Orthopedics

Sports Medicine Update 

Meniscal Repair Techniques Required for the Surgeon Performing Anterior Cruciate Ligament Reconstruction

Mark Lembach, MD; Darren L. Johnson, MD

Abstract

Anterior cruciate ligament (ACL) tears are a common injury treated surgically by orthopedic specialists. There is a high incidence of concurrent meniscal injury that must be recognized and appropriately treated by the surgeon. The surgeon must be prepared to address the full spectrum of meniscal injuries with complex meniscal repair techniques when performing ACL reconstruction to decrease the likelihood of reoperation or postoperative symptoms for the patient. [Orthopedics. 2014; 37(9):617–621.]

The authors are from the Department of Orthopaedic Surgery, University of Kentucky School of Medicine, Lexington, Kentucky.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Darren L. Johnson, MD, Department of Orthopaedic Surgery, University of Kentucky School of Medicine, 740 S Limestone St, K-415 Kentucky Clinic, Lexington, KY 40536-0284 ( dljohns@uky.edu).

Abstract

Anterior cruciate ligament (ACL) tears are a common injury treated surgically by orthopedic specialists. There is a high incidence of concurrent meniscal injury that must be recognized and appropriately treated by the surgeon. The surgeon must be prepared to address the full spectrum of meniscal injuries with complex meniscal repair techniques when performing ACL reconstruction to decrease the likelihood of reoperation or postoperative symptoms for the patient. [Orthopedics. 2014; 37(9):617–621.]

The authors are from the Department of Orthopaedic Surgery, University of Kentucky School of Medicine, Lexington, Kentucky.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Darren L. Johnson, MD, Department of Orthopaedic Surgery, University of Kentucky School of Medicine, 740 S Limestone St, K-415 Kentucky Clinic, Lexington, KY 40536-0284 ( dljohns@uky.edu).

Anterior cruciate ligament (ACL) injuries are a common knee injury treated by the sports medicine orthopedic subspecialist and general orthopedic surgeon. Anterior cruciate ligament injury is the most common complete ligamentous injury to the knee, and recent reports indicate that more than 250,000 ACL reconstructions are performed annually in the United States.1 Concomitant injuries to the knee with ACL tear, including meniscus tear, articular cartilage injury, and other ligamentous knee injuries, are likewise a common occurrence. Large published series of acute ACL injuries have demonstrated the presence of lateral meniscus tears at a rate of 59% to 62% and medial meniscus tears at a rate of 28.5% to 42%. In the setting of chronic ACL deficiency, lateral meniscus tears occur at a rate of 41.6% to 49%, whereas medial meniscus tears occur at a rate of 60% to 74%.2,3 Given the large numbers of ACL injuries treated operatively with reconstruction and the high rates of associated meniscal injury, the treating surgeon must be prepared to recognize and address the entire spectrum of meniscal pathology at the time of surgery.

Recognition and Reparability of Meniscus Tears

Meniscus tears in the ACL-deficient knee are due to instability of the knee where normal forces on the meniscus are exceeded and the secondary stabilizing capacity of the menisci has been overcome. Meniscal tears in acute ACL injury tend to be peripheral and in the posterior horns. The pivoting episode can occasionally result in a radial lateral meniscus tear in the body of the meniscus that penetrates peripherally all the way to the capsular attachment. Anterior cruciate ligament-intact knees and those with chronic ACL deficiency are more likely to have a degenerative component, particularly in the posterior horn of the medial meniscus, which is an important secondary knee stabilizer in the presence of ACL deficiency.

The preoperative evaluation of the patient with suspected ACL injury should include appropriate history, physical examination, and imaging to confirm both the presence of ACL tear and deficiency and potential concomitant knee pathology. The mechanism of injury, chronicity of injury, and number of knee instability episodes can give clues as to the likelihood of concurrent meniscal tear. Although physical examination of the acutely injured knee with effusion is difficult due to pain, guarding, and loss of motion, knee joint line tenderness is an indicator of meniscal tear. Absence of point tenderness, however, does not preclude the presence of a meniscus tear. Loss of knee range of motion, particularly inability to attain terminal knee extension with large flexion contracture, should raise suspicion of a displaced bucket handle meniscus tear in the intercondylar notch (Figure 1).

Intraoperative arthroscopic view from the lateral portal of a displaced bucket handle medial meniscus tear in the intercondylar notch of a left knee.

Figure 1:

Intraoperative arthroscopic view from the lateral portal of a displaced bucket handle medial meniscus tear in the intercondylar notch of a left knee.

In addition to thorough physical examination of the involved knee and lower extremity, specific tests to assess for meniscus tear, including the McMurray maneuver, Apley grind test, and Steinmann test, can provide further evidence in the evaluation of meniscus pathology, particularly in the chronically ACL-deficient knee. The authors routinely obtain both a standard knee radiographic series and magnetic resonance imaging (MRI) studies of the involved knee. In addition to confirming the diagnosis of ACL tear, MRI has a high sensitivity, specificity, and positive predictive value for identifying meniscal pathology in the presence or absence of ACL tear4 and can alert the surgeon to potential articular cartilage lesions and other knee ligamentous injuries that may need to be addressed operatively.

The vascularity of the meniscus is believed to play a role in the reparability and healing potential of meniscus tears. The blood supply of the meniscus is composed of the termination medial and lateral geniculate arteries that form the perimeniscal capillary plexus in the peripheral “red zone” of the meniscus tissue. The peripheral 10% to 25% of the lateral meniscus is vascularized, while the peripheral 10% to 30% of the medial meniscus is vascularized.5 More central white zone tears and tears that are degenerative and complex have less healing potential and should be considered for partial meniscectomy. The long-term outcome of meniscal tears treated with rasping or trephination without formal suture repair at the time of ACL reconstruction has been well studied. Tears of the lateral meniscus that are peripheral, stable, and posterior to the popliteus tendon are thought to heal well and have low rates of reoperation for meniscal pathology.6 Peripheral, stable, vertical, nondegenerative medial meniscus tears less than 1 cm in length likewise have low rates of reoperation and postoperative symptoms with treatment consisting of rasping and trephination alone.7

When addressing meniscal tears at the time of surgery, the surgeon must be able to confirm the presence, location, size, pattern, and stability of the tear with adequate arthroscopic visualization. The surgeon must then make the decision as to whether the tear should be repaired, is irreparable and should be treated with partial meniscectomy, or simply can be left in situ with high likelihood of successful healing and low likelihood of ongoing knee symptoms due to the tear.

Meniscal Repair Techniques

With all arthroscopic ACL reconstructions in the presence of acute or chronic ACL deficiency and in both the primary and the revision reconstruction settings, the authors recommend a complete diagnostic arthroscopic inventory of the knee joint to recognize, assess, and treat all lesions, including meniscal tears, appropriately. Patient positioning and use of arthroscopic leg holders must allow for full free access to the knee joint for accessory incisions and allow for necessary working space for the surgeon and assistants to perform needed repairs. The ability to provide adequate valgus force to open the medial compartment and varus force with flexion (ie, figure 4 position) to open the lateral compartment must be achieved to visualize the posterior horns of the medial and lateral menisci. Careful meticulous probing of the meniscal cartilage should be performed to evaluate the undersurface of the meniscus to ascertain the presence and stability of the tear. Alternating the placement of the arthroscope between portals allows for improved visualization. Displaced bucket handle tears should be gently reduced with a blunt instrument to minimize further tissue damage to the meniscus and to provide arthroscopic access to the involved tibiofemoral compartment from which the tear displaced. Once the decision for repair has been made, the same fundamental steps are followed and include reduction of displaced meniscal tissue, gentle rasping of the tear and surrounding synovial surfaces of the inner knee capsule, suture repair, and potential inclusion of biologic adjuncts to enhance the healing potential of repair.

Intraoperative arthroscopic view of a lateral meniscus root tear in a left knee. The detached root (*) is displaced from its insertion site on the tibia (A). An anterior cruciate ligament tibial guide is placed on the root insertion site for repair in a bone tunnel (B). Sutures passed through the meniscus root are relayed into the bone tunnel with a suture passer (C). Final repair is completed with the meniscal root reduced and repaired back to its native insertion site (D).

Figure 4:

Intraoperative arthroscopic view of a lateral meniscus root tear in a left knee. The detached root (*) is displaced from its insertion site on the tibia (A). An anterior cruciate ligament tibial guide is placed on the root insertion site for repair in a bone tunnel (B). Sutures passed through the meniscus root are relayed into the bone tunnel with a suture passer (C). Final repair is completed with the meniscal root reduced and repaired back to its native insertion site (D).

Inside-out meniscal repair (Figure 2) remains the gold standard repair technique and demonstrates superior mechanical properties, particularly with vertical mattress repair configurations.8 The authors’ indications for inside-out repair include bucket handle type meniscal tears, longitudinal tears greater than 3 cm in length, and large radial tears. The disadvantages of this technique include the need for an accessory medial or lateral incision for popliteal retractor placement to protect posterior neurovascular structures and for flexible needle retrieval. The retractors must protect the popliteal neurovascular structures. On the lateral side, the common peroneal nerve is at risk posteriorly and care must be taken not to tie sutures over the iliotibial band for more anteriorly placed sutures. On the medial side, the saphenous nerve is at risk and inadvertent suture ligation of the nerve can result in painful neuromas. Meniscal zone-specific cannulas are extremely helpful and should be present in the operating room during ACL reconstruction. This is the most technically demanding meniscal repair technique, and experienced assistants and operating room staff familiar with the technique are likewise advantageous. A secure and anatomic repair that is balanced with mattress sutures placed on both the superior and the undersurface of the tear is the goal. The authors prefer to use 2-0 permanent braided sutures placed approximately 5 mm apart.

Intraoperative arthroscopic view of the final repair of the displaced bucket handle medial meniscus tear depicted in Figure 1. Mattress sutures are evenly spaced and placed both on the undersurface and to the surface of the meniscus.

Figure 2:

Intraoperative arthroscopic view of the final repair of the displaced bucket handle medial meniscus tear depicted in Figure 1. Mattress sutures are evenly spaced and placed both on the undersurface and to the surface of the meniscus.

Outside-in meniscal repair is a useful repair technique for tears of the anterior body of the menisci and tears extending into the anterior horns. Although repair equipment is commercially available, the technique can be efficiently performed with 1 or 2 18-gauge spinal needles and free suture. It requires small accessory incisions to retrieve and tie sutures over the knee capsule. The authors rarely find it necessary to perform repairs with this technique, but it is a useful skill that should be known to the surgeon if a reparable anterior meniscal tear is encountered.

All-inside suture repair devices have become a useful tool for the ACL surgeon for several reasons. They have the advantages of mechanical properties and resistance to failure9,10 comparable to inside-out suture repairs, allow for rapid secure repairs, and do not require secondary incisions. Indications include small tears that are less than 3 cm in length or as an adjunctive technique with inside-out suture repairs for a hybrid construct. Posterior horn meniscus repair (Figure 3) with an all-inside suture obviates the need to pass an inside-out suture in the most posterior aspect of the knee, where visualization and retrieval can be difficult. The risk of posterior neurovascular injury is still present with these devices. Many device companies offer all-inside suture repair devices. The authors prefer to use the FAST-FIX (Smith & Nephew, Andover, Massachusetts) device for all-inside repair and do not recommend the use of non-suture all-inside devices, such as meniscal arrows or darts, which can become dislodged with the associated complications of third body cartilage wear and synovitis.

Intraoperative arthroscopic view of a red-white zone vertical tear of the lateral meniscus that extends anteriorly just past the popliteus tendon in a right knee (A). The tear is repaired in vertical mattress fashion with all-inside suture devices (B).

Figure 3:

Intraoperative arthroscopic view of a red-white zone vertical tear of the lateral meniscus that extends anteriorly just past the popliteus tendon in a right knee (A). The tear is repaired in vertical mattress fashion with all-inside suture devices (B).

Root tears of the posterior horn of the lateral meniscus occur with 7% to 12% of ACL injuries11 and their recognition and treatment can be challenging (Figure 4). Root tears of the medial meniscus are typically degenerative and are not necessarily associated with ACL tear.11 Arthroscopic inspection and probing of the lateral meniscus posterior root attachment should be performed in the lateral compartment as well as the intercondylar notch. The insertion of the posterior root of the lateral meniscus is just posterior and adjacent to the tibial insertion of the posterolateral bundle of the ACL. To perform repair, the root tissue must be reduced into its bony insertion site (Figure 5). The authors’ preferred technique involves passing 2 looped high-strength #2 braided sutures through the detached lateral meniscal root. Antegrade or retrograde suture passing devices from a shoulder arthroscopy set are useful to pass and relay sutures through the meniscal tissue. A small bone tunnel, 4 or 5 mm in diameter, is created in the tibia using a tibial ACL guide placed at the root insertion site. Care must be taken not to converge with the ACL tibial tunnel. The sutures are retrieved with a looped suture retrieval device. The meniscal repair is secured by passing the sutures through the soft tissue of the ACL graft or the sartorial fascia and tibial periosteum. Alternatively, the sutures from the meniscal repair can be tied over a suture button.

Intraoperative arthroscopic view of a lateral meniscus root tear in a left knee. The detached root (*) is displaced from its insertion site on the tibia (A). An anterior cruciate ligament tibial guide is placed on the root insertion site for repair in a bone tunnel (B). Sutures passed through the meniscus root are relayed into the bone tunnel with a suture passer (C). Final repair is completed with the meniscal root reduced and repaired back to its native insertion site (D).

Figure 4:

Intraoperative arthroscopic view of a lateral meniscus root tear in a left knee. The detached root (*) is displaced from its insertion site on the tibia (A). An anterior cruciate ligament tibial guide is placed on the root insertion site for repair in a bone tunnel (B). Sutures passed through the meniscus root are relayed into the bone tunnel with a suture passer (C). Final repair is completed with the meniscal root reduced and repaired back to its native insertion site (D).

Intraoperative arthroscopic view of a radial tear of the lateral meniscus of a right knee (A). The tear extends peripherally to the capsule and contains a horizontal component more peripherally (B). Inside-out sutures are placed to repair the tear (C) with the addition of a fibrin clot incorporated and tied into the tear site to complete and augment the repair (D).

Figure 5:

Intraoperative arthroscopic view of a radial tear of the lateral meniscus of a right knee (A). The tear extends peripherally to the capsule and contains a horizontal component more peripherally (B). Inside-out sutures are placed to repair the tear (C) with the addition of a fibrin clot incorporated and tied into the tear site to complete and augment the repair (D).

Biologic augmentation of meniscal repair includes the incorporation of autologous fibrin clot or platelet-rich plasma to increase local concentrations of growth and anabolic factors at the tear site. There is natural biologic augmentation for meniscal repair in the setting of concurrent ACL reconstruction due to the postoperative hemarthrosis that results from drilling bone tunnels and notchplasty. The authors prefer a fibrin clot augmentation for the indications of radial tears that include tear extension in the avascular zone of the meniscus and in rare cases of revision meniscal repair with or without concurrent ACL reconstruction. Autologous blood is taken from a peripheral venipuncture and slowly stirred with a sintered glass rod in a metallic receptacle. The resultant blood clot is tied to a resorbable suture, incorporated into the tear site, and sutured into place on the outer knee capsule. This augmentation is typically performed with inside-out repair but can be included with an all-inside repair as well (Figure 5). The details and steps for fibrin clot-augmented meniscal repair have been well described previously.12

The decision to perform meniscus allograft transplantation is made preoperatively so an appropriate size graft can be obtained and the required instrumentation is available. It should be considered for the patient who has had previous total or subtotal meniscectomy in the setting of ACL deficiency, given the patient meets appropriate criteria for age and habitus. Likewise, lower limb alignment, articular cartilage status, and multi-ligamentous stability must meet appropriate indications or can be appropriately corrected with concurrent surgery.

Outcomes of Meniscus Repair With ACL Reconstruction

Traditionally, meniscus repair in the setting of concurrent ACL reconstruction has been considered to have higher success rates due to the type and location of tears seen with ACL injury as well as the additional positive benefits of hemarthrosis on meniscus healing. A recent meta-analysis with 5-year follow-up criteria showed failure rates of meniscus repair, with failure defined as reoperation or clinical failure, ranging from 20.2% to 24.3%.13 These results do not show significant difference when comparing for repair technique or ACL deficiency status.

Conclusion

When performing an ACL reconstruction, the surgeon must be prepared to recognize and treat the entire spectrum of pathology in the knee. This is especially evident with the high frequency of concomitant meniscal tear with ACL injury. Given the high likelihood of their presence as well as the varied nature of meniscal tears in this setting, tear recognition and treatment decisions regarding meniscal tears are of utmost importance to improve postoperative outcomes.

References

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10.3928/01477447-20140825-06

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