Review Question - QID 217906

This patient presents with a meniscal root tear involving the posterior horn of the medial meniscus. This patient has no appreciable arthritis on radiographic imaging and therefore should undergo meniscal root repair to its native insertion on the tibia.

The menisci serve many functions including stabilization, shock absorption, maintaining joint congruity, proprioception, and knee joint lubrication. One of their primary objectives is to provide load transmission through circumferential hoop tension. Meniscal root tears are biomechanically as detrimental as total meniscectomies in the knee joint due to loss of hoop tension and resultant marked increased peak contact pressures. Meniscal root tears have been shown to result in chronic pain, instability, and rapid progression of arthritis. Therefore, meniscal root tears serve as an independent subtype of meniscal tears that warrant special consideration. Partial meniscectomy, meniscal root repair, and arthroplasty all serve as viable treatment options. Nonoperative management and partial meniscectomy have both been shown to have poor long-term outcomes with high conversion rates to arthroplasty due to continued pain and dysfunction. Meniscal root repair to the tibia has shown promising outcomes, even in older cohorts, and is considered the gold standard treatment. If the patient has pre-existing arthritis on radiographic imaging, arthroplasty can be considered as well.

Krych and colleagues reviewed the 2-year outcomes of non-operative treatment of medial meniscal posterior horn root tears at their institution. They found that non-operative treatment was associated with poor clinical outcomes, worsening arthritis, and a relatively high rate of conversion to arthroplasty (>33% at a mean of 32 months). The authors stated their study provides a natural history benchmark to counsel patients about expected outcomes in these injuries and if nonoperative management is pursued.

Chung and colleagues retrospectively reviewed the long-term outcomes comparing partial meniscectomy and meniscal root repair in medial meniscal root tears treated at their institution. They found that meniscal root repair was more effective than partial meniscectomy in terms of all clinical and radiologic outcomes with significantly lower conversion to arthroplasty at 5-year follow-up. They concluded that meniscal root repair can and should be treated with refixation to the tibia with better outcomes than partial meniscectomy.

LaPrade and colleagues evaluated the results of meniscal root repair among patients within their institution’s prospectively collected database. They compared patient-centered outcomes after transtibial pull-out repair for posterior root tears in patients <50 years versus >50. They found that patient outcome significantly and comparably improved after meniscal root repair to the tibia in both cohorts despite laterality, medial versus lateral meniscal root tears, or patient age. They concluded that transtibial double-tunnel pull-out meniscal root repair improved function, pain, and activity level with delayed progression of knee osteoarthritis.

Figure A shows the AP radiographic image of a left knee without significant osteoarthritis or other appreciable injuries. B shows a meniscal root tear involving the posterior horn of the medial meniscus of the patient’s left knee.

Answer 1. Nonoperative management of meniscal root tears is associated with poor functional outcomes. While this may be considered in patients with sedentary lifestyles, this high-functioning patriot deserves the best knee this country can give him.
Answer 2. Partial meniscectomy has similar long terms as nonoperative management and should not be considered in high-functioning individuals with active lifestyles.
Answer 3. Total meniscectomy is an antiquated surgical option that would lead to rapid progression of osteoarthritis and would be appreciated as Fairbank’s changes on radiographic imaging.
Answer 5. In the setting of pre-existing or rapidly developing arthritis, unicompartmental knee arthroplasty is certainly an appropriate treatment option. This patient’s presenting radiographic images do not show appreciable osteoarthritis and therefore he should be treated with meniscal root fixation to the native tibia.