Arthroscopic Transtibial Pull-Out Repair for Meniscal Posterior Root Tear: The Slip Knot Technique

Abstract

A meniscal root tear can increase the tibiofemoral contact pressure to approximate that of total meniscectomy and eventually lead to degenerative change. An anatomic and stable meniscal root repair is essential in restoring the tibiofemoral contact pressure back to that of a normal knee. Suture anchor technique and pull-out suture technique are the 2 main arthroscopic root repair procedures with equivalent success; nonetheless, there remains a lack of an optimal technique with a biomechanical property matching that of the intact root. This article presents a technically simple, fast, and robust pull-out suture construct that incorporates 2 slip-knot locking loops at the meniscus-suture interface. This technique can be used for both medial and lateral posterior root repair, as well as concomitantly with cruciate ligament reconstruction.

Fig 1

Left knee arthroscopy, viewing from the anterolateral portal with knee in 90° flexion (figure-of-4) position. (A) A torn ACL (arrow). (B) Viewing the posterior lateral compartment reveals an oblique radial tear (arrow) of LMPR about 7 mm from its insertion site. ACL, anterior cruciate ligament; LMPR, lateral meniscus posterior root; LFC, lateral femoral condyle; LTC, lateral tibial condyle; PCL, posterior cruciate ligament.

Fig 2

A half hitch (arrow) is made at the midportion of a 2-0 FiberWire suture (Arthrex, Naples, FL) on the post of Knee Scorpion (Arthrex).

Fig 3

Left knee arthroscopy of posterior lateral compartment, viewing from the anteromedial portal with knee in 90° flexion (figure-of-4) position. A Knee Scorpion is inserted from the anterolateral portal via the PassPort Cannula to pass the working limb of the 2-0 FiberWire through the torn end of lateral meniscus. LFC, lateral femoral condyle; LMPH, lateral meniscus posterior horn.

Fig 4

After being passed through the meniscus upon piercing of Scorpion needle, the working limb is captured by the upper jaw of Scorpion, retrieved out the joint from the anterolateral portal, and conveniently brought passed through the half hitch made earlier on the post of Scorpion (Fig 2) to form a slip knot.

Fig 5

Left knee arthroscopy of posterior lateral compartment, viewing from the anteromedial portal with knee in 90° flexion (figure-of-4) position. The knot proceeds to slide into the joint through the PassPort Cannula and creates a locking loop at the meniscus (arrow). LFC, lateral femoral condyle; LMPR, lateral meniscus posterior root; LTC, lateral tibial condyle.

Fig 6

Left knee arthroscopy of posterior lateral compartment, viewing from the anteromedial portal with knee in 90° flexion (figure-of-4) position. A second slip knot (arrow), using the preloaded 2-mm-width FiberTape (Arthrex) on a 4.75 mm Swivelock (Arthrex), is made looping the meniscus 5 mm medial to the first knot for a 2-locking-loop meniscus-suture configuration. LFC, lateral femoral condyle; LTC, lateral tibial condyle.

Fig 7

Left knee arthroscopy of posterior lateral compartment, viewing from the anteromedial portal with knee in 90° flexion (figure-of-4) position. After all 4 suture limbs of the 2 slip knots been shuttled through the transtibial tunnel, the meniscal root is securely reduced to the bone socket with the prominent knots nicely embedded to avoid chondral abrasion. An additional side-to-side approximation of torn end of LMPR and its stump is made by using an all-inside suture (JuggerStitch, Zimmer Biomet, Warsaw, IN, USA) (arrow). Asterisk indicates the ACL femoral tunnel. ACL, anterior cruciate ligament; LFC, lateral femoral condyle; LMPR, lateral meniscus posterior root; LTC, lateral tibial condyle.

Fig 8

Placement of a 4.75-mm SwiveLock anchor for tibial fixation of the pull-out suture construct on the anteromedial tibial cortex.