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M. THAUNAT, N. JAN, J.M. FAYARD, C. KAJETANEK, C.G. MURPHY, B. PUPIM, R. GARDON, B. SONNERY-COTTET
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of patients. These lesions are very frequently
encountered with concomitant rupture of the
anterior cruciate ligament. They are very rarely
isolated and they certainly occurred during the
ligament rupture mechanism. The only
circumstances in which we meet similar lesions
(vertically oriented tears of the posterior
segment of the MM) outside a context of
ligament rupture are the cases of isolated
bucket handle medial meniscus tears. During
the same period only four patients underwent
suturing of the posterior segment of the medial
meniscus without ACL reconstruction. We then
decided to exclude this patient when deciding
to publish the series in order to have a more
homogeneous group of patient. These four
patients had the same technique using a suture
hook device through a posteromedial approach.
Despite the development of new devices, the
failure rate of the repair of medial meniscus
posterior horn tears remains high [7, 14]. With
classic anterior portals, a failure to visualize
the posterior horn of the MM may result in
insufficient debridement of the lesion, while
hybrid suture anchor placement may be at risk
becoming a blind procedure. Furthermore, with
visualization from anterior portals alone, it is
not always possible to be sure to achieve a
complete closure of the lesion. The risk is to
fail to flip the anchors in the gap between the
central and peripheral zone of the injured
meniscus and to leave the lesion open [15].
Without an excellent view of the lesion,
meniscal repair devices may induce different
complications like migration or breakage of the
implant [15, 16] leading to iatrogenic cartilage
damage [8]. Hence, a better healing rate of
posterior horn MM lesions may be expected
through a better visualization, allowing for an
improved diagnosis [17], an improved quality
of the debridement prior to the repair and the
control of a complete closure of the lesion [18].
Better visualization also allows the placement
of vertical sutures perpendicular to the deep
fibers of themenisci, which are biomechanically
more adapted. The reduction of the lesion is
visualized during the procedure, which is not
possible in the all inside implantation. The
same hook device can be used to do more than
one suture.
When we compare our healing rate to those
previously reported using this method of
suture, we found an abnormally high rate of
recurrent meniscal lesions. However, our
healing rate at the location of the initial tear
was comparable to the rate of 96.4% reported
by Ahn
et al.
in a recent study with a second
look arthroscopy [19]. In the current study, the
high rate of recurrent tear was explained by
newly formed injuries which were confirmed
on the surface of 5 menisci. It is conceivable
that these injuries were attributable to a residual
cleft left by the path of the suture lasso and
maintained by the use of a strong N° 2 non
absorbable suture. These clefts on the avascular
meniscal substance may remain in situ without
healing and would favor the recurrence of a
more centrally located lesion in the white/
white zone. We decided to change our suture
from a strong non-resorbable suture to a PDS
suture in order to reduce the risk of newly
formed injury. From a biomechanical point of
view, PDS 0 and PDS 1 sutures are re
commended for meniscal sutures to guarantee
a high primary stability, a small amount of
gapping, and fewer partial tissue failure [20]
and was used by Ahn
et al.
and they did not
report any newly formed injury in their series
of 140 knees who had a second look arthro
scopy at a mean follow up of 37.7 months after
an all inside suture of the posterior segment of
the medial meniscus through a posteromedial
portal [19]. However, in these 5 cases the
amount of meniscectomy was decreased when
compared with the initial lesion. We believe as
advocated by Pujol
et al.
[21] that the meniscus
can be partially saved and that a risk of a partial
failure should be taken when possible.
The disadvantages of the all inside suture
technique through a PM portal are that the
second incision is necessary requiring more
operative time. There is also a significant
learning curve in placing and tying the sutures.
There is also a potential risk for synovial fistula
[22] but we did not encounter any in our series.
The main risk of the posteromedial access is
the saphenous nerve and vein injury. The
popliteal artery, common fibular nerve, and
tibial nerve are situated more laterally.