---

Meniscus Repair Criteria

Vascularity Zones (the Foundation of Decision-Making)

---

Tears That Can DEFINITELY Be Repaired

• Single vertical (longitudinal) tears in the peripheral vascular portion (red-red or red-white zone, within 3 mm of the meniscosynovial junction)
• Tear is displaceable (unstable on probing)
• Length >1 cm (shorter peripheral tears of ≤7 mm with <3 mm displacement can often heal with rasping alone, without sutures)
• Minimal damage to the body of the meniscus
• Acute presentation (fresh tear with good tissue quality)

---

Patient-Related Criteria (Bailey & Love's Surgery, 28th Ed)

---

Conditional Repairs (Certain Circumstances)

• Tears 3-5 mm from the meniscosynovial junction may be repaired when:
  • Tourniquet deflation confirms vascularity (rasping produces bleeding)
  • Patient is young and active with minimal meniscal body damage
  • ACL reconstruction is performed concomitantly (hemarthrosis enhances healing)
  • Trephination with an 18-gauge spinal needle can be used to stimulate bleeding and create vascular access channels in borderline tears

---

Special Tear Types

• Posterior root tears (10-20% of tears): must be repaired in non-arthritic knees to prevent cartilage overload and degeneration - transtibial tunnel + button fixation
• Ramp lesions: peripheral posterior horn medial meniscal tears from ACL pivot shift - repair recommended
• Radial tears: complete radial tears to the meniscosynovial junction should be repaired (horizontal mattress) to preserve load-distribution function; a 2026 systematic review (PMID 42432690) confirms favorable healing rates for surgical repair of radial tears
• Bucket-handle tears: acute displaced bucket-handle tears in young patients are candidates for repair; keep patient non-weight bearing on crutches until MRI confirms, to prevent fragment damage

---

Contraindications to Repair

• Degenerative/chronic tears with distorted, fixed tissue
• White-white zone (avascular inner third) - if repair attempted, requires fibrin clot or biologic augmentation
• Significant chondral damage (Outerbridge III-IV)
• Horizontal cleavage tears in older patients - generally resect
• Unstable ACL-deficient knee (relative contraindication unless concurrent ACL reconstruction)

---

Repair Technique Selection (Box 56.3, Campbell's)

---

Campbell's Core Principles

"Preserve functional meniscus; resect and contour damaged tissue. Repair the meniscus to protect the cartilage; repair the cartilage to protect the meniscus."

• Campbell's Operative Orthopaedics 15th Ed 2026, pp. 3059-3065
• Bailey and Love's Short Practice of Surgery 28th Ed, p. 585

---

Topics for Case Presentation: Periprosthetic Femur Fracture Around Right Hip Hemiarthroplasty

---

1. THE ORIGINAL PROCEDURE - Hemiarthroplasty Right Hip

Why it was done (the background diagnosis)

• Femoral neck fracture - most common indication
• Garden classification of femoral neck fractures:
  • Garden I (incomplete/impacted), II (complete undisplaced), III (partial displacement), IV (complete displacement)
  • Garden III and IV = displaced intracapsular fractures - primary indication for hemiarthroplasty
• Pauwels classification (angle of fracture line): Type I <30°, Type II 30-50°, Type III >50° - relevant to biomechanical stability
• AO/OTA classification of femoral neck fractures

Indications for Hemiarthroplasty vs. other options

• NICE guidelines: THA preferred if patient walks independently (no more than a stick), expected to perform ADLs for >2 years, no contraindication to THA
• Hemiarthroplasty advantages: shorter operative time, less blood loss, lower dislocation rate (0.9% vs 1.6% for THA)
• Hemiarthroplasty disadvantages: risk of acetabular erosion/wear, no ability to resurface acetabulum

Implant types in hemiarthroplasty

• Unipolar (Austin Moore, Thompson): single articulation at native acetabulum - higher acetabular wear
• Bipolar: inner and outer articulations - theoretically less acetabular wear (long-term data show no significant difference)
• Cemented vs. uncemented:
  • Cemented: lower risk of periprosthetic fracture, risk of bone cement implantation syndrome (BCIS)
  • Uncemented: higher fracture risk, especially intraoperatively with press-fit stems

Surgical approaches

• Posterior approach (Moore): most common, higher dislocation risk
• Anterolateral (Watson-Jones): lower dislocation rate
• Direct lateral (Hardinge): risk of abductor damage

---

2. ANATOMY - Proximal Femur and Implant

Bony anatomy

• Femoral head, neck, greater and lesser trochanters
• Femoral shaft - cortical thickness, medullary canal dimensions
• Calcar femorale - dense cortical bone at inferomedial neck-shaft junction
• Anterior bow of the femur (relevant to stem fit and fracture pattern)

Vascular anatomy

• Medial and lateral circumflex femoral arteries (from profunda femoris)
• Retinacular vessels along femoral neck - critical for femoral head vascularity
• Perimeniscal capillary plexus not applicable here - focus on periosteal blood supply of diaphysis

Implant-bone interface zones

• Metaphyseal fit (proximal), diaphyseal fit (distal)
• Stem tip = stress riser - highest risk zone for fracture

---

3. PERIPROSTHETIC FEMUR FRACTURE (PPF) - Core Topic

Definition

Epidemiology and Risk Factors

• Incidence after primary THA: <1% to 2.3% postoperatively; 0.8% at 5 years, 3.5% at 10 years
• Incidence after hemiarthroplasty is similar, slightly higher with uncemented stems
• Projected to rise 4.6% per decade due to increasing arthroplasty burden
• Patient risk factors: osteoporosis, female sex, rheumatoid arthritis, Paget's disease, osteolysis, revision surgery (6x higher risk), old age
• Implant risk factors: uncemented stem (higher risk than cemented), poor cortical index, previous osteolysis/lysis around stem

Timing

• Intraoperative: calcar crack during insertion of press-fit stem - may be unrecognized
• Early postoperative: propagation of unrecognized intraoperative fracture
• Late postoperative: low-energy fall onto background of osteoporosis or periprosthetic osteolysis

---

4. CLASSIFICATION - The Most Important Topic

Vancouver Classification (Standard - must know in detail)

• B1: fracture around stem tip, stem is well-fixed - treat with ORIF (plate + screws ± strut allograft)
• B2: fracture around stem tip, stem is loose - revision arthroplasty to long stem
• B3: fracture around loose stem + significant bone loss - revision + allograft/proximal femoral replacement

Key clinical challenge: Distinguishing B1 from B2 intraoperatively (implant stability testing) and radiographically.

Intraoperative Vancouver Classification

Unified Classification System for Periprosthetic Fractures (UCPF)

• More recently proposed, applicable across all joints

---

5. CLINICAL PRESENTATION AND WORKUP

History

• Original indication for hemiarthroplasty (displaced NOF fracture)
• Mechanism of current injury (low-energy fall vs. spontaneous)
• Pre-fracture hip symptoms: mechanical thigh pain or groin pain = suggests loosening even before fracture
• Comorbidities: osteoporosis (on bisphosphonates?), rheumatoid arthritis, steroid use, metabolic bone disease
• Functional status pre- and post-hemiarthroplasty

Examination

• Pain, deformity, shortening, external rotation of the limb
• Neurovascular status (sciatic nerve, femoral nerve)
• Skin condition, wounds (previous surgical scars)
• Signs of infection (warmth, erythema, discharge)

Investigations

• AP pelvis and lateral hip X-ray (baseline comparison with old films is essential)
• Full-length femur X-ray - to assess entire stem and distal extent of fracture
• CT scan - fracture pattern, bone stock assessment, implant positioning
• Look for: stem subsidence, cement mantle fracture, endosteal scalloping/osteolysis (loosening signs)

• FBC, ESR, CRP - rule out periprosthetic joint infection (PJI) as a differential
• Serum calcium, phosphate, ALP, PTH - metabolic bone disease
• Renal function (bisphosphonate use, contrast for CT)
• Clotting, group and save (pre-operative)

• Bone scan/SPECT - assess implant loosening (increased uptake around stem tip = loose)
• White cell scan - if PJI suspected

---

6. TREATMENT - The Heart of the Presentation

Treatment Algorithm Based on Vancouver Type

Non-operative Treatment

• Only for: truly non-displaced fractures, patient unfit for surgery, or minimal functional demands
• Non-displaced B fractures: protected weight bearing + teriparatide (PTH analogue) - 100% union in B1, 75% in B2 in one series

ORIF Techniques for B1

• Locking plates with unicortical screws/cables proximal (around stem), bicortical screws distal
• Cortical strut allografts - onlay grafts supplementing plate fixation, biologic augmentation
• Cable-plate systems (e.g., Dall-Miles)

Revision Arthroplasty for B2/B3

• Long-stem uncemented revision femoral component (bypasses fracture by 2+ cortical diameters)
• ± adjuvant lateral plate or cortical strut allograft
• Check acetabular component stability - may need concomitant acetabular revision
• Pre-operative planning: obtain original operative note, manufacturer details for component compatibility

Special Surgical Considerations

• Bone cement implantation syndrome (BCIS) if cementing a new stem
• Intraoperative cerclage wires for calcar cracks during stem insertion
• Need for bone graft - autograft (iliac crest) or allograft struts

---

7. COMPLICATIONS

Early

• Re-fracture
• Implant failure (stem subsidence, plate breakage)
• Infection / Periprosthetic Joint Infection (PJI)
• Dislocation
• Neurovascular injury (sciatic nerve palsy - risk if leg lengthened >3-5 cm)
• DVT / PE (high risk in elderly post-arthroplasty)
• BCIS

Late

• Non-union
• Malunion
• Aseptic loosening of revised stem
• Heterotopic ossification
• Acetabular erosion (hemiarthroplasty-specific)

Mortality

• PPF carries high 1-year mortality in elderly patients - equivalent to the original hip fracture
• 8-fold higher mortality rate vs age-matched controls; ~11% in some ORIF series
• Functional outcomes (Oxford Hip Score) are worse than revision THA for other causes

---

8. POSTOPERATIVE REHABILITATION AND WEIGHT BEARING

• Weight bearing status depends on fracture type and fixation
• B1 (ORIF): protected weight bearing until radiologic evidence of healing
• B2/B3 (revision with long stem): often immediate full weight bearing if stem bypasses fracture adequately
• DVT prophylaxis (LMWH / DOACs), physiotherapy, fall prevention
• Osteoporosis management: calcium, vitamin D, bisphosphonates (note: hold until fracture heals)

---

9. RELEVANT SCORES AND OUTCOME MEASURES

• Oxford Hip Score (OHS) - functional outcome
• Harris Hip Score - widely used in hip arthroplasty
• Parker Mobility Score - pre-fracture mobility assessment
• ASA grade - anaesthetic risk
• Nottingham Hip Fracture Score - 30-day mortality prediction

---

10. IMPORTANT DIFFERENTIAL DIAGNOSES TO MENTION

• Periprosthetic Joint Infection (PJI) - can cause pathological fracture; elevated ESR/CRP; use ICM (International Consensus Meeting) criteria
• Aseptic loosening without fracture
• Stress fracture vs. insufficiency fracture (osteoporotic)
• Pathological fracture from metastatic disease (rule out with bone scan + primary workup if suspected)

---

Summary of Key Learning Points for Your Case