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1. Meniscus Repair
Dr RAJAT JANGIR MS Orth
Consultant Shoulder & Knee Surgeon
Professor, Mahatma Gandhi Hospital, Jaipur
Fellowship Secretary - Indian Cartilage Society

2. Why to do it ??
— Restore Function
— Maintain Load transmission
— Minimize Contact Stress
— Contribute to Stability
— Chondroprotection

3. Question ????
..….BUT THEN SHOULD EVERY MENISCUS BE REPAIRED?
No
“APPROPRIATE & INFORMED DECISION REQUIRED”
Only 20% repairable.
.
*Fairbank et al. JBJS 1948;30B:664-70 *Chatain et al. Knee Surg 2001;9:15-18

4. Zones
Poulsen M, Johnson D. Meniscal injuries in the young, athletically active patient. The Physician and sportsmedicine1870.

5. Principle for Repair
Stimulation of the healing potential and Stabilization of the defect *
1. Stimulation- peri-meniscal synovial abrasion and/or fibrin clot placement.
2. Stability-
— Incomplete
— Short tear length
— Augmented by suture approximation, immobilization, & postoperative non-weight bearing.
*Newman A, Daniels A, Burks R. Principles and Decision Making in Meniscal Surgery. Arthroscopy: The Journal of
Arthroscopic and Related Surgery. 1993;9(1):33-51.

6. When to repair…...

7. When to repair

8. Avoid repairing….
— Chronic complex tears
— Degenerative tears
— Unstable knee (without reconstruction)- retear 40%
— Associated Grade IV osteochondral defects

9. Meniscal Repair vs Resection
Repair is Indicated if score ≤4

10. TECHNIQUE
— Inside-Out repairs
— Outside-In repairs
— All-Inside repairs
Hybrid repairs is combination

11. APPROACH MENISCAL TEARS LIKE FRACTURE FIXATION !
— Preparation 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
— Hybrid Techniques are useful especially in deformed, displaced buckets
— Accessory Portals to improve access and fixation configuration

12. — Perpendicular placement of implants every 5 mm
— Grab circumferential fiber bundle to ensure optimal purchase strength
— Ensure that implants are not proud (intra-or extraarticular)
— Avoid stuffing the meniscus with stress riser inducing implants
— Rehabilitation: Individualized

13. Techniques Indications
Outside-in sutures Anterior horn tears,
mid-third tears,
radial tears,
complex tears,
reduction of bucket-handle tears
Inside-out sutures Posterior horn tears,
mid-third tears,
displaced bucket-handle tears,
peripheral capsular tears,
meniscal allografts
Fixator implants (first-generation
devices)
Posterior horn tears,
tears with >2-3 mm rim width,
vertical/longitudinal tears
Suture-based devices (second-
generation devices)
Posterior horn tears,
tears with >2-3 mm rim width,
vertical/longitudinal tears
From Sgaglione NA: Instructional course 206. The biological treatment of focal articular cartilage lesions in the knee: future trends? Arthroscopy 19:154, 2003.

14. Inside out repair
— Easy to learn and reproduce
— Zone specific cannula
— Highly recommended with long term data

15. Inside out repair

16. Inside out repair-Medial meniscus

17. Inside out repair
Advantage: Disadvantage:
Highest mechanical
strength
ØNeurovascular
injury
ØIncisions

18. Outside-In technique
Suture retriever
Suture retrieved and knot tied
outside capsule

19. Outside in repair-Orientation of needles

20. Outside in repair
ADVANTAGE DISADVANTAGE
ØLess risk of neurovascular
injury
ØArticular cartilage damage is
less
Arthroscopic knot tying

21. ALL INSIDE REPAIR
Specialized equipment's and intraarticular suture tying skills are required

22. First Generation:
Bioresorbable implants
(A) Meniscus Arrow (Conmed Linvatec).
(B) Meniscal Dart (Arthrex)
(C) BioStinger (Conmed Linvatec).

23. First Generation
ADVANTAGE DISADVANTAGE
Ø Quick and easy
Ø Bioabsorbable
Ø Limited compression
Ø Variable resorption
Ø Foreign body reaction
Ø Brittle
Ø Chondral injury

24. All inside repair systems
(A) FasT-Fix (Smith & Nephew)
(B) Max Fire (Biomet)
(A) Meniscal Cinch (Arthrex)
(B) Rapid Loc (DePuy Mitek)

25. Device Properties
— Double extracapsular 5mm(PEEK & PLLA) implant bar anchors
— 2-0, non-absorbable, UHMW poly-ethelene ULTRABRAID Suture
— Built-in, adjustable depth penetration limiter is adjustable from 10 mm to 18 mm from the tip
of the needle
— The curved delivery needle is optimally shaped to allow vertical mattress sutures to be inserted
on either the femoral or tibial surfaces of the meniscus.

26. Second Generation
ADVANTAGE DISADVANTAGE
Ø Least invasive
Ø Suture based Design
approaches strenth of vertical
matress
Ø Braided suture is
compressible, less rigid, safer
in contact with cartilage
Ø Two point fixation allows
adjustable compression
across the tear
Ø Learning curve
Ø Cost
Ø Long term results not
documented

27. STEPS

28. PEARLS
— Visualization/Portal Placement/Spinal Needle Vectors
— Thorough site preparation debridement, rasping
— Asses the Geometry of tear, provisional reduction
— Accessory incisions/proper retractor placement
— Select repair devices and method that optimize tear pattern
— Individualize rehab

29. REHABILITATION: Individulize
— Isolated repair: immobilize the knee in full extension for 7 to 10 days and allow weight bearing
with crutches.
— ACL reconstruction: knee is immobilized for 2 weeks in full extension with immediate weight
bearing.
— Active range of motion from 0 to 90 degrees of flexion twice daily for 20 minutes can be started
immediately postoperatively.
— After 2 weeks, progressive range of motion, and thigh-strengthening exercises are begun.
— Weight bearing and range of motion should not be done at the same time, however, until about 4
weeks after surgery.