The Menisci (eBook)

Robert F. LaPrade, MD, PhD, is a Complex Knee and Sports Medicine Surgeon at the Steadman Clinic in Colorado, USA, where he is Co-Director of both the Sports Medicine Fellowship Program and the Athletic Training Fellowship Program. In addition, he is Chief Medical Officer at the Steadman Philippon Research Institute and Affiliate Faculty in the Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University. Dr. LaPrade is currently Chair of the ISAKOS Sports Medicine Committee and a member of the ISAKOS Program Committee. He is also a member of the American Journal of Sports Medicine (AJSM) Ethics Committee, a member of the American Orthopaedic Society for Sports Medicine (AOSSM) Board of Directors, and AOSSM Research Chair. He has published 276 articles in peer-reviewed journals and was editor of the 2006 book Posterolateral Knee Injuries:  Anatomy, Function and Treatment (Thieme, New York) as well as co-editor of a recent iBook, Complex Knee Surgery Made Easy.

Preface 5
Contents 6
1: Meniscus Anatomy 8
1.1 Introduction 8
1.2 Medial Meniscus 8
1.2.1 Zone 1: Anterior Root 8
1.2.2 Zone 2: Anteromedial Zone 9
1.2.3 Zone 3: At the Level of the Medial Collateral Ligament 10
1.2.4 Zone 4: Posterior Horn 10
1.2.5 Zone 5: Posterior Root 10
1.3 Lateral Meniscus 10
1.3.1 Anterior Root 10
1.3.2 Anterior Horn 11
1.3.3 Area at the Level of Hiatus Popliteus 11
1.3.4 Meniscofemoral Ligaments 13
1.3.5 Posterior Root 13
Bibliography 14
2: The Biomechanical Function of the Menisci 16
2.1 Introduction 16
2.2 Microscopic Composition of Menisci and How It Relates to Function 16
2.3 Biomechanical Properties of Menisci 17
2.3.1 Viscoelasticity 17
2.3.2 Response to Compression 18
2.3.3 Response to Tension 19
2.3.4 Response to Shear 19
2.4 Functional Properties of Menisci 19
2.4.1 Size, Shape, and Load Transmission 19
2.4.2 Joint Stability 20
2.4.3 Lubrication and Nutrition 20
2.4.4 Proprioception 21
2.4.5 Shock Absorption 21
2.4.6 Functional Movements of Menisci 21
2.5 Pathology Resulting in a Dysfunctional Meniscus 21
2.6 Meniscus-Associated Ligaments 22
2.6.1 Anterior Intermeniscal Ligament (Transverse Geniculate Ligament) 22
2.6.2 Coronary Ligaments 22
2.6.3 Meniscotibial Ligaments 22
2.6.4 Deep Medial Collateral Ligament (dMCL) 23
2.6.5 Anterior and Posterior Meniscofemoral Ligaments (aMFL/pMFL) 23
2.6.6 Meniscofibular Ligaments 23
References 23
3: Classification of Meniscal Tears 28
3.1 Introduction 28
3.2 Classification of the Meniscal Tears 28
3.2.1 Trillat’s Classification 29
3.2.2 MRI Classification of Meniscal Tears 29
3.2.3 ISAKOS Classification 29
3.2.3.1 Tear Depth 29
3.2.3.2 Tear Location: Rim Width 29
3.2.3.3 Local Tear: Radial Location 31
3.2.3.4 Patterns of Meniscal Tears 31
Longitudinal Vertical Tear 31
Horizontal Meniscus Tear 31
Radial Meniscus Tear 31
Flap or Parrot-Beak Tears 31
Complex Tears, Degenerative Flap 31
3.2.4 Classification of Discoid Meniscus 32
3.2.5 Classification of Degenerative Meniscal Tears 32
3.2.6 Meniscal Root Tears 33
3.2.7 Classification of Medial Meniscal Capsular Tears 34
References 35
4: Meniscectomy: Updates on Techniques and Outcomes 37
4.1 Introduction 37
4.2 Updates on Meniscectomy Techniques 38
4.2.1 Tourniquet, Inflow Pump and Arthroscopic Portals 38
4.2.2 Techniques to Improve Meniscectomy Execution 40
4.2.3 Video Device 41
4.3 Updates on Meniscectomy Outcomes 42
4.3.1 Inflammation Markers and Meniscectomy 44
4.3.2 Age, Gender, BMI, Functional Request and Meniscectomy 45
4.3.3 Knee Adaption and Meniscectomy 45
4.3.4 Return to Play and Meniscectomy 46
4.3.5 Complications and Meniscectomy 46
4.3.6 Evidence-Based Medicine (EBM) and Meniscectomy 47
References 51
5: Meniscal Root Tears: A Missed Epidemic? How Should They Be Treated? 54
5.1 Introduction 54
5.2 Anatomy 55
5.3 Meniscal Root Biomechanics 55
5.4 Natural History of Root Tears 56
5.5 Diagnosis 56
5.5.1 Physical Examination 56
5.5.2 Imaging 58
5.6 Classification Systems 59
5.7 Treatment 59
5.7.1 Transtibial Pullout Repair for Posterior Meniscus Root Tears 60
5.8 Postoperative Rehabilitation 62
5.9 Outcomes 62
References 64
6: Meniscal Ramp Lesions: Diagnosis and Treatment Strategies 67
6.1 Introduction 67
6.2 What Is a Ramp Lesion? 67
6.3 How Do Ramp Lesions Occur? 68
6.4 How Common Are Ramp Lesions? 69
6.5 Why Are Ramp Lesions Important? 69
6.6 How Do You Diagnose a Ramp Lesion? 70
6.7 How Can I See a Ramp Lesion Arthroscopically? 71
6.8 If I See a Ramp Lesion, How Should I Treat It? 73
6.9 How Do I Rehabilitate Ramp Lesion Repairs? 74
6.10 What Do I Tell My Patients About the Outcome of Ramp Lesion Repairs? 75
References 77
7: Peripheral Meniscal Tears: How to Diagnose and Repair 80
7.1 Introduction 80
7.2 Diagnosis 82
7.2.1 Physical Examination 82
7.3 Imaging 84
7.3.1 Standard Radiographs 84
7.3.2 Ultrasound 85
7.3.3 Magnetic Resonance Imaging 85
7.3.4 CT Arthrography 85
7.4 Surgical Techniques 86
7.4.1 Inside-Out Repair 86
7.4.2 Outside-In Repair 88
7.4.3 All-Inside Technique 88
7.5 Outcomes 89
7.6 Rehabilitation 90
References 91
8: Radial Meniscal Tears: Updates on Repair Techniques and Outcomes 95
8.1 Introduction 95
8.2 Diagnosis 96
8.3 Treatment 97
8.3.1 Nonoperative Treatment of Radial Tears 97
8.3.2 Partial Meniscectomy of Radial Tears 98
8.3.3 Repair of Meniscal Radial Tears 99
8.3.3.1 Inside-Out Meniscal Radial Repair Technique 99
8.3.3.2 All-Inside Radial Repairs 100
8.4 Postoperative Rehabilitation Protocol 102
8.5 Outcomes of Radial Tear Repairs 102
8.6 Conclusions/Future Directions 103
References 103
9: All-Inside Meniscal Repair: Updates on Technique 105
9.1 Introduction 105
9.2 Indications for Meniscal Repair 106
9.3 Placement of Meniscal Sutures 106
9.4 Meniscal Repair Technique 106
9.5 All-Inside Meniscal Repair Technique 106
9.5.1 Anatomical Considerations on All-Inside Meniscal Repair 108
9.5.2 Biomechanical Considerations for All-Inside Meniscal Repairs 108
9.5.3 Outcomes of All-Inside Meniscal Repairs 108
References 109
10: Step-By-Step Surgical Approaches for Inside-Out Meniscus Repair 111
10.1 Indications 111
10.2 Benefits 112
10.3 Preoperative Planning 112
10.3.1 Special Equipment 112
10.4 Positioning and Setup 113
10.5 Repair Technique 113
10.5.1 Exposure 113
10.5.2 Posteromedial Approach 113
10.5.3 Posterolateral Approach 113
10.5.4 Preparing the Tear 113
10.6 Repair Principles 114
10.7 Passing the Suture 115
10.8 Suture Tying 116
10.9 Repair Assessment 116
10.10 Closure 116
10.11 Adjuncts 116
10.12 Outcomes 116
10.13 Complications 117
10.14 Pearls 117
10.15 Pitfalls 117
References 118
11: The Role of Alignment in Meniscal Tears and the Role of Osteotomy 119
11.1 Introduction 119
11.2 How Does Alignment Relate to Meniscus Tears and Degeneration? 120
11.3 Principles of Realignment Osteotomy 121
11.4 Evidence for Realignment Osteotomy with Meniscal Deficiency 122
11.5 Surgical Technique of Osteotomy 123
11.5.1 Patient Assessment 123
11.5.2 Osteotomy Planning 123
11.5.3 Degree of Correction 124
11.5.4 MOWHTO Technique (Fig. 11.3) 124
11.5.5 LOWHTO Technique (Fig. 11.4) 125
11.5.6 MCWDFVO Technique (Fig. 11.5) 127
References 128
12: Outside-in Meniscal Repair: Technique and Outcomes 130
12.1 Introduction 130
12.2 Surgical Technique 131
12.3 Outcomes 135
12.4 Discussion 135
References 136
13: Biological Augmentation of Meniscal Repairs 137
13.1 Introduction 137
13.2 Healing and Vascular Anatomy 137
13.3 Vascular Access Channels and Synovial Abrasion 138
13.4 Point-of-Care Blood Products 139
13.5 Scaffolds 140
13.6 Stem Cell Therapy 141
References 144
14: Meniscal Repair Outcomes: Isolated Versus Combined with Other Procedures 147
14.1 Introduction 147
14.2 Overall Results 148
14.3 Factors Affecting Outcomes after Meniscus Repair 149
14.3.1 Outcomes After Isolated Repair 150
14.3.2 Outcomes After Meniscus Repair Combined with Other Procedures 151
References 152
15: Treatment of Meniscus Degeneration and Meniscus Cysts 155
15.1 Introduction and Outline 155
15.2 Meniscal Mucoid Degeneration and Cysts 156
15.2.1 Definition and Etiology of Meniscal Mucoid Degeneration 156
15.2.2 Clinical Features of Meniscal Tears due to Mucoid Degeneration and Cysts 156
15.2.3 MRI Findings 157
15.2.4 Arthroscopic Findings and Tear Types 158
15.3 Treatment 158
15.3.1 Treatment of Degenerative Meniscal Tears 158
15.3.2 Treatment of Meniscal Cysts 160
15.3.3 Authors’ Method 161
References 162
16: Discoid Menisci and Their Treatment 165
16.1 Introduction 165
16.2 Anatomy 165
16.3 Incidence 166
16.4 Classifications 166
16.5 Diagnosis 166
16.6 Imaging 167
16.6.1 Radiography 167
16.6.2 Ultrasonography 167
16.6.3 Magnetic Resonance Imaging 167
16.7 Associated Pathology with a Discoid Meniscus 168
16.8 Treatment 168
16.8.1 Conservative Treatment 168
16.8.2 Partial Meniscectomy and Meniscoplasty (Saucerization) 168
16.8.3 Partial Meniscectomy and Meniscus Repair 168
16.9 Treatment Outcome 171
References 172
17: Meniscal Allograft Transplantation: Updates and Outcomes 174
17.1 Introduction 175
17.2 Graft Procurement 175
17.2.1 Laws and Regulations 175
17.2.2 Donor Selection and Suitability 176
17.2.2.1 Eligibility 176
17.2.2.2 Physical Examination 176
17.2.2.3 Testing 176
17.2.3 Graft Harvesting 176
17.2.3.1 Time Limits 176
17.2.3.2 Facilities and Personnel 176
17.2.4 Graft Treatment 176
17.2.4.1 Primary Processing of the Meniscal Allograft 176
17.2.4.2 Graft Sterilization 176
17.2.5 Graft Storage 177
17.2.5.1 Fresh Viable Grafts 177
17.2.5.2 Cryopreserved Grafts 177
17.2.5.3 Lyophilization 177
17.2.5.4 Fresh-Frozen Grafts 177
17.2.6 Sizing of the Meniscus 177
17.2.6.1 Sizing of the Donor Meniscus 177
17.2.6.2 Sizing of the Recipient 177
17.3 Indications for Meniscal Allograft Transplantation 178
17.3.1 Indications 178
17.3.2 Contraindications 178
17.4 Preoperative Issues 179
17.4.1 Examinations and Investigations 179
17.4.2 Obtaining a Meniscus Allograft 179
17.5 Surgery 179
17.5.1 Surgical Technique 179
17.5.2 Medial Meniscus Allograft Transplantation: Bone-Plug Technique 180
17.5.2.1 Graft Preparation 180
17.5.2.2 Placement of the Meniscus Allograft 180
17.5.2.3 Variations of This Technique 182
17.5.3 Medial Meniscus Allograft Transplantation: Soft Tissue Technique with Bone Tunnels 182
17.5.4 Lateral Meniscus Allograft Transplantation: Bone Bridge Techniques 182
17.5.4.1 Graft Preparation 182
17.5.4.2 Placement of the Meniscus Allograft 182
17.5.4.3 Variations of This Technique 183
17.5.5 Lateral Meniscus Allograft Transplantation: Soft Tissue Technique 184
17.5.6 Lateral Meniscus Allograft Transplantation: Bone-Plug Technique 184
17.5.7 Open Technique for Meniscal Allograft Transplantation 184
17.5.8 Combination with Other Procedures 184
17.5.9 Discussion of Differences Between the Techniques 184
17.5.9.1 Clinical Outcome 184
17.5.9.2 Graft Extrusion 184
17.5.9.3 Radiological Outcome 185
17.5.9.4 Complications, Failures and Reoperations 185
17.5.9.5 Experimental/Biomechanical Studies 185
17.5.10 Conclusion 185
17.6 Rehabilitation Following Meniscal Allograft Transplantation 185
17.6.1 Factors Influencing the Rehabilitation Programme 185
17.6.2 Rehabilitation Programme 185
17.7 Outcomes of Meniscal Allograft Transplantation 187
17.7.1 Patient-Reported Outcomes 187
17.7.2 Survival Rates 188
17.7.3 Radiologic Outcomes 188
17.7.4 Return to Sports 189
17.7.5 Complications 189
References 189
Erratum to: All-Inside Meniscal Repair: Updates on Technique 194
Index 195