Meniscus repair: red, white and root....Meniscus repair: red, white and root. Centre Hospitalier de Luxembourg Orthopaedic Surgery Sports Medicine Luxembourg Research Laboratory Institute

Romain Seil, MD, PhD

Meniscus repair: red, white and root.

Centre Hospitalier

de Luxembourg Orthopaedic

Surgery

Sports Medicine

Research Laboratory

Luxembourg

Institute of Health

ICRS meeting, Sorrento, Italy, 09-2016

crp-sante.lu 2

Bench to bedside in meniscal repair

Translational surgery/surgical science

Vascularity

Biomechanics

Histology / anatomy

Surgical technology

crp-sante.lu 3

Petersen W Acta Orthop Scan 1995

New born

50 y. 18 y.

11 mo.

Vascularity

crp-sante.lu 4

Takeda Y, JBJS-B, 1998

MRI asymptomatic children

Prevalence „abnormal“ signal (%)

Vascularity

crp-sante.lu 5

Red -

red

Red -

white

White -

white

Courtesy of Prof. C. Fink, Innsbruck, Austria

Vascularity

crp-sante.lu 6

Vascularity

22 y.o. professional ballet dancer

crp-sante.lu 7

Vascularity

22 y.o. professional ballet dancer

crp-sante.lu 8 8

• ♂ 14 y. football

• open physes

• ACL & medial meniscus repair

Association with ACL tears

chl.lu

MM

Posterior capsule

Vascularity

Interindividual variation needs further

analysis

crp-sante.lu 9

Load transmission – shock absorption - stability

Biomechanics

crp-sante.lu 10 10

Allaire R, JBJS-A, 2008

Marzo JM, JAAOS, 2009

Medial meniscus root avulsion

+ total meniscectomy

Meniscal root tears

crp-sante.lu 11 11

Prevention of joint collapse ?

Repair of medial meniscal root tear

crp-sante.lu 12 12 chl.lu

Meniscal root tears

crp-sante.lu 13

West RV, Arthroscopy 2004

Type III:

Complex tears

(radial & vertical)

A

C

L LM

Meniscal root tears

Type I:

Root avulsion

Type II:

Radial tears @

< 1 cm from insertion

chl.lu

Complete Incomplete

Functional meniscectomy

« Phantom meniscus »


crp-sante.lu 14 14

Ventral

Lat.

Biomechanics

Medial Lateral

If isolated:

Low-energy trauma

Traumatic vs. degenerative

Biomechanically

deleterious

If associated with ligament

injuries:

High-energy trauma

Rarely isolated

Lesser biomechanical

impact

Contribute to rotational

laxity & pivot shift

Seil R, OTSR 2010; Forkel P KSSTA 2015

crp-sante.lu 15 chl.lu


Symptoms

Medial meniscus root tears

Floating knee

Vacuum

Mechanical AND inflammatory (night) pain

Joint line pain

Effusion

Frequent relation with trauma (miss step)

DD: activated OA

♂ 52 y.

crp-sante.lu 16

Transosseous refixation:

1. Identify insertion site

2. Load meniscus

3. Tibial tunnel

4. Fixation

Repair technique

Meniscal root tears

crp-sante.lu 17 17

♂ 43 years, isolated MM root avulsion

chl.lu

Repair of medial meniscal root tear

crp-sante.lu 18

Type I avulsion

♂ 21 y., football

(axial compression trauma + torsion and flexion)

chl.lu

@ 1 y.

Before surgery

Medial meniscal root tears

crp-sante.lu 19 19

♀ 58; axial compression trauma


crp-sante.lu 20 20



crp-sante.lu 21 21



Associations with aseptic

osteonecrosis

(Robertson DD, JBJS-B 2009

Sung JH, Arthroscopy 2013)

Reduced success rates

(60%, Feucht et al. Arthroscopy 2016)

Long term results?

Biological healing potential ?

crp-sante.lu 22 22 chl.lu

Lateral meniscus root tear

115Knee Surg Sports Traumatol Arthrosc (2015) 23:112–118

1 3

b) [11]. In cases with type 2 lesions, a side-to-side repair

using an all-inside suture was performed.

Discussion

The most important finding of this study was the high num-

ber of concomitant PLMRTs in association with ACL tears.

The hypothesis that PLMRTs are a common concomitant

injury with ACL injury was proven by these results. All

PLMRTs were classified arthroscopically, and the MFL

was identified in 27 of the total 32 root tears using a probe.

In the other 5 cases, the MFL was torn or not detectable;

therefore, these cases were defined as type 3 tears. Only

a few studies have reported PLMRTs to be a typical con-

comitant injury with acute ACL injury [5, 7, 26, 28]. The

overall PLMRT prevalence of 14 % identified in our study

(out of all cases with ACL tears) is slightly higher than that

published in previous reports, which reported a prevalence

of only 7–12 % [1, 26, 28]. However, although the previous

studies classified different types of PLMRTs, they did not

assess the status of the MFL [1, 28].

The results of the present study show that the biome-

chanical classification system for PLMRTs that we used is

a suitable tool for intraoperative classification of PLMRTs.

Because previous biomechanical studies have revealed

that a complete meniscus detachment (PLMRT and MFL

rupture) has a different impact compared with an avul-

sion injury [4, 9, 10], it is important to classify PLMRTs

to accurately estimate the biomechanical impact of a given Fig. 3 Lateral root tears: a type 1, avulsion; b type 2, radial tear; c

type 3, complete posterior detachment

Table 1 Prevalence of medial and lateral meniscus root tears is pre-

sented

The lateral meniscus root tears are subdivided according to their

shape and the integrity of the meniscofemoral ligament

87

32

102

2

0

20

40

60

80

100

120

meniscus tear root tear

lateral

medial

Fig. 4 Diagram showing the prevalence of meniscus tears and root

tears

14%

1%

Prevalence

(n)

n=228 ACL reconstrcutions

Forkel P, KSSTA 2015

Association with ACL injuries

crp-sante.lu 23 23

Lesion transforms posterior segment

into Wrisberg-type “discoid” meniscus

Ahn JH, Knee 2008

Type II

Watanabe type III

« Wrisberg » (< 10%)

Lateral meniscus root tears

Forkel P, Arthroscopy 2014

Lesser biomechanical consequence if presence of MFL

crp-sante.lu 24 24

Lateral meniscus root tears

crp-sante.lu 25

Vascularity & biomechanics

• Usually isolated

• Functional complete meniscectomy

• Repair to restore stable rim

• 50 % healing rate

chl.lu

♂ 15 y., football, stable knee

Yoo JC, Arthroscopy 2007 Van Trommel MF, Arthroscopy 1998

crp-sante.lu 26 26

Histology / anatomy

Fibre bundles

Courtesy of Prof. C. Fink, Innsbruck, Austria


Stoller DW, 1987

Histology / anatomy

crp-sante.lu 28

Horizontal tears

♂ 35 y., running, degenerative meniscus

Histology / anatomy

crp-sante.lu 29

Suture systems Hybrid techniques

In-out

(Needles & flexible

cannulas)

FasT-Fix

(Smith & Nephew)

Out-in

(standard IV needles &

shuttle relays – micro

lassos)

MaxFire

(Biomet)

Meniscal Viper

(Arthrex)

Meniscal Cinch

(Arthrex)

Spectrum II

(Conmed-Linvatec)

RapidLoc

(DePuy Mitek)

chl.lu

Surgical technology

crp-sante.lu 30

Bedi A , Arthroscopy 2010

Amin KB Arthroscopy 1999

Barenius B, KSSTA 2013, Robb C, KSSTA 2014

Pujol N, KSSTA 2009, Cox CL, Am J Sports Med 2014

ACL & medial meniscus injury

ACL reconstruction has a 4.9 times higher

failure risk with meniscal loss

Medial meniscus repair worse results than

partial meniscectomy or lateral repairs

chl.lu

The medial meniscus problem

Medial meniscus repairs

need to be improved !

Surgical technology


Gillquist technique

ACL #

PCL

ACL + meniscosynovial lesion

Surgical technology

crp-sante.lu 32

Posterior view, 90° knee flexion, right knee

MFC

27 y.o. man; football injury

Surgical technology

crp-sante.lu 33


MFC


Surgical technology

crp-sante.lu 34


MFC

« Bankart-like » lesion


Surgical technology

crp-sante.lu 35

Posterior view, 90° knee flexion, left knee

MFC

14 y.o. boy; football injury

Surgical technology

crp-sante.lu 36 36

From: Sonnery-Cottet B, Gunepin FX, Seil R, AJSM 2014

chl.lu

Anatomy



Posteromedial meniscocapsular lesions

increase tibiofemoral joint laxity with ACL

deficiency and reconstruction.

Stephen J.M, Halewood C, Kittl C, Bollen S, Williams A, Amis A.A.

Submitted to AJSM 2015.

Biomechanics


Halewood SJM, Am J Sports Med, 2016

Ahn JH, AJSM 2011

crp-sante.lu 38


• Football (p=0,06)

+

• Recurrent tear (p=0,07)

+

• High velocity / impact (p<0,01)

+

• None in partial tears (p=0,02)

+

• Association with high grade pivot & Lachman

(p<0,05)

• High velocity accidents

• « Big » instabilities

Seil R, Najfeld M, Mouton C, ESSKA 2014, SFA 2015 & 2016

Own prospective cohort

- 131 ACL reconstructions

- 29 patients with meniscosynovial lesion (22%)

crp-sante.lu 39

10-15% root tears

20-30% ramp lesions

20-30% ‘classic’ meniscus tears

> 50% of repairable meniscus injuries

The main new feature in ACL surgery in

2016 is meniscal repair

Summary

ACL-associated meniscus lesions

crp-sante.lu 40

Meniscal repair & benefit: big potential

Several „new“ types of lesions

Fast development of surgical techniques

(100% all inside)

Repairs technically challenging

(Basic) science needed

Surgery: indications, surgical techniques,

outcome Basic science: anatomy & biology

Summary

chl.lu

crp-sante.lu 41

ESSKA president: Romain Seil

Congress president: Jon Karlsson

Scientific chairs: Gino Kerkhoffs

Michael Hirschmann

Fares Haddad

Meniscus repair: red, white and root....Meniscus repair: red, white and root. Centre Hospitalier de Luxembourg Orthopaedic Surgery Sports Medicine Luxembourg Research Laboratory Institute

Documents