Arthroscopic Meniscus Repair
Kayla Aikins MS2, and Brian Gilmer, MD
Introduction
The lateral and medial menisci are located between the femur and the tibia and function as shock absorbers which redistribute force across the tibial plateau. The menisci decrease the load experienced by the knee joint and are important for proper functioning and alignment. In addition, they serve as cartilage lubricators and stabilizers. When the meniscus becomes damaged, one option for treatment is a meniscus repair.
Indications
The meniscus can become damaged in a multitude of ways, and only sometimes will require repair. At times, meniscus injuries can be self-limiting and heal on their own. For example, younger athletes have the capacity to heal meniscus tears on their own. In addition, if injury affects the lateral third of the meniscus, patients have a greater chance of healing on their own1.
Trauma or injury can affect the meniscus. Most of the time, you will experience pain in the knee if there is damage. The pain may be described as “shooting” and worsens with rotation of the knee or when squatting. Patients may also experience instability of the knee, inflammation, and locking of the joint. In addition, patients may experience a loss of range of motion in the knee joint, an inability to extend the knee, or a snapping/clicking sound with movement. Surgery is indicated for patients with meniscal injury who do not respond to RICE, NSAIDs, physical therapy, or cortisone injections2. In addition, degenerative processes indicate surgery and are characterized by gradual increasing pain in the knee as well as inflammation. Degeneration can result in meniscus rupture and abrupt pain.
It is important for surgeons to determine which tears are acute and need repair and which ones are part of a more global degenerative process. These are often in older patients without a history of an acute injury.
Causes
Meniscus damage can be caused by:
- Sports injuries
- Any abrupt motion in which the knee twists while the foot remains planted.
- Aging
- Degenerative processes/arthritis
Diagnosis
Meniscal injuries can be diagnosed by a careful history (that means listenting to the patient and what their symptoms are), physical exam findings, such as tenderness over the joint and specific tests called, McMurray’s Thessaly’s and Apley’s to name a few. Often there is pain with deep knee flexion and loss of motion with variable amounts of swelling.
Weight bearing x-rays are obtained to determine how much pre-existing arthritis there is.
If suspicion is high, MRI is often obtained to evaluate the cartilage and look for tears. An MRI is a three dimensional map of water in the knee. There is always a small amount of fluid in the knee and this is helpful since the meniscus is rubbery like a gasket and should not have any fluid leaking into it. If you see a white line of fluid in the meniscal tissue, this is diagnostic of a tear.
Procedure
To start out, patients are given regional or general anesthesia and placed in a supine (on your back) position. An arthroscopic camera is inserted into the knee to visualize the surgical site, identify the meniscus tear, and help repair the cartilage. In addition, fluid is pumped into the knee space to help visualize the cartilage3. The cartilage is either gently shaved to clean up frayed edges and to stimulate healing, or a trephanation needle is used to place small holes in the meniscus. The lining of the meniscus will also be scraped to generate blood flow4. At this time, sutures and anchors are used to pull together the torn pieces of the meniscus. If there is a meniscus root tear, the meniscus must be re-attached to the bone. This procedure usually takes 30 minutes to an hour. The surgery is performed as a same day surgery and you can go home the same day.
Post-operative care
After the surgery, the patient must elevate the knee and apply cold packs for the first several days. A brace may also be recommended. Pain from the incision is minimal and should dissipate in 2-3 days. Patients should expect to engage in protective weight bearing using crutches for a minimum of four weeks. Full weight-bearing may be permitted by the fifth week. Recovery from surgery is relatively quick, and most patients can return to work in just two weeks. The patient will also be given recommended exercises to strengthen the joint and should attend physical therapy. A total recovery is expected in 4-6 months5.
Risks and complications
Complications of meniscus repair surgery are rare, but all surgeries have risks. Several potential risks of this surgery include the chance of developing arthritis later in life, blood clots from stasis, infection, injury to vasculature and blood vessels near the knee, and stiffness of the joint6.
Dr. Gilmer’s Take
For most simple meniscal repairs I prefer a zone – specific approach. I will use all inside sutures as seen in the video for posterior horn tears, and inside – out sutures for the meniscal body and anterior horn. I have a separate technique for the anterior horn where sutures are placed arthroscopically and secured to an anchor on the front edge of the tibia cartilage. Tears that involve more than one zone will have a hybrid repair using one or more of the techniques above.
I am aggressive about preserving this important shock absorber of the knee, but in some cases a partial meniscectomy of some tissue is required and I will repair the remainder. I suppose I need a different name for this but I still refer to it as a ‘hybrid repair’.
Meniscal repair is common with ACL injuries. And we know there is better healing when ACL surgery is performed at the same time. Surgeons think/assume this is because of the bone marrow contents which are released from drilling the ACL tunnels and the bleeding this causes. So in cases where the ACL is ok, but the meniscus needs a repair I will drill holes in the bone to create bleeding or harvest bone marrow from the femur bone and inject it into the repair site to optimize healing and several studies have supported this technique.
Brian Gilmer, MD
October 2023
References:
- Kurzweil PR, Cannon WD, DeHaven KE. Meniscus Repair and Replacement. Sports Med Arthrosc Rev. 2018 Dec;26(4):160-164. doi: 10.1097/JSA.0000000000000224. PMID: 30395058.
- Krych AJ, Hevesi M, Leland DP, Stuart MJ. Meniscal Root Injuries. J Am Acad Orthop Surg. 2020 Jun 15;28(12):491-499. doi: 10.5435/JAAOS-D-19-00102. PMID: 31693530.
- Petersen W, Karpinski K, Bierke S, Müller Rath R, Häner M. A systematic review about long-term results after meniscus repair. Arch Orthop Trauma Surg. 2022 May;142(5):835-844. doi: 10.1007/s00402-021-03906-z. Epub 2021 Apr 28. PMID: 33913009; PMCID: PMC8994714.
- DeHaven KE. Meniscus repair. Am J Sports Med. 1999 Mar-Apr;27(2):242-50. doi: 10.1177/03635465990270022301. PMID: 10102109.
- Ghazi Zadeh L, Chevrier A, Farr J, Rodeo SA, Buschmann MD. Augmentation Techniques for Meniscus Repair. J Knee Surg. 2018 Jan;31(1):99-116. doi: 10.1055/s-0037-1602247. Epub 2017 May 2. PMID: 28464195.
- O'Donnell K, Freedman KB, Tjoumakaris FP. Rehabilitation Protocols After Isolated Meniscal Repair: A Systematic Review. Am J Sports Med. 2017 Jun;45(7):1687-1697. doi: 10.1177/0363546516667578. Epub 2016 Oct 7. PMID: 28256906.
Kayla Aikins is currently a second-year medical student at the University of Nevada, Reno School of Medicine.
