The American Journal of Sports Medicine http://ajs.sagepub.com/
Meniscus Suture Repair: Minimum 10-Year Outcomes in Patients Younger Than 40 Years Compared With Patients 40 and Older J. Richard Steadman, Lauren M. Matheny, Steven B. Singleton, Nicholas S. Johnson, William G. Rodkey, Bernardo Crespo and Karen K. Briggs Am J Sports Med published online July 17, 2015 DOI: 10.1177/0363546515591260 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/07/17/0363546515591260
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Meniscus Suture Repair Minimum 10-Year Outcomes in Patients Younger Than 40 Years Compared With Patients 40 and Older J. Richard Steadman,* MD, Lauren M. Matheny,* MPH, Steven B. Singleton,* MD, Nicholas S. Johnson,* MD, William G. Rodkey,* DVM, Bernardo Crespo,* MD, and Karen K. Briggs,*y MPH Investigation performed at the Steadman Philippon Research Institute, Vail, Colorado, USA Background: Few studies have compared outcomes after meniscus suture repair in patients younger than 40 years versus patients 40 years and older. Purpose: To document failure rates and long-term outcomes after meniscus suture repair by a single surgeon, using the insideout technique, at a minimum 10-year follow-up in patients younger than 40 years versus those 40 years and older. Study Design: Cohort study; Level of evidence, 3. Methods: This study included all patients 18 years or older who underwent meniscus suture repair with the inside-out technique by a single surgeon between January 1992 and December 2003. Patients were divided into 2 cohorts according to age: \40 years (cohort 1) and 40 years (cohort 2). If patients underwent subsequent knee surgery, all subsequent reports, whether performed by the original treating surgeon or by a different surgeon elsewhere, were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surgery treated the same area of the meniscus as repaired in the index surgery. Patients completed a subjective questionnaire at minimum of 10 years after arthroscopy. Outcomes measures included Lysholm, Tegner, and patient satisfaction with outcome. All data were collected prospectively. Results: The surgeon performed 339 meniscus repairs between 1992 and 2003. The study included 181 knees in 178 patients, who had a mean age of 33 years (range, 18-70 years). Cohort 1 contained 136 knees; 16 patients (12%) were lost to follow-up and 47 (35%) underwent a subsequent knee arthroscopy. Cohort 2 contained 45 knees; 2 patients (4.4%) were lost to follow-up, 3 patients had a total knee arthroplasty, and 12 patients (28%) underwent a subsequent knee arthroscopy. In cohort 1, the meniscus repair failure rate was 5.5% (6/110), and in cohort 2 it was 5.3% (2/38) (P = .927). There was no significant difference in failure rate based on which meniscus was repaired (P = .257), concomitant anterior cruciate ligament (ACL) reconstruction (P = .092), or microfracture (P = .674). Average follow-up time for cohort 1 was 16.1 years (range, 10.0-21.9 years), with 82% follow-up (n = 73/ 89); average follow-up time for cohort 2 was 16.2 years (range, 10.1-21.0 years), with 93% follow-up (n = 28/30). There were no significant differences in outcomes scores after meniscus suture repair based on age cohort or meniscus side, presence of an ACL tear, or concomitant microfracture procedure. Conclusion: Meniscus repair failure rate was not different in patients who were younger than 40 years versus those who were 40 years or older at time of meniscus index surgery. Patients who underwent meniscus suture repair had high function and high patient satisfaction at an average of 16 years after meniscus suture repair, and no differences were seen based on age. Keywords: meniscus suture repair; revision; outcomes; over 40 years old
Meniscus tears are one of the most commonly diagnosed orthopaedic injuries. Most meniscus tears are treated with debridement; however, with new information regarding the importance of preservation of meniscus tissue, the number of repairs has increased.1 Removal of tissue surrounding the torn meniscus can often result in reduced protection of the surrounding articular cartilage surfaces.3 Previous studies have also shown that when large amounts of the menisci are excised, patients are more likely to develop knee osteoarthritis (OA) and knee deformities such as ridge formation, joint space narrowing, and flattening of the femoral condyle at an increased rate.9,12,20 Knee
y
Address correspondence to Karen K. Briggs, MPH, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO 81657, USA (email: [email protected]). *Steadman Philippon Research Institute, Vail, Colorado, USA. One or more of the authors has declared the following potential conflict of interest or source of funding: The Steadman Philippon Research Institute has received financial support not related to this study from the following: Smith & Nephew, Arthrex Inc, Siemens Medical Solutions USA, and Ossur Americas. The American Journal of Sports Medicine, Vol. XX, No. X DOI: 10.1177/0363546515591260 Ó 2015 The Author(s)
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pain and decreased function have been reported at longterm follow-up after partial or total meniscectomy.22 From 2001 to 2005 the number of meniscus repair surgeries doubled, indicating a preferential shift toward meniscus repair.1 Various arthroscopic techniques are available for meniscus repair, including all-inside, outside-in, and inside-out.8,11,17,18,21,25 Short- to midterm follow-up has been reported with failure rates ranging from 0% to 30% and a pooled failure rate of 17% for repair of isolated meniscus tears using the inside-out suture technique; however, few long-term studies exist.10 Although multiple studies have documented outcomes after meniscus suture repair, few studies have compared outcomes after meniscus repair in patients younger than 40 years versus patients 40 years and older. Failure rates in patients 40 and older have been documented to range from 9% to 27%.4,14,19 However, it is unclear whether there is a significant difference in subsequent surgery rates and outcomes after meniscus suture repair in a single surgeon cohort, based on age, due to the high variability in results among previous studies.4,7,14,19 The purpose of this study was to document failure rates and long-term outcomes after meniscus suture repair using the inside-out technique by a single surgeon at a minimum 10-year follow-up in patients younger than 40 years versus patients 40 years and older. Our hypothesis was that older patients would have lower outcomes scores but would require fewer subsequent surgeries.
METHODS This study was approved by the institutional review board at the Vail Valley Medical Center in Vail, Colorado. Inclusion criteria were patients 18 years or older who underwent primary meniscus suture repair by a single surgeon using an inside-out technique between 1992 and 2003. Patients were excluded from this study if they were younger than 18 years of age, had undergone previous meniscus surgery, had an associated fracture, or had a multiligamentous knee injury, not including the medial collateral ligament (MCL) or the anterior cruciate ligament (ACL). Detailed operative data and intraoperative findings were documented at the time of surgery. All patients in the study were contacted to determine whether they had undergone a subsequent knee surgery. If patients indicated that they had undergone subsequent knee surgery, all subsequent knee surgery reports, whether performed by the original treating surgeon or by a different surgeon elsewhere, were reviewed. Subsequent surgery reports were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surgery treated the same area of the meniscus that was repaired during the index surgery. Both reviewers’ decisions were independently documented, and failure was based on consensus of reviewers. A third reviewer was used if there was no consensus. Patients who had not undergone a subsequent surgery were asked to complete a subjective questionnaire at a minimum of 10 years after the index meniscus surgery and
each consecutive year thereafter. Outcomes measures collected were the Short Form–12 (SF-12) physical component summary (PCS) and mental component summary (MCS)24 as well as condition-specific outcomes including the Lysholm score15 and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score.5 Although a previous study demonstrated that Tegner activity scale differs with age in a normal population,6 activity was measured by the Tegner activity scale23 to report general activity level in both cohorts 10 years after treatment. Patient satisfaction with outcome was measured on a 1 to 10 scale with 10 being very satisfied and 1 being very unsatisfied.
Operative Technique All patients had surgical indications based on their symptoms, as confirmed by clinical and imaging evaluation. All procedures were performed by the senior author (J.R.S.), and the decision between meniscectomy or meniscus repair was made at the time of the surgical procedure based on the evaluation of meniscus tear pattern, tissue quality, healing potential, and reparability. If the tear was amenable to suturing, an accessory medial or lateral incision, depending on the affected meniscus side, was made to protect the neurovascular structures and retrieve the needles. All meniscus repairs were performed after a standard inside-out technique using braided polyester and/or polyethylene monofilament suture. Sutures (suture range, 25) were placed to ensure that a stable meniscus repair was obtained. Concomitant ligamentous or chondral injuries were also addressed. All patients followed a similar rehabilitation protocol, consisting of 6 weeks of total nonweightbearing immediately after surgery, progressing to protected weightbearing as tolerated. Patients were allowed to discontinue use of crutches when able to walk without a limp. Passive range of motion (ROM) exercises without load were encouraged starting on postoperative day 1, progressing to active ROM with limited flexion to 90° for the first 6 weeks. Stationary biking and strengthening exercises were initiated at the 6-week postoperative time point and were progressed according to patient tolerance. Patients who underwent concomitant chondral or ligamentous reconstruction surgery had a modified rehabilitation program based on the type of concurrent surgical procedures that were performed.
Statistical Analysis Data were tested for normal distribution by use of the Kolmogorov-Smirnov Z test. Comparisons of variables between the 2 cohorts were performed with independent samples t tests for normally distributed data. Comparisons of 2 categorical data were compared by use of chi-square tests. For Lysholm score, nonparametric univariate analyses were performed with the Wilcoxon rank sum test for comparison of 2 independent groups. For Tegner activity scale and patient satisfaction with outcome, nonparametric univariate analyses were performed with the MannWhitney U test for comparison of 2 independent groups.
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TABLE 1 Descriptive Characteristics of Each Cohort, Including Demographics, Concomitant Surgical Findings, and Procedures at Index Meniscus Suture Repair Surgerya
Age, mean (range), y Sex, n Duration of follow-up, mean (range), y Medial meniscus suture repair, % (n) Lateral meniscus suture repair, % (n) Medial and lateral meniscus suture repair, % (n) Anterior cruciate ligament reconstruction, % (n)
Cohort 1 (n = 136 knees)
Cohort 2 (n = 45 knees)
P Value
27 (18-39) 93 males, 43 females 16 (10-22) 63 (85) 32 (43) 5 (8) 45 (62)
50 (40-70) 23 males, 22 females 16 (10-21) 73 (33) 22 (10) 4 (2) 24 (11)
\.001b .036b .826 .230 .186 .714 .012b
a
Cohort 1 consists of patients \40 years of age. Cohort 2 consists of patients 40 years of age. Significance level set at alpha \.05.
b
For nonnormally distributed data, nonparametric analysis with the Spearman rho correlation coefficient was used to determine linear correlation between 2 variables. Statistical analysis was performed using SPSS (v 19.0; SPSS Inc) software package. All reported P values are 2-tailed, with an alpha level of .05 indicating significance.
RESULTS The surgeon performed 339 meniscus repairs between 1992 and 2003. A total of 181 knees in 178 patients met the inclusion criteria and were included in this study (Figure 1). The mean age of the included patients was 33 years (range, 18-70 years). Patients were divided into 2 cohorts. Cohort 1 consisted of patients younger than 40 years (n = 136 knees), and cohort 2 consisted of patients 40 years and older (n = 45 knees). There was a significant difference in the number of patients who underwent a concomitant ACL reconstruction in cohort 1 (45%) compared with cohort 2 (24%) (P = .012). Descriptive characteristics of each cohort, including demographics, concomitant surgical findings, and procedures at index meniscus suture repair surgery, are documented in Table 1. In cohort 1 (136 knees), 16 patients (12%) were lost to follow-up and 47 (35%) underwent a subsequent knee arthroscopy (Figure 1). Of these 47 patients, 37 had operative reports available for review. Reasons patients underwent subsequent arthroscopy are listed in Table 2. Mean time to subsequent arthroscopy for cohort 1 was 5.4 years (range, 0.1-19.9 years). For cohort 1, the meniscus repair failure rate was 5.5% (6/110). Descriptive information for all patients who were considered a meniscus repair failure is documented in the Appendix (available online at http://ajsm.sagepub.com/ supplemental). In cohort 2 (45 knees), 2 patients (4.4%) were lost to follow-up and 3 patients had a total knee arthroplasty at a mean 11.5 years (range, 9.8-14.4 years) after index meniscus surgery. Twelve patients (28%) underwent a subsequent knee arthroscopy and 7 had operative reports available for review. Reasons patients underwent subsequent knee arthroscopy are recorded in Table 2. Mean time to subsequent arthroscopy for cohort 2 was 8.3 years (range, 0.1-16.6 years). For cohort 2, the meniscus repair
Figure 1. Flow chart describing patient cohorts and patient selection. TKR, total knee replacement.
failure rate was 5.3% (2/38). Descriptive information for all patients who were considered a meniscus repair failure is documented in the Appendix. There was no significant difference in the number of meniscus repair failures between cohort 1 and cohort 2 (P = .927). No significant difference was found in the number of subsequent arthroscopies between age cohorts (P = .518). Also, no significant differences were found in meniscus repair failure rate and which meniscus was repaired (medial vs lateral) (P = .257), concomitant ACL reconstruction (P = .092), or microfracture (P = .674).
Outcomes Outcomes data were available for 73 of 89 (82%) patients in cohort 1 and 28 of 30 (93%) patients in cohort 2. The average follow-up for cohort 1 was 16.1 years (range, 10.0-21.9 years). The average follow-up for cohort 2 was 16.2 years (range, 10.1-21.0 years). No significant differences were
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TABLE 2 Reasons for Subsequent Knee Arthroscopy After Index Meniscus Suture Repaira Reason for Second Arthroscopy
Cohort 1 (n = 37 knees)
Cohort 2 (n = 10 knees)
11 6 9 6 3 2 0
2 3 0 2 2 0 1
New meniscus tear on index meniscus due to reinjury Lysis of adhesions or scarring Anterior cruciate ligament tear Failed meniscus suture repair Chondral defect Arthroscopy for degenerative joint disease Hardware removal a
There were 59 patients who underwent a second surgery and 47 operative reports available for review.
TABLE 3 Postoperative Outcomes in Age Cohorts for Patients Who Did Not Undergo Subsequent Knee Surgery After Index Meniscus Suture Repaira Cohort 1 (n = 73/89)
Cohort 2 (n = 28/30)
P Value
86 (53-100) 5 (1-9)
86 (53-100) 3 (0-7)
.333 \.001b
Lysholm Tegner activity scale, median (range) WOMAC Pain Stiffness Function Total SF-12 Physical component summary Mental component summary Patient satisfaction with outcome, median (range)
1 1 3 6
(0-9) (0-5) (0-27) (0-37)
54.0 (25.7-62.0) 53.1 (23.9-61.8) 10 (1-10)
2 2 6 9
(0-10) (0-6) (0-31) (0-45)
.375 .515 .617 .919
52.3 (33.1-60.3) 54.6 (36.8-61.8) 9.5 (1-10)
.899 .167 .449
a
Results are reported as mean (range) unless otherwise indicated. SF-12, Short Form–12; WOMAC, Western Ontario and McMaster Universities Arthritis Index. b Statistically significant difference between cohorts (P \ .05).
found in outcomes scores after meniscus suture repair based on age cohort (Table 3). A significant difference in Tegner activity scale between cohort 1 and cohort 2 was noted (P \ .001); however, Tegner activity scale and age have a significant correlation, which may explain the significant difference in activity level between the 2 age cohorts (r = 20.284, P = .005). In all patients, there were no differences based on meniscus side (medial vs lateral), presence of an ACL tear, or whether patients had a concomitant microfracture procedure at index meniscus suture repair surgery. No significant differences were found in Lysholm score, Tegner activity scale, or patient satisfaction with outcome based on meniscus side (medial vs lateral) (Table 4), presence of an ACL tear (Table 5), or concomitant microfracture procedure (Table 6). Years of follow-up did not correlate with any outcomes scores (P . .05).
DISCUSSION In this study, patients who underwent primary meniscus suture repair at 40 years of age and older had similar knee function, satisfaction with outcome, and meniscus repair failure rates as those patients who were younger than 40 years
old when evaluated at a minimum 10 years after index surgery. There was a significant difference in the number of patients who underwent a concomitant ACL reconstruction; however, no significant differences in outcomes were seen between the 2 cohorts, except for activity level, which has been shown to be significantly correlated with age in a normal population.6 Overall, patients had high function and high satisfaction with outcome regardless of age. Previous studies have documented age as a predictor of meniscus suture repair failure, with younger patients more likely to fail than older patients.1,2,13,14 However, previous studies have included multiple repair techniques by more than 1 surgeon, younger patients due to limited number of patients older than 40 years, and follow-up less than 10 years.1,2,4,12,13 Barrett et al4 reported on patients 40 years or older who had meniscus suture repair surgery. Fourteen percent of the patients were symptomatic on physical examination, and 3 of 37 (8%) required repeat arthroscopy, which confirmed that the meniscus repair had not healed.4 While our study had similar results, Barrett’s study was limited to 2-year follow-up and did not have a younger group for comparison. In a large study of a statewide database, subsequent meniscectomies were seen in 8.9% of meniscus repairs.14 One factor associated with subsequent meniscectomy was
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TABLE 4 Postoperative Outcomes Among Patients Who Underwent Medial Versus Lateral Meniscus Suture Repaira
Meniscus suture repair failure, no. of patients Lysholm Tegner activity scale, median (range) WOMAC Pain Stiffness Function Total SF-12 Physical component summary Mental component summary Patient satisfaction with outcome, median (range)
Medial Meniscus (n = 87)
Lateral Meniscus (n = 43)
P Value
6 86 (53-100) 4 (0-9)
1 86 (57-100) 6 (1-9)
.491 .249
2 1 5 7
(0-10) (0-6) (0-31) (0-45)
2 1 4 6
53.9 (33.1-62.0) 52.8 (23.9-61.6) 10 (1-10)
(0-8) (0-6) (0-17) (0-22)
.441 .566 .912 .649
53.9 (33.1-62.0) 52.8 (23.9-61.6) 9 (1-10)
.476 .603 .333
a There were 51 patients who were excluded from analysis because they had both medial and lateral meniscus tears. One failure was not included in the table because it involved both medial and lateral meniscus tears. Results are reported as mean (range) unless otherwise indicated. SF-12, Short Form–12; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
TABLE 5 Postoperative Outcomes Among Patients With and Without an Anterior Cruciate Ligament (ACL) Tear at Index Surgery ACL Tear (n = 141)
No ACL Tear (n = 40)
P Value
6 84 (61-100) 4.5 (1-9) 9.5 (4-10)
2 87 (53-100) 5 (0-9) 10 (1-10)
.213 .718 .816
Meniscus suture repair failure, No. of patients Lysholm, mean (range) Tegner activity scale, median (range) Patient satisfaction with outcome, median (range)
TABLE 6 Postoperative Outcomes After Meniscus Suture Repair Among Patients With and Without Concomitant Microfracture at Index Surgery Microfracture (n = 21)
No Microfracture (n = 13)
P Value
1 87 (53-100) 5 (0-9) 9.5 (1-10)
7 84 (61-100) 4.5 (1-8) 10 (1-10)
.293 .817 .423
Meniscus suture repair failure, No. of patients Lysholm, mean (range) Tegner activity scale, median (range) Patient satisfaction with outcome, median (range)
isolated meniscus repairs without concomitant ACL reconstruction. However, patients over 40 with isolated meniscus repairs were at decreased risk if compared with patients under 20. In addition, subsequent meniscectomy rates were dependent on surgeon volume and experience.14 In that study, it is unclear whether subsequent meniscectomies involved the same area of the repair, and no outcomes data were available. In our study, all repairs were done by 1 surgeon, and the details regarding subsequent arthroscopies were documented. Another study reported a case-adjusted failure rate of 27% at 7.5 years.7 The study reported that younger age was a factor associated with failure and that all failures happened within 4 years of repair. At follow-up, all of the patients had normal to nearly normal knees according to the International Knee Documentation Committee (IKDC) score; however, only isolated tears were included. We found that isolated tears were not commonly seen in our
population. It is unclear why we had so few; however, it may be due to activity level or the sport they were participating in when the injury occurred. Melton et al16 reported on patients undergoing meniscus suture repair and ACL reconstruction. With 69% follow-up at an average of 10 years, the distribution of Lysholm scores showed that the majority of patients had scores greater than 80 points. This observation is similar to the outcomes we found at a minimum of 10 years after meniscus repair. Most studies in the literature have varying definitions of meniscus repair failure. In the current study, all patients were contacted to determine whether they had undergone a subsequent knee surgery. If patients indicated that they had undergone subsequent knee surgery, all subsequent reports were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surgery treated the same area of the meniscus that was
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repaired in the index surgery. Most studies have defined failure as subsequent meniscectomies. We thought it was critical to determine whether failure actually happened at the repair site. Most of these failures occur within the first 2 years after repair. Other subsequent arthroscopies included meniscus damage located in areas other than the repair site at an average of 5 years in the younger cohort and 8 years in the older cohort. The initial damage to the meniscus that was repaired may put other areas of meniscus tissue at risk of future degeneration; however, our purpose was to determine failure of the repair. More research is needed to determine whether meniscus repair puts other parts of the meniscus at risk for future damage.
Limitations Data were reviewed retrospectively; however, all data were collected prospectively. Not all patients who underwent a subsequent surgery at an outside institution had operative reports available for review. With this length of follow-up, some reports from other institutions were destroyed. Since failure was determined by findings at subsequent arthroscopy, patients whose repairs failed but who did not have subsequent surgery would not have been detected as failures. In addition, there was limited magnetic resonance imaging or objective clinical examination data. The size of each comparison cohort may have limited the statistical power of the study; however, this study examined a consecutive series of patients treated by 1 surgeon. The goal of this study was to determine the outcomes after primary meniscus repair; therefore, outcomes were only collected for patients who did not undergo a subsequent knee surgery, which may bias outcomes toward a more favorable result. However, all differences in outcomes scores were within the minimal detectable change of the instrument.
CONCLUSION Meniscus repair failure rate was not different in patients who were younger than 40 years versus those who were 40 years and older at time of meniscus index surgery. Patients who underwent meniscus suture repair had high function and high patient satisfaction at an average of 16 years after meniscus suture repair, and there were no differences in failure rate or outcomes based on age.
REFERENCES 1. Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. 2. Bach BR Jr, Dennis M, Balin J, Hayden J. Arthroscopic meniscal repair: analysis of treatment failures. J Knee Surg. 2005;18(4):278284.
3. Baratz ME, Fu FH, Mengato R. Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med. 1986;14(4): 270-275. 4. Barrett GR, Field MH, Treacy SH, Ruff CG. Clinical results of meniscus repair in patients 40 years and older. Arthroscopy. 1998;14(8):824-829. 5. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15(12):1833-1840. 6. Briggs KK, Steadman JR, Hay CJ, Hines SL. Lysholm score and Tegner activity level in individuals with normal knees. Am J Sports Med. 2009;37(5):898-901. 7. Eggli S, Wegmu¨ller H, Kosina J, Huckell C, Jakob RP. Long-term results of arthroscopic meniscal repair: an analysis of isolated tears. Am J Sports Med. 1995;23(6):715-720. 8. Englund M, Roemer FW, Hayashi D, Crema MD, Guermazi A. Meniscus pathology, osteoarthritis and the treatment controversy. Nat Rev Rheumatol. 2012;8(7):412-419. 9. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30(4):664-670. 10. Grant JA, Wilde J, Miller BS, Bedi A. Comparison of inside-out and all-inside techniques for the repair of isolated meniscal tears: a systematic review. Am J Sports Med. 2012;40(2):459-468. 11. Henning CE, Lynch MA, Clark JR. Vascularity for healing of meniscus repairs. Arthroscopy. 1987;3(1):13-18. 12. Jackson JP. Degenerative changes in the knee after meniscectomy. Br Med J. 1968;2(5604):525-527. 13. Kurosaka M, Yoshiya S, Kuroda R, Matsui N, Yamamoto T, Tanaka J. Repeat tears of repaired menisci after arthroscopic confirmation of healing. J Bone Joint Surg Br. 2002;84(1):34-37. 14. Lyman S, Hidaka C, Valdez AS, et al. Risk factors for meniscectomy after meniscal repair. Am J Sports Med. 2013;41(12):2772-2778. 15. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154. 16. Melton JT, Murray JR, Karim A, Pandit H, Wandless F, Thomas NP. Meniscal repair in anterior cruciate ligament reconstruction: a longterm outcome study. Knee Surg Sports Traumatol Arthrosc. 2011; 19(10):1729-1734. 17. Morgan CD. The ‘‘all-inside’’ meniscus repair. Arthroscopy. 1991; 7(1):120-125. 18. Morgan CD, Casscells SW. Arthroscopic meniscus repair: a safe approach to the posterior horns. Arthroscopy. 1986;2(1):3-12. 19. Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscus tears extending into the avascular zone with or without anterior cruciate ligament reconstruction in patients 40 years of age and older. Arthroscopy. 2000;16(8):822-829. 20. Roos H, Laure´n M, Adalberth T, Roos EM, Jonsson K, Lohmander LS. Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one years, compared with matched controls. Arthritis Rheum. 1998;41(4):687-693. 21. Scott GA, Jolly BL, Henning CE. Combined posterior incision and arthroscopic intra-articular repair of the meniscus: an examination of factors affecting healing. J Bone Joint Surg Am. 1986;68(6):847-861. 22. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51(3):517-526. 23. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43-49. 24. Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220-233. 25. Warren RF. Arthroscopic meniscus repair. Arthroscopy. 1985;1(3): 170-172.
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Meniscus Suture Repair: Minimum 10-Year Outcomes in Patients Younger Than 40 Years Compared With Patients 40 and Older J. Richard Steadman, Lauren M. Matheny, Steven B. Singleton, Nicholas S. Johnson, William G. Rodkey, Bernardo Crespo and Karen K. Briggs Am J Sports Med published online July 17, 2015 DOI: 10.1177/0363546515591260 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/07/17/0363546515591260
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On behalf of: American Orthopaedic Society for Sports Medicine
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AJSM PreView, published on July 17, 2015 as doi:10.1177/0363546515591260
Meniscus Suture Repair Minimum 10-Year Outcomes in Patients Younger Than 40 Years Compared With Patients 40 and Older J. Richard Steadman,* MD, Lauren M. Matheny,* MPH, Steven B. Singleton,* MD, Nicholas S. Johnson,* MD, William G. Rodkey,* DVM, Bernardo Crespo,* MD, and Karen K. Briggs,*y MPH Investigation performed at the Steadman Philippon Research Institute, Vail, Colorado, USA Background: Few studies have compared outcomes after meniscus suture repair in patients younger than 40 years versus patients 40 years and older. Purpose: To document failure rates and long-term outcomes after meniscus suture repair by a single surgeon, using the insideout technique, at a minimum 10-year follow-up in patients younger than 40 years versus those 40 years and older. Study Design: Cohort study; Level of evidence, 3. Methods: This study included all patients 18 years or older who underwent meniscus suture repair with the inside-out technique by a single surgeon between January 1992 and December 2003. Patients were divided into 2 cohorts according to age: \40 years (cohort 1) and 40 years (cohort 2). If patients underwent subsequent knee surgery, all subsequent reports, whether performed by the original treating surgeon or by a different surgeon elsewhere, were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surgery treated the same area of the meniscus as repaired in the index surgery. Patients completed a subjective questionnaire at minimum of 10 years after arthroscopy. Outcomes measures included Lysholm, Tegner, and patient satisfaction with outcome. All data were collected prospectively. Results: The surgeon performed 339 meniscus repairs between 1992 and 2003. The study included 181 knees in 178 patients, who had a mean age of 33 years (range, 18-70 years). Cohort 1 contained 136 knees; 16 patients (12%) were lost to follow-up and 47 (35%) underwent a subsequent knee arthroscopy. Cohort 2 contained 45 knees; 2 patients (4.4%) were lost to follow-up, 3 patients had a total knee arthroplasty, and 12 patients (28%) underwent a subsequent knee arthroscopy. In cohort 1, the meniscus repair failure rate was 5.5% (6/110), and in cohort 2 it was 5.3% (2/38) (P = .927). There was no significant difference in failure rate based on which meniscus was repaired (P = .257), concomitant anterior cruciate ligament (ACL) reconstruction (P = .092), or microfracture (P = .674). Average follow-up time for cohort 1 was 16.1 years (range, 10.0-21.9 years), with 82% follow-up (n = 73/ 89); average follow-up time for cohort 2 was 16.2 years (range, 10.1-21.0 years), with 93% follow-up (n = 28/30). There were no significant differences in outcomes scores after meniscus suture repair based on age cohort or meniscus side, presence of an ACL tear, or concomitant microfracture procedure. Conclusion: Meniscus repair failure rate was not different in patients who were younger than 40 years versus those who were 40 years or older at time of meniscus index surgery. Patients who underwent meniscus suture repair had high function and high patient satisfaction at an average of 16 years after meniscus suture repair, and no differences were seen based on age. Keywords: meniscus suture repair; revision; outcomes; over 40 years old
Meniscus tears are one of the most commonly diagnosed orthopaedic injuries. Most meniscus tears are treated with debridement; however, with new information regarding the importance of preservation of meniscus tissue, the number of repairs has increased.1 Removal of tissue surrounding the torn meniscus can often result in reduced protection of the surrounding articular cartilage surfaces.3 Previous studies have also shown that when large amounts of the menisci are excised, patients are more likely to develop knee osteoarthritis (OA) and knee deformities such as ridge formation, joint space narrowing, and flattening of the femoral condyle at an increased rate.9,12,20 Knee
y
Address correspondence to Karen K. Briggs, MPH, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO 81657, USA (email: [email protected]). *Steadman Philippon Research Institute, Vail, Colorado, USA. One or more of the authors has declared the following potential conflict of interest or source of funding: The Steadman Philippon Research Institute has received financial support not related to this study from the following: Smith & Nephew, Arthrex Inc, Siemens Medical Solutions USA, and Ossur Americas. The American Journal of Sports Medicine, Vol. XX, No. X DOI: 10.1177/0363546515591260 Ó 2015 The Author(s)
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pain and decreased function have been reported at longterm follow-up after partial or total meniscectomy.22 From 2001 to 2005 the number of meniscus repair surgeries doubled, indicating a preferential shift toward meniscus repair.1 Various arthroscopic techniques are available for meniscus repair, including all-inside, outside-in, and inside-out.8,11,17,18,21,25 Short- to midterm follow-up has been reported with failure rates ranging from 0% to 30% and a pooled failure rate of 17% for repair of isolated meniscus tears using the inside-out suture technique; however, few long-term studies exist.10 Although multiple studies have documented outcomes after meniscus suture repair, few studies have compared outcomes after meniscus repair in patients younger than 40 years versus patients 40 years and older. Failure rates in patients 40 and older have been documented to range from 9% to 27%.4,14,19 However, it is unclear whether there is a significant difference in subsequent surgery rates and outcomes after meniscus suture repair in a single surgeon cohort, based on age, due to the high variability in results among previous studies.4,7,14,19 The purpose of this study was to document failure rates and long-term outcomes after meniscus suture repair using the inside-out technique by a single surgeon at a minimum 10-year follow-up in patients younger than 40 years versus patients 40 years and older. Our hypothesis was that older patients would have lower outcomes scores but would require fewer subsequent surgeries.
METHODS This study was approved by the institutional review board at the Vail Valley Medical Center in Vail, Colorado. Inclusion criteria were patients 18 years or older who underwent primary meniscus suture repair by a single surgeon using an inside-out technique between 1992 and 2003. Patients were excluded from this study if they were younger than 18 years of age, had undergone previous meniscus surgery, had an associated fracture, or had a multiligamentous knee injury, not including the medial collateral ligament (MCL) or the anterior cruciate ligament (ACL). Detailed operative data and intraoperative findings were documented at the time of surgery. All patients in the study were contacted to determine whether they had undergone a subsequent knee surgery. If patients indicated that they had undergone subsequent knee surgery, all subsequent knee surgery reports, whether performed by the original treating surgeon or by a different surgeon elsewhere, were reviewed. Subsequent surgery reports were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surgery treated the same area of the meniscus that was repaired during the index surgery. Both reviewers’ decisions were independently documented, and failure was based on consensus of reviewers. A third reviewer was used if there was no consensus. Patients who had not undergone a subsequent surgery were asked to complete a subjective questionnaire at a minimum of 10 years after the index meniscus surgery and
each consecutive year thereafter. Outcomes measures collected were the Short Form–12 (SF-12) physical component summary (PCS) and mental component summary (MCS)24 as well as condition-specific outcomes including the Lysholm score15 and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score.5 Although a previous study demonstrated that Tegner activity scale differs with age in a normal population,6 activity was measured by the Tegner activity scale23 to report general activity level in both cohorts 10 years after treatment. Patient satisfaction with outcome was measured on a 1 to 10 scale with 10 being very satisfied and 1 being very unsatisfied.
Operative Technique All patients had surgical indications based on their symptoms, as confirmed by clinical and imaging evaluation. All procedures were performed by the senior author (J.R.S.), and the decision between meniscectomy or meniscus repair was made at the time of the surgical procedure based on the evaluation of meniscus tear pattern, tissue quality, healing potential, and reparability. If the tear was amenable to suturing, an accessory medial or lateral incision, depending on the affected meniscus side, was made to protect the neurovascular structures and retrieve the needles. All meniscus repairs were performed after a standard inside-out technique using braided polyester and/or polyethylene monofilament suture. Sutures (suture range, 25) were placed to ensure that a stable meniscus repair was obtained. Concomitant ligamentous or chondral injuries were also addressed. All patients followed a similar rehabilitation protocol, consisting of 6 weeks of total nonweightbearing immediately after surgery, progressing to protected weightbearing as tolerated. Patients were allowed to discontinue use of crutches when able to walk without a limp. Passive range of motion (ROM) exercises without load were encouraged starting on postoperative day 1, progressing to active ROM with limited flexion to 90° for the first 6 weeks. Stationary biking and strengthening exercises were initiated at the 6-week postoperative time point and were progressed according to patient tolerance. Patients who underwent concomitant chondral or ligamentous reconstruction surgery had a modified rehabilitation program based on the type of concurrent surgical procedures that were performed.
Statistical Analysis Data were tested for normal distribution by use of the Kolmogorov-Smirnov Z test. Comparisons of variables between the 2 cohorts were performed with independent samples t tests for normally distributed data. Comparisons of 2 categorical data were compared by use of chi-square tests. For Lysholm score, nonparametric univariate analyses were performed with the Wilcoxon rank sum test for comparison of 2 independent groups. For Tegner activity scale and patient satisfaction with outcome, nonparametric univariate analyses were performed with the MannWhitney U test for comparison of 2 independent groups.
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TABLE 1 Descriptive Characteristics of Each Cohort, Including Demographics, Concomitant Surgical Findings, and Procedures at Index Meniscus Suture Repair Surgerya
Age, mean (range), y Sex, n Duration of follow-up, mean (range), y Medial meniscus suture repair, % (n) Lateral meniscus suture repair, % (n) Medial and lateral meniscus suture repair, % (n) Anterior cruciate ligament reconstruction, % (n)
Cohort 1 (n = 136 knees)
Cohort 2 (n = 45 knees)
P Value
27 (18-39) 93 males, 43 females 16 (10-22) 63 (85) 32 (43) 5 (8) 45 (62)
50 (40-70) 23 males, 22 females 16 (10-21) 73 (33) 22 (10) 4 (2) 24 (11)
\.001b .036b .826 .230 .186 .714 .012b
a
Cohort 1 consists of patients \40 years of age. Cohort 2 consists of patients 40 years of age. Significance level set at alpha \.05.
b
For nonnormally distributed data, nonparametric analysis with the Spearman rho correlation coefficient was used to determine linear correlation between 2 variables. Statistical analysis was performed using SPSS (v 19.0; SPSS Inc) software package. All reported P values are 2-tailed, with an alpha level of .05 indicating significance.
RESULTS The surgeon performed 339 meniscus repairs between 1992 and 2003. A total of 181 knees in 178 patients met the inclusion criteria and were included in this study (Figure 1). The mean age of the included patients was 33 years (range, 18-70 years). Patients were divided into 2 cohorts. Cohort 1 consisted of patients younger than 40 years (n = 136 knees), and cohort 2 consisted of patients 40 years and older (n = 45 knees). There was a significant difference in the number of patients who underwent a concomitant ACL reconstruction in cohort 1 (45%) compared with cohort 2 (24%) (P = .012). Descriptive characteristics of each cohort, including demographics, concomitant surgical findings, and procedures at index meniscus suture repair surgery, are documented in Table 1. In cohort 1 (136 knees), 16 patients (12%) were lost to follow-up and 47 (35%) underwent a subsequent knee arthroscopy (Figure 1). Of these 47 patients, 37 had operative reports available for review. Reasons patients underwent subsequent arthroscopy are listed in Table 2. Mean time to subsequent arthroscopy for cohort 1 was 5.4 years (range, 0.1-19.9 years). For cohort 1, the meniscus repair failure rate was 5.5% (6/110). Descriptive information for all patients who were considered a meniscus repair failure is documented in the Appendix (available online at http://ajsm.sagepub.com/ supplemental). In cohort 2 (45 knees), 2 patients (4.4%) were lost to follow-up and 3 patients had a total knee arthroplasty at a mean 11.5 years (range, 9.8-14.4 years) after index meniscus surgery. Twelve patients (28%) underwent a subsequent knee arthroscopy and 7 had operative reports available for review. Reasons patients underwent subsequent knee arthroscopy are recorded in Table 2. Mean time to subsequent arthroscopy for cohort 2 was 8.3 years (range, 0.1-16.6 years). For cohort 2, the meniscus repair
Figure 1. Flow chart describing patient cohorts and patient selection. TKR, total knee replacement.
failure rate was 5.3% (2/38). Descriptive information for all patients who were considered a meniscus repair failure is documented in the Appendix. There was no significant difference in the number of meniscus repair failures between cohort 1 and cohort 2 (P = .927). No significant difference was found in the number of subsequent arthroscopies between age cohorts (P = .518). Also, no significant differences were found in meniscus repair failure rate and which meniscus was repaired (medial vs lateral) (P = .257), concomitant ACL reconstruction (P = .092), or microfracture (P = .674).
Outcomes Outcomes data were available for 73 of 89 (82%) patients in cohort 1 and 28 of 30 (93%) patients in cohort 2. The average follow-up for cohort 1 was 16.1 years (range, 10.0-21.9 years). The average follow-up for cohort 2 was 16.2 years (range, 10.1-21.0 years). No significant differences were
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TABLE 2 Reasons for Subsequent Knee Arthroscopy After Index Meniscus Suture Repaira Reason for Second Arthroscopy
Cohort 1 (n = 37 knees)
Cohort 2 (n = 10 knees)
11 6 9 6 3 2 0
2 3 0 2 2 0 1
New meniscus tear on index meniscus due to reinjury Lysis of adhesions or scarring Anterior cruciate ligament tear Failed meniscus suture repair Chondral defect Arthroscopy for degenerative joint disease Hardware removal a
There were 59 patients who underwent a second surgery and 47 operative reports available for review.
TABLE 3 Postoperative Outcomes in Age Cohorts for Patients Who Did Not Undergo Subsequent Knee Surgery After Index Meniscus Suture Repaira Cohort 1 (n = 73/89)
Cohort 2 (n = 28/30)
P Value
86 (53-100) 5 (1-9)
86 (53-100) 3 (0-7)
.333 \.001b
Lysholm Tegner activity scale, median (range) WOMAC Pain Stiffness Function Total SF-12 Physical component summary Mental component summary Patient satisfaction with outcome, median (range)
1 1 3 6
(0-9) (0-5) (0-27) (0-37)
54.0 (25.7-62.0) 53.1 (23.9-61.8) 10 (1-10)
2 2 6 9
(0-10) (0-6) (0-31) (0-45)
.375 .515 .617 .919
52.3 (33.1-60.3) 54.6 (36.8-61.8) 9.5 (1-10)
.899 .167 .449
a
Results are reported as mean (range) unless otherwise indicated. SF-12, Short Form–12; WOMAC, Western Ontario and McMaster Universities Arthritis Index. b Statistically significant difference between cohorts (P \ .05).
found in outcomes scores after meniscus suture repair based on age cohort (Table 3). A significant difference in Tegner activity scale between cohort 1 and cohort 2 was noted (P \ .001); however, Tegner activity scale and age have a significant correlation, which may explain the significant difference in activity level between the 2 age cohorts (r = 20.284, P = .005). In all patients, there were no differences based on meniscus side (medial vs lateral), presence of an ACL tear, or whether patients had a concomitant microfracture procedure at index meniscus suture repair surgery. No significant differences were found in Lysholm score, Tegner activity scale, or patient satisfaction with outcome based on meniscus side (medial vs lateral) (Table 4), presence of an ACL tear (Table 5), or concomitant microfracture procedure (Table 6). Years of follow-up did not correlate with any outcomes scores (P . .05).
DISCUSSION In this study, patients who underwent primary meniscus suture repair at 40 years of age and older had similar knee function, satisfaction with outcome, and meniscus repair failure rates as those patients who were younger than 40 years
old when evaluated at a minimum 10 years after index surgery. There was a significant difference in the number of patients who underwent a concomitant ACL reconstruction; however, no significant differences in outcomes were seen between the 2 cohorts, except for activity level, which has been shown to be significantly correlated with age in a normal population.6 Overall, patients had high function and high satisfaction with outcome regardless of age. Previous studies have documented age as a predictor of meniscus suture repair failure, with younger patients more likely to fail than older patients.1,2,13,14 However, previous studies have included multiple repair techniques by more than 1 surgeon, younger patients due to limited number of patients older than 40 years, and follow-up less than 10 years.1,2,4,12,13 Barrett et al4 reported on patients 40 years or older who had meniscus suture repair surgery. Fourteen percent of the patients were symptomatic on physical examination, and 3 of 37 (8%) required repeat arthroscopy, which confirmed that the meniscus repair had not healed.4 While our study had similar results, Barrett’s study was limited to 2-year follow-up and did not have a younger group for comparison. In a large study of a statewide database, subsequent meniscectomies were seen in 8.9% of meniscus repairs.14 One factor associated with subsequent meniscectomy was
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TABLE 4 Postoperative Outcomes Among Patients Who Underwent Medial Versus Lateral Meniscus Suture Repaira
Meniscus suture repair failure, no. of patients Lysholm Tegner activity scale, median (range) WOMAC Pain Stiffness Function Total SF-12 Physical component summary Mental component summary Patient satisfaction with outcome, median (range)
Medial Meniscus (n = 87)
Lateral Meniscus (n = 43)
P Value
6 86 (53-100) 4 (0-9)
1 86 (57-100) 6 (1-9)
.491 .249
2 1 5 7
(0-10) (0-6) (0-31) (0-45)
2 1 4 6
53.9 (33.1-62.0) 52.8 (23.9-61.6) 10 (1-10)
(0-8) (0-6) (0-17) (0-22)
.441 .566 .912 .649
53.9 (33.1-62.0) 52.8 (23.9-61.6) 9 (1-10)
.476 .603 .333
a There were 51 patients who were excluded from analysis because they had both medial and lateral meniscus tears. One failure was not included in the table because it involved both medial and lateral meniscus tears. Results are reported as mean (range) unless otherwise indicated. SF-12, Short Form–12; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
TABLE 5 Postoperative Outcomes Among Patients With and Without an Anterior Cruciate Ligament (ACL) Tear at Index Surgery ACL Tear (n = 141)
No ACL Tear (n = 40)
P Value
6 84 (61-100) 4.5 (1-9) 9.5 (4-10)
2 87 (53-100) 5 (0-9) 10 (1-10)
.213 .718 .816
Meniscus suture repair failure, No. of patients Lysholm, mean (range) Tegner activity scale, median (range) Patient satisfaction with outcome, median (range)
TABLE 6 Postoperative Outcomes After Meniscus Suture Repair Among Patients With and Without Concomitant Microfracture at Index Surgery Microfracture (n = 21)
No Microfracture (n = 13)
P Value
1 87 (53-100) 5 (0-9) 9.5 (1-10)
7 84 (61-100) 4.5 (1-8) 10 (1-10)
.293 .817 .423
Meniscus suture repair failure, No. of patients Lysholm, mean (range) Tegner activity scale, median (range) Patient satisfaction with outcome, median (range)
isolated meniscus repairs without concomitant ACL reconstruction. However, patients over 40 with isolated meniscus repairs were at decreased risk if compared with patients under 20. In addition, subsequent meniscectomy rates were dependent on surgeon volume and experience.14 In that study, it is unclear whether subsequent meniscectomies involved the same area of the repair, and no outcomes data were available. In our study, all repairs were done by 1 surgeon, and the details regarding subsequent arthroscopies were documented. Another study reported a case-adjusted failure rate of 27% at 7.5 years.7 The study reported that younger age was a factor associated with failure and that all failures happened within 4 years of repair. At follow-up, all of the patients had normal to nearly normal knees according to the International Knee Documentation Committee (IKDC) score; however, only isolated tears were included. We found that isolated tears were not commonly seen in our
population. It is unclear why we had so few; however, it may be due to activity level or the sport they were participating in when the injury occurred. Melton et al16 reported on patients undergoing meniscus suture repair and ACL reconstruction. With 69% follow-up at an average of 10 years, the distribution of Lysholm scores showed that the majority of patients had scores greater than 80 points. This observation is similar to the outcomes we found at a minimum of 10 years after meniscus repair. Most studies in the literature have varying definitions of meniscus repair failure. In the current study, all patients were contacted to determine whether they had undergone a subsequent knee surgery. If patients indicated that they had undergone subsequent knee surgery, all subsequent reports were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surgery treated the same area of the meniscus that was
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repaired in the index surgery. Most studies have defined failure as subsequent meniscectomies. We thought it was critical to determine whether failure actually happened at the repair site. Most of these failures occur within the first 2 years after repair. Other subsequent arthroscopies included meniscus damage located in areas other than the repair site at an average of 5 years in the younger cohort and 8 years in the older cohort. The initial damage to the meniscus that was repaired may put other areas of meniscus tissue at risk of future degeneration; however, our purpose was to determine failure of the repair. More research is needed to determine whether meniscus repair puts other parts of the meniscus at risk for future damage.
Limitations Data were reviewed retrospectively; however, all data were collected prospectively. Not all patients who underwent a subsequent surgery at an outside institution had operative reports available for review. With this length of follow-up, some reports from other institutions were destroyed. Since failure was determined by findings at subsequent arthroscopy, patients whose repairs failed but who did not have subsequent surgery would not have been detected as failures. In addition, there was limited magnetic resonance imaging or objective clinical examination data. The size of each comparison cohort may have limited the statistical power of the study; however, this study examined a consecutive series of patients treated by 1 surgeon. The goal of this study was to determine the outcomes after primary meniscus repair; therefore, outcomes were only collected for patients who did not undergo a subsequent knee surgery, which may bias outcomes toward a more favorable result. However, all differences in outcomes scores were within the minimal detectable change of the instrument.
CONCLUSION Meniscus repair failure rate was not different in patients who were younger than 40 years versus those who were 40 years and older at time of meniscus index surgery. Patients who underwent meniscus suture repair had high function and high patient satisfaction at an average of 16 years after meniscus suture repair, and there were no differences in failure rate or outcomes based on age.
REFERENCES 1. Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. 2. Bach BR Jr, Dennis M, Balin J, Hayden J. Arthroscopic meniscal repair: analysis of treatment failures. J Knee Surg. 2005;18(4):278284.
3. Baratz ME, Fu FH, Mengato R. Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med. 1986;14(4): 270-275. 4. Barrett GR, Field MH, Treacy SH, Ruff CG. Clinical results of meniscus repair in patients 40 years and older. Arthroscopy. 1998;14(8):824-829. 5. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15(12):1833-1840. 6. Briggs KK, Steadman JR, Hay CJ, Hines SL. Lysholm score and Tegner activity level in individuals with normal knees. Am J Sports Med. 2009;37(5):898-901. 7. Eggli S, Wegmu¨ller H, Kosina J, Huckell C, Jakob RP. Long-term results of arthroscopic meniscal repair: an analysis of isolated tears. Am J Sports Med. 1995;23(6):715-720. 8. Englund M, Roemer FW, Hayashi D, Crema MD, Guermazi A. Meniscus pathology, osteoarthritis and the treatment controversy. Nat Rev Rheumatol. 2012;8(7):412-419. 9. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30(4):664-670. 10. Grant JA, Wilde J, Miller BS, Bedi A. Comparison of inside-out and all-inside techniques for the repair of isolated meniscal tears: a systematic review. Am J Sports Med. 2012;40(2):459-468. 11. Henning CE, Lynch MA, Clark JR. Vascularity for healing of meniscus repairs. Arthroscopy. 1987;3(1):13-18. 12. Jackson JP. Degenerative changes in the knee after meniscectomy. Br Med J. 1968;2(5604):525-527. 13. Kurosaka M, Yoshiya S, Kuroda R, Matsui N, Yamamoto T, Tanaka J. Repeat tears of repaired menisci after arthroscopic confirmation of healing. J Bone Joint Surg Br. 2002;84(1):34-37. 14. Lyman S, Hidaka C, Valdez AS, et al. Risk factors for meniscectomy after meniscal repair. Am J Sports Med. 2013;41(12):2772-2778. 15. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154. 16. Melton JT, Murray JR, Karim A, Pandit H, Wandless F, Thomas NP. Meniscal repair in anterior cruciate ligament reconstruction: a longterm outcome study. Knee Surg Sports Traumatol Arthrosc. 2011; 19(10):1729-1734. 17. Morgan CD. The ‘‘all-inside’’ meniscus repair. Arthroscopy. 1991; 7(1):120-125. 18. Morgan CD, Casscells SW. Arthroscopic meniscus repair: a safe approach to the posterior horns. Arthroscopy. 1986;2(1):3-12. 19. Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscus tears extending into the avascular zone with or without anterior cruciate ligament reconstruction in patients 40 years of age and older. Arthroscopy. 2000;16(8):822-829. 20. Roos H, Laure´n M, Adalberth T, Roos EM, Jonsson K, Lohmander LS. Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one years, compared with matched controls. Arthritis Rheum. 1998;41(4):687-693. 21. Scott GA, Jolly BL, Henning CE. Combined posterior incision and arthroscopic intra-articular repair of the meniscus: an examination of factors affecting healing. J Bone Joint Surg Am. 1986;68(6):847-861. 22. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51(3):517-526. 23. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43-49. 24. Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220-233. 25. Warren RF. Arthroscopic meniscus repair. Arthroscopy. 1985;1(3): 170-172.
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