Meniscal Injury Pathway Updated: 10/18/2016

Meniscal Repair - Inside Out

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Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Determine pathology using MRI

  • radial tear
  • horizontal cleavage tear
  • displaced bucket handle tear
  • meniscal root tear
  • discoid meniscus

2

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical Instrumentation

  • standard knee arthroscopy setup
  • double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles

2

Room setup and Equipment

  • standard OR table with choice of leg holder or post
  • patient is supine on bed
  • tourniquet may be used
G

Scope Insertion

1

Mark out the anatomy of the knee

  • draw out the patella, patellar tendon, medial and lateral joint lines and the posterior contours of the medial and lateral femoral condyles
  • mark future portals as well as the incision for the medial / lateral meniscus repair

2

Place anterolateral portal

  • an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella
  • insert the blunt trocar at the same angle as incision
  • place scope in the trocar after removing the inner cannula

3

Place anteromedial portal

  • created under direct visualization once the medial compartment is entered
  • use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal
  • the medial portal should be located just superior to the medial meniscus and able to provide access to the medial meniscal root if needed
H

Diagnostic Arthroscopy

1

Visualize

  • suprapatellar pouch
  • undersurface of the patella and trochlear groove
  • lateral and medial gutters
  • medial compartment
  • visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment
  • the foot will be positioned on your opposite hip for control
  • medial meniscus, medial femoral condyle, and medial tibial plateau
  • once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage
  • intercondylar notch – ACL/PCL
  • use the probe to assess the ACL and PCL
  • Lateral compartment
  • the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment
  • lateral meniscus, lateral femoral condyle, and lateral tibial plateau
  • a probe is used to assess the lateral meniscus and cartilage
I

Meniscal Tear Evaluation and Preparation

1

Diagnose tear and determine configuration if present

  • investigate superior and inferior portion of the meniscus with the probe
  • check the capsule attachment of the meniscus by pulling the meniscus from the posterior capsule gently
  • assess the meniscal root

2

Check location of tear if present

  • assess the zone of tear and decide if the tear is repairable

3

Check stability, size and extent of tear

  • extent
  • partial or complete
J

Exposure

1

Make incision posteriomedially or posterolaterally for needle capture

  • posteromedial incision
  • place the knee in 20 to 30 degrees of flexion
  • make a 4 to 6 cm incision just posterior to the medial collateral ligament
  • the incision should be one third above and two thirds below the joint
  • incise longitudinally through the sartorial fascia and continue the dissection anterior to the semimembranosus deep to the head of the gastrocnemius without violating the capsule.
  • posterolateral incision
  • place knee in 90° of flexion
  • this allows the peroneal nerve, popliteus and lateral inferior geniculate artery to fall posteriorly
  • make a 4 to 6 cm incision just posterior to the lateral collateral ligament anterior to the biceps femoris tendon
  • the incision should be one third above and two thirds below the joint
  • incise longitudinally through the iliotibial band and continue the dissection staying superior and anterior to the biceps tendon to protect the peroneal nerve.
  • proceed deep and anterior to the lateral head of the gastroc without violating the capsule.
K

Inside-Out Repair

1

Place a popliteal retractor "Henning retractor" against the capsule

  • a needle driver can be clamped to the retractor and held secure to the leg with a sterile coban to help hold the retractor in place

2

Place a single or double lumen cannula through the arthroscopic portals

  • the long flexible needles can be passed through the cannula by an assistant and slowly progressed at 1 cm increments until visualized at the medial or lateral incision through the retractor

3

Capture the needles one at a time as they pass through the capsule and cut the suture free from the needles.

  • be sure not to pull either suture all the way through until both needles are passed
  • keep each pair of sutures together for later repair with the knee in full extension.

4

Tension then tie the sutures over the capsule

  • the sutures are tensioned to simulate the tying. the knee is then brought into extension during the suture tying so that the capsule is not tightened.
  • ensure that the sutures are directly on the capsule prior to suture tying.
L

Treats Intraoperative and Immediate Postoperative Complications

1

Treat any intraoperative complications

2

Treat any immediate postoperative complications

N

Wound Closure

1

Use 3-0 and 4-0 biosyn for closure

2

Apply steristrips

3

Cover with tegaderm and occlusive dressings

Postoperative Patient Care
 

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