How is a meniscal repair performed?

Meniscal repair is necessary for reparable meniscal tears in the kneeA meniscal repair is considered for suitable candidates with a meniscal tear. If the meniscus is repairable then an attempt to repair it should be made. This will prevent further disability and reduce the risk of developing arthritis in the knee in later years. A meniscal repair, while not an emergency procedure, should be performed early to ensure the best results. But what are the techniques used to perform a repair?..

I need a meniscal repair..but what is the meniscus?

The meniscus is c-shaped cartilage structure in the knee. There are two such structures in each knee. The medial meniscus is found on the inner part of the knee. The lateral meniscus is found on the outer part. They are located between the femur above, and the tibia below. They are made out of fibrocartilage.

The meniscus functions as a supporting structure in the knee. It provides a small amount of stability and position-sense. It also helps with lubrication. A meniscal tear can occur at any age group. It is uncommon in children, however. It is more common after trauma in younger people. In older people the cartilage may have become weaker. A tear may arise from minor injury or even just with repetitive activity or overuse.

Symptoms of a meniscal tear

A beak-type meniscal tear causing symptoms of locking

An example of a beak-type meniscal tear causing symptoms of locking

These may include pain on the sides of the knee, swelling and clicking (read: Three signs that you may have a meniscus tear).  Occasionally there may be locking. When this happens the knee does not want to straighten fully. Sometimes it feels as if there is something caught inside the joint preventing movement.

The diagnosis can sometimes be made clinically. If there is any doubt an MRI scan will be needed.

Can a meniscus tear heal on its own?

Unfortunately, the meniscus has a poor of supply. Once it is torn it usually does not heal without treatment. If a meniscal tear is small, stable and located in an area with good blood supply in a young and healthy patient, it may heal. The chances of this are slim. Sometimes tears which have not been treated may become pain-free. This may lead one to think the tear has healed when in fact it has not.

What happens if you leave a torn meniscus untreated?

This may be associated with the development of a painful arthritis in later years. This may require further surgery such as a total knee replacement. A meniscal tear can also cause continued pain and swelling in the knee. This may limit activities of daily living and sporting activities.

Sometimes a torn fragment of meniscal tissue may get stuck in the knee and caused it to become “locked”. This means that you cannot straighten the knee fully. You will have difficulty in standing and walking. This situation usually requires urgent surgery.

If the knee already has arthritis then specific treatment of a meniscus tear may not make any difference to the outcome. Surgery is mostly indicated in a patient with otherwise healthy knees.

Meniscal repair or removal (meniscectomy)?

Meniscal tear suitable for repair

A vertical tear in the posterior horn of the meniscus in an area with good blood supply – suitable for repair. The tear is debrided (cleaned) with a meniscal rasp before the repair

There are a few factors to consider when deciding between a meniscal repair and a simple removal of the torn fragment (meniscectomy). This is the topic of some debate. The decision will be made after discussion with your surgeon. It is usually made on factors such as your age and general health, your activity levels, and the tear age, type and location.

Meniscal repair technique

There are three techniques which are used. These techniques may overlap or be used together (hybrid technique). The choice of technique depends on surgeon preference and experience, and the location and type of tear. The three techniques are:

  1. The “all-inside” technique
  2. The “inside-out” technique
  3. The “outside-in” technique

Meniscal repairs are usually performed arthroscopically through small “stab” incisions. Depending on the technique, however, some of the procedure may involve open surgery. This will then involve a separate, bigger cut on the skin. Arthroscopic surgery is associated with faster recovery times and minimal scarring.

“All-inside” meniscal repair

If the “all-inside” technique is used, the entire repair is done arthroscopically. This is used when the tear is located at the back or main portion of the cartilage (posterior horn and body tears). A special device is used through one of the small arthroscopy portals to insert a stitch into the meniscus. Usually more than one stitch is needed. If more than three or four are required then a different technique may be preferred, e.g. inside-out meniscal repair.

“Inside-out” meniscal repair

With this method stitches are placed into the meniscus from inside the knee. The stitch enters through one of the small arthroscopy portals at the front of the knee. This is done under direct vision using the arthroscopy camera. The needle used to place the stitch is long and flexible. The needle is passed right through the meniscus and out the skin behind the cartilage. Several stitches are usually in this repair. An incision must be made on the skin on the side of the knee to allow the needles to pass through. Once the stitches have been passed they are tied and the knot will be outside the knee joint (but under the skin).

The advantage of this repair is that it is a strong repair as many stitches are usually used. The stitches themselves are inexpensive. This technique is used when there is a very large tear requiring multiple stitches. This is often the case with a large “bucket-handle” meniscus tear. These tears can involve almost the entire length of the meniscus.

“Outside-in” meniscal repair

This is the least commonly used method. The needle and stitch is inserted from the outside of the knee through the skin. The needle therefore passes through the meniscus from the peripheral end of the cartilage. The stitch is retrieved inside the knee under direct vision with the arthroscopy camera. It is then passed back through the meniscus and out the skin again.

Once the stitches are in place they are tied with the knot on the outside of the knee in a similar way to the “inside-out” technique. This technique is useful for “hard-to-reach” tears in the front of the meniscus (anterior horn).

Can you walk immediately after a meniscus repair?

After a meniscal repair, the repair must be protected. This means a period of not taking weight on the knee. I usually recommend non-weight-bearing or touch weight-bearing for six weeks. You will need two crutches to get around. You will also require a brace. This is to prevent the knee from bending more than 90°. If the knee bends more than this it creates excessive pressure on the repair site. This can cause the repair to fail.

How long does it take to recover from meniscus repair surgery?

Meniscal tears are performed using arthroscopyAt six weeks the brace is discarded and you will be allowed to start taking weight on the leg again. You will then be allowed to progress to full weight-bearing status. This is best done in conjunction with physiotherapy and rehabilitation. Return to running and sport is possible at around four months or later.

In summary…

A meniscal repair is the first-choice procedure if you have a meniscal tear, but within reason. A successful result is essential to prevent arthritis developing in the knee in later years. This success of a meniscal repair depends on many factors. The tear should be repairable. An attempted repair on a meniscus with poor healing potential will likely fail. This will result in further surgery. Success is also dependent on patient factors. This may include general medical health and compliance with post-operative instructions.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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