LIVRE JDG 2016

REPAIR OF MENISCAL RAMP LESIONS THROUGH A POSTEROMEDIAL PORTAL DURING ACL RECONSTRUCTION…

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tears located in the central third of the medial

meniscus (white/white zone) for which an

isolated suture with an all-inside suture im

plant (Fas T Fix device, Smith & Nephew,

Andover, MA) or a partial meniscectomy was

performed

knee

dislocations,

major

concomitant procedures such as high tibial

osteotomy

other

knee

ligament

reconstructions. We prospectively evaluated

132 consecutive patients in whom 132 medial

menisci underwent a medial meniscus repair

through a posteromedial approach in

conjunction with ACL reconstruction. An MRI

had

been

performed

systematically

preoperatively. A tear of the medial meniscus

had been suspected on the preoperatively on

MRI for only 80 of the 132 patients. A

systematic arthroscopic exploration of the

posterior horn of the MM was performed. The

first stage of the exploration was achieved

through standard anterior portals including a

meticulous probing of the posterior horn. Then,

the posterior horn of the MM was explored

through the anterolateral portal with the scope

positioned deep in the notch, for visualization

of the posterior rim of the posterior horn. In

cases where a meniscal lesion was suspected,

probing of the posterior horn through an

additional posteromedial portal was done in

order to diagnose hidden tears [11]. Repair was

performed within the rim of less than 3mm

(capsulomeniscal junctionand red-red zone) or

3 to 5mm (red-white zone) of an unstable torn

meniscus, including bucket handle tears. All

were longitudinal tears, and were repaired at

the same time as ACL reconstruction.

Surgical technique

During the procedure, the patients are placed

supine on the operating table with a tourniquet

placed high on the thigh. The knee is placed at

90° of exion with a foot support to allow for a

full range of knee motion. We use a standard

high lateral parapatellar portal for the

arthroscope and the medial parapatellar portal

for the instruments. In case of a dislocated

bucket-handle tear, reduction is performed.

The possibility of engaging the probe in the

posterior segment of the meniscus and of

bringing it under the condyle is an indirect sign

of lesion and instability criteria. The direct

visualization of the posteromedial compartment

must always be done in order to diagnose and

repair these lesions.

Even if no sign of unstable meniscus is

diagnosed through the anterior approach, a

systematic exploration of the posterior segment

is performed. A trans-notch visualization of the

posteromedial compartment is systematically

performedwith the knee in 90°. The arthroscope

is introduced by the anterolateral portal in the

triangle limited by the medial condyle, the PCL

and the tibial spines. After the contact with this

zone, the arthroscope can pass through the

space at the condyle border when applying a

valgus force first in flexion and then in

extension. An internal rotation is applied to the

tibia to help visualization; this causes the

posterior tibial plateau to subluxe and a

posterior translation of the middle thirds

segment. With this maneuver two thirds of

peripheral lesions from the posterior segment

up to the medium segment can be seen. In case

of tear of the posterior segment, a posteromedial

approach is performed. Transillumination

allows the surgeon to observe the veins and

nerves that must be avoided. The point where

the needle is introduced is above the hamstring

tendons, 1cm posterior to the medial femoro-

tibial joint line. The knee must be flexed at 90°

to avoid the popliteal structures. The needle

must be introduced from outside to inside, in

the direction to the lesion. The approach is

done with a number 11- blade scalpel under

arthroscopic control, and dissection via the

same approach, again under arthroscopic

control. The all inside suture can then be

performed (fig. 2). Firstly, the lesion is debrided

and edges of the tear are trimmed with a shaver.

A left curved hook is used for a right knee and

vice versa. The 25° hook (Suture lasso, Arthrex,

Naples, FL) loaded with a N° 2 nonresorbable

braided composite suture (Fiberstick, Arthrex,

Naples, FL) is introduced through the

posteromedial portal. The foot is positioned in

maximal internal rotation in order to take away

the medial condyle from the posterior segment

of the meniscus. The suture hook is manipulated

by hand so that the sharp tip penetrates the

peripheral wall of the medial meniscus from