IndicationsRim width - Distance of meniscal tear from

meniscosynovial junction-Warren & Arnockzy< 3 mm-high rate3-5 mm - variable >5 mm – not suitable for repairCannon-Success rate 74% with rim widths 2

to 3.9mm , 50 % with rim widths 4 to 5 mm

Favourable factors for healingYoung patientsAcute traumaLongitudinal tearsIncomplete tearsTears < 8 mm

Poor success rate is withChronic degenerative tearsACL deficient knee-DeHaven-failure rate 46%

vs 5%in stable knee over 10-year study Cannon-83% success rate combined meniscus repair & ACL reconstruction compared to overall success rate of 75%

Older age groupAxial malalignment

Open repairTear in posterior third of meniscusTraumatic separation of meniscosynovial

junctionRoutine arthroscopy

Tears are unappreciatedNon anatomic repair

Results-Cannon et al100% success rate for stable kneeChronic tears-failure rate 33%Acute tears –failure rate 14%

                              

                              

                              

Results-Outside in repair -Warren et al87% successful outcome69%-Asymptomatic-complete healing18%-Slightly symptomatic-partial healing13%-Meniscus failed to heal

Advantages - Outside in repairRisk of articular cartilage damage is lessPrecise placement of suturesVertical placement of suturesExcellent visualisationInjury to saphenous vein and nerve avoidedEasy access to anterior portion of meniscusUseful for suturing meniscal replacement

Disdvantages - Outside in repairDifficult to put perpendicular sutures in far

posterior partMulberry knot may potentially abrade the

articular surface before absorptionPermanent sutures must be brought through

anterior portalExperience is needed for accurate placement

of needle

Complications-Outside In repairNerve injury-Common peroneal nerve and

saphenous nerveLimitation of extensionInfectionFailure to heal-avascularity,degenerative

tear,instability,inadequate stabilization of tears,obliquity of sutures,lack of early protection,repeat injury

Inside out repairMore difficult due to limited space

Inside out repair-Lateral meniscus

Complications- Inside out repairNeurovascular injuryArtcicular scuffing and coring of meniscus by

cannulas and needles

All inside repairIndications are similar to open meniscal

repairAdditional posteromedial and posterolateral

portals requiredSpecialized equipments and intraarticular

suture tying skills are required

Meniscal arrowSelf reinforced Polylactic acidBegins to degrade in 4-6 months , absorbed

in 18 –24 monthsPull out strength comparable to horizontal

mattress sutures

Results-Meniscal arrow Kristensen et al

Meniscal repair in avascular zoneMarc Rubman et al-25%-Healed,38%-Partially

healed,36%-Failed ,Clinically-80%-asymptomatic

DeHaven-Healing enhancement techniques

Overall ResultsEvaluation-Clinical,Arthrography ,MRIHenning-75% failures were asymptomatic Cannon-50% failures were asymptomatic Morgan-All anatomic failures were

symptomaticIncompletely healed but stable menisci

behave clinically as completely healed menisci and should not be rated as failures

Overall ResultsTear length- Failure rate-15%-<2cm , 20%-

2to3.9cm , 59%-4-5cmTime of repair- Failure rate-17%-< 8 weeks

28%-> 8 weeksSide of repair-Failure rate-Lateral-16% ,

Medial repair-30%

Overall ResultsSuture material-Barrett et al –Failure rate-

Nonabsorbable-0%,Absorbable- 18% Warren and Morgan-Comparable results with both sutures

Ability to remain healed over time-Eggli et al-7.5 years f/u 73% meniscus survival rate DeHaven-10 years f/u 79% survival rate

Overall ResultsBiomechanical function- weightbearing AP

radiographs in extension and 45 degree flexion - 85% were normal

Fibrin glue-Ishimura et alFibrin glue-Tear in vascular area and is not

degeneratedFibrin glue containing marrow cells-Tear in

avascular areaFibrin glue containing marrow cells with

suturing-Degenerative tear

Fibrin glueSolution A-Purified dense

fibrinogen,Aprotinin,factorXIIISolution B-Thrombin,CaCl2

                              

Gene Therapy-Hideyuki Goto et alTissue engineered meniscal tissueTransgeneHealing in avascular zone can be improved

by transfer of genes encoding appropriate growth factors

RehabilitationControversy-Accelerated rehab protocol vs

conservative approachBasic science studies and animal studies – in

favour of accelerated protocol-Klein et al,Dowdy et al

Clinical studies-Shelbourne et al,Barber-No difference in rates of healing between two

Asahina et al – Concern about clinically asymptomatic partially healed tears

Rehabilitation-Scott et al Tailoring the post op protocol to the type of

meniscal tearBucket handle and vertical longitudinal tearsRadial and complex tears

THANK YOU

Collagen scaffold-Kevin et alTemplate for the regeneration of meniscal

cartilage