Arthroscopic Transtibial Pull-Out Repair of Medial Meniscus Posterior Root Tear With a Whip Running Suture Technique

Abstract

Medial meniscus posterior root tear is a disruptive injury causing significant sequelae. Several techniques to repair and maintain the native function of the medial meniscus have been introduced, but limitations have been reported in terms of their results. In this current note, the authors introduce the arthroscopic transtibial pull-out repair with whip running suture technique, which may not only avoid the potential risk of meniscus cut-through by the suture material but also optimize the reduction of the extruded meniscus. By suturing the posteromedial capsule and peripheral meniscus, more medialization force can be directly applied to the extruded part of the meniscus, and normal hoop tension can be restored.

Technique Video

Video 1

Step-by-step description of the arthroscopic pull-out repair of medial meniscus posterior root tear with whip running suture technique. The video shows the arthroscopy of the left knee. Standard anterolateral and anteromedial portal are used for the initial inspection. After the posteromedial and posterolateral portal are made using the transillumination technique, the posterior trans-septal portal is established. The main procedures of this technique are done under visualization through the trans-septal portal with a 30° scope. After establishing the healing bed for the root repair, guide pin is inserted with the ACL drilling guide (110° setting; Arthrex, Naples, FL). Then, a 45° curved suture hook loaded with a no. 2 PDS suture material is inserted through the posteromedial portal. The posterior capsule and the medial meniscus posterior horn on the posteromedial corner are penetrated by the suture hook. The sharp tip of the suture hook is advanced from the posterior capsule into the femoral surface of the medial meniscus. At the point 5 mm lateral to the first penetration, the posterior horn of the medial meniscus is penetrated by the same suture hook loaded with a no. 1 nylon suture material from the tibial side to the femoral side in a vertical direction. Using the shuttle relay technique, the second suture of the nylon is exchanged with the first suture of the PDS. At this stage, the whip running stitch involving the posteromedial capsule is completed. Using a crescent suture hook loaded with a no. 2 PDS, the simple vertical suture is made penetrating the root stump 5 to 10 mm medial to the stump end. At the point 5 mm apart from the previous suture, the third suture is done using the same crescent hook and suture material. In this stage, 1 whip running suture and 2 simple vertical sutures are completed. After reaming the trans-tibial tunnel for pulling out the suture strands, a wire loop is advanced through the reamer into the posteromedial portal. After checking all 6 strands of the 3 sutures are engaged properly within the wire loop, the wire is withdrawn out of the tibial tunnel. Under the maintenance of such adequate tension, the PDS strands are post-tied and fixed with a 3.5 mm cortical screw and washer on anterior cortex of the tibia. (PDS, polydioxanone.)