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Arthroscopic Meniscectomy

PRE-PROCEDURE
INDICATIONS
  • General indications:
    • Failure of nonoperative management
      • Nonoperative management includes activity modification, antiinflammatory medications, and rehabilitation.
      • Intraarticular steroid injections are also helpful.
    • Ongoing daily symptoms that interfere with activities of daily living or sporting activities
CONTRAINDICATIONS
  • Some meniscal lesions do not necessarily require operative intervention:
    • Vertical longitudinal tears that are stable to probing and are less than 10 mm
    • Partial thickness tears that involve less than 50% of the meniscal thickness and are stable to probing
    • Radial tears less than 3 mm
  • Significant osteoarthritis is a relative contraindication.
  • Some meniscal lesions can be repaired.
    • The most common criteria for meniscal repair include:
      • A vertical longitudinal tear more than 1 cm in length located within the vascular zone
      • A tear that is unstable and displaceable into the joint
      • An informed and cooperative patient who is active and under 40 years of age
      • A knee that either is stable or will be stabilized simultaneously with a ligamentous reconstruction
      • A bucket handle portion and remaining meniscal rim that are in good condition
EQUIPMENT
  • Standard knee arthroscopy set
ANATOMY
  • Differences between medial and lateral meniscus:
    • Medial is more semicircular.
    • Medial is larger.
    • Medial is anchored more securely to joint capsule.
      • Medial is attached securely to medial collateral ligament (MCL).
      • Lateral is not attached to lateral collateral ligament (LCL).
    • Medial undergoes less displacement on knee flexion.
  • Medial meniscus attachments
    • Anterior horn anchored immediately in front of anterior cruciate ligament (ACL)
    • Posterior horn anchored between posterior cruciate ligament (PCL) and posterior attachment of the lateral meniscus
  • Lateral meniscus attachments
    • Anterior horn anchored immediately posterolateral to ACL attachment
    • Posterior horn anchored anterior to posterior attachment of medial meniscus
    • The posterior horn of the lateral meniscus has a variable meniscofemoral ligament.
  • Primarily composed of type I collagen
  • The medial and lateral inferior genicular arteries supply the menisci.
<B>A</B>, Unstable 2-cm, peripheral tear of meniscus. Meniscus is being repaired with stacked vertical mattress suture. <B>B</B>, Incomplete undersurface tear of medial meniscus. This can be treated with abrasion to stimulate local healing, followed by placement of one or two sutures. <B>C</B>, Complete 2-cm tear in avascular zone of meniscus. This type of tear is generally treated with excision, but if repair is attempted, use of fibrin clot and other local stimuli should be considered. From Phillips BB: Arthroscopy of lower extremity. In Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
Figure 9 :  A, Unstable 2-cm, peripheral tear of meniscus. Meniscus is being repaired with stacked vertical mattress suture. B, Incomplete undersurface tear of medial meniscus. This can be treated with abrasion to stimulate local healing, followed by placement of one or two sutures. C, Complete 2-cm tear in avascular zone of meniscus. This type of tear is generally treated with excision, but if repair is attempted, use of fibrin clot and other local stimuli should be considered. From Phillips BB: Arthroscopy of lower extremity. In Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.


PROCEDURE
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Two-portal technique for bucket handle tears of lateral meniscus. <B>A</B>, Displaced bucket handle tear of lateral meniscus probed. <B>B</B>, After reduction of displaced bucket handle tear, posterior attachment is partially released with scissors. <B>C</B>, Anterior attachment is released with scissors. <B>D</B>, Tenuous remaining posterior attachment is avulsed with grasper and extracted. From Phillips BB: Arthroscopy of lower extremity. In Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
Figure 12 :  Two-portal technique for bucket handle tears of lateral meniscus. A, Displaced bucket handle tear of lateral meniscus probed. B, After reduction of displaced bucket handle tear, posterior attachment is partially released with scissors. C, Anterior attachment is released with scissors. D, Tenuous remaining posterior attachment is avulsed with grasper and extracted. From Phillips BB: Arthroscopy of lower extremity. In Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.


POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Vertical Longitudinal (Bucket Handle) Tears
  • Post-Procedure: Horizontal, Oblique, Radial, and Complex Tears

Post-Procedure: Vertical Longitudinal (Bucket Handle) Tears

POST-PROCEDURE CARE
  • Immediate full weight bearing
  • Active and passive range-of-motion exercises begun immediately postoperatively
  • NSAID at 2 weeks
  • Return to full activity typically at 4-6 weeks, when there is full range of motion
COMPLICATIONS
  • Deep vein thrombosis
  • Recurrent effusions
  • Incomplete removal of tear
  • Iatrogenic injury
  • Synovial cutaneous fistula
ANALYSIS OF RESULTS

Partial meniscectomy achieves good to excellent results in approximately 90% of patients at 4 years of follow-up.

OUTCOMES AND EVIDENCE
  • Bucket handle tears
    • Partial meniscectomy with preservation of meniscal rim
    • Schimmer et al reported 92% good to excellent results at 4-year and 78% at 12-year follow-up after arthroscopic partial meniscectomy in 119 patients.
      • Articular cartilage damage was the main determinant of long-term function.
        • 62% of patients had good to excellent results if chondral damage was present.
        • 95% had good to excellent results if normal articular cartilage was present at the time of arthroscopic surgery.
Procedure: Vertical Longitudinal (Bucket Handle) Tears

Post-Procedure: Horizontal, Oblique, Radial, and Complex Tears

POST-PROCEDURE CARE
  • Immediate full weight bearing
  • Active and passive range-of-motion exercises begun immediately postoperatively
  • NSAID at 2 weeks
  • Return to full activity typically at 4-6 weeks, when there is full range of motion
COMPLICATIONS
  • Deep vein thrombosis
  • Recurrent effusions
  • Incomplete removal of tear
  • Iatrogenic injury
  • Synovial cutaneous fistula
ANALYSIS OF RESULTS

Partial meniscectomy achieves good to excellent results in approximately 90% of patients at 4 years of follow-up.

OUTCOMES AND EVIDENCE
  • Bucket handle tears
    • Partial meniscectomy with preservation of meniscal rim
    • Schimmer et al reported 92% good to excellent results at 4-year and 78% at 12-year follow-up after arthroscopic partial meniscectomy in 119 patients.
      • Articular cartilage damage was the main determinant of long-term function.
        • 62% of patients had good to excellent results if chondral damage was present.
        • 95% had good to excellent results if normal articular cartilage was present at the time of arthroscopic surgery.
Procedure: Horizontal, Oblique, Radial, and Complex Tears
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