PMC9453023_01
(a-d) Arthroscopic findings. (a) Chronic ACL tear. (b) The torn edge of the LMPR was defected. (c) Reduced MM bucket handle tear (white arrows) extending from the body to the posterior horn. (d) Complete radial tear of the posterior horn of the MM (black arrowhead). Abbreviations: LTP: lateral tibial plateau; LFC: lateral femoral condyle; p-MFL: posterior meniscofemoral ligament (Wrisberg ligament); MTP: medial tibial plateau; MFC: medial femoral condyle; MMPH: medial meniscus posterior horn.
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An arthroscopic evaluation revealed that the ACL was torn, with only the scar tissue remaining (Figure 1(a)). The LM posterior root (LMPR) was detached and defected about more than 12 mm (Figure 1(b)). After reduction of the displaced MM, the bucket handle tear of the MM extended from the body to the posterior horn (Figure 1(c)). The complete radial tear at the posterior horn of the MM extended from the central to the peripheral lesion near the bucket handle tear (Figure 1(d), supple Fig. 1).
(a-d) Arthroscopic findings and illustrations of the tunnel positions and postoperative three-dimensional computed tomography. (a) Repaired bucket handle tear of the MM. (b) Repaired radial tear of the posterior horn of the MM. (c) A 6 mm gap between the edge of the repaired LMPR and the bone aperture site remained. (d) Reconstructed ACL. (e) Illustration of the tunnel locations for the pullout repair of the LMPRT and the reconstruction of the AM bundle and the PL bundle. (f) The tibial tunnel for the LMPRT (arrowhead) was placed separately with a tunnel for the PL bundle (black arrow) and the AM bundle (white arrow).
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After reduction of the displaced MM into its appropriate anatomic position, 6 sutures were performed using 2-0 Wayolax (Matsuda Ika Kogyo, Tokyo, Japan) using the inside-out technique in the vertically stacked way for the bucket handle tear (Figure 2(a)). Following the repair of the bucket handle tear, a cross-stitch with two perpendicular sutures in an "X" configuration was performed using 2-0 Wayolax sutures using inside-out technique for the radial tear (Figure 2(b)). Following the procedure, an approximately 6 mm gap between the edge of the LMPR and the root insertion site remained (Figure 2(c)). The two bundles were passed from the tibial tunnel to the femoral tunnel through two leading sutures using the EndoButton CL device (Smith & Nephew) (Figure 2(d)). These bundles were fixed using the tenodesis screw (Arthrex), and the passing sutures were tied under the 5.0 mm cancellous screw, similar to the repair suture for LMPRT (Figure 2(e)). The aperture location of the tibia was confirmed by computed tomography examination after the surgery (Figure 2(f)).
Comparison of the (a-d) preoperative and (e-h) postoperative MRI findings. (a) Preoperative MRI showed a linear defect in the coronal plane (dotted area). (b) The length of the lateral meniscus extrusion (LME) was 3.1 mm (length between dashed lines). (c, d) The reference lines of the sagittal plane are shown as dotted lines in (a) (C and D, respectively). Ghost sign in two consecutive sagittal planes with a 10 mm interval (dashed area). (e) One year after the operation, the preoperative gap was filled with tissue continuous to the tibial attachment of the LMPR in the coronal plane. (f) The length of LME was 1.6 mm (1 year postoperatively). (g, h) The reference lines of the sagittal plane are shown as dotted lines in (e) (G and H, respectively). The disappearing ghost sign in two consecutive sagittal planes with a 10 mm interval (arrowhead).
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Preoperative MRI of the coronal plane revealed the tissue loss of the LMPRT (Figure 3(a)), and the length of the LM extrusion (LME) was 3.1 mm (Figure 3(b)). The tissue loss of LMPRT was also found in sagittal planes with a 10 mm interval as a ghost sign (Figures 3(c) and 3(d)). The one-year postoperative MRI of the coronal plane revealed continuous tissue regeneration, and the LME improved to 1.6 mm (Figures 3(e) and 3(f)). The regeneration tissue might be small; the signal intensity was slightly high in T2 fat saturation serials (not similar in signal to the normal meniscus) but had a triangular shape in the sagittal plane (Figures 3(g) and 3(h)).
Arthroscopic findings during the second-look arthroscopy. (a) Reconstructed ACL. (b) The repaired LMPR healed with continuity to its insertion site (arrow). (c) The repair sutures were cut out (arrowhead). (d) The synovial coverage around the root attachment. (e) The repaired MM bucket handle tear completely healed. (f) An approximately 1 cm defect remained at the central margin of the repaired radial tear (swallow-tail arrow).
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Second-look arthroscopy at 12 months postoperatively revealed that the maturation of the reconstructed ACL graft was good, with good graft integrity, tension, and synovial coverage (Figure 4(a)). The repaired LMPR healed with continuity to the root attachment (Figures 4(b)-4(d)), although the repair sutures were cutout (Figure 4(c)), and synovial coverage around the root attachment was found (Figure 4(d)). The MM bucket handle tear was completely healed (Figure 4(e)); however, an approximately 1 cm defect remained at the central margin of the radial tear, needing marginal debridement (Figure 4(f)).