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Arthroscopic medial menisectomy and chondroplasy of knee

    Overview

    Professional Guidelines Included
    Learn the Arthroscopic medial menisectomy and chondroplasy of knee surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Arthroscopic medial menisectomy and chondroplasy of knee surgical procedure.
    The meniscus is a vital component of the knee. Its function is to transmit load over as wide an area as possible between the femur and tibia. From the advent of arthroscopic techniques, the meniscus has often been the site of surgical intervention. Unfortunately most of this historic effort has been in performing meniscectomy or partial meniscectomy.
    As arthroscopic ability improved and the industry developed devices to help surgeons, then preservation surgery became more prevalent, although meniscal repair unfortunately is still less common than partial meniscectomy.
    However when the meniscus is sufficiently degenerate to the extent that a repair will not hold, then there is still a role for partial and even sub-total meniscectomy to remove unstable meniscal tissue. It must be stressed though, that the vast majority of degenerative meniscal tears can safely be managed non-operatively.
    The meniscus degenerates as part of the degenerative process in arthritis. Consequently there are often incidental diagnoses made of meniscal ‘tears’ on MRI which really represent the start of arthritis.
    There has been much controversy about the role of arthroscopic meniscectomy. On one side the proponents of non-operative management saying there is no role for arthroscopic meniscectomy for the degenerate meniscus, whereas there have been two sets of guidelines (ESSKA and BASK) developed from experienced user groups, with Delphi Consensus principles, to target the appropriate use of arthroscopic techniques in selected cases.
    The BASK guidelines dissuade surgeons from performing arthroscopic surgery on degenerative menisci in ‘arthritic knees’, but promote urgent arthroscopic assessment for locked knees ideally repairing the meniscus. The BASK guidelines also describe the concept of the ‘target lesion’ which represents a specific flap of meniscal tear which is perceived to be the site of mechanical symptoms and pain. This is particularly relevant for tears extruded into the medial gutter lying underneath the meniscus.
    On the opposite side of the fence where Physiotherapy or off-loader bracing should be the main weapon is the degenerate complex tear with maceration of the meniscal tissue and no discrete flap tear.
    This technique describes my technique for partial meniscectomy; this represents less than half of the arthroscopic meniscal procedures I perform.
    It is also vital to remember that in a degenerative meniscal lesion, appropriate non-operative management should be attempted prior to surgical intervention, once the decision has been made that this is not a repairable tear. Sometimes there is a role for steroid injection, be that ultrasound-guided, direct intra-articular or palpation-directed peri-articular at the site of maximal tenderness.
    The two key papers related to this giving practical guidelines are listed below, but please also look at the Results section for more key papers on Meniscectomy:
    Arthroscopic meniscal surgery: a national society treatment guideline and consensus statement.
    Abram SGF, Beard DJ, Price AJ; BASK Meniscal Working Group.
    Bone Joint J. 2019 Jun;101-B(6):652-659. doi: 10.1302/0301-620X.101B6.BJJ-2019-0126.R1.
    PMID: 31154847

    The Knee Meniscus: Management of Traumatic Tears and Degenerative Lesions
    Philippe Beaufils, Roland Becker, Sebastian Kopf, Ollivier Matthieu, Nicolas Pujol
    EFORT Open Reviews
    2017 May 11;2(5):195-203. doi: 10.1302/2058-5241.2.160056. eCollection 2017 May.
    PMID: 28698804 PMCID: PMC5489759 DOI: 10.1302/2058-5241.2.160056

    Readers will find the following OrthOracle techniques also of interest:
    Arthroscopic lateral meniscal repair with fibrin clot and bone marrow aspirate -Smith and Nephew Fast Fix 360 system.
    Meniscal repair using Smith and Nephew fast-fix 360 system and knee arthroscopy
    Trans-tibial meniscal root repair using Smith and Nephew Firstpass mini
    Knee arthroscopy
    Knee arthroscopy and microfracture of osteochondral defect

    Indications

    INDICATIONS
    The indications for partial meniscectomy rely on there being mechanical symptoms and a meniscal tear which is not repairable or which the patient wants removing in the knowledge that a meniscal repair would require careful post-operative rehabilitation which they are not able to undertake often for work reasons.
    With degenerative meniscal lesions the indications are clearly displayed in the BASK meniscal guidelines document and flow diagram. In summary there needs to be a discrete target lesion (e.g. a displaced flap inrolled under the meniscus and sitting in the meniscal gutter) or failure of nonoperative management.
    SYMPTOMS & EXAMINATION
    History
    There is usually a clear cut history of a traumatic event in young’ meniscal tears whereas in the middle-aged population this can be noticing the pain the day after exercise or whilst squatting or twisting. The nature of this event varies, but there are common themes. Usually the patient has a healthy knee prior to the event and they are involved in a sudden weight bearing event during which they feel a ‘pop’ or ‘crack’ in the knee. The patient may have landed heavily on the leg for example during a change of direction, but in isolated meniscal injuries they do not describe the excruciating pain and visceral nauseation associated with an ACL injury. The patient is usually able to stand and bear weight, but does not normally continue playing. Swelling may come on quickly (similar to an ACL injury when the tear is peripheral and well vascularised) but usually the swelling starts later, up to 24 hours afterwards.
    Sub-acutely patients with meniscal injury complain of pain and swelling usually after deep flexion or twisting activities, or an inability to perform such activities , guarding the knee. Locking (an inability to fully extend the knee) may be permanent or intermittent, but is relatively rare. However mechanical symptoms where the patient feels something catching are much more common.
    There are different types of meniscal tear recognised and these have certain recognised patterns to the history, which are though by no means diagnostic.
    Circumferential longitudinal tears – these often swell up quicker and are more obvious to the referring doctor. The most obvious of course is the bucket-handle tear in which a
    Radial tears – usually acute with a heavy landing which drives the femoral condyle into the meniscus, splitting the meniscus to cause meniscal extrusion. The injury does not settle but the knee is not acutely locked and so referral can be delayed.
    Horizontal tears – may be less acute in presentation as the remaining meniscus generally functions better and the patient may attempt returning to sport and suffer a second event.
    Root tears – tend to occur as part of a serious acute knee often multi-ligament injury, or more commonly in an older population in isolation of any ligament injury. In the middle-aged population and injured meniscal root presents with a history of increased activity (squatting, twisting or dancing) immediately noticing something ‘going’ in the knee and then usually a slower presentation to the knee services because of self-management initially and then a resistance to image or refer because of their age.
    Degenerative complex tears with a displaced flap – such as in this case usually present with a history of pain and swelling coming on following an activity such as dancing, gardening, squatting or twisting. There can be dramatic event which is noticed but equally this can be a delayed picture with swelling and pain developing from 24 hours. The patients dislike getting in/out of the car, squatting down to put on shoes and turning over in bed (often catching the toes on the bedclothes gives pain in the knee).
    Examination
    Weight bearing status varies depending on the chronicity, morphology and type of tear. Meniscal tear patients may be full weight bearing to completely non-weight bearing. Squatting though usually reveals a preference to load through the non-injured side
    Inspection – Look for previous portals, the presence of swelling and in particular on the lateral side with the knee at 30 degrees, the presence of a lateral meniscal pseudo-cyst. This is an extrusion of meniscal tissue which mimics a cyst often from a radial lateral meniscal tear.
    Effusion – normally there a knee effusion which can be large initially, but most commonly a moderate effusion detected on sweep testing.
    Tenderness – the joint line on the side of the meniscal lesion is usually tender. In medial tears this is normally posteriorly whereas in lateral tears this is normally more anterior.
    Ligament examination – a full ligament assessment must be made of the ACL / PCL / MCL / LCL and posterolateral corner.
    Specific tests such as the McMurray and Thessaly tests may be appropriate. The McMurray test involves palpation of the joint line during passive flexion/extension of the knee joint with alternating internal and external rotation – a positive test equates to a palpable click on the joint line during the McMurray combined movement, usually with the medial joint on internal rotation and the lateral joint on external rotation. The Thessaly test is a variation of the McMurray but with the patient weight-bearing through the injured knee; the patient should be supported ( I ask the patient to support their weight on the back of a chair) and then squat to 30 degrees and rotated externally (lateral meniscal provocation with a positive test if painful on the lateral joint line) or internally rotated ( medial meniscal provocation with a positive test if there is medial joint line pain).
    IMAGING
    In the acute setting with a history of trauma simple AP and lateral Radiographs should be performed to rule out fractures. In non-acute cases there may be a role for alignment views (for example if repair or root repair is being considered)
    MRI however is by far the most important investigation to confirm the tear site and morphology as well as concomitant ligament or chondral injury. Careful attention should be paid to the non-injured parts of the meniscus to give an idea on potential integrity of meniscal tissue to contemplate repair.
    The presence of peri-articular inflammation and cysts should also be noted.
    In this particular case there was no history of trauma and no symptoms to suggest pre-existing arthritis and consequently I requested an MRI alone. However if symptoms persist following treatment then I would arrange alignment views to ensure there is no significant medial overload in the meniscal-deficient joint.
    ALTERNATIVE OPERATIVE TREATMENT
    The patient should have understood that this is not a repairable lesion and that they have failed non-operative management. Thus there are no other simple surgical procedures that can be used in this setting but if there is evidence of significant overload and a failing joint then osteotomy should be discussed to off load the damaged joint compartment.
    However it is quite common to discuss the potential for meniscal repair but where not possible then to proceed to partial meniscectomy. Consequently medial meniscal repair is an alternative treatment which should be undertaken where at all possible
    NON-OPERATIVE MANAGEMENT
    Analgesia, crutches, off-loader braces and physiotherapy.
    Occasionally if a non-repairable or questionably repairable meniscal tear is not settling down I instil low concentration local anaesthetic and steroid (Triamcinolone 40mg) around the tender joint line at the site of the maximal inflammation on MRI
    CONTRAINDICATIONS
    Repairable tears – vascularized zone tears with a simple pattern should be repaired.
    Degenerative tears which are undisplaced and present acutely should be treated non-operatively initially. Only if these are failing to settle should consideration be given to partial meniscectomy.
    Active infection in the knee or at other sites in the body.
    A patient who is unfit for anaesthetic

    Setup

    I like to set up the patient without a tourniquet, feet over the end of the table and a side support. I prepare the patient in the same manner for all arthroscopic surgery and so it is important to look up my technique of Arthroscopic Lateral Meniscal Repair with Fibrin Clot as the early set up is identical.
    It is important to be aware after likely operative procedures prior to positioning and establishing portal placement. Four example for medial work it is important to have the lateral support positioned distally on the femur fairly close to the knee; whilst for lateral joint work it is often useful to remove during the post during the procedure

    Operation – 1

    Coronal MRI scan of an irreparable medial meniscal tear.

    Sagittal MRI scan showing the high signal in the posteromedial meniscus (1) reaching the inferior articular surface indicative of a tear.
    Notice that the signal is very different in the posterior horn compared to the anterior horn. Whilst there is clearly a line indicating a tear, the line is blurry and this suggest some softening either side of the tear, pushing me towards meniscectomy rather than repair. However the real decision is in theatre once the consistency of the meniscus has been palpated arthroscopically.

    Axial MRI image showing an irreparable mid and posterior medial meniscal tear.

    The patient is positioned with feet over the end of the tablePlease look up the Arthroscopic Lateral Meniscal Repair technique on Orthoracle written by me as this gives a comprehensive ‘how to’ guide for preparation and draping. I have summarised the process in this technique with some key slides.
    I like to set up the patient without a tourniquet, feet over the end of the table and a side support.
    However remember that in the lateral joint this side support may reduce the ability to move into the classic ‘figure of 4’ position – particularly important if there is also lateral sided work to be done.
    Please remember the Gel pad on the corner of the table and a foot pump on the opposite limb.
    Also position the Monitor over the patient to avoid the surgeon twisting during the procedure.

    Skin preparation starting on the knee.
    I use 2% Chlorhexidine in Alcohol. This may be obtained through a proprietary brand as seen in this image (Chloraprep) or may be applied with a standard swab and Rampleys Forceps – please check the percentage is 2%.
    The foot is then prepared with Chlorhexidine
    Two gloves are applied to the foot allowing access to prepare the heel.
    The heel is then prepared with Chlorhexidine
    The top glove over the toes is then pulled around the heel
    The whole lower limb and knee are then prepared twice with Chlorhexidine
    An impervious U-Drape is applied around the thigh to cut-off the non-prepared area
    An additional large drape is then used to augment the U-drape and properly cover the table allowing for knee flexion intra-operatively
    An arthroscopic drape is then applied

    Local anaesthetic infiltration with adrenaline around the portals for analgesia and bleeding control
    The arthroscopic light lead is secured to the drapes.
    I like to use the same order with the light lead most lateral, then irrigation, then Radiofrequency device or shaver and suction.
    The irrigation system is then applied to the drape
    Here a squeezable chamber device is used which provides a burst of fluid by simple hand pressure from the operating surgeon or assistant.

    The radio-frequency ablation device is then secured on the drapes
    This is a Flo-50 from Smith and Nephew which allows a variable power of radio-frequency and suction to be used within the knee.
    A suction tube is then passed through the drape holes for security
    White balance of the arthroscopic camera is performed

    From the anterolateral portal reasonable views of the patella medial and lateral facets are obtained. However if there is concern over patellofemoral mal-tracking or assessment for patella alta and then a superolateral portal should be made.
    Please see my technique on Orthoracle for medial patellofemoral ligament reconstruction and tibial tuberosity osteotomy.

    Trochlea assessment is made by tracking the scope down the trochlear sulcus into the femoral notch and then assessing both the medial and lateral sides of the trochlea

    The anterolateral portal is made high and close to the patella / patella tendon and used for initial knee visualisationThe first anterolateral portal is generally in the same place in each arthroscopic procedure. This should be at the most superior aspect to the tibia-femoral joint line, but close to the patella.
    However additional portals need fine tuning depending on the land procedure. In this case the medial portal will be lower (ie more inferior) and more anterior to allow access to the postero-medial joint for the antero-medial portal.

    The working portal position will modified by what work is needed, and is often anteromedial.The arthroscope is introduced and a standard arthroscopic visualisation of the knee joint performed.
    It may be worth readers refreshing their memory about the mechanics of knee arthroscopy by reading Andrew Pearce’s OrthOracle technique Knee arthroscopy and partial medial menisectomy and also Faisal Hussain’s technique knee arthroscopy
    It is imperative to have a clear, standard arthroscopic sweep around the knee. This is covered in the linked techniques above, but my standard diagnostic sweep is:
    Supra-Patella Pouch
    Medial and Lateral Gutters
    Patellofemoral joint
    Notch including ACL / PCL
    Medial Joint – look for a Meniscal Flounce (as described by Peter Myers) which is a ‘wave’ or ‘ripple’ in the leading free edge of the meniscus indicating the meniscus is likely to be intact
    Lateral Joint
    Sometimes it is necessary to perform posteromedial portals for posterior viewing / arthroscopic work eg as in PCL reconstruction or some Meniscal Ramp lesions.
    The working portal position will modified by what work is needed – this can be pre-determined for the imaging, but I find that an efficient diagnostic sweep is useful first.
    Once an additional portal is made, then the arthroscopic probe can be introduced and menisci probed.

    The lateral gutter is then inspected for any loose bodies or damage to the Popliteus Tendon.In cases of Popliteus Tendon damage the stump can be seen in the lateral gutter, but this is not the case here.
    To access the lateral gutter, one needs to lift up the operating hand to move over the lateral plical folds

    The arthroscope is then introduced into the medial joint, after assessment of the lateral joint space.This shows the medial femoral condyle with a central area of chondropathy (1) and medial meniscal tear (2)

    Lateral joint assessment reveals excellent joint chondral surfaces and an intact lateral meniscus.
    Lateral Femoral Condyle
    Lateral Meniscus
    Lateral Tibial Plateau

    Medial meniscal flap tear (1), mobile in the tibia-femoral joint.
    For a flap tear to form there needs to be radial or oblique tear in the meniscus which allows the mobile free edge to be unstable. Usually in the degnenerative tear there is also a horizontal component and this gives rise to the term ‘parrot beak’ where the point of the free edge can move inside a cleavage plane – usually the flap is anterior and the cleavage is posterior.

    Percutaneous needling of the posterior oblique ligament allows vastly improved access the joint with much less risk of iatrogenic chondral injury.This is performed with a needle or a Venflon.
    I prefer a Grey Venflon (the actual needle part) as this is a longer device which is useful in the larger patient. In addition the bevel of the needle is larger and whilst this sounds more traumatic, actually allows the surgeon more control to introduce less of the needle into the posterior oblique ligament to effect a smaller release.
    In this image I have inserted the needle (1) into the joint at the site of the tear for teaching purposes.
    This technique is described on both the tibial side or the femoral side….personally I prefer to release the joint from the tibial side as I find the posteromedial corner of the tibia easier to palpate as a landmark for which to aim the needle.
    The key steps for a posteromedial release of the posterior oblique ligament (POL) which is the posterior most component of the Medial Collateral Complex are:
    Apply Valgus force with slight knee flexion. This is best achieved by placing the operator’s for on a small stool or upturned bowl. The operator stands on the medial side of the patient’s leg and leans against the side support in approximately 20degrees flexion.
    Next palpate the posteromedial corner -in slender patients the POL can be palpated. However in heavier patients this is not possible. Instead the proximal, posterior medial tibia should be palpated.
    The needle / Venflon should then be aimed percutaneously at the POL – which is on the knee joint capsule – not inta-articular.
    With experience this takes 1-3 passes of the bevel into the POL, but when learning it can take multiple passes to achieve an opening posteriorly.

    Once the posterior-oblique MCL is needled, the joint opens sufficiently to allow good & safe visualisation including seeing and probing the posterior root attachment of the medial meniscus (1)

    The Flo 50 Radiofrequency device from Smith and Nephew
    This is a very useful piece of kit which allows ablation of tissue with the medium and high power settings, but on the low power setting is safe for chondral work to remove the mobile flaps of tissue without damaging the surrounding areas.

    The flap of medial meniscal tissue is excised initially using the Flo 50 Coblator from Smith and NephewI am using this on medium power in this slide.
    The Flo 50 has a very small zone of Radiofrequency and so minimises potential iatrogenic damage to the rest of the joint.

    The degenerative meniscal tissue is excised by moving posteriorly away from the healthy meniscus and capsule
    Once I have demarcated the degenerative meniscal tissue I usually increase power to ‘high’ but it is vital to keep the tip of the Radio-Frequency device in view at all times when active so that the chondral surfaces are protected.

    Notice the flap of meniscal tissue marked (1). I did not want to use the Flo 50 here as it is too close to healthy articular surface….

    Arthroscopic instruments are then used to remove any fine edges that may catch and propagate, which would risk the tear recurringThe loose flap of meniscal tissue is divided off with an arthroscopic punch…..this is straight angled upbighter. There are options of right and left up-cutting punches but in the posterior knee a straight punch usually works well.
    Have a meniscal grasper ready before you perform this step.
    When you are learning, leave a small strand of meniscus and then insert the grasper to retrieve the flap, manually breaking the small strand by pushing deeper into the knee then removing.

    This flap of meniscal tissue is retrieved by an arthroscopic grasper.

    The anterior extent of the medial meniscal tear is checked and the free flaps of tissue trimmed back with a radio-frequency device.I am using the Flo 50 on medium power here, but as I activate the probe and the suction is working, I lift up the meniscus, taking it away form the tibial chondral surface.

    The medial femoral condyle lesion is then chondroplastied with radio-frequency.Notice how I have oriented the Flo 50 ‘along’ the lesion (1) so that the RF device (2) is parallel rather than perpendicular to the joint to minimise spread of thermal energy into the chondral surface.

    Operation – 2

    There is a second chondral lesion on the medial (towards the midline) aspect of the medial femoral condyle.
    Again, notice how the lesion (1) is accessed by the Flo 50 probe (2) parallel to the joint surface. This minimises potential damage from the radio frequency ablation device.
    Due to the design of the Flo 50 Werewolf with the bevelled edge the potential for chondral damage is significantly reduced.


    The two Medial femoral condyle chondral defects (1&2) after chondroplasty to remove unstable surfaces.

    A final probing of the meniscus after partial meniscectomy to ensure stability of the remaining tissue.In essence one should leave as much meniscus as possible – remember that meniscectomy is the last resort if there is inability to repair.
    There is clearly a balance though as an unstable meniscal flap will simply re-tear.
    Remember that the vast majority of tears do NOT need surgery and it is only those where there is a discrete flap of meniscus (usually lying under the meniscus or enrolled into the medial gutter) that should really undergo meniscectomy.

    The arthroscopic portals are sutured with 3-0 MonocrylI use a modified vertical mattress suture across the dermis and cutting the knot flush so that there is no wound care for the patient other than removing the steri-strips and dressing applied in the next slide…..

    Steri-strips and a dressing are applied.I do not use any over bandaging with wool and crepe.

    Post Operative

    Day case
    Fully weight bear – occasionally crutches are required for balance for a couple of days
    No chemical VTE prophylaxis required
    No further imaging
    The patient can shower immediately
    The patient performs all their wound care – they should remove the dressing at 14 days. If there is any concern they simply contact the office / hospital and attend for me to review if there is still concern following discussion with the patient and sometimes with a photograph or video-consultation
    Out-patient review at 6-8 weeks post-operatively.

    Recommended Reading

    There has been considerable interest in meniscectomy from the orthopaedic and wider medical audience over the last 10 years. I have listed some key papers below.
    In summary there is no doubt that too many arthroscopic meniscectomies were performed and this gave rise to a number of high profile studies including RCTs of non-operative management versus Arthroscopic Partial Meniscectomy (APM). I have tried to list a balanced set of papers starting with the sham study of Sihvonen from 2013 which showed no benefit of partial meniscectomy over a sham incision. The Gauffin paper showed a benefit of APM with physiotherapy compared to physio alone. The review paper shows that meniscal repair had a lower failure rate and higher patient satisfaction than partial meniscectomy.
    It must also be remembered that there are potential complications of meniscectomy and this is well address by the Abrams 2018 paper in the Lancet. The risk of sustaining a PE after arthroscopy is 0.078% higher in the surgical group than the general population. Similarly there is an increased risk of infection with arthroscopy of 0.135%. This means that for every 1390 fewer arthroscopies performed, one PE would be saved. Similarly for every 749 fewer arthroscopies, one septic arthritis would be avoided. The risks of complication are very low, but not absent and therefore it is important that we direct surgery to the correct cases.
    For this reason the British Association of the Surgery for the Knee (BASK) established a meniscal working group and after a Delphi Consensus approach they published a guideline for the treatment of meniscal lesions (Abram et al BJJ 2019). The same authors performed a metanalysis on RCTs of APM versus non-operative management and they concluded that APM should not be the treatment for ALL patients with meniscal tears, but there may well be a small to moderate benefit of APM over physiotherapy for a group of non-arthritic patients with meniscal tears. Again this RCT ties in with the BASK guidelines and the ESSKA guidelines – surgery is for a selective group of patients, repair if possible, partial meniscectomy for certain groups (eg mechanical symptoms not settling with non-operative means)
    Key papers:
    Sihvonen R, Paavola M, Malmivaara A, et al.. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear.
    N Engl J Med 2013;369:2515–2524.
    Gauffin H, Tagesson S, Meunier A, Magnusson H, Kvist J. Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study.
    Osteoarthritis Cartilage 2014;22:1808–1816
    Xu C, Zhao J. A meta-analysis comparing meniscal repair with meniscectomy in the treatment of meniscal tears: the more meniscus, the better outcome?
    Knee Surg Sports Traumatol Arthrosc 2015;23:164–170.
    Abram SGF, Judge A, Beard DJ, Price AJ. Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England.
    Lancet 2018;392:2194–2202
    Abram SGF, Hopewell S, Monk AP, et al.. Arthroscopic partial meniscectomy for meniscal tears of the knee: A systematic review and meta-analysis.
    Br J Sports Med 2019.
    Arthroscopic meniscal surgery: a national society treatment guideline and consensus statement.
    Abram SGF, Beard DJ, Price AJ; BASK Meniscal Working Group.
    Bone Joint J. 2019 Jun;101-B(6):652-659. doi: 10.1302/0301-620X.101B6.BJJ-2019-0126.R1.

    Reference

    • orthoracle.com

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