Meniscus surgery: Indications for repair

Several basic sciences studies have laid the foundation for successful meniscal repair. There are currently four techniques for meniscal repair that are popular: open, “inside-out,” “outside-in,” and “all-inside.” Because of near universal development of late osteoarthritis after total and even partial meniscectomy, there has been increased emphasis on preserving the meniscus whenever possible, and greater interest in expanding the indications for meniscal repair. This article suggests several indications for repair and summarizes the key components of each technique. The use of “enhancing” techniques, such as fibrin clot, fibrin glue, and various grafting techniques, may expand future indications for meniscal repair.     

“All-inside” arthroscopic meniscus repair

The arthroscopic “all-inside” meniscus suturing technique offers the arthroscopist a way of placing vertically oriented sutures through peripheral posterior horn tears located posterocentral without the risks of nerve, vessel, or posterior capsular entrapment inherent in both the “outside-in” and the “inside-out” arthroscopic methods. This technique introduces new instrumentation that allows the surgeon to both place sutures and tie suture knots intra-articularly under arthroscopic control.     

Arthroscopic meniscal repair: “Inside-out” technique

Good results with the “inside-out” technique of meniscal repair depend on a number of factors: selection of the proper tears for repair, identification of the appropriate patients in whom to carry out repair, stimulation of the tear to generate a vigorous healing response, and stabilization by proper suturing methods. A number of different cannula systems have been developed, but close adherence to technical details are critical to success with any system.Vertical or oblique placement of sutures provide for a more anatomic and secure repair, and enough sutures on both the femoral and tibial surfaces are required for adequate stabilization. Serious complications can occur, most significantly damage to the popliteal neurovascular structures, the peroneal nerve, and the saphenous nerve and its branches. Thorough knowledge of knee anatomy is critical to avoid complications as is the use of accessory posterior corner incisions, the exposure of the posteromedial and posterolateral capsule, and the use of a popliteal retractor for safe retrieval of the repair needles.     

Indications and techniques for use of a fibrin clot in meniscal repair

Clinical and experimental studies have demonstrated the importance of the meniscus in load transmission, stability, shock absorption, and articular cartilage nutrition in the knee joint. As a result, clinicians have emphasized preservation of the injured meniscus when possible. Meniscal healing is dependent on a blood supply or factors derived from serum. An exogenous fibrin clot placed in a stable lesion in an avascular portion of the meniscus can support a reparative response by providing such serum factors. In this review, the authors describe the basic science aspects of meniscal repair and the indications, technique, and results of meniscal repair using an exogenous fibrin clot. Directions for future research on meniscal repair and replacement based on increasing understanding of meniscal biology are briefly discussed.     

Functional anatomy and biomechanics of the meniscus

The meniscus is no longer considered the evolutionary remnant in the knee joint.Rather, it is now well established as an important structure that is integral to the complex biomechanics and proper functioning of the knee. The medial and lateral menisci form two crescent-shaped wedges of fibrocartilage between the femoral condyles and tibial plateaus.The knee joint biomechanics are based on a complex interaction of these intra-articular structures. The functions ascribed to the menisci include load transmission, shock absorption, stability, proprioception, joint lubrication, and joint nutrition. Load transmission generally is accepted as one of its primary functions. The menisci transmit a portion of the axial forces across the knee joint by converting this load into “hoop stresses.” This is accomplished by their unique shape, composition, and anatomic attachments. The menisci are relatively mobile structures and their motion during knee flexion also is determined by their shape and soft tissue attachments/constraints. Preservation of the meniscal functions is essential, and the authors review the basic anatomic and biomechanical concepts necessary to understand techniques for repair and restoration of these functions.     

Future directions in meniscal surgery

Despite the considerable technological advances in arthroscopic surgery in the past decade, it is of concern that meniscal repair is not being done in many cases where the meniscus tear is reparable and the patient, if properly informed, would desire it.There is accumulating evidence that the long-term benefits of meniscal repair significantly outweigh those of partial meniscectomy. But success must be tempered by looking at longer follow-up assessments than we are accustomed to doing.DeHaven found that the average time between surgery and failure was 4 years, in a study averaging 11 years of follow-up. Meniscal repairs in isolated tears of the meniscus are significantly less successful than repairs of meniscal tears associated with anterior cruciate ligament (ACL) reconstruction. There is evidence that isolated meniscal tears in ACL-stable knees occur in menisci that are significantly more degenerated compared with menisci having tears associated with ACL disruption. Improved techniques of meniscal repair include the abrasion of both sides of the tear site, the use of increased numbers of vertically oriented nonabsorbable sutures, the insertion of a fibrin clot into the tear site, and the development of completely inside-the-knee suturing techniques. In the future, meniscal repair will become simpler and faster to perform. As a result, more meniscal repairs will be attempted. Over the next decade, we will see increasing research in the role of meniscal allografts and collagen (or other material) substitutes for the meniscus in patients with segmental defects or complete loss of the meniscus.     

半月板桶柄样撕裂关节镜下行缝合修补术疗效分析

目的探讨关节镜下半月板缝合修补术在半月板桶柄样撕裂(bucket-handle tear,BHT)中的治疗价值。方法 2014年4月—2017年4月陕西省第四人民医院收治90例BHT患者,根据随机数字表法将其分成关节镜下修补组、部分切除组各45例。部分切除组行半月板部分切除术,男性26例,女性19例;年龄18～56岁,平均32. 91岁;左膝25例,右膝20例;致伤原因:道路交通伤19例、运动伤21例、其他5例。关节镜下修补组行关节镜下半月板缝合修补术,男性27例,女性18例;年龄18～59岁,平均34. 29岁;左膝28例,右膝17例;致伤原因:道路交通伤17例、运动伤21例、其他7例。两组均上门随访12个月,在末次随访时评估愈合情况。利用Lysholm评分系统评估患者术前、末次随访时膝关节功能变化,并经MRI检查分析术前、术后6个月、末次随访时的膝关节活动度,观察术后并发症发生率。结果关节镜下修补组治愈率为97. 78%,较部分切除组的95. 56%差异无统计学意义(P> 0. 05)。关节镜下修补组末次随访时Lysholm评分高于部分切除组,差异有统计学意义(P <0. 05)。关节镜下修补组膝关节活动度术后6个月(133. 92±3. 65)°、末次随访时(142. 56±5. 46)°大于部分切除组(124. 63±3. 27)°、(135. 38±5. 13)°,差异有统计学意义(P <0. 05)。关节镜下修补组并发症发生率为4. 44%,较部分切除组的13. 33%差异无统计学意义(P> 0. 05)。结论关节镜下行半月板缝合修补术能促进膝关节功能恢复,改善膝关节活动度,并发症发生率低,值得临床推广。     

Mid-term clinical results of medial meniscus repair with the meniscus arrow in the unstable knee

The medial meniscus is a secondary stabilizer to anterior tibial translation and provides significant stability, especially in an ACL-deficient knee. The purpose of this study is to evaluate the clinical outcome of medial meniscus repair in the unstable knee. Between 1997 and 2002, 11 patients, with a mean age of 25.8 years (range 15–39 years), underwent all-inside medial meniscus repair, using the Meniscus Arrow, for unstable medial meniscus tear in ACL-deficient knees. For various reasons none of these patients underwent ACL reconstruction. The average follow-up was 73 months (range 52–91 months). There were three failures (27.3%) defined as the need for reoperation and partial meniscectomy. The mean Tegner activity score decreased from 6.75 (pretrauma) to 4.5 (postoperatively). The average Lysholm and subjective IKDC scores were 83 and 77.4, respectively. Two patients were graded as B (nearly normal) and six as C (abnormal), according to the IKDC knee evaluation form. KT-2000 arthrometry demonstrated that sagittal knee laxity was more than 5 mm in all knees (side to side difference). MRI demonstrated grade three signal alterations at the repair site of meniscus in three patients and signs of cartilage damage in two patients. All patients were asymptomatic during daily activities but seven out of eight reported pain or effusion after sports. Medial meniscus repair in the ACL-deficient knee is not contraindicated. The need of reducing the level of physical activity is essential.     

Arthroscopic all-inside repair techniques of lateral meniscus anterior horn tear: a technical note

Although the conventional outside-in technique is especially useful for repairing tears in the anterior portion of the meniscus, it has a disadvantage of making an additional 1–2 cm sized skin incision and tying knots subcutaneously over the capsule. Therefore we devised two all-inside repair techniques of lateral meniscus anterior horn tear according to the site of meniscal tear, meniscosynovial junction or red–red zone. Because these techniques are modified methods of the outside-in meniscal repair using a spinal needle, they are as simple as conventional outside-in technique. In addition they have advantages of vertical mattress suture, which is an important characteristic of the all-inside repair, and no additional incision. We recommend these techniques as an alternative method for repairing an anterior horn tear of the lateral meniscus.     

Complications of meniscal repair

Meniscal repair (open or arthroscopic) should be in the armamentarium of every orthopedist who performs knee surgery. The purpose of this article is to present the complications inherent in general knee arthroscopy as well as those specific to meniscal repair. Specific complications of meniscal repair discussed are (1) failure of the repair to heal, (2) neurovascular complications, (3) arthrofibrosis, and (4) infection.The authors also present techniques and recommendations to minimize these potential complications. Medial and lateral knee anatomy, with respect to standard surgical approaches for midhorn and posterior horn repairs, is discussed. Finally, the authors present their recommendations to minimize the failure-to-heal rate of meniscal repair.     

Arthroscopic all-inside repair for a tear of posterior root of the medial meniscus: a technical note

This technical note describes a new arthroscopic technique to repair a tear of posterior root of the medial meniscus. Cartilage at the insertion area of the posterior horn of the medial meniscus (PHMM) was removed using a curved curette inserted through an anteromedial portal. A metal anchor loaded with two FiberWires (Arthrex, Naples, FL) was placed at the insertion area of the PHMM through a high posteromedial portal. A PDS suture was passed the PHMM by curved suture hook through the anteromedial portal. Two limbs of the PDS were then used to pass two limbs of the FiberWire through the meniscus. The same procedure was repeated for the second FiberWire suture. The sutures were tied, achieving secure fixation of the posterior meniscal root at the anatomic insertion.     

Arthroscopic all-inside repair of anterior horn tears of the lateral meniscus using a spinal needle

Several techniques have been used for the arthroscopic repair of anterior horn tears of the lateral meniscus. A commonly used method is the outside-in technique. This technique is known to be the most appropriate and safest technique for peripheral tears of the anterior horn of the lateral meniscus. But it has the disadvantage of making an additional 1-2 cm sized skin incision and tying knots subcutaneously over the capsule. Irritation may also occur. We have developed a new alternative repair method to prevent this skin incision and preserve the normal biomechanics of the lateral meniscus during motion. These techniques are modified methods of the outside-in meniscal repair using a spinal needle. They are as simple as conventional outside-in technique. In addition, they have advantages of vertical mattress suture, which is an important characteristic of the all-inside repair, and no additional incision. We recommend these methods as an alternative technique for repairing an anterior horn tear of the lateral meniscus.     

The diagnosis and management of meniscus injuries in the skeletally immature athlete

Meniscus injuries of the knee in skeletally immature athletes are uncommon. Although the epidemiology of theseinjuries is inadequately documented in the literature, it is clear that meniscus injuries in children are often found with congenitally abnormal menisci. In the adolescent, these injuries are often found with associated ligamentous injury. Longitudinal and peripheral injury patterns prevail. Because of these injury patterns and the enhanced healing potential of youth, meniscus repair is preferred more often in youths than in adults. The Snapping Knee syndrome is typically associated with discoid menisci in children and youth. Watanabe described a classification of discoid menisci that includes the unstable Wrisberg ligament type as well as the partial and complete types. No treatment is required for the asymptomatic discoid meniscus, but the symptomatically unstable meniscus may be repaired and the symptomatic stable partial or complete discoid meniscus saucerized or, if torn, replaced if possible. Although meniscus replacement is theoretically an attractive alternative choice of treatment over excision or debridement, not enough is known about clinical outcomes and safety to justify their use in the skeletally immature patient.     

Open techniques for repair of largeand massive rotator cuff tears

Rotator cuff tears can be a significant source of shoulder pain and weakness. Repair of full-thickness tears canimprove patient satisfaction and functional outcome. Several repair techniques have been described in the literature; these include arthroscopic and open approaches. Although arthroscopic repair has been popularized in the recent literature, it may not be optimal for some cases of large or massive rotator cuff tears. Open approaches allow greater access for mobilization and enable placement of bone tunnels for bone-tendon repair. The surgeon may readily release bursal and articular sided adhesions and mobilize the retracted tendon to its anatomic footprint on the greater tuberosity. This article describes 2 surgical approaches of open repair, the mini-open and formal open approach. Furthermore, useful techniques for tendon mobilization, bone-tendon repair, and postoperative rehabilitation for the management of large and massive rotator cuff tears are described.     

Strength of different meniscus suturing techniques

We measured and compared the primary stabilities of five different meniscal suturing techniques. The techniques tested were horizontal mattress, vertical mattress, knot-end, vertical, and vertical loop. Twenty bovine medial menisci were cut to simulate peripheral longitudinal tears and repaired with one of the five suture techniques. Then the two parts of the meniscus were pulled using the Instron Tensometer until failure occurred. Knot-end techniques gave inferior results (mean ultimate failure strength 64 ± 5 N) compared with the other techniques. Vertical mattress failed at 130 ± 3 N, vertical loop at 128 ± 4.5 N, horizontal mattress at 98 ± 5 N and vertical suturing at 136 ± 2.7 N. This study shows the superior mechanical characteristic of the vertical suturing technique. Received: 15 October 1996 Accepted: 15 February 1997