Pullout Repair Associated With a Bridging Suture Using FiberLink for the Medial Meniscus Posterior Horn/Root Tear

Transtibial pullout repair for the medial meniscus (MM) posterior root tear has become the gold standard. However, an optimal repair technique has not yet been established for MM posterior horn (MMPH) tear with a sufficient root remnant. We describe a pullout repair technique associated with a bridging suture using FiberLink (Arthrex, Naples, FL) for the MMPH tear. In this bridging suture technique, the simple cinch stitch is applied to the root remnant and MMPH. The loop end of the FiberLink is inserted into the MMPH, and its free-end is inserted into the root remnant. Next, the suture is tensioned and tied on the superior surface of the MMPH. The bridging suture and the additional simple stitch applied to the MMPH are pulled out through the tibial tunnel and fixed to the tibia on an expected tension. This technique might lead to better meniscal healing of the tear site, because it involves bridging of the MMPH and root remnant, and lower risk of suture cut-out owing to the biomechanical strength

Tibial Tunnel Positioning Using the Posterolateral (PL) Divergence Guide in Anterior Cruciate Ligament Reconstruction

The aim of this study was to evaluate tunnel coalition and inter-tunnel distance by comparing the tibial tunnel position in double-bundle anterior cruciate ligament (ACL) reconstruction performed with a conventional guide versus a posterolateral (PL) divergence (PLD) guide. Subjects were 43 patients (ACL tip aimer: 20 knees; PLD guide: 23 knees) who underwent double-bundle ACL reconstruction between September 2014 and December 2017. In all cases, the tibial tunnel position, tunnel edge distance and tunnel angles were evaluated based on CT images. Clinical outcome was evaluated using the Lachman test, pivot-shift test, and Lysholm score. Tibial tunnel positions were similar between the conventional and PLD guide groups, while tibial tunnel edge distance was significantly less in the conventional group. Tunnel coalition was observed in 5 knees in the conventional and no knees in the PLD guide group. Distance between two tibial tunnel centers was 9.1 mm for the tip aimer, and 10.5 mm for the PLD guide. Creation of the PL tunnel tended to involve insertion from a more medial aspect for the PLD guide group than the conventional guide group. No differences in clinical outcomes were noted. The PLD guide can be used to create anatomically-positioned PL tunnels, and reduce the probability of occurrence of tunnel coalition

A newly-developed guide can create tibial tunnel at an optimal position during medial meniscus posterior root repairs

Background During transtibial pullout repair of medial meniscus (MM) posterior root tears (MMPRTs), accurate tibial tunnel creation within the anatomic MM posterior root attachment seems critical. This study aimed to evaluate the tibial tunnel position created by a newly-developed Precision guide during pullout repair of MMPRTs. Methods In 40 patients who underwent transtibial pullout repairs, the tibial tunnel was created using the Unicorn Meniscal Root (UMR) (n = 20) or Precision guide (n = 20). Three-dimensional computed tomography images of the tibial surface were evaluated postoperatively, using Tsukada's measurement method. The expected anatomic center of the MM posterior root attachment was defined as the center of three tangential lines corresponding to anatomic bony landmarks. The expected anatomic center (AC) and the tibial tunnel center (TC) were evaluated using the percentage-based posterolateral location on the tibial surface. The difference in the mediolateral and anteroposterior percentage distance between the AC and TC was calculated, as was the absolute distance between the AC and TC. Results The mean AC was located 77.4% posterior and 40.1% lateral. The mean TC was similar in the UMR and Precision guide groups. There was no significant difference in the mediolateral percentage distance (UMR 3.9% vs. Precision 3.6%, p = 0.405), but a significant difference was observed in the anteroposterior percentage distance (UMR 3.5% vs. Precision 2.6%, p = 0.031). The mean absolute distance between the AC and TC was 3.9 mm and 3.5 mm (UMR and Precision guide groups, respectively) (p = 0.364). Conclusions The new Precision guide can create tibial tunnel in an optimal and stable position during pullout repair of MMPRTs

Combining pullout suture and retrograde screw fixation for anterior cruciate ligament tibial eminence avulsion fractures: A case report

This report describes a novel arthroscopic technique for the treatment of anterior cruciate ligament (ACL) tibial eminence avulsion fractures. A 16-year-old boy who was diagnosed with a left ACL tibial eminence avulsion fracture was treated by arthroscopic fixation. Two bone tunnels were created from the anterior tibial cortex into the fracture bed, and a strong suture passed through the ACL just above its insertion was pulled out through them for reduction and fixation. A retrograde cannulated screw fixation was added for stronger fixation. Weight-bearing and range of motion exercises were started immediately after surgery. Radiographically, bone union was obtained 6 months postoperatively. During second-look arthroscopy (24 months postoperatively), there was no loss of reduction and no subsequent meniscal or cartilage injuries. At that point, the Lysholm score was 95, and the International Knee Documentation Committee score was 96

Postoperative clinical outcomes of unicompartmental knee arthroplasty in patients with isolated medial compartmental osteoarthritis following medial meniscus posterior root tear

Background: Cartilage degradation progresses rapidly following medial meniscus posterior root tear (MMPRT). Unicompartmental knee arthroplasty (UKA) has been performed for medial compartmental osteoarthritis following MMPRT. We evaluated the clinical and radiographic outcomes of UKA for medial compartmental osteoarthritis after an untreated MMPRT. Methods: Twenty-one patients who underwent UKA for isolated medial compartment osteoarthritis following MMPRT were retrospectively investigated. Clinical outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score and knee range of motion. The posterior tibial slope and tibial component inclination were evaluated using plain radiographs. Results: The mean follow-up periods were 25.5 +/- 13.8 months. Clinical outcomes improved significantly postoperatively. The mean postoperative knee extension angle was-1.1 degrees +/- 2.1 degrees, and the knee flexion angle was 134.3 degrees +/- 4.9 degrees. The posterior tibial slope angle decreased from 9.0 degrees +/- 2.0 degrees preoperatively to 5.4 degrees +/- 1.8 degrees postoperatively, and postoperative tibial component inclination at the final follow-up was 2.9 degrees +/- 1.1 degrees varus. No aseptic loosening or deep infections were observed. Conclusion: UKA significantly improved clinical outcomes and could be a viable surgical option for treating isolated medial compartmental osteoarthritis accompanied by untreated MMPRT

Medial meniscus posterior root repairs: A comparison among three surgical techniques in short-term clinical outcomes and arthroscopic meniscal healing scores

Background Medial meniscus (MM) posterior root repairs lead to favorable clinical outcomes in patients with MM posterior root tears (MMPRTs). However, there are few comparative studies in evaluating the superiority among several pullout repair techniques such as modified Mason–Allen suture, simple stitch, and concomitant posteromedial pullout repair. We hypothesized that an additional pullout suture at the MM posteromedial part would have clinical advantages in transtibial pullout repairs of the MMPRTs. The aim of this study was to compare the clinical usefulness among several types of pullout repair techniques in patients with MMPRTs. Methods Eighty-three patients who underwent arthroscopic pullout repairs of the MMPRTs were investigated. Patients were divided into three groups using different pullout repair techniques: a modified Mason–Allen suture using FasT-Fix all-inside meniscal repair device (F-MMA, n = 28), two simple stitches (TSS, n = 30), and TSS concomitant with posteromedial pullout repair using all-inside meniscal repair device (TSS-PM, n = 25). Postoperative clinical outcomes and semi-quantitative arthroscopic meniscal healing scores (0–10 points) were evaluated at second-look arthroscopies. Results No significant differences among the three groups were observed in patient demographics and preoperative clinical scores, except for preoperative Lysholm scores. At second-look arthroscopies, there were no significant differences among the three techniques in postoperative clinical outcomes and meniscal healing scores. Conclusions This study demonstrated that the TSS-PM pullout repair technique did not show better scores in postoperative clinical outcomes and meniscal healings compared with the F-MMA and TSS techniques. Our results suggest that the concomitant posteromedial pullout suture may have no clinical advantage in the conventional pullout repairs for the patients with MMPRTs

Steep posterior slope of the medial tibial plateau is associated with ramp lesions of the medial meniscus and a concomitant anterior cruciate ligament injury

Background: Medial meniscus (MM) tears are associated with both acute and chronic anterior cruciate ligament (ACL) insufficiency and can lead to degenerative changes in the knee. ACL reconstruction (ACLR) combined with the meniscal repair was reported to result in decreased anterior knee joint laxity with evidence of improved patient-reported outcomes in the long term. However, a subtle tear of the MM posterior segment, also known as a ramp lesion, is difficult to detect on conventional magnetic resonance imaging (MRI) and is frequently missed in ACL-deficient knees. However, there are few studies about the associations between bone geometry and ramp lesion of the MM. This study aimed to compare sagittal medial tibial slope (MTS), medial tibial plateau depth (MTPD), and coronal tibial slope (CTS) between ACL-injured knees with and without ramp lesion of the MM. We hypothesised that patients with ramp lesion of the MM and a concomitant ACL injury have a steeper MTS and shallower MTPD than those without ramp lesion of the MM. Methods: Twenty-seven patients who underwent ACLR (group A), and 15 patients with combined MM repair (group AM) were included in the study. Anterior tibial translation (ATT) was measured under general anaesthesia just before surgery using a knee arthrometer. MRI was performed in the 10 degrees-knee-flexed position. The MTS and MTPD were measured on sagittal view, and the CTS was measured on coronal view. These parameters were compared between the groups. Differences in MRI measurements or patient demographics between the groups were evaluated using the Mann-Whitney U test. Results: No significant difference was observed in demographic data and post-operative side-to-side difference in ATT between both groups. Pre-operative ATT was significantly higher in group AM than in group A (P = 5.0 degrees than in those with MTS = 5.0 degrees, an occult MM ramp lesion should be strongly suspected, and surgeons should prepare for MM repair in combination with ACLR

Two simple stitches for medial meniscus posterior root repair prevents the progression of meniscal extrusion and reduces intrameniscal signal intensity better than modified Mason-Allen sutures

Purpose Medial meniscus posterior root tears (MMPRTs) can cause severe medial extrusion of the medial meniscus (MMME) and the progression of knee degenerative changes, inducing a high signal intensity of the meniscus on magnetic resonance imaging (MRI). Although MMME and intrameniscal signal intensity (IMSI) reportedly decreased within 3 months after MMPRT repair, no previous studies have reported these changes after a 1-year follow-up. This study aimed to investigate the 1-year postoperative changes in MMME and IMSI on MRI after using different suture techniques. Methods Overall, 33 patients with MMPRT were evaluated, 22 underwent FasT-Fix-dependent modified Mason–Allen suture (F-MMA) repair, and 11 underwent two simple stitches (TSS) repair. MRI examinations were performed preoperatively and 1 year postoperatively. MMME and IMSI were determined using MRI. Results A significant decrease in postoperative MMME was observed in the TSS group (4.1 ± 1.0) relative to that in the F-MMA group (5.1 ± 1.4, P = 0.03). A significant decrease in postoperative IMSI (0.75 ± 0.14) was observed relative to preoperative IMSI in the TSS group (P  Conclusions The most important finding of this study is that TSS repair yielded a greater decrease in MMME and IMSI than F-MMA repair in patients with MMPRT. These results suggest that TSS repair is more useful for restoring loading stress to the posterior horn of the medial meniscus

Comparison of two simple stitches and modified Mason-Allen suture for medial meniscus posterior root tear based on the progression of meniscal posterior extrusion: A retrospective cohort study

Purpose: Medial meniscus (MM) posterior root (PR) tear leads to severe MM posterior extrusion (PE), resulting in rapid knee cartilage degeneration. MMPR repairs are recommended to reduce MMPE, especially during knee flexion. However, the difference in MMPE between different repair techniques remains unknown. This study aimed to investigate preoperative and postoperative MMPE following several pullout repair techniques. We hypothesized that a technique using two simple stitches (TSS) would be more useful than FasT-Fix-dependent modified Mason-Allen suture (F-MMA) to prevent the progression of MMPE in knee extension. Methods: This retrospective study included 35 patients who underwent MMPR repair. To compare MMPE, patients were divided into two groups according to the use of F-MMA while grasping the posterior capsule and TSS without grasping it. Open magnetic resonance imaging was performed at 10 degrees and 90 degrees knee flexion preoperatively, and at 3 and 12 months postoperatively, and the MMPE of both groups was evaluated. Results: A significant difference was observed between preoperative and 3-month postoperative MMPE at 90 degrees knee flexion in both groups (p Conclusions: Both repairs were found to be useful to reduce MMPE in knee flexion. Further, F-MMA repair increased MMPE in knee extension, unlike TSS repair. These findings suggest that TSS might have more advantages for load distribution when standing or walking

Knee Flexion-induced Translation of Pullout Sutures Used in the Repair of Medial Meniscus Posterior Root Tears

Medial meniscus posterior root tears (MMPRTs) have recently attracted considerable interest in orthopedics. To date, no in vivo human study has investigated suture translation changes in repaired MMPRTs with different degrees of knee flexion. This study examined suture translation at various degrees of knee flexion in 30 patients undergoing medial meniscus posterior root repair using the modified Mason-Allen suture technique between August 2016 and September 2017. Intraoperatively, sutures were provisionally fixed to an isometric positioner at the tibial site of the desired meniscal attachment, and the suture translation was measured at 0°, 30°, 60°, and 90° of knee flexion. The results showed significant increases in mean suture translation at the knee flexion positions from 0° to 30°, 30° to 60°, and 60° to 90° (p<0.01 for all). Our findings indicate that surgeons should carefully assess the degree of knee flexion at the moment when the meniscus is refixed by surgical sutures