Arthroscopic meniscus repair: Meniscal root repair

OVERVIEW

Chapter synopsis

Meniscal root tears result in a dysfunctional meniscus that is associated with rapid degenerative changes within the compartment due to increased stress on the cartilage and bone.
Repair of meniscal root tears in the appropriate clinical setting has been shown to improve functional and radiographic outcomes.

Important points

Patients who are young or with minimal degenerative changes in the affected compartment should be considered for root repair.
Suture fixation can be achieved with transtibial bone tunnels or intra-articular suture anchors.

Clinical and surgical pearls

Obtain weight-bearing radiographs preoperatively to ensure minimal joint space narrowing.
To decrease the risk of iatrogenic chondral damage, ensure adequate view of and access to the root by clearing synovial tissue and performing a percutaneous MCL release on the medial side.

Clinical and surgical pitfalls

Root repair in the setting of advanced arthritis provides minimal benefit.
Avoid over-tensioning the repair to prevent suture pull-out through meniscal tissue.

Video available

Technique demonstrated: transtibial tunnel fixation with two parallel tunnels

Meniscal root tears are defined as avulsions of the meniscus tibial attachment or radial tears within 1 cm of the meniscal root insertion. These injuries produce a dysfunctional meniscus, resulting in meniscal extrusion, altered joint kinematics, and the development of osteoarthritis due to failure of the hoop stress dispersion and, as a result, increased tibiofemoral contact pressure. Historically, these injuries were not repaired or were treated with total or partial meniscectomy to achieve short term benefits. However, research linking meniscal deficiency secondary to a root tear to the rapid advancement of arthritic changes within the compartment has highlighted the importance of meniscal root repair in certain patient populations. ^,

Meniscal root tears, particularly of the medial side, can be associated with the development of femoral or tibial bone marrow stress lesions and insufficiency fractures—an entity occasionally referred to as SONK (Spontaneous Osteonecrosis of the Knee). This name is a misnomer, however, as the bone is not necrotic and does not respond to standard treatments for osteonecrosis. Pathophysiologically, stress overload occurs due to the dramatic increase in contact forces that are sustained upon tearing of the meniscal root. It is suggested that the insufficiency fracture and localized edema lead to a state of relative decreased vascularity due to an increased pressure gradient, which may delay fracture healing. This can lead to severe pain, subchondral collapse, and rapid development of arthritis. Lateral meniscus root tears, conversely, are less common and typically occur in younger patients with concomitant ligamentous injury.

Meniscal root repair has emerged as the treatment of choice for patients with root tears and minimal pre-existing degenerative changes within the given compartment, as this procedure restores the function of the meniscus. The long-term goal of repair is to prevent or delay the onset of degenerative joint disease. In this chapter, we describe the indications and surgical techniques for meniscal root repair.

Preoperative considerations

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