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Repair of the Torn Meniscus

- Meniscal Anatomy and Physiology:
    - medial meniscus
            - bucket handle meniscus tear 
posterior horn tears of medial meniscus 
    - lateral meniscus
            - discoid meniscus
    - indications for repair:
            - 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;
                     - see: management of meniscal tears in the ACL deficient knee
                     - 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;
                    - ref: Arthroscopic meniscal repair using an exogenous fibrin clot. 
                             Surgical techniques for arthroscopic meniscal repair
            - horizontal cleavage tear:
                    - The repair of horizontal cleavage tears yields higher complication rates compared to meniscectomy: a systematic review.
                    - Meniscal repair associated with a partial meniscectomy for treating complex horizontal cleavage tears in young patients may lead to excellent long-term outcomes.
                    - Arthroscopic All-Inside Repair of Medial Meniscus Grade 2 Horizontal Cleavage Tear Using Additional Posteromedial Portal.
                    - Vertical Lasso and Horizontal Lasso Sutures for Repair of Horizontal Cleavage and Horizontal Oblique Meniscal Tears: Surgical Technique and Indications.
                    - Platelet-Rich Fibrin Clot-Augmented Repair of Horizontal Cleavage Meniscal Tear.
                    - Circumferential Suture Repair of Isolated Horizontal Meniscal Tears Augmented With Fibrin Clot.
                    - Horizontal Cleavage Meniscus Tear Treated With All-inside Circumferential Compression Stitches
                    - Management of traumatic meniscal tear and degenerative meniscal lesions. Save the meniscus
                    - Changes in Contact Area in Meniscus Horizontal Cleavage Tears Subjected to Repair and Resection
                    - Repair of isolated horizontal meniscal tears with all-inside suture materials using the overlock method: outcome study with a minimum 2-year follow-up
                    - Meniscal Repair of Degenerative Horizontal Cleavage Tears Using Fibrin Clots: Clinical/Arthroscopic Outcomes in 10 Cases.
                    - Arthroscopic repair of horizontal meniscal cleavage tears with marrow-stimulating technique
                    - Repair of horizontal meniscus tears: a systematic review.
                    - Clinical outcomes of open meniscal repair of horizontal meniscal tears in young patients
                    - Repair of horizontal meniscal cleavage tears with exogenous fibrin clots
                    - A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study Evaluating Meniscal Healing, Clinical Outcomes, and Safety in Patients Undergoing Meniscal Repair of Unstable, Complete Vertical Meniscal Tears (Bucket Handle) Augmented with Platelet-Rich Plasma.

- Technique:
    - equipement: (see Arthrex, Mitek, Linvatec, Smith-Nephew)
          - 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;
    - medial repair technique 
    - lateral repair technique 
    - meniscal debridement 
    - outside to in - arthroscopic technique:
             - main advantage is that there is a low risk of neurovascular injury, since needles are passed thru precise thru the capsule;
             - main disadvantage is that suture placement thru the meniscus may not be precise;
    - inside to out - arthroscopic technique: 

    - fibrin clot:
          - it was originally recommended that an exogenous blood clot be placed into the meniscal repair site, but this is probably
                    not necessary;
          - Johnson LL (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;
          - references:
                  - Characteristics of the Immediate Postoperative Blood Clot Formation in the Knee Joint.   
                  - Meniscal repair using an exogenous fibrin clot. An experimental study in dogs
                  - Arthroscopic meniscal repair using an exogenous fibrin clot.
                  - Preparation of an exogenous fibrin clot.
    - 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:
                  - Failure strengths of different meniscal suturing techniques.
                  - Meniscus suture techniques: a comparative biomechanical cadaver study.
                  - The effect of suture type on meniscus repair. A clinical analysis.

- 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;
    - references:
          - Accelerated rehabilitation for meniscus repairs.
          - Meniscus repair rehabilitation with concurrent anterior cruciate reconstruction. 
          - Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens.


Long-Term Outcome After Arthroscopic Meniscal Repair Versus Arthroscopic Partial Meniscectomy for Traumatic Meniscal Tears 

Meniscal repair. Description of a surgical technique.

Long-term results of open meniscal repair.

Open meniscus repair. Technique and two to nine year results

Combined posterior incision and arthroscopic intra-articular repair of the meniscus. An examination of factors affecting healing.

Arthroscopic meniscus repair: a safe approach to the posterior horns

Failure strengths of different meniscal suturing techniques.

Second look arthroscopy after meniscal repair. Factors affecting the healing rate.

The effect of meniscus compression on the biomechanical properties of repaired meniscal lesions. Winner of the AGA-DonJoy Award 2003

Dynamic Contact Mechanics of the Medial Meniscus as a Function of Radial Tear, Repair, and Partial Meniscectomy

Anatomic Localization of the Popliteal Artery at the Level of the Knee Joint: A Magnetic Resonance Imaging Study. 

Changes in Tibiofemoral Contact Mechanics Following Radial Split and Vertical Tears of the Medial Meniscus. An in vitro investigation of the efficacy of arthrospopic repair

Posterior Horn Medial Meniscal Root Repair With Cruciate Ligament/Medial Collateral Ligament Combined Injuries

Mitek Omnispan