the knee joint || arthroscopic meniscectomy

Chapter 10

J.C. Panisset, J.L. Prudhon Arthroscopic meniscectomy

Summary

T he basic principles of arthroscopic menis-cectomy are described. After reminding the diff erent installations and the diffffff erent ens-ffff

sential and complementary instruments, menis-cectomy techniques are described making the dif-ference between the lateral meniscectomy and the medial meniscectomy.

Introduction

The knee arthroscopy (1) <Comp: Delete theendnotes, in superscript, once the referencelist is properly styled.>is successful thanks to the first pioneers and meniscectomy is no moreachieved through arthrotomy anymore. This technical procedure requires a long training to get a great efficiency and an innocuous menis-cectomy implementation. An important learn-ing curve is needed to achieve easily and safely ameniscectomy for the patient. The bases of thissurgery must be accurately acquired to answer to the different pathologic situations of themeniscus.We have made the difference between the medialmeniscectomy and the lateral meniscectomy, which must be carried out differently since they have their own characteristics. Actually, the por-tals are not the same, and the installation may be slightly different. Postoperative managementis also not comparable. Arthroscopy for menis-cectomies remains a surgical procedure with possible risks. These risks must be precisely assessed and explained to the patient. To con-clude, a meniscectomy will only be carried out after an accurate diagnosis, requiring modern imagery; arthrography, arthro-scanner, andMRI. The expected time for recovery is short,but long terms consequences will be explained to the patient.

Installation

Tourniquet

Its use has become systematic for a better sur-geon comfort. Actually, by avoiding any bleeding we improve the intra-joint visibility. Nevertheless, several studies (2–4) have shown that muscular cells could be altered, which is proved by electro-myographic modifications. Thfi ese alterations are Thvisible among 22% of patients after 15 min of tour-niquet and among 80% of patients after 60 min of tourniquet, which is an exceptional case after a meniscectomy. Th e revolving to normal state can Thlast for several months (5–6 months), without any long-term damage.Some studies have shown (5) that the use of tour-niquet was increasing the post-surgery pains and the risk of post-surgery complications and, above all, had a negative eff ect on physiotherapy, essen-fffftially from the muscular sideration.So, it is absolutely possible and better to achieve ameniscectomy without any tourniquet, above all, after a period of training.Therefore, the use of tourniquet must last a short time. Obviously, the counter-indications must be respected, such as the vascular ante-cedents. An irrigation of good quality must be respected to allow a good intra-joint visibility with or without tourniquet. The current use of an arthro-pump can also be an alternative to the tourniquet use.

The installation

Th ere are two main possible installations, accord-Thing to the surgeon habits:– Patient is installed in dorsal decubitus, the leg

being free at the end of the table, with the thigh fastened.

– Patient supine the lower limb lying down on the table, with a wedge on the lateral side of the thigh, and another wedge at the end of the foot (Fig. 1).

et al., The Knee Joint © Springer-Verlag France, Paris 2012M. Bonnin

110 The Traumatic Knee

niquet. Th is pressure must be weak to avoid any Thrisk of compartmental syndrome.

Th e fiTh rst technique is the most often used for a fimeniscectomy since it enables a suffi cient rinsing ffiout of the joint. The second benefiTh t is to be economi-fical too. Th e arthro-pump is often used with a shaver, Thso the indication will depend on the use of this tool, which is quite useful in degenerative lesions.

The instrumentation

Equipment has highly evolved since the origin of arthroscopy. To achieve a meniscectomy, few tools are required. Th ey must be chosen with care and Thexperimented before purchase, because of their high cost.We have the choice between motorized tools (shaver), whose use in meniscectomies is not compulsory. Arthroscopic optics and a camera are unavoidable. Th e ideal optics is generally a great Thangular optics (25° or 30°), and a 70° optics is rarely necessary. The optics will be selected to be Thautoclave to answer to the modern specificationsfiof sterilization. Th e camera will be mono CCD or Ththree CCD type. The fiTh rst type is highly suffifi cientffifor the meniscectomy procedures. Arthro trocar sleeve enables the penetration of the optics in theknee and the frontal irrigation opposite the arthro-scope itself, which improves the display.

Non-motorized tools Th e palpater hookTh is the fi rst instrument that is fiintroduced into the knee by the instrumental por-tal. Th ere must be a 3-mm mossy hook at its end Thto palpate without producing cartilage injuries. It must be suffi ciently rigid to enable a meniscus ffireduction. Th anks to its size, we can assess the Thspread and the depth of injuries. With the gradu-ations on its surface, we can appreciate the size of the lesions.Basket forceps, named rongeurs, are unavoid-able since they enable to perform or to complete a meniscectomy. Many types come to the market

Each of these installations has its own advantagesand disadvantages.• Th e pendent leg position enables to carry outTh

an arthroscopy without any lateral help, and thethigh fi xation permits a good control of rota-fitions that is very important in meniscectomies.Th e exploration of the lateral compartment is Thmade without the Cabot handling, which tendsto obstruct the irrigation of this compartment. Nevertheless, patello-femoral joint exploration isdiffi cult and requires an extension of the patient’s ffifoot against the examiner. On the other hand, there are more important asepsis mistakes due to the low position of the foot.

• Th e position of the lying leg enables an excellentThvision of the femoro-patellar joint; it requiresthe Cabot handling for the exploration of the lat-eral compartment and procedures on the lateralmeniscus. Th is Cabot handling is achieved by put-Thting the foot on the opposed knee, while imposinga fl exion and a slight varus constraint. Thfl e wholeThlateral meniscus is visualized by this technique. For the exploration of the medial meniscus, a val-gus constraint is held by positioning the foot onthe arthroscopist’s hip. Th us, by playing with the Thflexion and extension of the knee, the explorationflof the medial compartment is carried out without any diffi culty. We must keep moderated on the ffivalgus constraints as the developed strength can be important and risks of medial collateral liga-ment lesions are possible (Picture 2).

Irrigation

Th ere are two possibilities to achieve a meniscec-Thtomy:– Simple irrigation by gravity using physiological

salt solution, which drip is placed at a high level to get a good intra-joint pressure; in addition, a blood pressure cuff could be interesting.ff

– Arthro-pump, which enables a constant pressure in the joint, the pressure adjusted on the bloodpressure, limiting the bleeding in case of no tour-

Fig. 1 – classical installation , patient in dorsal decubitus. Fig. 2 – Valgus constraint to open the medial compartment.

Arthroscopic meniscectomy 111

be regularly checked up and sharpened, to avoid any surprise along the intervention, modifying the surgical procedure and its length.

Motorized toolsTh e shaver is not compulsory to carry out a menis-Thcectomy. Meanwhile, it enables to straighten the meniscus wall, to complete a difficult meniscec-ffitomy of the posterior segment of the medial or lateral meniscus. Its use is more interesting in the lateral meniscus cysts that can be treated by intra-joint portal. At last, it permits to straighten a flap fllocated on the lower side or to neaten an anterior segment of the lateral meniscus.Th e motorized blades are alternatively used, which Thenables the spontaneous throwing away of menis-cus parts. Th ey are small to slide under the con-Thdyles without damaging cartilage. Some blades can be twisted.Th e laser use to achieve a meniscectomy is more Thand more reported. Since it is expensive, its useis not common. Its harmlessness is not proven; cartilage injuries can occur after a too long use, and they depend on the dose (energy) and length of the use. Th e meniscectomy is implemented by Thcauterization. Th is technique is not yet common, Thso works are being carried out to precise modifica-fitions and eff ects of laser on cartilage.ffffTh e fiTh rst studies achieved in the departments of fiProf. Beaufi ls and Prof. Benoît since 1992 had fishown the immediate harmlessness and effi ciency ffiof laser Ho:Yag. Th is retrospective study showed Ththe superiority of laser meniscectomy vs. the clas-sical arthroscopic technique. A randomized study carried out by Blin and colleagues (7) in 1995, com-paring mechanical arthroscopic meniscectomy and laser meniscectomy, did not show the superiority of laser to achieve an arthroscopic meniscectomy. Laser can represent an extra advantage in certain cases such as locked knees, but its excessive cost and its limited use must not justify such a pur-chase. We are unaware of the long-term effect on ffffcartilage and under-chondral bone.

Medial meniscectomies

Fundamentals

Before deciding a medial meniscectomy, it is highly recommended to have a precise diagnosis of the type of lesion of this meniscus and its location. It is even very important to precise exactly the car-tilage state of the knee. These precautions enable Thto warn the patient about the surgery follow-ups. A retrospective study (8) that we have carried

with diff erent sizes, diffffff erent shapes, and several ffffangulations.Th e basic surgery box must contain a right 3.5-mm Thforceps that can reach the posterior segment and a 90° angled forceps working on the meniscus ante-rior segment. It can be completed with bigger ron-geurs of 4.5 and 5 mm, providing a faster splitting up of the meniscus tissue, in the most easily acces-sible zones.Many rongeurs come to the market; with distal angulations, with a handle curved to the right or to the left. Th ese diffTh erent types of rongeurs are ffffvery practical and can perform an easier meniscec-tomy. Th eir use is not unavoidable, and their cost This high.Th e most useful rongeur is the one which permits toThslide under the condyle without the risks of produc-ing cartilage lesions. For this purpose, it must be of double curve with upper concavity in its distal third.It is commonly named «curved on the flat side».flScissors are useful to start a meniscectomy in medium segment elegantly, their use is not advis-able in posterior segment since they are very bulky and the cartilage lesion risk is high. There Thare straight scissors and angled scissors at their end to choose a more accurate and proper angle. A 3.5-mm diameter seems to be a good compromisebetween effi ciency and low bulking.ffiTh e forcepsTh is essential; this forceps in its prin-ciple presents two small teeth at its ends, which are going to bite the meniscus. It is aimed either toremove a free fragment from the joint or to draw the meniscus that is not still detached (three-por-tal technique). Its use is only recommended in theanterior compartment of the joint. Actually, since it is bulky, its passage through the condyle is lim-ited. It is advisable to select a forceps whose open-ing and closing can be done with only two fi ngersfieither from the left hand or from the right hand.Th e meniscotomesTh are straight or curved. Also named tenotomes or Smillie scissors, their use mainly concerns the three-portal technique. So,the meniscus excision is performed on a drawn meniscus. One must be cautious while using these instruments; it is advisable to have very sharp scissors to avoid any escape and a poste-rior escape in particular, which could be brought about by an excessive pressure on the instrument.That is why single-use tenotomes exist where theThblade can be replaced as a bistouri blade. As ever in surgery, any strain on these instruments must be avoided. We can fi nd also 90° angled menisco-fitomes that can be useful in diffi cult conditions,ffion an anterior segment of the lateral meniscus for instance.Th ese instruments represent the minimum for aThmeniscectomy, possibly completed according tothe practices of the surgeon. The instruments must Th


– With the patient over 50 years: the simple x-ray standing up with a schuss x-ray will enable todetermine a posterior narrowing (Picture 5).

Complementary examinations will be discussed according to the context. An arthro-scanner is ideal to target cartilage lesions and their depth and spread. But an MRI is interesting (9) to avoid an osteonecrosis of the medial condyle, which can be a diff erential diagnosis of the degenerative medial ffffmeniscus lesion.Th ese precautions will enable to perform a menis-Thcectomy in the best conditions by limiting the risksof complications (10).Th e employed technique depends on the operator Thhabit and on the meniscus lesion type. Two previ-ous procedures must be solved before starting themeniscectomy:– Adjusted meniscectomy or splitting up– Partial or subtotal meniscectomySeveral studies (11,12) have shown that there was a direct relation between the long-term result and the importance of the meniscectomy. This isThan important argument to achieve “economical” meniscectomies.In most of the cases, it is advisable to remove the meniscus lesion as a whole. Th is is easy when it is a Thbucket handle. In other cases, the progressive split-ting up by rongeurs is necessary. Very often there is anassociation of the two techniques. The meniscus tis-Thsue must be left sound and safe by the meniscectomy.Th e meniscectomy is said to be total if it concerns Ththe capsule-meniscus junction, i.e., if the meniscus wall is removed. Trillat (13,14) has shown that itwas important to keep the meniscus wall by per-forming an intra-wall meniscectomy. The menis-Thcectomy is said to be partial when a good meniscus wall is left. It is the basic technique, and it enables to remove the mobile part and leaves a stable meniscus remnant.Th e meniscectomy is performed as far as the cir-Thcular fi bers of the meniscus wall. We speak of a fi

out with the Société Française d’Arthroscopiehas shown the evolution of meniscectomies over15 years. Th is study has shown that there were Th22% of radiographic abnormalities concerning a medial femoro-tibial reshape or an interline nar-rowing. Th e long-term result is much better with a Thyoung patient, with a traumatic lesion and a con-servation of the meniscus wall without any carti-lage lesion.This is to say, we must extremely be cautious toThcarry out a meniscectomy for a patient older than 50 years. Th is indication should only be done in Thcase of the uneffi ciency of a good medical treat-ffiment.Th erefore, it is recommended to perform paraclini-Thcal examinations before any minescectomy:– With the patient younger than 50 years: simple

face and profi le x-ray with monopodal stand upfiand a 30° axial view of the patella. An arthro-TDM or an MRI enable to precise the meniscuslesion (Pictures 3 and 4).

Picture 3 – arthro-TDM vertical medial meniscus tear.

Picture 4 – MRI and medial meniscus lesion. Picture 5 – Schuss X Ray, medial narrowing.


along the medial condyle, then in the intercondylar notch, and fi nally in the lateral femoro-tibial com-fipartment in the Cabot position. Th is exploration is Thvery important; it must be performed before doingthe second instrumental portal. It enables to pre-cise the type of lesion and mainly its importance. It enables to check the cartilage state and a possible diffi culty to set the knee into forced valgus.ffiTh e antero-medial portal will be performed by Thtrans-illumination in the dihedral antero-medial angle above the anterior segment of the medial meniscus. Th en the palpater will be introduced andThpalpate both menisci on their two sides by lifting them and the two cruciate ligaments. The antero-Thmedial portal will be more or less high and medial according to the lesion localization.

Bucket handle and vertical longitudinal lesion (Picture 7)Th e two-portal technique needs only one instru-Thment, the arthroscope being in the second portal. To treat a dislocated bucket handle of the medial meniscus with this technique, we must perform the following:(a) Reduce the meniscus lesion with the hook

(Fig. 1).Th e arthroscope is introduced through the antero-Thlateral portal. Th e palpater is introduced through Ththe antero-medial portal, the reduction is per-formed by a pressure at the top of the handle and by a slight valgus strain at the tibia level, and the increase of the fl exion is often necessary to achieve flthe reduction.(b) Cut the posterior part at the posterior segment

levels (Fig. 2).Th is procedure is performed by the antero-medial Thportal, with a rongeur, a bistouri, or a tenotome. It is advisable to leave a small fl ap to avoid thefl

subtotal meniscectomy when the importance of the lesion requires the excision as far as the menis-cus wall of an important functional segment of ameniscus, for instance, a posterior segment.P. Beaufi ls (15) has risen this problem of a «partial fimeniscectomy» and suggests to use a terminology making reference, on the one hand, to the inter-ested segments and, on the other hand, to the meniscus excision quantity for each segment. TheThexcision of the whole back segment of the medial meniscus is called total meniscectomy of the pos-terior segment and not partial meniscectomy.Th is terminology is very important for the writingThof the surgical report and to assess the evolution.

Techniques

It is a standard to oppose the two-portal technique and the three-portal technique.

Two-portal technique (Picture 6)The antero-medial and antero-lateral portals areThsuffi cient to achieve the majority of medial menis-fficectomies.First, the antero-lateral portal will be performed to introduce the arthro-trocar sleeve and the arthro-scope. Th is portal will be performed in the dihedral Thangle formed by the lateral edge of the inside patel-lar tendon and the point of the patella up at 1.5 cmfrom the upper edge of the lateral tibial plateau. Arthro trocar sleeve will be introduced after cut-ting the skin and the patella with a bistouri. TheTharthro trocar sleeve will be directed to the inter-condylar notch, the knee being flexed at 30° or 45°.flTh en, the arthroscope will be directed to the kneeThfemoro-patellar joint, knee being in extension,to start the knee exploration. The latter will beThsystematic, with the following exploration in themedial femoro-tibial compartment by going down

Picture 6 – two portal approach, medial portal for arthroscope and lateralportal for other tools. Picture 7 – Bucket handle of medial meniscus.


escape of the meniscus once the anterior part isbeing cut. Th is procedure is more easily done with Tha valgus strain on the tibia to open the medial compartment. Th us, the arthroscope goes more Thdeeply into the medial compartment giving a higher visibility of the posterior segment of the medial meniscus.(c) Cut the anterior part (Figs. 3 and 4).There are two techniques to do this procedure: Theither with angled scissors through the antero-medial portal or with an inversion of optics and instrument.With the fi rst technique, we must be careful not to fileave a too big stump on the anterior segment; theantero-medial portal is not easy. With the second technique, the optics is placed through the antero-medial portal and the instrument, and a rongeurthrough the antero-lateral portal. This methodThenables a direct access of the anterior segment by the rongeur or scissors.(d) Remove the bucket handle with a forceps.The forceps grasps the meniscus fragment at the Thlevel of the anterior segment. A soft tear is enoughto break the posterior bridge.Some problems can occur:

Fig. 1

Fig. 2Fig. 3

Fig. 4

– Diffi culties of reduction exist with the aging ffibucket handles. We must insist in doing little fl exion extension movements associated with a flvalgus strain while straining the top of the han-dle with a more rigid palpater or sometimes the mossy arthro trocar.


– In case of an impossibility of reduction, it enablesto cut the posterior segment of the medial menis-cus with a fi ne rongeur or a curved meniscotome fiintroduced by the antero-medial portal. Th is ges-Thture is diffi cult and requires to take very cautious ffimeasures in the process not to damage the pos-terior cruciate ligament.

– Th e loss of the meniscal fragment may occur. It Thmust be avoided if what has been described previ-ously is respected. Th e most annoying is the going Thback of the posterior segment if the anterior seg-ment is removed fi rst. Otherwise, we must look fifor the fl ap to be dislocated at the front with the flpalpater at the rear of the medial condyle. Then,Thit will be fi xed on a forceps introduced by a second fiantero-medial portal performed outside the firstfione. To avoid the lost of the fragment, a second antero-medial portal may be done. Meanwhile,some artifi ces are possible, such as the passage fiof a suture thread by the antero-medial portal, which will permit the tear and even the extrac-tion of the bucket handle after the section of theposterior segment (16).

Th e procedure fiTh nishes with a neat checking of the fimeniscus remnant by the palpater and a regulariza-tion with a rongeur. In case of a longitudinal lesion, lesion of type 3 of Trillat, the principle is identical.

Meniscus fl apMeniscus fl aps are resected, and the meniscus is flregularized according to the lesion spread.(a) Postero-medial fl ap with medial base (Fig. 5)flTh e flTh ap resection is made by introducing a ron-flgeur through antero-medial portal, the optics being antero-laterally located. Th e regularization is Thspread as far as the posterior segment. Th e rongeur This placed uphill from the lesion. The flTh ap is extractedfleither by the forceps or directly by the rongeur. TheThmeniscus remnant is carefully checked.(b) Postero medial fl ap with posterior base (Fig. 6)flTh is type of flTh ap is diffifl cult to extract since it dislo-fficates back to the posterior segment. Th e regulariza-Th

Picture 8 – Medial fl ap displaced under the meniscus.

tion is done by a rongeur introduced by the antero-medial portal, the optics being antero-lateral. ThisThpart of the posterior segment is often narrow, the passage of the rongeur is delicate, and a val-gus strain must be applied to open this compart-ment. Th e condyle cartilage lesion must be avoided Thby opening up the rongeur. A small-sized rongeur with upper concavity curve is used at its best.(c) Medial fl ap displaced under the meniscusflTh e flTh ap base is located in the anterior segment or flmedial of the meniscus. Th e palpater introducedThthrough the antero-medial portal extracts this lesion (Pictures 8 and 9). We can switch the instruments and optics in the diff erent portals. Thffff e arthroscope This introduced through the antero-medial portal and the instruments through the antero-lateral portal. Th e rongeur starts the meniscectomy at the base Thof the fl ap on the anterior or medial segment. Its flaccess is direct. Th e meniscectomy is then per-Thformed to the posterior segment with the rongeur introduced through the antero-medial portal. TheThfl ap is extracted and the meniscus regulated.fl

Fig. 5

Fig. 6


this posterior segment raises occasional problems with locked knees, and a manual postero-medial pressure by the assistant enables the posterior seg-ment to go into the medial compartment. This arti-Thfi ce is often useful on degenerative meniscus.fiTh erefore, the lesion is totally removed. SometimesThit is useful to do this one-part meniscectomy in two parts. Indeed, to have a better visibility of the pos-terior segment, the anterior segment is split off by ffa transverse incision at the level of the medial seg-ment. Th e anterior fragment is removed fiTh rst.fi

Three-portal techniquesTh is technique, commonly used by J.L. Prudhon Thenables to perform a “one-part” meniscectomy in front of any type of medial meniscus lesion. It per-mits to maintain under strain the meniscus frag-ment during the whole meniscectomy.With this technique, it is compulsory to use themedian portal of Gillquist (17) for the arthroscope in «the one-part meniscectomy». A third portal can also be used for the treatment of a bucket handle or a longitudinal lesion.

One-part meniscectomyTh ree main steps are necessary:Th(a) Section of the anterior strip (Fig. 7)Th e optics is in median situation, through the patellar Thtendon 1 cm below the top of the patella. A first ante-firo-medial instrumental portal is carried out above the anterior meniscus segment. Th e section of the free Thedge of the meniscus is performed with a 11 mm bis-touri or with a 60° angled scissor introduced through the antero-medial portal, and this section is carried on as long as obtaining a 1/2-cm meniscus flap.fl(b) Section of the medial segment (Fig. 8)A second antero-lateral instrumental portal is carried out, lower than the arthroscopic medial portal. A for-ceps is introduced through this portal and draws the meniscus fl ap previously detached. A 3 mm menisco-fltome is introduced through the antero-medial portal and goes progressively into the diedre of: (Picture 10)

Tear lesionHorizontal tear of the medial meniscus requires a large excision, named “regulated meniscectomy or one part-meniscectomy.” Th is meniscectomy can be Thperformed successfully by a two-portal technique. It can assess the quantity of the removed meniscustissue.(a) Incision in the anterior segmentThis incision is directly made by bistouri throughThthe antero-medial portal, the arthroscope located in antero-lateral. Th is incision goes the farthest to Ththe medial and posterior segment with a tenotome or a rongeur introduced through the antero-medial portal. This anterior section can also be made with a Throngeur introduced through the antero-lateral por-tal while the arthroscope is into the antero-medial portal and displays the anterior segment.(b) Section of the medial segmentThis section is performed either through the antero-Thmedial portal with angled scissors or a bistouri or through the antero-lateral portal with a rongeur. Th e palpater enables to check the anterior sectionThand, above all, to move the fl ap to assess the size of flthe base on the posterior segment.(c) Section of the posterior segmentTh e rongeur is introduced through the antero-me-Thdial portal, with a valgus strain, the section being made at the fl ap base. Thfl e section is performed to Ththe medial segment. A little tractus must be left not to lose the meniscus fragment.(d) Extraction of the meniscusTh e forceps introduced through the antero-medial Thportal grasps the meniscus fragment through its anterior segment. Th e posterior tractus splits offTh ffunder the traction. Th e meniscus remnant is checked Thout and regulated with a rongeur. Th e regulation of Th

Picture 9 – The palpater introduced through the antero-medial portalextracts this lesion.

Fig. 7 – Section of the anterior strip.


– inside the detached meniscus segment;– outside the meniscus wall.Th is progression is carried on as far as the angle Thpostero-medial point, and then backward themedial condyle.Th e meniscus segment detached in such a way Thcan then be dislocated in the intercondyle notch. Th is is the guarantee of the total section of medialThstrips of the meniscus.(c) Section of the posterial strip (Fig. 9)It is easy if the segment is dislocated. The for-Thceps introduced through the antero-lateral portal strongly draws the meniscus while the menisco-tome cuts the posterior strip. The meniscotome is Thintroduced through the antero-medial portal and the optics through the medial portal.Sometimes a rongeur can be used to help this pro-cedure. By this technique, the meniscus lesion is

totally removed (Fig. 10). Th e meniscectomy is Thcompleted on demand with the rongeur.

Bucket handle and longitudinal lesionWe have previously seen in the treatment of thebucket handle and longitudinal lesions that there was a risk to lose the meniscus fl ap by the two-flportal technique. Th us, we absolutely can carry Thout a third portal to give a strain to the meniscus fl ap. With this technique, it is not compulsory to flcarry out a patellar tendon portal but a classicalarthroscopic antero-lateral portal.Th e meniscectomy procedure includes the following:Th(a) Reduction of the meniscus lesion with the pal-

pater hookTh e arthroscope is introduced through the antero-Thlateral portal. Th e palpater is introduced through Ththe antero-medial portal.(b) Section of the posterior strip at the level of the

posterior segmentTh is procedure is performed through an antero-Thmedial portal, with a rongeur, a bistouri, or a teno-tome, while leaving a small-size posterior strip.(c) Section of the anterior stripTh is procedure is performed through the antero-Thmedial portal with angled scissors, or throughthe antero-lateral portal with a rongeur. Then, weThcarry out a closer and lower portal to the patellar tendon through a meniscotome, or a rongeur can be introduced.

Picture 10 – A 3 mm meniscotome is introduced through the antero-me-dial portal and goes progressively into the diedre of : inside the detachedmeniscus segment and outside the meniscus wall.

Fig. 8 – Section of medial segment with meniscotome, through the antero-medial portal, and the forceps draws the anterior segment by the antero-lateral portal.

Fig. 9 – Section of the posterior strip.

Fig. 10 – Removing the meniscus fl ap.


related to skin plans, which considerably hampersthe tool introduction. To avoid this phenomenon, it is appropriate to make the portal in the Cabot position, which enables to have a direct access to the lateral compartment.Th e common technique uses the antero-lateral Thportal for the arthroscope and the antero-medial portal as a tool portal. Th e gestures on the antero-Thlateral meniscus can be also carried out by using the medial portal for the arthroscope and the ante-ro-lateral for the tools to reach the posterior seg-ment of the lateral meniscus. We should not hesi-tate in changing the tool and arthroscopic portals to improve the vision conditions on the one handbut also the ergonomic placement of the tools on the other hand.

Bucket handle, longitudinal injuries (Picture 12)

In case of dislocated bucket handle, it is compul-sory to reduce the lesion.– Th e reductionTh (Fig. 11) is performed with a pal-

pater hook introduced through the antero-me-dial portal. The latter is sometimes diffiTh cult and ffirequires the mobilization of the joint in flexionflwith a varus strain to open the lateral compart-ment.

– Th e section of the posterior strip is performed Ththrough the medial portal with scissors or forceps (Fig. 12), the optics being in antero-lateral posi-tion. Sometimes, it is necessary to go through the lateral portal (Fig. 13) if the longitudinal fis-fisure is in the most posterior part of the posterior segment.

A small posterior bridge will be kept.

(d) Extraction of a bucket handle with a forceps and a complete posterior section

Th e forceps grasps the meniscus flTh ap at the levelflof the anterior segment. This forceps is introduced Ththrough the medial portal closest to the patellar tendon. A soft traction strains the meniscus frag-ment, while the meniscotome or the rongeur com-pletes the posterior section. These latter tools are Thintroduced through the portal closest to the patel-lar tendon.With this technique, we can cut the anterior seg-ment before the posterior segment since the latterwill be handled by a forceps.Th e procedure ends by a careful checking of the Thmeniscus remnant with the palpater and a regula-tion with the rongeur. In the case of a longitudi-nal lesion, Trillat type 3 lesion, the principle is thesame.

Lateral meniscectomies

The lateral meniscus shows anatomic particular-ities different from those of the medial menis-cus. The accessibility of the anterior segmentis often difficult. Its thickness is more impor-tant and can raise some problems of section. The existence of the popliteus tendon and itshiatus makes this meniscus more fragile, and the meniscectomy must preserve the meniscusbridge at the utmost in front of the hiatus, not to transform a partial meniscectomy in a total one. In case of the break of the meniscus bridge, the posterior segment is too much unsteady tobe kept.Th e lateral meniscus presents anatomic variations Th(discoid meniscus) and may need a meniscectomy. In addition, it is the core of cystic formations,which are in fact pseudocyst meniscus more often related to longitudinal fissure meniscus injuries or fiacross clivages.

Portals

Two portals are usually sufficient to perform a ffilateral meniscectomy. The antero-lateral portal is Thsuffi cient to explore the whole meniscus from itsffianterior segment to its posterior segment. It willbe carried out in the same way as in the medial meniscectomy.Th e antero-medial portal is generally located Thhigher to treat a medial meniscus lesion. It will be done by trans-illumination that avoids injuring a superfi cial vascular element.fiTh e Cabot position (Picture 11) or the simple varusThposition and medial rotation slide the patellar plans

Picture 11 – medial portal for lateral meniscus tear in cabot position.


– Th e section of the anterior stripTh (Fig. 13) is also performed either with a rongeur or a bistouriintroduced through the medial portal or with 90° angled scissors introduced through the lateral portal. The meniscus section must be neat and Thmust grasp the whole lesion at once, to avoid a fl ap being left on the anterior segment, which isflmore diffi cult to regulate when the bucket handle ffiis removed.

– The lesion extraction (Fig. 14) is carried out with a forceps introduced through the medial portal. The meniscus is regulated with a ron-geur, and the meniscus remnant is palpatedwith care.

Sometimes the lateral bucket handle is hard to be treated, even with an impossibility to reduce thelesion. Th en, the bucket handle must be cut in site. ThTh erefore, a third portal can be useful to hold the Thfragment. While cutting the bucket handle in site, care should be taken not to damage the anterior cruciate ligament.

Fig. 11 – Reduction of the bucket handle.

Picture 12 – Bucket handle of lateral meniscus. Fig. 12 – Section of the posterior strip through the medial portal.

Fig. 13 – Section of the anterior strip.

Fig. 14 – Extraction of the lesion with the forceps.


lateral portal for the posterior segment and firstfimedial portal for the anterior and median seg-ments.It is sometimes diffi cult to reach one of the two ffileaves on the anterior segment or at the junc-tion. Th us, the 90° angled rongeurs are useful; Ththey are introduced through the medial portal (Picture 14). Th e shaver can be helpful to treat Ththe anterior lesions by using a curved blade or a right blade.

Radial lesions

Th ey are frequent in the median segment. ThTh eThregulation through the antero-medial portal is easy since the tool is opposite the lesion. TheThregulation is carried out from part to part of the lesion. It is performed with a rongeur by split-ting up. Th e free side must be regular at the end Thof the surgery. We must take care to respect themeniscus bridge in front of the popliteus hiatus(Picture 13).

Picture 13 – lateral meniscus and respect of the popliteus hiatus.

Meniscus strips

The pedicle of the strip is cut offTh , and the free side ffregulated to avoid any step. Th e danger is to lose Ththe strip when cutting it. Th e use of a rongeur as Tha forceps is ever possible with small strips; oth-erwise, a thin tractus must be left, which will betracted with a proper forceps. The tools are more Thoften introduced through the antero-medial por-tal. If the strip has its base on the posterior seg-ment, the antero-lateral instrumental portal isvery interesting.

Horizontal clivage

Th is kind of lesions often spread from the anterior Thsegment to the posterior segment. The fiTh rst stepfiof the treatment is to palpate the whole lesion toassess its spread and, above all, its relation with the hiatus popliteus.Th e regulation is more often carried out through aThsplitting up with a rongeur alternating the portals:

Picture 14 – treatment of an anterior lesion of lateral meniscus with the 90°angled rongeur.

Cyst of the lateral meniscus (Figs. 15–18)

Th e therapeutics of lateral meniscus cysts has Thdeeply evolved, from Phemister (18), who was practicing a total medial meniscectomy through arthrotomy, to Muddu (19), who proposed the treatment by corticoid infi ltration. Chassaingfi(20,21) proposes to treat the cyst by arthroscopy. Parisien (22) as well uses the shaver to perform the cyst intra-joint debridement.Th e aim of arthroscopy is, on the one hand, to treat Ththe meniscus lesion by respecting the meniscus wall and, on the other hand, to treat the excisionof the cyst content.Th e arthroscopy has enabled to limit the impor-Thtance of the meniscectomy, and the latter is partial while maintaining a maximum of sane tissue and,above all, the meniscus bridge en regard of the hia-tus popliteus.Th e surgery starts by the treatment of the menis-Thcus lesion by respecting the meniscus wall. For some people, the treatment stops there; the cyst is cured when the meniscus lesion is treated. Th en,Th


a splitting up with a rongeur is very efficient but ffilaborious. Th e procedure starts from the axialThside often thick, diffi cult to split up, and getting ffiaway under the rongeur. Th us, we must go fromThthe antero-medial to the antero-lateral portal, to reach the free side in the best conditions. The ron-Thgeur introduced through the lateral portal begins

the notch opposite the cyst is opened with a ron-geur or with a meniscotome (23).Th e last step of the surgery is the exeresis of theThcyst content. At best, it is removed by using amotorized blade or «shaver» introduced through the meniscus communication of the cyst. TheThshaver sweeping inside the cyst will sharpen thecyst walls and raises a bleeding improving the cicatrization. Th e angled shaver is useful when the Thperforation is located in the anterior segment or atthe junction of the anterior and median segments. Hulet and Locker (24,25) point out that the recidi-vation of the cyst is in most of the cases due to anunsatisfactory treatment of the meniscus lesion.Persistant meniscus lesion of the anterior seg-ment. According to him, the use of angled instru-ments and the change of portal are imperative to leave no lesion.

Discoid meniscus (Picture 15)

This type of meniscus can be at the origin of Tha painful lateral syndrome, above all, when itcracks. Th e partial meniscectomy or «menisco-Thplasty» is sometimes very difficult, and a subto-ffital meniscectomy is often necessary. A meniscuswith a proper shape must be reshaped. Therefore,Th

Fig. 15

Fig. 16

Fig. 17 Fig. 18

Picture 15 – discoid meniscus.


Physiotherapy is systematically proposed, and some physiotherapy sessions sound to be profit-able. Physiotherapy must be soft and unpainful. For this goal, a precise protocole must be given to the physiotherapist. The goal is to recoverthe knee mobility without any pain. The work of muscular strengthening is carried out with a lot of care with the association of systematic stretching of the anterior and posterior muscu-lar chains.At last, we must be pinpoint that the follow-ups of the lateral meniscectomy are longer and more dif-fi cult than the medial meniscectomy (29).fi

Conclusion

Th e meniscectomy techniques have become daily Thprocedures of an orthopaedist surgeon. Mean-while, these procedures must not be generalized since these procedures require a long learning curve to be correctly performed. Th e surgery indi-Thcation must be decided with great care and caution since the consequence of a meniscectomy may be severe with the probability of a long-term arthritis development.A good development of a meniscectomy is per-formed with an accurate surgery indication, andadditional proper examinations are asked respect-ing the technical principles.

References

Watanabe M, Ikeuchi H L’arthroscopie. Encycl Med Chir, 1. Paris, Appareil locomoteur, 14001:10, 4-1981<AQ: Pleasecheck Refs. 1, 6, and 10 for completeness. Please provide year of publishing in these refs.>Dobner JJ, Nitz AJ (1982) Post meniscectomy tourniquet2. palsy and functionnal sequelae.Am J Sports Med 10:211–214Johnson DS, Stewart H, Hirst P, Harper NJ (2000) Is tour-3. niquet use necessary for knee arthroscopy. Arthroscopy 16:648–651Th orbald J, Ekstarnd J, Hamberg P, Gillquist J (1985) Mus-Th4. cle rehabilitation after arthroscopic meniscectomy with or without tourniquet control. A preliminary randomized study. Am J Sports Med 13:133–135Daniel DM, Lumkong G, Stone ML, Pedowitz RA (1995) 5. Eff ects of tourniquet use in anterior cruciate ligament ffffreconstruction. Arthroscopy 11:307–311Orengo P, Zahlaoui J Chirurgie des ménisques. Encycl Med6. Chir, Paris, Techniques chirurgicales, Orthopédie trauma-tologie, 44785, 4.10.06, 18 pBlin JL, Tremoulet J, Hardy Ph, 7. et al. (1995) Méniscecto-mie au laser Holmium:Yag versus méniscectomie méca-nique sous arthroscopie. Etude comparative prospective randomisée. (Résulats précoces sur 96 sujets) nnales de la Société Française d’arthroscopie

Chatain F, Robinson Ah, Adeleine P, 8. et al. (2001) The natural Thhistory of the knee following arthroscopy medial meniscec-tomy. Knee Surg Sports Traumatol Arthrosc 9:19–27

the meniscoplasty on the posterior segment. Wecontinue in the median segment far from the meniscus wall. Later we can change arthroscopeand tools to cut the anterior part of the meniscus with the rongeur introduced through the medial portal. At least, we remove the fl ap, and the rem-flnants become like a normal meniscus with the time (26).

The follow-ups

Th e arthroscopy ends up with a cautious clean-Thing of the knee. Any meniscus fragments must be removed off , without any remnants in the portal,ffsources of chronic pains. Th e tourniquet is released Thbefore the joint draining off; this enables to ensure ffno intra-joint important bleeding or at the portallevels.Th e closure of the portals is carried out by severalThways: unresorbable wires, resorbable wires, or even adhesive bandage.Some infl ammatory granulomes have beenflobserved at the entry points. These induration Thpoints may come from small meniscus fragments embedded in the portal. A particularly cautious cleaning must be done a these portals.Th is surgery is often carried out in ambulatory Thhospitalization. Th e procedure can be performed Thunder local anesthesia as shown by Béguin and Locker (27,28); nevertheless, the other forms of anesthesia are more currently carried out: rachi-anesthesia, crural block and general anaesthesia.Patients go out the same day of the surgery. TheThsurgeon must provide information to the patienton the surgery and its expected follow-ups.Th e surgery report is an important moment. It Thmust be accurate, and precise the amount of the removed meniscus, the remaining part, and the aspect of the meniscus wall. Finally, it is important to precise whether this meniscectomy has beendiffi cult, laborious, or easy. Thffi is is an indicator for Ththe evolution and the meniscectomy prognosis. Itmust also give details on the cartilage state with the diff erent steps of gravity and the extension of fffflesions for a long-term prognosis. Th e iconogra-Thphy is an important element: photo or video. TheThdevelopment of the digital photography and soft-ware for fi ling these photos are interesting data for fithe clinical fi le of the patient.fiTh e walking is possible at once without any help. ThSports activity is possible after 1 month post-sur-gery in case of no complication and, above all, in the context of a traumatic meniscus lesion. In thecontext of degenerative lesions, sports activity willdepend above all on the degree of coexistent carti-lage lesions.


Muddu BN, Barrie JL, Morris MA (1992) Aspiration19. and injection for meniscal cysts. J Bone Joint Surg 74-b(4): 627–628Chassaing V, Parier J, Artigala P (1985) L’arthroscopie20. opératoire dans le traitement du kyste du ménisque externe. J Med Lyon 66(1406):449-453Chassaing V (1985) Chirurgie du genou par arthroscopie.21. Conf. d’enseignement de la SOFCOT 1985, n 23, pp. 103–120. Expansion scientifi que Française, ParisfiParisien JS (1990) Arthroscopic treatment of cysts of the22. menisci. Clin Orthop 252:154–158Glasgow MMS, Allen PW, Blakeway C (1993) Arthroscopic 23. treatment of cysts of the lateral méniscus. J Bone Joint Surg 75-b(2):299–302Hulet C (1993) Les kystes du ménisque externe. Etude 24. rétrospective d’une série de 124 kystes traités par arthros-copie. Th èse Médecine 1993 CaenThLocker B, Hulet C, Vielpeau C (1992) Lésions traumatiques 25. des ménisques du genou.Editions techniques. Encycl Méd Chir (Paris, France), Appareil locomoteur, 14084 A10:12Vandermeer RD, Cunnigham FK (1989) Arthroscopic 26. treatment of the discoid lateral meniscus: results of long terme follow-up. Arhroscopy 5:101–109Beguin J, Locker B (1981) Arthroscopie du genou sous 27. anesthésie locale. J Med Lyon 1932:7–9Locker B, Beguin J, Thomassin G,Th28. et al. (1990) L’anesthésie intra-articulaire en arthroscopie du genou. Rev Chir Orthop 76(Suppl 1):152–153Panisset JC, Neyret P (2002) Méniscectomie sous 29. arthroscopie. Encycl Med Chir. Techniques chirurgicales- Orthopédie-traumatologie, 44-765:12

Folinais D, Th elen Ph (1993) L’imagerie des ménisques desTh9. genoux après 50 ans. Rev Chir Orthop 79:320–334Panisset JC Conduite à tenir en cas d’échec du traitement10. arthroscopique. Actualités dans la rééducation. Le genoudégénératif. Sauramps Médical 10/2000Northmore-Ball MD, Dandy DJ (1982) Long term results11. of arthroscopic partial meniscectomy. Clin Orthop167:34–42Neyret Ph, Walch, Dejour H (1988) La méniscectomie12. interne intra-murale selon la technique de A. Trillat: résul-tats à long terme de 258 interventions. Rev Chir Orthop74:637–646Trillat A (1973) Les lésions méniscales internes. Les13. lésions méniscales externes. Chirurgie du genou. JournéesLyonnaises de chirurgie du genou. 04/1971. Simep, ed.,VilleurbanneTrillat A (1962) Lésions traumatiques du ménisque interne14. du genou, classifi cation anatomique et diagnostic clinique.fiRev Chir Orthop 48:551–560Beaufi ls P (1993) L’arthroscopie opératoire dans lafi15.pathologie mécanique du genou. Apport et limites. Cahiers d’enseignement de la SOFCOT. Conférences d’enseignement, pp. 93–108Binnet Mehmet SMD, Gurkan Ilksen MD, Cetin Cem MD 16.(2000) Arthroscopic resection of bucket-handle tears with the help of a suture punch: a simple technique to shorten operating time. Arthroscopy 16(6):665–669Gillquist J, Oretorp N (1982) Arthroscopic partial menis-17.cectomy. Clin Orthop 167:29–33Phemister DB (1923) Cysts of th lateral semi-lunar carti-18.lage of the knee. JAMA 80(9):593–595

the knee joint || arthroscopic meniscectomy

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