Authors:
Jyothiprasanth M. MD.
Senior Consultant Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India
Jithin C R. MD.
Associate Consultant Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India.
Venkatesh Kumar S . MD.*
Consultant Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India.
Aghosh MC. MD.
Consultant Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India.
Akhil Thomas. MD.
* email: aghoshnair@gmail.com
All authors have declared that there was no conflict of interest during this study.
INTRODUCTION
The anterior horn of the lateral meniscus is a key structure in the knee joint, contributing significantly to load distribution, shock absorption, and joint stability. Injuries to this part of the meniscus, often resulting from sports activities, can lead to substantial functional impairment if not appropriately treated. The complexity of the meniscus's structure, along with its limited vascular supply, particularly in the anterior horn, makes the repair of tears in this region a challenging endeavor.
Recently, the development of all-suture anchors has revolutionized meniscal repair by offering a less invasive, yet highly effective, option. All-suture anchors are composed entirely of suture material, eliminating the need for rigid implants and thus reducing the risk of damage to surrounding tissues.
The biomechanical properties of all-suture anchors allow for secure fixation in the meniscal tissue, providing the necessary stability for healing while maintaining the flexibility required to accommodate the dynamic environment of the knee . Studies have demonstrated promising outcomes in patients treated with all-suture anchors for meniscal repairs, reporting significant improvements in knee function and a reduction in postoperative complications compared to traditional techniques.
This publication seeks to explore the role of all-suture anchors in the repair of anterior horn tears of the lateral meniscus. We will review the biomechanics of the lateral meniscus, outline the surgical technique for using all-suture anchors, and assess the clinical outcomes reported in recent studies.
TECHNIQUE
- Patient in supine position under suitable Anesthesia.
- Diagnostic arthroscopy using standard anteromedial portal.
- Identifying the pathology, in this case the tear in the anterior horn of lateral meniscus.
- A working anterolateral portal and an accessory anterolateral portal made.
- A passport cannula inserted through the accessory AL portal.
- A 2.7 mm single loaded suture anchor passed through the passport cannula.
- Anchor drilled using a curved suture anchor guide and sutures taken through the passport cannula to avoid anterior tissue bridge.
- Knee scorpion used to pass the suture through the substance of the meniscus .
- Running sutures are made in the meniscus and the knot is cut at 3mm length.
- Stability of the repair assessed using probe .
- After the final construct is assessed, the excess fluid is drained, and the incision is closed in layers using 2-0 vicryl sutures followed by skin staplers .
- After surgery the patient is placed in a long knee immobilizer in full extension and allowed to bear partial weight for 3 weeks .
- Physical therapy is initiated on post operative day one to begin working on passive range of motion exercises .
RESULTS
The integrity of the AHLM is important for normal knee kinematics, and the tear of AHLM increases the peak contact pressures over the lateral and medial tibiofemoral compartments.
Among the prevailing methods of the meniscus repair (outside-in, inside-out, and all-inside), outside-in is the preferred method of repairing AHLM. This technique uses inexpensive material like spinal needles and sutures like polydioxanone for the repair.
The thin nature of the anterolateral capsule is fraught with increased chances of a cutting through of the suture. Another recently published method uses a suture anchor for the fixation of the AHLM after taking a lasso loop around the meniscus tissue.
A lasso loop around the AHLM may lead to strangulation of the meniscus tissue and may impede the healing.
Presently, the literature supports repairing AHLM with outside-in repair.
Because of the thin nature of the anterolateral capsule and fewer attachments of the capsule to the lateral meniscus, imparting more mobility to the lateral meniscus, we feel the outside-in method of repair would constrain the excursion due to multiple sutures taken from the capsule and the meniscus.
The distance between the capsule and the anterior horn of the meniscus is more and the movement of meniscus-capsular junction is more in the anterior than middle and posterior during flexion and extension of the knee. This will in turn cause failure of repair when we attach the meniscus to the capsule.
Whereas in this method the suture anchor is fixed to the tibia which avoids strain on the repair and reduces the risk of failure .
Our patient had no complaints of anterior knee pain due to knot irritation or soft tissue strangulation.
She was assessed to have full range of motion of 0-120 on follow up and no pain or instability or locking during full weight bearing .
REFERENCE
- Allen A.A.Caldwell JrGLFu F.H. Anatomy and biomechanics of the meniscus. Op Tech Orthop. 1995; 5: 2.
- Chen D.Li Q.Sun Y.Qin J.Yao Y.Jiang Q. Arthroscopic management for the unstable inferior leaf of the lateral meniscus anterior horn and associated cysts through a direct inframeniscal portal: A retrospective study. Biomed Res Int. 2017; 20179264907.
- El-Assal M.Mostafa M.Abdel-Aal A.El-Shafee, M. Arthroscopy alone or in association with open cystectomy: In treatment of lateral meniscal cysts. Knee Surg Sports Traumatol Arthrosc. 2003; 11: 30-32.
- Menge T.J.Dean C.S.Chahla J.Mitchell J.J.LaPrade. R.F. Anterior horn meniscal repair using an outside-in suture technique. Arthrosc Tech. 2016; 5: e1111-e1116.
- Fu G.Pang J.Li G.Lu J.Chen J. Arthroscopic repair for the anterior horn of the lateral meniscus with suture anchor. Arthrosc Tech. 2023; 12: e635-e638.
- Rodeo S.A. Arthroscopic meniscal repair with use of the outside-in technique. Instr Course Lect. 2000; 49: 195-206.
Download PDF version
