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Meniscus Repair All Inside

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

D

Simulation

1

Cadaveric demonstration of surgical approach and therapeutic skill

2

Sawbones demonstration of proper instrumentation

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 arthroscopy pump
  • motorized meniscal shaver
  • toothed grasper
  • double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles

2

Room setup and Equipment

  • standard OR table with leg holder

3

Patient Positioning

  • supine
  • leg holders
  • place leg holder 5 to 8 cm proximal to the superior pole of the patella to maximize control of the limb
  • contralateral leg is placed in a well leg holder
  • foot of the bed is dropped
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

2

Place anterolateral portal

  • use 22 gauge needle on syringe and bury the needle
  • make wheal at skin and then 11 blade in same direction as the needle
  • place scope in same direction as needle and blade
  • hug the patellar tendon

3

Place anteromedial portal

  • place knee in 30 degrees of flexion with valgus moment applied
  • use a spinal needle to assess direction and appropriate superior/inferior direction.
  • visualize with lateral portal
H

Diagnostic Arthroscopy

1

Visualize

  • suprapatellar pouch
  • patellofemoral joint (take picture)
  • place bump under heel prn
  • lateral gutter
  • look for loose bodies and peripheral tears of LM
  • get MFC in view
  • bring knee into slight flexion and valgus as you go into medial compartment.
  • foot goes on to opposite hip and use standee to stabilize your foot
  • medial meniscus (take picture)
  • drop leg to flexion (bump should be under knee)

2

Establish far anteromedial portal

  • use 18-gauge needle to make sure that you clear the MFC and can get to the 2 o’clock (LEFT) or 10 o’clock (RIGHT) knee

3

Visualize

  • medial compartment - probe medial meniscus, articular cartilage
  • intercondylar notch – ACL/PCL (take picture)
  • lateral compartment – probe lateral meniscus, articular cartilage (take picture)
I

Meniscal Tear Evaluation and Preparation

1

Check for flounce sign

  • flounce sign is a fold in the free, nonanchored inner edge of the medial meniscus
  • presence of the flounce sign indicates an intact medical meniscus

2

Check for meniscal mobility

  • use probe to examine tear
  • probe the anterior, posterior, superior and inferior aspects of the meniscal tear
  • normal mobility is 4 mm for the posterior horn of the medial meniscus and 1 cm for the lateral meniscus

3

Check stability, size and extent of tear

  • extent
  • partial or complete

4

Check location

  • zone of tear
J

Exposure

1

Place the scopes

  • place a 70 degree arthroscopy the intercondylar notch from either the anteromedial or anterolateral portal
  • when advancing the arthroscope into the posteromedial compartment begin at the anterolateral portal pass under the PCL
  • when advancing into the posterolateral compartment
  • begin from the anteromedial portal pass under the ACL using an arthroscope sheath loaded with a semiblunt obturator

2

Place the 70 degrees scope

  • after the sheath is in the correct position, exchange the obturator for the 70 degree arthroscopic lens
  • position the lens in the desired posterior compartment

3

Identify the posterior horn

  • rotate 90 degrees so that the posterior horn can be viewed across the posterior compartment

4

Place cannula

  • place an 8 mm diameter cannula posteriorly onto the posterior compartment
  • advance and aim for the center of the joint
  • the knee should be in 90 degrees of flexion to enlarge the posterior capsular recess and to avoid injury to the peroneal nerve
  • with the knee in 90 degrees of flexion place the cannula into the posteromedial compartment beginning in the soft spot above the medial palpable hamstring tendons behind and above the joint line
  • avoid the saphenous nerve on the medial side by placing the operative portal above the medial hamstring tendons with the knee flexed 90 degrees
K

All Inside Repair

1

Manipulate the synovium

  • excoriate the local synovium with a rasp to stimulate local bleeding to obtain a vascular fibrous response after surgery

2

Prepare the tear

  • for tear preparation place a rasp through the posterior cannula while viewing through the notch the meniscofemoral portion of the tear
  • place the rasp anteriorly while viewing anteriorly for the meniscotibial portion of the tear

3

Place sutures

  • place the sutures using a meniscal repair suture hook through the posterior operative cannula
  • the suture hook is a cannulated 16 gauge needle with a hook shaped end attached to a shaft
  • handle with a roller device that feeds the suture through the lumen of its cannulated length
  • suture hooks are produced with three types of terminal angular designs to accommodate variable angles of approach and tear anatomy

4

Adjust the hook

  • manipulate the hook by hand so that the sharp tip penetrates the posteriorinferior stable rim first

5

Advance the hook

  • advance across the tear into the mobile fragment from inferior to superior
  • after the hook has spanned both sides of the meniscal tear advance 12 to 14 inches of monofilament suture (0-0 or 1-0 PDS) into the posterior compartment

6

Withdraw the tool out of the tear and up the posterior cannula

  • leave the suture across the tear in a vertical orientation

7

Tie suture knots

  • grasp the free end of the suture in the posterior compartment
  • bring it up the posterior cannula so that both ends of the suture are out of the cannula
  • advance four sequential half hitched throws down the posterior cannula with a double holed knot pusher to produce a double stacked square knot that apposes the meniscal tear at the suture site

8

Cut sutures

  • cut the suture tails intraarticularly and repeat the process as many times as necessary to stabilize the tear
L

Treat Intraoperative and Immediate Postoperative Complications

1

Step 1 of treating intraoperative complications

2

Step 2 of treating intraoperative 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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