Rehabilitation following meniscal repair: a systematic review

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  1. Robert C Spang Threei,
  2. http://orcid.org/0000-0002-5439-5277Michael C Nasr2,
  3. Amin Mohamadi2,
  4. Joseph P DeAngelisone,
  5. Ara Nazarian2,three,
  6. Arun J Ramappai
  1. 1 Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical Schoolhouse, Boston, Massachusetts, United states
  2. two Center for Avant-garde Orthopaedic Studies, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Department of Orthopaedic Surgery, Yerevan State Medical Academy, Yerevan, Armenia
  1. Correspondence to Dr Arun J Ramappa; aramappa{at}bidmc.harvard.edu

Abstract

Objective To review existing biomechanical and clinical evidence regarding postoperative weight-bearing and range of movement restrictions for patients following meniscal repair surgery.

Methods and data sources Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, we searched MEDLINE using following search strategy: (((("Weight-Begetting/physiology"[Mesh]) OR "Range of Move, Articular"[Mesh]) OR "Rehabilitation"[Mesh])) AND ("Menisci, Tibial"[Mesh]). Additional manufactures were derived from previous reviews. Eligible studies were published in English and reported a rehabilitation protocol following meniscal repair on human. We summarised rehabilitation protocols and patients' consequence among original studies.

Results Seventeen clinical studies were included in this systematic review. There was wide variation in rehabilitation protocols amongst clinical studies. Biomechanical evidence from small cadaveric studies suggests that college degrees of articulatio genus flexion and weight-bearing may be safe following meniscal repair and may not compromise the repair. An accelerated protocol with immediate weight-bearing at tolerance and early motility to non-weight-bearing with immobilising upwards to 6 weeks postoperatively is reported. Accelerated rehabilitation protocols are not associated with higher failure rates following meniscal repair.

Conclusions There is a lack of consensus regarding the optimal postoperative protocol post-obit meniscal repair. Small clinical studies support rehabilitation protocols that let early move. Additional studies are needed to ameliorate analyze the coaction between tear type, repair method and optimal rehabilitation protocol.

  • arthroscopy
  • knee surgery
  • articulatio genus injuries
  • sporting injuries
  • rehabilitation

This is an Open Access article distributed in accordance with the Artistic Commons Attribution Not Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this piece of work not-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/past-nc/4.0/

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  • arthroscopy
  • genu surgery
  • human knee injuries
  • sporting injuries
  • rehabilitation

What is already known?

  • The menisci reduce stress by increasing the contact area betwixt the femur and tibia.

  • Meniscal repair is becoming a more appealing treatment for meniscal injuries.

  • There is a wide variation between postoperative rehabilitation protocols following meniscal repair.

What are the new findings?

  • At that place is no consensus regarding postoperative rehabilitation protocol for meniscal repair.

  • The quality of existing show is depression.

  • An accelerated rehabilitation protocol may be safely implemented for advisable patients.

  • Further studies are needed to determine an optimal rehabilitation protocol.

Introduction

The menisci reduce stress by increasing the contact surface area between the femur and tibia. They buffer confronting axial, rotational and shearing forces nigh the articulatio genus during motion.one The loss of meniscal tissue localises tibiofemoral contact and leads to progressive arthrosistwo three and functional decline in the long term.iv To prevent these degenerative changes, meniscal repair has become more than common.5 Kim et al six documented a 25% increase in medial and lateral meniscal repairs between 1996 and 2006. Even though the majority of surgeries on the meniscus remain meniscectomies, Abrams et al vii establish that betwixt 2005 and 2022 more isolated meniscal repairs were performed in the USA without an increase in the number of meniscectomies. Meniscal repairs may be performed more frequently because there has been a meaning advance in surgical techniques and repair devices (figure 1A–E). Historically, the gold standard for meniscal repair has been the inside-out technique (effigy 1C,D). Long flexible needles are used to pass sutures through the tissue under arthroscopic guidance.eight The sutures are then retrieved using a separate incision and are tied over the articulation capsule. This technique may place neurovascular structures at hazard and requires an additional incision.9 To avert the morbidity associated with an inside-out repair, 'all-inside' arthroscopic techniques have been developed (figure 1A,B). These include anchor-based repairs and suture-based repairs. The most pop of these designs employ pre-tied sutures between not-absorbable anchors. The anchors are deployed when an introducer is passed through the meniscal tear and the joint capsule (figure 1E,F). In a study of porcine meniscal repairs,10 the within-out technique was significantly stronger compared with recent all-within repair devices. A study on fresh-frozen human being menisci11 showed no difference. Although potentially less invasive than the inside-out technique, all-inside repairs can result in neurovascular injury, irritation from anchors and implant failure.12

Several factors may influence meniscal healing. The most important may be the meniscal blood supply. Scapinellixiii in 1968 and Arnoczky and Warrenxiv in 1982 described the limited peripheral blood supply to the outer ane-third to one-quarter of the meniscus. From this finding, peripheral meniscal tears (ie, tears in the 'cherry-crimson' zone) are felt to have ameliorate healing potential (effigy 2A).

The timing and type of meniscal tear may as well touch on healing. Acute, traumatic tears tend to accept college healing rates than chronic, atraumatic tears.15 Longitudinal tears are more amenable to repair due to their vertical orientation (figure 2B), whereas radial tears extending to the key relatively avascular 'white-white' zone are more challenging. Some surgeons have reported success when repairing bucket-handle tears extending to the white-white zone.xvi

Age is some other topic for consideration. Preserving meniscal tissue is peculiarly of import for the long-term health of immature athletes, and younger patients may accept a higher healing potential. In ane study of 26 patients aged 17 years or younger, none required a echo surgery at an boilerplate of v years of follow-up.17 In another report on two very young cases, meniscal repair for traumatic tears followed past limited weight-bearing rehabilitation resulted in a positive outcome.18 When historic period is not a factor, a meta-assay investigating outcomes at least v years after meniscal repair showed a pooled failure rate of 23.one%.19

As biomechanical factors, postoperative range of move (ROM) and weight-bearing status can bear upon meniscal healing later on repair. The coaction between tear type and knee biomechanics tin can assist define the most appropriate postoperative plan.

Restricting a patient'due south postoperative ROM intends to limit the take chances of re-tear. Cadaveric studies have shown that femorotibial contact pressures increment with knee flexion.20 If the ROM is restricted, the meniscal repair may be protected from increased mechanical stress.21 Still, Richards et al 22investigated the furnishings of compressive loads in porcine longitudinal lateral meniscus repairs and found that weight-begetting reduced the meniscus and stabilised the repair. The highest compressive forcefulness occurred at full extension and the lowest was at 90° of flexion. Beyond 100° of flexion, information technology increased steadily (figure 3). Higher pressures were seen with internal rotation of the tibia, suggesting torsional forces may be different than axial loads. Conversely, for radial tears, axial loading might displace, rather than reduce, the injury.22 Of note, cadaveric investigations are limited in their ability to recreate the biomechanics of the human knee in vivo and are non able to predict how specific rehabilitation protocols impact a meniscal repair. For this reason, rehabilitation post-obit a meniscal repair is particularly conservative in an effort to protect the repaired meniscus.

Figure 3

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Figure 3

(A) The pressure transducer 'P' was placed in the lateral meniscal cut and the knee was cycled into flexion and extension. (B) Intrameniscal pressures were reflected in neutral, internal, and external rotation.

Postoperative rehabilitation aims to foster healing after meniscal repair and facilitate the patient'southward return to full part. Generally, these programmes are initially focused on protecting the repair while regaining ROM and gradually introducing progressive strengthening en route to a render to preinjury activity level. At nowadays, there is a paucity of bear witness to support one best practice and in that location is a high degree of variability amid postoperative rehabilitation programmes. Considering the increased frequency and development of meniscal repairs, this review intends to summarise the best-bachelor evidence and practices regarding the postoperative care and rehabilitation of patients undergoing a meniscal repair.

Methods

Search strategy and information sources

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, on xv June 2022 we conducted an electronic search on MEDLINE with the following search strategy: (((("Weight-Begetting/physiology"[Mesh]) OR "Range of Motion, Articular"[Mesh]) OR "Rehabilitation"[Mesh])) AND ("Menisci, Tibial"[Mesh]). Additional sources included references of previous reviews.xix 23 24

A full of 453 studies were screened for eligibility. Only studies published in the English language in peer-reviewed journals were considered. Review papers, commentaries and studies on rehabilitation protocol following meniscectomy were excluded. Finally, 17 studies were included in the review (figure iv).

Bibliographic data, patients' characteristics, rehabilitation protocol and clinical result were recorded. Patient's outcome included meniscal healing, return to activities and clinical assessments based on the original studies. Nosotros did not confirm collected data by authors. The level of evidence for original studies is reported for each written report.25

Cochrane tool for evaluating risk of bias was used for assessing the methodological quality of the included studies.

Results

Seventeen clinical studies including 798 patients were reviewed in this systematic review. There was wide variation in methodological quality of clinical studies. The majority of studies had considerable risk of bias (table 1).

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Table i

Assessment of risk of bias using Cochrane tool

A restricted rehabilitation protocol was used for 438 patients. An accelerated protocol with immediate weight-bearing at tolerance was used in 360 patients. Three studies compared restricted and accelerated protocol, which did not show any significant difference in complication rate or functional cess (table 2).

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Tabular array 2

Previously published rehabilitation protocols

Although a meta-analysis was not possible, it seems accelerated rehabilitation protocols are not associated with higher failure rates following meniscal repair.

Word

Many rehabilitation programmes propose avoiding weight-bearing forces as an important goal in the firsthand postoperative catamenia to protect the repair from high compressive and shear forces. An MRI study of weight-bearing and non-weight-bearing knees establish that the relative tibiofemoral movements of the loaded knee were similar to those in the unloaded articulatio genus. However, the medial femoral condyle moves approximately 4 mm inductive when the genu bends from total extension to x° of flexion while begetting weight. In the unloaded genu, the position of the medial femoral condyle did not change from extension to flexion. Laterally, the femoral condyle rolls forward 13 mm from 110° to sixty° of flexion and i mm from 60° to 0° in the unloaded knee.26 In isolation, this pattern of move suggests that non-weight-bearing knee flexion would be prophylactic to 110° for medial meniscal repairs and to 60° for lateral meniscal repairs. Notwithstanding, this finding has non been validated clinically.

Becker et al twenty investigated changes in the meniscofemoral contact pressure after meniscal repair. Knees were loaded to approximately 50% of body weight, and meniscofemoral contact pressure was measured (Tekscan, Boston, Massachusetts, United states of america) while cycling the human knee from extension to 90° of flexion. They found that meniscofemoral pressures increased in both compartments every bit the knee flexed and that meniscal repair had no bear on. Their study did not investigate the effect of this pressure departure on the meniscal repair, nor did they include torsional forces or higher affect loading. Ganley et al 27 sought to further investigate articulatio genus flexion and loading on meniscal healing in a cadaveric model. They produced full-thickness posteromedial meniscal tears in cadaveric knees and imbedded metal markers into the tear following repair. Using CT scans, the mark position was assessed at 30°, 60° and 90° of genu flexion after loading of 100 lbs to simulate fractional weight-bearing. They determined that neither flexion angle, loading nor suture had a significant impact (figures 5 and 6). In this way, accelerated rehabilitation programme with partial weight-bearing may be appropriate. Torsional forces, higher degrees of flexion and loads larger than 100 lbs were not assessed.

Lin et al 28 sought to assess the upshot of postoperative ROM post-obit meniscal repair using a cadaveric model. They created a 2.v cm posteromedial meniscal tear and repaired information technology with inside-out vertical mattress sutures (figure 7A). They measured the deportation at high degrees of flexion (90°, 110° and 135°) when loaded (figure 7B). Specimens were subjected to simulated open up-chain flexion and extension with a load of 29 Due north practical to the hamstrings and 150 Due north to the quadriceps, exceeding the normal joint reactive force encountered during active knee flexion.28 In accordance with the findings of Richards et al 22 and Ganley et al, 27 they constitute that neither the meniscal tear nor the meniscal repair demonstrated significant gapping. Rather they compressed in the transverse aeroplane when flexed from 90° to 135°s while subjected to physiologic loads. They conclude that 'non-restrictive un-resisted open chain ROM protocols do not identify undue stress on meniscal repairs'.

Figure 7

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Figure 7

(A) Schematic of roentgen stereophotogrammetric analysis bead pair placement in relation to tear. Distances measured by vectors: a—absolute, b—transverse and c—vertical. (B) Changes in separation for each vector. Positive values indicate widening. Negative values indicate compression. MCL, medial collateral ligament region of posterior horn of medial meniscus; mid mail service, centre of posterior horn; post root, posterior root surface area of medial meniscus.

Early weight-bearing might enhance the mechanical surround promoting healing and allowing earlier functional recovery and return to sport.22 Information technology has been shown that early on weight-bearing as tolerated and limited ROM resulted in adequate outcomes (ie, Lysholm score of 71.5) at 17 month follow-up.29 While Becker's cadaveric findings may convalesce concern over iatrogenic cartilage damage from implants, the hypothetical danger of increased meniscofemoral pressures with knee joint flexion after meniscal repair has not been shown to impact clinical outcomes.20

Some authors recommend immobilisation in full extension, reportedly due to the ascertainment that peripheral posterior horn tears move away from the sheathing in flexion and reduce in extension.18 30–32 This recommendation stems from direct viewing of peripheral posterior horn tears using a lxx° arthroscope and observing the reduction of these tears during passive knee extension. However, this observation and the subsequent exercise of immobilising meniscal repairs in extension has not been shown to be beneficial clinically and may not exist relevant to other tear types. Some investigators recommend immobilisation in various degrees of flexion,32–34 and others still advocate for limited early motility. Despite more aggressive protocols allowing for free ROM immediately postoperatively, 90° of flexion appears to be a comfy restriction for surgeons.35 Up to 85% of the load travels through the menisci with the knee in 90° of flexion, while less (l%) of the load passes through the meniscus in extension.36

Additionally, meniscal dynamics using MRI three-dimensional reconstructions show that during articulatio genus flexion, the posterior excursion of the medial meniscus is v.one mm and the lateral meniscus is 11.2 mm.37 However, a more than recent written report past Lin suggests that higher degrees of flexion may exist safety.28 There is no clinical evidence that limiting weight-begetting and/or knee flexion improves healing rates. Long-term outcome studies are lacking.

Accelerated rehabilitation protocols

A number of investigators have advocated for accelerated rehabilitation protocols (figure viii).38–41 In a prospective randomised trial, Lind et al 28 compared the impact of a 'free rehabilitation' regimen versus 'restricted rehabilitation'.35 Sixty patients underwent isolated repair of a vertical meniscal lesion using an all-inside technique. They were randomised by rehabilitation regimens. The 'free' group was allowed to range the articulatio genus 0°–xc° immediately while maintaining the human knee in touch-down weight-bearing for 2 weeks, and weight-bearing as tolerated thereafter. They were allowed to return to contact sports at four months. The 'restricted' grouping wore a hinged brace for 6 weeks and gradually increased their ROM to 90°. They were affect-downwards weight-bearing for 6 weeks, followed past eventual return to sport at 6 months. The authors constitute no difference in the healing rate. At second-expect arthroscopy, at that place were ix and ten failures in the gratis and restricted rehabilitation groups, respectively. In that location was no difference in functional consequence scores at 2 years. From this experience, the authors concluded that free rehabilitation was safe without a higher failure charge per unit.

Kocabey et al 42 reported excellent results using rehabilitation guidelines specific to the tear's characteristics. For anterior-posterior longitudinal tears less than 3 cm, they promoted weight-bearing equally tolerated without a brace. ROM progressed to 125° between 3 and 6 weeks. For tears greater than 3 cm, weight-begetting was allowed in a locked brace. ROM was express to 0°–125° until vi or eight weeks. Return to sport was immune after 3 months. For complex and radial tears, patients were required to wear a caryatid in which they were weight-bearing as tolerated ranging from 0° to 125° for 6 to 8 weeks. They returned to sport between iv and 5 months.

Mariani et al 40 followed 22 patients who underwent an exterior-in meniscal repair. They were allowed to bear weight immediately without ROM restrictions. On re-examination with an MRI at an average of 28 months afterward surgery, merely three of 22 patients showed signs of re-tear with greater than ane mm of gapping. Based on this feel, they advocated for more aggressive rehabilitation regimens.36

There remains a concern regarding the safety of accelerated rehabilitation in the setting of a radial meniscal tear. Most studies investigating rehabilitation after meniscal repair have included patients with a longitudinal tear. However, since radial tears experience distraction forces and increased strain with axial loading, information technology is thought that a more conservative postoperative rehabilitation arroyo may be prudent in this setting.43 Choi et al 44 and Haklar et al 45 reported on their experiences repairing isolated radial tears of the lateral meniscus. Choi et al 44 used a weight restriction protocol, whereas Haklar used a dual restriction protocol.

Overall, at that place is considerable variability in the rehabilitation following a meniscal repair. In that location is no articulate consensus regarding the ideal programme (table 2). On the one manus, Noyes express weight-begetting initially for four–6 weeks, with ROM progressively advanced to 135° of flexion over 6 weeks.46 At the other end of the spectrum, O'Shea and Shelbourne 47 published favourable results after unrestricted ROM with weight-bearing equally tolerated kickoff iii days afterward surgery. Similarly, Bryant et al 48 allowed weight-bearing to tolerance with the knee locked in extension for 3 weeks, then WBAT with unlimited ROM thereafter. The impact of weight-bearing combined with twisting or pivoting movements on the repaired meniscus has not been adequately investigated. Furthermore, rehabilitation protocols with respect to meniscal repair with or without augmentation accept not been evaluated.

Return to sport

The decision to repair a meniscus influences both the long-term health of the genu as well every bit the more immediate ability to return to activity. The postoperative handling is an important consideration that should be discussed with the patient when because a meniscus repair. Meniscal preservation offers long-term benefits. However, because the recovery requires a longer period of immobilisation with restrictions and delays the return to sport, some athletes might not want to have a meniscal repair. In one study of 45 meniscal repairs in aristocracy athletes, 81% returned to sports, with the vast majority dorsum to their prior sporting level.49 The mean render to sport was 5.6 months (range 3–8 months) for an isolated meniscal tear, compared with 11.8 months for ACL reconstruction with meniscal repair.

Meniscal repair in association with ACL reconstruction

Accelerated, or aggressive, rehabilitation is important post-obit ACL reconstruction to improve ROM.41 Several studies have shown that accelerated rehabilitation is condom following ACL reconstruction with meniscal repair.40 50 In a series of 63 consecutive patients, 58 meniscal tears were repaired arthroscopically using an within-out technique at the time of ACL reconstruction. Hairdresser et al fifty promoted a rapid render to total function. Patients were aggressively rehabilitated to playing non-contact pivoting sports at 10–12 weeks, with unlimited activity using a derotational brace equally early as 3–4 months once adequate motility (0°–120°), good force and no effusion were accomplished. With regards to meniscal repairs, the authors noted a lack of consensus regarding rehabilitation protocols and called restrictions into question.

Many surgeons do non restrict patients after meniscal repair in the setting of concurrent ACL reconstructions. It has been hypothesised that meniscal repairs do good from an abundance of healing factors due to the intra-articular haemorrhage present during an ACL reconstruction. In a matched cohort report past Wasserstein et al,51the patient accomplice with concomitant ACL reconstruction was constitute to have a meniscal reoperation rate of 9.7% compared with 16.7% in the meniscus repair alone cohort. Conversely, in an ACL-scarce knee, meniscal repairs are decumbent to failure due to the persistent mechanical stress on the tissue.31 52 53

Conclusion

Meniscal repair is an important procedure that aims to preserve tissue and prevent future arthrosis. While handling may alleviate symptoms and allow for a timely return to activity, at that place is a lack of consensus regarding the optimal postoperative rehabilitation protocol. Moreover, there is scarce evidence supporting many current practices. Biomechanical testify suggests that high degrees of articulatio genus flexion may be safe, but these data are express to a few cadaveric studies. The impact of rotation and torsion forces has not been determined, but have implications for the return to sport and piece of work. It is unclear whether larger joint forces associated with running or jumping threaten the meniscal repair.

An accelerated rehabilitation protocol may exist safely implemented for appropriate patients, but it is unclear how the type of meniscal tear and the repair technique should affect the postoperative programme. Boosted biomechanical studies are needed to better clarify the interplay between tear type, repair method, knee joint loading, knee joint positioning and torsional forces. Clinical studies investigating these specific elements will assist to optimise patient outcomes.

Acknowledgements

The authors would like to acknowledge the generosity of Mr. Joseph Fallon for providing funding for this project.

References

  1. i.↵
  2. 2.↵
  3. 3.↵
  4. 4.↵
  5. 5.↵
  6. 6.↵
  7. vii.↵
  8. 8.↵
  9. nine.↵
  10. 10.↵
  11. 11.↵
  12. 12.↵
  13. xiii.↵
  14. 14.↵
  15. 15.↵
  16. xvi.↵
  17. 17.↵
  18. 18.↵
  19. 19.↵
  20. twenty.↵
  21. 21.↵
  22. 22.↵
  23. 23.↵
  24. 24.↵
  25. 25.↵
  26. 26.↵
  27. 27.↵
  28. 28.↵
  29. 29.↵
  30. 30.↵
  31. 31.↵
  32. 32.↵
  33. 33.↵
  34. 34.↵
  35. 35.↵
  36. 36.↵
  37. 37.↵
  38. 38.↵
  39. 39.↵
  40. xl.↵
  41. 41.↵
  42. 42.↵
  43. 43.↵
  44. 44.↵
  45. 45.↵
  46. 46.↵
  47. 47.↵
  48. 48.↵
  49. 49.↵
  50. 50.↵
  51. 51.↵
  52. 52.↵
  53. 53.↵
  54. 54.
  55. 55.

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