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Abstract & Commentary
Synopsis: Properly selected meniscal tears can be repaired effectively, regardless of patient age.
Source: Barrett GR, et al. Clinical results of meniscus repair in patients 40 years and older. Arthroscopy 1998;14 (8):824-829.
The majority of meniscal tears occurring in patients older than the age of 40 are degenerative, complex tears not amenable to repair. In Barrett and colleagues’ cases over a six-year period, 47 meniscal tears (6%) in the 40 years and older age group were repairable. Most tears involved the peripheral third of the meniscus in a vertical or bucket handle configuration. Tears were repaired with an inside-out suture technique in all but six patients in whom the tear was repaired with the T-Fix all inside repair method. Sixty percent of patients had concomitant anterior cruciate ligament (ACL) reconstruction.
After excluding workers comp patients and their one failed ACL reconstruction patient, Barrett et al evaluated 37 patients with a minimum two-year follow-up. Clinical evaluation by history, examination, and radiographs revealed an overall healing rate of 86.5%. Those patients with more chronic tears, horizontal or complex patterns, tear lengths greater than 2 cm, or tears extending into the central, avascular portion of the meniscus had a trend toward failure of the repair, but these variables did not achieve statistical significance given the small number of patients in each group. Patients with ACL reconstructions healed 95% of repairs, whereas those with ACL stable knees not requiring reconstruction healed only 73% of meniscal repairs. This difference was statistically significant.
The importance of the meniscus has been firmly established for load transmission, joint stability, congruity, and shock absorption. Preserving as much meniscus as possible, ideally by meniscal repair, helps prevent future degenerative changes in a directly proportional manner.
Many factors have been demonstrated to affect healing rates for meniscal repairs.1,2 Concomitant ACL reconstruction, with the large hemarthrosis filled with growth factors bathing the repair within the fibrin clot, yields healing rates of 85-95% in the literature and in this study. Isolated repairs in ACL-stable knees have healing rates of 50-80%, compared to 73% in this study. Other factors are related to tear characteristics: vertical tears without complex patterns heal better, tears involving the vascularized outer third of the meniscus also do better, and smaller tears (< 2.5 cm in length) also heal better.
Although increased patient age may make repairable tears more uncommon due to age-related weakening of the meniscus resulting in a more degenerative, complex tear pattern, patient age has not conclusively been shown to affect healing rates. Barrett et al have shown healing rates comparable to those in the literature for younger patients. This study effectively affirms that conventional criteria for meniscal repairability should drive the decision toward meniscal repair rather than patient age.
1. Cannon WD Jr, Vittor JM. The incidence of healing in arthroscopic meniscus repairs in ACL reconstructed knees versus stable knees. Am J Sports Med 1992;20: 176-181.
2. Cooper DE, et al. Meniscal repair. Clin Sports Med 1991;10:529-548.