Meniscus repair rehabilitation with concurrent anterior cruciate reconstruction

Meniscus Repair Rehabilitation With Concurrent Anterior Cruciate Reconstruction

F. Alan Barber, M.D., and Sarah D. Click, D.M.A.

Summary: Meniscal repair is preferable to meniscectomy because of the recog- nized benefits of the meniscus and the consequences of its loss. The most appro- priate rehabilitation program after meniscus repair is unclear. Many meniscus repairs occur in association with anterior cruciate ligament (ACL) reconstructions. An accelerated program permitting early full weight bearing, unrestricted motion, and no limitations on pivoting sports after the resolution of the postoperative effusion and full motion is established encourages patient and surgeon acceptance of the meniscus repair. To evaluate the success of meniscus repair in this accelerated rehabilitation program, a consecutive series of 63 patients with 65 meniscus tears undergoing arthroscopic meniscus repair were followed for a minimum of 2 years. There were seven failures (11%) at an average follow up of 38 months. The average patient age was 26 (range, 13 to 44). Arthroscopic relooks were done in 26%. Successful meniscal healing occurred in 92% of repairs done with ACL reconstructions, but only 67% of meniscus repairs performed in ACL-deficient knees, and 67% of meniscus repairs done in stable knees with no ACL injury. There was no statistical difference in the failures for acute and chronic meniscus tears, nor in the age of the patient undergoing the meniscal repair. Published rehabilitation protocols differ considerably on the three main issues of immobilization, weight bearing, and return to pivoting sports. These data show a meniscus repair success rate consistent with other published series. No modification of an ACL reconstruction accelerated rehabilitation program is needed for meniscus repairs performed in conjunction with the reconstruction. Key Words: Meniscus repair - - Rehabilitation--Meniscectomy.

T he meniscus influences articular compressive forces, joint stability, load transmission, shock ab-

sorption, joint congruity, both flexion and extension, cartilage nutrition and joint lubrication, and contributes to joint stability, especially in the anterior cruciate ligament (ACL)-deficient knee.l4 Meniscus repair is pre- ferred to meniscectomy to avoid the degenerative re- suits that follow this removal. 1-7 Several repair techniques are available: inside-out, 3'4'815 outside- in, 2'16-18 inside-inside, 19 and open. 2°-24

From the Piano Orthopedic and Sports Medicine Center, Piano, Texas, U.S.A.

Address correspondence and reprint requests to F. Alan Barber, M.D., F.A.C.S., Piano Orthopedic and Sports Medicine Center, 5228 West Piano Pkwy, Piano, TX 75093, U.S.A.

© 1997 by the Arthroscopy Association of North America 0749-8063/97/1304-153353.00/0

Various factors appear to promote meniscus healing. 13'2331 However, recent data suggest that the postoperative rehabilitation protocol is not one. 32 A review of the numerous articles addressing meniscus repair fails to show any objective basis or physiological ratio- nale for the various restrictions found in repair rehabilitation protocols. Postoperative restrictions can reduce the attractiveness of the meniscus repair to both the patient who desires a rapid return to sports and the surgeon who must advocate these restrictions. The fre- quent association of repairable tears with torn ACL adds concerns about the influence of an accelerated rehabilitation program on meniscal healing rates. Our hypothesis is that there is no need to restrict the usual postoperative rehabilitation for a meniscus repair. This report presents the results of an unrestricted postoperative rehabilitation program that permits immediate un-

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 4 (August), 1997." pp 433-437 433

434 F. A. BARBER AND S.D. CLICK

limited weight bearing, full unbraced motion, and ag- gressive exercise with no restrictions on pivoting sports.

METHODS AND MATERIALS

Patients undergoing arthroscopic inside-out meniscus repairs were evaluated by examination and questionnaire. The questionnaire covered demographic and historical data to include age, sex, mechanism of injury, injury activity, time from injury to surgery, preex- isting procedures, preoperative symptoms, activity levels, and bracing, as well as similar data for the postoperative status. Objective data included surgical findings, associated procedures, and physical examination (Lachman's, drawer, flexion rotation drawer, and McMurray's tests, effusion, atrophy, and motion both preoperatively and postoperatively). Videotapes, operative reports, and clinical records were also reviewed. A minimum 24-month follow-up was required.

The rehabilitation program targeted a rapid return to full function. Bracing was not used. Crutch use was minimized to only allow for patient comfort. Full motion and immediate full weight beating were allowed. The same postoperative exercise program used for meniscectomy patients was used for the "isolated" meniscus repair and permitted a return to all activities, including pivoting sports, once adequate motion (0 ° to 120°), good strength, and no effusion were achieved. Patients with an ACL reconstruction were rehabilitated using an accelerated program during which half of the patients were weaned from their crutches in the first week, and all were off their crutches by the second week after surgery. A continuous passive motion ma- chine was used during this period until flexion to 115 ° was achieved. Prone hangs and bridging exercises were emphasized until full extension was secured. A night splint was used to encourage full extension for the first 2 weeks. Bicycling began in the first 2 weeks, advancing to stairmaster-type exercises, always main- taining a closed chain program. Running was allowed at 6 to 8 weeks, noncontact pivoting sports at 10 to 12 weeks, and full unlimited activity in all sports with a derotational brace as early as 3 to 4 months postoper- ation once full extension, flexion to 120 °, and no effusion were achieved.

The inside-out meniscal repair technique used both 2 - 0 braided polyester sutures and #0 PDS sutures in- serted with a zone specific cannula system (Linvatec, Largo, FL), exiting posteromedially or posterolaterally through portals, and tied down on the capsule to avoid soft tissue damage. The peripheral meniscal material

was first debrided with a basket forceps and the peripheral synovium "stimulated" by a motorized shaver. Fibrin clots and meniscal trephination were not used.

Relook arthroscopies were performed in some cases to evaluate meniscal symptoms or to debride infrapa- tellar scarring associated with an ACL reconstruction. The meniscal repair was considered a failure if at relook arthroscopy incomplete healing (including both partial- or full-thickness meniscus defects) was ob- served, or if the patient showed objective meniscal signs such as persistent effusions, locking, or a positive McMurray' s test.

RESULTS

A total of 63 patients were included, with 65 meniscus repairs. The average age was 26 (range, 13 to 44), and the average follow-up was 38 months (range, 24 to 72 months). Relook arthroscopies were done in 17 (26%) of these, and there were seven confirmed meniscus repair failures, for a global failure rate of 11%.

Acute tears were repaired in 46, of which seven failed, for an 85% success rate. Chronic tears were repaired in 19, of which none failed, for a 100% success rate. Knee stability was classified as unstable, stable with intact ACLs, and stable after ACL reconstruction. A stable knee had both a negative pivot shift and a Lachman's test of no greater than 1 + (opening of less than 5 mm). 33 Unstable knees showed any pivot shift or a Lachman's test of 2+ (opening of 5 to 10 ram) or more.

There were three repairs in unstable knees with one failure (67% success rate). There were three repairs in knees with intact ACLs with one failure (67% success rate). There were 58 repairs in knees that were stable after an intraarticular ACL reconstruction with five failures (92% success rate). Thirty-six repairs were done using nonabsorbable sutures (seven failures), and 29 repairs used absorbable sutures (no failures).

There were 49 male patients (two had both medial meniscus and lateral meniscus repaired) and 14 female patients. There were 58 medial meniscus repairs and seven lateral meniscus repairs. Two patients had both menisci repaired. The right knee was involved in 46 and the left in 19.

The patient's ages were grouped by decade. Sixteen patients were 19 or younger, 25 were in their third decade, 21 in their fourth decade, and two older than 40 years. Four of the failures were in patients younger than 20, and three others were in patients in their fourth decade.

MENISCUS REPAIR REHABILITATION 435

DISCUSSION

The postoperative treatment for a meniscus repair can be a significant limiting factor for both the patient and the surgeon considering meniscus repair. Periods of immobilization, limited weight bearing, and sports restriction may lead to a decision to perform a meniscectomy instead of a meniscus repair. Yet, there are few objective data offered to support the restrictions of the various rehabilitation protocols. Meniscal preservation should be the objective whenever possible. The consequences of meniscectomy, even a limited one, are inferior long-term to a successful meniscus repair. The literature shows an amazing lack of consen- sus about rehabilitation protocols, yet the results are generally the same. This calls into question the whole basis for any restrictions.

Rehabilitation protocols usually address three areas: immobilization, weight bearing, and the return to pivoting sports. Some authors recommend immobilization for various periods up to 8 weeks. 34 Some recommend this immobilization be in full extension, 2'16'35-37 based on observations that a peripheral posterior horn tear moves away from the capsule in flexion and reduces into position in extension.16 Other proponents of immediate postoperative immobilization recommend various flexed positions. 3"8'9-12'rS"t72°'23,24,35'3739 This advice con-

trasts with those who advocate limited early motion after repair. ~3'H'4°-42

Weight bearing is also controversial. A non-weight- bearing status for varying periods is recommended by s0me,3,8.9.11.12A4,15,17.23,34,35,37,38 whereas others permit early partial weight bearing, m'13̀ 2°'23'z4'36̀ a°-42 and still

others place no restrictions on the immediate postoperative weight bearing. 2'~6'37

Recommendations for a return to pivoting sports after meniscus repair range from 4 months or l e s s 2'10'16'24 t o 6 months3,8,9,11,12,17,20,34,35,38A2,43 o r

more.1314'1637'4°'41 Some authors do not discuss this 9 15 17233536 aspect of rehabilitation. • . . . . . . .

An "accelerated" approach was initially advocated by Shelbourne et al., 44 who also report no difference in meniscus healing rates between an accelerated and a conventional rehabilitation program. The benefits of functional stress in promoting healing are well recog- nized for fracture treatment. Early weight bearing will actually allow for quicker fracture healing. A similar process may influence the meniscal healing results, and early physiological loading, such as in weight bearing, may be beneficial to the overall healing process.

A meniscus repair performed in an ACL-deficient joint has a higher failure rate than a repair in a stable

joint. 3'4'1°'14A5"16'17'2°'22 This may be influenced by the

kinematics of the posterior horn of the medial meniscus in the ACL-deficient knee. The external rotation of the tibia during terminal extension around the central vertical rotation axis of the femur may concentrate the abnormal stresses of the loose ACL-deficient knee at the repair site and block the healing process. ~6 Addi- tionally, because the repetitive trauma of continuing subluxation episodes is sufficient to lead to late meniscal tearing in ACL-deficient knees, it is not unreason- able to believe that a once repaired and healed meniscus could fail by retearing with the same mechanism that would tear a previously untorn meniscus in the ACL-deficient knee.

This study found a high success rate (92%) at an average 38 months' follow-up in meniscus repairs performed in conjunction with an ACL reconstruction. The hemarthrosis associated with an ACL reconstruction may enhance meniscus healing by providing che- motactic and growth factors to the site of meniscal repair ~7 and explain why meniscus repairs done in conjunction with an ACL reconstruction have a better prognosis. 16,2o Another contributing factor could be the debris associated with the notchplasty and tunnel placement in the femur and tibia. These debris also may stimulate an inflammatory healing response not found in the unreconstructed knee, leading to better healing rates. The "fresh, longitudinal" nature of the meniscal tear often found associated with ACL tears also may improve the prognosis. The solitary meniscal tear may have a more degenerative or chronic tear pattern not as conducive to healing.

Our selection criteria for a meniscus suitable for repair includes longitudinal tears that are within the red-red or red-white region. This is typically within 5 mm of the synovial meniscal junction. Bucket handle tears that are locked into the notch are technically a significant challenge, but should not be excluded out of hand. Although they may have a reduced healing frequency 37 and may have additional tears that compro- mise the meniscal integrity, attempts at repair often result in the preservation of part if not all of the meniscus. Relook operations have shown that the middle and anterior portions of these 4+-cm-long tears have healed well, even if the posterior horn has retorn or failed to fully heal. This also does not count the benefit of "stabilization" of the tear to provide for some meniscal function even if the tear does not fully heal.

The recent realization that the "accelerated" rehabilitation program will actually enhance the recovery after an ACL reconstruction has placed an increased emphasis on advancing knee function as rapidly as the

436 F. A. BARBER AND S.D. CLICK

knee can accept it. 45 The concern exists that a meniscus repair, using any of the previously referenced rehabilitation protocols, may negatively influence this accelerated ACL program by requiring a slower pace. The concern also may exist that accelerated ACL rehabilitation may negatively affect the success rate of a meniscus repair. These data show that, especially in the ACL reconstructed patient, a meniscus repair will heal just as well with the accelerated program as before. The surgeon does not need to modify the ACL rehabilitation routine when a concomitant meniscus repair is performed.

Surgeons focus on the development and refinement of surgical techniques and pay less attention to postoperative management. The ability to return patients to normal activity levels after meniscal repair with an accelerated rehabilitation program makes this proce- dure more attractive to both patients and surgeons and should result in increased efforts to preserve the torn meniscus. The benefits of meniscal preservation in the ACL-reconstructed knee are significant. Meniscal repair in a knee also undergoing ACL reconstruction should not delay the accelerated rehabilitation program, which has been shown to provide better results. These data support an accelerated postoperative program that rapidly returns the patient with a meniscus repair to full function. Our criteria for the release to full function include resolution of the effusion, good strength, full extension, and flexion to 120 ° .

Acknowledgment: The authors greatly appreciate the as- sistance of James N. Click, P.A.-C., and Victor Gonzales, O.R.T., in the data collection for this manuscript.

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Meniscus repair rehabilitation with concurrent anterior cruciate reconstruction