Vadhera Amar S, DeFroda Steven F, Lee Jonathan S, Singh Harsh, Gursoy Safa, Kunze Kyle N, Verma Nikhil N, Chahla Jorge
Division of Sports Medicine, Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA.
Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA.
Video J Sports Med. 2023 Feb 9;3(1):26350254221141904. doi: 10.1177/26350254221141904. eCollection 2023 Jan-Feb.
The meniscal roots are essential for preserving the structural and biomechanical properties of the tibiofemoral joint. Posterior meniscal root avulsions can cause meniscal extrusion, joint space narrowing, and progressive knee arthritis. Iatrogenic avulsions after malpositioning of the transtibial tunnels during anterior cruciate ligament (ACL) reconstruction have previously been reported in the literature to account for poor long-term outcomes seen in some patients following ACL reconstruction. Therefore, correct transtibial tunnel placement during ACL reconstruction is essential to avoid iatrogenic meniscal damage.
Patients are indicated for surgery when presenting with a verified, symptomatic, complete meniscal root tear seen on advanced imaging or diagnostic arthroscopy. Contraindications for a root repair include the development of advanced osteoarthritis in the ipsilateral compartment, older age, and malalignment in the affected compartment.
The ACL graft was appreciated and noted to be vertical and posterior relative to its native anatomical position, violating the lateral posterior horn root attachment. A full lateral posterior meniscal root avulsion was then confirmed directly adjacent to the graft tunnel. A curette was used to prepare the footprint of the lateral meniscal root on the posterolateral tibia for the 2-tunnel transtibial pull-out tunnels, and a grasper was used to position the torn meniscal root back into its anatomical site. Two ultrabraided sutures were passed through the posterior horn of the lateral meniscus using a suture passer. These were then passed through the tunnels into the body of the meniscal root and reduced to its native anatomical position. The suture repair was then secured over an Endobutton Fixation Device at 90° of knee flexion through each tunnel into its native anatomical position while confirming its adequate tension by viewing arthroscopically.
Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities.
DISCUSSION/CONCLUSION: This injury underscores the importance of an accurate tibial tunnel placement during ACL reconstruction to avoid posterior meniscal root injuries and other associated complications. Physicians should consider such pathology in the differential diagnosis of patients presenting with persistent pain and instability following a primary ACL reconstruction.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
半月板根部对于维持胫股关节的结构和生物力学特性至关重要。半月板后根部撕脱可导致半月板挤出、关节间隙变窄以及进行性膝关节炎。先前文献报道，在前交叉韧带（ACL）重建过程中胫骨隧道位置不当导致的医源性撕脱是部分患者ACL重建术后长期效果不佳的原因。因此，ACL重建术中正确放置胫骨隧道对于避免医源性半月板损伤至关重要。
当患者经先进影像学检查或诊断性关节镜检查证实存在有症状的半月板根部完全撕裂时，即适合手术治疗。根部修复的禁忌症包括同侧关节腔出现晚期骨关节炎、年龄较大以及患侧关节腔排列不齐。
观察到ACL移植物相对于其天然解剖位置呈垂直且靠后的状态，侵犯了外侧后角根部附着点。随后在移植物隧道紧邻处直接证实存在外侧半月板后根部完全撕脱。使用刮匙在胫骨后外侧为双隧道经胫骨拉出隧道准备外侧半月板根部的附着区，并用抓钳将撕裂的半月板根部放回其解剖位置。使用缝线穿引器将两根超编织缝线穿过外侧半月板后角。然后将这些缝线穿过隧道进入半月板根部主体，并复位至其天然解剖位置。在膝关节屈曲90°时，通过每个隧道将缝线修复固定在Endobutton固定装置上，使其回到天然解剖位置，同时通过关节镜观察确认其张力合适。
术后2年内，预计患者的整体膝关节特定生活质量会有所改善，疼痛减轻，并能成功恢复活动。
讨论/结论：该损伤强调了ACL重建术中准确放置胫骨隧道以避免半月板后根部损伤及其他相关并发症的重要性。医生在对初次ACL重建后出现持续疼痛和不稳定的患者进行鉴别诊断时应考虑到这种病理情况。
作者证明已获得本出版物中出现的任何患者的同意。如果个体可能被识别，作者在提交本稿件以供发表时已包含患者的豁免声明或其他书面形式的批准。
