Arthroscopic Management for the Unstable Inferior Leaf of the Lateral Meniscus Anterior Horn and Associated Cysts through a Direct Inframeniscal Portal: A Retrospective Study

Arthroscopy strategy to obtain surgical access to peripheral lateral tibial plateau for arthroscopic assisted reduction & internal fixation of fractures

Current standard of open surgical approach for lateral tibial plateau fractures is lateral submeniscal arthrotomy for obtaining visual and instrumentation access to peripheral meniscus covered part where fractures are often located. Anterior parapatellar arthrotomy is used less often as it is associated with soft tissue complications and provides access to only central uncovered part. Lateral submeniscal arthrotomy achieves necessary access by surgical division of meniscotibial attachments and superior retraction of thus detached meniscus. Arthroscopic reduction and internal fixation (ARIF), with its portals placed anteriorly obtains efficient viewing as well as instrumentation access to central part but; only tangential viewing access to peripheral concealed part of joint surface in mid-lateral and posterior part and none at all in anterior and anterolateral part. Further, considering meniscotibial attachment of meniscus remains intact in ARIF, manoeuvrability of instruments in narrow submeniscal space even in posterior and mid-lateral area is severely constrained. ARIF as it is practiced now, therefore remains merely a monitoring and evaluation tool at least in peripheral meniscus concealed area. Direct elevation of depressed articular fragment often undertaken in ORIF by submeniscal arthrotomy, remains therefore unexploited in ARIF. This article describes a strategy to achieve arthroscopically; visual and instrumentation access similar to open submeniscal arthrotomy to conduct interventions equivalent to those carried out in ORIF.

Arthroscopic inferior leaf meniscectomy of the involved anterior horn in the lateral meniscus horizontal tear via an accessary extreme far anteromedial portal

BACKGROUND

An accessory extreme far anteromedial portal can improve visualisation and ease inferior leaf meniscectomy in patients with lateral meniscal anterior horn horizontal tears. However, the therapeutic outcomes of adding an accessory extreme far anteromedial portal remain unclear. This study aimed to evaluate the clinical efficacy of adding an accessory extreme far anteromedial portal for treating lateral meniscal horizontal tears involving the anterior horns.

METHODS

This retrospective study included 101 patients with anterior horn involvement in lateral meniscal horizontal tears who underwent arthroscopic unstable inferior leaf meniscectomy between January 2016 and December 2020. The pathologies were diagnosed using physical examinations and magnetic resonance imaging. The anterior horn involved in the lateral meniscal horizontal tears was treated using inferior leaf meniscectomy. The primary endpoints were changes in the visual analogue scale, Lysholm, International Knee Documentation Committee, and Tegner scores at the final follow-up. The secondary endpoint was meniscal cure rate at 3 months postoperatively. The preoperative and postoperative functional scores were compared. The occurrence of complications was recorded.

RESULTS

All patients were followed up for an average of 4.9 ± 1.2 years (range 2.3-7.5 years). After 4 months, none of the patients experienced pain, weakness, instability, or tenderness in the lateral joint line, achieving an imaging cure rate of 98%. At the final follow-up, significant postoperative improvements were observed in the average values of the visual analogue scale score (3.5 ± 0.7 vs. 0.7 ± 0.6), Lysholm score (62.7 ± 4.4 vs. 91.8 ± 3.1), International Knee Documentation Committee score (61.9 ± 3.7 vs. 91.7 ± 9.5), and Tegner score (2.0 ± 0.7 vs. 6.1 ± 0.7). Excellent Lysholm scores were obtained in 81 patients, and good outcomes were obtained in 18 patients, with an excellent-to-good rate of 98.0%.

CONCLUSIONS

Inferior leaf resection via the accessory far anteromedial portal is a safe treatment option for the involved anterior horn in lateral meniscal horizontal tears. This approach enhances visibility and facilitates surgical procedures, with minimal complications.

LARAI portal provides a safe method for lateral meniscus repair: three-dimensional computed tomography and cadaveric assessment

BACKGROUND

Lateral, All-Round and All-Inside (LARAI) portal is a viewing or working portal for observing and repairing the lesions of the lateral meniscus. However, there are safety concerns about popliteal artery (PA) injuries during the procedure. This study aimed to assess the safe distance between the trajectory of the LARAI portal and PA.

MATERIALS AND METHODS

Both three-dimensional computed tomography (3D-CT) and cadavers were used to simulate the LARAI portal trajectory. In the 3D-CT study, between January 2020 and September 2020, 45 participants who underwent computed tomography angiography were included in the study. The shortest distance from the PA to the simulated trajectory needle (PS) was measured using 3D-CT. Mean -3SD -2 was calculated to assess the safety of the LARAI portal trajectory. If this value was more than zero, the trajectory was considered "safe." In the cadaveric study, lower limbs from seven fresh-frozen cadavers were used to establish the "safe" trajectories of the LARAI portal, and the PS was measured.

RESULTS

In the 3D-CT study, the longest PS (P < 0.001) was found 20 mm lateral to the edge of the patellar tendon trajectory at 0 mm from the posterior cruciate ligament (PCL). Safe trajectories were also found 10 mm, 15 mm, and 20 mm lateral to the edge of the patellar tendon at 0 mm from the PCL, as well as the 20 mm lateral to the edge of the patellar tendon at 3 mm from the PCL. The cadaveric study showed that the average PS of all safe trajectories closely adjoined to PCL was greater than 14 mm.

CONCLUSIONS

The LARAI portal trajectory in the "figure of four" is safe, and the optimal insertion point is 10-20 mm lateral to the edge of the patellar tendon and closely adjoined to the posterolateral margin of the PCL at knee joint line level.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Repair for the Anterior Horn of the Lateral Meniscus With Suture Anchor

The anterior horn tear of the lateral meniscus, often accompanied with local parameniscal cysts, is usually managed by cysts debridement and meniscus repair with the outside-in technique (OIT). However, a big gap between the meniscus and anterior capsule would be produced after cysts debridement and be difficult to be closed by the OIT. Or, the OIT would result in knee pain because of the overly tight knots. Therefore, we devised an anchor repair technique. Following the cysts resection, the anterior horn of the lateral meniscus (AHLM) is fixed at the anterolateral edge of the tibial plateau with 1 suture anchor, and then followed by suturing the AHLM with the surrounding synovium to promote healing. We recommend this technique as an alternative method for repairing an AHLM tear accompanied with local parameniscal cysts.

Arthroscopic Assisted Reduction and Internal Fixation of Tibial Plateau Fractures by Viewing and Instrumentation Access Through Coexisting Meniscus Tear: Case Series

Meniscus tear coexisting with tibial plateau fractures may be found in 2-49% of cases. Literature accepts that torn meniscus can be retracted towards the center to improve visualization of the peripheral plateau which is ordinarily concealed by the overlying meniscus. We hypothesized that easing in microscope through a coexisting tear may be much less disruptive with little or no adverse effects with respect to either the propagation of tear or its later repair. This strategy improved visualization as well as the extended reach of interventional instrumentation access to otherwise concealed areas of plateau and endoscopic trans-focal access to a vertical limb of fracture split on the anterior cortex of proximal tibia without any impact on the stability of repaired meniscus. The experience in a series of six cases is shared.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00703-7.

Arthroscopic all-inside repair with suture hook for horizontal tear of the lateral meniscus at the popliteal hiatus region: a preliminary report

Background

Arthroscopic surgery procedures vary depending on the types of meniscus tear, including meniscectomy and meniscus repair. Among the several types of meniscus tear, the horizontal tear of the lateral meniscus at the popliteal hiatus region is a common injury, and its surgical treatment is still inconsistent.

Methods

Between January 2018 and October 2018, 20 patients who underwent all-inside repair with suture hook for the horizontal tear of the lateral meniscus at the popliteal hiatus region were recruited. Any operative complication was recorded, and postoperative MRI scans were conducted at the 6 months. The clinical results were graded based on the scale of the Lysholm knee score preoperatively and at follow-up.

Results

No operative complications were recorded. Postoperative MRIs at the 6 months showed that there was no re-tear for all patients, though signal intensity remained high in T2-weighted MRI in the lateral meniscus for nine cases. The average preoperative Lysholm knee score was 58.6 ± 10.1, which increased significantly to 89.3 ± 7.8 (t = − 11.01, p = 0.001) at the last follow-up. Recurrence or aggravation of symptoms was not noted at the final follow-up.

Conclusion

All-inside repair with suture hook may be a good option for the horizontal tear of the lateral meniscus at the popliteal hiatus region which preserves the meniscus; avoids iatrogenic injury on the adjacent popliteal tendon, common peroneal nerve, and inferior lateral geniculate artery.

Arthroscopic minimum saucerization and inferior-leaf meniscectomy for a horizontal tear of a complete discoid lateral meniscus: Report of two cases

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Arthroscopic minimum saucerization and inferior-leaf meniscectomy at 2-year follow-up.

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Preserving more than 10 mm width could obtain excellent clinical outcomes.

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Leaving more meniscal tissue might prevent meniscal extrusion.

Introduction

Treatment of a horizontal tear of a complete discoid lateral meniscus (DLM) is still controversial. Preserving peripheral rim as a normal shape of the meniscus with single-leaf resection is a conventional treatment, however meniscal function could not be fully restored.

Presentation of case

A 28-year old woman and a 34-year old woman experienced knee pain and had restricted knee extension. MRI showed horizontal tears of complete DLM in both patients. Arthroscopic minimum saucerization preserving more than 10 mm peripheral rim and inferior-leaf meniscectomy was performed. Two years after the surgery, the patient had no pain and no restriction of ROM. MRI showed the remaining superior-leaf maintained about half its width and no progression of coronal/sagittal extrusion.

Discussion and conclusion

As resecting more meniscal tissue has been considered to be a cause of degeneration or extrusion of the meniscus, arthroscopic minimum saucerization, preserving more meniscal tissue than standard saucerization, and inferior-leaf meniscectomy can be an alternative treatment option of horizontal tears of complete DLM with satisfying clinical and radiological results.