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Abstract & Commentary
Synopsis: Repair of a torn meniscus in the adolescent patient can lead to full healing in a high percentage of cases.
Source: Mintzer CM, et al. Meniscal repair in the young athlete. Am J Sports Med 1998;26:630-633.
The effectiveness of surgical repair of torn knee menisci is believed to vary both with the extent and severity of the meniscal tear and the age of the patient. Mintzer and colleagues applied a standard technique of surgical repair of the torn meniscus to a group of adolescent athletes seen and treated at one institution. This is a retrospective review of the results of the treatment of all the patients so managed over a 10-year period. There was a minimum follow-up of two years and an average follow-up of five years. The patients ranged in age from 11 to 17 years. There were 12 medial meniscal repairs and 17 lateral meniscal repairs. More than half of the patients had anterior cruciate ligament (ACL) tears that were reconstructed arthroscopically at the same time the meniscal surgery was performed; indeed, 13 of the 17 lateral meniscal repairs also had a torn ACL. There was considerable delay from injury to surgical treatment, ranging from three days to 27 months and averaging a little bit more than six months.
All tears were in the posterior horn of the menisci and 28 of the 29 tears were within 2 mm of the meniscal-synovial junction, involving either the "red on red" zone (22 of 28) or the "red on white" zone (6 of 28). The tears had an average length of 2.3 cm, ranging from 1.5 to 3 cm in length.
The follow-up evaluation included a history, physical examination, and a SF-36 health status survey. Knee function was documented by the use of standardized knee function scores.
Most significantly, virtually all patients returned to their pre-injury level of activity and no patient underwent additional surgery to treat recurrent meniscal abnormalities. Physical examination demonstrated no intra-articular effusions, no joint line tenderness, no positive McMurray’s test, and, thus, virtually no clinical signs of persistent meniscal pathology. The patients’ functional scores indicated that 85% were functioning at extremely high physical activity levels and all but two patients returned to their previous level of athletic activity.
This is an impressive retrospective review of one surgeon’s experience with meniscal repair. Mintzer et al conclude that in this adolescent population, properly selected meniscal tears should be repaired surgically and that an excellent result can usually be expected. They were very selective with regard to the lesions that they chose to repair: those near the meniscal-synovial reflection. In addition, they aggressively reconstructed a torn ACL whenever it was present. Doing so certainly provides additional stability for the knee and protects the meniscus from a subsequent repeat tear.
Mintzer et al attribute their 100% rate of healing in part at least to the fact that there may be " .a greater potential for healing based on more extensive vascularity of the younger menisci." Certainly, the patients’ youth worked in their favor.
It seems to me that it is imperative that we become as aggressive as possible about the repair and retention of knee menisci in adolescents. This article demonstrates that they do have an excellent potential to heal as long as the tear is near the meniscal-synovial junction. Removal of a torn meniscus in such a young person probably will predispose him or her to degenerative changes in the years to come.
One of the shortcomings of this article is that Mintzer et al do not have objective evidence of healing as demonstrated by biopsy or re-look arthroscopy (except for one patient). Thus, we are dependent upon the history and physical examination to draw the conclusions from this study. Certainly, the clinical course has been quite good for virtually all the patients and re-look arthroscopy, with or without biopsy, would be hard to justify. MRI scans of a selected number of these patients, however, could have demonstrated the quality of the repair and the structure of the retained repaired meniscus.
Mintzer et al expressed distress that the average time from injury until surgery was more than six months. This delay did not appear to affect the surgical result adversely. However, it is the hope of Mintzer et al that this article will raise the level of awareness of the potential for effective surgical treatment, both among primary care physicians and even surgeons " .who did not think that such young patients could have meniscal tears that would need to be addressed surgically." Certainly, one of the take-home messages from this article is that adolescents who have sustained knee injuries and who may have a torn meniscus should be evaluated promptly by a surgeon versed in the arthroscopic techniques of surgical repair.