Chapter 37 Meniscal Repair and Transplantation
Surgical Overview
• The menisci allows for a more congruous articulation between the already incongruent femoral condyle and tibial plateau.
• The lateral meniscus picks up 70% of the load transmitted across the lateral compartment, whereas the medial meniscus and articular cartilage share the load.
• Each meniscus is divided anatomically into horizontal thirds: the posterior horn, mid-body, and anterior horn.
• Menisci are divided into vertical thirds when looking at blood supply. The outer edge of each meniscus has a rich blood supply from the medial and lateral genicular arteries.
1 Vascularization decreases approaching the inner portion of the meniscus and becomes dependent upon diffusion.
2 Because of the poor blood supply, tears that approach the inner avascular area have a more difficult time with healing.
• The arthroscopic inside-out surgical technique involves the placement of sutures across the meniscus inside the joint, and the sutures are then tied down outside the joint capsule. This technique has been successful with tears to the middle one-third and, to some degree, tears of the posterior horns.
• The arthroscopic outside-in surgical technique involves the placement of a suture with a Mulberry knot to one side of the meniscal tear inside the joint, and then sutures are tied on the joint capsule. This technique has been advocated in repairing tears to the mid-one-third and anterior horn regions.
• The arthroscopic all-inside surgical technique involves the placement of a suture, screws, and/or darts through an arthroscopic portal to stabilize the tear.
1 Because it does not make use of any incisions, the all-inside technique is favorable in decreasing the risk of iatrogenic neurovascular damage.
• Meniscus allograft transplant (MAT) has evolved into a primarily arthroscopic technique in which a cadaveric meniscus is inserted into a meniscus deficient knee.
1 The cadaveric meniscus is supplied by a tissue bank. Although there are no set standards, most tissue banks determine implant size through estimates made from radiographs.
• With a medial meniscus replacement, two bone plugs, one to the anterior horn and another to the posterior horn, are inserted in their respective tibial tunnels while sutures along the rim hold the graft in place.
Rehabilitation Overview
• Rehabilitation programs following meniscal repair and transplantation should reflect an optimal environment for healing.
• Surgical technique, type of repair fixation, location of the repair, concomitant procedures, and surgeon’s preference will have a direct influence on weight-bearing status, range of motion (ROM) restrictions, and treatment progressions. Therefore, communication between the surgeon and rehabilitation specialist, particularly in the early protective phases of rehabilitation, is vital.
• Customarily, following meniscal repair and transplantation procedures, immediate ROM is encouraged. Early motion has been shown to minimize the deleterious effects of immobilization, such as articular cartilage degeneration, excessive adverse collagen formation, and pain.
• Weight-bearing following meniscal repair will be typically progressive throughout the early postoperative period.
• Weight-bearing following meniscal transplantation and meniscal repairs involving complex or radial tears will be limited to toe-touch ambulation for the first 4 weeks.
• The involved knee is maintained in full extension, donning a double-upright hinged brace locked at 0 degrees during the designated protection phase, regardless of which meniscal procedure was performed.
• The pre-surgical status of the patient, any associated pathology, and a comprehensive evaluation will each play an important factor in designing an individualized rehabilitation program for each patient.
1 An elite athlete may progress faster as a result of greater preoperative muscle strength as compared to a nonathlete in weak physical condition.
• Subjective complaints and physical findings ascertained during evaluations and continual reassessments will direct the rehabilitation program to the proper speed and direction.
• The realistic goals of the patient, surgeon, and rehabilitation specialist should be discussed and defined early in the postoperative course.
1 The patient should be brought to understand the magnitude of his or her surgery and the timetable for recovery.
• The patient should be made aware of his or her role in the rehabilitative process. The patient’s compliance to activity modifications and home therapeutic exercises is vital for a successful outcome.
• Postoperative guidelines following these procedures abide by a criteria-based progression. ROM and strength requirements are to be met before advancement to subsequent phases.
Meniscal Repair Guidelines Postoperative Phase I (Weeks 0 to 6)
TREATMENT STRATEGIES
• Quadriceps reeducation (quadriceps sets with electrical muscle stimulator [EMS] or electromyography [EMG])
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