Medial Meniscal Root Tears: When to rehab? When to repair? When to debride. Christopher Betz, DO Orthopedics Sports Medicine Bristol, CT

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1 Medial Meniscal Root Tears: When to rehab? When to repair? When to debride Christopher Betz, DO Orthopedics Sports Medicine Bristol, CT

2 Disclosure Consultant Mitek Smith and Nephew-biologic patch

3 Good Life Lessons Bad

4 Why is the Root Important Why repair Meniscal extrusion Articular cartilage loss

5 Why is the Root Important Why repair Insufficiency fractures

6 Why is the Root Important Why repair Inability to resist hoop stress

7 Why is the Root Important Why repair Lead to rapid OA

8 Radial Root Tears May be radial root tear Radial tear within 1cm of the root attachment Similar loading characteristics as root tears Up to 28% of all root tears in some series Bin,Arthroscopy 2014

9 What is the Root?

10 Anatomy Medial meniscal posterior root tear Johannsen,AJSM 2012 Distnce from apex of MTE(medial tibial eminance) 0.7mm lateral 9.6mm posterior Boney attachment Adjacent to PCL On the downsloap of the posterior aspect of MTP

11 anatomy Lateral meniscus root attachment Anterior lateral meniscal root(lara)associate d with ACL tibial attachment Broad lateral posterior attachments Distance from apex of LTE 4.2mm lateral 1.5mm posterior

12 Classification of Posterior Root Type 1partial stable root tear Type 2 complete radial tear within 9!mm of the bony root attachment Type 3 bucket-handle tear with complete root detachment tears LaPrade et al.

13 Classification of Posterior Root Type 4 complex oblique or longitudinal tear with complete root detachment Type 5 bony avulsion fracture of the root attachment tears LaPrade et al.

14 Associated injuries with root tears MM root tears Chondral injuries LM root tears ACL tears 10X more likely to have ACL tear than pts with MM root tears All 4 root tears associated with Iatrogenic tears Matheny : Knee Surg Sports Traumatol Arthrosc 2015

15 Who Has a Root Tear

16 Meniscal Root Patient Describes hearing a pop with deep sqaut Pain with deep flexion or squatting Posterior knee pain Possible palpable extrusion

17 Clinical exam Deep posterior knee pain +- med joint line pain Valgus stress test may demonstrate extrusion Can be associated with lachman 3+/posterior drawer

18 Meniscal ghost sign Lack of meniscal signal on saggital view MRI Where normal signal intensity of the meniscus becomes white SONK(spntaneous osteonecrosis knee=pmm root tear until proven otherwise

19 Now What do We Do?

20 Treatment Algorithm Bhatia ajsm 2014

21 Treatment Algorithm Bhatia ajsm 2014

22 Treatment Algorithm

23 Menisectomy/Non-op/Meniscal Repair Menisectomy indicated in patients with symptomatic, chronic tears in the setting of degenerative joint disease Non-op treatment recommended for patients with chronic, asymptomatic repairs with advanced degenerative joint disease & poor surgical candidates Tx: NSAIDs, activity modification, corticosteroids, bracing Meniscal repair indicated for acute tears in the absence of chondral injury (Based on tear pattern)

24 Meniscus root tears why need to fix PH root tear equivalent to total medial meniscectomy Allaire jbjs 2008 PH MM root repair restores contact pressure to normal Repair is cost saving intervention Radial root tears(near root tears)equivalent to root tears Faucett ajsm 2018

25 Meniscus root tears why need to fix Faucett ajsm 2018

26 Who do you Trust?

27 The Old

28 The New

29 DO IT RIGHT Anatomic PH MM root repair restores contact area and minimize peak contact pressure Bhatia AJSM 2014

30 fix Non anatomic repair does not improve contact pressures Must release scar and anatomically reduce the meniscus during repair

31 When to fix MM type II=extrusion, bone marrow edema,lower grade cartilage lessions LM type II=extrusion,meniscofemoral ligamanets torn

32 Two types of fixation Transtibial pullout technique Suture anchor No diff in pts older than 50 or younger than 50 Lapade acta orthop 2016

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34 Transtibial pullout technique Advantages Reproducible (avoid difficult right angle of anchor technique) Can use a tibial guide Drilling of tibial tunnels Enhance healing elluding growth factors and mesenchymal stem cells Acurate position restores contact pressures Bhatia ajsm 2014

35 Transtibial pullout technique Disadvantages Construct weaker fixation to tibia than native root Difficult to drill though anatomic root site Tibial bone tunnels can interfere with concomitant ligament reconstruction tunnels Bungee effect-suture abrasion and tear

36 Suture Anchor Repair Advantages Does not require tibial tunnels Easier placement of the anchor at the native root attachment Avoid bungee effect Stronger construct during cycling Bhatia ajsm 2014

37 Disadvantages Suture Anchor Repair Optimal location and orientation of the suture anchor unknown Requires a high posterior medial portal

38 improvements Root tears particularly radial tears poor blood supply=biologics