The efficacy of the pull-out and all-inside techniques for the treatment of Laprad type II medial meniscus posterior root tear

doi:10.21203/rs.3.rs-5268194/v1

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Research Article

The efficacy of the pull-out and all-inside techniques for the treatment of Laprad type II medial meniscus posterior root tear

https://doi.org/10.21203/rs.3.rs-5268194/v1

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Purpose

To investigate the therapeutic effect of Pull-out technique and All-inside technique on Laprad type II medial meniscus posterior root tear (MMPRT).

Methods

A total of 95 patients were included in this study. Kellgren Lawrence (K-L) grade was recorded by knee X-ray after surgery, and knee cartilage injury grade, subchondral cyst, subchondral edema, insufficiency fracture, meniscal extrusion and meniscal healing were recorded by MRI. International Knee Literature Committee Knee Assessment Scale (IKDC) score, Lysholm score and VAS score were used to evaluate knee joint function.

Results

There were no significant differences in K-L grade, knee cartilage injury grade, subchondral cyst, subchondral edema and insufficiency fracture between two groups (p > 0.05). The extrusion rate and degree of medial meniscus in pull-out repair group were 88.68%, 3.43 ± 0.71mm, while those in the all-inside repair group were 90.48%, 3.41 ± 0.80mm, with no statistical difference (p > 0.05). There were no significant differences in postoperative IKDC scores and Lysholm scores (p > 0.05).

Conclusion

Both pull-out repair and all-inside repair can improve knee joint function in the treatment of Laprad type II PMMRT.

Medial meniscus posterior root tear

Meniscal repair

Pull-out repair

All-inside repair

Medial meniscus posterior root tear (MMPRT) refers to radial tear within 1 cm of the medial meniscus root attachment, or complete avulsion of the soft tissue or bone structure of the root attachment. Most of these injuries are degenerative injuries caused by chronic repetitive low-energy movements [1]. The stress-dispersion ability of the meniscus is impaired due to the failure of the annular fiber structure, which leads to stress osteonecrosis of cartilage and subchondral bone, and the induction of osteoarthritis.

Previous studies have shown that conservative treatment often results in poorer functional recovery, more severe osteoarthritis, and a higher rate of arthroplasty [2, 3]. Meniscectomy has also been widely used for the treatment of MMPRT, and early studies suggested it was effective in improving the patients’ symptoms [4]. However, long-term follow-up studies have demonstrated that 35% of patients show radiological progression of osteoarthritis during follow-up [5], and the final rate of arthroplasty is 36–56% [6, 7].Due to the poor results of conservative treatment and meniscectomy, restoring the meniscus stress dispersion by repairing the continuity of the meniscus fibrous loop structure has become a new target in the treatment of MMPRT. Indeed, biomechanical repair can restore the normal contact area and peak pressure of the tibiofemoral joint [8, 9]. Compared with meniscectomy, repair surgery is able to slow the progression of arthritis [10, 11]. Therefore, once MMPRT is diagnosed, root repair has become the preferred method of treatment.

Kim et al. [13] applied pull-out repair technique to the treatment of MMPRT and achieved satisfactory therapeutic effects. Since then, a large number of biomechanical and clinical observational studies have been conducted around pull-out repair technology [14–21]. With the development of meniscus repair technology, especially the wide application of meniscus suture device, new treatment methods called all-inside techniques are provided [22–26]. So far, there have been few reports on the comparative study of the two repair methods in the treatment of MMPRT. To compare the efficacy of pull-out repair technique and all-inside repair technique in the treatment of MMPRT, we conducted a retrospective study to compare the functional prognosis and imaging progression of osteoarthritis between the two techniques.

Material

This study reviewed the data of patients with MMPRT treated with pull-out repair or all-inside repair in our hospital from June 2018 to June 2022.

Inclusion criteria: (1) diagnosis consistent with Laprad type II MMPRT [28]; (2) clinical symptoms correlating with MRI findings; (3) duration of the disease less than 6 months; (4) age between 18 and 60 years; and (5) a minimum of 2 years of follow-up.

Exclusion criteria: (1) congenital knee deformity; (2) concomitant injury of the knee joint (fracture, ligament injury, or other meniscus injury); (3) varus alignment more than 5° before operation; (4) preoperative Outerbridge grade[27] ≥ 3; and (5) body mass index (BMI) > 30.

Methods

All surgical procedures were performed by two senior surgeons. A standard anterolateral portal (longitudinal incision) was used for arthroscopic visualization. An anteromedial portal (transverse incision) was used for MMPRT guide. When the medial space of the knee joint was narrow and the root exposure was difficult, the "pie-crusting" technique was used to release the medial collateral ligament to assist the exposure of the medial compartment [29].

Pull-out repair group

The tissue structure of the posterior root attachment of the medial meniscus was carefully identified under the microscope. The residual posterior root tissue at the negative attachment of the posterior root of the meniscus and the degenerative tissue at the free end were thoroughly debrided and freshened with the planer and the meniscus rub. Then, a 2.5-mm-diameter tibial bone tunnel was created with the MMPRT guide. The posterior dense tissue attachment point of the root was used as the intra-articular exit of the bone tunnel, and the anterior medial cortex of the proximal tibia was used as the extra-articular exit of the bone tunnel. The No. 2 nonabsorbable sutures (Smith & Nephew) were inserted into the posterior root of the medial meniscus and fixed in the form of loop stitches. The sutures were drawn out of the joint by lasso through the tibial tunnel. Under continuous arthroscopic observation, the sutures were tightened with the knee bent at 90° and fixed to the anterior medial cortex of the tibia with the help of a button (Smith & Nephew). After the repair was completed, the arthroscope was turned to the medial portal for observation with the knee bent at 120° to observe the tension of the suture site. Figure 1.

All-inside repair group

Before repair, we first performed debridement and freshened the posterior root stump. The posterior root was sutured with vertical mattress suture using FasT-Fix (Smith & Nephew). The method was as follows: A needle tip was penetrated into one limb of the meniscus 5 mm from the free edge to deliver the first suture bar anchor. Then, the second penetration was performed across the tear line at the opposite end of the meniscus, also 5 mm from the free edge. The suture was tightened to join the two broken ends. The same procedure was repeated one more time. As a result, two parallel sutures were performed 5 mm away from each tear limb. After the repair was completed, the arthroscope was turned to the medial portal for observation with the knee bent at 120° to observe the tension of the suture site. Figure 2.

Muscle strength exercises were started immediately after surgery. During the first 3 weeks, the affected limb was immobilized in a knee extension brace, and weight-bearing was avoided. Flexion was allowed in the range of 30° from the fourth week after surgery. In weeks 5–6, flexion was increased by 25° per week, and partial weight-bearing was gradually started. In weeks 7–8, the range of flexion increased to 120°, and there was gradual transition to full weight-bearing. Physical exercise was prohibited within 6 months after surgery.

Assessment methods

Clinical function evaluation

The Lysholm Knee Scale [30] and the International Knee Literature Committee Knee Assessment Scale (IKDC) [31] were evaluated before surgery and at final follow-up by the same author who was not involved in surgery.

Imaging evaluation

Radiographic data were evaluated, including plain radiographs and Magnetic resonance imaging (MRI) scans. The Kellgren–Lawrence scoring system [32] was used to evaluate the status of osteoarthritis. MRI was used for the diagnosis, evaluation of meniscus extrusion, and judgment of posterior root healing [28]. In accordance with the International Cartilage Repair Society (ICRS) grading scores [33], focal cartilage lesions of the medial condyle of the femur and the medial plateau of the tibia were graded on MRI images before and after surgery. Subchondral edema, subchondral cysts and insufficiency fractures were ALSO recorded on MRI images [34, 35]. Meniscal extrusion was measured from the outer margin of the medial tibial plateau to the outer edge of the medial meniscus on the images showing maximal extrusion [36]. Meniscal healing was classified as complete-union (continuity in sagittal, coronal, and axial MRI views), partial-union (loss of continuity in any 1 view), and non-union (no continuity in any view) [37].

3.Theory and calculation

Qualitative data were recorded using absolute values. Chi-square test and Fisher's exact test were used for comparative analysis of qualitative data. The continuous data were first tested for normality. Data conforming to normal distribution were recorded by mean ± standard deviation (SD), and independent-samples t test was used for intergroup comparison, whereas paired t test was used for intragroup comparison.

A total of 95 patients were included in this study. There were no statistically significant differences between the two groups in terms of age, sex, affected side, BMI, trauma history, course of disease, follow-up time, and Outerbridge grade. Table 1.

Table 1

Demographic and clinical characteristics of patients
	pull-out group	All-inside group	p- value
Number of patients	53	42
Age(years)	51.91 ± 5.63	53.10 ± 6.08	0.326
Sex (male/female)	14/39	10/32	0.772
Side involved (left/right)	20/33	15/27	0.839
Body mass index (kg/m²)	27.32 ± 5.76	27.13 ± 6.28	0.645
Trauma history (yes/no)	14/39	12/30	0.815
Duration from injury to surgery(weeks)	7.00 ± 3.76	6.69 ± 3.21	0.672
follow-up period (months)	26.25 ± 1.66	26.36 ± 1.68	0.747
Outerbridge grade(0/s/1/2)	8/16/24/5	6/10/19/7	0.722

There were no statistically significant differences in cartilage injury grade, subchondral cysts, subchondral edema, and insufficiency fractures between the two groups at the final follow-up. The ratio of complete healing/partial healing/non-healing was 71.70%/24.53%/3.77% in the pull-out repair group, and 71.43%/21.43%/7.14% in the all-inside repair group (P = 0.936). We observed no significant differences in the incidence and degree of meniscus extrusion between two groups (P = 0.770). Table 2.

Table 2

Imaging progression of osteoarthritis between two groups
	pull-out group	All-inside group	p- value
K–L grade (0/Ⅰ/Ⅱ/Ⅲ/Ⅳ)
Preoperatively	18/25/10/0/0	12/26/4/0/0	0.279
Postoperatively	15/27/8/3/0	9/27/4/2/0	0.641
ICRS grade(0/Ⅰ/Ⅱ/Ⅲ/Ⅳ)
Preoperatively	16/24/13	11/21/10	0.884
Postoperatively	13/23/14/3	8/22/9/3	0.794
Subchondral cysts
Preoperatively	14/39	12/30	0.815
Postoperatively	18/35	16/26	0.676
Subchondral edema
Preoperatively	16/37	11/31	0.668
Postoperatively	13/40	8/34	0.523
Insufficiency fractures
Preoperatively	7/46	5/37	0.849
Postoperatively	8/45	7/35	0.835
Meniscal healing (Complete / Partial / Nonhealed)	38/13/2	30/9/3	0.740
Extrusion
Preoperatively	37/16	29/13	0.936
Postoperatively	47/6	38/4	0.770
Extrusion(mm)
Preoperatively	2.63 ± 1.28	2.67 ± 1.20	0.893
Postoperatively	3.43 ± 0.71	3.41 ± 0.80	0.903

IKDC score, Lysholm score showed no statistically significant differences between two groups Table 3, Fig. 3.

Table 3

IKDC score and Lysholm scores of two groups
Group	Number of patients	IKDC Score		Lysholm Score
Group	Number of patients	Preoperatively	Postoperatively	Preoperatively	Preoperatively
pull-out group	53	38.92 ± 7.54	74.11 ± 7.49	43.42 ± 5.88	43.42 ± 5.88
all-inside group	42	40.49 ± 5.58	74.05 ± 6.77	42.81 ± 4.83	42.81 ± 4.83
p- value		0.265	0.965	0.591	0.591

The posterior horn of the medial meniscus, which bears most of the stress applied to the medial compartment. Therefore, this area is more prone to traumatic or degenerative rupture [38, 39]. Once root injury occurs, the biomechanical changes are the same as after total meniscectomy [40]. Due to the particularity of living habits, Asian women have a higher risk of damage to the posterior medial meniscus root [41]. According to the morphology, there are six types of MMPRT, Laprad II refers to complete radial tear within 9 mm of the center of the root attachment, which is the most common type of MMPRT [42].

The long-term results of conservative treatment and meniscectomy for MMPRT are not satisfactory. Conservative treatment, meniscectomy, and meniscus repair result in osteoarthritis in 95.1%, 99.3%, and 53.0% of the cases, respectively [43]. Worse functional recovery is associated with female gender, increased BMI, and meniscus extrusion [44]. The purpose of surgical repair of the posterior root is to restore the continuity of the annular structure of the meniscus, the stability of the patellofemoral joint, and the pressure distribution of the medial compartment. The repair methods include pull-out repair [14–21], all-inside repair [22–26], anchor suture repair [45].

Pull-out repair is a classic technique, which has been used for more than 20 years [12, 13]. Similarly, no obvious progression of cartilage and subchondral bone lesions were observed after repair [15]. Postoperative root healing is a concern for clinicians, because the healing of the posterior root is closely related to the functional prognosis. Previous studies have found that the healing rate of pull-out repair is 97%, of which 62% is completely healed [16]. According to the study by Cho et al. [17], all patients had improved function after repair, but the functional improvement was more obvious in the healing group. In this study, the meniscus healing rate after the pull-out repair was 96.23%, which is basically consistent with previous studies, and the postoperative function of patients improved significantly compared with that before surgery.

To ensure the therapeutic effect of pull-out repair, the first step is to fellow the contraindications of surgery [16]. The judgment of the footprint of the medial meniscus is another keypoint [18]. The autopsy found that the posterior root of the medial meniscus is connected to the tibial plateau through dense fibers, and the footprint is behind the medial intercondylar ridge of the tibia, outside the inflection point of the articular cartilage of the medial plateau of the tibia, and anterior medial to the attachment point of the posterior cruciate ligament (PCL) of the tibia [19]. A layer of "shining fibers" behind the dense fibers was not considered to be part of the root attachment. A distinction should be made in determining anatomic stops [20]. When there is meniscus extrusion, especially when there is adhesion of the posterior joint capsule, the in situ fixation cannot restore the normal mechanical environment of the knee joint [21], and the release of the root tissue of the posterior meniscus is necessary for anatomical reconstruction.

The side-to-side repair technique can theoretically achieve anatomical repair of the posterior tibial root without changing the original physiological characteristics of the meniscus. The main advantages of all-inside meniscus suture are lower invasiveness, reduced technical difficulty, avoiding additional incisions or tibial tunnel drilling, and avoiding interference with the bone tunnel during ligament reconstruction. The all-inside repair method can reduce the peak pressure of the medial compartment of the tibiofemoral joint after MMPRT, and its stiffness and failure load are similar to those of the pull-out repair technique [22–24]. Kyoung et al. [24] found that the healing rate of all-inside suture was higher than that of pull-out repair (96 vs. 81%), and the functional prognosis of the former was significantly better than that of the latter. Our study confirmed that the healing rates of the all-inside repair and pull-out repair group were 96.23% and 92.86%, respectively, with no significant difference. The clinical observation study conducted by Jason suggesting that FasT-Fix suture could be used as an alternative method to treat MMPRT [25].

Meniscus extrusion is an important factor that induces knee osteoarthritis [46, 47]. Previous studies have shown that although the meniscus extrusion could not be corrected after MMPRT repair, all patients show improvement in knee function after surgery [48, 49]. In our study, neither pull-out repair method not all-inside repair were able to reverse meniscus extrusion, and the progression of osteoarthritis could also be observed. It has been suggested that the combined centralization of posterior meniscus root repair can reduce the extrusion of medial meniscus and restore the function of load distribution [50]. An observational study by Krych et al. [12] also showed that posterior meniscal root repair combined with centralized surgery resulted in significant improvements in postoperative pain, function, and quality of life, and reported high surgical satisfaction. Therefore, centralization of meniscus during posterior root repair is a problem worthy of further study.

This study had several limitations. First, the main limitation of this study is its retrospective nature. Second, the study's follow-up time was insufficient to assess the long-term efficacy of either treatment. Third, only MRI was used to evaluate the healing of the posterior meniscus root without the second postoperative microscopic examination, and the results were not intuitive enough.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Medical Ethics Committee of Huzhou First People's Hospital (No 2024KYLL015-02).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

The authors declare that they agree to publish

Funding

This work was supported by the Zhejiang province public welfare technology application research project [grant numbers LTGD24H060001]; Medical Science and Technology Project of Zhejiang province [grant number 2024KY1649].

Author Contribution

Zheyuan Shen wrote the original draft. Rong Wu searched the literature and screened it. Dan Cai and Qiaoying Peng conducted data curation.Heng Li and Songhua Guo are responsible for the supervision of the study. Zhanfeng Zhang reviewed and revised the manuscript.

Acknowledgement

The authors would like to thank Huanyan Yang and Jinghao Shen.

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The efficacy of the pull-out and all-inside techniques for the treatment of Laprad type II medial meniscus posterior root tear

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Abstract

Figures

Introduction

Material and methods

Material

Methods

Pull-out repair group

All-inside repair group

Assessment methods

Clinical function evaluation

Imaging evaluation

3.Theory and calculation

Results

Discussion

Declarations

Ethics approval

Consent to participate

Consent to publish

Funding

Author Contribution

Acknowledgement

References

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