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A Way Forward

11

Meniscal tears

Meniscal tears are the most common

traumatic pathology presenting to the

modern day knee surgeon.The menisci

act as important load sharers and shock

absorbers in the knee and meniscectomy

massively increases the future risk of

developing osteoarthritis of the knee.

Meniscal repair

In the past, meniscal tears were

treated by open total meniscectomy.

Subsequently, efforts were made to

repair meniscal tears where possible,

but this involved difficult open techniques

with significant potential complications.

More recently, technical advances have

enabled meniscal tears to be repaired

arthroscopically very effectively, and

meniscal preservation, where possible,

is now the vogue.

The menisci have a naturally poor

blood supply, which comes from the

periphery and supplies only the outer

1/3 of the tissue.Thus, many tears even

if stitched back together would not

actually have the natural tendency to

heal, and thus the repair would in time

fail.The indications for meniscal repair

are, therefore, quite specific.

Indications for meniscal repair

- Younger patients, as meniscal tissue

in older patients is more likely to be

degenerate.

- Fresh traumatic tears.

- Tears in the peripheral vascularised

‘red zone’.

Relative contraindications to

meniscal repair

- Widespread degeneration within

the knee.

- Complex degenerative tears.

- Tears in the inner poorly-vascularised

‘white’ zone.

Overall, somewhere in the region of

approximately 20% of meniscal tears

are actually repairable. My personal

preference in terms of surgical technique

is the use of the Smith & Nephew

Fast-Fix meniscal repair device, which

consists of a suture attached to two tiny

anchors, linked by a slip knot, allowing

a fully arthroscopic repair technique.

The results of meniscal repair are now

well-reported, with success rates in the

region of 90% at 5 years. However, the

true benefit of meniscal repair will really

show itself in 10 or 20 years time, when

we hope to see significantly reduced

rates of osteoarthritis in the knee.

Meniscal replacement

For those patients with a completely

absent meniscus from previous surgery,

one option is the technique of meniscal

allograft transplantation.This involves

surgical implantation of donor meniscal

tissue. Meniscal transplantation has gained

significant popularity in the US, with

over 4000 meniscal transplants having

already been performed to date. Meniscal

transplantation has been shown to provide

good pain relief, with success rates in

excess of 80% at 5 years’ follow-up. Again,

the real proof of this procedure will be

the degree to which degenerative

changes in the knee may be delayed

or avoided in the longer term.

One further highly interesting recent

development is the Menaflex Collagen

Meniscal Implant.This is a prosthetic

collagen scaffold, manufactured from

bovine Achilles tendon, which is surgically

fixed into the defect in a meniscus.

Feasibility studies have demonstrated

biocompatibility and excellent ingrowth

of meniscal-like tissue into the scaffold

after implantation, with early clinical

studies demonstrating decreased pain

and increased function.

The possibility of using genetic

engineering to regrow one’s own

damaged meniscal tissue in-situ is still

a long way off, but genuine and exciting

progress in the area of meniscal surgery

is being made, and the motto of ‘

meniscal

preservation where possible, meniscal

replacement where indicated

’ most

certainly holds true.

An Update on

State-of-the-Art

Surgery for the

Menisci

mr ian mcdermott

Consultant Knee Surgeon –

The London Knee Clinc

For further information on arthroscopic knee surgery, meniscal tears, meniscal repair, meniscal transplantation

or the Menaflex Collagen Meniscal Implant, please contact us at:

The London Knee Clinic, St Olaf House, 27 Tooley Street, London SE1 2PR

Tel: +44 (0) 20 7407 3069 Fax: +44 (0) 20 7407 3138 Email:

[email protected]

Figure ( ii. ) –

Fast-Fix Meniscal Repair.

Figure ( iii. ) –

The Menaflex Collagen

Meniscal Implant.

Figure ( i. ) –

Arthroscopic

View of a

MeniscalTear.

www.londonkneeclinic.com