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Editorial Commentary: We Know We Need to Fix Knee Meniscal Radial Root Tears—But How Best to Perform the Repairs?
Editorial Commentary: We Know We Need to Fix Knee Meniscal Radial Root TearsdBut How Best to Perform the Repairs? Robert F. LaPrade, M.D., Ph.D.
Abstract: The present work further contributes to building the base of the research pyramid by noting the importance of repairing knee meniscal radial root tears. Because of the extensive biomechanical studies that have now been published on the restoration of joint mechanics and with what I believe results in a higher likelihood of an improved healing environment with securing the meniscus root tear down to bone, I would strongly recommend that when one does see a meniscus root tear that the transtibial pullout root repair technique be considered over a side-to-side repair. The biggest challenge going forward is to validate and improve the healing potential of knee meniscal radial root repairs.
See related article on page 1060
I
n the article, “Comparison of Tibiofemoral Contact Mechanics After Various Transtibial and All-Inside Fixation Techniques for Medial Meniscus Posterior Root Radial Tears in a Porcine Model,” Drs. Chung, Choi, Bae, Ha, Jun, Wang, and Kim1 have compiled an excellent work in helping to further build the base of the research pyramid in understanding the biomechanics and treatment of meniscal root tears. In this particular case, the authors used a porcine knee model to create a type II radial tear of the posterior horn of the medial meniscus2 and performed different suturing techniques for a root repair to assess the effects on tibiofemoral contact mechanics.1 The authors found similar results to other studies, whereby a radial tear of the meniscus was found to increase peak contact pressures and decrease surface contact areas, but the unique part of their study was that they evaluated different meniscal suturing techniques to assess the effects on the tibiofemoral contact mechanics. The authors assessed the repairs using simple sutures, modified Mason-Allen sutures, and all-inside fixation using a FAST-FIX 360 device. They found that peak contact Vail, Colorado The author reports the following potential conflicts of interest or sources of funding: R.F.L. receives consultancy fees and royalties from Arthrex, Ossur, and Smith & Nephew. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2017 by the Arthroscopy Association of North America 0749-8063/171344/$36.00 https://doi.org/10.1016/j.arthro.2017.11.009
pressures and contact surface areas significantly improved after fixation, regardless of the fixation method. In general, the authors found that MasonAllen sutures did relatively better, but that the study had insufficient power to accurately detect any differences between the various fixation methods. Although one can argue that this animal model is not the ideal comparative anatomy model for assessing meniscal repairs in humans,3 it does provide further information on the pieces of the puzzle for when and how to perform meniscal radial root repairs. I believe that the issue of the “when” has already been answered. Krych et al.,4,5 in 2 separate articles, reported that the nonoperative treatment of posterior horn medial meniscus root tears was associated with a significant increase in worsening arthritis and poor clinical outcomes at 5-year follow-up,4 whereas partial medial meniscectomies for medial meniscus posterior horn root tears provided no benefit and were essentially equal to nonoperative treatment.5 The same research group as the present study, led by Chung et al.,6 have also reported that comparing results between partial meniscectomies and meniscal root repairs at a minimum of 5 years of follow-up demonstrated that there was a significant progression toward increased osteoarthritis and decreased functional outcomes in patients treated with partial meniscectomies compared with meniscal root repairs. This current study, combined with the results of other biomechanical and clinical studies,7-9 answers the
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 4 (April), 2018: pp 1069-1071
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EDITORIAL COMMENTARY
Fig 1. Illustration of the transtibial pullout repair technique for a tear of the posteromedial meniscal root of the right knee. A complete radial tear is located 3 mm from the bony attachment. The two-simple-stitches method of suture fixation is shown. The anterior and posterior sutures are shuttled down their respective tunnels. The sutures are tied over a cortical fixation device (Endobutton, Smith & Nephew, Andover, MA) with the knee flexed at 90 to secure the root repair. (Reproduced with permission from LaPrade et al.11).
“when” with a definitive answerdwhenever one finds an appropriate patient,9 meniscal root tears should be repaired. The hardest part of the meniscal root repair treatment problem is the “how.” When I first started treating this pathology over a decade ago, my first initial treatment was to approach the knee from posterior, place sutures in the posterior horn tear of the root tear, and then tie the sutures over a screw and washer posteriorly. I used this technique because the instruments were not available to perform a root repair very effectively arthroscopically. Then over the course of a few years, I started using rotator cuff repair instruments to access the tear from the back of the knee and then shuttling the sutures anteriorly to tie them over a button on the anteromedial tibial cortex. Our technique has now evolved to using 2 small tunnels and a self-capture suture device to place the sutures through the meniscus in a 2-simple suture technique and to shuttle the sutures down the tibial tunnels and tie them over a cortical button (Figure 1).10-12 As the authors imply in their results, complex suture techniques, such as the Mason-Allen technique, are very difficult to perform in this tight space because we are still in our infancy on the development of surgical devices to make it easy for the “masses” to perform
meniscal root repairs safely and efficiently. As Chung et al.1 have noted, the medial joint space is quite tight and it is difficult to pass sutures. The authors also commented on the use of an all-inside device (FAST-FIX 360) to attempt to repair meniscal root repairs. In my clinical experience, I have found that obtaining sufficient tissue to perform a sideto-side repair at the root attachment for these radial tears, as well as obtaining sufficient biologic healing, is very difficult. Because of the extensive biomechanical studies that have now been published on restoration of joint mechanics and with what I believe results in a higher likelihood of an improved healing environment with securing the meniscus down to bone, I would strongly recommend that when one does see a meniscus root tear that the transtibial pullout root repair technique be considered over a side-to-side repair. This article by Chung et al. reports that repair of radial posterior horn medial meniscus root tears improves peak contact pressures and joint contact surface areas. They also note that these repairs did not restore the biomechanical loading properties back to normal, which may be a function of the differing proximal tibial anatomy of the porcine knee. In our previous studies, we did find in the human knee that we were able to restore joint biomechanical properties essentially back to normal with radial meniscal root repairs7,8 and that the biggest reason we could not restore joint loading was when the meniscal root repair was performed in a nonanatomic position.13 I believe the biggest challenge going forward is to validate and improve the healing potential of meniscal radial root repairs. The meniscus itself does not have intrinsic capabilities to heal robustly back down to bone, so an improved means of healing, such as using 2 transtibial tunnels to provide a broader surface area for the meniscus to be apposed to the decorticated bone, as well as other techniques to further assist and accelerate healing, possibly with the use of biologics such as platelet-rich plasma or bone marrow aspirate concentrate, should be investigated. This would potentially allow us to accelerate the rehabilitation protocols so that we can improve overall patient function and allow for a quicker return to activities. Overall, the evidence is overwhelming now that we need to perform meniscal root repairs,14 but the biggest question going forward is how to perform them quickly and efficiently for those who do not perform them as frequently, as well as to improve the means to obtain improved healing of the meniscus to bone to accelerate a quicker return to activities.
References 1. Chung KS, Choi CH, Bae TS, et al. Comparison of tibiofemoral contact mechanics after various transtibial and
EDITORIAL COMMENTARY
2.
3.
4.
5.
6.
7.
all-inside fixation techniques for medial meniscus posterior root radial tears in a porcine model. Arthroscopy 2018;34: 1060-1068. LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF. Meniscal root tears: a classification system based on tear morphology. Am J Sports Med 2015;43:363-369. Takroni T, Laouar L, Adesida A, Elliot JA, Jomha NM. Anatomic study: Comparing the human, sheep, and pig knee meniscus. J Exp Orthop 2016;3:35. Krych AJ, Reardon PJ, Johnson NR, et al. Nonoperative management of medial meniscus posterior root tears as associated with worsening arthritis and poor clinical outcome at 5-year follow-up. Knee Surg Sports Traumatol Arthrosc 2017;25:383-389. Krych AJ, Johnson NR, Mohan R, Dahm DL, Levy BA, Stuart MJ. Partial meniscectomy provides no benefit for symptomatic degenerative medial meniscus posterior root tears [published online February 9, 2017]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-017-4454-5. Chung KS, Ha JK, Yeom CH, et al. Comparison of clinical and radiologic results between partial meniscectomy and refixation of medial meniscus posterior root tears: A minimum 5-year follow-up. Arthroscopy 2015;31: 1941-1950. Padalecki JR, Jansson KS, Smith SD, et al. Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: In situ
8.
9.
10.
11.
12.
13.
14.
1071
pull-out repair restores derangement of joint mechanics. Am J Sports Med 2014;42:699-707. LaPrade CM, Jansson KS, Dornan G, Smith SD, Wijdicks CA, LaPrade RF. Altered tibiofemoral contact mechanics due to lateral meniscus posterior horn root avulsions and radial tears can be restored within situ pullout suture repairs. J Bone Joint Surg 2014;96:471-479. LaPrade RF, Matheny LM, Moulton SG, James EW, Dean CS. Posterior meniscal root repair: Outcomes of an anatomic transtibial pull-out technique. Am J Sports Med 2017;45:884-891. LaPrade RF, LaPrade CM, James EW. Recent advances in posterior meniscal root repair techniques. J Am Acad Orthop Surg 2016;23:71-76. LaPrade CM, LaPrade MD, Turnbull TL, Wijdicks CA, LaPrade RF. Biomechanical evaluation of a transtibial pull-out technique for posterior medial meniscus root repairs using 1 and 2 transtibial tunnels. Am J Sports Med 2015;43:899-904. Chahla J, Moulton SG, LaPrade CM, Dean CS, LaPrade RF. Posterior meniscal root repair: The transtibial double tunnel pull-out technique. Arthrosc Tech 2016;5:E291-E296. LaPrade CM, Foad A, Smith SD, et al. Biomechanical consequences of a nonanatomic posterior medial meniscus root repair. Am J Sports Med 2015;43:912-920. Feucht MJ, Kuhle J, Bode G, et al. Arthroscopic transtibial pull-out repair for posterior medial meniscus root tears: A systematic review of clinical, radiographic, and secondlook arthroscopy results. Arthroscopy 2015;31:1808-1816.
Abstract: The present work further contributes to building the base of the research pyramid by noting the importance of repairing knee meniscal radial root tears. Because of the extensive biomechanical studies that have now been published on the restoration of joint mechanics and with what I believe results in a higher likelihood of an improved healing environment with securing the meniscus root tear down to bone, I would strongly recommend that when one does see a meniscus root tear that the transtibial pullout root repair technique be considered over a side-to-side repair. The biggest challenge going forward is to validate and improve the healing potential of knee meniscal radial root repairs.
See related article on page 1060
I
n the article, “Comparison of Tibiofemoral Contact Mechanics After Various Transtibial and All-Inside Fixation Techniques for Medial Meniscus Posterior Root Radial Tears in a Porcine Model,” Drs. Chung, Choi, Bae, Ha, Jun, Wang, and Kim1 have compiled an excellent work in helping to further build the base of the research pyramid in understanding the biomechanics and treatment of meniscal root tears. In this particular case, the authors used a porcine knee model to create a type II radial tear of the posterior horn of the medial meniscus2 and performed different suturing techniques for a root repair to assess the effects on tibiofemoral contact mechanics.1 The authors found similar results to other studies, whereby a radial tear of the meniscus was found to increase peak contact pressures and decrease surface contact areas, but the unique part of their study was that they evaluated different meniscal suturing techniques to assess the effects on the tibiofemoral contact mechanics. The authors assessed the repairs using simple sutures, modified Mason-Allen sutures, and all-inside fixation using a FAST-FIX 360 device. They found that peak contact Vail, Colorado The author reports the following potential conflicts of interest or sources of funding: R.F.L. receives consultancy fees and royalties from Arthrex, Ossur, and Smith & Nephew. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2017 by the Arthroscopy Association of North America 0749-8063/171344/$36.00 https://doi.org/10.1016/j.arthro.2017.11.009
pressures and contact surface areas significantly improved after fixation, regardless of the fixation method. In general, the authors found that MasonAllen sutures did relatively better, but that the study had insufficient power to accurately detect any differences between the various fixation methods. Although one can argue that this animal model is not the ideal comparative anatomy model for assessing meniscal repairs in humans,3 it does provide further information on the pieces of the puzzle for when and how to perform meniscal radial root repairs. I believe that the issue of the “when” has already been answered. Krych et al.,4,5 in 2 separate articles, reported that the nonoperative treatment of posterior horn medial meniscus root tears was associated with a significant increase in worsening arthritis and poor clinical outcomes at 5-year follow-up,4 whereas partial medial meniscectomies for medial meniscus posterior horn root tears provided no benefit and were essentially equal to nonoperative treatment.5 The same research group as the present study, led by Chung et al.,6 have also reported that comparing results between partial meniscectomies and meniscal root repairs at a minimum of 5 years of follow-up demonstrated that there was a significant progression toward increased osteoarthritis and decreased functional outcomes in patients treated with partial meniscectomies compared with meniscal root repairs. This current study, combined with the results of other biomechanical and clinical studies,7-9 answers the
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 4 (April), 2018: pp 1069-1071
1069
1070
EDITORIAL COMMENTARY
Fig 1. Illustration of the transtibial pullout repair technique for a tear of the posteromedial meniscal root of the right knee. A complete radial tear is located 3 mm from the bony attachment. The two-simple-stitches method of suture fixation is shown. The anterior and posterior sutures are shuttled down their respective tunnels. The sutures are tied over a cortical fixation device (Endobutton, Smith & Nephew, Andover, MA) with the knee flexed at 90 to secure the root repair. (Reproduced with permission from LaPrade et al.11).
“when” with a definitive answerdwhenever one finds an appropriate patient,9 meniscal root tears should be repaired. The hardest part of the meniscal root repair treatment problem is the “how.” When I first started treating this pathology over a decade ago, my first initial treatment was to approach the knee from posterior, place sutures in the posterior horn tear of the root tear, and then tie the sutures over a screw and washer posteriorly. I used this technique because the instruments were not available to perform a root repair very effectively arthroscopically. Then over the course of a few years, I started using rotator cuff repair instruments to access the tear from the back of the knee and then shuttling the sutures anteriorly to tie them over a button on the anteromedial tibial cortex. Our technique has now evolved to using 2 small tunnels and a self-capture suture device to place the sutures through the meniscus in a 2-simple suture technique and to shuttle the sutures down the tibial tunnels and tie them over a cortical button (Figure 1).10-12 As the authors imply in their results, complex suture techniques, such as the Mason-Allen technique, are very difficult to perform in this tight space because we are still in our infancy on the development of surgical devices to make it easy for the “masses” to perform
meniscal root repairs safely and efficiently. As Chung et al.1 have noted, the medial joint space is quite tight and it is difficult to pass sutures. The authors also commented on the use of an all-inside device (FAST-FIX 360) to attempt to repair meniscal root repairs. In my clinical experience, I have found that obtaining sufficient tissue to perform a sideto-side repair at the root attachment for these radial tears, as well as obtaining sufficient biologic healing, is very difficult. Because of the extensive biomechanical studies that have now been published on restoration of joint mechanics and with what I believe results in a higher likelihood of an improved healing environment with securing the meniscus down to bone, I would strongly recommend that when one does see a meniscus root tear that the transtibial pullout root repair technique be considered over a side-to-side repair. This article by Chung et al. reports that repair of radial posterior horn medial meniscus root tears improves peak contact pressures and joint contact surface areas. They also note that these repairs did not restore the biomechanical loading properties back to normal, which may be a function of the differing proximal tibial anatomy of the porcine knee. In our previous studies, we did find in the human knee that we were able to restore joint biomechanical properties essentially back to normal with radial meniscal root repairs7,8 and that the biggest reason we could not restore joint loading was when the meniscal root repair was performed in a nonanatomic position.13 I believe the biggest challenge going forward is to validate and improve the healing potential of meniscal radial root repairs. The meniscus itself does not have intrinsic capabilities to heal robustly back down to bone, so an improved means of healing, such as using 2 transtibial tunnels to provide a broader surface area for the meniscus to be apposed to the decorticated bone, as well as other techniques to further assist and accelerate healing, possibly with the use of biologics such as platelet-rich plasma or bone marrow aspirate concentrate, should be investigated. This would potentially allow us to accelerate the rehabilitation protocols so that we can improve overall patient function and allow for a quicker return to activities. Overall, the evidence is overwhelming now that we need to perform meniscal root repairs,14 but the biggest question going forward is how to perform them quickly and efficiently for those who do not perform them as frequently, as well as to improve the means to obtain improved healing of the meniscus to bone to accelerate a quicker return to activities.
References 1. Chung KS, Choi CH, Bae TS, et al. Comparison of tibiofemoral contact mechanics after various transtibial and
EDITORIAL COMMENTARY
2.
3.
4.
5.
6.
7.
all-inside fixation techniques for medial meniscus posterior root radial tears in a porcine model. Arthroscopy 2018;34: 1060-1068. LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF. Meniscal root tears: a classification system based on tear morphology. Am J Sports Med 2015;43:363-369. Takroni T, Laouar L, Adesida A, Elliot JA, Jomha NM. Anatomic study: Comparing the human, sheep, and pig knee meniscus. J Exp Orthop 2016;3:35. Krych AJ, Reardon PJ, Johnson NR, et al. Nonoperative management of medial meniscus posterior root tears as associated with worsening arthritis and poor clinical outcome at 5-year follow-up. Knee Surg Sports Traumatol Arthrosc 2017;25:383-389. Krych AJ, Johnson NR, Mohan R, Dahm DL, Levy BA, Stuart MJ. Partial meniscectomy provides no benefit for symptomatic degenerative medial meniscus posterior root tears [published online February 9, 2017]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-017-4454-5. Chung KS, Ha JK, Yeom CH, et al. Comparison of clinical and radiologic results between partial meniscectomy and refixation of medial meniscus posterior root tears: A minimum 5-year follow-up. Arthroscopy 2015;31: 1941-1950. Padalecki JR, Jansson KS, Smith SD, et al. Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: In situ
8.
9.
10.
11.
12.
13.
14.
1071
pull-out repair restores derangement of joint mechanics. Am J Sports Med 2014;42:699-707. LaPrade CM, Jansson KS, Dornan G, Smith SD, Wijdicks CA, LaPrade RF. Altered tibiofemoral contact mechanics due to lateral meniscus posterior horn root avulsions and radial tears can be restored within situ pullout suture repairs. J Bone Joint Surg 2014;96:471-479. LaPrade RF, Matheny LM, Moulton SG, James EW, Dean CS. Posterior meniscal root repair: Outcomes of an anatomic transtibial pull-out technique. Am J Sports Med 2017;45:884-891. LaPrade RF, LaPrade CM, James EW. Recent advances in posterior meniscal root repair techniques. J Am Acad Orthop Surg 2016;23:71-76. LaPrade CM, LaPrade MD, Turnbull TL, Wijdicks CA, LaPrade RF. Biomechanical evaluation of a transtibial pull-out technique for posterior medial meniscus root repairs using 1 and 2 transtibial tunnels. Am J Sports Med 2015;43:899-904. Chahla J, Moulton SG, LaPrade CM, Dean CS, LaPrade RF. Posterior meniscal root repair: The transtibial double tunnel pull-out technique. Arthrosc Tech 2016;5:E291-E296. LaPrade CM, Foad A, Smith SD, et al. Biomechanical consequences of a nonanatomic posterior medial meniscus root repair. Am J Sports Med 2015;43:912-920. Feucht MJ, Kuhle J, Bode G, et al. Arthroscopic transtibial pull-out repair for posterior medial meniscus root tears: A systematic review of clinical, radiographic, and secondlook arthroscopy results. Arthroscopy 2015;31:1808-1816.