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. 2025 Feb 10;14(5):103457. doi: 10.1016/j.eats.2025.103457

Arthroscopic Knotless Anchor Through High Posterolateral Portal for Treating Medial Meniscal Posterior Root Tears

Zenan Tian 1, Jianlong Ni 1, Wang Wei 1, Ruiying Li 1, Dazhi Wang 1, Zhihao Chen 1, Zhibin Shi 1,∗
PMCID: PMC12177453  PMID: 40547976

Abstract

Surgery can repair medial meniscal posterior root tears to restore the biological function of the meniscus. Transtibial pullout repair is most common, but suture anchor repair offers great biomechanical stability and avoids the bungee effect. Suture anchor repair through the posteromedial portal has limitations, which have been widely reported. This article describes our technique using a knotless anchor through the high posterolateral portal for the treatment of medial meniscal posterior root tears; it can achieve an anatomic repair. Through the use of the high posterolateral portal, an excellent degree of verticality between the suture anchor and the anatomic footprint of the medial meniscal posterior root can be achieved. Additionally, we summarize the advantages, disadvantages, pearls, and pitfalls of the technique.

Technique Video

Download video file (52.1MB, mp4)

A medial meniscal posterior root tear (MMPRT) is defined as a tear that occurs within 1 cm of the posterior tibial attachment of the medial meniscus.1 MMPRTs account for 10% to 21% of meniscal tear cases, and the incidence is expected to increase as the population ages.2,3 Research has shown that the MMPRT is functionally and biomechanically comparable to total meniscectomy.4 It is associated with the medial meniscal compression, contributing to degenerative knee osteoarthritis (OA) progression.5, 6, 7, 8

Surgical repair is the preferred treatment to restore the biological function of the meniscus.9,10 Transtibial pullout repair offers more simplicity than suture anchor repair for MMPRTs, but suture anchor repair is also a very important and effective repair for MMPRTs.9,11,12 Kim et al.,13 through a prospective clinical comparative study, found that both transtibial pullout repair and suture anchor repair yielded good outcomes in the treatment of MMPRTs, with similar clinical results. In terms of biomechanics, suture anchor repair is superior to transtibial pullout repair under cyclic loading conditions, load-to-failure testing, and compressive loading conditions.9,14,15 In addition to establishment of the standard anteromedial portal (AMP) and anterolateral portal (ALP), there is a need to establish a high posteromedial portal for suture anchor repair.16,17 Owing to the anatomic characteristics of the medial meniscal posterior root (MMPR) attachment area, there are potential issues associated with the high posteromedial portal for suture anchor placement, such as insufficient verticality, risk of injury to the saphenous nerve, and potential damage to the medial femoral condyle (MFC) cartilage.17, 18, 19, 20

This article describes our technique using a knotless anchor through the high posterolateral portal (HPLP) for the treatment of MMPRTs, inserting the posterior root back into the anatomic footprint again. This technique allows for the suture anchor to have significant verticality and stability, reducing the risk of common peroneal nerve injury and avoiding damage to the MFC. Additionally, this technique can be performed simultaneously with osteotomy.

Surgical Technique

Step 1: Preparation for Surgery and Establishment of Standard Portals

After appropriate anesthesia, the patient is placed in the supine position with the operative knee (left knee) flexed at 90°. A high thigh pneumatic tourniquet is used for hemostasis. On the basis of the preoperative markings on the surgical knee, the standard AMP and ALP are established. The AMP serves as the surgical portal and can be adjusted downward to facilitate safe passage of instruments beneath the MFC. The ALP is used as the observation portal and can be adjusted downward and positioned closer to the patellar tendon to provide better visualization of the MMPR. Continuous valgus stress and external rotation of the lower leg, along with the pie-crusting technique, are applied to widen the medial joint space for the surgical procedure and avoid iatrogenic cartilage injury.

Step 2: Determination of Lesion and Attachment of Posterior Root

A 30° arthroscope through the ALP is used to visualize MMPR and its adjacent anatomic structures, with the aim of determining the type of injury (Fig 1A). Through the AMP, the arthroscopic shaver system is used to trim the edges and surrounding synovium of the MMPRT (Fig 1B). This facilitates subsequent surgery steps. Next, the attachment of the posterior root on the anatomic footprint is determined. A curette and burr are used to carefully scrape and remove the articular cartilage in the attachment down to the subchondral bone of the tibial plateau, which increases the healing surface area and helps secure the posterior root on the anatomic footprint (Fig 1C).

Fig 1.

Fig 1

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Determination of lesion and attachment of posterior root. (A) Identification of medial meniscal posterior root (MMPR) tear (arrow). (B) Trimming of edges and surrounding synovium of lesion. (C) Removal of bone bed from attachment. The AMP is the surgical portal and the ALP is the viewing portal. (MFC, medial femoral condyle; MTP, medial tibial plateau.)

Step 3: Suturing of Tear

The EasyPass suture passer (Rejoin), loaded with Orthocord sutures (synthetic nonabsorbable sutures; Johnson & Johnson), enters the articular cavity through the AMP. The first Orthocord suture (purple) is inserted approximately 5 mm from the MMPRT, while the second Orthocord suture (blue-white) is inserted approximately 10 mm from the MMPRT (Fig 2 A and B). Subsequently, the 2 Orthocord sutures are tightened to assess the stability (Fig 2C).

Fig 2.

Fig 2

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Suturing of medial meniscal posterior root tear. (A, B) Suturing of tear by 2 Orthocord sutures. (C) Tightening of 2 Orthocord sutures. The black arrow indicates the first suture, and the red arrow indicates the second suture. The AMP is the surgical portal and the ALP is the viewing portal. (MFC, medial femoral condyle; MTP, medial tibial plateau.)

Step 4: Establishment of HPLP and Insertion of Knotless Suture Anchor

The HPLP is established approximately 10 to 15 cm above the posterolateral joint line, between the iliotibial band and the biceps femoris tendon (Video 1). An 18-gauge spinal needle is used to determine the direction and location, and the preliminary channel is established for the HPLP (Fig 3 A-C). During the procedure, the operative knee is kept flexed at 90° and the spinal needle is kept as close to the femur as possible. This is perceived to maintain a safe distance from the common peroneal nerve, thus significantly reducing the risk of nerve injury. The spinal needle is removed, and a blunt trocar is used to enter the channel and separate the surrounding tissues. Then, a sterile arthroscopic portal cannula is placed, usually a plastic portal cannula (TracPort; Rejoin). Because of the patient’s high body mass index, the plastic portal cannula is insufficient in length, so it is replaced with a metal portal cannula. (High body mass index is one of the contraindications for suture anchor repair. However, given the combination of the patient’s condition and preoperative examination findings, the patient willingly accepts this repair.) A suture clamp is used to pull out the 2 Orthocord sutures through the HPLP (Fig 3D). A metal bone punch through the cannula is used to create a guide hole at the appropriate angle on the anatomic footprint. The guide hole should be made as perpendicular as possible to the bone surface of the attachment, which is believed to enhance the stability of the suture anchor and improve long-term outcomes (Fig 3E). The bone punch is removed, and the 2 Orthocord sutures are threaded into the 4.75-mm Healix Advance BR knotless suture anchor (Johnson & Johnson). The suture anchor is rotated into the guide hole with appropriate tension, and high stability of the MMPR is ensured (Fig 3F). Next, the sutures are cut at the appropriate location, continuing the surgical procedure with combined distal femoral osteotomy (DFO). Finally, the stability of the medial meniscus and the anchor is assessed through arthroscopy under artificial stress during flexion, extension, and rotation (Video 1).

Fig 3.

Fig 3

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Establishment of high posterolateral portal (HPLP) and repair of medial meniscal posterior root tear by knotless suture anchor. (A, B) Patient positioning and locations of spinal needle insertion site (stars), HPLP, standard anteromedial portal (AMP), and anterolateral portal (ALP). (C) Use of spinal needle to preliminarily establish HPLP. (D) Pullout of 2 Orthocord sutures through HPLP. (E) Use of bone punch to create guide hole. (F) Placement of knotless suture anchor (arrow) into prepared guide hole. The AMP is the surgical portal and the ALP is the viewing portal. (MFC, medial femoral condyle.)

Postoperative Protocol

Postoperatively, the patient is asked to perform daily quadriceps strengthening exercises and straight leg raises. A knee brace is worn for 4 weeks. Next, the patient gradually increases weight-bearing activities until reaching full weight bearing after 2 months. Full flexion and squatting exercises are permitted after 3 months. Complete physical activity recovery is expected by 6 months. Preoperative and postoperative imaging examinations show that the patient’s knee joint function has recovered well after combining suture anchor repair and DFO (Fig 4).

Fig 4.

Fig 4

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(A, B) Preoperative sagittal (A) and coronal (B) magnetic resonance imaging suggesting medial meniscal posterior root tear (arrows). (C, D) Postoperative frontal (C) and lateral (D) radiographs showing postoperative changes of combined suture anchor repair and distal femoral osteotomy, with good position of internal fixation (triangles).

Discussion

In this article, we describe our technique using a knotless anchor through the HPLP to treat MMPRTs. Additionally, we summarize the advantages and disadvantages of the technique (Table 1).

Table 1.

Advantages and Disadvantages of Technique

Advantages
 Through the HPLP, the posterior root can be accurately inserted into the anatomic footprint without slippage to other areas.
 Inserting the suture anchor through the HPLP allows a very high degree of verticality between the anchor and the anatomic footprint.
 This technique requires no tibial tunnels and does not affect simultaneous ligament reconstruction or high tibial osteotomy.
 This technique has no bungee effect and provides great biomechanical outcomes.
Disadvantages
 Establishing the HPLP is challenging and requires experienced orthopaedic surgeons.
 There is a risk of injuring the common peroneal nerve and accompanying blood vessels.
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HPLP, high posterolateral portal.

Surgical repair is considered the preferred treatment for MMPRTs, which includes transtibial pullout repair and suture anchor repair.9,17,21, 22, 23 Transtibial pullout repair is commonly chosen by most doctors because of its simplicity and favorable prognosis. However, suture anchor repair is superior to transtibial pullout repair in certain aspects,9,14,17,24,25 including no bungee effect, greater stability, no bone tunnel, and fewer bone injuries, as well as greater tensile strength and better long-term outcomes.

Anatomic reduction of MMPRTs has been proved to restore the complete knee contact area and contact pressure, but accurately inserting the MMPR into the anatomic footprint presents challenges.26, 27, 28, 29 A high posteromedial portal is often created to insert the MMPR into the anatomic footprint during suture anchor repair.30,31 However, when using the posteromedial portal to insert the suture anchor, there is a steep learning curve associated with the positioning of the suture anchor.30, 31, 32 This can cause the suture anchor to slip during insertion and even lead to failure of anatomic repair. In this technique, we use the HPLP to treat MMPRTs. Through the HPLP, the suture anchor can be accurately and vertically inserted into the anatomic footprint. Besides, anchor slippage does not easily occur, and the anchor has a high degree of verticality with the anatomic footprint. Thus, the risk of injury to the common peroneal nerve and accompanying blood vessels is decreased. We preliminarily determine and mark the HPLP opening location by combining preoperative magnetic resonance imaging and physical examination findings. When establishing the HPLP, we insert the spinal needle slowly and cautiously from the posterior-lateral-superior direction moving toward the anterior-medial-inferior direction while closely monitoring. During the surgical procedure, the knee is kept flexed at 90° and continuous valgus stress is applied to increase the distance between the HPLP and the neurovascular structures. These methods can be observed in Video 1 and Fig 1, Fig 2, Fig 3, Fig 4.

We usually use this technique in conjunction with osteotomy for the treatment of degenerative knee OA. Knee joint correction osteotomy can be performed at the distal femur (i.e., DFO) or proximal tibia (i.e., high tibial osteotomy).33, 34, 35, 36 Our technique has significant advantages combined with high tibial osteotomy. However, it is necessary to consider the type of knee OA and the patient’s preference to determine an appropriate osteotomy to combine with this technique. The pearls and pitfalls of the technique are summarized in Table 2.

Table 2.

Pearls and Pitfalls of Technique

Pearls
 The operative knee should be kept flexed at 90° and continuous valgus stress should be applied, along with the pie-crusting technique, to widen the medial joint space and facilitate the surgical procedure.
 The HPLP is established about 10-15 cm above the joint line and close to the femur, which can reduce the risk of injury to the common peroneal nerve.
 Through the HPLP, the suture anchor is easily inserted into the anatomic footprint.
 Trimming the tear and the undersurface of the medial meniscus, as well as the bone bed of the attachment, can improve repair outcomes.
Pitfalls
 If the tear is severe and cannot be repaired surgically or if the tear is small and can be treated conservatively, it may be necessary to abandon the suture anchor repair.
 If meniscal extrusion is severe, meniscal centralization can be used after the suture anchor repair.
 Appropriate tension should be applied to the sutures while inserting the suture anchor.
 The repair effect should be confirmed under artificial stress after inserting the knotless suture anchor.
Open in a new tab

HPLP, high posterolateral portal.

In summary, our technique uses the HPLP for suture anchor repair to treat MMPRTs. The use of the HPLP offers several advantages, especially allowing the suture anchor to be accurately and vertically inserted into the anatomic footprint of the MMPR. In addition, the suture anchor cannot easily slip.

Disclosures

All authors (Z.T., J.N., W.W., R.L., D.W., Z.C., Z.S.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Footnotes

Z.T. and J.N. are co-first authors.

Supplementary Data

Video 1

Use of knotless anchor through high posterolateral portal (HPLP) for treatment of medial meniscal posterior root tear (MMPRT). The anchor can be accurately and vertically inserted into the anatomic footprint of the medial meniscal posterior root (MMPR). Step 1 consists of preparation for surgery and establishment of standard portals. After appropriate anesthesia, the patient is placed in the supine position with the operative knee (left knee) flexed at 90°. On the basis of the preoperative markings on the surgical knee, the standard anteromedial portal (AMP) and anterolateral portal (ALP) are established. The AMP is the surgical portal and the ALP is the viewing portal. Step 2 consists of determination of the lesion and the attachment of the posterior root. The MMPR and its adjacent anatomic structures are visualized to determine the type of injury. The arthroscopic shaver system is used to trim the edges and surrounding synovium of the MMPRT. Next, the attachment of the posterior root on the anatomic footprint is determined. A curette and burr are used to carefully scrape and remove the articular cartilage in the attachment down to the subchondral bone of the tibial plateau. Step 3 consists of suturing the tear. The EasyPass suture passer, loaded with Orthocord sutures (synthetic nonabsorbable sutures), enters the articular cavity through the AMP. The first Orthocord suture (purple) is inserted approximately 5 mm from the MMPRT, while the second Orthocord suture (blue-white) is inserted approximately 10 mm from the MMPRT. Subsequently, the 2 Orthocord sutures are tightened to assess the stability. Step 4 consists of establishing the HPLP and inserting a knotless suture anchor. The HPLP is established approximately 10 to 15 cm above the posterolateral joint line, between the iliotibial band and the biceps femoris tendon. An 18-gauge spinal needle is used to determine the direction and location, and the preliminary channel is established for the HPLP. The spinal needle is removed, and a blunt trocar is used to enter the channel and separate the surrounding tissues. Then, a sterile arthroscopic portal cannula is placed. A suture clamp is used to pull out the 2 Orthocord sutures through the HPLP. A metal bone punch through the cannula is used to create a guide hole at the appropriate angle on the anatomic footprint. The bone punch is removed, and the 2 Orthocord sutures are threaded into the 4.75-mm Healix Advance BR knotless suture anchor. The suture anchor is rotated into the guide hole with appropriate tension, and high stability of the MMPR is ensured. Then, the sutures are cut at the appropriate location. Finally, the stability of the medial meniscus and the knotless anchor is assessed.

Download video file (52.1MB, mp4)

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Supplementary Materials

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Video 1

Use of knotless anchor through high posterolateral portal (HPLP) for treatment of medial meniscal posterior root tear (MMPRT). The anchor can be accurately and vertically inserted into the anatomic footprint of the medial meniscal posterior root (MMPR). Step 1 consists of preparation for surgery and establishment of standard portals. After appropriate anesthesia, the patient is placed in the supine position with the operative knee (left knee) flexed at 90°. On the basis of the preoperative markings on the surgical knee, the standard anteromedial portal (AMP) and anterolateral portal (ALP) are established. The AMP is the surgical portal and the ALP is the viewing portal. Step 2 consists of determination of the lesion and the attachment of the posterior root. The MMPR and its adjacent anatomic structures are visualized to determine the type of injury. The arthroscopic shaver system is used to trim the edges and surrounding synovium of the MMPRT. Next, the attachment of the posterior root on the anatomic footprint is determined. A curette and burr are used to carefully scrape and remove the articular cartilage in the attachment down to the subchondral bone of the tibial plateau. Step 3 consists of suturing the tear. The EasyPass suture passer, loaded with Orthocord sutures (synthetic nonabsorbable sutures), enters the articular cavity through the AMP. The first Orthocord suture (purple) is inserted approximately 5 mm from the MMPRT, while the second Orthocord suture (blue-white) is inserted approximately 10 mm from the MMPRT. Subsequently, the 2 Orthocord sutures are tightened to assess the stability. Step 4 consists of establishing the HPLP and inserting a knotless suture anchor. The HPLP is established approximately 10 to 15 cm above the posterolateral joint line, between the iliotibial band and the biceps femoris tendon. An 18-gauge spinal needle is used to determine the direction and location, and the preliminary channel is established for the HPLP. The spinal needle is removed, and a blunt trocar is used to enter the channel and separate the surrounding tissues. Then, a sterile arthroscopic portal cannula is placed. A suture clamp is used to pull out the 2 Orthocord sutures through the HPLP. A metal bone punch through the cannula is used to create a guide hole at the appropriate angle on the anatomic footprint. The bone punch is removed, and the 2 Orthocord sutures are threaded into the 4.75-mm Healix Advance BR knotless suture anchor. The suture anchor is rotated into the guide hole with appropriate tension, and high stability of the MMPR is ensured. Then, the sutures are cut at the appropriate location. Finally, the stability of the medial meniscus and the knotless anchor is assessed.

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Articles from Arthroscopy Techniques are provided here courtesy of Elsevier

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