Nicholas A. Sgaglione and Michael J. Angel
DEFINITION
A meniscus tear results in mechanical disruption of the gross structure of the medial or lateral meniscus or both.
The goals of meniscus repair are to preserve and optimize meniscus function and to restore joint biomechanics.
ANATOMY
The medial meniscus and the lateral meniscus are crescent-shaped and triangular in cross section.
The medial meniscus is C-shaped. It covers about 64% of the tibial plateau. Its width varies from anterior to posterior, with an average of 10 mm (FIG 1).
The lateral meniscus is more circular. It covers about 84% of the tibial plateau, with an average width of 12 to 13 mm.
The menisci are fibrocartilaginous structures made up of collagen (90% type I and the remainder made up of types II, III, V, and VI), fibrochondrocytes, and water.
The collagen fibers are arranged in a circumferential pattern in the peripheral third, whereas the inner two thirds is organized with a combination of radial and circumferential fibers (see Fig 3A in Chap. SM-33).
The menisci function to deepen the articular surface of the tibial plateau, providing shock absorption and compensating for gross incongruity between the articulating surfaces, acting as joint stabilizers. They provide joint lubrication and maintenance of synovial fluid and assist in providing nutrition of articular cartilage.16
The vascular supply comes from the perimeniscal capillary plexus supplied by the medial and lateral inferior and superior geniculate arteries. The plexus penetrates the meniscus peripherally and its abundance decreases as it crosses centrally.
This difference in vascularity creates the red-red, red-white, and white-white zones.2
The meniscus contains free nerve endings and corpuscular mechanoreceptors, providing pain and proprioception in the knee joint.16
FIG 1 • Anatomy of the meniscus, showing the average sizes of the components of the medial and lateral meniscus with the average amount of tibial plateau coverage.
PATHOGENESIS
Acute tears typically occur in younger patients from compression and rotational injury of the knee joint as it moves from a flexed to an extended position.
Degenerative tears are typically chronic in nature, are found in older patients, are complex, and are usually irreparable.
Medial meniscus tears most often occur in the stable knee or chronic anterior cruciate ligament (ACL)-deficient knee, whereas lateral tears occur more often in younger patients with acute ACL tears.
Associated injuries are often found. The “terrible triad” consists of tears of the lateral meniscus, ACL, and medial collateral ligament. It is often sustained from a hyperextension with a valgus stress, such as during a “clipping” injury in football.
Tears may be classified according to anatomic zone (as described by Cooper et al7), vascularity (red-red, red-white, white-white), or by tear pattern.
Tear patterns are described as horizontal, radial, longitudinal, bucket-handle, oblique, or complex (see Fig 2 in chap. SM-33).7
NATURAL HISTORY
Walker and Erkman24 in 1975 found that with loads up to 150 kg, the lateral meniscus bore most of the weight bearing in that compartment, whereas the medial meniscus shared about 50% of the load with the articulating surfaces of the tibiofemoral joint.
Partial and total meniscectomy has been shown to increase the contact stresses exerted on the articular cartilage, resulting in its degeneration and ultimately osteoarthritis.
After partial meniscectomy, femoral–tibial contact areas decrease by about 10%, with peak local contact stresses (PLCS) increasing by about 65%. After total meniscectomy, contact areas decrease about 75% and PLCS increases about 235%.3
PLCSs and contact areas were found to be the same with meniscus repair.3
Partial meniscectomy has been shown to improve prognosis and decrease chondral wear compared to total meniscectomy.
PATIENT HISTORY AND PHYSICAL FINDINGS
The history should include location of pain (joint line tenderness), recent traumas, prior injuries and surgery, as well as evidence of effusions, locking, catching, or instability (which may indicate associated ligamentous pathology).
In addition, questions should be asked about the patient's age, function, activity level, occupation, goals, expectations, and other pertinent medical problems. These will help the surgeon decide on nonsurgical versus surgical treatment and resection versus repair.
A complete examination of the knee should be performed, including evaluation for:
Anterior and posterior ligament injury: Lachman, anterior and posterior drawer, pivot shift, along with a history of hearing a “pop” with injury and acute swelling
Posterolateral corner injury: injury of the popliteus tendon, iliotibial band, popliteofibular ligament, biceps, and posterior capsule. Asymmetry on the dial (external rotation) test is the most sensitive examination.
Collateral ligament injury: Medial and lateral collateral ligament injuries may be assessed by palpation and widening with varus–valgus stresses at 30 degrees and at full extension.
The examiner should also:
Inspect for effusion. The presence of diffuse joint effusion is not specific enough. A localized swelling at the joint line may indicate a parameniscal cyst.
Palpate all ligament and tendon insertions, as well as the patellofemoral joint; this may indicate associated pathology.
Evaluate range of motion. Loss of extension or locking may relate to a displaced or bucket-handle tear. Pain with squatting may indicate a posterior horn tear.
Perform the McMurray test to evaluate varus–valgus stress. Positive valgus stress indicates a medial meniscus tear. Positive varus stress indicates a lateral meniscus tear.
Perform the Apley test to look for a meniscus tear. Relief on distraction is found if a meniscus tear is the only pathology, but no relief will be found if a concomitant collateral ligament injury is present.
Perform the Childress test, which is positive if the patient has pain or mechanical blocking; this may indicate a meniscus tear.
While assessing for the Merkel sign, pain with internal rotation of tibia is consistent with a medial meniscus tear; pain with external rotation is consistent with a lateral meniscus tear.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Plain radiographs should be taken to evaluate for bony pathology, extremity alignment, arthritis, chondrocalcinosis, or findings consistent with associated injuries such as a Segond sign (ACL injury), osteochondritis dissecans lesion, or osteochondral fracture.
Typically four views are obtained: a 30- or 45-degree posteroanterior flexion weight-bearing view, a true lateral view, a notch view, and a patella skyline view.
Magnetic resonance imaging (MRI) is not always indicated to evaluate for meniscal pathology, but it is typically used and helpful in evaluation of associated injuries when a meniscus tear is suspected. The sensitivity of MRI for meniscus tears is reported as high as 96%, with a specificity of 97%.13
MRI classification is as follows.
Grade 1: small focal area of increased signal, not extending to the joint surface
Grade 2: linear area of increased signal, not extending to the joint surface
Grade 3: linear area of increased signal extending to the joint surface
A linear abnormality is identified as extension to the articular surface on two consecutive images and is considered to have a high likelihood of being a true tear (FIG 2A).
A bucket-handle tear may be identified by the “double PCL” (posterior cruciate ligament) sign (FIG 2B,C).
FIG 2 • A,B. Lateral and PA MRIs of meniscus tears. C. MRI of medial bucket-handle meniscus tear and double PCL sign. D,E. Sagittal and coronal MRIs of discoid lateral meniscus tears.
Evaluation of the meniscus postoperatively presents a challenge because the repair site becomes filled with fibrous scar and may continue to produce abnormal MR signal on postoperative imaging. Currently the best method of evaluation is with a gadolinium-enhanced MRI.
A discoid meniscus may be evident on MRI as a rectangular meniscus on all slices as opposed to the wedge shape typically seen. It is more commonly found in the lateral meniscus (FIG 2D,E).
DIFFERENTIAL DIAGNOSIS
ACL or PCL tear
Medial or lateral collateral ligament tear
Osteochondritis dissecans lesion
Patellofemoral syndrome
Osteoarthritis
Chondrocalcinosis
NONOPERATIVE MANAGEMENT
Conservative treatment options include physical therapy, nonsteroidal anti-inflammatory medications, steroid injections, and activity modification.
Typically, a stable longitudinal tear in the periphery less than 10 mm is likely to heal on its own.
Bracing usually is not indicated in the treatment of meniscus tears.
The expected result of nonoperative treatment is improved symptoms in 6 weeks, with return to full activities by 3 months.
SURGICAL MANAGEMENT
Intervention may proceed after failure of conservative treatment or more urgently if the patient shows mechanical symptoms such as locking or catching. These may represent loose bodies or an unstable torn meniscus (ie, bucket-handle tear), which can cause significant articular damage if left untreated.
With all meniscus pathology, the goal is to preserve as much meniscus as possible.
Repair versus resection
The potential long-term benefit of repairing the meniscus is chondroprotection.
The surgeon should consider tear location, pattern, vascularity, and associated pathology when determining whether to repair or resect the meniscus.
The surgeon should consider the patient's age, activity level, overall health, and compliance with a limited postoperative activity regimen.
When resection is performed, all efforts should be made to preserve as much viable meniscus as possible. Mobile, unstable meniscus fragments should be resected, leaving a smooth contour.
The meniscosynovial junction should be preserved because this is where the circumferential collagen fibers form the predominant amount of “hoop stresses.”
The surgeon should consider leaving a stable tear alone. An unstable tear will be easily mobilized, displaced at least 7 mm, and/or will have the ability to “roll” (FIG 3).
FIG 3 • Intraoperative evaluation of the ability to “roll” the meniscus.
Preoperative Planning
Before the surgery, all radiologic studies should be reviewed.
The knee should be examined under anesthesia before beginning the surgery in an attempt to detect associated pathology.
The healing potential for a meniscus repair in conjunction with an anterior cruciate ligament reconstruction is far superior to that of a repair alone.
The surgeon should discuss with the patient the risks and benefits of the surgery as well as the principle of informed consent.
All patients should be apprised of the possibility of meniscus resection versus repair.
They should understand the implications of each in terms of shortand long-term consequences and postoperative rehabilitation protocols.
The surgeon may discuss the potential for associated pathology and may obtain a better understanding of the patient's treatment preferences before entering the operating room.
This may be a particularly crucial conversation with an elite athlete who would prefer to undergo a resection in an attempt to return to competitive sport faster.
The anesthesia used is typically decided on by the anesthesiologist and orthopedist before entering the operating room. General anesthesia or a laryngeal mask airway (LMA) may be used.
We prefer to have the anesthesiologist provide sedation in conjunction with a local anesthetic administered by the surgeon.
We typically use a mixture of 0.5% bupivacaine and 1% lidocaine with epinephrine in equal proportions. About 30 to 40 cc is injected intra-articularly, and about 5 cc is injected into each portal site.
Positioning
Typically the patient is lying supine.
The two most popular methods of leg support are a knee holder (thigh immobilizer) and a lateral post.
The knee holder should be placed perpendicular to the position of the femur at a level above the patella and portals that allows for a valgus force on the knee. The end of the table is dropped down below 90 degrees from horizontal to allow both legs to hang freely from the knees.
The lateral post should be placed above the patella and angled outwardly to allow for a valgus force on the operative knee. This technique is performed without dropping the end of the table. The surgeon should check that the knee may be taken through a range of motion by abducting the leg against the lateral post with flexion of the knee off the side of the table.
A tourniquet may be placed on the upper thigh if bleeding is suspected, such as in débridement of a hypertrophic fat pad.
Padding of the contralateral leg is used to prevent pressurerelated injury to the bony prominences or superficial nerves.
Approach
The typical portal sites are a superomedial, anteromedial, and anterolateral portal (FIG 4).
The superomedial portal is typically made proximal to the superior pole of the patella in line with the medial border of the patella (medial to the quadriceps) and is directed in an oblique manner into the joint. This portal is typically used for outflow or inflow.
The anterolateral portal is created by making a small (about 6 mm) stab incision 1 cm proximal to the joint line and 1 cm lateral to the patella tendon. This area can be identified as the “soft spot.” This portal is used for insertion of the arthroscope.
The anteromedial portal is considered the working portal for insertion of instruments. It is typically made under direct visualization by inserting a spinal needle into the medial “soft spot” 1 cm medial to the patella tendon and 1 cm proximal to the joint line.
Accessory portals may include superolateral, posteromedial, posterolateral, midpatella, central, far medial, or lateral (Fig 4).
The tears may be stimulated to heal with either rasping or trephination.
Rasping may be performed with either an arthroscopic shaver or a meniscal rasp that lightly abrades both the tibial and femoral edges of the tear site, as well as the meniscosynovial junction, to stimulate vascularity.
Trephination is performed by inserting a long 18-gauge needle either percutaneously or through the arthroscopic portals across the meniscus tear to create vascular channels. The surgeon should avoid perforation of the meniscus surface, causing further injury.
FIG 4 • Placement of the standard (superolateral, anteromedial,and anterolateral) and accessory arthroscopic portals (superolateral, anteromedial, and anterolateral) and accessory arthroscopic portals in the knee.
TECHNIQUES
INSIDE-OUT TECHNIQUE
This technique requires passage of double-loaded 2-0 or 0 nonabsorbable sutures with long flexible needles passed arthroscopically through thin cannulas (TECH FIG 1).
It is best used for posterior horn, middle third, peripheral capsule, and bucket-handle tears.
Before passage of the sutures, an incision is made posteromedial or posterolaterally to capture the needles as they exit through the capsule. In this manner, all neurovascular structures are protected.
For passage of a needle through the medial compartment, the knee is placed in 20 to 30 degrees of flexion to avoid tethering the capsule.
A 4- to 6-cm posteromedial incision is made just posterior to the medial collateral ligament, extending about one-third above and two-thirds below the joint line.
Dissection is continued anterior to the sartorius and semimembranosus musculature, deep to the medial head of the gastrocnemius.
The posterolateral incision is made with the knee in 90 degrees of flexion to allow the peroneal nerve, popliteus, and lateral inferior geniculate artery to fall posteriorly.
A 4- to 6-cm incision is made just posterior to the lateral collateral ligament, anterior to the biceps femoris tendon, extending one-third above and two-thirds below the joint line.
Dissection is continued between the iliotibial band and the biceps tendon and then proceeds deep and anterior to the lateral head of the gastrocnemius.
On exposure of the capsule, a “spoon” or popliteal retractor is placed against the capsule to visualize the exiting needles.
A single- or double-lumen cannula is passed through the arthroscopic portals to the site of the tear.
Long flexible needles are then passed through the cannula, piercing the meniscus above and below the tear site and creating vertical mattress sutures.
The needles are captured one at a time by an assistant who is retracting on the capsule. Care is taken not to pull either suture all the way through until both needles are passed.
The sutures are then tensioned and tied to the capsule while viewing the repair arthroscopically.
TECH FIG 1 • Inside-out repair technique. A. Diagram of technique. B. Skin incision on medial side. C. Skin incision on lateral side. D. Intraoperative image and popliteal retractor in place. E. The cannulas used to pass the needles.
OUTSIDE-IN TECHNIQUE
This technique is performed by passing multiple long 18-gauge spinal needles percutaneously from outside of the knee to inside the knee joint (TECH FIG 2).
This technique is best performed on tears of the anterior and middle third, as well as radial tears.
Needles should be spaced about 3 to 5 mm apart.
The needle should enter the joint through the periphery to achieve a vertical or horizontal mattress suture configuration.
An absorbable monofilament suture is passed into the joint.
A second needle with a wire retriever trocar is passed through the tear to retrieve the suture.
After tensioning of the mattress suture, a 3- to 5-mm skin incision is made near the suture strands and blunt dissection carried down to the capsule with a hemostat.
A probe may be used to retrieve the sutures and tie them down to the capsule under direct visualization, taking care to avoid incarceration of any neurovascular structures.
TECH FIG 2 • Outside-in repair technique. A. Illustration of horizontal mattress technique without intra-articular knots. B. Placement of needles. C,D. Arthroscopic views of passage of knots. E.Arthroscopic view of mattress suture with outside-in technique.
ALL-INSIDE FIXATION TECHNIQUE
Multiple proprietary fixation devices are available with variations on the popular reverse-barbed fishhook design (eg, Meniscus Arrow, Bionx, Blue Bell, PA; Biostinger, and ConMed Linvatec, Largo, FL; Dart, Arthrex, Naples, FL) (TECH FIG 3).
They are also referred to as first-generation fixators.
These devices are best used in vertical longitudinal tears in the red-white zone of the posterior horn.
They are typically made of bioabsorbable copolymers such as poly-L-lactic acid and poly-D-lactic acid.
After identification of the tear site, accurate measurement of the size of the meniscus is performed with an arthroscopic measuring device.
Insertion of the fixator must be performed perpendicular to the tear and parallel to the tibial surface.
Fixators can be placed at 3- to 5-mm intervals.
Care must be taken to implant the fixator so that it is seated flush or countersunk to the meniscus surface while spanning the tear equally on both sides to appropriately compress the tear.
TECH FIG 3 • Use of arthroscopic fixator. A. Meniscal fixators. B. Placement of meniscal arrow.
ALL-INSIDE SUTURE FIXATION TECHNIQUE
Multiple proprietary designs are available (eg, FasT-Fix, Smith and Nephew, Andover, MA; RapidLoc, Mitek, Westwood, MA) (TECH FIG 4).
They are also referred to as second-generation fixators.
The suture fixators are designed to allow repair of the meniscus with mattress sutures without creating an incision through the skin.
The devices deploy two absorbable or nonabsorbable suture anchors with attached nonabsorbable sutures between them.
The sutures can then be arthroscopically tied or they may come pretied, depending on proprietary design.
After preparing the tear in the standard manner, the fixator should be inserted from the contralateral portal.
Use of a curved needle provides the surgeon with more options compared to the straight needle with regard to position and reduction and insertion angles.
Insertion of the needle through a sheath or insertion cannula prevents the delivery system from getting caught on loose tissue.
The surgeon starts the repair from the center and works outward. This avoids gapping, ruffling, and dog-ears.
The use of an outside-in stay suture may aid in holding the reduction until the mattress sutures can be placed.
The devices are placed perpendicular to the tear.
The first anchor should be placed superiorly and posteriorly and the second should be placed inferiorly and anteriorly across the tear to create a vertical mattress.
The knot pusher is used to slide and manually assist in cinching down the knot; however, the surgeon should avoid overtightening and puckering the repair.
The devices are placed about 4 to 5 mm apart.
TECH FIG 4 • Use of arthroscopic suture fixators. A,B. Design of two commercially available suture fixators. C,D. Placement of arthroscopic sutures in mattress configuration. E. The “self-tying” arthroscopic knot thrown with a suture fixator.
REPAIR BIOLOGIC AUGMENTATION METHODS
These techniques are indicated in cases of isolated meniscus repair (no concomitant ACL reconstruction) in which there is concern for healing.
It is generally accepted that results of meniscus repair are improved when performed in conjunction with ACL reconstruction. The reason for the success is theoretically secondary to the release of intraosseous growth factors and cytokines when bone tunnels are drilled.
Several methods have been used in an attempt to recreate that biologic advantage.
Trephination or rasping may be performed in an attempt to increase vascularity delivered to the tear site.
The use of fibrin clot or platelet-rich fibrin matrix attempts to deliver biologically active factors directly to the repair site.
The fibrin clot technique introduces a concentrated autologous platelet-rich matrix to the repair site. The platelet-rich matrix technique is a refinement of the fibrin clot technique designed to deliver a more concentrated and volume-stable matrix to the repair site.
The fibrin clot is performed by first obtaining 30 to 50 mL of blood from the patient intraoperatively and transferring it to a glass container. The blood is stirred with a sintered glass rod. A clot will form, which is blotted dry and then inserted using an arthroscopic grasper to the repair site. The clot is best placed with the fluid flow turned down and is best placed on the tibial site of the repair (TECH FIG 5A,B).
The platelet-rich fibrin matrix technique is performed by obtaining a smaller sample of autologous blood intraoperatively (about 10 mL) and placing it in a centrifuge for about 20 minutes. After centrifugation is completed, the fibrin matrix is retrieved and placed arthroscopically into the repair site in similar fashion to the fibrin clot. Proprietary technology is available (Cascade Autologous Platelet System, MTF, Edison, NJ) to perform this method (TECH FIG 5C,D).
TECH FIG 5 • Preparation and placement of a fibrin clot (A,B) and of platelet-rich fibrin matrix (C,D).
POSTOPERATIVE CARE
Postoperative care must be individualized based on tear geometry, repair construct strength, associated surgical procedures, and surgeon preference.
In the operating room, our patients are placed in a knee immobilizer or hinged brace locked in extension.
A patient with an isolated meniscus repair will remain partially weight bearing with crutches for about 1 month.
Early range of motion is performed passively from postoperative day 1.
Typically, range of motion is limited to 90 degrees for the first 3 weeks for nondisplaced meniscus tears and 4 to 6 weeks for displaced bucket-handle tears.
Crutches are discontinued when the patient shows good quadriceps function and no antalgia.
Return to pivoting sports ranges from 4 to 6 months, or when the patient has no point tenderness or effusion and can show full extension and painless terminal flexion.
OUTCOMES
The success rate of meniscus repair has been estimated at 50% to 90%, with a higher likelihood of success when repair is performed in conjunction with an ACL reconstruction.
Early studies by Cannon and Vittori6 reported on inside-out repairs of 90 knees. Overall clinical success was found to be 82%. Those repaired in conjunction with ACL reconstruction had a 93% success rate while isolated repairs were successful in only 50% of cases.
Henning et al19 reported on 260 repairs in 240 patients with follow-up of about 2 years. On arthroscopic second-look or arthrogram evaluation, inside-out repairs had a 62% success rate, with 17% incompletely healed and 21% not healed. Ninety-two percent of the knees were stable and ACL reconstruction was performed on 80% of them.
Rodeo et al17 found an overall success rate of 87% with use of the outside-in technique in 90 patients. He noted failure in 38% of the unstable knees, 15% in stable knees, and 5% in ACL-reconstructed knees.
Studies have shown inside-out vertical mattress suture placement to be the strongest fixation technique, whereas the all-inside suture fixators provide excellent repair strength. The all-inside first-generation fixators have shown inferior results compared to the newer fixators.
Biomechanical testing of longitudinal tears in adult porcine meniscus showed mean load to failure of inside-out vertical mattress sutures to be 80.4 N, FasT-Fix 70.9 to 72.1 N (vertical and horizontal configuration), the Dart 61.7 N, horizontal sutures 55.9 N, Rapidloc 43.3 N, and Meniscus Screw (Arthrotek, Biomet, Warsaw, IN) 28.1 N.4
Two recent studies showed early and intermediate success of Rapidloc.
One study found a 90.7% success rate with the use of Rapidloc to repair 54 menisci in 49 patients with an average follow-up of 34.8 months.15
Another prospective analysis of 32 meniscus repairs performed with Rapidloc, at an average of 32 months of follow-up, found clinical success in 87.5% of patients.5
A recent study of 61 menisci repaired with the FasT-Fix found, at an average follow-up of 18 months, a 90% success rate. ACL reconstruction was performed in 62% of them. Excellent or good clinical results were found on Lysholm knee scoring in 88%.10
Spindler et al22 compared 47 inside-out suture repairs to 98 all-inside meniscal arrow repairs, with clinical failure as defined as reoperation. They found seven failures in each group, but the mean time to follow-up was 68 months for the inside-out repairs and only 27 months for the all-inside group.
One study of 60 meniscus repairs using the meniscal arrow showed a failure rate of 28% on MRI and repeat arthroscopy at a mean follow-up of 54 months. They found an increasing rate of significant complications in addition to meniscus repair failure, including chondral scoring, fixator breakage, and joint-line irritation.11
Lee and Diduch12 also showed deteriorating results with first-generation fixators. They studied 32 meniscus repairs, all performed exclusively with arrows in conjunction with an ACL reconstruction. They reported a success rate of 90.6% at a mean follow-up of 2.3 years; subsequent reports of those same patients found a 71.4% success rate at a mean follow-up of 6.6 years.
COMPLICATIONS
The overall incidence of complications from arthroscopic meniscus surgery is 0.56% to 8.2%.21
Meniscus repair surgery has a higher complication rate than meniscus resection, with reports as high as 18%.20
Commonly discussed complications include infection, deep vein thrombosis, vascular injury, and neurologic complications.
The rate of infection is 0.23% to 0.42%, with an increasing incidence associated with extended operating time, extended tourniquet time, performance of multiple concurrent procedures, and a history of prior surgeries.1
There is no clear consensus on the use of prophylactic perioperative antibiotics.
There are published reports of an increased incidence of infection associated with intra-articular corticosteroid injections given intraoperatively.14
When an infection has been diagnosed after a repair, it is appropriate to leave the implant or sutures in place; however, there is a higher failure rate associated with it.
The incidence of deep vein thrombosis ranges from 1.2% to 4.9% after arthroscopic knee surgery.8 No clear consensus exists with regard to perioperative anticoagulation.
The overall incidence of vascular complications is 0.54% to 1.0%, with complications including popliteal artery injury, pseudoaneurysm, and arteriovenous fistulas.9
Neurologic complications include direct or indirect nerve injury or complex regional pain syndrome. The overall incidence is 0.06% to 2.0%.18
Medial meniscus repairs using an inside-out or outside-in technique can result in saphenous neuropathy or neuropraxia, with reports of up to 43% of cases.23
More recent reports of neuropathy with all-inside techniques have yet to be published.
The most common complications associated with the insideout and outside-in techniques are traumatic neuropathy to the saphenous or peroneal nerves.
The all-arthroscopic implant fixators can be associated with complications such as retained fragments that fail to resorb, broken implants, fixator migration, and inflammatory responses to the implant. A retained implant may cause further chondral damage secondary to implant abrasion.11
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