Dimitrios Tsoukas, MD, MSc Director Minimally Invasive Orthopaedic Sports Medicine Surgery Center MIOSMED (ISAKOS approved Teaching Center)

Meniscus Repair Tips and Tricks

The menisci are wedge shaped, semilunar structures that occupy the space between the distal femur and proximal tibia within the knee joint.

The menisci are composed of fibrochondrocytes encased within a dense extracellular matrix of predominantly Type I collagen. The remainder of the menisci dry weight is composed of elastin and proteoglycan molecules.

Loss of Meniscal function leads to progressive degenerative joint disease Arthritis risk (20% for repair vs 60% for menisctomy FU 8 years- Stein AJSM2010) Ziad Noun, MD

Criteria of repairability Patient age Activity Level Tear Location+++ Tear Configuration Duration of the Tear Presence of Associated Injuries ( ACL) 0 1 2 3 Ziad Noun, MD

Ideal candidate for meniscal repair Young active patient with an unstable vertical tear, greater than 10 mm in length located in the peripheral 3 to 5 mm of the meniscus. Performed concomitantly with ACLR

Indications have been broadened Horizontal tear in young patient Radial tear (Lateral meniscus: lower the bar) 93% complete & partial healing on MRI FU 36 months Nam Hong Choi AJSM 2011 Meniscus root tear Better clinical results & Less Joint narrowing Vs Menisectomy (Sang Bum Kim, AJSM2011)

Principles of meniscus repair Preoperative Planning Arthroscopic evaluation Freshen up the tear Stimulate healing Repair the meniscus Check stability Preparation is what counts !!! MRI sensitivity for reparability 93% Thoureux et Al. arthroscopy 2006 Ziad Noun, MD

Techniques ‘Outside-in’ ‘Inside-out’ 3. ‘All-inside’

Outside - In . Indication: Anterior third of meniscus . small incisions (nick & spread) to capsule to avoid nerve injury . no special instrumentation required (spinal needle) . Simple & inexpensive technique . Disadvantage: Posterior horn . 84% healed on repeat Arthroscopy, Morgan AJSM 1991 Ziad Noun, MD

Outside – In Technique Use a probe on the meniscus to keep the meniscus reduced against the capsule To place 2 adjacent sutures to create a mattress suture they should be pulled out through a cannula in an anterior portal

Inside - Out Most commonly done (worldwide) the “gold standard” Zone specific cannula through contra-lateral portal (single & double barreled) Main Issue: N-V injury / Posterior Incisions - Ziad Noun, MD

Inside – Out Technique Posterior incision: Use ankle dorsiflexion to locate the gastroenemius tendon. Establish clear exposure of the posteromedial or posterolateral joint capsule. Use vertical mattress sutures for superior strength because they capture best the circumferentially oriented collagen fibers of the meniscus. Maintain a postion of knee flexion: this will allow susceptible structures to fall away from the surgical field.

All Inside Suture devices Rigid devices: Arrows, Darts, Staples Hook, bird pick, Viper New suture device, tensionable: Crossfix (Cayenne), Covidien Rigid devices: Arrows, Darts, Staples Early Tensionable device (suture + Fixator) FasT-Fix (S&N) RapidLoc (DePuy-Mitek) • New tensionable device (UHMWPE) Ultra FasT-Fix (S&N) => FasT-Fix 360 RapidLoc A2 => OMNISPAN (DePuy-Mitek) MaxFire (Biomet) Meniscal Cinch (Arthrex) Ziad Noun, MD

All inside technique Be sure the implant is not prominent on the meniscal surface to avoid articular surface injury. Motion loss can be prevented by tying the sutures with the knee in full extension to avoid inadvertent capture of the joint capsule.

All inside technique With large medial meniscus bucket-handle tears the anterior horn may be difficult to access: create an additional high lateral (parapatellar) portal. When inserting the delivery needle rotate it to place it perpendicular to the meniscal surface as possible.

With concomitant ACLR, the meniscal repair sutures are placed first but are not tied until the ACL graft is secured.

Large bucket-handle tear: the first suture should be placed in the middle of the handle fragment to reduce the tear with subsequent sutures placed anterior and posterior to this first suture.

AVOID INJURY TO NEUROVASCULAR STRUCTURES Medial side: maintain the knee near full extension and passing the needle posterior the semitendinosus tendon, diminishes the likelihood of injury to the saplenous vein and nerve and their infrapatellar bronche, deflate the tourniquet – if used – prior the wound closure

Lateral side: the needles entering from outside – in must remain anterior to the biceps tendon to avoid the peroneal nerve.

Which technique is best Suture repair provides superior biomechanical stability, although clinical success rate does not necessarily correlate with the strength of the repair. Biologic factors may be of greater importance to the success of meniscal repair than the surgical technique Decision on the most appropriate repair technique should not rely on biomechanical parameters alone. R Becker (Arthroscopy 2009) Ziad Noun, MD

Which technique where Posterior Horn Body Inside Out Outside In All Inside Body Inside Out Outside In Anterior Horn