Summary

Survey study on the current trends for rehabilitation following meniscus repair depending on tear morphology.

Abstract

Introduction

Meniscus repair has correspondingly become more popular, with promise of preservation of joint mechanics and hopes of preventing secondary arthritis. However, it is not clear the optimal rehabilitation protocol, with regards to the duration of limitation of range of motion and weight bearing, following repair of various meniscal tear types. It is prudent for orthopaedic surgeons to understand the current contextual landscape of how practitioners recommend rehabilitating patients that undergo meniscal repair.

Methods

This is a cross-section observational survey study. A de-identified survey was designed using arthroscopic images from six cases of meniscal repair: Radial tear at popliteal hiatus, medial meniscus posterior root repair, lateral meniscus radial tear, lateral meniscus horizontal tear, medial meniscus red-white zone bucket-handle repair, and medial meniscus red-red zone longitudinal peripheral tear. This survey was distributed to American Orthopaedic Society for Sports Medicine (AOSSM) members by e-mail. Questions were designed to elicit, from the surveyed surgeons, their recommendations for duration of limitation of: 1. range of motion, and 2. weight bearing status, for each case. Additionally, use of meniscal repair adjuncts, including bracing and use of biologics, was elicited from the same cohort.

Results

451 completed surveys were obtained from 2973 AOSSM members (15.2%). A majority of AOSSM members recommend bracing after repair of tears that lost hoop integrity (83.3%) and that had intact hoop integrity (76%). A majority of members report use of synovial rasping/trephination (86.0%) and notch microfracture (66.5%), while a minority report use of more involved biologic supplementations including classic fibrin clot (4.9%), platelet-rich plasma (8.9%), and bone marrow aspirate concentrate (2.9%). Timing of return to weight-bearing and range of motion appear to depend on hoop stress integrity; tears with intact hoop integrity were, on average, permitted to return to weight bearing more quickly (1.4 weeks for partial weight bearing, 3.6 weeks for full weight bearing), versus tears that demonstrated loss of hoop integrity (3.9 weeks for partial weight bearing, 6.2 weeks for full weight bearing). Hoop integrity also appears to affect return to full range of motion, with tears that had a loss of hoop integrity demonstrating a longer period of post-operative restriction of range of motion. Full flexion was permitted at an average of 5.0 weeks for tears with intact hoop stress, versus 5.8 weeks for tears with loss of hoop stress. Out of the six cases presented, the most cautious tear types for post-repair rehabilitation were a radial tear at the popliteal hiatus, followed by a medial meniscus posterior root tear.

Conclusions

Overall, a majority of AOSSM practitioners brace after meniscal repair. A majority of practitioners perform in situ adjuncts for biological healing, while a minority adds extrinsic biologics. Although there is no consensus on how each tear type should be rehabilitated following repair, initial tear hoop stress integrity appears to substantially affect rehabilitation decision-making, with loss of hoop stresses triggering a more conservative approach to rehabilitation, both with regards to permissive return to range of motion and weight bearing.