Sports Medicine: Just the Facts

CHAPTER 58 • KNEE MENISCAL INJURIES 347

repair versus resection, tolerance for risk of failure,

expectations, age, and underlying condition of the

joint (Klimkiewicz and Shaffer, 2002).

• The determinants of successful healing of a torn
  meniscus include tear location and configuration.


• No more than the peripheral one-third of the meniscus
  has a vascular supply. Therefore, the central 70–80%
  demonstrates inferior conditions for healing.


• It is important to classify the location of the tear rela-
  tive to the blood supply of the meniscus, in order to
  predict repair potential.
  •Tear classification based on location is as follows:
  red–red tear, located at the meniscal periphery within
  the vascular zone; red–white, no blood supply from
  the inner surface of the lesion; and white–white,
  located in the avascular zone.


• Red–red tears have the greatest potential for healing,
  and white–white the least (Klimkiewicz and Shaffer,
  2002).

NONOPERATIVE MANAGEMENT

•Surgical treatment is recommended for most meniscal
tears, except those causing minor symptoms in less
active patients.

• If nonoperative management is selected, treatment is
  directed at minimizing symptoms of pain and
  swelling.
  •A trial of activity modification, rehabilitation, and
  nonsteroidal anti-inflammatory medications is war-
  ranted until symptoms abate. This may be successful;
  however, symptoms may recur.

OPERATIVE MANAGEMENT

• Arthroscopic treatment of meniscal injuries has
  become one of the most common orthopedic surgical
  procedures in the United States (Greis et al, 2002a).


• Operative treatment of meniscus tears is warranted in
  patients with high physical demands associated with
  work or sport, as the activity modification required to
  reduce symptoms often is not acceptable.
  •Surgical indications include symptoms that affect
  activities of daily living, work or sport; failure to
  respond to nonsurgical management; absence of other
  causes of knee pain identified by radiographs or other
  imaging.


• Results of early treatment of peripheral tears (sus-
  pected with development of an effusion over the first
  48 h) are improved with surgical repair performed
  within the first 4 months from the time of injury (ide-
  ally less than 10 weeks) (Greis et al, 2002b).
  
  
  • Additional predictors of favorable outcome from
    repair include peripheral location (within 3 mm of
    the meniscosynovial junction), patient age less than
    30 years, tear length less than 2.5 cm, tear of the lat-
    eral meniscus, and simultaneous ACL reconstruc-
    tion (secondary to intra-articular bleeding and fibrin
    clot formation) (Greis et al, 2002b; Eggli et al,
    1995).
  
  
  • The goal of meniscal surgery is to maximize meniscal
    preservation. Tears with the potential to heal should
    be repaired.
    •Tears most likely to heal without treatment include
    tears less than 10 mm in length, tears with less than 3
    mm displacement on arthroscopic probing, partial
    thickness tears (<50% meniscal depth), and radial
    tears less than 3 mm in length (Klimkiewicz and
    Shaffer, 2002).
  
  
  • Arthroscopic rasping of the tear and synovium, or
    trephination, of these tears to encourage neovascular-
    ization, may encourage healing, and may be success-
    ful in as many as 90% of cases (Klimkiewicz and
    Shaffer, 2002; Greis et al, 2002b).
  
  
  • Displaced tears that result in a block to motion should
    be treated expeditiously.
  
  
  
  

MENISCUS REPAIR

• Repair techniques include open, arthroscopically-
  assisted, and all arthroscopic repair.
  •Traditional techniques for repair utilize suture fixa-
  tion, passed using a variety of devices that are tied
  through a posterior counter-incision.


• Meniscus repair implants continue to evolve since
  their introduction in the mid-1990s. Current genera-
  tion implants incorporate a suture based repair, and
  allow for an all arthroscopic technique.


• Criteria for meniscus repair include complete vertical
  longitudinal tear >10 mm in length, location within
  the peripheral 10–30% of the meniscus (or within 3–4
  mm of the meniscosynovial junction), displaceable
  more than 3–5 mm on arthroscopic probing, no sig-
  nificant secondary joint degeneration or deformity,
  and a stable knee (Klimkiewicz and Shaffer, 2002;
  Greis et al, 2002b).


• Situations not meeting the above criteria must be indi-
  vidualized. It may be appropriate to extend the indi-
  cations in younger individuals, or in cases where
  resection would lead to nonfunctional remaining
  tissue (Klimkiewicz and Shaffer, 2002).


• Suture repairs should be performed with vertical mat-
  tress stitches when possible, as these demonstrate
  superior repair strength compared to the horizontal
  pattern (Greis et al, 2002b).