This document discusses meniscal tears, including types of tears, anatomy, function, biomechanics, diagnosis, and treatment options. It provides an overview of the meniscus, noting its crescent shape, fibers, and vascularity. Types of tears include longitudinal, radial, horizontal, complex, and bucket handle tears. Diagnosis involves physical exam maneuvers like McMurray's test and imaging like MRI. Treatment options discussed include arthroscopic partial meniscectomy, open or arthroscopic repair, and all-inside repair techniques. Outcomes and complications of procedures are also summarized.

1. Dr Sujit Jos MS(Orth), MRCS Ed
Sr. Consultant – Division of Joint Replacements and Sports Medicine
PVS Memorial Hospital, Kochi, Kerala

2. Meniscal tears
} Among most common injuries seen in orthopedic
practice
} Arthroscopic partial menisectomy one of the most
common orthopedic procedures

3. Types of meniscal tears
} Longitudinal tear
} radial tear
} horizontal tear
} Complex tear
} Parrot beak tear
} Bucket handle tear
} meniscal root tear

4. Pathoanatomy
} Overview
} Crescent shaped and have
triangular cross section
} Fibers have circumferential
orientation
} Anterior and posterior
root attachments prevent
extrusion
} Lateral covers 84% of the
condylar surface,12mm
wide, 3-5mm thick
} Medial covers 64%,10mm
wide, 3-5mm thick

5. } Vascularity
} Genicular arteries
} 50% vascularized at birth
} 10-25% in adults
} Makes healing very difficult
} 3 vascular zones
} Red-red
} Red-white
} White-white
Pathoanatomy

6. } Collagen Organization
} Circumferential fibers
} Radial Fibers
} Fine superficial layer around
outside
Pathoanatomy

7. } Load Sharing
} Increases contact area between femur and tibia
} Decreases contact stress on articular cartilage
} Increases congruity
} Provides stability
} Aids in lubrication
Meniscal function

8. } In extension, 50% of the load is absorbed
} At 90° flexion, 90% load-sharing
} Beyond 90°, forces predominate through posterior horns
Biomechanics

9. } Meniscal excursion with
knee flexion
} 11.2 mm excursion of lateral
meniscus
} 5.1 mm excursion of medial
meniscus
¨ Capsule
¨ Deep MCL
¨ Coronary ligament
Meniscal Excursion

10. } 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 tears have
pressures similar to complete
meniscectomy
Biomechanics

12. } Small effusion
} Joint LineTenderness
} McMurray
} Apley
} Thessaly
} ROM generally normal
} Bucket handle block
} Tight due to effusion
Physical Exam

13. McMurray

14. McMurray

15. Apley’s Compression Test

16. Thessaly Test

17. } Plain films to assess for
bony injury and OA
} MRI is the gold standard
of diagnosis
Imaging

18. • Typically seen in younger patients
• High association with ACL tears
• 90% of LVT in MM and 83% in LM are associated withACL tears
Longitudinal Vertical Tears

21. • This is a LVT with central
margination
• Most frequent type of
displaced tear
• Double PCL
• Double Anterior Horn
• Absent Bow
Bucket Handle Tears

23. • Involves the free edge and propagates peripherally
• Usually degenerative
• Older patients
Horizontal Tears

26. • Also involve free edge,but path is perpendicular to long axis
• Drastically affect ability to resist hoop stresses
• Deeper the tear,the more drastic the biomechanical consequences
Radial Tears

27. Radial Tears

28. Radial Tear

29. • AKA vertical flap tear
• Starts as a radial tear
• Propagates as a longitudinal
Parrot Beak Tears

30. Parrot Beak Tear

31. } Goal is to debride tear and
leave stable rim
} Preservation is ideal
} 80% satisfactory function at
5 yrs
} Lateral debridement = faster
degeneration
Meniscectomy

32. Bucket Handle Tear Flap Tear

33. Radial Tear Degenerative Tear

34. Partial Menisectomy

35. } Indications
} Radial
} Flap
} Horizontal
} Complex
} White-white tears
Meniscectomy

36. } Predictors of Positive Result
} < 40yo
} Normal alignment
} Minimal arthritis at initial scope
} Single fragment tear
Meniscectomy

37. } Relative Contraindications
} Advanced OA
} Complex tears
} Poor tissue quality
} ACL deficiency
Surgical Repair

38. Open Repair
} Rarely used
} Numerous studies have proven reduced surgical
morbidity with arthroscopic repair
} Reserved for peripheral tears in the posterior horn

39. Inside–out meniscus repair
} “Gold standard” for meniscal repair
} Due to ability to place
} Vertical and horizontal sutures
} On femoral and tibial surfaces of the meniscus
} Difficult to do in the posterior third of the menisci
} Requires dissection of neurovascular structures
} Morbidity

40. 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

41. } 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
Outside-In Repair
Meniscus Mender kit

42. 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

43. } 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
devices allow placement of
sutures in the meniscus
without the aid of an
external incision or a suture
fixator system
All Inside

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

45. Fastfix 360

46. Posterior horn repair – All inside

47. Meniscus root repair

49. Ramp lesion- menisco-capsular separation

50. 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

51. Tips for minimizing error
} Let your assistant hold the camera while your hands are
free to control the Fastfix 360
} Reverse curve needle is useful for tibial side repair
} Avoid over cinching the knot – can cut through

52. Outcomes
} Success rates for all techniques 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 conjunction with ACL repair

53. } Failure to heal
} Stiffness
} Articular surface damage
} NV structure damage
Complications

54. Transplantation
} Indications:
} Recurrent pain after partial or total debridement
} symptomatic with ADLs
} <50yo
} Contraindications:
} Malalignment
} Laxity
} Inflammatory arthritis
} Advanced OA

55. Outcomes
} Widely varying reports of success (Country differences)
} Subjective improvement in tibiofemoral pain
} No clear long-term benefit in preventing OA has been
established
} Grafts seem to do better when placed with a bone block
} Preserving some peripheral rim helps to avoid extrusion
} Variety of meniscal scaffold options being investigated in
animals

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62. Take home

63. Dr Sujit Jos MS(Orth), MRCS Ed.
Sr. Consultant – Department of Orthopedic Surgery
Joint Replacements and Sports Medicine
PVS Memorial Hospital, Kaloor, Kochi
Email: docjoints@gmail.com
Web: www.docjoints.com