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Hidden Lesions of the Posterior Horn of the Medial Meniscus A Systematic

Arthroscopic Exploration of the Concealed Portion of the Knee

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Hidden Lesions of the Posterior

Horn of the Medial Meniscus
A Systematic Arthroscopic Exploration
of the Concealed Portion of the Knee
Bertrand Sonnery-Cottet,*y MD, Jacopo Conteduca,y MD, Mathieu Thaunat,y MD,
Francxois Xavier Gunepin,z MD, and Romain Seil,§|| MD, PhD
Investigation performed at the Centre Orthopédique Santy and Hôpital Privé Jean Mermoz,
Lyon, France

Background: Anterior cruciate ligament (ACL) tears are frequently associated with meniscal lesions. Despite improvements in
meniscal repair techniques, failure rates remain significant, especially for the posterior horn of the medial meniscus.
Purpose: To determine whether a systematic arthroscopic exploration of the posterior horn of the medial meniscus with an addi-
tional posteromedial portal is useful to identify otherwise unrecognized lesions.
Study Design: Case series; Level of evidence, 4.
Methods: In a consecutive series of 302 ACL reconstructions, a systematic arthroscopic exploration of the posterior horn of the
medial meniscus was performed. The first stage of the exploration was achieved through anterior visualization via a standard
anterolateral portal. In the second stage, the posterior horn of the medial meniscus was visualized posteriorly via the anterolateral
portal with the scope positioned deep in the notch. In the third stage, the posterior horn was probed through an additional poster-
omedial portal. A x2 test and logistic regression analysis were performed to determine if the time from injury to surgery was asso-
ciated with the meniscal tear pattern.
Results: A medial meniscal tear was diagnosed in 125 of the 302 patients (41.4%). Seventy-five lesions (60%) located in the
meniscal body were diagnosed at the first stage of the arthroscopic exploration. Fifty lesions located in the ramp area were diag-
nosed: 29 (23.2%) at the second stage and 21 lesions (16.8%) at the third stage after minimal debridement of the superficial soft
tissue layer. The latter type of lesion is called a ‘‘hidden lesion.’’ Altogether, the prevalence of ramp lesions in this population was
40%. Meniscal body lesions (odds ratio, 2.6; 95% confidence interval, 1.18-5.18; P \ .02) were found to be significantly corre-
lated with a longer delay between injury and surgery.
Conclusion: Posterior visualization and posteromedial probing of the posterior horn of the medial meniscus can help in discov-
ering a higher rate of lesions that could be easily missed through a standard anterior exploration. In numerous cases, these le-
sions were ‘‘hidden’’ under a membrane-like tissue and were discovered after minimal debridement through a posteromedial
portal.
Keywords: anterior cruciate ligament; meniscal lesion; meniscosynovial; meniscocapsular; ramp lesion; hidden lesion

The prevalence of meniscal lesions in anterior cruciate lig-
ament (ACL) tears has been shown to be between 47% to
61% in ACL registries.1,16 The most common intra-
articular lesion associated with ACL ruptures involves
the posterior horn of the medial meniscus (MM).24 Specific
types of lesions of the MM such as meniscosynovial or
meniscocapsular tears cannot be diagnosed arthroscopi-
cally from the anterior compartment. These lesions have
been described in the 1980s by Strobel,31 who called
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546514522394
Ó 2014 The Author(s)
them ‘‘ramp’’ lesions. Increased attention has been paid
to this entity over the past few years.2,7,21,28 It has been
shown that they are associated with ACL tears 9% to
17% of the time,7,21 and they cannot be recognized on pre-
operative magnetic resonance imaging (MRI) scans.7,21,28
To visualize them properly, the posterior compartment
needs to be inspected. Various methods have been
described to improve visualization of the posteromedial
corner of the knee.5,6,11,14,20,21,32 Several techniques and
good clinical results have been described for meniscal
repairs via an additional posteromedial portal.2,4,23,27
The purpose of this article is to describe the systematic
surgical exploration required to avoid missing these
lesions. Our first hypothesis was that a systematic

1
2 Sonnery-Cottet et al The American Journal of Sports Medicine

arthroscopic exploration of the posterior horn of the MM

with an additional posteromedial portal is essential to
identify these otherwise unrecognized lesions arthroscopi-
cally. The second hypothesis was that visualization alone
is in some cases insufficient to recognize meniscocapsular
lesions, which may be hidden under synovial or scar tissue.

MATERIALS AND METHODS

Between August 2012 and January 2013, a consecutive
series of 302 primary ACL reconstructions performed by
the first author (B.S.-C.) with a systematic exploration of
the posteromedial compartment were evaluated. All
patients presented after a knee trauma with clinical, radio-
graphic, and MRI signs of an ACL tear. All of them were
unable to resume their previous level of activity because
of instability symptoms and were scheduled for ACL recon-
struction. Exclusion criteria were ACL revision proce-
dures, knee dislocations, major concomitant procedures
such as high tibial osteotomy or other knee ligament recon-
structions, and previous partial meniscectomy. This study
received institutional review board approval.
Surgical Exploration
During the procedure, the patients were placed supine on the
operating table with a tourniquet placed high on the thigh.
The knee was placed at 90° of flexion with a foot support to
allow for full range of knee motion. We used a standard
high lateral parapatellar portal for the arthroscope and
a medial parapatellar portal for the instruments.29 The pres-
ence of medial and lateral meniscal tears was documented.
A systematic arthroscopic exploration and repair of the
MM were performed in 4 steps with a classic 30° arthro-
scope, as follows.21
Step 1: Standard Arthroscopic Exploration. The pres-
ence of a meniscal tear and its pattern were evaluated
through standard anterior visualization via an anterolat-
eral portal with meticulous probing of the meniscal tissue
(Figure 1A).
Step 2: Exploration of Posteromedial Compartment. To
gain access to the posteromedial compartment, the arthro-
scope was introduced through the anterolateral portal
deeply into the notch and underneath the posterior cruci-
ate ligament. Sometimes, the assistance of a blunt trocar
was necessary if the passage of the camera was difficult.
In this position, the optical lens is rotated to allow for
good visualization of the posteromedial compartment and
especially the meniscocapsular junction to assess the pres-
ence of a ramp lesion. A 70° arthroscope was not required
in any of the cases.
Figure 1. (A) Anterior translation of the posterior horn of the
medial meniscus (MM) during anterior probing. (B) Visualiza-
tion of the posterior compartment and exploration of a super-
ficial layer with a needle. (C) After minimal debridement, (D)
discovery of a ‘‘hidden’’ lesion of the MM.
Step 3: Creation of Posteromedial Portal. A standard
posteromedial portal was created under direct arthroscopic
visualization of the posteromedial capsule. The entry point
was localized with a needle to find a safe entry point. Then,
a skin incision and subcutaneous dissection were per-
formed. The portal entry was just above the meniscus,
proximal to the medial femoral condyle. The posterior
horn of the MM was explored with a needle or a probe to
detect an eventual ramp lesion (Figure 1B). The posterior
horn could be directly visualized by switching the arthro-
scope to the posteromedial portal.
Step 4: Meniscal Repair Procedure. Suture repairs of
a ramp or hidden lesion of the posterior horn of the MM
were performed with the use of a suture hook device
(QuickPass suture lasso; Arthrex, Naples, Florida, USA)
introduced through the posteromedial portal. The suture
hook was passed in 1 step from superior to inferior in the
posterior meniscal fragment and then from inferior to
superior in the anterior meniscal fragment. A suture relay
was first introduced through the suture hook device and
retrieved with an arthroscopic suture grasper through
the posteromedial portal. A nonabsorbable suture secured
to the suture relay was passed through the meniscus and
knotted with an arthroscopic knot pusher.

*Address correspondence to Bertrand Sonnery-Cottet, MD, Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008 Lyon, France (e-mail:
sonnerycottet@aol.com).
y
Centre Orthopédique Santy and Hôpital Privé Jean Mermoz, Lyon, France.
z
Clinique Mutualiste de la Porte de l’Orient, Lorient, France.
§
Sports Medicine Research Laboratory, Public Research Centre for Health, Luxembourg, Luxembourg.
||
Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg–Clinique d’Eich, Luxembourg, Luxembourg.
One or more of the authors has declared the following potential conflict of interest or source of funding: B.S.-C. is a paid consultant, receives research
support, and has made presentations for Arthrex. M.T. is a paid consultant, receives research support, and has made presentations for Arthrex.
Vol. XX, No. X, XXXX
TABLE 1
Association Between Time From Injury to Surgery and Incidence of Meniscal Lesionsa
Time From Injury to Surgery
\6 wk (n = 62)
Overall meniscal lesion (n = 177) 32 (51.6)
Lateral meniscal lesion (n = 52) 12 (19.3)
Medial meniscal lesion (n = 125) 20 (32.2)
Medial meniscal ramp lesion 12 (19.3)
Medial meniscal body lesion 8 (12.9)
a
Values are expressed as n (%) unless otherwise indicated. P \ .05 considered to be statistically significant. OR, odds ratio.
Figure 2. Flowchart of the arthroscopic diagnosis of tears of
the medial meniscus (MM). PM, posteromedial.
The presence of a medial or lateral meniscal tear was
documented for each patient. For a medial meniscal tear,
the arthroscopic exploration step at which the tear diagno-
sis was effectively performed and the tear location were reg-
istered. The latter was described as a ramp lesion when it
was located at the peripheral attachment (synovial-menis-
cal junction or red-red zone),21 while other meniscal lesions
were defined as lesions of the meniscal body.
Statistical Analysis
Statistical analysis was performed using Epi Info software v
3 (Centers for Disease Control and Prevention, Atlanta,
Georgia, USA). To determine if the time from injury to sur-
gery was associated with the meniscal tear pattern, the
patients were divided into 2 groups (time to surgery \6
weeks and .6 weeks). A x2 test was performed to identify
associations with the overall meniscal lesion, the group of
medial meniscal lesions, the group of lateral meniscal
lesions, the group of medial meniscal ramp lesions, and
the group of medial meniscal body lesions. Associations
were reported as the odds ratio (OR) with a 95% confidence
interval (CI). A P value of .05 was considered as significant.
Lesions of the Posterior Horn of the Medial Meniscus 3
.6 wk (n = 240) OR 95% CI P Value
145 (60.4) 1.43 0.82-2.50 ..20
40 (16.6) 0.83 0.41-1.70 ..50
105 (43.7) 1.63 0.90-2.94 ..10
38 (15.8) 0.78 0.38-1.60 ..30
67 (27.9) 2.60 1.18-5.18 \.02
RESULTS
A total of 302 patients who underwent ACL reconstruc-
tions (238 men and 64 women) were included in the study.
The mean patient age at the time of surgery was 28 years
(range, 14-57 years). The mean time from injury to surgery
was 9.7 months (range, 0-202 months). We found a total of
125 medial (41.4%) and 52 (17.2%) lateral meniscal tears.
Both a medial and a lateral meniscal tear were found in
26 patients (8.6%). Among the 125 tears of the MM, 75
(60%) medial meniscal body lesions were diagnosed
through a standard anterior portal exploration, 29
(23.2%) ramp lesions were diagnosed during exploration
of the posteromedial compartment, and 21 (16.8%) were
discovered at step 3 by probing the tear through a postero-
medial portal and after minimal debridement of a superfi-
cial soft tissue layer with a motorized shaver. This type of
lesion is called a ‘‘hidden lesion’’ (Figure 1, C and D). A
flowchart of the arthroscopic diagnosis of medial meniscal
tears is presented (Figure 2).
Among the 125 lesions of the MM, we performed 96
(76.8%) suture repairs. Forty-six were repaired through
the anteromedial portal with all-inside meniscal suture
anchors. The other 50 lesions corresponding to peripheral
tears of the posterior horn (ramp and hidden lesions)
were repaired through the posteromedial portal with
a suture hook device (QuickPass suture lasso) (Figure 3).
Partial meniscectomy had to be performed in 23
patients (18.4%) for irreparable tears. In 6 cases, the lesion
was stable and left in place. No specific complication
related to the posteromedial approach was encountered
in this series.
Meniscal body lesions (OR, 2.6; 95% CI, 1.18-5.18; P \
.02) were found to be significantly correlated with the
time from injury to surgery beyond 6 weeks. There was
no association with time from injury to surgery for the
other types of meniscal lesions (Table 1).
DISCUSSION
The most important finding of this study was that the
application of a systematic surgical algorithm including
posteromedial inspection and probing has improved the
diagnostic accuracy of the lesions in the posterior horn of
4 Sonnery-Cottet et al The American Journal of Sports Medicine

Figure 3. (A) Suture of the posterior horn of the medial meniscus through the anteromedial portal with a hybrid suture. (B) Poster-
omedial view of the anchor unable to flip behind the posterior rim. (C, D) Suture through the posteromedial portal with a hook. (E)
Suture relay and (F) final suture with a nonabsorbable suture.

Figure 4. Hidden lesion of the posterior horn of the medial meniscus.

the MM. In this way, we were able to confirm the presence
of a tear in 50 (40%) of the 125 lesions of the MM, many of
which would have been possibly missed through standard
anterior portals.4,28 Also, 42% (21/50) of the lesions diag-
nosed via inspecting the posterior compartment appeared
only after superficial soft tissue debridement and were
classified as ‘‘hidden lesions.’’
In some cases, these lesions could be suspected by ante-
rior probing, revealing a slightly increased mobility of the
undersurface of the MM, which may have been classified
previously as partial meniscal tears. So far, the analyses
of the function of the meniscotibial ligament and the differ-
entiation of injuries to this specific zone have been insuffi-
cient in the orthopaedic literature. Anatomically, the
circumferential collagen fibers of the medial meniscal
body are prolonged posteriorly to the meniscotibial
ligament, which attaches to the subchondral bone of the
tibia distal to the joint space. This structure represents
a fibrocartilaginous transitional zone, possibly assisting
with the progressive stiffness transition between ligamen-
tous and bony tissues. The posterior horn is well attached
to the tibia, preventing its posterior displacement during
knee motion. Damage to the posterior part, involving the
posteromedial corner and/or the posterior meniscotibial
ligament, could lead to instability of the posterior horn.22
One can hypothesize that hidden lesions represent an
injury to the meniscotibial ligament (Figure 4), which
may be suspected but not confirmed from an anterior por-
tal by visualization. Viewing the posteromedial structures
and additional probing of the meniscosynovial region
through a posteromedial compartment can help in assess-
ing the integrity of this transitional zone and the amount
Vol. XX, No. X, XXXX
of proximal extension of the lesion in the meniscus. With-
out this thorough inspection and palpation, these lesions
would otherwise easily remain undiagnosed and may prog-
ress over time.19 Although these lesions were initially
described in the 1980s by Strobel31 and early repair techni-
ques were developed by Morgan23 in the early 1990s, they
received little attention in later years and are still
unknown to many surgeons.7
Multiple studies have shown a high tear rate of the pos-
terior horn of the MM in ACL-deficient knees. Several of
them have also shown that the majority of errors in arthro-
scopic diagnoses result from the failure to recognize
peripheral tears of the posterior horn of the MM, which
are not adequately visualized from anterior por-
tals.13,15,17,18,32 Ireland et al17 demonstrated a 5.8% inci-
dence of failure to diagnose tears of the posterior horn of
the MM in a series of 135 knee arthroscopic surgeries
and emphasized the difficulty in visualizing the posterior
third of the MM as a result of obstruction by the medial
femoral condyle. Gillies and Seligson13 reported a 14% inci-
dence and Kimori et al18 reported a 15% incidence of over-
looked tears of the posterior horn of the MM at
arthroscopic surgery. Bollen7 recently described a series
of meniscocapsular lesions, which could be diagnosed
only by a systematic inspection of the posterior compart-
ment. These lesions were associated with ACL injuries
and were present in 9.3% of their prospective series of
183 ACL reconstructions. A combined mild anteromedial
rotatory subluxation was suspected in this group. Liu
et al21 described a prevalence of 16.6% in a series of
868 consecutive arthroscopic ACL reconstructions. This
corresponds exactly to the rate of lesions that we identi-
fied through direct visualization and probing of the post-
eromedial compartment in our series. In contrast with
Liu et al,21 we did not find a higher prevalence of ramp
lesions in patients with chronic tears (.6 weeks). This
difference may be because of the low number of patients
with a time from injury to surgery of longer than 1 year
in our series (19% vs 36% in Liu et al21). In the acute
group (\6 weeks), we found a higher rate of ramp lesions
(19.3% vs 12.7% in Liu et al21). This difference may be
caused by the additional diagnosis of hidden ramp lesions
in our series.
The question of how to improve the accuracy of the
arthroscopic diagnosis of lesions of the posterior horn of
the MM is not new. Carson9 suggested that most of the
problems created by the tight knee can be solved by simply
adhering to a good surgical technique and using a leg holder
for joint distraction, a large inflow cannula, and good surgi-
cal equipment. Another solution consists of pie crusting of
the medial collateral ligament11,26 to open a narrow medial
joint space. Although this allows for improved anterior visu-
alization, it does not offer a good view of the peripheral area
of the posterior horn of the MM. Visualization of the trans-
condylar notch with a 70° arthroscope can also be used to
enhance the field of vision of the posterior compartment.6
Our experience indicates that even when these recommen-
dations are implemented, there are still many knees in
which the posteromedial corner remains impossible to eval-
uate properly via anterior portals only.
Lesions of the Posterior Horn of the Medial Meniscus 5
Despite the development of new devices, the failure rate
of repairs of the posterior horn of the MM remains
high.10,28 With classic anterior portals, a failure to visual-
ize the posterior horn of the MM may result in a lack of bio-
logical debridement of the lesion, and hybrid suture
anchor placement may risk becoming a blind procedure.
Furthermore, with visualization from anterior portals
alone, it is not always possible to ensure achieving com-
plete closure of the lesion. The risk is to fail to flip the
anchors in the gap between the central and peripheral
zones of the injured meniscus and to leave the lesion
open (Figure 3B). Moreover, without an excellent view
of the lesion, the meniscal repair devices may induce dif-
ferent complications such as migration or breakage of the
implant,8,33 leading to iatrogenic cartilage damage.30
Hence, in our opinion, a better healing rate of lesions of
the posterior horn of the MM may be expected through
better visualization, allowing for an improved diagnosis,
improved quality of debridement before the repair,3,12,25
and control of complete closure of the lesion through
a posteromedial portal with a simple suture without an
anchor (Figure 3).4
The main strength of our study is the detailed prospec-
tive documentation of arthroscopic findings in a large num-
ber of patients who underwent ACL reconstruction.
Weaknesses of this study include the absence of correlation
studies to evaluate an association between the arthroscopic
finding and preoperative clinical and imaging data.
CONCLUSION
Posterior visualization and posteromedial probing of the
posterior horn of the MM can help in discovering a higher
rate of lesions that could be easily missed through a stan-
dard anterior exploration. In numerous cases, these lesions
were ‘‘hidden’’ under a membrane-like tissue and were dis-
covered after minimal debridement through a posterome-
dial portal. This additional portal allows for better
visualization, easier access, and sufficient debridement
before repair.
ACKNOWLEDGMENT
The authors thank Professor Deiary Kader for his kind
help.
REFERENCES
1. Ahldén M, Samuelsson K, Sernert N, Forssblad M, Karlsson J, Kartus
J. The Swedish National Anterior Cruciate Ligament Register: a report
on baseline variables and outcomes of surgery for almost 18,000
patients. Am J Sports Med. 2012;40:2230-2235.
2. Ahn JH, Kim SH, Yoo JC, Wang JH. All-inside suture technique using
two posteromedial portals in a medial meniscus posterior horn tear.
Arthroscopy. 2004;20:101-108.
3. Ahn JH, Lee YS, Yoo JC, Chang MJ, Koh KH, Kim MH. Clinical and
second-look arthroscopic evaluation of repaired medial meniscus in
anterior cruciate ligament-reconstructed knees. Am J Sports Med.
2010;38:472-474.
6 Sonnery-Cottet et al
4. Ahn JH, Wang JH, Yoo JC. Arthroscopic all-inside suture repair of
medial meniscus lesion in anterior cruciate ligament–deficient knees:
results of second-look arthroscopies in 39 cases. Arthroscopy.
2004;20:936-945.
5. Amin KB, Cosgarea AJ, Kaeding CC. The value of intercondylar
notch visualization of the posteromedial and posterolateral
compartments during knee arthroscopy. Arthroscopy. 1999;15:
813-817.
6. Bedi A, Dines J, Dines DM, et al. Use of the 70° arthroscope for
improved visualization with common arthroscopic procedures.
Arthroscopy. 2010;26:1684-1696.
7. Bollen SR. Posteromedial meniscocapsular injury associated with
rupture of the anterior cruciate ligament: a previously unrecognized
association. J Bone Joint Surg Br. 2010;92:222-223.
8. Calder SJ, Myers PT. Broken arrow: a complication of meniscal
repair. Arthroscopy. 1999;15:651-652.
9. Carson WG Jr. Arthroscopic techniques to improve access to poste-
rior meniscal lesions. Clin Sports Med. 1990;9:619-632.
10. Ellermann A, Siebold R, Buelow JU, Sobau C. Clinical evaluation
of meniscus repair with a bioabsorbable arrow: a 2- to 3-year fol-
low-up study. Knee Surg Sports Traumatol Arthrosc. 2002;10:
289-293.
11. Fakioglu O, Ozsoy MH, Ozdemir HM, Yigit H, Cavusoglu AT, Loben-
hoffer P. Percutaneous medial collateral ligament release in arthro-
scopic medial meniscectomy in tight knees. Knee Surg Sports
Traumatol Arthrosc. 2013;21(7):1540-1545.
12. Gershuni DH, Skyhar MJ, Danzig LA, Camp J, Hargens AR, Akeson
WH. Experimental models to promote healing of tears in the avascu-
lar segment of canine knee menisci. J Bone Joint Surg Am.
1989;71:1363-1370.
13. Gillies H, Seligson D. Precision in the diagnosis of meniscal lesions:
a comparison of clinical evaluation, arthrography, and arthroscopy.
J Bone Joint Surg Am. 1979;61:343-346.
14. Gillquist J, Hagberg G, Oretorp N. Arthroscopic examination of the
posteromedial compartment of the knee joint. Int Orthop.
1979;3:13-18.
15. Gold DL, Schaner PJ, Sapega AA. The posteromedial portal in knee
arthroscopy: an analysis of diagnostic and surgical utility. Arthros-
copy. 1995;11:139-145.
16. Granan LP, Inacio MC, Maletis GB, Funahashi TT, Engebretsen L.
Intraoperative findings and procedures in culturally and geographi-
cally different patient and surgeon populations: an anterior cruciate
ligament reconstruction registry comparison between Norway and
the USA. Acta Orthop. 2012;83:577-582.
17. Ireland J, Trickey EL, Stoker DJ. Arthroscopy and arthrography of the
knee: a critical review. J Bone Joint Surg Br. 1980;62:3-6.
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav
View publication stats
The American Journal of Sports Medicine
18. Kimori K, Suzu F, Yamashita F, Sakakida K, Hirasawa Y. Evaluation
of arthrography and arthroscopy for lesions of the posteromedial cor-
ner of the knee. Am J Sports Med. 1989;17:638-643.
19. Kobayashi K, Nakayama Y, Shirai Y, Narita T, Mori A. Meniscal tears
after anterior cruciate ligament reconstruction. J Nippon Med Sch.
2001;68:24-28.
20. Lewicky RT, Abeshaus MM. Simplified technique for posterior knee
arthroscopy. Am J Sports Med. 1982;10:22-23.
21. Liu X, Feng H, Zhang H, Hong L, Wang XS, Zhang J. Arthroscopic
prevalence of ramp lesion in 868 patients with anterior cruciate liga-
ment injury. Am J Sports Med. 2011;39:832-837.
22. Mariani PP. Posterior horn instability of the medial meniscus a sign of
posterior meniscotibial ligament insufficiency. Knee Surg Sports
Traumatol Arthrosc. 2011;19:1148-1153.
23. Morgan CD. The ‘‘all-inside’’ meniscus repair. Arthroscopy.
1991;7:120-125.
24. Noyes FR, Chen RC, Barber-Westin SD, Potter HG. Greater than 10-
year results of red-white longitudinal meniscal repairs in patients 20
years of age or younger. Am J Sports Med. 2011;39:1008-1017.
25. Ochi M, Uchio Y, Okuda K, Shu N, Yamaguchi H, Sakai Y. Expression
of cytokines after meniscal rasping to promote meniscal healing.
Arthroscopy. 2001;17:724-731.
26. Pape D, Duchow J, Rupp S, Seil R, Kohn D. Partial release of the
superficial medial collateral ligament for open-wedge high tibial
osteotomy. Knee Surg Sports Traumatol Arthrosc. 2006;14:141-148.
27. Park IS, Kim SJ. New meniscus repair technique for peripheral tears
near the posterior tibial attachment of the posterior horn of the medial
meniscus. Arthroscopy. 2006;22:908.e1-908.e4.
28. Seil R, VanGiffen N, Pape D. Thirty years of arthroscopic meniscal
suture: what’s left to be done? Orthop Traumatol Surg Res.
2009;95:S85-S96.
29. Sonnery-Cottet B, Archbold P, Zayni R, et al. High lateral portal for
sparing the infrapatellar fat-pad during ACL reconstruction. Orthop
Traumatol Surg Res. 2011;97:870-873.
30. Sonnery-Cottet B, Mortati R, Gadea F, Thaunat M, Moyere F, Chou-
teau J. Osteolysis of the tibial plateau after meniscal repair with
hybrid suture anchor. Knee Surg Sports Traumatol Arthrosc.
2013;21(9):2137-2140.
31. Strobel MJ. Menisci. In: Fett HM, Flechtner P, eds. Manual of Arthro-
scopic Surgery. New York: Springer; 1988:171-178.
32. Tolin BS, Sapega AA. Arthroscopic visual field mapping at the periph-
ery of the medial meniscus: a comparison of different portal
approaches. Arthroscopy. 1993;9:265-271.
33. Wilmes P, Lorbach O, Brogard P, Seil R. Complications with all-
inside devices used in reconstructive meniscal surgery. Orthopade.
2008;37:1088-1089, 1091-1095, 1097-1098.