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Regarding “Repair Augmentation of Unstable, Complete Vertical Meniscal Tears With Bone Marrow Venting Procedure: A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study”

      We read with great interest the review “Repair Augmentation of Unstable, Complete Vertical Meniscal Tears With Bone Marrow Venting Procedure: A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study”" by Kaminski et al.
      • Kaminski R.
      • Kulinski K.
      • Kozar-Kaminska K.
      • Wasko M.K.
      • Langner M.
      • Pomianowski S.
      Repair augmentation of unstable, complete vertical meniscal tears with bone marrow venting procedure: A prospective, randomized, double-blind, parallel-group, placebo-controlled study.
      We appreciate the authors for their research and summary of this simple and convenient technique, which has been widely used by quite a few sports medicine surgeons to improve the meniscal healing rate during meniscal repair. However, we have some concerns regarding the rationale for bone marrow elements on meniscus repair.
      Meniscal tears repaired in conjunction with anterior cruciate ligament (ACL) reconstruction have demonstrated improved healing rates when compared with those repaired in isolation.
      • Wasserstein D.
      • Dwyer T.
      • Gandhi R.
      • Austin P.C.
      • Mahomed N.
      • Ogilvie-Harris D.
      A matched-cohort population study of reoperation after meniscal repair with and without concomitant anterior cruciate ligament reconstruction.
      • Cannon W.D.
      • Vittori J.M.
      The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees.
      • Henning C.E.
      • Lynch M.A.
      • Clark J.R.
      Vascularity for healing of meniscus repairs.
      In view of the reasons for this difference, Scott et al.
      • Scott G.A.
      • Jolly B.L.
      • Henning C.E.
      Combined posterior incision and arthroscopic intra-articular repair of the meniscus. An examination of factors affecting healing.
      put forward the viewpoint that the extensive hemarthrosis and secondary generalized synovitis that occur after ligament reconstruction using arthrotomy may promote healing in some ways. Freedman et al.
      • Freedman K.B.
      • Nho S.J.
      • Cole B.J.
      Marrow stimulating technique to augment meniscus repair.
      stated that the improved rate of healing in meniscus repair combined with ACL reconstruction is mainly due to the release of marrow elements into the joint, which has been recognized by a host of scholars. Since then, a series of studies have suggested that blood and bone marrow elements may improve meniscal healing.
      • Keller R.E.
      • O’Donnell E.A.
      • Medina G.I.S.
      • et al.
      Biological augmentation of meniscal repair: A systematic review.
      ,
      • Anz A.W.
      • Rodkey W.G.
      Biological enhancement of meniscus repair and replacement.
      In this research, the authors conducted a randomized controlled study to compare the effectiveness of bone marrow elements on meniscus repair and indicated that the bone marrow-venting procedure results in a significant improvement in the rate of meniscus healing (100% vs 76%, P = .0035). However, because of the requirements of close fitting and sealing between the ligament and bone tunnel during ligament reconstruction, the tunnel is blocked when the graft has been fixed, and the marrow elements can no longer be released into the articular cavity; residual elements in the cavity also may be depleted by arthroscopic irrigation fluid and subsequent intra-articular drains. Although it has been proven that the concentration of a series of growth factors in the ACL reconstruction group was greater than that in the meniscectomy group within 30 minutes after surgery,
      • de Girolamo L.
      • Galliera E.
      • Volpi P.
      • et al.
      Why menisci show higher healing rate when repaired during ACL reconstruction? Growth factors release can be the explanation.
      ,
      • Galliera E.
      • De Girolamo L.
      • Randelli P.
      • et al.
      High articular levels of the angiogenetic factors VEGF and VEGF-receptor 2 as tissue healing biomarkers after single bundle anterior cruciate ligament reconstruction.
      meniscal healing is a relatively long-term process. With the closure of the bone canal and continuous drainage after surgery, whether the concentration of growth factors in the joint cavity can be maintained at a high level in the long term to augment healing deserves further study. This makes the relationship between bone marrow elements and increased healing rate of meniscus repair combined ACL reconstruction deserving of further comment. Is biological augmentation not the main cause of the difference in healing rates? Are the re-establishment of knee kinematics and longer rehabilitation the key factors for this difference? Perhaps research on joint kinematics and rehabilitation protocol are of vital significance.
      Again, we appreciate the authors for their work on this study, and other researchers also have shown that the bone marrow venting procedure can improve the rate of meniscus healing.
      • Dean C.S.
      • Chahla J.
      • Matheny L.M.
      • Mitchell J.J.
      • LaPrade R.F.
      Outcomes after biologically augmented isolated meniscal repair with marrow venting are comparable with those after meniscal repair with concomitant anterior cruciate ligament reconstruction.
      ,
      • Ahn J.H.
      • Kwon O.J.
      • Nam T.S.
      Arthroscopic repair of horizontal meniscal cleavage tears with marrow-stimulating technique.
      However, we hope to discuss with authors the relationship between the improved meniscus healing rate with combined ACL reconstruction and bone marrow elements stimulation.

      Supplementary Data

      References

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        • Wasko M.K.
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