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Scientific Articles   |    
Meniscal Repair Outcomes at Greater Than Five YearsA Systematic Literature Review and Meta-Analysis
Jeffrey J. Nepple, MD1; Warren R. Dunn, MD, MPH2; Rick W. Wright, MD1
1 Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes-Jewish Hospital Plaza, West Pavilion 1130, St. Louis, MO 63010. E-mail address for R.W. Wright: rwwright1@aol.com
2 Department of Orthopaedics and Rehabilitation, Vanderbilt University School of Medicine, 1215 21st Avenue South, Nashville, TN 37232
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Investigation performed at the Sports Division, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri

A commentary by Armando F. Vidal, MD, is linked to the online version of this article at jbjs.org.



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Dec 19;94(24):2222-2227. doi: 10.2106/JBJS.K.01584
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Abstract

Background: 

Meniscal repair offers the potential to avoid the long-term articular cartilage deterioration that has been shown to result after meniscectomy. Failure of the meniscal repair can occur several years postoperatively. Limited evidence on the long-term outcomes of meniscal repair exists.

Methods: 

We performed a systematic review of studies reporting the outcomes of meniscal repair at a minimum of five years postoperatively. Pooling of data and meta-analysis with a random-effects model were performed to evaluate the results.

Results: 

Thirteen studies met the inclusion criteria. The pooled rate of meniscal repair failure (reoperation or clinical failure) was 23.1% (131 of 566). The pooled rate of failure varied from 20.2% to 24.3% depending on the status of the anterior cruciate ligament (ACL), the meniscus repaired, and the technique utilized. The rate of failure was similar for the medial and the lateral meniscus as well as for patients with an intact and a reconstructed ACL.

Conclusions: 

A systematic review of the outcomes of meniscal repair at greater than five years postoperatively demonstrated very similar rates of meniscal failure (22.3% to 24.3%) for all techniques investigated. The outcomes of meniscal repair at greater than five years postoperatively have not yet been reported for modern all-inside repair devices.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Frank R. Noyes, M.D. and Sue D. Barber-Westin, B.S.
    Posted on January 02, 2013
    Failure Rate Assessed with MRI
    Cincinnati Sportsmedicine, Cincinnati, Ohio, USA

    We congratulate the authors on their systematic review and meta-analysis of 13 studies that reported the outcomes of meniscus repair a minimum of 5 years postoperatively. We did want to comment on a point raised in the Discussion section (page 2225), "None of the included studies focused on the rate of failure assessed with use of second-look arthroscopy or MRI imaging." In fact, our study (reference #19) did use MRI as one factor to determine the long-term (mean, 16.8 years) success rate in 29 meniscus repairs. In our abstract, we stated, "The long-term success rate was determined in 29 repairs (88%) by the presence of normal or nearly normal parameters from 2 validated rating systems, assessment of magnetic resonance imaging and weightbearing posteroanterior radiographs by independent physicians, and follow-up arthroscopy when required." We believe a crucial aspect and strength of our study was the use of images obtained in a 3 Tesla magnetic resonance imaging scanner with cartilage-sensitive pulse sequences and T2 mapping, read and rated by an independent experienced musculoskeletal radiologist (Hollis Potter, M.D.). This was the first long-term clinical study that we were aware of that used extensive criteria, including 3T MRI with T2 mapping and weight-bearing radiographs, to determine the success rate of meniscus repair.

    We reported that 3 repairs that were asymptomatic (with normal radiographs) had actually failed according to MRI criteria. Two other knees (also asymptomatic) were also considered failed based on radiographic criteria. If these criteria had not been used, the failure rate would have been 21% (6 of 29 repairs) instead of 38% (11 of 28).

    It is important to realize that our study pertained exclusively to the repair of meniscus tears that extended into the central avascular region in young, athletic patients less than 20 years of age. It was interesting that the authors' meta-analysis (of seven studies that provided information on the vascular zone of the meniscus repairs) found a pooled failure rate of 20.9% for tears located in the red-red zone, nearly identical to the 20.7% rate for tears located in the red-white zone. In our experience, repairs of tears in the red-red zone have a smaller failure rate, typically 5-10%. However, this difference could be due to many factors including the type of meniscus repair, number of sutures used, program of rehabilitation, patient age, and activity level resumed postoperatively.

    We agree with the authors that clinical failure, obtained with a thorough clinical examination, is the most feasible basis on which to assess results of meniscus repair. We stress that weight-bearing radiographs and MRI are also crucial adjuncts to this analysis. We continue to recommend repair of meniscus tears whenever possible, especially in younger active patients.

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