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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 32  |  Issue : 1  |  Page : 49-58

Evaluation of the results of arthroscopic meniscal repair


1 Department of Orthopaedic Surgery, Faculty of Medicine, Benha University, Benha, Egypt
2 Student Hospital, Mansoura University, Mansoura, Egypt

Date of Submission25-May-2015
Date of Acceptance30-May-2015
Date of Web Publication26-Nov-2015

Correspondence Address:
Mahmoud M El-Sherbiny
Student Hospital, 60 Elgalaa st, in front of Faculty of Education, Mansoura University, Mansoura, 35516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-208X.170559

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  Abstract 

Introduction
Menisci have a role in optimal knee function. Meniscal preservation in younger active individuals presenting with symptomatic meniscal disease is important. The success of meniscal repair depends on appropriate meniscal bed preparation and the surgical technique.
Patients and methods
A prospective study of 20 cases of post-traumatic meniscal tear was conducted during the period between March 2012 and December 2013. All cases were subjected to arthroscopic evaluation to confirm the diagnosis and ensure they fulfilled the criteria for repair on the basis of site, size, description, and associated injury of the tear. The inclusion criteria were vertical longitudinal tear from 1 to 3 cm in length in the red-red or red-white zone. The exclusion criteria were patient age older than 45 years, white-white zone tear, radial tear, and complex degenerative meniscal tear. The Lysholm score and International Knee Documentation Committee (IKDC) subjective and objective knee scores were used preoperatively and postoperatively for presentation of overall results. All cases were treated by means of the all-inside arthroscopic repair technique using a FasT-Fix meniscal repair device.
Results
Twenty patients were followed up for an average of 60 weeks. The mean age of the patients was 20.95 ± 1.60 years; the average suture used was 2.85; 70% had isolated meniscal injury, and 30% had associated anterior cruciate ligament (ACL) tear; the average tear length was 1.91 cm. The mean preoperative and postoperative Lysholm scores were 38.25 and 91.20, respectively. The mean preoperative and postoperative IKDC subjective evaluation results were 31.28 and 91.44, respectively. The preoperative IKDC objective evaluation results revealed 16 (80%) patients with severely abnormal knees (grade D) and four (20%) patients with abnormal knees (grade C). The postoperative IKDC objective evaluation results revealed two (10%) patients with abnormal knees (grade C), three (15%) patients with nearly normal knees (grade B), and 15 (75%) patients with normal knees (grade A). There is better improvement in scores if ACL reconstruction is performed simultaneously with meniscal repair, the procedure is performed for vertical longitudinal tears, the tear is in the 'red-red' zone, and the tear length is less than 21 mm. There were no differences in functional results on the basis of repair of medial meniscus or lateral meniscus, acute or chronic injuries, or age.
Conclusion
Better outcome of meniscal repair was seen in patients with vertical longitudinal tear in the red-red zone with a tear length of less than 21 mm and associated with ACL reconstruction.

Keywords: FasT-Fix, meniscus tear, meniscus repair


How to cite this article:
ElSayed MM, Alhusseiny AM, Montaser MG, El-Sherbiny MM. Evaluation of the results of arthroscopic meniscal repair. Benha Med J 2015;32:49-58

How to cite this URL:
ElSayed MM, Alhusseiny AM, Montaser MG, El-Sherbiny MM. Evaluation of the results of arthroscopic meniscal repair. Benha Med J [serial online] 2015 [cited 2017 Nov 18];32:49-58. Available from: http://www.bmfj.eg.net/text.asp?2015/32/1/49/170559


  Introduction Top


The menisci are important for optimal knee function as they play an essential biomechanical and structural role in joint load-bearing distribution, stability, congruence, articular cartilage homeostasis, and proprioception. Meniscal preservation in young active individuals presenting with symptomatic meniscal disease is important [1] . The decision of the type of treatment must be taken by considering the tear pattern, site, vascularity, size, stability, patient's age, tissue quality, and associated pathology within the knee joint and the patient's goals [2] . Current options for meniscus injury include nonoperative treatment, meniscectomy, repair, and transplantation [3] .

Techniques for meniscal repairs include open or arthroscopic techniques; arthroscopic techniques include inside-out repairs, outside-in repairs and all-inside repairs [2] .

The success of meniscal repair depends on appropriate meniscal bed preparation and surgical technique and is also influenced by biologic factors such as tear rim width and associated ligamentous injury [4] .

Inside-out repair may also be associated with an increased risk for neurovascular injury, increased surgical time, and postoperative pain, as well as needle-stick injury to the surgical team. For these reasons, all-inside repair has become the preferred technique among many orthopedic surgeons [5] .

The aim of this prospective study was to evaluate the clinical outcome of arthroscopic meniscal repair in the knee.


  Patients and methods Top


Between March 2012 and December 2013, 20 patients with meniscal injuries were subjected to arthroscopic evaluation to confirm the diagnosis and ensure they fulfilled the inclusion criteria needed for repair, based on site, size, description, and associated injury of the tear.

The inclusion criteria were symptomatic meniscal tear, patient age less than 45 years, vertical longitudinal tear, tear length 1-3 cm, tear location in the red-red or red-white zone, tear reducible at the time of arthroscopy, and adequate tear site apposition.

The exclusion criteria were patient age greater than 45 years, tear location in the white-white zone, radial tear, and complex degenerative meniscal tear.

Preoperative evaluation

Patients underwent a careful evaluation of their history and data pertaining to age, mode of trauma, duration, symptoms, and disabilities were recorded.

All patients underwent full clinical examination of their knee, including meniscal tests (joint-line tenderness, McMurray test, Apley grind test, Boehler test, Thessaly test, Childress test, Finochietto test, Steinman's first test, and Steinman's second test) and tests to exclude related conditions - namely, anterior cruciate ligament (ACL) tests (anterior drawer test, Lachman test, lateral pivot shift test of Maclntosh), tests for posterior cruciate ligament (PCL) injuries (posterior sag sign, posterior drawer quadriceps active test, Dial test), knee effusion tests (patellar ballottement test, fluid displacement test), collateral ligament test (varus and valgus stress tests, and examination of the upper and lower attachments of the collateral ligaments, in which bruises, swelling, and tenderness denoted collateral ligament injuries), Slocum test (anteromedial and anterolateral drawer tests of Slocum and Larson), Hughston tests (posterolateral and posteromedial drawer tests), and chondromalacia patella tests (patellar compression against the femoral surface, direct patellar articular surface palpation after its medial displacement). The uninvolved leg was used as reference for comparison with the involved leg.

Plain radiographs in different views (anteroposterior, lateral, tunnel, merchant view) were taken to exclude other pathologies. MRI was used in this study, as it is the most informative diagnostic tool for delineation of different knee problems. Sagittal and coronal MRI can provide information on tear size, configuration, displacement, and location. Chondral injury, ligament injuries, and other pathologies can be seen and accounted for.

Procedure

The all-inside technique with the FasT-Fix device with or without ACL reconstruction was used for the meniscal repair. Each FasT-Fix device contains two 5-mm polymer suture bar anchors with a pretied self-sliding knot of no. 0 nonabsorbable United States Pharmacopia (USP) braided polyester suture material. FasT-Fix devices are provided with a curved 17-G needle of 22°, which is associated with a FasT-Fix split plastic cannula for easier introduction of the device into the knee joint, as well as with a depth limiter, meniscal rasp, and FasT-Fix knot pusher-suture cutter ([Figure 1]a).
Figure 1 (a) FasT-Fix meniscal repair device, shaver, and vaper. (b) Vertical longitudinal tear (VLT). (c) Rasping by means of a shaver. (d) Plastic tube positioning. (e) Second suture insertion during repair. (f) Tensioning. (g, h) After repair using a FasT-Fix device.



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The decision of general or spinal anesthesia, based on the patient's, anesthesiologist's, and surgeon's preferences, is taken preoperatively.

After diagnostic arthroscopy, the morphology of the meniscus tear was determined ([Figure 1]b). The tear length and rim width are defined, and the tear is prepared by removing any unhealthy tissue at the edges of the tear; a healing response is encouraged by means of a rasping or motorized shaver ([Figure 1]c). In case of a dislocated bucket-handle tear, reduction was performed with a probe. The depth of the tear is measured and the white graduated depth sleeve is cut to length. When utilizing the split cannula, it is important to rotate the split cannula 90° so that the tip of the needle faces away from the slot in the cannula ([Figure 1]d). The needle is inserted through the appropriate portal using the split plastic cannula to keep it from becoming attached to the soft tissue ([Figure 1]e).

Withdraw the split plastic cannula as much as required, or completely remove it. Reduce the meniscus tear with the needle and pass the needle through both parts of the meniscus and into the joint capsule. Withdraw the needle from the meniscus with a slight oscillating motion to release the first suture anchor into the capsule and soft tissue behind the meniscus. Tug the suture gently to test the fixation of this implant. Slide the gold trigger forward on the handle to advance the second anchor to the fully seated line at the distal needle tip. Reposition the needle 5 mm away from the first and insert it through the torn meniscal tissue again.

Withdraw the needle from the meniscus with a slight oscillating motion to release the second suture barn into the capsule and soft tissue behind the meniscus and then remove the delivery needle from the knee joint ([Figure 1]f). Pull the free end of the suture anchor firmly to remove any slack and partially tighten the repair. Thereafter, advance the single-lumen knot pusher to tighten the repair completely. Cut the suture and deploy additional devices until the repair is complete ([Figure 1]g and h).

If the patient had an ACL injury, arthroscopic reconstruction was conducted after the meniscus repair using a hamstring autograft with interference screw fixation.

Postoperative care

At the end of the procedure, a hemovac was used only in ACL reconstructed cases. A simple absorptive sterile dressing was applied to the skin, along with a compression bandage and a hinged knee brace. Monitoring of peripheral circulation, motor and sensory innervation, and cooling and elevation of the extremity were carried out. Dressings were kept clean and dry, and crutches were prescribed after surgery. All patients except those who underwent meniscal repair in conjunction with an ACL reconstruction were discharged the next day after receiving discharge instructions and prescriptions for pain medicines and antibiotics; patients who underwent meniscal repair in conjunction with an ACL reconstruction were discharged on the third day after removal of the drainage. Gentle range of motion (ROM) exercises should be initiated as soon as possible after surgery. The immobilizer/brace can be removed for exercises; otherwise, it should be left on at all times for optimal healing of the meniscal repair. Quadriceps sets and straight leg raises should be started the day after surgery and are designed to increase the strength of the knee. All patients were reviewed after 1 week for evaluation and dressing of surgical wounds. After 12-14 days stitches were removed and the patient was assessed for any warning signs (persistent or increased pain, significant swelling in the knee, increasing pain in the calf muscle, warmth and edema).

Postoperative rehabilitation

The postoperative physical therapy for a meniscus repair can be divided into early (immediate postoperative and early rehabilitation) and late rehabilitation phases (functional progression and return to sport or occupation) [6] .

The immediate postoperative phase

Immediate postoperative therapy starts after surgery and lasts ~1 month. It includes a postoperative hinged knee brace locked in full extension, a quadriceps set, ankle pumps, touch-down weight-bearing with crutches in extension (0°) during the first week, and partial weight-bearing during the next week (walking in extension in 0° and range of motion increased up to 0-30°). From 2 to 4 weeks the range of motion is increased to 0-60° and hamstring and calf stretching exercises are allowed. Full weight-bearing (FWB) with crutches and wall sits is allowed at 4-6 weeks and range of motion becomes 0-90°. At the end of these 6 weeks, the knee brace is discontinued.

Early rehabilitation phase (weeks 6-8)

The patient is instructed to perform FWB and wall sits, and starts to wean from the crutch and to move the knee in full active range of motion.

Functional progression (weeks 9-12)

The patient is instructed to use a stationary bike and a stair climber.

Return to activity (weeks 12-24)

The patient is instructed to use a stationary bike, perform squats, and climb stairs. Hop testing and double-limb and single-limb squatting were used to assess the patient before initiating a running program and before returning to sport.

If the meniscal repair is performed in conjunction with an ACL reconstruction, the usual ACL reconstruction protocol should be followed. This involves placing the knee in full extension immediately. Touch weight-bearing on crutches is continued for the first 6 weeks.

Follow-up evaluation

All patients were evaluated preoperatively and this was repeated postoperatively at 24 and 48 weeks by means of the modified Lysholm questionnaire [7] and the International Knee Documentation Committee (IKDC) [8] .

Statistical analysis

The collected data were revised, coded, tabulated, and entered into a PC using the SPSS software package (release 20.0.1; SPSS Inc., Chicago, Illinois, USA). Suitable analysis was carried out according to the type of data obtained for each parameter.

Descriptive statistics

Descriptive statistics were presented as mean ± SD, and minimum and maximum values (range) for numerical data and as frequency and percentage for non-numerical data.

Analytical statistics

The paired T-test was used to assess the statistical significance of the difference between two means in one group over time or before and after an event. Evaluations were made before and after the operation at 24 and 48 weeks.

Case presentation

Case 1

An 18-year-old male patient suffered a left knee-twisting injury during a football match 1 week before presentation. He noticed acute painful swelling of his knee, with marked difficulty and pain during FWB. Clinical examination revealed moderate knee swelling, locked knee at 20°, and moderate to severe tenderness over the lateral joint line. Meniscal tests and tests for instability were difficult to perform, as it was very painful. Plain radiograph revealed no abnormalities, whereas MRI showed grade III meniscal signal of flipped meniscus sign involving the posterior horn of the lateral meniscus (LM), with mild effusion ([Figure 2]). Arthroscopically a displaced bucket-handle tear of the LM was found at the red-red zone extending from the posterior horn to the body of the meniscus with a length of about 25 mm. After rasping and reduction of the displaced tear, the tear was repaired by all-inside technique using a FasT-Fix meniscal repair device with four sutures ([Figure 3]).
Figure 2 MRI of no. 3 showing bucket-handle tear of the lateral meniscus (flipped meniscus sign).




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Figure 3 Arthroscopic view of case no. 3. (a) Bucket handle tear (BHT). (b, c) Suture insertion during repair. (d) FasT-Fix knot pusher-suture cutter. (e) Postoperative MRI after 1 year showing complete healing of the tear. (f) T Fix device.



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He had a preoperative modified Lysholm score of 17 points (poor score) and a postoperative score of 90 points (good score). The preoperative IKDC subjective score was 26.43 (poor score) and the postoperative score was 90.80 (excellent score).

Case 2

A 19-year-old male patient suffered a right knee-twisting injury 1 week before presentation. He noticed acute painful swelling of his knee, with marked difficulty and pain during FWB. He also noticed that his knee was locked immediately after trauma and he presented to us with an acutely locked knee. Clinical examination revealed moderate knee swelling, locked knee at 20°, and moderate to severe tenderness over the lateral joint line. Meniscal tests and tests for instability were difficult to perform because of severe pain. Plain radiograph revealed no abnormalities, whereas MRI showed grade III meniscal signal of flipped meniscus sign involving the posterior horn of the LM, with mild effusion ([Figure 4]).
Figure 4 MRI of case no. 2 showing bucket-handle tear of the lateral meniscus (flipped meniscus sign).


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Arthroscopically a displaced bucket-handle tear of the LM was found at the red-red zone extending from the posterior horn to the body of the meniscus with a length of about 20 mm. Other structures were intact. After rasping and reduction of the displaced tear, the tear was repaired by the all-inside technique using a FasT-fix meniscal repair device with three sutures ([Figure 5]).
Figure 5 Arthroscopic view of case no. 2. (a) Bucket handle tear (BHT). (b, c) Suture insertion during repair. (d) Postoperative MRI after 1 year showing complete healing of the tear.



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He had a preoperative modified Lysholm mean score of 12 points (poor score) and a postoperative mean score of 95 (excellent score). The subjective mean preoperative IKDC score was 20.68 (poor score) and the mean postoperative score was 94.25 (excellent score).


  Results Top


This prospective study consisted of 20 patients, 19 (95%) male and one (5%) female; their ages at the time of surgery ranged from 19 to 25 years, with a mean of 20.95 ± 1.60 years. Six (30%) patients had right knee injuries, and 14 (70%) patients had left knee injuries. Sports-related accidents were the cause of injury in 13 (65%) patients, road traffic accidents were the cause of injury in three (15%) patients, and falls were the cause in four (20%) patients. All patients underwent a follow-up of 60 weeks; the average suture used was 2.85, and the average tear length was 1.91 cm.

All patients were operated upon within 8 weeks from injury. Eleven (55%) meniscal tears were rated acute (injury-to-repair interval ≤21 days), and nine (45%) meniscal tears were rated chronic (injury-to-repair interval >21 days).

The mean and range of 'injury-to-repair' intervals for the acute and chronic cases were 17.18 days (10-20 days) and 35.11 days (25-50 days), respectively.

Intraoperative finding revealed that 14 (70%) patients had isolated medial injuries and six (30%) patients had meniscus injuries associated with ACL tear.

Four (20%) patients had left posterior horn medial meniscus (MM) injuries, two (10%) patients had left middle horn MM injuries, two (10%) patients had left posterior horn MM extending to the body injuries, five (25%) patients had left posterior horn LM injuries, one patient had left posterior horn LM extending to the body injury, four (20%) patients had right posterior horn MM injuries, and two patients had right posterior horn LM injuries (10%) ([Table 1]).
Table 1 Intraoperative finding as regards meniscal tear sites


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The preoperative modified Lysholm score ranged between 9 and 58 points with a mean of 38.25 points (SD = 14.61). The mean postoperative score at 48 weeks was 91.20 points (SD = 5.50) (Graph 1).



The mean preoperative IKDC subjective evaluation was 31.28 (range 19.54-44.82, SD = 7.73); all patients had poor scores. The mean postoperative IKDC subjective evaluation at 48 weeks was 91.44 (range 79.13-95.40, SD = 4.26); 15 (75%) patients had excellent scores, three (15%) patients had good scores, and two (10%) patients had fair scores (Graph 2).



The preoperative IKDC objective evaluation results showed 16 (80%) patients with severely abnormal knees (grade D) and four (20%) patients with abnormal knees (grade C). The postoperative IKDC objective evaluation results at 48 weeks showed two (10%) patients with abnormal knees (grade C), three (15%) patients with nearly normal knees (grade B), and 15 (75%) patients with normal knees (grade A) (Graph 3).



Preoperatively, all patients had discontinued their previous level of activity/sports. Postoperatively, at 24 weeks four (20%) patients could not resume their previous level of activity/sports, six (30%) patients had returned to sports with lower performance level, and 10 (50%) patients had regained their previous performance level in activity/sports. Postoperatively at 48 weeks, 16 (80%) patients had regained their previous performance level in sports and four (20%) patients had returned to sports with lower performance.

The mean modified Lysholm score and mean subjective IKDC score preoperatively were 38.25 (SD = 14.61) and 31.28 (SD = 7.73), respectively. The mean postoperative score at 48 weeks was 91.20 (SD = 5.50) and 91.44 (SD = 4.26), respectively. The mean difference in improvement in the scores was 52.70 and 60.16, respectively, and was statistically significant. This signifies that scores improve postoperatively with time and physiotherapy.

The mean postoperative Lysholm score and IKDC subjective score for the 19-20-year age group were 91.33 and 91.56 (SD = 2.73 and 4.87), respectively, whereas in the 19-20-year age group the mean postoperative Lysholm score and IKDC subjective score were 91.09 and 91.33 (SD = 7.17 and 3.93), respectively. This signifies that there was no significant statistical difference in the postoperative score of both groups.

The mean postoperative Lysholm score and IKDC subjective score for the ACL reconstructed group were 94.25 and 93.67 (SD = 0.50 and 1.48), respectively, whereas in isolated meniscal repair cases the mean postoperative Lysholm score and IKDC subjective score were 90.37 and 90.88 (SD = 5.93 and 4.57), respectively. This signifies better improvement of scores if ACL reconstruction is performed simultaneously with meniscal repair.

The mean postoperative Lysholm score and IKDC subjective score for the vertical longitudinal tear group were 93.72 and 93.32 (SD = 3.37 and 1), respectively, whereas in bucket-handle tear cases the mean postoperative Lysholm score and IKDC subjective score were 88.11 and 89.14 (SD = 6.17 and 5.57), respectively. This signifies better improvement of the score in the vertical longitudinal tear group.

The mean postoperative Lysholm score and IKDC subjective score for the 'red-red' zone group were 93.83 and 93.30 (SD = 3.24 and 0.95), respectively, whereas in the red-white zone group the mean postoperative Lysholm score and IKDC subjective score were 87.25 and 88.64 (SD = 5.99 and 5.74), respectively. This signifies better improvement in scores in the 'red-red' zone group.

The mean postoperative Lysholm score and IKDC subjective score for the acute meniscal tear group were 91.27 and 92.48 (SD = 6.48 and 1.30), respectively, whereas in the chronic meniscal tear group the mean postoperative Lysholm score and IKDC subjective score were 91.11 and 90.16 (SD = 4.40 and 6.41), respectively. This signifies that there was no significant statistical difference in the postoperative score between the two groups.

The mean postoperative Lysholm score and IKDC subjective score for the MM tear group were 91.66 and 91.48 (SD = 5.14 and 3.78), respectively, whereas in the LM tear cases the mean postoperative Lysholm score and IKDC subjective score were 90.50 and 91.37 (SD = 6.30 and 5.17), respectively. This signifies that there was no significant statistical difference in the postoperative score between the two groups.

The mean postoperative Lysholm score and IKDC subjective score for the 10-15 mm tear group were 96.33 and 93.53 (SD = 3.21 and 0.62), respectively. The mean postoperative Lysholm score and IKDC subjective score for the 10-15 mm tear group were 91.57 and 92.19 (SD = 4.07 and 3.88), respectively, whereas in the 21-25 mm tear cases the mean postoperative Lysholm score and IKDC subjective score were 84.33 and 85.81 (SD = 7.63 and 4.03), respectively. This signifies that there was significant statistical difference in the postoperative score of groups and a high incidence of meniscal healing with small tears.

Summary of postoperative results in relation to age, injury-to-repair interval, associated ACL reconstruction, zone, side, location, and length of tear are shown in [Table 2].
Table 2 Summary of postoperative results


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Postoperatively all patients were evaluated with MRI. There were 16 asymptomatic patients in which MRI showed that 13 menisci had healed and three menisci had partially healed. Four patients were symptomatic and MRI showed that two menisci had healed, one meniscus had partially healed, and one meniscus had not healed. MRI showed that of the 12 menisci in which the tear was in the red-red zone 11 menisci had healed and one meniscus had partially healed, and of the eight menisci in which the tear had been in the red-white zone three menisci had healed, three menisci had partially healed, and two menisci had not healed.


  Discussion Top


The meniscus has a critical role in load transmission across the knee joint and is believed to contribute to joint stability. The meniscus also provides shock absorption [9] . Meniscal repair has become increasingly popular over the past two decades among those who perform arthroscopic surgery, and arthroscopic meniscal repair has evolved from inside-out and outside-in to all-inside repair techniques [10] .

Ra et al. [11] reviewed inside-out repair of complete radial tears of the meniscus with a fibrin clot. Eleven of 12 cases showed complete healing on MRI and six of seven patients who underwent a second-look arthroscopic examination showed a completely healed meniscus at a mean of 30.3 months' follow-up.

This was followed by the outside-in procedure, which was introduced by Warren [12] with the aim to diminish the risk of fibular nerve injury in lateral meniscal repairs, with focus on preventing neurovascular injury.

Venkatachalam et al. [13] reported that 78.6% of patients showed clinically successful outcomes at a mean of 21 months' follow-up. Sobhy et al. [14] experienced improvement in the median Lysholm (34-88) and the median IKDC subjective scores (25-88). The results of meniscus repair rates vary from 50 to 91%.

The all-inside meniscal repair technique was introduced and initially consisted of bioabsorbable devices such as arrows, darts, or staples. It presented potential benefits such as ease of use, adaptability to different types of injury, reduced duration of operations, and diminished morbidity [15] .

Lee and Diduch [16] reviewed 32 meniscal repairs using meniscus arrow with concomitant ACL reconstruction. They reported that there was a clinical success rate of 90.6% at a mean follow-up of 2.3 years, which deteriorated to 71.4% at 6.6 years of follow-up.

The FasT-Fix device was developed as a modification of the Smith and Nephew FasT-Fix device, with the main aim of achieving suture resistance equal to that provided by the inside-out technique [9] .

The Lysholm knee score and the Tegner activity scale and IKDC score showed overall acceptable psychometric performance for outcome measures of meniscus injuries of the knee [17],[18] .

This study had concentrated on evaluation of the all-inside arthroscopic repair technique using a FasT-Fix meniscal repair device in the treatment of meniscal tear. This study was conducted between March 2012 and December 2013 and involved 20 cases. The mean duration of follow-up was 60 weeks, ranging between 48 and 72 weeks.

The results of our study also matched the published results of Barber et al. [19] and DeHaan et al. [20] .

The score in our study was lower than that of Popescu et al. [21] as the Lysholm and Tegner score was 95 because of the smaller number of concomitant ACL reconstruction cases and short follow-up in our study.

The score in our study was lower than that of Choi et al. [22] as the mean postoperative Lysholm score was 94.1 (SD-7.2) because of short-term follow-up and small number of simultaneous ACL reconstruction cases.

Also, the result of our study was lower than that of Pujol et al. [23] as the mean postoperative Lysholm score was 94.7 because of the short-term follow-up and small number of simultaneous ACL reconstruction cases.

Many factors such as age, chronicity of tear, length of tear, location of tear, and ACL reconstruction at the time of meniscal repair influence the outcome of meniscal repair.

In our results, outcome was not related to patient age. Kotsovolos et al. [24] showed that age did not affect the clinical outcome. Fok and Yau [25] showed that clinical and radiological outcome was not related to patient age.

There is a belief that the best outcome results of suturing came from factors in hemarthrosis generated during the ACL reconstruction [26] .

In our study the score improved if ACL reconstruction was performed simultaneously with meniscal repair. However, Kotsovolos et al. [24] showed that age, length of tear, simultaneous ACL reconstruction, chronicity of injury, and location of tear did not affect the clinical outcome. Fok and Yau [25] showed the mean postoperative IKDC for patients with concurrent ACL reconstruction to be 83, whereas in isolated meniscal repair cases the mean postoperative IKDC subjective score was 93.3.

Majeed et al. [27] showed that the outcome of meniscal repair was statistically significantly better if ACL reconstruction was performed simultaneously with meniscal repair.

In our study there was significant improvement in the score in the vertical longitudinal tear group. DeHaan et al. [20] showed a high failure rate (22%) for unstable vertical MM repairs with ACL reconstruction, especially for repairs done to tears in the red-white vascular zone.

In our study there was significant improvement in the score in the 'red-red' zone group. Kotsovolos et al. [24] found no significant differences between the clinical results of acute and chronic injuries. Further, Majeed et al. [27] showed no significant dependence of outcome on the location of the tear.

Regarding injury to 'repair interval', there was no significant statistical difference in the postoperative score of both groups. Further, Kotsovolos et al. [24] found no significant differences between the clinical results of acute and chronic injuries. However, Billante et al. [28] in a study of 38 meniscal repairs (11 chronic) using the RapidLoc PDS obtained a success rate of 84% in acute and 92% in chronic injuries.

In our study there were no differences in results according to repair of MM or LM. Popescu et al. [21] showed no differences in functional results according to repair of MM or LM. Pujol et al. [23] showed that there were no differences between lateral and medial menisci in stable and stabilized knees. However, Majeed et al. [27] showed that the failure rate was lower in cases of lateral meniscal repair.

In our study there was significant statistical difference in the postoperative score of groups and high incidence of meniscal healing with small tears. Bach et al. [29] could not prove an association between failure rate and length of the tear; further, Kotsovolos et al. [24] showed no association between outcome and length of the tear.

Second-look arthroscopy is still the gold standard in assessing meniscal healing. However, it is not feasible in routine clinical practice because of the invasiveness of the procedure [25] . In addition, the patients may not want to be followed up once their symptoms have disappeared after successful surgical management [27] . Using clinical symptoms to evaluate repaired meniscal tears provides only indirect evidence of successful healing, but is a well-accepted method of assessing healing after meniscal repair, although absence of symptoms does not always reflect the true status of the meniscus [23] . A sensitivity of 58% and specificity of 75% have been reported [30] .

As it is noninvasive and easily available, MRI is considered a better diagnostic means of evaluating meniscal healing. The evaluation of patients with residual symptoms after meniscal repair may be even more challenging because increased MRI signal intensity including grade 3 signal may be expected after successful meniscal repair. Such a signal may reflect either immature fibrovascular granulation tissue or mature fibrocartilaginous scar tissue at the repair site. Three criteria may be used to determine the presence of a new tear in a previously repaired meniscus: grade 3 signal intensity with increased intensity on T2-weighted images; a tear at a location other than at the prior repair; or a displaced meniscal fragment [31] . Consequently, its diagnostic value in meniscus repair is questioned. By combining several MRI sequences, a sensitivity of 92% and specificity of 99% have been reported [30] .

Majeed et al. [27] used clinical symptomatic resolution as the outcome measure in our patients to assess the failure rate. On the basis of this assessment, 83% of the meniscal repairs were assumed to have healed, as the patients had complete or significant resolution of their symptoms on subsequent regular follow-up. Seventeen percent (n = 23) of the meniscal repairs were considered to have failed to heal because of ongoing or recurrent symptoms in these patients (pain, swelling, locking).

Four patients experienced catching due to quadriceps weakness. One case had giving way occurring in sever excretion due to partial ACL tear and four cases had giving way rarely during sever exertion due to quadriceps weakness. One patient experience marked pain during severe exertion and 10 patients experienced inconstant and slight pain during severe exertion due to incomplete return of quadriceps muscle to its previous level. Physiotherapy was used to improve clinical outcome, with modification of activity levels. Two patients experienced effusion on severe exertion, which resolved completely with medication and physiotherapy. Ten patients experienced slightly impaired stair-climbing due to incomplete return of quadriceps muscle to its previous level and two patients due to effusion. Ten patients experienced lightly impaired squatting. These signify the importance of exercise programs in conjunction with physical therapy for a successful outcome.

Kotsovolos et al. [24] reported synovitis in the early postoperative period after meniscal repair with the FasT-Fix device in two patients. Hoffelner et al. [32] reported additional meniscal cysts in three of 27 patients on follow-up MRI.

In our research we reported short-term results and our sample size was small; longer follow-up and a large sample size are needed to justify the long-term effectiveness of the device in meniscal healing in stable and ACL-deficient knees, as well as to assess changes that may occur in the knee, whether meniscal healing is consistent over time, and identify and evaluate the factors that could help meniscus healing.


  Conclusion Top


Meniscal repair is the treatment of choice for vascular longitudinal tears of nondegenerated menisci. The knee should be stable or stabilized and well aligned. Proper bed preparation and meticulous surgical technique are essential.

The new all-inside repair devices are quick and easy and give equal results to the inside-out technique with no need for accessory wounds. It is important for every surgeon to use the instrument and devices correctly.

Better outcome was seen in the red-red zone, in cases of vertical longitudinal tear, when the tear length was less than 21 mm, and with ACL reconstruction. There were no differences in functional results on the basis of repair of MM or LM, acute or chronic injuries, and age.

The Fast-Fix meniscal repair system provides an all-inside method for meniscal repair. It appears to be a safe and effective procedure for the treatment of repairable meniscal tear with lower complications and high success rate.

Future work with a larger study group is needed for absolute determination of factors affecting the outcome. Longer follow-up is needed to study the long-term results of meniscal repair.

Acknowledgements

Nil.

Financial support and sponsorship

Nil.

Conflicts of interest

The authers declared that they have no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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