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

2. Meniscus Repair
Tips and Tricks

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

9. 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.

12. 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

13. Criteria of repairability
Patient age
Activity Level
Tear Location+++
Tear Configuration
Duration of the Tear
Presence of Associated Injuries ( ACL)
Ziad Noun, MD

14. 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

15. 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)

16. 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

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

18. 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

19. 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

20. 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

21. 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.

22. 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

23. 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.

24. 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.

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

26. 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.

27. 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

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

29. 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

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