Time for a paradigm change in meniscal repair: save the meniscus!
- Cite this article as:
- Seil, R. & Becker, R. Knee Surg Sports Traumatol Arthrosc (2016) 24: 1421. doi:10.1007/s00167-016-4127-9
One of the most important clinical achievements highlighted at the third international meeting “The Meniscus: Preserve the future”, held in Porto in early February this year , was the improvement made in the field of meniscal repair. The loss of the meniscus can be regarded as a pre-arthritic condition for the knee due to the loss of protective function [2, 3]. However, the tear pattern has a crucial impact on that risk, and it became obvious that the differentiation of tear types and repair techniques has resulted in significant progress over the last few years.
In 2016, numerous advanced techniques for meniscal repair are being performed, regardless of the site of the tear [4, 26]. There is no place in the knee that cannot be reached by the arthroscope. However, some of the repair techniques are in the early stages of development and require further improvement to reach global acceptance . They appear very promising, as many surgeons have adopted them in a short period of time.
Meniscus repair is gaining in popularity among an increasing number of surgeons. A better understanding, more sophisticated devices for meniscus repair and the increasing success rate might be some of the explanations. The increasing popularity of meniscus repair also includes meniscus lesions, which are associated with anterior cruciate ligament (ACL) injuries. At several European centres, meniscal repair procedures are now being performed in up to 40–60 % of all ACL reconstructions. In addition, these repairs are being extended increasingly to an athletic population and even professional athletes and football players. The medial meniscus in particular is becoming the focus of attention. As the main secondary stabiliser in anteroposterior laxity after an ACL injury, it is well known that this structure plays an important role in the long-term development of osteoarthritis and, as shown recently by Robb et al. , its absence negatively affects the fate of ACL graft survival. These are the reasons why efforts have recently been made to increase our understanding of medial meniscus tears , to rediscover certain types of injury like the meniscosynovial or ramp lesions [1, 5, 8, 19,23, 25] and to improve long-existing repair techniques [15, 20].
Another new development in meniscal repair relates to root tears, which have moved into focus over the last 5–10 years [6, 7, 11–13]. Unknown a decade ago, they are attracting extraordinary attention nowadays, from both a clinical and a research perspective. Lateral meniscus root tears frequently occur in conjunction with ACL injuries. For this reason, much more attention may be paid to the posterior horn of the lateral meniscus during ACL reconstructions nowadays . Root tears at the posterior horn of the medial meniscus are also detrimental. Although they may occur in younger individuals after an acute trauma, the majority of them can be observed after a minor event in patients over the age of 50 and particularly in women. The first meta-analyses show that the clinical results improved after surgery and the progression of osteoarthritis could be prevented in the short term in the majority of patients. Perfect results with complete healing and the reduction in meniscal extrusion were observed in about 60 % of patients . This is undoubtedly lower than what can be expected after meniscal repair in younger patients, but, given the age of the patients and the limited options for biological treatment alternatives, these results may be superior to what can be expected as a result of salvage procedures . In addition to this, two recent studies found an association between medial meniscus root tears and spontaneous aseptic osteonecrosis of the medial femoral condyle [22, 28]. Although the causal effect and the deeper understanding of this association still need to be proven, the occurrence of a sudden biomechanical change in the medial tibiofemoral compartment induced by a posterior meniscal root tear may explain the currently most recognised cause of spontaneous osteonecrosis in elderly patients, which is not osteoporosis  but an insufficiency fracture . This would further increase the evidence indicating that spontaneous osteonecrosis of the medial femoral condyle is not induced by arthroscopy [17, 18].