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Meniscal Repair: Technique: Sciencedirect
Meniscal Repair: Technique: Sciencedirect
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Review article
a r t i c l e i n f o a b s t r a c t
Article history: Meniscal repair aims to achieve meniscal healing, avoiding the adverse effects of meniscectomy. Longi-
Received 8 January 2017 tudinal vertical tears in a vascularized area are the reference indication. The technique generally uses
Accepted 16 April 2017 hybrid all-inside implants. The outside-in technique has other indications in more anterior tears. Healing
has been demonstrated on CT-arthrography and arthroscopy. Specific techniques have been developed
Keywords: for other pathological situations. Posterior meniscosynovial lesions in a context of chronic anterior laxity
Meniscus are identified by exploration of the posterior compartment, and fixed by all-inside hook suture. Hori-
Meniscal repair
zontal lesions in young athletes can be treated by open meniscal suture. Radial tears, when deep, can be
Longitudinal vertical tear
Meniscocapsular lesion
repaired. Root tears, when traumatic, can be treated by transosseous pullout reinsertion.
Ramp lesion © 2017 Elsevier Masson SAS. All rights reserved.
Horizontal cleavage
Root tear
Meniscal repair aims to achieve meniscal healing, avoiding the and a biological process of cicatrization, which requires prior abra-
adverse effects of meniscectomy. sion.
Meniscal repair techniques largely depend on the type of tear,
presupposing precise pre- and intra-operative assessment. The 1.1. Fixation must be solid
present paper does not deal with results or indications, including
the essential choice between abstention, repair and meniscectomy. Fixation uses knotted sutures, whatever the support. The
Suffice it to say that attitudes need inversing the paradigm, consid- sutures may be non-absorbable (ultra-high-molecular-weight
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ering the possibility of meniscal preservation before even partial polyethylene: UHMWPE) or with slow absorption (e.g., PDS ), to
meniscectomy. maintain solid fixation throughout the healing process, which takes
Rather than describing the various techniques, the presentation several months. Absorbable and non-absorbable anchors, arrows
will be based on various clinical situations, seeking to answer the and staples have all been abandoned, due to poor solidity and car-
following questions: tilage impingement [1,2].
Hybrid systems, associating suture (usually UHMWPE) and an
• which kind of repair in longitudinal vertical tears in stable knee absorbable or PEEK (polyether ether ketone) anchor, combine the
or with anterior cruciate ligament (ACL) tear? qualities of a minimally invasive implant and biomechanical prop-
• in ACL tear, do meniscocapsular (ramp lesions) lesions require a erties comparable to those achieved with simple suture (considered
specific technique? as the gold-standard) [1]. Fixation points are close together, every
• is open suture still indicated in certain cases, such as horizontal 5 to 7 mm, and preferably vertical rather than oblique or horizontal
cleavage, notably of the lateral meniscus, in young patients? (Table 1); the most resistant part of the meniscus is composed of
• how should radial tears be repaired? horizontally distributed collagen fibers, so that a vertical suture has
• how should meniscal root tears be repaired? a better hold than a horizontal one [4].
1. Basics common to all techniques 1.2. Abrasion is an essential step, and consists in abrading the
fibrous tissue on the two edges of the meniscus to obtain bleeding
Successful meniscal repair depends on a healing process, which tissue that is able to heal over. Such is the theory; what is the
is based on two fundamental principles: a solid primary fixation, evidence?
https://doi.org/10.1016/j.otsr.2017.04.016
1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.
S138 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
Abrasion “Aggressive” True peripheral partial Meniscal repair can be carried out on an ordinary table or with
resection of all meniscectomy the thigh clamped in a knee-holder. In the former case, a support
fibrous tissue
under the lateral side of the thigh facilitates valgus decoaptation
Suture placement Every 5–7 mm Inter-anchor interval > 5 mm
Orientation As much meniscal Vertical > oblique > horizontal
of the medial compartment, although it may hinder flexion-varus
tissue as mposible Double row > Single row (“Figure-4”) positioning to access the lateral meniscus.
involved in suture
Number of stitches 2 to 8 Add more at will 2.2. Anterior arthroscopic portals
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Fig. 3. Meniscal repair by FastTFix (Smith & Nephew).
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Fig. 7. FasTFix (Smith & Nephew) with inverted curve for meniscal repair via the
inferior side of the meniscus. (Formerly Fig. 6).
Fig. 6. Sutures should be at 5–7 mm intervals: example of horizontal, vertical and
oblique stitches.
Fig. 10. Meniscocapsular lesion of the posterior segment of the medial meniscus on
Fig. 9. Outside-in repair. (Coll. Franck Jouve). posteromedial approach (left knee).
Fig. 11. Eighteen year-old athlete with medial knee pain: a: CT-arthrography: normal; b: MRI: grade 2 intrameniscal cleavage tear, typical of overuse in young athletes.
S142 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
Fig. 12. Open repair of horizontal cleavage of the posterior segment of the medial meniscus; a: after meniscosynovial release, cleavage revealed in the peripheral wall: b:
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PDS 0 suturing; c: aspect after suture.
Fig. 13. PRP injection in horizontal cleavage before tying sutures. (Coll. N. Pujol). 2.8. To sum up
• lesion extension is not a criterion of unfeasibility. The chances 3. Is there a specific technique for medial meniscus
of success may be smaller, but the risk should be taken, having meniscocapsular (ramp) lesions?
warned the patient [18];
• peripheral tear is obviously a very important factor, often involv- Posterior meniscocapsular tears are associated with 15% to
ing two elements. Firstly, remodeling of meniscal tissue damaged 30% of ACL tears [3], and consist in very posterior tears that are
by iterative passage under the condyle: except in complex tears, uncicatrized or badly cicatrized. They do not necessarily show up
we do not see this as a contraindication, especially in the common on anterior arthroscopy [21], or visually or even on palpation, and
case of small partial radial tear within the displaced fragment. may cause extensive secondary meniscal tears, even after ligament
Secondly, a horizontal cleavage in the meniscal wall is more or reconstruction, contributing to rotational laxity [22].
less systematic, and not a contraindication; They are revealed by exploration of the posteromedial compart-
• a more difficult question is that of lesion instability. A meniscus ment (Fig. 10), either by direct visualization or by the collapse of a
with a tendency for recurrent intraoperative dislocation indicates poor-quality cicatricial synovial curtain (Video 7) [23].
a variable degree of retraction of the meniscal tissue and thus They cannot be treated by hybrid implants on an anterior
excessive traction on the sutures. If repair is decided on, the cen- approach. Rather, repair consists in passing sutures through the
tral area should be fixed first, to stabilize the meniscus, before posteromedial instrument portal, using a hook [24–26] through
continuing repair as described above; the posterior wall then the posterior capsule. These suture-passer
P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145 S143
ing sutures and tying knots, as in rotator cuff surgery. The technique
is difficult and requires a long learning curve.
4.1. Technique
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Fig. 15. Acute traumatic lesion of lateral meniscus root (right knee): a: lesion aspect; b: UHMWPE suture passed into the meniscus; PDS relay loop (deep blue) emerges
from transtibial tunnel (guide still in place); c: final aspect.
After freshening the edges, two sutures are made on either side extra-cortical button. UHMWPE sutures are preferable, for solid and
of the lesion, one peripheral (Fig. 14) and the other axial near the lasting fixation (Video10). Kodama [31] recommended the hybrid
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free edge, using an all-inside (hybrid implants, or hook technique) FastTFix system to fix the meniscus, with the free suture serving
or outside-in technique [3,11–20], depending on location (Video 9). for traction in extra-cortical fixation.
cartilage protection, with a low rate of secondary meniscectomy [15] Beaufils P, Charrois O, Cassard X. Meniscal repair. Rev Chir Orthop Reparatrice
[20,32,33]. Appar Mot 2004;90(8 Suppl) [3S:49-75].
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Received wisdom thus needs turning on its head: seek preser- [17] Henning CE. Arthroscopic repair of meniscus tears. Orthopedics
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failed meniscal repair. Am J Sp Med 2011;39:1648–52.
results have been promising, even over the long-term [35]. [19] Ahn JH, Lee SH, Yoo JC, Lee YS, Ha HC. Arthroscopic partial meniscectomy with
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[20] Pujol N, Tardy N, Boisrenoult P, Beaufils P. Long-term outcomes of all-inside
Disclosure of interest meniscal repair. Knee Surg, Sports Traumat, Arthrosc 2015;23:219–24.
[21] Peltier A, Lording TD, Lustig S, Servien E, Maubisson L, Neyret P. Posteromedial
P. Beaufils: occasional educational consultant for Smith & meniscal tears may be missed during anterior cruciate ligament reconstruction.
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Nephew and Zimmer/Biomet. Editor-in-Chief, OTSR-RCOT.
[22] Peltier A, Lording T, Maubisson L, Ballis R, Neyret P, Lustig S. The role of the
N. Pujol: occasional educational consultant for Smith & Nephew meniscotibial ligament in posteromedial rotational knee stability. Knee Surg
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[23] Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX, Seil R. Hidden lesions
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Appendix A. Supplementary data ration of the concealed portion of the knee. Am J Sports Med 2014;42:921–6.
[24] Morgan CD. The “all-inside” meniscus repair. Arthroscopy 1991;7:120–5.
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