The patient, a seventeen-year-old girl, injured her left knee in June 1988 in a fall from a bicycle. Initial treatment consisted of aspiration of a bloody effusion and physical therapy. Because of continued giving-way and pain, after two months, she sought a second opinion in this clinic. Examination at that time revealed a 2-plus effusion, but guarding prevented pivot-shift and McMurray testing. The Lachman test revealed normal findings. There was bruising overlying the patella and the lateral femoral condyle, and the lateral joint line was tender. She was unable to bear full weight on the extremity, and knee range of motion was limited and painful. Radiographs did not show a fracture or osseous loose body. Magnetic resonance imaging was not available in our region at that time. A tear of the anterior cruciate ligament or a bucket-handle tear of the lateral meniscus was suspected, and arthroscopic treatment was undertaken.
With the patient under anesthesia, the pivot-shift maneuver elicited a McMurray-like clunk. During the arthroscopy, an effusion and hemosiderin staining of the synovium were encountered. The articular cartilage of the lateral aspect of the patella and both femoral condyles showed scuffing, softening, and superficial fissures that were <1.5 cm in length. The medial meniscus and the cruciate ligaments were intact. The posterior root of the lateral meniscus had been completely avulsed and was folded onto itself and displaced into the intercondylar space anterior to the anterior cruciate ligament. A peripheral tear continued from the posterior root anteriorly in the red zone (the vascular portion of the meniscus, as compared with the avascular [white] zone) for a little more than half the length of the meniscus, where the tear entered the red-white boundary and continued anteriorly, ending finally in the white zone near the anterior horn. Approximately 80% of the meniscus had been torn (Fig. 1, A). Scuffing of the anterior root was noted, and a 5-mm piece of free-floating meniscus was found in the superior patellar pouch. Neither the ligament of Humphrey nor the ligament of Wrisberg was identified. The anterior cruciate ligament appeared to be intact. No other injury was noted.
The edges of the tear were abraded, and vascular channels were created. The posterior root was reattached with use of a technique previously reported in 1983 to secure the posterior root of meniscal prostheses in human cadavers and rabbits2. The tibial attachment of the posterior root was curetted and abraded. Two tunnels were drilled, with a slight superior inclination through the tibial plateau, starting from 4 cm inferior to the anteromedial portal and entering the joint at the attachment of the posterior root. A small custom-fabricated Steinmann pin with a 2-mm drill hole near the diamond tip and bearing a heavy suture was passed through the first tunnel and allowed to penetrate the meniscus, after which the suture was retrieved through an anterior portal. The Steinmann pin, bearing a second suture, was then passed through the second tunnel and allowed to penetrate the meniscus 5 mm transversely from the first suture placement, after which the second suture was retrieved through the same anterior portal and tied to the first. One of the sutures and the knot were then pulled back through the meniscus and tunnel so that the knot exited the tibia externally. The knot was cut, leaving a continuous suture thread in place through the meniscus and both tunnels. The procedure was repeated with use of two new meniscal penetration sites about 5 mm from the first pair (Fig. 1, A and B). The four suture ends were then pulled to snugly approximate the posterior root against its original attachment to the tibia. Once both sutures had been placed and the satisfactory position of the meniscus was confirmed, the individual suture pairs were tied, with secure fixation, over the anterior part of the tibia. Four nonresorbable single-loop vertical sutures were then placed. The first was posteromedial to the popliteal hiatus, the second, anterolateral to it; and the third, and fourth, progressively more anterior (Fig. 1, B). The sutures were placed so that they did not penetrate the same vertical planes within the body of the meniscus. The edges of the tear appeared to be secured by this fixation and did not separate as the joint was flexed and extended.
A posterior splint was applied for ten days after surgery, after which a hinged knee brace, set to allow 0° to 30° of flexion, was used. Quadriceps-setting exercises were started immediately after the operation. Ten days after surgery, weight-bearing was permitted with the brace locked in full extension. Six weeks after surgery, progressive weight-bearing was permitted with the brace set to allow 60° of flexion, and a progressive stationary cycling program was started. Three months after surgery, the brace was discontinued and progressive activities were instituted.
Twelve months later, the patient resumed teaching downhill-ski-racing techniques. Three years after the repair, she fell in a patch of heavy snow while using borrowed equipment. The bindings did not release, and she reinjured the left knee. At the time of arthroscopy, the anterior cruciate ligament was found to have ruptured. Chondromalacia of the femoral condyles was no longer evident, while the patella was unchanged. The posterior root of the lateral meniscus appeared normal and secure. A partial-thickness vertical cleft of the meniscus was found extending from the popliteal hiatus anteriorly. The cleft involved only the superior surface, extending into the body through one-third to one-half of its thickness. The tibial surface was completely intact. The cleft did not appear to be a recent tear. Rather, it seemed to be a residual from the most anterior portion of the original tear where it had entered the white zone. Reconstruction of the anterior cruciate ligament with use of a patellar tendon autograft was performed. The meniscal cleft was then abraded, and fibrin clot was sutured over it3. A rehabilitation program of early weight-bearing and range-of-motion exercise was started within forty-eight hours. The patient was advised to wear a brace while skiing.
Since then, she has regularly performed and instructed downhill telemark (i.e., free-heel) skiing without symptoms or complaints. At the time of the final follow-up, twenty years after the original injury, she completed the International Knee Documentation Committee (IKDC) subjective evaluation form4, achieving a score of 97.7 (75th percentile). At 12 cm above the patella, the circumference of the left thigh measured 1 cm less than that of the right. Full knee range of motion was present bilaterally.
At the time of follow-up, twenty years after the original injury, coronal T1-weighted and sagittal proton-density-weighted magnetic resonance images of the knee revealed patellofemoral and medial and lateral femorotibial osteophytes but preservation of the articular cartilage thickness. The anterior cruciate ligament was intact. Lateral meniscal radial displacement (extrusion) of 2 mm was present on the coronal view, and 3 mm of displacement was present on the sagittal view. The body of the lateral meniscus was also somewhat deformed in this region, as is typical of extruded menisci. The posterior root was otherwise normal in appearance. No evidence of loss of fixation could be seen. Grade-1 and grade-2 signal changes (i.e., increasingly abnormal intrameniscal signal) were noted throughout the body of the lateral meniscus5. Residuals from the original tear and suture passes were also visible in the body, appearing as signal abnormalities (Fig. 2, A and B). The medial meniscus demonstrated 2 to 3 mm of radial displacement on the coronal T1-weighted magnetic resonance images (Fig. 3, A and B). Weight-bearing flexion posteroanterior radiographs of both knees demonstrated osteophyte formation in the femorotibial joints, with preservation of joint-cartilage thickness (5 to 7 mm) laterally in the involved left limb as compared with that in the right limb. The space between the tibial spine and the medial side of the lateral femoral condyle as well as the extreme medial femorotibial joint space in the left limb was slightly narrowed when compared with the corresponding spaces in the right limb. Residuals of the anterior cruciate ligament reconstruction that had been performed seventeen years previously were also visible (Fig. 4).
Note: The author thanks Rhonda Makoske and Dr. Bruce Gendron, Chief of Radiology, both of Columbia Memorial Hospital, for their assistance.