Journal Club - What is the Failure Rate after Arthroscopic Repair of Bucket-Handle Meniscal Tears?

Journal Club is a recurring series where we highlight the latest orthopedic research while discussing the potential applications and ramifications for our patients.

Title

What is the Failure Rate After Arthroscopic Repair of Bucket-Handle Meniscal Tears? A Systematic Review and Meta-Analysis

Authors

Giuseppe Gianluca Costa, MD, Alberto Grassi, MD, Gianluca Zocco, MD, Angelo Graceffa, MD, Michele Lauria, MD, Giuseppe Fanzone,MD, Stefano Zaffagnini, MD, and Arcangelo Russo,MD

Journal

American Journal of Sports Medicine. 2022 May;50(6):1742-1752

Abstract

Background:

Meniscal repair has become the treatment of choice for meniscal tears, especially in the subset of bucket-handle meniscal tears (BHMTs). However, a comprehensive estimate of the corresponding failure rate is not available, thus maintaining doubts about the healing potential of these tears. Furthermore, a wide range of factors to predict high failure rates have been reported but with conflicting evidence.

Purpose:

To determine the failure rate after arthroscopic repair of BHMTs as reported in the literature, compare this with the failure rate of simple meniscal tears extracted from the same studies, and analyze the influence of factors previously reported to be predictive of meniscal repair failure.

Study Design:

Systematic review and meta-analysis; Level of evidence, 4.

Methods:

A systematic search was conducted by 2 independent reviewers using principal bibliographic databases (PubMed, Scopus, Cochrane Library, and EMBASE). After a stepwise exclusion process, 38 articles met the inclusion criteria. Failure rate data were analyzed with a random-effects proportional meta-analysis (weighted for individual study size), and forest plots were constructed to determine any statistically significant differences between BHMTs versus simple tears (longitudinal, radial, or horizontal), medial versus lateral BHMTs, isolated procedures versus repairs with concomitant anterior cruciate ligament reconstruction, and tears in red-red versus red-white zones. Moreover, a meta-regression analysis was conducted to evaluate the effect of patient age and sex, suture technique (in-out or all-inside), time from injury to surgery, mean number of stitches, and length of follow-up on failure rates.

Results:

The pooled failure rate was 14.8% (95% CI, 11.3%-18.3%; I2 = 77.2%). A total of 17 studies provided failure rates of both BHMT repairs (46/311 repairs) and simple tear repairs (54/546 repairs), demonstrating a significantly higher failure rate for BHMT repairs (risk ratio [RR] = 1.50; 95% CI, 1.05-2.15; I2 = 0%; P = .03). Medial BHMT repairs (RR = 1.94; 95% CI, 1.25-3.01; I2 = 0%; P = .003) and isolated repairs (RR = 1.77; 95% CI, 1.15-2.72; I2 = 0%; P = .009) had statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. Among the other factors evaluated with meta-regression, only the mean number of stitches showed a statistically significant effect on failure rates.

Conclusion:

Based on the currently available literature, this systematic review provides a reasonably comprehensive analysis of failure rate after arthroscopic BHMT repair; failure is estimated to occur in 14.8% of cases. Medial tears and isolated repairs were the 2 major predictors of failure.

Dr. Fury’s Analysis and Clinical Application:

Bucket-handle tears often compromise a large portion of the meniscus, a structure that is critical for the function and preservation of the knee joint. Therefore, recent literature has emphasized the importance of repairing the meniscus whenever possible. In this important systematic review, Dr. Costa and colleagues provide data on the outcomes after surgical repair of this significant knee injury. Of the 1300+ bucket-handle meniscal tears in their study, the pooled failure rate was 14.8%. This rate is significantly lower than previous studies, indicating that our modern techniques and implants may be contributing to improved outcomes. Despite this positive data, the study also demonstrated that bucket-handle tears remain a more challenging entity than simple tears, as there is a 50% increased risk of failure in bucket-handle repairs when compared to more simple tear types.

Medial meniscal bucket-handle tears and those undergoing isolated repairs demonstrated a higher risk of failure than lateral tears and those tears being repaired at the same time as an ACL reconstruction. The bone tunnels from ACL surgery allow for blood and other important reparative factors to beneficially impact the healing environment of the knee. In order to create a similar response when a concomitant ACL surgery is not needed, Dr. Fury will often inject bone marrow aspirate (BMA) or platelet-rich-plasma (PRP) to attempt to improve the biologic healing of a significant meniscal injury.

The majority of failures (61.5%) occurred between 6 months and 24 months. This time range likely coincides with an athlete’s return to higher level sporting activities and highlights the importance of optimizing strength, proprioception, and psychological readiness before returning to sport.

Although there was no difference in failure rates based on surgical technique, the number of sutures was demonstrated to have a significant effect on failure rates. This finding supports Dr. Fury’s philosophy to utilize whatever approach necessary (and often multiple approaches) in order to maximize the number of sutures to adequately repair the meniscus.

It is important to note that the authors defined failure as clinical failure or reoperation. Therefore, patients with asymptomatic but unhealed tears seen on followup imaging or surgery were not considered failures for the analysis. Therefore, this study’s conclusions only represent clinically significant failures, as some patients will have unhealed or partially healed portions of meniscus after surgery, but this may not cause symptoms.