Smith, Patrick A.

Purpose To compare short‐term outcomes of intratunnel anchor fixation versus transtibial pull‐through repair for meniscus root tears with a minimum of 12‐month follow‐up. Methods Patients who underwent primary meniscus root repair between 2011 and 2024 at a single institution were retrospectively reviewed. Inclusion criteria consisted of primary medial or lateral meniscus root repair using either intratunnel anchor fixation or transtibial pull‐through repair, availability of preoperative radiographs, and completion of postoperative patient‐reported outcome measures with a minimum of 12‐month follow‐up. The groups were propensity‐matched by age, sex, body mass index, operative side, root laterality, and concomitant procedures. Baseline radiographic characteristics (hip‐knee‐ankle angle and posterior tibial slope) were measured. Outcomes included Lysholm score, International Knee Documentation Committee score, Tegner activity score (preoperative and postoperative), Visual Analog Scale for pain at rest and with activity, satisfaction, subjective surgical outcome, and reoperations. Results Fifty patients who underwent intratunnel anchor fixation (mean age, 44 years) were propensity‐matched to 100 patients who underwent transtibial pull‐through repair (mean age, 41 years). Mean follow‐up was 1.5 years (range, 1.0‐2.3) in the intratunnel anchor group and 6.1 years (range, 2.7‐13.7) in the transtibial pull‐through group. Reoperation rates were 8% and 14%, respectively ( P = .43), with repair failure occurring in 4% and 6% ( P > .99). Preoperative and postoperative Tegner scores were similar between groups. Tegner minimal clinical important difference was 0.8, and 26.5% of intratunnel anchor patients achieved this compared with 0% of transtibial pull‐through patients. Patients in the intratunnel anchor cohort reported slightly lower Visual Analog Scale pain with activity (1.8 vs 2.5, P = .02). Postoperative Lysholm (87 vs 83, P = .05) and International Knee Documentation Committee scores (79 vs 76, P = .09) were comparable between groups. A greater proportion of intratunnel anchor patients achieved Patient Acceptable Symptomatic State compared with transtibial pull‐through patients for Visual Analog Scale with activity (74% vs 56%, P = .03) and Lysholm (66% vs 47%, P = .01). Most patients in both cohorts rated their outcome as “much better” or “slightly better” ( P = .49), and satisfaction scores were high. Conclusions At short‐term follow‐up, both the intratunnel anchor and transtibial pull‐through techniques showed high patient satisfaction and comparable overall clinical outcomes. There were no differences in reoperation rates between techniques. Level of Evidence Level III, retrospective comparative case series.

Background: Complex repairs of radial meniscal tears have shown increased fixation strength compared to conventional sutures. A simplified 2-suture hybrid and a novel dual tie-grip repair with interconnected vertical mattress sutures spanning the tear were tested and compared to all-inside double-horizontal and tie-grip repairs. Hypothesis: The dual tie-grip repair would increase the initial compression load across the tear and show the least cyclic displacement and highest failure strength. Study Design: Controlled laboratory study. Methods: A total of 40 porcine medial menisci were assigned to 4 repair groups: double-horizontal, hybrid, tie-grip, and dual tie-grip (10 per group). Results from tie-grip repairs were used to assess the effect of vertical mattress suture interconnection. After suture placement according to the described technique and fixation, the initial compressive load, stiffness, and relief displacement were measured. The repaired specimens underwent cyclic loading between 5 and 30 N over 1000 cycles (0.75 Hz), while cyclic stiffness and displacement were measured. Ultimate stiffness and load-to-failure were analyzed at 3.15 mm/s. Results: Analysis of variance revealed that dual tie-grip and hybrid repairs showed higher initial compressive load and relief displacement than the other techniques, with dual tie-grip repair reaching the highest values for both metrics (load: 19.3 ± 2.3 N [ P < .001]; displacement: 0.75 ± 0.19 mm [ P < .001]). The double-horizontal repair had the lowest initial stiffness ( P < .001). Cyclic displacement was lowest for the dual tie-grip repair and highest for the double-horizontal repair (both P < .001). All repaired specimens stiffened during cycling without intergroup differences. Analysis of covariance for stiffness over displacement revealed higher stabilization ( P < .040) with dual tie-grip repair and reduced stabilization ( P < .001) with double-horizontal repair. Despite comparable ultimate stiffness across groups, the dual tie-grip repair failed predominantly by suture rupture at the highest ultimate load (275.5 ± 26.2 N; P < .001), whereas the double-horizontal repair failed by tissue rupture the earliest (127.2 ± 15.9 N; P < .001). Conclusion: The dual tie-grip repair provided the highest initial compression across the radial meniscal tear, the lowest cyclic displacement, and the greatest load-to-failure among all techniques in a porcine cadaveric model. The simplified 2-suture hybrid repair showed higher initial compression than other repairs and comparable cyclic stability to the tie-grip repair. Clinical Relevance: The dual tie-grip repair provided high compression across the radial tear and strong resistance to cyclic displacement. Future clinical series assessing differences in healing rates among different repair groups are warranted.

Background: Optimized surgical fixation and meniscal stabilization during rehabilitation increase healing success. However, the latest generation of all-inside devices has not yet been biomechanically compared with inside-out suture tape (IO-ST) repair. Hypothesis: (1) The contact area of a suture anchor (SA) would compensate for a meniscal defect better than polyether ether ketone anchors (PA); (2) adjustable tensioning for all-inside meniscal repair fixation would result in higher initial load than IO-ST repair; and (3) stiffer constructs would decrease secondary displacement. Study Design: Controlled laboratory study. Methods: This study investigates human menisci (N = 39) via microscopic imaging and a biomechanical testing protocol. For the imaging protocol, needles of an all-inside SA or PA device and an IO-ST device were inserted after staining to measure the iatrogenic defect created by the needle insertion (n = 20) and the length, width, and meniscus contact area of deployed all-inside anchors (n = 6). For biomechanical testing, menisci with longitudinal bucket handle tears were prepared, and single stitches were repaired (each n = 9). After suture tensioning (50 N) and fixation, initial load, initial stiffness, and relief displacement were measured. Constructs underwent cyclic loading between 2 and 20 N, with 10,000 cycles (0.75 Hz), and stiffness and displacement were measured. Ultimate stiffness and load-to-failure were analyzed at 3.15 mm/sec. Results: All-inside needles created greater iatrogenic meniscal defects ( P < .001) than IO-ST repair. While PAs were longer ( P < .001), SAs were wider with a greater meniscal contact area (both P < .001). IO-ST repair resulted in the lowest initial load ( P < .001) and relief displacement ( P < .001), whereas SA repair resulted in a higher initial load ( P < .007) and stiffness ( P < .023) than PA repair. The overall stiffer SA fixation ( P < 001) significantly reduced cyclic displacement compared with other repairs ( P < .044). The PA group failed due to an anchor fracture at a significantly lower load (84.3 ± 10.7 N; P < .001) than the IO-ST (136.4 ± 10.5 N) and the SA repair (122.1 ± 17.5 N), with a suture-based failure mode. The ultimate stiffness of SA constructs was higher ( P < .045) than that of other repairs. Conclusion: While all-inside devices showed improved primary stability, the IO-ST construct demonstrated the highest load-to-failure. In a human cadaveric model, meniscal repair with a more compact and conforming SA was stiffer and reduced cyclic displacement compared with PA and IO-ST repair. Clinical Relevance: All-inside SA repair improved primary stability. Future clinical series will define the overall significance of healing rates.

Abstract Meniscus allograft transplant (MAT) can provide meaningful improvement in patient outcomes in those who are otherwise meniscus deficient. A common finding in the setting of a failed MAT is meniscus extrusion. Meniscus centralization is a technique performed to reduce the meniscus to its intra‐articular location and has been shown to improve postoperative pain and function in patients with an extruded meniscus. Prior techniques have been described for meniscus centralization in the setting of a meniscus root tear or with the use of single tension devices that are tensioned after meniscocapsular fixation. We present a minimally invasive technique for meniscus centralization that can be performed in conjunction with MAT using a centralization stabilization suture and re‐tensionable root‐fixation subchondral anchors that can be secured prior to meniscocapsular fixation. Technique Video video See video under supplementary data.

Background: Recent biomechanical evidence for adjustable suture anchor (ASA)–based posterior medial meniscus root (PMMR) fixation has shown promising results compared with conventional transtibial pull-out repair (TPOR). However, ASA fixation has not been evaluated in human tissue to 100,000 cycles. Hypothesis: ASA repair would lead to increased primary fixation strength and less cyclic displacement than conventional TPORs. Study Design: Controlled laboratory study. Methods: A total of 32 human medial menisci were used, 8 of which were intact specimens and served as native controls. For the others, PMMR tears were created and repaired using 3 different techniques (n = 8 group). Two conventional PMMR repairs were prepared consisting of two No. 2 simple sutures (TSS) and two No. 2 sutures in a Mason-Allen (MA) configuration, all tied over a cortical button. The knotless ASA repair was fixed in MA with repair sutures tensioned at 120 N (MA-120). The repairs’ initial force, stiffness, and relief displacement from the tensioned state toward repair unloading (2 N) were measured after fixation. All repair constructs were loaded for 100,000 cycles, with displacement and stiffness measured, and finally were pulled to failure. Results: The TPORs demonstrated similar primary fixation and cyclic loading behavior except for initial cyclic displacement (cycle 10). The ASA repair provided a higher initial repair load ( P < .001) and stiffness ( P < .001) with relief displacement similar to conventional TPORs. Lower initial cyclic displacement ( P < .011; cycle 10) with overall higher repair stiffness ( P < .011) resulted in significantly lower displacement ( P < .001) throughout testing for ASA repair. Although both TPORs were completely loose after 100,000 cycles, the ASA repair achieved near-native dynamic meniscal stabilization. The TSS repair had lower overall ultimate load ( P < .001) and ultimate stiffness ( P < .023) compared with the ASA repair. All repairs had lower ultimate stiffness and loads than the native meniscus ( P < .001). Conclusion: The ASA repair resulted in improved primary PMMR fixation that was stiffer with less cyclic displacement than conventional TPORs and approached that of the human meniscal function after 100,000 load cycles in a cadaveric model. However, all repair techniques had lower ultimate strength than the native human PMMR. Clinical Relevance: Knotless ASA meniscus root fixation resulted in higher tissue compression and less displacement in a cadaveric model; however, future clinical series with surveillance imaging will define the overall significance of healing rates.

Abstract Meniscal root tears have been shown to significantly impact tibiofemoral mechanics and contribute to accelerated development of osteoarthritis. A common finding in conjunction with a meniscal root tear is extrusion of the meniscus. Meniscal extrusion is an independent risk factor for tibiofemoral cartilage loss and the progression of osteoarthritis. Meniscus centralization was first introduced to directly address extrusion alongside root repair techniques. To date, reported techniques for meniscus centralization generally involve anchoring the meniscus directly to the tibia in some fashion, which can limit the normal anatomic motion of the meniscus. We present a technique for meniscus centralization that aims to maintain natural meniscal motion by utilizing the meniscotibial ligaments. Technique Video video See video under supplementary data.

Background: Lateral meniscal oblique radial tears (LMORTs) are the most common type of lateral meniscal tears and occur concomitantly with anterior cruciate ligament (ACL) tears in up to 12% of cases. Four types of LMORTs have been classified in the literature based on proximity to the meniscal root and extent of the tear. Type 1 and 2 LMORTs represent partial and complete posterior root tears less than 10 mm from the root insertion. Type 3 and 4 LMORTs are partial and complete posterior radial meniscus tears greater than 10 mm from the root insertion. Indications: Type 3 and 4 LMORTs can and should be addressed with an all-inside side-to-side repair at the time of ACL reconstruction. LMORTs that are not repaired at the time of ACL reconstruction can contribute to persistent instability and meniscal extrusion. Technique Description: Diagnostic arthroscopy is performed to evaluate the posterior aspects of both the medial and lateral meniscus. The medial leaflet is commonly flipped into the notch and scarred to ACL remnant. After identifying and isolating the medial leaflet, an arthroscopic suture passer is used to pass a suture from inferior to superior through the medial leaflet. A second suture is passed from inferior to superior through the lateral leaflet. This is used to shuttle the suture pass through the medial leaflet to the bottom of the meniscus, where it can be tied in a horizontal mattress fashion. The sutures are tied down with aide of an arthroscopic knot pusher. A second set of sutures is passed and used to shuttle a second suture that would be tied posterior to the first suture, again in a horizontal mattress fashion. This allows reduction of the fragments in apposition across the tear. Postoperatively, patients are allowed range of motion from 0° to 90° and to toe touch weightbearing for the first 4 weeks. Patients are advanced to weightbearing as tolerated at 5 weeks. Typical return to sport ranges from 6 to 9 months postoperatively. Results: Results have been published for 2-year outcomes of type 3 and 4 LMORT repairs and have demonstrated persistent improved patient-reported outcomes as well as healing rates that are greater than 80% and in some series approach nearly 100%. Discussion/Conclusion: Arthroscopic all-inside side-to-side surgical repair is a durable and reliable treatment option for patients presenting for ACL reconstruction with concomitant type 3 or 4 LMORT. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: While posterior medial meniscus root (PMMR) techniques have evolved, there remains a need to both optimize repair strength and improve resistance to cyclic loading. Hypothesis: Adjustable tensioning would lead to higher initial repair strength and reduce displacement with cyclic loading compared with previously described transtibial pull-out repair (TPOR) fixation techniques. Study Design: Controlled laboratory study. Methods: A total of 56 porcine medial menisci were used. Eight intact specimens served as a control for the native meniscus. For the others, PMMR tears were created and repaired with 6 different TPOR techniques (8 in each group). Fixed PMMR repairs were executed using 4 different suture techniques (two No. 2 cinch sutures, two cinch tapes, two No. 2 simple sutures, and two No. 2 sutures in a Mason-Allen configuration) all tied over a cortical button. Adjustable PMMR repairs using Mason-Allen sutures were fixed with an adjustable soft tissue anchor fixation tensioned at either 80 N or 120 N. The initial force, stiffness, and relief displacement of the repairs were measured after fixation. Repair constructs were then cyclically loaded, with cyclic displacement and stiffness measured after 1000 cycles. Finally, the specimens were pulled to failure. Results: The PMMR repaired with the 2 cinch sutures fixed technique afforded the lowest ( P < .001) initial repair load, stiffness, and relief displacement. The adjustable PMMR repairs achieved a higher initial repair load ( P < .001) and relief displacement ( P < .001) than all fixed repairs. The 2 cinch sutures fixed technique showed an overall higher cyclic displacement ( P < .028) and was completely loose compared with the native meniscus functional zone. Repairs with adjustable intratunnel fixation showed displacement with cyclic loading similar to the native meniscus. With cyclic loading, the Mason-Allen adjustable repair with 120 N of tension showed less displacement ( P < .016) than all fixed repairs and a stiffness comparable to the fixed Mason-Allen repair. The fixed Mason-Allen technique demonstrated a higher ultimate load ( P < .007) than the adjustable Mason-Allen techniques. All repairs were less stiff, with lower ultimate failure loads, than the native meniscus root attachment ( P < .0001). Conclusion: Adjustable TPOR led to considerably higher initial repair load and relief displacement than other conventional fixed repairs and restricted cyclic displacement to match the native meniscus function. However, the ultimate failure load of the adjustable devices was lower than that of a Mason-Allen construct tied over a cortical button. All repair techniques had a significantly lower load to failure than the native meniscus root. Clinical Relevance: Knotless adjustable PMMR repair based on soft anchor fixation results in higher tissue compression and less displacement, but the overall clinical significance on healing rates remains unclear.

Abstract The integrity of the posterior meniscus root attachment is vital for the preservation of knee joint biomechanics. Meniscus root tears treated nonoperatively or with meniscectomy lead to poor functional outcomes and progressive knee degeneration. Repair returns knee biomechanics back to the intact state and has an established record of positive mid‐term to long‐term results. Although transtibial pullout repair has been the gold standard, innovation is needed to overcome the limitations inherent to traditional approaches. The latest generation of transtibial pullout repair devices is adjustable, permits suture anchor placement directly into the root footprint, and has demonstrated encouraging early results in biomechanical analysis. This Technical Note describes an arthroscopic technique for medial meniscus posterior root repair that uses a knotless adjustable implant (SutureLoc; Arthrex) for aperture fixation via a transtibial approach with intratunnel soft anchor direct fixation and rip‐stop suture configuration. Technique Video video See video under supplementary data.

Background: Recently, the posterior horn lateral meniscal oblique radial tear (LMORT) was identified in 12% of acute anterior cruciate ligament (ACL) injuries. However, patient-reported outcomes for repair of this relatively common tear have not been reported. Purpose: To determine the minimum 2-year functional outcomes after LMORT repair at the time of ACL reconstruction (ACLR) compared to a matched cohort of patients who underwent isolated ACLR (iACLR). Study Design: Cohort study; Level of evidence, 3. Methods: Included were 100 patients (mean age at surgery, 21 years; range, 13-45 years) who underwent primary ACLR between 2010 and 2018. The mean follow-up period was 4.1 ± 2.0 years (range, 2.0-9.2 years). A total of 50 patients with surgically repaired LMORT type 3 or type 4 lesions, defined as partial or complete tears >10 mm from the root (LMORT group) were matched 1:1 based on age, date of surgery, and graft choice with 50 patients who underwent iACLR (iACLR group). The postoperative outcomes were compared between groups using the International Knee Documentation Committee subjective score (sIKDC) and the Tegner activity scale. An updated medical history was obtained via the electronic medical record to determine any subsequent complications and reoperations. Results: There was 1 ACL graft failure in each group as well as 5 (10%) reoperations per group. None of the patients in the LMORT group necessitated a lateral meniscal revision repair or partial meniscectomy. The LMORT and iACLR groups reported comparable sIKDC scores (92.5 ± 6.8 vs 91.9 ± 8.2, respectively; P = .712) as well as Tegner scores (6.7 ± 1.8 vs 6.6 ± 1.8, respectively; P = .910) at final follow-up. No failures of the LMORT repairs were reported. Conclusion: The study findings demonstrated that reoperations, graft failure rates, patient-reported outcomes, and patient activity levels at ≥2 years after type 3 and 4 LMORT repairs at the time of ACLR compared favorably with those of a matched cohort of patients who underwent iACLR with intact meniscus.