Dr. Chris Tucke...: Welcome to your Arthroscopy Association Arthroscopy Journal Podcast. I'm Dr. Chris Tucker from the Walter Reed National Military Medical Center and founding editor of the podcast. Today, we are discussing Meniscal repair techniques specifically for the middle and posterior thirds. I'm excited to be joined in this discussion by one of my current practice partners, Dr. Jon Dickens. Dr. Dickens is an active-duty Army surgeon, the current President of the Society of Military Orthopedic surgeons, and the Chief of Orthopedic Sports Medicine at Walter Reed. Dr. Dickens was an author of the Infographic Article titled Meniscal repair techniques for middle and posterior third chairs, which was published in the March 2021 issue of the Arthroscopy Journal. His co-authors include Zachary Aman and Travis Dekker. Jon, congratulations on your work, and welcome to the podcast.
Dr. Jon Dickens: Thank you for having me, Chris. It's a pleasure to be here.
Dr. Chris Tucke...: Can you first start us off with a brief background on your interest and experience with meniscus tears and why you were interested in producing this infographic?
Dr. Jon Dickens: Absolutely. And as you know, we really see a lot of these types of injuries in the military and getting them back to duty can be a challenge. You know, from some of the stuff that we've seen in our military population, it's up to 10 times more meniscus tears maybe than a civilian population and there's really just been a number of different modalities and evolving techniques that's come about relatively recently to address meniscal tears as well as efforts to save the meniscus. And so this was a natural extension of that sort of knowledge and need for new information that prompted us to do this.
Dr. Chris Tucke...: Great. I'd like to discuss each of the repair techniques outlined in your manuscript in detail, working through the technique, the applications and clinical implications. Let's start with what most considered to be the gold standard, the Inside-Out Repair. Can you describe for our listeners the technique involved in this repair and perhaps some of the tips you've acquired in your experience?
Dr. Jon Dickens: Yeah, absolutely. This is still my preferred or go to technique for challenging meniscus tears. It's really highly versatile can be used in a lot of different scenarios and is one where I'll use in any scenario where I feel like that's going to be a challenge to get meniscal healing. As you know, we use our standard anteromedial, anterolateral arthroscopy portals, but in combination with an accessory posteromedial or posterior lateral incision, depending on if we're addressing the medial or lateral meniscus, the posterior lateral window is just behind the FCL and is in a window of the posterior IT band and the biceps, this is to protect the perinatal nerve. I make this usually 90 degrees of flection to protect the nerve. The medial repair approach is posterior to the superficial MCL again, to protect the saphenous nerve with the interval between the gastrocs and the capsule.
In terms of pearls, I think having multiple different passes of sutures is key and is important for getting good meniscal healing. I also think it's important to include sutures both superior as well as inferior to the meniscus and this helps to really reduce and appropriately placed the meniscus back to its anatomic location. Certainly, if doing a concomitant ACL reconstruction and depending on how that's done, I think it's important to consider when to tie the meniscal repair. For me, I will oftentimes perform my ACL reconstruction and use a HyperFlex knee position. So, I will place my meniscal repair sutures, then do my ACL reconstruction and tunnel drilling, and then come back and tie my meniscal repair sutures to prevent stress on my repair during the HyperFlex position. And I think it's additionally useful or important to know that there's just a lot of new and evolving technology that's available to us.
Certainly these can be more challenging, but there's a self delivery zone, specific needles that are helpful now to potentially take some of the assistance that's needed with these out of the picture and there're different sorts of sutures, not just a standard suture, but more tape type sutures that may provide better time zero pullout strength.
Dr. Chris Tucke...: Excellent tips as my go-to as well and I think we share a lot of those same techniques based on our similar training histories. Next, can you discuss for us some of the advantages and disadvantages of this Inside-Out Repair technique?
Dr. Jon Dickens: To me, the most important advantage to this is that this is probably our most low profile approach to meniscus repair in terms of the diameter of puncture that's going through the meniscus. It allows also multiple fixation points. I think we can get 10, 12, an infinite number of passes through the meniscal tear and this is really important for establishing a good time zero repair and placing these perpendicular to a vertical mattress suture through meniscus and through capsule is also another advantage of this. There are some certainly disadvantages requires an additional incision that carries with, it's the complications that go with that probably most important is that it's requires an experienced, skilled assistant, both to deliver, but also to retrieve the meniscal needles and as such a longer surgical times is not unexpected after this.
Dr. Chris Tucke...: All right. Next, can we move on and describe the all inside repair, including the technique itself, perhaps some of the different differences and the various devices out there and some tips or tricks you've picked up along the way?
Dr. Jon Dickens: Absolutely. I think this is really what's changed more in recent years and has allowed us to get more efficient, maybe even a little bit more aggressive with our efforts to save the meniscus. There's capsular based repairs and these are really repairs that are through the meniscus and capsule as the name suggests and are ideal in addressing longitudinal type tears with an implant that's posterior to the capsule in a sliding knot intro, particularly. The meniscus space repairs use a combination of sutures that are passed all within the meniscus tissue and this is where we've really expanded our efforts to address the more challenging meniscus tears. These include horizontal or radial tears, as well as other types of tears, where in the prior history, we may have elected for a meniscus debridement. Several companies now have all inside meniscal repair sutures that allows us to place these sutures and then tie knots into articulary.
I think in terms of tips and tricks, certainly one of the more important things when doing this is to ensure that you have good visualization and with doing these all inside techniques, it's critical to have access and visibility to the meniscus and the meniscus tear. So with this technique, or really any meniscus repair where we need more room and more visibility, I would really encourage people to a pie crust or address the MCL. Particularly when doing the medial side, you can do this in a variety of different methods. You can use a spinal needle and PI cross from an inside-out a direction with the valgus force. You can also do this from outside in, but this really provides the much needed improved visualization and it can even just be one or two millimeters, but that's key to ensure that you get good exposure and you don't damage the surrounding articular cartilage.
Dr. Chris Tucke...: Excellent tips. One of the things I always try and teach the residents is that technique for that trephination of the MCL like you described. I think it's a huge advantage for safely performing these types of procedures without injuring the cartilage. What are some of the advantages and disadvantages of this all inside repair technique?
Dr. Jon Dickens: Number one, it doesn't require separate incisions. You can do it kind of more efficiently while you're addressing the rest of the issues that may be going on in that knee, it's easier, it doesn't require skilled assistance and so it has a lot of advantages that really make it fit in nicely to the workflow. It does have the larger delivery needle in meniscal penetration and so it's hard to place multiple implants and certainly cost becomes an issue there as well. We know that the risk of neurovascular injury is not insignificant, it's not common, but particularly when addressing those posterior and posterior tears of the lateral meniscus, it's probably more of a concern than other locations. So we don't want to over penetrate in those areas and it also requires Arthroscopic knot tie. So there is some concern of potential, not prominence or suture prominence that may be a theoretical disadvantage of these if you're doing a knot tie technique within the day.
Dr. Chris Tucke...: Can you share with us Jon, some of the evidence out there on the benefit of meniscus repair. In general and then more specifically, what's currently known about comparing the outcomes of these various techniques we just discussed.
Dr. Jon Dickens: So the retail rate for isolated meniscal repairs is generally between 15 and 20%. It might even be a little bit higher than that, depending on the type of population that you are addressing. It's a worse in tears that are in the red-white zone than the all red zone. So red zone, those tears that have a rim width of more than three millimeters, which implies its more in the red-white zone have a higher failure rate. Younger patients have a higher failure rate, lateral tears have a higher failure rate and as I mentioned before, the isolated repairs have a higher failure rate in conjunction with the ACL reconstruction. The outcomes of a meniscal repair are generally much improved and this is probably because of some of the biologic environment that allows for meniscal repair. Some of the studies still though demonstrates some high retail rates in the moon's study. They have reported up to 15% of their patients had a retainer after the ACL reconstruction and concomitant meniscus repair, but still generally speaking meniscal repair at the time of ACL reconstruction is much favorable and does much better than isolated meniscus repair.
In terms of the outcomes, the biomechanical string and an overall multiple systematic reviews have looked at this and whether it's inside-out or all inside, generally speaking, the outcomes and retail rates are equivalent.
Dr. Chris Tucke...: As you mentioned, we know that healing rates of meniscus repairs are better when done in combination with the ACL reconstruction, as opposed to the isolated repairs, which like you said, is thought to be linked to this postoperative intraarticular environment in the knee generated by the process of ACL tunnel rimming. Can you discuss for us some of the biological adjuncts that have been introduced along with meniscus repair to augment the healing process when these repairs are done in isolation?
Dr. Jon Dickens: Absolutely. It starts with a preparation of the meniscus repair and that can be done by abrasion of the surrounding capsule or the meniscal tear site or in trepidation to increase vascular channels perhaps within the meniscus intercondylar notch marrow venting is another technique. Again, this is similar to what we do at the time of an ACL when we're drilling our femoral and tibial tunnels and this attempts to replicate the biologic environment that we might see at the time of an ACL reconstruction. Other options include fiber and clots, which have been done historically and can be delivered into the repair site. Certainly those demonstrate improved a healing potentially and more recently we've seen increasing evidence from biologic adjuncts like platelet rich plasma, or concentrated bone marrow aspirin, which have shown early clinical as well as radiographic improvements in meniscal repairs.
Dr. Chris Tucke...: So we've covered a fairly decent amount of high value information on the approach to these tears techniques for repairing them and potentially what to do about biologically augmenting those repairs. So before we close, can you share with us your current approach in decision-making process with respect to treating an isolated meniscus tear and a repair technique?
Dr. Jon Dickens: First, I would say that our trends tends to be, to save the meniscus and make every effort to do that. I would rather have a meniscus repair attempted and to go back and debride that then to be debriefing more meniscus tears that should have been repaired. I think that certainly in an effort to prevent the longterm sequelae of osteoarthritis that comes about with the meniscus debridement. So with that said, even for tears that are red-white zone, radial tears, horizontal tears with the equipment that's at hand, I think we are better able to address those tears today with some of the technology that's available to us. For smaller vertical tears, maybe that are encountered at the time of an ACL, i tend to still use the all inside technique. And again, there's a variety of different methods or companies that can provide those implants. For larger bucket handle tears, whether they're in isolation or at the time of an ACL.
My preference is to do an inside-out a repair those in part because I have more confidence in my fixation, my ability to get more sutures across, but I also think it really helps me find tune my reduction and get a nice anatomic repair, which can be important for those larger bucket handle tears. And then lastly, in terms of the radial tears and horizontal tears, that's really where I think recently for me, it's been more of a shift to attempting to fix these with all inside meniscal based sutures and I've been very pleased with some of the early outcomes that I've seen both in my practice, but also in literature with fixing these.
Dr. Chris Tucke...: Jon, I want to congratulate you again on this work and thank you for sharing your time and your thoughts with us today.
Dr. Jon Dickens: Thanks, Chris. This is really a pleasure and such a tremendous job that you and AANA have done with this podcast. I can't tell you how many people and residents I've heard really tuning into this. So this is just a tremendous opportunity and thank you for having me.
Dr. Chris Tucke...: We appreciate that. Thanks for joining us.
Dr. Dickens’ article titled Meniscal Repair Techniques for Middle and Posterior Third Tears can be found in the March 2021 issue of the Arthroscopy Journal, which is available online at www.arthroscopyjournal.org. This concludes this edition of the Arthroscopy Journal podcast. The views expressed in the podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening, please join us again next time.