1. Pearls & Pitfalls In Meniscal Repair Nadhaporn Saengpetch, MD. Division of Sports Medicine, Department of Orthopaedics, Ramathibodi Hospital, Faculty of Medicine, Mahidol University

2. Objectives To gain a basic understanding of the relevant anatomy for meniscal injury To choose a proper repair technique for each type and location of tears To optimize the meniscal repair techniques and their healing To prevent any possible complication from meniscal repair

3. Anatomy

4. Normal Meniscus

5. Stable Tears Partial-thickness tears < ½ meniscal height Full-thickness oblique or vertical tears 3 mm with probing Radial tears < 5 mm

6. Unstable Tears Tear sizeHealing rate 2.0-3.9 cm60% 4.0 cm no ACL-R 33% 4.0 cm with ACL-R < 90% Cannon WD JBJS Am Feb 1994;294-311

7. Tear Pattern Vertical longitudinal Peripheral Bucket-handle Radial flap Horizontal cleavage Complex degenerative

8. Vertical Longitudinal …is the ideal situation for repair

9. Peripheral Any type of tears that do not disrupt the circumferential fibers, healing proceed rapidly and are similar to the normal meniscus

10. Bucket-handle Can displace to the front joint Chronic tear usually having additional radial components Not good for double or triple BH tears to be repaired

11. Pitfall for Identification of Chronic BH tear Locked knee The inner piece may transform and look like a normal meniscus Confuse some!

12. Radial Lower successful for repair Lost circumferential fiber* Posterior horn origin tears heal better than middle third Poor in load transmission ~ complete meniscectomy

13. Flap Often complex, oblique,anteriorly based tears of the posterior horn of MM The anterior leaf represents as a split BH tear Should be excised

14. Horizontal Cleavage Is not generally repairable Decide which one is the larger/stable leaf The unstable leaf should be excised Leaving up to 3 mm is acceptable

15. Complex Degenerative Not repairable

16. General Indications Repair concurrently with ACL-R Vertical longitudinal tears within 3 mm of the peripheral edge of the meniscus Tears measuring < 4 cm in length Tears with rim width measuring < 4 mm

17. Contraindications Tears > 4 cm length Stable meniscus tear in cruciate stable/unstable knees Complex, radial or flap tears Half-thickness tear Stable < 25 mm Incompatible lifestyle of patient who makes a healing in trouble Unlikely to heal following repair

18. Patient Variable Age Health Life style Physical demand

19. Age vs Meniscal Healing Cannon WD JBJS Am Feb 1994;294-311

20. Reparative Ability of Tear 1.Rim width 2.Tear length 3.Age of tear 4.Tear pattern 5.Ligamentous stability Belzer JP. JAAOS 1993; 1:41-47

21. Rim Width Vascular supply Must attach to the peripheral synovial attachment (PCP) will fill with the connective tissue from the synovium Clinical bleeding is not evident (>3 mm) Parameniscal abrasion improves healing Fibrin clot for healing improvement from 59% to 92% Henning CE. Clin Orthop 1990,252:64-72

22. Perimeniscal Capillary Plexus (PCP)

23. Tear Length Less than 1 cm can be left alone Direct determinant of the healing potential

24. Age of Tear 8 weeks is a golden period

25. Ligamentous Stability

26. Repair Techniques 1.Inside-out* 2.Outside-in 3.All-inside** 4.Open

27. Tears Location

28. Inside-out

29. Inside-out Arthroscopic Peripheral, unstable longitudinal tears Red-white zone, red-red zone

30. Basic Suturing Technique A third bend in the needle

31. Inside-out Technique A double-armed sutures with long flexible needles Long lasting nonabsorbable sutures are required

32. Lateral Approach

33. The peroneal nerve : greatest risk Popliteal v & a, a tibial nerve The knee 90º flexion, incise center/below the joint line Interval : biceps & ITB Using a speculum retractor

34. Medial Approach

35. Branches of saphenous nerve (The infrapatellar branch of saphenous nerve) Localized numbness/neuroma Knee flexion 90°, incise above the level of the joint line Interval : sartorius & capsule The Henning popliteal retractor

36. A Vertical Mattress Suture

37. Pearls A medicolegal standpoint, the consent should be “arthroscopy with meniscal surgery” Pts’ position : an uneffected limb in FABER position a surgical limb in flexion Fibrinous debris debridement & synovial excoriation is crucial to heal.

38. Rasping the Edge

39. Pearls Medial tears are naturally apposed as the knee is extended with MFC compression Unstable portion of LM may be sutured to the popliteus tendon

40. Pitfall MM repair : too superior of the incision, may retract & injure the sartorial branch LM repair : can’t keep the lateral head gastrocnemius behind the retractor

41. Complications Most at risk : a painful neuroma from the sartorial branch of the saphenous n. Rarely the peroneal n & popliteal a. 1.2-2.5% Most common for MM is reinjury Failure rate 11% (38% with unstable knees, 5% with stable knees) DeHaven KE Orthop Trans 1981;5:399- 400

42. A 23 y. man injury during military service, using 2-0 nonabsorbable suture 3 yrs later a painless mass Choi NH Arthroscopy Jan 2004;E1

43. Outside-in

44. Applicable for tears of the anterior and middle thirds of the meniscus Deliver suture through the lumen direct percutaneously from a known safe-zone portals

45. Outside-in Interference knots are placed on both surfaces to create a vertically oriented suture pattern

46. Outside-in

47. Pearls LM repair : either techniques, extension of the knee should be harmful for the peroneal nerve. It crosses the lateral joint line just behind the PLC, in the path for suturing MM repair : to avoid saphenous nerve injury, it is recommended to suture in knee extension to move all vulnerable structures away

48. Suture Portals PM PL

49. A 43 y.o. man, LM tear 2 months after the sx Kelly JD Arthroscopy May 2004;E10

50. All-inside

51. Unstable tears, mostly at the peripheral posterior horns of the menisci Need a special setup for 70° scope at PM and PL portals Using an arthroscopic knot tying techniques (suture techniques) and place them to the posterior of the knees Bioabsorbable material : suture, arrow, dart (nonsuture technique)

52. Safe-zone of the Cannulas PM cannulaPL cannula

53. Suture

54. Nonsuture

55. Cases Report : Complications

56. Hechtman KS Arthroscopy Mar 1999;207-210

57. Calder SJ Arthroscopy Sep 1999;651-652

58. The Clearfix screw Kumar A Arthroscopy Oct 2001;E34

59. What’s new? Bioabsorbable arrows (Bionx) is not recommended because of high failure rate (40%), potential cartilage damage The RapidLoc (Mitek) demonstrated poorer healing rate compared with inside-out repair in animal models, propered for posterior horn tears For the intact ACL, not aware of recent studies comparing the repair with the use of fibrin clot

60. Thank you