Meniscal repair

Download Meniscal repair

Post on 11-Jun-2015

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<ul><li> 1. IndicationsRim width - Distance of meniscal tear from meniscosynovial junction-Warren &amp; Arnockzy&lt; 3 mm-high rate3-5 mm - variable&gt;5 mm not suitable for repairCannon-Success rate 74% with rim widths 2 to 3.9mm , 50 % with rim widths 4 to 5 mm</li></ul> <p> 2. Favourable factors for healingYoung patientsAcute traumaLongitudinal tearsIncomplete tearsTears &lt; 8 mm 3. 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 &amp; ACL reconstruction compared to overall success rate of 75%Older age groupAxial malalignment 4. Open repairTear in posterior third of meniscusTraumatic separation of meniscosynovial junctionRoutine arthroscopyTears are unappreciatedNon anatomic repair 5. Results-Cannon et al100% success rate for stable kneeChronic tears-failure rate 33%Acute tears failure rate 14% 6. Results-Outside in repair-Warren et al87% successful outcome69%-Asymptomatic-complete healing18%-Slightly symptomatic-partial healing13%-Meniscus failed to heal 7. 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 8. 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 9. 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 10. Inside out repairMore difficult due to limited space 11. Inside out repair-Lateralmeniscus 12. Complications- Inside outrepairNeurovascular injuryArtcicular scuffing and coring of meniscus by cannulas and needles 13. All inside repairIndications are similar to open meniscal repairAdditional posteromedial and posterolateral portals requiredSpecialized equipments and intraarticular suture tying skills are required 14. Meniscal arrowSelf reinforced Polylactic acidBegins to degrade in 4-6 months , absorbed in 18 24 monthsPull out strength comparable to horizontal mattress sutures 15. Results-Meniscal arrowKristensen et al 16. Meniscal repair in avascularzoneMarc Rubman et al-25%-Healed,38%-Partially healed,36%-Failed ,Clinically-80%-asymptomaticDeHaven-Healing enhancement techniques 17. Overall ResultsEvaluation-Clinical,Arthrography ,MRIHenning-75% failures were asymptomaticCannon-50% failures were asymptomaticMorgan-All anatomic failures were symptomaticIncompletely healed but stable menisci behave clinically as completely healed menisci and should not be rated as failures 18. Overall ResultsTear length- Failure rate-15%- 8 weeksSide of repair-Failure rate-Lateral-16% , Medial repair- 30% 19. Overall ResultsSuture material-Barrett et al Failure rate- Nonabsorbable-0%,Absorbable- 18% Warren and Morgan-Comparable results with both suturesAbility 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 20. Overall ResultsBiomechanical function- weightbearing AP radiographs in extension and 45 degree flexion - 85% were normal 21. 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 22. Fibrin glueSolution A-Purified dense fibrinogen,Aprotinin,factorXIIISolution B-Thrombin,CaCl2 23. Gene Therapy-Hideyuki Goto etalTissue engineered meniscal tissueTransgeneHealing in avascular zone can be improved by transfer of genes encoding appropriate growth factors 24. RehabilitationControversy-Accelerated rehab protocol vs conservative approachBasic science studies and animal studies in favour of accelerated protocol-Klein et al,Dowdy et alClinical studies-Shelbourne et al,Barber-No difference in rates of healing between twoAsahina et al Concern about clinically asymptomatic partially healed tears 25. Rehabilitation-Scott et alTailoring the post op protocol to the type of meniscal tearBucket handle and vertical longitudinal tearsRadial and complex tears 26. THANK YOU 27. Collagen scaffold-Kevin et alTemplate for the regeneration of meniscal cartilage</p>

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