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Meniscus – Anatomic, Biologic, and
Biomechanical Factors That Affect
Tear Prognosis
Jeremy M. Burnham, MDUPMC Sports Medicine
July 22, 2017 – AOSSM Annual Meeting
What Affects Prognosis?
McDermott, Amis JBJS (Br) 2006
• 75% decrease in contact area
• 235% increase in peak pressures
What Affects Prognosis?
• Tear Factors
– Location
– Vascular Zone
– Tear Size
– Tear Pattern
• Injury
– Acute vs. Chronic
– Concomitant Injuries
– Alignment & Stability
• Patient
– Age, BMI, Activity
McDermott, Amis JBJS (Br) 2006
Meniscus Vascularity
• Entire meniscus is vascular at birth,
but inner 1/3 avascular by nine months
• In adults, outer 10-30% is vascular
• Formation of a clot is essential for
healing, and tears in the red-red zone
(outer 1/3) are most likely to heal
• Fibrin clots, abrading synovium
adjacent to repair, and “freshening up”
the tear site are ways to improve
healing
Meniscus Vascularity
Patient Age
• Older patients have less cellularity and decreased healing
response
– Retears more frequent in patients >30 (Eggli et al. AJSM 1995)
– Older patients had longer time to failure (Bach et al. J Knee Surg
2005)
• Mixed Clinical Results
– No RCTs
– Selection bias (most surgeons won’t repair degenerative tears)
Older Patients, Chronic Tears
• RCT, Level I Evidence
• 102 pts with knee pain and degenerative tear of the PH
of the medial meniscus
• Excluded: trauma, ligament deficiency, systemic
arthritis, osteonecrosis
Older Patients, Chronic Tears
Older Patients, Chronic Tears
• Average duration of symptoms prior to treatment ~8 mths
– Nonop: Medicine, PT 3x/wk for 3 wks, HEP for 8 wks
– Operative: Partial menisectomy
• Pain improved more quickly in operative group, but no difference
at 2 years
• No differences in satisfaction, Lysholm, or OA progression at 2
years
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Chronic, Complex Pattern, Older Patients
Acute Tears, Young or Old Patients
• Cohort study
• 339 meniscus repairs (136 <40y, 45 >40y)
• 4.4 to 12% lost to follow up
• Minimum follow-up 10 years
• All inside-out repairs
• No postoperative PRO difference (Lysholm, WOMAC, SF-12)
between groups
Acute Tears, Young or Old Patients
• Patients <40 and >40 improved similarly after meniscus repair
• Failure rate at minimum of 10 years ~5% in both groups
Meniscus Tear Pattern
• Tear Pattern
– More reparable tears found in
unstable as compared to stable
knees
– Double longitudinal and complex
tears have low rate of healing
– Horizontal cleavage tears may
be asymptomatic
– Partial radial tears in avascular
region may require only
debridement
– Complete radial tears and root
tears are equivalent to total
meniscectomy
(Starke et al. 2009; Image from Meniscus Tears, Noyes & Barber-Westin)
Radial Tear
Radial Tear
Tear Pattern - Meniscal Root Tears
• 9 fresh frozen cadaver knees
• Axial load of 1000N at 0, 30, 60, and 90 degrees
• Fuji pressure sensitive film
Meniscal Root Tears
Meniscal Root Tears
Radial Tear Near Root
Radial Tear Near Root
• 6 fresh frozen knees
• 1000 N Load at 0, 30, 45, 60, and 90 degrees
• Intact, Root avulsion, radial tear, and repair of each
• Tekscan sensors
Radial Tear Near Root
Radial Tear Near Root
Malalignment
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Concomitant Injury
• Concomitant Injury
– Meniscal repairs tend to heal better in association
with ACL reconstruction
• Stabilization of the knee decreases microtrauma
• Marrow elements introduced into the joint
Concomitant
Failure to Address Instability
27Trojani, KSSTA, 2011
Meniscus Repair - Outcomes
• 2012 systematic review of 13 studies (minimum 5 year follow-up)
• Pooled failure rate was 23% (or survival was 77%)
• Medial meniscus failure rate (24%) greater than lateral meniscus (20%)
• Failure rate similar between non weight bearing (25.7%) and partial
weight bearing (21.7%)
• Failure rate similar between immobilization (23.7%) and early motion
(22.7%)
Meniscus Repair - Outcomes
• Limitations:
– Variety of tear patterns and locations
– Variable population
– Missing information
Meniscus Repair - Outcomes
• 2012 systematic review of 19 studies
• 311 relevant patients (139 inside-out, 172 all inside)
• Pooled failure rate 17% for inside-out, 19% for all-inside
• Lysholm 88 for inside-out, 90 for all-inside (MCID 10)
• No difference in Tegner activity levels
Meniscus Repair - Outcomes
• Shorter operative time for all-inside (not quantifed)
• 9% nerve irritation in inside out versus 2% for all-inside
• Unable to quantify differences in chondral damage or scuffing
• Heterogenous studies
• No cost analysis
Acute Tears, Young or Old Patients
• Patients <40 and >40 improved similarly after meniscus repair
• Failure rate at minimum of 10 years ~5% in both groups
Meniscus Repair
• 293 Patients Patients <20 years old, single institution
• 129 primary repairs, 149 meniscectomies, 46 discoid saucerizations
• Mean follow-up 40 months (19-62 months)
• 13% revision rate
– Primary Repair Group = 18% Revision Rate
– Bucket Handle = 47% Revision Rate
– 76% were acute reinjury, 77% within one year
Repair vs. Meniscectomy
If 10% of meniscectomies changed
to repairs, would save $43 million
• Repairs may fail
more, but still more
cost effective
• Improves Outcomes
• Decreases overall
costs of treatment
Summary – Prognostic Indicators
Summary – Prognostic Indicators
• Success rate of repairs reported between 76-94%
• Repair more cost-effective
• Tear-specific
– Posterior radial tears = total menisectomy
– bucket handle = 47% failure of repair
• Patient-specific
– Older patients have less healing response, but can be less
functionally demanding
– Studies are mixed, results probably equivalent
• Injury-specific
– Chronic, degenerative tears = nonop
– ACL recon = improved healing, more repairable patterns
Thank You
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