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A Medial Meniscal Root Pullout Repair With the Use of a Tibial Tunnel Suturing Technique
A Medial Meniscal Root Pullout Repair With the Use of a Tibial Tunnel Suturing Technique Adinun Apivatgaroon, M.D., and Bancha Chernchujit, M.D.
Abstract: A meniscal root tear is one of the common knee injuries that can lead to degenerative changes in the knee joint. Meniscal root repairs can restore proper biomechanics of the knee joint. We have developed a suturing technique that uses a tibial tunnel for a pullout suture medial meniscal root repair. This is a straightforward technique that helps to promote simple suturing of the medial meniscal root, avoid iatrogenic injuries to the articular cartilage, and produce an additional working portal during a meniscal root repair.
T
he meniscus is a semilunar, wedge-shaped fibrocartilaginous structure that plays roles in the load bearing, load transmission, shock absorption, joint lubrication, and nutrition of articular cartilages.1 Meniscal injuries lead to decreasing tibiofemoral contact areas and increase the articular cartilage’s peak pressures. The meniscal root is the attachment of the meniscus to the tibial plateau, anterior and posterior, in both the medial and lateral menisci. Injuries of the meniscus root can affect the meniscal hoop tension and are associated with meniscal extrusion, increase peak contact pressures in the joint, and result in degenerative changes of the knee joint. Meniscal root repair has been shown to restore joint biomechanics to within normal limits.2 The treatments of meniscal root tears include nonsurgical management, partial meniscectomy, and meniscal root repair. The common repair techniques are arthroscopic transosseous suture repairs and suture anchor repairs that have been shown to produce good to excellent results.3 To date, there has not been shown to be any differences in terms of clinical evaluations, functional scores, and radiographic evaluation from either technique after a medial meniscal root repair.4
From the Department of Orthopedic Surgery, Faculty of Medicine, Thammasat University, Klong Luang, Rangsit, Prathumthani, Thailand. The authors report that they have no conflict of interest in the authorship and publication of this article. Received November 16, 2015; accepted February 4, 2016. Address correspondence to Adinun Apivatgaroon, M.D., Department of Orthopedic Surgery, Faculty of Medicine, Thammasat University, Paholyothin Road, Klong Luang, Rangsit, Prathumthani 12121, Thailand. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/151070/$36.00 http://dx.doi.org/10.1016/j.eats.2016.02.005
This technical note outlines a pullout suture medial meniscal root repair with the development of a suturing technique that uses a tibial tunnel. The technique uses a tibial tunnel and posteromedial portal to pass the suture through the tibial tunnel to the meniscal root in the cruciate configuration (Table 1).
Surgical Technique In the posterior root repair of the medial meniscus (Video 1), the preoperative setup, we place the patient in a supine position with the affected knee at 90 flexion with the use of a pneumatic tourniquet. Spinal anesthesia or general anesthesia is used according to the patient’s preference. The standard anterolateral portal is created first followed by the creation of an anteromedial working portal. After standard diagnostic arthroscopy, the medial meniscus is examined with an arthroscopic probe at approximately 20 to 30 knee flexion with a valgus and external foot rotation. The torn posterior root of the meniscus is identified. The Tibial Footprint and Tunnel Preparation The bony base of the meniscal root is refreshed with an arthroscopic shaver and the posteromedial portal is created with an outside-in technique performed under direct visualization. Then, a 7-mm cannula (Conmed Linvatec) is placed through the posteromedial portal. The transtibial anterior cruciate ligament guide pin (Acufex Director Drill Guide; Smith & Nephew) is inserted through the anteromedial portal with views obtained from the anterolateral portal. We then drill a 2.4-mm-diameter guide pin from the anteromedial aspect of the proximal tibia through the meniscal root
Arthroscopy Techniques, Vol 5, No 3 (June), 2016: pp e595-e599
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Table 1. Key Points Injuries of the meniscal root lead to long-term joint degeneration. Repair of the meniscal root has shown a significant improvement of the knee function. The pullout suture technique is one of the popular methods used in a meniscal root repair. The described technique is a simple method to help with practical suturing of the medial meniscal root that helps to avoid iatrogenic injuries to the articular cartilage and produce another working portal for meniscal root repairs.
footprint followed by reaming of the tibial tunnel with an EndoButton 4.5-mm drill (Smith & Nephew) (Fig 1). The Meniscal Repair Process The Nitinol (meniscal repair needle, ConMed Linvatec) is passed from the proximal tibia through the EndoButton drill hole and the medial meniscal root in a retrograde direction. The Nitinol with a No. 2 Ethibond suture (Ethicon, Johnson & Johnson) is pulled through the posteromedial portal (Fig 2). The meniscal suture is repeated using the Nitinol with a 2-0 polydioxanone suture (Johnson & Johnson). Then, the suture is passed through the same arthroscopic cannula. We have used a shuttle relay technique to pull 1 limb of the Ethibond back to the sutured meniscus and the tibial tunnel (Fig 3). The second No. 2 Ethibond is used to repair the meniscal root using the same technique as performed in the cruciate configuration (Fig 4). The 4 limbs of 2 Ethibond sutures are then pulled with adequate tension and secured with the EndoButton (Smith & Nephew) to the anterior cortex of the tibia (Fig 5). Postoperative Management A limited-motion, hinged knee brace is applied in 0 to 90 knee flexion for 6 weeks postoperatively, and then progressive knee flexion is done at approximately 10 to 20 per week without a knee brace until the patient has achieved normal range of motion. Partial weight bearing of less than 50% of the subjects’ body weight is allowed
Fig 2. Images show the steps in the suturing medial meniscal root through the tibial tunnel. (A) The Nitinol is passed through the tibial tunnel and the medial meniscus in the retrograde direction. (B, C) The Nitinol is pulled with a No. 2 Ethibond suture through the posteromedial portal (PM).
Fig 1. Images show the intra-articular finding from the anterolateral viewing portal of the right knee, supine position, and 90 knee flexion. (A) Medial meniscal root tear (red arrow). (B, C) Identification, preparation, and creation of the tibial tunnel (TT) under direct visualization.
TIBIAL TUNNEL SUTURING MENISCAL ROOT REPAIR
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Fig 3. Images show the complete first pullout suture. (A-C) Repeated suture in the anteriorposterior direction with the Nitinol and a 2-0 polydioxanone suture using a shuttle relay technique. (D) The meniscus after pulling both limbs of the first No. 2 Ethibond through the tibial tunnel portal.
until 6 weeks after the removal of the brace and then progressed to full weight bearing as tolerated. Quadriceps strengthening exercises are performed as soon as the patient is able to do so. Deep squatting exercises are permitted after 3 months and the patient may return to participating in sports 6 months postoperatively.
Discussion A partial meniscectomy does not restore the normal meniscal biomechanical functions. Medial meniscal root repair is believed to restore the normal knee biomechanics in terms of the maintenance of meniscal positioning, prevention of meniscal extrusion, and preservation of the meniscal function.5 There have been several reports regarding the results of posterior root repairs of medial menisci with good to excellent results. A study from Lee et al.,6 has reported on 21 knees with arthroscopic pullout suture repairs of the medial meniscus with a follow-up of more than 2 years and has evidenced that patients were able to improve their knee scores, postoperatively, with no significant changes in radiographic grades at their final follow-up. Ten of 21 patients have received a second-look arthroscopy, and 100% of them have shown to be completely healed. Cho and Song7,8 have reported on the technique of a pullout medial menisci root repair. In their study, 13 of 20 patients received second-look arthroscopies at an average of 7.1 months (5 to 24 months) postoperatively, but only 4 of the
13 patients had completely healed. However, the postoperative knee scores have shown improvement for all patients. Ahn et al.9 have shown the technique of the pullout suture using a trans-septal portal with the suturing done using a crescent-shaped suture hook from the posteromedial portal. Kim et al.10 have described the technique used to repair the medial meniscal root using a suture anchor. One study has shown superior biomechanical properties of the suture anchor repair technique when compared with the transtibial pullout repair.11 Currently, there have been no differences in terms of clinical evaluations, functional scores, and radiographic evaluation from both techniques after a medial meniscal root repair.4 Our technique has been developed using a posteromedial portal with a pullout meniscal posterior root repair with the passage of the suture from the tibial tunnel (Table 2). The technique has advantages in terms of the very simple method that has been performed to help with trouble-free suturing of the medial meniscal root, the production of another working portal during a meniscal root repair, avoiding iatrogenic injuries to the articular cartilage, and the restoration of the meniscal anatomies. This technique has limitation or risk that the surface area of the sutured meniscus maybe small if only the tibial tunnel portal is used for suturing; additional suturing from the posteromedial or anterior working portal may be needed in case of the small cruciate configuration of the sutures (Table 3).
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Fig 5. The 4 limbs of 2 Ethibond sutures are pulled and secured with the EndoButton to the anterior cortex of the tibia. Table 2. Pearls The torn meniscal root should be repaired to the meniscal footprint to restore the normal joint biomechanics. Posterior root repairs of medial menisci have shown the good to excellent results. With this technique, the direction of the tibial tunnel is the key to achieve the good meniscal sutures.
Table 3. Advantages and Risks and Limitations Advantages Very simple method that has been performed to help with troublefree suturing of the medial meniscal root Production of another working portal during a meniscal root repair May avoid iatrogenic injuries to the articular cartilage Risks and limitations Small surface area of the sutured meniscus if only the tibial tunnel is used for suturing
References
Fig 4. Images show the second pullout suture. (A, B) The same steps as of Figures 2 and 3 with the Nitinol and the second No. 2 Ethibond in the medial-lateral direction. (C) The double pullout sutures in the cruciate configuration (red arrow).
1. Makris EA, Hadidi P, Athanasiou KA. The knee meniscus: Structure-function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials 2011;32:7411-7431. 2. Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the posterior root of the medial meniscus: Similar to total meniscectomy. J Bone Joint Surg Am 2008;90:1922-1931. 3. Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears: Significance, diagnosis, and treatment. Am J Sports Med 2014;42:3016-3030. 4. Kim J-H, Chung J-H, Lee D-H, Lee Y-S, Kim J-R, Ryu K-J. Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: A prospective comparison study. Arthrosc J Arthrosc Relat Surg 2011;27:1644-1653. 5. Jones AO, Houang MT, Low RS, Wood DG. Medial meniscus posterior root attachment injury and degeneration: MRI findings. Australas Radiol 2006;50:306-313.
TIBIAL TUNNEL SUTURING MENISCAL ROOT REPAIR 6. Lee JH, Lim YJ, Kim KB, Kim KH, Song JH. Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: Radiographic and clinical results with a 2-year follow-up. Arthrosc J Arthrosc Relat Surg 2009;25: 951-958. 7. Cho JH. Modified pull-out suture in posterior root tear of the medial meniscus: Using a posteromedial portal. Knee Surg Relat Res 2012;24:124. 8. Cho JH, Song JG. Second-look arthroscopic assessment and clinical results of modified pull-out suture for posterior root tear of the medial meniscus. Knee Surg Relat Res 2014;26:106-113.
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9. Ahn JH, Wang JH, Yoo JC, Noh HK, Park JH. A pull out suture for transection of the posterior horn of the medial meniscus: Using a posterior trans-septal portal. Knee Surg Sport Traumatol Arthrosc 2007;15:1510-1513. 10. Kim J-H, Shin D-E, Dan J-M, Nam K-S, Ahn T-K, Lee D-H. Arthroscopic suture anchor repair of posterior root attachment injury in medial meniscus: Technical note. Arch Orthop Trauma Surg 2009;129:1085-1088. 11. Feucht MJ, Grande E, Brunhuber J, et al. Biomechanical comparison between suture anchor and transtibial pullout repair for posterior medial meniscus root tears. Am J Sports Med 2014;42:187-193.
Abstract: A meniscal root tear is one of the common knee injuries that can lead to degenerative changes in the knee joint. Meniscal root repairs can restore proper biomechanics of the knee joint. We have developed a suturing technique that uses a tibial tunnel for a pullout suture medial meniscal root repair. This is a straightforward technique that helps to promote simple suturing of the medial meniscal root, avoid iatrogenic injuries to the articular cartilage, and produce an additional working portal during a meniscal root repair.
T
he meniscus is a semilunar, wedge-shaped fibrocartilaginous structure that plays roles in the load bearing, load transmission, shock absorption, joint lubrication, and nutrition of articular cartilages.1 Meniscal injuries lead to decreasing tibiofemoral contact areas and increase the articular cartilage’s peak pressures. The meniscal root is the attachment of the meniscus to the tibial plateau, anterior and posterior, in both the medial and lateral menisci. Injuries of the meniscus root can affect the meniscal hoop tension and are associated with meniscal extrusion, increase peak contact pressures in the joint, and result in degenerative changes of the knee joint. Meniscal root repair has been shown to restore joint biomechanics to within normal limits.2 The treatments of meniscal root tears include nonsurgical management, partial meniscectomy, and meniscal root repair. The common repair techniques are arthroscopic transosseous suture repairs and suture anchor repairs that have been shown to produce good to excellent results.3 To date, there has not been shown to be any differences in terms of clinical evaluations, functional scores, and radiographic evaluation from either technique after a medial meniscal root repair.4
From the Department of Orthopedic Surgery, Faculty of Medicine, Thammasat University, Klong Luang, Rangsit, Prathumthani, Thailand. The authors report that they have no conflict of interest in the authorship and publication of this article. Received November 16, 2015; accepted February 4, 2016. Address correspondence to Adinun Apivatgaroon, M.D., Department of Orthopedic Surgery, Faculty of Medicine, Thammasat University, Paholyothin Road, Klong Luang, Rangsit, Prathumthani 12121, Thailand. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/151070/$36.00 http://dx.doi.org/10.1016/j.eats.2016.02.005
This technical note outlines a pullout suture medial meniscal root repair with the development of a suturing technique that uses a tibial tunnel. The technique uses a tibial tunnel and posteromedial portal to pass the suture through the tibial tunnel to the meniscal root in the cruciate configuration (Table 1).
Surgical Technique In the posterior root repair of the medial meniscus (Video 1), the preoperative setup, we place the patient in a supine position with the affected knee at 90 flexion with the use of a pneumatic tourniquet. Spinal anesthesia or general anesthesia is used according to the patient’s preference. The standard anterolateral portal is created first followed by the creation of an anteromedial working portal. After standard diagnostic arthroscopy, the medial meniscus is examined with an arthroscopic probe at approximately 20 to 30 knee flexion with a valgus and external foot rotation. The torn posterior root of the meniscus is identified. The Tibial Footprint and Tunnel Preparation The bony base of the meniscal root is refreshed with an arthroscopic shaver and the posteromedial portal is created with an outside-in technique performed under direct visualization. Then, a 7-mm cannula (Conmed Linvatec) is placed through the posteromedial portal. The transtibial anterior cruciate ligament guide pin (Acufex Director Drill Guide; Smith & Nephew) is inserted through the anteromedial portal with views obtained from the anterolateral portal. We then drill a 2.4-mm-diameter guide pin from the anteromedial aspect of the proximal tibia through the meniscal root
Arthroscopy Techniques, Vol 5, No 3 (June), 2016: pp e595-e599
e595
e596
A. APIVATGAROON AND B. CHERNCHUJIT
Table 1. Key Points Injuries of the meniscal root lead to long-term joint degeneration. Repair of the meniscal root has shown a significant improvement of the knee function. The pullout suture technique is one of the popular methods used in a meniscal root repair. The described technique is a simple method to help with practical suturing of the medial meniscal root that helps to avoid iatrogenic injuries to the articular cartilage and produce another working portal for meniscal root repairs.
footprint followed by reaming of the tibial tunnel with an EndoButton 4.5-mm drill (Smith & Nephew) (Fig 1). The Meniscal Repair Process The Nitinol (meniscal repair needle, ConMed Linvatec) is passed from the proximal tibia through the EndoButton drill hole and the medial meniscal root in a retrograde direction. The Nitinol with a No. 2 Ethibond suture (Ethicon, Johnson & Johnson) is pulled through the posteromedial portal (Fig 2). The meniscal suture is repeated using the Nitinol with a 2-0 polydioxanone suture (Johnson & Johnson). Then, the suture is passed through the same arthroscopic cannula. We have used a shuttle relay technique to pull 1 limb of the Ethibond back to the sutured meniscus and the tibial tunnel (Fig 3). The second No. 2 Ethibond is used to repair the meniscal root using the same technique as performed in the cruciate configuration (Fig 4). The 4 limbs of 2 Ethibond sutures are then pulled with adequate tension and secured with the EndoButton (Smith & Nephew) to the anterior cortex of the tibia (Fig 5). Postoperative Management A limited-motion, hinged knee brace is applied in 0 to 90 knee flexion for 6 weeks postoperatively, and then progressive knee flexion is done at approximately 10 to 20 per week without a knee brace until the patient has achieved normal range of motion. Partial weight bearing of less than 50% of the subjects’ body weight is allowed
Fig 2. Images show the steps in the suturing medial meniscal root through the tibial tunnel. (A) The Nitinol is passed through the tibial tunnel and the medial meniscus in the retrograde direction. (B, C) The Nitinol is pulled with a No. 2 Ethibond suture through the posteromedial portal (PM).
Fig 1. Images show the intra-articular finding from the anterolateral viewing portal of the right knee, supine position, and 90 knee flexion. (A) Medial meniscal root tear (red arrow). (B, C) Identification, preparation, and creation of the tibial tunnel (TT) under direct visualization.
TIBIAL TUNNEL SUTURING MENISCAL ROOT REPAIR
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Fig 3. Images show the complete first pullout suture. (A-C) Repeated suture in the anteriorposterior direction with the Nitinol and a 2-0 polydioxanone suture using a shuttle relay technique. (D) The meniscus after pulling both limbs of the first No. 2 Ethibond through the tibial tunnel portal.
until 6 weeks after the removal of the brace and then progressed to full weight bearing as tolerated. Quadriceps strengthening exercises are performed as soon as the patient is able to do so. Deep squatting exercises are permitted after 3 months and the patient may return to participating in sports 6 months postoperatively.
Discussion A partial meniscectomy does not restore the normal meniscal biomechanical functions. Medial meniscal root repair is believed to restore the normal knee biomechanics in terms of the maintenance of meniscal positioning, prevention of meniscal extrusion, and preservation of the meniscal function.5 There have been several reports regarding the results of posterior root repairs of medial menisci with good to excellent results. A study from Lee et al.,6 has reported on 21 knees with arthroscopic pullout suture repairs of the medial meniscus with a follow-up of more than 2 years and has evidenced that patients were able to improve their knee scores, postoperatively, with no significant changes in radiographic grades at their final follow-up. Ten of 21 patients have received a second-look arthroscopy, and 100% of them have shown to be completely healed. Cho and Song7,8 have reported on the technique of a pullout medial menisci root repair. In their study, 13 of 20 patients received second-look arthroscopies at an average of 7.1 months (5 to 24 months) postoperatively, but only 4 of the
13 patients had completely healed. However, the postoperative knee scores have shown improvement for all patients. Ahn et al.9 have shown the technique of the pullout suture using a trans-septal portal with the suturing done using a crescent-shaped suture hook from the posteromedial portal. Kim et al.10 have described the technique used to repair the medial meniscal root using a suture anchor. One study has shown superior biomechanical properties of the suture anchor repair technique when compared with the transtibial pullout repair.11 Currently, there have been no differences in terms of clinical evaluations, functional scores, and radiographic evaluation from both techniques after a medial meniscal root repair.4 Our technique has been developed using a posteromedial portal with a pullout meniscal posterior root repair with the passage of the suture from the tibial tunnel (Table 2). The technique has advantages in terms of the very simple method that has been performed to help with trouble-free suturing of the medial meniscal root, the production of another working portal during a meniscal root repair, avoiding iatrogenic injuries to the articular cartilage, and the restoration of the meniscal anatomies. This technique has limitation or risk that the surface area of the sutured meniscus maybe small if only the tibial tunnel portal is used for suturing; additional suturing from the posteromedial or anterior working portal may be needed in case of the small cruciate configuration of the sutures (Table 3).
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A. APIVATGAROON AND B. CHERNCHUJIT
Fig 5. The 4 limbs of 2 Ethibond sutures are pulled and secured with the EndoButton to the anterior cortex of the tibia. Table 2. Pearls The torn meniscal root should be repaired to the meniscal footprint to restore the normal joint biomechanics. Posterior root repairs of medial menisci have shown the good to excellent results. With this technique, the direction of the tibial tunnel is the key to achieve the good meniscal sutures.
Table 3. Advantages and Risks and Limitations Advantages Very simple method that has been performed to help with troublefree suturing of the medial meniscal root Production of another working portal during a meniscal root repair May avoid iatrogenic injuries to the articular cartilage Risks and limitations Small surface area of the sutured meniscus if only the tibial tunnel is used for suturing
References
Fig 4. Images show the second pullout suture. (A, B) The same steps as of Figures 2 and 3 with the Nitinol and the second No. 2 Ethibond in the medial-lateral direction. (C) The double pullout sutures in the cruciate configuration (red arrow).
1. Makris EA, Hadidi P, Athanasiou KA. The knee meniscus: Structure-function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials 2011;32:7411-7431. 2. Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the posterior root of the medial meniscus: Similar to total meniscectomy. J Bone Joint Surg Am 2008;90:1922-1931. 3. Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears: Significance, diagnosis, and treatment. Am J Sports Med 2014;42:3016-3030. 4. Kim J-H, Chung J-H, Lee D-H, Lee Y-S, Kim J-R, Ryu K-J. Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: A prospective comparison study. Arthrosc J Arthrosc Relat Surg 2011;27:1644-1653. 5. Jones AO, Houang MT, Low RS, Wood DG. Medial meniscus posterior root attachment injury and degeneration: MRI findings. Australas Radiol 2006;50:306-313.
TIBIAL TUNNEL SUTURING MENISCAL ROOT REPAIR 6. Lee JH, Lim YJ, Kim KB, Kim KH, Song JH. Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: Radiographic and clinical results with a 2-year follow-up. Arthrosc J Arthrosc Relat Surg 2009;25: 951-958. 7. Cho JH. Modified pull-out suture in posterior root tear of the medial meniscus: Using a posteromedial portal. Knee Surg Relat Res 2012;24:124. 8. Cho JH, Song JG. Second-look arthroscopic assessment and clinical results of modified pull-out suture for posterior root tear of the medial meniscus. Knee Surg Relat Res 2014;26:106-113.
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9. Ahn JH, Wang JH, Yoo JC, Noh HK, Park JH. A pull out suture for transection of the posterior horn of the medial meniscus: Using a posterior trans-septal portal. Knee Surg Sport Traumatol Arthrosc 2007;15:1510-1513. 10. Kim J-H, Shin D-E, Dan J-M, Nam K-S, Ahn T-K, Lee D-H. Arthroscopic suture anchor repair of posterior root attachment injury in medial meniscus: Technical note. Arch Orthop Trauma Surg 2009;129:1085-1088. 11. Feucht MJ, Grande E, Brunhuber J, et al. Biomechanical comparison between suture anchor and transtibial pullout repair for posterior medial meniscus root tears. Am J Sports Med 2014;42:187-193.