A 45-year-old man with knee pain
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A 45-year-old man presented with a 6-month history of posteromedial right knee pain and swelling after a twisting injury to his knee in the gym.
During the past 1 to 2 months, the man experienced worsening medial knee pain, made worse with deep flexion. The patient’s range of motion is 0° to 95°, with pain at the terminus of flexion. Further examination reveals intact cruciate and collateral ligaments. Plain radiographs of the right knee and standing long-leg radiographs demonstrate no significant osteoarthritis and neutral alignment, respectively. An MRI was obtained, which demonstrates a medial meniscal root tear with greater than 3 mm of extrusion in the sagittal plane (Figure 1).
Source: Robert F. LaPrade, MD, PhD
What are the best next steps in management of this patient?
See answer below.
Medial meniscal root repair
The patient was indicated for a medial meniscus root repair to retore meniscal function and prevent rapid degeneration of his medial compartment.
Medial meniscus repair technique
Repair began with the creation of anterolateral and anteromedial (AM) portals, followed by a diagnostic arthroscopy. The damaged meniscal root was probed to check the severity and pattern of the tear and a posteromedial portal was subsequently established. Once the tear was identified and gently debrided, the bony surface on the tibial plateau of the planned repair was decorticated with a curette. Using an arthroscopic grasper, it was ensured the meniscus had adequate mobility to reach the anatomic footprint.
Attention was then turned to creation of the transtibial tunnel. An initial incision for the transtibial tunnels was made just medial to the tibial tubercle. To best restore the footprint of the repair and increase the chance of biologic healing, two parallel transtibial tunnels were created at the location of the root attachment. To achieve this, an aiming device was used to position a drill pin, which was used to ream the first tunnel along the posterior aspect of the posterior root attachment. The second tunnel was then placed 5 mm anterior to the first tunnel. Tunnel position was confirmed arthroscopically and the two drill pins were removed, leaving the suture passing cannulas in place. A suture passing device was then introduced into the knee and suture was first passed through the posterior aspect of the detached medial meniscus root. This suture pass was made approximately 5 mm medial the lateral edge of the medial meniscus. This suture was then shuttled down the first tunnel/cannula via a looped wire and arthroscopic grasper. These steps were then repeated for the second suture, which was positioned through the midportion of the medial root, just anterior to the previously placed suture. The second suture was then shuttled down through the more anterior of the two transtibial tunnels. The sutures were then tied down over a cortical fixation device on the AM tibia (Figure 2). An arthroscopic probe was then introduced into the medial compartment to check the tension of the repair and ensure the root was repaired in an anatomic position. The knee was then taken through a range of motion to ensure the root was fixed in a stable manner.
Discussion
Meniscal root tears have gained increased attention during the past decade and account for 10% to 21% of all meniscal tears, affecting nearly 100,000 patients annually. Meniscal root tears can either be an avulsion of the insertion of the meniscus attachment to the tibial plateau or a complete radial tear within 1 cm of its insertion. This injury disrupts the continuity of the circumferential fibers of the meniscus and impairs the normal conversion of axial loads into transverse hoop stresses. This alteration in joint biomechanics leads to increased intra-articular pressure and can result in rapid acceleration of joint degeneration, making the prompt recognition and treatment of this injury pattern crucial. After anatomic repair of the root tear, normal knee joint loading is restored and OA progression can be slowed.
The two-tunnel repair technique described in this case allows for the restoration of the broad anatomical footprint of the medial meniscus root, a higher ultimate load to failure and the release of biological factors to enhance healing. Anatomic root repair is critical to the restoration of normal contact forces and there are both biomechanical studies and clinical evidence that greater than 3 mm of nonanatomic displacement significantly alters meniscus function and is associated with degenerative changes. Additionally, it is important to consider other patient factors, such as obesity (BMI >30 kg/m2), uncorrected malalignment and preexisting degenerative joint changes, when selecting patients who will benefit from root repair.
The clinical evidence of the benefits of meniscal root repair continues to grow. Kyu Sung Chung and colleagues reported that medial meniscus root repairs slowed the progression of arthritic changes compared with treatment with partial meniscectomy. Additionally, no patients in this study underwent total knee arthroplasty by 5-year follow-up, while 35% of those patients who underwent partial meniscectomy went on to subsequent conversion to TKA. A recent meta-analysis of 13 studies by Kyung-Han Ro and colleagues reported greater improvement of Lysholm scores, lower rates of progression to severe knee OA and fewer reoperations in those treated with root repair compared with partial meniscectomy.
Key points
- Meniscal root tears disrupt normal joint biomechanics resulting in increased intra-articular pressure.
- Prompt recognition and treatment of meniscal root tears is essential to prevent the rapid acceleration of joint degeneration.
- Anatomic root repair in appropriately selected patients can retore meniscus function and is associated with improved patient-reported outcome measures, lower rates of progression to severe OA and fewer reoperations and conversion to TKA compared with treatment with partial meniscectomy.
- References:
- Allaire R, et al. J Bone Joint Surg Am. 2008;doi:10.2106/JBJS.G.00748.
- Bonasia DE, et al. Orthop Rev (Pavia). 2015;doi:10.4081/or.2015.5792.
- Chung KS, et al. Am J Sports Med. 2017;doi:10.1177/0363546516662445.
- Chung KS, et al. Arthroscopy. 2015;doi:10.1016/j.arthro.2015.03.035.
- de Girolamo L, et al. Knee Surg Sports Traumatol Arthrosc. 2015;doi:10.1007/s00167-013-2712-8.
- Feucht MJ, et al. Arthroscopy. 2015;doi:10.1016/j.arthro.2015.03.022.
- LaPrade CM, et al. Am J Sports Med. 2014;doi:10.1177/0363546514544678.
- LaPrade CM, et al. Am J Sports Med. 2015;doi:10.1177/0363546514563278.
- LaPrade CM, et al. Am J Sports Med. 2015;doi:10.1177/0363546514566191.
- LaPrade RF, et al. Knee Surg Sports Traumatol Arthrosc. 2015;doi:10.1007/s00167-014-3395-5.
- Lerer DB, et al. Skeletal Radiol. 2004;doi:10.1007/s00256-004-0761-2.
- Padalecki JR, et al. Am J Sports Med. 2014;doi:10.1177/0363546513499314.
- Ro KH, et al. Orthop J Sports Med. 2020;doi:10.1177/2325967120962078.
- Sihvonen R, et al. New Engl J Med. 2013;doi:10.1056/NEJMoa1305189.
- Stärke C, et al. Arthroscopy. 2010;doi:10.1016/j.arthro.2009.08.013.
- For more information:
- Mark E. Cinque, MD, MS; Christopher M. LaPrade, MD; and Galvin J. Loughran, MD, can be reached at Stanford Medicine in Redwood City, California. Cinque’s email: mec89@stanford.edu. LaPrade’s email: claprade@stanford.edu. Loughran’s email: gjl42@stanford.edu. Robert F. LaPrade, MD, PhD, of Twin Cities Orthopedics in Edina, Minnesota, can be reached at laprademdphd@gmail.com.
- Edited by Mark E. Cinque, MD, MS, and Filippo F. Romanelli, DO, MBA. Cinque is a chief resident in the department of orthopedic surgery at Stanford. He will pursue a fellowship in sports medicine at The Steadman Clinic/Steadman Philippon Research Institute following residency completion. His interest is in complex knee surgery and multiligament reconstruction. Romanelli is a chief orthopedic resident at Rutgers – Jersey City Medical Center with an interest in adult reconstruction. He will be at New York University for his fellowship. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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