Posteromedial Meniscocapsular Lesions

Increase Tibiofemoral Joint Laxity With

Anterior Cruciate Ligament Deficiency,
and Their Repair Reduces Laxity
Joanna M. Stephen,* PhD, Camilla Halewood,* MEng, MBiolEng, Christoph Kittl,y MD,
Steve R. Bollen,z FRCS Ed Orth, Andy Williams,§ FRCS(Orth),
and Andrew A. Amis,*||{ FREng, DSc(Eng)
Investigation performed at Imperial College London, London, United Kingdom

Background: Injury to the posteromedial meniscocapsular junction has been identified after anterior cruciate ligament (ACL) rup-
ture; however, there is a lack of objective evidence investigating how this affects knee kinematics or whether increased laxity can
be restored by repair. Such injury is often overlooked at surgery, with possible compromise to results.
Hypotheses: (1) Sectioning the posteromedial meniscocapsular junction in an ACL-deficient knee will result in increased anterior
tibial translation and rotation. (2) Isolated ACL reconstruction in the presence of a posteromedial meniscocapsular junction lesion
will not restore intact knee laxity. (3) Repair of the posteromedial capsule at the time of ACL reconstruction will reduce tibial trans-
lation and rotation to normal. (4) These changes will be clinically detectable.
Study Design: Controlled laboratory study.
Methods: Nine cadaveric knees were mounted in a test rig where knee kinematics were recorded from 0° to 100° of flexion by use
of an optical tracking system. Measurements were recorded with the following loads: 90-N anterior-posterior tibial forces, 5-Nm
internal-external tibial rotation torques, and combined 90-N anterior force and 5-Nm external rotation torque. Manual Rolimeter
readings of anterior translation were taken at 30° and 90°. The knees were tested in the following conditions: intact, ACL deficient,
ACL deficient and posteromedial meniscocapsular junction sectioned, ACL deficient and posteromedial meniscocapsular junc-
tion repaired, ACL patellar tendon reconstruction with posteromedial meniscocapsular junction repair, and ACL reconstructed
and capsular lesion re-created. Statistical analysis used repeated-measures analysis of variance and post hoc paired t tests
with Bonferroni correction.
Results: Tibial anterior translation and external rotation were both significantly increased compared with the ACL-deficient knee
after posterior meniscocapsular sectioning (P \ .05). These parameters were restored after ACL reconstruction and meniscocap-
sular lesion repair (P . .05).
Conclusion: Anterior and external rotational laxities were significantly increased after sectioning of the posteromedial menisco-
capsular junction in an ACL-deficient knee. These were not restored after ACL reconstruction alone but were restored with ACL
reconstruction combined with posterior meniscocapsular repair. Tibial anterior translation changes were clinically detectable by
use of the Rolimeter.
Clinical Relevance: This study suggests that unrepaired posteromedial meniscocapsular lesions will allow abnormal meniscal
and tibiofemoral laxity to persist postoperatively, predisposing the knee to meniscal and articular damage.
Keywords: anterior cruciate ligament; meniscus; meniscocapsular lesion; knee stability; surgery

The firm attachment of the medial meniscus (MM) to the acting as a block as the tibia moves anteriorly and the fem-
posterior margin of the tibial plateau is well recognized.26,28 oral condyle engages against the MM.2,10,12,15,28 This results
This relationship permits the MM to serve as a secondary in increased posterior MM loading and is reflected in the
knee stabilizer when the anterior cruciate ligament (ACL) high numbers of peripheral MM posterior horn tears associ-
is deficient; the MM resists anterior tibial translation by ated with ACL rupture.8,19,22,23
Further, it has been hypothesized that contraction of
the semimembranosus at its insertion along the postero-
medial capsule may stress the peripheral meniscus, result-
The American Journal of Sports Medicine, Vol. 44, No. 2
DOI: 10.1177/0363546515617454 ing in meniscocapsular tearing.9 This could occur at the
Ó 2015 The Author(s) time of injury or during subsequent instability episodes

400
AJSM Vol. 44, No. 2, 2016 Posteromedial Meniscocapsular Lesions 401

in the subacute or chronic situation when ACL injury is was obtained. One knee was later found to have an ACL
known to excite the hamstrings muscles.24 The capsular lesion, leaving 9 knees, which had a mean age of 48 years
injury also might occur during the so-called medial contre- (range, 23-64 years; 5 male and 4 female). Specimens were
coup injury11 after subluxation of the lateral tibial plateau preserved in sealed polyethylene bags at –20°C, thawed for
and during subsequent reduction of the tibia. These lesions 24 hours before use, and then kept moist with water spray.
are typically not detected with magnetic resonance imaging The knee was prepared on one day and kept overnight in
(MRI) since the images are taken with the knee extended, a refrigerator at 4°C, and the experiment was completed
when the meniscocapsular separation is reduced.4,16 Indeed, the following day. The femur and tibia were cut to approx-
these lesions require careful intraoperative examination, imately 200 mm above and below the knee joint line, and
possibly necessitating the use of an additional posterome- soft tissues more than 150 mm from the joint line were
dial portal and certainly a viewing of the posteromedial removed. An intramedullary rod was cemented into the
recess by introduction of the arthroscope through the inter- femur. The femoral rod was secured in a rig that allowed
condylar notch, and therefore can often go undetected.25 the experimenter to apply manual passive knee flexion-
Injury of the posteromedial meniscocapsular attachment extension by moving the femur with the unconstrained
at the time of ACL injury, followed by suture repair, was tibia hanging vertically from 0° to 110° (Figure 1). The ana-
described in the 1980s by Hamberg et al8 and Woods and tomic axis along the shaft of the femur was set to 6° valgus
Chapman30 and more recently by Bollen.4 This lesion has relative to the test rig to align the mechanical axis of the
been identified in up to 30% of patients with ACL injury.16 knee to the test rig.31 A pot with a 500-mm-long rod extend-
Some orthopaedic surgeons, including authors of this paper, ing distally was cemented onto the distal end of the tibia. A
have become aware of subjective increases in anteroposterior Steinmann pin was drilled mediolaterally across the proxi-
laxity when this lesion is present and left unrepaired at the mal tibia, and semicircular hoops were mounted on this.
time of ACL reconstruction. Furthermore, they have noticed These could be connected to weights via pulleys and strings
considerable reduction in laxity on Lachman testing once the to impose anterior and posterior drawer forces without
lesion is repaired. However, the efficacy of various suture inhibiting natural coupled tibial rotation. A 200-mm-diame-
techniques to allow repair at the time of ACL reconstruction ter polyethylene disc was secured onto the hanging tibial
is under debate.25 To our knowledge, no biomechanical stud- rod. Hanging weights that were connected via a pulley and
ies have examined knee laxity in the presence of a posterome- string system at opposite poles of the disc enabled the appli-
dial meniscocapsular lesion with the ACL intact or deficient cation of internal and external tibial rotational torque. All
or determined whether any increased laxity can be reduced testing took place on the same day without removing the
with intraoperative repair. specimen from the test rig.
The aim of the present study, therefore, was to examine
the following hypotheses: (1) a posteromedial meniscocapsu-
lar lesion in ACL-deficient knees causes increased anterior Optical Tracking
or rotatory knee laxity, (2) intact knee laxity can be restored
with a patellar tendon ACL reconstruction and arthroscopic Tibiofemoral joint kinematics were measured by use of
meniscocapsular repair, (3) a posteromedial lesion in the a Polaris optical tracking system (NDI–Northern Digital
ACL-reconstructed knee causes greater rotational and ante- Inc) with passive Brainlab reflective markers (Brainlab)
rior laxity to persist than in a knee with the lesion repaired, mounted securely onto the tibia and femur. Sets of fiducial
and (4) any changes in knee laxity could be measured by use markers on the femur and tibia were digitized by use of
of a Rolimeter21 and so would be clinically detectable. a stylus probe after their fixation to anatomic landmarks.
The femoral coordinate system used the anatomic axis
(intramedullary rod) and a transverse axis from the medial
METHODS to lateral epicondyles, which were exposed via small inci-
sions. The tibial coordinate axis was defined by use of the
Specimen Preparation intramedullary axis and the most medial and lateral points
of the plateau.
Ten fresh-frozen cadaveric knees were obtained from a tis- Kinematic data were processed by use of Visual3D
sue bank after local research ethics committee approval (C-Motion Inc). Zero-degrees knee flexion was defined

{
Address correspondence to Andrew A. Amis, FREng, DSc(Eng), Biomechanics Group, Mechanical Engineering Department, Imperial College London,
London SW7 2AZ, UK (email: [email protected]).
*Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK.
y
Sporthopaedicum Berlin, Berlin, Germany.
z
The Yorkshire Clinic, Bingley, West Yorkshire.
§
Fortius Clinic, London, UK.
||
Musculoskeletal Surgery Group, Department of Surgery & Cancer, Imperial College London School of Medicine, London, UK.
One or more of the authors has declared the following potential conflict of interest or source of funding: This project was supported by a Fellowship
grant from Smith & Nephew (Endoscopy) division. J.M.S. was supported by a grant from the Fortius Clinic, London. C.H. was supported by a grant
from the EPSRC and the Wellcome Trust, via the Centre of Excellence for the Application of Technology to the Treatment of Osteoarthritis. These grant
monies were paid to research accounts of Imperial College London. CK was supported by a grant from the German-Speaking Arthroscopy Association.
Smith & Nephew provided arthroscopy instruments and suture anchors. AW and AAA received reimbursement from Smith & Nephew Co for presenting
lectures at surgical conferences. AAA/Imperial College London licensed an ACL drill guide patent to Smith & Nephew Co.
402 Stephen et al The American Journal of Sports Medicine

arthrometer.21 Anterior laxity was assessed with knees

positioned in the test rig to ensure standardization. The
Rolimeter frame was applied to the anterior aspect of the
tibial rod (with standard thickness padding added distally
to account for where the shin would be) and centered prox-
imally on the patella. Ink marks were made on the tibial
tuberosity and patella to ensure that the Rolimeter was
positioned consistently throughout testing. The feeler
was adjusted to rest over the tibial tuberosity to enable
examination of anterior tibial translation. The Rolimeter
was held in place by one examiner, while a surgeon manu-
ally applied a maximal anterior translation onto the tibia.
Three measurements were taken at both 30° and 90° of
flexion for each of the different knee states investigated.
All tests were performed by the same experienced ortho-
paedic surgeon.

Surgical Procedures
With the knee mounted in the test rig, standard arthros-
copy was undertaken through anterolateral and anterome-
dial portals to check that the specimen was suitable for
experimentation. The patellofemoral, medial, and lateral
compartments and the intercondylar notch were inspected
for integrity of the menisci, joint surfaces, and ACL. One
knee was found to be unsuitable due to ACL deficiency.
Three knees had early chondral damage.
Once the intact knee had been tested, the arthroscopy
was repeated and the ACL excised by use of a combination
of hand punches and power shaver. The knee was then
Figure 1. Test rig used for the study. The specimen position tested again.
was adjusted to approximately align knee and rig flexion- To create the peripheral meniscal lesion as described by
extension axes. (A) Manual passive flexion-extension move- Bollen,4 a Beaver knife was introduced through a proximal
ments were applied to the femur; the motion of the hanging posteromedial portal to access the posteromedial recess. The
tibia (B) was otherwise unconstrained. The anterior (C) and knife was rotated to provide the best curvature of blade to
posterior forces were applied with weights connected to create a peripheral lesion. The lesion was started laterally
the proximal tibia by cables passed over pulleys. Internal and taken medially to the junction of the posterior one-third
and external rotation torques were applied with weights (D) and anterior two-thirds of the meniscus (see the online
connected to both sides of a polyethylene disc secured at Video Supplement [Video 1], for this technique). The lesion
the end of the tibial intramedullary rod. was made through the whole thickness of the peripheral
meniscus. The cut was made while the arthroscope was
introduced via the anterolateral portal through the inter-
when the tibial and femoral rods were parallel in the sag- condylar notch and into the posteromedial recess. Subse-
ittal plane. Anterior-posterior translation was calculated as quent introduction of a probe via the anteromedial and
the perpendicular distance from the midpoint of the femoral posteromedial portals enabled inspection of the tear and
epicondylar axis to the tibial coronal reference plane. This the articular cartilage of the posterior medial tibia. The
test method has been used previously,6,14 with the tracking extent and depth of the lesion were confirmed by introduc-
system known to have a translational accuracy of 0.1 mm.13 ing the arthroscope through the posteromedial portal and
The intact knee at full extension (0° of flexion) was taken to also through the anteromedial portal into the medial gutter
be 0 mm translation and 0° rotation, and all measurements of the joint (Figure 2). With the arthroscope in the medial
were normalized to this. The motions described are tibial gutter, the medial limit of the tear that had been created
motion in relation to the femur. could be inspected. Once the accuracy of the knife-induced
tear was confirmed, the knee was tested again.
Clinical Laxity Measurement The tear was repaired by use of curved and reverse-
curved FastFix suture anchor devices (Smith & Nephew).
To measure clinically detectable anterior tibial translation, Although it has been stated that use of the FastFix device
a Rolimeter knee tester (Aircast Europa) was used. This is problematic for repairing these tears in this set-
has been found to have high intratester reliability18 and ting,5,25,29 we found the technique to be satisfactory: This
specificity and sensitivity equivalent to the KT-1000 was confirmed by introducing the arthroscope into the
AJSM Vol. 44, No. 2, 2016 Posteromedial Meniscocapsular Lesions 403

By introducing the Beaver knife through the posterior

portal, the surgeon was able to cut the suture line to restore
the tear to a state of instability. An arthroscope was intro-
duced via the anterolateral portal through the intercondylar
notch into the posteromedial recess to check this and also
via the posteromedial portal. Probing of the tear demon-
strated the restoration of instability. The knee was then
tested again. Finally, the reconstructed ACL was resected
by use of a combination of hand instruments and power
shaver. The final tests were then made on the knee.
After the tests were completed, the knees were removed
from the test rig and disarticulated to examine the deploy-
ment of the suture anchors into the posteromedial joint
capsule.

Testing Protocol
Figure 2. Creation of the posteromedial meniscocapsular
lesion in vitro, viewed from posteromedial portal. The 6 degrees of freedom data of the position of the tibia
with respect to the femur were recorded with no external
loads applied to the tibia, only the weight of the hanging
posteromedial recess via the anterolateral portal and also tibia and attached rod, which remained constant through-
by inspecting the repair via the posteromedial portal. out testing. The kinematic data were also recorded with
The repair was undertaken at approximately 10° of knee the following loads applied: 90-N tibial anterior drawer
flexion; near extension, the inferior recess of the postero- force, 90-N tibial posterior drawer force, 5-Nm tibial inter-
medial synovial cavity is drawn up to be closer to the pos- nal rotation torque, 5-Nm tibial external rotation torque,
terior horn of the MM (Video 1). The FastFix sutures could and a combined 5-Nm tibial external rotation torque and
be seen to pass through the tear and penetrate the poste- 90-N tibial anterior drawer force. The fifth load combina-
rior capsule (Video 2). If a repair were to be undertaken tion was used because it was hypothesized that the poster-
with the knee in a flexed position, then the width of the omedial meniscocapsular lesion would result in the largest
recess between meniscus and posterior capsule would cer- changes being in both anterior translation and external
tainly risk the FastFix anchors deploying in an intra- rotation laxity.
articular portion. Sutures were placed proximally at This test protocol of 6 loading conditions was repeated
5 mm apart. For every 3 superior sutures, on average, 1 with the knee in 6 states: (1) intact, (2) after arthroscopic
inferior surface suture was placed. Five sutures were ACL sectioning, (3) ACL deficient and posterior menisco-
placed in each knee to ensure stability of the whole tear capsular lesion created, (4) ACL deficient and posterior
when tested by probing (Video 3). The experiment started meniscocapsule repaired, (5) ACL patellar tendon recon-
by use of FastFix-360 anchors, but some longer FastFix- struction and posterior meniscocapsule repair, and (6)
Ultra devices became available and were used in the latter ACL reconstructed and capsular lesion re-created. During
part of the study. Once the tear had been repaired satisfac- each loading condition, 3 cycles of knee flexion-extension
torily, the knee was tested once again. between 0° and 110° were repeated manually.
After this, the ACL was reconstructed by use of a mid-
third patellar tendon graft. A 10-mm femoral socket was Data Analysis
drilled via the anteromedial portal. A 10-mm tibial tunnel
was drilled. The bone quality of the femur was never an Custom-written Matlab scripts (The MathWorks Inc) were
issue, but the bone was frequently soft on the tibial used to calculate mean tibial translations and rotations at
side. As a result, to improve fixation of the graft, the 10° intervals from 0° to 110° of flexion from the processed
bone blocks from the patella and tibia were crushed Visual3D motion data. The coordinate system was defined
down to 10-mm diameter to improve bone density. A sin- so that anterior tibial translation and external rotation
gle interference screw (8 mm 3 25 mm RCI screw, Smith were taken to be positive. Rolimeter readings were aver-
& Nephew) was used on the femur. An oversize screw (11 aged, and a mean value was recorded for each of the 2 flex-
mm 3 25 mm RCI) was required in the tibia, and the tib- ion angles (30° and 90°) in each knee state.
ial bone block sutures were tied over a screw placed in the A power calculation based on prior work that used the
tibial shaft. On all occasions, secure fixation was same optical tracking system14,21 determined that a sample
achieved. It was confirmed that knees could reach full size of 9 would allow identification of changes of transla-
physiological extension after ACL reconstruction. We tion and rotation of 1.9 mm and 1.2°, respectively, with
did not formally measure the position of ACL grafts, but 80% power and 95% confidence. Dependent variables
they were all performed by an experienced ACL surgeon were anterior and posterior translation, internal and
(A.W.) who checked the position arthroscopically. The external rotation, anterior translation and external load-
knee was then tested again. ing combined laxities, and Rolimeter measurements.
404 Stephen et al The American Journal of Sports Medicine

Figure 3. Tibial translation for the 6 states of the knee exam- Figure 4. The difference in anterior translation from the
ined with no external loading applied (mean values 6 SD; intact knee under 90-N anterior load for the 6 knee states
n = 9). ACL, anterior cruciate ligament; ACLR, ACL recon- examined. The horizontal datum axis represents the ‘‘neu-
structed; #, transected. tral’’ position of the tibia with the intact knee with no external
loading applied to it. Values above the datum axis represent
greater anterior translation laxity in response to 90-N anterior
Data were analyzed in SPSS (version 22.0; IBM Corp).
drawer force (mean values 6 SD; n = 9). ACL, anterior cruci-
Shapiro-Wilk tests confirmed that the data were normally
ate ligament; ACLR, ACL reconstruction; #, transected.
distributed.
The primary factors investigated were 6 knee states
(intact, ACL deficient, ACL deficient 1 meniscocapsular Anterior Translation
lesion, ACL deficient 1 meniscocapsular lesion repaired,
ACL reconstructed 1 meniscocapsular lesion repaired, Varying the state of the knee had a significant effect on
ACL reconstructed 1 meniscocapsular lesion re-created) anterior tibial translation after the application of a 90-N
and flexion angle (0°-100° at 10° intervals inclusive). Seven anterior translation force (P \ .001). At 30° with the knee
2-way repeated-measures analysis of variance (RM intact and a 90-N anterior translation force applied, the
ANOVA) were performed comparing the effects of knee tibia translated 2.8 mm; this increased to 11 mm after
state across the arc of knee flexion for each of the depen- ACL sectioning (P \ .0001) and further to 14 mm (P \
dent variables examined. Post hoc paired t tests with Bon- .001) after creation of the meniscocapsular lesion. Repairing
ferroni correction were applied when differences across the lesion reduced anterior translation to 10.1 mm (P =
test conditions were found in order to examine the 4 .001), and ACL reconstruction reduced this further to
hypotheses defined in the introduction. 4.1 mm (P \ .001) (Figure 4). Last, re-creating the menisco-
capsular lesion by cutting the meniscus sutures in the ACL-
reconstructed knee increased anterior tibial translation up
RESULTS to 7.1 mm (P = .01).

Neutral Loading
Posterior Translation
Knee state had a significant effect on tibial translation in
the knee when no external loading was applied (P \ No significant effect was identified on tibial posterior
.001). Sectioning the ACL and the deficient ACL in combi- translation laxity as a result of sectioning the ACL, crea-
nation with the meniscocapsular lesion resulted in tion of the meniscocapsular lesion, or their reconstruction
increased anterior tibial translation, which was restored and repair, respectively (P . .05).
with reconstruction and repair technique (Figure 3; see
the Appendix, available in the online version of this article
at http://ajsm.sagepub.com/supplemental, for tables of data Internal Rotation
including mean and SD). Flexion angle was also found to
have a significant effect (P = .001) on tibial translation, A trend was found for tibial internal rotation to increase
with anterior translation progressively increasing with after ACL sectioning, which was reduced with ACL recon-
deeper knee flexion. struction (Figure 5). However, no overall significant effect
Rather than present normal laxity data, the following was identified between the different knee states on inter-
sections display changes from normal, which has greater nal rotational laxity (P . .05). A significant effect of flexion
clarity regarding residual laxities after different stages of angle was identified (P \ .01), with greater effects identi-
the experiment. fied in early flexion (Figure 5).
AJSM Vol. 44, No. 2, 2016 Posteromedial Meniscocapsular Lesions 405

Figure 7. The difference of anterior translation laxity from the

Figure 5. The difference from the intact knee in tibial internal
intact knee when loaded in combined tibial 90-N anterior
rotation under 5-Nm internal rotation torque for the different
drawer force and 5-Nm external rotation torque for the dif-
knee states (mean values 6 SD; n = 9). ACL, anterior cruciate
ferent knee states (mean values 6 SD; n = 9). ACL, anterior
ligament; ACLR, ACL reconstructed; #, transected.
cruciate ligament; ACLR, ACL reconstructed; #, transected.

Figure 6. The difference from the intact knee in tibial exter- Figure 8. Rolimeter readings for anterior translation of the
nal rotation under 5-Nm external rotation torque for the dif- tibia (mean values 6 SD; n = 9). *P \ .05 vs the intact laxity
ferent knee states (mean values 6 SD; n = 9). ACL, anterior at each knee flexion angle. ACL, anterior cruciate ligament;
cruciate ligament; ACLR, ACL reconstructed; #, transected. ACLR, ACL reconstructed; #, transected.

External Rotation rotational load to the knee after ACL sectioning and crea-
tion of the meniscocapsular lesion (Figure 7). However, no
A significant effect was identified on external rotation as significant effect was identified on tibial anterior transla-
a result of changing the knee state across all angles of tion laxity as a result of varying knee state when the knees
knee flexion (P \ .01). Tibial external rotation increased were subjected to combined external rotational and ante-
significantly, by 2.5° at 20° of knee flexion, as a result of rior translation loads (P . .05).
the creation of the posterior meniscocapsular lesion in
the ACL-deficient knee as the meniscus was free to move
away from its tibial attachment. External rotation was Clinical Anterior Translation Measurement
reduced after meniscocapsular repair and increased again
after the repair was cut (Figure 6). A clear and significant trend was identified by the Rolimeter
data (P \ .001) (Figure 8). This was in agreement with the
anterior tibial translation data under a 90-N anterior load,
Combined External Rotation Plus Anterior Translation highlighting progressive increases in anterior tibial transla-
tion after ACL sectioning and meniscocapsular lesion crea-
A trend was noted for increased anterior tibial translation tion, which were restored after ACL reconstruction and
after the application of a combined anterior and external meniscocapsular repair. The Rolimeter data were consistent
406 Stephen et al The American Journal of Sports Medicine

at both 30° and 90° of flexion with changes in tibial transla- DISCUSSION
tion measured by optical tracking (Figure 8), which were
significantly higher in early knee flexion (P \ .01). This study identified significant increases in anterior tibial
translation and external rotation in ACL-deficient knees
after posteromedial meniscocapsular sectioning. These lax-
Effect of the Creation of a Posteromedial ities could be restored to intact values with surgical repair
Meniscocapsular Lesion in ACL-Deficient Knees of the meniscocapsular lesion and patellar tendon ACL
reconstruction. It was possible to detect changes in anterior
The addition of the posteromedial meniscocapsular lesion
tibial translation in the knees at different states during test-
to an already ACL-deficient knee resulted in significant
ing with the Rolimeter, indicating that these changes are
increases in anterior tibial translation from 0° to 60° inclu-
clinically detectable. In the presence of the meniscocapsular
sive (P \ .05) and external rotation at 0° to 40° inclusive
lesion, ACL reconstruction alone failed to restore normal
and 70° (P \ .05).
joint kinematics. The surgeon authors of this study (S.R.B.
and A.W.) have found that this residual laxity is clinically
Effect of Meniscocapsular Repair observable. This has obvious implications for the ACL graft,
in Combination With ACL Reconstruction given the risk of overload and potential compromise of out-
come. In the chronic situation, the combination of residual
Compared with when the ACL had been reconstructed by abnormal tibiofemoral joint laxity and pathological meniscal
patellar tendon graft and the meniscocapsular lesion was mobility implies an increased likelihood of damage and
still present, a significant reduction was noted in anterior degeneration of both the meniscus and the joint surfaces.
tibial translation when the lesion was repaired, at 0° to 60° It can therefore be recommended that surgeons inspect
(P \ .05). A similar effect of reduced external rotation after the posteromedial meniscocapsular junction routinely via
lesion repair in this state was identified from 0° to 40° and either an anterolateral or posteromedial portal during
70° to 90° inclusive (P \ .05). ACL reconstruction surgery to ensure that these lesions
Conversely, when the meniscocapsular repair was released are identified and treated to avoid any residual postopera-
and the ACL reconsctruction left intact, a significant increase tive laxity resulting from unrepaired lesions.
in anterior tibial translation (from 0°-50° inclusive; P \ .05) Posteromedial meniscocapsular lesions are becoming
and external tibial rotation (at 0°, 20°, 30°, 50°, 60°; all P \ more widely recognized.4,16,22,25 Prior work has demon-
.05) was noted. strated the importance of the posteromedial capsule in pro-
viding stability to the extended knee.20 However, to date,
Difference Between Intact Knees and no biomechanical studies have investigated the relation-
Those With the ACL Reconstructed ship between the posterior oblique ligament and ‘‘ramp’’
and Meniscocapsular Lesion Repaired lesions, such as the effect of such an injury on tibiofemoral
kinematics in ACL-deficient knees. This study identified
No significant differences were identified between the a significant effect of creating the meniscocapsular lesion
intact knees and those with the ACL reconstruction and in ACL-deficient knees, with both increased anterior trans-
meniscocapsular repair performed for either anterior tibial lation and external rotation laxity identified as a result
translation or external tibial rotation across any flexion (P \ .05). Failure to identify and treat these lesions may
angles from 0° to 110° (all P . .05). have implications for postoperative recovery, since menis-
cal injury is closely associated with functional outcome
Knee Laxity Changes Detected With the Rolimeter after ACL reconstructive surgery.27 However, further clin-
ical follow-up studies are required to determine whether
Rolimeter readings increased significantly as a result of cre- untreated posteromedial meniscocapsular lesions would
ating the meniscocapsular lesion, at both 30° and 90° of knee lead to symptomatic clinical instability or future medial
flexion (P \ .05). Readings were reduced when the menisco- compartment injury in patients after ACL reconstruction
capsular lesion was repaired in the ACL-reconstructed knee, alone.
at both flexion angles investigated (P \ .05). When the repair Repair of posteromedial meniscocapsular lesions
was released, a significant increase in anterior tibial transla- presents a surgical challenge, and high failure rates have
tion was measured by the Rolimeter at 30° (P \ .05). been reported.7,22 This study demonstrated that it is possi-
ble to repair posteromedial meniscocapsular lesions with
Suture Anchor Deployment FastFix repair sutures through traditional anterior portals
and that repairing the capsular lesion restored anterior
With 5 FastFix devices in each knee, there were 10 suture translation and external rotational laxities close to the
anchors in each, giving 90 anchors in total: 62 FastFix-360 intact state. Conversely, release of the repair resulted in
anchors, plus 28 FastFix-Ultra devices that were used in increased tibial anterior translation and external rotation.
knees 6 to 9 (3 or 4 Ultra devices were used in each of those Visualization of the posteromedial recess during the study
4 knees). Some of the 360 anchors had not engaged the cap- demonstrated that in knee flexion the posterior capsular
sule: 3 in knee 1, 2 in knee 2, 1 in each of knees 3 to 8, and wall folds and drops posteriorly and distally, whereas in
none in knee 9; all 28 of the Ultra anchors had deployed knee extension it is pulled proximally and held taut
correctly. against the back of the tibia (Video 1). For this reason,
AJSM Vol. 44, No. 2, 2016 Posteromedial Meniscocapsular Lesions 407

the repair sutures in the present study were placed with studies are required to investigate this further. The poste-
the knee in no more than 10° of flexion, when the capsular rior capsule was dissected from the tibia before the poste-
lesion was repaired. rior oblique ligament was detected. We did dissect the
A previous report25 suggested that FastFix sutures knees after the study, and it appeared likely that the pos-
could not adequately repair the meniscocapsular lesions terior oblique ligament fibers were separated from the tib-
described in this study. It was suggested that repair via ial attachment, but it was difficult to determine the precise
a posteromedial portal by use of a suture ‘‘shuttle’’ was anatomic state after the extensive testing in the area.
the only effective method. Because of the physical con- Finally, an increased anterior translation laxity was not
straints of the experimental rig used in the present study, found when the knees were tested in fixed external rota-
this technique was not possible. The only option was repair tion, and that is presumed to be due to the restraint from
with an ‘‘all-inside’’ suture device used as in the clinical sit- the deep and superficial parts of the medial collateral liga-
uation with insertion from anterior portals, but that tech- ment, which shares the load with the ACL when the knee
nique was also affected by access limitations. After the is in external rotation.20 It is not known how much these
experiment, 11 of 62 of the 360-type suture anchors were structures are affected by the injuries that cause postero-
found within the joint capsule, possibly as a result of medial capsular lesions.
inability to fully visualize the knee at the time of suture These results have shown that posteromedial menisco-
placement due to the constraints of the test rig, or possibly capsular lesions, which have been reported in up to 30%
due to the loading imposed during the tests (in the absence of patients after ACL injury,30 result in external rotation
of any healing response at ‘‘time zero’’), which could have and anterior translation laxities increasing by up to a fur-
pulled some anchors into the joint. The possibility of ther one-third compared with the ACL-deficient knee.
anchors left within the joint should not be ignored; careful These deficiencies are not eliminated with ACL reconstruc-
attention to deployment is imperative, and any anchors tion alone but can be successfully addressed via surgical
within the joint should be removed. The present study repair. Changes in knee laxity resulting from posterome-
clearly demonstrates biomechanical success of using the dial meniscocapsular lesions are clinically detectable, and
FastFix suture anchor system. The FastFix Ultra device surgeons should be vigilant in identifying these lesions at
has a longer needle and may therefore present advantages the time of surgical intervention, as evidence suggests
for repairs of these lesions: All 28 Ultra anchors had that they may not always be identified with MRI
deployed correctly. Future studies are therefore necessary scan.4,16 Clinical studies should now be conducted to con-
to identify optimal surgical techniques to address this spe- firm these findings in vivo.
cific meniscal lesion.
This experiment has inevitable limitations, many of A Video Supplement for this article is available in the online
which are inherent to all in vitro testing. Despite efforts version or at http://ajsm.sagepub.com/supplemental.
to source younger specimens, the mean specimen age
tested was above the typical age for this injury. Rolimeter
results reflect that AP laxity measurements in vitro dupli- REFERENCES
cate clinical laxity tests of the passive ligament restraints,
but knowledge about clinical rotational laxity is lacking.3 1. Ahn JH, Kim S-H, Yoo JC, Wang JH. All-inside suture technique
using two posteromedial portals in a medial meniscus posterior
Readings were taken from 0° to 100°, which may not repre-
horn tear. Arthroscopy. 2004;20(1):101-108.
sent the full range of knee motion demanded in some sport- 2. Allen CR, Wong EK, Livesay GA, Sakane M, Fu FH, Woo SLY. Impor-
ing populations that are most likely to be affected by this tance of the medial meniscus in the anterior cruciate ligament-
lesion. The loading conditions used in this study only sim- deficient knee. J Orthop Res. 2000;18(1):109-115.
ulated those used in clinical situations, and therefore mus- 3. Amis AA, Bull AM, Lie DT. Biomechanics of rotational instability and
cle loads were not applied. This avoided assumptions about anatomic anterior cruciate ligament reconstruction. Oper Tech
Orthop. 2005;15(1):29-35.
tissue loading; however, it is therefore not known how the
4. Bollen S. Posteromedial meniscocapsular injury associated with rup-
reconstruction or repair techniques would react to physio- ture of the anterior cruciate ligament: a previously unrecognised
logical loading conditions. These limitations were offset by association. J Bone Joint Surg Br. 2010;92(2):222-223.
the ability to make repeated measurements on the soft tis- 5. Calder SJ, Myers PT. Broken arrow: a complication of meniscal
sue procedures described on the same specimen, eliminat- repair. Arthroscopy. 1999;15(6):651-652.
ing patient- or specimen-related variability and enabling 6. Cuomo P, Rama KRBS, Bull AM, Amis AA. The effects of different
tensioning strategies on knee laxity and graft tension after double-
pairwise statistical comparisons to be performed. In addi-
bundle anterior cruciate ligament reconstruction. Am J Sports Med.
tion, as with all laboratory cadaveric testing, the findings 2007;35(12):2083-2090.
are only valid at time zero, and the biological effects of 7. Ellermann A, Siebold R, Buelow J, Sobau C. Clinical evaluation of
graft and tissue healing cannot be accounted for in this meniscus repair with a bioabsorbable arrow: a 2-to 3-year follow-
experiment, requiring further in vivo studies. The repair up study. Knee Surg Sports Traumatol Arthrosc. 2002;10(5):289-293.
technique described in this paper may not be possible in 8. Hamberg P, Gillquist J, Lysholm J. Suture of new and old peripheral
more chronic situations where reduction of the capsule to meniscus tears. J Bone Joint Surg Am. 1983;65(2):193-197.
9. Hughston JC. Knee Ligaments: Injury & Repair. Chicago, IL: Mosby;
the posterior meniscal wall does not happen in the
1993.
extended knee. In such cases, it is possible that a more spe- 10. Indelicato PA, Bittar ES. A perspective of lesions associated with
cific posteromedial approach and repair as previously ACL insufficiency of the knee: a review of 100 cases. Clin Orthop
described1,17 may be necessary. However, additional Relat Res. 1985;198:77-80.
408 Stephen et al The American Journal of Sports Medicine

11. Kaplan PA, Walker CW, Kilcoyne RF, Brown DE, Tusek D, Dussault 21. Schuster AJ, McNicholas MJ, Wachtl SW, McGurty DW, Jakob RP. A
RG. Occult fracture patterns of the knee associated with anterior cru- new mechanical testing device for measuring anteroposterior knee
ciate ligament tears: assessment with MR imaging. Radiology. laxity. Am J Sports Med. 2004;32(7):1731-1735.
1992;183(3):835-838. 22. Seil R, VanGiffen N, Pape D. Thirty years of arthroscopic meniscal
12. Keene GC, Bickerstaff D, Rae PJ, Paterson RS. The natural history of suture: what’s left to be done? Orthop Traumatol Surg Res.
meniscal tears in anterior cruciate ligament insufficiency. Am J 2009;95(8):85-96.
Sports Med. 1993;21(5):672-679. 23. Smith JP, Barrett GR. Medial and lateral meniscal tear patterns in
13. Khadem R, Yeh CC, Sadeghi-Tehrani M, et al. Comparative tracking anterior cruciate ligament-deficient knees: a prospective analysis of
error analysis of five different optical tracking systems. Computer 575 tears. Am J Sports Med. 2001;29(4):415-419.
Aided Surgery. 2000;5(2):98-107. 24. Solomonow M, Baratta R, Zhou B, et al. The synergistic action of the
14. Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T. Prospective clinical anterior cruciate ligament and thigh muscles in maintaining joint sta-
comparisons of anatomic double-bundle versus single-bundle ante- bility. Am J Sports Med. 1987;15(3):207-213.
rior cruciate ligament reconstruction procedures in 328 consecutive 25. Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX, Seil R. Hid-
patients. Am J Sports Med. 2008;36(9):1675-1687. den lesions of the posterior horn of the medial meniscus: a systematic
15. Levy I, Torzilli P, Warren R. The effect of medial meniscectomy on arthroscopic exploration of the concealed portion of the knee. Am J
anterior-posterior motion of the knee. J Bone Joint Surg Am. Sports Med. 2014;42(4):921-926.
1982;64(6):883. 26. Thompson W, Fu F. The meniscus in the cruciate-deficient knee. Clin
16. Liu X, Feng H, Zhang H, Hong L, Wang XS, Zhang J. Arthroscopic Sports Med. 1993;12(4):771-796.
prevalence of ramp lesion in 868 patients with anterior cruciate liga- 27. Trojani C, Sbihi A, Djian P, et al. Causes for failure of ACL reconstruc-
ment injury. Am J Sports Med. 2011;39(4):832-837. tion and influence of meniscectomies after revision. Knee Surg
17. Morgan CD. The ‘‘all-inside’’ meniscus repair. Arthroscopy. 1991; Sports Traumatol Arthrosc. 2011;19(2):196-201.
7(1):120-125. 28. Warren LF, Marshall JL. The supporting structures and layers on the
18. Muellner T, Bugge W, Johansen S, Holtan C, Engebretsen L. Inter- medial side of the knee: an anatomical analysis. J Bone Joint Surg
and intratester comparison of the Rolimeter knee tester: effect of Am. 1979;61(1):56-62.
tester’s experience and the examination technique. Knee Surg 29. Wilmes P, Lorbach O, Brogard P, Seil R. [Complications with all-
Sports Traumatol Arthrosc. 2001;9(5):302-306. inside devices used in reconstructive meniscal surgery]. Orthopade.
19. Noyes FR, Chen RC, Barber-Westin SD, Potter HG. Greater than 2008;37(11):1088-1089, 1091-1095, 1097-1098.
10-year results of red-white longitudinal meniscal repairs in patients 30. Woods GW, Chapman DR. Repairable posterior menisco-capsular
20 years of age or younger. Am J Sports Med. 2011;39(5):1008-1017. disruption in anterior cruciate ligament injuries. Am J Sports Med.
20. Robinson JR, Bull AMJ, Thomas RR, Amis AA. The role of the medial 1984;12(5):381-385.
collateral ligament and posteromedial capsule in controlling knee lax- 31. Yoshioka Y, Siu D, Cooke TD. The anatomy and functional axes of
ity. Am J Sports Med. 2006;34(11):1815-1823. the femur. J Bone Joint Surg Am. 1987;69(6):873-880.

For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.