Mostly known for load transmission, knee stability, shock absorption, lubrication, nutrition, and proprioception, the meniscus is an important structure for the protection of knee articular cartilage.1–3 Due to the risk of long-term pathologies, such as osteoarthritis resulting from meniscus lesions and lifetime degenerations of meniscus resulting from tears,4,5 more attention focused on knee protection or appropriate usage of knee was given to the rapid improvement of the quality of life. Meniscectomy is commonly used for meniscus lesions, while recent studies have proven its association with the onset of early osteoarthritis.6,7 However, meniscus suture can preserve the structure of the meniscus, which may avoid the early onset of knee osteoarthritis.8 Therefore, meniscus sutures have been used frequently,9–11 and this technique makes oriented sutures achievable and can preserve meniscus structures. However, meniscus suture was restricted by its device and operation time, making it more challenging compared with meniscectomy.8,10,12,13
A previous study has already suggested that postoperative rehabilitation played a role in the relativity of the improvement of joint stability,14 such as peripheral muscle training to improve dynamic joint stability. Therefore, postoperative rehabilitation for arthroscopic meniscus repair is essential, and the current concept of the program usually includes range of motion (ROM) exercise, weight-bearing training, and strength training.1,15 There are 2 common treatment approaches in patients undergoing meniscus repair: accelerated rehabilitation and restricted rehabilitation. Integrated into the existed research,16–19 the accelerated rehabilitation group encouraged participants to try free weight-bearing and reach full weight-bearing at most 4 weeks postoperatively. Also, it required a shorter period of restriction of joint passive or active ROM, and patients should reach full ROM at most 4 weeks postoperatively. The restricted rehabilitation group limited mobilization time, which normally accompanied the usage of a knee brace, and the weight-bearing period was postponed, averaging 2 to 4 weeks later than the accelerated group to reach full weight-bearing. Lee and Diduch20 made suggestions of full ROM immediate postoperatively, while Barber et al21 and Mariani et al22 recommended a progressive increase in ROM, but all agreed to reach full range after 4 weeks. Nevertheless, restricted rehabilitation was recommended for an average of 4 to 6 weeks of non-weight-bearing status, together with a restricted range within 90° in the first 4 weeks after surgery.23–25
Existing evidence supported that accelerated rehabilitation reduced the atrophy of both quadriceps and hamstrings,26 and a shorter immobilization time can avoid stiffness and shortened the time to return to sports.19 Chiang et al27 considered that early training in accelerated rehabilitation might negatively influence healing of the meniscus, and Yu and Paessler28 found that the increased micromotions in autografts resulted in the enlargement of the tibial tunnel. Additionally, augmented tibial tunnel enlargement may sacrifice knee stability. Tucciarone et al25 believed that a longer time with a limited ROM had advantages in postoperative outcomes, including sufficient time for graft healing without causing problems. The current idea on the optimal rehabilitation plan remains controversial and does not have a strong randomized controlled study (RCT) to provide strong evidence of comparisons between the 2 groups.
The purpose of this study was to perform a systematic review and meta-analysis to make comparisons between accelerated rehabilitation and restricted rehabilitation in patients with meniscus injury (either with or without anterior cruciate ligament [ACL] injury). The outcome measurements included clinical outcomes, failure rate, and tunnel enlargement. Functional outcomes suggested the current status of rehabilitation and the level of available abilities and are therefore of great importance. Tunnel enlargement was a specific index for patients with meniscus and ACL injury. We hypothesized that the accelerated rehabilitation group reported better self-reported function and had a lower failure rate and larger tunnel enlargement.
Methods
Search Strategy
Databases including PubMed, Ovid, Embase, and the Cochrane Library were searched up to November 2021. The systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline and checklist.29 The search strategy was performed by the Medical Subject Headings terms and keywords. Terms included (meniscus) AND (suture OR repair) AND (rehabilitation OR postoperative care OR weight-bearing).
Selection of Studies
The inclusion criteria were as follows: (1) Patients were diagnosed with isolated meniscus lesions or meniscus with ACL injury and no previous knee surgery. (2) Arthroscopic meniscus suture was used with a scheduled postoperative rehabilitation program. (3) Studies contained at least one of the indexes we included for the assessment of clinical outcomes. (4) Patients were age 18–60 years.
Exclusion criteria were (1) eniscal implantation or transplantation; (2) meniscus injuries accompanied with fractures or dislocations; (3) case reports, reviews, technique descriptions, editorial letters, expert opinions, or cadaveric studies; (4) no clinical outcome reported postoperatively; and (5) patients with severe cartilage lesions (International Cartilage Repair Society score system ≥ grade 3).
Data Extraction
Two authors independently screened and selected data. Data included by both authors would be included directly, while the data in the controversy would be discussed by 3 authors for inclusion. The other 2 authors independently extracted data from the studies, and disagreements were referred to the third author for consensus. The following items were extracted: author, publication year, level of evidence (based on the Oxford Center for Evidence Based Medicine),30 study design, sample size, patients’ average age, gender ratio, failure rate, and length of follow-up. Outcomes for all patients undergoing meniscus suture were the Lysholm score, Tegner score, Knee Injury and Osteoarthritis Outcome Score (KOOS score), and surgery failure rate. Tunnel enlargement was additionally evaluated for combined anterior cruciate ligament reconstruction (ACLR).
For studies measured at multiple timepoints, the last follow-up was considered. For tunnel enlargement evaluation, 3 locations, distal, middle, and proximal, were used in both the anterior–posterior view and the lateral view compared with the original tunnel diameters. We included the mean tunnel enlargement in the 2 views. For the surgical failure rate in isolated meniscus lesions, nonhealing meniscus at second-look arthroscopy and reoperation were included, while in meniscus with ACL injury group, a retear of the graft was included.
Risk of Bias Assessment
Two separate reviewers performed the assessment using the Physiotherapy Evidence Database (PEDro) scale for RCTs31 and the Methodological Index for Nonrandomized Studies scale (MINORS scale) for non-RCTs.32 The PEDro scale is a tool containing 11 items, and each item covers 1 (mentioned) or 0 (not mentioned), with a total of 11 points.31 A PEDro score ≥6 was considered moderate to high quality in this study,33 while a PEDro score <6 was considered of low quality. The MINORS scale, which contained 12 items with each outcome receiving 2 points, was categorized into 3 options: no information, insufficient information, and sufficient information. The total score was 24 for comparative studies. Because the included articles were all comparative studies, MINORS scores <12 were considered low quality, 12 to 17 were considered moderate quality, and 18 to 24 were considered high quality.32 Discrepancy of scoring was found between authors, such as one considered it provided specific randomization methods, while another considered the description incomplete, or one considered it provided the definition of appropriate statistical analysis, while another disagreed. All discrepancies were sent to the third author for reassessment.
Statistical Analysis
Review Manager (version 5.3) was applied for data analysis. For discontinuous variables, the odds ratio with 95% confidence interval (CI) in a fixed effect model was used, while the continuous variables were calculated with the mean difference (MD) and 95% CI. For the studies that did not report the SD,18,28,34,35 the P value was used to reversely deduct the t value, then the SE and SD were calculated with the formulas: SE = MD/t and
Heterogeneity of direct treatment comparisons was quantified with the I-squared (I2) statistic. I2 > 50% and P < .1 were considered high heterogeneity. Additionally, the difference was regarded as statistically significant when P value < .05.
Results
Identification of Eligible Studies
Among the 1657 articles, 1379 were retained after duplicates removed, then after screening and detailed selection, 11 were eligible for evaluation. Figure 1 shows a flow diagram of the eligible studies.
—A flow diagram of this study.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—A flow diagram of this study.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—A flow diagram of this study.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
Characteristics of the Included Studies
Considering the protocols presented in each study, different training sessions were found. In the restricted rehabilitation group, patients were asked for a 2-week immobilization and at least 3 weeks of partial weight-bearing, and to reach full ROM and full weight-bearing after 6 weeks in most researches. Moreover, strength training and activity participation were of slow progression. While in the accelerated rehabilitation group, patients were asked for immediate mobilization and weight-bearing, and were required to reach full ROM and full weight-bearing in 3 to 4 weeks after surgery. Strength training and activity participation started earlier than that in the restricted rehabilitation group, and the progression of practices were faster.
Several scales were used to discuss how the various studies categorized functional status. A total of 11 studies were included. Among the research included, 4 were RCTs, 5 were retrospective studies, and 2 were prospective studies. Based on the Oxford Center for Evidence Based Medicine grading, 4 were in level 1, 2 were in level 2, and 5 were in level 3. No included studies were found in very low level of evidence. Patients were categorized into accelerated rehabilitation programs and restricted programs, and the total number was 282:330. Notably, in Perkins et al’s research,36 patients with isolated meniscus lesions were included because patients with accompanying ACL injury underwent meniscectomy. In the research by Cristiani et al,37 4 groups were classified: 2 used restricted rehabilitation, and the other 2 used accelerated rehabilitation; therefore, we named each group as restricted 1, accelerated 1, restricted 2, and accelerated 2. Detailed characteristics are presented in Table 1, and detailed rehabilitation programs were presented in Table 2.
Baseline Information of the Included Studies and No Significant Difference Reported in All Studies in Age, Sex, or Side of Injury
| Study | Level of evidence | Design | Group | Total | Age | M:F | Med:Lat | R:L | Follow-up, y |
|---|---|---|---|---|---|---|---|---|---|
| Meniscus | |||||||||
| Shelbourne et al38 | 3 | Retrospective | Restricted | 17 | 21 (14–41) | 11:21 | 7 (5.6–9.2) | ||
| Accelerated | 39 | 28 (14–59) | 28:11 | 3.5 (2–5.9) | |||||
| Suganuma et al39 | 3 | Retrospective | Restricted | 8 | 23.6 (18–35) | 5:3 | 2.6 (2.1–4.3) | ||
| Accelerated | 19 | 26.5 (19–45) | 16:3 | 3.8 (2.5–5.9) | |||||
| Lind et al19 | 1 | RCT | Restricted | 28 | 26 (18–50) | 18:10 | 21:7 | ||
| Accelerated | 32 | 29 (18–47) | 23:9 | 21:11 | |||||
| Perkins et al36 | 3 | Retrospective | Restricted | 43 | 25.8 (10.5) | 23:20 | 28:15 | ||
| Accelerated | 12 | 23.6 (11.6) | 8:4 | 8:4 | |||||
| Meniscus + ACL | |||||||||
| Yu and Paessle28 | 3 | Retrospective | Restricted | 32 | 30.3 (10.3) | 20:12 | 0.5 | ||
| Accelerated | 33 | 31.2 (12.4) | 19:14 | 0.5 | |||||
| Hantes et al34 | 2 | Prospective | Restricted | 20 | 32.23 (10.27) | 11:9 | 12:2 | ||
| Accelerated | 35 | 37.29 (8.75) | 19:16 | 20:15 | |||||
| Beynnon et al42 | 1 | RCT | Restricted | 17 | 30.2 (16–46) | 9:8 | 7:6 | 1 | |
| Accelerated | 19 | 29.7 (16–48) | 13:6 | 7:5 | 1 | ||||
| Vadalà et al18 | 1 | RCT | Restricted | 23 | 30 (17–44) | 17:8 | 5:3 | ||
| Accelerated | 18 | 29 (16–42) | 13:5 | 4:1 | |||||
| Shimizu et al35 | 3 | Retrospective | Restricted | 10 | 31 (20.5–43.5) | 9:1 | 7:3 | 1 | |
| Accelerated | 10 | 30.5 (22.3–36) | 5:5 | 3:7 | 1 | ||||
| Tajima et al40 | 2 | Prospective | Restricted | 18 | 23.3 (15–48) | 7:11 | |||
| Accelerated | 19 | 23.9 (15–40) | 9:10 | ||||||
| Cristiani et al37 | 1 | RCT | Restricted 1 | 40 | 29.3 (6.4) | 25:15 | 4:9 | 18:22 | |
| Accelerated 1 | 40 | 28.5 (5.5) | 34:6 | 3:9 | 23:17 | ||||
| Restricted 2 | 40 | 28 (6.3) | 29:11 | 5:10 | 21:19 | ||||
| Accelerated 2 | 40 | 28.8 (6.3) | 27:13 | 7:12 | 20:20 |
Abbreviations: ACL, anterior cruciate ligament; F, female; L, left; Lat, lateral; M, male; Med, medial; R, right; RCT, randomized controlled study.
Summary of Restricted and Accelerated Rehabilitation Plans in All Studies Included
| ROM | Weight-bearing | |||
|---|---|---|---|---|
| Restricted | Accelerated | Restricted | Accelerated | |
| Meniscus | ||||
| Shelbourne et al38 | 6 wk: full ROM | 2 wk: full ROM | 6 wk: full WB | 2 wk: full WB |
| Suganuma et al39 | 3 wk: immobilized in plastic cast | 1 d: free ROM | 4 wk: partial WB 8 wk: full WB | 1 wk: partial WB 2 wk: full WB |
| Lind et al19 | 2 wk: 30° 4 wk: 60° 6 wk: 90° | 2 wk: 90° 4 wk: full ROM | 2 W: no WB 4 wk: touch WB 6 wk: free WB | 2 wk: touch WB 4 wk: free WB |
| Perkins et al36 | 6 wk: 90° | 6 wk: 90° | 6 wk: non or toe-touch WB | Immediate: free WB |
| Yu and Paessle28 | 6 wk: 90° | 1 wk: 90° 4 wk: full ROM | 6 kw: partial WB | Immediate: full WB |
| Hantes et al34 | 3 wk: 60° 6 wk: 90° | Immediate: free ROM | 3 wk: partial WB 6 wk: full WB | Immediate: full WB |
| Meniscus + ACL | ||||
| Beynnon et al42 | 4 wk: 90° 6 wk: 120° 8 wk: full ROM | 2 wk: 90° 3 wk: 120° 4 wk: full ROM | 2 wk: 50% of full WB 4 wk: full WB | 2 wk: full WB |
| Vadalà et al18 | 2 wk: full extension immobilization | Immediate: free ROM | Immediate: free WB | |
| Shimizu et al35 | 2 wk: immobilization | 3 d: immobilization | 3 wk: partial WB 6 wk: full WB | 10 d: partial WB 4 wk: full WB |
| Tajima et al40 | 1 wk: 90° 3 wk: 120° 4 wk: full ROM | 1 wk: 90° 3 wk: 120° 4 wk: full ROM | 2 wk: partial WB 5 wk: full WB | 1 wk: partial WB 4 wk: full WB |
| Cristiani et al37 | 6 wk: full ROM | 3 wk: full ROM | 6 wk: full WB | 3 wk: full WB |
| Strength training | Participation and activities | |||
|---|---|---|---|---|
| Restricted | Accelerated | Restricted | Accelerated | |
| Meniscus | ||||
| Shelbourne et al38 | 2 wk: isometric 4 wk: closed chain, resistance | 6 mo: return to functional activity | 4 wk: bike and swim as tolerated 8 wk: sports-specific functional progression strength work as needed | |
| Suganuma et al39 | 3 mo: sitting square on the heel 5 mo: sports activities | 1 mo: sitting square on the heels 3 mo: sports activities | ||
| Lind et al19 | 12 wk: running 6 mo: contact sports | 8 wk: running 4 mo: contact sports | ||
| Perkins et al36 | 6 mo: return to sport | |||
| Yu and Paessle28 | 3 wk: closed chain 6 wk: open chain | 10 wk: start running 6 mo: return to sport | ||
| Hantes et al34 | ||||
| Meniscus + ACL | ||||
| Beynnon et al42 | 5 wk: MMT 4–5 grade | 5 wk: MMT 4–5 grade | ||
| Vadalà et al18 | 2 d: isometric >6 wk: resistance isotonic and isokinetic | Immediate: isometric and progressive isotonic exercises | 3 mo: progressive functional activities (running) 4–6 mo: return to sport | 3 mo: progressive functional activities (running) 4–6 mo: return to sport |
| Shimizu et al35 | ||||
| Tajima et al40 | 3 mo: jogging and running 6 mo: return to athletic movement 8 mo: return to full sports | |||
| Cristiani et al37 | 6 wk: closed kinetic chain exercises (0°–50°), straight leg rises, heel rises | 3 wk: closed chain (0°–50°), straight leg rises, heel rises 6 wk: closed and open chain exercise (0°–90°) | 4 mo: start running 6 mo: sports-specific drills | 12 wk: start running and plyometric exercises; submaximum closed and open kinetic chain exercises 4 mo: sports-specific drills |
Abbreviations: ACL, anterior cruciate ligament; MMT, manual muscle strength test; ROM, range of motion; WB, weight-bearing.
Characteristics of Surgical Techniques in Both Groups
Patients in the isolated meniscus lesion group underwent meniscus sutures, 3 used inside-out technique,36,38,39 1 used vertical suture in 2 types of injuries,39 and 2 used all-inside technique.19,36 Suganuma et al39 discovered 3 types of medial meniscus lesions (longitudinal tear, bucket-handle tear, and vertical lesions) and used 2 techniques: vertical suture and all-inside technique. Also, Perkins et al36 applied both inside-out and all-inside techniques in their study. Patients in the meniscus with ACL injury group underwent ACLR surgery and meniscus suturing; only 3 reported the suture techniques,34,35,40 2 with inside-out technique,35,41 and 1 with outside-in technique.34 Four used semitendinosus and gracilis hamstring tendons for ACLR,18,28,34,35 2 used bone-patellar tendon-bone,37,42 and 2 used hamstring for reconstruction.26,40 There were 4 studies who reported the usage of double bundles in ACLR.18,35,37,41 Cristiani et al37 divided patients into patellar group and hamstring group, and compared the effectiveness of different grafts.
Characteristics of Self-Reported Function in Both Groups
Two studies reported KOOS scores,19,42 5 studies presented Tegner scores,19,38–40,42 and 4 reported Lysholm scores.34,38–40 Also, 4 studies examined the relationship between accelerated rehabilitation programs and tunnel enlargement and made comparisons.18,28,34,35 Additionally, 5 made comparisons of both the restricted and accelerated rehabilitation programs with the surgical failure rate.19,36,38,39,42 Subgroups were categorized as isolated meniscus lesions and meniscus with ACL injury and according to the first line and second line in each study in Table 3, respectively.
Characteristics of Self-Reported Function in Both Groups
| KOOS | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Symptom | Pain | ADL | Sports/recreation | QoL | ||||||
| Study | Bas | Las | Bas | Las | Bas | Las | Bas | Las | Bas | Las |
| Meniscus | ||||||||||
| Lind et al19 | 69 (17) | 77 (16) | 69 (22) | 82 (16) | 75 (24) | 89 (12) | 47 (28) | 61 (26) | 49 (18) | 62 (26) |
| 75 (19) | 83 (14) | 77 (17) | 87 (12) | 82 (17) | 91 (9) | 57 (33) | 70 (23) | 56 (23) | 61 (22) | |
| Meniscus + ACL | ||||||||||
| Beynnon et al42 | 68 (22) | 90 (12) | 77 (15) | 95 (6) | 86 (14) | 98 (3) | 60 (31) | 93 (9) | 36 (27) | 80 (18) |
| 67 (19) | 93 (6) | 78 (14) | 93 (12) | 88 (13) | 97 (10) | 57 (28) | 92 (17) | 40 (19) | 86 (14) | |
| Tegner | Lysholm | Tibial tunnel enlargement, mm | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Study | Follow-up | Bas | Las | Bas | Las | Failure, n | AP | L | AP% | L% |
| Meniscus | ||||||||||
| Shelbourne et al38 | 7 (5.6–9.2) | — | −1 (−3 to 0)a | — | 95 (9.8) | 2 | Not applicable | |||
| 3.5 (2–5.9) | — | −0.5 (−4 to 2)a | — | 94 (9.3) | 4 | |||||
| Suganuma et al39 | 2.6 (2.1–4.3) | 5.5 | 4.9 | 63.5 (11.1) | 86.5 (7.8) | 6 | ||||
| 3.8 (2.25–5.9) | 4.2 | 4.7 | 61.4 (9) | 97.1 (3.5) | 1 | |||||
| Lind et al19 | — | 5.1 (2.4) | 4.1 (2.1) | — | — | 8 | ||||
| — | 4.2 (2.2) | 4.5 (1.9) | — | — | 11 | |||||
| Perkins et al36 | — | — | — | — | — | 13 | ||||
| — | — | — | — | — | 48 | |||||
| Meniscus + ACL | ||||||||||
| Yu and Paessler28 | 0.5 | — | — | — | — | — | 1.17 (1.23) | 0.53 (1.13) | 12.34 | 4.81 |
| 0.5 | — | — | — | — | — | 1.99 (1.38) | 2.32 (1.59) | 20 | 22.9 | |
| Hantes et al34 | — | — | — | 46.7 (13) | 90.78 (5.7) | — | — | — | 23.34 | 24.49 |
| — | — | — | 51.4 (17) | 93.43 (8.6) | — | — | — | 49.52 | 48.14 | |
| Beynnon et al42 | 1 | 5.4 | 5.6 | — | — | 1 | — | — | — | — |
| 1 | 5 | 6.5 | — | — | 0 | — | — | — | — | |
| Vadalà et al18 | — | — | — | — | — | — | — | — | 2.8 | 10.7 |
| — | — | — | — | — | — | — | — | 9.6 | 17.2 | |
| Shimizu et al35 | 1 | — | — | — | — | — | — | — | 28.7 | 47.6 (42.7–51.6) |
| 1 | — | — | — | — | — | — | — | 33.5 (27.3–37.1) | 47 (44.9–50.7) | |
| Tajima et al40 | — | — | 7.2 (1.3) | — | 97.1 (3.1) | — | — | — | — | — |
| — | — | 7.2 (1.2) | — | 96.4 (3.4) | — | — | — | — | — | |
Abbreviations: ACL, anterior cruciate ligament; ADL, activity of daily living; AP, anterior–posterior view; Bas, baseline; KOOS, Knee Injury and Osteoarthritis Outcome Score, the maximum score is 100, representing healthy; L, lateral view; Las, last time follow-up; n, number of surgery failure; QoL, quality of life . Note: The maximum score of Lysholm is 100, and score ≥70 is considered of good condition; the maximum score of Tegner is 10, and score ≥6 can participate in sports activities. “—” representing data missing or not available.
aIn Shelbourne et al,38 data reported changes in the final follow-up rather than a specific functional score.
Risks of Bias
PEDro Score
The mean PEDro score in RCTs was 9 (ranging from 6 to 10). Although one study scored 6 points, which is slightly lower than the scores of the others, all RCTs included met the moderate to high-quality criteria. PEDro scores are presented in Table 4. One disagreement was discovered through the evaluation of Cristiani et al’s37 study in PEDro scale item 6 (blinding of therapists). After discussion, 3 authors considered that this study was dissatisfied with the blinding of therapists.
MINORS Score
The mean MINORS score in non-RCTs was 15.43 (ranging from 15 to 16). All non-RCTs included were at a high level. MINORS scores are presented in Table 5. Scores in item 3 (Prospective collection of data), 5 (Unbiased assessment of the study endpoint), 7 (Loss to follow-up less than 5%), and 8 (Prospective calculation of the study size) were low, which were considered related to the uncomplete reports of methodological part and a small sample size in each study.
MINORS Scores for 7 non-RCTs
| Title | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | Total |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Shelbourne et al38 | 2 | 2 | 1 | 2 | 0 | 2 | 0 | 0 | 2 | 2 | 2 | 0 | 15 |
| Yu and Paessler28 | 2 | 2 | 0 | 2 | 1 | 1 | 0 | 0 | 2 | 2 | 2 | 2 | 16 |
| Hantes et al34 | 2 | 2 | 0 | 2 | 1 | 2 | 0 | 0 | 2 | 2 | 1 | 1 | 15 |
| Suganuma et al39 | 2 | 2 | 2 | 1 | 0 | 2 | 0 | 0 | 2 | 2 | 2 | 0 | 15 |
| Shimizu et al35 | 2 | 2 | 0 | 2 | 2 | 1 | 2 | 0 | 2 | 2 | 1 | 2 | 16 |
| Perkins et al36 | 2 | 1 | 2 | 2 | 0 | 2 | 0 | 0 | 2 | 2 | 2 | 0 | 15 |
| Tajima et al40 | 2 | 2 | 1 | 1 | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 0 | 16 |
Abbreviations: MINORS, Methodological Index for Nonrandomized Studies; RCTs, randomized controlled studies.
Results of the Outcomes
Lysholm Score
According to the 4 studies reported the Lysholm score, 2 in isolated meniscus lesions,38,39 and the result in the accelerated rehabilitation group was found to be better than that in the restricted rehabilitation group in meniscus injury group, with a significant difference found in the Lysholm score (MD = −4.66; 95% CI, −8.6 to −0.73; P = .02; I2 = 88%). The other 2 with meniscus suture and ACL injuries34,40 reported that no difference was discovered (P = .93; Figure 2).
—Comparisons of the Lysholm score in the isolated meniscus lesion group (2.1.1) and meniscus with ACL injury group (2.1.2) in restricted rehabilitation and accelerated rehabilitation. ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—Comparisons of the Lysholm score in the isolated meniscus lesion group (2.1.1) and meniscus with ACL injury group (2.1.2) in restricted rehabilitation and accelerated rehabilitation. ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—Comparisons of the Lysholm score in the isolated meniscus lesion group (2.1.1) and meniscus with ACL injury group (2.1.2) in restricted rehabilitation and accelerated rehabilitation. ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
KOOS Score
Two studies (Lind et al19 in isolated meniscus lesions and Beynnon et al42 in meniscus with ACL injury) used the KOOS scale in 5 subscales, including symptoms, pain, activity of daily living, sports or recreation, and quality of life. For the isolated meniscus group, scores of symptoms, pain, activity of daily living, and quality of life showed better results in the accelerated group. For the meniscus with ACL injury group, items including symptoms and quality of life showed better outcomes in the accelerated group, while there were no significant differences in other indexes.
Tegner Activity Score
Four studies reported their Tegner results: 2 from the isolated meniscus lesion group (one without original data was excluded)19 and 2 from the meniscus with ACL injury group.40,42 No significant difference was discovered in the isolated meniscus group (P = .44). And although a slightly higher Tegner score was discovered in accelerated rehabilitation in Beynnon et al’s research at the 6-month follow-up, after synthesizing the included researches, no significance was presented (P = .73).42 The details are shown in Figure 3.
—Comparisons of the Tegner score between the restricted rehabilitation and accelerated rehabilitation groups (isolated meniscus lesion group and meniscus with ACL injury group). ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—Comparisons of the Tegner score between the restricted rehabilitation and accelerated rehabilitation groups (isolated meniscus lesion group and meniscus with ACL injury group). ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—Comparisons of the Tegner score between the restricted rehabilitation and accelerated rehabilitation groups (isolated meniscus lesion group and meniscus with ACL injury group). ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
Failure Rate
Five studies reported the failure rate in their follow-ups (4 in the isolated meniscus lesion group19,36,38,39 and 1 in the meniscus with ACL injury group).42 A forest plot of the results is presented in Figure 4. It was obvious that no significant difference was present in either the isolated meniscus lesion group (odds ratio = 1.35; 95% CI, 0.78 to 2.34; P = .28; I2 = 68%) or the meniscus with ACL injury group (odds ratio = 3.55; 95% CI, 0.14 to 93.01; P = .45; I2 not applicable).
—Comparisons of failure rates in the isolated meniscus lesion group and meniscus with ACL injury group in the 2 rehabilitation plans. ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—Comparisons of failure rates in the isolated meniscus lesion group and meniscus with ACL injury group in the 2 rehabilitation plans. ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—Comparisons of failure rates in the isolated meniscus lesion group and meniscus with ACL injury group in the 2 rehabilitation plans. ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
Tunnel Enlargement
Four studies reported the percentage of tibial tunnel enlargement changes from the anterior–posterior view (1) and the lateral view (2).18,28,34,35 In the meniscus with ACL injury group, the tibial tunnel enlargement percentage in the accelerated rehabilitation group was higher than that in the restricted rehabilitation group, with a significant difference at the tibial tunnel enlargement from the anterior–posterior view (MD = −7.08; 95% CI, −10.92 to −3.24; P = .0003; I2 = 0%) and the lateral view (MD =−10.33; 95% CI, −16.9 to −3.75; P = .002; I2 = 17%) (Figure 5).
—Comparisons of tibial tunnel enlargement between the restricted rehabilitation and accelerated rehabilitation in the meniscus with ACL injury groups in subgroups ([A] anterior–posterior view and [B] lateral view). ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—Comparisons of tibial tunnel enlargement between the restricted rehabilitation and accelerated rehabilitation in the meniscus with ACL injury groups in subgroups ([A] anterior–posterior view and [B] lateral view). ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
—Comparisons of tibial tunnel enlargement between the restricted rehabilitation and accelerated rehabilitation in the meniscus with ACL injury groups in subgroups ([A] anterior–posterior view and [B] lateral view). ACL indicates anterior cruciate ligament; CI, confidence interval.
Citation: Journal of Sport Rehabilitation 32, 3; 10.1123/jsr.2022-0069
Discussion
The most important finding of this study was that although the isolated meniscus lesion group and meniscus with ACL injury group shared almost the same rehabilitation plans (both in the accelerated group and the restricted group), a significant difference was discovered between the 2 subgroups. The accelerated program resulted in significantly better clinical results in self-reported functions than the restricted group in the isolated meniscus lesion group as indicated by the Lysholm scores. In the meniscus with ACL injury group, no higher surgical failure rate was discovered, but greater tibial tunnel enlargement was observed. Therefore, based on the included studies, it suggested that accelerated rehabilitation may result in better functional conditions than restricted rehabilitation postoperatively.
Recent studies compared restricted and accelerated rehabilitation plans in aspects including ROM and weight-bearing stages to discover significant differences. Some researchers suggested that accelerated rehabilitation postoperatively made patients with isolated meniscus lesions get better results, together without a higher retear rate or surgical failure rate.19,36,38,39 However, Harput et al3 provided the contrary conclusion, and they conducted a systematic review of rehabilitation plans for patients after meniscus suture. The review including 18 studies compared many aspects referring to immobilization time, ROM timing, and progression and timepoint of return to sport. Although the rehabilitation plans differed from one another, no significant difference was discovered at the 2-year and 5-year follow-ups. Also, O’Donnell et al26 concluded 15 rehabilitation protocols and categorized them into restricted and accelerated groups, while no consensus has been reached regarding the optimal ROM timing and weight-bearing status. The results in this study supported the suggestion that the accelerated rehabilitation can provide patients with a better self-reported function, and there was no difference between the retear rate and surgical failure rate.
For patients with meniscus accompanied by ACL injuries, accelerated rehabilitation also played a role in reducing adverse events.22,43 As mentioned in Mariani et al,22 who conducted meniscus suture and ACLR in research, accelerated rehabilitation effectively prevented knee stiffness and muscle atrophy. Coincidentally, Wright and Fetzer43 reported that it might take 1 year postoperatively to regain previous muscle strength and volume after ACLR. However, accelerated rehabilitation might result in higher tibial tunnel enlargement, which might increase the instability of the knee joint.28,34 Therefore, analysis of the existing research was of great importance, which might provide researchers with more information of rehabilitation planning and program selection. The results in this study shared the same conclusion with an enlargement of tibial tunnel enlargement, while no significant improvement was found in self-reported function or muscle strength.
In this study, only arthroscopic meniscus suture and ACLR were taken into consideration to reduce the heterogeneity of the results. Also, finite sample size and other influencing factors might influence the results. However, no meta-analysis has been conducted to compare restricted rehabilitation with accelerated rehabilitation, so this study can be the first to make comparisons and provide quantitative analysis.
Based on the analysis conducted in this research, the guiding significance of clinical practice lies in the recommendation of an accelerated rehabilitation program postoperatively. Nevertheless, due to the mechanism of tibial tunnel enlargement, more attention should be given to the rehabilitation process. Although the mechanism of tunnel enlargement was unclear, previous studies have suggested that in the accelerated program, early mobilization provided more micromotions of the graft both in the longitudinal and sagittal plane, resulting in a decrease in the osteo-walls, especially in allograft that may cause cell necrosis or inflammatory responses and, in turn, caused tibial tunnel enlargement.18,28,44,45
To restrict the micromotions, one of the effective ways was the use of knee brace and crutches.28,34 According to the existing studies reported of the orthosis usage, some researchers agreed on a hinged position in full extension in 4 to 6 weeks after surgery.8,46–49 While among the researchers, some suggested walking with the help of crutches,46–48 and others suggested immobilized.8,49 Additionally, different scales conducted by researchers who disagreed on the full extension immobilized position, such as Brucker et al50 who suggested to immobilize in a 30° flexion position, but no further discussion was found. Therefore, because of a nonuniform approach of immobilization in early exercises, a standard knee brace and crutch usage were of great significance and required further discovery in future rehabilitation plans.
Several limitations have been acknowledged in this study. First, we did not categorize meniscus lesion types in different studies, which might influence the postoperative rehabilitation plan. Second, indexes of functional status were reported differently in studies, as some reported the mean and SD score,19,39,40 while other studies reported the increased percentage,38 and therefore, some data were estimated by formula. Additionally, different scales conducted evaluations in several aspects and cannot be integrated, which made it hard to compare clinical results among all included studies. Finally, due to a lack of articles related to comparisons of accelerated and restricted rehabilitation plans in the meniscus lesion field, we included patients with isolated meniscus lesions and patients with meniscus and ACL injuries. Although the rehabilitation program in both groups were similar, patients with meniscus and ACL injuries might require a longer period of recovery. Future studies are expected to further discover optimal postoperative rehabilitation plans.
Conclusion
This was the first meta-analysis to evaluate the effects of postoperative rehabilitation for patients with meniscus lesions after suture. Patients with the isolated meniscus lesion in the accelerated group showed significantly higher mean self-reported function at final follow-up. Patients with the meniscus injury and ACL injury in the accelerated group did not present significantly higher functional scores, while it showed a significant increase in tibial tunnel enlargement. Therefore, the accelerated rehabilitation may be more recommended with higher self-reported functions without higher failure rate or extra adverse events. Still, an optimal postoperative rehabilitation program might be clarified by large sample–sized randomized trials with more aspects detected, such as objective strength testing, balance, gait patterns, for patients with meniscus lesions after arthroscopy.
Acknowledgments
This study was supported by the West China Hospital, Sports Medicine Center. Data can be found in databases including PubMed, Ovid, Embase, and the Cochrane Library, searched up to November 2021.
References
- 1.↑
Sherman SL, DiPaolo ZJ, Ray TE, Sachs BM, Oladeji LO. Meniscus injuries: a review of rehabilitation and return to play. Clin Sports Med. 2020;39(1):165–183. doi:10.1016/j.csm.2019.08.004
- 2.
Elmallah R, Jones LC, Malloch L, Barrett GR. A meta-analysis of arthroscopic meniscal repair: inside-out versus outside-in versus all-inside techniques. J Knee Surg. 2019;32(8):750–757. doi:10.1055/s-0038-1668123
- 3.↑
Harput G, Guney-Deniz H, Nyland J, Kocabey Y. Postoperative rehabilitation and outcomes following arthroscopic isolated meniscus repairs: a systematic review. Phys Ther Sport. 2020;45:76–85. doi:10.1016/j.ptsp.2020.06.011
- 4.↑
Pujol N, Barbier O, Boisrenoult P, Beaufils P. Amount of meniscal resection after failed meniscal repair. Am J Sports Med. 2011;39(8):1648–1652. doi:10.1177/0363546511402661
- 5.↑
Fox AJ, Wanivenhaus F, Burge AJ, Warren RF, Rodeo SA. The human meniscus: a review of anatomy, function, injury, and advances in treatment. Clin Anat. 2015;28(2):269–87. doi:10.1002/ca.22456
- 6.↑
Katz JN, Wright J, Spindler KP, et al. Predictors and outcomes of crossover to surgery from physical therapy for meniscal tear and osteoarthritis: a randomized trial comparing physical therapy and surgery. J Bone Joint Surg Am. 2016;98(22):1890–1896. doi:10.2106/jbjs.15.01466
- 7.↑
van de Graaf VA, Scholtes VA, Wolterbeek N, et al. Cost-effectiveness of early surgery versus conservative treatment with optional delayed meniscectomy for patients over 45 years with non-obstructive meniscal tears (ESCAPE study): protocol of a randomised controlled trial. BMJ Open. 2016;6(12):e014381. doi:10.1136/bmjopen-2016-014381
- 8.↑
Kim JH, Chung JH, Lee DH, Lee YS, Kim JR, Ryu KJ. Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: a prospective comparison study. Arthroscopy. 2011;27(12):1644–1653. doi:10.1016/j.arthro.2011.06.033
- 9.↑
Huber J, Lisiński P, Kłoskowska P, Gronek A, Lisiewicz E, Trzeciak T. Meniscus suture provides better clinical and biomechanical results at 1-year follow-up than meniscectomy. Arch Orthop Trauma Surg. 2013;133(4):541–549. doi:10.1007/s00402-013-1681-1
- 10.↑
Seo SS, Kim CW, Lee CR, et al. Second-look arthroscopic findings and clinical outcomes of meniscal repair with concomitant anterior cruciate ligament reconstruction: comparison of suture and meniscus fixation device. Arch Orthop Trauma Surg. 2020;140(3):365–372. doi:10.1007/s00402-019-03323-3
- 11.↑
Beaufils P, Pujol N. Meniscal repair: technique. Orthop Traumatol Surg Res. 2018;104(suppl 1):S137–S145. doi:10.1016/j.otsr.2017.04.016
- 12.↑
Grant JA, Wilde J, Miller BS, Bedi A. Comparison of inside-out and all-inside techniques for the repair of isolated meniscal tears: a systematic review. Am J Sports Med. 2012;40(2):459–468. doi:10.1177/0363546511411701
- 13.↑
Kurzweil PR, Cannon WD, DeHaven KE. Meniscus repair and replacement. Sports Med Arthrosc Rev. 2018;26(4):160–164. doi:10.1097/jsa.0000000000000224
- 14.↑
Fang CH, Liu H, Di ZL, Zhang JH. Arthroscopic all-inside repair with suture hook for horizontal tear of the lateral meniscus at the popliteal hiatus region: a preliminary report. BMC Musculoskelet Disord. 2020;21(1):52. doi:10.1186/s12891-020-3066-2
- 15.↑
VanderHave KL, Perkins C, Le M. Weightbearing versus nonweightbearing after meniscus repair. Sports Health. 2015;7(5):399–402. doi:10.1177/1941738115576898
- 16.↑
Kozlowski EJ, Barcia AM, Tokish JM. Meniscus repair: the role of accelerated rehabilitation in return to sport. Sports Med Arthrosc Rev. 2012;20(2):121–126. doi:10.1097/JSA.0b013e318253d7c6
- 17.
Barber FA. Accelerated rehabilitation for meniscus repairs. Arthroscopy. 1994;10(2):206–210. doi:10.1016/s0749-8063(05)80095-7
- 18.↑
Vadalà A, Iorio R, De Carli A, et al. The effect of accelerated, brace free, rehabilitation on bone tunnel enlargement after ACL reconstruction using hamstring tendons: a CT study. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):365–371. doi:10.1007/s00167-006-0219-2
- 19.↑
Lind M, Nielsen T, Faunø P, Lund B, Christiansen SE. Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens. Am J Sports Med. 2013;41(12):2753–2758. doi:10.1177/0363546513505079
- 20.↑
Lee GP, Diduch DR. Deteriorating outcomes after meniscal repair using the Meniscus Arrow in knees undergoing concurrent anterior cruciate ligament reconstruction: increased failure rate with long-term follow-up. Am J Sports Med. 2005;33(8):1138–1141. doi:10.1177/0363546505275348
- 21.↑
Barber FA, Schroeder FA, Oro FB, Beavis RC. FasT-Fix meniscal repair: mid-term results. Arthroscopy. 2008;24(12):1342–1348. doi:10.1016/j.arthro.2008.08.001
- 22.↑
Mariani PP, Santori N, Adriani E, Mastantuono M. Accelerated rehabilitation after arthroscopic meniscal repair: a clinical and magnetic resonance imaging evaluation. Arthroscopy. 1996;12(6):680–686. doi:10.1016/s0749-8063(96)90170-x
- 23.↑
Haas AL, Schepsis AA, Hornstein J, Edgar CM. Meniscal repair using the FasT-Fix all-inside meniscal repair device. Arthroscopy. 2005;21(2):167–175. doi:10.1016/j.arthro.2004.10.012
- 24.
Hoffelner T, Resch H, Forstner R, Michael M, Minnich B, Tauber M. Arthroscopic all-inside meniscal repair—does the meniscus heal? a clinical and radiological follow-up examination to verify meniscal healing using a 3-T MRI. Skeletal Radiol. 2011;40(2):181–187. doi:10.1007/s00256-010-0965-6
- 25.↑
Tucciarone A, Godente L, Fabbrini R, Garro L, Salate Santone F, Chillemi C. Meniscal tear repaired with fast-fix sutures: clinical results in stable versus ACL-deficient knees. Arch Orthop Trauma Surg. 2012;132(3):349–356. doi:10.1007/s00402-011-1391-5
- 26.↑
O’Donnell K, Freedman KB, Tjoumakaris FP. Rehabilitation protocols after isolated meniscal repair: a systematic review. Am J Sports Med. 2017;45(7):1687–1697. doi:10.1177/0363546516667578
- 29.↑
Page MJ, Moher D, Bossuyt PM, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160. doi:10.1136/bmj.n160
- 31.↑
de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55(2):129–133. doi:10.1016/s0004-9514(09)70043-1
- 32.↑
Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–716. doi:10.1046/j.1445-2197.2003.02748.x
- 33.↑
Albanese E, Bütikofer L, Armijo-Olivo S, Ha C, Egger M. Construct validity of the Physiotherapy Evidence Database (PEDro) quality scale for randomized trials: item response theory and factor analyses. Res Synth Methods. 2020;11(2):227–236. doi:10.1002/jrsm.1385
- 34.↑
Hantes ME, Mastrokalos DS, Yu J, Paessler HH. The effect of early motion on tibial tunnel widening after anterior cruciate ligament replacement using hamstring tendon grafts. Arthroscopy. 2004;20(6):572–580. doi:10.1016/j.arthro.2004.04.069
- 35.↑
Shimizu R, Adachi N, Ishifuro M, et al. Bone tunnel change develops within two weeks of double-bundle anterior cruciate ligament reconstruction using hamstring autograft: a comparison of different postoperative immobilization periods using computed tomography. Knee. 2017;24(5):1055–1066. doi:10.1016/j.knee.2017.06.013
- 36.↑
Perkins B, Gronbeck KR, Yue RA, Tompkins MA. Similar failure rate in immediate post-operative weight bearing versus protected weight bearing following meniscal repair on peripheral, vertical meniscal tears. Knee Surg Sports Traumatol Arthrosc. 2018;26(8):2245–2250. doi:10.1007/s00167-017-4665-9
- 37.↑
Cristiani R, Mikkelsen C, Wange P, Olsson D, Stålman A, Engström B. Autograft type affects muscle strength and hop performance after ACL reconstruction. A randomised controlled trial comparing patellar tendon and hamstring tendon autografts with standard or accelerated rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2021;29(9):3025–3036. doi:10.1007/s00167-020-06334-5
- 39.↑
Suganuma J, Mochizuki R, Yamaguchi K, et al. Cam impingement of the posterior femoral condyle in medial meniscal tears. Arthroscopy. 2010;26(2):173–183. doi:10.1016/j.arthro.2009.11.002
- 40.↑
Tajima T, Yamaguchi N, Nagasawa M, Morita Y, Nakamura Y, Chosa E. Early weight-bearing after anterior cruciate ligament reconstruction with hamstring grafts induce femoral bone tunnel enlargement: a prospective clinical and radiographic study. BMC Musculoskelet Disord. 2019;20(1):274. doi:10.1186/s12891-019-2653-6
- 41.↑
Hashimoto Y, Nishino K, Orita K, et al. Biochemical characteristics and clinical result of bone marrow–derived fibrin clot for repair of isolated meniscal injury in the avascular zone. Arthroscopy. 2022;38(2):441–449. doi:10.1016/j.arthro.2021.05.026
- 42.↑
Beynnon BD, Fiorentino N, Gardner-Morse M, et al. Combined injury to the ACL and lateral meniscus alters the geometry of articular cartilage and meniscus soon after initial trauma. J Orthop Res. 2020;38(4):759–767. doi:10.1002/jor.24519
- 43.↑
Wright RW, Fetzer GB. Bracing after ACL reconstruction: a systematic review. Clin Orthop Relat Res. 2007;455:162–168. doi:10.1097/BLO.0b013e31802c9360
- 44.↑
Simonian PT, Erickson MS, Larson RV, O’Kane JW. Tunnel expansion after hamstring anterior cruciate ligament reconstruction with 1-incision EndoButton femoral fixation. Arthroscopy. 2000;16(7):707–714. doi:10.1053/jars.2000.4635
- 45.↑
Cameron M, Buchgraber A, Passler H, et al. The natural history of the anterior cruciate ligament-deficient knee. Changes in synovial fluid cytokine and keratan sulfate concentrations. Am J Sports Med. 1997;25(6):751–754. doi:10.1177/036354659702500605
- 46.↑
Dragoo JL, Konopka JA, Guzman RA, Segovia N, Kandil A, Pappas GP. Outcomes of arthroscopic all-inside repair versus observation in older patients with meniscus root tears. Am J Sports Med. 2020;48(5):1127–1133. doi:10.1177/0363546520909828
- 47.
Ulku TK, Kaya A, Kocaoglu B. Suture configuration techniques have no effect on mid-term clinical outcomes of arthroscopic meniscus root repairs. Knee. 2020;27(3):676–682. doi:10.1016/j.knee.2020.04.017
- 48.↑
Moon HS, Choi CH, Yoo JH, et al. Mild to moderate varus alignment in relation to surgical repair of a medial meniscus root tear: a matched-cohort controlled study with 2 years of follow-up. Am J Sports Med. 2021;49(4):1005–1016. doi:10.1177/0363546520988072
- 49.↑
Ra HJ, Ha JK, Jang SH, Lee DW, Kim JG. Arthroscopic inside-out repair of complete radial tears of the meniscus with a fibrin clot. Knee Surg Sports Traumatol Arthrosc. 2013;21(9):2126–2130. doi:10.1007/s00167-012-2191-3
- 50.↑
Brucker PU, von Campe A, Meyer DC, Arbab D, Stanek L, Koch PP. Clinical and radiological results 21 years following successful, isolated, open meniscal repair in stable knee joints. The Knee. 2011;18(6):396–401. doi:10.1016/j.knee.2010.11.007
