Medial meniscus root repair — OrthopaedicPrinciples.com

Courtesy: Dr Strickland, Ashok Shyam TV, Ortho

Changing Perspective

Repair of medial meniscus root tears has gained momentum only in the last several years.
Historically, many of these tears—especially in middle-aged patients—were treated nonoperatively or with meniscectomy.
These are sometimes referred to as “underserved tears” because they were frequently missed or undertreated.

The key questions:

Which tears should not be fixed?
If operative, how should they be repaired?

Typical Clinical Presentation

Common patient profile:

Age: 40 to 50 years.
Low-energy injury (for example, stepping into a bathtub).
Sudden posterior knee pain.
Sensation of instability or buckling.
Normal radiographs.

Magnetic resonance imaging typically shows:

Detachment of the posterior horn of the medial meniscus from its root.
“Ghost sign” on sagittal sequences.
Increased signal on fat-suppressed images.

Important tip:
Always review fat-suppressed sequences carefully. Root tears are commonly missed.

Preoperative Considerations

Before offering repair:

Evaluate articular cartilage.
- Advanced arthritis predicts failure.
Assess alignment.
Counsel the patient that:
- Repair may not be possible.
- Surgery may be abandoned intraoperatively if arthritis is severe.
- Healing is not guaranteed.

Intraoperative Principles

1. Optimize Visualization

Perform medial collateral ligament pie-crusting if needed.
Adequate exposure is essential.
Poor visualization compromises repair quality.

2. Prepare the Footprint

Debride the root attachment site.
Curette to bleeding bone.
Create a biologically favorable surface for healing.
Soft tissue-to-bone healing is the goal.

3. Suture Passage

Multiple techniques are acceptable:

High-strength suture tape.
Luggage-tag configuration.
Simple stitch.
Mattress stitch.

Key requirement:

Meniscal tissue must be strong enough to hold sutures.
Poor tissue quality may require abandoning repair.

Surgeon preference varies:

Single-use or reusable suture passers.
All-in-one passing systems.
Loop-based suture constructs.

4. Tunnel Creation

Options include:

Standard anterior cruciate ligament tibial guide.
Root-specific tibial guide (easier posterior positioning).

Challenges:

Standard guides may not reach far enough posterior.
Dedicated guides improve accuracy.

After guide placement:

Drill tibial tunnel exiting at anatomic root footprint.

5. Fixation Methods

Several fixation strategies exist:

Tie sutures over a cortical button.
Bone bridge with dual tunnels.
Interference screw fixation.
Anchor-based footprint fixation.

Before final fixation:

Confirm adequate tension arthroscopically.
Ensure meniscus is well reduced to footprint.
Avoid under-tensioning.

Postoperative Protocol

Non–weight bearing for six weeks.
Increased risk of deep vein thrombosis.
Gradual return to activity thereafter.

Healing Rates and Expectations

Second-look arthroscopy studies show:

Approximately 70 percent healing rate.

Important patient counseling points:

Repair may not heal.
Symptom improvement is common even if healing is incomplete.
Long-term goal is joint preservation.

Biomechanical Rationale

Meniscus root tears function similarly to total meniscectomy:

Loss of hoop stress.
Increased tibiofemoral contact pressures.
Accelerated cartilage degeneration.

Biomechanical studies demonstrate:

Restoring the root to its footprint improves contact mechanics.
More anatomic reduction yields better load distribution.

Effect on Osteoarthritis Progression

Evidence suggests:

Lower progression to osteoarthritis compared with nonoperative management or meniscectomy.
Example data:
- Approximately 29 percent progression after repair.
- Approximately 39 percent without repair.

Although not completely protective, repair reduces risk.

Cost-Effectiveness

Studies indicate:

Root repair may be cost-effective long term.
Reduced progression to knee arthroplasty.
Lower overall lifetime treatment costs.

As healthcare systems emphasize value-based care, this becomes increasingly relevant.

When Not to Repair

Consider avoiding repair if:

Advanced medial compartment osteoarthritis.
Severe cartilage loss.
Poor tissue quality.
Significant malalignment without corrective osteotomy.

Key Takeaways

Medial meniscus root tears are frequently missed.
Fat-suppressed magnetic resonance imaging sequences improve detection.
Advanced arthritis predicts failure.
Adequate exposure and footprint preparation are essential.
Tissue quality determines feasibility.
Repair improves contact mechanics.
Approximately 70 percent healing rate.
Reduces risk of osteoarthritis progression.
Non–weight bearing protocol required.
Not every root tear is repairable.

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