Accelerated Rehabilitation After Arthroscopic Meniscal

Repair: A Clinical and Magnetic Resonance

Imaging Evaluation

Pier Paolo Mariani, M.D., Nicola Santori, M.D., Ezio Adriani, M.D.,
and Marco Mastantuono, M.D.

Summary: Twenty-two patients who underwent meniscal repair using the outside-
in technique combined with anterior cruciate ligament (ACL) reconstruction were
submitted to an accelerated rehabilitation protocol that included immediate full
range of motion and weightbearing. The patients were reviewed postoperatively
by means of clinical assessment and magnetic resonance imaging (MRI) after an
average of 28 months. Clinical evaluation was performed according to the Interna-
tional Knee Documentation Committee form, and sagittal knee laxity was measured
with a KT-2000 arthrometer (MedMetric Corp, San Diego, CA). The MRI scans
were obtained using a 0.2-T high-resolution MRI unit dedicated to the study of
limbs, and the meniscal signal was graded according to a modified Crues classifica-
tion. Overall, 77.3% of patients reported clinically good results. Loss of extension
of <5 ° was detected in only 2 patients (9.1%). Three out of 22 patients showed
clinical signs of meniscal retear. One of these patients had a second operation for
a bucket-handle tear. The presence of a full-thickness rim at MRI evaluation,
present in 10 patients (45.5%), did not correlate with the presence of clinical
symptoms of retear. Instead, the 3 symptomatic patients presented a complete rim
with a gap > 1 mm between the meniscal wall and the fragment of the posterior
horn. This finding is believed to be a more reliable indicator for retear following
meniscal repair. The low failure rate in this series suggests that an aggressive
rehabilitation regimen may be prescribed without deleterious effects in subjects
undergoing ACL reconstruction and concomitant meniscus repair. Key Words:
Meniscus repair--Arthroscopy--Rehabilitation--MRI--Knee joint.

he difficulty in regaining full range of motion after
T surgical repair of the anterior cruciate ligament
(ACL) is well known. To minimize this complication,
an accelerated rehabilitation regimen has recently been
adopted by some orthopaedic surgeons. 1 However,
there are some biological restrictions to this aggressive
protocol, such as a concomitant acute capsular injury
or meniscal tear suitable to repair. In fact, to protect
From the I Clinica Ortopedica (P. P. M., N.S., E.A. ) and H Diparti-
mento di Radiologia (M.M. ), Universit& "La Sapienza, " Rome, Italy.
Address correspondence and reprints requests to Pier Paolo Ma-
riani, M.D., Clinica Ortopedica Universit& "La Sapienza," Piazza
Aldo Moro 5, 00185 Rome, Italy.
© 1996 by the Arthroscopy Association of North America
0749-8063/96/1206-142753.00/0
meniscal healing after repair, many surgeons have
opted for less aggressive rehabilitation. Weightbearing,
joint motion and pivot activities are often restricted,
even though a general consensus is lacking on how
long these should be delayed. Some authors advocate
immobilization, 2-6 partial weightbearing, or both, in the
first 4 to 8 weeks postoperatively. 7-11 Immobilization
m a y be carried out at full extension 4'12a3 or at various
degrees of flexion. 2'3'5"83°'14Restricted joint motion and
weightbearing after a concomitant meniscal repair may
increase the risks o f arthrofibrosis following A C L sur-
gery. 15-19However, some authors 2°-23have recently pro-
posed more aggressive rehabilitation without reporting
deleterious effects. In 1988, Henning et al. 22 advocated
immediate knee motion and early partial weightbear-

680 Arthroscopy: The Journal o f Arthroscopic and Related Surgery, Vol 12, No 6 (December), 1996: p p 680-686
 MENISCAL REPAIR AND REHABILITATION
ing, whereas full weightbearing is proposed by Noyes
et al. 23 and Barber. 2° The purpose of this study was
to assess by clinical and magnetic resonance imaging
(MRI) evaluation the safety of an accelerated rehabili-
tation regimen following meniscal suture and concomi-
tant ACL reconstruction.
MATERIALS AND METHODS
The following inclusion criteria were established for
this prospective study: (1) chronic ACL insufficiency
with an injury-to-surgery interval of more than 6
months, (2) longitudinal tear of the medial posterior
horn in the vascular periphery, (3) tears longer than 1
to 1.5 cm, and (4) use of the same postoperative proto-
col at the same center under the supervision of a single
member of the staff. Exclusion criteria were (1) a his-
tory of meniscal lesions in the controlateral knee, (2)
posterior, medial or lateral laxity, and (3) lateral menis-
cal lesions.
From 1989 to 1991, 22 patients met the above crite-
ria. These patients were operated on by a single sur-
geon for chronic ACL lesion and for medial meniscus
tear. Mean age of the patients was 23 years (range, 17
to 38 years). The group consisted of 16 men and 6
women with 16 subjects having injury to the right
knee and 6 to the left knee. All subjects underwent
arthroscopically assisted ACL reconstruction with
bone-tendon-bone patellar autograft using the one-inci-
sion technique. The meniscal tear was repaired using
the outside-in technique with an 18-gauge spinal nee-
dle placed across the tear from the outside. A knotted-
end suturing technique 24'25 was performed using a 2-0
PDS suture. The perimeniscal synovial membrane and
the meniscal wall were thoroughly abraded with a rasp.
Sutures were placed before ACL surgery and tied at
the end of the ligamentous procedure.
Postoperatively, the patients followed the normal
accelerated rehabilitation protocol that we apply even
in the absence of meniscal repair. This involves contin-
uous passive motion from 0 ° to 90 ° starting the second
day after surgery and continues for 2 weeks with full
weightbearing as soon as tolerated. Immobilization in
a knee brace locked at 0 ° flexion is prescribed during
deambulation for the first month only. The use of a
brace is discontinued as the patient learns to walk with
a straight knee. Two to 4 weeks after surgery, workouts
are supplemented with closed kinetic chain exercises,
low-resistance stationary cycling, and swimming. Pro-
gressive resistance exercises are started 4 weeks post-
operatively. Running and biking are allowed after 2
months, and after a Cybex evaluation, tennis is allowed
681
after 3 months. Unrestricted return to training of pivot-
ing activities is permitted at 5 months and return to
agonistic sports without a functional brace is allowed
at 6 months.
Patients were evaluated both clinically and with
MRI at an average of 28 months (range, 24 to 32
months). Preoperative and postoperative evaluation in-
cluded assessment of clinical status with recordings of
knee instability and meniscal pathology. The informa-
tion collected included acute or chronic status, length
of tear, and demographic and historical data. Physical
examination included presence of effusions, joint line
tenderness, range of motion, meniscal signs, (McMur-
ray's and grinding tests), ligamentous signs (Lachman
test, pivot shift). Sagittal knee laxity was measured
with a KT-2000 arthrometer (MedMetric Corp, San
Diego, CA). All patients were evaluated using the In-
ternational Knee Documentation Committee (IKDC)
form that includes 8 different groups of evaluation:
patients subjective assessment of function and symp-
toms, range of motion, laxity, presence of crackling,
symptoms at the site of graft harvesting, radiographic
findings and functional evaluation. Each group in-
cludes several questions and the answers are classed
as A (normal), B (nearly normal), C (abnormal), or D
(severely abnormal). The worst answer determines the
final result of the group and the final overall result is
given by the worst score obtained in the first four
groups.
The MRI scans were obtained using a high-resolu-
tion unit utilizing a permanent ferrite magnet, designed
for the study of the extremities. Magnetic field intensity
was 0.2 T; gradient intensity 10 mT/m, and field of
view 16 cm. Coronal sagittal and axial images were
taken in all cases. Spatial resolution of 0.6 mm was
achieved by using 2- to 3-ram section thickness with
no intersection gap and 192 × 256 matrix acquisition.
Sequences used were SE T1 TR 680 TE 24 m/s and
SE T2 TR 2000 TE 90 1-n/s. Sagittal images in flexion
and full extension were acquired using a special device
that guides the joint in standardized planes of move-
ment. The MRI scans were independently evaluated
by an expert muscoloskeletal radiologist (M. M.) who
was blinded to the clinical data.
RESULTS
There were no significant intraoperative or postoper-
ative complications in this group of patients. The re-
sults were evaluated at follow-up by a single indepen-
dent examiner (N. S.). Results of the IKDC evaluation
are summarized in Table 1.
682 P. P. MARIANI E T AL.
TABLE 1. Postoperative Assessment According to IKDC Knee Ligament Evaluation Form
IKDC Categories 1 2 3 4
A 10 15 20
45.4% 68.2% 90.8%
B 8 6 2
36.4% 27.3% 9.1%
C 2 1 0
9.1% 4.5%
D 2 0 0
9.1%
NOTE. 1, subjectiveclinical outcome; 2, pain, swelling, giving-way; 3, range of motion; 4, ligament examination; 5, articular crepitism; 6,
pain at site of graft harvest; 7, radiographic alterations; 8, one-leg hop.
Subjective Clinical Outcome
The subjective clinical outcome is considered in the
first group of the IKDC form and the score is deter-
mined by two questions: " H o w does your knee func-
tion?" and " H o w does your knee affect your activity
level on a scale from 0 to 3?" On this section, 10
patients (45.4%) scored A and 8 patients (36.4%)
scored B, 2 patients (9.1%) scored C and 2 (9.1%)
scored D. The high incidence of poor results in this
section is mostly due to the second question, because
the patients, although satisfied with the surgical out-
come, experienced some reduction of their activity
level.
Symptoms
Three out of the 22 patients of this series complained
of symptoms of medial meniscus disorder. One of the
patients had a second operation, and a bucket-handle
tear was found at arthroscopy. The other 2 patients
refused an arthroscopic second-look for their meniscal
complaints. The meniscal tests were positive in these
3 patients and negative in the other 19 patients. Only
1 patient had a knee effusion, and this was the patient
who was operated on later for removal of a bucket-
handle tear.
In terms of pain, swelling, and giving-way, follow-
ing the IKDC parameters, 15 patients (68.2%) scored
A, 6 patients (27.3%) scored B, and 1 patient (4.5%)
scored C. The pain was reported during sport activities
and only in 1 during activities of daily life. Five of
these patients had pain localized at the anterior aspect
of the knee or at the patellar tendon defect.
Range of Motion
Full extension ( < 5 °) was restricted in only 2 sub-
jects (9.1%), and reached the anatomic zero position
in the others. Flexion deficit was not detected in this
series. All in all, 20 patients (90.8%) scored A in Group
3 of the IKDC, and 2 patients (9.1%) scored B.
5 6 7 8
12 21 12 10 21
54.5% 95.4% 54.5% 45.4% 95.4%
8 1 8 10 1
36.4% 4.5% 36.4 45.4% 4.5%
2 0 2 2 0
9.1% 9.1% 9.1%
0 0 0 0 0
Ligament Examination
All 22 knees appeared stable both clinically and at
the instrumented measurements. Twelve patients
(54.5%) scored A, 8 (36.4%) scored B, and 2 scored
C (9.1%) in Group 4 of the IKDC form, which deals
with knee stability. Anterior stability measured with
the KT-2000 arthrometer showed that the preoperative
average side-to-side differences at 30 lbs was 7.2
(+2.3) mm and at follow-up became 1.9 (+ 1.6) ram.
The side-to-side differences at manual maximum were
on average 7.0 mm preoperatively. The postoperative
side-to-side differences were < 3 mm in 16 cases and
between 3 and 5 mm in the remaining 5 cases with an
average of 1.5 mm at follow-up. The pivot shift test
was negative in 20 patients (90.9%) and a glide was
detected in the other 2 patients (9.1%). In the 3 patients
with signs of medial meniscus pathology, knee stability
was recorded as good both at clinical examination and
with the KT-2000 arthrometer. We did not find any
relationship between knee stability and recurrence of
tear.
Sections 5 through 8 of the IKDC form are not
mandatory for the final result, but these are nonetheless
reported in detail in Table I. In section 5, which con-
cerns articular crepitism, only 1 patient had moderate
patellofemoral crepitism but without pain. In section
6 (pain at the site of graft harvest) 12 patients (54.5%)
had no pain, 8 had (36.4%) mild discomfort, and 2
(9.1%) had moderate pain. None of the patients re-
ported severe pain. In section 7, radiographic alter-
ations, 10 patients (45.4%) showed no side-to-side dif-
ference; 10 patients (45.4%) showed minor alterations,
always in the medial compartment; and 2 patients
(9.1%) showed moderate alterations, one in the medial
and the other in the lateral compartment. Section 8
records side-to-side difference in performing the one-
leg hop, and all patients but 1 were able to jump with-
out restrictions. At the 2-year follow-up IKDC evalua-
 MENISCAL REPAIR A N D REHABILITATION 683

TABLE 2. Final Evaluation According to IKDC Knee y e n , 29 5 weeks by Ryu and Dunbar, ~° and 3 weeks by
Ligament Standard Evaluation Form McLaughlin et al. 21 Other surgeons propose early par-
IKDC Final tial weightbearing. 7-11 Similar disagreement can be
Evaluation Group A Group B Group C Group D found for joint motion and return to pivoting activities,
with resumption after 4, 6, or more than 6 months.
Pazienti (%) 2 (9.1%) 15 (68.2%) 3 (13.6%) 2 (9.1%)
The various postoperative regimens have shown minor
to significant differences, and the as yet poorly under-
stood healing rates of meniscal repairs have led the
tion, 9.1% of the patients were in group A, 68.2% in surgeons to suggest various restrictions. Experimental
B, 13.6% in C, and 9.1% in D (Table 2). studies show that lesions of the vascular portion of the
meniscus heal completely after 10 weeks and that it
MRI Evaluation takes several months for the return of normal appear-
We graded the MRI of the posterior meniscal horn ance fibrocartilage. 3° Four to 5 weeks are usually re-
according to a modified Crnes classification. 26 In grade quired for early histological evidence of meniscal re-
0, the posterior meniscal horn has a homogeneous low-
signal-intensity structure; in grade 1, an incomplete
rim extends to only one of the meniscal surfaces; in
grade 2, a complete rim is present at the site of the
previous tear, which appears as a line of high signal
intensity through a full-thickness defect but without
diastasis; in grade 3, a complete rim with a gap greater
than 1 mm (Figs 1 and 2) is present. In Crues' original
classification, the grade 3 signal correlates poorly with
the existence of retears following meniscal repair, 27
and for this reason in our classification we consider
the presence of diastasis as predictive of retear. The
possibility of obtaining images in both flexion and ex-
tension may be useful to determine the stability of a
previously repaired meniscus when a full-thickness
high signal is present. In our MRI analysis we observed
that the gap increases in full extension when an unsta-
ble meniscal tear is present, probably because the pos-
terior capsule pulls the posterior horn.
In terms of MRI, we found overall satisfactory re-
sults in 86.4% of our patients. Using the modified clas-
sification, 6 patients (27.3%) fell into group 0, 3 pa- ( I
tients (13.6%) into group 1, 10 patients (45.5%) into
group 2, and 3 patients (13.6%) into group 3. We ob-
served a gap between the meniscal wall and posterior
horn fragment in all 3 symptomatic patients. Average
diastasis in group 3 was 2.2 mm (range, 1.4 to 3 ram).

DISCUSSION

The literature describes a variety of rehabilitative

protocols after meniscal suture. In an attempt to protect
the repaired meniscus, many surgeons advocate re-
stricted weightbearing and knee motion or immobiliza-
tion. Immobilization is recommended in full extension
by some, 4'12'~3 or in various degrees of flexion by oth-
ers. 5-8'1°'28 Full weightbearing is postponed for various
amounts of time: 8 weeks by Scott et al. 5 and Della-
FIG 1. Classification of the appearance of the posterior meniscal
horn on MRI following meniscal repair. (A) The meniscal horn
completely healed (grade 0); (B) an incomplete rim (grade 1); (C)
a complete rim at the site of a previous tear (grade 2); (D) a rim
with diastasis (grade 3).
684 P. P. MARIANI ET AL.

FIG 2. MRI of a posterior horn after meniscal repair. (A) Grade 0; (B) grade 1 with an incomplete rim; (C) grade 2 with a complete rim
in an asymtomaticpatient; (D) grade 3 with diastasis within the scar of a previous repair.

pair. Zhongnan et al. 31 in their experimental study on
rabbits reported that an acute tear may heal by simply
immobilizing the knee without the need to suture the
lesion. On the other hand, Kawai et al. 32 conclude that
postoperative immobilization may not be necessary for
meniscal healing. The optimum rehabilitation regimen
has yet to be identified, and the lack of scientific data
in the literature does not allow us to endorse a specific
rehabilitation program.
Recently, in an attempt to restore normal knee func-
tion as early as possible, some authors have carried out
a more aggressive rehabilitation protocol 2°~23 without
deleterious consequences for meniscal healing. Mc-
Laughlin et al. 21 reported an 80% success rate after an
aggressive rehabilitation in patients undergoing con-
current meniscal repair and ACL reconstruction. Bar-
ber 2° did not find statistically significant differences
between two groups of patients with restricted and
unrestricted postoperative regimens. In both studies,
clinical evaluation was carried out at follow-up. Bu-
seck and Noyes 33 carried out arthroscopic evaluation
after an aggressive rehabilitation regimen following
meniscal repair in conjunction with ACL reconstruc-
tion. They found that 80% of meniscal repairs healed
completely, 14% healed partially, and 6% failed.
Different methods have been used to evaluate the
success of a meniscal repair. Clinical evaluation alone
is not reliable because of the presence of many asymp-
tomatic retears. Instead, the evaluation of previously
sutured meniscus tears by arthrography 34 has given re-
sults of better than 90% of accuracy. Arthography has
thus become the gold standard in the evaluation of
repaired menisci. However, there are obvious draw-
backs in prescribing arthrography in healthy patients
after ACL surgery. The same problems are encoun-
tered with arthroscopy, which is also poorly accepted
by patients when the sole justification for its use is
simply to document healing. Moreover, although both
these techniques evaluate the continuity of the menis-
cal surface, they do not allow direct evaluation of inter-
 MENISCAL REPAIR AND REHABILITATION
nal meniscal structure. On the other hand, MRI can
display abnormal internal signals regardless of the state
of the surface. Although the use of MRI has been less
compelling for the postoperative follow-up of meniscal
repair, it remains a practical method of evaluation. A
potential pitfall of MRI is the persistence postopera-
tively of meniscal signal abnormalities, which may be
confused with meniscal retear. The increase in signal
intensity with T2 weighted images has been reported
as an important predictive finding; however, it has only
60% sensitivity. Although complete healing might be
expected to restore a normal signal, corresponding to
that from a homogeneous meniscus, if the meniscus
heals with fibrovascular scar tissue, signal abnormali-
ties will appear on images during the healing period.
Kent et al. 35 showed the persistence of signal abnor-
malities in sutured menisci 6 months after surgery.
Further, Arnoczky et al. 36 in their experimental study
show that repaired issue yields an increased MRI signal
after 26 weeks, even though the tissue had modulated
from fibrovascular scar tissue into fibrocartilage.
Clues et al) 6 reported that when considering only
grade 3 signal intensity on MRI as consistent with
meniscal tear, the scans agreed with surgical findings
in 91% of cases. However, several reports 27'37-39 now
indicate that evaluation of menisci that have undergone
surgery is less reliable or specific when the diagnosis
of a retear is carried out solely by the presence of a
linear signal intensity (grade 3). Moreover, LaPrade et
al. 4° have recently shown an incidence of asymptom-
atic tear (1.9%) or grade 2 signal (24.1%) in a series
of young asymptomatic patients.
The only MRI finding accurately predictive of retear
in a previously sutured meniscus is the presence of
diastasis within a linear signal intensity extending to
the articular meniscal surfaces. Evaluation of acquired
sagittal images in flexion and in full extension, using
specialized equipment, is also important diagnosti-
cally. Using this method, it is possible to differentiate,
in a previously sutured meniscus, a high signal inten-
sity within the meniscal scar from a hyperintense signal
due to diastasis; only the latter is a sure sign of retear.
This last result was the only finding in our MRI exami-
nations strongly consistent with the clinical history of
our 3 symptomatic patients. Evaluation of the cases
that showed linear signal intensity without diastasis is
more uncertain because all these patients had neither
complaints nor symptoms. Here, however, even if we
cannot be certain of meniscal healing, the meniscus
seems clinically stable and functionally valid. Many
experimental studies 35'36 confirm that MRI signal ab-
normalities after meniscal suture are quite common but
685
no evidence exists on the meaning and evolution of
these findings. More long-term studies and control
group studies would be useful to better understand the
real meaning of these MRI signal abnormalities.
The overall incidence of treatment failure of the
meniscal suture reported in the literature is confusing,
ranging from 4% to 25%. This variability depends on
different factors, such as the type of lesion (central or
peripheral, acute or chronic tears, isolated or associated
with ACL lesion), the technique used, the suture type
and, lastly, the assessment method (clinical, arthro-
graphic, arthroscopic). According to anatomic assess-
ment, our failure rate after accelerated rehabilitation
was similar to that reported in the literature for similar
types of meniscal tears. Our results show a successful
clinical outcome in 19 out of the 22 repaired menisci at
2-year follow-up. We should point out that this group
included only cases with slight restriction of extension,
with an average loss of 3.5 °. In the literature, the inci-
dence of arthrofibrosis after concomitant ACL surgery
and meniscal repair is reported to be high, ranging from
10% 19 to 19%. TM Moreover, the incidence of extension
deficit is even higher, whereas our results from follow-
ing a more aggressive postoperative regimen showed
a very low incidence of restricted range of motion.
CONCLUSIONS
Accelerated rehabilitation after meniscal repair ap-
pears to be safe, and the incidence of retears evaluated
clinically and by MRI assessment is in line with those
reported in the literature. If meniscal suture is per-
formed in conjunction with ACL reconstruction, an
accelerated rehabilitation regimen helps prevent ar-
throfibrosis, a well-known complication of major liga-
mentous reconstructive procedures. The reliability of
MR1 in evaluating meniscal suture outcome is contro-
versial. We have found that only a complete rim with
a gap within the meniscal rim has a predictable chance
of retear. MRI evaluation of the knee performed in
flexion and extension may detect this finding. Some
doubts still remain in a Crues grade 2 finding. We did
not find any correlation between the presence of a
complete rim and patient symptomatology. In this case,
it would be more useful to perform arthrography or
arthroscopy to evaluate the meniscal healing.
REFERENCES
1. ShelbourneKD, Wilckens JH, MollabashyA, DeCarlo M. Ar-
throfibrosis in acute anterior cruciate ligament reconstruction.
The effect of timing of reconstructionand rehabilitation.Am J
Sports Med 1991;19:323-326.
686 P. P. M A R I A N I
2. Barber FA, Stone RG. Meniscal repair an arthroscopic tech-
nique. J Bone Joint Surg Br 1985;67:39-41.
3. Miller DB. Arthroscopic meniscus repair. Am J Sports Med
1988; 16:315-320.
4. Morgan CD, Casscells SW. Arthroscopic meniscus repair: a safe
approach to the posterior horn. Arthroscopy 1986;2:3-12. 24.
5. Scott GA, Jolly BL, Henning CE: Combined posterior incision
and arthroscopic intra-articular repair of the meniscus. J Bone 25.
Joint Surg Am 1986;68:847-861.
6. Stone RG, Miller GA. A technique of arthroscopic suture of
torn menisci. Arthroscopy 1985; 1:226-232. 26.
7. Barber FA. Meniscus repair: Results of an arthroscopic tech-
nique. Arthroscopy 1987;3:25-30.
8. Lindenfeld TN. Arthroscopically aided meniscal repair. Ortho- 27.
pedics 1989; 10:1293-1296.
9. Marzo JM, Warren RF, Arnoczky SP, Nicholas SJ. Arthroscopic
meniscal repair review of the out-side-in technique. Am J Knee 28.
Surg 1991;4:164-171.
10. Ryu RK, Dunbar WH. Arthroscopic meniscal repair with two- 29.
year follow-up: A clinical review. Arthroscopy 1988;4:168-173.
11. Schilden JLV. Improvements in rehabilitation of the postmenis- 30.
cectomized or meniscal repaired patient. Clin Orthop 1990;252:
73-79.
12. Morgan CD, Wojitys EM, Casscells CD, Casscells SW. Arthros- 31.
copic meniscal repair evaluated by second-look arthroscopy. Am
J Sports Med 1991; 19:632-627.
13. Sommerlath K, Hamberg P. Healed meniscal tears in unstable 32.
knees: A long-term followup of seven years. Am J Sports Med
1989;17:161-163. 33.
14. Rosenberg TD, Scott SM, Coward DB, Dunbar WH, Ewing W,
Johnson CL, Paulos LE. Arthroscopic meniscal repair evaluated
with repeat arthroscopy. Arthroscopy 1986;2:14-20. 34.
15. Graf B, Uhr F. Complications of intrarticular anterior cruciate
ligament reconstruction. Clin Sports Med 1988; 7:835-848.
16. Noyes FR, Mangine RE, Barber SD. The early treatment of 35.
motion complications after reconstruction of the anterior croci-
ate ligament. Clin Orthop 1992;277:217-228.
17. Shelboume KD, Johnson GE. Locked bucket-handle meniscal 36.
tears in knees with chronic anterior cruciate ligament deficiency.
Am J Sports Med 1993;21:779-782.
37.
18. Austin KS, Sherman OH. Complications of arthroscopic menis-
cal repair. Am J Sports Med 1993;23:864-869. 38.
19. Cosgarea AJ, Sebastianelli WJ, DeHaven KE. Prevention of
arthrofibrosis after anterior cruciate ligament reconstruction us-
ing the central third patellar tendon autograft. Am J Sports Med
1995;23:87-92. 39.
20. Barber FA. Accelerated rehabilitation for meniscus repairs.
Arthroscopy 1994; 10:206-210.
21. McLaughlin J, DeMaio M, Noyes FR, Mangine RE. Rehabilita- 40.
tion after meniscus repair. Orthopedics 1994; 17:465-471.
22. Henning CE, Clark JR, Lynch MA, Stalbaumer R, Yearout KM.
ET AL.
Arthroscopic meniscus repair with a posterior incision. Instr
Course Lea 1988; 37:209-221.
23. Noyes FR, Mangine RE, Barber SD. Early knee motion after
open and arthroscopic anterior cruciate ligament reconstruction.
Am J Sports Med 1987; 15:149-160.
Warren RF. Arthroscopic meniscus repair. Arthroscopy 1985;
1:170-172.
Warner JJP, Miller MD, Warren RF. Meniscal repair using the
outside-in technique. Sports Med Arthroscopic Rev 1993; 1:145-
151.
Crues JV, Mink J, Levy TL, Lotysh M, Stoller DW. Meniscal
tears of the knee: Accuracy of MR imaging. Radiology 1987;
164:445-448.
Bronstein R, Kirk P, Hurley J. The usefulness of MRI in evaluat-
ing menisci after meniscus repair. Orthopedics 1992;15:149-
152.
Jakob RP, Staubli HU, Zuber K, Esser M. The arthroscopic
meniscal repair techniques and clinical experience. Am J Sports
Meal 1988; 16:137-142.
DeHaven KE. Meniscus repair in the athlete. Clin Orthop 1985;
198:31-35.
Arnoczky SP, Warren RF. The microvasculature of the meniscus
and its response to injury: An experimental study in the dog.
Am J Sports Med 1983;11:131-141.
Zhongnan Z, Yinkan X, Wenming Z, Zhihua Z, Shihuan O.
Suture and immobilization of acute peripheral injuries of the
meniscus in rabbits. Arthroscopy 1986;2:227-233.
Kawai Y, Fukubayashi T, Nishino J. Meniscal suture. An experi-
mental study in the dog. Clin Orthop 1989;243:286-293.
Buseck MS, Noyes FR. Athroscopic evaluation of meniscal re-
pairs after anterior cruciate ligament reconstruction and immedi-
ate motion. Am J Sports Med 1991; 19:489-494.
Tegtmeyer CJ, McCue FC, Higgins SM, Ball DW. Arthrography
of the knee: A comparative study of the accuracy of single and
double contrast techniques. Radiology 1979; 132:37-41.
Kent RH, Pope C, Lynch JK, Jokl P. Magnetic resonance im-
aging of the surgically repaired meniscuc: Six-months follow-
up. Magn Res Irnag 1991;9:335-341.
Arnoczky SP, Cooper TG, Stadelmaier DM, Hannafin JA. Mag-
netic resonance signals in healing menisci: An experimental
study in dogs. Arthroscopy 1994; 10:552-557.
Deutsch AL, Mink JH. MR imaging of the postoperative menis-
cus. Radiology 1988; 169:20-26.
Deutsch AL, Mink J.H, Fox JM, Arnoczky SP, Rothman BJ,
Stoller DW, Cannon WD Jr. Peripheral meniscal tears: MR
findings after conservative treatment or arthroscopic repair. Ra-
diology 1990; 176:485-488.
Farley TE, Howell SM, Love KF, Wolfe RD, Neumann CH.
Meniscal tears: MR and arthrographic findings after arthroscopic
repair. Radiology 1991; 180:517-522.
LaPrade RF, Burnett II QM, Veenstra MA, Hodgman CG. The
prevalence of abnormal magnetic resonance imaging findings in
asymptomatic knees. Am J Sports Med 1994;22:739-745.