Meniscal repairs have been under-utilised by surgeons
Update from ISAKOS 2019 – David Mitchell
David Mitchell has been to the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine biannual meeting, this time in Mexico. There is a number of repairable meniscal tears, that sadly are incorrectly treated with meniscectomy by some surgeons. A more aggressive approach to repairing the menisci is appropriate and main stream.
Meniscal root tears are not very uncommon. They often occur without trauma, perhaps squatting, this most commonly occur in middle aged, but have a rapid progression to arthritis. Typically, from “pop” to full thickness wear of the compartment of the knee is only 12 months, surgery is urgent. They can be repaired irrespective of age, the cases I’ve done have been aged up to 69 years, with a rapid relief of pain. The patient is often overweight, this is not a disaster if the tear is repaired. Malalignment is a problem – more than 5 degrees of varus probably means the surgery won’t work as an isolated procedure. Weight bearing status is restricted for 6 – 8 weeks, and squatting needs to be avoided for 3 months or more. The case below from some years ago has done well, but the suture repair now is more likely to be two fibre tapes.
Horizontal cleavage tears are the most common, and in older patients, resecting the unstable part makes most sense. However, in young patients, and they are seen even in teenagers, they can be repaired. Sometimes a meniscal cyst is present too – this can easily be addressed at the same time. The surgery requires a fibrin clot technique. The success in patients 12 – 40 years of age have been reliable, the case below had an unstable part removed, the remains part repaired including fibrin clot, looking red.
Radial tears can be repaired although reinforcement of the meniscus with circumferential sutures before doing the radial repair may improve the results. The equipment required for all this surgery is at Ballarat Day Procedure Centre, ready to go, as the requirement to do a repair unexpectedly does occur. The paradigm shift has occurred over the last decade, the clinical data is clear.
The recovery for meniscal repairs of course is different – weight bearing is restricted for radial & root tears for six weeks, i.e. the patient requires crutches, and sometimes for two months or more. Range of movement and squatting restrictions are commonly applied for three months. But the long term results are better. Very nice instruments like the Smith & Nephew Novostich Pro won’t be available until mid 2020.