Abstract
Background:
Horizontal meniscal cleavage tears often occur in older individuals and have a degenerative component. Commonly, these are managed with partial meniscectomy. However, this results in significantly decreased contact area and increased peek contact forces. Arthroscopic repair has shown comparable results with repairs of other tear types.
Indications:
Cerclage repair is performed for a horizontal cleavage tear in individuals without significant arthritis and in whom partial meniscectomy would remove an unacceptably large portion of meniscal tissue.
Technique Description:
Using standard arthroscopy portals, a self-retrieving suture passing device is used to pass a #0 high-strength suture through the periphery of the meniscus. Arthroscopic knots are tied on the superior surface of the meniscus and pushed as far posteriorly as possible. A small 1-cm incision is made just through skin on the proximal, posteromedial border of the tibia. Through this a spinal needle is placed percutaneously to pass a Chia into the joint just posterior to the knot. A curved spinal needle from an outside-in meniscal repair kit may be used as this provides a better trajectory to tears closer to the root attachment. The Chia and suture limbs are retrieved out the front of the knee, and then the suture tails are shuttled out the back of the knee. This is repeated until the repair is complete. The suture limbs are then cut below skin.
Results:
After arthroscopic all-inside repair of horizontal cleavage tears, patients do well. Outcomes are similar to repairs of other meniscal tear types. In all, 80% of patients are satisfied with their results, and there is an 11% to 12% failure rate which is comparable to other types of tear repairs.
Discussion:
All-inside cerclage repair should be considered for individuals sustaining a horizontal cleavage tear. This preserves meniscal tissue compared to partial meniscectomy and yields good healing rates and outcomes.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
In this video the authors will describe a method for repairing a medial meniscus horizontal cleavage tear using a cerclage technique.
The authors have the following disclosures to report.
Horizontal cleavage tears occur more commonly in older individuals and have a degenerative component. Commonly, these are managed with partial meniscectomy, but this results in significantly increased contact forces and wear. Repair yields good outcomes and similar complications rates as compared to repairs of other meniscal tear types. Surgeons should consider repair of horizontal cleavage tears in individuals with minimal arthritis, when partial meniscectomy removes an unacceptably large portion of meniscus, in those without significant malalignment, and in those without significant comorbidities that would decrease the chance of healing.
Our case involves a 51-year-old male who presented to the clinic with right knee pain. He endorsed some variable symptoms over the past several years but noted recent, acute exacerbations over the last few months. The first time he noted worsening was while playing tennis. His symptoms were further exacerbated following a recent motor vehicle accident. He had occasional effusions and pain that did not significantly improve with oral non-steroidal anti-inflammatory drugs (NSAIDs). On exam, he had range of motion from 0 to 120°, and he had provocation of his pain with deep flexion. There was no effusion upon presentation, but he did have medial joint line tenderness and a positive McMurray. His exam was otherwise normal, and he was ligamentously stable.
Radiographs obtained during his visit demonstrated some trace narrowing of the medial compartment but no evidence of clinically significant arthritic changes such as subchondral sclerosis, subchondral cyst formation, or osteophytes.
Video of the sagittal and coronal magnetic resonance imaging (MRI) sequences is shown here. You can see a large horizontal cleavage tear extending from the body of the medial meniscus to the root attachment.
On these selected still images, the red arrows mark the horizontal tear. Differentiating this from a more common oblique tear is that this tear starts all the way from the periphery of the meniscus and exits out the apex centrally rather than out the inferior meniscal surface, as is more common. On the coronal slice, one can appreciate the extent of this tear.
Options to consider include the following as the literature on the topic is not conclusive and will be discussed later on. Partial meniscectomy is an option. However, in this active individual our goal was to preserve as much meniscal tissue as possible with a repair while educating the patient on the risks of failure to heal. All-inside devices are an option, although cost may be a consideration with their use. An inside-out method would increase the morbidity of the procedure due to the extra approach. Finally, an all-inside cerclage technique with a self-retrieving suture passer allows good compression of the leaflets. This is a cheaper alternative to all-inside devices, although possibly technically more demanding.
This diagram will show the step-by-step approach for all the inside repair of the horizontal cleavage tear of the medial meniscus. The tear is directly through the midsubstance of the meniscus. The correlation between the diagram and the MRI can been seen in this slide. Anterior is to the left, and posterior is to the right.
First a self-retrieving suture passing device is used through the anteromedial portal to pass a high-strength suture from the inferior to superior aspect of the meniscus as peripherally as possible.
Using the limb coming from the superior aspect of the meniscus as the post, alternating half hitches are thrown and synched down with the knot pusher being aware that the desired placement of the knot is as posterior as possible. Leaving the knot too anteriorly can cause abrasion of the femoral condyle on the knot-stack.
Meanwhile, a small 1-cm incision is made on the posteromedial aspect of the proximal tibia just through skin. A straight or a curved spinal needle from the outside-in meniscus repair kit may be used depending on which provides the best angle. It is then placed into the joint as may be done with an outside-in repair, but in this situation, just above the meniscus adjacent to the previously tied knot. A Chia is then passed into the joint and retrieved from the same anteriomedial working portal.
After ensuring there are no soft tissue bridges, the Chia is used to shuttle the sutures out the back of the knee, and they are then cut underneath the skin. This extra step of pulling the sutures out the back is done to ensure the knot-stack is pulled as posteriorly as possible preventing abrasion of the femoral condyle.
In the preoperative area, our anesthesia providers discuss and typically provide a regional block for post-operative pain control. Once in the operating room and asleep, the patient is positioned supine on a standard operating room table with all bony prominences well-padded. A sequential compression device (SCD) is placed on the nonoperative leg. A non-sterile thigh tourniquet is placed and the lateral post is positioned so to provide adequate counterforce for valgus stress. The leg is prepped and draped in typical fashion, and the procedure commences with a standard diagnostic arthroscopy after exsanguinating the leg and raising tourniquet.
Once in the medial compartment, the tear is located. It is noted to have a radial component at the meniscal body. Turning the camera to the posterior horn, complex tearing of the leaflets is noted.
There is also a flap that can be pulled into the joint. A shaver is used to gently debride the meniscal tissue back to a stable rim allowing for investigation of the posterior root. The root is stable although the cleavage tear does extend up to the root. A percutaneous release of the superficial medial collateral ligament (MCL) with an 18-g spinal needle just proximal to the joint line is performed. This will allow better visualization and decrease the chance of iatrogenic cartilage injury. With probing of the leaflets, one can better appreciate the extent of the tearing and the minimal meniscal tissue that would remain if a partial meniscectomy were performed.
A #0 high-strength suture has been passed in the periphery of the meniscus adjacent to the root with a self-capturing suture passer. Alternating half-hitches have been thrown and synched with a knot pusher securing the knot on the superior surface of the meniscus. A spinal needle is introduced into the posterior knee through a small, 1-cm incision off the posteromedial border of the proximal tibia. Through this a Chia is threaded. The Chia is pulled out the inferomedial working portal with an atraumatic grasper, and the spinal needle is removed. Next the Chia and sutures are simultaneously pulled through the portal to ensure no soft tissue bridge. Alternatively, a cannula may be placed.
Once the sutures are threaded through the loop in the Chia, the Chia and suture limbs are pulled out the back of the knee. An arthroscopic probe may be used to ensure the knot stack is pushed as posteriorly as possible out of the joint. This process is repeated several more times until the repair is complete.
A curved spinal needle from the outside-in meniscal repair kit may be used to allow a better trajectory when trying to capture the sutures placed more laterally in the medial meniscus.
The repair is probed confirming a good repair with closure and compression of the cleavage tear. The radial tear component was trimmed to allow a smooth transition into the repair construct. A total of 4 stitches were required for this repair.
Immediately following surgery cryotherapy is commenced and a hinged knee brace is applied. This is set to restrict motion between 0 and 90°. It is locked in extension until the nerve block has resolved after which is remains unlocked. Patients are made 50% weight bearing with crutches for the first 6 weeks. Physical therapy is commenced following surgery with goals of achieving easy 0 to 90° range of motion, re-activating the quadriceps, and performing low resistance exercises.
Between 6 and 10 weeks, motion and weight bearing are progressed and strengthening exercises are advanced. By 10 weeks, patients may be able to progress to activity specific exercises. Plyometrics, running, and cutting are slowly incorporated as tolerated at the discretion of the physical therapist. Most patients are able to return to sports between 5 and 6 months after surgery.
When performing this technique, portal position should be carefully planned to ensure good access to all regions of the meniscus. Depending on ease of access to the medial compartment, a percutaneous release of the MCL from just above the joint may need to be performed. It is critical not to cause iatrogenic injury to the cartilage during meniscus repair. When passing suture with the self-retrieving device, it should be passed as peripherally as possible in the meniscal tissue. While tying, the superior limb should be the post and knots must be pushed as posteriorly as possible to avoid chondral abrasion. Knot tension should be enough to compress the meniscal leaflets but not so great as to significantly imbricate the edges.
Overall outcomes following isolated meniscal repair show good results with 89% of individuals returning to pre-injury activity level including 86% of professional athletes. There is about a 20% failure rate with isolated repairs. The average return to play time is around 5-6 months, although some studies suggest up to 8.5 months. Horizontal cleavage tears account for 12% to 35% of all meniscal tears. They are more likely to occur in older individuals, occur without trauma, and contain some intrasubstance degeneration.
For these reasons, these are commonly managed by debriding one or both leaflets until they are stable. However, biomechanical studies have shown that removing even one leaflet significantly decreases contact area and increases the peak contact pressure. The concern is that this results in accelerated compartment wear. As repair results in similar contact area and contact pressure to the intact state, the hope is that repair prevents of delays degenerative changes. This however, has not been proven. The available literature is relatively small and comprised of small, retrospective studies. Within this literature, repair of horizontal cleavage tears shows a comparable rate of healing compared to repair of other tear types. 80% of patients are satisfied with their results, and the failure rate is similar to other repairs—between 11 and 12 percent.
It is important to educate patients about the risks of repair as meniscectomy has a lower complication and failure rate than repair. However, for an active individual without degenerative changes, repair may be good option.
References may be found here.
We thank you for watching this video.
Footnotes
Submitted April 11, 2022; accepted July 27, 2022.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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.
