Hello, my name is Kalechi Okoroha. I'll be presenting on the in-season athlete with a meniscus tear, how I manage these players. I'd like to thank the arthroscopy association in North America for giving me the opportunity to give this talk. I have no disclosures relevant to this talk. In this presentation, we're going to briefly talk about the anatomy of the meniscus, how these players present with meniscus tears, the different meniscal tear types, treatment options for the in-season athlete, and clinical results. We know about the anatomy of the meniscus, with the medial meniscus being wider posteriorly, whereas the lateral meniscus is more C-shaped and covers more of the tibial articular surface. We know that the periphery of the meniscus, up to one-third of the medial and lateral meniscus are vascularized. What does the meniscus function? We know it functions in low transmission and shock absorption through their circumferential longitudinal fibers. It also increases the joint congruity, as we know the tibial surface is more flat. The meniscus also functions to reduce joint contact stresses and provides joint lubrication and nutrition. What about low transmission? One extension, the lateral meniscus transmits 70 percent of the joint load, whereas the medial meniscus transmits 50 percent of the joint load. However, overall, the medial meniscus transmits 65-70 percent extension and the lateral meniscus 30-35 percent. Now, this increases in inflection, where studies have found that in 90 degrees of inflection, the meniscus transmits up to 85 percent of the load. How do players present? Well, it's usually an acute injury or the knee gives way. Patients will have some delayed swelling or stiffness and they're going to have pain, especially with twisting or rotation. They might have difficulty straightening the knee and might have locking. Here you see in this play of Jimmy, watch his right leg as he comes down, this non-contact injury and he suffers a meniscus tear. What about imaging? We're going to get plain film to assess for any bony injury or arthritis. However, MRI is going to be your gold standard and what you're going to get pretty quickly in these high-level athletes. What are some of your common tear types? On the traumatic population, they're going to be young and athletic active individuals. These tears are often going to be associated with ACL tears and your vertical longitudinal tears are going to be most common. These traumatic tears are most amenable to repair. Other type of tears are your degenerative tears. These are going to happen in your older patients. They're going to have pre-existing degenerative changes. The tear types are going to be your horizontal cleavage, your flap tears, or your complex tears. These are really going to have minimal healing capacity and not going to be amenable to repair. What are the treatment factors? Well, we know what we're looking for as physicians. We're looking for mechanical symptoms. We're going to analyze the tear type. We're going to look for any player limitations in their function. Ultimately, we want them to have full range of motion and strength before returning to play. We're always concerned about player longevity and what other concurrent injuries there are and do those require surgery. However, as a team physician, you got to be aware of other factors that the team or the player might have in mind. And these have to do with season timing of the injury, the contract status of the player, the playoff potential of the team or any trade potential in the player. And these don't necessarily change your treatment factors, but there's something you want to keep on your mind as the player or the team might find these important. What are your treatment options? So your conservative options are going to be more than your peripheral tears, your non-displaced tears, usually under a centimeter in that peripheral one third. You're going to want to know that the player has full function, range of motion and strength. And then you want to keep in mind your other factors. You're going to treat players surgically if they have any kind of displaced or severe tear type. They have any mechanical symptoms such as catching or locking, or they have concurrent injuries that require surgery, such as ACL rupture. When you're performing a meniscal pair, what are you going to consider? You want to consider the location of the tear, the configuration of the tear, any complexity or chronicity of the tear, and also the patient age and compliance, which are in postoperative rehabilitation protocol. And then you also always want to make sure you have stability of the knee as that can affect recurrence rates. This infographic in arthroscopy defined how we traditionally did meniscus repairs and some newer techniques. At the top, you see the inside out repair, which is really the gold standard. It allows for low profile needles passing through the meniscus and retrieval out through a posterior meter or posterior lateral port. It does require a skill assistance to retrieve the long needles and avoid a neurovascular injury. And then you're going to tie your knots over the capsule. With newer techniques, you can do an all insider repair, either capsular base or meniscal base. With capsular base, use a device of your choice, but it allows for extra capsular anchors. However, there's a large meniscal penetration to these anchors. And the meniscal base, use a meniscal suture passing device that uses small meniscal penetration and does not tether the meniscus to the capsule. However, in this technique, you require arthroscopic knot tying. And these new techniques have allowed for less assistance and lower technical difficulty. What is the ideal tear? So the ideal tear is ideally an acute vertical tear and a longitudinal tear in the vascular periphery of the meniscus and a young patient with a stable knee. This is a picture of the outside technique. You see the posterior lateral portal on the left and you pass your suture needles through and retrieve them through the outside and tie your sutures over the capsule. And you want to be cognizant of any neurovascular structures, particularly distally with the perineal nerve shown in the bottom picture. What is your all inside techniques? This is shown anywhere from 66% to 93% success rate in the literature. What you want to do is prepare your tear with either meniscal trepanation or a rasp to get some insights on bleeding and healing. You're going to impose your tear edges, passing one limb of device through the meniscus and then the second device, either through the capsule on the top or the bottom to perform a vertical mattress suture. And it's important to get sutures above and below the meniscus to do a circumferential repair and give your highest incidence of healing. So after you pass both ends, you're going to tighten your suture here. It's going to impose the edges. And then you cut your suture and you have all inside repair. What are our clinical results? Well, this study in KSSTA evaluated 29 football players with isolated meniscal tears with five-year follow-ups. And they found a 6.7 in a revision rate and an 89% return to sport rate at 4.3 months. When following these players longer at six years, they found that 45% were still playing and 28% at the same level. When these players were asked why they weren't playing, they said it had less to do with the knee and more to do with their lack of playing football in the future. A second study by Critch and colleagues evaluated 85 wrestlers with isolated meniscal tear with six-year follow-up. This study found a 21% revision rate in the repair group versus a 3% revision rate in the meniscectomy group at two and a half years. They found an 89% return to sport rate and a 65% return to competition rate. So what happens when these patients are followed with longer follow-up? Well, this study by Critch and colleagues evaluated 44 players under the age of 18 with isolated medial meniscus repairs with 17-year follow-up. And they found a high 42% failure rate with 80% of complex meniscus tears failing, 47% of bucket-handled tears, and 80% of simple repairs. And they found no difference in PROs between the tear types. A second study by Cole and colleagues did a systematic review of 19 studies and it hit 872 patients at an average follow-up of 56 months. And they found a high return to sport rate at 89 to 90% at final follow-up and significant improvement in all patient-reported outcomes. So what is clinical success? We know that return to sport is often subjective and inconsistent. My return to sport may be a player returning to practice or a scrimmage, whereas traditional return to sport rates are reported as players returning to in-game play. We know that most players return to sport irrespective of healing, so we need to really standardize our definition of what is clinical success. Where our study really defined clinical outcome terms in terms of what is the minimal clinically important difference, what is the substantial clinical benefit, and what is the patient acceptable symptomatic state when looking at PROMIS scores. So what do we know from the literature? We know that there's a high return to sport rate after meniscal repairs. We know there's a decreased revision rate when a meniscectomy versus meniscal repairs. And we know that our complex and bucket of hand no-tears do worse. We know that when performing a concomitant ACL reconstruction there's a better outcome with meniscal repairs. And we know that there's a high revision rate when meniscal repairs are long-term follow-up. We also know that there's increase in patient-reported outcomes regardless of our treatment type. So what is your role as a team physician? You want to always do what's best for the player. You want to have an informed discussion considering all the patient factors. Remember that second opinions are common and you might have to facilitate that for your player. And ultimately your goal is to resolve any kind of pain or mechanical symptoms the player is having. When performing surgery, you want to preserve meniscus whenever possible and let the player know that second surgery is possible with a meniscal repair. Thank you everyone for your time and your attention.

meniscus tears

treatment options

surgical techniques

clinical outcomes

team physicians