Revision Transtibial Medial Meniscal Root Repair With Concomitant Medial Opening-Wedge Proximal Tibial Osteotomy

Morgan D. Homan, Luke V. Tollefson, Nicholas I. Kennedy, Robert F. LaPrade
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Abstract

Complete meniscal root tears disrupt dispersion of axial loading forces through hoop stresses. This increases point-loading on tibiofemoral cartilage and leads to chondromalacia and accelerated osteoarthritis (OA). Posterior root tears may be treated successfully with a transtibial pullout repair. Varus malalignment also leads to increased medial compartment pressures, increasing the risk of early OA and putting increased stress on the meniscus and stabilizing knee ligaments. In particular, revision medial meniscal root repairs without correction of varus malalignment are at increased risk of failure. Genu varum may be corrected with a medial opening-wedge proximal tibial osteotomy (OW PTO). Meniscal root repairs are indicated for acute or chronic tears in active patients with healthy cartilage. OW PTO is indicated for varus malalignment in ambulatory patients with healthy cartilage, or who are at risk for failure of meniscal or ligamentous procedures. After exposure of the osteotomy site, arthroscopy is performed through the incision and the revision posterior meniscus root repair is performed via a double-tunnel transtibial pullout technique. The positioning of these tunnels is modified superiorly so as to not cross the planned osteotomy site. The osteotomy is then performed by drilling 2 guide pins under fluoroscopy to delineate the plane of the cut. An OW plate is placed, and the root repair is tensioned last. Double-tunnel transtibial pullout repairs increase meniscal fixation contact surface and have been shown to be biomechanically superior to all-inside fixation techniques. Medial OW PTO restores knee alignment and reduces supra-anatomic stresses in the medial compartment, additionally decreasing the risk of a revision medial meniscus repair failure. Biomechanical studies have shown that meniscal root tears are functionally equivalent to complete meniscectomy. Varus malalignment increases the risk of medial meniscal tears, and reduces the risk of a successful long-term repair. We describe a technique for a revision transosseous posterior root repair with concomitant proximal tibial osteotomy, with discussion of surgical pearls and pitfalls. This technique restores anatomic position and native function of the medial meniscus while correcting tibiofemoral malalignment that could jeopardize the repair. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.
翻修经胫骨内侧半月板根修复术,同时进行胫骨近端内侧开刃截骨术
半月板根部完全撕裂会通过箍应力破坏轴向负荷力的分散。这增加了胫股软骨的点负荷,导致软骨软化症和加速骨关节炎(OA)。后根部撕裂可通过经胫骨拉出修复术成功治疗。屈曲不正也会导致内侧室压力增加,增加早期 OA 的风险,并增加半月板和稳定膝关节韧带的压力。尤其是在未矫正内翻错位的情况下进行翻修性内侧半月板根部修复,失败的风险更大。可通过内侧开口楔形胫骨近端截骨术(OW PTO)矫正半月板根部外翻。半月板根部修复适用于软骨健康的活动期患者的急性或慢性撕裂。OW PTO 适用于软骨健康的非卧床患者或半月板或韧带手术有失败风险的患者的屈曲畸形。暴露截骨部位后,通过切口进行关节镜检查,并通过双隧道经胫骨拉出技术进行翻修后半月板根部修复。这些隧道的位置向上移,以避免与计划的截骨部位交叉。然后,在透视下钻入 2 个导针,划定截骨平面,进行截骨。放置 OW 板,最后张紧根部修复。双隧道经胫骨拉出修复增加了半月板固定接触面,在生物力学上优于全内侧固定技术。内侧OW PTO可恢复膝关节对齐,减少内侧室的超解剖应力,从而降低翻修内侧半月板修复失败的风险。生物力学研究表明,半月板根部撕裂在功能上等同于完全半月板切除术。屈曲不正会增加内侧半月板撕裂的风险,并降低长期修复成功的风险。我们介绍了一种同时进行胫骨近端截骨术的经骨后半月板根部翻修修复术,并讨论了手术要点和陷阱。该技术可恢复内侧半月板的解剖位置和原生功能,同时纠正可能危及修复的胫股骨错位。作者证明已征得本出版物中出现的任何患者的同意。如果个人身份可能被识别,作者已附上免责声明或其他书面形式。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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