Arthroscopic Horizontal Cleavage Repair Techniques

Horizontal cleavage tears (HCT) have historically been treated either conservatively or with partial or total meniscectomy. This treatment algorithm has largely been based on concerns surrounding technical difficulty of repair, healing rates due to involvement of the avascular zone of the meniscus, and possible suture failure due to mechanical stress on the repair. Biomechanically, HCTs can increase contact pressures by as much as 70% in the knee joint. Furthermore, leaflet resection or meniscectomy cannot improve this increase in contact pressure, while repair can bring contact pressures back to within 15% of baseline forces. Evolving techniques have led to attempted repair of HCTs with a goal of preserving meniscus function and preventing long-term sequela. In general, HCTs should be attempted to be repaired or partially repaired in patients that are active, historically younger than 40 years old, and have no significant comorbidities, a BMI of less than 35, normal lower limb mechanical axis, KL grade <= 2, and a willingness to comply with post-operative rehabilitation protocols. Strong consideration for repair should also be given to tears that are less than 3 months old, are associated with intra-articular ligamentous injury, and appear to be repairable on diagnostic arthroscopy. Arthroscopic evaluation and preparation of the tear should include rasping or trephination to increase stimulation of bleeding in the repair site. The repair configuration can be done in several ways, with the goal to provide circumferential compression between the two leaflets. Biologic adjuncts such as platelet-rich protein (PRP), bone marrow aspirate, and fibrin clot augmentation can be used to try and increase healing potential. Post-operative rehabilitation protocols depend on the complexity of the tear. Any radial components, or an extremely large tear often will require weight bearing restrictions. The authors’ preferred treatment is partial weight bearing for 2 weeks and crutch use for 4 weeks for simple horizontal cleavage tears (<50% meniscus involvement, tear pattern simple with no complexity). For large tears (>50% meniscus) and complex tear patterns, non-weight bearing is initiated for 2–4 weeks, and crutch use is continued for a total 4–6 weeks. Also, range of motion is limited to flexion to 90 degrees for the first 4 weeks to avoid added stress to repair in flexion past 90 degrees. Return to sport is often around 5–7 months depending upon progression of rehabilitation.