- Email: [email protected]
Medial Meniscus Posterior Root Tear Repair Using a 2-Simple-Suture Pullout Technique
Medial Meniscus Posterior Root Tear Repair Using a 2-Simple-Suture Pullout Technique Tarek Mohamed Samy, M.D., Wael A. M. Nassar, M.D., Zeiad Mohamed Zakaria, M.D., and Ahmed Khaled Farrag Abdelaziz, M.Sc.
Abstract: Medial meniscus posterior root tear is one of the underestimated knee injuries in terms of incidence. Despite its grave sequelae, using simple but effective technique can maintain the native knee joint longevity. In the current note, a 2-simple-suture pullout technique was used to effectively reduce the meniscus posterior root to its anatomic position. The success of the technique depended on proper tool selection as well as tibial tunnel direction that allowed easier root suturing and better suture tensioning, without inducing any iatrogenic articular cartilage injury or meniscal tissue loss. Using anterior knee arthroscopy portals, anterolateral as a viewing portal and anteromedial as a working portal, a 7-mm tibial tunnel starting at Gerdy tubercle and ending at the medial meniscus posterior root bed was created. The 2 simple sutures were retrieved through the tunnel and tensioned and secured over a 12-mm-diameter washer at the tibial tunnel outer orifice. Anatomic reduction of the medial meniscus posterior root tear was confirmed arthroscopically intraoperatively and radiologically by postoperative magnetic resonance imaging.
M
edial meniscus posterior root tear (MMPRT) is a disruption that occurs within 1 cm of the meniscus posterior horn attachment to the tibial plateau,1 a condition that simulates total meniscectomy due to loss of meniscal biomechanical function.2 Both the arthroscopic repair by pullout suture technique as described by Shino et al.3 and anchor fixation as described by Engelsohn et al.4 are the 2 most commonly used techniques to deal with such an injury. To date, there are no solid criteria throughout the published literature to support the best technique in terms of optimum results. The current Technical Note describes a reproducible pullout technique using a 2-simple-suture configuration to repair MMPRT. The cornerstones of this technique are the direction, the size of the tibial tunnel, and the simplicity of the suture configuration, which
From the Department of Orthopaedic Surgery, Ain Shams University, Cairo, Egypt. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 2, 2016; accepted January 3, 2017. Address correspondence to Ahmed Khaled Farrag Abdelaziz, M.Sc., Orthopaedic Surgery, Ain Shams University, 65 Alfath Buildings, Nasr City, Cairo, Egypt 11471. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/16947/$36.00 http://dx.doi.org/10.1016/j.eats.2017.01.001
collectively allow enough meniscal tissue to be pulled within the tunnel under good tension.
Surgical Technique MMPRT repair (Video 1) was done under general or regional anaesthesia; the patients were positioned in a supine position with the operated leg hanging to the side of the table. A side post was put in all cases, and a high above-knee pneumatic tourniquet was used for hemostasis. In addition, it serves as a fulcrum point between the operated limb and the side post, to achieve effective valgus moment that can open the medial knee compartment. Portals Creation and Medial Collateral Ligament Stretching The anterolateral viewing portal had to be as low and as close to the patellar tendon as possible, to provide better viewing of the root of the posterior horn medial meniscus. The anteromedial working portal had to be as low as possible to facilitate instruments’ passage safely below the medial femoral condyle. A cannula was used to verify the accuracy of the anteromedial portal location under arthroscopic vision and whether it could provide the perfect trajectory needed to deploy instrumentation through it. Continuous valgus stressing maneuvers were sufficient to stretch the medial collateral ligament for a few millimeters of medial joint compartment widening.
Arthroscopy Techniques, Vol 6, No 3 (June), 2017: pp e579-e583
e579
e580
T. M. SAMY ET AL.
Fig 1. Patient supine, left knee flexed 30 and valgus force applied on a side post at tourniquet level. Images seen through the anterolateral viewing portal while the anteromedial portal is the working portal. (A) The medial meniscus posterior root tear (white arrow): the tear edges as well as root undersurface were refreshened using a 3.5-mm shaver (S). (B) The meniscal root bed was curetted down to cancellous bone using a curettage spoon (asterisk) to increase the healing surface area. (C) A suturepassing Lasso device (L) was used to pass No. 0 Prolene suture (black arrow) through the meniscal root, leaving at least 5 mm between the piercing point and the tear edge. This step was repeated to pass another No. 0 Prolene relay suture at a posterior piercing point with at least 5 mm between the 2 piercing points. Both relay sutures were replaced with No. 2 Fiberwire. (MFC, medial femoral condyle; MTC, medial tibial condyle.)
Preparation of the Root and Its Bed After general knee exploration, the tear edges were refreshened and the undersurface of the posterior horn was scratched using a 3.5-mm shaver. Curettage of the articular cartilage down to the cancellous bone of the tibial plateau at the chosen site of meniscal root reimplantation was carried out next to increase the healing surface area and help root reattachment to its bed. Two simple sutures were passed through the torn root before quickly drilling the tunnel to avoid loosening the intraarticular pressure. A suture-passing lasso device (Quick pass suture Lasso, 45 curved tip right/left 1.8-mm tip with a thumb wheel, disposable lasso; Arthrex, Naples, FL) was passed in an upward-to-downward direction, loaded with No. 0 Prolene (blue monofilament; Ethicon, Somerville, NJ) to act as a relay shuttle (Fig 1). The relay suture was used to pass No. 2 Fiberwire (38”/ 96.5 cm blue/white; Arthrex) through the meniscal root with at
least 5 mm distance between both sutures and the tear edge. Creation of the Tibial Tunnel The tip of a low-profile tibial ACL marking hook for drill guide (Arthrex) was applied at the chosen reimplantation point (Fig 2). The guide base containing the bullet was placed at the Gerdy tubercle to be oriented from an anterior, inferolateral position to a posterior superior-medial trajectory (Fig 3). This gives a better direction of sutures pulled in line with the meniscal circumferential fibers. An ACL guide pin (2.4 mm; Arthrex) was drilled through the aiming device until its tip appeared at the desired reimplantation site. A 7-mm cannulated drill bit was the preferred choice because it allowed much of the meniscal root substance to be reimplanted into the tibial plateau. A curettage spoon was applied over the guidewire tip to avoid
Fig 2. Patient supine, left knee flexed 30 and valgus force applied on a side post at tourniquet level. Images seen through the anterolateral viewing portal whereas the anteromedial portal is the working portal. (A) A low-profile anterior cruciate ligament guide was introduced till the prepared reimplantation point and a 2.4-mm guide pin was drilled through. (B) A curettage spoon (S) was used to protect femoral articular cartilage while a 7-mm drill bit was reamed over the guide pin (small black arrow). (C) The 4 limbs were retrieved through the tibial tunnel using a right-angled probe, and the meniscal root was buried into the tibial tunnel (large black arrow). The sutures were tensioned over a 12-mm-diameter washer placed at the tibial tunnel outer orifice, with the knee in 15 flexion, and the tension was checked using a probe (P). (MFC, medial femoral condyle; MTC, medial tibial condyle.)
MEDIAL MENISCUS POSTERIOR ROOT PULLOUT REPAIR
e581
Fig 3. (A) Posterior coronal magnetic resonance imaging cuts showing medial meniscus posterior root tear (blue arrow). (B) Patient supine, left knee flexed 30 and valgus force applied on a side post at tourniquet level, the arthroscope was applied through the anterolateral viewing portal (black arrow), the ACL guide was applied through the anteromedial working portal (blue arrow), the ACL guide bullet was placed at the Gerdy tubercle (white arrow), and a 2.4-mm guide pin was drilled through the guide to the root reimplantation point (yellow arrow). (C) Lateral fluoroscopy view, showing the guide pin in place (blue arrow) where the last few millimeters (articular surface) were penetrated under fluoroscopy after removing the ACL guide device. A low-profile curettage spoon is introduced to protect the articular cartilage and neurovascular bundle during tunnel reaming (black arrow). (ACL, anterior cruciate ligament; L, lateral; M, medial.)
neurovascular bundle injury or iatrogenic femoral condyle articular cartilage injury. Suture Retrieval and Securing the Suture Knots The 4 limbs of the 2 simple sutures were retrieved using a right-angled probe introduced through the tibial tunnel. The meniscal root was confirmed by direct arthroscopy to be pulled inside the tibial tunnel for better healing. At this point, the operated limb was extended at the side of the operating table with only 15 of flexion, which allowed direct arthroscopic visualization of the meniscal root while tensioning the 4
limbs over a 12-mm-diameter washer put at the tibial tunnel outer opening. Each simple suture had 2 limbs, and only 1 limb from each simple suture was passed through the washer. The washer was then allowed to slide over those 2 suture limbs, passing through it until it reached the tibial tunnel outer orifice. Owing to the larger diameter of the washer (12 mm), it stopped at the tibial tunnel outer orifice without sinking inside the tibial tunnel, as a result of its smaller diameter (7 mm). Using the washer as a bridge, the 2 suture limbs passing through it were knotted with the other 2 suture limbs making 5 half-hitch knots, with the final one in a
Fig 4. Patient supine, left knee flexed 15 and valgus force applied on a side post at tourniquet level. (A) The 4 limbs of the 2 simple sutures were retrieved through the tibial tunnel outer orifice at the Gerdy tubercle (transparent arrow), and a single limb from each suture (white arrow) was passed through a 12-mm-diameter washer (blue arrow). (B) Using the washer as a bridge, the 2 suture limbs passing through it were knotted with the other 2 suture limbs making 5 half-hitch knots, with the final one in a locking mode (green arrow).
e582
T. M. SAMY ET AL.
Table 1. Tips 1. A side post provides a stable fulcrum point to produce an effective valgus moment that can open the medial knee compartment by gradually stretching the medial collateral ligament. 2. Pie-crusting technique is an alternative popular technique to open the medial knee compartment for better visualization and medial meniscus posterior root tear repair, but moderate to severe postoperative pain should be anticipated. 3. Low-profile instruments help protect the articular cartilage and facilitate repair maneuvers. 4. Ring forceps can be introduced through the tibial tunnel and to retrieve the 4 limbs of the sutures in a quicker and easier approach than the right-angled probe.
locking mode (Fig 4). The knots were tightened to the degree that maintained the desired tension on the meniscal root and prevented suture slackness. No drains were used intentionally to allow postoperative hemarthrosis, which helps the healing potential and to keep the stem cells retrieved from the tibial tunnel reaming. Postoperative Follow-Up and Rehabilitation Programs After surgery patients were allowed to mobilize noneweight bearing on crutches for 6 weeks. A hinged knee brace was applied for the first 2 weeks with the leg in a fully extended position. Patients were instructed to perform quadriceps muscleestrengthening exercise as well as straight-leg raising exercises several times daily starting immediately postoperatively as tolerated. Patients were allowed an increase in active range of motion by 30 every 2 weeks till reaching 135 . Gradual weight bearing started at 6 weeks. Full flexion and squatting were allowed 3 months after the surgery. Patients returned to full activity 6 months postoperatively.
Discussion The current technique showed significant improvements in the functional outcomes as well as magnetic resonance imaging signs. Similarly, Lee et al.,5 in their study using a 2-simple-suture configuration in 25 patients, reported improvement in Lysholm and Tegner scores. Table 2. Pitfalls 1. Forceful reaming over the guide pin can cause pin breakage, with the pin tip protruding inside the knee joint and the other end within the tibial tunnel, wasting time and causing more damage to remove it. 2. Using smaller suture sizes will increase the risks of sutures cutting through the meniscus and fixation failure. 3. Using sutures with lower tensile strengths, e.g., Prolene, in contrast to Fiberwire, will increase the risks of suture rupture and fixation failure as well. 4. Suture tensioning without simultaneous arthroscopic visualization and tension probing can lead to suture laxity, a condition that mandates repetition of the whole operative steps.
Although Neogi et al.6 reported significant functional improvements using only physiotherapy on 33 patients with MMPRT for 2 years’ follow-up, they reported significant osteoarthritis progression. Kim et al.,7 in their retrospective study of 58 patients with MMPRT who underwent either meniscectomy or repair, using a similar surgical technique, reported more functional improvement and less arthritis progression within the repair group, the mean follow-up was 48.5 months. Significant improvement in both absolute and relative meniscal extrusion was recorded with the current technique. Similar results were reported by Kim et al.,8 who applied pullout repair to 22 MMPRT cases with a mean follow-up of 25.9 months. The current technique was constructed to allow easy, quick, and safe MMPRT repair. The advantages (Table 1) of the described technique include effective suture-pulling trajectory. By creating the tibial tunnel from an inferolateral position at the Gerdy tubercle to a superomedial position at the root bed, this tunnel direction made an obtuse angle in the coronal and the axial planes between the circumferential fibers of the medial meniscus and the retrieved suture limbs. Consequently, this minimized the killer angle and facilitated a better line of pull, allowing proper meniscal tensioning. Moreover, adequate bed for meniscal root tear healing was created by scratching the undersurface of the posterior horn medial meniscus as well as curetting its articular cartilage bed; this maximized the healing area by adding the posterior horn medial meniscus bed to the created 7-mm tunnel, probably increasing the healing probabilities. Finally, a sufficient amount of meniscal root tissue was reimplanted into the tibial tunnel under proper tensioning of the medial meniscus. Owing to the large size of the tibial tunnel (7 mm), the posterior root of the medial meniscus can be pulled inside the tunnel; this provides a better anchorage point of the root as the root will be incorporated within the tibial tunnel bone healing, which will also maximize the healing potential. Nevertheless, some limitations (Table 2) should be anticipated. The risk of sutures cutting through the meniscal root remains a possibility that could inevitably lead to failure. This can be avoided by having an adequate amount of meniscal tissue between the tear edge and the points of suture passage through the root. Finally, utmost care should be followed when reaming the tibial tunnel to avoid neurovascular bundle or femoral articular cartilage injuries.
References 1. 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 2014;43:363-369.
MEDIAL MENISCUS POSTERIOR ROOT PULLOUT REPAIR 2. Cerminara AJ, LaPrade CM, Smith SD, Ellman MB, Wijdicks CA, LaPrade RF. Biomechanical evaluation of a transtibial pull-out meniscal root repair challenging the bungee effect. Am J Sports Med 2014;42:2988-2995. 3. Shino K, Hamada M, Mitsuoka T, Kinoshita H, Toritsuka Y. Arthroscopic repair for a flap tear of the posterior horn of the lateral meniscus adjacent to its tibial insertion. Arthroscopy 1995;11:495-498. 4. Engelsohn E, Umans H, DiFelice GS. Marginal fractures of the medial tibial plateau: Possible association with medial meniscal root tear. Skeletal Radiol 2007;36:73-76. 5. Lee DW, Kim MK, Jang HS, Ha JK, Kim JG. Clinical and radiologic evaluation of arthroscopic medial meniscus root tear refixation: Comparison of the modified
e583
Mason-Allen stitch and simple stitches. Arthroscopy 2014;30:1439-1446. 6. Neogi DS, Kumar A, Rijal L, Yadav CS, Jaiman A, Nag HL. Role of nonoperative treatment in managing degenerative tears of the medial meniscus posterior root. J Orthop Traumatol 2013;14:193-199. 7. Kim SB, Ha JK, Lee SW, et al. Medial meniscus root tear refixation: Comparison of clinical, radiologic, and arthroscopic findings with medial meniscectomy. Arthroscopy 2011;27:346-354. 8. Kim JH, Chung JH, Lee DH, Lee YS, Kim JR, Ryu KJ. Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: A prospective comparison study. Arthroscopy 2011;27:1644-1653.
Abstract: Medial meniscus posterior root tear is one of the underestimated knee injuries in terms of incidence. Despite its grave sequelae, using simple but effective technique can maintain the native knee joint longevity. In the current note, a 2-simple-suture pullout technique was used to effectively reduce the meniscus posterior root to its anatomic position. The success of the technique depended on proper tool selection as well as tibial tunnel direction that allowed easier root suturing and better suture tensioning, without inducing any iatrogenic articular cartilage injury or meniscal tissue loss. Using anterior knee arthroscopy portals, anterolateral as a viewing portal and anteromedial as a working portal, a 7-mm tibial tunnel starting at Gerdy tubercle and ending at the medial meniscus posterior root bed was created. The 2 simple sutures were retrieved through the tunnel and tensioned and secured over a 12-mm-diameter washer at the tibial tunnel outer orifice. Anatomic reduction of the medial meniscus posterior root tear was confirmed arthroscopically intraoperatively and radiologically by postoperative magnetic resonance imaging.
M
edial meniscus posterior root tear (MMPRT) is a disruption that occurs within 1 cm of the meniscus posterior horn attachment to the tibial plateau,1 a condition that simulates total meniscectomy due to loss of meniscal biomechanical function.2 Both the arthroscopic repair by pullout suture technique as described by Shino et al.3 and anchor fixation as described by Engelsohn et al.4 are the 2 most commonly used techniques to deal with such an injury. To date, there are no solid criteria throughout the published literature to support the best technique in terms of optimum results. The current Technical Note describes a reproducible pullout technique using a 2-simple-suture configuration to repair MMPRT. The cornerstones of this technique are the direction, the size of the tibial tunnel, and the simplicity of the suture configuration, which
From the Department of Orthopaedic Surgery, Ain Shams University, Cairo, Egypt. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 2, 2016; accepted January 3, 2017. Address correspondence to Ahmed Khaled Farrag Abdelaziz, M.Sc., Orthopaedic Surgery, Ain Shams University, 65 Alfath Buildings, Nasr City, Cairo, Egypt 11471. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/16947/$36.00 http://dx.doi.org/10.1016/j.eats.2017.01.001
collectively allow enough meniscal tissue to be pulled within the tunnel under good tension.
Surgical Technique MMPRT repair (Video 1) was done under general or regional anaesthesia; the patients were positioned in a supine position with the operated leg hanging to the side of the table. A side post was put in all cases, and a high above-knee pneumatic tourniquet was used for hemostasis. In addition, it serves as a fulcrum point between the operated limb and the side post, to achieve effective valgus moment that can open the medial knee compartment. Portals Creation and Medial Collateral Ligament Stretching The anterolateral viewing portal had to be as low and as close to the patellar tendon as possible, to provide better viewing of the root of the posterior horn medial meniscus. The anteromedial working portal had to be as low as possible to facilitate instruments’ passage safely below the medial femoral condyle. A cannula was used to verify the accuracy of the anteromedial portal location under arthroscopic vision and whether it could provide the perfect trajectory needed to deploy instrumentation through it. Continuous valgus stressing maneuvers were sufficient to stretch the medial collateral ligament for a few millimeters of medial joint compartment widening.
Arthroscopy Techniques, Vol 6, No 3 (June), 2017: pp e579-e583
e579
e580
T. M. SAMY ET AL.
Fig 1. Patient supine, left knee flexed 30 and valgus force applied on a side post at tourniquet level. Images seen through the anterolateral viewing portal while the anteromedial portal is the working portal. (A) The medial meniscus posterior root tear (white arrow): the tear edges as well as root undersurface were refreshened using a 3.5-mm shaver (S). (B) The meniscal root bed was curetted down to cancellous bone using a curettage spoon (asterisk) to increase the healing surface area. (C) A suturepassing Lasso device (L) was used to pass No. 0 Prolene suture (black arrow) through the meniscal root, leaving at least 5 mm between the piercing point and the tear edge. This step was repeated to pass another No. 0 Prolene relay suture at a posterior piercing point with at least 5 mm between the 2 piercing points. Both relay sutures were replaced with No. 2 Fiberwire. (MFC, medial femoral condyle; MTC, medial tibial condyle.)
Preparation of the Root and Its Bed After general knee exploration, the tear edges were refreshened and the undersurface of the posterior horn was scratched using a 3.5-mm shaver. Curettage of the articular cartilage down to the cancellous bone of the tibial plateau at the chosen site of meniscal root reimplantation was carried out next to increase the healing surface area and help root reattachment to its bed. Two simple sutures were passed through the torn root before quickly drilling the tunnel to avoid loosening the intraarticular pressure. A suture-passing lasso device (Quick pass suture Lasso, 45 curved tip right/left 1.8-mm tip with a thumb wheel, disposable lasso; Arthrex, Naples, FL) was passed in an upward-to-downward direction, loaded with No. 0 Prolene (blue monofilament; Ethicon, Somerville, NJ) to act as a relay shuttle (Fig 1). The relay suture was used to pass No. 2 Fiberwire (38”/ 96.5 cm blue/white; Arthrex) through the meniscal root with at
least 5 mm distance between both sutures and the tear edge. Creation of the Tibial Tunnel The tip of a low-profile tibial ACL marking hook for drill guide (Arthrex) was applied at the chosen reimplantation point (Fig 2). The guide base containing the bullet was placed at the Gerdy tubercle to be oriented from an anterior, inferolateral position to a posterior superior-medial trajectory (Fig 3). This gives a better direction of sutures pulled in line with the meniscal circumferential fibers. An ACL guide pin (2.4 mm; Arthrex) was drilled through the aiming device until its tip appeared at the desired reimplantation site. A 7-mm cannulated drill bit was the preferred choice because it allowed much of the meniscal root substance to be reimplanted into the tibial plateau. A curettage spoon was applied over the guidewire tip to avoid
Fig 2. Patient supine, left knee flexed 30 and valgus force applied on a side post at tourniquet level. Images seen through the anterolateral viewing portal whereas the anteromedial portal is the working portal. (A) A low-profile anterior cruciate ligament guide was introduced till the prepared reimplantation point and a 2.4-mm guide pin was drilled through. (B) A curettage spoon (S) was used to protect femoral articular cartilage while a 7-mm drill bit was reamed over the guide pin (small black arrow). (C) The 4 limbs were retrieved through the tibial tunnel using a right-angled probe, and the meniscal root was buried into the tibial tunnel (large black arrow). The sutures were tensioned over a 12-mm-diameter washer placed at the tibial tunnel outer orifice, with the knee in 15 flexion, and the tension was checked using a probe (P). (MFC, medial femoral condyle; MTC, medial tibial condyle.)
MEDIAL MENISCUS POSTERIOR ROOT PULLOUT REPAIR
e581
Fig 3. (A) Posterior coronal magnetic resonance imaging cuts showing medial meniscus posterior root tear (blue arrow). (B) Patient supine, left knee flexed 30 and valgus force applied on a side post at tourniquet level, the arthroscope was applied through the anterolateral viewing portal (black arrow), the ACL guide was applied through the anteromedial working portal (blue arrow), the ACL guide bullet was placed at the Gerdy tubercle (white arrow), and a 2.4-mm guide pin was drilled through the guide to the root reimplantation point (yellow arrow). (C) Lateral fluoroscopy view, showing the guide pin in place (blue arrow) where the last few millimeters (articular surface) were penetrated under fluoroscopy after removing the ACL guide device. A low-profile curettage spoon is introduced to protect the articular cartilage and neurovascular bundle during tunnel reaming (black arrow). (ACL, anterior cruciate ligament; L, lateral; M, medial.)
neurovascular bundle injury or iatrogenic femoral condyle articular cartilage injury. Suture Retrieval and Securing the Suture Knots The 4 limbs of the 2 simple sutures were retrieved using a right-angled probe introduced through the tibial tunnel. The meniscal root was confirmed by direct arthroscopy to be pulled inside the tibial tunnel for better healing. At this point, the operated limb was extended at the side of the operating table with only 15 of flexion, which allowed direct arthroscopic visualization of the meniscal root while tensioning the 4
limbs over a 12-mm-diameter washer put at the tibial tunnel outer opening. Each simple suture had 2 limbs, and only 1 limb from each simple suture was passed through the washer. The washer was then allowed to slide over those 2 suture limbs, passing through it until it reached the tibial tunnel outer orifice. Owing to the larger diameter of the washer (12 mm), it stopped at the tibial tunnel outer orifice without sinking inside the tibial tunnel, as a result of its smaller diameter (7 mm). Using the washer as a bridge, the 2 suture limbs passing through it were knotted with the other 2 suture limbs making 5 half-hitch knots, with the final one in a
Fig 4. Patient supine, left knee flexed 15 and valgus force applied on a side post at tourniquet level. (A) The 4 limbs of the 2 simple sutures were retrieved through the tibial tunnel outer orifice at the Gerdy tubercle (transparent arrow), and a single limb from each suture (white arrow) was passed through a 12-mm-diameter washer (blue arrow). (B) Using the washer as a bridge, the 2 suture limbs passing through it were knotted with the other 2 suture limbs making 5 half-hitch knots, with the final one in a locking mode (green arrow).
e582
T. M. SAMY ET AL.
Table 1. Tips 1. A side post provides a stable fulcrum point to produce an effective valgus moment that can open the medial knee compartment by gradually stretching the medial collateral ligament. 2. Pie-crusting technique is an alternative popular technique to open the medial knee compartment for better visualization and medial meniscus posterior root tear repair, but moderate to severe postoperative pain should be anticipated. 3. Low-profile instruments help protect the articular cartilage and facilitate repair maneuvers. 4. Ring forceps can be introduced through the tibial tunnel and to retrieve the 4 limbs of the sutures in a quicker and easier approach than the right-angled probe.
locking mode (Fig 4). The knots were tightened to the degree that maintained the desired tension on the meniscal root and prevented suture slackness. No drains were used intentionally to allow postoperative hemarthrosis, which helps the healing potential and to keep the stem cells retrieved from the tibial tunnel reaming. Postoperative Follow-Up and Rehabilitation Programs After surgery patients were allowed to mobilize noneweight bearing on crutches for 6 weeks. A hinged knee brace was applied for the first 2 weeks with the leg in a fully extended position. Patients were instructed to perform quadriceps muscleestrengthening exercise as well as straight-leg raising exercises several times daily starting immediately postoperatively as tolerated. Patients were allowed an increase in active range of motion by 30 every 2 weeks till reaching 135 . Gradual weight bearing started at 6 weeks. Full flexion and squatting were allowed 3 months after the surgery. Patients returned to full activity 6 months postoperatively.
Discussion The current technique showed significant improvements in the functional outcomes as well as magnetic resonance imaging signs. Similarly, Lee et al.,5 in their study using a 2-simple-suture configuration in 25 patients, reported improvement in Lysholm and Tegner scores. Table 2. Pitfalls 1. Forceful reaming over the guide pin can cause pin breakage, with the pin tip protruding inside the knee joint and the other end within the tibial tunnel, wasting time and causing more damage to remove it. 2. Using smaller suture sizes will increase the risks of sutures cutting through the meniscus and fixation failure. 3. Using sutures with lower tensile strengths, e.g., Prolene, in contrast to Fiberwire, will increase the risks of suture rupture and fixation failure as well. 4. Suture tensioning without simultaneous arthroscopic visualization and tension probing can lead to suture laxity, a condition that mandates repetition of the whole operative steps.
Although Neogi et al.6 reported significant functional improvements using only physiotherapy on 33 patients with MMPRT for 2 years’ follow-up, they reported significant osteoarthritis progression. Kim et al.,7 in their retrospective study of 58 patients with MMPRT who underwent either meniscectomy or repair, using a similar surgical technique, reported more functional improvement and less arthritis progression within the repair group, the mean follow-up was 48.5 months. Significant improvement in both absolute and relative meniscal extrusion was recorded with the current technique. Similar results were reported by Kim et al.,8 who applied pullout repair to 22 MMPRT cases with a mean follow-up of 25.9 months. The current technique was constructed to allow easy, quick, and safe MMPRT repair. The advantages (Table 1) of the described technique include effective suture-pulling trajectory. By creating the tibial tunnel from an inferolateral position at the Gerdy tubercle to a superomedial position at the root bed, this tunnel direction made an obtuse angle in the coronal and the axial planes between the circumferential fibers of the medial meniscus and the retrieved suture limbs. Consequently, this minimized the killer angle and facilitated a better line of pull, allowing proper meniscal tensioning. Moreover, adequate bed for meniscal root tear healing was created by scratching the undersurface of the posterior horn medial meniscus as well as curetting its articular cartilage bed; this maximized the healing area by adding the posterior horn medial meniscus bed to the created 7-mm tunnel, probably increasing the healing probabilities. Finally, a sufficient amount of meniscal root tissue was reimplanted into the tibial tunnel under proper tensioning of the medial meniscus. Owing to the large size of the tibial tunnel (7 mm), the posterior root of the medial meniscus can be pulled inside the tunnel; this provides a better anchorage point of the root as the root will be incorporated within the tibial tunnel bone healing, which will also maximize the healing potential. Nevertheless, some limitations (Table 2) should be anticipated. The risk of sutures cutting through the meniscal root remains a possibility that could inevitably lead to failure. This can be avoided by having an adequate amount of meniscal tissue between the tear edge and the points of suture passage through the root. Finally, utmost care should be followed when reaming the tibial tunnel to avoid neurovascular bundle or femoral articular cartilage injuries.
References 1. 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 2014;43:363-369.
MEDIAL MENISCUS POSTERIOR ROOT PULLOUT REPAIR 2. Cerminara AJ, LaPrade CM, Smith SD, Ellman MB, Wijdicks CA, LaPrade RF. Biomechanical evaluation of a transtibial pull-out meniscal root repair challenging the bungee effect. Am J Sports Med 2014;42:2988-2995. 3. Shino K, Hamada M, Mitsuoka T, Kinoshita H, Toritsuka Y. Arthroscopic repair for a flap tear of the posterior horn of the lateral meniscus adjacent to its tibial insertion. Arthroscopy 1995;11:495-498. 4. Engelsohn E, Umans H, DiFelice GS. Marginal fractures of the medial tibial plateau: Possible association with medial meniscal root tear. Skeletal Radiol 2007;36:73-76. 5. Lee DW, Kim MK, Jang HS, Ha JK, Kim JG. Clinical and radiologic evaluation of arthroscopic medial meniscus root tear refixation: Comparison of the modified
e583
Mason-Allen stitch and simple stitches. Arthroscopy 2014;30:1439-1446. 6. Neogi DS, Kumar A, Rijal L, Yadav CS, Jaiman A, Nag HL. Role of nonoperative treatment in managing degenerative tears of the medial meniscus posterior root. J Orthop Traumatol 2013;14:193-199. 7. Kim SB, Ha JK, Lee SW, et al. Medial meniscus root tear refixation: Comparison of clinical, radiologic, and arthroscopic findings with medial meniscectomy. Arthroscopy 2011;27:346-354. 8. Kim JH, Chung JH, Lee DH, Lee YS, Kim JR, Ryu KJ. Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: A prospective comparison study. Arthroscopy 2011;27:1644-1653.