone Joint Surg Br 1983;65:383-387. Wasserstein D, Dwyer T, Gandhi R, Austin PC, Mahomed N, Ogilvie-Harris D. A matched-cohort population study of reoperation after meniscal repair with and
2543
without concomitant anterior cruciate ligament reconstruction. Am J Sports Med 2013;41:349-355. Wu IT, Hevesi M, Desai VS, et al. Comparative outcomes of radial and bucket-handle meniscal tear repair: A propensity-matched analysis. Am J Sports Med 2018;46:2653-2660. Woodmass JM, Johnson JD, Wu IT, Saris DBF, Stuart MJ, Krych AJ. Horizontal cleavage meniscus tear treated with all-inside circumferential compression stitches. Arthrosc Techniques 2017;6:e1329e1333.