Meniscus surgery is either to repair meniscus or to ressect it. Earlier menissectomy was the regular surgery done by arhroscopic surgeon for meniscus injury,but now meniscus repair is on increasing trends in the arthroscopic surgeon for meniscus injury.

1. MENISCUS SURGERY
RESECT OR REPAIR
Dr. Amit Mishra
(Professor BRD Medical College,
Gorakhpur)

2. INTRODUCTION
• Meniscus was usually considered vestigeal
• Easier to resect than repair :Bias
• Recent past decade: importance of meniscus
evaluated and understood.
• Following removal –Cartilage overloading and
aggravated degeneration

3. THE BIG QUESTION…
But then should every meniscus be repaired?
NO
Appropriate & informed decision required.
Only 20% repairable

4. Function of meniscus
1. Load transfer
2. Shock absorption
3. Stress reduction
4. Stabilization
5. Lubrication

5. BIOMECHANICS
.In extension, 50 % of the load is absorbed
.At 90 degree flexion, 90% load sharing
.Beyond 90 degree, forces predominate through posterior horns

6. BIOMECHANICS
 Complete removal of
meniscus results in 2-3x
increase in contact stress
 Removal of inner 1/3 =10%
reduction in contact area and
65% increase in stress
 Increase loss of meniscal
tissue= increase contact
stress
 Medial meniscal root tear
have pressure similar to
complete meniscectomy

7. IMAGING
 Plain x-ray to asses for
bony injury and OA
 MRI is the gold standard
of diagnosis

8. MENISCAL EXCURSION
 Meniscal excursion with
knee flexion
. 11.2 mm excursion of
lateral meniscus
.5.1 mm excursion of medial
meniscus
.Capsule
.Deep MCL
.Coronary ligament

9. BLOOD SUPPLY
• Vascularised portion:
. 30% of medial meniscus.
.10-25% of lateral meniscus
• Popliteus hiatus_-posterolateral
meniscus- worst supply
• Commonly referred zones:
o Red
o Red white
o White

11. PATHOPHYSIOLOGY…..
Acute knee injuries with ACL intact-medial
meniscal injury is 5 times more likely than
lateral.
Acute knee injuries with ACL ruptured-Lateral
meniscus more likely to be involved.
Acl is previously disrupted-lateral meniscus
injury is more likely than medial.
Repetitive deep squatting- medial meniscus
injured(20:1).

12. So how to deal with them!!!
• Supervised neglect
• Meniscectomy
• Meniscus repair
• Still elusive to us:
 meniscus transplant
 Meniscus scaffolds.
 Meniscal replacement

13. Leave (Neglect) them alone!!!
• Undisplaced stable medial/lateral meniscal
tears.
• Short undisplaced stable ones- Synovial
abrasion
• Short stable ones –trephination.

14. MENISCAL RESECTION
• Types:
• Partial meniscectomy.
• Subtotal meniscectomy.
• Total meniscectomy.
• Resect as less as possible .
• Conservative approach

15. Resection of Bucket Handle tear

16. MENISCAL REPAIR: WHY TO DO IT?
Restore Function
Maintain Load Transmission & minimize Contact
Stresses
Contribute to stability
Reduce Articular cartilage wear:
“Chondroprotection”

17. INDICATION
• Reparability- geometry, technical fixation
• Healing potential - biological manipulation
• Associated Surgery – recovery time consolidation
• Patient preferred – long term outcome concern

18. Relative Contraindication
• Advanced OA
• Complex tears
• Poor tissue quality
• ACL deficency

19. MENISCAL REPAIR: WHEN TO DO IT?
• Acute tears (less deformity)
• Peripheral tears: RED ZONE & red/white zone
• Unstable tears:
- Tear length > ½ of meniscus.
- subluxates under the condyle.
• Young < 40 years.
• Stable knee profile

20. AVOID REPAIRING!!!!
• Chronic complex tears .
• Degenarative tears .
• Unstable knee(without reconstruction)
• Rule of thirds:
-ACL deficient knee – 30%
-ACL stable knee – 60%
-ACL reconstructive knee – 80-90%
• Associated Gd. lV osteochondral defects.
• Old age

22. PEARLS AND PITFALLS:
APPROACH MENISCAL TEAR LIKE FRACTURE FIXATION!
• Prepration of tear is essential step, consider the tear a
“Nonunion”
• Enhancement techniques: debride/abrade/trephinate/clot
• Reduce tear accurately and maintain reduction throughout
fixator placement
• Anchoringstitch (PDS) or spinal needle aids in maintaining
reduction
• Hybrid Techniques are useful especially in deformed,
displaced buckets
• Acessory portals to improve acess and fixation
configuration

23. • Perpendicular placement of implants every
5mm
• Grab circumferential fibre bundle to ensure
optimal purchase strength
• Ensure that implants are not proud (intra –
and /or extraarticular)
• Avoid stuffing the meniscus with stress riser
inducing implants
• Rehabilitation: Individualize – protection,wt
bearing, motion ,return to sports

24. Repair technique
Open /outside – in/inside – out/All – inside
Suture – based vs. fixator – based techniques

27. OPEN REPAIR
• Rarely used
• Numerus studies have proven reduced surgical
morbidity with arthroscopic repair
• Resreved for peripheral tears in the posterior
horn

28. INSIDE-OUT MENISCUS REPAIR
• “gold standard” for
meniscus repair
• Due to ability to place
• Vertical and horizontal
suture
• On femoral and tibial
surfaces of the meniscus
• Difficult to do in the
posterior third of the
menisci
• Requires dissection of
neurovascular structures.
• morbidity

29. Inside-out Repair…
• Suture passed on either
side of tear with needle
cannula
• Suture is brought out of
capsule
• A small skin incision is
made
• Suture is tied down to
capsule
• Posterior horn repairs

30. OUTSIDE-IN MENISCUS REPAIR
• Sutures passed through
the meniscus from the
outside
• Eliminates need for larger
incision
• Generally suited for
anterior repair
• Studies have shown similar
results with both
techniques
Meniscus Mender kit

31. Outside –in meniscus repair
• Limited access to
posterior third of
meniscus
• Difficult to place vertical
mattress suture
• Difficult to place sutures
in tibial surface of
meniscus

32. ALL INSIDE
• All-inside repair devices
were developed to reduce
surgical time, prevent
complications resulting
from external approaches,
and allow access to tears of
the posterior horn
• Fourth generation repair
device allow placement of
suture in meniscus without
the aid of an external
incision or a suture fixator
system

33. All Inside
• Self –adjusting with the
anchor located behind
the capsule with a
sliding knot that can be
tensioned appropriately
by the surgeon
• Mechanical studies
show comparable
strength to outside-in
sutures

34. Fastfix 360

35. Posterior horn repair-All inside

36. Meniscus root repair

38. Ramp lesion - menisco-capsular seperation

39. Tips for minimizing error
• Adequate joint distension and visualization of
meniscus
• Prepare the meniscus tear site properly
• Choose the portal which allows the delivery
needle to be inserted perpendicular to the
tear

40. Continue…
• Let your assistant hold the camera while your
haands are free to control the Fastfix 360
• Reverse curve needle is useful for tibial side
repair
• Avoid over cinching the knot- can cut through

41. OUTCOMES
• Success rates for all technique reported 70-
95%
• Second- look scopes show lower success rates
of 45-91%
• Ligamentous laxity decreases success rate to
30-70%
• 90% success reported in conjuction with ACL
repair

42. COMPLICATIONS
• Failure to heal
• Stiffness
• Articular surface
damage
• NV structure damage

43. TRANSPLANTATION
INDICATIONS:
• Recurrent pain after partial
or total replacement
• Symptomatics with ADLs
• < 50 yr
CONTRAINDICATIONS:
• Malalignment
• Laxity
• Inflamatory arthritis
• Advanced OA

44. OUTCOMES
• Widely varying reports of success (country differences)
• Subjective improvement in tibiofemoral pain.
• No clear long-term benefit in preventing OA has been
establised
• Grafts seem to do better when placed with a bone block.
• Preserving some peripheral rim helps to avoid extrusion.
• Variety of material scaffold optios being investigated in
animal

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