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Most meniscal tears should be resected, untreated rather than repaired
Probably only a maximum 20% of all meniscal tears are reparable, according to Donald H. Johnson, MD, FRCSC, director of the Sports Medicine Clinic at Carleton University in Ottawa, Ontario, Canada.
Johnson noted at Orthopedics Today Hawaii 2011 that the ideal tear to repair is a vertical, posterior segment, peripheral red-on-red tear, as opposed to red-on-white or white-on-white. “However, most meniscal tears are red-on-white,” he said. “The hope is that some form of biologic augmentation, such as platelet-rich plasma (PRP), will improve the healing rate of the red-on-white tears.”
Repair/no repair indications
Other indications for meniscal repair include acute tears, tears that range in size from 1 cm to 2.5 cm, patients who are younger than 40 years old, and those with associated ACL repair.
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Tears that can be left untreated are lateral flap root tears and undisplaced stable medial/lateral meniscal tears. “An unstable tear consists of a tear length that is more than one-half of the meniscus and the fragment subluxes under the condyle with probing,” Johnson told Orthopedics Today. “The meniscus also rolls when it is probed and there is delamination of the fibers with shredding of the meniscus.”
Johnson shared photos of several types of meniscal tears with the course attendees, who could then respond on what they felt was appropriate treatment: repair, resect or leave alone. “Is this a stable tear or is this a degenerative tear? Should you repair or not?” Johnson asked. “Overall, you should resect 85% of the tears. The other 15% or so you repair. My technique is usually to use sutures.”
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Images: Johnson DH |
Augmentation
Although Johnson believes his case challenges to the audience were “pretty much of a slam dunk” as to the appropriate treatment choice, “there is a fairly wide variation of what clinicians might do.” A short stable tear does not require a repair, he said. “But sometimes you can do some form of augmentation, such as PRP.” However, when performing ACL reconstruction, “you are going to have lots of blood in the joint, so you don’t need to use PRP,” Johnson said.
Short stable tears can also be treated with trephination as an attempt to increase the vascularity for healing. Hence, “you don’t need an expensive implant to stabilize the tear,” Johnson said. “You only use an implant or sutures when you can demonstrate that the tear is unstable and that it is not degenerative. Some tears are unstable, but they are degenerative, so you would not repair.”
Johnson said he was surprised by the number of respondents who would attempt repairs on tears that do not need repairing. A few years ago, Johnson reviewed 2,001 cases of ACL reconstruction he performed, of which there were 241 meniscal repairs (roughly 11%). “Most of those repairs were on large bucket-handle tears that were sutured, with a 25% failure rate.” In retrospect, “I was repairing more tears than I should have. On the other hand, 75% of patients still had their meniscus.”
Despite Johnson’s observation that many clinicians slightly overtreat the meniscus, “What is the downside? If it fails, it means a second operation, during which part of the meniscus is resected.” Conversely, if failure can be avoided, “then you have achieved a nearly normal meniscus and knee. Resecting small portions of the meniscus probably has a small effect.”
However, resecting large bucket-handle tears may cause some degenerative changes 20 years down the road, he noted. – by Bob Kronemyer
Reference:
- Johnson DH. Meniscal repair. Presented at Orthopedics Today Hawaii 2011. Jan 16-19, 2011. Koloa, Hawaii.
- Donald H. Johnson, MD, FRCSC, can be reached at Sports Medicine Clinic, Carleton University, 125 Colonel By, Ottawa, Ontario, Canada K1S5B6; 613-520-3510; e-mail: donnie@carletonsportsmed.com.
- Disclosure: Johnson is a consultant for Arthrex.
