الفهرس 
ACKNOWLEDGMENTOnly 14 pages are availabe for public view
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Abstract
The essential goal of meniscal repair is protecting the knee from long term degenerative changes by the cushion like and stabilizing effect of the menisci. This work was done on 20 cases to study meniscal repair and its results using all inside repair techniques applied arthroscopically, in order to evaluate the best method for meniscal repair &healing.
In patients studied, meticulous selection was done with clinical examination playing a major role in suspecting tears. MRI, was a major diagnostic tool that helped tear identification as well as identification of ligamentous injuries and other associated knee problems. Patient age and time elapsed from injury was recorded for every case being important factors that might affect repair outcome dramatically. Tests like the McMurray test and joint line tenderness were performed for all cases with suspected meniscal injuries. The site, length & zone of tear were observed, all pre & postoperative data were documented according to the International Knee documentation Committee (IKDC).
Intra-operative findings and difficulties as well as repair techniques were studied. Operative time was recorded in order to monitor the progress of our technical skills. Tight knees were met intra operative in 40% (n= 8) cases in the all cases .Marked valgus was at times required to help open the affected compartment. Number of fixatives used as well as meniscal quality were all recorded in order to provide information about the criteria for repair success.
Postoperative evaluation of the repair was mainly done clinically considering the asymptomatic cases to be healing repairs. MRI was tried as a tool for evaluation of healing but it showed large number of false positive results.
A second look arthroscopy was done for 5 persistently symptomatic cases revealing 4 failed repairs (20%) and 1partially healed case (5%). Rehabilitation was carried out in a gradual way to avoid any unwanted loads on the repair especially in the early postoperative period.
The overall clinical success rate was (80%) as compared to the lower success rate detected by MRI (35%) for healed cases.
from this work, it is advisable to take in consideration the following points:
The best age recommended for meniscal repair should not exceed a maximum of 35 to 40 years to avoid poor meniscal quality.
Obesity may compromise meniscal repairs and those patients are better treated with a partial meniscectomy.
Delay of repair from the time of injury increases the incidence of degenerative changes developing in both the knee and the meniscus. Muscle wasting is also increased by a prolonged time from injury. Therefore, repair is best done as early as possible post-injury (within a month).
Preoperative MRI showed high accuracy as regard case selection and for confirming clinical suspicion. It is a beneficial preoperative diagnostic tool.
Intra-operative tourniquet in required as it provides a bloodless field thus reducing the operative time.
Working portal is switched between the standard antero-medial and antero-lateral portals according to tear site. A tear of the posterior third of the medial meniscus is repaired through the infero-medial portal whereas a tear of the body or the anterior horn is easier to deal with through the infero-lateral portal as the working portal.
The following criteria are essential in meniscal tear selection for repair in order to increase the incidence of the repair success:
1) Tear length should be within 10 to 25 mm.
2) Tear site should show no or minimal damage to meniscal substance (i.e. good quality).
3) Peripheral tears and menisco-capsular separations are the most suitable sites for repair.
Partial meniscectomy is recommended for tears longer than 30 mm especially if they show degenerative changes or lie in the more central aspect of the meniscus (avascular white-white zone). A posterior third tear in an excessively tight knee may require a partial meniscectomy as well due to the inaccessibility of the tear site.
All-inside repair devices need continuous practice at various tear sites in order to get familiar and gain more technical experience.
Tear rasping and edge freshening are important procedures to increase vascularity thus enhancing the healing process.
Postoperatively, repair success assessment relied mainly on the clinical outcome during the postoperative evaluation rather than MRI findings that showed high incidence of false positive results showing persistence of tears in clinically asymptomatic cases.
Postoperative weight bearing should be prohibited for at least four weeks together with knee protection using any kind of knee support preferably a hinged knee brace being rigid enough to provide maximum protection. Very gradual weight bearing over the next 6 weeks is allowed to avoid any unwanted stresses on the repair site. Isometric quadriceps exercises should be started from day one postoperative.
Passive range of motion is allowed from the 3rd week and increased gradually thereafter till the beginning of the 3rd month after which active range is started provided the patient is clinically asymptomatic.
Muscle strengthening should not be allowed before the 3rd month postoperative to avoid unwanted stresses on the healing meniscus.
Return to sports should not be allowed before the 6th month after which it should be started gradually allowing enough time for the meniscus to heal.
Second look arthroscopy should be reserved only for cases with residual clinical complaint. Any failed repairs are better treated with partial meniscectomy due to meniscal damage and fibrotic quality of the previously repaired meniscus.