Arthroscopic Medial Meniscus Root Repair With Transtibial Ripstop Technique

Background: Meniscal root tears are radial tears occurring at or within 1 cm of the meniscal root attachment. These injuries have been shown to be the biomechanical equivalent of a total meniscectomy and are thought to be responsible for a rapid progression of osteoarthritis if left untreated. Indications: Meniscal root repair is indicated if possible, with the exception of patients who have diffuse Outerbridge 3-4 osteoarthritis of the ipsilateral compartment, those who are poor surgical candidates due to age or medical comorbidity, or in whom nonsymptomatic tears are found incidentally. Technique Description: Standard 2-portal arthroscopy is performed. Once a medial root tear has been identified and concomitant pathology has been addressed, we typically begin the repair by trephinating the deep medial collateral ligament with an 18-gauge needle to enhance visualization and avoid iatrogenic cartilage injury. Arthroscopic shaver is used to debride the meniscal root as needed. A meniscal root guide is introduced into the joint and an incision is made on the anteromedial tibia for outside-in drilling of a transosseous tunnel. Drilling is performed with a 5-mm retroreaming device, and a 10-mm socket is created. Nonabsorbable suture is then passed through the meniscus using a self-capture device in an inverted mattress configuration, following by 2 cinch stitches. The sutures are then shuttled into the transosseous tunnel, and the meniscal root is reduced and tensioned in full extension, with the sutures being fixated into a suture anchor on the anteromedial tibia. Results: A recent large systematic review of 1086 patients undergoing treatment of meniscal root tear via either debridement or nonoperative management compared with meniscal repair found that conversion to total knee arthroplasty occurred in 11% to 54% of those managed via debridement or nonoperative care versus 0% to 1% for those with root repair. Discussion/Conclusion: Currently, meniscal root repair offers the greatest improvement and lowest risk of conversion to arthroplasty following meniscal root tear. The present technique offers a durable repair that we believe combines ease of execution with decreased risk of suture pull-out, by creating a ripstop-type construct. Long-term outcome studies are needed for this and other root repair techniques.

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Arthroscopic repair of the meniscus

EFORT Open Reviews ◽

10.1302/2058-5241.3.170059 ◽

2018 ◽

Vol 3 (11) ◽

pp. 584-594 ◽

Cited By ~ 14

Author(s):

Alfonso Vaquero-Picado ◽

E. Carlos Rodríguez-Merchán

Keyword(s):

Platelet Rich Plasma ◽

Meniscal Repair ◽

Cartilage Degeneration ◽

Reoperation Rate ◽

Root Tear ◽

Bone Marrow Stimulation ◽

Meniscal Root ◽

Meniscal Root Tear ◽

Points Of View ◽

Inside Out

From the biomechanical and biological points of view, an arthroscopic meniscal repair (AMR) should always be considered as an option. However, AMR has a higher reoperation rate compared with arthroscopic partial meniscectomy, so it should be carefully indicated. Compared with meniscectomy, AMR outcomes are better and the incidence of osteoarthritis is lower when it is well indicated. Factors influencing healing and satisfactory results must be carefully evaluated before indicating an AMR. Tears in the peripheral third are more likely to heal than those in the inner thirds. Vertical peripheral longitudinal tears are the best scenario in terms of success when facing an AMR. ‘Inside-out’ techniques were considered as the gold standard for large repairs on mid-body and posterior parts of the meniscus. However, recent studies do not demonstrate differences regarding failure rate, functional outcomes and complications, when compared with the ‘all-inside’ techniques. Some biological therapies try to enhance meniscal repair success but their efficacy needs further research. These are: mechanical stimulation, supplemental bone marrow stimulation, platelet rich plasma, stem cell therapy, and scaffolds and membranes. Meniscal root tear/avulsion dramatically compromises meniscal stability, accelerating cartilage degeneration. Several options for reattachment have been proposed, but no differences between them have been established. However, repair of these lesions is actually the reference of the treatment. Meniscal ramp lesions consist of disruption of the peripheral attachment of the meniscus. In contrast, with meniscal root tears, the treatment of reference has not yet been well established.Cite this article: EFORT Open Rev 2018;3:584-594. DOI: 10.1302/2058-5241.3.170059

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Utilization of Transtibial Centralization Suture Best Minimizes Extrusion and Restores Tibiofemoral Contact Mechanics for Anatomic Medial Meniscal Root Repairs in a Cadaveric Model

The American Journal of Sports Medicine ◽

10.1177/0363546519844250 ◽

2019 ◽

Vol 47 (7) ◽

pp. 1591-1600 ◽

Cited By ~ 16

Author(s):

Blake T. Daney ◽

Zachary S. Aman ◽

Joseph J. Krob ◽

Hunter W. Storaci ◽

Alex W. Brady ◽

...

Keyword(s):

Contact Mechanics ◽

Contact Pressure ◽

Posterior Border ◽

Root Tear ◽

Meniscal Extrusion ◽

3 Dimensional ◽

Anatomic Repair ◽

Pull Out ◽

Meniscal Root ◽

Root Repair

Background: Although posterior medial meniscal root (PMMR) repairs are often successful, postoperative meniscal extrusion after a root repair has been identified as a potential clinical problem. Purpose/Hypothesis: The purpose was to quantitatively evaluate the tibiofemoral contact mechanics and extent of meniscal extrusion after a PMMR repair. It was hypothesized that the addition of a centralization suture (into the posterior medial tibial plateau) would help restore normal joint load-bearing characteristics and restore the native amount of meniscal extrusion after a root tear. Furthermore, we hypothesized that the amount of meniscal extrusion would be greatest in loaded and flexed knees when measured at the posterior border of the medial collateral ligament (MCL). Study Design: Controlled laboratory study. Methods: Meniscal extrusion and tibiofemoral contact mechanics were measured using 3-dimensional digitization and pressure sensors in 10 nonpaired, human cadaveric knees. The PMMR of each knee was tested under 6 states: (1) intact; (2) type 2A PMMR tear; (3) anatomic transtibial pull-out root repair; (4) anatomic transtibial pull-out repair with centralization; (5) nonanatomic transtibial pull-out repair; and (6) nonanatomic transtibial pull-out repair with centralization, with randomization of the order of conditions 3 and 4, and 5 and 6. The testing protocol loaded knees with a 1000-N axial compressive force at 4 flexion angles (0°, 30°, 60°, 90°) in each state. Meniscal extrusion was measured with a 3-dimensional coordinate digitizer at 0° and 90° in both the loaded and unloaded states and calculated from the difference from the articular margin of the tibia to the periphery of the meniscus. Peak contact pressure, contact area, and total contact pressure were also recorded for all states at all flexion angles. Statistical analysis investigated the independent effects of flexion, state, and loading using 3 distinct 2-factor models. Results: Differences in the contact mechanics between repair techniques were most notable at higher flexion angles, demonstrating significantly higher average and peak contact pressures for nonanatomic repair states when compared with anatomic repairs with and without centralization (all P < .05). In unloaded knees at full extension, the magnitude of medial meniscal extrusion was significantly higher at the posterior border of the MCL compared with the posterior medial tibia ( P < .001) and adjacent to the root attachment on the tibia locations ( P < .001). Both anatomic repair states had no significant difference in the degree of extrusion when compared with the intact state. Conclusion: The anatomic transtibial pull-out root repair and the anatomic transtibial pull-out root repair with centralization techniques best restored contact mechanics of the knee and meniscal extrusion when compared with root tear and nonanatomic repair states at time zero. There were no significant differences in contact pressure or magnitude of extrusion between the anatomic repair state and the anatomic repair with centralization state. We found that extrusion is best measured in the coronal plane at the posterior border of the MCL for unloaded knees. However, the degree of extrusion increased as the knee was loaded and flexed to 90°. Clinical Relevance: When there are concerns about meniscal extrusion with a medial meniscal root repair, the addition of a centralization suture may be beneficial for patients in reducing pathologic meniscal extrusion and restoring joint contact mechanics.

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Posterior lateral meniscal root tear due to a malpositioned double-bundle anterior cruciate ligament reconstruction tibial tunnel

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-014-3273-1 ◽

2014 ◽

Vol 23 (12) ◽

pp. 3670-3673 ◽

Cited By ~ 7

Author(s):

Christopher M. LaPrade ◽

Kyle A. Jisa ◽

Tyler R. Cram ◽

Robert F. LaPrade

Keyword(s):

Anterior Cruciate Ligament ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Tibial Tunnel ◽

Double Bundle ◽

Root Tear ◽

Cruciate Ligament Reconstruction ◽

Meniscal Root ◽

Meniscal Root Tear ◽

Anterior Cruciate

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Long-Term Outcome After Arthroscopic Meniscal Repair Versus Arthroscopic Partial Meniscectomy for Traumatic Meniscal Tears

The American Journal of Sports Medicine ◽

10.1177/0363546510364052 ◽

2010 ◽

Vol 38 (8) ◽

pp. 1542-1548 ◽

Cited By ~ 240

Author(s):

Thomas Stein ◽

Andreas Peter Mehling ◽

Frederic Welsch ◽

Rüdige von Eisenhart-Rothe ◽

Alwin Jäger

Keyword(s):

Meniscal Repair ◽

Partial Meniscectomy ◽

Meniscal Tears ◽

Arthroscopic Partial Meniscectomy ◽

Term Outcome ◽

Long Term Outcome

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Meniscal Root Tear: A Missed Epidemic?

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00465 ◽

2019 ◽

Vol 7 (11_suppl6) ◽

pp. 2325967119S0046

Author(s):

Nadia Nastassia Ifran

Keyword(s):

Physical Examination ◽

Shock Absorber ◽

Lateral Meniscus ◽

Meniscal Tears ◽

Root Tear ◽

Injury Patterns ◽

Radiological Findings ◽

Meniscal Root ◽

Meniscus Tears ◽

Meniscal Root Tear

Meniscal root tears often go unnoticed and represent unique injury patterns with unique biomechanical consequences. Meniscal root tear occurs about 10-21% of all meniscal tears. Almost 10% of ACL tears involving posterior lateral meniscus tears. Meniscal root tears interrupt the continuity of the circumferential fibers, hence meniscus will fail to function as a shock absorber and load distributor. The biomechanical implication is the accelerated degeneration of the joint comparable to total meniscectomy. Repair of meniscal root tear will reduce contact pressure and increase contact area biomechanically similar to the uninjured meniscus. However, the repair must be done as anatomic as possible. Otherwise, the goal of restoring the meniscus function may not be achieved. Sign and symptoms, physical examination and radiological findings that may suggest a meniscal root tear will be discussed in this paper. Moreover, an overview of the management will also be described.

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