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Submeniscal Portal for Horizontal Cleavage Tear with Parameniscal Cyst of the Lateral Meniscus

Authors:
Technical Note
Submeniscal Portal for Horizontal Cleavage Tear with
Parameniscal Cyst of the Lateral Meniscus
Brittany M. Woodall, D.O., Nicholas Elena, M.D., Asher B. Mirvish, B.A., Edward C. Shin, M.D.,
Neil P. Pathare, M.D., Patrick J. McGahan, M.D., and James L. Chen, M.D., M.P.H.
Abstract: Horizontal cleavage tears of the medial and lateral meniscus can be difcult to treat using the standard
anteromedial or anterolateral arthroscopy portals. In this Technical Note, we present a new surgical technique to better
manage the inferior leaet of horizontal cleavage tears of the medial and lateral meniscus and their associated para-
meniscal cysts.
Debridement of meniscal tears can have varying
difculty depending on the location and type of
tear. The standard anteromedial and anterolateral
portals are the mainstay portals of knee arthroscopy;
however, inappropriate instrument trajectory through
these portals can lead to articular cartilage damage.
1,2
Accessing tears of the anterior horn of the lateral
meniscus or the inferior leaet of the meniscus can
prove difcult from the anteromedial portal.
1,3
The
purpose of this Technical Note is to describe an
arthroscopic portal that allows easier access and
improved debridement of difcult or complex tears of
the medial and lateral meniscus. The submeniscal
portal decreases the risk of iatrogenic articular
cartilage damage and provides more complete access
to the menisci and associated parameniscal cysts.
Technique
The patient is placed supine on a standard operative
table and anesthetized using general anesthesia. A
tourniquet is placed around the proximal thigh and the
operative leg is placed in an arthroscopic leg holder
(Mizuho OSI, Union City, CA). The operative leg is
prepared with preoperative skin prep solution from the
midthigh to the foot and is then draped in the usual
Fig 1. Anterior view of the right knee. (A) Anterolateral
portal. (B) Anteromedial portal. (C) Lateral submeniscal
portal. (D) Medial submeniscal portal.
From the Advanced Orthopaedics and Sports Medicine, San Francisco,
California, U.S.A.
The authors report the following potential conicts of interest or sources of
funding: J.L.C. reports personal fees from Arthrex, outside the submitted
work. Full ICMJE author disclosure forms are available for this article online,
as supplementary material.
The investigation was performed at Advanced Orthopaedics and Sports
Medicine.
Received November 27, 2017; accepted January 18, 2018.
Address correspondence to Brittany M. Woodall, D.O., Advanced Ortho-
paedics and Sports Medicine, 450 Sutter St., Suite 400, San Francisco, CA
94108, U.S.A. E-mail: Brittany@aosportsmed.com
Ó2018 by the Arthroscopy Association of North America. Published by
Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
2212-6287/171456
https://doi.org/10.1016/j.eats.2018.01.006
Arthroscopy Techniques, Vol 7, No 5 (May), 2018: pp e529-e532 e529
sterile fashion. This procedure uses 3 to 4 portals: the
standard anteromedial (Fig 1B) and anterolateral por-
tals (Fig 1A), in addition to the lateral submeniscal
portal (Fig 1D) and/or the medial submeniscal portal
(Fig 1C). The anterolateral portal is created using a No.
11 blade (Braun Medical, Bethlehem, PA) to make a
vertical incision adjacent to the lateral border of the
patellar tendon at the level of the joint line. The knee is
then entered using a blunt trocar and scope sheath
(Arthrex, Naples, FL). The trocar is replaced with the
304.0-mm arthroscope (Arthrex) and a complete
diagnostic arthroscopy is performed, inspecting for
associated chondral damage, loose bodies, or meniscus
tears (Fig 2). A 22-gague spinal needle (Braun Medical)
is used to localize the anteromedial portal under
arthroscopic visualization, and an incision is made in
the same vertical fashion. While viewing from the
anteromedial portal, the patients leg is placed in the
gure-4 position and a 22-gauge spinal needle is
used to needle-localize the lateral submeniscal portal
(Fig 3A), while taking care to avoid the neurovascular
and adjacent ligamentous structures. A blunt trocar is
then used to dilate the tract to the lateral meniscus,
and this is then replaced by the 4.0-mm shaver
(Arthrex) (Fig 3B-D). The shaver is used to debride
the unstable inferior leaet of the meniscus tear,
which would otherwise not be reachable through the
standard anteromedial portal. The lateral meniscus after
Fig 2. Horizontal cleavage tear of the lateral meniscus before
debridement, viewing from the anteromedial portal of the
right knee.
Fig 3. Viewing from the anteromedial portal of the right knee: (A) Needle localization of the lateral submeniscal portal. (B) Blunt
trocar placement to develop tract for shaver. (C and D) Debridement of the unstable inferior leaet.
e530 B. M. WOODALL ET AL.
section of the unstable inferior leaet is shown in
Figure 4. These aforementioned steps are demonstrated
in Video 1. The same procedure can be performed on
the medial side, with the knee in 90of exion. While
viewing from the anterolateral portal, a 22-gauge
needle can be used to needle-localize the medial sub-
meniscal portal (Fig 1C), while also taking care to avoid
important neurovascular structures. A blunt trocar
can then be used to dilate the tract and replace with the
4.0-mm shaver to resect an unstable inferior leaet of
the medial meniscus.
Anatomic Considerations
With any surgical approach, the anatomic relations of
nearby structures need to be considered. With the
lateral approach, one must consider the relation be-
tween the lateral meniscus, lateral collateral ligament
(LCL), popliteus tendon, lateral inferior geniculate
Fig 4. Horizontal cleavage tear of the lateral meniscus after
debridement, viewing from the anteromedial portal of the
right knee.
Fig 5. Lateral view of the right knee demonstrating antero-
lateral (A) and lateral submeniscal (C) portals, with anatomic
considerations labeled.
Fig 6. Medial view of the right knee demonstrating ante-
romedial (B) and medial submeniscal (D) portals, with
anatomic considerations labeled.
Table 1. Advantages and Risks of Submeniscal Portal
Advantages
Easier access to the inferior leaet of the meniscus
More thorough debridement of the inferior leaet
Risks
Iatrogenic injury to surrounding soft tissue structures (lateral
inferior geniculate artery, LCL, MCL, common peroneal nerve,
saphenous nerve)
Iatrogenic injury to articular cartilage
Recurrent hemarthrosis
Synovial cutaneous stula
LCL, lateral collateral ligament; MCL, medial collateral ligament.
SUBMENISCAL PORTAL FOR CLEAVAGE TEAR e531
artery, and common peroneal nerve (Fig 5).
4,5
The LCL
and popliteus tendon are narrow tubular structures that
are often palpable and easily avoided; however,
iatrogenic injuries to these structures are possible.
4,5
The lateral inferior genicular artery passes underneath
the origin of the gastrocnemius, deep to the LCL at
the level of the joint, and passed over the lateral limb
of the arcuate ligament and the lateral meniscus.
4,5
An unrecognized injury to this artery can cause
recurrent hemarthrosis.
4,5
The common peroneal
nerve descends obliquely along the lateral aspect of
the knee toward the bular head.
4,5
With the medial approach, one must consider the
relation among the medial meniscus, medial collateral
ligament, and the infrapatellar branch of the saphenous
nerve (Fig 6).
6,7
The medial collateral ligament is a
atter and wider structure than the LCL and may be
injured with the medial submeniscal approach;
therefore, this approach may be contraindicated with
an associated medial collateral ligament injury.
6,7
The
infrapatellar branch of the saphenous nerve has a
highly variable course and may be at risk with access
to the medial aspect of the knee.
6,7
Discussion
Horizontal cleavage tears of the body or anterior horns
of the menisci can be difcult to treat through standard
anteromedial or anterolateral portals. Since these tears
are not amendable to repair, the treatment of choice is
either a partial meniscectomy or subtotal meniscec-
tomy.
1,2
Goals of a meniscectomy are to remove unstable
fragments, smooth any sudden contour changes of the
meniscus rim, and to leave as much healthy meniscus
as possible.
1,2
To achieve these goals, the surgeon
needs easy access to the tear site.
Other authors have described 3 portal techniques using
a probe (Kim and Park
8
) or a small skin hook retractor
(Na et al.
3
) to retract the superior leaf in order to aid in
the debridement of the inferior leaet of the horizontal
tear. Our proposed technique uses a 4.0-mm shaver
through a submeniscal portal that allows easier access
and a more thorough debridement of the inferior leaet
of horizontal cleavage tears of either the medial or lateral
meniscus (Fig 4). Additionally, our proposed technique
allows for decompression of the parameniscal cyst wall
though an outside-in approach. Although our proposed
technique has advantages, there are also risks involved,
as stated in Table 1; however, we do not consider these
risks as more signicant than standard arthroscopy.
1-3,8,9
References
1. Mordecai SC, Al-Hadithy N, Ware HE, Gupte CM. Treat-
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2. Jiang D, Luo X, Ao Y, et al. Risk of total/subtotal menis-
cectomy for respective medial and lateral meniscus injury:
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gender and ACL rupture in 6034 Asian patients. BMC Surg
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3. Na SI, Woo MS, Lee JM, Kim MK. A new surgical tech-
nique of arthroscopic partial meniscectomy for unstable
inferior leaf of the anterior horn in a horizontal tear of
lateral meniscus. Knee Surg Relat Res 2013;25:147-149.
4. Davies H, Unwin A, Aichroth P. The posterolateral corner
of the knee. Anatomy, biomechanics and management of
injuries. Injury 2004;35:68-75.
5. Mihalko WM, Krackow KA. Anatomic and biomechanical
aspects of pie crusting posterolateral structures for valgus
deformity correction in total knee arthroplasty: A cadaveric
study. J Arthroplasty 2000;15:347-353.
6. Kerver AL, Leliveld MS, den Hartog D, Verhofstad MH,
Kleinrensink GJ. The surgical anatomy of the infrapatellar
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anteromedial knee surgery. J Bone Joint Surg Am 2013;95:
2119-2125.
7. Todor A, Caterev S, Nistor DV. Outside-in deep medial
collateral ligament release during arthroscopic medial
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e532 B. M. WOODALL ET AL.
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