Introduction
Meniscal root repair is a surgical procedure that can be indicated in the treatment of severe, symptomatic meniscal root tears located in the knee. Case series suggest that meniscal root repair can successfully treat symptomatic isolated meniscal root tears, improving pain and function.
In simpler terms, a meniscal root tear is a serious injury where the meniscus, a piece of cartilage that provides a cushion between your thighbone and shinbone, becomes detached from its anchoring point in the knee. This procedure aims to reattach the torn meniscal root to its place, restoring the normal function of the meniscus.
Indications
Meniscal root repair is indicated in symptomatic meniscal root tears, patients with a stable knee or those who have undergone concurrent procedures to achieve stability, patients without significant osteoarthritis, and young, high-demand patients who are not a candidate for meniscal transplantation.
Meniscal root repair is contraindicated in: instances of advanced degenerative changes affecting the knee; uncorrected lower extremity malalignment; uncorrected ligamentous instability; inflammatory arthritis.
Causes
Meniscal root tears can be caused by:
- Sudden twist or quick turn during sports activity
- Heavy or awkward lifting
- Knee injury or trauma
- Degenerative changes due to aging
These are more common in patients in their 5th to 6th decades and females seem to be effected more than males. There is an association with elevated body mass index as well.
Diagnosis
A typical history for medial meniscal root tears is different from standard meniscal tears. The patient will often have a period of knee pain that seems to have come out of nowhere. The pain will be mild but nagging. Sometimes a patient will even present with an MRI that is read as “normal”, but in fact you can see that the meniscus is beginning to extrude.
After a period this will then yield to a brief moment, often something that seemed very minor, followed by severe pain and difficulty even bearing weight.
What is happening here, I suspect, is that with the sudden complete loss of the radial meniscal fibers the joint is suddenly overloaded. It is though, in that moment, the patient suddenly had no functional meniscus at all. Biomechanically this is exactly what has happened as the meniscus is extruded and loses all ability to function as a shock absorber. When this happens I like to proceed to surgery relatively soon if the meniscus is to be repaired.
Procedure
Meniscal root repair involves a surgical procedure where the torn meniscal root is reattached to its anchoring point in the knee. This is typically done using an arthroscopic technique, which involves small incisions and the use of a camera to guide the surgery.
From a technical perspective, if the tear has been long standing or there is significant extrusion of the meniscus Dr. Gilmer prefers to add an additional suture or centralization suture to help augment these tears.
These tears are more technically complex than standard meniscal repair and the rehab is similarly more challenging.
An example of a meniscal root repair using a technique very similar to Dr. Gilmer’s preferred technique is here
Post-Operative Care
Post-operatively, there is a period of limited weight-bearing and immobilization for the first 6 weeks. The knee is allowed to move 0-90 degrees in a brace but without putting weight on the leg. During this time our team utilizes blood flow restriction therapy and TENS or NMES (neuromuscular electrical stimulation) to reduce the atrophy that occurs during healing of the repair. Physical therapy is advised to regain knee strength and mobility for about 3 months postoperatively and then some patients will transition to a bridge program. Full return to sports activities is typically advised to wait until 6months post-op in my practice, depending on the individual case.
Risks and Complications
As with any knee surgery, possible risks include knee stiffness, infection, blood clots, nerve and blood vessel damage, and ligament injuries. Common side effects of meniscal root repair include joint pain, back pain, joint swelling, and joint effusion. Ultimately, if these repairs fail, or are avoided the alternative is partial knee replacement or UKA
Dr. Gilmer’s Take-
The idea of meniscal root repair is very compelling for a variety of reasons. Mostly if repaired acutely this can restore the shock absorbing function of the meniscus and prevent the development of early arthritis. It is a procedure that can greatly improve a patient's quality of life and overall knee function if successful. However, it requires a dedicated postoperative rehabilitation program and a thoughtful patient selection to ensure the best possible outcome. Some patients may ultimately do better, faster, with UKA, but because the trauma seems trivial it is often difficult to get buy in from patients who seemed to have just had a ‘simple meniscus tear’. We spend a lot of time emphasizing how different these are from the standard meniscal tear and why the treatment options are different.
Brian Gilmer, MD August 2023
References
- LaPrade, C. M., James, E. W., Cram, T. R., Feagin, J. A., Engebretsen, L., & LaPrade, R. F. (2015). Meniscal root tears: a classification system based on tear morphology. The American journal of sports medicine, 43(2), 363-369.
- Feucht, M. J., Kühle, J., Bode, G., Mehl, J., Schmal, H., Südkamp, N. P., ... & Niemeyer, P. (2015). Arthroscopic transtibial pullout repair for posterior medial meniscus root tears: a systematic review of clinical, radiographic, and second-look arthroscopic results. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 31(9), 1808-1816.
- Chung, K. S., Ha, J. K., Yeom, C. H., Ra, H. J., Jang, H. S., Choi, S. H., & Kim, J. G. (2014). Comparison of clinical and radiologic results between partial meniscectomy and refixation of medial meniscus posterior root tears: a minimum 5-year follow-up. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 30(1), 33-39.
- Kim, J. H., Chung, J. H., Lee, D. H., Lee, Y. S., Kim, J. R., & Ryu, K. J. (2011). Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: a prospective comparison study. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 27(12), 1644-1653.
- Sonnery-Cottet, B., Conteduca, J., Thaunat, M., Gunepin, F. X., & Seil, R. (2014). Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic exploration of the concealed portion of the knee. The American journal of sports medicine, 42(4), 921-926.
