Chapter 54 The menisci are of paramount importance to knee function and play critical roles in load transmission, shock absorption, secondary knee stabilization, and joint lubrication. Numerous studies have established the unfavorable natural history and progression to osteoarthritis associated with removal of meniscal tissue, resulting in decreased femoral contact area and significant increases in contact stresses and chondral overload.1,2 Therefore meniscus preservation in the young, prearthritic knee should be prioritized for all tears with patterns, tissue quality, and vascularity that are amenable to repair. The evolution and advancement of arthroscopic surgical techniques have improved the ability to access and repair meniscal lesions. The outside-in technique was first described by Warren as an alternative method to decrease the risk of neurovascular injury with repair.3 Whereas inside-out and all-inside techniques have evolved for meniscal repair and are particularly useful to address posterior horn lesions, the outside-in technique is a powerful and invaluable approach for repairable tears of the body and anterior horn. It is also useful to repair the anterior extension of bucket-handle tears or meniscus transplants. A meniscal tear is one of the most common orthopedic injuries, often resulting from a traumatic event such as forceful twisting or pivoting (resulting in a “popping sensation”). Patients often report swelling and localized pain in the knee on the side of the tear. Depending on the size of the tear, patients will have varying ability to bear weight on the affected side. Patients may also report locking or catching of the knee, which is most likely caused by entrapment of the meniscus in the notch or between articular surfaces.4 Typical examination findings of a meniscus tear include the following: • Quadriceps weakness and atrophy • Pain with terminal flexion (posterior horn) and/or extension (anterior horn) • Locked knee (bucket-handle tears) • Pain with provocative maneuvers such as the Apley grind or McMurray test, in which an axial load and twisting moment are applied to the knee to precipitate symptoms from a meniscal lesion These physical examination findings are sensitive but not specific for meniscal pathology. Chondral injury, subchondral fractures, bone contusions, collateral ligament injury, or symptomatic plicas of the knee may cause an overlapping constellation of examination findings. It is also critical to assess the knee for stability of the cruciate ligaments, collateral ligaments, and posterolateral complex. Although meniscal injuries can occur in isolation, they are frequently accompanied by ligamentous injury. Concomitant anterior cruciate ligament (ACL) reconstruction is favorable in the setting of combined ACL and meniscal injury and has been shown to improve the rates of successful healing after meniscal repair.5 • Recognition of the meniscus tear, location, and pattern. The peripheral third of the meniscus (“red-red”) zone offers the greatest vascularity and the most favorable prognosis for healing after a repair. Recognition of pattern is also critical, because vertical, longitudinal tears may be more amenable to repair, whereas radial, complex, and horizontal cleavage tears are often treated more effectively with partial meniscectomy. This preoperative information allows for more effective counseling with the patient regarding intraoperative expectations, postoperative rehabilitation, and the natural history of the injury. • Associated chondral injury or bone contusion. Focal chondral defects may mimic meniscal pathology or be present in combination with a meniscus tear and may be treated simultaneously with a marrow stimulation (microfracture) or whole-tissue transplantation procedure. In contrast, diffuse chondral degeneration may be a relative contraindication to surgical intervention and may compromise the outcomes of surgical treatment of meniscal injury. • Integrity of the cruciate, collateral, posterolateral corner ligament complexes. • Peripheral “red-red” or “red-white” zone tears • Longitudinal (“vertical”) tear pattern • Tears of the body or anterior horn that are accessible via an outside-in trajectory without significant risk of neurovascular injury • Bucket-handle meniscus tears with anterior horn extension • Acute injury with reducible tear pattern Relative contraindications to meniscal repair with an outside-in technique include the following: • Diffuse chondral degeneration or injury • Irreparable, complex tear patterns • Chronic tears with compromised tissue quality for suture fixation • Posterior horn or root injuries with significant risk for neurovascular injury with an outside-in approach • Tears in the central “red-white” or “white-white” zones • An unstable knee with cruciate, collateral, or posterolateral corner insufficiency
Arthroscopic Meniscus Repair
Outside-in Technique
Preoperative Considerations
Related posts:
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Autologous Chondrocyte Implantation in the Knee
Allografts for Anterior Cruciate Ligament Reconstruction
Surgical Treatment of Posterolateral Instability of the Elbow
Primary Repair of Osteochondritis Dissecans in the Knee
Arthroscopic Meniscus Repair: All-Inside Technique
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