Arthroscopic repair of the meniscus: Surgical management and clinical outcomes

Abstract

From the biomechanical and biological points of view, an arthroscopic meniscal repair (AMR) should always be considered as an option. However, AMR has a higher reoperation rate compared with arthroscopic partial meniscectomy, so it should be carefully indicated.Compared with meniscectomy, AMR outcomes are better and the incidence of osteoarthritis is lower when it is well indicated.Factors influencing healing and satisfactory results must be carefully evaluated before indicating an AMR.Tears in the peripheral third are more likely to heal than those in the inner thirds.Vertical peripheral longitudinal tears are the best scenario in terms of success when facing an AMR.'Inside-out' techniques were considered as the gold standard for large repairs on mid-body and posterior parts of the meniscus. However, recent studies do not demonstrate differences regarding failure rate, functional outcomes and complications, when compared with the 'all-inside' techniques.Some biological therapies try to enhance meniscal repair success but their efficacy needs further research. These are: mechanical stimulation, supplemental bone marrow stimulation, platelet rich plasma, stem cell therapy, and scaffolds and membranes.Meniscal root tear/avulsion dramatically compromises meniscal stability, accelerating cartilage degeneration. Several options for reattachment have been proposed, but no differences between them have been established. However, repair of these lesions is actually the reference of the treatment.Meniscal ramp lesions consist of disruption of the peripheral attachment of the meniscus. In contrast, with meniscal root tears, the treatment of reference has not yet been well established. Cite this article: EFORT Open Rev 2018;3:584-594. DOI: 10.1302/2058-5241.3.170059.

Keywords: arthroscopic repair; meniscus; results; surgical techniques.

Fig. 1

Anatomy of the meniscal complex and Cooper zones. Note. ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; H, Humphrey ligament; W, Wrisberg ligament.

Fig. 2

Microstructure of the meniscus. On a sectioned meniscus, we can differentiate three main layers: (1) the superficial layer is a mesh of collagen fibres, (2) the second layer is composed of collagen fibres in lamellar disposition, (3) collagen fibres are disposed longitudinally in the deep layer, (4) blood supply enters by capsular side within the connective tissue.

Fig. 3

Types of meniscal tear. A: radial tear. B: longitudinal vertical tear. C: horizontal tear.

Fig. 4

Vertical longitudinal tear repair. A: inside-out technique, with knots tied over the capsule. B: all-inside technique, with anchors over the capsule.

Fig. 5

Bucket-handle tear repair by all-inside technique. A: bucket-handle tear. B: reduction of tear and provisional knot. C: complete reduction and tied knot.

Fig. 6

Radial tear repair with and all-inside technique.

Fig. 7

Outside-in repair. 7A: Two spinal needles are introduced through both fragments with a non-absorbable suture. This suture is recovered through one portal with a suture retriever. Definitive suture is knotted to these sutures and passed through the meniscus fragments. 7B: Definitive sutures (stripped) are tied and knotted over the external wall of the capsule.