The Impact of Age on Knee Injury Treatment Focus on the Meniscus Dr. Alvin J. Detterline, MD Sports Medicine and Orthopaedic Surgery Towson Orthopaedic Associates University of Maryland St. Joseph Medical Center
Disclosures Consultant Ceterix Orthopaedics
Types of Knee Injuries Extra-articular Muscle Tendon Nerve Intra-articular Ligament Bone Cartilage Articular Cartilage Meniscus
Extra-articular Injuries Muscle Pediatric Strains Overuse injuries Treatment is generally relative rest Adult Muscle tears (high grade strains) Treatment is again relative rest Improve flexibility
Extra-articular Injuries Tendon (Quadriceps or Patella Tendon) Pediatric Tendonitits Overuse injuries Rarely ever anything serious Adults Early degeneration of the tendon Traumatic ruptures from low energy injury Likely need for orthopaedic evaluation to determine extent of injury
Extra-articular Injuries Nerve Rarely implicated in either younger or older individual Usually related to major knee injury (devastating) Knee dislocation Multi-ligament knee injury Treatment focused on initial stabilization of the knee joint
Intra-articular Injuries Ligament Younger individual ACL very common MCL more likely during adolescence Older individual ACL most commonly associated with other injuries Meniscus Articular cartilage Beware of co-existing arthritis Treatment based upon activity level of the patient
Intra-articular Injuries Bone Pediatric and adolescent patient Worry about fractures around the physis Tibial eminence fractures Adults Tibial plateau fractures Patella fractures Concern for osteoporosis
Intra-articular Injuries Cartilage 2 types of cartilage Articular cartilage Coats the ends of the bones Tread on the tires Meniscus Shock absorber
Intra-articular Injuries Articular cartilage Pediatrics Osteochondritis dissecans Patellar dislocations with chondral shear injury Adults Focal chondral defects relatively uncommon Presentation or progression of joint deterioration (osteoarthritis) much more common
Intra-articular Injuries Meniscus Critical structure for the knee Most important age-dependant structure in the knee Younger the patient equals more critical to preserve
Meniscal Injuries Meniscus tears will not heal with observation Inability for stabilization of the tissue Relatively poor blood supply for healing Treatment is generally surgical Partial meniscectomy Meniscal repair MAJOR DIFFERENCE!
Treatment Meniscectomy Quick recovery High rates of osteoarthritis Rangger et al, AJSM 2016 Meniscal repair Longer initial recovery Concern for lack of healing
Meniscal Injuries Factors affecting treatment Condition of the joint Presence or absence of osteoarthritis Condition of the meniscal tissue Viable and structurally sound Compromised from degeneration or maceration Bottom line Is the joint able to be preserved or is the horse out of the barn?
Meniscal Function Load distribution Shock absorption Joint stabilization
Meniscal Tears Vertical Radial Horizontal Root
Meniscal Healing Similar to fracture healing Need anatomic reduction Favorable biologic environment Initial stabilization
Methods of Repair Inside out Considered gold standard Time consuming Need good assistant(s) Increased pain and potential morbidity Outside in Limited access to all parts of meniscus All inside Differences in technique
All-inside Technique Multiple devices Fixation through the capsule Simple Fast Readily reproducible
Problems with All-inside Technique Compresses femoral side Allows gapping of tibial side Non-anatomic reduction of meniscal tear Courtesy Justin Saliman, MD
Non-anatomic Reduction Tibial sided gapping Probably more important to fix the tibial side rather than the femoral side
Synovial Fluid Invasion Fills gap on tibial side and prevents complete healing of meniscus Potential reason for poorer healing results
Poor Fracture Fixation Concept of prebending plates Capsular anchor-based allinside repair technique does not allow tibial sided compression Circumferential stitch technique allows for opposite side compression similar to proper fracture fixation techniques
Circumferential Stitch Innovative all-inside meniscal repair technique Compresses both femoral and tibial sides Avoids gapping Avoids need to incorporate the capsule Potential for improved healing Potential to repair multiple tear patterns Courtesy Justin Saliman, MD
Circumferential Stitch Suture passer similar to other devices used in the shoulder for rotator cuff repair Smaller jaw designed to allow for work in tight compartments of the knee
Vertical Tears Circumferential compression No capsular bunching No neurovascular risk May perform in the popliteal hiatus
Vertical Tears Circumferential Stitch Biomechanical evaluation of an allinside suture-based device for repairing longitudinal meniscal tears. Masoudi et al, Arthroscopy 2015 Compared all-inside anchor-based, inside-out, and circumferential stitch repair constructs The all-inside circumferential repairs and the inside-out repairs showed significantly higher loads to failure than the allinside anchor-based repairs After cyclic loading, inside-out repair had higher gap formation Courtesy Justin Saliman, MD
Vertical Tears
Radial Tears Commonly treated with partial meniscectomy Detrimental effects on the contact mechanics of the knee Bedi et al, JBJS 2010 Significant potential for healing Ho et al, KSSTA 2013 Anderson et al, Arthroscopy 2010 Noyes et al, JBJS 2010
Radial Tears Inside-out technique considered gold standard Repair does not restore peak contact location to normal Bedi et al, JBJS 2010 Prevents meniscal mobility with tether to the capsule Normal meniscus moves with flexion Thompson et al, AJSM 1991
Radial Tears Circumferential stitch compared to inside - out Less displacement Higher failure load Greater stiffness Beamer et al, Arthroscopy 2014
Radial Tears Circumferential stitch Uniform compression No need to incorporate the capsule and capture the meniscus Potential to maintain meniscal mobility through flexion Courtesy Justin Saliman, MD
Radial Tears
Horizontal Cleavage Tears Resecting one leaflet Makes it look prettier Decreased contact area Increased contact pressure Koh et al, JBJS 2016 Haemer et al, CORR 2007
Horizontal Cleavage Tears Repair Restores mechanical function of meniscus Beamer et al, Arthroscopy 2016 Similar healing rates Kuzweil et al, Arthroscopy 2014 Courtesy Justin Saliman, MD
Horizontal Cleavage Tears Circumferential stitch Uniform compression Limits invasion of synovial fluid Courtesy Justin Saliman, MD
Horizontal Cleavage Tears
Root Tears Results in extruded meniscus Yamagami et al, Knee 2017 Severe loss of meniscal function Bhatia et al, AJSM 2014 Risk for progressive OA Han et al, Arthroscopy 2010 Guermazi et al, Radiology 2013 Repair can restore more normal knee kinematics LaPrade et al, JBJS 2014 Allaire et al, JBJS 2008
Root Repair Stitches placed through horn tissue Trans-tibial tunnel drilled Sutures fixated on anterior tibial cortex
Root Repair
Complex Repair Repeat arthroscopy 2 years s/p repair
Post-operative Rehab Vertical or horizontal tears Brace locked in full extension for weightbearing for 4 weeks Unrestricted ROM initially No squatting past 90 degrees for 3 months Return to sports 5-6 months Radial or root tears Nonweightbearing for 6 weeks Radial No restriction on ROM Root 0-90 degrees for first 4 weeks
Summary Many different types of meniscal tear patterns can be repaired with an all-inside technique Consider repair over partial meniscectomy for joint preservation Advantages of circumferential stitch technique Anatomic reduction of meniscus Circumferential compression of tear Most similar to anatomic fracture reduction Potentially less costly Especially true when considering large tears requiring multiple stitches for fixation
Summary Disadvantages of circumferential stitch technique More time consuming Arthroscopic knot tying necessary Concern for knots abrading articular cartilage Have not seen in over 100 cases Precise portal placement is key Repair rather than resect the meniscus Especially in a young patient
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