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Meniscal Repair - Inside Out

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • evaluate for
  • knee pain
  • mechanical symptoms
  • pain or swelling with ADLs and sports
  • joint line tenderness
  • knee effusion
  • associated with decreased quadriceps strength
  • positive McMurrays, Apley grind and Thesaly tests

2

Interprets basic imaging studies

  • standing radiographs
  • 30 degree flexion lateral
  • AP weightbearing in extension
  • 45 degree PA flexion weightbearing views
  • identify fairbanks changes
  • discoid meniscus on radiograph
  • tibial spine hypoplasia, widening of the lateral joint line or flattening of the lateral femoral condyle on AP view.

3

Prescribes and manages non-operative treatment

  • Injects/aspirates knee
  • guides trial of medical managment
  • NSAIDS
  • attempts trial of physical therapy
  • quad strength closed chain

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • prescribe Nsaids
  • remove sutures
  • diagnose and management of early complications
  • limit range of motion to 90° for the first three weeks for nondisplaced meniscus tears and six weeks for displaced bucket handle tears
  • postop: 4-6 week postoperative visit
  • discontinue crutches
  • return to pivoting sports when full range of motion is present, no effusion, and can show full extension and painless terminal flexion
  • usually at 4-6 months
  • diagnosis and management of late complications
  • postop: 1 year Postoperative Visit
B

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • MRI
  • 3-T gives excellent visualization on pathology.
  • useful in distinguishing tear, location and morphology
  • MRI abnormality of thickened "bow tie" on coronal view on greater than 3 cuts with continuity of the anterior horn and posterior horn on 5 mm thick saggital view cut is diagnostic for discoid meniscus
  • MRI classification of tears
  • grade one small: focal area of increased signal not extending to the joint surface
  • grade two: linear area of increased signal not extending to the joint surface
  • grade three: linear area of increased signal extending to the joint surface

2

Provides complex nonoperative treatment

  • concomitant injuries
  • ligament
  • fractures

3

Modifies and adjusts post-operative treatment plan as needed

  • knee arthrofibrosis
  • continued pain
C

Preoperative H & P

1

Obtain history and perform basic physical exam

  • history
  • Age
  • Gender
  • HPI
  • PMHx
  • identify medical co-morbidities that might impact surgical treatment
  • Social history
  • physical exam
  • ROM
  • joint effusion
  • joint tenderness
  • complete neurovascular exam of extremity.

2

Order basic imaging studies

  • order triplanar standing radiographs of the knee

3

Perform operative consent

  • describe complications of surgery including
  • pain
  • infection
  • neurovascular injury
  • loss of motion
  • degenerative joint disease [DJD])

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

O

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • schedule follow up in 2 weeks
  • outpatient physical therapy
  • place in a knee immobilizer or hinged brace locked in extension
  • partially weight-bearing with crutches for one month
  • passive range of motion starting postop day one
  • limit range of motion to 90°
R

Complex Patient Care

1

Treat complex complications

 

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