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

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.
Accessing tears of the anterior horn of the lateral
meniscus or the inferior leaet of the meniscus can
prove difcult from the anteromedial portal.
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.
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
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:
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://
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.
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
Easier access to the inferior leaet of the meniscus
More thorough debridement of the inferior leaet
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.
artery, and common peroneal nerve (Fig 5).
and popliteus tendon are narrow tubular structures that
are often palpable and easily avoided; however,
iatrogenic injuries to these structures are possible.
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.
An unrecognized injury to this artery can cause
recurrent hemarthrosis.
The common peroneal
nerve descends obliquely along the lateral aspect of
the knee toward the bular head.
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).
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.
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.
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-
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.
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
) or a small skin hook retractor
(Na et al.
) 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.
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Full-text available
Objective To describe an arthroscopic technique for giant meniscal cyst excision with preservation of the functional meniscus, report the short‐ and medium‐term outcomes, and assess magnetic resonance imaging (MRI) for follow‐up imaging evaluations. Methods A total of 54 consecutive patients with symptomatic meniscal cysts were admitted to the Second Xiangya Hospital of Central South University between 2014 and 2019. Nine patients with giant meniscus cysts (six females and three males) were included in this study. The age range of the patients was 6–34 years. All patients underwent a complete physical examination, X‐ray, Doppler ultrasound, and MRI of the knee preoperatively. After an arthroscopic diagnosis of a meniscal rupture with a giant meniscal cyst, partial meniscectomy, ablation of the cyst, and suturing of the retainable meniscus were performed. Lysholm and International Knee Documentation Committee (IKDC) scores were used preoperatively and at the most recent follow‐up. Clinical outcomes were classified into four categories: excellent, good, fair, and poor. During the last visit, all patients underwent MRI to assess the recurrence of the cyst and meniscal suture healing. Results Preoperative MRI and arthroscopic examination revealed giant meniscal cysts combined with meniscal tears and congenital discoid meniscus, and all giant meniscal cysts occurred in the lateral meniscus. The main types of meniscal tears were horizontal and complex tears. The cysts were unicystic in one case and multicystic in eight cases. The mean size of the cysts on the MRI was 5.86 cm × 2.24 cm × 2.48 cm. The mean follow‐up periods were 37.5 (19–60) months. Clinical outcomes were excellent in six patients and good in three patients. The postoperative scores were significantly improved compared to the preoperative scores (Lysholm: 90.78 ± 4.60 vs. 54.56 ± 7.25; IKDC: 96.2 ± 3.46 vs. 61.69 ± 3.36; p
Purpose To analyze clinical outcomes and survivorship of meniscal horizontal cleavage tear (HCT) repairs with hopes of guiding future treatment decisions. Methods Standard systematic review methodology was used. A comprehensive search of PubMed was conducted on July 1, 2019. Inclusion criteria were articles that were published in English, involved human subjects, and reported on at least one outcome following repair of HCTs. Exclusion criteria included: technique guides and reviews, studies without full text available, and HCT outcomes not separated from other repair groups. Effect heterogeneity was determined using the I² measure. Forest plots were created in addition to a random effects model to demonstrate results. Results The systematic review yielded 19 studies evaluating 289 knees in a total of 273 patients. At most recent follow-up, there was a high probability of return to sport (93.1% or 67/72). Overall, 74% of patients (67/90) were symptom-free at last follow-up, and 80% expressed satisfaction with their overall result (80/100). The most frequently reported subjective outcome was the Lysholm Score, which improved from a preoperative study range of 48-79 (I²=20.7%, p=0.283) to a postoperative study range of 56-99 (I²=49%, p=0.081). The next most commonly reported was the Subjective International Knee Documentation Committee Score (IKDC), which improved from a preoperative study range of 16-49 (I²=47.7%, p=0.125) to a postoperative study range of 72-95 (I²=0%, p=0.660). There was an overall 11.7% reported risk of reoperation, with most involving revision meniscectomy. Rates of complications beyond failure of fixation were overall very low, with infrequent reports of septic arthritis and transitory dysesthesias. Conclusions The short to intermediate-term results of repair of HCTs is comparable to prior studies. Survivorship is comparable to repairs of other types of meniscus tears with high rates of return to sport and low complication rates.
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Background To evaluate the risk factor associated with total or subtotal meniscectomy for respective medial and lateral meniscus injury. Methods The data of all the meniscus injured patients undergoing arthroscopy in our institute between January 15th, 2000 and December 31st, 2008 was collected and 6034 patients with 7241 injured menisci met the inclusion criteria. The mean patient age was 33.6 ± 14.9 years and there were 4785 males and 2456 females with 3568 medial and 3673 lateral menisci. The decision tree approach was applied to investigate the correlation of the tear type, the duration of complaint, age, gender, ACL rupture and total/subtotal meniscectomy for respective medial and lateral meniscus. Results The tear type was associated with both medial (χ2 = 70.901, P < 0.001) and lateral (χ2 = 268.019, P < 0.001) total/subtotal meniscectomy. The strongest risk of total/subtotal meniscectomy of both medial and lateral meniscus tear was shown for the complex tear followed by the longitudinal, oblique, horizontal and radial tear of the medial meniscus and followed by horizontal, longitudinal, radial and oblique tear of the lateral meniscus. The risk of total/subtotal medial meniscectomy was significantly elevated for the patients with complex tear and the age of ≤40 years old (χ2 = 21.028, P < 0.001) and those with the oblique, horizontal or radial tear accompanied by ACL rupture (χ2 = 6.631, P = 0.01). Besides, the duration of complaint was also associated with total/subtotal meniscectomy of the medial longitudinal tear with ACL rupture (χ2 = 17.155, P < 0.001). On the other side, the risk of total/subtotal lateral meniscectomy was significantly elevated for the complex tear of the female patients (χ2 = 5.877, P = 0.015) with no ACL rupture (χ2 = 50.501, P < 0.001). The ACL rupture was associated with a decreased risk of total/subtotal meniscectomy for all the types of the lateral meniscus (complex: χ2 = 50.501, P < 0.001; horizontal: χ2 = 20.897, P < 0.001; oblique: χ2 = 27.413, P < 0.001; longitudinal and radial: χ2 = 110.85, P < 0.001). Conclusion Analyzing data from a big sample available in an Asian patient database, we found different risk factors associated with total/subtotal meniscectomy for respective medial and lateral meniscus. Identifying patients at high risk for total/subtotal meniscectomy may allow for interventions after meniscus injury.
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Treatment options for meniscal tears fall into three broad categories; non-operative, meniscectomy or meniscal repair. Selecting the most appropriate treatment for a given patient involves both patient factors (e.g., age, co-morbidities and compliance) and tear characteristics (e.g., location of tear/age/reducibility of tear). There is evidence suggesting that degenerative tears in older patients without mechanical symptoms can be effectively treated non-operatively with a structured physical therapy programme as a first line. Even if these patients later require meniscectomy they will still achieve similar functional outcomes than if they had initially been treated surgically. Partial meniscectomy is suitable for symptomatic tears not amenable to repair, and can still preserve meniscal function especially when the peripheral meniscal rim is intact. Meniscal repair shows 80% success at 2 years and is more suitable in younger patients with reducible tears that are peripheral (e.g., nearer the capsular attachment) and horizontal or longitudinal in nature. However, careful patient selection and repair technique is required with good compliance to post-operative rehabilitation, which often consists of bracing and non-weight bearing for 4-6 wk.
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We introduce a new arthroscopic partial meniscectomy technique using a three portals and a small skin hook retractor to remove unstable inferior leaf in horizontal meniscal tear that involved the anterior portion of the lateral meniscus. The patient is positioned for a standard knee arthroscopy. After careful estimation of the depth and extent of the cleft and stability of the superior and inferior leaves is done through the standard anteromedial portal, a small skin hook retractor is inserted through the standard anterolateral portal to raise the dominant superior leaf of anterior horn, then the unstable inferior leaf is excised with a 90° rotary punch and a motorized shaver through the extreme far anteromedial portal. This technique is useful method to remove unstable inferior leaf of anterior horn of lateral meniscus which is difficult to remove with a standard technique.
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Development of synovial knee fistulae following arthroscopic knee surgery is a rare but under-reported complication. The diagnosis and treatment of this complication is described in a series of four patients. Synovial knee fistula formation is a benign complication and in the majority of patients it can be treated conservatively with immobilization until healing occurs. The presence of infection should always be excluded.
Arthroscopic partial medial meniscectomy is a very common orthopaedic procedure performed for symptomatic , irreparable meniscus tears. It is usually associated with a very good outcome and minimal complications. In some patients with tight medial compartment, the posterior horn of the medial meniscus can be difficult to visualize, and access in this area with instruments may be challenging. To increase the opening of the medial compartment, after valgus-extension stress position of the knee, different techniques of deep medial collateral ligament release have been described. The outside-in pie-crusting technique shown in this technical note has documented effectiveness and good outcomes with minimal or no morbidity.
Background: Iatrogenic injury to the infrapatellar branch of the saphenous nerve is a common complication of surgical approaches to the anteromedial side of the knee. A detailed description of the relative anatomic course of the nerve is important to define clinical guidelines and minimize iatrogenic damage during anterior knee surgery. Methods: In twenty embalmed knees, the infrapatellar branch of the saphenous nerve was dissected. With use of a computer-assisted surgical anatomy mapping tool, safe and risk zones, as well as the location-dependent direction of the nerve, were calculated. Results: The location of the infrapatellar branch of the saphenous nerve is highly variable, and no definite safe zone could be identified. The infrapatellar branch runs in neither a purely horizontal nor a vertical course. The course of the branch is location-dependent. Medially, it runs a nearly vertical course; medial to the patellar tendon, it has a -45° distal-lateral course; and on the patella and patellar tendon, it runs a close to horizontal-lateral course. Three low risk zones for iatrogenic nerve injury were identified: one is on the medial side of the knee, at the level of the tibial tuberosity, where a -45° oblique incision is least prone to damage the nerves, and two zones are located medial to the patellar apex (cranial and caudal), where close to horizontal incisions are least prone to damage the nerves. Conclusions: The infrapatellar branch of the saphenous nerve is at risk for iatrogenic damage in anteromedial knee surgery, especially when longitudinal incisions are made. There are three low risk zones for a safer anterior approach to the knee. The direction of the infrapatellar branch of the saphenous nerve is location-dependent. To minimize iatrogenic damage to the nerve, the direction of incisions should be parallel to the direction of the nerve when technically possible. Clinical relevance: These findings suggest that iatrogenic damage of the infrapatellar branch of the saphenous nerve can be minimized in anteromedial knee surgery when both the location and the location-dependent direction of the nerve are considered when making the skin incision.
Correction of valgus deformity during total knee arthroplasty is usually carried out by releasing lateral supporting structures from the femoral side of the joint. A new technique has been advocated that involves multiple stabs of the scalpel blade or pie crusting of the posterolateral corner. It is the hypothesis of this study that the correction achieved by using this technique occurs when the lateral collateral ligament is effectively released and that the common peroneal nerve may be at risk. Using a cadaveric model with 6 knees tested, significant differences were determined between 2 separate pie crusting steps as well as between releasing the lateral collateral ligament and popliteus tendons. Anatomic dissection studies also showed that in full extension the peroneal nerve may be less than the depth of a number 11 blade (16 mm) from the posterolateral corner, and the nerve may be at risk during this technique. These results show that major deformity correction obtained using the pie crusting technique is probably through effective release of the lateral collateral ligament.
The structures within the posterolateral corner of the knee have recently been "re-discovered" providing a very important role in maintaining the stability of the knee. Injury to the posterolateral corner is not common but neither is it rare; it is usually damaged in combination with rupture of one of the cruciate ligaments in direct and indirect trauma to the knee. When reconstructing a knee to restore stability following such injuries, it is important to recognise damage to the posterolateral corner so that this can be corrected. Ignored damage to this region may result in continuing knee instability and resultant failure of cruciate ligament reconstruction. We present a review of the anatomy and biomechanics of the structures in the posterolateral corner. This is then related to the diagnosis of injuries to the region via history, examination and imaging. We then discuss the management of injuries to the posterolateral corner describing our preferred method of repair.
The unstable inferior leaf of the anterior horn in the horizontal tear of the lateral meniscus is a challenging lesion to the arthroscopist. However, there are no devices for it and no proper procedures are introduced. We describe a new arthroscopic technique of partial meniscectomy by using three portals. This technique uses a unique portal, extreme far anteromedially.