Arthroscopic Meniscal Repair

Abstract

Menisci is an important fibrocartilagenous crescents that keeps the congruity between the femur and tibia, Moreover it plays a major role in shock absorption, load transmission, nutrition, motion lubrication, proprioception, and joint stability especially in ACL deficient knees. As the orthopedic community started to understand the vast important role of menisci as an indispensable structure, and the drastic degenerative effect of their loss; they began to study the different methods of its salvage. Meniscal tears could be encountered by direct contact or non-contact injuries especially if body twists on stable foot. Tears are classified according to their direction in relation to meniscal surface; they could be longitudinal, radial, oblique, T-shaped, horizontal cleavage, flap, or complex tears. In addition, Tears could be described according to the rim width and the arthroscopic appearance of the tear edges into: red -red-, red-white, and white-white tears. The best tear to heal and the most commonly encountered clinically is the acute vertical longitudinal, red-red tears which occur in young adolescents with stable knees or with concomitant ACL reconstruction in the same setting. Other factors that favor meniscal healing are: lateral meniscus tears, short tears, choosing one of the locked meniscal repair techniques, and-- utilization of one of the healing enhancement methods. Diagnosis of meniscal tear is not an easy task, but it needs an experience and a full clinical picture analysis. MRI is a powerful diagnostic tool that replaced the invasive arthrography, but still it has its false positive and false negative results. Meniscal repair has different techniques; open, arthroscopic inside out, arthroscopic outside-in, and arthroscopic all-inside techniques, and one should choose the most appropriate, strong, easy, and feasible method of fixation to master. Inside-out technique may fill all these criteria, although in posterior horn meniscus tears it may need to do invasive postero-medial incision which may affect neurovascular structures. Outside-in method is the best method for anterior horn meniscus tears, as it has the easiest method for suture handling at the anterior knee compartment. All-inside method was technically difficult and did not gain worldwide spread, until the revolution of meniscal repair devices was introduced in 1990s by T-Fix and bioabsorbable meniscal screws; however, Chondral injury, inflammatory foreign-body reactions, implant failure, and cystic haematoma formation have also been documented complications with bioabsorbable screws. In fact, hybrid fixation; combining inside-out or outside-in methods with the all-inside meniscal repair devices could be the best and safest method for meniscal fixation. Postoperative rehabilitation program must be followed to secure the meniscal fixation. Previously, it was thought that immobilization is the best method to give safety to meniscal repair, but now it is strongly believed that immobilization is detrimental on meniscal healing. Also, gradual weight bearing is important especially for longitudinal tears but the radial tears, as axial loading has a compressing effect on longitudinal tears but has a distracting effect on radial tears. Evaluation of meniscal repair is a very important issue as previously strict parameters were put to evaluate meniscal repair as regard their anatomical healing when viewed arthroscopically. Nowadays, evaluation is more dependent on the clinical and functional outcome of' the patients.