Summary

A novel surgical technique to repair a horizontal cleavage tear of the posterior horn of the medial meniscus is reported in young patients.

Abstract

Background

The management of horizontal cleavage meniscus tears (HCMT) can be challenging. Several treatment options have been proposed including nonoperative and surgical options. Both have advantages and negative aspects. Partial meniscectomy may lead to early osteoarthritis as well as post-meniscectomy syndrome. Parameniscal cysts have been reported not only with nonoperative management but also in cases of repair failure or absence of healing. Repair techniques initially aim to promote the healing process through isolated repair of the 2 superficial leaflets of fibril layers and debridement of the intermediate layer of collagen fiber bundles. While they provided good outcomes in the short term, they are also associated with a decrease of the meniscal volume which may be detrimental for joint preservation in the long term.

Objectives
To describe an original surgical technique in an adolescent patient with a chronic, symptomatic medial HCMT, using a quadriceps tendon autograft and vertical sutures to augment and repair the tear, in order to preserve meniscal anatomy and volume, as well as to seal the meniscus to prevent the occurrence or recurrence of a parameniscal cyst.

Study Design and Methods
This surgical technique is applied in the context of an athletic adolescent patient who presented with left-sided chronic sharp medial knee pain. On clinical examination she had persistent posteromedial pain on axial loading with positive medial meniscus signs. MRI displayed a subtle intra-articular effusion and revealed a HCMT involving the posterior horn of the medial meniscus reaching from its central avascular part to its peripheral wall. Standard anterolateral and anteromedial portals as well as a standard superomedial outflow portals were established at arthroscopy. The tear was inspected to determine whether both leaflets were adequate to proceed to its repair. The avascular central rim and frayed inner portions of the superior and inferior leaflets were removed using a mechanical shaver. The fibrinous tissue at the tear interface was rasped and the peripheral capsule stimulated with a shaver to initiate some bleeding. A 3x5x20 mm quadriceps tendon strip was harvested and placed into the horizontal cleavage tear. Vertical sutures were made using Fast-Fix anchors and an outside-in technique at the most medial part of the tear. Stability and tightness of the repair was tested with a probe as well as with repetitive knee flexion-extension movements.

Results

The augmentation technique with an autologous quadriceps tendon strip allowed for a more anatomic repair in comparison with previously published procedures. This was confirmed by postoperative MRI at 3 months showing volume restoration similar to the native meniscus, without tissue narrowing or shrinkage.

Conclusion

By filling the void between both leaflets of the torn meniscus with an autologous quadriceps tendon graft, the Quadriceps Tendon Augmentation Technique restores the volume and height of the meniscus in HCMT and may induce a sealing effect as well as improved joint preservation capacities in comparison with an isolated repair. Future experimental and prospective cohort studies will need confirm this proof-of-concept.