Rekonstrukcja łąkotek.pdf

SCRIPTA MEDICA (BRNO) –78 (3): 135–150, August 2005

SUTURE OF MENISCUS

PAŠA L. 1,2 , VIŠŇA P. 3

1 Traumatological Hospital, Brno

2 Department of Traumatology, Faculty of Medicine, Masaryk University. Brno

3 Department of Traumatology, Clinic of Surgery, Second Medical Faculty, Charles University,

Prague

Received after revision August 2005

A b s t r a c t

Meniscus rupture is one of the most frequent injuries of the knee joint. Treatment usually in-

volves removal of the injured part of meniscus, or meniscectomy. Postoperatively, however, overload-

ing and degeneration of the knee compartment often occur, followed by signs of arthritic changes. As

a consequence of this process, the morbidity of patients significantly increases, resulting in increased

consumption of medications. Ultimately this disorder requires Total Endoprosthesis Implantation.

With the advent of arthroscopy in the 1980s, meniscectomy was more carefully performed to pre-

serve the uninjured portion of the meniscus. Overloading in the particular compartment is therefore

lower, and more cartilage is preserved.

As arthroscopy developed, especially regarding overview of the joint, and with new knowledge of

the biomechanics of the knee joint, recent measures aim to preserve the meniscus. This study focuses

on techniques of suturing injured menisci via arthroscopy.

Several factors are vital in assessing preservation of the meniscus: the type of rupture, injury site

(red-red, red-white zone), the time elapsed after injury, joint stability, and overall biomechanical de-

generation of the joint. Three basic techniques of meniscal suture are described: outside-in, inside-out,

and all-inside. PDS stitches of 0– and 1–gauge were used. The stitches were applied arthroscopically.

In the case of knee joint instability, it is appropriate to repair the ligaments and/or cartilage simultane-

ously. Postoperatively, joint fixation via a rigid splint is used, with early rehabilitation under limited

motion and loading. Ambulation is recommended from the 7th week after surgery, while light sports

or jogging are postponed until 3 months after operation.

Between 1994 and 2001, the authors performed a total of 242 sutures of the meniscus; 192 of the

medial meniscus; 50 lateral; and in 7 patients, sutures of both menisci were done simultaneously. The

range of the patients’ age was 14 to 72 years. Concomitant plastic surgery of the ACL was done in

48 patients; reinsertion of the ACL in 12 patients; mosaicoplasty in 6 cases; and early plastic surgery

of the ACL (within 3 months of meniscal suture) was done on 16 patients.

Re-rupture of the meniscus was observed in 8 patients. These exclusively involved the medial me-

niscus, each time via renewed injury. The treatment was performed by meniscectomy in 6 patients, and

by resuture in 2. Lysholm score in 1 year: excellent and good results were 96 %.

Preservation of the injured meniscus is paramount, especially for its biomechanical properties.

Concurrent or early treatment of the joint instability via ligament repair is fully indicated. This is the

only way to ensure and renew correct biomechanics of the knee joint. Mid-term results show either

good or very good outcomes after these conservative procedures.

Arthroscopically assisted early suturing of the injured menisci in the well-perfused zone (red-red,

red-white) assures beneficial possibilities for tissue healing and enables restoration of the correct bio-

mechanics of the knee joint.

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K e y w o r d s

Meniscus, Suture, Arthroscopy

INTRODUCTION

Injury of the meniscus accounts for one of the most frequent traumatic afflic-

tions of the knee joint. Treatment regimens (including the one that we used) have

already been described early in the 19th century. William Hey described trauma

of the meniscus as an “internal derangement of the knee”. Thomas Annandale’s

work “Excision of Semilunar Cartilage Resulting in Perfect Restoration of Joint

Movement” (1885) acclaimed the good to excellent results after removal of injured

meniscus via arthrotomy ( 5,10 ).

Many years later the long-term results following removal of the meniscus were

demonstrated. Presently, the consequences after meniscectomy (subtotal to total)

are known. These include overloading the relevant compartment with consequent

early degeneration of the cartilage. The resulting discomfort may torment the patient

in their professional or social capacities. Morbidity increases, as does consumption

of medications, and ultimately the need for total knee replacement.

The first published meniscus suture was done by Thomas Annandale , who sutured

the anterior horn of the medial meniscus on November 16, 1883. His patient report-

edly returned to work with a fully functional knee 10 weeks postoperatively ( 5 ).

The first arthroscopically assisted meniscus suture was done by Hiroshi Ikeuchi

in 1969. DeHaven tried suture of the menisci via a posteromedial or posterolateral

arthrotomy in the following year. General application of this method began after

1980, when Henning developed the instrumentarium and step-by-step instruction for

the inside-out technique ( 5, 7 ).

With the advent of arthroscopic techniques in the 80s in the Czech Republic,

treatment of the injured meniscus has undergone a radical transformation. The sub-

total or total meniscectomy previously performed via arthrotomy was replaced via

the more delicate partial meniscectomy. This spared joint capsule damage and pre-

served the healthy portion of the meniscus. The outcome is that overloading of the

particular compartment is lower and thus the cartilage is preserved ( 8 ).

Most recently, we have also tried to preserve the damaged tissue, and if possible,

reattach (via suture and meniscopexy) the injured meniscus ( 6 ).

This paper describes the possibility of meniscus suture using absorbable stitches,

and presents the mid-term results.

MATERIALS AND METHODS:

Menisci are fibrochondral semilunar pads on the internal and external surfaces of the knee joint.

On split section, they have a triangular shape which perfectly fills the space from the centre to the

periphery of the load-bearing component of the joint, so that pressure on the joint is optimally distrib-

uted to the greatest surface area. This form concurrently helps stabilise movement within the joint and

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dampens transmitted forces. This is also due to its flexibility. Menisci also enable even lubrication of

the synovial fluid, thereby helping with nutrition of the cartilage.

The shape of the femoral condyles is not spherical. Rather, the curvature of the joint surface is

accentuated dorsally. Loading in that particular area changes, too, depending on movement of the

joint. Biomechanical studies have demonstrated that more than 50 % of vertical loading is transferred

by the menisci when the knee is in full extension, while under 90° flexion, over 85 % is transferred. It

is therefore clear that after removal of meniscus, the particular compartment is overloaded. Removal

of one third of the meniscus (25–35 %) results in an increase of contact pressure to the cartilage by up

to 350 % of the original value ( 10 ).

Patients who have had their meniscus removed following trauma often have no significant difficul-

ties within the first months or years. Severity depends on the percentage of meniscus removed; on the

patient’s weight; on work or sports loading; on the state of cartilage at the time of injury; on the joint

axis; on joint stability, and many other factors. After a longer period of time (5 or more years, but

earlier in some cases) pain and swelling of the operated joint can occur during loading (or after longer

ambulation). These are the first signs of overloading. The consequent radiodiagnostic changes, natural

with increasing age, are only secondary, irreversible signs.

A very frequent consequence after total or subtotal meniscectomy on the loading compartment is

chondromalacia and subsequent gonarthrosis.

The goal of surgery is to preserve physiological conditions of the joint so as to prevent its degen-

eration.

Injury of the meniscus, rupture, disintegration or abruption are very variable. Preservation of the

meniscus is dependent upon several important factors –type of rupture, localisation of injury, time

elapsed after injury, joint stability, and overall biological age of the joint.

T YPES OF RUPTURE

The majority of loading of the meniscus occurs during knee flexion in the posterior half of the

meniscus. Under the influence of many factors (rotation, extension or flexion mechanism of force,

knee instability, strength of muscle groups, chondromalacia of the particular compartment, etc.), joint

structures are overloaded, and rupture or abruption of the overloaded meniscus occurs. Obviously, the

resulting size of the fissure can be a consequence of both one single sudden trauma or several recurring

smaller traumas. The fissure can be vertically longitudinal, oblique, radial, or horizontal. There may be

degenerative fibrosis and its combinations.

With respect to meniscus nutrition and healing, the position of the fissure is important. The fibro-

chondral tissue of the meniscus is nourished by two sources. Elemental nutrition is brought by vessels

that are located only at the base of the meniscus. Distally, this vascular nutrition wanes on the internal

margin of the interior and exterior surface of the meniscus. It is possible to divide the meniscus trans-

versally into three parts based upon its vascular supply: (i) very well nourished, or the so-called red

zone, which incorporates approximately 1/3 of the meniscus; (ii) the middle area, a relatively narrow

red-white zone with only sporadic vessels; and (iii), the so-called white zone with no vascular nutrition.

The tissue of the meniscus is also nourished by the intra-articular fluid. The extent of this nutrition is,

however, low.

It is generally known that only nourished tissue can heal. This is why the location of a fissure and

the time elapsed after injury are crucial to healing.

Acute fissures (up to one week after injury) at the base of meniscus (i.e. the red zone) are most

amenable to suturing. Here the tissue quality is good and the bleeding fissure is easily seen. When an

injury is inveterate and the quality of the meniscus is good, it is also possible to suture it. It is, however,

necessary to perform curettage to the base of the meniscus, and in this way create conditions salubri-

ous for tissue healing.

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S UTURE TECHNIQUES

Many techniques of meniscopexy (suture and reinsertion of the meniscus) have been described.

Absorbable or nonabsorbable stitches may be used, along with special absorbable implants of vari-

ous types and makes. The strength of these various sutures differs. The strength of a well inserted

double vertical PDS stitch No. 1 is 130 newtons; that of a simple vertical stitch, 80 N; while a hori-

zontal mattress stitch holds 56 N. The strength of absorbable implants for suturing the meniscus is

between 27–57 N. Typically, insertion of these implants in the posterior corner of the meniscus is

easier than suturing. The strength of this fixation and the cost of the applied material differ extensively.

( Tables 1, 2 ).

Here the authors present the basic techniques of suturing the meniscus using absorbable PDS

stitches.

In essence, there are three basic techniques of suture of the meniscus:

The outside-in technique (insertion of the fibre from outside the joint inwards) using pink injec-

tion needles (12 x 40). It is possible to thread PDS monofilamental fibre of maximal size 1, into the

needle.

The simplest method is fixation of such threaded fibres by a knot inside the meniscus. The fibre is

inserted through the working portal out of the joint, a knot is created at the end of the fibre, and the

stitch is moved back (Mulberry stitch). After approximating the edges of the fissure, the two fibres are

always knotted together outside of the joint capsule.

Knotting together two such threaded fibres on the intra-articular side is a little more difficult. Two

needles with PDS stitches are threaded in by approximately 3 mm, both ends are threaded simultane-

ously through the working portal, the knot is tied and pushed into the joint again. Simultaneous thread-

ing is essential to prevent entrapment of synovial or other tissue between the particular fibres of the

suture. This would impede cinching up the stitch to the meniscus. Fixation outside the joint capsule is

done using the aforementioned technique.

Table 1

alone

+ primary

LCA-plasty

+ early

LCA-plasty

+ LCA

reinsertion

total

MM suture 131

192

ML suture

35 9

rerupture

Table 2

Lysholm score

Excellent

Good

Fair

Poor

Separate

meniscus repair

Meniscus repair +

LCA reconstruction

Other variants may be used to ensure the knot is on the meniscal rather than the intra-articular side:

3a) Threading a knot between two fibres is difficult, and the threaded fibre can furthermore break.

In this case, a dilating knot on the threaded fibre can be used. This knot dilates the hole for the 2–fi-

bred knot, and so its chance of breaking is smaller.

3b) The threaded needle technique is optimal, although a little more difficult than the above-men-

tioned methods. Two pink injection needles are used, threaded with PDS fibres of calibres No. 1 or 0.

One of them goes past the tip of the needle, so that it can be circled around (approx. 10–15 cm), and

thereby a noose for the fibre in the second needle is created. The end of the fibre in the second needle

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is inserted into this noose so that it is completely hidden. The needle is passed into the noose in the

required place and a noose is created in the joint. The second needle enters the noose for a distance

of 3–4 mm. The noose is tightened, and this removes the fibre from the joint. It is suitable to thread

several centimetres of the fibre (it can be performed also out of the joint with the aid of the working

portal, but this is not necessary). In this manner, a “U” stitch is created without the intra-articular knot.

Fixation is performed again by tying outside of the joint capsule. Of course, it is possible to change the

direction of needle-threading, but the principle is the same. By this method, a fissure on the anterior

three quarters of the meniscus can be sutured.

The inside-out technique (stitch placed on the meniscus directed outwards from the joint)

Special instruments are needed for this technique. Double-lumen cannula suturing instruments of

various forms and angulations enable optimal placing of sutures. It is however essential that there is

no space between the two barrels (channels for both needles and stitches), but the space for threading

the fibre loose (8–shaped on the cut). The needle for this type of suture is longer than the positioning

cannula, with a sharp point, and with an eyehole at its end (a PDS stitch No. 1 can be used without

problems). It most closely resembles needles ordinarily used for sewing. It is moreover flexible, so it

can be threaded into angulated cannulas. Fixation of these stitches is also made by knotting outside

the joint capsule. This technique is both simple and quick. It is applicable for the central two quarters

of the meniscus, but the necessary instrumentation is required.

The all-inside technique (everything – including the insertion and knotting is inside the joint)

This technique is the most difficult. It is used for the posterior 1/4 to 1/3 of the meniscus. Again,

special instruments and special working portals are necessary.

In the area of the posterior corner of the medial meniscus:

The fiberscope is inserted via an anterolateral (AL) portal through the intercondylar fossa along

the cruciate ligaments. A posteromedial (PM) portal should be used as a working port. A threaded

cannula with obturator, which is otherwise commonly used in shoulder joint surgery, is inserted

through this portal. Placement of the stitch through a fissure in the posterior corner is done using

two methods. When special instruments for suturing soft tissue with various shapes are available (De-

schamps,...), the sewing instrument is inserted with the stitch in the joint. The stitch over the fissure

of the meniscus is inserted and then the end is threaded through the cannula outwards, and the knot

tightened up to the meniscus.

Should these instruments not be available, the needle for lumbar puncture can be used, as can

puncture needles of greater calibre of a length of 15–20 cm. These needles are more robust than the

usual injection needle. It is necessary to slightly bend the tip of the needle (the last 1 cm). This needle

is inserted through an anteromedial (AM) portal under visual control, and the point of the needle

passes through the fissure. With this method, there is a risk of accidentally inserting the needle into the

popliteal area and thus neurovascular structure injury. For these reasons, the depth of insertion should

be controlled both optically and mechanically. A firm instrument is inserted through the cannula

which displaces the synovial membrane. In this way a space is formed so the needle can be pierced out

of the meniscus safely. In this way, a channel is formed for freely moving the inserted needle. A suture

is threaded through both the needle and the cannula outwards, and the needle is slowly removed from

the joint. It is necessary to extract both ends of the inserted stitch out simultaneously through one

working port, where good knotting of the stitch should be possible. No other tissue should be trapped

between the fibres (i.e. synovial epithelium or subcutaneous tissue) that could hinder firm cinching of

the knot. The stitch is then knotted using a stitcher.

In the posterior corner of the lateral meniscus:

The method is the same as on the medial side. In some cases it is possible to place the suture via

AL access without introducing a posterolateral (PL) portal, especially when the knee is in the proper

position (over 90º flexed, externally rotated, and in varus deviation). If this configuration is ineffective,

the PL access is elected (similar to technique IIIa). Here, one must be careful to choose the right posi-

tion of the portal to prevent possible injury of the fibular nerve.

The posterior corner of the lateral meniscus is more mobile from a physiological point of view, and

so insertion of sutures is easier. It is necessary to heed the position of the popliteal muscle. Stitches

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