Name: Meniscus Root Tears: See It, Fix It
Uploaded: 2018-04-23T00:00:00Z
Channel: Arthrex
Description: Aaron Krych, MD, (Rochester, MN) presents a meniscal root repair, the data supporting the technique, and long-term clinical results.

<p>Aaron Krych, MD, (Rochester, MN) presents a meniscal root repair, the data supporting the technique, and long-term clinical results.</p>

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VPT1-01084-EN | A | Meniscus Root Tears: See It, Fix It

Aaron J. Krych

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Meniscus Root Tears: See It, Fix It

My name is Aaron Critch from Mayo Clinic Sports Medicine, and it's my pleasure to speak to you on meniscus root tears. See it? Fix it. I'd like to acknowledge my partner, Mike Stewart at Mayo Clinic as we've developed a lot of these concepts together. So why do we fix root tears? Well, with a root tear, there is loss of hoop stress. Often meniscus extrusion and increased contact pressure similar to a total meniscectomy. We've all seen this patient in our clinic. Acute tear with extrusion of the meniscus. Early subchondral edema and cartilage change. And you can see in this 59 year old knee significant progression of bone on bone arthritis within one year, which ends up with metal and plastic. We've looked at arthritis progression on serial MRIs following root tear. This is an illustrative example of five subsequent MRIs in one patient that first show a partial root tear. This progresses to a complete root tear with Of the extrusion. Now we see subchondral, bone edema and cartilage change, stress reaction in the bone. And finally, a significant number of these patients will end up with subchondral collapse. For diagnosis, we have to have a high index of clinical suspicion, normal signs and symptoms of meniscus tear. But this is an MRI or arthroscopy diagnosis. We need to look at every MRI axial cut for a radial tear near the root, the ghost sign on the sagittal image, and truncation or extrusion on the coronal image on the medial side. It's relatively easy to see on the lateral side. However, this is more challenging because of the meniscal femoral ligament and proximity to the PCL. We looked at 45 consecutive arthroscopic proven root tears at our institution, and only 1 in 3 were diagnosed on preoperative MRI. So you must probe the lateral meniscus root in every ACL case. And you have to be prepared with an efficient root repair technique. So what are our treatment options? Well we looked at non-operative management in 52 patients over five years of follow up 87% failure rate, with almost 1 in 3 getting knee replacement surgery. I'll still get asked the question why don't you just perform a partial meniscectomy? Well, it doesn't work if you compare it to our Nonoperative group. Really similar outcomes in this group of 54% rate of arthroplasty. When we compare partial meniscectomy to root repair in this study, a minimum five year follow up, the root repair had superior outcome with 0% conversion to knee replacement. The question is when should we fix them? Well, in the young patient with a traumatic lesion and normal cartilage always these are often associated with a concomitant ligament injury. In the degenerative situation our indications are evolving. But current contraindications include subchondral collapse, significant x ray narrowing, uncorrected varus, and significant obesity. This is a nice study looking at repair versus conservative management, and no surprise that the repair group did better. However, when repairs were performed with uncorrected verysmall alignment or grade three cartilage changes, they did no better than the conservative group. Here's a patient of mine, a 44 year old, very fit and active gentleman who presents with a root tear, but you can see already cartilage loss subchondral edema. He has x ray narrowing as well as varus malalignment on his coronal standing view. So in this young 44 year old we do perform meniscus root repair. But in this case we more importantly offload that medial compartment by performing an iBalance valgus producing tibial osteotomy. And at one year, he's back pain free to full activities. How should we fix them? Mike Stewart and I have developed our preferred technique, which is trans portal Transtibial. Step number one is to create an anatomic socket or decortication using a FlipCutter. Step number two is to use the knee Scorpion to pass 2 or 3 cinch sutures with FiberLink. Our technique is published last year in arthroscopy. The root repair kit is very convenient. You have to open up one piece of equipment to get on with these cases, especially when they're not diagnosed Preoperatively. Diagnosis again is absolutely key. Here's an example of a lateral meniscus, which appears relatively normal. This was called normal on the MRI. But you don't know there's a root tear until you actually probe that posterior root. Again, in every case of ACL tear you should be doing this, as was mentioned by Tommy Diberardino. On the medial side, often an MCL lengthening will improve your visualization. You can perform a medial reverse notch plasty and take down the medial tibial spine, but you must see these lesions. You must create a space in which to work. So you take something from mission Impossible to something that's very accomplishable in your hands. I then check mobility of the root to make sure that this gets back to the anatomic footprint. Sometimes in the medial menisci they are extruded. In this case we're actually releasing it from the posterior capsule. This will facilitate some mobility to the meniscus root, so I can get it back to its anatomic origin and restore hoop stresses in that meniscus. Really pay attention to the anatomy. Anatomy is absolutely key, as Doctor Laprad taught us. These meniscus roots originate off of the articular cartilage. If we're off as as little as five millimeters, we're not going to recreate contact area or mean contact pressures. How do we hit that anatomic target. It's with the trans tibial root guide. In my experience has hit it every time. The advantages of the root repair guide are several. First, it has a concave design which allows you to work in the back of the knee underneath the femoral condyle. It has a marking hook to hook the back of the tibia, rather than floating an ACL type of guide. It has calibrations unique to that patient's anatomy, and the adjustable pin placement with the swivel handle allows no torque on the guide, and when you obtain two point fixation, it's reliable. You hit your target, in this case, the guides through the through the medial portal to the anteromedial face of the tibia, and you can see with the guide pin we hit our target without any torque on the guide. Here's an example of a lateral meniscus tear. Here we place the guide through the ipsilateral lateral portal to the anteromedial face of the tibia. And you can see here we can trust our guide. We don't even have to see the guide pin because it hits the spot. Here you can see anatomic placement of a 3.5mm guide pin. Again this is off the articular cartilage where the meniscus root lives. We then exchange this 3.5mm guide pin for a six millimeters FlipCutter with the FlipCutter. You can decide whether you just wish to decorticate the bone or whether you want to create a small socket. I'm typically going to a depth of about five millimeters now, and then we simply exchange a shuttling suture. In this case, I'll use a TigerStick replaced with the FlipCutter, which will help facilitate further passage of our shuttling sutures through the tibia. I then place that out the opposite portal of where I'm going to pass sutures. So it's out of the way. Something I've been recently doing in the past 12 to 18 months is also taking an arthroscopic curette. Again, the goal is to get meniscal tissue compression on a large bleeding footprint of bone. And in this case, we're able to increase that footprint by also curating some of the subchondral bone away. So it gives you a better chance for healing. You can see here a nice targeted footprint passing the sutures. The meniscal Scorpion has been a game changer. Its low profile allows you to work in the back of the knee. You can pass it through a single anterior portal. It's self retrieving and really allows precise suture placement. Along with Pat Smith and Mike Stewart, we looked at optimal suture configuration for root repair, and we found that the cinch stitch was easier to pass, had less cyclic displacement, and a similar load to failure than a more complicated double locking loop stitch. And that's our preferred configuration. So here we place a passport cannula through the ipsilateral portal. You can see this provides a nice direct trajectory. In this case, you can see the frame of the meniscus where it evolves from the bone. And this frame actually guides our suture placement. So here replacing an old FiberLink. The advantage of the FiberLink is that you can place the lasso on the shaft of the knee Scorpion. And then when you simply retrieve it, it actually creates a cinch stitch for you. Here we'll alternate FiberLink and TigerLink. I usually use 2 or 3 of these cinch sutures. In this case, we'll use three to completely control that posterior horn root segment. You can see, once we very efficiently pass the sutures, then we simply retrieve our shuttling TigerLink that we passed earlier. And this will help facilitate shuttling transtibial. So then we can tension those sutures once we have the final repair. You can see we've established normal anatomy of that lateral compartment. And this gives a very strong, robust repair that's very stable to probing and gives you confidence with rehabilitation. When we look at clinical results, SOS data shows significant improvements in pain scores as early as six weeks and out to two years. When we look at function, significant improvement by six months and continued improvement in function out to two years. This study was recently published. 91 patients seven year follow up with increased scores in this group, they only had four failures and a 92% survival at eight years. So now we're starting to see some longer term outcomes with durability in these repairs. In conclusion, it's important to recognize to treat root tears to improve our patients pain. Prevent rapid articular cartilage progression. The indications for root avulsion repair are evolving. The trans portal transtibial technique provides a reproducible solution for root repairs. Thank you.

Meniscus Root Tears: See It, Fix It

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