Meniscal Repair

Definition/Description

Meniscal repair or arthroscopic meniscectomy is a surgical procedure to repair a torn meniscus through keyhole surgery. It involves arthroscopic (keyhole) surgery to remove some or all of the meniscus from the tibio-femoral joint of the knee. The procedure may include a complete meniscectomy where. removal of the meniscus and meniscal rim or partial removal of only a portion of the meniscus. This can vary from a minor trimming of the damaged edge to anything short of removing the edges. It is a minimally invasive surgical procedure usually performed as an outpatient in a day clinic when a meniscal tear is too large for surgical repair of the meniscus. [1] . Factors affecting success include location of patient age of tear and sample age and any associated injury.

Where nonoperative treatment provides only modest relief of symptoms in the long term, these benefits may become increasingly ineffective as the affected meniscus deteriorates over time. In such cases, an arthroscopic partial meniscectomy can be very effective in improving a patient’s quality of life.

Clinically Relevant Anatomy

The meniscus of the knee is a crescent-shaped fibrocartilaginous structure that increases tibio-femoral joint alignment while also distributing friction and body weight. There are differences between the medial and lateral menisci:[2]

• The medial meniscus is larger and C-shaped. It fuses with the medial collateral ligament [3]
• The smaller lateral meniscus is O-shaped. This is more flexible than the medial meniscus and fuses with the popliteus. [3]

The main functions of the menisci are:

• Distribute the stress on the knees when bearing weight
• Provide shock absorption
• As an auxiliary joint stabilizer (will act as a joint stabilizer in ACL-deficient knee menisci [4]
• Provides nutrition and lubrication to articular cartilage
• Facilitate joint gliding
• Prevent hyperextension and
• Protect the joint margins.

During knee flexion, the femoral condyle slides posteriorly on the tibial plateau along with tibial internal rotation. During knee flexion, the lateral meniscus undergoes twice the anteroposterior translation of the medial meniscus. This translation prevents femoral contact Posterior tibial plateau. [5]

Zones of the meniscus

The menisci are divided into three regions: red-red, red-white, and white-white. These areas are divided by vascularization and healing potential.

1. Red – The red area is the peripheral area of the menisci. It is very well vascularized and has a good healing rate. The vascularization of the medial and lateral meniscus varies between 20-30 % and 10-25 % width in patients.
2. The red-white area is the middle third and is less vascular, but can sometimes heal.
3. Leucorrhea has no capillaries at all, so it cannot heal.

Epidemiology

Meniscal disease is one of the most common intra-articular knee injuries in the United States, second only to the knee joint, with an incidence of 12% to 14%, or 61 cases per 100,000 population [6][7][8] ]. It is the most common reason for orthopedic surgeons to perform surgery surgeon. The mean annual incidence of meniscal lesions was 0.066%. More male patients (595%) underwent isolated meniscus repair than female patients (405%). This is the same as male patients (60%) who underwent both meniscus repair and ACL repair ligament. So the majority of patients undergoing meniscus repair are men. [9][10]

Skiing after football and rugby is a sport with increased risk of acute meniscus injury. Among injuries affecting the knee, Majewski et al (2006) suggested that most injuries involved the anterior cruciate ligament (ACL), medial and lateral menisci. In the same study, it was also Arthroscopic treatment was observed in 85% of patients with meniscal and ACL injuries [10]. Generally speaking, meniscal tears mostly occur in middle-aged and elderly patients and are caused by long-term degeneration.

A third of the lesions in younger patients are sports-related injuries due to overextending or exerting too much force in cutting or twisting motions. More than 80% of meniscal tears are associated with anterior cruciate ligament (ACL) injury.

Meniscus lesions in children are different from those in adults. In children, more than 70% are isolated meniscus injuries, most of the time caused by sports-related twisting of the knee. [11]

For degenerative meniscal tears, there is strong evidence that age (greater than 60 years), gender (male), work-related kneeling and squatting, and persistent climbing of stairs greater than 30 flights are risk factors for meniscal tears. There is also strong evidence that sedentary Hours of dacey can reduce the risk of degenerative meniscal tears [12]. Barbara et al suggested that waiting more than 12 months between ACL injury and reconstructive surgery was a risk factor for developing a medial meniscus tear [13] [14].

Clinical Presentation

• Joint line tenderness and effusion.
• Complaints of “clicking”, “locking up” and “giving way” are common.
• Functional Instability of the Knee [15] A list of special tests to assess knee stability can be found on the Physiology of the Knee page.
• Symptoms are usually worsened by intolerable activities such as squatting and kneeling that cause knee flexion and weight bearing due to stiffness and pain [16]

Differential Diagnosis

• As with other diagnoses, joint line tenderness can be a false positive; osteochondral defect in osteoarthritis, collateral ligament injury, or fracture. [17][18] Effusion can also occur when there is a problem with the bones of the cruciate ligament or articular cartilage.
• Knee flexion and weight bearing usually exacerbate symptoms; activities such as squatting and kneeling are not tolerated. But the same is true for patients with other conditions, such as patella patella fractures and Sinding Larsen Johansson syndrome.

• Complaints of “clicking”, “locking up” and “giving way” are common. Patients also complain of “getting out of the way” when suffering from an ACL injury. Feelings of instability and locking are also common in osteochondritis dissecans.

Diagnostic Tests and Procedures

A relevant history, physical examination and appropriate imaging studies are required to make the diagnosis. [18]

• Joint line tenderness is reported to be the best common test for meniscal injury [19]
• The McMurray test is positive if there is a pop or snap at the joint line when the patient’s knee is bent and rotated.
• Apley’s test is performed with the patient prone and the examiner hyperbends the knee and rotates the tibial plateau over the condyles.
• Steinman’s test is performed on a supine patient with knee flexion and rotation.
• Ege’s test is performed with the patient squatting down, hearing/feeling an audible and palpable click in the area of the meniscal tear. The patient’s foot is turned outward to detect a medial meniscus tear and inward to detect a lateral meniscus tear.
• Thessaly Test.
• Meniscal imaging is an important tool in surgical decision-making for meniscal tears. Accurate imaging of the meniscus is critical for assessing the damaged area and selecting the most appropriate treatment. Imaging is also an important tool in postoperative management and treatment Follow up and identify any further injuries. Currently, magnetic resonance imaging (MRI) scans are the imaging technique of choice. Other techniques are radiography computed tomography (CT) scan computed tomography (CT) arthrography and magnetic resonance arthrography. [4]
  The advantages of MRI in the diagnosis of meniscal lesions are: Earlier detection of grade I and II tears Extra-articular structures are also visible No radiation, MRI is a non-invasive imaging technique. [20]

Meniscus tears are graded as follows:

Grade I: Discrete central degeneration – intrameniscal lesion with enhanced signal not associated with articular surface [23]

Grade II: Extensive central degeneration – larger inner meniscal region with increased signal intensity, again not connected to the articular surface. Orientation may be horizontal or linear [23]

Grade III: Meniscal tear – increased signal intensity within the meniscus and disruption of the articular surface contour. May be associated with displacement of meniscal fragments or surface step formation [23]

Grade IV: Complex meniscal tear – multiple disruptions of the meniscal surface

The presence of a tear in the red versus white area of the meniscus is critical because the long-term positive prognosis for tear repair is only good in the vascularized red area.

Outcome measures

• Western Ontario Meniscus Evaluation Tool (WOMET)
• Numeric Rating Scale for pain (NRS)
• Pain Visual Analog Scale (VAS)
• Knee outcome survey (KOS)
• Knee Injury and Osteoarthritis Outcome Score (KOOS)
• Draws Lysholm Knee Score [24]

Medical Management

Indication for surgery

After a definitive diagnosis of a meniscus tear, the first step is to decide whether to treat the lesion surgically or nonoperatively.

Other factors that may affect the decision to operate include:

1. Patient factors (such as age comorbidities and compliance)
2. Tear characteristics such as the location of the tear and the tear type of the tear and the fact that the tear is stable or unstable. Surgery is necessary when the tear is unstable. [25] [26]

Clear indications for surgery include complete or large incomplete longitudinal medial tears and large flap tears of the lateral meniscus near the base known as flexural tears. [27]

It must be noted that non-surgical treatment of meniscal tears in young athletes is rarely successful and usually requires repair of the torn meniscus [18]

Asymptomatic or stable degenerative or nondegenerative tears can be treated nonoperatively, but in symptomatic cases surgically. [28] It must then be determined whether meniscal repair or meniscectomy is appropriate. When normal surgical treatment is not appropriate Total meniscectomy is an option. Factors to consider are:

• The clinical evaluation
• Related lesions
• Exact type, location and extent of meniscus tear [29]

Degenerative meniscal tissue. An unstable knee without concomitant surgical stabilization. Complicated meniscus tears or radial tears in the central avascular zone tear joint infections and localized skin disorders. [27]

Tenuta JJ et al. Rim width was also found to be an important factor, as repairs wider than 4 mm did not heal. [30]

When ACL reconstruction is performed concurrently with meniscus repair, several studies have reported increased success rates [31][32][33][34]

Small degenerative meniscal tears are usually treated conservatively with rest NSAIDs, activity modifications and physical therapy to reduce the load on the joint. In cases where non-surgical methods are used, a good level of strength must be achieved and maintained Avoid the affected leg and activities that require rotation or sudden changes in direction. If the tear is large in an area of hypovascularization, or if conservative treatment fails to reduce the associated pain and joint dysfunction, surgery is the next step [35].

Repair of the meniscal injury should be strongly considered in cases of concurrent anterior cruciate ligament (ACL) reconstruction of peripheral and longitudinal tears and in younger patients. Reduced chance of healing in complex or degenerative tears Central and unstable tears knee. There are many restorative techniques available. [25] Regardless of age, it is recommended to preserve the meniscus tissue as much as possible – for active patients. [36] Meniscus tears amenable to repair include unstable tears >1 cm in length and 20% to 30% occur peripherally or In the so-called red-red zone. Those tears closer to the red-white junction may also heal, and the decision to repair should be made at the clinician’s discretion. The ideal target for repair is a vertical longitudinal tear that occurs within 3mm of the outer edge.

Outcome Measures

R.P. Walter et al found an overall meniscal repair success rate of 85-90%. [36] Meniscal repair outcomes were significantly improved in patients who also underwent ACL reconstruction. (91%) while those with a history of ACL disease The reconstructed meniscus had a significantly poorer repair success rate (63%). Bohnsack found a cure rate of 86-95%. Meniscal Repair The overall success rate for treating the meniscus is high. [37] In most studies, they performed a second MRI to confirm that the lesion had healed. a patient is He is considered cured when there is no lesion on the second MRI and the patient is able to resume his normal life/activities.

Locked bucket handle meniscal tears heal at a high rate when repaired as an isolated surgical procedure; even full weight bearing and mobilization are permitted before reconstruction and when the tear is in the white-on-white area. [9] Age or time between injury and surgery does not affect numbers Heal with meniscus repair. [11]

Surgical Techniques

The type of surgery used depends largely on the type of tear and its location. The most common surgical injury to the knee is a torn meniscus [20] [38] The goal of surgery is to preserve as much healthy tissue as possible. [36]

Surgical repair of the meniscus does better in the long run than partial meniscectomy. But recovery takes longer. [37] Here is something an athlete has to consider: whether or not he wants to return to the sport as quickly as possible. Meniscus repair can be done by opening it from the inside out Outside-in and all-in techniques. But not all meniscal tears heal with meniscal tear patterns, and the presence of adequate vascularity is key. [39]

Types of Surgical Repair

There are 4 types of surgical repair:

1. Open
2. Inside-out
3. Outside-in
4. All-inside.

Whether meniscus repair is performed under arthroscopic visualization, inside-out or outside-in, or even an all-inside technique, there are some common steps that must be followed. There must be tear debridement and fixation in the arthroscopic setting. [40] For each operation, they had to remove loose Both surfaces of the partially torn should be sanded and vascularization should be encouraged. [37] The all-internal technique is attractive due to the reduction in operative time and the simplicity of the technique. Short-term results for all-inside techniques are positive; however good long-term data These technologies are lacking. [4]

Patients who repair a peripheral meniscal tear typically progress faster than those who repair a tear that extends into the central third or who receive a meniscal transplant. [25]

The advantage of a meniscectomy is that only the damaged tissue is removed. Importantly, round collagen fibers may not be cut. [37][9] When this happens, the meniscus loses its function as a weight distributor and the risk of osteoarthritis then increases. Meniscectomy is a long-term conservative aftercare. A period of maximum prognosis is required to obtain the best treatment.

Patients who have undergone arthroscopic partial meniscectomy often initially experience knee swelling and loss of range of motion (ROM), and in the long run they may develop increased joint laxity and osteoarthritis. [11]

Meniscus injuries are often associated with damage to the anterior cruciate ligament, collateral ligaments, or articular cartilage. [41][5] This associated injury also affects functional recovery after arthroscopic meniscectomy. [18][25][36][4]

Open technique

The advantage of this technique is better preparation of the tear surface. However, only the most peripheral tears in the red-red zone are suitable for this technique, the main disadvantage of which is the risk of nerve damage. This technique is not often used these days up.

The capsule is incised posterior to the collateral ligament, opening the synovium for direct access to the posterior meniscus and tear, provided it is a vertical peripheral longitudinal tear. In the case of a horizontal tear, dissection of the meniscal synovial margins is required To expose the peripheral meniscus rim and horizontal cleavage. [40] [42]

Inside-out technique

This technique is often used for tears in the posterior horn or meniscal body, and the tear must be in the red-red or red-white zone. [40][43][44] Absorbable or nonabsorbable 2-0 or 0 suture threaded from medial knee to protected zone on lateral knee Joint capsule using a long, flexible needle. The suture is retrieved through the extra-articular posteromedial or posterolateral incision. The posterior neurovascular structures are protected by large retractors. The knot is tied extra-articularly above the capsule. [40][42] This technique has It is considered the gold standard for meniscus repair due to proven long-term results, but there is still a risk of neurovascular complications. [40] [44] [45]

Outside-in technique

The technique is used in the anterior horn of the meniscus and was originally designed to reduce the risk of neurovascular complications. [40][46] A hollow 18-gauge spinal needle was passed through the tear from the outside to the inside. Once the tip of the needle is seen, the suture is passed through The ipsilateral approach is through the arthroscopic approach. Tie a distraction knot at the end of the suture and pull the suture back. Repeat the process and tie the free ends to the capsule in twos through the auxiliary skin incision until the tear is stable. sutures can be placed Balance repairs alternately on the femoral and tibial surfaces of the menisci. [40]

All-inside technique

This technique can be used to repair extreme posterior corner tears. Traditionally, all interior repairs have been performed using a variety of equipment such as staples and screws. Most of these devices are bioabsorbable and consist of rigid poly-L-lactic acid (PLLA). [40] [39] [45] [47] The newest device is the self-adjusting suture device. They are based on the same principles as other devices. Anchors are positioned posterior to the capsule, and sutures are compressed and secured by the sliding knot to secure the axial meniscal segment. These implants have the potential to deform and deform Moves with the meniscus during weight bearing and reduces the risk of cartilage wear. These devices are the RapidLoc FasT-Fix and the Meniscal Cinch. [40] Advantages of all internal repair include ease of use, avoidance of auxiliary incisions, shortened operative time, and reduced neurovascular risk Structure, especially for better strength of suture devices. [40] [39] [47]

Complications

Little people. [48] studied complications in 10,262 patients who underwent meniscus repair. Of the 10,262 patients, 168% had complications. These complications are: hemarthrosis infection thromboembolic disease anesthesia complications instrument malfunction reflex sympathetic dystrophy ligament injury Fractures and nerve damage. Hemarthrosis is the most common complication, while nerve damage is the least common. There were no reports of vascular injury. Austin et al [49] highlighted a 7% incidence of saphenous neuropathy.

Physical Therapy Management

Pre-Operative

During the preoperative phase of total knee arthroplasty and ACL reconstruction, quadriceps strength training has been shown to improve knee function and improve postoperative quality of life. [11][41][5] also proved that neuromuscular electricity Stimulation Improves Quadriceps Strength in Knee Osteoarthritis Patients Most patients opting for meniscus repair do so on a short-term basis because there is little preoperative physical therapy. But if rapid surgical intervention is not possible for anyone We hypothesized that quadriceps training would also be beneficial in patients undergoing meniscus repair.

Neuromuscular electrical stimulation (NMES) induces muscle contraction by applying a transcutaneous electrical current to the terminal branches of motor neurons. In subjects with knee osteoarthritis, NMES increases quadriceps strength and improves functional performance, and has been found to be associated with exercise therapy. NMES also has beneficial effects on muscle mass. An additional benefit of this approach is the reduction of postoperative muscle atrophy through exercise prerehabilitation [50]

Pre-operative risk factors

Meniscectomy is a safe procedure even in elderly patients. However, patients with increased comorbidities and a history of smoking were at increased risk of adverse events and/or postoperative readmission regardless of age.

Post-Operative

Postoperative supervised rehabilitation has been advocated and studied as part of short- and long-term follow-up after arthroscopic partial meniscectomy. [11]

The goal of rehabilitation is to restore the patient’s function according to individual needs. It is important to consider whether the type of surgery to repair the meniscus has coexisting types of knee pathology (especially ligamentous laxity or degeneration of articular cartilage) Age, preoperative knee status (including time between injury and surgery), reduced range of motion or strength, and patient expectations and motivation for meniscus rupture. [20][37][9]

Exercise has been recognized as an effective treatment for patients with degenerative knees, improving knee function and limiting joint pain. There is strong evidence that physical activity plays an important role in reducing symptoms and improving muscle strength and physical performance. [11]

During the first week after surgery, rehabilitation includes progressive weight bearing with crutches. Early goals after surgery are: control of pain and swelling, maximum knee range of motion (ROM), and full weight-bearing walking. There is no load limit, the load is tolerated by patients.

Over the next 3 weeks, the goal is to normalize gait and increase knee range of motion as tolerated by the patient. Muscle-strengthening proprioception and balance exercises are performed around the third week.

It is only recommended to return to sports/activities when the quadriceps’ muscle strength is at least 80% on the parallel side. However, competitive level sports are not indicated until at least 90% of the muscle strength of the affected limb is reached.

Typically, patients return to work after 1 to 2 weeks to sporting activities after 3 to 6 weeks and to competition after 5 to 8 weeks [51].

Phases of Rehabilitation

• Phase 1: Acute Phase (1-10 days after surgery) .

Goals are to reduce inflammation restore where motion and muscle re-educate the quadriceps. The exercises recommended for the first phase are: long arc quadricep short arc quadricep hamstring curls (open chain exercises) cycling and leg presses (Closed chain exercises ).

• Phase 2: Subacute Phase (10 days-4 weeks after surgery) .

Goals are to restore muscle strength and endurance to re-establish full and pain-free ROM with a gradual return to activities and to reduce normal gait distractibility. More concentric/eccentric exercises for the hip and knee should be included in the open chain exercises from level 1. Closed chain exercises in phase 2 can resist terminal knee extension partial squats (not complete) step up/down development of ankle for function and flexibility training.

• Stage 3: Advanced Activity Phase (4-7 weeks postoperatively) .

The goals of the final phase are to improve muscle strength and endurance maintain full ROM and return to full sports or activities. This phase is based on progression to dynamic single leg standing plyometrics running and sport specific training.

General points in the therapy:

• Control the pain and inflammation – Cryotherapy analgaesics NSAIDs. As rehabilitation progresses, strategies may need to continue to be used to control residual pain and inflammation
• Regain good knee control [11]
• Repeat ROM (Range of motion) [11]- ROM exercises within any limit of range requested by the consultant [20] .
  • Restore the flexibility [11]
  • Restore muscle function [11]- specific strengthening exercises including quadriceps (A medial meniscus lesion affects M. Vastus mediaalis.[41]) hamstrings calf hip strength.
• The exercise program should consist of both advanced and eccentric exercises to gain extra muscle mass as well as neuromuscular function. [11] .
• Optimizing Neuromuscular Coordination—Proprioceptive Reeducation
• Progression Weightbearing – Weightbearing and joint stress are necessary to enhance the function of the meniscus repair and therefore should be progressed as directed by the consultant. Excessive shear forces can be damaging and should be avoided initially.
• Rehabilitation protocols after meniscectomy can be aggressive because the knee anatomy should not be overprotected during the healing phase. Rehabilitation includes ice ultrasound therapy friction massage joint mobilization calves raising steps extensors Work out and ride a bike. [52] Underwater treatment should not begin until the wound is completely closed to prevent an increased risk of infection.

The use of myoelectric biofeedback during the early rehabilitation phase after meniscus repair helps patients control their muscles. It can help with physical activities that require better neuromuscular coordination and control. For these reasons, one may consider EMG Biofeedback as an important component of rehabilitation after meniscus repair. EMG biofeedback was not associated with the degree of pain swelling or other postoperative symptoms. The technique is a painless, non-invasive method that can be used for muscle recovery. This technique can Use in all stages of rehabilitation. [4]

Physical activity 3 times a week for 4 months improved knee function by more than 35%. [11] Any rehabilitation program should be written on the patient Every patient is different and will respond differently to rehabilitation. a large part of the result Depends on how quickly and accurately the diagnosis is confirmed.

Patients undergoing meniscus repair should perform open-chain exercises without resistance. Because of the study by David L. et al. Supporting it doesn’t put undue stress on the meniscus repair. (Level of Evidence: 4)[37]

Findings from a number of studies support weight-bearing restriction for the first 4 to 8 weeks after meniscus repair. In theory, weight bearing alone should not damage the healing meniscus tissue because hoop stress is absorbed primarily around the meniscus. However, the burden is The combination of tibiofemoral rotation during knee flexion can generate shear forces that can disrupt the healing meniscus tissue. [5]

Standardized ‘cookbook’ protocols and individualized plans – based on the surgical approach to the meniscus repair as a coexisting knee arthritis (ligamentous laxity or OA) meniscal tear type patient – should be avoided no years before surgery kneestatus (including time between injury and surgery) Loss of ROM and strength and patient’s athletic expectations and motivation – should be encouraged.Accelerated meniscal repair rehabilitation programs that permit full knee ROM and full weight bearing are becoming more common with return to full activity only 10 weeks after surgery.[5]

Key Research

Include links and high-quality evidence reviews here (case studies should be added to new pages through the case study system)

Resources

Arthroscopic meniscal repair from the Orthopedic Hospital of Houston[5]

Timothy BrindleJohn Nyland and Darren L. Johnson (2001) The Meniscus: A Review of Basic Principles Applied to Surgery and Reconstruction. Journal of Athletic Training 36 (2) 160-169.