Courtesy: Dave Lee, Ashok Shyam, Ortho TV

Arthroscopic Management of Medial Meniscus Tear with Parameniscal Cyst

Patient Presentation

A female patient in her thirties presented with right knee pain for three years.
Symptoms began after a fall from a motorbike.
Complaints included:
- Pain during standing and walking
- Pain while climbing stairs
- Night pain
The patient did not report instability of the knee.

Clinical Examination

Range of Motion

No fixed flexion deformity was observed.
No hyperextension was present.
The knee demonstrated full painless motion from full extension to approximately one hundred thirty five degrees of flexion.

Joint Examination

No joint effusion was noted.
Patellar tracking and patellar glide were normal.

Palpation

Marked tenderness along the medial joint line, particularly in the posterior region.

Ligament Stability Tests

Anterior cruciate ligament testing was stable.
Posterior cruciate ligament testing was stable.
Varus and valgus stress tests were negative.

Overall, the knee was stable without evidence of ligament injury.

Gait

The patient walked without an antalgic gait.

Radiographic Evaluation

Long Leg Alignment Radiograph

Mechanical axis passed slightly medial to the medial tibial spine.
Overall limb alignment was near neutral.

Standard Knee Radiographs

Medial and lateral joint spaces were preserved.
No significant degenerative changes were identified.

Magnetic Resonance Imaging Findings

Magnetic resonance imaging demonstrated:

A horizontal tear of the medial meniscus extending from the posterior horn to the mid portion of the meniscus.
A parameniscal cyst associated with the medial meniscus.
Degenerative changes within the meniscus.

The cyst was seen adjacent to the tear, suggesting fluid extrusion through the meniscal defect.

Diagnosis

The patient was diagnosed with:

Horizontal tear of the medial meniscus
Associated parameniscal cyst

Surgical Treatment Plan

The planned arthroscopic procedure included:

Decompression of the parameniscal cyst
Repair of the horizontal medial meniscus tear
Augmentation of the repair using arthroscopic sutures

The goal of surgery was to preserve the meniscus and restore joint stability while relieving symptoms caused by the cyst.

Arthroscopic Findings

During arthroscopy, the intra-articular findings differed slightly from the preoperative imaging.

Observations included:

A large flap tear of the medial meniscus extending from the body to the posterior horn.
The tear involved both the superior and inferior meniscal leaflets.
Degenerative changes were present in the posterior horn region.

The tear configuration resembled a long flap component rather than a simple horizontal cleavage tear.

Surgical Technique

Initial Preparation

The tear edges were first freshened using a shaver.
The surgeon then identified the tract connecting the meniscal tear to the parameniscal cyst.

Cyst Decompression

The cyst was decompressed by accessing it from the joint side.
Decompression allowed the cystic contents to drain into the joint cavity.

Meniscal Bed Preparation

The posterior horn region was carefully debrided and rasped to create a vascular healing environment.
Care was taken near the meniscal root.

Decision Between Repair and Resection

The surgeon considered two options:

Partial resection of the unstable flap
Meniscal repair

Factors influencing the decision included:

Patient age
Tear configuration
Desire to preserve meniscal tissue

Ultimately, meniscal repair was chosen.

Meniscal Repair Technique

Initial Stabilization

The tear was first stabilized using all-inside sutures.

Additional Repair

Because the tear extended into the body of the meniscus, inside-out suturing techniques were subsequently used.

Inside-Out Suturing

Multiple sutures were placed through the meniscus from inside the joint outward through the capsule.
Approximately four sutures were placed to stabilize the tear.

Advantages of Inside-Out Technique

Lower failure rates compared with all-inside devices in certain tear patterns
Lower cost
Less meniscal tissue damage
Greater flexibility in suture placement

Inferior Leaflet Stabilization

Additional sutures were placed to capture the inferior leaflet of the meniscal tear, which had been mobile.

This helped restore the anatomical relationship of the meniscal layers.

Biological Augmentation

After completing the repair, additional steps were planned to improve healing.

These included:

Microfracture of the intercondylar notch to release marrow elements
Consideration of biological augmentation techniques to enhance healing

Meniscal Repair Considerations

Differences Between Medial and Lateral Meniscus Healing

Healing potential differs between the medial and lateral meniscus.

Lateral Meniscus

Better vascular supply
Higher healing potential
Preservation strongly recommended

Medial Meniscus

Lower vascularity
Higher failure rates after repair
Degenerative tears may have limited healing potential

Clinical Implications

Although repair of medial meniscal tears may fail in some cases, meniscal preservation remains desirable because:

Meniscal loss increases the risk of osteoarthritis.
Meniscal tissue contributes to load distribution and joint stability.

Surgical Technical Tips

Important technical considerations during meniscal repair include:

Adequate visualization of the medial compartment
Medial collateral ligament pie-crusting if necessary to improve access
Careful placement of sutures using appropriate cannulas
Protection of surrounding structures during inside-out suturing

Postoperative Assessment

Following repair:

The meniscus appeared stable on probing.
Sutures secured both superior and inferior meniscal layers.

The procedure concluded after confirming adequate fixation.

Key Points

Horizontal medial meniscus tears can be associated with parameniscal cysts.
Arthroscopic decompression of the cyst combined with meniscal repair is an effective treatment strategy.
Inside-out suturing techniques remain a reliable method for complex meniscal repairs.
Meniscal preservation is preferred whenever possible to protect long-term knee joint health.

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