- See:
Lateral Meniscus:
General Discussion of Meniscal Repair:
- Indications:
- any peripheral nondegenerative longitudinal tears < 3
cm;
- if tear is w/in 3 mm of the periphery, it is considered vascular;
- area 3-5 mm from periphery is grey zone, & > 5 mm from periphery is considered avascular; (see
vascularity of the meniscus)
- unstable tears or tears within vascular zone that are > 7 mm are repairable;
- mobile, single, vertical, longitudinal tear of the meniscus limited to vascular outer one-third of the meniscal substance;
- Relative Contra-indications:
- tears greater than 3 cm do not seem to heal, following surgery;
- transverse tears, even in the periphery, do not seem to heal;
- do not repair flap tears,
radial tears, cleavage tears, or vertical tears with secondary lesions that extend into avascular inner 2/3 of meniscus, except in young teen agers;
- ligamentous instability is a relative contraindication to repair;
- w/ ACL insufficiency, the rate or re-tearing approaches 40%, especially in younger acitve individuals, and therefore
ACL reconstruction should be performed at the same surgery;
-
management of combined meniscal tears and ACL tears;
- references
-
Arthroscopic meniscal repair using an exogenous fibrin clot.
- Surgical techniques for arthroscopic meniscal repair.
PM O'Meara.
Orthop Rev. Vol 22. 1993. p 781-790.
- Position:
- knee flexion of 70-90 deg allows
peroneal nerve to move posteriorly;
- Incision: (see:
lateral compartment of the knee)
- 5 cm vertical incision centered over posterolateral corner, just posterior to the
LCL;
-
peroneal nerve is identified;
- surgical dissection procedes between the posterior edge of the IT band (retracted anteriorly) and the anteiror border
biceps (retracted posteriorly;)
- further exposure reveals the gastrocnemius which is also retracted posteriorly;
- gastroc muscle is identified by flexing and extending the ankle;
- the interval between the posterolateral capsule and the gastroc is defined;
-
peroneal nerve position:
- proximally the nerve lies behind the head of the gastrocnemius;
- distally the nerve lies behind the biceps;
- knee is flexed to at least 45 deg to allow the peroneal nerve to fall posteriorly;
- Inside-Out Mensical Repair Technique:
- advantages: this technique allows for precise placement of sutures in the mensicus;
- disadvantages: this technique does not allow for precise placement of sutures thru the capsule, and therefore there is some
potential for neurovascular injury;
- equipement:
- single or double barrel cannula system;
- table spoon or small spade retractor;
- long keith needles w/ either 2-0 or O absorable or non absorbable;
- if absorabable sutures are chosen, use prolene;
- meniscal debridement:
- fibrin clot:
- it was originally recommended that an exogenous blood clot be placed into the meniscal repair site, but this is probably not necessary;
- LL Johnson MD, 1991, has demonstrated that during and following arthroscopic surgery, blood clot generated during
the case attaches to the surgically incised surfaces (including debrided edges of the meniscal tear);
- w/ this evidence, it may not be necessary to apply and exogenous clot, since the majority of blood clot is formed from synovial bleeding;
- ref: Characteristics of the Immediate Postoperative Blood Clot Formation in the Knee Joint. LL Johnson MD
Arthroscopy: The Journal of Arthroscopic and Related Surgery. Vol 7(1), 1991. p 14-23.
-
suture passage:
- w/ the knee in flexion, all needles should pass anterior to the biceps tendon inorder to avoid injury to the peroneal nerve;
- sutures may pass thru the popliteus w/o complication;
- consider using the anteromedial portal to pass sutures thru the lateral meniscus in a more lateral direction (which will avoid the posterior N/V structures);
-
suture spacing:
- enough sutures are placed to avoid gaps of more than 3-5 mm;
- sutures can be placed in horizontal, oblique, or verticle direction;
- verticle suture placement may be stronger due to the circumferential orientation of the collagen bundles (see
microscopic anatomy);
- horizontal sutures are almost as strong as verticle sutures, but are more apt to cause eversion of the opposite meniscal surface;
- eversion is avoided by placing sutures on both the superior and inferior mensical surface;
- always place the anterior suture first, so that the view of the posterior suture is not obstructed;
- concomitant ACL reconstruction:
- when performing an meniscal repair along with ACL reconstruction, meniscal repair is done first without tourniquet followed by ACL
reconstruction w/ tourniquet inflated;
- references:
Arthroscopic meniscal repair using an exogenous fibrin clot.
Surgical techniques for arthroscopic meniscal repair.
PM O'Meara.
Orthop Rev. Vol 22. 1993. p 781-790.
- Post Op Rehab:
- Wt bearing as tolerated in brace locked in extension;
- ROM is allowed when not wt bearing;
- atheletics are permited in 4-6 months;
- Complications:
-
peroneal nerve injury:
Peroneal nerve dysfunction as a complication of lateral meniscal repair: A case report and anatomic dissection.
K Jurist, P Greene, A Shirkhoda.
Arthroscopy. Vol 5. 1989. p 141.
Meniscal repair. Description of a surgical technique.
Long-term results of open meniscal repair.
Preparation of an exogenous fibrin clot.
Open meniscus repair.
DeHaven K, Black K, Griffiths H:
Am J Sports Med 1989;17:788-795.
Combined posterior incision and arthroscopic intra-articular repair of
the meniscus. An examination of factors affecting healing.
The arthroscopic meniscal repair: Techniques and clinical experience.
Jakob RP, Staubli HU, Zuber K, et al:
Am J Sports Med 1988;16(2):137-142.
Arthroscopic meniscus repair: a safe approach to the posterior horns.
An organ culture model for assaying wound repair of the fibrocartilaginous knee joint meniscus.
MeWebber RJ, York L, Vander Schilden JL, et al:
Am J Sports Med 1989;17:393.
Open meniscus repair, technique and 2 to 9 year results.
DeHaven K, Black K, Griffiths H: Am J Sports Med 1989;17:788-795.
Arthroscopic meniscal repair using an exogenous fibrin clot.
Meniscal repair using an exogenous fibrin clot. An experimental study in dogs.
Failure strengths of different meniscal suturing techniques.
Second look arthroscopy after meniscal repair. Factors affecting the healing rate.
Complications in arthroscopy:
The knee and other joints.
NC Small.
Arthroscopy. vol 2. 1986. p 253.
Long term results of arthroscopic meniscal repair: an analysis of isolated tears.
S. Eggli et al.
Am J. Sports Med. Vol 23. p 715-720. 1995.
The incidence of healing in arthroscopic meniscal repairs in ACL reconstructed knees versus stable knees.
WD and JM Vittori.
Am. J. Sports Med.
Vol 20. p 176. 1992.
