Meniscal injuries are common; decision to resect or repair is important. Then comes how to repair and what device to choose.

1. ARTHROSCOPIC
MENISCUS SURGERY:
RESECT OR REPAIR
Dr Dhananjaya Sabat MS, DNB, MNAMS
Assistant Professor
Department of Orthopedics
Maulana Azad Medical College, New Delhi

2. INTRODUCTION
 Mensicus was usually considered vestigeal.
 Easier to resect than repair: bias.
 Recent past decade: importance of meniscus
evaluated & understood.
 Following removal - Cartilage overloading and
aggravated degeneration.
Fairbank et al. JBJS 1948;30B:664-70.
F. Chatain et al. Knee Surg 2001;9:15-18.

3. THE BIG QUESTION….
But then should every meniscus
be repaired?
No
Appropiate & informed decision required.
Only 20% repairable.

4. FUNCTION OF MENISCUS
1. Load transfer.
2. Shock absorption.
3. Stress reduction.
4. Stabilization.
5. Lubrication.

5. BLOOD SUPPLY
 Vascularised portion:
 30% of medial meniscus.
 10-25% of lateral meniscus.
 Popliteus haitus – posterolat.
Meniscus – worst supply.
 Commonly referred zones:
 Red
 Red/white
 White

6. TYPES OF TEARS
1.Radial
2.Longitudinal (bucket handle)
3. Horizontal
4. Oblique
5. Flap

7. PATHOPHYSIOLOGY…….
 Acute knee injuries with ACL intact - medial
meniscal injury is 5 times more likely than lateral.
 Acute knee injuries with ACL ruptured - lateral
meniscus more likely to be involved.
 ACL is previously disrupted - lateral meniscal injury
is more likely than medial.
 Repetitive deep squatting - medial meniscus injured
(20:1).

8. SO WHAT TO DO WITH THEM!!!!
Supervised neglect
Meniscectomy
Meniscus repair
 Still elusive to us:
 Meniscal transplant.
 Meniscal scaffolds.
 Meniscal replacement.

9. LEAVE (NEGLECT) THEM ALONE!!!
Undisplaced stable medial/lateral
meniscal tears.
Short undisplaced stable ones –
synovial abrasion.
Short stable ones – trephination.

10. MENISCAL RESECTION
 Types:
 Partial meniscectomy.
 Subtotal meniscectomy.
 Total meniscectomy.
Resect as less as possible.
Conservative approach.

11. RESECTION OF BUCKET HANDLE TEAR

12.  Restore Function
 Maintain Load Transmission & Minimize Contact
Stresses
 Contribute to Stability
 Reduce Articular Cartilage Wear:
"Chondroprotection"
MENISCAL REPAIR: WHY TO DO IT?

13. INDICATIONS
 Reparability – geometry, technical, fixation
 Healing Potential – biological manipulation
 Associated Surgery – recovery time consolidation
 Patient Preferred - long term outcome concerns

14. MENISCAL REPAIR: WHEN TO DO IT?
 Acute tears (less deformity).
 Peripheral tears: RED ZONE & red/white.
 Unstable tears:
 Tear length >1/2 of meniscus.
 Subluxates under the condyle.
 Young <40 years.
 Stable knee profile.

15. AVOID REPAIRING!!!!!
 Chronic complex tears.
 Degenerative tears.
 Unstable knee (without reconstruction).
 Rule of thirds:
 ACL deficient knee – 30%.
 ACL stable knee – 60%.
 ACL reconstructed knee – 80-90%.
 Associated Gd. IV osteochondral defects.
 Old age.

16. TEAR PATTERNS & THEIR POTENTIAL TO
REPAIR

17. PEARLS AND PITFALLS:
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
 Anchoring Stitch (PDS) or spinal needle aids in maintaining
reduction
 Hybrid Techniques are useful especially in
deformed, displaced buckets
 Accessory Portals to improve access and fixation
configuration

18.  Perpendicular placement of implants every 5 mm
 Grab circumferential fiber bundle to ensure optimal
purchase strength
 Ensure that implants are not proud (intra- and / or
extraarticular)
 Avoid stuffing the meniscus with stress riser inducing
implants
 Rehabilitation: INDIVIDUALIZE –
protection, WB, Motion, Return to Sport

19. REPAIR TECHNIQUES
 Open / Outside – in / Inside – out / All – inside
 Suture – based vs. fixator – based techniques

20. BIOMECHANICS OF REPAIR
 Vertical suture. BETTER
 Resorbable anchors.
 Horizontal suture.
 Mulberry knot.
WORSE

21. TECHNIQUES OF REPAIR….
ALL INISDEINSIDE OUTOUTSIDE IN

22. REPAIR TECHNIQUES & GENERAL
INDICATIONS

23. INSIDE-OUT MENISCAL REPAIR
THE GOLD STANDARD…
 Easy to learn and reproduce.
 Most popular.
 Good suture placement.
 Vertical.
 Horizontal.
 Zone specific cannulas.
 Highly recommended with long term data.

24. INSIDE – OUT TECHNIQUES
 Incision made first: 2/3 inferior to joint line
 Popliteal retractor anterior to gastrocnemius
 Insert cannula (single vs. double) / needle thru
contralateral portal
 Updates: Mechanical gun needle insertion
system / Malleable passing needles
 2 –0 vs. 0 nonabsorbable braided synthetic
suture (Prefer 0)
 Vertical mattress: single vs. double patterns
 Tie suture knots while visualizing tear site

25. POSTEROMEDIAL INCISION
 3 to 4 cm made in 90 degrees of flexion
mostly below joint line
 Incise just superior to sartorius / Posterior to
MCL / deep & superior to SM
 Retractor deep and anterior to medial
gastrocnemius
 Pass sutures in 20 degrees of flexion
POSTEROLATERAL INCISION
 3 to 4 cm made in 90 degrees of flexion and
just posterior to ITB
 Stay posterior to LCL & keep short head of
biceps femoris tendon posterior
 Retractor deep and anterior to lateral
gastrocnemius head
 Pass sutures in 90 degrees of flexion

26. OUTSIDE IN TECHNIQUE
 Warren 1985
 18gz spinal needle, 0 PDS

27. ANTERIOR PART LATERAL MENISCAL TEAR
REPAIR : OUTSIDE IN

28. SUTURE TECHNIQUES
 STRENGTH: 70-113 Newtons
 COMPRESSION ACROSS
TEAR SITE
 VERSATILITY: suture pattern
 EXPERIENCE: clinically
documented
 SAFETY: outcome published
 TIME CONSUMING
 ACCESSORY INCISION
 ASSISTANT NECESSARY
 NEEDLE STICK RISKS
 MORE DISSECTION/
MORE PAIN
 ARTHROFIBROSIS
ADVANTAGES DISADVANTAGES

29.  A. ALL INSIDE FIXATOR TECHNIQUE (FIRST GEN.):
Arrows, Staples, Biostinger, Darts
 B. ALL INSIDE SUTURE TECHNIQUE (SECOND GEN.):
FasT – Fix, RapidLoc, MaxFire, Cinch
ALL INSIDE REPAIR
TECHNIQUE

30. ALL INSIDE FIXATOR TECHNIQUE
ALL-INSIDE TECHNIQUES WITH BIOABSORBABLE MATERIAL

31. FIRST GENERATION TECHNIQUES
 QUICK/ REDUCED OR TME
 EASY INSERTION
 SINGLE HANDED TECHNIQUE
 ALL ARTHROSCOPIC
 BIORESORBABLE
 REDUCED STRENGTH
 LIMITED COMPRESSION
 VARIABLE RESORPTION
PROFILE
 FOREIGN BODY REACTION
 BRITTLE / BREAKAGE
 CHONDRAL INJURY
ADVANTAGES DISADVANTAGES

32. SECOND GENERATION
SUTURE –BASED DEVICES
A. FasT-Fix (Smith and Nephew, 2001)
 Double extracapsular 5mm (PEEK & PLLA) implant bar anchors
 Ultra FasT – Fix / High Strength Suture
 Pre-tied self–sliding integrated irreversible knot, curved knot pusher
 Self-contained delivery needles (straight or 220 curved / reverse)
 Metallic portal skid / Split sheath cannula / reverse curved device
B. RapidLoc (DePuy / Mitek, 2001)
 Extracapsular 5 x 1.5mm PLLA " backstop ”
 2/0 extended resorption Panacryl suture or 2/0 Ethibond
 Intraarticular 4.5x 2.5x 0.25mm thick PLLA " top hat “
 Pre-tied self-sliding knot seats top hat & cinches to "backstop“
 Straight and curved (120 and 270) delivery needles
 Updated PDS absorbable top hat (2003)

33. C. MaxFire (BioMet Sports Medicine, 2008)
 Preloaded suturing ergonomic delivery device w zoned
cannulae
 2/0 MaxBraid high strength suture
 # 5 polyester "Suture pledget" anchors
 Suture within suture "zip loop" sliding / cinching construct
D. Meniscal Cinch (Arthrex, 2008)
 Preloaded suturing ergonomic delivery device w trochars
 Curved / integrated needles w adjustable depth stop setting
 2/0 Fiberwire high strength suture and pretied sliding knot
 Double extracapsular 5 mm PEEK anchors

37. SECOND GENERATION DEVICES
 All – Inside / All – Arthroscopic
techniques / less invasive
 Suture – based design approaches
strength of vertical mattress
pattern
 Braided suture is
compressible, less rigid & safer in
contact with articular cartilage
 Two point fixation construct
allows adjustable Compression
across tear site
 Learning Curves Must
Be Addressed
 Protrusion and Soft
Tissue Inflammation /
Chondral Injury
 Cost of Implants
 Failure rates and
clinical outcomes not
fully documented
ADVANTAGES DISADVANTAGES

38. REPAIR OF BUCKET HANDLE TEAR…

39. CLINICAL RESULTS
A. Inside-out Nonabsorbable suture techniques / 147
cases
 Outcome rigidly defined: Henning's criteria
 Healed <10% Cleft / Partial Healing <50% cleft / Failed
>50% cleft
 2/3 of anatomic failure do well at 7-10 months
 90 second looks or arthrogram / overall success 82% /
clinical success 91%
 93% success in ACL cases / 50% in isolated.
(Cannon, Am J Sports Med: 20, 1992)

40. B. Prospective comparison of 47 inside – out repairs
vs. 98 Arrow repairs
 IO repair f/u 68 mos & Arrow f/u 27mos / Rehab Same:
NWB x 5 - 6 wks
 Complications: 13% Saph Neuropraxia in IO / 1% Arrow
tip irritation
 Similar success with both methods: 88% suture vs. 89%
arrows
(Spindler, Am J Sports Med: 31, 2004)

41. C. Retrospective study of 38 consecutive pts with 39
tears repaired with Arrows
 All underwent ACLR / avg tear 21mm long / all in
posterior horn / 31 med & 8 lat
 F/U avg 2.3yrs (18-39 mos) Clinical success in 90.6%
(29of 32 pts)
(Gill and Diduch, Arthroscopy:18, 2002)
D. Extended F/U 32 pts. at mean of 6.6 years revealed
deteriorating success (71.4%)
 Hypotheses: Incomplete Healing, PLLA
Resorption, Reduced Durability
(Lee and Diduch, Am J Sports Med: 33, 2005)

42. E. 57 pts with 60 Arrow consecutive repairs w avg F/U
54 mon (36 – 70)
 12 repairs in ACL NL knees / 45 repairs in assoc. ACLR
knees
 Overall Failure 28% (17/60): 42% in ACL NL knees
(5/12) / 20% in ACLR (9/45)
 26% reop rate / 6 of 17 (35%) failures had chondral
scoring (10% Overall)
 Conclusion: Avoid Arrows in Bucket Handle
Tears, Peripheral Detachments & ACL Defic.
(Kurzweil, Arthroscopy: 21, 2005)

43. F. Retro. review of 66 consecutive pts w 75 meniscal
repairs using RapidLoc device
 20 pts. w 21 meniscal tears were excluded: study grp –
54 tears in 46 pts
 Mean F/U: 34.8 months (24 – 50) / All repairs in assoc w
ACLR
 Postop: Brace with PWB & ROM 0 to 600 x 2 wks w RTS
at 6 mos
 Success 90.7% / IKDC & VAS scores / 8 second looks:
no chondral injury
(Quinby, Am J Sports Med: 34, 2006)

44. G. Prospective study of 58 pts undergoing 61 repairs
with FasT – Fix System
 18 mon f/u (14 -28) / Avg age 32.6 (16 – 54 yrs)
 36% isolated & 64% of repairs performed with concurrent
ACLR
 Avg tear size 31.6 mm / avg # of suture devices used
was 4.4
 Postop: Brace with PWB & ROM to 0 to 600 x 3wks /
Progress to FWB 6 wks
 RTS 5 mos / No chondral injuries noted in 2 relooks
 Lysholm scores: 88% Success equal in isolated & in
ACLR – assoc cases
(Kotsovolos; Arthroscopy: 22, 2006)

45. H. Level 4 Case series of 118 pts (98% retrieval) who
underwent repair c Arrows
 Mean F/U 4.7 years (range 1.8 – 7.7 years) / Mean age 26 yrs (
8 – 68)
 38% failed requiring reop and 41% verified clinical failures
 Mean time to reop: 17 mos (1 – 75)
 Conclusion of authors: "search for better all – inside
techniques"
(Gifstad; Am J Sports Med: 35, 2007)
I. Level 3 Comp Study of 88 RapidLoc (RL) pts.vs. 85 Tfix vs.
92 FasTFix
 All Pts underwent ACLR and studied w IKDC / Lysholm
 Mean F/U: 24.5 mos (20 – 26)
 Success Similar: RL (86%) / T-Fix (87%) / Fast – Fix (92%)
(Kalliakmanis, Arthroscopy: 2008)

46. J. Level 4 Retro. Case Series of 38 RapidLoc repairs in 30
pts.
 All Pts. underwent ACLR and studied w VAS / Tegner Scale
 Mean F/U: 30.4 mos (21 – 56)
 Success Similar: 86.7%
(Billante, Arthroscopy: 2008)
K. Level 4 Case Series of 41 FasT - Fix repairs
 71% underwent ACLR and studied w Lys / Tegner Scale /
IKDC / Cinci
 Mean F/U: 30.7 mos (12 – 58)
 Success Similar: 83%
(Barber, Arthroscopy: 2008)

47. GENERAL MENISCUS REPAIR PEARLS
 Visualization / Portal Selection / Spinal Needle Vectors
 Thorough Tear Site Preparation / Debridement / Rasping
 Assess Geometry of Tear / Center Tear & Provisional
Reduction
 Dissect Accessory Incisions / Proper Retractor
Placement / Visualize Needles
 Select Repair Device / Method that Optimizes Tear Type
& Pattern
 Individualize Rehab Protocols

48. EVOLVING DEVICE DEVELOPMENTS:
PRP PROJECT
Versatile, easier and quicker arthroscopic
insertion and delivery
Improved and more predictable
bioabsorbable polymers
Biological manipulation of meniscal healing
Induction & promotion of healing through
PRP applications

49. CONCLUSIONS
 Multiple Factors Determine Resection vs. Repair: Goals of
Patient
 Technique Advances Emphasize Less Invasive
Approaches & Suture
 Multiple Repair Devices are Valuable Attractive Tools:
Surgeon’s Preference
 The Devices Are NOT All the Same: Realize
Bioabsorbables Are Not Equal

50.  Indications Must Remain Stringent: Don't "Over-repair OR
Over-resect“
 Individual Device Learning Curves Can Be Significant
 Approach Meniscus Repair Like Fracture Fixation of a
Nonunion
 Consider Healing Enhancement Techniques / Fibrin Clot
in Isolated Repairs
 Postop Protocols: "Case by Case": "Recognize At Risk
Repairs"