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Inside-out Repair of Extensive Meniscal Tears Using Posteromedial and Posterolateral Neurovascular Protective Windows.

ABSTRACT: Three popular repair techniques for preserving the torn meniscus are the all-inside, outside-in, and inside-out techniques. Among these, the inside-out technique has shown low failure rates, and it therefore remains the gold-standard technique for repairing the torn meniscus. For extensive and chronic meniscal tears, proper use of this technique has become fundamental for knee surgeons. Nevertheless, challenges in using this technique include a higher risk of catching the neurovascular bundles on the posteromedial and posterolateral sides of the knee and difficulties in reducing and stabilizing chronically displaced meniscal fragments. In this article, the inside-out technique is revisited with an emphasis on anatomic details of how to avoid the neurovascular bundles while addressing extensive and chronic meniscal lesions.

SUBMITTER: Hetsroni I

PROVIDER: S-EPMC7823103 | biostudies-literature | 2021 Jan

REPOSITORIES: biostudies-literature

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Inside-out Repair of Extensive Meniscal Tears Using Posteromedial and Posterolateral Neurovascular Protective Windows.

Hetsroni Iftach I Mann Gideon G Marino Gabriel G Ohana Nissim N

Arthroscopy techniques 20210120 1

Three popular repair techniques for preserving the torn meniscus are the all-inside, outside-in, and inside-out techniques. Among these, the inside-out technique has shown low failure rates, and it therefore remains the gold-standard technique for repairing the torn meniscus. For extensive and chronic meniscal tears, proper use of this technique has become fundamental for knee surgeons. Nevertheless, challenges in using this technique include a higher risk of catching the neurovascular bundles o ...[more]

PMID: 33532219

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Project description:BackgroundIn irreducible bucket-handle medial meniscal tears (BHMMTs), the displaced central fragment is rotated 180° or more, meaning reduction is impossible without derotation of the tear. In chronic cases, the rotated meniscus is deformed and degenerated; thus, the issue of reproducibility and repairability arises. This study presents the clinical outcomes of chronic irreducible and unstable locked BHMMTs. Radiological outcomes were also evaluated using magnetic resonance imaging (MRI).MethodsThis is a retrospective study of 37 patients with 11 cases of irreducible BHMMT and 26 cases of reducible but unstable chronic BHMMT who underwent operations between 2011 and 2016. Posterior arthroscopy was performed after temporary meniscus fixation using a provisional needle fixation technique. After the posterior repair with vertical mattress sutures was completed using an all-inside technique, the classic outside-in technique was performed for the anterior third of the meniscus. The Lysholm, International Knee Documentation Committee (IKDC), and Tegner activity scores were obtained from all patients before surgery and at the latest follow-up. Radiological evaluations were performed using MRI before surgery and at 6 months postoperatively.ResultsBetween 2011 and 2016, a total of 37 consecutive patients with irreducible and chronic BHMMTs underwent surgery. The average postoperative follow-up was 7.2 ± 1.4 years (mean ± SD). Postoperative Lysholm (89.57 ± 2.7) and IKDC (87.22 ± 3.2) scores improved significantly at the last follow-up when compared with the pre-operative scores (38.44 ± 4.5 and 23.52 ± 7.8, respectively). According to the Tegner activity scale, patients' postoperative activity levels remained unchanged compared to preoperative levels at the last follow-up.ConclusionPosterior knee arthroscopy with the all-inside posterior suture and inside-out anteromedial suture technique presented in this study yielded excellent clinical outcomes when used to repair chronic irreducible or unstable BHMMTs.Level of evidenceLevel IV.

Project description:BackgroundMeniscal tears are traditionally classified into traumatic versus degenerative tears. Although this classification plays a major role in clinical decision making, no consensus exists on the exact definition of a traumatic or degenerative tear, and the histopathological basis for this classification is unclear.PurposeTo assess the histological degree of meniscal degeneration in patients with a traumatic meniscal tear, as compared with intact meniscal tissue and osteoarthritic meniscal tissue.Study designDescriptive laboratory study.MethodsTraumatically torn meniscal tissue was collected during arthroscopic partial meniscectomy. As a control group, intact meniscal tissue was used from transfemoral amputations or direct postmortem dissections. Meniscal tissue from osteoarthritic knees was obtained during total knee replacement surgery. Meniscal tissue was processed, stained, and histologically analyzed with the Pauli scoring system (range, 0-18), comprising the subdomains surface integrity, cellularity, collagen organization, and matrix staining. Scoring was performed by 2 independent observers, blinded to condition, region, and patient data of the meniscus.ResultsThe traumatic meniscal tear group contained 43 patients (34 men; median age, 29 years; median body mass index [BMI], 24 kg/m2); the intact meniscal tissue group, 8 patients (3 men; median age, 58 years; median BMI, 30 kg/m2); and the osteoarthritic group, 14 patients (4 men; median age, 66 years; median BMI, 28 kg/m2). After adjustment for sex, age, and BMI, patients with a traumatic meniscal tear had a significantly higher histological score than patients with intact meniscal tissue (2.7-point difference; P = .035). Histological score between the traumatic and osteoarthritic groups was not different.ConclusionTraumatically torn menisci possess a higher degree of degeneration than intact menisci. Our results suggest that patients with a traumatic meniscal tear may already have had a certain degree of meniscal degeneration. These findings potentially challenge the classic view of traumatic versus degenerative meniscal tears.Clinical relevanceOur findings provide a better understanding of the tissue condition of a torn meniscus. This knowledge may help clinicians decide on choice of treatment and may lead to new perspectives to prevent knee osteoarthritis in patients with a torn meniscus.

Dataset Information

Inside-out Repair of Extensive Meniscal Tears Using Posteromedial and Posterolateral Neurovascular Protective Windows.

Publications

Inside-out Repair of Extensive Meniscal Tears Using Posteromedial and Posterolateral Neurovascular Protective Windows.

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