import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: 1cm posterior to posterior capsule at level of PCL, courses through popliteal fossa medially **Risk**: Penetration during posterior horn repairs if needles/devices directed >10mm posteriorly through capsule **Protection**: Maintain knee flexion 70-90° during posterior horn repair (relaxes posterior structures), limit needle/device depth to <10mm past capsule, direct needles horizontally not posteriorly, use blunt retractor for inside-out technique **Injury Recognition**: Pulsatile bleeding, expanding hematoma, loss of distal pulses - requires immediate vascular surgery consultation **Location**: Adjacent and lateral to popliteal artery in popliteal fossa, courses with artery **Risk**: Similar to artery - penetration during posterior horn repairs, may be injured even if artery spared **Protection**: Same precautions as popliteal artery - controlled depth, appropriate knee flexion, horizontal needle direction **Injury Recognition**: Rapid hemarthrosis, non-pulsatile bleeding, may not be immediately apparent - monitor for post-operative swelling and compartment syndrome **Location**: Descends 1-2cm posterior to MCL at joint line level, emerges between sartorius and gracilis tendons, travels with great saphenous vein superficial to deep fascia **Risk**: 1-5% injury rate during inside-out medial meniscal repair despite retractor use, highest risk if incision placed >2cm posterior to MCL or retractor inadequate **Protection**: Vertical posteromedial incision exactly 1cm posterior to MCL (palpate MCL edge), blunt retractor between capsule and neurovascular structures during needle passage, pass needles close to capsule not deep, palpate retractor position continuously **Injury Recognition**: Immediate medial leg numbness, dysesthesia, burning pain - often permanent, no effective treatment, devastating for patients despite "minor" sensory nerve **Location**: Wraps around fibular neck 2-3cm distal to joint line laterally, very superficial in subcutaneous tissue at risk zone **Risk**: Injury during lateral meniscal inside-out repair (rarely performed for this reason), also at risk from lateral portal placement if too inferior **Protection**: Inside-out lateral repair rarely performed - if necessary, make incision at joint line not distal, use retractor, pass needles horizontally. All-inside technique preferred for lateral repairs. Lateral portals placed at joint line level, not distal. **Injury Recognition**: Foot drop, inability to dorsiflex ankle/extend toes, sensory loss dorsal foot - devastating motor injury requiring immediate decompression if acute compression, otherwise observation/bracing **Location**: Runs with saphenous nerve posteromedially, 1-2cm posterior to MCL, superficial to deep fascia **Risk**: Transection during posteromedial incision for inside-out repair or by needles if retractor inadequate **Protection**: Careful dissection during posteromedial incision identifying vein early, protect with retractor during needle passage **Injury Recognition**: Bleeding from incision, post-operative hematoma formation, ecchymosis tracking down medial leg - usually managed conservatively with compression but may require evacuation if large ## Ideal Candidates for Meniscal Repair **Age and Activity Level** - Young patients <40 years (healing potential highest) - Active lifestyle with desire to return to sport/demanding activities - Motivated for extended rehabilitation (4-6 months vs 6-12 weeks for meniscectomy) - Understanding that repair has 10-20% failure risk requiring possible meniscectomy **Tear Characteristics - Critical Selection Criteria** **Zone (Vascularity)** - Most important factor: - Red-red zone (outer 0-3mm): Excellent vascularity, 90-95% healing, ideal for repair - Red-white zone (3-5mm from periphery): Moderate vascularity, 80-85% healing with ACL, reasonable for repair - White-white zone (inner >5mm): Avascular, <40% healing, generally NOT repairable (except with augmentation) - Assessment: Look for bleeding from tear edges (indicates red zone), measure distance from meniscocapsular junction with probe **Tear Pattern**: - Vertical longitudinal: Best pattern for repair (oriented parallel to collagen fibers), 80-90% healing - Bucket-handle: Complete vertical longitudinal with displacement, excellent if reducible, 85-90% healing - Radial tear at root insertion: Specialized repair technique (pullout sutures to bone), 70-80% healing - Horizontal cleavage: Generally NOT repaired (degenerative), consider partial meniscectomy - Complex/degenerative: NOT repairable, meniscectomy - Radial mid-substance: Generally NOT repaired (poor healing due to perpendicular collagen orientation), meniscectomy **Tear Length and Stability**: - Length >10mm: Sufficient for repair with multiple fixation points (4-5mm spacing) - Length <10mm: May heal spontaneously if stable, or single device sufficient - Unstable tear: Displacement >3mm with probing indicates need for repair - Stable tear: May observe if <10mm, acute, red-red zone **Tear Acuity**: - Acute <12 weeks: Fresh tissue, good healing potential, 85-90% healing - Subacute 12 weeks to 6 months: Reasonable healing, 75-85% with ACL - Chronic >6 months: Poorer healing 60-70%, consider augmentation (trephination, PRP) **Tissue Quality**: - Good quality: Firm, red appearance, bleeding edges, no fraying - proceed with repair - Poor quality: Degenerative, frayed, white/gray appearance, no bleeding - meniscectomy - Cannot assess quality until arthroscopy - intra-operative decision required **Associated ACL Reconstruction**: - Concurrent ACL dramatically improves healing: 60-70% isolated to 80-90% with ACL - Mechanism: Blood and growth factors from tunnel drilling - Makes borderline tears (red-white, questionable tissue, chronic) much better candidates - 40-50% of ACL tears have associated meniscal tears - always examine both menisci systematically **Contraindications - When to Perform Meniscectomy** Absolute: - White-white zone location (avascular, won't heal) - Degenerative complex tear (macerated tissue, multiple planes) - Unreducible tear (cannot restore anatomy) - Active infection Relative: - Age >50 years (lower healing potential, lower demand) - Sedentary lifestyle (repair benefit reduced) - Chronic tear >12 months with poor tissue quality - Radial mid-substance tear (poor healing due to collagen orientation) - Previous failed repair (revision repair has lower success 50-70%) - Patient unable/unwilling to comply with extended rehabilitation **Decision-Making Framework** High priority for repair (80-90% success): - Red-red zone, vertical longitudinal, acute <12 weeks, age <30, concurrent ACL, good tissue Reasonable for repair (70-80% success): - Red-white zone, bucket-handle, subacute <6 months, age 30-40, concurrent ACL Borderline for repair (60-70% success): - Red-white zone, chronic, age 40-50, no ACL - consider augmentation (trephination) Not suitable for repair (<40% success): - White-white zone, degenerative, complex, radial mid-substance, age >50 - perform meniscectomy **Counseling Patients** Benefits of repair vs meniscectomy: - Preserves meniscal function (shock absorption, load distribution, joint stability) - Reduces long-term OA risk (meniscectomy increases OA 5-10x at 10-20 years) - Lateral meniscectomy worse than medial (>200% vs >50% contact pressure increase) - Even partial meniscectomy accelerates cartilage degeneration Trade-offs of repair: - Extended rehabilitation 4-6 months vs 6-12 weeks for meniscectomy - ROM restriction controversial (0-90° for 4-6 weeks traditional vs full ROM modern) - 10-20% failure risk requiring possible later meniscectomy - Slightly higher complication risk (neurovascular injury 1-5% for inside-out) - Additional cost for all-inside devices ($500-800 per device) Expected outcomes: - 80-90% healing with concurrent ACL reconstruction at 2-5 years - 60-70% healing for isolated repair without ACL - If failure occurs, typically within first year (70-80% of failures) - Failed repair can still undergo meniscectomy - no harm trying if criteria met - Return to sport 4-6 months minimum (vs 6-12 weeks for meniscectomy) ## All-Inside vs Inside-Out vs Outside-In Techniques **My Technique Preference Algorithm** **First Choice - All-Inside (70-80% of my repairs)**: - Vertical longitudinal tear in body or mid-posterior horn (within 5-10mm of PCL) - Bucket-handle tear with reducible fragment - Any tear pattern where I can access both sides with device - Patient preference for minimal incision/morbidity - Advantages: faster, lower morbidity, equivalent outcomes, no nerve risk - Limitations: cost, implant complications 2-5%, difficult far posterior horn access **Second Choice - Inside-Out (20-25% of my repairs)**: - Far posterior horn tear (>10mm posterior to PCL) where all-inside access difficult - Revision repair (can remove old devices, place sutures precisely) - Large complex tear requiring multiple sutures with precise placement - Cost-conscious healthcare system (low implant cost) - Advantages: excellent posterior access, precise fixation, long-term data, low implant cost - Limitations: nerve injury 1-5%, incision morbidity, slower procedure **Rarely Use - Outside-In (<5% of my repairs)**: - Isolated anterior horn tear (rare indication for repair) - Anterior horn tear combined with other technique for posterior horn - Advantages: good anterior access, low cost, minimal morbidity - Limitations: very limited applications, technically challenging, limited experience **Hybrid Approach (Occasional)**: - Large bucket-handle tear: all-inside for body, inside-out for far posterior horn - Multiple tears: different techniques for different locations - Failed all-inside: convert to inside-out for revision **Technique Selection Decision Tree** Step 1: Assess tear location - Body or mid-posterior horn → All-inside (first choice) - Far posterior horn (>1cm from PCL) → Inside-out (better access) - Anterior horn → Outside-in (rarely needed) or all-inside if reachable Step 2: Assess tear complexity - Simple vertical longitudinal <15mm → All-inside (faster, easier) - Complex or large bucket-handle >20mm → Inside-out (precise fixation) or hybrid - Revision repair → Inside-out (can address previous failure) Step 3: Consider patient factors - Patient prefers minimal morbidity → All-inside (no incision) - Cost limitation → Inside-out (low implant cost) - Previous nerve injury or concern → All-inside (lower nerve risk) Step 4: Assess surgeon experience - Comfortable with all-inside devices → All-inside for most tears - Extensive inside-out experience → May prefer inside-out for control - Limited meniscal repair experience → All-inside (easier learning curve) ## Meniscal Vascularity and Healing Potential **Meniscal Blood Supply - Anatomic Zones** The meniscus has zonal vascularity that determines healing potential: **Red-Red Zone (Outer 0-3mm)**: - Excellent vascularity from peripheral meniscocapsular vessels (superior/inferior lateral and medial geniculate arteries) - Capillary penetration from capsule extends 3mm into meniscal substance - Healing rate: 90-95% with appropriate repair - All repair techniques successful in this zone - Assessment: Active bleeding from tear edges indicates red-red zone **Red-White Zone (3-5mm from periphery)**: - Moderate vascularity with some capillary penetration - Variable healing potential dependent on precise location within zone - Healing rate: 80-85% with ACL reconstruction, 60-70% without ACL - Reasonable for repair especially with concurrent ACL - Assessment: Minimal bleeding or none, but tissue appears healthy/viable **White-White Zone (Inner >5mm)**: - Avascular - no capillary penetration - Nutrition by synovial fluid diffusion only (adequate for metabolism but NOT for healing) - Healing rate: <40% without augmentation - Generally NOT repaired unless augmentation used (trephination to reach bone marrow) - Assessment: No bleeding, white/gray appearance **Lateral vs Medial Meniscus Vascularity**: - Lateral meniscus: Slightly better vascularity overall (covers larger percentage of meniscus) - Medial meniscus: Red zone 3-4mm, white zone starts earlier - Lateral meniscal preservation more critical (>200% contact pressure increase if removed vs >50% medial) **Age-Related Vascular Changes**: - Children <18 years: More extensive vascularity (red zone may extend 5-6mm), excellent healing potential - Adults 18-40 years: Standard vascularity (3-5mm red zone), good healing potential - Adults >40 years: Reduced vascularity (red zone may be only 2-3mm), decreased healing potential - Elderly >60 years: Minimal vascularity, poor healing potential even in peripheral zone **ACL Reconstruction Effect on Healing** Concurrent ACL reconstruction improves meniscal healing 60-70% isolated to 80-90% with ACL: **Mechanisms**: 1. Blood flow: Femoral and tibial tunnel drilling creates bleeding which reaches meniscal tear via joint effusion and synovial circulation 2. Growth factors: Bone marrow contains BMPs, TGF-β, PDGF which promote meniscal healing 3. Inflammatory response: ACL surgery creates healing environment with inflammatory cells and cytokines 4. Notchplasty: If performed, additional bone marrow exposure 5. Hemarthrosis: Blood clot may form at tear site providing scaffold for healing **Clinical implications**: - Makes borderline tears (red-white zone, chronic, questionable tissue) much better candidates for repair - Should have low threshold for repair when performing concurrent ACL - Always examine both menisci systematically during ACL surgery (40-50% have tears) - Even small stable-appearing tears may benefit from repair with ACL - Medial posterior horn tear most common pattern with ACL injury **Healing Time Course** Meniscal healing occurs over 3-6 months: - Weeks 0-4: Inflammatory phase - hematoma formation, inflammatory cells migrate to tear - Weeks 4-12: Proliferative phase - fibroblasts produce collagen, granulation tissue fills tear - Weeks 12-24: Remodeling phase - collagen matures, tissue strengthens, vascularity decreases - 6-12 months: Full maturation - healing complete, but tissue never identical to native meniscus **Factors enhancing healing**: - Younger age (<30 years) - Acute injury (<12 weeks) - Red-red or red-white zone location - Vertical longitudinal tear pattern (oriented with collagen fibers) - Concurrent ACL reconstruction - Good tissue quality (firm, vascular) - Adequate fixation (compression, stability) **Factors impairing healing**: - Older age (>50 years) - Chronic injury (>6 months) - tissue degenerates, inflammation resolves - White-white zone (avascular) - Radial or complex tear pattern (perpendicular to collagen fibers) - Isolated repair without ACL - Poor tissue quality (degenerative, frayed) - Inadequate fixation (gap >1mm, unstable) **Biological Augmentation Strategies** For tears with suboptimal healing potential, augmentation may help: **Trephination (Marrow Venting)**: - Technique: Create small channels (1-2mm drill or awl) from peripheral meniscus to subchondral bone - Mechanism: Bone marrow blood and stem cells reach tear site - Indications: White-white zone tears (normally unrepairable), chronic tears, revision repairs - Evidence: Mixed - some studies show improved healing 40% to 60-70%, others no benefit - I use selectively for borderline tears, not routine **Fibrin Clot**: - Technique: Create clot from patient blood, place in tear gap before fixation - Mechanism: Clot provides scaffold for cell migration and healing - Indications: Large tears with gap >2mm, white-white zone tears - Evidence: Historically used extensively, now less common (modern devices provide compression) - I rarely use (devices achieve good compression without clot) **Platelet-Rich Plasma (PRP)**: - Technique: Inject PRP into repaired tear site at surgery conclusion - Mechanism: Growth factors (PDGF, TGF-β, VEGF) promote healing - Indications: Suboptimal healing potential (chronic, red-white zone, no ACL) - Evidence: Limited - small studies suggest possible benefit, large RCTs lacking - I do not use routinely (additional cost, unproven benefit) **Meniscal Rasping/Abrading**: - Technique: Rasp peripheral capsular surface to create bleeding - Mechanism: Enhances vascular supply to tear site - Indications: Routine for all repairs - Evidence: Well-established - standard practice - I perform routinely in all repairs (critical step) **Stem Cell/Growth Factor Injections**: - Experimental - not standard practice - Limited evidence in meniscal repair context - I do not use ## Post-operative Protocol and Rehabilitation **Immediate Post-operative (Day 0-1)** Analgesia: - Multimodal: Paracetamol 1g QID regular, NSAIDs (celecoxib 200mg BD or ibuprofen 400mg TDS) short-term 5-7 days - Opioids: Endone 5-10mg PRN (avoid routine use, 3-5 days maximum) - Local anesthetic: 20ml 0.25% marcaine with epinephrine injected at surgery (joint and portals) - Ice therapy: Cryotherapy device or ice packs 20min every 2-3 hours for 48-72 hours Immobilization (Controversial): - Traditional: Brace locked in extension for ambulation, unlock 0-90° for sleep - Modern: No brace, or hinged brace 0-90° ROM immediately - My approach: Individualize based on tear pattern: - Large posterior horn tear (>15mm): Brace 0-90° for 4-6 weeks - Small/moderate body or anterior horn tear (<15mm): No brace or early unlock - Rationale: Posterior horn tears have highest stress in flexion >90°, may benefit from ROM restriction Weight-bearing (Controversial): - Traditional: Partial weight-bearing (30-50% bodyweight) with crutches for 4 weeks - Modern: Weight-bearing as tolerated (WBAT) immediately with crutches for comfort - My approach: WBAT with crutches for 1-2 weeks (comfort), advance to full weight-bearing by 2 weeks - Evidence: No clear benefit to restricted weight-bearing for healing (meniscal stress primarily from ROM not axial loading) Early exercises: - Quadriceps sets (isometric) - 10 reps every hour awake (prevent atrophy) - Ankle pumps - 20 reps every 2 hours (DVT prevention) - Straight leg raises - when quad control adequate (usually day 2-3) - Hamstring sets - gentle isometric VTE prophylaxis: - Mechanical: TED stockings, intermittent pneumatic compression device if available - Pharmacological: Not routine for arthroscopy unless high-risk patient (previous VTE, obesity, cancer, immobility) - Early mobilization most important **Weeks 0-2 (Protection Phase)** Goals: - Reduce pain and swelling - Restore full extension (prevent flexion contracture) - Achieve independent ambulation - Regain quad activation ROM: - Traditional protocol: 0-90° flexion limit (if large posterior horn tear) - Modern protocol: Full ROM immediately (if small/moderate tear) - Extension: Full extension CRITICAL - use prone hangs or extension board if lacking - My approach: Individualize - restrict to 0-90° for large posterior horn, full ROM for smaller tears Weight-bearing: - Progress from crutches to full weight-bearing by 2 weeks - Normalize gait pattern Exercises: - Continue quad sets, SLR, ankle pumps - Prone hangs for extension (10min TDS if extension lacking) - Seated knee flexion to ROM limit - Pool walking if available (reduced joint load) Precautions: - Avoid deep flexion (>90° if restricted protocol) - Avoid rotation/pivoting - Avoid squatting - No impact activities Follow-up: - Wound check 10-14 days (suture removal) - Clinical assessment (ROM, effusion, quad function) **Weeks 2-6 (Early Rehabilitation)** Goals: - Full ROM (if not already achieved) - Restore normal gait - Progressive strengthening - Reduce effusion completely ROM: - Traditional: Continue 0-90° restriction until 6 weeks (for large posterior horn tears) - Modern/small tears: Full ROM progressing to >120° flexion - Extension: Must have full extension by 4 weeks (prevent contracture) Weight-bearing: - Full weight-bearing, no crutches - Normal gait pattern Exercises: - Stationary cycling (light resistance, seat high to limit flexion if ROM restricted) - Closed chain: Wall squats 0-60°, leg press 0-60°, step-ups (low step) - Open chain: Quad extensions 90-40° (avoid terminal extension load), hamstring curls - Pool exercises: Walking, light swimming (no breaststroke kick) - Core strengthening - Progressive resistance training Precautions: - Avoid deep squatting (>90° flexion) - Avoid pivoting/twisting - Avoid impact - Avoid forced flexion past ROM restriction if applicable Follow-up: - 6 weeks: Clinical exam, assess ROM/strength/effusion - X-ray if concurrent ACL reconstruction (tunnel position, hardware) - MRI not routine (cannot assess healing reliably <4 months) **Weeks 6-12 (Progressive Loading)** Goals: - Full unrestricted ROM (including flexion >120°) - Progress to single-leg strengthening - Proprioception and balance training - Sport-specific preparation begins ROM: - Remove all restrictions by 6 weeks (even for large posterior horn tears) - Progress flexion to full (>135°) - Maintain full extension Exercises: - Progress closed chain: Deeper squats 0-90°, lunges, step-downs - Single-leg: Balance, single-leg squats, single-leg deadlifts - Plyometrics: Box jumps (low height), lateral bounds, skipping - Cycling: Increase resistance, outdoor cycling - Swimming: All strokes including breaststroke - Sport-specific: Light drills without pivoting/cutting Precautions: - Still avoid deep squatting (>120° flexion) until 12 weeks - Avoid full-speed pivoting/cutting - Monitor for effusion (sign of excessive activity) Criteria to progress to running phase: - Full ROM - Minimal/no effusion - Quad strength >70% compared to contralateral - Single-leg hop >70% compared to contralateral - No pain with activities **Weeks 12-16 (Running Phase)** Goals: - Initiate running program - Progress to agility drills - Sport-specific training Running: - Begin with walk/jog intervals - Progress to continuous running - Increase distance then speed - Monitor for pain/effusion Agility: - Cutting drills (initially at 50% speed) - Figure-8 running - Shuttle runs - Lateral movements Sport-specific: - Individual sport drills - Non-contact practice - Skills training Criteria to progress to return to sport: - Pain-free running including sprinting - No effusion - Quad strength >85% of contralateral - Hamstring strength >90% of contralateral - Hop testing >85% of contralateral (single, triple, crossover, timed) - Completed sport-specific training without symptoms **Months 4-6 (Return to Sport)** Goals: - Safe return to full unrestricted sport/activity - Complete rehabilitation Testing: - Clinical exam: Full ROM, no effusion, no tenderness, stable examination - Strength: Isokinetic testing showing >90% quad strength, >95% hamstring strength vs contralateral - Functional: Hop testing >90% on all tests - Psychological: Confidence and readiness to return (IKDC, ACL-RSI scores if applicable) - Imaging: Consider MRI at 4-6 months if borderline (assess healing) - but NOT routine Return to sport decision: - Minimum 4 months from surgery (regardless of function) - 6 months preferred for competitive athletes - Must meet all objective criteria above - Gradual return: Non-contact → limited contact → full contact over 2-4 weeks **Long-term (6-12 months and beyond)** Maintenance: - Continue strengthening 2-3x weekly - Address any bilateral deficits - Monitor for symptoms Re-injury prevention: - Neuromuscular training - Technique optimization (especially if concurrent ACL) - Load management Follow-up: - 4-6 months: Assess healing clinically, imaging if symptoms - 12 months: Final assessment, discharge if doing well - 2-5 years: Long-term outcome assessment (research protocols) **Rehabilitation Controversies and Evidence** **ROM Restriction**: - Traditional teaching: 0-90° for 4-6 weeks to protect repair - Rationale: Biomechanical studies show meniscal stress increases with flexion >90° - Modern challenge: RCTs comparing restricted vs unrestricted ROM show no difference in healing rates - Current evidence: Mixed - no definitive answer - My approach: Individualize based on tear pattern and stability **Weight-bearing Restriction**: - Traditional teaching: Partial weight-bearing for 4-6 weeks - Rationale: Reduce meniscal load during healing - Modern challenge: Meniscal stress primarily from ROM not axial loading; WBAT may actually promote healing via loading - Current evidence: No clear benefit to restriction - My approach: WBAT for all patients **Return to Sport Timing**: - Traditional: 6 months minimum - Modern: 4 months if functional criteria met - Evidence: No clear threshold - individualize based on healing, function, sport demands - My approach: Minimum 4 months, prefer 6 months for competitive athletes, require objective criteria **Biological Healing vs Biomechanical Stability**: - Key question: When is repair actually healed? - MRI cannot reliably assess healing <4 months (inflammatory changes) - Second-look arthroscopy shows healing is incomplete at 4-6 months but functionally adequate - Biomechanical testing: Repaired meniscus regains ~60-80% of native strength by 6 months - Clinical outcome: Most failures occur within first year (70-80% of failures), suggesting those that survive early period likely healed adequately ## Clinical Outcomes and Evidence Base **Healing Rates - Pooled Data from Systematic Reviews** **All-Inside Technique**: - With ACL reconstruction: 80-90% healing at 2-5 years (multiple studies) - Without ACL: 60-70% healing at 2-5 years - Failure rate: 10-20% overall, higher without ACL (20-30%) - Time to failure: 70-80% of failures within first year - Second-look arthroscopy: Shows variable healing quality - some fully integrated, others fibrous union **Inside-Out Technique**: - With ACL reconstruction: 85-90% healing at 5-10 years (longest follow-up data) - Without ACL: 65-75% healing at 5-10 years - Failure rate: 10-15% with ACL, 25-35% without ACL - Long-term durability: 15-year data shows maintained function in successful repairs **Comparative Studies**: - Multiple RCTs and systematic reviews comparing all-inside vs inside-out - Conclusion: Equivalent healing rates for suitable tear patterns (body and mid-posterior horn) - All-inside advantages: Lower morbidity, faster procedure, less nerve injury - Inside-out advantages: Better far posterior horn access, lower cost, longer follow-up data - Meta-analysis (2022): No significant difference in failure rate (RR 0.98, 95% CI 0.71-1.35) **Prognostic Factors - What Predicts Success?** **Positive predictors** (higher healing rates): - Concurrent ACL reconstruction (single strongest predictor - improves healing 20-30%) - Red-red zone location (90-95% vs 80-85% red-white vs <40% white-white) - Acute injury <12 weeks (85-90% vs 75-80% subacute vs 60-70% chronic) - Young age <30 years (85-90% vs 75-80% age 30-40 vs 60-70% age >40) - Vertical longitudinal pattern (85-90% vs 70-80% bucket-handle vs <40% radial) - Tear length 10-20mm (optimal for multiple fixation points) - Medial meniscus (slightly better than lateral - 82% vs 78% in meta-analysis) **Negative predictors** (lower healing rates): - White-white zone location (<40% healing without augmentation) - Chronic injury >6 months (60-70% healing) - Older age >50 years (50-60% healing) - Radial mid-substance tear (<40% healing - biomechanically unfavorable) - Complex/degenerative tear pattern (<30% healing - should not be attempted) - Isolated repair without ACL (60-70% vs 80-90% with ACL) - Lateral meniscus posterior horn (more difficult technically) - Large tear >30mm (technically challenging, may have multiple repair failure) **Patient-Reported Outcomes** **Successful Repair**: - IKDC scores: Mean 85-90 at 2 years (excellent function) - Lysholm scores: Mean 90-95 at 2 years (excellent function) - KOOS scores: Pain 90-95, Symptoms 85-90, ADL 95-100, Sport 85-90, QOL 85-90 - Return to sport: 80-85% return to pre-injury level, 90-95% return to some sport - Patient satisfaction: 85-90% satisfied or very satisfied **Failed Repair** (requiring meniscectomy): - IKDC scores: Mean 75-80 at 2 years (still good, better than primary meniscectomy) - Lysholm scores: Mean 80-85 at 2 years - Attempting repair does not worsen outcomes compared to primary meniscectomy - Delayed meniscectomy (after failed repair) has similar outcomes to primary meniscectomy - Therefore, no harm in attempting repair if criteria met (even if fails, can salvage with meniscectomy) **Comparison to Meniscectomy** **Short-term (1-2 years)**: - Meniscectomy: Faster recovery (6-12 weeks), higher short-term satisfaction (immediate symptom relief) - Repair: Slower recovery (4-6 months), lower short-term satisfaction (prolonged restrictions) - Paradox: Meniscectomy feels better initially but worse long-term **Long-term (5-15 years)**: - Meniscectomy: Progressive OA development (5-10x increased risk), declining function scores, many develop pain - Repair (successful): Preserved meniscal function, lower OA risk (similar to normal knee), sustained good function - Repair (failed → meniscectomy): Similar to primary meniscectomy long-term **Radiographic OA Progression**: - Meniscectomy: 50-60% develop radiographic OA by 10 years, 70-80% by 20 years - Partial meniscectomy: Better than total but still 40-50% OA by 10 years - Successful repair: 10-20% develop OA by 10 years (closer to intact meniscus) - OA severity: More severe with greater amount of meniscus removed - Lateral worse than medial: Lateral meniscectomy has >200% contact pressure increase vs >50% medial **Contact Pressure Studies** (Biomechanical Evidence): - Intact meniscus: Distributes 50-70% of knee contact forces - Partial meniscectomy: Increases contact pressure 50-100% depending on amount removed - Total meniscectomy: Increases contact pressure >200% (lateral) or >50% (medial) - Successful repair: Restores contact pressure to near-normal - Implication: Even partial meniscectomy significantly increases cartilage load → OA **Cost-Effectiveness Analysis** **All-Inside vs Inside-Out**: - All-inside higher initial cost (devices $1500-4000) but lower overall cost (less operative time, no incision complications) - Inside-out lower device cost but higher overall cost (longer OR time, potential nerve injury treatment) - Cost-effectiveness studies: All-inside slightly favored in most analyses **Repair vs Meniscectomy**: - Repair higher initial cost (devices, longer surgery, extended rehab) - Meniscectomy lower initial cost but higher long-term cost (OA treatment, potential arthroplasty) - 15-year cost analysis: Repair is cost-effective if healing rate >60% (assuming OA prevention) - QALY analysis: Repair gains ~0.5 QALY due to reduced OA and better long-term function **Complication Rates - Pooled Data** **Repair Failure**: 10-20% overall - Symptoms: Recurrent pain, catching, locking, swelling - Diagnosis: Clinical +/- MRI (although MRI has high false positive rate for "re-tear") - Management: Revision repair (50-70% healing) or meniscectomy (definitive) - Timing: 70-80% of failures within first year **Neurovascular Injury**: 1-5% for inside-out, <1% for all-inside - Saphenous nerve: Most common (1-5% inside-out medial), permanent numbness/dysesthesia - Common peroneal nerve: Rare (<1% inside-out lateral), devastating motor deficit - Popliteal vessels: Very rare (<0.1%) but catastrophic **Infection**: 0.3-1% - Similar to routine arthroscopy - Septic arthritis: Requires washout and antibiotics - Superficial infection (inside-out incision): Antibiotics usually sufficient **Stiffness/Arthrofibrosis**: 2-5% - More common with ROM restriction protocols - Prevention: Early ROM (if safe for repair), aggressive extension work - Treatment: Manipulation under anesthesia (if <12 weeks), arthroscopic lysis (if chronic) **Implant Complications** (all-inside only): 2-5% - Migration: Device backs out causing pain/catching - Prominence: Device palpable causing irritation - Chondral damage: Device in joint (technical error) eroding cartilage - Synovitis: Foreign body reaction to implant - Device fracture: Rare with modern devices - Management: Device removal arthroscopically (usually resolves symptoms) **Persistent Pain**: 5-10% - May represent occult repair failure, other pathology (cartilage damage), or unrelated pain - Evaluation: MRI (limited reliability), diagnostic arthroscopy if considering intervention - Management: Conservative initially, possible revision or meniscectomy **Re-tear at Different Location**: 5-10% - New tear separate from repair site - More common in patients with meniscal pathology (underlying tissue quality issues) - Management: Based on new tear characteristics (may be repairable or require meniscectomy) **Evidence Gaps and Ongoing Research** **Optimal Rehabilitation Protocol**: - ROM restriction vs unrestricted - no definitive answer despite multiple studies - Need large RCT with long-term follow-up and standardized protocols **White-White Zone Repair with Augmentation**: - Trephination, PRP, stem cells - limited evidence, small studies - Need rigorous trials to determine if augmentation allows successful white-zone repair **Repair Construct Biomechanics**: - Optimal number of fixation points, spacing, suture configuration unclear - Device comparison studies limited by industry bias - Need independent biomechanical and clinical comparison **Biologic Enhancement**: - Multiple biologics proposed (PRP, bone marrow aspirate, growth factors) - Evidence limited to small case series - Need large RCTs with validated outcome measures **Partial vs Complete Repair**: - For large tears, is partial repair of repairable portion worthwhile? - Limited evidence - some studies suggest partial repair better than complete meniscectomy - Need comparative studies **Revision Repair**: - Success rates 50-70% reported but limited data - Technique optimization unclear - Need registry data and long-term studies ### Step 1: Diagnostic Arthroscopy & Tear Assessment Systematic diagnostic arthroscopy via standard anterolateral viewing portal and anteromedial working portal. Examine: suprapatellar pouch, patellofemoral joint, medial gutter, medial meniscus (posterior horn, body, anterior horn with probe), lateral gutter, lateral meniscus, intercondylar notch (ACL/PCL), chondral surfaces all compartments. Assess meniscal tear comprehensively: Location (posterior horn/body/anterior horn), Zone (red-red/red-white/white-white based on distance from periphery and vascularity - look for bleeding edges indicating red zone), Pattern (vertical longitudinal, bucket-handle, radial, horizontal, complex, degenerative), Length (measure with arthroscopic ruler or probe - need >10mm for repair), Stability (probe test - displacement >3mm indicates unstable tear requiring repair), Tissue quality (firm/friable, vascular/avascular, acute/degenerative appearance), Reducibility (can displaced fragment be restored to anatomic position). Document thoroughly with photos and measurements. **Technical Tip**: EXAM KEY - Systematic tear assessment determines repairability. I evaluate zone (vascularity) by observing for bleeding from tear edges and measuring distance from meniscocapsular junction with probe - red-red zone (outer 0-3mm) has active bleeding and 90-95% healing; red-white zone (3-5mm) may have minimal bleeding with 80-85% healing with ACL; white-white zone (inner >5mm) has no bleeding and <40% healing without augmentation. I assess pattern - vertical longitudinal and bucket-handle are favorable (oriented with collagen fibers) with 80-90% healing; radial mid-substance is unfavorable (<40%) due to perpendicular orientation. I probe the tear to assess stability and reducibility - must be able to restore anatomic position with probe for successful repair. Concurrent ACL reconstruction improves healing dramatically (60-70% to 80-90%) making borderline tears better candidates. - Inadequate assessment leading to inappropriate meniscectomy - missing repairable tear removes meniscus unnecessarily increasing long-term OA risk 5-10x - Overestimating repairability - attempting repair of white-white zone degenerative tear leads to failure and patient dissatisfaction - Missing concurrent ACL injury - affects decision-making and healing potential significantly - Iatrogenic chondral damage during probing - use gentle technique to avoid creating new pathology - Misidentifying tear pattern - complex degenerative tears are NOT repairable despite potentially appearing as vertical longitudinal ### Step 2: Tear Preparation & Debridement Prepare tear edges to create optimal healing environment. Using arthroscopic shaver at low speed or motorized burr, gently debride any frayed or degenerated tissue from tear edges while preserving maximum meniscal substance (unlike meniscectomy where goal is removal - here goal is minimal debridement). Use meniscal rasp (hand instrument with small teeth) to abrade both sides of tear creating raw bleeding surfaces - this is critical as healing depends on bleeding surface apposition. Use rasp on peripheral capsular surface of meniscus to enhance vascular supply from meniscocapsular junction - gentle multiple passes create punctate bleeding. For bucket-handle tears, reduce displaced fragment back to anatomic position using probe or grasper - may require flexion/extension and varus/valgus stress to achieve reduction. Assess reduction stability - fragment should stay reduced without constant pressure. If cannot achieve stable reduction, tear is not suitable for repair. Create bleeding surface but preserve tissue - excessive debridement defeats purpose of repair. **Technical Tip**: EXAM KEY - Tear preparation is critical for healing success. I use meniscal rasp to abrade tear edges and peripheral capsule creating bleeding surface - this brings vascularity and healing cells to avascular tear site. The rasp creates controlled micro-trauma without removing tissue. I minimize shaver use (only for obviously frayed tissue) because excessive debridement removes meniscal substance reducing function. For bucket-handle tears, achieving anatomic reduction is essential - I manipulate the knee into flexion/extension and varus/valgus while using probe to guide fragment back to normal position. If reduction cannot be maintained with probe alone, the tear likely has associated tissue damage making repair less favorable. Healing depends on: bleeding surface contact, vascularity, anatomic reduction, stable fixation. - Excessive debridement removing too much meniscus - defeats purpose of repair which is to preserve meniscal function - Inadequate abrading resulting in poor healing surface - smooth non-bleeding edges will not heal together - Cannot achieve stable reduction in bucket-handle tear - contraindication to repair, should consider meniscectomy - Damage to articular cartilage from shaver or rasp - use controlled technique and protect cartilage - Creating unstable meniscal remnant - excessive debridement may destabilize even if repair successful ### Step 3: All-Inside Repair Technique (Most Common Current Practice) Select all-inside device based on tear location and surgeon preference (Fast-Fix, FiberStitch, Sequent, Omnispan, etc. - all have similar results). Insert device through working portal (anteromedial for medial meniscus, anterolateral for lateral meniscus). Position device across tear perpendicular to meniscal surface - this is critical for proper anchor deployment. Deploy first anchor on capsular (peripheral/inferior) side of tear - advance device trigger to release anchor which should deploy OUTSIDE joint capsule (confirm arthroscopically by switching portals). Advance device across tear to opposite (central/superior) side. Deploy second anchor on central side of tear. Tensioning mechanism pulls anchors together compressing tear - some devices have adjustable tension, others pre-set. Remove device deployment system. Verify both anchors properly positioned OUTSIDE joint and tear edges well-approximated. Repeat device insertion for additional fixation points along tear length - typical spacing 4-5mm between devices. For 15mm tear, use 3-4 devices; for 25mm tear, use 5-6 devices. Too few devices (spacing >5mm) results in inadequate compression and healing failure. Visualize from opposite portal to confirm capsular anchor deployment and no intra-articular implant. Test repair stability with probe - should resist moderate force without gapping. **Technical Tip**: EXAM KEY - All-inside technique has become my preferred method for most meniscal repairs due to equivalent healing rates (80-90% with ACL) without accessory incision and neurovascular risk. Critical technical points: (1) Ensure anchors deploy OUTSIDE joint capsule not inside - switch portals to visualize capsular side and confirm anchor position outside joint; intra-articular anchor causes chondral damage and failure. (2) Maintain device perpendicular to meniscal surface during deployment - angled deployment causes anchor malposition. (3) Adequate number of devices - I place device every 4-5mm along tear (closer spacing provides better compression); insufficient devices is common technical error leading to failure. (4) Verify compression - tear edges should be in contact with <1mm gap; visible gap indicates failure risk. Main limitations: Implant cost ($500-800 per device, need 3-6 devices typically = $1500-4000), difficult access to far posterior horn (>10mm posterior to PCL), implant complications (migration/prominence 2-5%). - Anchor deployment inside joint space - CRITICAL ERROR causing chondral damage, loose body, catching, pain; requires device removal and re-repair; prevented by confirming capsular deployment from opposite portal before advancing - Incomplete anchor deployment - device failure with anchor not fully released; cannot provide fixation; must remove and replace device - Too few devices or excessive spacing (>5mm) - inadequate compression leads to gap >1mm and healing failure; need device every 4-5mm along tear - Anchor penetration through capsule injuring neurovascular structures - rare but reported; usually saphenous nerve (medial) or peroneal nerve (lateral); prevented by controlled anchor deployment depth - Device breakage during deployment - rare with modern devices; requires removal of broken components and replacement; maintain smooth trigger activation ### Step 4: Inside-Out Repair Technique (For Posterior Horn or Revision) Create posteromedial safety incision for medial meniscal repair: 3-4cm vertical incision positioned exactly 1cm posterior to palpable MCL at joint line level (mark MCL edge with skin marker before incision). Dissect through subcutaneous tissue carefully identifying and protecting great saphenous vein and saphenous nerve (usually travel together 1-2cm posterior to MCL). Incise deep fascia longitudinally. Blunt dissection down to joint capsule. Insert curved blunt retractor (Army-Navy or custom meniscal repair retractor) between capsule and neurovascular structures - this protects saphenous nerve during needle passage. Palpate retractor position to confirm covering neurovascular zone. Inside knee: Insert meniscal repair needle system through cannula in working portal. Using straight or curved cannulated needles (choose based on tear location and access angle) pre-loaded with 2-0 non-absorbable suture (Ethibond preferred), pass needle from inside knee through meniscal tear (penetrate meniscus 3-4mm from tear edge on both sides), through capsule, exiting at posteromedial incision OVER the protective retractor. Advance needle completely until tip visible outside. Repeat needle passage for additional sutures - typically place 2-4 sutures depending on tear length at 4-5mm spacing. Outside incision: Retrieve all needle tips ensuring they exited safely over retractor. Secure sutures using tying posts or pass ends through small capsular drill holes and tie directly over capsule. Tie sutures with knee flexed 30-40° to avoid over-compression. Cut suture tails. Remove retractor. Test repair stability arthroscopically. **Technical Tip**: EXAM KEY - Inside-out is historical gold standard with longest follow-up data (85-90% healing at 5-10 years) and I use for far posterior horn tears where all-inside access is difficult, or for revision repairs. Critical safety: Posteromedial incision MUST be exactly 1cm posterior to MCL (more posterior increases nerve injury risk); I palpate and mark MCL edge before incision. Blunt retractor between capsule and neurovascular structures is mandatory but does NOT eliminate nerve injury risk (still 1-5% injury rate). I ensure needles pass close to capsule (not deep where vessels are) and exit over retractor by palpating retractor continuously and checking needle tips as they emerge. I tie sutures over capsule (not just tying posts) for stronger fixation. Multiple sutures at close spacing (4-5mm) provide better compression than single suture. Lateral inside-out rarely performed due to common peroneal nerve wrapping around fibular neck - all-inside preferred for lateral tears. - Saphenous nerve injury - occurs in 1-5% despite retractor protection; incision >2cm posterior to MCL increases risk; injury causes permanent medial leg numbness/dysesthesia; no effective treatment; devastating despite "minor" sensory nerve - Inadequate neurovascular protection - retractor must be positioned between capsule and nerve/vein; palpate retractor continuously during needle passage; if needle does not exit over retractor, at high risk for nerve injury - Needles directed too posteriorly - penetrating deep to capsule toward popliteal vessels (1cm posterior to capsule); catastrophic vascular injury though rare; maintain horizontal needle direction not posterior angulation - Great saphenous vein injury - causes hematoma; usually managed conservatively but may require evacuation - Sutures too far apart (>5mm spacing) - inadequate compression results in gap >1mm and healing failure; need close spacing for good compression ### Step 5: Implant Verification & Repair Assessment After completing all-inside device deployment or inside-out suture passage, meticulously verify repair quality before concluding procedure. Switch between viewing portals (view from anterolateral and anteromedial) to visualize repair from both sides. For all-inside repairs: Confirm all anchors deployed OUTSIDE joint capsule on meniscocapsular junction - see anchor footprint on capsular side, no anchors visible intra-articularly. Verify no protruding implants or suture loops in joint. Check tear edges well-approximated with <1mm gap throughout length. For inside-out repairs: Ensure all needles exited at posteromedial incision safely over retractor. Verify sutures not twisted or caught on other structures. Arthroscopically confirm sutures visible on capsular side compressing tear. Assess meniscal reduction: Displaced fragments (bucket-handle) restored to anatomic position with smooth meniscal contour. Test stability: Probe repair gently then progressively with more force - well-fixed repair should resist moderate probing without gapping >1mm. Move knee through ROM: Full extension to 120° flexion - repair should remain stable without impingement or catching. Check for pulsatile bleeding suggesting arterial injury (rare but critical to identify). Document repair quality with arthroscopic photos from multiple portals showing pre-repair tear, repair configuration, final result. **Technical Tip**: EXAM KEY - Verification is critical because technical errors (intra-articular anchor, inadequate compression) if not corrected immediately will lead to early failure. I systematically verify from BOTH portals: (1) Anterolateral view shows meniscal surface and tear approximation; (2) Anteromedial view (for medial meniscus) or anterolateral view (for lateral meniscus) allows visualization of capsular side confirming anchors outside joint. Cannot adequately assess from single portal - must switch. I probe the repair testing stability - stable repair resists moderate force; if probe easily gaps tear >1mm, fixation is inadequate requiring additional device or re-repair. I look for well-approximated edges with good compression - visible gap indicates healing failure risk. ROM testing: Repair should remain stable through full motion; if impingement or loss of motion occurs, repair may be over-compressed or mal-positioned requiring revision. Any concern about implant position mandates device removal and replacement - cannot accept suboptimal repair. - Implant inside joint space - causes chondral damage, catching, pain; requires removal; prevented by viewing from opposite portal before completing repair - Inadequate compression with gap >1mm between tear edges - indicates likely healing failure; must place additional device or revise technique immediately - Missed neurovascular injury - check for pulsatile bleeding suggesting arterial penetration (rare but catastrophic); non-pulsatile rapid hemarthrosis suggests venous injury - Accepting unstable repair - probe testing showing easy gapping indicates fixation failure; will fail early; should revise immediately rather than accept poor quality - Loss of motion - repair should not limit ROM; restriction suggests impingement or over-compression requiring revision ### Step 6: Biological Augmentation (Selective Use for High-Risk Tears) Consider biological augmentation for tears with suboptimal healing potential - NOT routine for standard red-red or red-white zone tears with ACL reconstruction. Trephination (marrow venting) technique: Using 1-2mm drill bit or awl, create 2-3 small channels from peripheral meniscus perpendicular to tear plane reaching subchondral bone of tibial plateau. Channels allow bone marrow blood and stem cells to reach tear site. Typically drill through meniscus 5-10mm from tear site to access bone. Observe marrow bleeding from channels ("marrow venting"). Indications: White-white zone tears (normally unrepairable), chronic tears >6 months, revision repairs, tears without concurrent ACL. Evidence mixed - some studies show improved healing from 40% to 60-70%, others no benefit. Fibrin clot technique: Draw 10-20ml patient blood in sterile syringe, create clot by gentle agitation, place clot in tear gap before fixation providing scaffold for cell migration. Historically used extensively but now less common with modern compression devices. PRP injection: Inject platelet-rich plasma (prepared from patient blood via centrifugation) into repaired tear site at surgery conclusion. Contains growth factors (PDGF, TGF-β, VEGF) theoretically promoting healing. Limited evidence - small studies suggest possible benefit, no large RCTs. I use trephination selectively for borderline tears (white-white zone that patient insists on attempting repair, chronic >6 months without ACL, revision). I do not use PRP routinely (unproven benefit, additional cost). **Technical Tip**: EXAM KEY - For standard red-red or red-white zone tears with concurrent ACL reconstruction, biological augmentation is NOT necessary as baseline healing rate is 80-90%. I consider augmentation for higher-risk scenarios where baseline healing is 40-60%: white-white zone location (normally unrepairable), chronic tear >6 months without ACL, revision repair, isolated repair in older patient. Trephination is my preferred augmentation - creates channels from tear to vascularized bone allowing marrow elements to reach avascular zone. Technique: 1-2mm drill bit, 2-3 channels spaced 5mm apart, perpendicular to tear, reaching subchondral bone. Evidence is limited but suggests possible improvement from ~40% to 60-70% healing. Over-reliance on augmentation is mistake - cannot salvage truly unrepairable tears (degenerative complex, massive tissue loss). Most important healing factors remain: vascular zone, tear pattern, patient age, concurrent ACL - augmentation cannot overcome poor fundamentals. - Over-reliance on augmentation for inappropriate tears - cannot salvage white-white zone degenerative complex tears; augmentation may marginally improve healing but cannot overcome poor fundamentals - Excessive trephination creating too many or large holes - weakens meniscal structure; limit to 2-3 small 1-2mm channels - PRP/biological injections without evidence - increased cost and complexity without proven benefit in routine cases; I avoid unless research protocol - Delaying appropriate meniscectomy - attempting repair of truly unrepairable tear with augmentation gives false hope; better to perform meniscectomy if clearly not suitable - Drilling through articular cartilage - trephination must access bone through peripheral meniscus not through cartilage ### Step 7: Concurrent ACL Reconstruction (Common Scenario) When meniscal repair performed with concurrent ACL reconstruction: Complete meniscal repair FIRST before ACL reconstruction. Rationale: Better visualization with intact ACL, no graft to avoid during meniscal work, can assess meniscal stability before ACL reconstruction. Alternative approach: Some surgeons perform ACL first for knee stability during meniscal probing - valid but I prefer meniscal repair first. After meniscal repair verification, proceed with ACL reconstruction: Femoral and tibial tunnel drilling/reaming, graft passage, fixation using standard technique. The ACL reconstruction process (drilling, reaming, bone debris) creates blood flow and growth factors that enhance meniscal healing - this is well-established effect improving healing from 60-70% isolated to 80-90% with ACL. Mechanism: Bone marrow elements (blood, stem cells, growth factors including BMPs, TGF-β, PDGF) from tunnel drilling reach meniscal tear via hemarthrosis and synovial circulation. Effect is so significant that borderline tears (red-white zone, chronic, questionable tissue quality) become much better candidates with concurrent ACL. During ACL graft passage and fixation, protect meniscal repair - avoid excessive force that might disrupt repair. After ACL reconstruction completion, re-examine meniscal repair to ensure still stable. 40-50% of ACL tears have associated meniscal tears (medial posterior horn most common pattern) - always examine both menisci systematically during ACL surgery. **Technical Tip**: EXAM KEY - Concurrent ACL reconstruction is single strongest predictor of meniscal repair success, improving healing from 60-70% to 80-90%. This makes tears that might be borderline for isolated repair (red-white zone, chronic >6 months, questionable tissue quality) much better candidates with ACL. I have low threshold for attempting repair during ACL surgery. I counsel patients: Meniscal repair adds 15-20 minutes to surgery and requires extended rehab (4-6 months vs 3-4 months for isolated ACL) but preserves meniscal function long-term. Even if repair fails (10-20% risk), delayed meniscectomy has similar outcomes to primary meniscectomy, so no harm in attempting. Meniscectomy accelerates cartilage degeneration even with stable ACL reconstruction - medial meniscectomy increases contact pressure >50%, lateral >200%. During ACL surgery, I always examine both menisci systematically - approximately 40-50% have tears requiring decision about repair vs meniscectomy vs observation. - Missing meniscal tear during ACL surgery - failure to systematically examine both menisci means potentially repairable tear gets missed; later presents as post-ACL pain - Inappropriate meniscectomy - removing repairable meniscus during ACL surgery worsens long-term outcomes; ACL effect makes repair more favorable - Damage to meniscal repair during ACL reconstruction - graft passage and fixation can disrupt repair if not careful; protect repair during subsequent steps - Not counseling about extended rehabilitation - meniscal repair requires 4-6 months protected ROM vs 3-4 months for isolated ACL; patient must understand trade-off - Over-aggressive early rehab - ACL protocols often emphasize early ROM but meniscal repair may require restriction; individualize protocol ### Step 8: Final Assessment & Comprehensive Documentation Perform systematic final assessment before concluding procedure: (1) Repair integrity - all sutures/anchors secure, no loose devices, no broken implants; (2) Tear approximation - edges in contact with <1mm gap throughout length; (3) Stability testing with probe - resist moderate force without gapping; (4) ROM testing - knee through full passive extension to >120° flexion without repair impingement, catching, or loss of motion; (5) Meniscal reduction - displaced fragments (bucket-handle) anatomically reduced with smooth contour; (6) No loose bodies - no implants, debris, or broken instruments in joint; (7) Other compartments - re-examine medial/lateral compartments and patellofemoral joint for iatrogenic injury; (8) Hemostasis - no active bleeding, no pulsatile bleeding suggesting vascular injury. Document meticulously with arthroscopic photographs: Pre-repair tear (multiple views showing location, zone, pattern), repair configuration (fixation points, technique used, device type/number), final result (tear approximation, meniscal reduction). Operative note documentation: Tear characteristics (location: posterior horn/body/anterior horn; zone: red-red/red-white/white-white with distance from periphery; pattern: vertical longitudinal/bucket-handle/radial; length: measured in mm; stability: unstable/stable); tissue quality (good/fair/poor; vascular/avascular); repair technique (all-inside specific devices and number, or inside-out number of sutures); concurrent procedures (ACL reconstruction); post-op plan (ROM restrictions, weight-bearing, brace use, rehab protocol). This documentation is critical for follow-up management if symptoms recur - knowing exact repair configuration helps assess for failure vs new tear. **Technical Tip**: EXAM KEY - Thorough final assessment prevents technical errors from being missed. I systematically verify: stability (probe test should show solid repair), ROM (full extension to >120° flexion without catching - limited ROM indicates problem), tear approximation (<1mm gap predicts healing), no intra-articular implants (causes chondral damage). I document extensively with photos and detailed operative note. This is important because if patient has symptoms at 3-6 months follow-up, I need to know: exact tear location and repair configuration to determine if symptoms represent failure at repair site vs new tear elsewhere; technique used (affects interpretation of MRI findings); baseline tissue quality (poor quality may have been marginal for repair, lower threshold for accepting failure). Testing stability: gentle probe test first (should be stable), then progressively more force (well-fixed repair resists moderate force). Testing ROM: Repair should NOT limit motion - if flexion <120° or extension lacking, suggests impingement or over-compression requiring revision immediately. - Inadequate documentation - makes follow-up management difficult if symptoms recur; cannot determine if failure, new tear, or unrelated pathology without knowing baseline - Loss of motion - meniscal repair should not limit ROM; restriction suggests impingement, over-compression, or associated pathology requiring revision - Accepting unstable repair - probe test showing easy gapping indicates fixation failure; will fail early; should revise immediately rather than hope for healing - Missing concurrent pathology - always re-examine all compartments after repair; easy to focus on meniscal repair and miss chondral damage, other meniscal tear, loose body - Not testing ROM - assuming ROM will be normal without checking; limitation may require revision or indicate technical problem ### Step 9: Irrigation, Closure & Post-operative Immobilization Copious arthroscopic irrigation with 2-3 liters normal saline via arthroscopic pump to remove blood, debris, and inflammatory mediators (reduces post-operative synovitis and pain). Inject intra-articular local anesthetic for post-operative pain control: 20ml 0.25% marcaine (bupivacaine) with epinephrine 1:200,000 into joint and portal sites (lasts 6-12 hours, reduces immediate post-op pain significantly). For inside-out repairs: Close posteromedial incision in layers to prevent hematoma and wound complications: (1) Capsule with 2-0 absorbable suture (Vicryl) - interrupted or running; (2) Deep fascia with 2-0 Vicryl; (3) Subcutaneous tissue with 3-0 Vicryl - minimize dead space; (4) Skin with 3-0 monocryl subcuticular or 3-0/4-0 nylon interrupted or staples. Meticulous hemostasis in layers. For all-inside repairs: No incision beyond portals. Close arthroscopic portals: Single 3-0 or 4-0 nylon interrupted suture each portal (anterolateral, anteromedial). Apply sterile dressing: Gauze over portals/incisions, elastic bandage compression dressing (reduces swelling), or bulky dressing. Apply cryotherapy device if available (reduces pain and swelling). Post-operative immobilization (CONTROVERSIAL - surgeon-dependent): Traditional approach: Hinged knee brace locked in extension for ambulation, unlock to 0-90° for sleep and early exercises - continue 4-6 weeks for large posterior horn tears. Modern approach: No brace, or brace unlocked 0-90° immediately allowing controlled ROM from day 1. My approach: Individualize based on tear pattern and repair stability - large posterior horn tear (>15mm, far posterior) gets brace with 0-90° ROM restriction for 4-6 weeks; small/moderate body or anterior horn tear (<15mm, good stability) gets no brace or early ROM unrestricted. **Technical Tip**: EXAM KEY - Thorough irrigation reduces inflammatory response and post-op pain. I inject 20ml 0.25% marcaine with epinephrine intra-articularly and into portals - this provides excellent immediate post-op analgesia (6-12 hours) allowing patient comfort and early exercises. For inside-out repairs, meticulous layered closure of posteromedial incision is important to prevent hematoma (which can cause pain, nerve irritation, infection risk) - I ensure hemostasis at each layer and close deep fascia separately from subcutaneous. Portal closure prevents synovial fistula formation (rare but problematic if occurs). Post-operative bracing is controversial area with mixed evidence. Traditional teaching: restrict ROM to 0-90° for 4-6 weeks to protect repair during healing (based on biomechanical data showing meniscal stress increases >90° flexion). Modern challenge: RCTs show no difference in healing between restricted vs unrestricted ROM. I individualize: Large posterior horn tears where I have concern about stability get 0-90° brace for 4-6 weeks; smaller tears with excellent stability after repair get full ROM immediately. All patients avoid deep flexion/squatting until 4-6 months regardless of brace use. - Inadequate irrigation - increased post-operative synovitis, pain, and potentially adhesion formation - Poor closure of inside-out incision - hematoma formation (painful, infection risk, nerve irritation), wound dehiscence - Synovial fistula from portals - persistent drainage from portal sites; prevented by proper portal closure with suture; if occurs, requires secondary closure - Over-aggressive early ROM without individualization - theoretical risk of repair disruption for large unstable posterior horn tears; safe approach is to restrict ROM for concerning tears - Too conservative ROM restriction unnecessarily - causes stiffness without benefit for small stable tears; need to balance protection vs mobility ### Step 10: Post-operative Instructions & Rehabilitation Protocol Provide detailed post-operative instructions to patient and physiotherapist (critical for success as meniscal repair requires PROTECTED rehabilitation unlike meniscectomy): **Weight-bearing**: WBAT (weight-bearing as tolerated) with crutches for comfort 1-2 weeks, progress to full weight-bearing without aids by 2 weeks. Some surgeons restrict to partial weight-bearing (50%) for 4 weeks but evidence does not support benefit (meniscal stress primarily from ROM not axial loading). **ROM (Range of Motion) - CONTROVERSIAL**: Traditional protocol: 0-90° flexion restriction for 4-6 weeks (especially large posterior horn tears) using hinged brace, rationale is biomechanical data showing meniscal stress increases >90° flexion. Modern protocol: Full ROM immediately allowed including flexion >120°, based on RCTs showing no difference in healing rates. My approach: INDIVIDUALIZED - Large posterior horn repair (>15mm, far posterior): 0-90° restriction with brace for 4-6 weeks, then gradual increase; Small/moderate body or anterior horn repair (<15mm): Full ROM from day 1 including >120° flexion. All patients regardless of protocol: Avoid deep flexion >120° and squatting/kneeling until 4-6 months (maximal meniscal hoop stress occurs at deep flexion and with rotation). **Exercises week 0-2**: Quadriceps sets (isometric) 10 reps every hour preventing atrophy, ankle pumps 20 reps every 2 hours preventing DVT, straight leg raises when quad control adequate (day 2-3), hamstring sets gentle isometric. Week 2-6: Stationary cycling (light resistance, seat high if ROM restricted), closed chain exercises (wall squats 0-60°, leg press 0-60°, step-ups low step), pool exercises. Week 6-12: Progress to full ROM unrestricted, deeper squats/lunges, single-leg exercises, proprioception training, sport-specific preparation. Month 3-4: Running program if criteria met. Month 4-6: Return to sport if healing confirmed and functional criteria met (strength >85%, hop testing >85%, no pain/swelling). **Analgesia**: Multimodal - paracetamol 1g QID regular, NSAIDs short-term 5-7 days (celecoxib 200mg BD or ibuprofen 400mg TDS), opioids PRN minimal (endone 5-10mg, avoid routine use, 3-5 days maximum). Ice therapy 20 minutes every 2-3 hours for 48-72 hours. **VTE prophylaxis**: Mechanical (TED stockings, intermittent pneumatic compression if available), early mobilization most important, pharmacological NOT routine for arthroscopy unless high-risk patient (previous VTE, obesity, cancer, prolonged immobility). **Follow-up schedule**: 2 weeks - wound check and suture removal, assess ROM/effusion/quad function; 6 weeks - clinical exam, assess ROM/strength, X-ray if concurrent ACL (tunnel position); 4-6 months - assess healing clinically, consider MRI if symptoms or borderline for sport clearance, functional testing for return to sport clearance. **Return to sport**: Minimum 4 months from surgery (prefer 6 months for competitive athletes), must meet objective criteria (full ROM, strength >85% contralateral, hop testing >85%, no pain/swelling, completed sport-specific training), gradual return over 2-4 weeks (non-contact → limited contact → full contact). **Counseling**: Emphasize that meniscal repair rehabilitation is MORE restrictive and LONGER (4-6 months) than meniscectomy (6-12 weeks) to protect repair during healing. Trade-off is meniscal preservation reducing long-term arthritis risk. Failure risk 10-20% may require later meniscectomy but attempting repair does not worsen outcomes. Compliance with restrictions critical for success - patients who return to sport early (<4 months) or deep squat early (<4-6 months) have higher failure rates. **Technical Tip**: EXAM KEY - Post-operative rehabilitation for meniscal repair is MORE restrictive than meniscectomy and this must be clearly explained to patient pre-operatively. The extended rehab (4-6 months vs 6-12 weeks for meniscectomy) is trade-off for meniscal preservation and reduced long-term OA risk. ROM protocol is controversial: Traditional strict restriction (0-90° for 4-6 weeks) based on biomechanics vs modern unrestricted based on RCTs showing no difference. I individualize: Large posterior horn tears get restriction (these have highest stress in flexion), small tears get full ROM. All patients avoid deep flexion/squatting until 4-6 months regardless (maximal meniscal stress). Weight-bearing I allow WBAT immediately (evidence shows no benefit to restriction, meniscal stress primarily from ROM not loading). Return to sport minimum 4 months requires objective criteria (ROM, strength, hop testing, imaging if borderline) - early return (<4 months) increases failure risk. Patient compliance is critical - non-compliance with deep flexion restriction or early sport return common causes of failure. - Too aggressive rehabilitation - theoretical risk of repair failure especially for large posterior horn tears; deep flexion/squatting before 4-6 months creates maximal meniscal stress potentially disrupting repair - Too conservative rehabilitation unnecessarily - excessive ROM restriction (beyond 6 weeks) or prolonged weight-bearing restriction causes stiffness and weakness without proven benefit - Patient non-compliance with restrictions - very common problem; patients feel good at 6-8 weeks and resume activities too early; need extensive counseling about extended timeline and failure risk with early return - Early return to sport before 4 months - increases failure risk; need minimum healing time regardless of functional status; also need objective criteria (imaging if borderline) - Inadequate counseling about extended rehab - patients unprepared for 4-6 month timeline become frustrated; must explain trade-off (extended rehab vs meniscal preservation) pre-operatively ## References 1. 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Am J Sports Med. 2011;39(8):1648-1652. doi:10.1177/0363546511402661 6. Kurzweil PR, Friedman MJ. Meniscus: resection, repair, and replacement. Arthroscopy. 2015;31(9):1777-1789. doi:10.1016/j.arthro.2015.03.033 7. Tachibana Y, Sakaguchi K, Goto T, et al. Repair integrity evaluated by second-look arthroscopy after arthroscopic meniscal repair with the FasT-Fix during anterior cruciate ligament reconstruction. Am J Sports Med. 2010;38(5):965-971. doi:10.1177/0363546509356977 8. Westermann RW, Wright RW, Spindler KP, et al. Meniscal repair with concurrent anterior cruciate ligament reconstruction: operative success and patient outcomes at 6-year follow-up. Am J Sports Med. 2014;42(9):2184-2192. doi:10.1177/0363546514538742 9. Nwachukwu BU, McFeely ED, Nasreddine A, et al. Arthroscopic versus open repair of medial meniscus posterior root tears: a systematic review and meta-analysis. Am J Sports Med. 2017;45(12):2993-3001. doi:10.1177/0363546516687277 10. 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Meniscal Repair - All-Inside and Inside-Out Techniques

Meniscal Repair - All-Inside and Inside-Out Techniques