[ clinical commentary ] FRANK R. NOYES, MD1 • TIMOTHY P. HECKMANN, PT, ATC2 • SUE D. BARBER-WESTIN, BS3 Meniscus Repair and Transplantation: A Comprehensive Update he menisci provide several vital mechanical functions in the ies focused on repair of simple longitudi- knee joint. They act as a spacer between the femoral condyle nal tears located in the periphery or outer and tibial plateau and, when there are no compressive weight- one-third region of the meniscus, many studies have now been published on the bearing loads across the joint, limit contact between the T outcome of repair of complex multiplanar articular surfaces. The menisci provide shock absorption to the knee tears that extend into the central third joint during walking and are believed to assist in overall lubrication avascular region, and have reported en- of the articular surfaces.36,75 Following meniscectomy, the tibiofemoral couraging success rates.40 Unfortunately, not all meniscus tears contact area decreases by approximately Preservation of meniscal tissue and can be repaired, especially if considerable 50%, while the contact forces increase function is paramount for long-term joint tissue damage has occurred. In appropri- 2-fold to 3-fold.2,32,74 Meniscectomy fre- function, especially in younger patients ate patients, meniscus transplantation quently leads to irreparable joint damage, who are athletically active. Since early offers the potential to restore partial including articular cartilage degenera- reports of meniscus repair in the 1980s, load-bearing meniscus function, decrease tion, flattening of articular surfaces, and considerable attention has been made to symptoms, and provide chondropro- subchondral bone sclerosis.26,49,66,79 Poor improve surgical techniques, understand tective effects.20,73,77 Transplantation of long-term clinical results have been re- appropriate indications, and enhance human menisci is no longer considered ported by many investigators following postoperative rehabilitation to restore experimental, as over 30 clinical studies partial and total meniscectomy.3,34,54,57,58,61 normal joint function. While early stud- involving hundreds of patients have been published.41 While the results of this op- eration vary, studies continue to justify TTSYNOPSIS: Preservation of meniscal tissue is high compressive and shear forces can disrupt paramount for long-term joint function, especially healing meniscus repair sites and transplants. the procedure in young patients who have in younger patients who are athletically active. Immediate knee motion and muscle strengthening undergone meniscectomy and have pain Many studies have reported encouraging results are initiated the day after surgery. Variations are or articular cartilage damage in the men- following repair of meniscus tears for both simple built into the rehabilitation protocol according to iscectomized tibiofemoral compartment. longitudinal tears located in the periphery and the type, location, and size of the meniscus repair, In the 5 years since our last update if concomitant procedures are performed, and if complex multiplanar tears that extend into the on this topic in the JOSPT,22 further central third avascular region. This operation articular cartilage damage is present. Meniscus re- longer-term data have been published is usually indicated in active patients who have pairs located in the periphery heal rapidly, whereas 30,48,62 tibiofemoral joint line pain and are less than 50 complex multiplanar repairs tend to heal more supporting both meniscus repair 63,69,73,76,77 years of age. However, not all meniscus tears are slowly and require greater caution. The authors and meniscus transplantation. repairable, especially if considerable damage has have reported the efficacy of the rehabilitation The operative techniques and rehabilita- occurred. In select patients, meniscus transplanta- programs and the results of meniscus repair and tion programs remain relatively similar, transplantation in many studies. J Orthop Sports tion may restore partial load-bearing meniscus as do the indications and contraindica- Phys Ther 2012;42(3):274-290, Epub 4 September function, decrease symptoms, and provide tions. Newer magnetic resonance imag- chondroprotective effects. The initial postoperative 2011. doi:10.2519/jospt.2012.3588 ing (MRI) techniques, including use of a goal after both meniscus repair and transplanta- TTKEY WORDS: knee rehabilitation, meniscus tion is to prevent excessive weight bearing, as repair, meniscus transplant 3-T scanner with cartilage-sensitive pulse sequences and T2 mapping, have provid- 1Chairman and Medical Director, Cincinnati SportsMedicine & Orthopaedic Center, Cincinnati, OH; President, Cincinnati SportsMedicine Research and Education Foundation, Cincinnati, OH. 2Director of Rehabilitation, Cincinnati SportsMedicine & Orthopaedic Center, Cincinnati, OH. 3Director of Clinical and Applied Research, Cincinnati SportsMedicine Research and Education Foundation, Cincinnati, OH. Address correspondence to Sue D. Barber-Westin, Cincinnati SportsMedicine Research and Education Foundation, 10663 Montgomery Rd, Cincinnati, OH 45242. E-mail: [email protected] 274 | march 2012 | volume 42 | number 3 | journal of orthopaedic & sports physical therapy 42-03 Noyes.indd 274 2/29/2012 6:55:53 PM Axial lower-limb alignment is measured Indications and Contraindications TABLE 1 using full standing, hip-knee-ankle for Meniscus Repair weight-bearing radiographs in knees that Indications demonstrate varus or valgus alignment • Meniscus tear with tibiofemoral joint line pain on physical examination. Varus or val- • Patients younger than 50 years of age or patients in their fifties who are athletically active gus malalignment is also a contraindica- • Concurrent knee ligament reconstruction or osteotomy tion to meniscus transplantation (unless • Meniscus tear reducible, good tissue integrity, normal position in the joint once repaired corrected with a high tibial or femoral • Peripheral single longitudinal tears: red-red, 1 plane; reparable in all cases, high success rates osteotomy). MRI is obtained using a pro- • Middle-third region: red-white (vascular supply present) or white-white (no blood supply); often reparable with ton-density-weighted, high-resolution, 18,50 reasonable success rates fast spin-echo sequence to determine • Outer-third and middle-third regions, longitudinal, radial, horizontal tears: red-white, 1 plane; often reparable the status of the articular cartilage and Contraindications menisci. As viewed on MRI, advanced • Meniscus tears located in inner-third region knee joint arthrosis, with flattening of the • Chronic degenerative tears in which the tissue is of poor quality and not amenable to suture repair femoral condyle, concavity of the tibial • Longitudinal tears less than 10 mm in length plateau, and osteophytes, is a contraindi- • Incomplete radial tears that do not extend into the outer-third region cation for meniscus transplantation. • Patients older than 60 years of age • Patients unwilling to follow postoperative rehabilitation program MENISCUS REPAIR Reprinted from Noyes and Barber-Westin,40 with permission. Indications he indications and contraindi- ed advanced, noninvasive insight into the popping, clicking, or catching) during cations for meniscus repair are ultrastructure of hyaline cartilage. This joint compression and flexion and exten- Tshown in TABLE 1 and have been allows detection of early degenerative sion, lack of full extension, and a positive described in detail elsewhere.40,44 Can- changes before discernible loss of carti- McMurray test.33 The clinical examina- didates are active patients who have lage thickness is visible on conventional tion may reveal tenderness on palpation tibiofemoral joint line pain and usually MRI. Use of this technology allows for a at the posterolateral aspect of the joint, at less than 50 years of age, or in their fif- better assessment of the chondroprotec- the anatomic site of the popliteomeniscal ties and athletically active.62 The patient tive effects of these operations and the attachments. The McMurray test is per- must be willing to follow the rehabilita- integrity of the repair site or transplant formed in maximum flexion, progressing tion program, including protected weight tissue. from maximum external rotation to in- bearing for up to 6 weeks. Those in whom ternal rotation, then back to external ro- complex tears are repaired must agree to CLINICAL EVALUATION tation. With maximum internal rotation, avoid strenuous activities and deep knee this test may produce a lateral, palpable flexion for 4 to 6 months to prevent tear- thorough history is taken and snapping sensation, representing an an- ing and failure of the repair. Meniscus questionnaires are used to rate terior subluxation of the posterior horn of tears are classified at arthroscopy accord- A symptoms, functional limitations, the lateral meniscus. ing to location, type of tear, and integrity sports and occupational activity levels, In all patients, radiographs are taken and damage to meniscal tissue and the and patient perception of the overall during the initial examination. These meniscus attachment sites. This classi- knee condition according to the Cincin- include an anteroposterior view of both fication and a meticulous arthroscopic nati Knee Rating System.6 A compre- knees in full extension, a lateral view at inspection of the tear site determine if hensive knee examination is performed 45° of flexion, and an axial view