Fig 1 - uploaded by Kempland C. Walley
Content may be subject to copyright.
Source publication
Purpose
A device for all-inside suture-based meniscal repairs has been introduced (NovoStitch; Ceterix, Menlo Park, CA) that passes the suture vertically through the meniscus, thereby encircling the tear, and does not require an additional incision or extra-capsular anchors. Our aim was to compare this all-inside suture-based repair with an inside-...
Similar publications
Purpose
The purpose of this study is to classify the discoid lateral meniscus (DLM) according to the signal and shape in magnetic resonance imaging (MRI), and to provide information not only in diagnosis but also in treatment.
Materials and Methods
We reviewed 162 cases who diagnosed with DLM by MRI and underwent arthroscopic procedures from April...
Background:
The cause of spontaneous osteonecrosis of the knee (SONK) and postarthroscopic osteonecrosis of the knee is unknown, and the mechanisms involved have been poorly characterized. Hypothesis/Purpose: The purpose of this study was to perform a detailed systematic review of the literature to examine proposed etiological mechanisms for SONK...
Background:
Total meniscectomy leads to knee osteoarthritis in the long term. The poly(ε-caprolactone) (PCL) scaffold is a promising material for meniscal tissue regeneration, but cell-free scaffolds result in relatively poor tissue regeneration and lead to joint degeneration.
Hypothesis:
A novel, 3-dimensional (3D)-printed PCL scaffold augmente...
Objective
To determine the outcomes after combined inside-out and all-inside repair technique of bucket-handle meniscus tears.
Methods
A retrospective review was made of patients with bucket-handle meniscus tears repaired with combined techniques, using the all-inside technique in posterior meniscal tears and the inside-out technique in the middle...
The fibrocartilaginous menisci dwell between the articular surfaces of the knee and play a crucial role in healthy joint loading. They transmit forces, absorb shock, and enhance the stability of the joint. Traumatic injury and/or degenerative changes disrupt the mechanical function of these tissues. These changes can lead to the early onset and acc...
Citations
... The first approaches to quantify meniscal tear gapping were simplified uniaxial ex vivo tensile tests using standard testing machines. [20][21][22][23][24][25][26][27][28] Other groups have utilized magnetic resonance imaging (MRI) [29][30][31][32] 35,36 leading to significant debate. From a technological point of view, meniscus gapping was assessed optically by movement deflection, [20][21][22][23][24][25][26][27][28] MRI, [29][30][31][32] arthroscopically 33,34 and Roentgen stereophotogrammetric analysis (RSA). ...
... [20][21][22][23][24][25][26][27][28] Other groups have utilized magnetic resonance imaging (MRI) [29][30][31][32] 35,36 leading to significant debate. From a technological point of view, meniscus gapping was assessed optically by movement deflection, [20][21][22][23][24][25][26][27][28] MRI, [29][30][31][32] arthroscopically 33,34 and Roentgen stereophotogrammetric analysis (RSA). 35,36 To the best of the authors' knowledge, meniscal tear gapping has only been studied independently of the related tibiofemoral contact pressure, which is an important contributor to a healthy knee joint. ...
Meniscal tearing can increase the contact pressure between the tibia and femur by causing gapping of torn meniscus tissue. The aim of this study was to quantify gapping behaviour of radial and longitudinal tears and their impact on peak contact pressure and mean contact area. Twelve porcine knee joints underwent unicondylar, convertible osteotomy for exact tear application and consecutive suturing. Six tantalum marker beads were positioned along meniscus tears. The joints were preloaded with sinusoidal loading cycles ranging between 0 N and 350 N. Peak load was held constant and two synchronised Roentgen stereophotogrammetric analysis x‐ray images were obtained to evaluate gapping, peak contact pressure and mean contact area in the native, torn and repaired states. There was no change in gapping or peak contact pressure in longitudinal tear. By contrast, the radial tear led to a significant gapping when compared to the native state, while the inside‐out suture was able to restore gapping in parts of the meniscus. An increase in contact pressure after radial tear was detected, which was again normalised after suturing. The most important finding of the study is that longitudinal tears did not gap under pure axial loading, whereas radial tears tended to separate the tear interfaces.
This article is protected by copyright. All rights reserved.
... 4 When compared to inside-out repairs, circumferential compression stitches placed with the Novostitch device (Smith & Nephew, Andover, MA) demonstrated lower displacement (gap formation) at high cyclic loading. 19 Moreover, circumferential compression stitches have demonstrated the highest load to failure of all meniscus repair patterns. 19,20 Subsequent cadaveric testing has also demonstrated that circumferential compression stitches of HCTs return tibiofemoral contact pressures to near normal-normal levels. ...
... 19 Moreover, circumferential compression stitches have demonstrated the highest load to failure of all meniscus repair patterns. 19,20 Subsequent cadaveric testing has also demonstrated that circumferential compression stitches of HCTs return tibiofemoral contact pressures to near normal-normal levels. 21 which are anterior to the femoral origin of the anterior cruciate ligament (ACL) and allow for bone marrow elements to leak into the joint space. ...
... 13 Additionally, suture-based devices eliminate implant pull-through as a mode of failure for repairs and also eliminate implant-related complications. 19,23,24 On the other hand, there is a distinct possibility of knot-slippage as a mode of failure. As a consequence, there is an increased importance of secure knot tying when using these devices. ...
Horizontal cleavage tears (HCTs) are challenging meniscal tear patterns, as they split the meniscus into inferior and superior leaflets, while also involving the central, less vascular portions of the meniscus. Circumferential compression sutures using an all-inside self-retrieving suture passing device like the Novostitch Pro (Smith & Nephew, Andover, MA) have demonstrated the ability to create stable repair constructs with uniform compression across both leaflets in the setting of HCTs. Additionally, biological augmentation of meniscal repairs using a marrow venting procedure (MVP) has demonstrated superior clinical outcomes relative to isolated meniscal repairs. Thus, the purpose of this technical note is to outline our procedure for implementing circumferential compression sutures and biologic augmentation using an MVP for repairing an HCT of the lateral meniscus.
... This device has also been tested in the setting of longitudinal tears. Masoudi et al. compared the Novostitch to inside-out repair and all-inside capsular based repair and found that the meniscal based repair had higher loads to failure than the allinside capsular based repair and lower cyclic displacement than the inside-out repair [56]. Further, traditionally difficult to address lateral meniscus tears in the popliteal hiatus region can be repaired since the suture can be placed around the periphery of the meniscus without entrapping the popliteal tendon [51]. ...
Purpose of Review
The indications for partial meniscectomy are becoming increasingly limited, and recent evidence suggests that the meniscus should be preserved whenever possible. Because of its many proposed advantages, all-inside meniscus repairs are becoming increasingly common. This review discusses the indications, advantages, disadvantages, and biomechanical and clinical outcomes of all-inside meniscus repair.
Recent Findings
All-inside meniscus repair demonstrates equal functional outcomes, healing rates, and complications compared to inside-out repair of vertical longitudinal and bucket-handle tears with the advantages of decreased surgical time and faster post-operative recovery. In addition, return-to-sport and activity levels are high following all-inside repair regardless of whether concomitant anterior cruciate ligament reconstruction is performed. Biomechanical studies have demonstrated advantages of all-inside meniscal based repairs on radial and horizontal tears.
Summary
All-inside meniscus repair compares favorably to inside-out repair of vertical longitudinal and bucket-handle tears and continues to increase in popularity. Both capsular based and meniscal based repairs can be used to repair a variety of tear patterns. While biomechanical results are encouraging, further research on the clinical outcomes of meniscal based repairs is needed to elucidate the role of these techniques in the future.
... Suture fixation is an important biomechanical parameter in successful meniscal repair and is required to withstand the different loads applied [39]. [7,31,50]. Additional biomechanical testing was conducted and investigated the stiffness and load to failure of menisci. ...
Purpose
Meniscus allograft transplantation (MAT) is a possible treatment for patients suffering with pain after meniscectomy. Here, peracetic acid (PAA) sterilised meniscus transplants were investigated on whether they would provide an adequate alternative to fresh-frozen transplants in their viscoelastic and mechanical properties.
Methods
In this analysis, 31 menisci donors (26 male and 5 female) were included. The average donor age was 49.87 years, ranging from 32 to 65 years. Menisci of matched pairs of knees underwent chemical sterilisation while counterparts were left fresh-frozen. Stiffness and load to failure were determined via suture retention. Further menisci were analysed while attached to the tibial bone block using a novel test device to mimic physiological load distribution. Meniscus relaxation, stiffness and failure loads were determined. Histology and biphasic properties of the menisci were examined and results were analysed using paired t-tests.
Results
A novel custom built test device allowed the application of physiological loads for suture retention testing and revealed no significant differences between PAA sterilised (14.85 ± 4.46 N/mm, 50.49 ± 17.01 N) and fresh-frozen (18.26 ± 4.46 N/mm, 59.49 ± 21.07 N) regarding stiffness and failure load, respectively. Furthermore, initial 200 N loading showed significantly higher strain in sterilised menisci (18.87 ± 1.56) compared to fresh frozen (13.81 ± 1.04). Load relaxation experiments demonstrated significantly lower relaxation for sterilised menisci (77.71 ± 1.62) compared to fresh-frozen (89.11 ± 1.00, p -value < 0.0001).
Conclusion
Peracetic acid sterilised human menisci performed equally to fresh-frozen counterparts in a suture retention test and in physiological failure testing providing an adequate alternative. However, meniscus relaxation, biphasic properties and strain were shown to be significantly different between the groups. A common problem of MAT is graft extrusion or shrinkage, therefore the parameters measured here should be considered and may influence meniscus extrusion after transplantation.
Level of evidence
n/a (experimental study)
... Previous studies evaluated the suture methods of the meniscus repair [1,2,20,23]. Aık et al. compared the suture strength using bovine knees in meniscal repair among 5 suture techniques; horizontal mattress, vertical mattress, knot-end, vertical, and vertical loop, and described that the largest ultimate failure load occurred in the vertical mattress suture technique. ...
... There was no statistical difference in the ultimate failure load between each group, and all subjects in all groups showed knot failure. The previous reports also indicated that the failure mode in the load to failure test was mainly the knot failure [1,2,20,23]. Then, the suture can be damaged in tying a knot the knot tying procedure for the meniscus repair may made a weak point in the stitching. ...
Purpose
The inside-out meniscal repair is widely performed to preserve the function of meniscus. In this technique, the outer suture is passed through the capsule as well as the outer meniscus, while the inner suture is inserted into the meniscus. The aim of this study was to biomechanically compare the suture stability between meniscus-meniscus and meniscus-capsule suture methods for the longitudinal meniscal tear with inside-out technique.
Methods
Twenty-seven porcine knees were dissected to maintain the femur-medial capsule/meniscus-tibia complex, and the inner meniscus was cut off along the meniscus circumferential fiber with 3 mm width of the peripheral meniscus preserved. After one needle with a 2-0 polyester suture was inserted into the inner portion of the meniscus, the other needle was inserted through 1) the peripheral meniscus (Group A), 2) capsule just above the meniscus (Group B), and 3) capsule at 10 mm apart from the meniscus-capsule junction (Group C) in the inside-out manner. Then, the suture was manually tied on the capsule. The suture gap at the repair site during 300 times of cyclic loading and the ultimate failure load in the load-to-failure test were measured. The statistical significance of the data between two groups in each combination was considered by Bonferroni correction, following a one-way analysis of variance.
Results
In the cyclic loading test, the suture gap was 0.68 ± 0.26 mm in Group A, 1.08 ± 0.36 mm in Group B, and 1.94 ± 0.57 mm in Group C with a significant difference. In the load-to-failure test, the ultimate failure load was 59.1 ± 13.6 N in Group A, 60.0 ± 7.9 N in Group B, and 57.4 ± 4.7 N in Group C, and there was no significant difference.
Conclusion
The stitching region in the inside-out technique for longitudinal meniscal tear affected the stability of the tear site, and stitching the mid-substance region of the meniscus provides good stability in response to cyclic tensile loading. In addition, the stitching region did not affect the ultimate failure load.
Clinical relevance
In the inside-out meniscal repair, the outer suture should be inserted into the remaining peripheral meniscus or the capsule near the meniscus.
... 15,28 In our study, menisci were randomly assigned to the repair groups, and no further differentiation between medial and lateral samples was made, which is common practice in other studies as well. 7,23,31,34 Because this is a biomechanical evaluation of a worstcase scenario simulating a perpendicular load on singlepassage vertical meniscal repair, the results might not be unconditionally transferred to actual patients, bearing in mind complex knee kinematics including rotational and shear forces. 8 On the other hand, a particular strength of this work is that, to the best of our knowledge, the present study is the only available report investigating a potential relationship between construct stiffness and cheese-wiring under cyclic loading conditions. ...
Background
Cheese-wiring, the suture that cuts through the meniscus, is a well-known issue in meniscal repair. So far, contributing factors are neither fully understood nor sufficiently studied.
Hypothesis/Purpose
To investigate whether the construct stiffness of repair sutures and devices correlates with suture cut-through (cheese-wiring) during load-to-failure testing.
Study Design
Controlled laboratory study.
Methods
In 131 porcine menisci, longitudinal bucket-handle tears were repaired using either inside-out sutures (n = 66; No. 0 Ultrabraid, 2-0 Orthocord, 2-0 FiberWire, and 2-0 Ethibond) or all-inside devices (n = 65; FastFix360, Omnispan, and Meniscal Cinch). After cyclic loading, load-to-failure testing was performed. The mode of failure and construct stiffness were recorded. A receiver operating characteristic curve analysis was performed to define the optimal stiffness threshold for predicting meniscal repair failure by cheese-wiring. The 2-tailed t test and analysis of variance were used to test significance.
Results
Loss of suture fixation was the most common mode of failure in all specimens (58%), except for the Omnispan, which failed most commonly because of anchor pull-through. The Omnispan demonstrated the highest construct stiffness (30.8 ± 3.5 N/mm), whereas the Meniscal Cinch (18.0 ± 8.8 N/mm) and Ethibond (19.4 ± 7.8 N/mm) demonstrated the lowest construct stiffness. The Omnispan showed significantly higher stiffness compared with the Meniscal Cinch ( P < .001) and Ethibond ( P = .02), whereas the stiffness of the Meniscal Cinch was significantly lower compared with that of the FiberWire ( P = .01), Ultrabraid ( P = .04), and FastFix360 ( P = .03). While meniscal repair with a high construct stiffness more often failed by cheese-wiring, meniscal repair with a lower stiffness failed by loss of suture fixation, knot slippage, or anchor pull-through. Meniscal repair with a stiffness >26.5 N/mm had a 3.6 times higher risk of failure due to cheese-wiring during load-to-failure testing (95% CI, 1.4-8.2; P < .0001).
Conclusion
Meniscal repair using inside-out sutures and all-inside devices with a higher construct stiffness (>26.5 N/mm) was more likely to fail through suture cut-through (cheese-wiring) than that with a lower stiffness (≤26.5 N/mm).
Clinical Relevance
This is the first study investigating the impact of construct stiffness on meniscal repair failure by suture cut-through (cheese-wiring).
... In cadaver models, suture repair successfully restores joint biomechanics to within normal conditions for posterior root tears [74] and bucket-handle tears [75]. There are certain meniscus tears in which placement of accurate sutures for meniscus repairs can be achieved with modern commercial suture instrumentation (flexible all-inside devices), such as longitudinal tears in the R/R region [76]. We recommend avoiding the use of only 2-3 sutures for all-inside repairs because of the uncertain tensile strength that is required to provide stability during early postoperative rehabilitation. ...
This chapter summarizes data in the current literature regarding return to sport (RTS) after meniscus surgery from 58 studies encompassing 2755 patients. There were 755 patients in 15 studies that underwent meniscectomy, 948 patients in 25 studies that had meniscus repair, and 1052 patients in 18 studies that underwent meniscus transplantation. Rates for return to preinjury sport, return to any type of sport, failures (meniscus repairs and transplants), and progression of knee osteoarthritis are provided. An analysis of the postoperative rehabilitation criteria for RTS described by each study is presented. Although high RTS rates were noted in a few meniscectomy studies in this chapter, these were offset by deterioration in radiographic knee osteoarthritis in 60–90% of patients followed >6 years postoperatively. A recommendation is made to preserve meniscus tissue and function through modern repair procedures whenever possible, especially in children and adolescent athletes. While sports are feasible after meniscus transplantation, the majority of studies recommend return to only low-impact or general athletic training due to pre-existing articular cartilage damage.
... However, there were statistically significant differences among the groups in ultimate failure load. Compared with that of the other groups, the stiffness of the C group was significantly lower a , b , d : p < 0.01; c : p = 0.02; e : p = 0.01 modes were meniscal cut-outs with No. 2-0 Force Fiber (Teleflex Medical, Research Triangle Park, NC) (Masoudi et al. 2015). In the present study, the ultimate failure load of the FWRM was 96.6 N, which was higher than those of the other two sutures, although the failure mode in all of the suture types was knot breakage with no meniscal cutout. ...
... Most available cadavers are from elderly patients who are likely to have degenerated menisci that introduce the risk that the biomechanical results would vary among specimens. Because several studies have shown that porcine menisci have properties comparable to those of human menisci Stone, 1985, 2009;Fantasia et al. 2012;Joshi et al. 1995;Buckland DM et al. 2015;Masoudi et al. 2015), we selected undamaged porcine menisci to perform our study with high precision. Second, we did not investigate the consequences of suture shape in meniscus repair after surgery because the outcomes in this study were measured at time zero after surgery. ...
Background
In the meniscal repair procedures, a high ultimate load capacity and low cyclic creep at the repair site are favorable and lead to good biological incorporation of the tear site after surgery. Previous biomechanical tensile tests of the meniscal sutures have identified the suture knot as the weakest point. We hypothesized that the strength of a suture knot depends on the suture shape, and therefore, we compared three differently shaped suture materials composed of the same material and quantity per length. The purpose of this study was to determine whether a novel flat and wide repair material (FWRM), which consists of braided multi-threads that are cross-sectionally flat and wide, improves the ultimate load of knot breakage in a biomechanical experiment using a porcine trans-capsular meniscal repair model. Methods
Eighteen fresh-frozen porcine knees (n = 6 in each group) were used. A longitudinal tear in the middle segment of the medial meniscus was created and repaired with a trans-capsular inside-out method using the following suture materials: No. 2–0 braided polyester conventional suture, hollow suture, and FWRM. After the separation of the inner segment of the meniscus with leaving, the suture stability of the repaired menisci was biomechanically analyzed with a video camera system for widening after a cyclic load between 5 and 20 N was applied 300 times. Ultimate failure load and stiffness at 5 mm/ min were also analyzed. ResultsWe found no significant difference in suture widening after cyclic load tests [conventional suture, mean 0.51 mm (S.D. 0.39 mm); hollow suture, mean 0.23 mm (S.D. 0.11 mm); and FWRM, mean 0.54 mm (S.D. 0.08 mm)]. The failure mode in all specimens was knot breakage. Compared with those of the other groups, the ultimate failure load of FWRM was statistically significantly higher in the load-to-failure tests (conventional suture, mean 58.8 N [S.D. 8.25 N]; hollow suture, mean 79.4 N [S.D. 10.2 N]; and FWRM, mean 97.4 N [S.D. 3.65 N]; p < 0.05). ConclusionFWRM improves the ultimate load of knot breakage without altering stability. This material may contribute to safe and stable meniscus repair.
... Because the loss of meniscal tissue can lead to secondary knee osteoarthritis [10][11][12], considerable emphasis has been placed on conserving meniscal tears in the hope of preserving force dissipation. Nonetheless, meniscal repair of longitudinal tears is only successful in cases of stable sutures, with a reported healing rate of 75% [13][14]. Vascularity of the parameniscal area, which is estimated to cover 10 to 30% of the total surface area of the meniscus, suggests that the potential healing of a stable meniscal tear is comparable to that of other vascularised tissues, provided that the meniscal tear is stable and there is no articular lax- ity [3,15,16]. ...
... In this case, the success rate in the present study was 12.5%. Many papers have shown that chronic laxity leads to a high rate of atraumatic meniscal tears, and good clinical results have been reported with meniscal non-treatment in conjunction with ACL reconstruction for small vascular meniscal tears [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][22][23][24]. Pierre et al. published a series of 86 patients undergoing surgery for ACL reconstruction and associated meniscal tears [24]. ...
Oxygen-ozone therapy is a minimally-invasive technique for the treatment of lumbar disc herniation, with uncertain efficacy and great prejudice mainly due to its use without rational basis or appropriate controls. We try to evaluate the real effectiveness of intradiscal ozone therapy for the treatment of low-back pain, in order to supply further evidence about this promising mini-invasive technique. A comprehensive search of PubMed, Medline, Cochrane, Embase, and Google Scholar databases was performed, covering the period between 1980 and 2015. Various combinations of the following words were used: "ozone", "ozone injection", "intradiscal ozone", "low back pain", "spine". The ozone injection therapy was studied only at intradiscal sites. Peridural, facet joints, sacroiliac joints, juxtaforaminal, and intramuscular paravertebral sites intervention trials were excluded. Furthermore, each study was evaluated for the following variables: study type, type of spine disease, number of patients, injected dose and ozone concentration, follow-up period, clinical outcome at the end of follow-up period and complications. A study was judged positive if the ozone intradiscal injection were clinically effective with statistically significant improvement from baseline (P<0.05). Eight studies involving 4155 patients treated with intradiscal ozone injection were included in the review. All selected studies provided outcome evaluation at 6 months or longer (range: 6-120 months) and all included patients were adults with LBP or sciatica due to lumbar disc herniation treated by the ozone therapy. Pain reduction and functional state were considered as primary outcomes. When reported, Visual Analogue Scale was the most employed pain measurement. Functional state has been evaluated by Oswestry Disability Index or MacNab score. There were no heavy complications in all the evaluated trials. Moreover, five case reports concerning related complications were analysed but not included in the review. Intradiscal ozone injection can be considered as a feasible option for the treatment of herniated disc showing a good safety profile in the majority of treated patients. Nevertheless, our review depicts a huge lack of high-quality evidence on this interesting topic. To date, the use of intradiscal ozone injection therapy as a treatment for LBP cannot be motivated by the best available evidence.
... Because the loss of meniscal tissue can lead to secondary knee osteoarthritis [10][11][12], considerable emphasis has been placed on conserving meniscal tears in the hope of preserving force dissipation. Nonetheless, meniscal repair of longitudinal tears is only successful in cases of stable sutures, with a reported healing rate of 75% [13][14]. ...
... Many papers have shown that chronic laxity leads to a high rate of atraumatic meniscal tears, and good clinical results have been reported with meniscal non-treatment in conjunction with ACL reconstruction for small vascular meniscal tears [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][22][23][24]. ...
Background:
Management of small and stable meniscal tears within the vascular zone at the time of anterior cruciate ligament (ACL) reconstruction is controversial. The purpose of this study was to evaluate the outcome of meniscal tear left in situ at the time of ACL reconstruction.
Methods:
Using the IKDC, KT-1000 and the Tegner Activity Score (TAS), we retrospectively analysed 175 cases of ACL reconstruction with meniscal tears performed from 2006 to 2012. Patients with residual laxity on clinical assessment were identified and considered as a subgroup. Clinical outcome and failure rate were evaluated.
Results:
In 83 patients (47.4%), a meniscal tear was left in situ at the time of ACL reconstruction: 45 were medial and 38 were lateral. Patients were clinically reassessed with a minimum follow-up of 24 months. The overall failure rate of conservative meniscal treatment in patients with objective residual laxity was 87.5%, and 6.7% in patients with a stable knee (P<0.001). Those with stable knees had higher postoperative IKDC subjective scores (P=0.0022) and TAS (P<0.0001). Patients without residual laxity had higher failure rate for the medial meniscus compared with lateral meniscus - 10.5% versus 2.7% (P=0.36)-and the red-red zone had lower revision rate compared with the red-white zone (P=0.0322).
Conclusions:
The conservative treatment of small and stable peripheral tears of the medial and lateral menisci had low failure rate and no described complications. In our series residual laxity significantly increased the failure rate.
Level of evidence:
level IV, therapeutic case series.
