Abstract
Background:
Meniscus surgery remains one of the most common orthopaedic surgeries performed in the United States each year, with radial tear patterns being a common subset. In young, active patients with mechanical symptoms, surgery is often indicated. While management via partial meniscectomy predominates historically in tears of this type, recent success has been found in surgical repair. As repair techniques continue to evolve, this case demonstrates the use of the traction suture to maintain anatomic reduction throughout repair, ultimately resulting in a low-tension construct.
Indications:
Meniscal repair is indicated for traumatic tears in individuals with minimal to no underlying osteoarthritis in the knee. The authors believe utilization of the traction suture is indicated for any repair of radial tears of the lateral meniscus where maintaining reduction might be difficult to aid in an ultimately low-tension construct.
Technique Description:
The patient is placed in a supine position. Standard anteromedial and anterolateral portals are made, and standard diagnostic arthroscopy is performed. The meniscus tear is inspected and classified. A traction suture is placed in the posterior aspect of the body of the meniscus, bolstered by capsular fixation in an inside-out method to aid in the reduction of central tears. Care is taken to maintain reduction by pulling traction on this suture throughout the repair. In the case presented here, we proceeded with repair utilizing a hashtag configuration, with a combination of vertical and horizontal mattress sutures through an inside-out technique and a posterolateral approach. Following repair, the remaining white-white tissue is debrided, and the knee is ranged through a complete arch of motion to ensure the tear remains reduced throughout this range.
Results:
Results specific to the use of the traction suture on outcomes of repair are forthcoming. The authors of this study have performed several studies on radial meniscus tear repairs and outcomes previously, demonstrating improvements in patient-reported outcomes as well as favorable biomechanical outcomes.
Discussion/Conclusion:
Surgical intervention should be considered for symptomatic radial meniscus tears extending to the capsule of the lateral meniscus, especially in young athletes. The use of the traction suture can be helpful to maintain reduction throughout repair, ultimately allowing for a repair under minimal tension.
Patient Consent Disclosure Statement:
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, we present the evolution of tensionless repair for traumatic radial tears of the lateral meniscus through the use of 3 patient cases. Several strategies to facilitate successful repair are presented, highlighted by the use of the traction suture to maintain anatomic reduction of the tear throughout the repair, resulting in a final construct under low tension.
These are our disclosures. One or more of the authors has declared a potential conflict of interest as specified in the VJSM Conflict of Interest Statement.
Background
Meniscus repair is one of the most commonly performed operations by orthopaedic surgeons each year, at an estimate of 10% to 20% of all orthopaedic surgeries. 3 Radial meniscus tears are a certain subset of meniscus tears that are oriented perpendicular to the circumferential fibers of the meniscus.3,4 These tears have significant biomechanical consequences, resulting in loss of hoop stresses and ultimately increasing contact forces across the knee.1,6 Historically, radial tears were thought to be irreparable and thus were managed via partial meniscectomy in most cases.4,9 However, recent evidence has demonstrated repair of radial meniscal tears results in improved restoration of native knee biomechanics and clinical outcomes compared to meniscectomy.5-7 With this evidence, new techniques to increase reliability and ease of repair of these difficult tear patterns remain necessary.
The purpose of this video is to demonstrate the utility of a traction stitch and illustrate the evolution of its usage through this author's perspective when repairing radial tears. This stitch is indicated in any repair where maintaining the reduction of the tear may be technically difficult and is used in conjunction with the hashtag method of repair. The first case will demonstrate the tensionless hashtag repair without the utilization of a traction stitch. The second case first shows the result of a repair with only a horizontal mattress suture, followed by the use of a traction stitch and hashtag repair on the contralateral side. Finally, the third case utilizes the traction stitch, bolstered with capsular fixation to maintain reduction during the hashtag repair.
Indications
In the first case, we present a 16-year-old girl with knee pain after an abnormal landing from a rebound. Imaging revealed an anterior cruciate ligament injury, a peripheral tear in the medial meniscus, and a radial tear in her lateral meniscus. This patient is a candidate for repair due to a traumatic tear in a knee without osteoarthritis (OA).
For this patient, we started with a diagnostic knee arthroscopy. Based on the review of preoperative imaging, it was anticipated that we would discover a large radial meniscus tear that would require preparation of the repair bed, as well as multiple approaches to repair the tear in a hashtag orientation. This first case shows a hashtag repair done without the use of a traction stitch.
Technique Description
All patients presented had the same setup and positioning. The appropriate knee is marked, and preoperative antibiotics are given. The patient is positioned supine with the operative leg draped free. A tourniquet is placed on the operative thigh, followed by the utilization of a lateral post and foot bump. A sterile stocking is applied to the foot and lower leg.
Portals are created in standard fashion and followed by diagnostic arthroscopy. The lateral meniscus reveals a significant radial tear as expected, and the site of repair is then prepared via synovial abrasion and rasping. Next, using an all-inside, self-capturing suture device, vertical mattress sutures are thrown parallel to the tear along both sides to act as rip stops for the horizontal repair. Next, side-to-side horizontal mattress sutures are thrown across the tear, reducing the tear anatomically. Multiple are thrown in this fashion to create the hashtag repair, tying them from periphery to central and slowly extending the knee to avoid capturing the knee and causing gapping when full extension is reached. Finally, this tensionless repair is assessed for stability through range of motion, and any additional removal of the white-white zone lateral discoid meniscus may be performed.
Next, we present a 16-year-old boy who presents 10 weeks after a basketball injury with swelling and lateral right knee pain and catching. His physical examination reveals 1+ effusion, range of motion from full extension through 140, pain on hyperflexion, tenderness to palpation along the lateral joint line, and a positive McMurry's test. Imagining of the left knee reveals an effusion and a significant radial tear with notable gapping of the lateral meniscus. This was repaired with standard horizontal sutures only, without a traction stitch or utilizing the hashtag method, resulting in significant tension on repair. This repair unfortunately failed, resulting in further compromise of the lateral compartment. Imaging shows significant scar tissue at the failure site and horizontal cutouts where the suture pulled through the meniscus. Arthroscopy of the repair further reveals how suture pulled through the meniscus, elongating the repair tissue. This patient ultimately required a lateral meniscus transplant and cartilage restoration surgery. However, at 10 months postoperatively, this same patient returned with pain and swelling on the contralateral side after sustaining a left knee injury while making a cut during football. Imaging revealed a joint effusion and another radial tear of the lateral meniscus with a significant amount of gapping, further shown by arthroscopy.
With the same indications mentioned earlier, he proceeded with repair in the same manner described earlier. However, before beginning the hashtag repair, an initial vertical mattress suture was placed within the posterior half of the lateral meniscus to act as a traction stitch. This traction stitch was used to reduce and maintain the meniscus in anatomic position, instead of relying on the horizontal mattress stitch to reduce the tear. The rest of the procedure progressed according to the hashtag repair steps described earlier by placing vertical mattress sutures first on either side of the tear to serve as rip stops with horizontal mattress sutures over the vertical mattress.
The final evolution of this repair comes with a 16-year-old boy who presented for initial evaluation of a knee injury sustained 11 days prior while playing lacrosse. He had pain with motion and clicking with walking. On examination, the patient had a right knee effusion, tenderness to palpation about the lateral joint line, and range of motion from full extension to 130° of flexion. His intra-articular ligamentous examination is normal. However, he does demonstrate a positive McMurray's sign.
On imaging, radiographic studies of the right knee demonstrate findings consistent with a knee effusion without any obvious osseous injury. Magnetic resonance imaging (MRI) demonstrates evidence of a radial tear of the lateral meniscus. With the same indications mentioned earlier, he is deemed a candidate for repair.
The lateral meniscus tear is first inspected arthroscopically, which confirms significant gapping, and the site is prepared as described earlier, ensuring reduction is possible in the process. Next, the vertical mattress suture is placed within the posterior half of the lateral meniscus to act as a traction stitch to reduce the meniscus.
At this point, a roughly 4-cm incision is made over the posterolateral aspect of the knee, just posterior to the lateral collateral ligament (LCL), and a curved speculum is kept in this area until the completion of the repair to protect neurovascular structures in this area.
With the meniscus reduction maintained by the traction stitch, 3 vertical mattress sutures are then placed in the posterior portion, securing it to the capsule. An additional vertical mattress suture is placed in the anterior portion of the meniscus, again suturing to the capsule. At this time, the procedure progresses as previously described to create a hashtag repair, beginning with vertical mattress sutures to act as rip stops followed by side-to-side horizontal mattress sutures above the vertical sutures across the tear. These are then sequentially tied from the remains on the traction stitch, and the meniscus remains in its anatomic position. The traction suture can thus be removed or tied.
Results
At this point, the stability of the repair is assessed by taking the knee through its full range of motion and watching for gapping. Following irrigation, the incisions can be closed in a standard fashion, and a sterile dressing is applied.
Discussion/Conclusion
Incorrect placement of the traction suture may lead to malreduction of the tear and serve to add tension rather than minimize it. Once reduced properly, anchoring to the capsule further minimizes this risk as it holds the anatomic reduction. Repair failure can be as high as 13%; although the failure rate for this technique has not been studied, it is important to properly counsel patients on this risk. 2 Despite the risk of OA development in the knee being significantly lower compared to meniscectomy, repair patients are still over 2 times more likely to develop OA compared to the general population. 8 Finally, with the posterolateral approach to the knee, injury to neurovascular structures can be seen, so utilizing a speculum, as in this case, can minimize this risk.
The knee brace should be locked in extension for the first 2 weeks. Range of motion exercises should be limited to 0° to 90° for the first 4 weeks postoperatively. The patient is kept on strict nonweightbearing for a period of 6 weeks.
Our return-to-sport guidelines are as follows: the patient should have full pain-free range of motion, strength at or greater than 90% compared to their contralateral side on isokinetic testing, no reactive effusion with sport-specific activity, and normalized mechanics with functional athletic movements. Most return to sport somewhere between 5 and 8 months.
While studies on outcomes regarding tensionless repair utilizing traction sutures to maintain reduction of the meniscus are forthcoming, prior studies conducted by this study group have demonstrated improvement in patient-reported outcomes as well as the biomechanical success of the hashtag repair.5,7
Footnotes
Submitted July 7, 2024; accepted October 17, 2024.
One or more of the authors has declared the following potential conflict of interest or source of funding: D.C.F. is a consultant for Smith & Nephew, Linvatec, Vericel, Depuy Synthes, and Moximed. 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.
