What is the recommended management for a 50‑year‑old woman with a complete posterior root tear of the medial meniscus and a complex tear of the posterior horn and body?

Management of Medial Meniscus Posterior Root and Complex Tears in a 50-Year-Old Woman

Arthroscopic transtibial pullout repair is the recommended surgical treatment for this patient, as posterior root tears are biomechanically equivalent to total meniscectomy and lead to rapid progression of medial compartment osteoarthritis if left untreated. 1, 2

Rationale for Surgical Intervention

• Complete posterior root tears destroy the meniscus's ability to withstand hoop strain, resulting in contact pressure increases identical to the meniscectomized state. 2
• Biomechanical studies demonstrate that root tears adjacent to the posterior attachment site cause significantly decreased contact area and increased mean contact pressure compared to the intact meniscus at all flexion angles beyond 0°. 2
• Untreated root tears lead to meniscal extrusion (>2 mm overhang beyond the medial tibial plateau), accelerated cartilage degeneration, and early progression to total knee replacement. 3, 4
• The complex tear involving the posterior horn and body further compromises meniscal function and supports the need for comprehensive repair rather than partial meniscectomy. 1

Surgical Technique Selection

The transtibial pullout technique is preferred over suture anchor repair for anatomic restoration:

• The transtibial approach involves drilling a tunnel from the anterior proximal tibia to the anatomic insertion site of the meniscal root, passing sutures through the medial root, retrieving them through the tunnel, and securing with a cortical button on the anterior tibial cortex. 4
• Anatomical repair is critical—non-anatomic tibial tunnel placement results in increased strain, early failure, and rapid cartilage degeneration. 3
• The anterior arthroscopic approach with medial collateral ligament pie-crusting release provides good visualization of the footprint and sufficient working space while avoiding iatrogenic chondral injury. 5
• In situ pullout repair restores joint mechanics to the intact state and reestablishes the posterior anchor point, improving load distribution in the medial compartment. 2

Important Technical Considerations

• Strict surgical indications must be met: assess pullout strength potential, degree of bony degenerative changes, mechanical alignment, and Kellgren-Lawrence grade before proceeding. 1
• The complex tear of the posterior horn and body should be addressed concurrently with the root repair to restore circumferential fiber integrity. 1
• Consider supplemental centralization techniques with suture anchor fixation of the meniscal body at the peripheral medial plateau to reduce meniscal extrusion. 4

Expected Outcomes

• Root repair demonstrates complete healing and restoration of normal knee kinematics when performed anatomically. 1
• Medial meniscal root repair is associated with improved patient-reported outcomes and reduced rate of knee replacement compared to non-operative management or meniscectomy. 4
• Patients typically resume activities of daily living within one year post-operatively when proper anatomic repair is achieved. 3

Critical Pitfall to Avoid

Non-anatomic repair is the primary cause of failure—ensure precise tunnel placement at the anatomic root insertion site, as even minor deviations lead to abnormal strain patterns, early re-tear, and progression to osteoarthritis requiring eventual knee replacement. 3