Aaos Meniscus Repair

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Arthroscopic Meniscus Repair

Don Johnson MD

Director Sports Medicine Clinic Carleton University

Associate Professor Orthopedic Surgery University of Ottawa

Ottawa ON Canada

Introduction

Sutures, stingers, arrows, darts, and screws. Does all this sound

confusing? You bet it is. The hot topic in meniscal repair is the use of

bioabsorbable devices to repair the tear. This is a complex topic, and it is difficultto separate fact from hype. Each company has their own device made with

various combinations of polymers with appropriate lab pullout strength studies to

justify their use. This summary will hopefully unravel some of the truths and

myths.

Indications and Contraindications.

First of all, who is a candidate for meniscal repair? The algorithm for meniscal

repair should consider the following factors

Location

o The ideal type of meniscal tear to consider repairing is the

peripheral tear. This is also referred to as the red on red tear,

indicating the degree of vascularity. This tear is amenable only to

suture repair. Most commonly the tear is in the red on white region,

which also has an acceptable successful repair rate when

bioabsorbable devices are used. Morphology of the tear

o Size

The short tear of 1-2 cm has a better successful repair rate

o Appearance

The vertical longitudinal tear is ideal for repair

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Dont consider repairing degenerative horizontal cleavage

tears or flap tears.

Patient factors

o Non compliant patient should not be considered for repair

o The younger patient has a higher success rate. The older patient

often has the type of degenerative tear that is non repairable.

o The rehab must be modified to avoid flexion in the immediate post-

op period.

o 50% of ACL tears are associated with meniscal tears.

In summary, the best candidate for meniscal repair is the young compliant patient

with a 2 cm long peripheral longitudinal meniscal tear. You should always

consider a meniscal repair, rather than a menisectomy in the young athlete to

protect his articular cartilage for the future.

Which tears can you leave alone?

Shelbourne has shown that the short 1 cm 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 menisectomy rate.

This is an incomplete posterior horn lateral tear that is stable. This tear can be

left alone.

Some of the incomplete tears can also be treated by trephination.

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This stable incomplete tear of the medial meniscus is trephinated in 3 places with

a number 18 gauge needle. In a study by Zhongnan, good results were obtained

by trephination alone in this type of tear.

This is a repairable longitudinal posterior segment tear of the medial meniscus.

This tear should be repaired early to prevent its extension into a bucket handle

tear.

The techniques of meniscal repair.

Inside out Suture repair.

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The suture repair of the meniscus using non-absorbable vertical loop sutures

placed from inside out.

The arthroscopic inside out suture repair originally described by Henning

is the gold standard. Rosenberg popularized the double cannula system to place

the horizontal sutures. The success rate of this type of repair is about 80%.

Johnson described the outside in suture technique. The vertical loop suture was

shown by Dervin to be twice as strong as the horizontal loop suture. Multiple

vertical loops of non-absorbable material placed 5 mm apart on the superior and

inferior surface provides the best repair. Morgan, using the spectrum tissue

repair system, described all inside repairs. With the advent of the bioabsorbable

devices this technique has largely been abandoned. The advantages of the

suture repair technique are that it is proven to be efficacious and cost effective.

The disadvantages of the suture technique is that the second incision is required

that requires more time and usually a second assistant. There is also a potential

for needle sticks and neuro-vascular complications. There is also a significant

learning curve in placing and tying the sutures. The medial meniscus is repaired

in extension and the lateral meniscus is repaired in the figure four position.

In light of the proven success of the suture repair we should think seriously about

abandoning this technique in favour of the easier to perform repair with the

bioabsorbable devices.

Inside out suture repair The technique

Examining the meniscus and preparing the edges of the tear

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The displaced meniscus tear is reduced and the edges are rasped.

Making the posterior incision on the medial side

The posteromedial incision is made just behind the MCL and anterior to

the saphenous nerve. The incision should be centered with 2/3 below the

joint line. The superficial fascia is incised, and by blunt dissection the

posterior capsule is exposed. A retractor is placed posteriorly to guide the

needles anteriorly and to protect the saphenous nerve.

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Making the posterior incision on the lateral side

The posterolateral incision is made just behind the lateral collateral

ligament. The LCL can be palpated by placing a varus force on the knee.

The incision should be 2/3 below the joint line. The superficial fascia and

then the ilio-tibial band is divided. The posterior capsule is exposed by

blunt dissection. A retractor is placed posteriorly to protect the peroneal

nerve.

Placing the sutures into the meniscus

The sutures are placed with long needles down the zone specific cannula. Thesutures may be placed either in a vertical or horizontal fashion. The vertical have

a better pullout strength. The sutures may be placed on top or under the

meniscus. In this series of pictures the needle is initially placed through the

capsule, and then through the meniscal fragment.

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Retrieving and tying the sutures

The sutures are retrieved through the posterior incision and tied over the capsule

with the knee in extension. To ensure that the sutures are tight the anterior group

of sutures can be tied to the posterior sutures.

The technique of meniscal repair using the BioStinger

The cannulated BioStinger. The cannulated devices make placement of the

device more accurate and the reduction of the tear easier.

Preparing the meniscus

The tear should be initially probed to determine if it is suitable for repair.

The edges of the tear should be debrided of fibrous tissue with a rasp or a small

shaver. Pavlovich has described the technique of stimulation of the meniscal

synovial border with electrocautery. The principle is to lightly burn the synovium

to produce a healing response.

The monopolar electrode is used to stimulate the synovium at the tear.

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Zhongnan demonstrated that the meniscus and the rim may be

trephinated to produce vascular access channels.

The sutures and the bioabsorbable devices must be placed accurately to

reduce the tear and hold it until it is healed. A hybrid approach for large bucket

handle tears is to use sutures in the middle segment to reduce and hold the

bucket tear and then use the bioabsorbable devices in the difficult to repair

posterior horn region.

The technique of the Biostinger insertion

The appropriate length of BioStinger is selected, usually 13 mm, and loaded on

the cannulated wire of the delivery unit.

The cannula is placed against the meniscus, 2 mm of cannulated wire is

delivered into the torn fragment. The fragment is then reduced to the peripheral

rim. This step is similar to the inside out suture repair using the zone specific

cannulas with the long meniscus repair needles.

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When the torn fragment is reduced, the cannulated wire is advanced into the rim

using the slider bar on the side of the device.

The BioStinger is inserted into the meniscus by depressing the plunger on the

end. The meniscus can be felt to ratchet into the meniscus.

Alternately, the insertion of the wire and BioStinger can be done with a 3

step trigger on the meniscus gun. This pushes the fixator into the tissue, but does

not shoot it in. The first pull advances the wire 2 mm to reduce the tissue. The

second pull advances the wire 13 mm into the tissue and the 3 pull advances the

BioStinger along the wire into the meniscus.

To prevent the cannulated wire from bending, firm pressure must be

exerted on the cannula to keep this against the meniscus. The cannula is backed

up 5 mm and the head of the BioStinger inspected to be sure that it is

countersunk under the surface of the meniscus.

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This photo demonstrates that the meniscal fixator must be countersunk below the

surface of the meniscus.

BioStinger Advantages

Low profile head

Molder PLLA

4 rows of prongs

cannulated insertion similar to inside out suture repair

same load to failure as the horizontal suture

fast and easy to perform

BioStinger Disadvantages

Expensive

Damage to articular surface due to prominent head

Damage to neurovascular structures due to over penetration with the

BioStinger

Learning curve for insertion at the correct angle and position in the

meniscus.

Difficult in tight, small knee

Prolonged time for resorption of the PLLA material

Relative Contraindications for the use of meniscal fixators

Peripheral tear at the meniscal synovial junction. The fixator must have 3+

mm of tissue to grasp

Lateral meniscal tear at the popliteus junction. This is an open space

around the tendon that requires sutures to approximate the tissue.

Chronic displaced bucket handle tear. This may be repaired with a hybrid

technique of sutures and fixators.

Small tight knee in young patient. It is difficult to insert the cannula under

the condyle and into the correct position on the meniscus. The long

needles of the sutures can be bent and directed into the correct position.

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Clinical Results

Peter Kurzweil reported on the results at the AANA 1999 fall course in San

Diego.

Albrecht-Olsen 34 patients 21% failure

Saul Schrieber 37 patients 5% failure

Peter Kurzweil 40 patients 12%

Kurzweil discussed and commented on his failures of repairs with the use of the

bioabsorbable arrow. The 5 failures in the 40 patients all occurred in the first 10

patients related to the learning curve. He found that 2 failures were due to flexion

injuries in the first 3-5 weeks. 3 were due to large peripheral bucket tears that

were displaced at the time of diagnosis. Based on his experience he suggested

that there should be no accelerated rehab with no flexion or squatting for 4

months. He suggests that you combine the repair techniques of suture and

arrows for large displaced bucket tears. He also cycles the knee after the repair

to make sure that the bucket tear does not re-dislocate into the notch. He avoids

the bioabsorbable devices in the red on red tears, in the popliteal tendon region,

in small tight knees, and in large displaced bucket handle tears.

Schepis reported on his results with bioabsorbable arrows in a poster at the

Academy in 2001

His suture repair rate was 6.9%. This increased to 19% with the introduction of

arrows. He followed 38 patients over 2 years. ACL reconstruction was performed

in 22/38 cases. The successful repair rate was 94% as assessed by chart review,

phone interview and clinical evaluation. There was a 7% failure rate in stable non

ACL reconstruction cases. However, 31% had temporary local irritability to the

arrow, but only 1 had persistent symptoms.

We reported on our meniscal repair results in a poster at the AANA spring

meeting and a podium presentation at the annual Canadian Orthopedic Meeting.

There were 262 meniscal repairs in 2100 ACL reconstructions. In 1990 the

suture repair rate was 8.9%, and this increased to 19% with the use of meniscal

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fixators. The outcome of suture repair, fixators repair and the hybrid repair was

the same as measured by the Tegner, Lysholm, and Cincinnati scale. The failure

rate was 4% for fixators, 12% for hybrids and 25% for sutures. The high failure

rate for the sutures was probably due to the repair of chronic displaced bucket

handle tears.

Summary

Meniscus repair in a suitable patient with the appropriate tear is

efficacious. The use of the bioabsorbable devices should be used judiciously and

in large tears in combination with sutures. At the present time we do not know

how much fixation is required to allow a torn meniscus to heal, consequently any

of the devices may work. The stimulation of the synovium with the subsequent

bleeding and the production of a fibrin clot may be all that is necessary to

promote healing of the meniscal tear. The final outcome of the procedure is

judged by the clinical result.

My current approach is to use non-absorbable sutures from inside out,

with a separate incision to retrieve the sutures and tie them over the capsule. I

use the bioabsorbable fixators in the posterior, difficult to access region. If he tear

is small, 2 cm, I may use the fixators alone.

Above all, do no harm.

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