Presentation on Meniscus repair vs meniscectomy

1. Dr Sujit Jos MS(Orth), MRCS Ed
Sr. Consultant – Division of Joint Replacements and Sports Medicine
PVS Memorial Hospital, Kochi, Kerala

2. Meniscal tears
} Among most common injuries seen in orthopedic
practice
} Arthroscopic partial menisectomy one of the most
common orthopedic procedures

3. Types of meniscal tears
} Longitudinal tear
} radial tear
} horizontal tear
} Complex tear
} Parrot beak tear
} Bucket handle tear
} meniscal root tear

4. Pathoanatomy
} Overview
} Crescent shaped and have
triangular cross section
} Fibers have circumferential
orientation
} Anterior and posterior
root attachments prevent
extrusion
} Lateral covers 84% of the
condylar surface,12mm
wide, 3-5mm thick
} Medial covers 64%,10mm
wide, 3-5mm thick

5. } Vascularity
} Genicular arteries
} 50% vascularized at birth
} 10-25% in adults
} Makes healing very difficult
} 3 vascular zones
} Red-red
} Red-white
} White-white
Pathoanatomy

6. } Collagen Organization
} Circumferential fibers
} Radial Fibers
} Fine superficial layer around
outside
Pathoanatomy

7. } Load Sharing
} Increases contact area between femur and tibia
} Decreases contact stress on articular cartilage
} Increases congruity
} Provides stability
} Aids in lubrication
Meniscal function

8. } In extension, 50% of the load is absorbed
} At 90° flexion, 90% load-sharing
} Beyond 90°, forces predominate through posterior horns
Biomechanics

9. } Meniscal excursion with
knee flexion
} 11.2 mm excursion of lateral
meniscus
} 5.1 mm excursion of medial
meniscus
¨ Capsule
¨ Deep MCL
¨ Coronary ligament
Meniscal Excursion

10. } Complete removal of meniscus
results in 2-3X increase in contact
stress
} Removal of inner 1/3 = 10%
reduction in contact area and 65%
increase in stress
} Increase loss of meniscal tissue =
increase contact stress
} Medial meniscal root tears have
pressures similar to complete
meniscectomy
Biomechanics

12. } Small effusion
} Joint LineTenderness
} McMurray
} Apley
} Thessaly
} ROM generally normal
} Bucket handle block
} Tight due to effusion
Physical Exam

13. McMurray

14. McMurray

15. Apley’s Compression Test

16. Thessaly Test

17. } Plain films to assess for
bony injury and OA
} MRI is the gold standard
of diagnosis
Imaging

18. • Typically seen in younger patients
• High association with ACL tears
• 90% of LVT in MM and 83% in LM are associated withACL tears
Longitudinal Vertical Tears

21. • This is a LVT with central
margination
• Most frequent type of
displaced tear
• Double PCL
• Double Anterior Horn
• Absent Bow
Bucket Handle Tears

23. • Involves the free edge and propagates peripherally
• Usually degenerative
• Older patients
Horizontal Tears

26. • Also involve free edge,but path is perpendicular to long axis
• Drastically affect ability to resist hoop stresses
• Deeper the tear,the more drastic the biomechanical consequences
Radial Tears

27. Radial Tears

28. Radial Tear

29. • AKA vertical flap tear
• Starts as a radial tear
• Propagates as a longitudinal
Parrot Beak Tears

30. Parrot Beak Tear

31. } Goal is to debride tear and
leave stable rim
} Preservation is ideal
} 80% satisfactory function at
5 yrs
} Lateral debridement = faster
degeneration
Meniscectomy

32. Bucket Handle Tear Flap Tear

33. Radial Tear Degenerative Tear

34. Partial Menisectomy

35. } Indications
} Radial
} Flap
} Horizontal
} Complex
} White-white tears
Meniscectomy

36. } Predictors of Positive Result
} < 40yo
} Normal alignment
} Minimal arthritis at initial scope
} Single fragment tear
Meniscectomy

37. } Relative Contraindications
} Advanced OA
} Complex tears
} Poor tissue quality
} ACL deficiency
Surgical Repair

38. Open Repair
} Rarely used
} Numerous studies have proven reduced surgical
morbidity with arthroscopic repair
} Reserved for peripheral tears in the posterior horn

39. Inside–out meniscus repair
} “Gold standard” for meniscal repair
} Due to ability to place
} Vertical and horizontal sutures
} On femoral and tibial surfaces of the meniscus
} Difficult to do in the posterior third of the menisci
} Requires dissection of neurovascular structures
} Morbidity

40. Inside-out Repair
} Suture passed on either side
of tear with needle cannula
} Suture is brought out of
capsule
} A small skin incision is made
} Suture is tied down to
capsule
} Posterior Horn Repairs

41. } Sutures passed through the
meniscus from the outside
} Eliminates need for larger
incision
} Generally suited for anterior
repair
} Studies have shown similar
results with both techniques
Outside-In Repair
Meniscus Mender kit

42. Outside-in meniscus repair
} Limited access to posterior third of meniscus
} Difficult to place vertical mattress suture
} Difficult to place sutures in tibial surface of meniscus

43. } All-inside repair devices
were developed to reduce
surgical time, prevent
complications resulting from
external approaches, and
allow access to tears of the
posterior horn
} Fourth-generation repair
devices allow placement of
sutures in the meniscus
without the aid of an
external incision or a suture
fixator system
All Inside

44. } Self-adjusting, with the
anchor located behind the
capsule and with a sliding
knot that can be tensioned
appropriately by the surgeon
} Mechanical studies show
comparable strength to
outside-in sutures
All Inside

45. Fastfix 360

46. Posterior horn repair – All inside

47. Meniscus root repair

49. Ramp lesion- menisco-capsular separation

50. Tips for minimizing error
} Adequate joint distension and visualization of meniscus
} Prepare the meniscus tear site properly
} Choose the portal which allows the delivery needle to be
inserted perpendicular to the tear

51. Tips for minimizing error
} Let your assistant hold the camera while your hands are
free to control the Fastfix 360
} Reverse curve needle is useful for tibial side repair
} Avoid over cinching the knot – can cut through

52. Outcomes
} Success rates for all techniques reported 70-95%
} Second-look scopes show lower success rates of 45-91%
} Ligamentous laxity decreases success rate to 30-70%
} 90% success reported in conjunction with ACL repair

53. } Failure to heal
} Stiffness
} Articular surface damage
} NV structure damage
Complications

54. Transplantation
} Indications:
} Recurrent pain after partial or total debridement
} symptomatic with ADLs
} <50yo
} Contraindications:
} Malalignment
} Laxity
} Inflammatory arthritis
} Advanced OA

55. Outcomes
} Widely varying reports of success (Country differences)
} Subjective improvement in tibiofemoral pain
} No clear long-term benefit in preventing OA has been
established
} Grafts seem to do better when placed with a bone block
} Preserving some peripheral rim helps to avoid extrusion
} Variety of meniscal scaffold options being investigated in
animals

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62. Take home

63. Dr Sujit Jos MS(Orth), MRCS Ed.
Sr. Consultant – Department of Orthopedic Surgery
Joint Replacements and Sports Medicine
PVS Memorial Hospital, Kaloor, Kochi
Email: docjoints@gmail.com
Web: www.docjoints.com