Meniscal repair indications have not really changed in recent
years. Typically younger, more active patients with concomitant ACL
reconstruction and peripheral-third vertical tears continue to be the
“best” repair candidates. However, even in these “ideal”
candidates, meniscal repair continues to represent a significant challenge.
While most will not dispute that vertical tears greater than 1 cm in the
peripheral-third of the meniscus should be repaired, there has been new
attention on repairing posterior root tears. With these root tear repairs, an
inside-out repair is not feasible due to the posterior midline placement of the
needles and the passage of the suture.
Strength of meniscal repair
There has been a significant change in meniscal repair technique in the
last few years. While inside-out
vertical mattress repair is the gold standard, an
all-inside vertical mattress repair pattern is becoming more
common. Studies performed within the last 2 to 3 years have shown equal
pull-out strength between all-inside and
inside-out repair techniques, without the extra incisions and
morbidity of inside-out repair. Barber and colleagues in 2009 showed that the
newer all-inside suture devices have equal or greater
pull-out strength and cyclic load to failure strength
compared with suture-only repairs like in an inside-out repair. However, in an
earlier study in 2000, Barber also showed that a double-vertical suture-only
construct was statistically stronger than any of the implants — although,
the article is 10 years old, and many newer generations of all-inside meniscal
repairs have emerged with newer suture material.
In a brief discussion of the two articles, the double vertical meniscal
repair tested in 2000 used 2-0 Mersilene sutures and had a pull-out strength of
113 N. In the article from 2009, the suture tested was mostly no. 0
ultrahigh molecular weight polyethylene (UHMWPE) suture,
which had 109 N to 124 N pull-out strengths. Given that, a viable fixation
option is to fix vertical meniscal tears with all-inside, suture-only devices
in a double vertical pattern with UHMWPE suture. This particular method will
help avoid gapping on the tibial surface that can be seen with vertical
mattress sutures placed only on the superior surface of the meniscus. The
suture-only meniscal repair can also reduce any vascular, nervous or soft
tissue entrapment that can be seen with meniscal repair implants.
There have been numerous studies to show the higher occurrence of
lateral compared to medial meniscus tears with acute ACL rupture. While there
has been extensive literature to favor repairing vertical peripheral tears, a
slightly different tear representing a more significant challenge is the
posterior lateral meniscal root tear (Figures 1, 2).
Arthroscopic view of the left knee posterior lateral meniscus
root tear, which goes greater than 50 % of the root.
Image: Nord KD
knee posterior lateral meniscus root tear involving more than 50% of the
Image: Cayenne Medical, Inc.
The increase in difficulty lies not in the diagnosis, but the care of
these tears. Simple meniscectomy for small radial tears on the free edge of the
meniscus is not being argued, but rather radial tears that extend greater than
50% of the meniscus pose a significant problem. Performing a
partial meniscectomy of the root tear can destabilize the
entire meniscus and lead to further mechanical symptoms or early onset
osteoarthritis. Inside-out fixation of a root tear is not feasible, and
all-inside techniques do not restore the anatomy, which is a meniscus anchored
to the posterior central tibia plateau. With conventional all inside suture
techniques, the root would no longer be anchored to the tibia, but rather to
the posterior capsule.
ACL guide at the insertion of the lateral meniscus of a right knee. The guide
pin is in the corner of the guide.
Image: Nord KD
The following is a new technique for posterior lateral
meniscal root tears/avulsions using a suture-only meniscal
device, passing the sutures through a bone tunnel and tying over a button on
the tibial cortex. This technique is also applicable to medial meniscal root
All-suture meniscal repair
The rationale for this device is to simplify suture passage and
eliminate the need for more cumbersome suture-passing or shuttling device(s).
This particular device passes two simultaneous needles through the meniscus,
and then has a suture grabber that grabs one end and pulls the strand into the
other needle, thus throwing the suture completely behind and around the
meniscus and capsule. When you remove the device, there is a pre-tied Weston
knot that slides down into position and can be tensioned with a knot pusher.
Two half-hitches can be added if desired.
The premise for this technique stems from recent article by Harner and
colleagues repairing medial meniscal root tears over a bone tunnel. The
difference in this article is this technique encompasses passing an all suture
fixation in a 90-90 pattern with a different meniscal repair device, as opposed
to a utilizing a suture passer. The suture is then brought out through a bone
tunnel and tied over a button.
If there are any concomitant procedures to be done, then they must be
addressed first. In the figures shown on page 12, there was a concomitant ACL
disruption and if there is one present, we recommend first drilling both the
femoral and tibial tunnels; however, do not pass the ACL graft before drilling
the meniscal bone tunnel or prior to passing the sutures through the meniscus.
This technique article will not discuss the steps performed in ACL
reconstruction, as that is beyond the scope of this article.
Shown is the 90-90 technique. A horizontal
mattress pattern is placed with the CrossFire (Cayenne Medical Inc.) followed
by a second vertical mattress suture to give two pairs of suture 90° to
Images: Cayenne Medical, Inc.; Nord
Capturing the meniscal root
Once the other pathology has been addressed, a tunnel is drilled at the
meniscal root insertion utilizing an ACL drill guide (Figure 3). Ideally, from
a line-of-sight perspective, the bone tunnel should be drilled from the medial
tibia parallel to an ACL tibial tunnel, as it would be for a medial root tear.
However, since in this case there was a concomitant ACL reconstruction being
performed also, the bone tunnel was taken from just lateral to the tibial
tubercle to avoid any tunnel encroachment. The size of the tunnel does not need
to be large, only a 5- or 6-mm tunnel. After the tunnel is drilled, then using
an all-inside suture only meniscal repair device, CrossFix (Cayenne Medical
Inc.), the posterior horn of the lateral meniscus is “captured” with
the suture in a 90-90 fashion, giving a Mason-Allen-like suture configuration.
With this particular meniscal repair device, there are dual prongs of the
device that pass the suture simultaneously through the meniscus. There is a
Weston knot built in to the device, and this is automatically passed when the
device is fired, and the knot is advanced when the device is withdrawn. By
passing one suture in a horizontal mattress fashion, then one in a vertical
mattress fashion, there is 90-90 fixation through the meniscus (Figure 4).
Next, a suture retriever is fed through the bone tunnel, the suture ends are
retrieved and pulled distally out of the bone tunnel (Figure 5).
The ACL graft (or other ligaments being repaired) can then be passed,
tensioned, and fixed. The last step will be to tie the posterior horn sutures
over a button because the hyperflexion needed for ACL drilling and the cyclic
tensioning can stress the no. 0 suture, and breakage can occur. Once any
ligamentous reconstruction has been completed, then the sutures can be tied
over a button on the tibial cortex with the knee in flexion. We recommend tying
the respective sutures from each pair together, but also taking a suture from
each pair and tying it to a suture from the other pair — if suture AA is
tied, and BB is tied, then take a suture A and suture B and tie them together
giving two AB knots also over the button (Figure 6).
retriever passed through bone tunnel to retrieve sutures.
Image: Cayenne Medical, Inc.
Anatomic meniscal root restoration
A significant advantage to this technique is anatomic restoration of the
root to the tibial surface, as well as significant bony bleeding from the ACL
reconstruction and the bone tunnel drilled for the meniscus. This results in
significant healing factors in the joint available for healing of the meniscus
and healing of the bone to the meniscal root.
We recommend limiting rehabilitation to partial weight-bearing with a
hinged knee brace locked in extension, and no flexion greater than 90° for
4 weeks. After 4 weeks, the patient and therapist can resume ACL rehab as
outlined by the respective surgeon.
In summary, this is a new technique for posterior horn lateral meniscal
root tears using the CrossFix meniscal repair system, a suture-only meniscal
repair device and tying the sutures through a bone tunnel over a button. We
feel that this particular repair technique better restores the meniscal anatomy
than previous all-inside repairs, and avoids the neurovascular structures at
risk during an inside-out repair.
- Barber FA, Herbert MA. Meniscal repair devices.
- Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Sutker MJ.
Biomechanical Testing of New Meniscal Repair Techniques Containing Ultra
High–Molecular Weight Polyethylene Suture. Arthroscopy. 2009;
- Harner CD, Mauro CS, Lesniak BP, Romanowski JR. Biomechanical
consequences of a tear of the posterior root of the medial meniscus. Surgical
technique. J Bone Joint Surg (Am). 2009;91:Suppl 2:257-70.
- Keith D. Nord, MD, MS, can be reached at Sports, Orthopedics &
Spine, 569 Skyline Dr. Suite 100, Jackson, TN, 38301; 731-427-7888 or
888-SPORTDR; e-mail: firstname.lastname@example.org. He has received an honorarium from
Cayenne Medical for teaching.
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