Abstract
Background:
Lesions of the posterolateral parts of the lateral meniscus are commonly treated with all-inside suture repair. The popliteal tendon is one of the few anatomic structures available to attach these anchor systems. However, this method is controversial and its biomechanical effects are unknown.
Hypothesis:
Suture fixation of the lateral meniscus to the popliteal tendon significantly affects the mobility of both structures involved.
Study Design:
Descriptive laboratory study.
Methods:
Six fresh-frozen human knee specimens were tested using a biaxial servohydraulic testing machine. Ten loading cycles of ±10° internal-external rotation were performed under 100 N axial load and 30° joint flexion. The popliteal muscle was constantly loaded with 44 N. A 3-dimensional optical measurement system recorded the movement of the lateral meniscus, popliteal tendon, and lateral femoral condyle. The resultant torque was also measured. Each knee joint was tested without and with suture fixation of the lateral meniscus to the popliteal tendon. All-inside suture repairs were performed under arthroscopic control.
Results:
Fixation of the lateral meniscus to the popliteal tendon resulted in a significant reduction in both (absolute and relative) movement of the components involved. On average, the absolute displacement of the lateral meniscus decreased by 34.3% (1.2 mm; P < .001) and that of the popliteal tendon proximal to the suture by 18.8% (0.3 mm; P = .02). There was a 23.5% (0.8 mm; P < .001) reduction in relative movement between the lateral femoral condyle and lateral meniscus, a 17.1% (0.6 mm; P = .004) reduction between the lateral femoral condyle and popliteal tendon distal to the suture, and a 25.0% (0.7 mm; P < .001) reduction between the lateral meniscus and popliteal tendon proximal to the suture. Regarding the measured torque, a significant reduction of 2.0 Nm (18.2%; P = .04) was measured for femoral internal rotation.
Conclusion:
All-inside suture fixation of the lateral meniscus to the popliteal tendon shows significant biomechanical effects.
Clinical Relevance:
Our results suggest increased tension on the suture with possible implications for meniscal healing. These findings may require adaptation of postoperative management, considering more restrictive treatments or resorbable suture anchors.
Keywords: knee, lateral meniscal lesion, popliteal tendon, all-inside fixation
Meniscal tears are among the most common surgically treated knee injuries. 11 Even though nonoperative treatment of certain meniscal tears is possible and has shown good clinical results in the past, 9 in recent decades, the trend toward meniscal preservation surgery has developed rapidly. 4 The aim of these procedures is to preserve the stabilizing and load-distributing function of the meniscus and to prevent the development of osteoarthritis.1,4,12 Most meniscal tears occur in the medial meniscus, while the lateral meniscus is less commonly affected.12,15 When lateral meniscal tears occur, the posterolateral parts of the meniscus are often involved. 17 This may cause problems due to the close anatomic relationship with the popliteal hiatus, where the meniscus lacks a connection to the joint capsule.8,23,27 All-inside suture repair is usually the treatment of choice for posterior-located tears of the lateral meniscus.2,22 To avoid unstable suture placement around the popliteal hiatus, the popliteal tendon can serve as an anchor point.21,24,27 However, this technique is not without controversy. 13 On one hand, Ouanezar et al 21 and Mhaskar et al 18 show good clinical results and low failure rates after all-inside meniscal repair using the popliteal tendon, and the results of a biomechanical study by Lopez et al 14 on 9 human knee specimens have proven a stable meniscal suture even under load. On the other hand, there is a recent study by Séguineau et al 24 on 22 human knee specimens that showed a suture failure in 40% after a single extension-flexion cycle. Another pathology that may require suturing of the posterior horn of the lateral meniscus is hypermobility of the lateral meniscus.3,13 This can occur when the popliteomeniscal fascicles are torn, which is an injury that is often combined with other injury patterns affecting the anterior cruciate ligament or the posterolateral corner.3,13,16,26,28 Therefore, a profound biomechanical understanding is necessary to interpret such results.
To the best of our knowledge, no study has investigated the biomechanical effects of lateral meniscal fixation on the popliteal tendon. We therefore aimed to investigate the biomechanical effects of all-inside lateral meniscal repairs in which the meniscus is attached to the popliteal tendon, with the hypothesis that this significantly influences the mobility of the lateral meniscus and the popliteal tendon.
Methods
Specimen Preparation
Ethical approval for the study was given by the ethics committee of the Rostock University Medical Center. Data protection requirements were considered.
Six right-sided fresh-frozen human cadaveric knees were used in this study. The donors had a mean age of 78.7 years (range, 59-87 years) and were equally divided between male and female specimens. Apart from usual age-related changes, the specimens had no osteoarthritis and had not undergone meniscal surgery during their lifetime. The surrounding soft tissues were carefully dissected to expose the joint capsule, which remained anatomically intact. An approach window was then prepared into the posterior lateral joint capsule, allowing a clear view of the lateral femoral condyle, the posterior horn of the lateral meniscus, and the popliteal tendon (Figure 1A).
Figure 1.
(A) Dissected human knee joint with identification of posterior lateral femoral condyle (1), lateral meniscus (2), and popliteal tendon (3). (B) Dissected human knee joint with an arthroscopic all-inside fixation of the lateral meniscus to the popliteal tendon (point markers were applied to the components for 3-dimensional optical measurement).
During the biomechanical evaluation, an arthroscopic all-inside fixation of the lateral meniscus to the popliteal tendon was performed by a board-certified sports orthopaedic surgeon (C.L.) (Figure 2). First, 2 standard arthroscopic portals were created (anteromedial and anterolateral). The lateral meniscus was exposed arthroscopically (camera via the anterolateral portal), and a FiberStich all-inside meniscal repair system (Arthrex GmbH) was inserted via the anteromedial portal. The meniscal repair was performed with the device according to the manufacturer's instructions. Both stitches were inserted through the meniscus into the popliteal tendon in a vertical orientation. The correct positioning of the suture anchors was verified extra-articular with a view of the exposed popliteal tendon. The anchors were then tightened and cut according to the manufacturer's instructions. Figure 1B presents the suture fixation of the popliteal tendon to the meniscus.
Figure 2.
Schematic drawing of an all-inside suture fixation of the lateral meniscus (LM) to the popliteal tendon (PT). The stitches are aligned vertically (blue solid line). F, lateral femoral condyle; T, tibial plateau.
Biomechanical Evaluation
The proximal femoral shaft as well as the distal tibial and fibular shaft were embedded in metal pots, using a self-curing polymer (Rencast FC52 Polyol and Isocyanate; Huntsman Advanced Materials) and a filler (DT 082-1 Aluminiumhydroxid; Gößl + Pfaff GmbH) in equal parts of polyol, isoccyanate and filler. The specimens were positioned in a biaxial servohydraulic testing machine (INSTRON® 8874; Instron) in 30° flexion using a tilting table and neutral internal-external rotation. The 30° flexion was chosen due to technical limitations. Because meniscal suture placement is normally performed in a flexion-varus position, an attempt was made to come close to this. However, a maximal flexion of 30° was possible in the test setup. To simulate popliteal muscle and tendon tension, the popliteal muscle was stitched up with surgical sutures attached to a 4.5-kg weight (approximately 44 N). According to Harner et al, 10 this corresponds to 50% of the maximal contraction force of the popliteal muscle. Figure 3 illustrates the test setup.
Figure 3.
The test setup for biomechanical evaluation of the right knee specimens with and without arthroscopic all-inside fixation of the popliteal tendon to the lateral meniscus. 3D, 3-dimensional.
The biomechanical evaluation was first performed with the native knee joint (after creation of the posterolateral capsular window). Subsequently, a second biomechanical evaluation was performed to assess the effect of the all-inside fixation of the popliteus tendon to the lateral meniscus. The knees were left in the test machine during the arthroscopic procedure to guarantee similar positioning in the test machine for both conditions.
The biaxial servohydraulic testing machine was equipped with a load cell with a force capacity of ±25 kN and a torque capacity of ±100 N·m used to evaluate the biomechanical behavior. The WaveMatrix program (Version 1.3; Instron) was used to create and control the desired load sequence. In the first step of the test procedure, an axial load of 100 N was applied to the 30° flexed knee joint. In the next step, the femur was sinusoidally loaded with a ±10° internal-external rotation for 10 cycles at 0.25 Hz while the axial load was kept constant and the resultant torque was measured. Finally, the joint was returned to a neutral rotation position, and the axial load was reduced. This was done 3 times for each knee joint before and after the all-inside fixation.
3-Dimensional Optical Measuring System
Additionally, the 3-dimensional optical measurement system ARAMIS 5M with 23-mm lenses (Carl Zeiss GOM Metrology GmbH) was used to record the movement of the lateral meniscus, the popliteal tendon, and the femoral condyle over the entire test procedure. At the beginning of each test day, the system was calibrated using the corresponding calibration plate.
For the evaluation, marker points were attached to the meniscus, the lateral femoral condyle, and the popliteal tendon (Figure 3). For each test run, 900 images were recorded at a frequency of 5 Hz. The images were analyzed using the associated software GOM Suite 2021 (Version 3.1; Carl Zeiss GOM Metrology GmbH). Four point components were defined to analyze their relative and absolute movements: lateral femoral condyle, lateral meniscus, popliteal tendon distal to the all-inside suture fixation, and popliteal tendon proximal to the all-inside suture fixation (Figure 4). For each point component, a reference point was determined from the points permanently detected by the optical measurement system. To detect the absolute displacement of the lateral meniscus and the popliteal tendon distal and proximal to the suture, the maximal displacement of the fitting points during rotation was measured in relation to the initial value in the neutral position. To determine the relative movement of the components to each other, the following changes in distance of the reference points were defined and their maximum was evaluated:
Figure 4.
A 3-dimensional optical measurement was performed by defining 4 reference points (×F: reference point of the lateral femoral condyle; ×M: reference point of the lateral meniscus; ×P,d: reference point of the popliteal tendon distal to the all-inside suture fixation; ×P,p: reference point of the popliteal tendon proximal to the all-inside suture fixation) based on the femoral point component (1), meniscal point component (2), popliteal tendon distal to the all-inside suture fixation point component (3), and popliteal tendon proximal to the all-inside suture fixation point component (4) and measurement of the relative changes of the distance between these reference points as well as the absolute movement. All displacements were referred to the femoral condyle, which was defined as a fixed body.
- Femoral condyle to lateral meniscus (Δ[×F−×M])
- Femoral condyle to popliteal tendon distal to the suture (Δ[×F−×P,d[)
- Femoral condyle to popliteal tendon proximal to the suture (Δ[×F−×P,p])
- Lateral meniscus to popliteal tendon distal to the suture (Δ[×M−×P,d])
- Lateral meniscus to popliteal tendon proximal to the suture (Δ[×M−×P,p])
The femoral condyle was defined as the fixed point.
Data Evaluation and Statistical Analysis
The recorded values from the testing machine and the optical measuring system were exported to Microsoft Excel (Version 16.78.3; Microsoft). The first 5 measurement cycles were considered preconditioning, which is usually applied in biomechanical tests to reduce variation between test specimens.6,7 The remaining 5 cycles were used for the evaluation. Statistical analysis was performed using IBM SPSS Statistics (Version 27.0.1; IBM). Data were expressed as absolute values or as mean ± SD (range). The Shapiro-Wilk test was used to test for normal distribution. Depending on this, either the t test or the Wilcoxon signed-rank test was used to determine significant differences between groups. Data with P < .05 were considered statistically significant.
Results
All test cycles were able to be carried out without technical problems and without suture breakage.
Relative Movements Between Components
The maximal change in distance between the lateral femoral condyle and the lateral meniscus (illustrated in Figure 5) was on average 3.4 ± 0.5 mm (2.6-4.3 mm) before and 2.6 ± 0.6 mm (0.9-3.7 mm) after suturing. This represents a reduction of 23.5%, which is highly significant (P < .001). The difference in relative movement between the lateral femoral condyle and the popliteal tendon proximal to the suture was not significant (P > .05). However, there was a significant reduction between the lateral femoral condyle and the popliteal tendon distal to the suture (P = .004) with a mean distance change of 0.6 mm (17.1%). Comparing the relative movements between the lateral meniscus and popliteal tendon proximal to the suture, there was a highly significant change in distance (P < .001). The mean change in distance between these 2 components was 2.8 ± 1.1 mm (0.9-4.3 mm) before and 2.1 ± 0.7 mm (1.0-3.2 mm) after suturing, a reduction of 25.0%. No significant difference was found between the lateral meniscus and the popliteal tendon distal to the suture (P > .05). The results are summarized in Table 1.
Figure 5.
Schematic drawing of the posterolateral capsular window as it is mapped by the 3-dimensional optical measuring system. Numbers refer to the lateral femoral condyle (1), the lateral meniscus (2), the popliteal tendon (3), and the lateral collateral ligament (4). Red points indicate the reference points for the components between which the maximal distance changes were measured exemplified by the red arrow.
Table 1.
Relative Movements Between the Reference Points of the Defined Components a
| Change in Distance, mm | Mean Difference, mm | Difference, % | P | ||
|---|---|---|---|---|---|
| Without Meniscal Suture Fixation | With Meniscal Suture Fixation | ||||
| Δ(×F−×M) | 3.4 ± 0.5 (2.6-4.3) |
2.6 ± 0.6 (0.9-3.7) |
0.8 | 23.5 | <.001 |
| Δ(×F−×P,p) | 2.0 ± 0.3 (1.2-2.4) |
1.7 ± 0.4 (0.8-2.5) |
0.3 | 15.0 | >.05 |
| Δ(×F−×P,d) | 3.5 ± 0.9 (2.1-4.6) |
2.9 ± 0.7 (2.0-3.9) |
0.6 | 17.1 | .004 |
| Δ(×M−×P,p) | 2.8 ± 1.1 (0.9-4.3) |
2.1 ± 0.7 (1.0-3.2) |
0.7 | 25.0 | <.001 |
| Δ(×M−×P,d) | 2.5 ± 0.9 (1.0-3.3) |
2.2 ± 0.8 (1.0-3.2) |
0.3 | 12.0 | >.05 |
Data are presented as mean ± SD (range). Δ(×F−×M), femoral condyle to lateral meniscus; Δ(×F−×P,d), femoral condyle to popliteal tendon distal to the suture; Δ(×F−×P,p), femoral condyle to popliteal tendon proximal to the suture; Δ(×M−×P,d), lateral meniscus and popliteal tendon distal to the suture; Δ(×M−×P,p), lateral meniscus and popliteal tendon proximal to the suture.
Absolute Displacements of the Lateral Meniscus and the Popliteal Tendon
When analyzing the absolute displacement of the lateral meniscus and the popliteal tendon itself (×M, ×P,p, ×P,d), the following results were obtained.
Over the entire rotational movement, the displacement of the lateral meniscus before suturing was 3.5 ± 0.7 mm (2.4-4.7 mm). After suture placement, the mean displacement was 2.3 ± 0.8 mm (0.0-3.0 mm). This results in a significant reduction in movement of 34.3% (P <.001). Considering the popliteal tendon proximal to the suture, there was a mean displacement of 1.6 ± 0.6 mm (0.2-2.3 mm) before and 1.3 ± 0.6 mm (0.2-2.3 mm) after suturing, which is a significant reduction in movement of 18.8% (P = .02). There was no significant difference in the absolute displacement of the popliteal tendon distal to the suture (P > .05). The results are presented in Table 2.
Table 2.
Absolute Displacement of the Reference Points Defined by the Point Components a
| Change in Distance, mm | Mean Difference, mm | Difference, % | P | ||
|---|---|---|---|---|---|
| Without Meniscal Suture Fixation | With Meniscal Suture Fixation | ||||
| ×M | 3.5 ± 0.7 (2.4-4.7) |
2.3 ± 0.8 (0.0-3.0) |
1.2 | 34.3 | <.001 |
| ×P,p | 1.6 ± 0.6 (0.2-2.3) |
1.3 ± 0.6 (0.2-2.3) |
0.3 | 18.8 | .02 |
| ×P,d | 3.8 ± 0.9 (2.7-5.9) |
3.4 ± 0.8 (1.3-4.4) |
0.4 | 10.5 | >.05 |
Data are presented as mean ± SD (range). ×M, lateral meniscus; ×P,p, popliteal tendon proximal to the suture; ×P,d, popliteal tendon distal to the suture.
Measured Torque During Femoral Internal and External Rotation
During femoral internal rotation, the mean torque was 11.0 ± 3.9 N·m (5.6-21.1 Nm) before meniscal suture repair and 9.0 ± 2.6 Nm (5.0-13.9 N·m) afterward. This corresponds to a significant reduction in torque of 18.2% (P = .04). Concerning femoral external rotation, no significant difference could be found (P > .05). The results are shown in Table 3.
Table 3.
Measured Torque During Femoral Internal and External Rotation a
| Torque, Nm | Mean Difference, N·m | Difference, % | P | ||
|---|---|---|---|---|---|
| Without Meniscal Suture Fixation | With Meniscal Suture Fixation | ||||
| Internal rotation | 11.0 ± 3.9 (5.6-21.1) |
9.0 ± 2.6 (5.0-13.9) |
2.0 | 18.2 | .04 |
| External rotation | 12.2 ± 4.9 (5.4-19.2) |
12.8 ± 5.4 (4.0-19.6) |
0.6 | −4.9 | >.05 |
Data are presented as mean ± SD (range).
Discussion
The main findings of our present study are that all-inside fixation of the lateral meniscus to the popliteal tendon led to a significant reduction in absolute displacement of the lateral meniscus by 34.3% (1.2 mm) and of the popliteal tendon proximal to the suture by 18.8% (0.3 mm). The reduction in relative movement between the lateral femoral condyle and the lateral meniscus (23.5%; 0.8 mm) and the lateral meniscus and the popliteal tendon proximal to the suture (25.0%; 0.7 mm) was also found to be highly significant. Therefore, our initial hypothesis was proven.
The mean lateral meniscal displacement (3.5 mm) without suture repair in our study is consistent with the results of Simonian et al 25 who found a mean displacement of 3.6 mm in a human cadaveric study using 90° of flexion and 10 Nm axial loading. In the same study, a significant increase in meniscal mobility was observed when the popliteomeniscal fascicles were transected, 25 resulting in a lateral meniscal hypermobility. 3 Our study shows a significant reduction in lateral meniscal displacement due to its fixation to the popliteal tendon, so that the procedure could be considered a treatment for lateral meniscal hypermobility. 3 However, Laver et al 13 and Séguineau et al 24 did not recommend this procedure because of suture loosening. The question remains as to whether the popliteal tendon can be used as a fixed anchor point. Good clinical results have already been demonstrated in the repair of vertical lateral meniscal tears.18,21 The authors explained this in part by the fact that the intra-articular part of the popliteal tendons shows little movement. However, Stäubli and Birrer 26 showed that the popliteal tendon was moving during rotation of the knee joint. They described an inferolateral displacement of the popliteal tendon during tibial internal rotation and a superolateral displacement during tibial external rotation. 26 Our study showed that the popliteal tendon moved between 1.6 mm (proximal part) and 3.8 mm (distal part) with a significant reduction in the proximal part after fixation. The relative movement between the lateral meniscus and the proximal part of the popliteal tendon was also significantly reduced by suturing. These movements may contribute to increased tension on the suture, which could potentially affect meniscal healing. Although the changes in movement detected in this study were in the millimeter to submillimeter range, they can be expected to occur with every movement of the knee over a long period of time postoperatively. This alteration in the biomechanics of the joint can have a potential influence on the function and healing of the meniscus. However, these are theoretical considerations, as it is unknown to what extent these small but significant changes have a clinical effect.
Furthermore, the comparison with the study by Ouanezar et al 21 should be treated with caution, as this large clinical study included lateral meniscal repairs, all of which were combined with reconstruction of the anterior cruciate ligament. Given this concomitant pathology, an additional stabilization effect of the lateral meniscus and the popliteal tendon could be considered helpful beside the risk of meniscal suture loosening resulting in the good clinical outcomes presented. 21
Fixation of the lateral meniscus to the popliteal tendon does not affect the torque applied during femoral external rotation, as demonstrated in the present study. This can be explained by the fact that during femoral external rotation, the popliteal tendon is displaced inferolaterally resulting in a less tense muscle. 26 The reason for the significant reduction in torque measured during femoral internal rotation, according to the results presented here, is difficult to explain, as tibial external rotation (corresponding to femoral internal rotation in our study) is limited by tension in the popliteal muscle.5,19,20,26 One possible explanation would be that the suture reduces the load-bearing cross section of the tendon, and this leads to a reduction in torque applied with possible effects on joint stability. This issue requires further research.
An arthroscopic view of the lateral meniscus is usually achieved through a flexion-varus (so-called “figure 4 position”). 2 The meniscal suture is usually carried out in the same position.18,29 The position of the lower leg (internal/external rotation) could play a role in this respect; future examination, therefore, should consider whether a certain position of the lower leg should be ensured when placing the suture. In a recent human cadaveric study, Séguineau et al 24 performed an all-inside suture repair of the lateral meniscus with fixation to the popliteal tendon. They detected a loosening of the suture after a single extension-flexion cycle with a maximal flexion of 90° and returning to figure 4 position at the end. These findings should be considered when deciding on postoperative treatment, especially as many regimens allow passive flexion of 90° directly after surgery.18,29 In our study, there was no influence on the suture because of a change in knee position, as the meniscal suture was performed at 30° flexion, as was the following rotation test.
Limitations
It should be pointed out that this is a time-zero study and changes over time, such as meniscal tissue healing or potential suture breakage, may alter the findings seen in this study.
The study was based on a small number of knee joints from human body donors who were on average 78.7 years old, an age at which meniscal suture repair is usually no longer performed. Besides, age-related changes and dissection of the posterolateral corner to allow optical measurement may have influenced biomechanical behavior. Because the examination was performed on cadaveric knees, muscle traction of the popliteus could only be simulated, and no statements can be made about the healing of the suture repair.
Furthermore, suturing was performed on intact menisci. Possible additional influences due to a meniscal tear or meniscal hypermobility could not be depicted. All-inside sutures of the lateral meniscus are usually performed in the figure 4 position under 90° knee flexion. However, the test could not be carried out at higher degrees of flexion than the 30° used because of technical limitations. Finally, it should be noted that although the measured effects are statistically significant, they are in the millimeter to submillimeter range. The extent to which these effects are large enough to have a clinical effect cannot be assessed on the basis of this cadaveric study.
Conclusion
All-inside fixation of the lateral meniscus to the popliteal tendon has significant biomechanical effects, causing a reduction in the movement of the lateral meniscus and the popliteal tendon proximal to the suture. Furthermore, it influences the torque applied during femoral internal rotation. Possible effects on suture stability and healing potential should be considered in the follow-up treatment of patients who have undergone such surgery. As our results suggest increased tension on the suture, using restrictive postoperative regimens might be required. Resorbable suture anchors could avoid cutting out during increasing activity and restore motion between meniscus and popliteus after initial rigid fixation. The question of which types of pathology and patient groups are suitable for fixation of the lateral meniscus to the popliteal tendon requires further research.
Acknowledgments
The authors thank Mario Jackszis for support during development of the test setup and Nele Hammersdorfer for help in preparing the knee joints.
Footnotes
Final revision submitted December 26, 2024; accepted January 31, 2025.
The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. 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.
Ethical approval for this study was obtained from the University Medical Center Rostock (No. A 2020-0098).
ORCID iDs: Thomas Tischer 
https://orcid.org/0000-0002-3942-0235
Christoph Lutter https://orcid.org/0000-0001-6349-7817
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