Meniscal repair


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Meniscal repair

  1. 1. IndicationsRim width - Distance of meniscal tear from meniscosynovial junction-Warren & Arnockzy< 3 mm-high rate3-5 mm - variable>5 mm – not suitable for repairCannon-Success rate 74% with rim widths 2 to 3.9mm , 50 % with rim widths 4 to 5 mm
  2. 2. Favourable factors for healingYoung patientsAcute traumaLongitudinal tearsIncomplete tearsTears < 8 mm
  3. 3. Poor success rate is withChronic degenerative tearsACL deficient knee-DeHaven-failure rate 46% vs 5%in stable knee over 10-year study Cannon-83% success rate combined meniscus repair & ACL reconstruction compared to overall success rate of 75%Older age groupAxial malalignment
  4. 4. Open repairTear in posterior third of meniscusTraumatic separation of meniscosynovial junctionRoutine arthroscopy Tears are unappreciated Non anatomic repair
  5. 5. Results-Cannon et al100% success rate for stable kneeChronic tears-failure rate 33%Acute tears –failure rate 14%
  6. 6. Results-Outside in repair-Warren et al87% successful outcome69%-Asymptomatic-complete healing18%-Slightly symptomatic-partial healing13%-Meniscus failed to heal
  7. 7. Advantages - Outside in repairRisk of articular cartilage damage is lessPrecise placement of suturesVertical placement of suturesExcellent visualisationInjury to saphenous vein and nerve avoidedEasy access to anterior portion of meniscusUseful for suturing meniscal replacement
  8. 8. Disdvantages - Outside in repairDifficult to put perpendicular sutures in far posterior partMulberry knot may potentially abrade the articular surface before absorptionPermanent sutures must be brought through anterior portalExperience is needed for accurate placement of needle
  9. 9. Complications-Outside In repairNerve injury-Common peroneal nerve and saphenous nerveLimitation of extensionInfectionFailure to heal-avascularity,degenerative tear,instability,inadequate stabilization of tears,obliquity of sutures,lack of early protection,repeat injury
  10. 10. Inside out repairMore difficult due to limited space
  11. 11. Inside out repair-Lateralmeniscus
  12. 12. Complications- Inside outrepairNeurovascular injuryArtcicular scuffing and coring of meniscus by cannulas and needles
  13. 13. All inside repairIndications are similar to open meniscal repairAdditional posteromedial and posterolateral portals requiredSpecialized equipments and intraarticular suture tying skills are required
  14. 14. Meniscal arrowSelf reinforced Polylactic acidBegins to degrade in 4-6 months , absorbed in 18 –24 monthsPull out strength comparable to horizontal mattress sutures
  15. 15. Results-Meniscal arrowKristensen et al
  16. 16. Meniscal repair in avascularzoneMarc Rubman et al-25%-Healed,38%-Partially healed,36%-Failed ,Clinically-80%-asymptomaticDeHaven-Healing enhancement techniques
  17. 17. Overall ResultsEvaluation-Clinical,Arthrography ,MRIHenning-75% failures were asymptomaticCannon-50% failures were asymptomaticMorgan-All anatomic failures were symptomaticIncompletely healed but stable menisci behave clinically as completely healed menisci and should not be rated as failures
  18. 18. Overall ResultsTear length- Failure rate-15%-<2cm , 20%-2to3.9cm , 59%-4-5cmTime of repair- Failure rate-17%-< 8 weeks 28%-> 8 weeksSide of repair-Failure rate-Lateral-16% , Medial repair- 30%
  19. 19. Overall ResultsSuture material-Barrett et al –Failure rate- Nonabsorbable-0%,Absorbable- 18% Warren and Morgan-Comparable results with both suturesAbility to remain healed over time-Eggli et al-7.5 years f/u 73% meniscus survival rate DeHaven-10 years f/u 79% survival rate
  20. 20. Overall ResultsBiomechanical function- weightbearing AP radiographs in extension and 45 degree flexion - 85% were normal
  21. 21. Fibrin glue-Ishimura et alFibrin glue-Tear in vascular area and is not degeneratedFibrin glue containing marrow cells-Tear in avascular areaFibrin glue containing marrow cells with suturing- Degenerative tear
  22. 22. Fibrin glueSolution A-Purified dense fibrinogen,Aprotinin,factorXIIISolution B-Thrombin,CaCl2
  23. 23. Gene Therapy-Hideyuki Goto etalTissue engineered meniscal tissueTransgeneHealing in avascular zone can be improved by transfer of genes encoding appropriate growth factors
  24. 24. RehabilitationControversy-Accelerated rehab protocol vs conservative approachBasic science studies and animal studies – in favour of accelerated protocol-Klein et al,Dowdy et alClinical studies-Shelbourne et al,Barber-No difference in rates of healing between twoAsahina et al – Concern about clinically asymptomatic partially healed tears
  25. 25. Rehabilitation-Scott et alTailoring the post op protocol to the type of meniscal tearBucket handle and vertical longitudinal tearsRadial and complex tears
  26. 26. THANK YOU
  27. 27. Collagen scaffold-Kevin et alTemplate for the regeneration of meniscal cartilage