Meniscal Arrows: Hitting the Target

Abstract & Commentary

Synopsis: Approximately 40 patients with combined ACL reconstruction and meniscal repair with the Bionx Arrow were retrospectively evaluated at an average of just over 2 years following surgery. The study reported a success rate of just over 90%.

Source: Gill SS, Diduch DR. Arthroscopy. 2002;18:569-577.

The Bionx meniscal arrow was one of the first commercially available bioabsorbable "all-inside" meniscal repair devices. Until recently, independent clinical evaluation of the arrow has not been presented or published. The present article represents one of several recent reports of clinical success with this device.

Gill and Diduch retrospectively evaluated 38 patients with 39 meniscal tears repaired with meniscal arrows with concurrent anterior cruciate ligament (ACL) reconstruction. An average of 2.5 arrows were used per case, and central 1/3 patellar tendon autografts were used for all ACL reconstructions. Evaluation, at an average of 2.3 years (range, 18-39 months) was accomplished in 32 patients with formal IKDC ratings, visual analog scores, KT-2000, and subjective history. Twenty-four patients were re-examined, and all 32 patients completed subjective evaluation. Repeat arthroscopy was only done in 1 patient for an unrelated problem. IKDC evaluation (which did not include all parameters for those patients who were not examined) demonstrated normal (A) results in 11 patients, nearly normal (B) results in 18, and 3 failures. Visual analog scores, recorded on a scale of 0-10 with lower scores indicating no problem with vigorous return to sports, were reported to be an average of 1.1-1.3. KT-2000 evaluation demonstrated that no patients had a side-to-side difference of over 3 mm. Gill and Diduch emphasize that careful technique and patient selection are keys to successful meniscal repair using the Bionx arrow.

Comment by Mark D. Miller, MD

This paper reflects the growing consensus that meniscal repair can be successfully accomplished with "all-inside" devices. These devices have become enormously popular because of the ease of insertion and marked reduction in the time required for meniscal repair. The Bionx meniscal arrow is representative of an entire generation of these devices that have a head and barbs that can be inserted into a meniscus to reduce and stabilize a meniscal tear. It is important to emphasize, however, that there have been a number of case reports that have described numerous complications associated with the use of these devices. These complications include migration, cyst formation, breakage, and, perhaps of most concern, articular cartilage damage. It is also important to recognize, as Gill and Diduch have pointed out, some meniscal tears cannot be successfully fixed with these devices. Additionally, again as recognized by Gill and Diduch, the meniscal repairs reported in the present study were done under ideal conditions—peripheral tears with concurrent ACL reconstruction. In all other cases, the use of arrows, or any all-inside technique, should be done with caution, and the gold standard remains inside-out vertical mattress sutures. A new generation of meniscal repair devices (Smith & Nephew’s Fas-T-Fix and Mitek Worldwide’s Rapid Loc) are attractive because they allow tensioning of the meniscal repair. However, we recommend caution with these devices as well until laboratory and clinical studies of these devices have been accomplished. New research into more rapidly dissolving polymers, sutures, and techniques will likely result in another generation of devices in the near future. Once again, however, all of these devices must be compared to vertical mattress sutures.

Dr. Miller, Associate Professor, UVA Health System, Department of Orthopaedic Surgery, Charlottesville, VA, is Associate Editor of Sports Medicine Reports.