Transcript to see the presentation

Dimitrios Tsoukas, MD, MSc
• Director Minimally Invasive Orthopaedic
Sports Medicine Surgery Center MIOSMED
(ISAKOS approved Teaching Center)
Meniscus Repair
Tips and Tricks
The menisci are wedge shaped,
semilunar structures that occupy the
space between the distal femur and
proximal tibia within the knee joint.
The menisci are composed of
fibrochondrocytes encased within a
dense extracellular matrix of
predominantly Type I collagen.
The remainder of the menisci dry
weight is composed of elastin and
proteoglycan molecules.
Loss of Meniscal function leads to
progressive degenerative joint disease
Arthritis risk (20% for repair vs 60% for
menisctomy FU 8 years- Stein AJSM2010)
Ziad Noun, MD
Criteria of repairability
•
•
•
•
•
•
Patient age
Activity Level
0 1 2
Tear Location+++
3
Tear Configuration
Duration of the Tear
Presence of Associated Injuries ( ACL)
Ziad Noun, MD
Ideal candidate for meniscal repair
• Young active patient with an unstable vertical tear, greater
than 10 mm in length located in the peripheral 3 to 5 mm of
the meniscus. Performed concomitantly with ACLR
Indications have been broadened
• Horizontal tear in young patient
• Radial tear (Lateral meniscus: lower the bar)
93% complete & partial healing on MRI FU 36 months
Nam Hong Choi AJSM 2011
• Meniscus root tear
Better clinical results & Less
Joint narrowing Vs
Menisectomy
(Sang Bum Kim, AJSM2011)
Principles of meniscus repair
•
•
•
•
•
•
Preoperative Planning
Arthroscopic evaluation
Freshen up the tear
Stimulate healing
Repair the meniscus
Check stability
MRI sensitivity for reparability 93%
Thoureux et Al. arthroscopy 2006
Preparation is what counts !!!
Ziad Noun, MD
Techniques
1. ‘Outside-in’
2. ‘Inside-out’
3. ‘All-inside’
Outside - In
. Indication: Anterior third of meniscus
. small incisions (nick & spread) to capsule to avoid nerve injury
. no special instrumentation required (spinal needle)
. Simple & inexpensive technique
. Disadvantage: Posterior horn
. 84% healed on repeat
Arthroscopy, Morgan AJSM 1991
Ziad Noun, MD
Outside – In Technique
• Use a probe on the meniscus to keep
the meniscus reduced against the
capsule
• To place 2 adjacent sutures to create
a mattress suture they should be
pulled out through a cannula in an
anterior portal
Inside - Out
-Most commonly done (worldwide)
the “gold standard”
-Zone specific cannula through
contra-lateral portal
(single & double barreled)
-Main Issue: N-V injury / Posterior
Incisions
Ziad Noun, MD
Inside – Out Technique
Posterior incision:
Use ankle dorsiflexion to locate the gastroenemius
tendon. Establish clear exposure of the
posteromedial or posterolateral joint capsule.
Use vertical mattress sutures for superior strength
because they capture best the circumferentially
oriented collagen fibers of the meniscus.
Maintain a postion of knee flexion: this will allow
susceptible structures to fall away from the surgical
field.
• Suture devices
All Inside
- Hook, bird pick, Viper
- New suture device, tensionable: Crossfix (Cayenne), Covidien
• Rigid devices: Arrows, Darts, Staples
• Early Tensionable device (suture + Fixator)
- FasT-Fix (S&N)
- RapidLoc (DePuy-Mitek)
• New tensionable device (UHMWPE)
- Ultra FasT-Fix (S&N) => FasT-Fix 360
- RapidLoc A2 => OMNISPAN (DePuy-Mitek)
- MaxFire (Biomet)
- Meniscal Cinch (Arthrex)
Ziad Noun, MD
All inside technique
Be sure the implant is not prominent on
the meniscal surface to avoid articular
surface injury.
Motion loss can be prevented by tying
the sutures with the knee in full
extension to avoid inadvertent capture
of the joint capsule.
All inside technique
With large medial meniscus buckethandle tears the anterior horn may be
difficult to access: create an additional
high lateral (parapatellar) portal.
When inserting the delivery needle
rotate it to place it perpendicular to the
meniscal surface as possible.
With concomitant ACLR, the meniscal
repair sutures are placed first but are
not tied until the ACL graft is secured.
Large bucket-handle tear:
the first suture should be placed in the
middle of the handle fragment to
reduce the tear with subsequent sutures
placed anterior and posterior to this
first suture.
AVOID INJURY TO
NEUROVASCULAR STRUCTURES
Medial side:
maintain the knee near full extension
and passing the needle posterior the
semitendinosus tendon, diminishes the
likelihood of injury to the saplenous
vein and nerve and their infrapatellar
bronche, deflate the tourniquet – if used
– prior the wound closure
Lateral side:
the needles entering from outside – in
must remain anterior to the biceps
tendon to avoid the peroneal nerve.
Which technique is best
• Suture repair provides superior biomechanical
stability, although clinical success rate does not
necessarily correlate with the strength of the repair.
• Biologic factors may be of greater importance to
the success of meniscal repair than the surgical technique
• Decision on the most appropriate repair technique
should not rely on biomechanical parameters alone.
R Becker (Arthroscopy 2009)
Ziad Noun, MD
Which technique where
Posterior Horn
All Inside
Body
Inside Out
Outside In
Anterior Horn