Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Factors Affecting Meniscus Tear Healing and Prognosis - AOSSM Lecture

1,396 views

Published on

Treatment of meniscus tears has advanced significantly over the last several years. Newer techniques and technology have improved healing, and studies have shown improved longterm outcomes with meniscus repair versus meniscectomy.

Published in: Health & Medicine
  • Be the first to comment

Factors Affecting Meniscus Tear Healing and Prognosis - AOSSM Lecture

  1. 1. Meniscus – Anatomic, Biologic, and Biomechanical Factors That Affect Tear Prognosis Jeremy M. Burnham, MD UPMC Sports Medicine July 22, 2017 – AOSSM Annual Meeting
  2. 2. What Affects Prognosis? McDermott, Amis JBJS (Br) 2006 • 75% decrease in contact area • 235% increase in peak pressures
  3. 3. What Affects Prognosis? • Tear Factors – Location – Vascular Zone – Tear Size – Tear Pattern • Injury – Acute vs. Chronic – Concomitant Injuries – Alignment & Stability • Patient – Age, BMI, Activity McDermott, Amis JBJS (Br) 2006
  4. 4. Meniscus Vascularity • Entire meniscus is vascular at birth, but inner 1/3 avascular by nine months • In adults, outer 10-30% is vascular • Formation of a clot is essential for healing, and tears in the red-red zone (outer 1/3) are most likely to heal • Fibrin clots, abrading synovium adjacent to repair, and “freshening up” the tear site are ways to improve healing
  5. 5. Meniscus Vascularity
  6. 6. Patient Age • Older patients have less cellularity and decreased healing response – Retears more frequent in patients >30 (Eggli et al. AJSM 1995) – Older patients had longer time to failure (Bach et al. J Knee Surg 2005) • Mixed Clinical Results – No RCTs – Selection bias (most surgeons won’t repair degenerative tears)
  7. 7. Older Patients, Chronic Tears • RCT, Level I Evidence • 102 pts with knee pain and degenerative tear of the PH of the medial meniscus • Excluded: trauma, ligament deficiency, systemic arthritis, osteonecrosis
  8. 8. Older Patients, Chronic Tears
  9. 9. Older Patients, Chronic Tears • Average duration of symptoms prior to treatment ~8 mths – Nonop: Medicine, PT 3x/wk for 3 wks, HEP for 8 wks – Operative: Partial menisectomy • Pain improved more quickly in operative group, but no difference at 2 years • No differences in satisfaction, Lysholm, or OA progression at 2 years
  10. 10. 10
  11. 11. 11 Chronic, Complex Pattern, Older Patients
  12. 12. Acute Tears, Young or Old Patients • Cohort study • 339 meniscus repairs (136 <40y, 45 >40y) • 4.4 to 12% lost to follow up • Minimum follow-up 10 years • All inside-out repairs • No postoperative PRO difference (Lysholm, WOMAC, SF-12) between groups
  13. 13. Acute Tears, Young or Old Patients • Patients <40 and >40 improved similarly after meniscus repair • Failure rate at minimum of 10 years ~5% in both groups
  14. 14. Meniscus Tear Pattern • Tear Pattern – More reparable tears found in unstable as compared to stable knees – Double longitudinal and complex tears have low rate of healing – Horizontal cleavage tears may be asymptomatic – Partial radial tears in avascular region may require only debridement – Complete radial tears and root tears are equivalent to total meniscectomy (Starke et al. 2009; Image from Meniscus Tears, Noyes & Barber-Westin)
  15. 15. Radial Tear
  16. 16. Radial Tear
  17. 17. Tear Pattern - Meniscal Root Tears • 9 fresh frozen cadaver knees • Axial load of 1000N at 0, 30, 60, and 90 degrees • Fuji pressure sensitive film
  18. 18. Meniscal Root Tears
  19. 19. Meniscal Root Tears
  20. 20. Radial Tear Near Root
  21. 21. Radial Tear Near Root • 6 fresh frozen knees • 1000 N Load at 0, 30, 45, 60, and 90 degrees • Intact, Root avulsion, radial tear, and repair of each • Tekscan sensors
  22. 22. Radial Tear Near Root
  23. 23. Radial Tear Near Root
  24. 24. Malalignment 24
  25. 25. Concomitant Injury • Concomitant Injury – Meniscal repairs tend to heal better in association with ACL reconstruction • Stabilization of the knee decreases microtrauma • Marrow elements introduced into the joint
  26. 26. Concomitant
  27. 27. Failure to Address Instability 27 Trojani, KSSTA, 2011
  28. 28. Meniscus Repair - Outcomes • 2012 systematic review of 13 studies (minimum 5 year follow-up) • Pooled failure rate was 23% (or survival was 77%) • Medial meniscus failure rate (24%) greater than lateral meniscus (20%) • Failure rate similar between non weight bearing (25.7%) and partial weight bearing (21.7%) • Failure rate similar between immobilization (23.7%) and early motion (22.7%)
  29. 29. Meniscus Repair - Outcomes • Limitations: – Variety of tear patterns and locations – Variable population – Missing information
  30. 30. Meniscus Repair - Outcomes • 2012 systematic review of 19 studies • 311 relevant patients (139 inside-out, 172 all inside) • Pooled failure rate 17% for inside-out, 19% for all-inside • Lysholm 88 for inside-out, 90 for all-inside (MCID 10) • No difference in Tegner activity levels
  31. 31. Meniscus Repair - Outcomes • Shorter operative time for all-inside (not quantifed) • 9% nerve irritation in inside out versus 2% for all-inside • Unable to quantify differences in chondral damage or scuffing • Heterogenous studies • No cost analysis
  32. 32. Acute Tears, Young or Old Patients • Patients <40 and >40 improved similarly after meniscus repair • Failure rate at minimum of 10 years ~5% in both groups
  33. 33. Meniscus Repair • 293 Patients Patients <20 years old, single institution • 129 primary repairs, 149 meniscectomies, 46 discoid saucerizations • Mean follow-up 40 months (19-62 months) • 13% revision rate – Primary Repair Group = 18% Revision Rate – Bucket Handle = 47% Revision Rate – 76% were acute reinjury, 77% within one year
  34. 34. Repair vs. Meniscectomy If 10% of meniscectomies changed to repairs, would save $43 million • Repairs may fail more, but still more cost effective • Improves Outcomes • Decreases overall costs of treatment
  35. 35. Summary – Prognostic Indicators
  36. 36. Summary – Prognostic Indicators • Success rate of repairs reported between 76-94% • Repair more cost-effective • Tear-specific – Posterior radial tears = total menisectomy – bucket handle = 47% failure of repair • Patient-specific – Older patients have less healing response, but can be less functionally demanding – Studies are mixed, results probably equivalent • Injury-specific – Chronic, degenerative tears = nonop – ACL recon = improved healing, more repairable patterns
  37. 37. Thank You 37

×