Preoperative Patient Care Operative Techniques E Preoperative Plan 1 Determine pathology using MRI Presence of discoid meniscus Presence of tear and type displaced bucket handle radial horizontal cleavage/intrasubstance degeneration Presence of peripheral instability Presence of associated lateral femoral condyle OCD F Room Preparation 1 Surgical instrumentation arthroscopy pump arthroscopic shaver meniscal punches straight, up-angled, curved right and left punches, back-biting punches 30 degree arthroscope Consider small arthroscope in young patient 2 Room setup and equipment standard OR table with or without leg holder 3 Patient positioning supine leg hangs off side of bed for portal creation Figure 4 position for work in lateral compartment I Probing for Stability and Tears 1 Asses the stability of the meniscus assess the stability of the posterior horn, body and anterior horn of the lateral meniscus instability is present in any portion of the lateral meniscus if it can be translated halfway across the tibial plateau in a respective direction Sometimes there is no apparent attachment between the capsule and meniscus and other times the attachment appears attenuated J Saucerization 1 Measure peripheral meniscus use a probe to measure the amount of peripheral meniscus that will be intact after saucerization Goal is 6 - 8 mm rim 2 Saucerize the meniscus the most reliable instrument to use for saucerization is an arthroscopic punch supplement with angled biters to remove any abnormal tissue anteriorly 3 Remeasure the rim measure the remaining rim frequently with a probe at least 6 - 8 mm of tissue of the lateral meniscus should be left intact 4 Use shaver to smooth down the meniscal rim K Stabilization of the Anterior Horn and/or Body Outside In Technique 1 Stimulate bleeding rasp the knee capsule and the meniscal edge to stimulate bleeding 2 Position the lateral meniscus if needed, hold in place with a grasper 3 Place needles and sutures There are a few needle options. The most commonly used is a straight spinal needle and a flexible suture passing device. Insert needle through skin, capsule and meniscus at desired location. Place suture passing device through needle so it emerges in the joint. Retrieve out the medial portal with arthroscopic grasper (preferably a crab claw type grasper). Remove the needle from the knee. At this point, the suture passing device will be percutaneously placed through the skin, capsule and meniscus. One end of the suture passing device will be exiting through the medial arthroscopic portal. Load a suture onto the end of the suture passer that is outside the arthroscopic portal. Pull on the other end of the suture passer to pull the suture through the meniscus. At this point, one end of the suture will be through the meniscus and emerging percutaneously through skin on the outside of the knee and the other end will still be coming out the arthroscopic portal. Place the spinal needle a second time through skin, capsule and meniscus. Ideally, the needle emerges at a place that is 2-4 mm apart from the first location. Pass suture passer through needle and retrieve through arthroscopic portal in similar fashion. Remove needle from knee leaving suture passer in place. Load the other end of the suture on the suture passer and pull passer back through meniscus such that both ends of the suture are through the meniscus and exiting percutaneously through the skin. Repeat these steps until sufficient sutures are placed to secure meniscus tear/instability. Once all sutures are placed, make an incision (typically horizontal) near the exit points of the sutures on the skin. Bluntly dissect down to capsule and retrieve all sutures through this incision. Tie sutures against the capsule while visualizing arthroscopically to ensure appropriate reduction of the meniscus. If horizontal cleavage tear extends to capsule, may have to place sutures directly above and below meniscus to create "haybail" suture to compress leaflets together Suture can be absorbable monofilament or nonabsorbable suture Ideal suture configuration will involve vertical mattress sutures above and below meniscus Amount of sutures will vary depending on size of unstable portion of meniscus L Stabilization of the Posterior Horn and/or Body Inside Out Technique 1 Make skin incision Wearing a headlamp is helpful for this procedure. Make vertical incision just behind the lateral collateral ligament at the joint line To determine the level of the joint line, observe the light of the camera through the skin when it is inserted into the lateral compartment 2 Place retractor Identify the interval between iliotibial band and the biceps femoris tendon Place the retractor superior to the biceps to protect the peroneal nerve 3 Expose the meniscus Bluntly elevate the lateral head of the gastrocnemius tendon from the posterior knee joint capsule Place a broad retractor anterior to gastroc muscle to maintain exposure and protect neurovascular structures during needle passage. 4 Stimulate bleeding rasp the lateral meniscus and the capsular edges to promote bleeding 5 Place cannula Place cannula through lateral portal to allow easy needle passage May need to establish an accessory portal inferior to standard lateral portal to optimize needle trajectory 6 Pass needles and sutures Use a double arm meniscal repair needle Insert needles sequentially through the cannula and retrieve posterior to capsule Place in vertical mattress fashion above and below meniscus Tie sutures over capsule Postoperative Patient Care O Postoperative Management 1 Patient disposition Most cases can be done on outpatient basis 2 Weight bearing restrictions This is variable and is surgeon and tear-type dependent. Generally, 4-6 weeks of TTWB or PWB Some tear types may allow WBAT with knee in full extension 3 Range of motion restrictions Also variable but will typically be restricted to no more than 90 degrees of motion for 4-6 weeks post op to minimize cam rollback stresses from lateral femoral condyle on meniscus repair 4 Physical Therapy Will typically commence 1-2 weeks after surgery Usually for 3-6 months post-op 5 Return to activities Variable and depends on tear type, rehab progress, etc. Typically will be 3-6 months after surgery.