Kurzweil, Peter R.

Purpose This prospective, multicenter trial evaluates the clinical success (as measured by reoperation rates and improvements in patient‐reported outcome measures) of using circumferential compression stitches with all‐suture techniques for horizontal cleavage tears (HCTs) of the meniscus. Methods Investigators enrolled 30 patients (mean age, 38.2 years; standard deviation, 11.1 years) aged 18 to 60 years with HCTs in the symptomatic compartment at 8 centers in the United States who underwent HCT repair with all‐suture circumferential stitches using a self‐retrieving all‐inside suture passing device. Postoperative follow‐up visits were conducted at 6 months, 1 year, and 2 years. Study outcomes included freedom from reoperation of the index meniscus repair site; knee pain and function, as measured by International Knee Documentation Committee Knee evaluation (IKDC), Knee injury and Osteoarthritis Outcome Score, Lysholm Knee Scale, and Tegner Activity Scale; and serious complications observed during the study. Minimal clinically important difference at 1 year was assessed for IKDC and Lysholm. Results Twenty‐three patients had 2‐year follow‐up data available. Freedom from reoperation was 96.0% at 6 months (26/27, 91.7% at 1 year [23/25], and 82.6% at 2 years [19/23]). Significant improvement was observed in over baseline at 2 years for IKDC (36.7‐82.5; P < .001), Knee injury and Osteoarthritis Outcome Score (52.2‐89.3; P < .001), Lysholm (50.2‐87.4; P < .001), and Tegner scores (3.3‐5.3; P = .007). Minimal clinically important difference was met or exceeded for IKDC and Lysholm scores at 1 year 69.2% and 65.4% of patients, respectively. Four patients (6.7%) experienced serious complications, of which 2 were assessed as being related to the procedure. Conclusions Repair of HCTs using all‐suture circumferential stitches placed with a self‐retrieving all‐inside suture passing device leads to a favorable reoperation rate (17.4%), significant improvements in clinical outcomes, and an acceptable rate of serious complications (6.7%) at 2 years, supporting the viability of this treatment approach in this indication. Level of Evidence Level IV, therapeutic case series.

Abstract Meniscus tears are commonly encountered in the clinical and operative setting and vary in presentation, including bucket‐handle, radial, and horizontal cleavage tears. Historically, tears were treated with benign neglect or partial meniscectomy. However, a great deal of subsequent research has highlighted the biomechanical consequences of tears and meniscectomy, including increased peak local contact forces, progressive postmeniscectomy arthritis, and subsequent arthroplasty. With the advent and evolution of repair devices, increasing attention is being turned to the ideal restorative treatment of meniscus tears. Successful meniscus repair is centered about the ABCs of repair: Anatomic reduction, Biologic preparation and augmentation, and Circumferential compression. Recent advances in repair techniques have included microfracture of the intercondylar notch to provide healing factors and marrow cells for augmented healing, all‐inside suture devices enabling the reduction and fixation tears without the need for additional assistants and the morbidity of inside‐out exposure, and circumferential compression combined with clot augmentation to reduce and fix horizontal cleavage tears and recreate biomechanics to within 15% of baseline contact forces. Clinical outcomes of meniscus repair using modern techniques have been promising, with reapproximation of native joint biomechanics, substantial improvements in patient subjective outcome scores, and satisfactory reoperation rates. With implementation of the ABCs of meniscus repair as well as the continued expansion of the orthopedic surgeons' meniscus repair toolbox, restoration and preservation of the meniscus are increasingly possible across the spectrum of tear types.

Background: Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. Purpose: To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. Study Design: Meta-analysis and cost-effectiveness analysis. Methods: A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. Results: Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. Conclusion: Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.