28-year-old soccer player with medial knee pain
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A 28-year-old male soccer player presented with acute onset of left knee pain and swelling following an awkward twisting motion during a game.
The patient reported feeling a popping sensation at the time of injury and was unable to continue playing. Physical examination revealed medial joint line tenderness, positive McMurray and Apley’s tests, and limited range of motion. MRI demonstrated a complete radial tear of the medial meniscus without concomitant injury to other intra-articular structures.
Source: Robert F. LaPrade, MD, PhD
What are the best next steps in management of this patient?
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Medial meniscal radial repair
The patient was indicated for a medial meniscus radial tear repair to restore meniscal function and prevent rapid degeneration of his medial compartment.
Medial meniscus radial tear repair technique
The patient was positioned supine on the operating table. The contralateral leg was placed in a leg holder, and the operative leg was positioned in 90° of flexion with the foot of the bed dropped.
Standard medial and lateral arthroscopic portals were created adjacent to the patellar tendon. A diagnostic arthroscopy was performed to assess concomitant ligamentous or chondral injuries. The ACL and PCL were found to be intact. There were grade 1 changes along the cartilage surfaces of the medial and lateral femoral condyles. The lateral meniscus was uninjured.
Once in the medial compartment, a radial tear of the medial meniscus was confirmed. A meniscus rasp was utilized to lightly debride the tear edges. Attention was then turned toward creating the exposure needed for inside out repair. A vertical incision was centered over the joint line and dissection was made through the sartorius fascia; the interval anterior to the medial gastrocnemius was developed and a retracting device was inserted to protect the posterior structures and allow needle capture. Dual meniscus repair needles loaded with 2-0 nonabsorbable sutures were utilized and passed through the meniscus using a mechanical insertion device. Horizontal sutures spanning a radial tear were placed and tied sequentially with the knee in 90° of flexion. The meniscus was tested using an arthroscopic probe to ensure complete restoration of meniscal anatomy.
Postoperatively, the patient was made non-weight-bearing for the first 6 weeks. Passive range of motion was restricted from 0° to 90° of flexion for the first 2 weeks and then progressively increased as tolerated. Partial protected weight-bearing and cycling on a stationary bicycle were introduced at 6 weeks. An unloader brace was utilized to protect the medial repair as full weight-bearing was introduced. Deep squatting, leg lifting and cross-legged sitting were prohibited for 4 months postoperatively, after which the patient began resuming low-impact activities as tolerated.
Discussion
This case report presents the successful repair of a radial tear of the medial meniscus utilizing an inside-out surgical technique. This case highlights the importance of early recognition, appropriate surgical intervention and structured rehabilitation for optimal outcomes. Historically, radial tears were often treated with meniscectomy due to an incomplete understanding of the biomechanical consequences of these tears and the technical difficulty associated with repair. Complete radial meniscus tears result in the disruption of the circumferential fibers of the meniscus, compromising the ability of the meniscus to appropriately distribute hoop stresses and decrease tibiofemoral contact pressure. Failure to recognize and treat such injuries can result in rapid progression of irreversible degenerative changes and subsequent medial compartment osteoarthritis.
Previous studies have shown encouraging outcomes for radial tear repair, albeit mostly in small case series. Abdullah Foad, MD, demonstrated the self-limited ability of radial tears to heal, emphasizing the importance of repair for tears extending into the vascular zone. Uur Haklar, MD, and colleagues studied outcomes after inside-out horizontal suture repair of radial tears and reported a mean postoperative Lysholm score of 94.2 at a mean 31-month follow-up. Other studies have similarly reported favorable results after repair of radial meniscus tears using different surgical techniques, such as inside-out horizontal suture repair or all-inside suture techniques. However, in the largest series, the technique used in this case demonstrated excellent outcomes that were comparable with the outcomes of the repair of vertical meniscus tears at a mean of 3.5 years. Taken together, biomechanical and clinical outcomes data support the repair of radial tears to prevent altered load distribution, increased contact stresses and accelerated joint degeneration.
Key points
- Identification of radial meniscus tears is critical to allow for prompt repair to restore the circumferential fibers of the meniscus and prevent rapid progression of the accelerated joint degenerative process.
- Radial meniscus tears can be safely and efficiently repaired arthroscopically utilizing an inside-out surgical technique with horizontal sutures spanning the radial tear.
- A structured rehabilitation program is critical for both protecting the meniscal repair, as well as promoting return of knee range of motion and strength in recovering athletes.
- Reference:
- Anderson CJ, et al. J Bone Joint Surg Am. 2012;doi:10.2106/JBJS.K.01710.
- Choi NH, et al. Am J Sports Med. 2009;doi:10.1177/0363546509339010.
- Cinque ME, et al. Am J Sports Med. 2017;doi:10.1177/0363546517704425.
- Foad A. Knee Surg Sports Traumatol Arthrosc. 2012;doi:10.1007/s00167-011-1660-4.
- Haklar U, et al. Knee. 2008;doi:10.1016/j.knee.2008.05.012.
- Harper KW, et al. AJR Am J Roentgenol. 2005;doi:10.2214/AJR.04.1024.
- Kidron A, et al. Arthroscopy. 2002;doi:10.1053/jars.2002.30650.
- Lee SJ, et al. Am J Sports Med. 2006;doi:10.1177/0363546506286786.
- Ode GE, et al. Am J Sports Med. 2012;doi:10.1177/0363546512453291.
- Padalecki JR, et al. Am J Sports Med. 2014;doi:10.1177/0363546513499314.
- van Trommel MF, et al. Arthroscopy. 1998;doi:10.1016/S0749-8063(98)70002-7.
- 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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