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Synopsis: Noyes and Barber-Westin emphasize that congruent reduction of the meniscus, closely placed vertical mattress sutures, and nonaggressive rehabilitation are keys to success.
Source: Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscus tears extending into the avascular zone with or without anterior cruciate ligament reconstruction in patients 40 years of age and older. Arthroscopy 2000;16(8):822-829.
It is only within the last part of the 20th century that we have appreciated the importance of the meniscus for long-term function of the knee. Meniscal repair has been advocated in a variety of forums, but unfortunately it is still not a routine procedure for most orthopaedic surgeons. To their credit, Noyes and Barber-Westin have been among the most prominent advocates of meniscal repair. In a recent article, they reported successful results with repair of meniscal tears that extended into the avascular zone.1 In the present article, they report success with repair of these same tears in an older population.
Noyes and Barber-Westin report the clinical results of meniscal repairs performed in 30 patients who were 40 years of age or older. Of note, 72% of these patients also had concomitant ACL reconstruction. Important points regarding their surgical technique include rasping and placement of multiple stacked vertical mattress sutures using an inside-out technique. Partial weight-bearing and early restricted flexion was emphasized postoperatively. Follow-up at two years or longer demonstrated excellent or good results in 88% of these patients. Almost all patients returned to their same level of sports activity.
Successful results of meniscal repair in tears that extend into the avascular zone, an area that until recently has been considered incapable of healing, is tremendous! Extending these results to a population older than 40 years of age is even more amazing! Those readers who do not routinely perform meniscal repairs should take heed. However, several words of caution are appropriate. First, note that the senior author is very experienced in meniscal repair. Careful technique cannot be overemphasized. The meniscus must be reduced to its normal position, prepared, and then repaired with multiple vertical mattress sutures on both the top and the bottom of the meniscus. These results cannot be extrapolated to shooting a couple of arrows into the meniscus. Note also that the majority of these tears were fixed at the time of ACL reconstruction. Numerous studies have highlighted that concurrent ACL reconstruction enhances the success of meniscal repair. Finally, note that the rehabilitation program is anything but aggressive. Nevertheless, these results are encouraging and should inspire all of us to "push the envelope" regarding meniscal repair!
1. Rubman MH, et al. Arthroscopic repair of meniscal tears that extend into the avascular zone. Am J Sports Med 1998;26:87-95.