5-in-5

The Risk of Iatrogenic Peroneal Nerve

Injury in Lateral Meniscal Repair
and Safe Zone to Minimize the Risk
Based on Actual Arthroscopic Position
An MRI Study
Chaiwat Chuaychoosakoon,* MD , Pattira Boonsri,y MD, Pramot Tanutit,y MD,
Teeranan Laohawiriyakamol,y MD, Tanarat Boonriong,* MD, and
Wachiraphan Parinyakhup,*z MD
Investigation performed at the Faculty of Medicine, Prince of Songkla University,
Songkhla, Thailand

Background: Lateral meniscal repair using an all-inside meniscal repair device involves a risk of iatrogenic peroneal nerve injury.
To our knowledge, there have been no previous studies evaluating the risk of injury with the knee in the standard operational fig-
ure-of-4 position with joint dilatation in arthroscopic lateral meniscal repair.
Purpose: To evaluate and compare the risk of peroneal nerve injury and establish the safe and danger zones in repairing the lat-
eral meniscus through the anteromedial, anterolateral, or transpatellar portal in relation to the medial and lateral borders of the
popliteal tendon (PT).
Study Design: Descriptive laboratory study.
Methods: Using axial magnetic resonance imaging (MRI) studies of knees in the figure-of-4 position with joint fluid dilatation at
the level of the lateral meniscus, we drew direct lines to simulate a straight all-inside meniscal repair device deployed from the
anteromedial, anterolateral, and transpatellar portals to the medial and lateral borders of the PT. If the line passed through or
touched the peroneal nerve, a risk of iatrogenic peroneal nerve injury was noted, and measurements were made to determine
the safe and danger zones for peroneal nerve injury in relation to the medial or lateral border of the PT.
Results: Axial MRI images of 29 adult patients were reviewed. Repairing the lateral meniscus through the anteromedial portal in
relation to the lateral border of the PT and through the anterolateral portal in relation to the medial border of the PT had a 0% risk
of peroneal nerve injury. The ‘‘safe zone’’ in relation to the medial border of the PT through the anterolateral portal was between
the medial border of the PT and 9.62 6 4.60 mm medially from the same border.
Conclusion: It is safe to repair the body of the lateral meniscus through the anteromedial portal in the area lateral to the lateral
border of the PT or through the anterolateral portal in the area medial to the medial border of the PT.
Clinical Relevance: There is a risk of iatrogenic peroneal nerve injury during lateral meniscal repair. Thus, we recommend repair-
ing the lateral meniscal tissue through the anteromedial portal in the area lateral to the lateral border of the PT and using the ante-
rolateral portal in the area medial to the medial border of the PT, as neither of these approaches resulted in peroneal nerve injury.
Additionally, the surgeon can decrease this risk by repairing the meniscal tissue using the all-inside meniscal device in the safe
zone area.
Keywords: all-inside meniscal repair; iatrogenic injury; lateral meniscus; peroneal nerve; popliteal artery

Meniscal injury is a common occurrence in knees with intra- treatment,17 normally by an all-inside, inside-out, or
articular pathology. Meniscal repair is the recommended outside-in technique. The repair technique depends signifi-
cantly on patient characteristics, tear type, and morphology.
All-inside meniscal repair is commonly used in repairing the
The American Journal of Sports Medicine body and/or posterior horn of the medial and/or lateral
2022;50(7):1858–1866
DOI: 10.1177/03635465221093075
meniscus because it is easiest to do, achieves good stability,9
Ó 2022 The Author(s) and decreases operative time. However, as with any

1858
AJSM Vol. 50, No. 7, 2022 The Risk of Peroneal Nerve Injury in Lateral Meniscal Repair 1859

surgery, there is a chance of iatrogenic peroneal nerve and/

or posterior neurovascular structure (popliteal artery, popli-
teal vein, and/or tibial nerve) injury during this proce-
dure.9,16 In lateral meniscal repair, earlier studies have
reported incidences of the peroneal nerve and popliteal arte-
rial injuries of up to 0.6% and 0.03%, respectively4,7,19,20;
these injuries can cause irreversible limb ischemia leading
to amputation or, rarely, even death.15
The popliteal tendon (PT) is an intra-articular structure
located close to the lateral meniscus that is easy to identify
and visualize during arthroscopic surgery. Repairs to the
lateral meniscus with an all-inside meniscal repair device
that involve capsular penetration close to the medial or lat-
eral border of the PT can endanger the peroneal nerve at the
posterolateral aspect of the knee joint.6,10,11 There have
been many cadaveric or magnetic resonance imaging
(MRI) studies evaluating the risk of the iatrogenic peroneal
nerve and/or posterior neurovascular structure injury dur-
ing all-inside meniscal repair. However, all previous cadav-
eric studies on meniscal repairs evaluated the peroneal
nerve and/or posterior neurovascular structure of this area
using midfemoral to midtibial knee joint speci-
mens.2,5,6,12,13,18,21 Several factors can influence the out-
come of arthroscopic lateral meniscal repair, which could
lead to inaccurate results from such cadaveric studies. First,
when using a midthigh to midleg section, the tension from
the various neurovascular structures, muscles, and tendons
around the knees will be lower than the tension in a living
person or a full-body cadaver. Second, the previous studies
did not simulate the actual ‘‘figure-of-4’’ arthroscopic posi-
tion used in surgeries during the measurements; however,
the distances from the tip of the meniscal repair device to
the neurovascular structures are different in each knee
position.2,6 For the MRI studies, the neurovascular risk of
all-inside meniscal repair was assessed on preoperative
MRI scans with the knee in extension or 90° of flexion
with no joint dilatation, which involves different distances
than the actual arthroscopic position (figure-of-4 with joint
dilatation) (Figure 1).1,3,5
To our knowledge, no previous studies have evaluated
the risk of the iatrogenic peroneal nerve and popliteal
artery injury based on the actual knee position during
operation. The purpose of this study was to compare the
risk of peroneal nerve injury in actual patients in ‘‘real-
life’’ surgical positions when repairing the lateral meniscal
tissue using the medial and lateral borders of the PT as
references through the anteromedial, anterolateral, and
transpatellar portals by measuring the closest distances
from the tip of the simulated straight all-inside meniscal
repair device to the peroneal nerve. We hypothesized
that (1) repairing the lateral meniscal tissue in relation
Figure 1. A magnetic resonance imaging scan of a knee in
(A) the extended position without joint dilatation and (B) fig-
ure-of-4 position with joint dilatation. The popliteal tendon
(PT), peroneal nerve (PN), and popliteal artery (PA) are out-
lined with white, yellow, and red, respectively.
to the lateral border of the PT through the anteromedial
portal would have a lower risk than through the anterolat-
eral and transpatellar portals, and (2) repairing the lateral
meniscal tissue in relation to the medial border of the PT
through the anterolateral portal would have a lower risk
than through the anteromedial and transpatellar portals.
METHODS
This prospective study was approved by the Ethics Com-
mittee of the Faculty of Medicine of Prince of Songkla Uni-
versity. The study enrolled 79 patients who underwent
arthroscopic anterior cruciate ligament reconstruction
between January 1, 2018, and December 31, 2020. Of
these, 50 patients who had associated medial or lateral
meniscal ligament injury, concomitant meniscal and/or
cartilage surgeries, or a history of knee surgery were
excluded.
After the operation, the patient was immediately taken
for a postoperative MRI of the knee. Before transferring
the patient to the MRI room, the joint fluid pressure was
maintained at 50 mmHg using an arthroscopic pump sys-
tem to maintain knee joint distention. The MRI of the
knee was done with the knee in the figure-of-4 position
with a varus force of 120 N to open the lateral compart-
ment of the knee joint, which is similar to the actual posi-
tion during arthroscopic lateral meniscal repair.
Preliminary scout MRI localizers of the knee in the fig-
ure-of-4 position were done in the axial, coronal, and sagit-
tal planes. Oblique axial images of the knee in the figure-

z
Address correspondence to Wachiraphan Parinyakhup, MD, Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, 15 Karn-
janavanich Road, Hat Yai, Songkhla 90110, Thailand (email: psu.wachi@gmail.com).
*Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
y
Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
Submitted October 11, 2021; accepted March 10, 2022.
One or more of the authors has declared the following potential conflict of interest or source of funding: Funding was received from the Faculty of Med-
icine, Prince of Songkla University (REC 60-180-11-1). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not
conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
1860 Chuaychoosakoon et al The American Journal of Sports Medicine

Figure 2. Axial drawings of a knee showing the measurements from the anteromedial (AM) portal to the lateral border of the pop-
liteal tendon (PT), the medial border of the PT, and the lateral border of the popliteal artery (PA). (A) First, a direct line L1 was
drawn from the AM portal to the lateral border of the PT, passing 14 mm beyond the joint capsule. The closest distance C1
was measured from the direct line L1 to the peroneal nerve (PN). Second, a direct line L2 was drawn from the AM portal to
the medial border of the PT, passing 14 mm beyond the joint capsule. The closest distance C2 was measured from the direct
line L2 to the PN. A direct line L3 was drawn from the AM portal to the lateral border of the PA. The safe zone was defined as
the area between the direct line L2 and the direct line L3 on the posterior edge (P1) of the lateral meniscus. (B) A risk of iatrogenic
peroneal injury was deemed if the direct line L1 or the direct line L2 passed through the PN. If there was a deemed risk of PN injury
from the direct line L1, the distance from the joint capsule to the border of the PN was measured (S1) and a direct line L11 was
drawn from the AM portal to the lateral border of the PN and the danger zone was defined as the area between the direct lines L1
and L11 (D1), and the safe zone was defined as the area beyond the danger zone at the level of the meniscocapsular junction. If
the direct line L2 passed through the PN, it was deemed to indicate a risk of iatrogenic PN injury. The distance from the joint
capsule to the border of the PN was measured (S2) and a direct line L21 was drawn from the AM portal to the medial border
of the PN, and the danger zone was defined as the area between the direct lines L2 and L21 (D2), and the safe zone was defined
as the area beyond the danger zone to the direct line L3 on the posterior edge (P1) of the lateral meniscus. AL, anterolateral; PV,
popliteal vein; TN, tibial nerve; TP, transpatellar.

of-4 position were obtained in a plane aligned to the tibial
plateau. The oblique axial slice, which included most of the
lateral meniscus, was used as the reference image for the
measurements (see Figure 1B).
The study evaluated the chance of iatrogenic peroneal
nerve injury during all-inside meniscal repair through
the anteromedial, anterolateral, and transpatellar portals
using the medial or lateral border of the PT as a landmark.
Anteromedial, anterolateral, and transpatellar portals
were simulated at the level of the meniscus. The medial
border of the patellar tendon was set as the anteromedial
portal and the lateral border of the patellar tendon was
set as the anterolateral portal, while the midpoint of the
patellar tendon was set as the transpatellar portal.
The depth of the needle tip of the all-inside meniscal
repair device for lateral meniscal repair is recommended to
be placed between 14 mm and 18 mm in the body and/or
posterior lateral meniscal repair area in surgical practice.
In this study, a direct line was used to simulate an all-
inside meniscal repair device, with the distal end of the
direct line representing the tip of the all-inside meniscal
repair device and extending 14 mm past the joint capsule.
Assessing the Risk of Peroneal Nerve Injury and the
Safe Zone From the Anteromedial, Anterolateral, and
Transpatellar Portals in Relation to the Medial and
Lateral Borders of the PT
A direct line (blue lines [L1, L2, L4, L5, L7, and L8] in Fig-
ures 2, 3, 4) was drawn from the anteromedial, anterolat-
eral, or transpatellar portal to the lateral or medial
border of the PT, terminating at a point 14 mm beyond
the joint capsule. The closest distance was measured
from each line to the border of the peroneal nerve (black
lines [C1, C2, C4, C5, C7, and C8] in Figures 2A, 3A, and
4A). In cases where this line crossed or contacted the pero-
neal nerve, indicating a deemed injury, the distance from
the joint capsule to the border of the peroneal nerve was
measured (yellow lines [S1, S2, S4, S5, S7, and S8] in
AJSM Vol. 50, No. 7, 2022 The Risk of Peroneal Nerve Injury in Lateral Meniscal Repair 1861

Figure 3. An axial drawing of a knee showing the measurements from the anterolateral (AL) portal to the lateral border of the
popliteal tendon (PT), the medial border of the PT, and the lateral border of the popliteal artery (PA). (A) First, a direct line L4
was drawn from the AL portal to the lateral border of the PT, passing 14 mm beyond the joint capsule. The closest distance
C4 was measured from the direct line L4 to the peroneal nerve (PN). Second, a direct line L5 was drawn from the AL portal to
the medial border of the PT, passing 14 mm beyond the joint capsule. The closest distance C5 was measured from the direct
line L5 to the PN. A direct line L6 was drawn from the AL portal to the lateral border of the PA. The safe zone was defined as
the area between the direct line L5 and the direct line L6 on the posterior edge (P2) of the lateral meniscus. (B) A risk of iatrogenic
peroneal injury was deemed if the direct line L4 or the direct line L5 passed through the PN. If there was a deemed risk of PN injury
from the direct line L4, the distance from the joint capsule to the border of the PN was measured (S4) and a direct line L41 was
drawn from the AL portal to the lateral border of the PN and the danger zone was defined as the area between the direct lines L4
and L41 (D4), and the safe zone was defined as the area beyond the danger zone at the level of the meniscocapsular junction. If
the direct line L5 passed through the PN, it was deemed to indicate a risk of iatrogenic PN injury. The distance from the joint
capsule to the border of the PN was measured (S5) and a direct line L51 was drawn from the AL portal to the medial border
of the PN, and the danger zone was defined as the area between the direct lines L5 and L51 (D5), and the safe zone was defined
as the area beyond the danger zone to the direct line L6 on the posterior edge (P2) of the lateral meniscus. AM, anteromedial; PV,
popliteal vein; TN, tibial nerve; TP, transpatellar.

Figures 2B, 3B, and 4B), and a new direct red line was
drawn from the same portal to the border of the peroneal
nerve (red lines [L11, L21, L41, L51, L71, and L81] in Fig-
ures 2B, 3B, and 4B). The ‘‘danger zone’’ was defined as the
area between the initial line (blue line) and the new line
(red line) at the level of the meniscocapsular junction
(red-shaded areas [D1, D2, D4, D5, D7, and D8] in Figures
2B, 3B, and 4B) and the ‘‘safe zone’’ was defined as the area
beyond the danger zone (green-shaded areas in Figures 2B,
3B, and 4B).
Assessing the Safe Zone to Prevent Popliteal Artery
Injury From the Anteromedial, Anterolateral, and
Transpatellar Portals in Relation to the Medial Border
of the PT
A direct line was drawn from the anteromedial, anterolat-
eral, or transpatellar portal to the lateral border of the pop-
liteal artery, passing 14 mm through the joint capsule
(purple lines [L3, L6, and L9] in Figures 2B, 3B, and 4B).
The safe zone was defined as the area between the direct
line (blue lines [L2, L5, and L8] in Figures 2B, 3B, and
4B) and the direct line (purple lines [L3, L6, and L9] in
Figures 2B, 3B, and 4B) on the posterior edge (green lines
[P1, P2, and P3] in Figures 2A, 3A, and 4A) of the lateral
meniscus.
If the direct line (blue lines [L2, L5, and L8] in Figures
2B, 3B, and 4B) passed through the peroneal nerve, the
safe zone (green shade [P1, P3, and P3] in Figures 2B,
3B, and 4B) was defined as the area between the direct
line (red lines [L21, L51, and L81] in Figures 2B, 3B, and
4B) and the direct line (purple lines [L3, L6, and L9] in Fig-
ures 2B, 3B, and 4B) on the posterior edge of the lateral
meniscus.
All distances were measured 3 times by 2 experienced
musculoskeletal radiologists (P.T. and T.L.). Interobserver
and intraobserver reliabilities were assessed by calculating
Kappa and intraclass correlation coefficient values for cat-
egorical and continuous measurements, respectively. The
findings are presented using descriptive statistics (means
6 SDs) and incidence risk ratios. Statistical analysis was
performed with the R program and epicalc package (Ver-
sion 3.4.3; R Foundation for Statistical Computing). The
statistical significance of the deemed risks of iatrogenic
peroneal nerve injury was assessed using the chi-square
test of independence and associations, with P \ .05 consid-
ered to be statistically significant.
1862 Chuaychoosakoon et al The American Journal of Sports Medicine

Figure 4. An axial drawing of a knee showing the measurements from the transpatellar (TP) portal to the lateral border of the
popliteal tendon (PT), the medial border of the PT, and the lateral border of the popliteal artery (PA). (A) First, a direct line L7
was drawn from the TP portal to the lateral border of the PT, passing 14 mm beyond the joint capsule. The closest distance
C7 was measured from the direct line L7 to the peroneal nerve (PN). Second, a direct line L8 was drawn from the TP portal to
the medial border of the PT, passing 14 mm beyond the joint capsule. The closest distance C8 was measured from the direct
line L8 to the PN. A direct line L9 was drawn from the TP portal to the lateral border of the PA. The safe zone was defined as
the area between the direct line L8 and the direct line L9 on the posterior edge (P3) of the lateral meniscus. (B) A risk of iatrogenic
peroneal injury was deemed if the direct line L7 or the direct line L8 passed through the PN. If there was a deemed risk of PN injury
from the direct line L7, the distance from the joint capsule to the border of the PN was measured (S7) and a direct line L71 was
drawn from the TP portal to the lateral border of the PN and the danger zone was defined as the area between the direct lines L7
and L71 (D7), and the safe zone was defined as the area beyond the danger zone at the level of the meniscocapsular junction. If
the direct line L8 passed through the PN, it was deemed to indicate a risk of iatrogenic PN injury. The distance from the joint
capsule to the border of the PN was measured (S8); a direct line L81 was drawn from the TP portal to the medial border of
the PN; the danger zone was defined as the area between the direct lines L8 and L81 (D8); and the safe zone was defined as
the area beyond the danger zone to the direct line L9 on the posterior edge (P3) of the lateral meniscus. AM, anteromedial;
AL, anterolateral; PV, popliteal vein; TN, tibial nerve.

RESULTS 5A). There was a statistically significant difference in the

Overall, 29 knee MRI scans (26 men and 3 women) were
included in the study. The mean age of the patients was
31.4 6 10.7 years. Of the 29 MRI scans, 2 were of knees
that had undergone surgery to remove a loose body, and
27 were of knees that had a reconstructed anterior cruciate
ligament.
We found essentially zero risk when repairing the lat-
eral meniscal tissue through the anteromedial portal in
relation to the lateral border of the PT or the anterolateral
portal in relation to the medial border of the PT.
The Risk of Peroneal Nerve Injury and the Safe Zone in
Relation to the Lateral Border of the PT
There was also no risk of iatrogenic peroneal nerve injury
when repairing the lateral meniscus through the antero-
medial portal in relation to the lateral border of the PT,
while the risks of iatrogenic peroneal nerve injury in all-
inside lateral meniscal repair in relation to the lateral bor-
der of the PT through the anterolateral and transpatellar
portals were 13.79% and 12.07%, respectively (Figure
risk of iatrogenic peroneal nerve injury between repairing
through the anteromedial and anterolateral portals (P =
.010) and between repairing through the anteromedial
and transpatellar portals (P = .019); however, there was
no statistically significant difference between repairing
through the anterolateral and transpatellar portals (P =
.999). In cases of iatrogenic peroneal nerve injury related
to the lateral border of the PT, the mean distances from
the joint capsule to the border of the peroneal nerve in
repairing through the anterolateral and transpatellar por-
tals were 11.64 6 2.26 mm and 10.44 6 2.11 mm, respec-
tively. The mean closest distances from the simulated all-
inside meniscal repair device to the border of the peroneal
nerve in repairing through the anteromedial (C1), antero-
lateral (C4), and transpatellar (C7) portals were 17.26 6
10.71 mm, 9.03 6 7.60 mm, and 12.83 6 10.12 mm,
respectively.
The safe zones in repairing the lateral meniscal tissue
in relation to the lateral border of the PT through the ante-
rolateral portal and the transpatellar portal were beyond
1.96 6 0.62 mm laterally from the lateral border of the
PT and beyond 1.87 6 0.46 mm laterally from the lateral
border of the PT, respectively (Figure 6).
AJSM Vol. 50, No. 7, 2022
Figure 5. Axial drawings of a knee showing the risk of iatrogenic peroneal nerve (PN) injury during all-inside lateral meniscal repair
in relation to (A) the lateral and (B) medial borders of the popliteal tendon (PT) through the anteromedial (AM), anterolateral (AL),
and transpatellar (TP) portals. The black, red, and blue lines simulate a straight all-inside meniscal repair device inserted through
the AM, AL, and TP portals, respectively. PA, popliteal artery; PV, popliteal vein; TN, tibial nerve.
The Risk of Peroneal Nerve Injury and the Safe Zone in
Relation to the Medial Border of the PT
There was no risk of iatrogenic peroneal nerve injury in
repairing the lateral meniscus through the anterolateral
portal in relation to the medial border of the PT, while
the risks of iatrogenic peroneal nerve injury during all-
inside lateral meniscal repair in relation to the medial bor-
der of the PT through the anteromedial and transpatellar
portals were 22.41% and 12.07%, respectively (Figure
5B). There was a statistically significant difference in the
risk of iatrogenic peroneal nerve injury between repairing
through the anterolateral and anteromedial portals (P \
.001) and between repairing through the anterolateral
and transpatellar portals (P = .019). However, the differ-
ence between repairing through the anteromedial and
transpatellar portals was not statistically significant (P =
.219). In cases of iatrogenic peroneal nerve injury related
to the medial border of the PT, the mean distances from
the joint capsule to the border of the peroneal nerve in
repairing through the anteromedial and transpatellar por-
tals were 10.57 6 0.76 mm and 11.37 6 0.72 mm, respec-
tively. The mean closest distances from the simulated all-
inside meniscal repair device to the border of the peroneal
nerve in repairing through the anteromedial (C2), antero-
lateral (C5), and transpatellar (C8) portals were 9.20 6
5.54 mm, 12.99 6 7.26 mm, and 9.48 6 6.33 mm,
respectively.
The safe zone in repairing the lateral meniscal tissue in
relation to the medial border of the PT through the antero-
medial portal (P1) was between 2.71 6 0.66 mm and 15.84
6 4.52 mm medially from the medial border of the PT;
through the anterolateral portal (P2) was between the
medial border of the PT and 9.62 6 4.60 mm medially
from the same border; and through the transpatellar portal
The Risk of Peroneal Nerve Injury in Lateral Meniscal Repair 1863
(P3) was between 1.76 6 0.95 mm and 12.22 6 4.90 mm
medially from the medial border of the PT (Figure 6).
There were high interobserver and intraobserver corre-
lations. The Kappa correlation coefficient of all assess-
ments ranged between 0.71 and 0.99, and the intraclass
correlation coefficient of all assessments ranged from
0.69 to 0.99.
DISCUSSION
In our study, we found that when simulating lateral menis-
cal tissue repair using a simulated all-inside meniscal
repair device through the anteromedial, anterolateral, or
transpatellar portal, there was a risk of iatrogenic peroneal
nerve injury. Repairing the lateral meniscal tissue in rela-
tion to the lateral border of the PT through the anterome-
dial portal was safer than through both anterolateral and
transpatellar portals, but repairing the lateral meniscal
tissue in relation to the medial border of the PT through
the anterolateral portal was safer than through both the
anteromedial and the transpatellar portals. The interob-
server reliability of the measurements between the 2 mus-
culoskeletal radiologists who did all measurements ranged
from substantial to almost perfect agreement.
An all-inside meniscal repair device can endanger the
peroneal nerve when the repair involves damage close to
the medial and/or lateral borders of the PT and the tear
type warrants meniscocapsular repair because the pero-
neal nerve is located at the posterolateral aspect of the
knee joint. There have been several cadaveric and MRI-
based studies that evaluated the risk of iatrogenic peroneal
nerve injury during lateral meniscal repair2,5,6,12,13,18,21;
however, the results of these studies may not have accu-
rately represented the true operative situation. The
1864 Chuaychoosakoon et al
Figure 6. The safe and danger zones in repairing the lateral meniscal tissue in relation to the lateral and medial borders of the
popliteal tendon (PT) through the (A) anteromedial (AM), (B) anterolateral (AL), and (C) transpatellar (TP) portals. PA, popliteal
artery; PN, peroneal nerve; PV, popliteal vein; TN, tibial nerve.
cadaveric studies may have been inaccurate because they
all used midleg to midthigh cadaveric sections, which
would have less than normal muscle and neurovascular
tensions, and also were not evaluated in the actual surgical
figure-of-4 arthroscopic position. There are similar prob-
lems with the previous MRI-based studies, which again
would have questionable findings because the MRI images
were taken with the knee in a slightly flexed position or 90°
flexed position without knee joint dilatation, which again
does not reflect the actual operative arthroscopic position.
Only 1 previous cadaveric study6 and 1 MRI-based
study5 evaluated the risk of peroneal nerve injury related
to the PT. Cuéllar et al6 based their study on midthigh to
midleg cadaveric limbs at 0°, 45°, and 90° of knee flexion
and found that all-inside lateral meniscal repair via the
anterolateral portal was safer than via the anteromedial
portal. In that study, the mean distances between the
medial border of the PT and the peroneal nerve at 0°,
The American Journal of Sports Medicine
45°, and 90° of knee flexion were 7.0 6 4.0 mm, 12.0 6
4.3 mm, and 16.0 6 3.3 mm, respectively. The weakness
of this cadaveric study was that it did not evaluate the dis-
tances with the knee in the figure-of-4 position with appro-
priate varus force, which is the actual arthroscopic
situation for lateral meniscal repair. The previous MRI
study5 evaluated the risk of iatrogenic peroneal nerve
injury related to the medial and lateral borders of the PT
with the knee in a slightly flexed position and found
a risk of iatrogenic peroneal nerve injury in repairing the
lateral meniscal tissue through both the anteromedial
and the anterolateral portals related to both the medial
and the lateral borders of the PT. They found that repair-
ing the lateral meniscal tissue in relation to the medial bor-
der of the PT through the anterolateral portal was safer
than through the anteromedial portal; however, the ante-
rolateral portal was more dangerous than the anterome-
dial portal in repairing the lateral meniscal tissue in
AJSM Vol. 50, No. 7, 2022 The Risk of Peroneal Nerve Injury in Lateral Meniscal Repair
relation to the lateral border of the PT. Our findings eval-
uating the risk of peroneal nerve injury in the figure-of-4
position with joint dilatation were different from the
cadaveric and MRI-based studies. To decrease the risk of
iatrogenic peroneal nerve injury, we recommend repairing
the lateral meniscal tissue through the anteromedial por-
tal in the area lateral to the lateral border of the PT, and
using the anterolateral portal in the area medial to the
medial border of the PT, as we found no incidence of pero-
neal nerve injury using either of these approaches. For
additional safety, the surgeon should repair the body of
the lateral meniscal tissue in the safe zones our study iden-
tified to avoid the risk of peroneal nerve injury. The safe
zones in repairing the lateral meniscal tissue via the ante-
rolateral and transpatellar portals in relation to the lateral
border of the PT began at 1.96 6 0.62 mm and 1.87 6
0.46 mm from the lateral border of the PT, respectively.
Also, the safe zones in repairing the lateral meniscal tissue
via the anteromedial and transpatellar portals in relation
to the medial border of the PT were medial to the medial
border of the PT 2.71 6 0.66 mm and 1.76 6 0.95 mm,
respectively. However, to repair the lateral meniscal tissue
related to the lateral border of the PT through the antero-
lateral or transpatellar portal, the surgeon should ensure
that the all-inside meniscal repair device does not pene-
trate beyond the joint capsule more than 11.64 6
2.26 mm or 10.44 6 2.11 mm, respectively. Moreover, in
relation to the medial border of the lateral meniscal tissue,
the surgeon should not allow the all-inside meniscal repair
device to penetrate beyond the joint capsule further than
10.57 6 0.76 mm through the anteromedial portal and
11.37 6 0.72 mm through the transpatellar portal.
There is a risk of iatrogenic popliteal artery injury in
repairing the posterior horn of the lateral meniscus. In
cadaveric studies, Mao et al12 and Massey et al13 compared
the risk of popliteal artery injury during all-inside menis-
cal repair between repairing through the anteromedial
and anterolateral portals in cadaveric knees dissected mid-
thigh to midleg and found that repairing through the ante-
rolateral portal had a greater risk of inadvertent injury to
the popliteal artery than through the anteromedial portal.
Gilat et al8 evaluated the risk of iatrogenic popliteal artery
injury based on MRI scans with the knee in slight flexion
and found that passing a simulated straight meniscal
repair device close to the posterior cruciate ligament via
both the anteromedial and the anterolateral portals
incurred a risk of iatrogenic popliteal artery injury.
Because a popliteal artery injury can cause serious morbid-
ity and even mortality in rare cases, our study evaluated
the safe zone in repairing the posterior lateral meniscal tis-
sue to decrease the chance of iatrogenic popliteal artery
injury in relation to the medial border of the PT, which is
easy to identify during arthroscopic surgery. We found
that the safe zone was greater when repairing the posterior
meniscal tissue through the anteromedial portal than
when repairing it through the anterolateral or transpatel-
lar portal. The safe zone in repairing the lateral meniscal
tissue using the medial border of the PT through the ante-
romedial portal was between 2.71 6 0.66 mm and 15.84 6
4.52 mm medially from the medial border of the PT. If the
1865
posterior horn of the lateral meniscus must be repaired in
a danger zone, the surgeon should not use a penetration
depth of the tip of the all-inside meniscal repair device
more than 8.8 6 0.8 mm or 8.0 6 0.9 mm when repairing
through the anteromedial or the anterolateral portal,
respectively.14 Additionally, the surgeon can use the ratio
of the tip penetration depth to the knee circumference (at
the joint level) to determine the safety penetration depth
of the needle—it is safe if the ratio1 is \ 0.05.
Our study had some limitations. First, the PT runs
obliquely when passing the knee joint, which can lead to
measurement variations. We minimized the effect of such
differences by using axial MRI images passing through
the center of the meniscus. Second, we used a direct line
to simulate a direct all-inside meniscal repair device, and
the risk of iatrogenic peroneal nerve injury may be differ-
ent when using a curved all-inside meniscal repair device.
Third, applying the results from this study in clinical prac-
tice through the anteromedial portal may meet interfer-
ence from intra-articular structures, such as the lateral
femoral condyle or the tibial spine, which can interfere
with the proper deployment of the all-inside meniscal
repair device. Fourth, the surgeon should exercise caution
when using the findings of this study to create portals in
different locations because different approaches may
require different distances.
CONCLUSION
There is a risk of iatrogenic peroneal nerve injury during
lateral meniscal repair. Our detailed study found, how-
ever, that it is safe to repair the body of the lateral menis-
cus through the anteromedial portal in the area lateral to
the lateral border of the PT or through the anterolateral
portal in the area medial to the medial border of the PT.
ACKNOWLEDGMENT
The authors sincerely thank Boonsin Tangtrakulwanich of
the Department of Orthopedics, Faculty of Medicine of Prince
of Songkla University and Bancha Chernchujit of the Depart-
ment of Orthopedics, Faculty of Medicine of Thammasat Uni-
versity for their suggestions on studying the safety knowledge
gap in lateral meniscal repairs; and Nannapat Pruphetkaew
of the Epidemiology Unit, Faculty of Medicine of Prince of
Songkla University, for providing statistical support; Kon-
warat Ninlachart for assistance with the demonstration
drawings; and Dave Patterson for his editing support.
ORCID iD
Chaiwat Chuaychoosakoon https://orcid.org/0000-0001-
7537-1306
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