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Meniscal Repair 4 Chris O’Grady, M.D Update on Treatment of Meniscal Injuries Basic Clinical Future Science • Presentation • Biologics • Anatomy • Diagnosis • PRP • Biomechanics • Treatment • Stem Cells • Rehabilitation 2 Function --joint filler (incongruous condyles) -2.5 greater contact area when mensicus present -prevent capsular/ synovial impingement -joint lubrication/ synovial distribution -load (40-60% of standing load -stability (esp. rotatory) 3 Function Medial Meniscus Lateral Meniscus Secondary stabilizer to AP 200-300% increase in translation in ACL deficient lateral compartment knee contact stresses when (more capsular attachment) removed (convex lateral Follows tibia- more likely to plateau) be torn with rotatory force 4 Radin et al., CORR, 1984 - Load transmission increases in flexion vs ext 5 Fukubayashi et al. 1980 Anatomy Histo: Fibrocartilage Composition Water 65%-75% Organic matter 25%-35% 75% Collagen Type I – 90% Types II, III,IV, V, VI, XVIII 25% Other Proteoglycans, DNA, Elastin 7 Anatomy Triangular cross section Provide structural integrity “concavity” of the articulation Dissipates forces/friction across medial/lateral compartments Axial Compression Horizontal hoop stress Creates shear forces 8 Anatomy Structure Mesh network: Arranged obliquely, radially, and vertically Prevents shear Bundles: Radial Located at surface and midsubtance Prevent longitudinal tears Circumferential Disperses compressive loads (hoops around wooden barrel) Anatomy Medial Meniscus C-Shaped structure Less mobile Firmly attached to capsule Deep MCL at mid body Posterior fibers of anterior horn merge with transverse ligament Periphery of meniscus attached to capsule through coronary ligaments Medial Meniscus Wider in diameter than the lateral meniscus 9-10 mm wide 3-5 mm thick Covers 51-74% of condyle Lateral Meniscus Semi-circular in shape More mobility Less peripheral attachments Popliteal Hiatus Anterior and posterior horns attach closer to each other than medial meniscus Anterior horn attaches adjacent to ACL Posterior horn attaches behind inter-condylar eminence Lateral Meniscus Covers more tibia 75-93% of condyle 12-13 mm wide 3-5 mm thick Meniscofemoral ligaments Humphrey & Wrisberg Run from posterior horn of lateral meniscus to medial femoral condyle Major Role Stabilize PH of Lateral Meniscus Minor role Stabilizing posterior tibial translation with compromised PCL 14 Humphrey – Sag MRI Anterior to PCL 15 Discoid Meniscus Incidence of 3.5-5% Usually lateral, but 20% bilateral 16 Discoid Meniscus Type I-Complete Type II-Incomplete Type III-Wrisberg subtype Watanabe Classification 17 Blood Supply PeriMeniscal Capillary Pleux 18 Blood Supply 50-100% of meniscus vascular at birth 9 months: Inner 1/3 rd avascular By age 10: Mature Peripheral 10-25% of lateral vascular Peripheral 10-30% of medial vascular Inner 2/3rds by synovial fluid diffusion 19 Arnoczky et al AJSM 1982 20 Vascularity Zones Red-Red Fully vascular Excellent healing potential Red-White Border of vascular supply Good healing potential White-White Relatively avascular Poor healing prognosis Cannon et al, Basic Clinical Future Science • Presentation • Biologics • Anatomy • Diagnosis • PRP • Biomechanics • Treatment • Stem Cells • Rehabilitation 22 Epidemiology Incidence (acute tears) 60-70 cases/100,000 people per year Male:Female Ratios 2.5-4:1 Younger Acute Older Degenerative (MMT) 1/3 occur with ACL tear Acute: LMT Chronic: MMT 23 Basic Clinical Future Science • Presentation • Biologics • Anatomy • Diagnosis • PRP • Biomechanics • Treatment • Stem Cells • Rehabilitation 24 History Mechanism Twisting, change in direction, or hyper-flexion injury Feeling a “pop” Acute pain or swelling Slow-forming effusion Locking/catching sensation Degenerative tears(>40) often more atraumatic with a chronic history Postmenisectomy syndrome – “toothache pain” after menisectomy 25 Physical Exam Inspection Mild to moderate joint effusion Usually no ecchymosis Limb alignment ROM Typically normal However, longitudinal bucket handle tears may block full extension Stability Associated ligamentous injury Physical Exam Palpation Joint line tenderness 27 McMurray British Journal of Surgery 1942 MMT: 90deg, valgus, ER, ext knee + click Sen:59% Spec: 93-97% 28 Apley Grind Test JBJS 1947 Prone, 90deg Stabilize thigh Compress joint, ER Sen: 41% Spec: 86-93% 29 Thessaly Maneuver JBJS 2005 20 deg flex (IR, ER) Harrison, Clin J Sport Med, 2009: 66 patients with +Thessaly, 65 had arthroscopic findings of meniscal tear Sen 90% Spec 97.7% Ege’s Test Squat with full hip ER/ IR 31 Imaging Weight bearing Don’t miss OA X-rays: AP/Laterals Merchant/Sunrise 30-45 degree flexion views Calcifications CPPD 32 Discoid Meniscus Widening Squaring Cupping Hypoplastic 33 Imaging MRI: Diagnostic procedure of choice 95% accuracy High NPV Grading system 0, I, II, III Grade III consistent with complete tear Arthroscopy still gold standard Look for condylar edema (increased contact pressure on condyle when meniscus torn) 34 MRI Grading 0: normal I: globular increase in signal with no extension to surface II: near signal increase that does not extend to surface III: increased signal that abuts the freed edge of meniscus Indicates tear 35 Discoid Meniscus – Bow Tie Sign 3 or more 5mm cuts with continuity of meniscus 36 MRI Complex tear “Double PCL” – Bucket Handle 37 Arthrography 38 Classification of Tears Common Meniscal Tears 40 Radial Tear 41 AANA Advanced Arthroscopy: The Knee Horizontal Tear AANA Advanced Arthroscopy: The Knee Bucket-Handle Tear 43 AANA Advanced Arthroscopy: The Knee Meniscal Root Tears Milder symptoms Joint line pain Less mechanical symptoms (only 9-14%) Posterior knee pain with deep flexion McMurray + 57% Effusion + 14% Lee et al Arthroscopy 2009 Root Tears -3mm extrusion on mid coronal -condylar edema Extruded meniscus Ghost sign LaPrade et al, AJSM March 2014 Basic Clinical Future Science • Presentation • Biologics • Anatomy • Diagnosis • PRP • Biomechanics • Treatment • Stem Cells • Rehabilitation 46 Treatment Options Depends on Symptoms Affect on ADLs, Work, Sports 47 Nonsurgical Options RICE Wt Loss Bracing (unloader) Injections Physical Therapy ROM Strengthening NSAIDs 48 Surgical Options 1. Leave alone 2. Meniscectomy Promote healing only surgical morbidity and improves function Stable contoured rim Preserve as much tissue as possible Long-term risks? 3. Meniscal repair 4. Meniscal transplant Ideal treatment for the ideal Symptomatic patient too young situation for a TKA Vertical mattress sutures gold standard 1. Leave alone… Stable partial tears Leave tourniquet down to Stable longitudinal tears assess bleeding: < 10 mm length Rasping < 3-5 mm displacement Trephination Do not displace into notch Marrow stimulation, PRP, etc. Do not touch femoral condyle Enhance biologic healing response E.g. notch microfx Degenerative tears with significant OA Short radial tears: < 3 mm in length 50 2. Meniscectomy Indications 51 2. Meniscectomy 52 2. Meniscectomy Technique 53 3. Repair Options Inside- Open Out Outside- All- In Inside 54 Open Meniscal Repair Trans-capsular approach with capsule and synovium opened for visualization Indications: Tight compartments Peripheral tears in posterior horns Disadvantages: Larger approach Greater tissue trauma Open Meniscal Repair Results 80-90% survival rate after 13 years DeHaven Clin Sports Med 1990 Rockborn and Gillquist JBJS Br 2000 Muellner AJSM 1999 MRI data included, but unreliable method to assess healing Arthroscopic Inside-Out Advantage: Consistent/More accurate suture placement Gold Standard Disadvantages: Risk of neurovascular injury 75-91% survival/healing Barrett et al Arthroscopy 1998 Johnson et al AJSM 1999 Arthroscopic Inside-Out Advantage: Consistent/More accurate suture placement Gold Standard Disadvantages: Risk of neurovascular injury 75-91% survival/healing Barrett et al Arthroscopy 1998 Johnson et al AJSM 1999 Arthroscopic Inside-Out Advantage: Consistent/More accurate suture placement Gold Standard Disadvantages: Risk of neurovascular injury 75-91% survival/healing Barrett et al Arthroscopy 1998 Johnson et al AJSM 1999 Arthroscopic Outside In Advantage: Less neurovascular risk Good for tears in anterior horn and body Disadvantage: Less accurate suture placement 65-78% survival/healing Morgan et al AJSM 1991 Rodeo et al AJSM 1999 Plasschaert et al AJSM 1998 60 Arthroscopic All-Inside Advantages: Decreased neurovascular risk Minimally Invasive Decreased operative time Similar success rates New Gold Standard? All-Inside Device Comparisons Mehta, AJSM, 2009: FastFix (S&N) vs. Meniscal Cinch (Arthrex) vs. MaxFire (Biomet) Ultimate load to failure FastFix 86.1N, Meniscal Cinch 85.3N, MaxFire 64.5 N Gap formation (after 100 cylces) MaxFire: 6.7 mm Meniscal Cinch: 4.07mm FastFix: 3.59mm No significant difference after 500 cycles More Comparisons… Barber et al Arthroscopy 2011 Methods Outside-In Vertical Mattress with both Ethibond and Orthocord All-Inside: Meniscal Cinch, MaxFire, FastFix, Sequent (ConMed), OmniSpan Gap Formation and Load to Failure Results No significant differences except MaxFire = bad • Isolated Bucket Handle Meniscus Tears (19 studies) 2012 • 2 Level II Studies, 1 Level III • 17% failure inside out vs 19% all inside (No sig diff) • Similar Patient reported outcome scores • Complications • Inside
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