Arthroscopic Meniscal Root Repair

Andrew G. Geeslin

Jorge A. Chahla

Robert F. Laprade

Preoperative Workup

• Anteroposterior, Rosenberg, sunrise, long-leg alignment, and lateral knee radiographs are obtained in all patients.

• Magnetic resonance imaging is routinely obtained in the evaluation of meniscal root tears (77% sensitive, 72% specific, positive predictive value 22%, and negative predictive value 97%). The following are signs of root tears (Fig. 37-1):

• Meniscal extrusion (>3 mm) and edema of the femoral condyle on a coronal section.

• Sagittal view demonstrating the absence of the posterior horn of the meniscus (“ghost sign”) or a thin fluid interposition at the native root attachment location.

• If obtained at the correct height, the axial view may also demonstrate a displaced root tear with fluid interposition between the root and the native attachment location.

Indications/Contraindications

• Indications

• Acute, traumatic root tears (Figs. 37-2 and 37-3) in patients with normal or nearly normal cartilage (Outerbridge <3) and minimal joint space narrowing (Kellgren-Lawrence <3).

• Chronic symptomatic root tears in physiologically young or middle-aged patients with normal or nearly normal cartilage (Outerbridge <3) and minimal joint space narrowing (Kellgren-Lawrence <3).

• Contraindications

• Poor surgical candidates (multiple comorbidities or advanced age), those with advanced osteoarthritis (grade 3 or 4 chondromalacia of the ipsilateral compartment), and those with asymptomatic chronic meniscal root tears are excluded from surgical repair.

• Patients with significant mechanical axis malalignment involving the affected compartment may have inferior outcomes; consideration should be given to correction of the mechanical axis concurrently or before the meniscal root repair.

Sterile Instruments, Equipment

• Arthroscopy monitor, light source, fluid pump

• Arthroscope, shaver, radio-frequency probe

• Arthroscopic probe, grasper, arthroscopic scissors

Figure 37-1 | Visualization of meniscal root tears in three planes via magnetic resonance imaging. A. Coronal T2-weighted section demonstrating medial meniscal extrusion (arrow) (left knee). B. Axial image demonstrating fluid interposition in the region of meniscus root and posterior horn at the location of a radial root tear (arrow) (right knee). C. Sagittal image demonstrating ghost sign (arrow) (right knee). (Reproduced from Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears: significance, diagnosis, and treatment. Am J Sports Med. 2014;42(12):3016-3030, with permission.)

• Aiming device, drill sleeve, drill

• Cannula for suture passing

• Cannula for possible accessory posteromedial or posterolateral portal

• Arthroscopic suture passer

• Implants

• High-strength, nonabsorbable no. 2 suture

• Suture button

Figure 37-2 | Root tear classification including partial tear, complete tear (at varying distance and obliquity relative to the anatomic root attachment), combined meniscal tear patterns, and bony avulsions. (Reproduced from LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF. Meniscal root tears: a classification system based on tear morphology. Am J Sports Med. 2015;43(2):363-369, with permission.)

Figure 37-3 | Illustration of a left knee lateral meniscal posterior root tear with an intact posterior meniscofemoral ligament (pMFL). Lateral meniscal posterior root tears may also occur in the setting of a torn or absent pMFL. (Reproduced from LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF. Meniscal root tears: a classification system based on tear morphology. Am J Sports Med. 2015;43(2):363-369, with permission.)

Positioning (Fig. 37-4)

• The patient is positioned supine with the foot of the bed dropped.

• The surgical extremity is placed in a thigh holder with a well-padded thigh tourniquet.

• Contralateral extremity is placed in a well-leg holder with the bony prominences well padded.

Figure 37-4 | Patient positioning on the operating table is shown. The surgical limb (left) is placed into a leg holder, allowing the surgeon to freely manipulate the knee during the procedure. The nonoperative limb is kept on a well-padded abduction stirrup.

Surgical Approach

• Standard anterolateral and anteromedial parapatellar portals and possibly posteromedial or posterolateral accessory portal are used.

• A diagnostic arthroscopy is performed to identify concomitant meniscal, chondral, and ligamentous pathology.

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