Meniscus repair Indication & Techniques.ppt

Meniscus repair Made easy

1. Meniscus Repair
Techniques & Recent Advancement
Dr. Moazzam Jah
Arthroscopy & Sports Injury Clinic
Nishat Hospital, Lucknow.

2. Why Repair ?

3. Changing concepts

4. Changing concepts
1897: Functionless remnants of intra-articular leg muscles.
Bland-Button J,: Ligaments: Their nature & Morphology 2nd ed. London JK Lewis
Essential biomechanical role in the joint in:
Load bearing and distribution & Transmission,
A/P stability,
Congruence,
Articular cartilage Lubrication & Nutrition,
Proprioception.
Greis PE, Bardana DD, Holmstrom MC, et al. Meniscal injury: I. Basic science and evaluation.
J Am Acad Orthop Surg 2002;10(3):168 –76.
McDermott ID, Amis AA. The consequences of meniscectomy. J Bone Joint Surg Br
2006;88(12):1549–5
1–
Anatomy & Function

5. Changing concepts
Treatment
“a far too common error is shown in incomplete
removal of the injured meniscus”.
McMurray TP. The semilunar cartilages. British J Surg 1942:29, 407-414.
“radiographic changes seen after meniscectomy
which include ridge formation, narrowing of joint
space & flattening of femoral condyle”
Fairbanks TJ. Knee joint changes after meniscectomy. JBJS (Br). 1948:30, 664-667

6. How meniscus is helpful

7. Meniscusevenlydistributes
theaxialstresstowholeof
thetibialsurfacebythe
mechanismofHoopstress.
Intact meniscal Roots & peripheral
circumferential fibres are
essential for this mechanism.
Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the
posterior root of the medial meniscus. Similar to total meniscectomy.J Bone Joint Surg Am
2008;90:1922-1931.
Marzo JM, Gurske-DePerio J. Effects of medial meniscus posterior horn avulsion and repair on
tibiofemoral contact area and peak contact pressure with clinical implications. Am J Sports Med
2009;37:124-129.

8. Worsening radiographic progression of OA in patient
with <50% meniscal rim remaining compared to patients
with >50% meniscal rim.
After partial meniscectomy, contact areas decreased
approximately 10%, and peak local contact stresses (PLCS)
increased approximately 65%.
Baratz ME, Fu FH, Mengato R: Meniscal tears: the effect of meniscectomy and of repair on
intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med.
1986 Jul-Aug;14(4):270-5.
.

9. Although repairs does not reduce the incidence of OA but
definitely it improves subjective outcome as shown in Lysholm
grade

11. MRI remains the gold standard to plan

12. Meniscus

14. 1.symptoms of meniscal injury that affect activities of daily living, work,
or sports, such as instability, locking, effusion, and pain
2.positive physical findings of joint line tenderness, joint effusion,
limitation of motion, and provocative signs, such as pain with
squatting, a positive pinch test result, or a positive McMurray test
result;
3.failure to respond to nonsurgical treatment, including activity
modification, medication, and a rehabilitation program;
4.ruling out of other causes of knee pain identified by patient history,
physical examination, plain radiographs, or other imaging studies
Fabricant PD, Jokl P. Surgical outcomes after arthroscopic partial meniscectomy. J
Am Acad Orthop Surg 2007;15(11):647–53.
Metcalf RW, Burks RT, Metcalf MS, et al. Arthroscopic meniscectomy. Operative
arthroscopy, vol. 3. Philadelphia: Lippincott Williams & Wilkins; 1996. p. 263.
When to operate on Meniscus

15. Indications for repair
Acute (< 8 weeks), symptomatic tears
Vertical, longitudinal tears
Peripheral, red-red/red-white tears
> 7–10 millimeters (mm) in length
Unstable: > 3 mm of excursion
Non-deformed, viable tissue
Concomitant reconstructive surgery: ACL or articular
cartilage
procedures (provides growth factors for its healing).
Patient ready for long post-op protocol.
NICHOLAS A. SGAGLIONE, M.D.: Meniscus Repair: Update on New Techniques: Techniques in Knee Surgery
1(2):113–127, 2002

17. Contraindications for repair
Degenerative non-clinically correlative tears in older patients
Complex pattern tears
White-white avascular tears
Tears < 7-10 mm in length
Stable, incomplete tears (Partial tear: < 50% of vertical ht.
Shallow radial tear: < 3mm depth)
Degenerative, nonviable tissue
Associated infectious, rheumatoid or collagen vascular diseases
Patient recovery or rehabilitation compliance is an issue
NICHOLAS A. SGAGLIONE, M.D.: Meniscus Repair: Update on New Techniques: Techniques in Knee Surgery
1(2):113–127, 2002

18. SURGICAL TECHNIQUES
Open
Arthroscopy Assisted

19. Arthroscopy Assisted
Suturing
Implants: FIRST GENERATION (Fixators)
Suturing using Implant : SECOND GENERATION
Suturing using FibreStitch Implants: THIRD GENERATION

20. Suturing
Outside-in
Inside-out
According to the direction of delivery of the suture in meniscus

21. Joint Opening
Medial: Pie-Crusting
Lateral: Figure of 4

22. Always do it for medial meniscus repair to facilitate
Medial joint-line opening.
Pie-Crusting
Release posterior portion of MCL just distal to Medial
Epicondyle. POL

23. Before repair
Do not forget to freshen the tear site using a
meniscal rasp
or a synovial resector
OR
Do Trephination: Multiple needle pricks at the tear site
Okuda K, Ochi M, Shu N, Uchio Y. Meniscal rasping for repair of
meniscal tear in the avascular zone.Arthroscopy1999; 15: 281e6

24. Outside-in
Mulberry Knots
Mainly for
body
& Ant .
Horn
Tears.

25. Outside-in

26. Small stab incisions
No special instrumentation required
Best indication is anterior third tears
BUT
Difficult to aim & locate the exact site of exit inside
the joint.
(Injury to the surface of meniscus increases on
repeated attempts)
Time consuming.
Outside-in

27. Outside-in

28. Inside out
“Gold standard of meniscus repair”
Henning CE, Clark JR, Lynch MA, Stallbaumer R, Yearout KM, Vequist SW. Arthroscopic meniscus
repair with a posterior incision.Instr Course Lect.1988;37:209-21.
Torn Meniscus can be held
reduced by the
suture passing jig.

29. Inside out

30. Inside out

31. Inside out
Safety Incision

32. Good visualization
Good suture placement
Ability to insert vertical and horizontal sutures on
both surfaces of the meniscus
Most Stable repair
BUT
Risk to neurovascular structures
Requires posterior incisions
Inside out

33. Complications of Suturing technique
Neuro-vascular injury: Saphenous neuropathy,
Peroneal nerve palsy
popliteal artery pseudoaneurysm
Infection
Thrombophlebitis,
Failure of meniscal healing.

34. Implants: FIRST GENERATION (Fixators)
All-Inside

35. Sutures using Implant : SECOND GENERATION
All-Inside

36. All-Inside

37. All-Inside
Good visualization
Quick, simple technique
Avoids the need for posterior incisions
Lower risk of neurovascular injury
Ability to insert vertical and horizontal sutures
on the superior & inferior surfaces of the meniscus

38. BUT
Costly
“All-inside techniques have a higher rate of local soft tissue
irritation, swelling, and implant migration or breakage”
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: 459e68.

39. All-Inside in special conditions
“Union Jack”
Repair

40. Kalliakmanis A1, Zourntos S, Bousgas D, Nikolaou P.
Comparison of arthroscopic meniscal repair results
using 3 different meniscal repair devices in anterior
cruciate ligament reconstruction patients.
Arthroscopy.2008 Jul;24 (7):810-6.
Success rates:
92.4% for FasT-Fix (Smith & Nephew),
87% for T-Fix (Acufex Microsurgical),
86.5% for RapidLoc (DePuy Mitek)

41. Repair Techniques and Indications
Outside-in sutures Anterior horn tears, midthird tears,
radial tears, complex tears,
reduction of bucket-handle tears
Inside-out sutures Posterior horn tears, midthird tears,
displaced bucket-handle tears,
peripheral capsular tears, meniscal
allografts
Fixator implants (first- Posterior horn tears, tears with
generation devices) >2-3 mm rim width, vertical/
longitudinal tears
Suture-based devices Posterior horn tears, midthird tears,
(second & third-generation) bucket-handle tears, radial tears

42. Inside-out V/s All-inside
Isolated repairs: Without ACLR

43. Inside-out V/s All-inside
With ACLR

45. Meniscal Root Tears
Root helps in maintaining hoop stress mechanism
Tear or avulsion causes increase in the contact pressure
MCL, ACL injuries, knee dislocations or reverse Segond
fractures

46. Meniscal Root Tears
Extrusion of the medial meniscal body
Greater than 3 mm of displacement of the medial
meniscal body in the midcoronal plane is considered pathologic
extrusion,

47. Meniscal Root Tears

48. Rehab. Protocol
2-4 weeks
Start ROM ex. upto 90º
FWB with brace in extension & with crutches or walker
Quad. setting.
Passive extn. using heel prop.

49. 4-6 weeks
Same + SLR
Short arc lift for VMO
Toe Raise
Wall slide: CKC of knee
Hip abduction
Rehab. Protocol

50. 6-12 weeks
Rehab. Protocol
Same as before +
Full Rom to be achieved
FWB without braces & crutches.
Stationary bicycle with forefoot on paddle
Hamstring curls
Step up & down exercises: ask the
patient to climb stairs slowly (Few steps
daily)
Quads, Hams, & TA stretching

51. Rehab. Protocol

52. Healing rates of repaired meniscus
Distance from periphery: within 2 mm = 90%,
within 3 mm = 74%,
4 to 5 mm away = 50%
Tear length: less than 2 cm = 90%
greater than 4 cm = 50%
Cannon WD Jr, Vittori JM. The incidence of healing in arthroscopic meniscal repairs in
anterior cruciate ligament-reconstructed knees versus stable knees. Am J Sports
Med 1992;20(2):176–81.

53. Outer 4mm region is
amenable to repair.
R-R Zone
R-W Zone: augmentation
with PRP

54. Healing rates of repaired meniscus
Repairs of tears less than 8 weeks old heal more frequently than
older tears.
There is a higher rate of healing in the medial meniscus then in
the lateral meniscus as it is more mobile & less vascular at the periphery
Cannon WD Jr, Vittori JM. The incidence of healing in arthroscopic meniscal repairs in
anterior cruciate ligament-reconstructed knees versus stable knees. Am J Sports
Med 1992;20(2):176–81.

55. Meniscal Repair should be done prior to
ACL reconstruction or articular cartilage procedures.
in or inside-out techniques, sutures should be tied over the capsule after doing ACLR.

56. Biological Enhancement of Repair
Fibrin clot: Provide a chemotactic and mitogenic stimulus
to the reparative process.
Serve as scaffolding over which fibrous tissue
may from
PRP: provides growth factors:
vascular endothelial growth factor (VEGF),
transforming growth factor beta (TGF-B),
platelet-derived growth factor (PDGF)
Bone Marrow Derived Mesenchymal Stem Cell
Laura E. Scordino, MD , Thomas M. DeBerardino, MD *Biologic Enhancement of
Meniscus Repair Clin Sports Med31 (2012) 91–100

57. Any patient with continuous joint line
pain at 3 months should have a MRI
done and subsequent arthroscopy to
evaluate healing of the repaired
meniscus
ISAKOS 2013 Paper #188: The Impact of Free or Restricted Reha-bilitation After Meniscus
Repair. A Prospective Randomized Clinical Trial. MARTIN LIND, PROF, MD, PHD, DENMARK,
BENT LUND, MD, DENMARK, PETER FAUNOE, MD, DENMARK, SVEND ERIK CHRISTIANSEN,
MD, DENMARK
TORSTEN NIELSEN, MS, DENMARK $ Div of Sports Trauma, Aarhus University Hospital, Aarhus,
Denmark

58. What to do when repair fails or you end up doing near
total meniscectomy

59. Meniscal Allograft Transplant

60. Meniscal Allograft Transplant

61. Meniscal Allograft Transplant

62. Improves symptoms,
function,andqualityoflife
at7-to-14yearsoffollow-up
Theoverallfailurerate
(needforkneearthroplasty)
is10-29%atlong-term
follow-up;
Allowsreturntosamelevel
ofcompetitionin75-85%of
patientsatshort-tomid-
termfollow-up
Associated cartilage
proceduresorACLRto
MATdoesnotworsenthe
results;

63. Meniscal Allograft
Collagen Meniscal Implant (CMI)
Small Intestine Submucosal (SIS) Implant
Adult Mesenchymal Stem Cell Implants
Tissue Engineered Meniscus: Scaffolds + Cells
Meniscal Substitute

64. Partial meniscus loss (Medial only at present)
Need to have an intact rim of meniscus over entire length
No unstable segments
Lesion in red/red or red/white zone
Notsuitable for total meniscus replacement
No uncorrected axial malalignment
Meniscal Substitute
Indications

65. Meniscal Substitute
Collagen Meniscal Implant (CMI)
Anne Christiane Theodora
Vrancken, Pieter Buma, and Tony
George van TienenSynthetic
meniscus replacement: a review
Int Orthop. 2013 Feb; 37(2): 291–
299.

66. Polyurethane Polymeric Implant (Actifit)
Meniscal Substitute
Anne Christiane Theodora Vrancken, Pieter Buma, and Tony George van TienenSynthetic meniscus
replacement: a reviewInt Orthop. 2013 Feb; 37(2): 291–299.

67. Meniscal Substitute

68. “Asymptomatic meniscal tears are common 60-70%”
Zanetti M, Pfirrmann CW, Schmid MR, et al. Patients with suspected meniscal tears:
prevalence of abnormalities seen on MRI of 100 symptomatic and 100 contralateral
asymptomatic knees. AJR Am J Roentgenol 2003;181(3):635–41.
Bhattacharyya T, Gale D, Dewire P, et al. The clinical importance of meniscal tears
demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone
Joint Surg Am 2003;85-A(1):4 –9.
Boden SD, Davis DO, Dina TS, et al. A prospective and blinded investigation of
magnetic resonance imaging of the knee. Abnormal findings in asymptomatic subjects.
Clin Orthop Relat Res 1992;(282):177–85.
Treat the patient, Not the MRI