The document discusses the management of knee cartilage defects and meniscus tears. It covers the anatomy and composition of articular cartilage, causes and classifications of cartilage lesions, and treatment approaches. For cartilage defects, treatments include non-operative options like physical therapy, injections, and supplements, as well as surgical repairs like debridement, microfracture, and mosaicplasty that aim to relieve symptoms or stimulate tissue growth. Proper rehabilitation is important for healing following many procedures.

1. MANAGEMENT OF
KNEE CARTILAGE DEFECT &
MENISCUS TEAR
RIZQI DANIAR ROSANDI
FK UNIVERSITAS BRAWIJAYA
APRIL 2020
Pengampu : Dr. dr. Edi Mustamsir, Sp. OT (K)

2. KNEE CARTILAGE DEFECT
Spectrum of disease entities from single, focal defects to advanced degenerative
disease of articular (hyaline) cartilage

3. EPIDEMIOLOGY
Incidence:
• 5-10% of people > 40 years old have high grade
chondral lesions
Location:
• Chronic ACL tear
 anterior aspect of lateral femoral chondyle and
posterolateral tibial plateau
• Osteochondritis dissecans
70% of lesions found in posterolateral aspect of medial
femoral condyle

4. ANATOMY OF KNEE CARTILAGE
Function
• decreases friction and distributes loads
• exhibits stress-shielding of the solid matrix
components
Types
• Hyaline
• Elastic
• Fibrous

5. FUNCTIONS OF CARTILAGE

6. Elastic Cartilage
Fibrous Cartilage or
“Fibrocartilage”
3 Types of Cartilage
Tissue
Hyaline Cartilage

7. ANATOMY OF ARTICULAR CARTILAGE
COMPOSITION
Extracellular
matrix
Cells
Water (65-80%)
Proteoglican (10-
15%)s
Collagen (type II )
(10-20%)
Chondrocytes

9. matrix
matrix
matrix
matrix
matrix
Composed mostly of an intercellular material called “matrix” – ground
substance is gel-like

10. matrix
matrix
matrix
matrix
matrix
cells
Tissue cells are the contained in this intercellular matrix but are “far” apart, relatively speaking

11. NOURISHMENT & METABOLISM
 Cartilage is avascular
 Nourished by
 synovial fluid at the surface
 subchondral bone at the base
 Relies on glycolysis for ATP production

12. BIOMECHANICS OF ARTICULAR
CARTILAGE

13. MICROSTRUCTURE OF
CARTILAGE
• The cells of cartilage are chondroblasts and chondrocytes.
• Chondrocytcs manufacture, secrete, organize and maintain the organic
component of the extracellular matrix.
• The organic matrix, is composed of dense network of fine collagen fibrils.

14. WATER
• The fluid component of articular cartilage is also essential
to the health of this avascular tissue because it permits
gas, nutrient, and waste product movement back and
forth between chondrocytes and the surrounding nutrient-
rich synovial fluid
• Most of the water thus occupies the inter space of the
ECM and is free to move when a load or pressure
gradient or other electrochemical motive forces are
applied to the tissue.
60 to 85% is
water

15. COLLAGEN
• Collagens consist of 3 polypeptide
chains that form a triple helix
• They can be divided into fibrillar
collagens(types I, II, III, V and
XI), which form the framework
of the tissue
60 to 70% of the dry
weight

16. • More than 20 different types collagen identified so far,
the functions of all of these types have not been
determined.
• The fibril-forming collagens (types I, II, III, V, and XI) are
the
most common.
• Type I collagen, comprising 90% of the total collagen
in the body, is found in almost all connective tissue,
including tendons, ligaments, menisci, fibrocartilage,
joint capsules,
bones, labra, and skin.
• Type II collagen is found mainly in hyaline articular
cartilage and in the nucleus pulposus in the center of the
intervertebral disks.
• Type III collagen is found in the skin.

17. PROTEOGLYCAN
.
A large protein-polysaccharide molecule composed of a
protein core to which one or more glycosaminoglycans
(GAGs) are attached.
30% of the dry
weight

18. STRUCTURAL AND PHYSICAL INTERACTION AMONG
CARTILAGE COMPONENTS
• The closely spaced sulfate and
carboxyl charge dissociate in
solution at physiological pH leaving
a high concentration of fixed
negative charges that create strong
intramolecular and intermolecular
repulsive forces.
When cartilage is compressed, the
negatively charged sites on aggrecan
are pushed closer together, which
increases their mutual repulsive force
and adds to the compressive stiffness of
the cartilage.

19. LAYERS OF ARTICULAR CARTILAGE
• Composed of three zones & tidemark
• zones based on the shape of the chondrocytes and the orientation of the type II collagen

20. PATHOPHYSIOLOGY
MOI
ACUTE TRAUMA
CHRONIC
REPETITIVE
PATHOMECHANIC:
IMPACTION FORCES > 24 MPa  disrupt normal
cartilage
CELLULAR BIOLOGY:
 LIMITED SPONTANEUS HEALING
 WORSEN OVER TIME

21. MECHANICAL STRESS RESPONSE
Physiologic Excess Stress
Stimulates matrix
synthesis & inhibits
chondrolysis
Suppresses matrix
synthesis & promotes
chondrolysis
Repetitive Loading:
• Moderate running 
cartilage thickness &
proteoglycan conten
• Strenuos loading 
cartilage thinning &
proteoglycan loss
• Immobilizations  cartilage
thinning, softening &
proteoglycan loss
Cellular
Response
Mechanosensory
organ : Primary cilia
Mechanical signals :
integrin

22. THE EFFECTS OF EXERCISE ON HUMAN
ARTICULAR CARTILAGE
• Enhance synovial movement for cartilage nutrition
• Dynamic (cyclic) loading is beneficial to matrix
synthesis.

23. WEAR MECHANISM
Forms of
Lubrication
• Elastohydrodynamic
• Boundary (Slippery surfaces)
• Boosted (Fluid Entrapment)
• Hydrodynamic
• Weeping
• Adhesion
• Abrasion
• Transfer
• Fatique
• Third body

24. Resistive Exercise for Arthritic Cartilage Health (REACH): A randomized double-blind, sham-exercise controlled
trial
Angela K Lange*1, Benedicte Vanwanseele1, Nasim Foroughi1, Michael K Baker1, Ronald Shnier2, Richard M Smith1and

25. CARTILAGE LESION
CLASSIFICATION
Outerbridge Classification

26. ICRS CLASSIFICATION

27. BAD TO THE BONE

28. PRESENTATION
Precipating trauma
Some found incidentally
(MRI/ Artrhroscopy)
Asymtomatic vs localized
knee pain
Complain: effusion, motion
deficits, mechanical
symptom
Anamnesis
Inspection : joint laxitiy,
malalignment,
compartement overload
Motion : assess ROM,
ligamentous stability & gait
Physical
Exam

29. IMAGING
Radiographs
Indication : to rule out arthritis, bony defect & check
alignment
View : AP (standing)/ lateral/ merchant view
Optional : semiflexed 45 PA view, Long leg alignment
vies

30. IMAGING
CT- Scan
 Indication : better evaluation of bone
loss
 Findings: to measure TT-TG when
evaluating the patella-femoral joint
MRI
 Indication: Most sensitive for
evaluating focal defect
 Views:
 Fat-suppressed T2, proton density, T2
fast spin-echo (FSE)  improved
sensitivity and specificity over
standard sequences
 dGEMRIC (delayed gadolinium-
enhanced MRI for cartilage) & T2
mapping  evaluate cartilage defects
& repair

31. TT-TG MEASURE.. CT VS MRI??

32. MRI SEQUENCES
ON CARTILAGE
DEFECT

33. FAT-SUPPRESSED T2

34. PROTON DENSITY

35. THE FAT-SUPPRESSED FAST SPIN-ECHO
PROTON DENSITY WEIGHTED CORONAL
VIEW

36. T1-WEIGHTED SAGITTAL EXAM

37. Pollard et al., 2008: JBJS

38. Pollard et al., 2008: JBJS

39. TREATMENT
Davey, et al., 2016: BOS

40. NON-OPERATIVE
 an important pillar of treatment for articular cartilage defects and should be
discussed as an option prior to surgical intervention
Physical therapy &
exercise
NSAIDs
Intraarticular injection of
corticosteroids
Viscosupplementation
Biologic Therapy

41. PHYSICAL THERAPY & EXERCISE
 Effective symptom relief and longer-lasting
relief
 Contraindication if become more symptomatic
with increasing activity  rest
 A significant benefit of exercise is the potential
for weight loss

42. NSAIDS

43. INTRAARTICULAR CORTICOSTEROID

44. VISCOSUPPLEMENTATION
 Viscosupplementation is the process by
which pathological synovial fluid is
removed and replaced with HA-based
products
 Viscosupplementation with hyaluronic acid
provides longer improved function
Webb & Naido, 2018:
Orthopaedic Research &
Review

45. BIOLOGICAL THERAPY
 Biologic injections have shown
promise for conservative treatment of
articular cartilage lesions
 PRP may stimulate the recruitment
and expansion of mesenchymal stem
cells, the synthesis of hyaluronic acid,
and the production of extracellular
matrix

46. SURGICAL MANAGEMENT OF KNEE
ARTICULAR DEFECT

47. Palliative Techique
Restoration Techique
Repair Techique
Intended to relieve pain secondary
to chondral bone
Invoke stimulation of the
underlying subchondral bone
marrow
Debridement-
arthroscopic
Microfracture,
subchondral drilling,
abrasion arthroplasty
Attempt to transfer or produce
normal hyaline articular cartilage
Autologous chondrocyte
implantation (ACI),
osteochondral auto/allograft
Harris & Flanigan, 2011. Research Gate: Management of Knee Articular
Cartilage Injuries

48. PALLIATIVE TECHIQUE
 minimally-invasive, arthroscopic
surgeries intended to relieve pain due
to articular cartilage disease
 Debridement consists of removal of
unstable, loose flaps or fronds of
articular cartilage and loose bodies
 Definition also encompasses lavage,
which removes inflammatory joint fluid
containing catabolic enzymes.

49. CARTILAGE REPAIR TECHIQUES
 intend to stimulate the subchondral bone
marrow (marrow stimulation techniques,
MST)  to induce mesenchymal stem cell
infiltration into a chondral defect with
formation of a clot that may differentiate
into repair tissue.
 Microfracture, subchondral bone drilling,
and abrasion arthroplasty are MSTs
Cole el al., 2009. JBJS: Surgical
management of articular cartilage defects
in the knee

50. MICROFRACTURE
 Arthroscopic awls of variable angles
(0°, 30°, 45°, 60°, and 90°) may be used
to create multiple holes, the
microfractures, perpendicular to the
surface penetrated
 The sequence of hole creation should
be centripetal, from the periphery
inward, approximately 3-4 mm apart
and 3-4 mm deep
 Immediate continuous passive motion
(CPM) is indicated for at least 8 hours
per day for at least 8 weeks

51. CARTILAGE RESTORATION TECHNIQUE
 either transfer (mosaicplasty, osteochondral autograft and allograft) or
attempt to produce (cell-based treatments such as ACI) normal hyaline
articular cartilage.

52. OSTEOCHONDRAL GRAFT
Autograft/ Mosaicplasty
 Two similar techniques that harvest an osteochondral
plug(s) from a “less weight-bearing” part of the knee
and transplant them to a defect on a more weight-
bearing, articulating location
 can place one or many plugs of variable sizes to fill a
defect
 to limit the size transplanted to no greater than 4 or 5
cm2
 may be performed all-arthroscopically or via mini-
arthrotomy
 A sharp cutting harvester, perpendicular to the surface,
is impacted to a pre-determined depth and donor plug
is harvested
 The recipient site is prepared to accept the graft to the
correct depth. The plug is then placed press-fit via
instrumented manual impaction
Allograft
 Similar to those of autograft, with the
difference being the source of the
osteochondral plug
 concern for disease transmission, cell viability,
and host-graft immunogenicity exist
 for larger chondral and osteochondral defects
(usually greater than 2 to 4 cm2)
 most allografts are implanted via an
arthrotomy

53. OSTEOCHONDRAL AUTOGRAFT
(OAT)/ MOSAICPLASTY
Cole et al., 2009. JBJS :
Surgical management
of articular cartilage
defect in the knee

54. OSTEOCHONDRAL
ALLOGRAFT
Harris & Flanigan, 2011. Research Gate:
Management of Knee Articular Cartilage Injuries

55. AUTOLOGOUS CHONDROCYTE
IMPLANTATION (ACI)
 two-stage cartilage restoration technique indicated for lesions greater
than 2 cm2 on the femoral condyles, trochlea, or patella
 Stage 1 involves arthroscopic assessment of the defect and a full-
thickness cartilage biopsy
 Stage 2 involves cell implantation via arthrotomy under a periosteal or
collagen membrane patch or, more recently
 Premist : a biopsy and growth in culture of your own cells should
theoretically produce normal hyaline articular cartilage upon
implantation

56. AUTOLOGOUS CHONDROCYTE
IMPLANTATION (ACI)
Davies & Kulper, 2019: Bioengineering : Regenerative Medicine:
A Review of the evolution of Autologous Implantation (ACI)
Therpy

57. SUMMARY OF SURGICAL MANAGEMENT OF ARTICULAR
CARTILAGE DEFECT OF KNEE
Davies & Kulper,
2019:
Bioengineering :
Regenerative
Medicine: A
Review of the
evolution of
Autologous
Implantation
(ACI) Therpy
Harris & Flanigan, 2011. Research Gate:
Management of Knee Articular Cartilage Injuries

58. REHABILITATION STRATEGIC AFTER
KNEE ARTICULAR CARTILAGE REPAIR
Reinold et al., 2013. Journal Orthopaedic & Sports Physical Therapy : Current concepts in the rehabilitation
following articular cartilage repair procedure in the knee

59. PRINCIPLES OF REHABILITATION
 Individualization
 Create a healing environment
 Biomechanic of the knee
 Reduction of pain & effusion
 Restore soft tissue balance
 Restoring muscle function
 Enhance proprioception & neuromuscular control
 Controlling the application of loads
 Team communication

60. PHASE OF REHABILITATION
Proliferation phase
• Requires protection
• 4-6 weeks following surgery
• Gradually restore PROM & weigh bearing (partial) & enhance volitional
control of the quadriceps
Transition phase
• 4-12 weeks post surgery
• Gaining strength  progression of rehabilitation exercise (ROM, full
weigh bearing)
• Progression is controlled for strengthening exercises, proprioception
training, neuromuscular control drills, and functional drills

61. PHASE OF REHABILITATION
Remodelling phase
• Take places from 3-6 months post operatively
• continuous remodeling of tissue into a more organized structure  increasing
in strength & durability (independently)
• Low to moderate impact activities : bicycle riding, golfing, recreational walking
Maturation Phase
• Begin in range 4-6 months can last up 15-18 months post surgery
• Repair tissue reach its full maturation
• Duration of this phase varies based on several factors such as lesion size and
location, and the specific surgical procedure performed
• Gradually return to full premorbid activities as tolerated

62. TIME TABLE FOR SPECIFIC SURGERY
Mankin, 2019: Chester Knee Clinic & Cartilage
Repair Centre

63. MENISCUS TEAR
meniscal tears are common in young patients with sports-related injuries and older
patients as a degenerative condition

64.  Menisci is a crescentric shaped
fibro cartilagenous structures
between the condyles of femur &
tibia
 Peripheral edges are thick,
convex & fixed to inner surface
of capsule.
MENISCUS ANATOMY

65. MENISCUS ANATOMY
• Lateral meniscus: cover 84%of
condyle surface, 12-13 mmwide and
3-5 mm thick
• Medial meniscus: wider in diameter,
cover 64%of condyle surface, 10 mm
wide, 3-5 mm thick
MENISCUS ANATOMY

66. MENISCUS VASCULARITY
• 50% of meniscus is vascularized
at birth, and only 10-25%is
vascularizedin the adult
• Vascularity of meniscusimpact
the ability of repair to heal
• Divided into 3 zones

67. BLOOD SUPPLY
 Superior & Inferior
branches of medial &
lateral geniculate arteries
 Perimeniscal capillary
plexus within the synovium
& capsule

68. • Load transmission and shock
absorption
– 50% in extension, 85% in flexion
• Joint congruity and stability
– Between curved condyles and flat
plateus, as stabilizers
• Joint lubrication
– Distribute synovial fluid across
articular surface
• Joint nutrition
– Absorb and release to cartilage
• Proprioception
– Nerve ending provide sensory
feedback for joint position
MENISCUS FUNCTION

69. MENISCUS INJURY
• Meniscalinjuries occurs in 15%of ACL injuries
• 80%patients with history of ACL tears will likely tear their meniscus
• 70 %meniscalinjuries are to the medial meniscus
• Ages andmechanism ofinjury
- < 20, almost all were sport related cases(11 of 12)
- 20-29 g 64,5% sports related
- 30-39 g 30,5% sports related
- 40-49 and 50-59, only 19,6%and14,3%were sports related

70. MENISCALINJURIES
 Injury with rotational force ,on a partially flexed knee
.Eg:Foot ball players,Kabadi players
 Most common site- posterior horn
 Most common type- longitudinal tear
 Length ,depth, position of tear– position of the meniscus in relation to
condyles at the time of injury.

71. MECHANISM OF INJURY
• Commonly in sports activity such as in rugby and
getting up from squatting or crouching position
Sustained injury when standing on semi-
flexed knee, twist his body to one side
During the movement, meniscus is
sucked in and nipped as rotation occurs
between condyles of femur and tibia
Longitudinal tear of the meniscus

72. • A degenerated meniscus in the elderly may get
torn by minimal or no injury
MECHANISM OF INJURY

73. Predisposing Factors
 Trauma
 Meniscal cyst
 Decreased mobility of the meniscus
 Discoid meniscus
 Aging- degeneration
 Abnormal mechanical axis- ligamentous laxity
 Congenitaly relaxed joints
 Inadequate tone and musculature

74. MENISCUS TEARTYPES
• Acute vsdegenerativetear
• Stablevsunstable tear
• Complete vsincomplete (intra
substance) tear
• Location

75. ACUTE VS DEGENERATIVE TEAR
Acute
•Trauma, knee twisted in
weight bearing position
•Younger population
•Symptoms : pain, swelling,
locking
•May require surgery
Degenerative
•Degenerative, minor trauma
•Older population
•Minor symptoms, some
asymptomatic
•Mostly conservative

76. STABLE VS UNSTABLETEAR
Stable tear
• Does not move,may healon its own
• Tears in which the central portion cannot be
displacedmore than 3 mm
Unstable tear
• The meniscusmove abnormally
• It’s likely to be a problem if not surgically
corrected

77. COMPLETE VS INCOMPLETE TEAR
Complete tear
• Goes all the waythrough the
meniscus
• A piece of tissue is separated from
the rest of meniscus
Incomplete tear
• The tear isstill partly attached to
the body of meniscus

78. CLASSIFICATION OF MENISCAL TEAR
• Based on Location
 Red Zone: Outer third, vascularized
 Red-White Zone : Middle Third
 White Zone : Inner third, non-vascularized

79. MENISCAL TEARGRADING
Grade 0 : normal meniscus
Grade 1 : intrasubstance globular-appearing signal, not extending to the
articular cartilage
Grade 2 : linear increased signal pattern not extending to articular cartilage
Grade 3 : abnormal signal intersect the superior and/or inferior articular surface
of meniscus, an arthroscopically confirmable tear

80. PATTERNS OF TEAR
3 basicshapesof meniscal tear
•
•
•
•
•
•
•
•
Vertical/longitudinal : tears parallel to the long axisof
meniscus,dividing meniscusinto inner andouter part
Radial tear : tears perpendicular to long axisof meniscus
Horizontal tear : divide the meniscusinto atop andbottom part
(pita bread)
Complex tear : combination of these basicshapes
Bucket handletear : displacedlongitudinal tear
Flaptear : displacedhorizontal tear
Parrot beaktear : displacedradial tear
Root tear : radial tear located at meniscal root

81. TEAR PATTERNS
Horizontal cleavage tear
Meniscal root tear

82. DIAGNOSIS
•Clinical evaluation :
History of twisting injury
+ ligamentous injury
Effusion
Mechanicalsymptoms (clicking, popping, locking,etc)
Jointline tenderness
Provocative tests
• Imaging studies : weight bearing knee radiographs,
MRI
70-75% accuracy

83. PROVOCATIVE TESTS
• McMurray test
• Apley test
• Thessaly test
• Steinman test
• etc

84. PROVOCATIVE/ SPECIAL TEST
McMurray’s Test
The basic premise of the McMurray test is that
meniscus tears are trapped during certain knee
movements, with resultant pain and clunking.
• Full flexion of knee + external rotation + varus
force (adduction force)
• Gradually extended
• Pain or click felt over medial aspect of joint line at
certain angle
• Finding : tear of medial meniscus
• Similarly for lateral meniscus : flexion + internal
rotation + valgus force (abduction force)

85. PROVOCATIVE/ SPECIAL TEST
Apley’s
Test• The concept behind the Apley test is that
ligaments usually are painful when stressed in
distraction, whereas pain involving the meniscus
is felt with compression.
• Prone position, the knee flexed 90°, and the
femur stabilized with one hand,
• Distraction is applied with the other hand by
pulling upward on the ankle while rotating
medially and laterally. A varus and valgus force
may also be applied to further delineate whether
the MCL or the LCL might be the source of pain
(Apley distraction test).
• Compression is applied to alternately grind the
medial and lateral meniscus between the tibia
and femur, with gentle varus and valgus force
applied, while internally and externally rotating
and compressing the ankle downward (Apley

86. PROVOCATIVE/ SPECIAL TEST
• Duck walk test (Childress sign). The squatting position
places great stress on the posterior horns of both
menisci and is painful if the posterior horn is torn. The
patient is asked to squat and “walk like aduck.” Painin
combination withaclunk suggests a posterior horn
meniscus tear

87. DIFFERENTIAL DIAGNOSIS
 Loose bodies
 Osteochondritis dissecans

88. INVESTIGATIONS
 X-Ray: Knee AP/ Lateral & Intercondylar notch view
 Magnetic Resonance Imaging (MRI)-sensitivity
 Arthroscopy
 Arthrography (rare)

89. MRI OF MENISCALTEARS
• Non invasive
diagnostic of choice
• 90-98% accuracy
• High negative
predictive value
Normal meniscus Tornmeniscus
Johnson,1998; Brindle,2001

90. MRI OF MENISCALTEARS
• Know the anatomy
• Evaluateimagesof all sequencesof MRI
- Proton density weighted sequenceshas beenfavored
over T2-weighted sequencein detecting meniscaltear,
but in root tear coronal T-2weighted imagesshow
higher accuracy

91. MRI OF MENISCALTEARS
Bucket handle tear
Double
PCL sign
Horizontal
tear

92. MRI OF MENISCALTEARS

93. ARTHROSCOPY
 Gold standard for diagnosis and treatment
 Thorough inspection of menisci, ligaments &
cartilage is possible
 Anteromedial or anterolateral portals
 Full extent, type, site of tears & degenerative
changes can be seen

94. MENISCALTEAR
TREATMENT
• Non Surgical
• Surgical

95. NON SURGICAL
• Not all meniscustears causesymptoms, andmany
symptomatic tears become asymptomatic
• Teartypes that maybemanagednon surgically:
Stablelongitudinal tear < 10 mm length with < 3-5
mm displacement
Degenerative tears with significant OA
Short (< 3mm) radial tears
Stablepartial tears
• Non surgical therapy: Ice, NSAIDs, physicaltherapy
for ROM andgeneralstrengthening

96. SURGICALTREATMENT
Excision (Menisectomy)
Repair
Transplantation
Meniscus implant

97. MENISCECTOMY VS REPAIR
• Preserve the meniscuswhenever possible
• Preservation of meniscal tissue is paramount for long term
jont function

98. MENISCECTOMY
Principles of meniscectomy
• Remove as much unstable torn tissue
as possible, ....... but leave behind as
much normal tissue aspossible
• Partial, not total

99. ADVANTAGES OF PARTIAL OVER
TOTAL
Shorter operating time
Faster recovery
Better post operative function
Better self assessment of outcome
56

100. OPEN –OR- ARTHROSCOPIC?
 Long term results of arthroscopic meniscectomy are
comparable to skilful open partial meniscectomy.

101. APPROACHES
Medial meniscectomy
 Single anterio medial
 Second incision:Henderson posteromedial incision
Lateral meniscectomy
 Antero-lateral
 Anterolateral+posterolateral

102. POSTOPERATIVE
 Compressive bandage
 Knee immobilized in extension for 1 week
 Quadriceps exercises on next day.
 Crutch walking with partial weight bearing on next day
 Isometric exercises continued till 90 degree of flexion.

103. COMPLICATIONS
 Haemarthrosis
 Chronic Synovitis
 Synovial fistulae
 Painful neuromas
 Thrombophlebitis
 Infection
 Late degenerative arthritis
 Reflex sympathetic dystrophy

104. FAIRBANK’S CHANGES
 Post meniscectomy change
 Narrowing of joint space
 Flattening and squaring of femoral condyle
 Antero posterior osteophyte formation

105. REGENERATION OF MENISCI AFTER EXCISION
 After complete meniscectomy – fibrous regeneration within 6
weeks to 3 months
 Thinner and narrower than normal meniscus
 Decrease surface area and mobility.

106. MENISCUS REPAIR
70-75%successrate
Recent advances,better understanding of meniscus
functions,patophysiology,healing g meniscal
preservation become preferred treatment options
Broadening indications for repair :
repair in lessvascularzones
more complex tear configurations
biological augmentation

107. MENISCUS REPAIR
PRINCIPLES
Vascularity
- RedonRed
- Redon White
-White onWhite
Stability
- AssociateACL tear, reconstruct theACL
Rehabilitation
Patient Selection

108. MENISCUS REPAIR
STABILITY & REPAIR SUCCESS RATE
Ruleof thirds
ACL deficient knee 30%
ACL stable knee 60%
ACL reconstructed knee 80-90%
Cannon,1996;Warren, 1990;Yamamoto,1996

109. WHY BETTER RESULT?
• Younger patient
• Acute tear (lessdeformity, less degeneration)
• ‘Normal’ meniscusthat tore secondary to an
instability episode
• Longitudinal peripheral tears (red/white or red/red
zone)
• Hemarthrosis (chemotactic andgrowth factors)
• Protected rehabilitation secondary to reconstruction
(pain, slower motion)

110. MENISCUS REPAIR
PRINCIPLES - PATIENT SELECTION
Ideal Patient
Young
Acute tear (lessdeformity)
Compliant with rehabilitation
ACL recon in conjunction with repair
Smalltear (<2 cm)
Good vascularity
Lateral meniscus ?

111. MENISCUS REPAIR
INSTRUMENTS & IMPLANTS
Bioabsorbable implants :
A. MeniscalArrow,B.MeniscalDart
C.BioStinger
All inside suture repair
systems :
A. FasTFix
B.MaxFire
C. Meniscal Cinch
D.RapidLoc

112. MENISCUS REPAIR
TECHNIQUES
Open repair
Peripheral tears in posterior horn
Arthroscopic inside out meniscus repair
- “gold standard”
- well documented
Arthroscopic outside in meniscus repair
Arthroscopic all inside meniscal repair
- suture based
- implant based
Circumferential repair vs compression stich

113. OPEN MENISCALREPAIR
 For posterior 1/3rd tear not more than 2mm from the
menisco synovial junction
Advantage
 More precise suture placement
 Sutures placed vertically through meniscus
 Better preparation of site

114. ARTHROSCOPIC MENISCALREPAIR
 Patient selection
 Tear debridement of local synovial ,
meniscal and capsular abrasions
 Suture placement

115. SUTURE TECHNIQUES
 Inside-out : Gold standard
 Outside-in
 All inside

116. INSIDE- OUT TECHNIQUE ( Gold Standard)
 Use zone specific canulas to pass sutures
 Sutures are attached to flexible needle
 Brought out through a posterior skin incision
 Advantage :can be used in post.1/3 tear
 Disadvantage: neurovascular injury costly

117. OUTSIDE IN TECHNIQUE
 Sutures passed percutaneously across the
tear through 18 G spinal needle
 Knot is tied inside the joint
 Repeated every 4-5mm
 Advantage: simple, safe and cheap
 Disadvantage: cannot be used for
posterior.1/3rd tears

118. ALL INSIDETECHNIQUE
 For repair of posterior horn peripheral tear
 Needle is inserted into the meniscus & exits within the joint
 Specialised instrumentation needed.
 Allows placement of vertical sutures

119. Arthroscopic Repair- Disadvantages
Difficulty in intraarticular knot tying
No long term clinical studies
Time away from sports.

120. Knee is placed in a hinged brace and immediate range of
motion from 0-90 degrees is permitted.
Touchdown weight bearing is permitted immediately,
and
Full weight bearing is permitted at 6 weeks when the brace and
crutches are discarded.
No sports are allowed for 3 months.
If tear is large crutches are discarded at 8 weeks. No sports are
allowed for 6 months.
AFTER TREATMENT

121. MENISCUSTRANSPLANTATION
• Meniscus allograft
• For youngpatients who have undergone meniscectomy
• Unknown long term outcome

122. MENISCAL TRANSPLANTATION
 No long term study at present
 Meniscal allografts available.
 Survival rates better in patients with no degenerative
changes.
 Correctly sized implants with attached bone blocks
recommended.

123. MENISCAL TRANSPLANTATION
 Allograft and auto graft replacement
 Quadriceps, patellar tendon & infrapatellar pad of fat are used as
allogenic substitutes for meniscus
 No uniformly satisfactory results.

124. RECENT ADVANCES
 Bioabsorbable meniscal fixators (meniscal dart,arrow)
 Collagen meniscus implant-from bovine achilles tendon
 Synthetic scaffolds
 Future- gene therapy & Stem cells

125. MENISCUS REPAIR
FUTURE DIRECTIONS
• Improved biological solutions andincreased
capability to regenerate meniscal tissue
• Growth factors andgenetherapy to enhance
healing
• Incorporating meniscus fixation deviceswith
bioactive protein that augmentsrepair mechanism
• Cell-based techniques including stem cells

126. SUMMARY
• High incidence
• Preservation of meniscuswhenever possible
• Meniscectomy vs repair
• Result of repair will depend on : location of tear,
stability of knee and repair, patient selection and
rehabilitation after repair
• Meniscaltransplant for those with significant damage
of meniscus tissue
• Future : biological repair, augmentation of repair or
regeneration of meniscal tissue

127. THANK YOU
MALANG, 30 APRIL 2020