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    8 Pearls for Surgical Repair of a Torn Meniscus

    Why repair a torn meniscus?

    Because it’s an important structure for load dispersion, shock absorption, and load transmission through the knee, Jonathan A. Godin, MD, MBA, told attendees at ICJR’s 13th Annual Winter Hip & Knee Course. Loss of meniscus volume increases pressure on the article cartilage, he said, which can lead to arthritis in the compartment. [1-3]

    When non-operative management fails to relieve symptoms, surgery is performed to help reduce pain and improve function. Below are Dr. Godin’s 8 pearls for meniscus repair.

    Patient selection. The ideal patients for meniscus repair should have:

    • Normal or correctable limb alignment
    • Ligamentous stability
    • Intact articular cartilage
    • BMI less than 30

    Patients should also express a commitment and willingness to complete the rehabilitation program following repair.

    Preoperative workup. Dr. Godin obtains long-leg standing and stress radiographs to help determine which patients are appropriate candidates for meniscus repair. For example, if he can see from the standing radiographs that the patient is in varus alignment, he would recommend an osteotomy instead of meniscus repair; valgus alignment would put undue stress on the repair.

    Visualization. This comes into play primarily for medial meniscus repair. If the patient has a tight compartment, Dr. Godin does not hesitate to use a spinal need to pie-crust the medial collateral ligament and increase the gapping in the medial compartment. This improves visualization of the posterior horn of the medial meniscus.

    Tissue preparation. Don’t overlook medial tear preparation, Dr. Godin said; it’s important to a successful repair. Debride granulation tissue on both sides of the tear with a meniscal rasp or 3.5-mm shaver to maximize the healing response at the tear site.

    The right repair technique. The repair technique that is used depends on the tear pattern, size, and location, Dr. Godin said.

    • For root repair, use transtibial tunnels; Dr. Godin uses 2 tunnels.
    • For a radial tear, use an inside-out technique plus transtibial tunnels.
    • For a peripheral vertical tear, use an all-inside technique if it’s a smaller tear and an inside-out technique if it’s a larger tear.
    • For an anterior horn tear, use an outside-in technique.

    Augmentation when necessary. Biologically augmenting a meniscus repair with marrow venting is being investigated at Dr. Godin’s institution, The Steadman Clinic and Steadman Philippon Research Institute. In a study published in 2017, Dean et al [4] compared meniscus repair plus marrow venting with meniscus repair plus anterior cruciate ligament reconstruction and found no difference in outcomes. Dr. Godin said the procedure is quick – it only takes a couple of minutes – and adds no cost to the surgery.

    Transplantation as a last resort. Patients with symptomatic meniscal insufficiency that limits their activities of daily living and does not respond to non-operative management may be candidates for a meniscus transplant if they have:

    • Minimal evidence of degenerative changes in the affected compartment
    • Ligamentous stability
    • Normal coronal and sagittal alignment
    • Full knee range of motion

    The presence of advanced diffuse arthritic changes is a contraindication to meniscus transplant.

    Rehabilitation. Dr. Godin bases a patient’s weight-bearing status and progression on 4 factors:

    • Anatomic site of the tear
    • Tear pattern
    • Repair technique
    • Concomitant procedures

    For example, 6 weeks of non-weight-bearing is recommended for patients who had a root repair or radial repair, while patients who had a peripheral vertical repair have 2 weeks of non-weight-bearing, 2 weeks of partial weight-bearing, and then a crutch weaning process, Dr. Godin said.

    Click on the image of the root equivalent, full-thickness radial tear above to watch Dr. Godin’s presentation and take a deeper dive into his 8 pearls for meniscus repair.

    Faculty Bio

    Jonathan A. Godin, MD, MBA, is from The Steadman Clinic in Vail, Colorado, where he specializes in shoulder, knee, hip, and sports medicine surgery.

    Disclosures: Dr. Godin has disclosed that he is a paid consultant for Bioventus, Mitek, and Smith & Nephew.

    References

    1. Baratz ME, Fu FH, Mengato R. Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med. Jul-Aug 1986;14(4):270-5. doi: 10.1177/036354658601400405.
    2. Lee SJ, Aadalen KJ, Malaviya P, et al. Tibiofemoral contact mechanics after serial medial meniscectomies in the human cadaveric knee. Am J Sports Med . 2006 Aug;34(8):1334-44. doi: 10.1177/0363546506286786. Epub 2006 Apr 24.
    3. Sturnieks DL, Besier TF, Hamer PW, et al. Knee strength and knee adduction moments following arthroscopic partial meniscectomy. Med Sci Sports Exerc. 2008 Jun;40(6):991-7. doi: 10.1249/MSS.0b013e318167812a.
    4. Dean CS, Chahla J, Matheny LM, Mitchell JJ, LaPrade RF. Outcomes after biologically augmented isolated meniscal repair with marrow venting are comparable with those after meniscal repair with concomitant anterior cruciate ligament reconstruction. Am J Sports Med. 2017 May;45(6):1341-1348. doi: 10.1177/0363546516686968. Epub 2017 Feb 1.