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Meniscus Tears:Which Ones Need Repair?

Daniel E. Cooper, MDThe Carrell Clinic – Dallas

Head Team Physician – Dallas CowboysUS Consultant – Real Madrid CF

Goal: Prevent arthrosis

Restore Meniscal Function Avoid iatrogenic injury Avoid re-tear Avoid implant displacement

Meniscal Anatomy

Complex Fiber orientation

Not simple to restore

More complex to replace

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Meniscal Function

Medial and lateral are NOT alike!!

Attachments AP slide on tibia

during ROM (LM) Tear patterns are

different

Meniscal Blood Supply

Arnoczky, et al.

Lateral Compartment

Young athlete Huge problem Synovitis Arthrosis

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Medial Compartment

Young athlete Huge problem?

Not always Synovitis?

Not always Arthrosis?

Not always

No-Brainers – Do Not Repair

Complex tears Avascular flaps Avascular radial Degenerative soft tears Older patient (45 or 50+) Arthrosis in same compartment

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NFL Case Example:28 y/o WO – ACL+ BHMMT

NFL Case Example

Weigh desire to repair vs. technical feasibility and potential for long-term success

Keep in mind that you didn’t hurt the player

Don’t feel guilty for PMM Failed MMR – more likely to

impact career of ANY athlete (Generally more arthrosis)

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What Do You Need?

Good surgical assistant Surgical skill to do no harm (prioritize) Versatile single lumen I-O technique Versatile O-I technique (anterior horn) Good root guide and TOR technique Comfortable placing PM cannula for MM

rim rent tear repair All inside options - less critical and

expensive (Ceterex, Scorpion, implants)

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No-Brainers – Do Repair

Longitudinal peripheral tears Young patients Asso. Ligament surgery LM acute root avulsion w/ ACLT Really young kid – much more

aggressive – better healing, bigger problem long-term

Double longitudinal; big flaps; radial

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Meniscus Repair Decisions

Controversial Calls

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Controversial Calls

Chronic MM root avulsion w/ early extrusion

Horizontal tears thru rim (LM) Large PH LM flap tear w/ ACLT Complete LM radial tear

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Controversial Calls

Much higher failure rate Need good counselling w/ family Need good technique Imperative to avoid iatrogenic injury

(20 years of damage in 20 min) No matter what you do – future

surgery is likely (what type?) Really young + LMT = Push the limits

Dilemma

Most LM tears in athletes always lead to arthrosis - no matter what we do!

Repairs take the athlete out of sport for 3-4 months minimum

Arthrosis is often worse after failed MR than after PM

Instrumentation & implants are not benign - risk of iatrogenic chondral injury

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Summary

Be prepared - have good help and good instruments

Learn to be versatile with your MR techniques

Be aggressive with LMR in young pts Don’t feel guilty if you need to do a

partial mensicectomy Involve the patient in the decision Do no harm w/ your techniques!

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The Carrell Clinic

Thank You