Meniscal repair: Treatments, tricks and troubleshooting

Meniscal repair can be a fairly straightforward surgical procedure or it can be a frustrating experience for the surgeon. On occasion, after a prolonged period of time in surgery, often with the tourniquet inflated, the surgeon does not obtain a satisfactory repair and elects to perform a partial meniscectomy. I have also consulted on frustrated patients with symptoms related to an unsatisfactory repair and/or symptoms from the meniscal fixation device.

For more clinical insight into meniscal repairs, I turned to one of my partners, Peter R. Kurzweil, MD, who has had a long-term interest in this topic. I asked him to moderate this Round Table discussion to present clinically relevant and practical approaches that our readers may want to incorporate into their practices. He organized the questions and assembled the panel of experts to share their preferred method of meniscal repair as well as technical pearls and troubleshooting for difficult situations.

Douglas W. Jackson, MD
Chief Medical Editor

Round Table Participants Virtual Moderator Peter R. Kurzweil, MD Southern California Center for Sports Medicine Long Beach, Calif. John D. Kelly IV, MD Associate Professor and Vice Chair Orthopedic Surgery Temple University School of Medicine Temple University Hospital Philadelphia, Pa. Nicholas A. Sgaglione, MD Program Director, Department of Orthopaedics North Shore Long Island Jewish Health System Associate Professor of Orthopaedic Surgery Albert Einstein College of Medicine Manhasset, N.Y. John C. Richmond, MD Chair, Department of Orthopaedics New England Baptist Hospital Boston, Mass.

Peter R. Kurzweil, MD: What is your preferred method of meniscus repair?

John D. Kelly IV, MD: My preferred method of repair is largely dependent on the tear configuration. For simple peripheral tears I am inclined to use the RapidLoc system (DePuy-Mitek), because of its ease of insertion and gentle material properties. For chronic, unreduced bucket handle tears, I tend to use an inside-out, vertical mattress configuration using nonabsorbable suture. For anterior horn tears, I simply use an outside-in technique using PDS (polydioxanone) suture in a mulberry knot fashion.

Because the posterior horn of the medial meniscus is of great mechanical importance, I will sometimes attempt to approximate a radial posterior horn tear using an outside-in technique, employing a ‘shuttle relay.’ I will use the relay in order to effect a vertical mattress stitch in order to bridge the radial tear.

John C. Richmond, MD: My preference is to use a suture-based technique with either classic inside-out plus outside-in sutures for repairs of tears that are located further away from the meniscal-synovial junction. These would be tears where one is pushing the envelope on to try to get them to heal. I also use this technique on bucket-handle tears that have been displaced for a significant period of time, and are therefore deformed and difficult to restore to the anatomic position.

For tears that have a high likelihood of healing — very peripheral, recent tear, or associated ACL reconstruction — I am likely to use all-inside implants, which are also suture based. These would either be the Fast-Fix (Smith & Nephew) or the Rapidloc. With the Rapidloc device, one has to be very careful with the hard implant on the surface of the meniscus; if not appropriately recessed into the meniscus surface it may damage the articular cartilage of the femur.

Nicholas A. Sgaglione, MD: Currently, suture is my preferred repair method, which includes all-arthroscopic suturing methods, outside-in suturing and inside-out suturing.

Kurzweil: Most surgeons have gone away from first generation fixators, which were not ideal for peripheral tears and made it difficult to adjust tension after implantation. There were also iatrogenic problems related to their rigidity. I tend to perform hybrid repairs, using outside-in sutures for the anterior two-thirds and suture-based fixators for tears near the posterior horn. We all know to proceed with caution with tears posterior to the popliteus tendon, since the neuro-vascular bundle is not far away.

Kurzweil: Are there particular situations where you might choose to supplement the repair with blood clot or platelet-rich plasma (PRP)?

Kelly: I have precious little experience with blood clot or PRP. For tears which have a precarious blood supply, I will spend time with synovial abrasion or sometimes I will use an awl to stimulate bleeding in the intercondylar notch. I think repair stability is paramount in order to ensure healing and tear edges should be approximated in or near extension, especially for the medial side. Furthermore, for real problem tears, I may add 1 to 2 weeks of immobilization in extension.

With perhaps the “wisdom of experience,” I would like to share that I am not as aggressive with repair in some tear configurations. Shelbourne’s work on clinical parity between repaired “degenerative menisci” vs resection must be hearkened. Also, this same investigator related that stable tears of the posterior horn of the lateral meniscus can be treated well with mere trephination.

“I must concede that repair status is largely dependent on cruciate status, since most peripheral, repairable tears occur concomitantly with ACL insufficiency.” — John D. Kelly IV, MD

Richmond: I have not used PRP to date, but there certainly is basic science evidence to indicate that this is of potential value. I have, however, relied on microfracture of the lateral wall of the intercondylar notch in those patients who are not undergoing simultaneous ACL reconstruction. I just prepare the lateral notch anterior to the ACL by taking down the synovium with a shaver and making multiple pick holes into the medullary bone to encourage bleeding of bone marrow elements and clot formation in the joint.

Sgaglione: Biological augmentation of meniscal repairs using autologous fibrin clot or proprietary autologous platelet-rich fibrin matrix is indicated in my practice for at–risk isolated repairs.

At–risk repairs are defined as those tears that are classified as predominantly red-white zone “vascularly challenged” tears. Additionally, geometrically unstable tears may also be defined as at-risk repairs and are illustrated by extensive displaced bucket–handle tears with a component of deformity or full–thickness radial tears out to the periphery particularly in the posterior horn of the lateral meniscus in younger, active patients.

Isolated repairs are defined as meniscal repairs that are carried out in cases in which no associated ligament reconstruction, such as an ACL reconstruction, is concurrently performed.

Operative cost issues remain a concern; however, and using proprietary PRP methods adds costs to spin autologous blood — which is on the order of several hundred dollars per case.

This nonetheless may actually represent a cost-effective treatment when one considers cost-analysis issues associated with the long-term natural history of meniscal resection in the young active athletic patient population.

Kurzweil: During the preoperative visit, do you routinely discuss the possibility of meniscus repair, including the ramifications regarding work status and return to sports? Have you subsequently had patients opt for resection even though the meniscus was thought to be repairable?

Kelly: I try to mention to every patient the prospects of repair vs. resection and I believe they all know that my goal is to preserve as much meniscal tissue as possible. Virtually every patient in Philadelphia has an MRI in hand before surgery. This allows me to demonstrate to patients where the pathology lies and it also affords me the ability to somewhat predict reparability. I must concede that repair status is largely dependent on cruciate status, since most peripheral, repairable tears occur concomitantly with ACL insufficiency.

I do my best to “talk out” patients for resection and resist efforts by younger athletes to avoid the rehab with repair. When one frames what I would label as the “irrefutable argument,” it is hard for parents to consent to resection in the face of a repairable lesion. For example:

“Mom and Dad, you wouldn’t want me to do anything that is not in your son’s/daughter’s best interest, would you?” The answer to this question is uniformly in the negative and it simply puts the ball in their court.

I can recall only one patient in all my years of practice, who refused repair. Thankfully she was middle aged and her meniscal tear involved poor quality tissue.

Regarding the subject of resection, some unstable tears are best left alone. Some recent data from the University of Pittsburgh suggests that radial tears left unresected do a better job of protecting chondral surfaces than trimmed tissue. Clinically, this would be considered applicable to the clinically silent or incidentally discovered radial lesion.

Richmond: I discuss in detail the options of repair versus resection whenever there is MRI evidence indicating that the tear may be suitable for repair. The difference between repair and resection has a major effect on ability to return to physical work or sports early on. In 25 plus years of doing meniscus repairs, I have only had two patients opt for removal over repair. Both were potential college scholarship athletes who did not want to miss an upcoming season and, in spite of counseling both of them and their parents to the long-term advantage of repair over removal, both athletes and their parents strongly opted for removal.

Sgaglione: Absolutely. Informed consent and comprehensive counseling about the extended recovery times and rehabilitation constraints after meniscal repair are particularly essential.

This is very important in the athlete or active individual who may have issues with timing and preferences to return to sport as soon as possible. This consideration is sharpened if comparisons are made regarding meniscal resection and the meniscal repair is in fact isolated and not being performed along with an ACL reconstruction.

It is also essential to consider and cite that meniscal repair in the best of hands may be 70% to 90% successful, which is clearly a less optimal outcome, at least in the short term, compared to meniscal resection. For these reasons, certain patients and families do, in fact, opt for resection when all details are presented.

Kurzweil: These are all good points. When the overall recovery is not going to be significantly altered, such as during concomitant ACL reconstruction, patients and families are less concerned about the delay in return to sports or work. It is the patient who has the isolated, vertical, seemingly repairable meniscus on the preoperative MRI that this discussion is most crucial, since this is also the situation with a higher failure rate. I have also had athletes vying for scholarships and young laborers who could not afford significant time away from their sport or job opt for resection, even knowing the potential long-term consequences.

Kurzweil: Have you had any failures and do you discuss this possibility with patients beforehand?

Kelly: Of course I have had many failures and many, I suppose, were due to overly ambitious repairs. However, I must concede that some repairs in which I may have “pushed the envelope” have demonstrated clinical healing. I think I can do a better job of counseling patients about repair rates.

When the subject of failure does arise, I usually mention that “no bridges are burned” in the face of a failed repair. In fact, a quasi-functional repair does seem to confer at least some chondroprotective function. I believe my enthusiasm and belief in healing may sometimes get the best of me. I am quick to mention, however, that repair responses in the presence of ACL reconstruction are materially superior to isolated repairs.

Richmond: Yes, I strongly believe that if you are not having failures of meniscus repair, then you are not doing enough of them. My personal failure rate is in the 10% to 20% range. I discuss this in detail with the patient, and actually go into the surgery with an agreement with the patient that I will repair the meniscus if I think the odds of it healing are better than 75%. When I believe those odds drop down below 50%, it is usually my preference to perform partial meniscectomy unless there are mitigating circumstances such as articular surface damage. I try to educate the patient adequately to make an informed decision as to whether he or she would prefer repair vs. resection.

Sgaglione: Success vs. failure is cited and addressed prior to surgery.

My overall success rate for all repairs that are precisely indicated is on the order of 80% to 90% depending upon various clinical factors and prognosticators.

Kurzweil: It is important to create realistic expectations. Clearly none of us can guarantee success — we can only cite the odds of it. While it is important to be optimistic, this must be tempered with the 15% to 20% chance of needing a repeat surgery, even if you and the patient do everything perfectly.

Kurzweil: Regarding postoperative management, when do you let the patient weight-bear, return to sports or physically demanding jobs, and do you routinely suggest any form of deep vein thrombosis (DVT) prophylaxis?

Kelly: There is panoply of literature regarding the mechanical effects of weight-bearing. Although a recent study from Barber suggests axial loading may in fact increase repair compression, some clinical series suggest repair rates are superior with protected weight-bearing regimes. I think this is due to the diminution of shear, twisting stress with protected weight-bearing. Thus, depending on the tear “personality,” I will let some patients weight-bear early while with others I will exercise more caution. For problem tears, I restrict knee flexion to 90° for the first 4 to 5 weeks. Hyperflexion greatly increases propensity for bucket-handle tears to displace.

For most repairs, I prohibit deep squatting and torsional stress (sports) for 5 months. The avoidance of knee hyperflexion has served me well in minimizing recurrences, because inordinate stress is placed on the posterior horns during this activity.

As for prophylaxis, I have witnessed too many cases of DVT after routine arthroscopy. I therefore administer some form of antiplatelet agent – ASA (acetylsalicylic acid , aspirin) or NSAIDS, until ambulation.

Richmond: I allow my patients to weight-bear in full extension in an immobilizer from day 1. I limit their range from 0° to 90° of flexion for the first 4 weeks. During that time, I have them wear knee-high elastic stockings and taking aspirin for DVT prophylaxis. I try to limit the cutting sports and heavy construction work activities until they are 3 to 4 months post-op, 3 months if it is a peripheral tear, with good healing potential and 4 months of healing potential is reduced it by the tear being more central.

Sgaglione: Postoperative protocols are individualized depending upon the patient profile, type of tear, tissue viability, repair construct security, and associated pathology and surgical procedures.

In general, all patients are started immediately on range of motion with full extension and at least 90° of flexion. In larger, extensive bucket-handle type tears, I will limit terminal flexion for up to 6 weeks postoperative. Most patients are treated with partial weight–bearing for 4 to 6 weeks based upon comfort and the type of repair performed. In at-risk repairs, (particularly in full–thickness radial tears) weight–bearing is modified for up to 6 weeks with crutches.

On the issue of DVT prophylaxis, all patients who are advised to modify weight–bearing for any appreciable length of time are placed on some form of DVT prophylaxis most commonly aspirin.

Return to sports activities and stressful labor activities is advised based upon clinical signs of healing as defined as no antalgia, pain, effusion or soft–tissue swelling, restoration of full range of motion, absence of joint line tenderness over the repair site, and functional ability to run and cut. This usually translates to 3 to 6 months in most cases.

Kurzweil: One reason meniscus repairs do better with ACL reconstructions, I believe, is that the ligament surgery slows the patient postoperatively. Hence, I have favored nonaccelerated rehabilitation programs. My preference is to put the patient in a knee immobilizer for 4 weeks. During that time, they will toe-touch weight-bear with crutches the first 2 weeks, then may begin to weight-bear as tolerated between weeks 3 and 4. Crutches are discontinued by 1 month. Range of motion is encouraged starting week 3, although is limited to 90° initially. I tell patients to avoid squatting for 4 months, and don’t allow cutting sport for 6 months. I, too, have seen DVTs occur in this setting and now place all patients on 81 mg ASA for 6 weeks post-op.

Kurzweil: What about the cost of meniscus repair with the newer fixators, does cost play a role in your choice?

Kelly: Thankfully I work at a university medical center where cost is not quite as critical, although rapidly becoming more important. I have worked at surgicenters in the past and have definitely experienced more “hassle factor” in employing costly devices. The paradigm I strive to live by is “doing what is best for the patient is best for all involved.” Once I frame my arguments in terms of patient well-being, administrators are less likely to resist added, but now deemed necessary, expenses.

When one considers open or inside-out repairs, the added OR time, morbidity to the patient and potential complications that an open procedure confers, greatly mitigates any cost savings from avoidance of using a fixator. Our hospital has attempted to convince our knee surgeons to agree on one fixator, although with several surgeons on staff, their efforts have not met with success.

Richmond: I operate out of a surgicenter which is fully owned by our hospital. We are an orthopedic hospital, where the cost of implants is the second highest expense, after personnel, in our budget. Because of this, we are very concerned about implant pricing and set a maximum price that we are willing to pay for any implant. We will not allow that implant to be used within our institution, unless the manufacturer comes in with a price below our maximum. Because of our large volume, we have been very successful in using this to control our cost.

“It is important to create realistic expectations. Clearly none of us can guarantee success — we can only cite the odds of it.” — Peter R. Kurzweil, MD

Sgaglione: Newer generation meniscal repair devices, particularly the all-arthroscopic suture-based systems are costly. I believe cost issues are a real concern for all of us regardless of whether you own a surgery center or whether you operate in a large university hospital.

Various factors however must be kept in mind when considering this issue — the most important are patient outcome and safety.

If an all-arthroscopic suture repair can be performed less invasively and more quickly vs. an arthroscopic-assisted inside-out suturing method and is associated with less postoperative pain and less potential morbidity and has equivalent evidenced-based long term results, then cost analysis will be met. One technical pearl to suggest regarding this matter is the potential use of a hybridized approach incorporating the use of both inside-out suturing and all-arthroscopic suture devices.

This may represent a viable cost-effective option.

Kurzweil: First generation rigid fixators: Do you still use them?

Kelly: I have largely abandoned these first-generation devices. The longer-term follow up studies are discouraging with respect to repair rates. Furthermore, we have seen report after report of chondral injury due to the rigid and slowly dissolvable material properties of these devices. We must always be mindful of what we are placing in the confines of a very precisely engineered articular surface. We published a case report a few years back on a chondral injury sustained by a larger mulberry knot fashioned from PDS!

Richmond: I no longer use rigid fixators, which did have issues around migration and scoring the articular surface. I believe that suture based devices have reduced some of the problems related to the rigid implants. It also inherently makes more sense to me to repair a pliable tissue with an implant that is flexible.

For more information:

• John D. Kelly IV, MD, can be reached at Temple University, Department of Orthopedic Surgery, 3401 N. Broad St., Philadelphia, PA 19140; 856-985-0851; e-mail: johndkellyiv@aol.com. He has no direct financial interest in any products or companies mentioned in this article.
• Peter R. Kurzweil, MD, can be reached at 2760 Atlantic Ave., Long Beach, CA 90806-2755; 562-424-6666; e-mail: PKurzweil@aol.com. He receives institutional or research funding from Arthrex, Inc., institutional or research funding and stock options from Zimmer and is a consultant for Covidien Sports Medicine.
• John C. Richmond, MD, can be reached at New England Baptist Hospital, 125 Parker Hill Ave., Boston, MA 02120; 617-754-5545; e-mail: jrichmon@caregroup.harvard.edu. He is a consultant of DePuy-Mitek and received a fellowship grant from Smith & Nephew.
• Nicholas A. Sgaglione, MD, can be reached at Orthopedic Associates of Manhasset, P.C., 800 Community Drive, Manhasset, NY 11030; 516-627-8717; e-mail: nas@optonline.net. He receives miscellaneous funding from and is a consultant or employee of Smith & Nephew.