Mi Kun: How to Realize Meniscus Centralization
Some time ago, Many domestic friends listened to my class or watched my lecture video on the Internet and then discussed the problem of meniscus centralization with me, Meniscus centralization is indeed a relatively new topic in recent years. There are not many materials for reference and many debates. We have been working in this area for some time, and it is necessary to tell everyone our immature experience.
We all know that the posterior root of meniscus is different inside and outside; The posterior root of lateral meniscus is mainly caused by trauma, which is often combined with ACL injury; However, the posterior root of the medial meniscus is caused by degeneration of the knee joint, especially the medial compartment of the knee joint, and in most cases is accompanied by genu varus (osteoarthritis of the medial compartment of the knee joint). The treatment of posterior root injury of medial and lateral menisci will be different with different locations and reasons.
In addition to the radial tear of the posterior root of the medial meniscus, there is also an important problem of meniscus protrusion. Therefore, if the posterior root injury of medial meniscus is to be repaired, In addition to suturing the meniscus itself, the problem of knee joint degeneration and even varus should be considered, as well as how to solve the problem of medial meniscus protrusion. How conditions permit, every effort should be made to return the meniscus to its original position so as to restore the original function of the meniscus. This is the centralization of the meniscus!
The relationship between osteoarthritis of the medial compartment of the knee joint and the injury of the posterior root of the medial meniscus is as difficult to tell as the relationship between chicken and egg. Let's leave it alone. However, one thing is clear: the increase of the pressure in the medial compartment of the knee joint and the disappearance of the meniscus ring buckling effect after the tear of the posterior root of the meniscus will inevitably lead to the protrusion of the medial meniscus.
Let's review the anatomy of the meniscus, As we all know, the meniscus is firmly attached to the tibial plateau through the anterior and posterior horn ligaments of the meniscus and the tibial ligaments of the meniscus. These anatomical foundations are extremely important for us to understand the relationship between the posterior root injury of the medial meniscus and the protrusion of the meniscus and how to realize the centralization of the meniscus. They are also supported by the following corresponding literature.
Krych et al. used MRI examination to understand the relationship between meniscus tibial ligament function, medial meniscus dislocation and medial meniscus posterior root tear, and to determine the progress of meniscus protrusion. Results In a series of MRI scans of 27 symptomatic medial meniscus posterior root injuries of the knee joint, all patients showed meniscus tibial ligament rupture and related meniscus dislocation, and then developed into medial meniscus posterior root tear. This result explains the relationship between posterior root injury of medial meniscus and meniscus protrusion.
The main treatment for medial compartment osteoarthritis of knee joint with genu varus is high tibial osteotomy, and then the treatment of posterior root of medial meniscus, which is an important surgical principle! If we violate this principle during the operation, no matter how the posterior root of the medial meniscus is handled and how beautifully it is handled, it will be in vain in the end; On the contrary, a single high tibial osteotomy cannot correct the protrusion of the medial meniscus.
Bancha et al. have published articles in this field. He believes that simple transosseous fixation and repair technology for posterior root injury of medial meniscus cannot completely correct medial meniscus protrusion.
If you want to correct the meniscus protrusion, you must adopt the method of multi-bone canal suture repair and fixation. The purpose of one bone canal is to suture and repair the posterior root injury of the medial meniscus. The function of the other bone canal is to center the meniscus, correct the meniscus protrusion and reduce the tension at the posterior root injury.
Blake et al. also conducted similar research, using three-dimensional digital technology and pressure sensors to measure meniscus compression and tibial-femoral contact mechanics of posterior root injury of medial meniscus of knee joint of 10 unpaired cadavers. The medial meniscus posterior root injury was repaired through tibial tunnel at anatomical and non-anatomical positions, and was divided into centralized and non-centralized treatment groups. As a result, the average contact pressure and peak contact pressure of non-anatomical repair were significantly higher than those of anatomical repair when the knee joint flexion angle was larger. Moreover, centralized anatomical repair can better restore the contact mechanics of knee joint and correct meniscus protrusion.
Ryuichi et al. believed that the defect of transosseous repair was obvious for the injury of the posterior root of the medial meniscus. Instead, they used two suture anchors to repair the posterior root of the medial meniscus and center the meniscus. At the same time, they performed high osteotomy of the medial open tibia. He believes that HTO changes the force line of lower limbs, anchors are not affected by HTO surgery, meniscus centralization corrects meniscus protrusion, improves the healing rate of posterior root injury, and thus slows down the development process of knee osteoarthritis.
We have also used the above methods for treatment, and the results are not satisfactory. Only a few patients can correct meniscus protrusion. Why can't meniscus centralization be realized by repairing medial meniscus posterior root injury through bone canal or anchor even combined with HTO? There may be many reasons; The causes include meniscus degeneration and tear; Degeneration must affect the whole meniscus; The direct manifestation of degeneration is poor elasticity and difficulty in regression; Local causes such as osteophyte formation, contracture of meniscus tibial ligament, etc; These factors are difficult to return to its original position without treating meniscus; The broader reason is, of course, the force line of the lower limbs, which can be solved by HTO surgery. Of course, there must be other reasons that we cannot find or realize for the time being.
We can learn from the treatment of Bankart injury. The first step in arthroscopic repair of Bankart injury is to peel and release. Without sufficient peeling, it is impossible to pull the damaged glenoid lip back to its original position for suture and fixation! On the basis of stripping Bankart injury, the anterior glenoid is properly polished and freshened to promote healing. These shoulder arthroscopic surgery techniques are very useful for the treatment of medial meniscus posterior root injury.
According to the above analysis, we believe that the prerequisite for meniscus centralization of medial meniscus posterior root injury is peeling and release!
Let's look at the following typical case. Patient Mai X, female, 50 years old, suffered from right knee joint pain for 2 years. MRI showed posterior root injury of medial meniscus, meniscus protrusion and articular cartilage degeneration.
Full-length anterior radiograph of lower limbs confirmed varus deformity of knee joint. According to the comprehensive consideration of age, symptoms, MRI and full-length film of lower limbs, the diagnosis of osteoarthritis of medial compartment of knee joint, genu varus and posterior root injury of medial meniscus is clear.
We decided to perform HTO, medial meniscus posterior root repair and meniscus centralization.
Arthroscopic examination shows that ACL in intercondylar fossa is intact, which is very important for severe bone-to-bone medial compartment osteoarthritis of knee joint, because ACL fracture is a contraindication of unicondylar replacement surgery! Of course, these are not to worry about for sports medicine doctors, because we know whether ACL is good or bad through MRI reading before operation; If other conditions are especially suitable for unicondylar replacement, it is not difficult to reconstruct the injured ACL at the same time.
Arthroscopic patellofemoral articular cartilage is good. Even if a certain degree of patellofemoral joint wear is found, HTO and meniscus surgery will not be affected.
Arthroscopic examination shows that the cartilage of the lateral meniscus, femoral lateral condyle and tibial lateral plateau in the lateral compartment of the knee joint is very good, which is the most important of HTO surgery. If the lateral compartment of the knee joint is seriously worn, HTO surgery should not be selected.
Arthroscopically, cartilage wear of the medial condyle of femur and the medial plateau of tibia in the medial compartment of knee joint is seen. The femur is more obvious, but the subchondral bone is not exposed. Combined with the situation of the lateral compartment, HTO surgery is undoubtedly correct.
Arthroscopy clearly shows radial tear of posterior root of medial meniscus, all of which are consistent with our preoperative evaluation.
(2) Stripping and loosening
After systematic knee arthroscopy, if you don't have much experience, you can peel and release the meniscus first. The peeling instrument can borrow Bankart's injured instrument. Only after peeling and releasing can you have the confidence to go down. Experienced people often choose to perform HTO surgery first. After HTO surgery, a relatively open medial compartment of knee joint can be exposed without Pie-crusting technique.
Stripping and release can be carried out from the front. At this time, knee arthroscopy is observed through the anterior-external approach. Stripping instruments enter through the anterior-internal approach, mainly stripping the meniscus tibial ligament under the meniscus. Sharp stripping is used first, and then blunt polishing is used. It is best to polish some hyperplastic osteophytes and form fresh wounds. It is difficult to treat the body with anterior stripping.
Stripping and release can also be carried out on the medial side. At this time, another approach needs to be established below the meniscus on the medial side of the knee joint. First, it is positioned with a lumbar puncture needle, cut with a No.11 blade, and spread with a straight clamp. The stripping instrument enters from this approach and can be stripped to the lower part of the meniscus body and the posterior angle.
After peeling and loosening, you will feel that the meniscus is easy to reduce by grasping the meniscus and pulling it with tissue grasping forceps. Only on this basis can the posterior root of the medial meniscus be repaired and centered. Therefore, we have always believed that stripping and release is the premise of meniscus centralization.
(3) Drilling to repair bone tunnel
If the anchor method is selected for repair and centralization, it may be better to carry out it after HTO is completed. Anchors are not affected by HTO surgery, but the method of selecting anchors after DRGs charges is under great pressure. We use the traditional transosseous repair technique, which can not only drill the repair tunnel to suture the posterior root of medial meniscus and centralize it after HTO operation, but also drill the guide needle at the same time to save the operation time. HTO surgery has certain influence on drilling and repairing bone tunnels, but it can also be carried out smoothly.
We drilled two repair tunnels with ACL tibial sight. The front tunnel must be used for centralization. The rear tunnel has the function of centralization and reducing the tension of posterior root fissure of medial meniscus. Of course, you can also drill a bone tunnel closer to the stop point, just to suture and fix the posterior root of the medial meniscus.
(4) Repair and centralization
Then we will use the suture hook to sew the thread, Two No.2 Aixibang sutures are led respectively, and then the Aixibang sutures are led out to the medial side of the tibial tuberosity by using a lumbar puncture needle and a folded PDS-II suture, and Aixibang is tightened. The sutures can be directly knotted and fixed at the tibial tuberosity, and the meniscus can return to its original position, thus realizing meniscus centralization.
After the completion of centralization, the hook examination showed that the meniscus was stable and the posterior root fissure of the meniscus had no tension, at least achieving the expected purpose.
Finally, as mentioned earlier, the posterior root can be sutured by using the classic transosseous repair technique. However, for this somewhat complicated operation, we still need to do everything possible to save the operation time. Therefore, it is suggested to suture the posterior root tear of medial meniscus with a suture device or suture hook. We have also performed a group of patients with posterior root reconstruction, and the effect needs to be observed.
(5) Postoperative imaging
After the operation, the full-length film of the lower limb shows that the force line of the lower limb returns to normal, which is the goal that must be achieved in the treatment of osteoarthritis of the medial knee joint. No matter what the treatment outcome of the posterior root injury of the medial meniscus is, in general, as long as the force line is restored, the pain relief of the knee joint will be very good.
Postoperative MRI coronal view showed that medial meniscus protrusion was corrected.
MRI sagittal plane showed that the posterior angle of medial meniscus was full and the signal was good.
After meniscus peeling and release, meniscus centralization on the operating table can indeed be realized! However, this is only a preliminary and superficial work for us to carry out meniscus centralization. How effective the long-term effect is still requires long-term, systematic and large-scale clinical observation of cases. However, the indications, taboos, operating procedures, complications and so on of meniscus centralization are in a barren state and still need everyone to work together to improve and solve them.
Mi Kun, Director, Chief Physician and Professor of Department of Osteoarthrosis and Sports Medicine, Guangxi International Zhuang Medicine Hospital (Guangxi University of Chinese Medicine Affiliated International Zhuang Medicine Hospital).
Specialized in: Professor Mi Kun has accumulated rich experience in diagnosis and treatment of bone and joint injuries and diseases, The injury of nerves, blood vessels, tendons, ligaments, cartilage and meniscus and joint pain were deeply studied. Good at diagnosis and treatment of joint injuries and diseases, The treatment of various complex fractures and their complications, the correction of limb bone and joint deformities, limb function reconstruction, skin flap transplantation and modern advanced artificial joint surgery, especially arthroscopic minimally invasive surgery, have innovated many surgical methods. The treatment emphasizes function first and strives to return to exercise. It is the leader of Guangxi orthopedic sports medicine and arthroscopic surgery.
Source: Orthopedics Online Orthonline
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