Strength of Bioabsorbable ‘All-Inside’ Meniscal Repair Devices
December 1, 2000 3 minutes read
Strength of Bioabsorbable All-Inside’ Meniscal Repair Devices
ABSTRACT & COMMENTARY
Synopsis: In an independent study of various commercially available meniscal repair devices, none of these products were as strong as vertical mattress sutures.
Source: Barber FA, Herbert MA. Meniscal repair devices. Arthroscopy 2000;16(6):613-618.
Although newer bioabsorbable "all-inside" meniscal repair devices are enormously popular, surgeons must keep in mind that the mechanical strength of all of these products are weaker than conventional "inside-out" meniscal repair. Additionally, one must be careful about accepting manufacturer’s claims on face value. This study used a porcine meniscal model to determine the initial holding strength of various constructs. Mechanical testing was accomplished using similar parameters from other published studies and repeat testing yielded an accuracy with approximately 5% error. The results reported that a double-vertical mattress suture (top and bottom) using 2-0 nonabsorbable suture was at least twice as strong as any "all-inside" device. The strengths of the meniscal repair devices, according to this study, basically fall into two groups. The first group, about half as strong as the double-vertical suture, and two-thirds as strong as a single vertical suture, includes the BioStinger (Linvatec) and the T-Fix (Smith and Nephew Endoscopy) devices. The second group of devices, approximately one-third as strong as the double vertical sutures and two-fifths as strong as the single vertical suture, included the remaining devices (Meniscal Arrow [Bionx], Clearfix Screw [Innovasive Devices/Mitek], SDsorb Stable [Surgical Dynamics], Mitek repair system [Mitek], and the Biomet staple [Biomet]).
Comment by Mark D. Miller, MD
What I found to be the most remarkable point of this study is that Barber and Hebert’s findings are in stark contrast to "Final, Significant, and Valid Results" published in an advertisement in the American Journal of Sports Medicine the month prior to this article (August). In that advertisement, Bionx proposed that the Meniscus Arrow was stronger than vertical suture, the BioStinger, the Clearfix Screw, The Mitek system, and SD Sorb staples, in that order. On careful examination, they compared their device to PDS and not nonabsorbable suture, but this still does not explain the discrepancy.
What is clear is that a word of caution with the use of these devices is appropriate. Perhaps less aggressive rehabilitation may be necessary when using these devices. Perhaps these devices should not be used for large, complex tears. Perhaps these devices are appropriate only for repairs in conjunction with ACL reconstruction when the healing environment is optimal. There is a paucity of objective clinical studies to support these devices, so surgeons are left with only advertisers’ information on which to base their decisions. Additionally, numerous reports of breakage, synovitis, migration, and other problems with these devices should temper their use. I remain primarily a meniscal "sewer" using vertical mattress sutures and an inside-out technique. In fact, I prefer zero nonabsorbable sutures over 2-0 because I have experienced episodes of suture breakage using 2-0 sutures. Sure, "all-inside" devices are quicker, easier, and do not require an incision. . .but do they consistently work? Fundamental to these issues is the question of how strong is strong enough. Long-term clinical studies may provide the answer to that question, but in the interim, I am reminded of a line from an old television sitcom: "Danger, Will Robinson!"
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