Post on 09-Aug-2020
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
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Bench to bedside in meniscal repair
Translational surgery/surgical science
Vascularity
Biomechanics
Histology / anatomy
Surgical technology
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Petersen W Acta Orthop Scan 1995
New born
50 y. 18 y.
11 mo.
Vascularity
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Takeda Y, JBJS-B, 1998
MRI asymptomatic children
Prevalence „abnormal“ signal (%)
Vascularity
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Red -
red
Red -
white
White -
white
Courtesy of Prof. C. Fink, Innsbruck, Austria
Vascularity
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Vascularity
22 y.o. professional ballet dancer
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Vascularity
22 y.o. professional ballet dancer
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• ♂ 14 y. football
• open physes
• ACL & medial meniscus repair
Association with ACL tears
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MM
Posterior capsule
Vascularity
Interindividual variation needs further
analysis
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Load transmission – shock absorption - stability
Biomechanics
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Allaire R, JBJS-A, 2008
Marzo JM, JAAOS, 2009
Medial meniscus root avulsion
+ total meniscectomy
Meniscal root tears
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Prevention of joint collapse ?
Repair of medial meniscal root tear
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Meniscal root tears
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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
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Complete Incomplete
Functional meniscectomy
« Phantom meniscus »
Allaire R, JBJS-A, 2008
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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
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Allaire R, JBJS-A, 2008
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.
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Transosseous refixation:
1. Identify insertion site
2. Load meniscus
3. Tibial tunnel
4. Fixation
Repair technique
Meniscal root tears
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♂ 43 years, isolated MM root avulsion
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Repair of medial meniscal root tear
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Type I avulsion
♂ 21 y., football
(axial compression trauma + torsion and flexion)
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@ 1 y.
Before surgery
Medial meniscal root tears
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♀ 58; axial compression trauma
Medial meniscal root tears
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♀ 58; axial compression trauma
Medial meniscal root tears
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Medial meniscal root tears
♀ 58; axial compression trauma
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 ?
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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
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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
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Lateral meniscus root tears
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Vascularity & biomechanics
• Usually isolated
• Functional complete meniscectomy
• Repair to restore stable rim
• 50 % healing rate
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♂ 15 y., football, stable knee
Yoo JC, Arthroscopy 2007 Van Trommel MF, Arthroscopy 1998
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Histology / anatomy
Fibre bundles
Courtesy of Prof. C. Fink, Innsbruck, Austria
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Stoller DW, 1987
Histology / anatomy
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Horizontal tears
♂ 35 y., running, degenerative meniscus
Histology / anatomy
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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)
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Surgical technology
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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
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The medial meniscus problem
Medial meniscus repairs
need to be improved !
Surgical technology
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Gillquist technique
ACL #
PCL
ACL + meniscosynovial lesion
Surgical technology
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Posterior view, 90° knee flexion, right knee
MFC
27 y.o. man; football injury
Surgical technology
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Posterior view, 90° knee flexion, right knee
MFC
27 y.o. man; football injury
Surgical technology
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Posterior view, 90° knee flexion, right knee
MFC
« Bankart-like » lesion
27 y.o. man; football injury
Surgical technology
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Posterior view, 90° knee flexion, left knee
MFC
14 y.o. boy; football injury
Surgical technology
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From: Sonnery-Cottet B, Gunepin FX, Seil R, AJSM 2014
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Anatomy
ACL + meniscosynovial lesion
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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
ACL + meniscosynovial lesion
Halewood SJM, Am J Sports Med, 2016
Ahn JH, AJSM 2011
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ACL + meniscosynovial lesion
• 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%)
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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
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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
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ESSKA president: Romain Seil
Congress president: Jon Karlsson
Scientific chairs: Gino Kerkhoffs
Michael Hirschmann
Fares Haddad