The document discusses meniscus repair, detailing the frequency and implications of meniscal tears, particularly in athletes. It covers diagnostic methods, surgical techniques, and rehabilitation strategies, emphasizing the importance of preserving the meniscus for joint stability and function. Various case studies and research findings are presented to illustrate treatment outcomes and the biomechanics of meniscal injuries.

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. Meniscal Tears Cutting Sports: Tennis, Soccer Impact sports: Running, Skiing High Risk activities One million annual meniscus operations in the United States 1 85% meniscectomy 61 acute tears per 100,000 persons 2 2.5:1 (Male:Female) Incidence 1,2 American Academy of Orthopaedic Surgeons

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. Biomechanical Considerations Resection of the medial posterior horn increased tibiofemoral forces up to 68% 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.

5. Biomechanical Considerations Lateral meniscus covers 84% of the lateral tibial plateau versus 64% for the medial 1 More circular than the medial meniscus More uniform in width (average, 12 to 13 mm) Meniscal Excursion 2 : Lateral meniscal motion after 5 to 10 degrees flexion Medial meniscal displacement after 17 to 20 degrees of flexion. Medial meniscus has limited displacement and rotation due to the posterior oblique ligament. Increased mobility of the lateral meniscus can be responsible for the more frequent medial injuries 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. Diagnosing Tears Medical history 85-98% accurate in diagnosing tears 1 MRI 90-98% accurate 2,3 Using 3 criteria: abnormal signal, abnormal pathology, truncated or cleft. Knee palpation: 34-58% with ACL injury, 77% without 4,5 1 Johnson 1996 2 Brindle 2001 3 Andrish 1996 4 Boeree 1991 5 Anderson 1986 Clicking, popping, or locking Soreness Swelling Symptoms Clinical Examination

7. Complex Meniscal Tears Radial Parrot Beak Bucket handle Flap Peripheral Horizontal Vertical Capsular Separation 1 2 3 4 Courtesy of John Crues, MD

8. Meniscal Tears Abnormal signal with chronic ACL with Vertical Meniscal Tear

9. Meniscal Tears Abnormal meniscus morphology by MRI

10. Meniscal Tears Truncated abnormal triangle T1 Sagittal T2 Sagittal

11. Bucket Handle Tears Courtesy of John Crues, MD

12. Meniscal Tears Bucket handle T1 Sagittal T2 Sagittal

13. Meniscal Tears Locked Knee

14. Meniscal Tears Unstable Fragment

15. Meniscal Tears Displaced Fragment

16. Meniscal Cysts Parameniscal Cyst with Meniscal Tear

17. Popliteal (Baker’s) Cyst Causes Torn Meniscus (~80% of all cysts) Knee instability Arthritis Infection Acute trauma Symptoms Posterior knee lump with pain, aching, swelling Pronounced when standing Sensation of pressure from the lump Loss of range of motion from swelling Clinical Considerations 30% recurrence rate

18. Patient GC: Baker’s Cysts 73 YO Female Posterior Fluid accumulation Swelling, pain, stiffness, instability No crepitus No ROM loss Aspiration and cortisone (2003) Cyst excision (2005)

19. Intrameniscal Ossicle

20. Repair versus Meniscectomy: the Reason to Repair Joint Stability Balanced position of Femur and Tibia Force transmission Average stress reduced by 2-3x Joint lubricity Coefficient of friction 5x lower than ice/ice Shock Absorption Chondral Protection Preserve the Meniscus whenever possible

21. Fairbank’s Changes: Meniscus Excision Radiographic Changes Ridge Formation Narrowing of joint space Flattening of femoral condyle Formation of bone spurs

22. Degenerative Radiographic Changes Patient Example: MP1 5-Yr Post medial meniscectomy PA Flexion

23. Meniscectomy: What Not to Do Movie

24. Degenerative MR Changes Patient Example: MP 5 Months Post medial meniscectomy

25. Degenerative MR Changes Patient Example: MB 10 Months Post medial meniscectomy

26. Dogma of Meniscus Biology I: Vascular “Red Zone” Excellent healing Fibroblast-like II. “Red and White Zone” Good healing Periphery of vascularized region II: Avascular “White Zone” Poor healing Fibrochondrocytes, Type VI collagen 1 Mc Devitt CA, Webber RJ. The ultrastructure and biochemistry of meniscal cartilage. Clin Orthop. 1990;252:8-18. 2 Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med. 1982 Mar-Apr;10(2):90-5. I II III

27. Success rate Inverse Correlation Rim width Tear Length Patient age Knee instability/ACL deficiency BMI Success Rates Johnson (1999) 76% Cannon (1992) 82% Jakob (1998) 78% Ryu (1988) 87% Stone (1986) 56% Complete, 25% Partial Rosenberg (1986) 83% Complete, 17% Partial Long term healing rate? Re-tears? Restore normal function?

28. Patient Example: SA 16 year old female LaCrosse: Twisted knee Audible “Pop” Pain, Stiffness, Instablility Torn ACL Torn medial meniscus T1 MRI

29. SA: Preoperative Images STIR MRI: acute trauma PD MRI T1 MRI: Torn ACL

30. SA: Meniscoresis Movie

31. SA: Postoperative X-Ray

32. Patient Example: VT 30 year old male 1.5 month volleyball injury Knee giving way Pain, swelling, instability Torn ACL Torn lateral meniscus

33. VT: Tear Identification Medial compartment: probing the meniscus

34. VT: Tear Identification Lateral compartment: identification of the tear

35. VT: Meniscal Repair “ Hay Bale” Suture Technique (“Bala de Heno”)

36. Patient example: CD 20 y.o. male Twisted knee on wet stairs Pain, swelling, weakness, instability Torn ACL Bucket handle Tear (lateral) Peripheral tear (medial) T1 MRI

37. CD: Preoperative Images AP X-ray Lateral X-ray MRI: Torn ACL

38. CD: Stable Peripheral Tear Healing already initiated

39. CD: Bucket Handle Tear: Excise or Repair? Movie

40. CD: Postoperative X-Ray

41. Surgical Technique: Suture Repair Inside-Out through mini incisions Movie

42. Bucket Handle Tears repair young – fail old

43. Bucket Handle repair: Suture Technique Movie

44. Bucket Handle Repair

45. Fixation Devices Suture success rate 78% versus 56% for arrow or T Fix (Venkatachalam 2001) Problems: Migration Failure/Re-tear Patient discomfort

46. Bionix Arrow Bionix Implants, Inc.

47. Fixation Devices Biostinger Barber et. al, Arthroscopy 2005

48. Acufex T-Fix Sutures Smith and Nephew Endoscopy

49. Meniscus Reconstruction Collagen Meniscus Implant (CMI)

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. Meniscus Replacement Meniscus Allograft in the Arthritic Knee

52. Meniscus Repair: Rehabilitation General Considerations Daily Icing and elevation. Weight-bearing as tolerated. Walk with crutches. Hinged rehab brace (full extension): 4 weeks. Gait assessment to avoid compensatory patterns. No resisted leg extension machines No high impact or cutting / twisting activities: 4 months post-op.

53. Meniscal Tears: Prevention Muscular conditioning muscles absorb force Prevent abnormal rotations Ability to accept an eccentric load (elongation) Minimize impact: Non-impact training: bicycling Sorbothane shoe/boot inserts training on soft surfaces Flexibility, agility and strength workouts. Focus on Core. The conditioning program must be continued throughout the year. Decreasing the impact loading the knee joint:

54. Conclusions Save the meniscus if the tissue is healthy.

55. Thank You