Meniscal Repair

Seth Jerabek, MD

Dr. Jerabek or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Stryker, and serves as a paid consultant to Stryker.

Introduction

Meniscal injury is one of the most common knee injuries seen by orthopaedic surgeons. Meniscal tears can cause persistent pain, swelling, mechanical symptoms, and disability. As mentioned in the prior chapter (Meniscectomy/Chondroplasty), the menisci contribute significantly to the knee’s natural function, motion, and stability.

Often the decision to repair a meniscus is complex. The age and activity level of the patient—as well as the chronicity, location, and type of tear—all must be considered prior to indicating a patient for repair. Classically, the meniscus has been divided into three zones (red-red, red-white, and white-white) based on the vascularity of the meniscus. Given that the meniscus has a variable blood supply where the blood vessels enter from the periphery, the peripheral portion of the meniscus has the most pronounced blood supply, while the inner portion has the least blood supply and is essentially avascular (Figure 47.1). Tears in the red-red zone have the best blood supply, thus the best potential to heal a repair. Tears in the white-white zone have very little blood supply, thus are unlikely to heal with repair and are best treated with partial meniscectomy. Tears in the red-white zone are more controversial; the decision to repair depends on the age and demands of the patient as well as the type and location of the tear. For example, a young patient with an acute vertical tear has a better chance of healing than an older patient with a chronic, degenerative, horizontal tear. Associated injury and surgery may also affect the propensity to heal. Meniscal tears treated in conjunction with tibial plateau fracture fixation or reconstruction of cruciate ligaments are also felt to have a better prognosis for healing compared to isolated repairs.

Surgical Procedure: Meniscal Repair

Indications

Acute meniscus tear in the red-red or red-white zones
Full-thickness tear of at least 5 to 10 mm
Relatively young and active patient

Contraindications

Tears in the white-white zone
Advanced osteoarthritis
Chronic, degenerative tears
Older, inactive patients

Procedure

There are several techniques used to repair menisci, depending on the location of the tear and the surgeon’s preference. They can be repaired arthroscopically using an all-inside technique with suture passer with anchors, open surgery using an arthrotomy, or a combination of arthroscopy with an open approach. The last approach is done to visualize the joint capsule near the tear, and sutures are passed from the inside of the knee through the meniscus and capsule (inside-out technique) or from the outside of the knee through the capsule and meniscus (outside-in technique), facilitating repair (Figure 47.2). Most repairs are either all inside or inside-out with the exception of the less common anterior tears, in which an outside-in approach facilitates suture passage.

Postoperative Rehabilitation

Introduction

Rehabilitation after meniscal repair will be variable depending on the type and location of the repair. For example, a patient with a relatively stable, peripheral vertical tear repair may be advanced faster than a patient with an unstable, radial tear repair. The surgeon often determines the patient’s weight bearing and early motion restrictions during surgery. Flexion beyond 90° puts increased stress on a meniscal repair and is often limited for up to 6 weeks after surgery. Thus, it is critical for the surgeon and therapist to have specific recommendations and open communication with each patient with a meniscal repair. To follow is a “typical” rehabilitation strategy for meniscal repair, which may be modified based on the characteristics of each repair.

Figure 47.1 Illustration of the meniscis vasculature.

Functional Goals and Restrictions

Goals for the first 2 weeks after surgery include controlling pain and swelling, initiating knee motion, and regaining quadriceps activation. From weeks 2 to 6, the patient is still in a hinged knee brace, but can work on gaining motion to 90°, and can start muscle strengthening. At 6 weeks and onward, the patient comes out of the brace and works on regaining full motion and strength. Generally, patients can return to in-line sports such as bicycling and running at 3 months and pivoting sports at 6 months. The rehabilitation goals can be subdivided as follows.

Phase 1: Swelling and Symptom Control (Weeks 0–2)

Control swelling with ice and compression
Weight bearing as tolerated, with hinged knee brace locked in full extension and crutches (consider limited weight bearing depending on tear)
Gentle early motion when seated with maximum flexion between 60° to 90° depending on tear
Quadriceps activation

Phase 2: Early Motion and Strengthening (Weeks 2–6)

Weight bearing as tolerated, with hinged knee brace locked in full extension and crutches (consider limited weight bearing depending on tear)
Full extension and flexion to 90°
Begin muscle strengthening

Phase 3: Functional Return (Weeks 6–12)

Transition out of brace
Regain full motion
Muscle strengthening

Phase 4: Early Sports Training (Weeks 12–24)

Regain full muscle strength
Cardiovascular conditioning
In-line sports
Sport-specific training (speed and agility training)

Phase 5: Advanced Sport Activity (Week 24 Onward)

Return to pivoting sports

Figure 47.2 Illustration of meniscal repair.

Author’s Preferred Protocol

Phase 1 (Weeks 0–2)

Ice or a cooling device should be used for 20 minutes per hour for the first 48 to 72 hours (while awake). Thereafter, ice should be used at least three times per day for 20 minutes per treatment.
Weight bearing as tolerated with hinged knee brace locked in full extension and crutches (consider limited weight bearing depending on tear). If the patient has pain, limit weight bearing until pain free.
Sitting heel slides: Sitting in a chair with the brace unlocked, the patient should slide the heel toward the chair until 60° to 90° degrees of flexion is gained. Do not exceed 90°. Hold for 5 seconds, straighten leg, and repeat 20 times. Perform three sets per day (Figure 47.3).
Heel prop: With the patient in the sitting position, prop the foot on a foot stool or low table and allow for passive
extension. This exercise can be enhanced by adding quadriceps sets to the exercise, which would provide active extension. Hold the stretch for 10 minutes, three times daily, until full extension is gained (Figure 47.4).
Quadriceps setting: With the patient supine or sitting, the patient should activate the quadriceps and forcefully extend the knee for a 5-second hold. A rolled towel underneath the heel may allow for more aggressive extension and quadriceps firing. This should be performed 20 times, 3 sets per day (Figure 47.5).
Ankle pumps: This should be performed as much as possible to maintain circulation.