Abstract
The meniscal roots are critical in maintaining the normal shock-absorbing function of the meniscus. If a meniscal root tear is left untreated, meniscal extrusion can occur, rendering the meniscus nonfunctional, resulting in degenerative arthritis. Preservation of meniscal tissue with restoration of meniscal continuity is becoming the standard for meniscal root pathology. Not all patients are candidates for root repair; however, repair is indicated in active patients after acute or chronic injury with no significant osteoarthritis and malalignment. Two main repair techniques have been described: suture anchor (direct fixation) and transtibial pullout (indirect fixation). The most common root repair technique is a transtibial technique. In this technique, sutures are placed into the torn meniscal root and then shuttled down through the tunnel in the tibia to tie the repair distally. The option adopted in our technique is to fix the meniscal root distally by wrapping threads of FiberTape (Arthrex) around the tibial tubercle through a transverse tunnel posterior to the tibial tubercle with buried knots inside the transverse tunnel without the use of metal buttons or anchors. This technique provides secure tension for repair without loosening of knots and tension that occur when using metal buttons and avoiding irritation caused by metal buttons and knots in patients.
Meniscal root tears are increasingly recognized as an important pathology. Failure to recognize this pathology could lead to early-onset osteoarthritis of the ipsilateral knee joint compartment, similar to a total meniscectomy. Therefore, surgical treatment is necessary to restore meniscal function and to normalize contact pressures.1,2
The meniscal roots are critical in maintaining the normal shock-absorbing function of the meniscus. If a meniscal root tear is left untreated, meniscal extrusion can occur, rendering the meniscus nonfunctional, resulting in degenerative arthritis.1 Two main repair techniques have been described: suture anchor (direct fixation) and transtibial pullout (indirect fixation).3 Meniscal root repair using a suture anchor technique is technically challenging, requiring a posterior portal, as well as a curved suture-passing device that can be difficult to manipulate within the knee, with potential cartilage irritation due to knots. A transtibial pullout technique for meniscal root repair using standard arthroscopic portals and transtibial fixation facilitates a challenging procedure and allows for efficacy and familiarity.3
A transtibial technique is the most common root repair technique.2 In this technique, sutures are placed into the torn meniscal root and then shuttled down through the tunnel in the tibia to tie the repair into place. There are 2 main variants of the transtibial root repair technique; these include 1- and 2-tunnel techniques.2 Biomechanical studies have shown the ability of a single–tibial tunnel technique to restore tibiofemoral contact mechanics in both posterior meniscal roots.4
This article details an anatomic root repair procedure using a transtibial tunnel pullout technique with distal fixation of the meniscal root repair by a transverse tunnel posterior to the tibial tubercle with buried knots in the transverse tunnel without the use of metal buttons or anchors.
Surgical Technique
Patient Positioning and Anesthesia
The patient is positioned supine with the end of the table dropped (Video 1). After induction of general anesthesia, a well-padded high-thigh tourniquet is placed on the operative leg. Standard anterolateral and anteromedial portals are made adjacent to the patellar tendon. The joint is insufflated with normal saline solution and visualized with a 30° arthroscopic camera (Smith & Nephew, Andover, MA). An arthroscopic shaver (Smith & Nephew) is inserted into the knee, and any notable adhesions are removed. The damaged meniscal root should be probed to assess the tear pattern and perform an anatomic repair.
Tibial Tunnel Creation
The location of the planned root repair on the tibial plateau should be decorticated using a curved curette. A grasper can be used to position the torn meniscal root and determine the ideal location to perform the repair. An initial incision for the transtibial tunnel is made just medial to the tibial tubercle or through the same incision for harvesting hamstring graft for anterior cruciate ligament reconstruction. To best restore the footprint of the repair and increase the chance of biological healing, the transtibial tunnel is created at the location of the root attachment. An aiming device with a cannulated sleeve (Smith & Nephew) is used to position a drill pin. A tibial tunnel guide (Smith & Nephew) is then used to ream the tunnel. The tunnel is visualized arthroscopically to verify correct tunnel placement, and the drill pin is removed, leaving the cannula in place for passage of sutures.
Suture Passage Through Meniscal Root
A Knee Scorpion suture passer (Arthrex, Naples, FL) is used to pass a simple suture (FiberTape; Arthrex) through the far-posterior portion of the detached meniscal root, approximately 5 mm medial to its lateral edge for the medial meniscus or 5 mm lateral to its medial edge for the lateral meniscus. Most suture-passing devices have a suture-retrieving mechanism, so the sutures can be pulled out through the anteromedial or anterolateral portal as the device is removed. It is important to verify that there are no soft-tissue bridges in the arthroscopic portal with the passing sutures because soft-tissue bridges may result in tearing of the sutures through the meniscal root when the sutures are pulled down the tibial tunnel.
Before passing the second suture through the meniscus, the first suture is shuttled down through the tibial tunnel to avoid intra-articular suture interlacing. To accomplish this, a looped passing wire is placed up the tunnel cannula and the suture is shuttled down the tunnel. The steps are repeated with the second suture positioned through the midportion of the meniscal root, anterior to the first suture placed into the meniscus. The second suture is then pulled down through the tibial cannula.
Tibial Fixation of Meniscal Root Sutures
The free ends of the sutures shuttled down through the tibial tunnel are separated into 2 limbs, which include 1 end from each suture. One limb is wrapped around the tibial tubercle anteriorly and passed through the drilled transverse tunnel posterior to the tibial tubercle from the other side via a looped passing wire (Figs 1 and 2). Then the limb passed through transverse tunnel tied with second limb of suture shuttled down through the tibial tunnel, the Knots created is passed in the transverse tunnel laterally by a looped passing wire inside the transverse tunnel (Figs 3 and 4). The arthroscope and probe are reinserted into the knee to confirm that anatomic stable fixation has been obtained.
Fig 1.
Sawbones model (Sawbones, Vashon Island, WA) of right tibia. (A) The free ends of the sutures (FiberTape) are passed through the meniscal root and shuttled down through the tibial tunnel; a guidewire is passed through the transverse tunnel posterior to the tibial tubercle. (B-D) One limb is wrapped around the tibial tubercle anteriorly and passed through the transverse tunnel posterior to the tibial tubercle from the other side via a suture-passing wire.
Fig 2.
(A) Guidewire aiming transverse tunnel posterior to tibial tubercle in right knee through same incision used for hamstring graft harvesting in combined anterior cruciate ligament reconstruction. (B) Eyelet-passing pin through transverse tunnel posterior to tibial tubercle with shuttling suture loop. (C, D) Retrieval of shuttling suture loop from other side by artery forceps under skin without need for lateral incision to pass 1 limb of sutures from other side through transverse tunnel.
Fig 3.
(A) The 2 limbs are tied together. (B, C) The free ends of the knots formed are pulled inside the transverse tunnel to the other side (laterally) via a suture-passing wire. (D) The knots are buried inside the transverse tunnel completely, and the extra threads are cut (right tibia).
Fig 4.
(A) One limb from the free ends of the sutures is shuttled down through the tibial tunnel and loaded in shuttling suture loop to pass anteriorly around the tibial tubercle and enter the transverse tunnel from the other side. (B) The 2 limbs are tied together, forming knots. (C, D) An eyelet-passing pin is passed through the transverse tunnel to pull the knots formed inside the transverse tunnel to the other side without any prominent knots, which provides secure tension for repair, avoiding loosening of knots and irritation due to knots in patients (right knee).
Postoperative Rehabilitation
After meniscal root repair by the transtibial pullout technique, the patient should remain non–weight bearing for 6 weeks. Physical therapy should start as soon as possible after surgery, which should include early range-of-motion exercises in a safe zone of 0° to 90° of flexion for the initial 4 weeks. After 4 weeks, further increases in knee flexion are allowed as tolerated. Progressive advancement to full weight bearing begins at 6 weeks. Deep leg presses and squats at greater than 70° of knee flexion should be avoided for at least 3 months after surgery.
Discussion
The most common root repair technique is a transtibial pullout technique.4 The transtibial root repair technique, based on restoring the native anatomy of the root attachments, restores the contact areas and pressures to nearly normal values.1,2,5 Several studies have reported on the outcomes of meniscal root repairs. A systematic review of Level III and IV studies concluded that an arthroscopic transtibial pullout technique for posterior medial meniscal root repair yielded good to excellent functional outcome scores.6
The transtibial pullout technique facilitates anatomic repair with a high degree of accuracy. Attention to detail and accurate placement of the arthroscopic portals help to simplify anatomically accurate positioning of the posterior meniscal root on the tibial plateau. In addition, transtibial tunnel drilling may enhance meniscal healing owing to a biological augmentation effect caused by the influx of progenitor cells and growth factors from the bone marrow into the intra-articular space.7
Kim et al. published their results of 14 patients with a mean follow-up period of 48.5 months and found significant radiologic improvement (decrease in meniscal extrusion) on second-look arthroscopy in patients who underwent meniscal root repair compared with patients who underwent partial meniscectomy.8 Jung et al. reported no change in meniscal extrusion after suture anchor repair and may loosen and protrude into the joint over time.9
The described technique for meniscal root repair has several advantages over previously described techniques. First, the procedure can be completed through standard arthroscopic portals, and a posterior portal is not required. Second, the new variable-angle transtibial guide allows drilling to be performed accurately with minimal torque on the handle. Third, the suture passer allows firm capture of the meniscal root with a single passage of suture, minimizing surgical time. Fourth, distal fixation is achieved through the transverse tunnel (by wrapping sutures around the tibial tubercle, which has the thickest cross section of the tibial cortex) with buried knots inside the tunnel, avoiding knot slippage and irritation due to metal buttons or large knots of FiberTape in the patient, which may lead to subsequent removal; this technique provides secure tension for repair without any loosening that can occur with metal buttons.
During our previous cases, we found that if we tied the sutures directly over the bone bridge between 2 vertical tibial tunnels, with cyclic loading, the sutures would cut into the bone or knot slippage would occur and the repair would become loose over time. Therefore, we strongly advocate wrapping sutures around the tibial tubercle, which has the thickest cross section of the tibial cortex, to fix the meniscal sutures or tape in the tibia to minimize the chance of loosening over time. Overall, these advantages simplify a challenging procedure and allow for familiarity and efficacy. A list of advantages and limitations can be found in Table 1, and a list of pearls and pitfalls can be found in Table 2. Using this technique provides secure tension for repair without loosening of tension that occurs when using metal buttons and avoiding irritation caused by metal buttons and knots especially in thin patients.
Table 1.
Advantages and Limitations
| Advantages |
| Simple and easy-to-perform technique |
| Secure tension for repair |
| Avoidance of patient irritation due to knots and hardware |
| Cost saving |
| No reliance on fixation device to achieve fixation |
| Limitations |
| Improper placement of transverse tunnel, which may interfere with complete knot insertion inside tunnel |
| Technique cannot be used in patients with open physes |
| Avoidance of hamstring insertion in case of isolated meniscal root repair |
| Adjustment of transverse tunnel position in case of concomitant ACL reconstruction with BPTB graft or PCL reconstruction |
ACL, anterior cruciate ligament; BPTB, bone–patellar tendon–bone; PCL, posterior cruciate ligament.
Table 2.
Pearls and Pitfalls
| Pearls |
| Shuttling suture loop is retrieved under the skin, abolishing the need for a lateral skin incision. |
| There is a requirement to tie the free ends of sutures at least 5 times to make knots that fill the transverse tunnel. |
| Using a suture passer allows easier passing of sutures through the tunnel. |
| Tying the knots at the edge of the transverse tunnel allows complete insertion of the knots inside the tunnel. |
| Pitfalls |
| Placement of the transverse tunnel too posteriorly will lead to difficult retrieval of the shuttling suture loop. |
| Lower placement of the transverse tunnel may cause injury to the hamstring insertion. |
Footnotes
The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
Distal fixation of medial meniscal posterior root repair by pullout technique via transtibial tubercle fixation accompanied by anterior cruciate ligament reconstruction in left knee. The patient is positioned supine with the end of the table dropped. After creation of the tibial tunnel, sutures passage in the meniscal root and sutures shuttled in the tibial tunnel , pointing position of the transverse tunnel (2nd tunnel) posterior to tibial tubercle with guidewire with eyelet, then drilling tunnel with cannulated drill bit. The looped suture is passed through the eyelet of the guidewire, pulled to the other side, and then retrieved by artery forceps under the skin, without the need for a lateral incision. One limb from the free ends of the sutures shuttled down through the tibial tunnel (each limb consist of one free end from each FiberTape passed through meniscus root) is loaded in shuttling suture loop to pass anteriorly around the tibial tubercle and enter the transverse tunnel from lateral side. The 2 limbs of sutures shuttled down through tibial tunnel, one passed in the transverse tunnel is tied with second limb on medial side forming knots, then passing looped guide wire in the transverse tunnel laterally and loading free ends of knots created in the loop to pull the knots inside the transverse tunnel laterally without any protruding knots.
References
- 1.Stein J.M., Yayac M., Conte E.J., Hornstein J. Treatment outcomes of meniscal root tears: A systematic review. Arthrosc Sports Med Rehabil. 2020;2:251–261. doi: 10.1016/j.asmr.2020.02.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.LaPrade R.F., Floyd E.R., Carlson G.B., Moatshe G., Chahla J., Monson J.K. Meniscal root tears: Solving the silent epidemic. J Arthrosc Surg Sports Med. 2021;2:47–57. [Google Scholar]
- 3.Helito C.P., Melo L.D.P., Guimarães T.M., et al. Alternative techniques for lateral and medial posterior root meniscus repair without special instruments. Arthrosc Tech. 2020;9:1017–1025. doi: 10.1016/j.eats.2020.03.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Gannon N.P., Wise K.L., Macalena J.A. Arthroscopic transosseous repair of a medial meniscal posterior-root tear. JBJS Essent Surg Tech. 2021;11 doi: 10.2106/JBJS.ST.20.00031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Steineman B.D., LaPrade R.F., Haut Donahue T.L. Nonanatomic placement of posteromedial meniscal root repairs: A finite element study. J Biomech Eng. 2020;142 doi: 10.1115/1.4045893. [DOI] [PubMed] [Google Scholar]
- 6.Feucht M.J., Kuhle J., Bode G. Arthroscopic transtibial pullout repair for posterior medial meniscus root tears: A systematic review of clinical, radiographic, and second-look arthroscopic results. Arthroscopy. 2015;31:1808–1816. doi: 10.1016/j.arthro.2015.03.022. [DOI] [PubMed] [Google Scholar]
- 7.Kim M.T., Ha J.K., Lee S.W., et al. Medial meniscus root tear refixation: Comparison of clinical, radiologic, and arthroscopic findings with medial meniscectomy. Arthroscopy. 2011;27:346–354. doi: 10.1016/j.arthro.2010.08.005. [DOI] [PubMed] [Google Scholar]
- 8.Krych A.J., Nauert R.F., III, Song B.M., et al. Association between transtibial meniscus root repair and rate of meniscal healing and extrusion on postoperative magnetic resonance imaging: A prospective multicenter study. Orthop J Sports Med. 2021;9 doi: 10.1177/23259671211023774. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Jung Y.H., Choi N.H., Oh J.S., Victoroff B.N. All-inside repair for a root tear of the medial meniscus using a suture anchor. Am J Sports Med. 2022;40(6):1406–1411. doi: 10.1177/0363546512439181. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Distal fixation of medial meniscal posterior root repair by pullout technique via transtibial tubercle fixation accompanied by anterior cruciate ligament reconstruction in left knee. The patient is positioned supine with the end of the table dropped. After creation of the tibial tunnel, sutures passage in the meniscal root and sutures shuttled in the tibial tunnel , pointing position of the transverse tunnel (2nd tunnel) posterior to tibial tubercle with guidewire with eyelet, then drilling tunnel with cannulated drill bit. The looped suture is passed through the eyelet of the guidewire, pulled to the other side, and then retrieved by artery forceps under the skin, without the need for a lateral incision. One limb from the free ends of the sutures shuttled down through the tibial tunnel (each limb consist of one free end from each FiberTape passed through meniscus root) is loaded in shuttling suture loop to pass anteriorly around the tibial tubercle and enter the transverse tunnel from lateral side. The 2 limbs of sutures shuttled down through tibial tunnel, one passed in the transverse tunnel is tied with second limb on medial side forming knots, then passing looped guide wire in the transverse tunnel laterally and loading free ends of knots created in the loop to pull the knots inside the transverse tunnel laterally without any protruding knots.