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Arthroscopic partial meniscectomy
ARTHROSCOPIC PARTIAL MENISCECTOMY DANIEL T. HINKIN, MD, LT COL
Meniscal tears are among the most common problems surgically addressed in the practice of knee surgery. Arthroscopic partial meniscectomy has become the standard in managing meniscal damage not suitable for repair or allograft replacement. Current techniques involve low morbidity, rapid rehabilitation, and early return to functional activities. However, recent studies suggest that the optimistic early results of arthroscopic partial meniscectomy may deteriorate over time. KEY WORDS: arthroscopy, meniscectomy, meniscal tear
The history of identifying and treating meniscal tears begins in the 1800s with descriptions by William Hey and Thomas Annandale concerning "internal derangement of the knee" and its management.l'2 Arthroscopic evaluation of the meniscus was first described by Burman et al in the 1930s. 3-6 The preferred treatment for a torn meniscus was open total meniscectomy. Arthroscopic meniscus surgery was introduced in the 1960s by Watanabe and Ikeuchi in Japan. 7 Dr. Richard O'Connor developed the operating arthroscope in the 1970s. It was his pioneering work and refinement of techniques that led to the explosion of arthroscopic techniques in the 1970s and 1980s. s Subsequent improvements in equipment, technique, and training have made arthroscopic management of the torn meniscus the standard, replacing open total meniscectomy. 9
RATIONALE FOR PARTIAL MENISCECTOMY The physiology and pathology of the meniscus was not well understood w h e n total meniscectomy was the recommended treatment for meniscal damage. King and Smillie believed that the meniscus was invariably replaced by a fibrous tissue structure almost identical to the original meniscus. ~°'1~ In 1948, Fairbank wrote his classic treatise describing the potentially deleterious effects of total meniscectomy. 12 The previous widespread feeling that total meniscectomy was a benign procedure began to falter. 13"19 Researchers investigated the precise function of the meniscus. This research suggested that functions such as weight transmission, shock absorption, joint stability, joint lubrication, and nutrition were all diminished after meniscectomy. 18"2°-3° Seedhom and Hargreaves noted that partial meniscectomy reduced the weight-
transmitting function of the meniscus less than total meniscectomy, provided that the circumferential fibers of the meniscus are left intact 23"24 Several large studies have shown the short-term advantages of arthroscopic partial meniscectomy over open total meniscectomy. Reviews by McGinty et al, Northmore-Ball et al, Bergstrom et al, and Simpson et al all showed higher functional scores, less morbidity, shorter hospital stays, and more rapid return to work in patients with arthroscopic partial meniscectomies. 3~-34 A recent report by Youmans et al with a median follow-up time of 11.5 years s h o w e d 37% of patients had Fairbank 3 changes. 3s This is not significantly different from studies of open total meniscectomies. International Knee Documentation Committee ratings in the study showed 72% abnormal or severely abnormal knees. The conclusions of this study were that long-term follow-up of arthroscopic partial meniscectomies does not continue to show the dramatic differences compared with those of o p e n total m e n i s c e c t o m y t h a t w e r e o b s e r v e d in the short- a n d i n t e r m e d i a t e - t e r m f o l l o w - u p s . Preservation of meniscal tissue whenever possible was recommended. A distillation of the information available from the above studies results in a generalized treatment strategy in managing the torn meniscus. If possible, meniscal repair is the ideal solution. If meniscal repair is not possible, preservation of as much meniscal tissue as practical should be attempted, including preservation of the peripheral, circumferential fibers. Patients with large, complex tears with total loss of meniscal function should be considered for meniscal allografting. 9"24'35-38
DIAGNOSIS History
From the Sports Medicine Service, United States Air Force Academy, CO; and the Uniformed Services University of the Health Sciences, Bethesda, MD. Address reprint requests to Daniel T. Hinkin, MD, LT COL, USAF, MC, HQ USAFA/SGOSOS, 2354 Vandenberg Dr, Suite 1A99, USAF Academy, CO 80840-6290. This is a US government work. There are no restrictions on its use. 1048-6666/95/0501-0005500.00 28
The diagnosis of a torn meniscus can generally be made with a careful history and physical examination. The history is classically that of a twisting injury to the knee with subsequent joint line pain. Swelling, loss of motion, catching with weight-bearing, or loss of range of motion may ensue. The functional deficit can initially be
Operative Techniques in Orthopaedics, Vol 5, No 1 (January), 1995: pp 28-38
minimal, but pain localized to the joint line occurs with attempts at increased activity or impact loading. 39
Physical Examination Physical examination of the patient with a suspected meniscal tear should follow the pattern of the examiner's routine knee examination so as to preclude missing associated pathology. The knee is observed for signs of effusion or localized[ trauma. Thigh girth is measured 1 0 and 15 cm above the patella. Active and passive range of motion is measured. Palpation for points of tenderness is performed, especially along the patellar retinculum, collateral ligaments, and joint lines. Ligament stability testing is completed. The joint lines are palpated with the knee in flexion. We have found localized joint line tenderness to be the most frequent sign of meniscal pathology. Rotational testing of the joint in varus and valgus positions (McMurray test, Adson's test) can be helpful if positive,, but are nondiagnostic if negative. 4°'41 The patella is evahlated for signs of crepitus, maltracking, or instability. Other causes of knee pain, including the back, hip, and foot, should be evaluated. 42
Imaging Studies R a d i o g r a p h i c e v a l u a t i o n s h o u l d i n c l u d e anteriorposterior, lateral, tunnel, and patellar views. If degenerative changes are suspected, the posterior-anterior weight-bearing flexion view of Rosenberg should be obtained. 43 Arthrography and magnetic resonance imaging (MRI) have been widely used in the diagnosis of meniscat tears. 44-49 'The results of these tests are dependent on the experience and skill of the examiner. 39 These tests are not necessary in the routine diagnosis of suspected meniscal tears. If the study is positive, arthroscopy of the affected joint is indicated. If the examination is negative and symptoms persist, arthroscopy is indicated to diagnose the problem. Therefore, the study is unnecessary in the majority of cases. However, MRI may be indicated if the examination is confusing, the diagnosis unclear, or previous surgery has not resolved the problem. None of these imaging modalities surpass arthroscopy as the standard for diagnosis of meniscal pathology, 9,39,42,44,45
GENERAL SURGICAL PROCEDURES Unless extenuating circumstances exist, arthroscopic meniscal surgery can be performed on an outpatient basis. 9 General, regional, or local anesthesia can be used, although general and regional anesthesia provide better limb relaxation. Local anesthesia has been proven effective; 52-56 however, use of a tourniquet may be difficult. Many investigators recommend routine tourniquet use. 9 We do not routinely use a tourniquet unless blood in the field is a problem. Potential adverse effects of tourniquet use include t h r o m b o p h l e b i t i s a n d electromyographic changes to the quadriceps. 57's8 A leg holder or leg post is used to provide a fulcrum for varus/valgus stress of the knee. Although the leg holder provides optimal rotational control of the knee, it may compromise use of posterior portals. The leg post improves access posteriorly, but requires the use of the figure-of-four position to visualize the lateral compartment. 59 Whatever device is used, caution is urged to prevent injury to the collateral ligaments. Gravity flow or irrigation p u m p systems are used to maintain fluid flow. Gravity flow is safe, efficient, and inexpensive, but it may result in suboptimal flow in tight knees. 9 P u m p systems maintain constant pressure and flow, but they are expensive and may cause excessive fluid extravasation into the soft t i s s u e s . 60'61 We routinely use the arthroscopic pump. With careful monitoring of cannula position and p u m p flow rates, this equipment has been very safe. Instrumentation routinely used in arthroscopic meniscal surgery is well described in other texts, s9
ARTHROSCOPIC EXAMINATION OF THE KNEE It is absolutely critical to accurate arthroscopic diagnosis of knee pathology to develop a standardized, systematic m e t h o d of conducting the arthroscopic examination. Knowledge of available portals in developing this technique, and the ability to modify a technique to the changing nature of the patient's knee structure and pathology, are essential. A thorough discussion of techniques for viewing the entire meniscus is included elsewhere in this issue.
INDICATIONS FOR ARTHROSCOPY CLASSIFICATION OF MENISCAL TEARS The indications for arthroscopic and open meniscal surgery are identical. The decreased morbidity and more rapid return to function associated with arthroscopic techniques makes this the procedure of choice for the well-trained knee surgeon. These indications include: (1) typical symptoms of meniscal tear, including joint line pain, catching, effusion, locking, or giving way; (2) positive physical examination findings, including localized joint line tenderness, effusion, loss of motion, or provocative meniscal signs; (3) absence of other sources of knee pain; and (4) failure of nonsurgical treatment, including rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and a coordinated rehabilitation program. 8'9"5°'51 ARTHROSCOPIC PARTIAL MENISCECTOMY
Classification of the most commonly observed meniscal tear patterns helps in discussion of their presentation and surgical treatment options. Several investigators have described meniscal tear patterns. 9'39'51'62 These patterns generally fall into the categories of vertical longitudinal (bucket handle), oblique (flap, parrot beak), transverse (radial), horizontal (cleavage), and complex (degenerative) (Fig 1). Although vertical longitudinal or bucket-handle tears can occur anywhere in a meniscus, the majority occur in the posterior horn. The length of this tear can vary from less than 1 cm to two thirds of the circumference of the 29
A
B
Fig 1. Diagram of common meniscal tear patterns: (A) vertical longitudinal tear; (B) oblique tear; (C) transverse tear; (D) horizontal tear; and (E) complex tear.
meniscus. This tear pattern is frequently observed in association with anterior cruciate ligament (ACL) tears. 9 The inner portion of the meniscus may become unstable, causing mechanical symptoms or true locking of the knee. The meniscus may displace into the intercondylar notch and become fixed there chronically (Fig 2), or it may divide into two separate flaps, one based anterior and one posterior. Medial meniscus longitudinal tears tend to extend around more of the circumference of the meniscus than lateral tears because of increased fixation of the rim of the medial meniscus and its inability to absorb more energy by meniscal displacement before tearing. A small incomplete vertical tear may occur, most commonly in the posterior third of the meniscus, and is frequently associated with ACL tears. These tears can be unstable, causing characteristic clunking with rotational
Fig 2. Arthroscopic view of a displaced vertical longitudinal (bucket handle) tear of the medial meniscus. 30
activities. They are usually not observed initially, but become apparent with probing (Fig 3). 9'39 Oblique, flap, or parrot-beak tears are among those most commonly seen. They can occur anywhere along the meniscus, but are most commonly found at the junction of the posterior and middle thirds of the medial meniscus. The free edge of the flap may catch in the joint line, causing localized painful catching. The pain is generated from tugging on the meniscocapsular junction with weight-bearing, and such traction may result in propagation of the tear. 9 Several patterns of this tear can be visualized (Fig 4). The most common pattern is the single flap involving the posterior and/or middle thirds of the meniscus (Fig 4A). Double flaps are not uncommon, with one adjacent to the posterior central attachment of the meniscus and one closer to the middle third (Figs 4B and 5A). An isolated posterior flap may fold under the meniscus and become adherent and difficult to mobilize, or it may fold on its base and lie in the posteromedial compartment of the knee (Figs 4C, D, and 5B). Radial tears are most commonly observed in the lateral meniscus at the junction of the posterior and middle thirds. Small radial tears are probably not symptomatic, but the tear can propagate if the leading edge catches in
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Fig 3. Incomplete vertical longitudinal tear of the lateral meniscus. (A) Diagram, (B) arthroscopic view. DANIEL T. HINKIN
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margin loses its cohesion and a tear results. The meniscus is split into superior and inferior flaps, either of which can slide into the joint and cause mechanical symptoms (Fig 7). This type of tear is frequently associated with lateral meniscal cysts, 63 as discussed elsewhere in this issue. Degenerative or complex tears show tearing in multiple planes (Fig 8). They occur most commonly in patients older than 40 years of age and are usually associated with long-standing symptoms. The tear does not usually extend to the meniscocapsular junction. Chondromalacia of the adjacent articular surfaces is common, and plain radiographic degenerative changes may be visualized.
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TECHNIQUE OF MENISCAL RESECTION
Fig 4. Diagram of oblique meniscal tear patterns. (A) single flap in middle third; (B) double flaps; (C) superior surface posterior horn flap; and (D) inferior surface posterior horn flap,
the joint line. These tears will rarely extend to the peripheral rim, transecting the meniscus (Fig 6). Horizontal cleavage tears are believed to begin at the free margin of the midportion of the meniscus and extend toward the capsule. The sensitivity of MRI in knee meniscus pathology suggests that perhaps the inciting event is degenerative change in the body of the meniscus gradually extending toward the free margin until the thin free
Although each meniscal tear presents a unique challenge to the surgeon, general guidelines for meniscal surgery have been described by Metcalf: 9"51 (1) Remove all mobile fragments that can protrude into the joint line beyond the normal limits of the free margin of the meniscus. (2) Shape the r e m a i n i n g m e n i s c u s so that no s u d d e n changes in contour remain. Use more than one portal to confirm adequate contouring because parallax of the arthroscopic lens system can distort the actual meniscal contour. The use of more than one portal for instrumentation can facilitate smooth contouring (Fig 9). (3) Do not attempt to obtain a perfectly smooth rim. It is impossible to obtain an entirely smooth rim. Attempting to do so adds unnecessary time to the procedure and has been proven unnecessary because follow-up arthroscopic examinations show further rim remodeling at 6 to 9 months. 64 (4)Use the probe frequently before, during, and after the resection. This instrument provides the surgeon with the tactile feedback necessary to evaluate
Fig 5. Arthroscopic view of oblique meniscal tears. (A) Double flap tear of the medial meniscus; (B) inferior surface flap tear posterior-horn lateral meniscus. ARTHROSCOPIC PARTIAL MENISCECTOMY
31
Fig 6. Arthroscopic view of radial tear of the lateral meniscus.
the integrity of the meniscus and the need for further resection. (5) Protect the meniscocapsular junction if at all possible. Compromise of this area can result in mechanics similar to the knee with a total meniscectomy. 24"28"29"65 If unsure, leave more meniscal rim than less, especially adjacent to the popliteus hiatus. (6) Alternate between hand-operated and motorized instruments. Hand-operated instruments allow a more controlled resection and tactile feedback, while motorized instruments efficiently smooth frayed fragments and remove loose debris.
Fig 7. Arthroscopic view of horizontal tear of lateral meniscus. 32
Fig 8. Arthroscopic view of degenerative tear of the medial meniscus with adjacent chondromalacia of the medial femoral condyle.
SPECIFIC GUIDELINES Vertical Longitudinal Tear The vertical longitudinal tear can be addressed in a number of ways depending on its orientation, size, condition of the mobile fragment, stability, proximity to the meniscosynovial junction, and concomitant ligamentous injuries. Criteria for repair of these tears are discussed elsewhere in this issue. Weiss and DeHaven have described vertical longitudinal tear characteristics that make a tear relatively stable and at low risk for persistent symptoms. 66 These criteria include partial or full-thickness tears within the periphery of the meniscus and those nondisplaceable more than 3 mm from the meniscosynovial junction. This type of
Fig 9. Diagram of meniscal contouring using more than one instrumentation portal. (Reprinted with permission. 8) DANIEL T. HINKIN
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tear can probably be observed unless it is causing significant symptoms. Vertical longitudinal tears that do not meet the criteria for stability or repair and are symptomatic should be resected in a stepwise fashion: 9'51'64 (1) If the unstable fragment is displaced in the intercondylar notch (Fig 10A), it is reduced into its anatomic position (Fig 10B). This is accomplished by viewing through the contralateral anterior portal and placing a probe on the ipsilateral side. With the knee stressed to open the involved[ compartment, the meniscus is pushed into a reduced position as the knee is slowly extended. Occasionally, the displaced fragment is chronically deformed and cannot be reduced. Resection is then begun with the meniscus displaced. (2) A probe is used to define the limits of the tear. While visualizing: the posterior attachment of the tear ARTHROSCOPIC PARTIAL MENISCECTOMY
Fig 10. Diagrammatic representation of resection of a displaced vertical longitudinal tear. (A) Displaced vertical longitudinal tear; (B) Displaced segment is reduced into anatomic position. (C) Posterior attachment of tear is partially divided. (D) Anterior axilla is detached. (E) Anterior axilia is grasped and the posterior attachment is avulsed. (F) Alternatively, the anterior axiila is grasped and the posterior horn is detached under direct visualization. (G) The meniscal fragment is removed through an anterior portal. (H) The remaining rim is inspected and contoured. (Reprinted with permission. 9)
with the scope through the notch, a small straight or up-biting basket, or meniscal scissor is used to partially cut the posterior attachment (Fig 10C). This is only performed under direct visualization, especially on the lateral side where the posterior horn lies in close proximity to the posterior cruciate ligament. This cut leaves a bridge of meniscus small enough to be avulsed. If the cut cannot be viewed directly, proceed to resection of the anterior portion of the tear, and return to the posterior horn w h e n it is later put under tension. Dandy describes a technique wherein the posterior horn is completely detached at this point to prevent the mobile fragment from flipping up into the posterior compartment, thus complicating the resection. 67 (3) Detach the anterior axilla of the tear after confirming the direction and depth of the tear (Fig 10D). This cut is made with a basket, scissors, or hooked knife. Unless 33
the surgeon is very skilled, the knife can cause extensive damage to the adjacent articular cartilage and capsule. The resection should be in line with the desired final contour of the meniscal rim. If the meniscus is grasped before finishing this cut, a central portal as used by Gillquist is helpful for the resection. 6s (4) The anterior horn of the meniscus is grasped. If the fragment is grasped in midsubstance, it will buckle when attempts are made to remove it through a portal. We grasp the meniscus through an ipsilateral anterior portal before final resection of the anterior horn. This prevents the mobile fragment from disappearing behind the condyle. If the fragment folds posteriorly, a posteromedial or posterolateral portal can be established under direct visualization. A grasper is placed through this portal to secure the fragment. It is then avulsed or the remaining bridge is cut under direct visualization and the fragment removed. (5) The posterior horn is avulsed, and the fragment is removed (Figs 10 E,G). Frequently, the posterior horn is insufficiently divided before this maneuver. If excessive traction is required, the posterior horn is divided under direct visualization. Tension is applied t h r o u g h a grasper. An auxiliary portal at the joint line just anterior to the collateral ligament or through the patellar tendon is used for the cutting instrument (Fig 10F). (6) The remaining rim is inspected and contoured (Fig 10H). If at all possible, a rim of meniscal tissue should be left intact across the popliteus hiatus to preserve the integrity of the circumferential fibers (Fig 11). The surgeon should remember to look posteriorly with the scope directed through the notch to assure no loose or unstable fragments remain. If an incomplete vertical longitudinal tear fragment is unstable in a young person, it should be repaired. If resection is necessary, it is usually performed piecemeal because of its location. The remaining meniscus is contoured.
Oblique Tear Careful evaluation is performed with the scope and probe in standard anterior portals. The undersurface of the meniscus, adjacent gutter, and posterior compartment are fully visualized. The full extent of the flap and its base are evaluated. Any folded fragments are gently teased free and brought into view. The mobile segment is amputated at its base after securing the fragment with a grasper (Fig 12). If the flap is large and firm it is initially trimmed with hand held instruments, and contoured with motorized instruments. The remainder of the meniscus is contoured (Figs 13A and 14). If the piecemeal technique is used for the resection, motorized shavers are used to evacuate the loose debris.
Radial Tear Radial tears should be trimmed to prevent the corners from catching in the joint. The corners are resected with a basket forceps to provide tactile feedback and control the depth of resection. The meniscus is resected to the depth of the tear, and the r e m n a n t is contoured to present no sudden changes. The rim is then visualized from two portals to confirm adequate contouring (Fig 13B).
Horizontal Tear Resection of this type of tear is frequently difficult because of its peripheral extension and sometimes complex tear patterns. The first goal is to identify which leaf (superior or inferior) will be resected. The leaves should be probed separately to determine which is most unstable. Occasionally, both will be unstable and require some resection. Resection begins with basket forceps. Frequent probing and reassessment are necessary to limit the resection to only the tissue that is unstable. Occasionally, this will require total meniscectomy. The most unstable flap is resected to stable tissue. Every attempt should be made to preserve the other flap and maintain some meniscal function (Fig 13C).
Degenerative Tear Recognition of this tear pattern is easy, provided adequate exposure of the posterior horn is obtained. The posterior horn of the meniscus is softened and frayed. The meniscus is thoroughly probed. Major flaps are resected with basket forceps. Motorized suction resectors are useful for debriding loose or fibrillated fragments.
B
Fig 11. Arthroscopic view of remaining rim after resection of a vertical longitudinal tear. :}4
Fig 12. Diagram of (A) inferior surface flap tear folded under meniscus; (B) flap tear teased free with extent of resection indicated, (Reprinted with permission2) DANIEL T. HINKIN
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_.J Fig 13. Diagram of the extent of meniscal resection required for typical meniscal tear patterns: (A) oblique tear; (B) transverse tear; (C) horizontal tear; (D) degenerative tear,
drainage of the joint until the effluent is clear, 9 or with the arthroscopic pump and suction shaver. We use the arthroscopic pump for our procedures, and at the conclusion, the suction shaver is placed with the tip in the suprapatellar pouch. The scope cannula is directed into the joint lines and the gutters. The posterior capsule is compressed manually, and the knee is gently flexed and extended. Irrigation is performed until no further debris is visualized with the scope. Portals are closed with sterile strips, subcuticular absorbable sutures, or simple nonabsorbable sutures according to the surgeon's preference. We routinely inject the joint with 10 mL of 0.25% bupivacaine for postoperative pain control. This practice has been validated by several studies. 69'7° The portals are covered with adhesive strips, gauze dressing, and an elastic bandage. Oral NSAIDs have been effective in postoperative analgesia after these procedures, but neither NSAIDs nor oral corticosteroids have been conclusively shown to significantly enhance recovery from arthroscopic partial meniscectomy. 71-76 The patient should begin quadriceps setting exercises, straight leg raising, and calf p u m p s immediately. Crutches are used with weight-bearing as tolerated. Active range of motion is begun immediately. Showering is permitted 48 to 72 hours after surgery, but the w o u n d s should not be submerged until completely healed. An adhesive strip covers the wound after showering. Sutures are removed at 7 to 10 days. The patient is progressed to walking, swimming, and cycling as tolerated. Sports are resumed when the knee has full range of motion, no effusion, and the quadriceps and hamstrings have normal strength. 39
COMPLICATIONS
Fig 14. Arthroscopic view of posterior-horn lateral meniscus after excision of a flap tear and contouring.
All fibrillated segments need not be removed, and the capsular rim should be preserved if at all possible. Adjacent chondromalacia areas are debrided and/or drilled as indicated (Figs 13D).
Several large studies have documented a low complication rate associated with arthroscopic surgical procedures, ranging from 0.56% to 1.68% 77-82 Intraoperative complications include anesthesia problems, articular surface injury, instrument breakage, irrigation fluid leakage, ligament damage, and arterial or nerve injury. Postoperative complications include anesthesia problems, thrombophlebitis, hemarthrosis, infection, persistent effusion, and synovitis. Most intraoperative problems can be avoided by meticulous technique. Fluid leakage is most commonly caused by malposition or soft-tissue obstruction of the outflow cannula while using an arthroscopic pump. 82 We have found malpositioning a problem mostly in moving the knee into and out of the figureof-four position. It is our recommendation that the suprapatellar cannula position be re-evaluated whenever the knee is taken into and out of this position.
RESULTS POSTOPERATIVE CARE At the completion of the arthroscopic procedure, the joint is thoroughly irrigated to remove any loose debris. This can be accomplished with alternating distention and ARTHROSCOPIC PARTIAL MENISCECTOMY
Reports reviewing results of arthroscopic partial meniscectomy show improved short-term results compared with open total meniscectomy.~-91 Possible reasons for poor results have been investigated. 42"9°'92 More recent 35
l o n g e r - t e r m s t u d i e s raise q u e s t i o n s as to w h e t h e r these initial o p t i m i s t i c r e s u l t s will h o l d u p o v e r time. 35'92 Results of a r t h r o s c o p i c partial m e n i s c e c t o m y in p a t i e n t s older t h a n 40 y e a r s of age are d e p e n d e n t o n the p r e s e n c e of c o n c o m i t a n t d e g e n e r a t i v e c h a n g e s . 93-97 A r e v i e w of available r e p o r t s e v a l u a t i n g partial m e n i s c e c t o m y in the A C L - d e f i c i e n t k n e e s u g g e s t s t h a t this p r o c e d u r e can lead to satisfactory results if m e c h a n i c a l m e n i s c a l s y m p t o m s are t h e p r e s e n t i n g c o m p l a i n t . 9'98-1°° P a t i e n t e x p e c t a tions in t e r m s of j u m p i n g a n d s p o r t s r e q u i r i n g s u d d e n s t o p p i n g a n d p i v o t i n g s h o u l d be e v a l u a t e d b e f o r e considering this as a n isolated p r o c e d u r e .
CONCLUSION E v a l u a t i o n a n d m a n a g e m e n t of m e n i s c a l injuries h a s u n dergone a dramatic evolution over the past century. A r t h r o s c o p y h a s p r o v e n the g o l d s t a n d a r d for d i a g n o s i n g m e n i s c a l p a t h o l o g y a n d surgically r e s e c t i n g u n s t a b l e , irr e p a r a b l e tears. Patients can expect low morbidity, r a p i d rehabilitation, a n d q u i c k e r r e t u r n to f u n c t i o n a l activities t h a n w i t h o t h e r t e c h n i q u e s . M e t i c u l o u s p a t i e n t evaluation, appropriate counseling concerning patient expectations, a n d precise surgical t e c h n i q u e c o m b i n e to m a x i m i z e t h e p a t i e n t ' s o u t c o m e . R e c e n t r e v i e w s of the l o n g - t e r m effects of partial m e n i s c e c t o m y s u g g e s t t h a t e v e n w i t h p r e s e r v a t i o n of a p o r t i o n of the m e n i s c u s , deg e n e r a t i v e c h a n g e s m a y be inevitable. F u r t h e r critical e v a l u a t i o n of l o n g - t e r m results will h e l p p r o v i d e i n s i g h t into this d i l e m m a .
ACKNOWLEDGMENT W e are g r a t e f u l to D e b b i e Porter, U S A F A / D F E V G , for h e r graphics support.
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11. Smillie JS: Injuries of the Knee Joint (ed 4). Edinburgh, Churchill Livingstone, 1971, p 68 12. Eairbank TJ: Knee joint changes after meniscectomy. J Bone Joint Surg[Br] 30:664-670, 1948 13. Allen PR, Denham RA, Swan AV: Late degenerative changes after meniscectomy. Factors affecting the knee after operation. J Bone Joint Surg[Br] 66:666-671, 1984 14. Dandy DJ, Jackson RW: Meniscectomy and chondromalacia of the femoral condyle. J Bone Joint Surg[Am] 57:1116-1119, 1975 15. Elmer RM, Moskowitz RW, Frankel VH: Meniscal regeneration and post-meniscectomy degenerative joint disease. Clin Orthop 124:304-310, 1977 16. Fahmy NR, Williams EA, Noble J: Meniscal pathology and osteoarthrifts of the knee. J Bone Joint Surg[Br] 65:24-28, 1983 17. Johnson RJ, Kettlecamp DB, Clark W, et al: Factors affecting late results after meniscectomy. J Bone Joint Surg[Am] 56:719-729, 1974 18. Krause WR, Pope MH, Johnson RJ, et al: Mechanical changes in the knee after meniscectomy. J Bone Joint Surg[Am] 58:599-604, 1976 19. Tapper EM, Hoover NW: Late results after meniscectomy. J Bone Joint Surg[Am] 51:517-526, 1969 20. MacConaill MA: The movements of bones and joints. IIh The synovial fluid and its assistants. J Bone Joint Surg[Br] 32:244-252, 1950 21. Wang CJ, Walker PS: Rotatory laxity of the human knee joint. J Bone Joint Surg[Am] 56:161-170, 1974 22. Johnson RJ, Pope MH: Functional anatomy of the meniscus. Symposium on reconstruction of the knee. American Academy of Orthopaedic Surgeons, St Louis, MO, Mosby, 1978 23. Seedhom BB: Transmission of the load in the knee joint with special reference to the role of the menisci: 1. Anatomy, analysis and apparatus. Eng Med 8:207-219, 1979 24. Seedhom BB, Hargreaves DJ: Transmission of the load in the knee joint with special reference to the role of the menisci: II. Experimental results, discussion and conclusions. Eng Med 8:220-228, 1979 25. Markolf KL, Bargar WL, Shoemaker SC, et al: The role of joint load in knee stability. J Bone Joint Surg[Am] 63:570-585, 1981 26. Levy IM, Torzilli PA, Warren RE: The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg [Am] 64:883-888, 1982 27. Ahmed AM, Burke DL: In vitro measurement of static pressure distribution in synovial joints. I. Tibial surface of the knee. J Biomech Eng 105:216-225, 1983 28. Voloshin AS, Wosk J: Shock absorption of meniscectomized and painful knees. A comparative in-vivo study. J Biomed Eng 5:157161, 1983 29. Henning CE, Lynch MA: Current concepts of meniscal function and pathology. Clin Sports Med 4:259-265, 1985 30. Arnoczky SP, Adams M, De Haven K, et al: Meniscus, in Woo SY, Buckwalter JA(eds): Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1988, p 487-537 31. McGinty JB, Geuss LF, Marvin RA: Partial or total lateral meniscectomy: A comparative analysis. J Bone Joint Surg[Am] 59:763776, 1977 32. Northmore-Ball MD, Dandy DJ, Jackson RW: Arthroscopic, partial, and total meniscectomy. A comparative study. J Bone Joint Surg[Br] 65:400-404, 1983 33. Bergstrom R, Hamberg P, Lysholm J, et al: Comparison of open and endoscopic meniscectomy. Clin Orthop 184:133-136, 1984 34. Simpson DA, Thomas NP, Aichroth PM: Open and closed meniscectomy. A comparative analysis. J Bone Joint Surg[Br] 68:301-304, 1986 35. Youmans WT, Diveris JM, Mathien GM: The natural history of arthroscopic partial meniscectomy. Presented at the 20th Annual Meeting of the American Orthopaedic Society for Sports Medicine, Sun Valley, ID, July 1993 36. Henning CE: Current status of meniscus salvage. Clin Sports Med 9:567-576, 1990 37. DeHaven KE, Sebastianelli WJ: Open meniscus repair: Indications, technique, and results. Clin Sports Med 9:577-587, 1990 38. Cooper DE, Arnoczky SP, Warren RF: Arthroscopic meniscal repair. Clin Sports Med 9:589-607, 1990 39. Ciccotti MG, Shields CL, E1 Attrache N: Meniscectomy, in Fu DANIEL T. HINKIN
F(ed): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, pp 591-613 40. Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton-Century-Crofts, 1976 41. Evans PJ, Bell GD, Frank C: Prospective evaluation of the McMurray test. Am J Sports Med 21:604-609, 1993 42. Kitziger KJ, DeLee JC: Failed partial meniseectomy. Clin Sports Med 9:641-660, 1990 43. Rosenberg TD, Paulos LE, Parker RD, et al: Forty-five degree posteroanterior flexion weightbearing radiography of the knee. J Bone Joint Surg[Am] 70:1479-1483, 1988 44. Gillies H, Seligson D: Precision in the diagnosis of meniscal lesions: A comparison of clinical evaluation, arthrography, and arthroscopy. J Bone Joint Surg[Am] 61:343-346, 1979 45. Dumas JM, Eddie DJ: Meniscal abnormalities: Prospective correlation of double-contrast arthrography and arthroscopy. Radiology 160:453-456, 1986 46. Ekstrom JE: Arthrography, Where does it fit in? Clin Sports Med 9:561-566, 1990 47. Mink JH, Levy T, Crues JV III: Tears of the anterior cruciate ligament and menisci of the knee. MR imaging evaluation. Radiology 167:769-774, 1988 48. Reicher MA, Hartzman S, Duckwiler GR, et al: Meniscal injuries: Detection using MR imaging. Radiology 159:753-757, 1986 49. McGlade CT: Magnetic resonance imaging of the meniscus. Clin Sports Med 9:551-559, 1990 50. Johnson LL: Arthroscopic Surgery: Principles and Practice (ed 3). St Louis, MO, Mosby, 1986 51. Metcalf RW: The torn medial meniscus, in Parisien JS(ed): Arthroscopic Surgery. New York, NY, McGraw-Hill, 1988, pp 96-98 52. McGinty JB, Matza RA: Arthroscopy of the knee. Evaluation of an out-patient procedure under local anesthesia. J Bone Joint Surg [Am] 60:787-789, 1978 53. Yoshiya S, Kurosaka M, et al: Knee arthroscopy using local anesthetic. Arthroseopy 4:86-89, 1988 54. Ngo IU, Hamilton WG, Wichern WA, et al: Local anesthesia with sedation for arthroscopic surgery of the knee: A report of 100 consecutive cases. Arthroscopy I:237-241, 1985 55. Wredmark T, Lundh R: Arthroscopy under local anesthesia using controlled pressure-irrigation with prilocaine. J Bone Joint Surg[Br] 64:583-585, 1982 56. Eriksson E, Haggmark T, Saartok T, et al: Knee arthroscopy with local anesthesia in ambulatory patients. Methods, results and patient compliance. Orthopedics 9:186-188, 1986 57. Saunders KC, Louis DL, Weingarden SI, et al: Effect of tourniquet time on postoperative quadriceps function. Clin Orthop 143:194199, 1979 58. Dobner JJ, Nitz AJ: Postmeniscectomy tourniquet palsy and functional sequelae. Am J Sports Med 10:211-214, 1982 59. Crane L, Sullivan DJ: Instrumentation, in McGinty JB(ed): Operative Arthroscopy. New York, NY, Raven, 1991, pp 5-10 60. Noyes FR, Spievack ES: Extra-articular fluid dissection in tissues during arthroscopy. A report on clinical cases and a study of intraarticular and thigh pressures in cadavers. Am J Sports Med 10:346-351, 1982 61. Peek RD, Haynes DW: Compartment syndrome as a complication of arthroscopy. A case report and a study of interstitial pressures. Am J Sports Med 12:464-468, 1984 62. Patel D, Parisien JS: The torn lateral meniscus, in Parisien JS(ed): Arthroscopic Surgery. New York, NY, McGraw-Hill, 1988, pp 111112 63. Lantz B, Singer KM: Meniscal cysts. Clin Sports Med 9:707-725, 1990 64. Arnoczky SP, Warren RF, Kaplan N: Meniscal remodeling following partial meniscectomy--an experimental study in the dog. Arthroscopy 1:247-252, 1985 65. Renstrom P, Johnson RJ: Anatomy and biomechanics of the menisci. Clin Sports Med 9:523-538, 1990 66. Weiss CB, Lundberg M, Hamberg P, et al: Non-operative treatment of meniscal tears. J Bone Joint Surg[Am] 71:811-822, 1989 67. Dandy DJ: The bucket handle meniscal tear: A technique detaching the posterior segment first. Orthop Clin North Am 13:369-385, 1982 ARTHROSCOPIC PARTIAL MENISCECTOMY
68. Gillquist J, Hagberg G: A new modification of the technique of
arthroscopy of the knee joint. Acta Chir Scand 142:123-130, 1976 69. Kaeding CC, Hill JA, Katz J, et al: Bupivacaine use after knee arthroscopy: Pharmacokinetics and pain control study. Arthroscopy 6:33-39, 1990 70. Henderson RC, Campion ER, et al: Postarthroscopy analgesia with bupivacaine. A prospective, randomized, blinded evaluation. Am J Sports Med 18:614-617, 1990 71. Highgenboten CL, Jackson AW, Meske NB: Arthroseopy of the knee. Ten-day pain profiles and corticosteroids. Am J Sports Med 21:503-506, 1993 72. Nelson WE, Henderson RC, Almekinders LC, et al: An evaluation of pre- and postoperative nonsteroidal antiinflammatory drugs in patients undergoing knee arthroscopy. A prospective, randomized, double-blinded study. Am J Sports Med 21:510-516, 1993 73. Honig WJ: Clinical comparison of the analgesic efficacy of suprofen, diflunisal and placebo in the treatment of pain after meniscectomy. Pharmacology 27:74-80, 1983 (suppl 1) 74. Oglivie-Harris DJ, Bauer M, Corey P: Prostaglandin inhibition and the rate of recovery after arthroscopic meniseectomy: A randomized double-blind prospective study. J Bone Joint Surg[Br] 67:567571, 1985 75. Indelicato PA: Efficacy of diflunisal versus acetaminophen with codeine in controlling mild to moderate pain after arthroscopy. Clin Ther 8:164-169, 1986 76. Drez D, Ritter M, Rosenberg TD: Pain relief after arthroscopy: Naproxen sodium compared to propoxyphene napsylate with acetaminophen. South Med J 80:440-442, 1987 77. DeLee JC: Complications of arthroscopy and arthroscopic surgery: Results of a national survey. Committee on Complications of the Arthroscopy Association of North America. Arthroscopy 1:214220, 1985 78. Small NC: Complications in arthroscopy: The knee and other joints. Committee on Complications of the Arthroscopy Association of North America. Arthroscopy 4:253-258, 1986 79. Small NC: Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 4:215-221, 1988 80. Small NC: Complications in arthroscopic meniscal surgery. Clin Sports Med 9:609-617, 1990 81. McGinty JB: Complications of arthroscopy and arthroscopic surgery, in McGinty JB(ed): Operative Arthroscopy. New York, NY, Raven, 1991, pp 47-54 82. Bomberg BC, Hurley PE, Clark CA, et al: Complications associated with the use of an infusion pump during knee arthroscopy. Arthroscopy 8:224-228, 1992 83. Klein W, Schulitz KP: Arthroscopic meniscectomy. Technique, problems, complications and follow-up results. Arch Orthop Trauma Surg 101:231-237, 1983 84. Yocum LA, Keflan RK, Jobe FW, et al: Isolated lateral meniscectomy. A study of twenty-six patients with isolated tears, J Bone Joint Surg[Am] 61:338-341, 1979 85. Grana WA, Connor S, Hollingsworth S: Partial arthroscopic meniscectomy: A preliminary report. Clin Orthop 164:78-83, 1982 86. Hoshikawa Y, Kurosawa H, Fukubayashi T, et al: The prognosis of meniscectomy in athletes. The simple meniscus lesions without ligamentous instabilities. Am J Sports Med 11:8-13, 1983 87, Whipple TL, Caspari RB, Meyers JF: Arthroscopic meniscectomy. An interim report at three to four years after operation. Clin Orthop 183:105-14, 1984 88, Jorgensen U, Sonne-Holm S, Lauridsen F, et al: Long-term followup of meniscectomy in athletes---A prospective longitudinal study. J Bone Joint Surg[Br] 69:80-83, 1987 89. Metcalf RW, Coward DC, Rosenberg TD: Arthroscopic partial meniscectomy: A five year follow-up. Orthop Trans 7:504, 1983 90. Ferkel RD, Davis JR, Friedman MJ, et al: Arthroscopic partial medial meniscectomy: An analysis of unsatisfactory results. Arthroscopy 1:44-52, 1985 91. DelPizzo W, Fox JM: Results of arthroscopic meniscectomy. Clin Sports Med 9:633-639, 1990 92. Bolano LE, Grana WA: Isolated arthroscopic partial meniscectomy. Functional radiographic evaluation at five years. Am J Sports Med 21:432-437, 1993
37
93. Boe S, Hansen H: Arthroscopic partial meniscectomy in patients aged over fifty. J Bone Joint Surg[Br] 68:707, 1986 94. Jackson RW, Rouse DW: The results of partial arthroscopic meniscectomy in patients over forty years of age. J Bone Joint Surg[Br] 64:481-485, 1982 95. McBride GG, Constine RM, Hofmann AA, et al: Arthroscopic partial medial meniscectomy in the older patient. J Bone Joint Surg [Am] 66:547-551, 1984 96. Rand JA: Arthroscopic management of degenerative meniscus tears in patients with degenerative arthritis. Arthroscopy 1:253258, 1985
38
97. Bonamo JJ, Kessler KJ, Noah J: Arthroscopic meniscectomy in patients over the age of 40. Am J Sports Med 20:422-428, 1992 98. Marshall S, Levas MG, Harrah A: Simple arthroscopic partial meniscectomy associated with anterior cruciate-deficient knees. Arthroscopy 1:22-27, 1985 99. Shields CL Jr, Silva I, et al: Evaluation of residual instability after arthroscopic meniscectomy in ACL deficient knees. Am J Sports Med 15:129-131, 1987 100. Aglietti P, Buzzi R, Bassi PB: Arthroscopic partial meniscectomy in the anterior cruciate deficient knee. Am J Sports Med 16:597-602, 1988
DANIEL T. HINKIN
Meniscal tears are among the most common problems surgically addressed in the practice of knee surgery. Arthroscopic partial meniscectomy has become the standard in managing meniscal damage not suitable for repair or allograft replacement. Current techniques involve low morbidity, rapid rehabilitation, and early return to functional activities. However, recent studies suggest that the optimistic early results of arthroscopic partial meniscectomy may deteriorate over time. KEY WORDS: arthroscopy, meniscectomy, meniscal tear
The history of identifying and treating meniscal tears begins in the 1800s with descriptions by William Hey and Thomas Annandale concerning "internal derangement of the knee" and its management.l'2 Arthroscopic evaluation of the meniscus was first described by Burman et al in the 1930s. 3-6 The preferred treatment for a torn meniscus was open total meniscectomy. Arthroscopic meniscus surgery was introduced in the 1960s by Watanabe and Ikeuchi in Japan. 7 Dr. Richard O'Connor developed the operating arthroscope in the 1970s. It was his pioneering work and refinement of techniques that led to the explosion of arthroscopic techniques in the 1970s and 1980s. s Subsequent improvements in equipment, technique, and training have made arthroscopic management of the torn meniscus the standard, replacing open total meniscectomy. 9
RATIONALE FOR PARTIAL MENISCECTOMY The physiology and pathology of the meniscus was not well understood w h e n total meniscectomy was the recommended treatment for meniscal damage. King and Smillie believed that the meniscus was invariably replaced by a fibrous tissue structure almost identical to the original meniscus. ~°'1~ In 1948, Fairbank wrote his classic treatise describing the potentially deleterious effects of total meniscectomy. 12 The previous widespread feeling that total meniscectomy was a benign procedure began to falter. 13"19 Researchers investigated the precise function of the meniscus. This research suggested that functions such as weight transmission, shock absorption, joint stability, joint lubrication, and nutrition were all diminished after meniscectomy. 18"2°-3° Seedhom and Hargreaves noted that partial meniscectomy reduced the weight-
transmitting function of the meniscus less than total meniscectomy, provided that the circumferential fibers of the meniscus are left intact 23"24 Several large studies have shown the short-term advantages of arthroscopic partial meniscectomy over open total meniscectomy. Reviews by McGinty et al, Northmore-Ball et al, Bergstrom et al, and Simpson et al all showed higher functional scores, less morbidity, shorter hospital stays, and more rapid return to work in patients with arthroscopic partial meniscectomies. 3~-34 A recent report by Youmans et al with a median follow-up time of 11.5 years s h o w e d 37% of patients had Fairbank 3 changes. 3s This is not significantly different from studies of open total meniscectomies. International Knee Documentation Committee ratings in the study showed 72% abnormal or severely abnormal knees. The conclusions of this study were that long-term follow-up of arthroscopic partial meniscectomies does not continue to show the dramatic differences compared with those of o p e n total m e n i s c e c t o m y t h a t w e r e o b s e r v e d in the short- a n d i n t e r m e d i a t e - t e r m f o l l o w - u p s . Preservation of meniscal tissue whenever possible was recommended. A distillation of the information available from the above studies results in a generalized treatment strategy in managing the torn meniscus. If possible, meniscal repair is the ideal solution. If meniscal repair is not possible, preservation of as much meniscal tissue as practical should be attempted, including preservation of the peripheral, circumferential fibers. Patients with large, complex tears with total loss of meniscal function should be considered for meniscal allografting. 9"24'35-38
DIAGNOSIS History
From the Sports Medicine Service, United States Air Force Academy, CO; and the Uniformed Services University of the Health Sciences, Bethesda, MD. Address reprint requests to Daniel T. Hinkin, MD, LT COL, USAF, MC, HQ USAFA/SGOSOS, 2354 Vandenberg Dr, Suite 1A99, USAF Academy, CO 80840-6290. This is a US government work. There are no restrictions on its use. 1048-6666/95/0501-0005500.00 28
The diagnosis of a torn meniscus can generally be made with a careful history and physical examination. The history is classically that of a twisting injury to the knee with subsequent joint line pain. Swelling, loss of motion, catching with weight-bearing, or loss of range of motion may ensue. The functional deficit can initially be
Operative Techniques in Orthopaedics, Vol 5, No 1 (January), 1995: pp 28-38
minimal, but pain localized to the joint line occurs with attempts at increased activity or impact loading. 39
Physical Examination Physical examination of the patient with a suspected meniscal tear should follow the pattern of the examiner's routine knee examination so as to preclude missing associated pathology. The knee is observed for signs of effusion or localized[ trauma. Thigh girth is measured 1 0 and 15 cm above the patella. Active and passive range of motion is measured. Palpation for points of tenderness is performed, especially along the patellar retinculum, collateral ligaments, and joint lines. Ligament stability testing is completed. The joint lines are palpated with the knee in flexion. We have found localized joint line tenderness to be the most frequent sign of meniscal pathology. Rotational testing of the joint in varus and valgus positions (McMurray test, Adson's test) can be helpful if positive,, but are nondiagnostic if negative. 4°'41 The patella is evahlated for signs of crepitus, maltracking, or instability. Other causes of knee pain, including the back, hip, and foot, should be evaluated. 42
Imaging Studies R a d i o g r a p h i c e v a l u a t i o n s h o u l d i n c l u d e anteriorposterior, lateral, tunnel, and patellar views. If degenerative changes are suspected, the posterior-anterior weight-bearing flexion view of Rosenberg should be obtained. 43 Arthrography and magnetic resonance imaging (MRI) have been widely used in the diagnosis of meniscat tears. 44-49 'The results of these tests are dependent on the experience and skill of the examiner. 39 These tests are not necessary in the routine diagnosis of suspected meniscal tears. If the study is positive, arthroscopy of the affected joint is indicated. If the examination is negative and symptoms persist, arthroscopy is indicated to diagnose the problem. Therefore, the study is unnecessary in the majority of cases. However, MRI may be indicated if the examination is confusing, the diagnosis unclear, or previous surgery has not resolved the problem. None of these imaging modalities surpass arthroscopy as the standard for diagnosis of meniscal pathology, 9,39,42,44,45
GENERAL SURGICAL PROCEDURES Unless extenuating circumstances exist, arthroscopic meniscal surgery can be performed on an outpatient basis. 9 General, regional, or local anesthesia can be used, although general and regional anesthesia provide better limb relaxation. Local anesthesia has been proven effective; 52-56 however, use of a tourniquet may be difficult. Many investigators recommend routine tourniquet use. 9 We do not routinely use a tourniquet unless blood in the field is a problem. Potential adverse effects of tourniquet use include t h r o m b o p h l e b i t i s a n d electromyographic changes to the quadriceps. 57's8 A leg holder or leg post is used to provide a fulcrum for varus/valgus stress of the knee. Although the leg holder provides optimal rotational control of the knee, it may compromise use of posterior portals. The leg post improves access posteriorly, but requires the use of the figure-of-four position to visualize the lateral compartment. 59 Whatever device is used, caution is urged to prevent injury to the collateral ligaments. Gravity flow or irrigation p u m p systems are used to maintain fluid flow. Gravity flow is safe, efficient, and inexpensive, but it may result in suboptimal flow in tight knees. 9 P u m p systems maintain constant pressure and flow, but they are expensive and may cause excessive fluid extravasation into the soft t i s s u e s . 60'61 We routinely use the arthroscopic pump. With careful monitoring of cannula position and p u m p flow rates, this equipment has been very safe. Instrumentation routinely used in arthroscopic meniscal surgery is well described in other texts, s9
ARTHROSCOPIC EXAMINATION OF THE KNEE It is absolutely critical to accurate arthroscopic diagnosis of knee pathology to develop a standardized, systematic m e t h o d of conducting the arthroscopic examination. Knowledge of available portals in developing this technique, and the ability to modify a technique to the changing nature of the patient's knee structure and pathology, are essential. A thorough discussion of techniques for viewing the entire meniscus is included elsewhere in this issue.
INDICATIONS FOR ARTHROSCOPY CLASSIFICATION OF MENISCAL TEARS The indications for arthroscopic and open meniscal surgery are identical. The decreased morbidity and more rapid return to function associated with arthroscopic techniques makes this the procedure of choice for the well-trained knee surgeon. These indications include: (1) typical symptoms of meniscal tear, including joint line pain, catching, effusion, locking, or giving way; (2) positive physical examination findings, including localized joint line tenderness, effusion, loss of motion, or provocative meniscal signs; (3) absence of other sources of knee pain; and (4) failure of nonsurgical treatment, including rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and a coordinated rehabilitation program. 8'9"5°'51 ARTHROSCOPIC PARTIAL MENISCECTOMY
Classification of the most commonly observed meniscal tear patterns helps in discussion of their presentation and surgical treatment options. Several investigators have described meniscal tear patterns. 9'39'51'62 These patterns generally fall into the categories of vertical longitudinal (bucket handle), oblique (flap, parrot beak), transverse (radial), horizontal (cleavage), and complex (degenerative) (Fig 1). Although vertical longitudinal or bucket-handle tears can occur anywhere in a meniscus, the majority occur in the posterior horn. The length of this tear can vary from less than 1 cm to two thirds of the circumference of the 29
A
B
Fig 1. Diagram of common meniscal tear patterns: (A) vertical longitudinal tear; (B) oblique tear; (C) transverse tear; (D) horizontal tear; and (E) complex tear.
meniscus. This tear pattern is frequently observed in association with anterior cruciate ligament (ACL) tears. 9 The inner portion of the meniscus may become unstable, causing mechanical symptoms or true locking of the knee. The meniscus may displace into the intercondylar notch and become fixed there chronically (Fig 2), or it may divide into two separate flaps, one based anterior and one posterior. Medial meniscus longitudinal tears tend to extend around more of the circumference of the meniscus than lateral tears because of increased fixation of the rim of the medial meniscus and its inability to absorb more energy by meniscal displacement before tearing. A small incomplete vertical tear may occur, most commonly in the posterior third of the meniscus, and is frequently associated with ACL tears. These tears can be unstable, causing characteristic clunking with rotational
Fig 2. Arthroscopic view of a displaced vertical longitudinal (bucket handle) tear of the medial meniscus. 30
activities. They are usually not observed initially, but become apparent with probing (Fig 3). 9'39 Oblique, flap, or parrot-beak tears are among those most commonly seen. They can occur anywhere along the meniscus, but are most commonly found at the junction of the posterior and middle thirds of the medial meniscus. The free edge of the flap may catch in the joint line, causing localized painful catching. The pain is generated from tugging on the meniscocapsular junction with weight-bearing, and such traction may result in propagation of the tear. 9 Several patterns of this tear can be visualized (Fig 4). The most common pattern is the single flap involving the posterior and/or middle thirds of the meniscus (Fig 4A). Double flaps are not uncommon, with one adjacent to the posterior central attachment of the meniscus and one closer to the middle third (Figs 4B and 5A). An isolated posterior flap may fold under the meniscus and become adherent and difficult to mobilize, or it may fold on its base and lie in the posteromedial compartment of the knee (Figs 4C, D, and 5B). Radial tears are most commonly observed in the lateral meniscus at the junction of the posterior and middle thirds. Small radial tears are probably not symptomatic, but the tear can propagate if the leading edge catches in
A
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Fig 3. Incomplete vertical longitudinal tear of the lateral meniscus. (A) Diagram, (B) arthroscopic view. DANIEL T. HINKIN
,
B
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margin loses its cohesion and a tear results. The meniscus is split into superior and inferior flaps, either of which can slide into the joint and cause mechanical symptoms (Fig 7). This type of tear is frequently associated with lateral meniscal cysts, 63 as discussed elsewhere in this issue. Degenerative or complex tears show tearing in multiple planes (Fig 8). They occur most commonly in patients older than 40 years of age and are usually associated with long-standing symptoms. The tear does not usually extend to the meniscocapsular junction. Chondromalacia of the adjacent articular surfaces is common, and plain radiographic degenerative changes may be visualized.
\
TECHNIQUE OF MENISCAL RESECTION
Fig 4. Diagram of oblique meniscal tear patterns. (A) single flap in middle third; (B) double flaps; (C) superior surface posterior horn flap; and (D) inferior surface posterior horn flap,
the joint line. These tears will rarely extend to the peripheral rim, transecting the meniscus (Fig 6). Horizontal cleavage tears are believed to begin at the free margin of the midportion of the meniscus and extend toward the capsule. The sensitivity of MRI in knee meniscus pathology suggests that perhaps the inciting event is degenerative change in the body of the meniscus gradually extending toward the free margin until the thin free
Although each meniscal tear presents a unique challenge to the surgeon, general guidelines for meniscal surgery have been described by Metcalf: 9"51 (1) Remove all mobile fragments that can protrude into the joint line beyond the normal limits of the free margin of the meniscus. (2) Shape the r e m a i n i n g m e n i s c u s so that no s u d d e n changes in contour remain. Use more than one portal to confirm adequate contouring because parallax of the arthroscopic lens system can distort the actual meniscal contour. The use of more than one portal for instrumentation can facilitate smooth contouring (Fig 9). (3) Do not attempt to obtain a perfectly smooth rim. It is impossible to obtain an entirely smooth rim. Attempting to do so adds unnecessary time to the procedure and has been proven unnecessary because follow-up arthroscopic examinations show further rim remodeling at 6 to 9 months. 64 (4)Use the probe frequently before, during, and after the resection. This instrument provides the surgeon with the tactile feedback necessary to evaluate
Fig 5. Arthroscopic view of oblique meniscal tears. (A) Double flap tear of the medial meniscus; (B) inferior surface flap tear posterior-horn lateral meniscus. ARTHROSCOPIC PARTIAL MENISCECTOMY
31
Fig 6. Arthroscopic view of radial tear of the lateral meniscus.
the integrity of the meniscus and the need for further resection. (5) Protect the meniscocapsular junction if at all possible. Compromise of this area can result in mechanics similar to the knee with a total meniscectomy. 24"28"29"65 If unsure, leave more meniscal rim than less, especially adjacent to the popliteus hiatus. (6) Alternate between hand-operated and motorized instruments. Hand-operated instruments allow a more controlled resection and tactile feedback, while motorized instruments efficiently smooth frayed fragments and remove loose debris.
Fig 7. Arthroscopic view of horizontal tear of lateral meniscus. 32
Fig 8. Arthroscopic view of degenerative tear of the medial meniscus with adjacent chondromalacia of the medial femoral condyle.
SPECIFIC GUIDELINES Vertical Longitudinal Tear The vertical longitudinal tear can be addressed in a number of ways depending on its orientation, size, condition of the mobile fragment, stability, proximity to the meniscosynovial junction, and concomitant ligamentous injuries. Criteria for repair of these tears are discussed elsewhere in this issue. Weiss and DeHaven have described vertical longitudinal tear characteristics that make a tear relatively stable and at low risk for persistent symptoms. 66 These criteria include partial or full-thickness tears within the periphery of the meniscus and those nondisplaceable more than 3 mm from the meniscosynovial junction. This type of
Fig 9. Diagram of meniscal contouring using more than one instrumentation portal. (Reprinted with permission. 8) DANIEL T. HINKIN
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tear can probably be observed unless it is causing significant symptoms. Vertical longitudinal tears that do not meet the criteria for stability or repair and are symptomatic should be resected in a stepwise fashion: 9'51'64 (1) If the unstable fragment is displaced in the intercondylar notch (Fig 10A), it is reduced into its anatomic position (Fig 10B). This is accomplished by viewing through the contralateral anterior portal and placing a probe on the ipsilateral side. With the knee stressed to open the involved[ compartment, the meniscus is pushed into a reduced position as the knee is slowly extended. Occasionally, the displaced fragment is chronically deformed and cannot be reduced. Resection is then begun with the meniscus displaced. (2) A probe is used to define the limits of the tear. While visualizing: the posterior attachment of the tear ARTHROSCOPIC PARTIAL MENISCECTOMY
Fig 10. Diagrammatic representation of resection of a displaced vertical longitudinal tear. (A) Displaced vertical longitudinal tear; (B) Displaced segment is reduced into anatomic position. (C) Posterior attachment of tear is partially divided. (D) Anterior axilla is detached. (E) Anterior axilia is grasped and the posterior attachment is avulsed. (F) Alternatively, the anterior axiila is grasped and the posterior horn is detached under direct visualization. (G) The meniscal fragment is removed through an anterior portal. (H) The remaining rim is inspected and contoured. (Reprinted with permission. 9)
with the scope through the notch, a small straight or up-biting basket, or meniscal scissor is used to partially cut the posterior attachment (Fig 10C). This is only performed under direct visualization, especially on the lateral side where the posterior horn lies in close proximity to the posterior cruciate ligament. This cut leaves a bridge of meniscus small enough to be avulsed. If the cut cannot be viewed directly, proceed to resection of the anterior portion of the tear, and return to the posterior horn w h e n it is later put under tension. Dandy describes a technique wherein the posterior horn is completely detached at this point to prevent the mobile fragment from flipping up into the posterior compartment, thus complicating the resection. 67 (3) Detach the anterior axilla of the tear after confirming the direction and depth of the tear (Fig 10D). This cut is made with a basket, scissors, or hooked knife. Unless 33
the surgeon is very skilled, the knife can cause extensive damage to the adjacent articular cartilage and capsule. The resection should be in line with the desired final contour of the meniscal rim. If the meniscus is grasped before finishing this cut, a central portal as used by Gillquist is helpful for the resection. 6s (4) The anterior horn of the meniscus is grasped. If the fragment is grasped in midsubstance, it will buckle when attempts are made to remove it through a portal. We grasp the meniscus through an ipsilateral anterior portal before final resection of the anterior horn. This prevents the mobile fragment from disappearing behind the condyle. If the fragment folds posteriorly, a posteromedial or posterolateral portal can be established under direct visualization. A grasper is placed through this portal to secure the fragment. It is then avulsed or the remaining bridge is cut under direct visualization and the fragment removed. (5) The posterior horn is avulsed, and the fragment is removed (Figs 10 E,G). Frequently, the posterior horn is insufficiently divided before this maneuver. If excessive traction is required, the posterior horn is divided under direct visualization. Tension is applied t h r o u g h a grasper. An auxiliary portal at the joint line just anterior to the collateral ligament or through the patellar tendon is used for the cutting instrument (Fig 10F). (6) The remaining rim is inspected and contoured (Fig 10H). If at all possible, a rim of meniscal tissue should be left intact across the popliteus hiatus to preserve the integrity of the circumferential fibers (Fig 11). The surgeon should remember to look posteriorly with the scope directed through the notch to assure no loose or unstable fragments remain. If an incomplete vertical longitudinal tear fragment is unstable in a young person, it should be repaired. If resection is necessary, it is usually performed piecemeal because of its location. The remaining meniscus is contoured.
Oblique Tear Careful evaluation is performed with the scope and probe in standard anterior portals. The undersurface of the meniscus, adjacent gutter, and posterior compartment are fully visualized. The full extent of the flap and its base are evaluated. Any folded fragments are gently teased free and brought into view. The mobile segment is amputated at its base after securing the fragment with a grasper (Fig 12). If the flap is large and firm it is initially trimmed with hand held instruments, and contoured with motorized instruments. The remainder of the meniscus is contoured (Figs 13A and 14). If the piecemeal technique is used for the resection, motorized shavers are used to evacuate the loose debris.
Radial Tear Radial tears should be trimmed to prevent the corners from catching in the joint. The corners are resected with a basket forceps to provide tactile feedback and control the depth of resection. The meniscus is resected to the depth of the tear, and the r e m n a n t is contoured to present no sudden changes. The rim is then visualized from two portals to confirm adequate contouring (Fig 13B).
Horizontal Tear Resection of this type of tear is frequently difficult because of its peripheral extension and sometimes complex tear patterns. The first goal is to identify which leaf (superior or inferior) will be resected. The leaves should be probed separately to determine which is most unstable. Occasionally, both will be unstable and require some resection. Resection begins with basket forceps. Frequent probing and reassessment are necessary to limit the resection to only the tissue that is unstable. Occasionally, this will require total meniscectomy. The most unstable flap is resected to stable tissue. Every attempt should be made to preserve the other flap and maintain some meniscal function (Fig 13C).
Degenerative Tear Recognition of this tear pattern is easy, provided adequate exposure of the posterior horn is obtained. The posterior horn of the meniscus is softened and frayed. The meniscus is thoroughly probed. Major flaps are resected with basket forceps. Motorized suction resectors are useful for debriding loose or fibrillated fragments.
B
Fig 11. Arthroscopic view of remaining rim after resection of a vertical longitudinal tear. :}4
Fig 12. Diagram of (A) inferior surface flap tear folded under meniscus; (B) flap tear teased free with extent of resection indicated, (Reprinted with permission2) DANIEL T. HINKIN
P't
_.J Fig 13. Diagram of the extent of meniscal resection required for typical meniscal tear patterns: (A) oblique tear; (B) transverse tear; (C) horizontal tear; (D) degenerative tear,
drainage of the joint until the effluent is clear, 9 or with the arthroscopic pump and suction shaver. We use the arthroscopic pump for our procedures, and at the conclusion, the suction shaver is placed with the tip in the suprapatellar pouch. The scope cannula is directed into the joint lines and the gutters. The posterior capsule is compressed manually, and the knee is gently flexed and extended. Irrigation is performed until no further debris is visualized with the scope. Portals are closed with sterile strips, subcuticular absorbable sutures, or simple nonabsorbable sutures according to the surgeon's preference. We routinely inject the joint with 10 mL of 0.25% bupivacaine for postoperative pain control. This practice has been validated by several studies. 69'7° The portals are covered with adhesive strips, gauze dressing, and an elastic bandage. Oral NSAIDs have been effective in postoperative analgesia after these procedures, but neither NSAIDs nor oral corticosteroids have been conclusively shown to significantly enhance recovery from arthroscopic partial meniscectomy. 71-76 The patient should begin quadriceps setting exercises, straight leg raising, and calf p u m p s immediately. Crutches are used with weight-bearing as tolerated. Active range of motion is begun immediately. Showering is permitted 48 to 72 hours after surgery, but the w o u n d s should not be submerged until completely healed. An adhesive strip covers the wound after showering. Sutures are removed at 7 to 10 days. The patient is progressed to walking, swimming, and cycling as tolerated. Sports are resumed when the knee has full range of motion, no effusion, and the quadriceps and hamstrings have normal strength. 39
COMPLICATIONS
Fig 14. Arthroscopic view of posterior-horn lateral meniscus after excision of a flap tear and contouring.
All fibrillated segments need not be removed, and the capsular rim should be preserved if at all possible. Adjacent chondromalacia areas are debrided and/or drilled as indicated (Figs 13D).
Several large studies have documented a low complication rate associated with arthroscopic surgical procedures, ranging from 0.56% to 1.68% 77-82 Intraoperative complications include anesthesia problems, articular surface injury, instrument breakage, irrigation fluid leakage, ligament damage, and arterial or nerve injury. Postoperative complications include anesthesia problems, thrombophlebitis, hemarthrosis, infection, persistent effusion, and synovitis. Most intraoperative problems can be avoided by meticulous technique. Fluid leakage is most commonly caused by malposition or soft-tissue obstruction of the outflow cannula while using an arthroscopic pump. 82 We have found malpositioning a problem mostly in moving the knee into and out of the figureof-four position. It is our recommendation that the suprapatellar cannula position be re-evaluated whenever the knee is taken into and out of this position.
RESULTS POSTOPERATIVE CARE At the completion of the arthroscopic procedure, the joint is thoroughly irrigated to remove any loose debris. This can be accomplished with alternating distention and ARTHROSCOPIC PARTIAL MENISCECTOMY
Reports reviewing results of arthroscopic partial meniscectomy show improved short-term results compared with open total meniscectomy.~-91 Possible reasons for poor results have been investigated. 42"9°'92 More recent 35
l o n g e r - t e r m s t u d i e s raise q u e s t i o n s as to w h e t h e r these initial o p t i m i s t i c r e s u l t s will h o l d u p o v e r time. 35'92 Results of a r t h r o s c o p i c partial m e n i s c e c t o m y in p a t i e n t s older t h a n 40 y e a r s of age are d e p e n d e n t o n the p r e s e n c e of c o n c o m i t a n t d e g e n e r a t i v e c h a n g e s . 93-97 A r e v i e w of available r e p o r t s e v a l u a t i n g partial m e n i s c e c t o m y in the A C L - d e f i c i e n t k n e e s u g g e s t s t h a t this p r o c e d u r e can lead to satisfactory results if m e c h a n i c a l m e n i s c a l s y m p t o m s are t h e p r e s e n t i n g c o m p l a i n t . 9'98-1°° P a t i e n t e x p e c t a tions in t e r m s of j u m p i n g a n d s p o r t s r e q u i r i n g s u d d e n s t o p p i n g a n d p i v o t i n g s h o u l d be e v a l u a t e d b e f o r e considering this as a n isolated p r o c e d u r e .
CONCLUSION E v a l u a t i o n a n d m a n a g e m e n t of m e n i s c a l injuries h a s u n dergone a dramatic evolution over the past century. A r t h r o s c o p y h a s p r o v e n the g o l d s t a n d a r d for d i a g n o s i n g m e n i s c a l p a t h o l o g y a n d surgically r e s e c t i n g u n s t a b l e , irr e p a r a b l e tears. Patients can expect low morbidity, r a p i d rehabilitation, a n d q u i c k e r r e t u r n to f u n c t i o n a l activities t h a n w i t h o t h e r t e c h n i q u e s . M e t i c u l o u s p a t i e n t evaluation, appropriate counseling concerning patient expectations, a n d precise surgical t e c h n i q u e c o m b i n e to m a x i m i z e t h e p a t i e n t ' s o u t c o m e . R e c e n t r e v i e w s of the l o n g - t e r m effects of partial m e n i s c e c t o m y s u g g e s t t h a t e v e n w i t h p r e s e r v a t i o n of a p o r t i o n of the m e n i s c u s , deg e n e r a t i v e c h a n g e s m a y be inevitable. F u r t h e r critical e v a l u a t i o n of l o n g - t e r m results will h e l p p r o v i d e i n s i g h t into this d i l e m m a .
ACKNOWLEDGMENT W e are g r a t e f u l to D e b b i e Porter, U S A F A / D F E V G , for h e r graphics support.
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DANIEL T. HINKIN