- Email: [email protected]
A technique of arthroscopic suture of torn menisci
Arthroscopy: The Journal of Arthroscopic and Related Surgery
226-232 © 1985 Arthroscopy Association of North America
A Technique of Arthroscopic Suture of Torn Menisci Robert G. Stone, M.D., and Gary A. Miller, M.D.
Nineteen menisci in 16 patients were suitable for immobilization only, 14 were medial and five were lateral lesions. The average age was 27.7 years, ranging from 13 to 52 years. The average interval from onset of symptoms to surgery was 1.6 months. In general, these were lesions <10 mm long, stable with probing and not full thickness. There were 57 meniscal reattachments performed in 46 patients. Fifty-two menisci in 45 patients were sutured arthroscopically. Five were performed through an arthrotomy. Thirty-six patients had one meniscus stabilized. Two of these required repeat reattachment following earlier attempts. Five patients had medial and lateral meniscus reattachments arthroscopically. Four had one arthroscopic meniscus reattachment and one open meniscus reattachment in the same knee. Of those accomplished through arthrotomy, one was a posterior central detachment of the medial meniscus, one an anterior central detachment of the lateral meniscus, and one an anterior central detachment of the medial meniscus. Of the 52 arthroscopic meniscus reattachment procedures, 37 were medial and 15 lateral. They were longitudinal tears located 0-6 mm from the SMJ and 10-50 mm in length. There was a high incidence of associated injury, and 23 patients, which represented half of the group studied, had torn anterior cruciate ligaments. Intraarticular anterior cruciate ligament reconstruction using a patellar tendon graft was carried out in 10 patients. Repair of both menisci was required in seven of these knees. Extraarticular anterolateral reconstruction using iliotibial tenodesis was performed in five patients. Three patients had partial tears of the medial collateral ligament.
Since October, 1982 we have performed meniscal reattachments arthroscopically using the senior author's modification of Henning's technique (Henning CE, personal communication). The aims of the present investigation are: (1) to present a technique for arthroscopic meniscus reattachment; (2) to classify and present arthroscopic evidence of the meniscal blood supply; (3) to identify the potential complications of this procedure; (4) to determine if the percentage of repairable menisci decreases as the interval from injury to surgery increases; and (5) to present short-term results in arthroscopic meniscus repair. MATERIALS AND METHODS All meniscal lesions evaluated arthroscopically from October, 1982 to December, 1983 were studied. A total of 171 meniscal lesions in 139 patients were studied with reference to age, type of meniscal lesion, and the duration of symptoms or interval from injury to surgery. The lesions were classified into two categories: Those deemed healable and those deemed nonhealable. Of the 171 menisci, 95 (56%) were considered nonhealable: 59 were medial and 36 lateral. This category included those menisci with an excessively frayed inner rim (nine cases), disrupted bucket handle tears (11 cases), transverse tears (14 cases), flap tears (18 cases), some horizontal tears (nine cases), posterior medial complex disruptions (26 cases), degenerative tears associated with longitudinal components (six cases), and miscellaneous (two cases). The average patient age for this group was 44.9 years. The average interval from onset of meniscal symptoms to surgery was 13 months. Fifty-eight percent of the patients were 40 years or older. From the Department of Surgery, Division of Orthopedics, University of Texas Health Science Center, Dallas, Texas, U.S.A. Address correspondence and reprint requests to Dr. Robert G. Stone, 6t61 Harry Hines, Blvd., Suite 206, Dallas, TX 75235, U.S.A.
INSTRUMENTATION The following instruments were used: (1) two meniscus needles (10 in. in length and 0.0625 in. in diameter with a 25° angled tip) swedged onto a 40226
A R T H R O S C O P I C S U T U R E OF TORN M E N I S C I
in. 0-mersilene suture (author's design); (2) needle holding clamp (author's design); (3) tendon retractor (for posterior structures, author's design); (4) 2.7-mm basket forceps; (5) thimble; (6) camera system; (7) leg holder; (8) standard arthroscopic equipment including arthroscope; and (9) standard orthopedic equipment including clamps, etc. TECHNIQUE The reattachment is performed using the author's modifications of Henning's technique (personal communication) and the preceding instrumentation. The technique for arthroscopic reattachment of the medial meniscus will be discussed, followed by a few different points for the lateral meniscus. General anesthesia is used. Following the general anesthesia, a mixture of 1/2~ Xylocaine, 1/4% Marcaine, and 1/200,000 Epinephrine is injected in the anticipated portals of entry. The arthroscope is placed in the modified central portal and a 5.0-ram cannula is used for passage of basket forceps and meniscus needles for meniscal reattachment. The meniscal tear edges are debrided with a 2.7-mm basket forceps. The meniscus needles are passed through the inferior lateral portal through a cannula. The cannula and/or the needle tip must be viewed at all times. The first landmark puncture is started in the superior aspect of the meniscus 2 mm inward from the meniscal tear. If the meniscus tear is far posterior, the landmark stitch must still be started at or slightly posterior to the medial collateral ligament and anterior to the pes anserinus tendons. If the first landmark puncture is made at or slightly posterior to the medial collateral ligament, it will be safely anterior to the pes anserinus tendons. After the meniscus substance is punctured, the needle tip must be cautiously advanced in 5-mm increments until it tents the skin. The 20° angled tip must be directed medially to insure the proper area of skin tenting. An index finger with thimble is placed posteriorly on the pes anserinus tendons to insure that this landmark puncture will be directed medial and anterior to the pes anserinus tendon and saphenous nerve. A mixture of 1/2% Xylocaine, 1/4% Marcaine, and 1/200,000 Epinephrine is instilled into the subcutaneous tissue along the anticipated transverse skin incision. A 4-cm skin incision is performed parallel to the medial joint line in the region of the anticipated suture exits. The anterior aspect of the skin incision is started at the needle tip. The edges of
227
the skin are gently undermined down to the capsule with a small Metzanbaum scissor. The first meniscus needle is advanced through the incision and the tip is grasped with a clamp. The other swedged needle remains external to the cannula in the inferior lateral portal. The capsule is further delineated by blunt finger dissection. The tip of the second meniscus needle is passed through the tear in a similar fashion as the first, 2 mm anterior to the first suture entrance. It is cautiously advanced in 5-mm increments until it tents the capsule. The tendon retractor is then inserted and hooked under the capsular tent so that the meniscus needle is directed down the trough of the retractor. The meniscus needle is clamped and pulled through the incision. The ends of the first suture are then clamped and placed on a clamp holder. This completes the passage of the first suture. Each subsequent paired suture ends are clamped and placed on the clamp holder. A suture should be placed for each 5-mm of meniscus tear: thus for a 25-mm tear four such sutures are necessary. The sutures may be placed on the superior or inferior surface of the meniscus as needed for stability. Sutures may be placed horizontially or vertically as needed but we prefer vertical sutures when possible. The sutures are pulled taut to coapt the edges of the tear, after all sutures are placed. The tear is probed to assess stability. The matched sutures are tied outside of the capsule and under the skin, starting with the most posteriorly placed suture. The 4-ram skin incision is closed with a subcuticular suture. The technique for the lateral meniscus is the same as for the medial meniscus reattachment, except a cannula must be placed in the inferior medial portal for debridement of the meniscus edges and passage of the meniscus needle into the lateral meniscus. The first landmark stitch must always be anterior to the popliteal tendon and located at or slightly posterior to the lateral collateral ligament. If this rule is obeyed, then the meniscus needle tip will always exit anterior to the biceps tendon and therefore anterior to the peroneal nerve. This landmark puncture will also always serve as an anterior point for the transverse skin incision. A slit slightly anterior to the biceps tendon should be performed to admit the index finger and retractor. This is for stitches placed posterior and central to the popliteal tendon. Rehabilitation is vital to the success of the proArthroscopy, Vol. I, No. 4, 1985
228
R. G. S T O N E A N D G. A. M I L L E R T A B L E 1. Rating scale
Excellent: Score > 25 Generally near normal function with few or no signs or symptomatology Good: Score 21-24 Slight functional disability; few signs and mild symptomatology Fair: Score 15-20 Moderate functional disability; significant clinical signs and moderate symptomatology Poor: Score < 14 Severely disabled; marked signs and symptoms of a compromised knee
cedure. For the reattached meniscus associated with the anterior cruciate ligament tear, rehabilitation was generally dictated by the requirements for rehabilitation of the anterior cruciate ligament. For isolated meniscal lesions the following program was pursued. We suspect that this regimen can be shortened safely, although we have no firm evidence for this at this writing: Immobilization in a brace at 40° of flexion--0-2 weeks; immobilization in a brace permitting 40 to 90 ° of flexion against a springloaded r e s i s t a n c e - - 2 - 6 weeks; regaining complete range of motion, stationary bicycling, progressive muscle strengthening, linear running, and integration into turning, twisting and jumping--6 w e e k s 6 months; and return to s p o r t - - 6 months and after. RESULTS Assessment of clinical findings was performed to identify early trends in meniscus reattachment results. Prolonged follow-up will be required before conclusions may be reached regarding the final efficacy and advisability of the procedure. All but four patients were assessed at follow-up by telephone contact. All patients responded to an 18-point questionnaire judging subjective result. Greatest emphasis was placed upon the report of symptoms indicative of recurrent meniscal problems: popping, catching, locking, giving way, swelling, inability to squat, and pain. Although all patients were followed postoperatively at regular intervals, 23 patients (28 menisci) presented specifically for repeat examination in connection with the study. This included subjective evaluation, function tests, tenderness, assessment of muscle power, thigh circumference, range of motion, and stability. This evaluation form was modified from the Hospital for Special Surgery Knee Injury Summary (2). All patients were carefully Arthroscopy, Vol. 1, No. 4, 1985
T A B L E 2. Subjective results f o r each age group Result
<20
20-29
30-39
Excellent Good Fair Poor Totals
4 1
4 12 5 2 23
4 5 1 1 11
5
>40
Totals
2 1 3
12 18 8 4 42
evaluated for postoperative complications including numbness in the saphenous nerve distribution. A rating scale (Table 1) was modified from that of Marshall (1) with points being assessed for subjective and objective findings. Twenty-three patients (29 menisci) were evaluated objectively using the rating scale. There were seven excellent, nine good, six fair, and one poor results. The average follow-up was 6 months, ranging from 4 to 18 months. Nineteen additional patients were contacted by telephone and responded to our questionnaire making a total of 42 patients available for subjective evaluation. Both groups were combined to obtain the following results. Twelve patients (29%) with 14 menisci reported no subjective symptoms and full return to activity and were classified as excellent (Table 2). Eighteen patients (43%) with 19 menisci were classified as good results. Eight patients (19%) were classified as fair results. Four patients (10%) with four menisci were classified as poor results (Table 3). We demonstrated blood supply in 69% of the menisci sutured (Figs. 1-3). It was the same percentage for those >3 mm from the synovial medial junction as those at the synovial medial junction. The longer one waits to define a meniscus lesion, the less likely it is that it will be a candidate for meniscus suture. Eighty-one percent were candidates for meniscal suture if treated in the first 2 weeks after injury. Sixty-five percent were candidates if treated 2 - 6 weeks after injury. Thirty-eight percen t were candidates if treated 6 w e e k s - 6 months after injury, and 24% were candidates if treated 6 months or longer after injury. This represents a statistically significant linear trend in the data (significant at p < 0.001)(2). Complications included three cases (7%) of superficial cellulitis, one case of phlebitis (2%), and 16 (38%) of saphenous nerve neuropraxia. Two cases of the cellulitis were in patellar tendon grafts and all were treated with intravenous antibiotics for 10 days or less. One of the latter patellar tendon
ARTHROSCOPIC S UTURE OF TORN MENISCI
229
.... ~f
?
:)
i
FIG. 1. Blood flowing from apertures created in the meniscus by passage of K-wires with suture during meniscoresis and blood flowing from partially healed meniscus tear area.
FIG. 2. Blood flowing from apertures created in the meniscus by passage of K-wires with suture during meniscoresis and blood flowing from partially healed meniscus tear area.
grafts had an associated phlebitis treated with heparin. The most common complication in patients with medial meniscal reattachment was numbness along the medial aspect of the leg. The numbness ex-
tended to the skin over the medial malleolus in some cases. It most likely represents neuropraxia secondary to scar tissue entrapment of the sartorial branch of the saphenous nerve, or retraction of the pes anserinus tendons. Sixteen (38%) of the patients exhibited decreased sensation to light touch in the
N,
N
g
e 7
FIG. 3. Blood flowing from apertures created in the meniscus by passage of K-wires with suture during meniscoresis and blood flowing from partially healed meniscus tear area.
FIG. 4. Notch view of posterior horn of a medial meniscus. A posterior central detachment of the meniscus had been sutured 10 months earlier. The suture can be seen as the green pigmented area at the upper left corner and middle of the field, The suture had become incorporated into the meniscal substance 10 months following the surgery.
Arthroscopy, VoL 1, No. 4, 1985
230
R. G. S T O N E A N D G. A. M I L L E R
saphenous nerve distribution. The sensory deficit ranged in size from several square centimeters to an area of 12 by 17 cm. It lasted from 3-12 months and was bothersome in only three patients. Potential complications with the procedure can be catastrophic. These include damage to the popliteal artery and peroneal nerve. None of these occurred in our series. However, Rosenberg (3) reported injury to both structures in his survey.
DISCUSSION S. Arnoczky (personal communication) has observed that meniscal lesions in dogs do not heal with meniscal type fibrocartilage until eight months and speculates that intervals of several additional months may be required in humans for similar changes to occur. This is our rationale for using permanent suture. Permanent suture should stabilize the meniscus for the prolonged time, which may be required for healing to occur completely. Six patients who underwent meniscus reattachment using permanent suture (three by arthrotomy and three arthroscopically) were subsequently evaluated at repeat arthroscopy. This forms part of another report; however, there were no indications to suggest that joint surface damage had been produced by the sutures within 6-12 months. Indeed, it appeared that the sutures were being incorporated into the meniscus (Fig. 4). Preservation of the meniscus has been recognized to improve long-term results in knee injuries (4). Studies have demonstrated the role of the menisci in load transmission across the knee (5) and the dramatic changes in loading patterns of the tibiofemoral contact areas following m e n i s c e c t o m y (6,7). Complete meniscectomy has produced degenerative arthritic changes in many series (8,9). Partial meniscectomy caused less severe arthritic changes than did complete meniscectomy in comparison studies (I0). Degenerative change resulting from partial meniscectomy has been shown to correlate with the amount of meniscus removed (11). L y n c h and Henning (4) have reported a large series of meniscal lesions in patients who had undergone simultaneous anterior cruciate ligament reconstruction. Their findings illustrate that meniscal preservation in such patients produces better clinical results and less degenerative change than does total or partial meniscectomy.
Arthroscopy, Vol. 1, No. 4, 1985
The meniscus has been shown to contribute significantly to the stability of the knee (12). Hughston and Barrett have emphasized preservation of the medial meniscus in the treatment of acute anteromedial rotatory instability (13,14). They concluded that the "the meniscus must be repaired and saved whenever possible." Price and Allen also stressed meniscus reattachment in repair of medial ligamentous injuries (15). All these studies point to the concept that meniscal preservation may assist in prevention of instability and/or degenerative changes. Many investigators have observed the potential for healing of meniscal tears (16-24; Arnoczky S, Fowler PF, personal communication). King (18), in the classic study using canine subjects, noted that tears within the meniscal substance would heal if they traversed the synovial meniscal junction. Cox also found that meniscal lesions which entered the periphery demonstrated some attempt at healing (11). Cabaud studied the healing potential of transverse medial meniscal incisions extending to the meniscat rim in dogs and monkeys (25). Repair was performed with a single absorbable suture. At 4 months 38% of the menisci had healed completely and 56% showed partial healing. Using the rabbit, Heatley (26) demonstrated healing of incisions in the central portion of the meniscus after excision of the peripheral rim. Arnoczky (personal communication) has shown that 8 months appears to be required for fibrocartilage healing of longitudinal tears of the vascular zone of dog menisci. Scapinelli's (20) and Oretorp's (19) anatomical studies have shown that a portion of the meniscal substance in humans has a blood supply. Scapinelli suggested that only the outer third of the meniscus is vascularized by vessels coming from the periphery. Arnoczky (27) has demonstrated that the peripheral 10-30% of the meniscus has a blood supply. Arnoczky (28) has termed this supply the perimeniscal capillary plexus. The plexus originates in the capsular and synovial tissue of the joint. The vessels are arranged in a circumferential pattern with radial branches directed toward the center of the joint. The posteror and anterior horns are more vascular than the middle segment of the meniscus (11,27). The horn attachments are covered with a layer of vascular synovial tissue which sends small vessels which penetrate the stroma of the horn for distances of 1-2 mm (28). The small vessels penetrating the meniscal substance probably do so along the path of the middle perforating bundle, a trans-
A R T H R O S C O P I C S U T U R E OF TORN M E N I S C I
verse collagen system dividing the meniscus into superior and inferior regions (29). Our arthroscopic observations strongly suggest that the blood supply of the meniscus is not limited to the outer 25%. Arnoczky's observations were reached in cadaver knees, which were at least 50 years of age. Our arthroscopic observations were made in healthy patients who averaged 28 years of age. We observed blood supply in longitudinal tears as far as 6 mm from the SMJ. Both observations are compatible with the findings of Clark (30). Clark demonstrated that the blood supply of the neonate meniscus penetrates to the inner edge and gradually decreases with age. At 11 years blood vessels were located primarily in the peripheral onethird of the meniscus, but "still could be identified throughout the inner zones" (30). King (18)~showed that transverse lesions of the meniscus healed by ingrowth of connective tissue from the synovium. Heatley contends that an "essential prelude to meniscal healing is invasion by synovial ceils" (26). He suggested that sutures "appear to act as bridges for the passage of synovial cells to the meniscus." Arnoczky demonstrated that longitudinal lesions in the avascular portion of the meniscus would heal by fibrovascular scar if there were a connection to peripheral blood supply by way of a vascular access channel (28). Indeed Arnoczky suggests that the "zone of repair" may be extended further into the body of the meniscus by the creation of a vascular access channel. We are in agreement with this concept. It appears from arthroscopic observation that placement of sutures may create such a vascular access pathway or that the vascular area extends farther into the meniscal substance than previously thought. Blood supply in the adult human meniscus has been demonstrated arthroscopically as far as 6 mm into the meniscal substance and this may be a manifestation of an intramensical vascular network, which may include radial and longitudinal connecting vessels. These connecting longitudinal vessels may be responsible for bleeding demonstrated on the inner rim side of some meniscal tears. Studies by Wirth (31), Cassidy (32), Hamberg (17), DeHaven (33,34), Boucher (35), Annandale (36), and Ikeuchi (personal communication) have demonstrated that peripheral meniscal tears 0-3 mm into the substance can be repaired using standard arthrotomy incisions. It is not possible, however, to stabilize longitudinal tears 3-6 mm into the
231
meniscal substance using conventional open techniques. The arthroscopic technique outlined can be used for most longitudinal meniscal tears which are 0-6 mm into the substance of the meniscus. CONCLUSIONS Arthroscopic meniscus suture is a safe and adequate method for longitudinal tears of the medial and lateral menisci. Longitudinal tears with damaged inner rims are not candidates and should be resected arthroscopically. We recommend a great deal of caution in attempting meniscus reattachment in patients over age forty. The inner rim in Such patients may exhibit too extensive degeneration to permit them to hold sutures and heal. Certain precautions must be followed to avoid catastrophic complications. Proper instruments and skills are absolutely necessary. REFERENCES 1. Marshall JL, Fetto JF, Botero PM: Knee ligament injuries: A standardized evaluation method. Clin Orthop 1977; 123:115-29. 2. Maxwell AE: Analyzing qualitative data Methuen, London, 1976. 3. Rosenberg T: Paper presented at Arthroscopic Association of North America Meeting, New Orleans, April, 1984. 4. Lynch MA, Henning CE, Glick KR: Knee joint surface changes. Long term follow-up meniscus tear treatment in stable anterior cruciate ligament. Clin Orthop 1983; 172:148. 5. Walker PS, Erkman MJ: The role of the menisci in force transmission across the knee. Clin Orthop 1975;109:184-92. 6. Kettlecamp DB, Jacobs AW: Tibiofemoral contact area: Determination and implications. JBJS 1972;54A:249. 7. Krause WR, Pope MH, Johnson RJ, Wilder D: Mechanical changes in the knee after m e n i s c e c t o m y . J B J S 1976; 6A:599. 8. Fairbanks TJ: Knee joint changes after meniscectomy. JBJS 1948;30B:664-70. 9. Tapper EM, Hoover NW: Late results after meniscectomy. JBJS 1969;51A:517. 10. McGinty JB, Geuss LF, Marvin RA: Partial or total rneniscectomy. JBJS 1977;59A:763-6. 11. Cox JS: The degenerative effects of medial meniscal tears in dog's knees. Clin Orthop 1977;125:236-42. 12. Wang CJ, Walker PS: Rotatory laxity of the human knee joint. JBJS 1974;56A: 161-70. 13. Hughston JC, Barrett GR: Acute anteromedial rotatory instability. JBJS 1983;65A:145-53. 14. Hughston JC: Acute knee injuries in athletes. Clin Orthop 1962;23:114-32. 15. Price CT, Allen WC: Ligament repair in the knee with preservation of the meniscus. JBJS 1978;60A:61-5. 16. Danzig L, Resnick D, Gonsalves M, Akeson WH: Blood supply to the normal and abnormal menisci of the human knee. Clin Orthop 1983;172:271-6. 17. Hamberg P, Gillquist J, Lysholm J: Suture of new and old peripheral meniscus tears. JBJS 1983;65A:193-7.
Arthroscopy, Vol. 1, No. 4, 1985
232
R. G. S T O N E A N D G. A. M I L L E R
18. King D: The healing of s e m i l u n a r cartilages. J B J S 1936;18:333-42. 19. Oretorp N: On the diagnosis and treatment of meniscus and ligament injuries in the knee. Structure of the medial meniscus. Linkoping University Medical Dissertation No. 64,I:6,1978. 20. Scapinelli R: Studies in the vasculature of the human knee joint. Acta Anat Basel 1968;70:305-31. 21. Stone RG: Arthroseopic blood supply to the meniscus. Pres e n t e d at the I n t e r n a t i o n a l A r t h r o s c o p y A s s o c i a t i o n Meeting. Philadelphia, October, 1980. 22. Stone RG: Peripheral detachment in the menisci: A preliminary report. Orthop Clin N A 1979;10:643-57. 23. Stone RG, Ryan J, Nolan S: Meniscal preservation. In: Grana W, ed, Update in arthroscopic techniques. Baltimore: University Park Press, 1984. 24. Veth RPH, et al: Repair of the meniscus. An experimental investigation in r a b b i t s . Clin Orthop 1983;175:25862. 25. Cabaud HE, Rodkey WG, Fitzwater JE, et al: Medial meniscus repairs and experimental and morphologic study. Am J Sports Med 1981;9:129-34. 26. Heatley FW: The m e n i s c u s - - c a n it be repaired? An experimental investigation in rabbits. JBJS 1980;62B:397-402.
Arthroscopy, Vol. l, No. 4, 1985
27. Arnoczky S: Microvasculature of the human meniscus, Am J Sports M e d 1982;10:90-5. 28. Arnoczky S, Warren RF: The microvasculature of the meniscus and its response to injury; an experimental study in the dog. A m J Sports Med 1983;11:131-41. 29. Ferra-Rocca O, Vilalta C: Lesions of the meniscus. Part 1: Macroscopic and histologic findings. Clin Orthop 1980; 146:289-300. 30. Clark CR, Ogden JA: Development of the menisci of the human knee joint. Morphological changes and their potential role in childhood meniscal injury. JBJS 1983;65A:538-47. 31. Wirth CR: M e n i s c u s repair. Clin Orthop 1981;157: 153-60. 32. Cassidy RE, Shaffer AJ: Repair of peripheral meniscus tears: A preliminary report A m J Sports M e d 1981;9:20914. 33. DeHaven KE, Hales W: Peripheral menis6us repair in a young athlete. Orthop Consult 1983;4:7-12. 34. DeHaven KE: Peripheral meniscus repair: An alternative to meniscectomy. Orthop Transact 1981;5:399-400. 35. Boucher HH: Anterior marginal separation of the meniscus of the knee. JBJS 1964;46B:539-41. 36. Annandale T: An operation for displaced semilunar cartilage. Br Med J 1885;779.
226-232 © 1985 Arthroscopy Association of North America
A Technique of Arthroscopic Suture of Torn Menisci Robert G. Stone, M.D., and Gary A. Miller, M.D.
Nineteen menisci in 16 patients were suitable for immobilization only, 14 were medial and five were lateral lesions. The average age was 27.7 years, ranging from 13 to 52 years. The average interval from onset of symptoms to surgery was 1.6 months. In general, these were lesions <10 mm long, stable with probing and not full thickness. There were 57 meniscal reattachments performed in 46 patients. Fifty-two menisci in 45 patients were sutured arthroscopically. Five were performed through an arthrotomy. Thirty-six patients had one meniscus stabilized. Two of these required repeat reattachment following earlier attempts. Five patients had medial and lateral meniscus reattachments arthroscopically. Four had one arthroscopic meniscus reattachment and one open meniscus reattachment in the same knee. Of those accomplished through arthrotomy, one was a posterior central detachment of the medial meniscus, one an anterior central detachment of the lateral meniscus, and one an anterior central detachment of the medial meniscus. Of the 52 arthroscopic meniscus reattachment procedures, 37 were medial and 15 lateral. They were longitudinal tears located 0-6 mm from the SMJ and 10-50 mm in length. There was a high incidence of associated injury, and 23 patients, which represented half of the group studied, had torn anterior cruciate ligaments. Intraarticular anterior cruciate ligament reconstruction using a patellar tendon graft was carried out in 10 patients. Repair of both menisci was required in seven of these knees. Extraarticular anterolateral reconstruction using iliotibial tenodesis was performed in five patients. Three patients had partial tears of the medial collateral ligament.
Since October, 1982 we have performed meniscal reattachments arthroscopically using the senior author's modification of Henning's technique (Henning CE, personal communication). The aims of the present investigation are: (1) to present a technique for arthroscopic meniscus reattachment; (2) to classify and present arthroscopic evidence of the meniscal blood supply; (3) to identify the potential complications of this procedure; (4) to determine if the percentage of repairable menisci decreases as the interval from injury to surgery increases; and (5) to present short-term results in arthroscopic meniscus repair. MATERIALS AND METHODS All meniscal lesions evaluated arthroscopically from October, 1982 to December, 1983 were studied. A total of 171 meniscal lesions in 139 patients were studied with reference to age, type of meniscal lesion, and the duration of symptoms or interval from injury to surgery. The lesions were classified into two categories: Those deemed healable and those deemed nonhealable. Of the 171 menisci, 95 (56%) were considered nonhealable: 59 were medial and 36 lateral. This category included those menisci with an excessively frayed inner rim (nine cases), disrupted bucket handle tears (11 cases), transverse tears (14 cases), flap tears (18 cases), some horizontal tears (nine cases), posterior medial complex disruptions (26 cases), degenerative tears associated with longitudinal components (six cases), and miscellaneous (two cases). The average patient age for this group was 44.9 years. The average interval from onset of meniscal symptoms to surgery was 13 months. Fifty-eight percent of the patients were 40 years or older. From the Department of Surgery, Division of Orthopedics, University of Texas Health Science Center, Dallas, Texas, U.S.A. Address correspondence and reprint requests to Dr. Robert G. Stone, 6t61 Harry Hines, Blvd., Suite 206, Dallas, TX 75235, U.S.A.
INSTRUMENTATION The following instruments were used: (1) two meniscus needles (10 in. in length and 0.0625 in. in diameter with a 25° angled tip) swedged onto a 40226
A R T H R O S C O P I C S U T U R E OF TORN M E N I S C I
in. 0-mersilene suture (author's design); (2) needle holding clamp (author's design); (3) tendon retractor (for posterior structures, author's design); (4) 2.7-mm basket forceps; (5) thimble; (6) camera system; (7) leg holder; (8) standard arthroscopic equipment including arthroscope; and (9) standard orthopedic equipment including clamps, etc. TECHNIQUE The reattachment is performed using the author's modifications of Henning's technique (personal communication) and the preceding instrumentation. The technique for arthroscopic reattachment of the medial meniscus will be discussed, followed by a few different points for the lateral meniscus. General anesthesia is used. Following the general anesthesia, a mixture of 1/2~ Xylocaine, 1/4% Marcaine, and 1/200,000 Epinephrine is injected in the anticipated portals of entry. The arthroscope is placed in the modified central portal and a 5.0-ram cannula is used for passage of basket forceps and meniscus needles for meniscal reattachment. The meniscal tear edges are debrided with a 2.7-mm basket forceps. The meniscus needles are passed through the inferior lateral portal through a cannula. The cannula and/or the needle tip must be viewed at all times. The first landmark puncture is started in the superior aspect of the meniscus 2 mm inward from the meniscal tear. If the meniscus tear is far posterior, the landmark stitch must still be started at or slightly posterior to the medial collateral ligament and anterior to the pes anserinus tendons. If the first landmark puncture is made at or slightly posterior to the medial collateral ligament, it will be safely anterior to the pes anserinus tendons. After the meniscus substance is punctured, the needle tip must be cautiously advanced in 5-mm increments until it tents the skin. The 20° angled tip must be directed medially to insure the proper area of skin tenting. An index finger with thimble is placed posteriorly on the pes anserinus tendons to insure that this landmark puncture will be directed medial and anterior to the pes anserinus tendon and saphenous nerve. A mixture of 1/2% Xylocaine, 1/4% Marcaine, and 1/200,000 Epinephrine is instilled into the subcutaneous tissue along the anticipated transverse skin incision. A 4-cm skin incision is performed parallel to the medial joint line in the region of the anticipated suture exits. The anterior aspect of the skin incision is started at the needle tip. The edges of
227
the skin are gently undermined down to the capsule with a small Metzanbaum scissor. The first meniscus needle is advanced through the incision and the tip is grasped with a clamp. The other swedged needle remains external to the cannula in the inferior lateral portal. The capsule is further delineated by blunt finger dissection. The tip of the second meniscus needle is passed through the tear in a similar fashion as the first, 2 mm anterior to the first suture entrance. It is cautiously advanced in 5-mm increments until it tents the capsule. The tendon retractor is then inserted and hooked under the capsular tent so that the meniscus needle is directed down the trough of the retractor. The meniscus needle is clamped and pulled through the incision. The ends of the first suture are then clamped and placed on a clamp holder. This completes the passage of the first suture. Each subsequent paired suture ends are clamped and placed on the clamp holder. A suture should be placed for each 5-mm of meniscus tear: thus for a 25-mm tear four such sutures are necessary. The sutures may be placed on the superior or inferior surface of the meniscus as needed for stability. Sutures may be placed horizontially or vertically as needed but we prefer vertical sutures when possible. The sutures are pulled taut to coapt the edges of the tear, after all sutures are placed. The tear is probed to assess stability. The matched sutures are tied outside of the capsule and under the skin, starting with the most posteriorly placed suture. The 4-ram skin incision is closed with a subcuticular suture. The technique for the lateral meniscus is the same as for the medial meniscus reattachment, except a cannula must be placed in the inferior medial portal for debridement of the meniscus edges and passage of the meniscus needle into the lateral meniscus. The first landmark stitch must always be anterior to the popliteal tendon and located at or slightly posterior to the lateral collateral ligament. If this rule is obeyed, then the meniscus needle tip will always exit anterior to the biceps tendon and therefore anterior to the peroneal nerve. This landmark puncture will also always serve as an anterior point for the transverse skin incision. A slit slightly anterior to the biceps tendon should be performed to admit the index finger and retractor. This is for stitches placed posterior and central to the popliteal tendon. Rehabilitation is vital to the success of the proArthroscopy, Vol. I, No. 4, 1985
228
R. G. S T O N E A N D G. A. M I L L E R T A B L E 1. Rating scale
Excellent: Score > 25 Generally near normal function with few or no signs or symptomatology Good: Score 21-24 Slight functional disability; few signs and mild symptomatology Fair: Score 15-20 Moderate functional disability; significant clinical signs and moderate symptomatology Poor: Score < 14 Severely disabled; marked signs and symptoms of a compromised knee
cedure. For the reattached meniscus associated with the anterior cruciate ligament tear, rehabilitation was generally dictated by the requirements for rehabilitation of the anterior cruciate ligament. For isolated meniscal lesions the following program was pursued. We suspect that this regimen can be shortened safely, although we have no firm evidence for this at this writing: Immobilization in a brace at 40° of flexion--0-2 weeks; immobilization in a brace permitting 40 to 90 ° of flexion against a springloaded r e s i s t a n c e - - 2 - 6 weeks; regaining complete range of motion, stationary bicycling, progressive muscle strengthening, linear running, and integration into turning, twisting and jumping--6 w e e k s 6 months; and return to s p o r t - - 6 months and after. RESULTS Assessment of clinical findings was performed to identify early trends in meniscus reattachment results. Prolonged follow-up will be required before conclusions may be reached regarding the final efficacy and advisability of the procedure. All but four patients were assessed at follow-up by telephone contact. All patients responded to an 18-point questionnaire judging subjective result. Greatest emphasis was placed upon the report of symptoms indicative of recurrent meniscal problems: popping, catching, locking, giving way, swelling, inability to squat, and pain. Although all patients were followed postoperatively at regular intervals, 23 patients (28 menisci) presented specifically for repeat examination in connection with the study. This included subjective evaluation, function tests, tenderness, assessment of muscle power, thigh circumference, range of motion, and stability. This evaluation form was modified from the Hospital for Special Surgery Knee Injury Summary (2). All patients were carefully Arthroscopy, Vol. 1, No. 4, 1985
T A B L E 2. Subjective results f o r each age group Result
<20
20-29
30-39
Excellent Good Fair Poor Totals
4 1
4 12 5 2 23
4 5 1 1 11
5
>40
Totals
2 1 3
12 18 8 4 42
evaluated for postoperative complications including numbness in the saphenous nerve distribution. A rating scale (Table 1) was modified from that of Marshall (1) with points being assessed for subjective and objective findings. Twenty-three patients (29 menisci) were evaluated objectively using the rating scale. There were seven excellent, nine good, six fair, and one poor results. The average follow-up was 6 months, ranging from 4 to 18 months. Nineteen additional patients were contacted by telephone and responded to our questionnaire making a total of 42 patients available for subjective evaluation. Both groups were combined to obtain the following results. Twelve patients (29%) with 14 menisci reported no subjective symptoms and full return to activity and were classified as excellent (Table 2). Eighteen patients (43%) with 19 menisci were classified as good results. Eight patients (19%) were classified as fair results. Four patients (10%) with four menisci were classified as poor results (Table 3). We demonstrated blood supply in 69% of the menisci sutured (Figs. 1-3). It was the same percentage for those >3 mm from the synovial medial junction as those at the synovial medial junction. The longer one waits to define a meniscus lesion, the less likely it is that it will be a candidate for meniscus suture. Eighty-one percent were candidates for meniscal suture if treated in the first 2 weeks after injury. Sixty-five percent were candidates if treated 2 - 6 weeks after injury. Thirty-eight percen t were candidates if treated 6 w e e k s - 6 months after injury, and 24% were candidates if treated 6 months or longer after injury. This represents a statistically significant linear trend in the data (significant at p < 0.001)(2). Complications included three cases (7%) of superficial cellulitis, one case of phlebitis (2%), and 16 (38%) of saphenous nerve neuropraxia. Two cases of the cellulitis were in patellar tendon grafts and all were treated with intravenous antibiotics for 10 days or less. One of the latter patellar tendon
ARTHROSCOPIC S UTURE OF TORN MENISCI
229
.... ~f
?
:)
i
FIG. 1. Blood flowing from apertures created in the meniscus by passage of K-wires with suture during meniscoresis and blood flowing from partially healed meniscus tear area.
FIG. 2. Blood flowing from apertures created in the meniscus by passage of K-wires with suture during meniscoresis and blood flowing from partially healed meniscus tear area.
grafts had an associated phlebitis treated with heparin. The most common complication in patients with medial meniscal reattachment was numbness along the medial aspect of the leg. The numbness ex-
tended to the skin over the medial malleolus in some cases. It most likely represents neuropraxia secondary to scar tissue entrapment of the sartorial branch of the saphenous nerve, or retraction of the pes anserinus tendons. Sixteen (38%) of the patients exhibited decreased sensation to light touch in the
N,
N
g
e 7
FIG. 3. Blood flowing from apertures created in the meniscus by passage of K-wires with suture during meniscoresis and blood flowing from partially healed meniscus tear area.
FIG. 4. Notch view of posterior horn of a medial meniscus. A posterior central detachment of the meniscus had been sutured 10 months earlier. The suture can be seen as the green pigmented area at the upper left corner and middle of the field, The suture had become incorporated into the meniscal substance 10 months following the surgery.
Arthroscopy, VoL 1, No. 4, 1985
230
R. G. S T O N E A N D G. A. M I L L E R
saphenous nerve distribution. The sensory deficit ranged in size from several square centimeters to an area of 12 by 17 cm. It lasted from 3-12 months and was bothersome in only three patients. Potential complications with the procedure can be catastrophic. These include damage to the popliteal artery and peroneal nerve. None of these occurred in our series. However, Rosenberg (3) reported injury to both structures in his survey.
DISCUSSION S. Arnoczky (personal communication) has observed that meniscal lesions in dogs do not heal with meniscal type fibrocartilage until eight months and speculates that intervals of several additional months may be required in humans for similar changes to occur. This is our rationale for using permanent suture. Permanent suture should stabilize the meniscus for the prolonged time, which may be required for healing to occur completely. Six patients who underwent meniscus reattachment using permanent suture (three by arthrotomy and three arthroscopically) were subsequently evaluated at repeat arthroscopy. This forms part of another report; however, there were no indications to suggest that joint surface damage had been produced by the sutures within 6-12 months. Indeed, it appeared that the sutures were being incorporated into the meniscus (Fig. 4). Preservation of the meniscus has been recognized to improve long-term results in knee injuries (4). Studies have demonstrated the role of the menisci in load transmission across the knee (5) and the dramatic changes in loading patterns of the tibiofemoral contact areas following m e n i s c e c t o m y (6,7). Complete meniscectomy has produced degenerative arthritic changes in many series (8,9). Partial meniscectomy caused less severe arthritic changes than did complete meniscectomy in comparison studies (I0). Degenerative change resulting from partial meniscectomy has been shown to correlate with the amount of meniscus removed (11). L y n c h and Henning (4) have reported a large series of meniscal lesions in patients who had undergone simultaneous anterior cruciate ligament reconstruction. Their findings illustrate that meniscal preservation in such patients produces better clinical results and less degenerative change than does total or partial meniscectomy.
Arthroscopy, Vol. 1, No. 4, 1985
The meniscus has been shown to contribute significantly to the stability of the knee (12). Hughston and Barrett have emphasized preservation of the medial meniscus in the treatment of acute anteromedial rotatory instability (13,14). They concluded that the "the meniscus must be repaired and saved whenever possible." Price and Allen also stressed meniscus reattachment in repair of medial ligamentous injuries (15). All these studies point to the concept that meniscal preservation may assist in prevention of instability and/or degenerative changes. Many investigators have observed the potential for healing of meniscal tears (16-24; Arnoczky S, Fowler PF, personal communication). King (18), in the classic study using canine subjects, noted that tears within the meniscal substance would heal if they traversed the synovial meniscal junction. Cox also found that meniscal lesions which entered the periphery demonstrated some attempt at healing (11). Cabaud studied the healing potential of transverse medial meniscal incisions extending to the meniscat rim in dogs and monkeys (25). Repair was performed with a single absorbable suture. At 4 months 38% of the menisci had healed completely and 56% showed partial healing. Using the rabbit, Heatley (26) demonstrated healing of incisions in the central portion of the meniscus after excision of the peripheral rim. Arnoczky (personal communication) has shown that 8 months appears to be required for fibrocartilage healing of longitudinal tears of the vascular zone of dog menisci. Scapinelli's (20) and Oretorp's (19) anatomical studies have shown that a portion of the meniscal substance in humans has a blood supply. Scapinelli suggested that only the outer third of the meniscus is vascularized by vessels coming from the periphery. Arnoczky (27) has demonstrated that the peripheral 10-30% of the meniscus has a blood supply. Arnoczky (28) has termed this supply the perimeniscal capillary plexus. The plexus originates in the capsular and synovial tissue of the joint. The vessels are arranged in a circumferential pattern with radial branches directed toward the center of the joint. The posteror and anterior horns are more vascular than the middle segment of the meniscus (11,27). The horn attachments are covered with a layer of vascular synovial tissue which sends small vessels which penetrate the stroma of the horn for distances of 1-2 mm (28). The small vessels penetrating the meniscal substance probably do so along the path of the middle perforating bundle, a trans-
A R T H R O S C O P I C S U T U R E OF TORN M E N I S C I
verse collagen system dividing the meniscus into superior and inferior regions (29). Our arthroscopic observations strongly suggest that the blood supply of the meniscus is not limited to the outer 25%. Arnoczky's observations were reached in cadaver knees, which were at least 50 years of age. Our arthroscopic observations were made in healthy patients who averaged 28 years of age. We observed blood supply in longitudinal tears as far as 6 mm from the SMJ. Both observations are compatible with the findings of Clark (30). Clark demonstrated that the blood supply of the neonate meniscus penetrates to the inner edge and gradually decreases with age. At 11 years blood vessels were located primarily in the peripheral onethird of the meniscus, but "still could be identified throughout the inner zones" (30). King (18)~showed that transverse lesions of the meniscus healed by ingrowth of connective tissue from the synovium. Heatley contends that an "essential prelude to meniscal healing is invasion by synovial ceils" (26). He suggested that sutures "appear to act as bridges for the passage of synovial cells to the meniscus." Arnoczky demonstrated that longitudinal lesions in the avascular portion of the meniscus would heal by fibrovascular scar if there were a connection to peripheral blood supply by way of a vascular access channel (28). Indeed Arnoczky suggests that the "zone of repair" may be extended further into the body of the meniscus by the creation of a vascular access channel. We are in agreement with this concept. It appears from arthroscopic observation that placement of sutures may create such a vascular access pathway or that the vascular area extends farther into the meniscal substance than previously thought. Blood supply in the adult human meniscus has been demonstrated arthroscopically as far as 6 mm into the meniscal substance and this may be a manifestation of an intramensical vascular network, which may include radial and longitudinal connecting vessels. These connecting longitudinal vessels may be responsible for bleeding demonstrated on the inner rim side of some meniscal tears. Studies by Wirth (31), Cassidy (32), Hamberg (17), DeHaven (33,34), Boucher (35), Annandale (36), and Ikeuchi (personal communication) have demonstrated that peripheral meniscal tears 0-3 mm into the substance can be repaired using standard arthrotomy incisions. It is not possible, however, to stabilize longitudinal tears 3-6 mm into the
231
meniscal substance using conventional open techniques. The arthroscopic technique outlined can be used for most longitudinal meniscal tears which are 0-6 mm into the substance of the meniscus. CONCLUSIONS Arthroscopic meniscus suture is a safe and adequate method for longitudinal tears of the medial and lateral menisci. Longitudinal tears with damaged inner rims are not candidates and should be resected arthroscopically. We recommend a great deal of caution in attempting meniscus reattachment in patients over age forty. The inner rim in Such patients may exhibit too extensive degeneration to permit them to hold sutures and heal. Certain precautions must be followed to avoid catastrophic complications. Proper instruments and skills are absolutely necessary. REFERENCES 1. Marshall JL, Fetto JF, Botero PM: Knee ligament injuries: A standardized evaluation method. Clin Orthop 1977; 123:115-29. 2. Maxwell AE: Analyzing qualitative data Methuen, London, 1976. 3. Rosenberg T: Paper presented at Arthroscopic Association of North America Meeting, New Orleans, April, 1984. 4. Lynch MA, Henning CE, Glick KR: Knee joint surface changes. Long term follow-up meniscus tear treatment in stable anterior cruciate ligament. Clin Orthop 1983; 172:148. 5. Walker PS, Erkman MJ: The role of the menisci in force transmission across the knee. Clin Orthop 1975;109:184-92. 6. Kettlecamp DB, Jacobs AW: Tibiofemoral contact area: Determination and implications. JBJS 1972;54A:249. 7. Krause WR, Pope MH, Johnson RJ, Wilder D: Mechanical changes in the knee after m e n i s c e c t o m y . J B J S 1976; 6A:599. 8. Fairbanks TJ: Knee joint changes after meniscectomy. JBJS 1948;30B:664-70. 9. Tapper EM, Hoover NW: Late results after meniscectomy. JBJS 1969;51A:517. 10. McGinty JB, Geuss LF, Marvin RA: Partial or total rneniscectomy. JBJS 1977;59A:763-6. 11. Cox JS: The degenerative effects of medial meniscal tears in dog's knees. Clin Orthop 1977;125:236-42. 12. Wang CJ, Walker PS: Rotatory laxity of the human knee joint. JBJS 1974;56A: 161-70. 13. Hughston JC, Barrett GR: Acute anteromedial rotatory instability. JBJS 1983;65A:145-53. 14. Hughston JC: Acute knee injuries in athletes. Clin Orthop 1962;23:114-32. 15. Price CT, Allen WC: Ligament repair in the knee with preservation of the meniscus. JBJS 1978;60A:61-5. 16. Danzig L, Resnick D, Gonsalves M, Akeson WH: Blood supply to the normal and abnormal menisci of the human knee. Clin Orthop 1983;172:271-6. 17. Hamberg P, Gillquist J, Lysholm J: Suture of new and old peripheral meniscus tears. JBJS 1983;65A:193-7.
Arthroscopy, Vol. 1, No. 4, 1985
232
R. G. S T O N E A N D G. A. M I L L E R
18. King D: The healing of s e m i l u n a r cartilages. J B J S 1936;18:333-42. 19. Oretorp N: On the diagnosis and treatment of meniscus and ligament injuries in the knee. Structure of the medial meniscus. Linkoping University Medical Dissertation No. 64,I:6,1978. 20. Scapinelli R: Studies in the vasculature of the human knee joint. Acta Anat Basel 1968;70:305-31. 21. Stone RG: Arthroseopic blood supply to the meniscus. Pres e n t e d at the I n t e r n a t i o n a l A r t h r o s c o p y A s s o c i a t i o n Meeting. Philadelphia, October, 1980. 22. Stone RG: Peripheral detachment in the menisci: A preliminary report. Orthop Clin N A 1979;10:643-57. 23. Stone RG, Ryan J, Nolan S: Meniscal preservation. In: Grana W, ed, Update in arthroscopic techniques. Baltimore: University Park Press, 1984. 24. Veth RPH, et al: Repair of the meniscus. An experimental investigation in r a b b i t s . Clin Orthop 1983;175:25862. 25. Cabaud HE, Rodkey WG, Fitzwater JE, et al: Medial meniscus repairs and experimental and morphologic study. Am J Sports Med 1981;9:129-34. 26. Heatley FW: The m e n i s c u s - - c a n it be repaired? An experimental investigation in rabbits. JBJS 1980;62B:397-402.
Arthroscopy, Vol. l, No. 4, 1985
27. Arnoczky S: Microvasculature of the human meniscus, Am J Sports M e d 1982;10:90-5. 28. Arnoczky S, Warren RF: The microvasculature of the meniscus and its response to injury; an experimental study in the dog. A m J Sports Med 1983;11:131-41. 29. Ferra-Rocca O, Vilalta C: Lesions of the meniscus. Part 1: Macroscopic and histologic findings. Clin Orthop 1980; 146:289-300. 30. Clark CR, Ogden JA: Development of the menisci of the human knee joint. Morphological changes and their potential role in childhood meniscal injury. JBJS 1983;65A:538-47. 31. Wirth CR: M e n i s c u s repair. Clin Orthop 1981;157: 153-60. 32. Cassidy RE, Shaffer AJ: Repair of peripheral meniscus tears: A preliminary report A m J Sports M e d 1981;9:20914. 33. DeHaven KE, Hales W: Peripheral menis6us repair in a young athlete. Orthop Consult 1983;4:7-12. 34. DeHaven KE: Peripheral meniscus repair: An alternative to meniscectomy. Orthop Transact 1981;5:399-400. 35. Boucher HH: Anterior marginal separation of the meniscus of the knee. JBJS 1964;46B:539-41. 36. Annandale T: An operation for displaced semilunar cartilage. Br Med J 1885;779.