The Sequelae of Salvaged Nondegenerative Peripheral Vertical
Medial Meniscus Tears With Anterior Cruciate
Ligament Reconstruction
K. Donald Shelbourne, M.D, and Bart P. Rask, M.D.
Purpose: To determine the clinical sequelae of nondegenerative peripheral vertical medial meniscus
tears treated with abrasion and trephination alone (stable tears) or suture repair (unstable tears). Type
of Study: Cohort follow-up. Methods: At the time of anterior cruciate ligament reconstruction, 548
patients had nondegenerative peripheral vertical medial meniscus tears that were either left unsutured
or repaired. Of 548 menisci, 233 were stable and were abraded and trephined (AT group), 139 were
stable and left in situ (Situ group), and 176 were unstable and were repaired with sutures (Suture
group). An unstable tear was defined as a torn meniscus that could be displaced into the intercondylar
notch with a probe. Patients who had no medial or lateral meniscal tears at the time of ACL
reconstruction served as a control population (No Tear group, n ⫽ 526). Subjective follow-up was
obtained with a modified Noyes questionnaire. Results: Objective follow-up was obtained at a mean
of 4.8 ⫾ 1.7 years postoperatively. Subjective follow-up was obtained at a mean of 7.3 ⫾ 3.4 years
postoperatively. At a mean of 3.7 years (range, 4 months to 10.7 years) after the reconstruction, a
subsequent arthroscopy was required for 14 patients (6.0%) in the AT group, 15 patients (10.8%) in
the Situ group, 24 patients (13.6%) in the Suture group, and 15 patients (2.9%) in the No Tear group;
these numbers were not statistically significant. The mean total subjective score was not statistically
significantly different between groups. Conclusions: Repaired unstable peripheral vertical medial
meniscus tears have a failure rate of 13.6%, most retears occurring more than 2 years after repair. Of
stable peripheral vertical medial meniscus tears treated with abrasion and trephination, most (94%)
remain asymptomatic without stabilization. Key Words: Medial meniscus tear—Anterior cruciate
ligament.
M
eniscal tears present at the time of anterior
cruciate ligament (ACL) reconstruction present
surgeons with a treatment dilemma. Currently, it is not
possible for the surgeon to know whether a meniscus
tear present at the time of ACL reconstruction is or
will become symptomatic. Joint line tenderness with
an acute ACL injury does not correlate with meniscal
From the Methodist Sports Medicine Center, Indianapolis, Indiana (K.D.S.); and the Hillsboro Orthopaedic Group, Hillsboro,
Oregon (B.P.R.), U.S.A.
Address correspondence and reprint requests to K. Donald Shelbourne, M.D., Methodist Sports Medicine Center, 1815 N Capitol
Ave, Suite 530, Indianapolis, IN 46202, U.S.A. E-mail: (Tinker
Gray) tgray@methodistsports.com
© 2001 by the Arthroscopy Association of North America
0749-8063/01/1703-2571$35.00/0
doi:10.1053/jars.2001.19978
270
tears seen at the time of ACL surgery.1 Knees with
repaired menisci have been shown to have a lower
incidence of radiographic and clinical arthrosis than
knees with resected menisci.2 The surgeon must decide, based on the location and extent of the tear,
whether to repair, remove, or leave the tear in situ.
Recent advances in meniscal repair suture devices
have brought about an increase in meniscal repairs.
Lemos et al.3 reported that before the introduction of
meniscal arrows, 7% of all knee arthroscopies included a meniscal repair. After the introduction of the
meniscal arrow, the number increased to 19%. While
the availability of new all-inside repair devices has
made meniscal repair techniques easier and quicker
for the surgeon to perform, their actual need and
long-term efficacy have not been established, and
complications have occurred.4-10
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 270 –274
MEDIAL MENISCUS TEARS IN ACL RECONSTRUCTION
A better prognosis has been found with tears in the
periphery of the meniscus than tears in the more central,
less vascular zone,11,12 and with lateral meniscal tears
versus medial meniscus tears (MMTs).11,13,14 Common
indications for repairing meniscal tears are if they are in
the peripheral vascular zone, vertical, nearly full thickness, and at least 1 cm in length.15 Previous studies have
shown that peripheral vertical meniscus tears less than 1
cm in length treated at the time of ACL reconstruction
can be left in situ.16,17
There are no studies of peripheral vertical MMTs
greater than 1 cm in length that were treated without
suture repair. It has already been shown that many lateral
meniscus tears seen at the time of ACL surgery can be
left in situ without causing subsequent symptoms.18 It is
possible that certain MMTs may also be treated without
surgical repair and remain asymptomatic.
The purpose of our study was to determine the
long-term clinical sequelae of nondegenerative, peripheral, vertical tears of the medial meniscus seen at
the time of ACL reconstruction. Specifically, we
sought to determine if stable peripheral vertical
MMTs greater than 1 cm long could be treated successfully with abrasion and trephination alone. We
also sought to determine the clinical outcome of unstable peripheral vertical MMTs greater than 1 cm
long that were treated with suture repair.
METHODS
From May 1982 through October 1997, 2,543 autogenous patellar-tendon graft ACL reconstructions
were performed by the senior author. Arthroscopy was
performed immediately before the ACL reconstruction to assess and treat meniscal tears when present.
The data regarding the type of meniscus tear and the
treatment were compiled prospectively into a database. From the total population, 72 patients had
degenerative peripheral vertical MMTs that were removed and 548 patients had nondegenerative peripheral vertical MMTs that were determined to be salvageable, and these patients are the focus of this study.
The mean age of the study group was 23.0 ⫾ 7.2 years
(range, 12.7 to 53.7 years). The treatment of the menisci
was based on whether the meniscus, when probed, could
be displaced into the intercondylar notch so that the inner
edge of the meniscus touches medial femoral condyle at
the 7 o’clock position. All tears were greater than 1 cm
long. Menisci that could not be displaced into the intercondylar notch when pulled with the arthroscopic probe
were considered stable tears for the purpose of this study.
The stable tears were initially (1982 through 1988) left in
271
situ (Situ group, 139 patients). Later (1989 through
1997), these stable tears were treated by abrasion and
trephination (AT group, 233 patients). Tears that could
be displaced into the intercondylar notch with the probe
were considered unstable tears and were sutured using
the inside-out technique with No. 2-0 Ethibond suture
(Ethicon, Somerville, NJ) (Suture group, 176 patients).19
In most cases, the sutured menisci were abraded with a
motorized shaver before sutures were placed. For comparison, a group of 526 patients who underwent ACL
reconstruction during the same time period but had no
meniscal lesions served as a control group (No Tear
group). All patients were treated postoperatively with an
accelerated rehabilitation program.20
As part of our prospective follow-up of all patients
who undergo ACL reconstruction surgery, all patients
were asked to return for follow-up examinations more
than 2 years after surgery. If a patient returned to the
clinic at any time after surgery with meniscal tear
symptoms, a subsequent arthroscopy was performed
for evaluation and further treatment as needed. Information about the subsequent arthroscopy was recorded in the database. Information about patients
who sought further care elsewhere was obtained by
questionnaire and outside medical records.
The patients were evaluated subjectively with use of
a modified Noyes knee questionnaire.21 The questionnaire was sent to all patients at 6, 12, 18, and 24
months postoperatively and yearly thereafter. The survey was helpful for alerting the physician to a potential problem the patient might have had in the longterm after surgery. Patients were asked to rate locking
symptoms as either none, occasional, or frequent. If a
patient reported symptoms such as catching, locking,
or swelling, a staff member called the patient to request that he or she return for a physical examination.
One question on the survey specifically asked if the
patient had sought treatment elsewhere for any problems with the ACL reconstructed knee. If the patient
did seek treatment elsewhere, outside records were
obtained. A clinical failure of meniscal treatment was
described as any patient who required subsequent
arthroscopy, either by the senior author or other surgeon, for meniscal symptoms that required removal or
further repair.
Statistical Analysis
Statistical analysis was performed using SAS statistical package (SAS Institute, Cary, NC). Duncan’s
multiple-range test was used to determine statistical
significant difference between groups for objective
272
K. D. SHELBOURNE AND B. P. RASK
stability and subjective pain, stability, activity level,
and total scores. ␹-Square analysis was used to determine if statistically significant differences existed between groups for the rate of subsequent arthroscopy
for meniscal symptoms of the treated tears.
AT group also had a statistically shorter subjective
follow-up time (P ⬍ .001). The percentage of patients
reporting any locking symptoms was 4.3% in the AT
group, 5% in the Situ group, 7.3% in the Suture group,
and 7.1% in the No Tear group.
RESULTS
DISCUSSION
Objective follow-up examinations were performed
at a mean of 4.8 ⫾ 1.7 years after ACL reconstruction
(Table 1). The number of patients who required a
subsequent arthroscopy for medial meniscal symptoms is shown in Table 2. ␹-Square analysis showed
no statistically significant difference between groups
for the number of patients requiring a subsequent
arthroscopy for medial meniscus symptoms. The subsequent surgeries for medial meniscal symptoms for
all groups was performed at a mean of 3.7 years
(range, 4 months to 10.7 years) after the index ACL
reconstruction. Of the patients who had a subsequent
arthroscopy, 13 of 29 patients (45%) in the AT and
Situ groups and 18 of 24 patients (75%) in the Suture
group had the procedure more than 2 years after the
ACL reconstruction.
At a mean of 4.8 ⫾ 1.7 years after ACL reconstruction, the mean manual-maximum KT-1000 arthrometer stability difference between the ACL-reconstructed knee and noninjured knee was 1.7 ⫾ 1.7 mm
and the values were not statistically significantly different among groups (P ⫽ .1258).
The mean pain, stability, activity level, and total
subjective scores are reported in Table 3. The subjective stability scores and total scores were not statistically significantly different between groups. Patients
in the Suture group had statistically significantly lower
pain scores (reporting more pain; P ⬍ .001) and lower
activity scores (P ⬍ .001) than the other groups. The
This study concentrated on a homogenous group of
patients with peripheral vertical MMTs treated in conjunction with an ACL reconstruction. The results of
this study show the effectiveness of our clinical decision making for determining the need for suture repair
versus trephination treatment based on whether the
meniscus tear is stable or unstable (displaceable into
the intercondylar notch). It appears that stable tears,
even greater than 1 cm in length, can be treated with
abrasion and trephination alone.
Trephination has been shown in both animal and
clinical studies to enhance meniscal healing by creating vascular channels.10,22,23 Fox et al.24 treated incomplete peripheral vertical meniscal tears (not specified for lateral or medial) by trephination alone and
had 90% clinical success in 25 patients as determined
at 12 to 27 months of follow-up. Five patients required
repeat arthroscopies because of presumed meniscal
symptoms but all menisci had healed. All except 2 of
the tears were less than 1 cm long.
Orfaly et al.16 found that some MMTs left alone
during ACL reconstruction do remain asymptomatic
after a 2- to 6-year follow-up. The numbers in their
study were too small to suggest indications based on
length or stability of the tear. Weiss et al.17 showed
that MMTs of 1 cm or less can heal if left alone, but
the study did not evaluate tears greater than 1 cm long.
This is the first report of a large group of patients
who had stable peripheral vertical MMTs greater than
1 cm in length who were treated without suture repair.
We specifically wanted to determine if these stable
tears would remain asymptomatic in the long term.
The clinical results in this study showed that 10.8% of
patients in the Situ group compared with 6% of patients in the AT group required an arthroscopy for
subsequent meniscal tear symptoms. The follow-up
time in the AT group was shorter (3.2 years v 3.6
years); however, the mean time when symptomatic
patients required a second arthroscopy was similar in
both groups (2.3 and 2.5 years).
The clinical decision for meniscal repair treatment
in our patient population was determined by whether
the tear was stable or unstable (displaceable into the
intercondylar notch). It would appear that stable tears
TABLE 1. Number of Patients With Follow-Up Subjective
and Objective Data
Group
Total No.
of Patients
No. With
Subjective Data
No. With
Objective Data*
AT†
Situ‡
Suture§
No Tear㛳
233
139
176
526
184 (79%)
119 (86%)
155 (88%)
448 (85%)
149 (64%)
107 (77%)
143 (81%)
384 (73%)
* At a mean of 4.8 ⫾ 1.7 years after ACL reconstruction.
† Meniscus tears treated with abrasion and trephination.
‡ Meniscus tears treated by leaving the tear in situ.
§ Meniscus tears treated with suture repair.
㛳 Patients who had no meniscal tears.
MEDIAL MENISCUS TEARS IN ACL RECONSTRUCTION
273
TABLE 2. Patients Who Required Subsequent Arthroscopy for Symptoms of a MMT
Group
Total No.
of Patients
No. of Subsequent
Surgery
Time After ACL Reconstruction (yr)
Mean ⫾ SD (Range)
AT*
Situ†
Suture‡
No Tear§
233
139
176
526
14 (6.0%)
15 (10.8%)
24 (13.6%)
15 (2.9%)
2.3 ⫾ 1.5 (0.7-5.9)
2.5 ⫾ 1.7 (0.3-7.3)
4.3 ⫾ 2.7 (0.5-9.5)
5.0 ⫾ 3.3 (0.5-10.7)
* Meniscus tears treated with abrasion and trephination.
† Meniscus tears treated by leaving the tear in situ.
‡ Meniscus tears treated with suture repair.
§ Patients who had no meniscal tears.
longer than 1 cm can be treated successfully with
abrasion and trephination. Although current all-inside
methods for meniscal repair exist and can be used
easily with stable peripheral MMTs, the need for
repair has not been determined. It is also important to
consider the added cost and possible complications
that can occur with some of the all-inside meniscal
repair systems. Reported complications include weak
pullout strength, breaking or backing out of the device, posterior pain from protrusion, foreign body
reaction, cystic hematoma, and meniscal cysts.4-10 We
do not think that stable peripheral MMTs need stabilization to remain asymptomatic and that the use of an
all-inside repair is not worth the risk of complications.
We also sought to determine the clinical results of
meniscal repair with unstable peripheral MMTs. Studies of repaired MMTs show a healing success rate of
78% to 100%, as determined by second-look arthroscopy, arthrography, or MRI.11,14,25,26 The association
between healing, as viewed with arthroscopy, and
symptoms is not clear. Morgan et al.13 showed that on
second-look arthroscopy in 74 meniscal repairs, 62
were healed or incompletely healed and none was
symptomatic, whereas in 12 failed repairs all were
TABLE 3. Subjective Knee Scores (Mean ⫾ SD)*
Category
(Points)
Total (100)
Pain (20)
Stability (20)
Overall activity
(20)
Follow-up (yr)
AT†
Situ‡
Suture§
No Tear㛳
95.4 ⫾ 5.8 93.1 ⫾ 8.6 91.8 ⫾ 8.3 92.9 ⫾ 8.1
17.6 ⫾ 2.7 16.9 ⫾ 3.6 16.5 ⫾ 3.7 17.1 ⫾ 3.2
19.8 ⫾ 1.0 19.5 ⫾ 1.6 19.4 ⫾ 1.5 19.4 ⫾ 1.6
19.3 ⫾ 1.8 18.7 ⫾ 2.2 18.8 ⫾ 2.3 18.7 ⫾ 2.3
5.2 ⫹ 1.7 9.0 ⫹ 3.5 7.8 ⫹ 3.2 7.1 ⫹ 4.1
* Most recent score at ⬎2 years after surgery.
† Meniscus tears treated with abrasion and trephination.
‡ Meniscus tears treated by leaving the tear in situ.
§ Meniscus tears treated with suture repair.
㛳 Patients who had no meniscal tears.
symptomatic. DeHaven27 reported that all arthroscopically failed meniscal repairs presented with meniscal
symptoms or signs. Asahina et al.25 reported that, on
second-look arthroscopies in patients who were undergoing hardware removal, 9 patients with symptomatic MMTs had the presence of the original tear or a
new tear extending from the original tear. Conversely,
of 13 patients with incompletely healed menisci, 6
patients required additional meniscal surgery and only
2 of these patients were symptomatic. The authors did
not say if the tears were medial or lateral. On secondlook arthroscopy or arthrogram after ACL reconstruction, Cannon and Vittori11 found that, of 5 meniscal
failures, 3 patients had no symptoms, but they did not
mention if these tears were medial or lateral repairs. In
our study, of patients who had a meniscus repair,
13.6% required a subsequent arthroscopy for additional meniscal symptoms. This rate of failure seems
to be similar to that of other reports with greater than
2 years follow-up.2,22,28
We did not perform second-look arthroscopies to
determine the actual healing of the menisci. Instead,
we chose to look at the clinical symptoms as an
indirect method of determining the success of treatment. It is not known whether a meniscal tear that
does not appear healed on visual examination but
remains asymptomatic is able to distribute loads sufficiently enough to prevent premature arthrosis.
The time of follow-up is important to consider. In
the Suture group, 74% of patients required treatment
more than 2 years after their meniscus was repaired.
The mean time was 4.3 years. It would seem logical
that more failures would occur with time. Therefore,
long-term follow-up is imperative when determining
the clinical success of meniscal treatment.
The total subjective scores and the scores for pain,
stability, and activity were similar in all groups. The
percentage of patients reporting occasional or frequent
locking symptoms was low (4% to 7%) in all the
274
K. D. SHELBOURNE AND B. P. RASK
meniscal tear groups and was similar to the No Tear
group of patients who had no meniscal tears present at
the time of ACL reconstruction. By obtaining longterm subjective scores, we were able to track the
clinical symptoms of patients. We found the current
subjective scores of our study population to be encouraging for a continued low rate of symptoms with
unstable and stable peripheral vertical MMTs.
We conclude that repaired unstable peripheral vertical MMTs have a failure rate of 13.6%, with most
retears occurring more than 2 years after repair. Of
stable peripheral vertical MMTs treated with abrasion
and trephination, most (94%) remain asymptomatic
without stabilization.
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