The Management of Meniscal Pathology by Unknown

Author:Unknown
Language: eng
Format: epub
ISBN: 9783030494889
Publisher: Springer International Publishing

Medial Meniscus Root Repair Surgical Technique

Our preferred technique is suture repair of the meniscal root with transtibial fixation over a cortical button using a single tunnel [14]. The operative extremity is positioned in a leg holder and a tourniquet placed high on the thigh. The distal aspect of the leg holder should be about two to three fingerbreadths proximal to the proximal pole of the patella in order to best visualize the medial compartment when applying valgus stress, while also minimizing hip internal rotation. Standard anteromedial and anterolateral portals are made, and a diagnostic arthroscopy is performed. The anteromedial portal is established using spinal needle localization, ensuring a direct trajectory to the posterior horn of the medial meniscus can be achieved. This portal tends to be more lateral and inferior than a standard anteromedial arthroscopic portal. Once the portals are established, the root is examined and the nature of the tear is assessed.

Maximal valgus stress and external rotation of the tibia can provide a better view of the meniscal root. As previously mentioned, we often piecrust and release the deep MCL fibers to allow for medial joint space opening. This is done percutaneously using an 18-gauge spinal needle. The needle pierces the skin approximately 1 cm below the joint line just anterior to the posteromedial border of the tibia. The needle is used to make several passes through the deep MCL fibers while providing consistent valgus stress to the knee. As the MCL fibers are pierced, the tissue will gradually release. Occasionally, there will be a palpable and audible pop as the MCL releases completely. Releasing the deep MCL fibers facilitates suture passage and helps minimize iatrogenic damage to the femoral and tibial cartilage, and is associated with minimal morbidity in our experience.

Figures 7.9 and 7.10 show a step-by-step repair of an unstable medial meniscal posterior root tear. The root tear is first debrided with a shaver. If an unstable root is identified (Fig. 7.10a), debride the edges, and then pass two #0 nonabsorbable sutures using a self-retrieving suture passer (Fig. 7.10b and c) (Meniscal Scorpion, Arthrex, Naples, FL) approximately 5 mm apart in a cinch configuration (Fig. 7.10d). Often times, the more medially based suture is passed first and can be used as a traction suture to draw the meniscus anteriorly and allow better tissue purchase for the second suture, which is subsequently placed 2–3 mm from the root edge. Although a more complex suture configuration increases the pullout strength of the repair [48], we have found it not to be necessary in our practice as the strength of the construct outweighs the loads borne on the repair with a standard rehabilitation protocol [49].

Fig. 7.9Step-by-step arthroscopic repair of a MMPRT. (a) View of the meniscus prior to probing; (b) the meniscus is probed revealing the tear; (c) view of the meniscal root aiming guide in the correct position prior to reaming; (d) the tip of the flip cutter is seen after drilling through the tibia; (e) the first cinch

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