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Pullout repair of a medial meniscus posterior root tear using a FasT-Fix® all-inside suture technique
Orthopaedics & Traumatology: Surgery & Research 102 (2016) 951–954
Available online at
ScienceDirect www.sciencedirect.com
Technical note
Pullout repair of a medial meniscus posterior root tear using a FasT-Fix® all-inside suture technique Y. Kodama , T. Furumatsu ∗ , M. Fujii , T. Tanaka , S. Miyazawa , T. Ozaki Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
a r t i c l e
i n f o
Article history: Received 6 April 2016 Accepted 17 June 2016 Keywords: Medial meniscus Posterior root tear Pullout repair All-inside meniscal suture Arthroscopic treatment
a b s t r a c t A medial meniscus posterior root tear (MMPRT) may increase the tibiofemoral contact pressure by decreasing the tibiofemoral contact area. Meniscal dysfunction induced by posterior root injury may lead to the development of osteoarthritic knees. Repair of a MMPRT can restore medial meniscus (MM) function and prevent knee osteoarthritis progression. Several surgical procedures have been reported for treating a MMPRT. However, these procedures are associated with several technical difficulties. Here, we describe a technique to stabilize a torn MM posterior root using the FasT-Fix® all-inside meniscal suture device and a new aiming device. The uncut free-end of the FasT-Fix® suture can be used as a thread for transtibial pullout repair. Our procedure might help overcome the technical difficulties in arthroscopic treatment of a MMPRT. © 2016 Elsevier Masson SAS. All rights reserved.
1. Introduction The posterior root anchors the medial meniscus (MM) to the tibial plateau. Posterior root dysfunction is often caused by either acute injury or chronic degeneration [1], and it leads to abnormal biomechanics of the tibiofemoral joint and the inability to convert axial loads into transverse hoop stresses [2,3]. Although partial meniscectomy is used to manage a meniscal root tear, MM root disruption can affect the ability to withstand hoop strain, resulting in increased contact pressure and kinematic alteration of the affected compartment. Peak tibiofemoral contact pressures were previously found to be similar between a MM posterior root tear (MMPRT) and total meniscectomy of the MM [3]. The posterior root of the meniscus contains the perimeniscal capillary plexus and has radially arranged collagen fibrils [4]. A MMPRT is usually found in patients older than 50 years with degenerative changes of the knees [5]. However, the healing potential is lower in old patients than in young patients [6]; therefore, healing of the repaired meniscus might not be complete in older patients. Surgical indications of MMPRT repair in patients older than 50 years have been reported to include varus alignment < 5◦ , mild cartilage lesion (Outerbridge low grade I or II), and Kellgren–Lawrence grade 0–II in radiographs [7]. Transtibial pullout repair and suture anchor-dependent repair have been developed for arthroscopic treatment of a MMPRT [7,8].
∗ Corresponding author. Tel.: +81 862 357 273; fax: +81 862 239 727. E-mail address: [email protected] (T. Furumatsu). http://dx.doi.org/10.1016/j.otsr.2016.06.013 1877-0568/© 2016 Elsevier Masson SAS. All rights reserved.
However, there are several technical difficulties, and conventional pullout repair requires complex arthroscopic techniques. These procedures may induce iatrogenic injuries of the articular cartilage and additional tears of the MM posterior root. Here, we describe a technique to stabilize the torn MM posterior root using the FasT-Fix® all-inside meniscal suture device and a new aiming device (Smith & Nephew, Andover, MA, USA). Our technique aims to restore hoop tension and prevent cartilage damage, which can progress rapidly. The tear pattern was classified as previously described [9], and our technique is suitable for a MMPRT of type 2 (radial tear) or type 4 (oblique tear). 2. Operative technique The patient is placed supine, with a tourniquet. A standard anterolateral portal for arthroscopic visualization of the MM posterior root and its anatomical attachment, using a 30◦ arthroscope (Smith & Nephew). An anteromedial portal is used for the instruments. MMPRT repair is indicated in the absence of severe cartialage damage. The presence of a meniscal substance tear is evaluated via the anteromedial portal (Fig. 1A), and the type of meniscal root injury is defined. To accommodate a new aiming device (Smith & Nephew) and the FasT-Fix all-inside meniscal suture device (Smith & Nephew), synovial tissues surrounding the posterior cruciate ligament are removed using a motorized shaver and radiofrequency device. Additionally, scar-like tissue behind the meniscus and between the
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Y. Kodama et al. / Orthopaedics & Traumatology: Surgery & Research 102 (2016) 951–954
Fig. 1. Medial meniscus posterior root tear (MMPRT) (right knee) in a 67-year-old woman. A. Radial type 2 tear of the MM posterior root. B. The tip of the aiming device is placed at the anatomical insertion of the MM posterior root from the anteromedial portal. The shiny white fiber is seen (black arrow). C. A cannulated drill (4.0 mm) is inserted along with the guide pin. D. Two FasT-Fix anchors are inserted into the MM posterior root in an oblique orientation. E. The uncut free-end of the FasT-Fix suture is pulled out from the tibial tunnel. F. Tibial fixation is performed with the knee flexed at 40◦ , using a double-spike plate, with an initial tension of 20 N. MFC: medial femoral condyle; MIT: medial intercondylar tubercle
Fig. 2. The aiming device. A. Image of the new aiming device (Smith & Nephew). B–D. The aiming device is matched to the structure of the tibial plateau surface.
tibial articular surface and meniscocapsular ligament is removed with rasping from the posterior segment to the mid segment of the MM. The posterior root is approximately 9.6 mm posterior and 0.7 mm lateral to the apex of the medial tibial eminence [10]. This area is present posterior to the shiny white fibers that are a distinct visual landmark on the distal aspect of the MM posterior horn [11]. The aiming device (Fig. 2) is placed at this anatomical insertion of the MM posterior root. The aiming device can be narrowed to create an accurate tibial bone tunnel at the anatomical attachment of the MM posterior root, without damaging the articular surface of the medial femoral condyle (Fig. 1B, Fig. 2B–D). A 2.4-mm guide pin is inserted, using the aiming device, at an angle of 55◦ to the articular
surface, and a tibial tunnel is created with a 4.0-mm cannulated drill (Fig. 1C). The torn posterior root of the MM is grasped using the FasT-Fix 360 meniscal repair system (Smith & Nephew) [12]. Our technique involves a single FasT-Fix suture. The needle is penetrated into the meniscal root using the oblique or horizontal mattress suture technique via the anteromedial portal, and the knot of the inserted FasT-Fix is fastened adequately. The free-end of the FasT-Fix suture is preserved (Fig. 1D). The uncut free-end of the FasT-Fix suture is used for transtibial pullout repair. The free-end is moved into the transtibial tunnel using a suture manipulator (Fig. 1E). The pullout thread is pulled carefully with manual tension, while the knee
Y. Kodama et al. / Orthopaedics & Traumatology: Surgery & Research 102 (2016) 951–954
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Fig. 3. Fixation of the FasT-Fix suture. Tying method between a free-end of the FasT-Fix suture and the double-spike plate (A). The FasT-Fix suture is connected to the double-spike plate by multiple knots (B, arrow). The posterior horn of the medial meniscus is shifted posteriorly with an increase in the knee flexion angle (F, arrowheads). C and E. Fully extended knee position. D and F. The knee is flexed at 90◦ . The double-spike plate connected to the FasT-Fix suture moves proximally in the knee-flexed position (C and D).
is flexed or extended under visualization of the medial compartment. Usually, the posterior horn is moved behind to increase the tension applied to the thread as the knee is flexed. To prevent suture breakage, the thread is fastened 5–10 mm from the hole in the anteromedial tibial cortex. Tibial fixation is performed using double-spike plate and screw (Meira, Aichi, Japan), with the knee flexed at 40◦ and with an initial tension of 20 N (Fig. 1F, Fig. 3; Video). 3. Results MMPRT repair using FastT-Fix was performed in 6 cases. There were no intraoperative complications, such as iatrogenic cartilage injury and suture bar displacement in the joint. 4. Discussion Kim et al. reported that radiographic and clinical outcomes were similar between pullout repair and suture anchor techniques for the treatment of a MMPRT [8,13]; however, this technique should not be indicated in case of varus deformity or severe cartilage lesion [7,14]. The suture anchor technique is a good treatment
approach, but a posteromedial portal is needed [15]. Threading the MM posterior root using conventional all-inside suture devices in arthroscopic repair has technical disadvantages. Our FasT-Fix suture device technique is easy to perform. The aiming device is easy to manipulate in the narrow medial compartment (Fig. 2A–D). The FasT-Fix technique uses a tiny implant for suturing the peripheral attachment of the posterior horn of the MM via the standard anterior portal only, and it is therefore convenient. The loads that can cause failure of vertical sutures using FasTFix and Ethibond 2-0 have been reported to be 115.2 ± 1.6 N and 82.6 ± 0.8 N, respectively [16]. Another study showed that a load of approximately 60 N could cause failure of meniscal sutures; however, there was no difference in clinical outcomes, and high thread strength was found to improve the degree of meniscal extrusion [17]. Considering the posterior translation of the MM posterior segment (Fig. 3), we set the fixation tension to 15–20 N in order to prevent it from exceeding 60 N. Our repair technique is easier than traditional pullout techniques and the suture anchor technique, and the surgical device can be manipulated in a narrow working space, especially in the case of intact anterior cruciate ligament. Further studies with a large number of patients are needed to confirm the efficacy and safety of our technique.
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Y. Kodama et al. / Orthopaedics & Traumatology: Surgery & Research 102 (2016) 951–954
Disclosure of interest The authors declare that they have no competing interest. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.otsr.2016.06.013. References [1] Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears: significance, diagnosis, and treatment. Am J Sports Med 2014;42:3016–30. [2] Padalecki JR, Jansson KS, Smith SD, Dornan GJ, Pierce CM, Wijdicks CA, et al. Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: in situ pull-out repair restores derangement of joint mechanics. Am J Sports Med 2014;42:699–707. [3] 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;90:1922–31. [4] Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med 1982;10:90–5. [5] Bin SI, Kim JM, Shin SJ. Radial tears of the posterior horn of the medial meniscus. Arthroscopy 2004;20:373–8. [6] Rutten BP, Korr H, Steinbusch HW, Schmitz C. The aging brain: less neurons could be better. Mech Ageing Dev 2003;124:349–55. [7] Ahn JH, Jeong HJ, Lee YS, Park JH, Lee JW, Park JH, et al. Comparison between conservative treatment and arthroscopic pull-out repair of the medial meniscus root tear and analysis of prognostic factors for the determination of repair indication. Arch Orthop Trauma Surg 2015;135:1265–76.
[8] Jung YH, Choi NH, Oh JS, Victoroff BN. All-inside repair for a root tear of the medial meniscus using a suture anchor. Am J Sports Med 2012;40: 1406–11. [9] 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;27:1644–53. [10] 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;43:363–9. [11] Johannsen AM, Civitarese DM, Padalecki JR, Goldsmith MT, Wijdicks CA, LaPrade RF. Qualitative and quantitative anatomic analysis of the posterior root attachments of the medial and lateral menisci. Am J Sports Med 2012;40:2342–7. [12] Kise NJ, Drogset JO, Ekeland A, Sivertsen EA, Heir S. All-inside suture device is superior to meniscal arrows in meniscal repair: a prospective randomized multicenter clinical trial with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 2015;23:211–8. [13] 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;26:106–13. [14] Moon HK, Koh YG, Kim YC, Park YS, Jo SB, Kwon SK. Prognostic factors of arthroscopic pull-out repair for a posterior root tear of the medial meniscus. Am J Sports Med 2012;40:1138–43. [15] Kim JH, Shin DE, Dan JM, Nam KS, Ahn TK, Lee DH. Arthroscopic suture anchor repair of posterior root attachment injury in medial meniscus: technical note. Arch Orthop Trauma Surg 2009;129:1085–8. [16] Buckland M, Sadoghi D, Wimmer P, Vavken MD, Pagenstert P, Valderrabano GI, et al. Meta-analysis on biomechanical properties of meniscus repairs: are devices better than sutures? Knee Surg Sports Traumatol Arthrosc 2015;23:83–9. [17] 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 Mason-Allen stitch and simple stitches. Arthroscopy 2014;30:1439–46.
Available online at
ScienceDirect www.sciencedirect.com
Technical note
Pullout repair of a medial meniscus posterior root tear using a FasT-Fix® all-inside suture technique Y. Kodama , T. Furumatsu ∗ , M. Fujii , T. Tanaka , S. Miyazawa , T. Ozaki Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
a r t i c l e
i n f o
Article history: Received 6 April 2016 Accepted 17 June 2016 Keywords: Medial meniscus Posterior root tear Pullout repair All-inside meniscal suture Arthroscopic treatment
a b s t r a c t A medial meniscus posterior root tear (MMPRT) may increase the tibiofemoral contact pressure by decreasing the tibiofemoral contact area. Meniscal dysfunction induced by posterior root injury may lead to the development of osteoarthritic knees. Repair of a MMPRT can restore medial meniscus (MM) function and prevent knee osteoarthritis progression. Several surgical procedures have been reported for treating a MMPRT. However, these procedures are associated with several technical difficulties. Here, we describe a technique to stabilize a torn MM posterior root using the FasT-Fix® all-inside meniscal suture device and a new aiming device. The uncut free-end of the FasT-Fix® suture can be used as a thread for transtibial pullout repair. Our procedure might help overcome the technical difficulties in arthroscopic treatment of a MMPRT. © 2016 Elsevier Masson SAS. All rights reserved.
1. Introduction The posterior root anchors the medial meniscus (MM) to the tibial plateau. Posterior root dysfunction is often caused by either acute injury or chronic degeneration [1], and it leads to abnormal biomechanics of the tibiofemoral joint and the inability to convert axial loads into transverse hoop stresses [2,3]. Although partial meniscectomy is used to manage a meniscal root tear, MM root disruption can affect the ability to withstand hoop strain, resulting in increased contact pressure and kinematic alteration of the affected compartment. Peak tibiofemoral contact pressures were previously found to be similar between a MM posterior root tear (MMPRT) and total meniscectomy of the MM [3]. The posterior root of the meniscus contains the perimeniscal capillary plexus and has radially arranged collagen fibrils [4]. A MMPRT is usually found in patients older than 50 years with degenerative changes of the knees [5]. However, the healing potential is lower in old patients than in young patients [6]; therefore, healing of the repaired meniscus might not be complete in older patients. Surgical indications of MMPRT repair in patients older than 50 years have been reported to include varus alignment < 5◦ , mild cartilage lesion (Outerbridge low grade I or II), and Kellgren–Lawrence grade 0–II in radiographs [7]. Transtibial pullout repair and suture anchor-dependent repair have been developed for arthroscopic treatment of a MMPRT [7,8].
∗ Corresponding author. Tel.: +81 862 357 273; fax: +81 862 239 727. E-mail address: [email protected] (T. Furumatsu). http://dx.doi.org/10.1016/j.otsr.2016.06.013 1877-0568/© 2016 Elsevier Masson SAS. All rights reserved.
However, there are several technical difficulties, and conventional pullout repair requires complex arthroscopic techniques. These procedures may induce iatrogenic injuries of the articular cartilage and additional tears of the MM posterior root. Here, we describe a technique to stabilize the torn MM posterior root using the FasT-Fix® all-inside meniscal suture device and a new aiming device (Smith & Nephew, Andover, MA, USA). Our technique aims to restore hoop tension and prevent cartilage damage, which can progress rapidly. The tear pattern was classified as previously described [9], and our technique is suitable for a MMPRT of type 2 (radial tear) or type 4 (oblique tear). 2. Operative technique The patient is placed supine, with a tourniquet. A standard anterolateral portal for arthroscopic visualization of the MM posterior root and its anatomical attachment, using a 30◦ arthroscope (Smith & Nephew). An anteromedial portal is used for the instruments. MMPRT repair is indicated in the absence of severe cartialage damage. The presence of a meniscal substance tear is evaluated via the anteromedial portal (Fig. 1A), and the type of meniscal root injury is defined. To accommodate a new aiming device (Smith & Nephew) and the FasT-Fix all-inside meniscal suture device (Smith & Nephew), synovial tissues surrounding the posterior cruciate ligament are removed using a motorized shaver and radiofrequency device. Additionally, scar-like tissue behind the meniscus and between the
952
Y. Kodama et al. / Orthopaedics & Traumatology: Surgery & Research 102 (2016) 951–954
Fig. 1. Medial meniscus posterior root tear (MMPRT) (right knee) in a 67-year-old woman. A. Radial type 2 tear of the MM posterior root. B. The tip of the aiming device is placed at the anatomical insertion of the MM posterior root from the anteromedial portal. The shiny white fiber is seen (black arrow). C. A cannulated drill (4.0 mm) is inserted along with the guide pin. D. Two FasT-Fix anchors are inserted into the MM posterior root in an oblique orientation. E. The uncut free-end of the FasT-Fix suture is pulled out from the tibial tunnel. F. Tibial fixation is performed with the knee flexed at 40◦ , using a double-spike plate, with an initial tension of 20 N. MFC: medial femoral condyle; MIT: medial intercondylar tubercle
Fig. 2. The aiming device. A. Image of the new aiming device (Smith & Nephew). B–D. The aiming device is matched to the structure of the tibial plateau surface.
tibial articular surface and meniscocapsular ligament is removed with rasping from the posterior segment to the mid segment of the MM. The posterior root is approximately 9.6 mm posterior and 0.7 mm lateral to the apex of the medial tibial eminence [10]. This area is present posterior to the shiny white fibers that are a distinct visual landmark on the distal aspect of the MM posterior horn [11]. The aiming device (Fig. 2) is placed at this anatomical insertion of the MM posterior root. The aiming device can be narrowed to create an accurate tibial bone tunnel at the anatomical attachment of the MM posterior root, without damaging the articular surface of the medial femoral condyle (Fig. 1B, Fig. 2B–D). A 2.4-mm guide pin is inserted, using the aiming device, at an angle of 55◦ to the articular
surface, and a tibial tunnel is created with a 4.0-mm cannulated drill (Fig. 1C). The torn posterior root of the MM is grasped using the FasT-Fix 360 meniscal repair system (Smith & Nephew) [12]. Our technique involves a single FasT-Fix suture. The needle is penetrated into the meniscal root using the oblique or horizontal mattress suture technique via the anteromedial portal, and the knot of the inserted FasT-Fix is fastened adequately. The free-end of the FasT-Fix suture is preserved (Fig. 1D). The uncut free-end of the FasT-Fix suture is used for transtibial pullout repair. The free-end is moved into the transtibial tunnel using a suture manipulator (Fig. 1E). The pullout thread is pulled carefully with manual tension, while the knee
Y. Kodama et al. / Orthopaedics & Traumatology: Surgery & Research 102 (2016) 951–954
953
Fig. 3. Fixation of the FasT-Fix suture. Tying method between a free-end of the FasT-Fix suture and the double-spike plate (A). The FasT-Fix suture is connected to the double-spike plate by multiple knots (B, arrow). The posterior horn of the medial meniscus is shifted posteriorly with an increase in the knee flexion angle (F, arrowheads). C and E. Fully extended knee position. D and F. The knee is flexed at 90◦ . The double-spike plate connected to the FasT-Fix suture moves proximally in the knee-flexed position (C and D).
is flexed or extended under visualization of the medial compartment. Usually, the posterior horn is moved behind to increase the tension applied to the thread as the knee is flexed. To prevent suture breakage, the thread is fastened 5–10 mm from the hole in the anteromedial tibial cortex. Tibial fixation is performed using double-spike plate and screw (Meira, Aichi, Japan), with the knee flexed at 40◦ and with an initial tension of 20 N (Fig. 1F, Fig. 3; Video). 3. Results MMPRT repair using FastT-Fix was performed in 6 cases. There were no intraoperative complications, such as iatrogenic cartilage injury and suture bar displacement in the joint. 4. Discussion Kim et al. reported that radiographic and clinical outcomes were similar between pullout repair and suture anchor techniques for the treatment of a MMPRT [8,13]; however, this technique should not be indicated in case of varus deformity or severe cartilage lesion [7,14]. The suture anchor technique is a good treatment
approach, but a posteromedial portal is needed [15]. Threading the MM posterior root using conventional all-inside suture devices in arthroscopic repair has technical disadvantages. Our FasT-Fix suture device technique is easy to perform. The aiming device is easy to manipulate in the narrow medial compartment (Fig. 2A–D). The FasT-Fix technique uses a tiny implant for suturing the peripheral attachment of the posterior horn of the MM via the standard anterior portal only, and it is therefore convenient. The loads that can cause failure of vertical sutures using FasTFix and Ethibond 2-0 have been reported to be 115.2 ± 1.6 N and 82.6 ± 0.8 N, respectively [16]. Another study showed that a load of approximately 60 N could cause failure of meniscal sutures; however, there was no difference in clinical outcomes, and high thread strength was found to improve the degree of meniscal extrusion [17]. Considering the posterior translation of the MM posterior segment (Fig. 3), we set the fixation tension to 15–20 N in order to prevent it from exceeding 60 N. Our repair technique is easier than traditional pullout techniques and the suture anchor technique, and the surgical device can be manipulated in a narrow working space, especially in the case of intact anterior cruciate ligament. Further studies with a large number of patients are needed to confirm the efficacy and safety of our technique.
954
Y. Kodama et al. / Orthopaedics & Traumatology: Surgery & Research 102 (2016) 951–954
Disclosure of interest The authors declare that they have no competing interest. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.otsr.2016.06.013. References [1] Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears: significance, diagnosis, and treatment. Am J Sports Med 2014;42:3016–30. [2] Padalecki JR, Jansson KS, Smith SD, Dornan GJ, Pierce CM, Wijdicks CA, et al. Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: in situ pull-out repair restores derangement of joint mechanics. Am J Sports Med 2014;42:699–707. [3] 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;90:1922–31. [4] Arnoczky SP, Warren RF. Microvasculature of the human meniscus. Am J Sports Med 1982;10:90–5. [5] Bin SI, Kim JM, Shin SJ. Radial tears of the posterior horn of the medial meniscus. Arthroscopy 2004;20:373–8. [6] Rutten BP, Korr H, Steinbusch HW, Schmitz C. The aging brain: less neurons could be better. Mech Ageing Dev 2003;124:349–55. [7] Ahn JH, Jeong HJ, Lee YS, Park JH, Lee JW, Park JH, et al. Comparison between conservative treatment and arthroscopic pull-out repair of the medial meniscus root tear and analysis of prognostic factors for the determination of repair indication. Arch Orthop Trauma Surg 2015;135:1265–76.
[8] Jung YH, Choi NH, Oh JS, Victoroff BN. All-inside repair for a root tear of the medial meniscus using a suture anchor. Am J Sports Med 2012;40: 1406–11. [9] 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;27:1644–53. [10] 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;43:363–9. [11] Johannsen AM, Civitarese DM, Padalecki JR, Goldsmith MT, Wijdicks CA, LaPrade RF. Qualitative and quantitative anatomic analysis of the posterior root attachments of the medial and lateral menisci. Am J Sports Med 2012;40:2342–7. [12] Kise NJ, Drogset JO, Ekeland A, Sivertsen EA, Heir S. All-inside suture device is superior to meniscal arrows in meniscal repair: a prospective randomized multicenter clinical trial with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 2015;23:211–8. [13] 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;26:106–13. [14] Moon HK, Koh YG, Kim YC, Park YS, Jo SB, Kwon SK. Prognostic factors of arthroscopic pull-out repair for a posterior root tear of the medial meniscus. Am J Sports Med 2012;40:1138–43. [15] Kim JH, Shin DE, Dan JM, Nam KS, Ahn TK, Lee DH. Arthroscopic suture anchor repair of posterior root attachment injury in medial meniscus: technical note. Arch Orthop Trauma Surg 2009;129:1085–8. [16] Buckland M, Sadoghi D, Wimmer P, Vavken MD, Pagenstert P, Valderrabano GI, et al. Meta-analysis on biomechanical properties of meniscus repairs: are devices better than sutures? Knee Surg Sports Traumatol Arthrosc 2015;23:83–9. [17] 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 Mason-Allen stitch and simple stitches. Arthroscopy 2014;30:1439–46.