Meniscus Repair: Update

MICHELLE WOLCOTT, MD

ASSOCIATE PROFESSOR

CU SPORTS MEDICINE

DEPT. OF ORTHOPAEDICS

UNIVERSITY OF COLORADO

TEAM PHYSICIAN, UNIVERSITY OF COLORADO

TEAM PHYSICIAN, UNIVERSITY OF DENVER

Meniscus Repair: Update

No conflicts of interest

No disclosures

Knee Anatomy and

Biomechanics: Meniscus

Function:Load DistributionDeepens tibial surface2o stabilizer

Medial = C-shapedLateral = Semicircular

Meniscal Tears

Medial tears 3X more common than lateral tears

Lateral meniscus motion 2X greater

Young patients have more acute tears, often associated with ligamentous injuries

Older patients tend to have degenerative tears associated with cartilage wear/arthritis

Types of Meniscus Tears

Severity of Articular

Cartilage Wear=

Medial Meniscus Tear Morphology

and Chondral Degeneration of

the Knee: Is There a Relationship? Henry S, Mascarenhas R, Kowalchuk D,

Forsythe B, Irrgang JJ, Harner C

103 patients prospectively evaluated at the time of meniscal surgery

Chondral degeneration, tear morphology/location

Root/radial flap tears more strongly associated with medial compartment degeneration

Meniscus tears with increasing disruption of circumferential hoop fibers were significantly associated with cartilage lesions of increasing severity in both medial and lateral compartments

Knee Anatomy and

Biomechanics: Meniscus Perimeniscal capillary plexus provides blood

supply to the peripheral 1/3

Blood supply regresses with age

“Red-Red” zone and “Red-white” zone

Photos by McGinty:

Operative Arthroscopy

(1991)

(from Arnoczky and

Warren)

Meniscus Microanatomy

Meniscus Biomechanics

Biomechanics:

Hoop Stress

Vertical/Bucket Handle

Tears

Bucket Handle Tear

Meniscus Repair

Meniscus Repair

Inside-Out RepairGold Standard

Strongest Repair

Vertical Mattress

Meniscal Repair

Configuration

Best results with simple or single tears

Peripheral vertical tears best candidates

Deformed bucket-handle fragment not amenable to repair

Meniscal RepairAdvances in Biologics: Trephination, Fibrin clots, PRP growth factors, Stem cells

All Inside Techniques - Risks: Breakage, Migration, Synovitis, Chondral Injury, Decreased strength

Meniscal Root Tears/Radial

Tears

Meniscal Root

Tears/Radial Tears

Radial Tears

Radial Tears

Radial Tears

Meniscus Root Tears

Meniscal Root Tears

Acute tears associated with ligamentous injury

Most common is lateral root tear + ACL

Chronic tears associated with osteoarthritis

Risk factors

Female gender

Higher BMI

Relatively lower activity level

40s-50s

Varus alignment (for medial tears)

Chronic Tears

Medial more common

Relative immobility of medial meniscus

Most stress in axial loading

Secondary stabilizers

Meniscal Root Anatomy

Meniscofemoral Ligament

Biomechanics of Radial

Tears/Root Tears

Root tears increase medial compartment

loads by 25% in cadaveric studies

Increases external rotation and lateral

stabilization of the femur on the tibia

Repairing meniscus root tears restores

kinematics

Diagnosis

Symptoms may be similar to other types of meniscus

tears

Joint line tenderness

Pain with McMurrays

Swelling

Can also be nonspecific

Vague pain symptoms (posterior)

MRI

Arthroscopic Assessment

MRI

truncated triangle, cleft, marching cleft

and ghost meniscus signs

the use of all four signs increased the

detection rate for radial tears to 89%

MRI

Meniscus Extrusion

Meniscal Repair

Radial Repair

Radial Repair

Meniscus Root Repair

Meniscus Root Repair

Meniscus Root Repair

Meniscus Root Repair

Meniscus Root Repair

Results of Meniscus Repair

Cadaveric studies

Universally demonstrate

that biomechanics can

be restored with repair

Biomechanical Consequences of a Complete Radial Tear Adjacent to the Medial Meniscus Posterior Root Attachment Site

Padalecki, et. al. JBJS 2013

Results of Meniscus Repair

Meniscus Suture Repair: Minimum 10 yr Outcomes

in Patients Younger than 40 yrs Compared With Patients 40 and Older

Steadman, et al. AJSM 2015

No significant difference based on age (5.5% vs

5.3%)

82% vs 93% followup

No significant difference based on which meniscus

(med vs lat), concomitant ACL injury, microfracture

Results of Meniscus Repair

Arthroscopic Transtibial Pullout Repair for Posterior Medial Meniscal Root Tears: A Systematic Review of Clinical, Radiographic, and Second-Look Arthroscopic Results

Feucht, et al, Arthroscopy 2015

30 mos followup

Lysholm scores improved from 52.4 to 85.9

Radiographs – 84% showed no progression

MRI – 82% showed no progression of cartilage degeneration, 56% showed reduced meniscal extrusion

2nd look arthroscopy – healing status complete in 62%, partial in 34%, failed in 3%

Postoperative Rehab

No consensus

Limited data

Use sound principles and biomechanical

information

Biology? Timing

Postop Rehab – Meniscal

Repair

Protect the repair in first 4-6 weeks

Restricted WB in first 4-6 weeks

WBAT in full ext

NWB for root and radial tears

Restrict ROM 0-90 deg x 6 wks

Conclusions

Meniscus function is critical to a well-performing

knee

Protect and restore function when possible

Repair can restore biomechanics in the lab/short-

term

Conclusions

Future directions

Biologics

Improved instrumentation/technique

Long-term outcome

Acute vs Chronic tears

Diagnosis

Can we identify tears earlier

References

Han SB, Shetty GM, Lee DH et.al. Unfavorable Results of Partial Meniscectomy for Complete Posterior Medial Meniscal Root Tear With Early Osteoarthritis: A 5- To 8- Year Followup Study. Arthroscopy 2010; 26:1326-1332.

Lee JH, Young JL, Kim KB et.al. Arthroscopic Pullout Suture Repair of Posterior Root Tear of the Medial Meniscus: Radiographic and Clinical Results With a 2-Year Follow-up. Arthroscopy 2009; 25: 951-958.

Feucht MJ, Kuhle J, Bode G et.al. Arthroscopic TranstibialPullout Repair for Posterior Medial Meniscus Root Tears: A Systematic Review of Clinical, Radiographic, and Second-Look Arthroscopic Results. Arthroscopy 2015; 31: 1808-1816.

Choi CJ, Choi YJ, Lee JJ et.al. MRI Evidence of Meniscal Extrusionin Medial Meniscus Posterior Root Tear. Arthroscopy2010; 26: 1602-1606.

Bhatia S, LaPrade CM, Ellman MB et.al. Meniscal Root Tears: Significance, Diagnosis, and Treatment. AJSM 42: 3016-3030

References

Steadman JR, Matheny LM, Singleton SB et.al. Meniscus Suture Repair: Minimum 10-Year Outcomes in Patients Younger Than 40 Years Compared With Patients 40 and Older. AJSM 2015; 43: 2222 – 2227.

Branch EA, Milchteim C, Aspey BA et.al. Biomechanical Comparison of Arthroscopic Repair Constructs for Radial Tears of the Meniscus. AJSM2015; 43: 2270-2276.

Allaire R, Muriuki M, Gilbertson L et.al. Biomechanical Consequences of a Tear of the Posterior Root of the Medial Meniscus: Similar to Total Meniscectomy. JBJS 2008; 90: 1922-1931.

Hein CN, Deperio JG, Ehrensberger MT et.al. Effects of Medial Meniscal Posterior Horn Avulsion and Repair on Meniscal Displacement. The Knee2011; 18: 1Biomechanical Consequences of the a Complete Radial Tear Adjacent to the Medial Meniscus Posterior Root Attachment Site: In Situ Pull-Out Repair Restores Derangement of Joint Mechanics. AJSM 2013; 42: 699-707.

Henry S, Mascarenhas R, Kowalchuk D et.al. Medial Meniscus Tear Morphology and Chondral Degeneration of the Knee: Is There a Relationship? Arthroscopy 2012; 28: 1124-1134

Thank You