Meniscal Repair

Indications for Repair

 

Only 20% repairable

 

1. Red / Red longitudinal tear

- outer 3mm / meniscocapsular junction

 

Meniscal Tear Red RedMensical Repair all inside

 

2. Red / White longitudinal tear

- only one side of tear vascularised

 

Meniscal Red White TearMeniscal Tear Red White Repair

 

3. Young patient

 

Contraindications to repair 

 

1.  White / White

2.  Complex / Horizontal / Radial / Degenerative tears

3.  Tears that are stable & < 1 cm

4.  Meniscal tear in setting of torn ACL that is not being reconstructed

- high risk of re-tearing meniscus if knee unstable

 

Principles of Repair

 

1.  Debride tear 

- stimulate proliferative response

- remove mature scar

- with shaver / rasp

 

2.  Trephine meniscocapsular periphery

- with spinal needle to promote vascular channels

 

3.  Reduce mensical tear

 

4.  Suture placement

A.  Open repair

B.  Inside out

C.  All inside

D.  Outside in

 

5.  Increase chance of healing in isolated mensical repair

- fibrin clot

- intercondylar notch microfracture

 

Techniques

 

1.  Open repair

 

Tibial plateau ORIF

- common to need to repair capsular avulsion of LM

- repair with 4.0 PDS / ethibond

 

2.  Inside out

 

Inside out Mensical Repair Structures at Risk

 

Technique

 

Require

- double armed sutures with long flexible needles

- use single or double cannula system

 

Make open posteromedial / posterolateral approach

- retrieve the sutures needles as they exit the joint capsule

- protects neurological structures (saphenous / CPN) from needle or suture injury

- sutures then tied over capsule

- pass in flexion to protect structures

 

Pass the needles about the tear

- vertical or horizontal mattress sutures

- absorbable or non absorbable 2.0 suture

- every 2-3 mm

 

Tie sutures over capsule

- tie in extension or will break when patient extends leg

 

Meniscal Repair Inside OutMeniscal Repair Inside Out

 

Posteromedial incision

- placed at the posterior aspect of MFC

- knee at 90°

- 3-4 cm long vertical incision

- behind MCL

- protect saphenous nerve which runs in fat above the sartorius

- open sartorius fascia, retract to protect nerve

- displace medial head gastrocneumius posteriorly

- expose capsule

 

Posterolateral incision

- centred on joint line, just posterior to LCL

- knee at 90o

- above biceps and therefore CPN

- palpate LCL anteriorly

- Biceps is retracted inferiorly to protect CPN

- must dissect lateral gastronemius off capsule and retract

- this protects CPN and posterior neurovascular bundle

 

3.  All inside

 

Instruments

- meniscal arrows (Biostinger, Meniscus Arrow)

- meniscal screws

- meniscal suture anchors (FasT-Fix, RapidLoc)

 

Technique FasT - Fix

- ipsilateral portal to view

- contralateral portal for instruments

- 2 x absorbable sutures anchors posteriorly

- may have to change portals for mensical body sutures

- pass first bioabsorbable anchors through meniscus and capsule

- retract and advance second anchor

- place anchor through meniscus (horizontal) or into capsule alone (vertical)

- advance knot, cut

 

All inside 1All inside 2All inside 3All inside 4

 

Meniscal Repair Posterior FastfixMeniscal Repair Posterior Fastfix Suture x 2Meniscus Post Repair

 

3.  Outside in

 

Indicated for anterior horn tears

- very difficult to get angle on the tear

- either with all inside or inside out

 

A.  Option 1

- camera in portal opposite to tear

- insert spinal needle through capsule and tear

- insert 1 PDS via spinal needle

- retrieve suture via anterior portal, tie a knot in end

- secure meniscus with knot

- repeat above step

- tie 2 sutures over outside of capsule

 

Anterior horn Meniscal TearAnterior horn meniscal tear Repair 1Anterior horn meniscal tear Repair 2

 

B.  Option 2

- insert PDS via spinal needle as above

- insert second spinal needle with loop PDS

- retrieve first PDS through that loop

- then pull single ended PDS back out through capsule
- tie over capsule

 

C.  Company made sets

- insert 2 hollow bore needles through capsule and meniscus

- insert single ended suture through one needle separate needle

- insert wire loop through other needle and retrieve

- tie over capsule through separate skin incision

 

Outside in Meniscal MenderMeniscal Repair Outside In First NeedleMensical Repair Outside In 2nd needle

 

Mensical Repair Outside In Advance SutureMeniscal Repair Outside In Retrieve with LoopMeniscal Repair Outside In

 

D.  Anchor repair

- insert anterior suture anchor

- pass sutures through meniscus and tie down

- technique used in meniscal transplant

 

Lateral Meniscus Anterior Horn TearAnterior Horn Tear ReducedAnterior Horn Tear Suture Passage

 

Anterior Horn Tear Suture Passage 2Anterior Horn Tear SuturesAnterior Horn Tear Final Repair

 

Ramp lesion

 

Vumedi ramp repair

 

4.  Meniscal Root Repair

 

Definition

- tear of insertion of posterior horn of meniscus

- difficult to fix

- must repair down to bone

 

Technique

- ACL guide

- drill hole up into mensical root insertion

- use suture passer to secure meniscal root

- retrieve sutures down through bone tunnel in tibia

- tie over screw post

 

Mensical Root Repair 1Mensical Root Repair 2Mensical Root Repair 3Mensical Root Repair 4

 

Post operative rehab

 

Avoid weight bearing in flexion > 90o

- weight bear in extension / splint for 6 weeks

- range to 90o NWB