1. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

2. Arthroscopy Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

3. I. Anatomy Lateral meniscus mobility > medial Lateral meniscus mobility > medial Meniscofemoral ligaments Meniscofemoral ligaments – Anterior PCL - Humphry – Posterior PCL - Wrisberg ARTHROSCOPY Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

4. Arthroscopy Requirement 1-Patient with clear indication. 2-Good arthroscopy unit. 3-Experienced surgeon. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

5. Arthroscopy Principles Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

6. ARTHROSCOPY Histology Extracellular matrix: Extracellular matrix: Collagen Type I (90%) - circumferential Collagen Type I (90%) - circumferential Radial “Tie” fibers Radial “Tie” fibers Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

7. Vascular Anatomy Relatively Avascular Relatively Avascular Lateral & Medial Genicular Arteries Lateral & Medial Genicular Arteries Medial Meniscus 10-30% width Medial Meniscus 10-30% width Lateral Meniscus 10-25% width Lateral Meniscus 10-25% width Popliteus Tendon Area Decreased Vasculature LM Popliteus Tendon Area Decreased Vasculature LM Extracellular matrix: Extracellular matrix: ARTHROSCOPY Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

8. Meniscus Function Load Bearing.. Load Bearing.. 50% compressive load - ext. 50% compressive load - ext. 85% compressive load - 90o flexion 85% compressive load - 90o flexion Shock Absorption Shock Absorption Knee Joint Stability.. Knee Joint Stability.. Lubrication Lubrication Proprioception Proprioception ARTHROSCOPY Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

9. Effect of Meniscectomy General.. General.. Narrowing of joint space Narrowing of joint space Flattening femoral condyle Flattening femoral condyle Ridging margin femoral condyle (osteophyte) Ridging margin femoral condyle (osteophyte) Total Meniscectomy.. Total Meniscectomy.. Decreased contact area (50 to 70%) Decreased contact area (50 to 70%) Increased contact stress (40 to 70%) Increased contact stress (40 to 70%) Partial Meniscectomy Partial Meniscectomy Contact stresses may increase < 65% Contact stresses may increase < 65% May approach total meniscectomy May approach total meniscectomy Cont... ARTHROSCOPY Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

10. Meniscus Function Meniscus Function Healing Response - Peripheral Vascular Zone Healing Response - Peripheral Vascular Zone Cellular, Fibrovascular Scar Tissue - 10 weeks Cellular, Fibrovascular Scar Tissue - 10 weeks Repair Tissue Strength? Repair Tissue Strength? ARTHROSCOPY Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

11. Meniscus Injury I. Diagnosis Symptoms Symptoms History important History important Delayed effusion Delayed effusion Knee locking Knee locking Exam.. Exam.. Joint line tenderness Joint line tenderness Rotary tests Rotary tests McMurry McMurry Apley grind Apley grind ARTHROSCOPY Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

12. II. Diagnostic Testing Contrast Arthrography Contrast Arthrography Accuracy varies - optimal technique 83 to 93% Accuracy varies - optimal technique 83 to 93% MM > LM MM > LM Little use today Little use today MRI.. MRI.. Noninvasive, expensive Noninvasive, expensive 93 to 98% accuracy 93 to 98% accuracy Cost effectiveness Cost effectiveness MRI vs. clinical assessment MRI vs. clinical assessment ARTHROSCOPY Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

13. Diagnostic Arthroscopy Most Accurate…. Most Accurate…. Tear Posteromedial MM - Tear Posteromedial MM - Difficult Difficult 70 arthroscope advanced between the MFC and PCL into 70 arthroscope advanced between the MFC and PCL into posteromedial compartment posteromedial compartment Improved accuracy with posteromedial portal. Improved accuracy with posteromedial portal. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

14. Outpatient Arthroscopy Younger patients, healthy, Younger patients, healthy, local anesthesia.. local anesthesia.. 1 percent Xylocain (40 cc) 1 percent Xylocain (40 cc) ? cost effective ? cost effective Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

15. Meniscus Tears and Treatment I. Principles Avoid Total Meniscectomy Avoid Total Meniscectomy Partial Meniscectomy Partial Meniscectomy Removal as little as possible Removal as little as possible Blend and contour remaining meniscus.. Blend and contour remaining meniscus.. Meniscus Repair When Possible Meniscus Repair When Possible Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

16. Vertical Longitudinal Tear - Bucket Handle Younger patients…. Younger patients…. Partial meniscectomy - 2 or 3 Partial meniscectomy - 2 or 3 portal techniques portal techniques Repairable Repairable Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

17. Flap; Oblique Tears May represent anterior/ May represent anterior/ posterior leaf of “bucket” posterior leaf of “bucket” tear.. tear.. Typically, partial Typically, partial meniscectomy meniscectomy Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

18. Radial Tears…. More common mid-third LM. More common mid-third LM. >5mm, resect to base of tear. >5mm, resect to base of tear. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

19. Horizontal Cleavage Tears Often degenerative, not repairable. Often degenerative, not repairable. Leave - 3mm stable leaf of tear - Leave - 3mm stable leaf of tear - acceptable.. acceptable.. Degenerative Tears Older patient. ? articular cartilage degenerative changes Older patient. ? articular cartilage degenerative changes Multiple patterns, Rx - conservative Multiple patterns, Rx - conservative meniscal debridement meniscal debridement Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

20. Meniscal Cysts LM > MM LM > MM LM - typically associated cleavage tear mid-third LM LM - typically associated cleavage tear mid-third LM Diagnosis: MRI, arthrography Diagnosis: MRI, arthrography Mass LJL decreased with knee flexion, MJL often larger Mass LJL decreased with knee flexion, MJL often larger cystic mass cystic mass Treatment Treatment Arthroscopic PM and aspiration cyst Arthroscopic PM and aspiration cyst Arthroscopic PM and open cyst excision Arthroscopic PM and open cyst excision Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

21. Discoid Menisci LM > MM LM > MM 4 - 5% (range 0.4 - 16%) 4 - 5% (range 0.4 - 16%) Bilateral occurrence 20% Bilateral occurrence 20% Etiology: Etiology: Abnormal posterior meniscofemoral attachments to tibia Abnormal posterior meniscofemoral attachments to tibia Classification Classification Complete - cover LTP Complete - cover LTP Incomplete - larger than normal LM Incomplete - larger than normal LM Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

22. Discoid Menisci Clinical Presentation: Clinical Presentation: Snapping knee syndrome - “clunk” Snapping knee syndrome - “clunk” Pain, locking Pain, locking Many Asymptomatic Many Asymptomatic Diagnosis: Diagnosis: X-ray - widened LJ space soft tissue shadow X-ray - widened LJ space soft tissue shadow MRI MRI Treatment in symptomatic knee Treatment in symptomatic knee Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

23. Ossicles - Meniscus Mature bone within meniscus Mature bone within meniscus Post - traumatic Post - traumatic Pain Pain Diagnosis - radiographs Diagnosis - radiographs Treatment - dependent symptom - excision Treatment - dependent symptom - excision Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

24. Meniscus - General Considerations Patient age: < 50 years Patient age: < 50 years Increase healing rate vs. younger patients Increase healing rate vs. younger patients Active lifestyle Active lifestyle Rim width.. Rim width.. Red-red zone Red-red zone Red-white zone Red-white zone White-white zone - avascular White-white zone - avascular Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

25. Meniscus - General Considerations Age of Tear Age of Tear Tear Length Tear Length Leave alone: Leave alone: <1 cm - stable <1 cm - stable Partial thickness - 1/2 height Partial thickness - 1/2 height 7 to 10 mm, displaces <3 mm 7 to 10 mm, displaces <3 mm Resect Resect <1 cm and unstable <1 cm and unstable Repair or resect Repair or resect >1 cm and unstable: >1 cm and unstable: Tears 2.0 to 3.9 cm - 60% healing rate Tears 2.0 to 3.9 cm - 60% healing rate Tears >4 cm - 33% healing rate Tears >4 cm - 33% healing rate Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

26. Tear Pattern Good repair Good repair Vertical longitudinal - ideal Vertical longitudinal - ideal Displaceable bucket - minimal body damage Displaceable bucket - minimal body damage Poor - repair Poor - repair Oblique, flap tears Oblique, flap tears Radial tears Radial tears Horizontal cleavage Horizontal cleavage Degenerative tears Degenerative tears Significant locking of meniscus Significant locking of meniscus Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

27. Assoc. ACL Injury Meniscus repair - assoc. ACL reconstruction Meniscus repair - assoc. ACL reconstruction Increased healing rate with ACL Increased healing rate with ACL reconstruction reconstruction ? biomechanical; postop bleeding ? biomechanical; postop bleeding Decreased prognosis repair unstable ACL knee Decreased prognosis repair unstable ACL knee Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

28. I. Open Repair Peripheral Tear Post. One - Third Meniscus - 3 MM Rim Peripheral Tear Post. One - Third Meniscus - 3 MM Rim 5 yrs. - 89% Survival 5 yrs. - 89% Survival II. Inside Out Middle and Post. Horn Meniscus Middle and Post. Horn Meniscus Instrument System Pass Needles Through Meniscus Capsule Outside Instrument System Pass Needles Through Meniscus Capsule Outside Accessory Posteromedial and Posterolateral Incisions Accessory Posteromedial and Posterolateral Incisions Tie Sutures After ACL Reconstruction Tie Sutures After ACL Reconstruction 75% Healing 75% Healing Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

29. III. Outside In Suture Passed Percutaneously Suture Passed Percutaneously Any Type Tear Any Type Tear Sutures - Femoral or Tibial Surface Sutures - Femoral or Tibial Surface Survival rate 50% at 5 yrs. Survival rate 50% at 5 yrs. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

30. IV All Inside Newer Technique Newer Technique Demanding Surgical Technique Demanding Surgical Technique Results Short-Term - Excellent Results Short-Term - Excellent Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

31. All Technique May Employ Debridement of Tear.. Debridement of Tear.. Perimeniscal Synovial Abrasion - Perimeniscal Synovial Abrasion - Vascular Pannus Vascular Pannus Fibrin Clot: Fibrin Clot: Potent Chemotactic / metagenic stimuli Potent Chemotactic / metagenic stimuli Most common - isolated meniscal Most common - isolated meniscal repairs white-white zone?.. repairs white-white zone?.. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

32. Rehabilitation After Meniscus Surgery Little Restrictions with Partial Meniscectomy Little Restrictions with Partial Meniscectomy Meniscus Repair Meniscus Repair – Recent trends increased ROM, PWB, little bracing – Sports activities - 6 months Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

33. Arthroscopy - Complications Overall Complication Rate 1.68% Overall Complication Rate 1.68% Thrombophlebitis 0.1% Thrombophlebitis 0.1% Infection Rate.8% Infection Rate.8% – S. Aureus – S. Epi Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

34. Meniscus Repair Complications Nerve Injuries Nerve Injuries – Medial - saphenous – Lateral - peroneal Deep - Superficial Infection Deep - Superficial Infection Vascular injury Vascular injury Decreased ROM with ACL 14% Decreased ROM with ACL 14% Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

35. Osteochondritis Dissecans Segment of cartilage together with S.C. bone separated from articular surface….. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

36. Osteochondritis Dissecans Segment of cartilage together with S.C. bone separated from articular surface. Clinical Features: Clinical Features: – Unilateral Disease 74% – Males > Females 2x – Differentiate Juvenile from Adult O.D. – Ages 10 to 20 Years Most Common Cause of Loose Body in Young People. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

37. Osteochondritis Dissecans Etiology: Etiology: – Traumatic Symptoms Symptoms – Pain, Intermittent Effusion – Buckling, Clicking, Locking Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

38. Osteochondritis Dissecans Differential Diagnosis Differential Diagnosis – Ossification Defects – Osteonecrosis – Osteochondral Fracturs – Diagnostic Tests X-ray - tunnel view.. X-ray - tunnel view.. MRI.. MRI.. CT CT Locations Locations – Classical Position - MFC - Intercondylar Area Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

39. Treatment of OCD Juvenile O.D. Juvenile O.D. Fragment In Situ Lesion frequently heals – Non-operative management Minimal immobilization Minimal immobilization Quad strengthening Quad strengthening Activity restriction and observation Activity restriction and observation Symptoms Persist >10 wk - 12 wk Symptoms Persist >10 wk - 12 wk – Consider arthroscopy Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

40. Arthroscopic Treatment - O.D. Articular surface intact drilling? Articular surface intact drilling? In situ, hinged fragment In situ, hinged fragment – Prepare Bed Shaver, Reduce Fragment – Internal Fixation - Options – Acute - better prognosis than chronic O.D. Unstable, fragmented lesion Unstable, fragmented lesion – Remove Loose Body – Debride Crater, Drilling, Minor Abrasion, Microfracture technique Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

41. Test Knee locking is seen more frequently in OCD ACL tear Deg meniscal tear Bucket handle tear All of the above Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

42. Knee locking is seen more frequently in OCD ACL tear Deg meniscal tear Bucket handle tear All of the above Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

43. The posterior horn of the medial meniscus is clearly seen in Knee 90 degrees flexion Figure four position 30 degrees flexion and valgus 30 degrees flexion and varus Full extension Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

44. The posterior horn of the medial meniscus is clearly seen in Knee 90 degrees flexion Figure four position 30 degrees flexion and valgus 30 degrees flexion and varus Full extension Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby

45. Total menisectomy Decrease contact area 50-70% Increase stress 40-70% Cause flattening of the medial tibial condyle Is only indicated in preparation of meniscal transplant

46. Total menisectomy Decrease contact area 50-70% Increase stress 40-70% Cause flattening of the medial tibial condyle Is only indicated in preparation of meniscal transplant

47. Dr Saleh W Alharby alharby@ksu.edu..sa http:/faculty.ksu.edu.sa/DrSalehAlharby