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2. Approach to incomplete longitudinal meniscal tear Mohsen Mardani-Kivi, M.D Guilan University of Medical Sciences

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4. Definition

5. Treatment Options 5 Excise Leave alone Repair

6. Goal  Pain-free knee that does not lock or catch 6

7. Surgical Considerations  Patient age  <30 aggressively repair  >50 limited meniscectomy  30-50 technique/surgeon/patient preference 7

8. Surgical Considerations  Chronicity of the injury  Tear location  Tear length  Concomitant ACL injury  Warren -90% successful repairs with ACL reconstruction  Warren - 30-40% failure in unstable knees 8

9. Leave alone 9

10. Which tears can you leave alone?  Fitzgibbons has shown that the short 1cm stable tear that is associated with the ACL tear can be left alone. The follow up of the untreated tears shows no increase in late meniscal symptoms or increase in the late meniscectomy rate Fitzgibbons R, Shelbourne KD. “Aggressive” non-treatment of lateral meniscal tears seen during anterior cruciate ligament reconstruction. Am J Sports Med 1995;23:156- 159.

11.  This is an incomplete posterior horn lateral tear that is stable. This tear can be left alone. 11

12.  Tears of the lateral meniscus noted to be a) posterior horn avulsions b) vertical tears posterior to the popliteus tendon c) incomplete radial or flap tears have been reported to be associated with high clinical success rate if left “in situ” at the time of ACL reconstruction. Fitzgibbons R, Shelbourne KD. “Aggressive” non-treatment of lateral meniscal tears seen during anterior cruciate ligament reconstruction. Am J Sports Med 1995;23:156- 159.

13. REPAIR 13

14. Ideal Candidate for Repair  Young  Acute, longitudinal, peripheral tear  Repaired in conjunction with an ACL reconstruction 14

15. Ideal repair situation 15 Traumatic tear Acute injury Vascular zone Tear length >7mm Stable knee

16. Preparation of the Meniscus  Para-meniscal synovial abrasion to stimulate healing response (fibro-chondrocytes) 16

17.  This is a repairable longitudinal posterior segment tear of the medial meniscus. This tear should be repaired early to prevent it’s extension into a bucket handle tear. 17

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19. Augmentation

20.  Vascular Access Technique (VAC)  full thickness channels  may disrupt collagen architecture 20

21.  In a goat model, it was shown that vascular access channels can allow proliferation of fibro-vascular scar tissue from the vascular channel into the tear site.125 Zhang Z, Arnold JA, Williams T, McCann B. Repair by trephination and suturing of longitudinal injuries in the avascular area of the meniscus in goats. Am J Sports Med1995;23:35-41.

22. Augmentation  Trephination  18g needle, horizontal punctures in vascular zone  90% success rate 22

23.  This stable incomplete tear of the medial meniscus is trephinated in 3 places with a number 18 gauge needle. 23

24. Trephination  In a study by Zhongnan, good results were obtained by trephination alone in this type of tear. Zhongnan A Arnold JA. Trephination and Suturing of Avascular Meniscal Tears: A Clinical Study of the Trephination Procedure. Arthroscopy 1996;12:726-31

25.  21. Shelbourne KD. Patel DV, Adsit WS, Porter DA. Rehabilitation after meniscal repair  22. Shelbourne KD, Porter DA: Meniscal repair: Description of a surgical technique. Am J Sports Med 21:870-873, 1993 25

26. Augmentation  Synovial abrasion  Synovium adjacent to repair abraided  Augments normal response  W-W efficacy? 26

27. Augmentation  Synovial pedicles  raise flap based near meniscus  rotate and suture to avascular area  Fibrin clot  Provides factors required for repair  Defect heals with normal repair tissue  Induce and support healing in W-W 27

28. Fibrin Clot Technique  50 - 70cc venous blood  clot forms  clot tubularized or aspirated  cannula insertion or injected 28

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31. Augmentation  Fibrin glue  Adhesive better than natural clot  Lacks biological factors  alternative to suture of stable longitudinal posterior horn tears? 31

32. Augmentation  Laser  Tissue adhesion by coagulation  Stimulatory effect 32

33. Stem cell injection

34.  Aim: To evaluate the effects of bone marrow-derived mesenchymal stem cell and bone marrow elements on the healing of meniscal tears.  Conclusion: An injection of bone marrow into the meniscus tear site improves healing in a meniscal tear model as demonstrated by both light and electron microscopic findings. Duygulu F, Demrel M, Atalan G, et al. Effects of intra-articular administration of autologous bone marrow aspirate on healing of full-thickness meniscal tear: an experimental study on sheep. Acta Orthop Traumatol Turc 2012;46(1):61-67

35.  Aim: to evaluate the efficacy of mesenchymal stem cell transplantation as a cell source to promote meniscal healing, using cells from the green fluorescent protein (GFP) transgenic rat and organ culture model  They could detect transplanted GFP cells under a fluorescent microscope until 8 weeks after transplantation. In a clinical situation, mesenchymal stem cell transplantation is a promising new clinical strategy for the treatment of meniscal tears in the avascular zone. Izuta Y, Ochi M, Adachi N, et al. Meniscal repair using bone marrow-derived mesenchymal stem cells: experimental study using green fluorescent protein transg enic rats. The Knee 12 (2005) 217 – 223 Stem cell injection

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37. My preferred method for repairing of incomplete longitudinal tear

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