Trephination and suturing of avascular meniscal tears: A clinical study of the trephination procedure

doi:10.1016/S0749-8063(96)90178-4

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 12, Issue 6, December 1996, Pages 726-731

https://doi.org/10.1016/S0749-8063(96)90178-4 Get rights and content

Abstract

On the basis of animal studies, an arthroscopic surgical system and procedure of trephination plus suturing were designed for clinical practice. The system consists of a trephine with a tooth-like tip, a guide, and an ordinary arthroscopic power handle. The guide introduces the trephine to the tear without abrading articular cartilage and controls the depth of the trephination. The power handle connected to a suction system provides an inside-out cut core of meniscal tissue. Thirty-six patients with meniscal tears underwent arthroscopic trephination plus suturing (group TS) and 28 patients had suturing alone (group S). The follow-up was 25 to 78 months. Two symptomatic retears have occurred in group TS and 7 symptomatic retears in group S. The symptomatic retear rate of group TS was significantly smaller than group S (P < .01). It is indicated that the patients treated with trephination have fewer symptoms and lower clinical failure rate. Arthroscopic trephination is a safe and easy procedure.

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Cited by (46)

All-inside versus inside-out meniscal repair: A systematic review and meta-analysis
2021, Knee
Citation Excerpt :
This may explain the lower rate of meniscal healing for the all-inside group shown in this study. In addition to concomitant ACL reconstruction increasing meniscal repair healing rates, other surgical techniques have been shown to promote meniscal healing, such as trephination of the meniscal rim to stimulate bleeding [39], parameniscal synovial abrasion [40], interposition of fibrin clot into the tear [41] and microfracture of the intercondylar notch [38]. These were also not controlled for.
Meniscal repair using all-inside devices has garnered popularity compared to inside-out repair, yet few studies directly compare the two techniques in terms meniscal healing rates, surgical time, patient outcomes and incidence of complications.
A systematic literature review was performed using the Medline, Cochrane and Embase databases. English-language studies comparing all-inside and inside-out arthroscopic meniscal repair techniques directly were included. Randomised controlled trials (RCTs) and observational studies with at least 10 patients in each treatment arm were included. Meta-analyses were performed using a fixed effect (when I2 < 50%) or random effects model (I2 ≥ 50%).
A total of 1042 studies were identified with seven being sui for inclusion (n = 505 patients). These comprised of one RCT two prospective and four retrospective, comparative, observational studies. Meta-analyses demonstrated that there was a significant reduction in operating time favouring all-inside repair (ratio of means [ROM] 0.62, 95% confidence interval [CI] 0.48–0.79; p = 0.0002) based on 3 studies (n = 208 patients). Based on 5 studies (n = 370 patients), there was no significant difference in meniscal healing rates between the groups (OR 1.26, 95% CI 0.52–3.10; p = 0.61). Nerve injury was more common after inside-out repair. There was a 85% reduction in the odds of nerve injury with the all-inside technique (OR 0.15, 95% CI 0.05–0.47; p = 0.0013). A qualitative data analysis suggested no difference in functional outcomes between the two techniques.
All-inside meniscal repair is associated with reduced operative time and a lower odds of nerve injury complications compared to inside-out repair, without compromising meniscal healing or functional results.
Biologic Adjuvants in Meniscus Repair: A Review of Current Translational and Clinical Evidence
2020, Operative Techniques in Sports Medicine
Meniscus tears are common injuries in all age categories and cover a broad subset of lesions. Due to the lack of vascularization and blood clot formation, meniscus tears in the avascular zone possess poor healing potential. Preserving meniscus tissue however, is crucial to avoid early onset osteoarthritic changes in the knee joint. Meniscectomies are therefore, where possible, largely replaced by meniscus repair strategies. When tissue approximation (suturing) only is falling short for meniscal repair in the avascular zone, several types of biological augmentation can be recruited, which potentially benefits tear healing, and ultimately knee function. This review offers an overview of the current translational and clinical evidence regarding biologic augmentation methods for meniscus repair in a tear-type and location specific manner. Methods discussed include the use of mechanical stimulation with biological response ((para)meniscal rasping and trephination), bone marrow stimulation (± ACL reconstruction), external fibrin clot, platelet-rich plasma, cytokine/growth factor administration, and cell-based techniques.
Meniscus Repair Enhancement Options
2018, Operative Techniques in Sports Medicine
Citation Excerpt :
They found significantly better meniscal repair at 12 weeks in the PRP group compared to the control group. Moving from an animal model to clinical application, Griffin et al performed 35 isolated meniscus repairs with15 and without20 LP-PRP augmentation (delivered via fibrin matrix via absorbable suture) and compared clinical outcome scores at minimum 2-year follow-up.60 They found no difference in clinical outcome scores, reoperation rate, or rate of return to preoperative level of activities.
Meniscal tears are one of the most common pathologies of the knee. They can be managed with observation, partial meniscectomy, or repair. The limited vascularity of the meniscus central to the periphery limits the healing potential of meniscal tissue; however, recent development of biologic augments and surgical techniques have expanded the capability for meniscus repair; potentially avoiding partial meniscectomy in selected cases. The procedures and adjuncts include mechanical stimulation of the healing response, fibrin augmentation, bone marrow aspirate concentrate, mesenchymal stem cells, platelet-rich plasma, scaffolds, and others in development used either in isolation or combination. It is important for surgeons to become familiar with evolving biologic augmentation options to improve meniscal repair healing in an attempt to optimize the long-term health of the knee joint.
Rehabilitation and Return to Play Following Meniscal Repair
2017, Operative Techniques in Sports Medicine
Citation Excerpt :
Although both of these studies included few cases, this technique was successful and associated with return to the previous or close to the previous level of sports.45,86 Another bleeding stimulation technique which has been shown to significantly reduce retear rate following repair of tears extending to the white-white zone is trephination of vascular channels on the free meniscal edges.113 Other clinical applications that augment meniscal repair and may promote healing include microfracture of the intercondylar notch and platelet-rich plasma.86
The outcome of meniscal repair has been good to excellent with regard to functional restoration and return to play (RTP). Athletes represent the most demanding subgroup of patients as they have high expectations to return to their preinjury level of activity and in doing so they place maximum stress on any meniscal repair. Physical therapy rehabilitation protocols and RTP decision-making remains controversial in the setting of meniscal repair. Protective protocols had been the mainstay of treatment for many years, however, newer research has shown no harm and quicker RTP for longitudinal and bucket-handle tears located close to the outer vascular zone of the periphery of the meniscus using accelerated rehabilitation. Protective protocols and slower RTP remain the most prudent choice in complex, horizontal and radial tears or those extending into the middle to central third of the more avascular zone of the meniscus. The authors have therefore, with evidence from current publications, developed 2 separate protocols to treat both peripheral and complex tears. One accelerated and one protective protocol is established. During the preoperative planning, it would be helpful for the surgeon, patient, and family to know what can be expected with regard to the surgical success of meniscal repair and the likelihood of RTP in this active population. A literature review on the outcome of meniscal repair related to RTP was performed and revealed that the majority of patients succeed to RTP at the same or similar to their preinjury level, between 4 and 6 months following meniscal repair. Factors that may affect the outcome and RTP along with rehabilitative considerations following meniscal repair are discussed.
Meniscus Tears: Diagnosis, Repair Techniques, and Clinical Outcomes
2017, Noyes' Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes
Clinical healing rates of meniscus repairs of tears in the central-third (red-white) zone
2014, Arthroscopy - Journal of Arthroscopic and Related Surgery
To determine the clinical healing rate of repairs of meniscus tears that extend into the central one-third region and the factors that affect the outcome.
A systematic search of PubMed was conducted to determine the outcome of meniscus repairs in the red-white (R/W) zone. Inclusion criteria were as follows: English language, clinical trials published from 1996 to 2013, R/W tears analyzed separately from tears in other zones, arthroscopic suture-based repairs, and all evidence levels.
Of 344 articles identified, 23 met the inclusion criteria. There were 1,232 patients who had 1,326 meniscus repairs, of which 767 were in the R/W zone. Concurrent anterior cruciate ligament reconstruction was performed in 955 patients (78%). The mean age was 25 years, and the mean follow-up was 4 years. Evaluation criteria included clinical examination in 22 studies, follow-up arthroscopy in 15, magnetic resonance imaging in 6, weight-bearing radiographs in 3, and the International Knee Documentation Committee subjective score in 1. Overall, 637 (83%) of the repairs were considered clinically healed because no additional surgery was required and no obvious clinical meniscus symptoms were detected. This included 382 of 470 inside-out suture repairs (81%) and 255 of 297 all-inside suture repairs (86%). Twenty-two factors were assessed in 13 studies to determine their influence on the outcome, with varying results. Authors generally found that patient age, chronicity of injury, involved tibiofemoral compartment, gender, and concurrent anterior cruciate ligament reconstruction did not adversely affect the results. Insufficient data existed to assess the healing rates according to the type of meniscus tear except for single longitudinal tears. Complications were reported in 3% of the patients in this review. Long-term assessment of a chondroprotective effect of the repairs was conducted in only 2 studies.
An acceptable midterm clinical healing rate was found for R/W meniscus repairs, supporting this procedure when appropriately indicated. Long-term studies assessing the chondroprotective effect in the involved tibiofemoral compartment using magnetic resonance imaging and radiographs are needed.
Level IV, systematic review of Level I-IV studies.

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Original articleTrephination and suturing of avascular meniscal tears: A clinical study of the trephination procedure

Abstract

Clin Sports Med

Arthroscopy

Biomaterials

Arthroscopy

Arthroscopy

Meniscal tears: The effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee

Peripheral tears of the meniscus

Open Meniscus repair or excision

Clin Sports Med

Knee joint changes after meniscectomy

J Bone Joint Surg Br

Articular cartilage changes following meniscal lesions

The knee—The physiological joint

J Bone Joint Surg Am

Transmission of the load in the joint with special reference to the role of the menisci

Eng Med

Knee function after meniscus repair and total meniscectomy

Meniscus repair in knee ligament injuries

Acta Orthop Scand

Original article
Trephination and suturing of avascular meniscal tears: A clinical study of the trephination procedure