Abstract
Background:
Meniscal posterior root tears, which are often associated with anterior cruciate ligament (ACL) injury, lead to the loss of normal biomechanical and kinematic behavior of menisci. Several arthroscopic techniques have been introduced to address this kind of injury. In this video, a simple all-inside technique to repair posterior lateral root tear (PLRT) is presented.
Indications:
To repair type 1, type 2, and type 4 PLRT.
Technique:
The torn lateral meniscus root is sutured to the medial fibers of the posterior cruciate ligament (PCL), with an arthroscopic all-inside repair system, with the purpose of reproducing the stabilizing function of the meniscofemoral ligaments.
Results:
This procedure allows restoration of the correct position of the detached horn, and restores meniscal stability with satisfactory clinical outcomes.
Discussion/Conclusion:
The technique described represents a simple and fast arthroscopic all-inside procedure to repair PLRT in association with concomitant procedure, such as ACL reconstruction. However, outcome reports of this technique are still lacking in the literature, and further studies are needed to confirm the authors’ results.
This is a visual representation of the abstract.
Video Transcript
In this video, a surgical technique for lateral meniscus posterior root repair is reported, and its application in a clinical case is described.
The following are the authors’ disclosures.
The posterior lateral root tears (PLRT) are meniscal injuries often associated with anterior cruciate ligament (ACL) tear. To address, the PLRT is fundamental to fully restore knee biomechanical and kinematics behavior. Several arthroscopic techniques have been introduced to repair meniscal root tears. However, most of them are challenging and invasive procedures. The all-inside lateral posterior root-to-posterior cruciate ligament (PCL) fixation technique represents an extremely simple and fast technique which, in the authors’ experience, leads to stabilization of the menisci and satisfactory clinical outcomes.
Meniscal root tears are defined as avulsion injuries of the meniscotibial ligament or radial tears within 1 cm apart of the meniscus insertion site. The lateral meniscus posterior root tears are usually traumatic in nature and have been often reported in association with ACL injury.
According to the morphological features, a root tear classification was introduced by LaPrade and colleagues, in which 5 types of lesions were distinguished: partial stable root tears (type 1); complete radial tears within 9 mm from the bony root attachment (type 2); bucket-handle tears with complete root detachment (type 3), complex oblique or longitudinal meniscal tears with complete root detachment (type 4); and avulsion fracture of the meniscal root attachment (type 5).
The lesion of the horn fibers leads to the extrusion of menisci and to its inability to absorb the hoop stress associated with weight-bearing, with a similar biomechanical effect as a total meniscectomy.
Biomechanical studies showed that the lateral meniscus posterior root tear has been associated with increased peak pressure in the lateral compartment. Moreover, cadaveric studies reported that this kind of meniscal tears affected both translational and rotational knee kinematics in the ACL-deficient knee.
Moreover, biomechanical studies showed that the meniscofemoral ligaments (MFLs) play a key role in the stability of the posterior root, limiting extrusion of the lateral meniscus and preserving the contact mechanics within the knee.
Several surgical techniques have been described to reattach the posterior horn of both lateral and medial menisci, including fixation through transosseous tunnels or suture anchor fixation, with satisfactory biomechanical and clinical outcomes. However, these techniques represent challenging and invasive procedures for the surgeons.
In this video, a simple all-inside technique to repair PLRT is presented.
The all-inside PCL fixation technique described in this video is used by the authors in surgical practice for the treatment of type 1, type 2, and type 4 PLRT. In these types of root lesions, in the authors’ experience, the described technique allowed to achieve a correct position of the teared posterior horn and to restore the stability of the lateral meniscus.
The aim of the PLR-to-PCL repair technique is to restore the normal position and stability of the posterior horn by fixing it to the PCL fibers. The footprint of the posterior lateral meniscus root is located in the intertubercular area, posteromedial to the lateral tibial eminence, medial to the articular margin of the lateral tibial plateau, and posterior to the tibial insertion of the ACL.
The fibers of the posterior root of the lateral meniscus slide proximal and strictly associated with the lateral and anterior fibers of the distal part of the PCL. Moreover, the MFLs, which attach the lateral posterior root to the intercondylar portion of the medial femoral condyle, run along the surface of the PCL and represent a direct anatomical association between the lateral posterior root and the PCL.
The tear of the posterior tear leads to a hypermobility of the meniscus, with the loss of the normal position of the posterior horn.
In the posterior root repair technique described in this video, the torn lateral meniscus root is sutured to the medial fibers of the PCL, with the purpose to reproduce the stabilizing function of the MFLs. Finally, the suture is tensed and the posterior horn is fixed in the correct position. To perform this technique, an all-inside repair system was used.
The repair technique described in this video is very simple. The all-inside device (Truespan, DePuy Synthes) used by the authors to perform this technique is very comfortable, allowing to use only 1 hand and a simple trigger system.
First, the posterior horn of the meniscus is caught. Then it is fixed posteriorly to the medial fibers of the PCL. Finally, after that suture was tightened, the position of the posterior horn was restored, and it is strictly fixed to the anterior surface of the PCL.
In this video, a clinical case of a 24-year-old female volleyball player was presented. The patient had a noncontact left knee injury during a volleyball competition 2 weeks before and presented with pain and joint instability. Clinical examination and magnetic resonance imaging evaluation showed an ACL rupture. Moreover, a PLRT was suspected. Therefore, the patient was admitted to hospital with the program of ACL reconstruction and treatment of meniscal tear.
Standard arthroscopic anteromedial and anterolateral portals were performed.
The arthroscopic view confirmed the presence of a type 1/type 2 posterior root lesion of the lateral meniscus. The meniscal stability examination with the probe was performed, showing a hypermobility of the lateral meniscus due to the radial tear of the posterior horn insertion.
The rest of the meniscal structure appeared to be intact. Pulling on the detached posterior horn near the original footprint allowed the restoration of the normal position of the teared lateral meniscus.
Therefore, the goal of the meniscal treatment was to restore the posterior horn insertion at this point, fixing it in this position.
To achieve the posterior horn fixation, an all-inside repair was performed using a device with a 12-size needle and a 2-0 nonabsorbable suture (Truespan, DePuy Synthes), which was inserted inside the joint through the anteromedial arthroscopic portal.
The first plate of the stitch was positioned in the posterior horn of the meniscus; the second plate was positioned posteriorly in the medial part of the PCL. Then, after that suture was tensed, the tightening of the meniscus was obtained, and its correct position was restored. The stitch must be tensioned until the posterior horn achieves the correct position, without overtensioning the suture.
Range of motion exercise was started few days after the surgery, with a maximum flexion allowed of 90° for the first 2 weeks after surgery. After the first 2 weeks, exercise to gradually recover the full range of motion was started.
Partial weightbearing on the operated limb was allowed for the first 2 weeks after surgery. After the first 2 weeks, gradually full weightbearing on the operated limb was allowed.
At 2-month follow-up evaluation, the patient presented without pain and with a cool and dry knee, stable at the laxity test, and was allowed to gradually start running on the treadmill.
In conclusion, the all-inside lateral posterior root-to-PCL fixation technique represents an extremely simple and fast technique, which allows the restoration of the posterior horn position and meniscus stability. Moreover, it is very suitable in association with ACL reconstruction procedure. The main limitation of this video is that it still lacks reports about clinical outcomes of this technique in the literature, and therefore, further studies confirming the authors’ results are needed.
Footnotes
Submitted February 25, 2021; accepted April 19, 2021.
One or more of the authors has declared the following potential conflict of interest or source of funding: Materials and publication fees for this study were paid for by DePuy Mitek. S.Z. is a paid consultant for DePuy Mitek and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
