Thank you, everybody. I'm very much looking forward to presenting you today on how I manage horizontal cleavage tears of the meniscus. My title of this is when do I resect and when do I repair? My name is Scott Fawcett. I'm an orthopedic surgeon for the Centers of Advanced Orthopedics in Washington, D.C. Here are my disclosures. A lot has been in the news regarding meniscus tears. A lot of this is based off of recent randomized control studies looking at patients who have had meniscectomy in the setting of cartilage damage and the degenerative knee. A lot of it is not pretending very good for the role of meniscectomy. We need to better understand how to best manage these meniscus tears. I believe that meniscus repair should be your default option over meniscectomy. Today, I'm going to talk to you a little about meniscus tears. We'll briefly address the anatomy and function and why you should repair. We'll discuss the consequences of meniscectomy. I'll talk about how to repair, particularly repair concepts with horizontal cleavage tears and techniques. Then I'll talk to you about other techniques, including optimizing repair for both looking for the right patients to do this for, how to enhance your repair with biologics, and also discuss bracing. Meniscal anatomy and function. We all know that meniscus plays a huge role in transmitting force from the femur through the knee joint into the tibia. Basically, it brings that convex force of the femur into a concave side on the medial side, but the lateral side is actually fairly convex. That plays an even more important role in the meniscus. In particular, the percent of surface area on the lateral compartment and the role of the meniscus there in force transmission is key. As you can see in this slide right here, more than 50% of the lateral tibia plateau is covered by meniscus, as opposed to about 40% of the medial tibia plateau. The meniscus is mobile. You can see here, courtesy of Dr. Chawla, this video, there's more mobility on the lateral meniscus, which plays a role in terms of how you can fix this into what structures you should be fixing the meniscus. Meniscal function, we've already addressed. The role of meniscectomy is critical. In particular, the role of root tears is the equivalent of meniscectomy, but even horizontal cleavage tears play a role in force transmission within the knee. The risk of knee osteoarthritis after meniscus repair versus partial meniscectomy is not insignificant. There's a 70% increase in knee OA within 10 years after meniscectomy compared to repair. Most of these horizontal cleavage tears are the degenerative type. These are the types that are often being resected, but I think there's an opportunity to repair these. First, before we even get in the operating room, we need to better understand some of the pre-surgical conditions and considerations before indicating someone for any meniscus surgery. We need to specifically discuss with our patients the role of knee arthritis and how a meniscectomy or meniscus repair will affect the progress of that arthritis. Knowing full well and trimming out any meniscus will likely increase the role of arthritis, and that a repair will not make the arthritis go away. Smoking is a serious condition that has been shown in numerous studies to affect the role of healing of the meniscus. It's critical that we counsel our patients to at least take a small brief break from their smoking habits. I recommend six weeks before and for the six weeks afterwards. By that time, most patients who have quit for three months will quit for good. The role of diabetes is a caution. If this is uncontrolled, you really should get that controlled before considering doing arthroscopic surgery, as the risk of infection and non-healing can occur in either surgery. Obesity plays a role in the sensibility to be able to be braced in terms of meniscus repair, as well as the forced transmissions and their gait analysis can be severely affected in morbid obese patients. Rehabilitation is significant with repair, and we need to counsel our patients the impact that this will have on their lives so that they're prepared and are able to make a shared decision about the role of meniscectomy versus meniscus repair, both in the operating room and afterwards. Most patients have preconceived notions about what's going to happen. In this really important study done by Brophy's Group in St. Louis, 78% of patients were interviewed were not expecting a meniscectomy for their meniscus care. That's a key thing to talk to them about the potential for meniscectomy versus meniscus repair. Radiographic, we need to get those x-rays, rule out osteoarthritis. The MRI is critical. You can see that horizontal cleavage tear right here. We need to get a better look at the cartilage using both T1 and T2 sequences, and making sure that we don't have adjacent cartilage defects within that compartment. Thermal vent office arthroscopy is also very helpful in those questionable conditions of maybe a poor MRI artifact, not able to get an MRI or previous surgery. It's a fairly easy thing to be able to do in the office, and we can get very good results. As you can see here, just here in the office, this can be done just through a needle scope and can evaluate medial and lateral compartments as well as the patellofemoral compartment with very good resolution and be able to see everything we need to see, and counsel the patients on their potential for getting better. Briefly, I'll talk a little bit about the ABCs of meniscus repair. I try to include this in every talk. I talk about meniscus repair because I think it is critical. When talking about access, we really need to take that motto, first do no harm. Going in and doing an arthroscopy, which you have good cartilage, and just to go trim out a meniscus and then developing bad cartilage is a huge problem. As you can see here, gaining access to a tight compartment is critical. You can just do it with a percutaneous spinal needle, just coming along the MCL. You can see here we now have adequate space to diagnose. I think that this meniscus tear would be very difficult to identify with that tight compartment. We now have the ability to diagnose this and as well as treat this without causing cartilage damage in the femoral condom. We've shown in multiple studies that valgus stress radiographs normalize after just between three weeks and six months and no physical exam findings by three weeks and no complications with that release. What you really want to do is avoid this. This is not Dr. Brown, this is an image that he got to us. You really want to avoid this problem. This is a bad thing. This is a teenager kid with a meniscus tear, came in, did not get that same access I did, and now has created large iatrogenic damage to the medial femoral condyle and trimmed out in the tibial plateau and trimmed out the majority of the meniscus. Biology is important. There are ways to biologically enhance our meniscus repair using marrow venting, which is my preference. Clot amputation is very helpful and can be easily manipulated on the back table and placed within the knee joint. There are constructs that are key and getting that circumferential stitch is ideal because that's going to seal off your repair all the way around 360 degrees around the tear, whereas some of our anchor-based sutures may lead to a remnant area affecting the ability to heal only 50 to 40 percent of the meniscus tissue unless you're doing both femoral and tibial fixation. Some of the repair tips. My go-to stitch with the horizontal cleavage tear is the hay bale. You can argue here that my access was a little tight, but you're basically just going to go in there and put sutures from the front to the back and basically tie knots all the way around the meniscus tissue, bounding that up. You're going to blunt the edge of the meniscus a little bit, but you're going to maintain meniscus volume, and over time with weight bearing, that meniscus will return back to its natural state. In the horizontal meniscus literature, this is a study that was done by Dr. Ramaphosa's group showing that the impact of the tibial femoral contact fractures after horizontal cleavage tears restores them back to normal. Here we can see on the contact area that intact, the tear decreased. With repair, we're able to restore back to normal, whereas meniscectomy does not restore those. The biomechanical portions support repair of the meniscus rather than resection of meniscus tears, even though it seems so easy. And in the results of our first stitch study, looking at circumferential tear repairs of horizontal cleavage tears, we showed that we had near 100% healing on second look, 17% failure rate because of other issues other than the meniscus not healing. So this is another feature of the circumferential stitch that allows us to repair even during a popliteal hiatus, and that's another showing you here what the Hebel suture looks like. One year later, doing in-office arthroscopy, these are courtesy of Justin Sullivan, we can show there's adequate healing of that horizontal cleavage tear. I want to go over a few things on optimizing repair. Patient selection is critical. We no longer should be counseling our patients that because they're too old, they shouldn't have a repair. Multiple studies have shown that there's no difference in outcome and that the key difference is the status of the cartilage. Smoking and tobacco use does show a higher failure rate, and that's been shown in multiple studies, including this most recent one showing increased risk of failure after repair. But cartilage is the key thing. It needs to be there before the surgery so you can keep it there after the surgery. Biologic enhancement, again, I recommend using marrow venting. It's cheap, effective. Use a microproctor all, just to the notch, just anterior to the ACL footprint, and that should give you adequate mesenchymal blood cells to help improve the healing of the meniscus. Dr. LaPrade most recently showed that that had equivalent outcomes in terms of healing as compared to ACL with meniscus. Bracing helps. Bracing reduces the meniscal strain across there, and we use a brace-locking extension. In some cases, we even use a brace to help prevent an unloading brace to help improve symptoms and outcomes. The outcomes are very promising for meniscus repair. Multiple meta-analysis studies with midterm data have shown clinical benefits to repair over meniscectomy, both with Dr. Noyes and Dr. Xu. We all know that there's a high likelihood of healing with concomitant ACL reconstruction. So obviously, if there is an ACL, you should be doing the ACL and the meniscus together to get the best benefit. But if there isn't, look for that microproctor all and get that biologic healing with the same manner as we discussed before. Osteoarthritis is the most likely factor for failure rather than age. As Dr. Krantz has shown, there's no difference in any of these repair types. When he compared one of the two of the more difficult repair types of the buccaneal tears versus radial tears, and they both had reoperations at around 10%, very low rates, and you get good healing. This is a 28-year-old gentleman with a vertical-type tear showing that circumferential stitch with adequate healing at 12 weeks. When do I resect? Only in very specific cases. On very specific patient factors who are unwilling to do the rehabilitation, patients who are obese and have abnormal gait patterns, may have locking or catching or severe pain. Patients who are smoking, I may have to actually counsel them to avoid surgery. And some of those areas where we have small free-edge tearing of the white cell with unexpected cartilage damage that has progressed in between indicating them for surgery and not. So in summary, meniscal tears cause serious consequences. They cause surface contact areas and increased cartilage forces. Meniscectomy does not correct these consequences. Healed repairs are achievable for all types of tears, but you need to keep in mind to have multiple fixation points, use biological enhancement, and respectful rehabilitation. And lastly, meniscus repair has an excellent outcome and can slow the progression of future knee osteoarthritis. Thank you very much.

meniscus repair

orthopedic surgery

horizontal cleavage tears

knee osteoarthritis

patient selection