Meniscus repair


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The Stone Clinic is a sports medicine clinic in San Francisco, California, offering orthopaedic surgery and medical care, physical therapy and rehabilitation, and radiology imaging services. The Stone Clinic was founded by Kevin R. Stone, M.D., an orthopaedic surgeon, combining himself with a team of nurses, physical therapists, imaging specialists, and patient coordinators, in 1988 to focus on caring for injured athletes and people experiencing arthritis pain.
The Stone Clinic is founded on the goal of rehabilitating all patients to an operating level higher than before they were injured. The Stone Clinic specializes in sports medicine and injury treatment of knee, shoulder, and ankle joints. Stone has lectured and is recognized internationally as an authority on cartilage and meniscal growth, replacement, and repair. Stone and the Stone Clinic are known for the development of the paste grafting surgical technique in 1991, combined with meniscus replacement, which are biologic joint replacement procedures for the regeneration of the knee joint. Surgical procedures were subjected to rigorous outcomes analysis with the results reported in peer reviewed journals. The surgical techniques have been taught to surgeons in the US and worldwide, through lectures and videos.
Nursing students, medical students, residents, fellows, and other physicians from various institutions around the world, rotate through The Stone Clinic and mentor with Stone. The Stone Clinic hosts the annual Meniscus Transplantation Study Group Meeting as well as the annual Professional Women Athlete's Career Conference.

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Meniscus repair

  1. 1. Meniscus Repair Kevin R. Stone, M.D. Ann W. Walgenbach, RNNP, Abhi Freyer, Thomas J. Turek Stone Research Foundation San Francisco XXIV Congress of the Spanish Arthroscopy Association
  2. 2. Meniscal Tears <ul><li>Cutting Sports: Tennis, Soccer </li></ul><ul><li>Impact sports: Running, Skiing </li></ul>High Risk activities <ul><li>One million annual meniscus operations in the United States 1 </li></ul><ul><li>85% meniscectomy </li></ul><ul><li>61 acute tears per 100,000 persons 2 </li></ul><ul><li>2.5:1 (Male:Female) </li></ul>Incidence 1,2 American Academy of Orthopaedic Surgeons
  3. 3. A young patient with a lateral meniscus-deficient knee is doomed to the development of osteoarthritis, pain, and reduced knee function. What happens in a medial meniscus-deficient knee? It varies. Implications of Tears:
  4. 4. Biomechanical Considerations <ul><li>Resection of the medial posterior horn increased tibiofemoral forces up to 68% </li></ul><ul><li>1 Ahmed AM, Burke DL. In-vitro measurement of static pressure distribution in synovial joints. Part I. Tibial surface of the knee. J Biomech Eng 1983;105:216–25. </li></ul>
  5. 5. Biomechanical Considerations <ul><li>Lateral meniscus covers 84% of the lateral tibial plateau versus 64% for the medial 1 </li></ul><ul><li>More circular than the medial meniscus </li></ul><ul><li>More uniform in width (average, 12 to 13 mm) </li></ul><ul><li>Meniscal Excursion 2 : </li></ul><ul><ul><li>Lateral meniscal motion after 5 to 10 degrees flexion </li></ul></ul><ul><ul><li>Medial meniscal displacement after 17 to 20 degrees of flexion. </li></ul></ul><ul><ul><li>Medial meniscus has limited displacement and rotation due to the posterior oblique ligament. </li></ul></ul><ul><ul><li>Increased mobility of the lateral meniscus can be responsible for the more frequent medial injuries </li></ul></ul>1 Ferrer-Roca O, Vilalta C. Lesions of the meniscus. Part I: Macroscopic and histologic findings. Clin Orthop. 1980;146:289-300. 2 DePalma AF. Diseases of Knee: Management in Medicine and Surgery . Philadelphia: Lippincott; 1954
  6. 6. Diagnosing Tears <ul><li>Medical history 85-98% accurate in diagnosing tears 1 </li></ul><ul><li>MRI 90-98% accurate 2,3 </li></ul><ul><ul><li>Using 3 criteria: abnormal signal, abnormal pathology, truncated or cleft. </li></ul></ul><ul><li>Knee palpation: </li></ul><ul><ul><li>34-58% with ACL injury, 77% without 4,5 </li></ul></ul><ul><li>1 Johnson 1996 2 Brindle 2001 3 Andrish 1996 4 Boeree 1991 5 Anderson 1986 </li></ul><ul><li>Clicking, popping, or locking </li></ul><ul><li>Soreness </li></ul><ul><li>Swelling </li></ul>Symptoms Clinical Examination
  7. 7. Complex Meniscal Tears <ul><ul><li>Radial </li></ul></ul><ul><ul><li>Parrot Beak </li></ul></ul><ul><ul><li>Bucket handle </li></ul></ul><ul><ul><li>Flap </li></ul></ul><ul><ul><li>Peripheral </li></ul></ul><ul><ul><li>Horizontal </li></ul></ul><ul><ul><li>Vertical </li></ul></ul><ul><ul><li>Capsular Separation </li></ul></ul>1 2 3 4 Courtesy of John Crues, MD
  8. 8. Meniscal Tears <ul><li>Abnormal signal with chronic ACL with Vertical Meniscal Tear </li></ul>
  9. 9. Meniscal Tears <ul><li>Abnormal meniscus morphology by MRI </li></ul>
  10. 10. Meniscal Tears <ul><li>Truncated abnormal triangle </li></ul>T1 Sagittal T2 Sagittal
  11. 11. Bucket Handle Tears Courtesy of John Crues, MD
  12. 12. Meniscal Tears <ul><li>Bucket handle </li></ul>T1 Sagittal T2 Sagittal
  13. 13. Meniscal Tears Locked Knee
  14. 14. Meniscal Tears Unstable Fragment
  15. 15. Meniscal Tears Displaced Fragment
  16. 16. Meniscal Cysts <ul><li>Parameniscal Cyst with Meniscal Tear </li></ul>
  17. 17. Popliteal (Baker’s) Cyst <ul><li>Causes </li></ul><ul><li>Torn Meniscus (~80% of all cysts) </li></ul><ul><li>Knee instability </li></ul><ul><li>Arthritis </li></ul><ul><li>Infection </li></ul><ul><li>Acute trauma </li></ul><ul><li>Symptoms </li></ul><ul><li>Posterior knee lump with pain, aching, swelling </li></ul><ul><li>Pronounced when standing </li></ul><ul><li>Sensation of pressure from the lump </li></ul><ul><li>Loss of range of motion from swelling </li></ul><ul><li>Clinical Considerations </li></ul><ul><li>30% recurrence rate </li></ul>
  18. 18. Patient GC: Baker’s Cysts <ul><li>73 YO Female </li></ul><ul><li>Posterior Fluid accumulation </li></ul><ul><li>Swelling, pain, stiffness, instability </li></ul><ul><li>No crepitus </li></ul><ul><li>No ROM loss </li></ul><ul><li>Aspiration and cortisone (2003) </li></ul><ul><li>Cyst excision (2005) </li></ul>
  19. 19. Intrameniscal Ossicle
  20. 20. Repair versus Meniscectomy: the Reason to Repair <ul><li>Joint Stability </li></ul><ul><ul><li>Balanced position of Femur and Tibia </li></ul></ul><ul><li>Force transmission </li></ul><ul><ul><li>Average stress reduced by 2-3x </li></ul></ul><ul><li>Joint lubricity </li></ul><ul><ul><li>Coefficient of friction 5x lower than ice/ice </li></ul></ul><ul><li>Shock Absorption </li></ul><ul><li>Chondral Protection </li></ul>Preserve the Meniscus whenever possible
  21. 21. Fairbank’s Changes: Meniscus Excision <ul><li>Radiographic Changes </li></ul><ul><ul><li>Ridge Formation </li></ul></ul><ul><ul><li>Narrowing of joint space </li></ul></ul><ul><ul><li>Flattening of femoral condyle </li></ul></ul><ul><ul><li>Formation of bone spurs </li></ul></ul>
  22. 22. Degenerative Radiographic Changes <ul><li>Patient Example: MP1 </li></ul><ul><li>5-Yr Post medial meniscectomy </li></ul>PA Flexion
  23. 23. Meniscectomy: What Not to Do Movie
  24. 24. Degenerative MR Changes <ul><li>Patient Example: MP </li></ul><ul><li>5 Months Post medial meniscectomy </li></ul>
  25. 25. Degenerative MR Changes <ul><li>Patient Example: MB </li></ul><ul><li>10 Months Post medial meniscectomy </li></ul>
  26. 26. Dogma of Meniscus Biology <ul><li>I: Vascular “Red Zone” </li></ul><ul><ul><li>Excellent healing </li></ul></ul><ul><ul><li>Fibroblast-like </li></ul></ul><ul><li>II. “Red and White Zone” </li></ul><ul><ul><li>Good healing </li></ul></ul><ul><ul><li>Periphery of vascularized region </li></ul></ul><ul><li>II: Avascular “White Zone” </li></ul><ul><ul><li>Poor healing </li></ul></ul><ul><ul><li>Fibrochondrocytes, Type VI collagen </li></ul></ul><ul><li>1 Mc Devitt CA, Webber RJ. The ultrastructure and biochemistry of meniscal cartilage. Clin Orthop. 1990;252:8-18. </li></ul><ul><li>2 Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med. 1982 Mar-Apr;10(2):90-5. </li></ul>I II III
  27. 27. Success rate <ul><li>Inverse Correlation </li></ul><ul><ul><li>Rim width </li></ul></ul><ul><ul><li>Tear Length </li></ul></ul><ul><ul><li>Patient age </li></ul></ul><ul><ul><li>Knee instability/ACL deficiency </li></ul></ul><ul><ul><li>BMI </li></ul></ul><ul><li>Success Rates </li></ul><ul><ul><li>Johnson (1999) 76% </li></ul></ul><ul><ul><li>Cannon (1992) 82% </li></ul></ul><ul><ul><li>Jakob (1998) 78% </li></ul></ul><ul><ul><li>Ryu (1988) 87% </li></ul></ul><ul><ul><li>Stone (1986) 56% Complete, 25% Partial </li></ul></ul><ul><ul><li>Rosenberg (1986) 83% Complete, 17% Partial </li></ul></ul><ul><li>Long term healing rate? </li></ul><ul><li>Re-tears? </li></ul><ul><li>Restore normal function? </li></ul>
  28. 28. Patient Example: SA <ul><li>16 year old female </li></ul><ul><li>LaCrosse: Twisted knee </li></ul><ul><li>Audible “Pop” </li></ul><ul><li>Pain, Stiffness, Instablility </li></ul><ul><li>Torn ACL </li></ul><ul><li>Torn medial meniscus </li></ul>T1 MRI
  29. 29. SA: Preoperative Images STIR MRI: acute trauma PD MRI T1 MRI: Torn ACL
  30. 30. SA: Meniscoresis Movie
  31. 31. SA: Postoperative X-Ray
  32. 32. Patient Example: VT <ul><li>30 year old male </li></ul><ul><li>1.5 month volleyball injury </li></ul><ul><li>Knee giving way </li></ul><ul><li>Pain, swelling, instability </li></ul><ul><li>Torn ACL </li></ul><ul><li>Torn lateral meniscus </li></ul>
  33. 33. VT: Tear Identification Medial compartment: probing the meniscus
  34. 34. VT: Tear Identification Lateral compartment: identification of the tear
  35. 35. VT: Meniscal Repair “ Hay Bale” Suture Technique (“Bala de Heno”)
  36. 36. Patient example: CD <ul><li>20 y.o. male </li></ul><ul><li>Twisted knee on wet stairs </li></ul><ul><li>Pain, swelling, weakness, instability </li></ul><ul><li>Torn ACL </li></ul><ul><li>Bucket handle Tear (lateral) </li></ul><ul><li>Peripheral tear (medial) </li></ul>T1 MRI
  37. 37. CD: Preoperative Images AP X-ray Lateral X-ray MRI: Torn ACL
  38. 38. CD: Stable Peripheral Tear <ul><li>Healing already initiated </li></ul>
  39. 39. CD: Bucket Handle Tear: Excise or Repair? <ul><li>Movie </li></ul>
  40. 40. CD: Postoperative X-Ray
  41. 41. Surgical Technique: Suture Repair <ul><li>Inside-Out through mini incisions </li></ul>Movie
  42. 42. Bucket Handle Tears repair young – fail old
  43. 43. Bucket Handle repair: Suture Technique Movie
  44. 44. Bucket Handle Repair
  45. 45. Fixation Devices <ul><li>Suture success rate 78% versus 56% for arrow or T Fix (Venkatachalam 2001) </li></ul><ul><li>Problems: </li></ul><ul><li>Migration </li></ul><ul><li>Failure/Re-tear </li></ul><ul><li>Patient discomfort </li></ul>
  46. 46. Bionix Arrow Bionix Implants, Inc.
  47. 47. Fixation Devices <ul><li>Biostinger </li></ul><ul><li> Barber et. al, Arthroscopy 2005 </li></ul>
  48. 48. Acufex T-Fix Sutures <ul><li>Smith and Nephew Endoscopy </li></ul>
  49. 49. Meniscus Reconstruction Collagen Meniscus Implant (CMI)
  50. 50. CMI: Pre Op Versus Post Op Preoperative MRI: Meniscal Tear Arthroscopic view of tear Regenerated meniscus 6.6 Months Post-CMI Histology of regenerated meniscus 6.6 Months Post-CMI MRI 3 years post CMI
  51. 51. Meniscus Replacement <ul><li>Meniscus Allograft in the Arthritic Knee </li></ul>
  52. 52. Meniscus Repair: Rehabilitation <ul><li>General Considerations </li></ul><ul><li>Daily Icing and elevation. </li></ul><ul><li>Weight-bearing as tolerated. Walk with crutches. </li></ul><ul><li>Hinged rehab brace (full extension): 4 weeks. </li></ul><ul><li>Gait assessment to avoid compensatory patterns. </li></ul><ul><li>No resisted leg extension machines No high impact or cutting / twisting activities: 4 months post-op. </li></ul>
  53. 53. Meniscal Tears: Prevention <ul><li>Muscular conditioning </li></ul><ul><ul><li>muscles absorb force </li></ul></ul><ul><ul><li>Prevent abnormal rotations </li></ul></ul><ul><ul><li>Ability to accept an eccentric load (elongation) </li></ul></ul><ul><li>Minimize impact: </li></ul><ul><ul><li>Non-impact training: bicycling </li></ul></ul><ul><ul><li>Sorbothane shoe/boot inserts </li></ul></ul><ul><ul><li>training on soft surfaces </li></ul></ul><ul><li>Flexibility, agility and strength workouts. Focus on Core. </li></ul><ul><li>The conditioning program must be continued throughout the year. </li></ul>Decreasing the impact loading the knee joint:
  54. 54. Conclusions <ul><li>Save the meniscus if the tissue is healthy. </li></ul>
  55. 55. Thank You