MENISCUS

Meniscal Repair

Classical indications for Repair

Meniscal repair is classically performed for a longitudinal traumatic tear within the peripheral 10-30% of a healthy meniscus. The tear should be >1cm and repair is not indicated for incomplete tears. The knee should be stable or a concomitant ligament reconstruction should be performed.

Surgical decision making

Quite often the tears are not classical. Hence often one would have to repair the meniscus if there is a clinical case for saving the meniscus.

When to extend the indications?

1. Young patients
2. Acute longitudinal tear in the white-white area but still in the peripheral third that would otherwise result in resection of a large volume of meniscus
3. Chronic tear in the periphery (combine with augmentation techniques)
4. Large radial tear extending to peripheral rim

Techniques

Open Repair

Occasionally indicated in the anterior capsular tear in association with Tibial Plateau Fractures or whilst doing an Acute Open Ligament repair. (See picture of Acute Posterolateral corner injury with capsular meniscal tear).

Arthroscopic Repair

Inside out - Traditionally Gold Standard but unnecessary and difficult technique with only marginal improvement in load to failure and shear strength compared to all inside suturing. Henning popularised this technique in the 1980s. It is performed using zone specific cannulas and nonabsorbable sutures with a flexible long needle on either end. Make a small incision besides the exit point of the suture and dissect down with small curved scissors and hook the suture material into the wound to retrieve the sutures. Avoid making an incision directly on the exit point of the suture to avoid dividing the suture material. For more posterior repairs it may be safer to make a single larger incisions for safe dissection down to capsule to protect the nerves. If one is making a single large incision, it is placed posterior to the collateral ligament. A combination of superior and inferiorly placed sutures may be necessary to avoid meniscal eversion.

The structures commonly at risk are the saphenous nerve medially and the common peroneal nerve laterally. The popliteal vessels and tibial nerve can also be at risk. The knot should be tied directly on the capsule to avoid entrapping the nerve.

Outside in - No longer recommended. A suture is passed outside-in via a spinal needle across the tear. The suture is then pulled through an arthroscopy portal, a knot placed and then the knot is then pulled back against the meniscus and a further knot placed on the outside.

All inside - The newer all-inside sutures have comparable load to failure strength, shear strength and gapping to conventional vertical mattress sutures. Gapping is low with arrows but they fail early due to pull out from the rim.

First Generation:	Meniscal Arrow (Bionx implants)
	Sharp shooter (Linvatec)- PLLA
	Clearfix (Mitek)- PLLA
	Arthrotek Meniscal screw(Biomet)
Second Generation:	FasT-Fix- Smith & Nephew
	Ultra FasT-Fix- UltraBraid suture 2-0
	Rapidloc- Mitek- Ethibond or Panacryl suture 2-0
	Viper system- Arthrex- Fibrewire 2-0

This video shows a peripheral meniscal tear before repair.

This video demonstrates the Fastfix repair system.

This video shows the healed repair -

Suture type and placement

Sutures are best placed 3-5mm apart 3mm from tear edge. Vertical or oblique sutures are preferable but Horizontal sutures using FasT-Fix have still shown good healing rates though the biomechanical strength maybe inferior.

Horizontal vs vertical mattress

Gapping: Vertical fast-Fix 3.2mm Horizontal 4.4mm RapidLoc 4.6mm
Load to Failure: Vertical FasT-Fix 125.3N Horizontal 89.7N Rapidloc 87.1N
(Kocabey Arthroscopy 2006)

Oblique and vertical sutures had similar strengths on load to failure testing. Vertical fast-Fix better than horizontal FasT-Fix or RapidLoc.
Nyland J, Chang H, Kocabey Y, Nawab A, Brand J, Caborn DN. A cyclic testing comparison of FasT-Fix and RapidLoc devices in human cadaveric meniscus.
Arch Orthop Trauma Surg. 2008 May;128(5):489-94.

 

Postoperative rehabilitation

There are no good large prospective randomised studies to compare various rehabilitation programmes. In general restriction of flexion beyond 90 degrees is preferred to avoid shear forces on the meniscus. Similar forces also occur in the last few degrees of extension. Weight bearing is controversial. Both Shelbourne(1996) and Barber(1994) have shown satisfactory results with meniscal repair combined with accelerated rehabilitation. Hence it is recommended that accelerated rehabilitation be continued for meniscal repairs with concomitant ACL reconstruction. Most surgeons would still be more conservative in isolated meniscal repairs.

Outcomes

There are numerous studies with clinical follow-up showing good success rates. It is well known that there is a significant incidence of incomplete healing following meniscal repair. MRI scans and MR arthrograms are unreliable in the presence of previous meniscal repair.

The following table shows the studies where a second look arthroscopy has been used for follow-up.

Meniscal repair healing rates are higher when performed with a concomitant ACL reconstruction. More importantly meniscal repair rates are inferior if performed in an unstable knee.

Complications

The complications with meniscal repair are mainly failure (10%) and incomplete healing (15%). There is a risk of Nerve injury (Saphenous, Peroneal or Tibial) and vascular injury. Cohen showed that the distance between the tip of the needle and the popliteal artery is between 0-2mm if inserted to the hub of the needle.

There is a risk of arthrofibrosis with concomitant ACL reconstruction (10%).

References

Greis PE, Holmstrom MC, Bardana DD, Burks RT. Meniscal injury: II. Management.J Am Acad Orthop Surg. 2002 May-Jun;10(3):177-87. Review

Mesiha M, Zurakowski D, Soriano J, Nielson JH, Zarins B, Murray MM. Pathologic characteristics of the torn human meniscus. Am J Sports Med. 2007 Jan;35(1):103-12.

Boyd KT, Myers PT. Meniscus preservation; rationale, repair techniques and results. Knee. 2003 Mar;10(1):1-11. Review

Ahn JH, Wang JH, Yoo JC. Arthroscopic all-inside suture repair of medial meniscus lesion in anterior cruciate ligament--deficient knees: results of second-look arthroscopies in 39 cases. Arthroscopy. 2004 Nov;20(9):936-45

Haas AL, Schepsis AA, Hornstein J, Edgar CM. Meniscal repair using the FasT-Fix all-inside meniscal repair device. Arthroscopy. 2005 Feb;21(2):167-75.

Quinby JS, Golish SR, Hart JA, Diduch DR. All-inside meniscal repair using a new flexible, tensionable device. Am J Sports Med. 2006 Aug;34(8):1281-6.

Farng E, Sherman O. Meniscal repair devices: a clinical and biomechanical literature review. Arthroscopy. 2004 Mar;20(3):273-86. Review

Kimura M, Shirakura K, Hasegawa A, Kobuna Y, Niijima M. Second look arthroscopy after meniscal repair. Factors affecting the healing rate. Clin Orthop Relat Res. 1995 May;(314):185-91

Horibe S, Shino K, Nakata K, Maeda A, Nakamura N, Matsumoto N.Second-look arthroscopy after meniscal repair. Review of 132 menisci repaired by an arthroscopic inside-out technique. J Bone Joint Surg Br. 1995 Mar;77(2):245-9.

Uchio Y, Ochi M, Adachi N, Kawasaki K, Iwasa J.Results of rasping of meniscal tears with and without anterior cruciate ligament injury as evaluated by second-look arthroscopy. Arthroscopy. 2003 May-Jun;19(5):463-9

Noyes FR, Barber-Westin SD.Arthroscopic repair of meniscus tears extending into the avascular zone with or without anterior cruciate ligament reconstruction in patients 40 years of age and older. Arthroscopy. 2000 Nov;16(8):822-9

Rubman MH, Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears that extend into the avascular zone. A review of 198 single and complex tears. Am J Sports Med. 1998 Jan-Feb;26(1):87-95.

Cannon WD Jr, Vittori JM. The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees. Am J Sports Med. 1992 Mar-Apr;20(2):176-81

Rehabilitation

Shelbourne KD, Patel DV, Adsit WS, Porter DA. Rehabilitation after meniscal repair. Clin Sports Med. 1996 Jul;15(3):595-612. Review

Barber FA.Accelerated rehabilitation for meniscus repairs. Arthroscopy. 1994 Apr;10(2):206-10

Mariani PP, Santori N, Adriani E, Mastantuono M. Accelerated rehabilitation after arthroscopic meniscal repair: a clinical and magnetic resonance imaging evaluation. Arthroscopy. 1996 Dec;12(6):680-6.

Complications

Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy. 1988;4(3):215-21

Austin KS, Sherman OH. Complications of arthroscopic meniscal repair. Am J Sports Med. 1993 Nov-Dec;21(6):864-8

Cohen SB, Boyd L, Miller MD. Vascular risk associated with meniscal repair using Rapidloc versus FasT-Fix: comparison of two all-inside meniscal devices. J Knee Surg. 2007 Jul;20(3):235-40

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