Meniscus repair

/in /by

Defination

Keyhole surgery is used to repair a damaged meniscus in a meniscal repair. It is an outpatient, minimally invasive technique. Factors that determine success include the age and location of the tear, the patient’s age, as well as any other injuries that may have been sustained.

courtsey:orthobullet.com

Anatomy

The main meniscal functions are to distribute stress across the knee during weight bearing, to absorb shock, to serve as secondary joint stabilisers (in an anterior cruciate ligament deficient knee, menisci will serve as joint stabilisers [1], to provide articular cartilage nutrition and lubrication, to facilitate joint gliding, to prevent hyperextension, and to protect the joint margins.

In combination with tibial internal rotation, the femoral condyles slide posteriorly on the tibial plateau during knee flexion. During knee flexion, the lateral meniscus moves twice as far anteroposterior as the medial meniscus. This translation prevents the femur from hitting the tibial plateau’s posterior border. [2]

The meniscus is split into three zones: red-red, red-white, and white-white. The zones are distinguished by vascularization and consequently by the possibility for healing. The red-red zone is the meniscus’s periphery zone. It is extremely well vascularized and heals quickly. The vascularization of the medial and lateral meniscus varies amongst patients, ranging from 20-30 to 10-25 percent width. The red-white zone is the middle part of the body, with reduced vascularization but the ability to heel occasionally. Because there are no blood capillaries in the white-white zone, it cannot mend.

Epidimiology

Meniscal lesions are the most common intra-articular knee injury and the most prevalent reason for orthopaedic surgery. Meniscal lesions occur at a 0.066% yearly rate. [24] Male patients (59,5%) had more solitary meniscal repairs than female patients (40,5 percent ). This is similar to male patients (60%) receiving concurrent meniscal and anterior cruciate ligament repair. So most meniscal repair patients are men. [3]

Meniscal tears are common in middle-aged and older individuals due to deterioration.

Sports-related injuries cause one-third of lesions in young patients, due to cutting, twisting, hyperextension, or forceful motions. ACL damage occurs in over 80% of meniscus tears.

Children’s meniscal lesions vary from adult lesions. In youth, almost 70% are isolated meniscal lesions induced by sport-related knee twisting. [4]

Indication for procedure

Nonoperative therapy for meniscal injuries in young athletes is seldom effective, and repair is typically necessary. [5]

Meniscal repair should be considered if the tear is peripheral, longitudinal, with concomitant ACL restoration, and in younger individuals. Complex or degenerative tears, central tears, and unstable knee tears have a lower chance of healing. There are several mending methods. [6] When feasible, active patients should preserve meniscal tissue regardless of age.[7]Meniscal rips repairable include those > 1 cm in length and located in the outer 20% to 30% of the periphery, or the so-called red-red zone. The clinician’s discretion should be used to patch rips closer to the red-white zone’s junction. Vertical, longitudinal rips within 3 mm of the periphery rim are repairable.

Indication for surgery

First, a meniscal tear must be clearly diagnosed before deciding on surgical or non-surgical treatment. This choice is dependent on the patient’s age, co-morbidities, and compliance, as well as the tear’s location, age, pattern, and stability. Surgery is required for unstable tears. [6]>

Asymptomatic or stable degenerative or non-degenerative tears are non-surgically treated. Other tears, such as non-degenerative or symptomatic tears, are surgically addressed. [7] The second choice is between meniscal repair and meniscectomy. If none of the other surgical options work, complete meniscectomy is the final resort. 1) the clinical examination, 2) associated lesions, and 3) the kind, location, and amount of the meniscal tear. [8] The success rate is modified by combining meniscal repair with ACL restoration. Several research have concluded that the impact is either good or detrimental. [2] [5] [7] Tenuta JJ et al. discovered that the lesion’s breadth is essential, since no lesion wider than 4 mm healed. [5]

Differential diagnosis

Tenderness and effusion at the joint line. The joint line tenderness test, on the other hand, may be falsely positive in cases of osteoarthritis, osteochondral abnormalities, collateral ligament damage, or fractures. [5]

Effusion may also occur when the cruciate ligaments, bones, or articular cartilage are damaged.

• Flexing and loading the knee commonly worsens symptoms; movements such as squatting and kneeling are poorly tolerated. The same is true for individuals with different disorders such as chondromalacia patellae, fractures, and Sinding Larsen Johansson Syndrome.

• Common complaints include ‘clicking,’ ‘locking,’ and ‘giving way.’ Patients who have anterior cruciate ligament injuries also complain of ‘giving’ way. Osteochondritis dessecans is also associated with a sense of instability and locking.

Clinical presentation:• Joint line tenderness and effusion.• Symptoms are frequently worsened by flexing and loading the knee, activities such as squatting and kneeling are poorly tolerated.• Complaints of ‘clicking’, ‘locking’ and ‘giving way’ are common

Dignosis test

A relevant patient history, physical examination, and adequate imaging procedures are essential for establishing a diagnosis. [5]  The best common test for meniscal damage has been found to be joint line soreness. If a pop or snap at the joint line occurs when bending and twisting the patient’s knee, McMurray’s test is positive.

Apley’s test is conducted on a prone patient with the examiner hyperflexing the knee and rotating the tibial plateau on the condyles.

Steinman’s test is conducted on a supine patient by flexing and rotating the knee.

With the patient squatting, Ege’s Test is conducted, and an audible and palpable click is heard/felt over the location of the meniscus tear. A medial meniscus tear is detected by turning the patient’s feet outwards, while a lateral meniscus tear is detected by turning the patient’s feet inwards.

Meniscal imaging is an important decision-making tool in the surgical therapy of meniscus injuries. Accurate imaging of the meniscus is required to assess the affected region and choose the best therapy. Imaging is also useful for postoperative monitoring and therapy, as well as follow-up and the detection of any subsequent harm. Magnetic resonance imaging (MRI Scans) is the predominant imaging technology at the moment. Radiography, Computed Tomography (CT Scans) scan, Computed Tomography (CT) arthrography, and Magnetic Resonance Arthrography are further approaches. [1]

The benefits of MRI in the diagnosis of a meniscus lesion are as follows: grade I and grade II tears are recognised sooner, extra-articular structures are evident, there is no radiation, and MRI is a non-invasive imaging technology. [9]

Outcome measures

R.P.Walter et al. discovered an overall meniscal repair success rate of 85-90 percent. [7] Patients who had concurrent anterior cruciate ligament restoration had considerably better meniscal repair results. (91 percent), but those who had previously had anterior cruciate ligament restoration had a considerably lower meniscal repair success rate (63 percent ). Bohnsackdiscovered an 86-95 percent recovery rate. Meniscal repair has a high overall success rate in mending menisci. [10]

In the majority of the trials, a second MRI was performed to confirm whether or not the lesion had healed. When there is no lesion on the second MRI and the patient is able to resume his usual life/activities, the patient is regarded to have healed.

When treated as an independent procedure, locked bucket-handle meniscal rips heal at a rapid rate, even when full weight bearing and activity before reconstruction is permitted and the tear is in the white-on-white zone.[3] The number of persons healed by meniscal repair is unaffected by age or the interval between injury and operation.[4]

Surgical repairs are classified into four types: open, inside-out, outside-in, and all-inside.

For each procedure, the loose components must be removed, both sides of the tear must be sanded, and vascularity must be stimulated.

[10]

The all-inside procedures are appealing due to the reduced operating duration and easiness of the technique. The all-inside strategy yields favourable short-term effects; but, long-term evidence on these procedures is insufficient. [1]

Patients who have peripheral meniscus tears repaired improve more quickly than those who have tears in the middle one-third area repaired or who have meniscal transplantation. [6]

Meniscectomy has the benefit of removing just the injured tissue. It is critical that the circular collagen fibres not be severed. [10][3] When this occurs, the meniscus loses its role as a weight distributor, increasing the risk of Osteoarthritis.

Meniscectomy has the drawback of requiring extensive conservative aftercare. To get the greatest potential healing, there must be a time of maximal prognosis.

Patients who have had an arthroscopic partial meniscectomyoften have knee swelling, discomfort, and loss of range of motion (ROM), and they may develop greater joint laxity and osteoarthritis in the long run. [4]

Injuries to the anterior cruciate ligament, collateral ligaments, or joint cartilage are often associated with meniscal injuries. [8] [2] Such complications also have an impact on functional recovery after an arthroscopic meniscectomy. (Evidence Level: 3A) [5] [6] [7][1]

As part of the short- and long-term follow-up following arthroscopic partial meniscectomy, supervised rehabilitation has been recommended and examined. [4]

The purpose of rehabilitation is to restore a patient’s function depending on their specific requirements. The type of surgical procedure, which meniscus was repaired, the presence of coexisting knee pathology (particularly ligamentous laxity or articular cartilage degeneration), the type of Meniscus rupture, the patient’s age, preoperative knee status (including time between injury and surgery), decreased range of motion or strength, and the patient’s athletic expectations and motivations are all important factors to consider. [9] [10] [3]

Exercise has been proposed as an effective therapy for people suffering from knee degeneration in order to enhance knee function and reduce joint discomfort. There is significant evidence that physical exercise helps to lessen symptoms, enhance muscular strength, and physical abilities. [4]

Important aspects of the therapy

• manage pain and inflammation – cryotherapy, analgesics, NSAIDs, etc.

• Regaining strong knee control [4].

• Restore Range of Motion (ROM) [4]

– Range-of-motion exercises within any range restrictions specified by the consultant [9]

• Restore the ability to adapt [4]

• Bring back muscular function [4]- specialised strengthening exercises for the quadriceps (A medial meniscus lesion affects the strength of the M. Vastus medialis.[8]), hamstrings, calf, and hip

To achieve muscle growth and neuromuscular function, the workout programme should include both concentric and eccentric movements. [4]

• Improve neuromuscular coordination via proprioceptive reeducation

• Increase weight bearing – Because weight bearing and joint stress are required to improve the functioning of the meniscal repair, they should be increased as directed by the consultant. Excessive shear forces may be disruptive, thus they should be avoided at first. Physical activity three times per week for four months might result in a more than 35% improvement in knee function.

[4] Any rehabilitation programme should be developed on the patient’s body since each patient is unique and will respond differently to therapy.The findings are heavily influenced by the speed and precision with which the diagnosis is validated. Patients who have had meniscal repair should do unresistedopen chain activities. Because David L. et alresearch .’s shows that it does not put excessive strain on meniscal repairs. (LoE:4) [10 Many studies’ results support weight-bearing restrictions during the first 4 to 8 weeks following meniscal surgery.

In principle, weight bearing should not impair healing meniscal tissue since hoop stresses are absorbed predominantly at the meniscus’s perimeter. Weight bearing in association with tibiofemoral rotation during knee flexion, on the other hand, may generate shear stresses capable of damaging healing meniscal tissue. [2]

Individualized programmes based on the type of surgical procedure, which meniscus was repaired, the presence of coexisting knee pathology (ligamentous laxity or OA), the type of meniscal tear, the patient’s age, preoperative kneestatus (including the time between injury and surgery), loss of ROM and strength, and the patient’s athletic expectations and motivations should be encouraged.

Accelerated meniscal repair rehabilitation regimens that allow for complete knee ROM and weight bearing are becoming increasingly popular, with patients returning to full activity as soon as 10 weeks following surgery.[2]


References

  1. Timothy Brindle,John Nyland and Darren L. Johnson (2001) The Meniscus: Review of Basic Principles With Application to Surgery and Rehabilitation. Journal of Athletic Training, 36(2), 160–169.
  2. de Loës M., A 7-year study on risks and costs of knee injuries in male and female youth participants in 12 sports, Scandinavian Journal of Medicine & Science in Sports 2000: 10: 90-97. Level of evidence: 2A.
  3.  Eleftherios A.M., The knee meniscus: Structure, function, pathophysiology, current repair techniques and prospects for regeneration, Elsevier, 2011. Level of evidence: 1A
  4.  Poulsen MR, Johnson DL. Meniscal injuries in the young, athletically active patient. fckLRDepartment of Orthopaedic Sugery, University of Kentucky, Lexington, KY. Abstract.
  5.   Heckmann TP, Barber-Westin SD, Noyes FR. Meniscal repair and transplantation: indications, techniques, rehabilitation, and clinical outcome. J Orthop Sports Phys Ther. 2006 Oct;36(10):795-814. Abstract.
  6.  DeHaven Ke. Decision-making factors in the treatment of meniscus lesions. Clinical Orthopedics & Related Research 1990; (252) 49-54. Level of evidence: 5 (abstract)
  7.  Biedert RM., Intrasubstance Meniscal Tears: Clinical aspects and the role of MRI, Archives of Orthopaedic & Trauma Surgery 1993; 112 (3). Level of evidence: 3B
  8.  Bohnsack M, Ruhmann O. Arthroscopic meniscal repair with bioresorbable implants. Operative orthopadie und Traumatologie. 2006; 18 (5-6). Level of evidence: 2
  9.  F. Alan Barber et al., Meniscal repair techniques, Sports medicine and arthroscopy Review, Volume 15 (4), Pages 199-207, december 2007
  10.  BEAUFILS, P. The Meniscus, Springer-Verslag, Berlin Heidelberg,2010,397
  11.  N. Maffulli et al., Meniscal tears, Open Access Journal of Sports Medicine, Volume 1, Pages 45-54, 2010
  12.  Nam-Hong Choi et al., Comparison of Arthroscopic Medial Meniscal Suture Repair Techniques: Inside-Out Versus All-Inside Repair, The American Journal of Sports Medicine, 2009 Level of evidence: 2
  13.   K. A. Turman et al., All-Inside Meniscal Repair, Sports Health, Volume 1 (5), Pages 438–444, september 2009 Trommel, M.F. Meniscal Repair, Thela-Thesis, Amsterdam,1999.
  14.  K. H. Yoon et al., Meniscal repair, Knee Surgery & Related Research, Volume 26 (2), Pages 68-76, Juni 2014
  15.  Small NC., Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988; 4 (3); 215-221.l. Level of evidence: 2
  16.  Austin KS, Sherman OH. Complications of arthroscopic meniscal repair. Am J Sports Med 1993; 864-8; discussion 868-9. Level of evidence: 2
  17. Brent M,C.D, et: Effect of early active range of motion rehabilitation on outcome measures after partial meniscectomy; knee surg sports traumatol arthrosc (2009) 17: 607-616
  18. Andrews S. et al., The shocking truth about meniscus, Journal of Biomechanics, 44(16): 2737-40, Nov 2011. Level of evidence: 3A
  19. Bohnsack M, Ruhmann O. Arthroscopic meniscal repair with bioresorbable implants. Operative orthopadie und Traumatologie. 2006; 18 (5-6). Level of evidence: 2
  20. C. G. Nelson et al., Inside-Out Meniscus Repair, Arthroscopy Techniques, Volume 2, Issue 4, Pages e453–e460, november 2013
  21. Stärke C, Kopf S, Petersen W, Becker R. Meniscal repair. Arthroscopy. 2009 Sep;25(9):1033-44. Epub 2009 Feb 26. Abstract.