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Arthrosc Tech
Arthrosc Tech
Arthroscopy Techniques
2212-6287
Elsevier

S2212-6287(24)00148-8
10.1016/j.eats.2024.103039
103039
Technical Note
Knee
Simultaneous Meniscal Repair and Temporary Guided Growth Using a Tension Band Plate to Correct Alignment in Pediatric Discoid Lateral Meniscus Patients With Valgus Knee
Hashimoto Yusuke M.D., Ph.D. hussyyomu@omu.ac.jp
a∗
Nakagawa Keisuke M.D., Ph.D. b
Nishino Kazuya M.D., Ph.D. b
Tomihara Tomohiro M.D. c
Takahashi Daichi M.D. c
Nakamura Hiroaki M.D., Ph.D. b
Katsuda Hiroshi M.D. c
a Department of Health and Sport Management, Osaka University of Health and Sports Science, Osaka, Japan
b Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
c Department of Orthopaedic Surgery, Shimada Hospital, Osaka, Japan
∗ Address correspondence to Yusuke Hashimoto, M.D., Ph.D., Department of Health and Sport Management, Osaka University of Health and Sports Science, 1-1, Asashirodai, Kumatori-cho, Sennan-gun, Osaka, 590-0496, Japan. hussyyomu@omu.ac.jp
30 5 2024
9 2024
30 5 2024
13 9 10303925 1 2024
2 4 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Meniscal stabilization with saucerization has recently been recommended for discoid lateral meniscus (DLM) to preserve the meniscus shape and prevent the progression of osteoarthritis. However, axial alignment of the lower limb causes a significant valgus change after arthroscopic partial meniscectomy and can lead to progressive lateral osteoarthritic changes. Thus, valgus knees in patients with DLM are a suspected predictive factor for poor outcomes after DLM surgery. Valgus malalignment in pediatric patients can be corrected by temporarily tethering one side of the open physis using implant-mediated guided growth to generate differential growth in the coronal plane. This Technical Note describes simultaneous arthroscopic meniscal surgery and temporary hemiepiphysiodesis to treat DLM with valgus deformities to reduce the risk of future chondral damage to the lateral knee compartment.

Technique Video
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pmcDiscoid lateral meniscus (DLM) of the knee represents an abnormal morphologic variation of the meniscus, which typically covers a larger-than-usual area of the tibial plateau. Arthroscopic surgical repair of a torn DLM in children has favorable clinical outcomes in short- and long-term assessments with the restoration of motion and significant improvements in multiple patient-reported outcome scores.1,2 However, reports1,3,4 have described degenerative sequelae, including meniscal retears, lateral compartment osteoarthritis, and postoperative osteochondritis dissecans (OCD), as complications after DLM surgery. Partial meniscectomy and saucerization with repair of knees with a torn DLM sometimes progresses to valgus alignment and lateral compartment degeneration.5,6 Therefore, surgeons need to consider valgus knee correction and meniscal surgery in patients with DLM and valgus knees.

A coronal plane angular deformity can be corrected with less-invasive surgical techniques in pediatric patients by using implant-mediated guided growth. By temporarily tethering one side of an open physis to generate differential growth, osseous correction can be achieved with a low complication rate.7 This Technical Note describes simultaneous meniscal repair and temporally guided growth of a torn DLM in valgus knees to maintain adequate alignment.

Surgical Technique

This technique is indicated for DLM with valgus knee (Fig 1A), which sometimes involves peripheral tears or OCD with an open physis (Fig 1 B-D). With the patient in the supine position, a nonsterile tourniquet is applied to the proximal thigh of the operated leg. The usual arthroscopic evaluation is performed using anteromedial and anterolateral portals (Fig 2 A-C, Video 1).Fig 1 Preoperative images of the right knee of a 12-year-old boy. (A) The whole-leg standing radiograph. The preoperative alignment parameters are 60% in weight-bearing line ratio (white line; Mikulicz’s line), valgus 2.4° in the hip-knee-ankle angle, 88° in the medial proximal tibial angle, and 83° in the lateral distal femoral angle. (B) The Rosenberg view. Translucent areas of the lateral femoral condyle are visible in this view (white arrow). (C-D) Magnetic resonance images of the locked meniscus to the intercondylar notch and OCD lesion in (C) the coronal view and (D) the sagittal view. The meniscus is entirely displaced centrally toward the intercondylar notch (C; white arrow). and the amount of residual meniscus on the peripheral site is small (C and D; black arrows). Signal change in the subchondral bone without clear lesion margins is visible on the coronal and sagittal images (C and D; white arrow heads).

Fig 2 Arthroscopic findings of the right knee viewed from the anterolateral portal in the “figure 4” position. (A) The meniscus is entirely displaced centrally toward the intercondylar notch (black asterisk). (B) The small amount of the peripheral rim (black asterisk) bridging to the locked meniscus is confirmed. (C) A probe confirms softening of the cartilage surface without fissuring of the lateral femoral condyle (black asterisk).

Reduction sutures are applied using a Scorpion suture passer (Arthrex, Naples, FL) through the anterolateral portal (Fig 3A). Inside-out sutures are used to reduce and fix the meniscus to its anatomic position (Fig 3B). For the anterior segment of the lateral meniscus, transportal transcapsular sutures8 are applied by using the Scorpion passer and suture hook (CONMED Linvatec, Largo, FL) (Fig 3 C and D, Video 1). After treating the OCD lesion (Fig 4 A-D, Video 1), extraperiosteal plating is subsequently performed with 2 nonlocking screws under fluoroscopic guidance.7 Under a tourniquet, a 2-cm longitudinal incision is centered over the medial extent of the physis and oriented along the anatomic axis of the femur (Fig 5A). After soft-tissue dissection, a 1.5-mm K-wire is inserted into the medial extent of the physis in the coronal and sagittal planes to guide the positioning of the center of the growth plate under fluoroscopic guidance (Fig 5 B and C, Video 1). A 2-hole guided growth plate (eight-Plate; Orthofix, Lewisville, TX) is contoured and passed over the wire. The final placement of the plate and screws is confirmed extraperiosteally under the C-arm in the anteroposterior and lateral views, with the plate in the center of the lateral view to avoid any iatrogenic sagittal plane deformities. After drilling, 4.5-mm cannulated screws are then inserted and provisionally tightened down to the plate in the metaphysis and epiphysis (Fig 5D).Fig 3 Reduction and fixation for the shifted meniscus of the right knee in the “figure-4” position. (A) Reduction suture with Scorpion suture passer (Arthrex; white arrow) is passed with the anterior meniscus (black asterisk) through anterolateral portal, viewed from the anteromedial portal. (B) The dual meniscal repair needles loaded with 2-0 braided polyester sutures (black asterisk) penetrate the unstable portion of the meniscus through a cannula positioned in the anteromedial portal, viewed from the anterolateral portal. (C) Sutures with 2-0 FiberWire (black asterisk) are passed through the anterior horn by using a Scorpion suture passer and suture hook through anterolateral portal, viewed from the anteromedial portal. (D) Arthroscopic view from the anteromedial portal after reducing and fixing the meniscus to its anatomic position.

Fig 4 Drilling the OCD lesion under fluoroscopy of the right knee. To avoid perforating the physis, the location of OCD is confirmed by using a 1.5-mm Kirschner wire (white arrow) through the anterolateral portal with fluoroscopy. (A) The lateral view. (B) The A-P view. (C) Under arthroscopy viewed from the anteromedial portal, a Kirschner wire (white arrow) is inserted from the anterolateral portal. Intra-articular drilling is applied to the OCD lesion at 3-mm intervals. (D) Blood flow from bone marrow (black asterisk) is confirmed under arthroscopy viewed from the anterolateral portal. (A-P, anteroposterior; OCD, osteochondritis dissecans.)

Fig 5 Extra periosteal plating with 2 nonlocking screws under fluoroscopic guidance of the right knee. (A) A 2-cm surgical incision of the medial femoral side is created in the longitudinal direction. (B) A 1.5-mm K-wire (white arrow) is inserted into the medial extent of the physis under A-P fluoroscopy. (C) Under the lateral fluoroscopic view, the center of the growth plate is positioned. (D) A 2-hole guided growth plate (white arrow) is placed over the centering K-wire. (E and F) After 2 K-wires are placed on the proximal and distal holes, the final placement of the plate and the direction of screws are confirmed under the C-arm in the A-P view (E) and lateral view (F); the plate is in the center of the lateral view to avoid any iatrogenic sagittal plane deformities. (G and H) Solid screws (4.5 mm) are inserted and provisionally tightened down to the plate in the metaphysis and epiphysis in the A-P view (G) and in the lateral view (H). (A-P, anteroposterior; F, femoral side; P, patella T, tibial side.)

Postoperative Management

Patients are immobilized for 1 week using a brace, limited to a knee range of motion of 0° to 90° for 3 weeks and then allowed partial weight-bearing for 8 weeks. Patients may return to sports at 6 months after the procedure.

Discussion

Discoid saucerization procedures with or without repair have similar Lysholm scores and International Knee Documentation Committee scores as nondiscoid repair procedures and revision rates as those of nondiscoid repair procedures.2,9 However, total meniscectomy and partial meniscectomy for DLM can change the lower-limb alignment to valgus (1°-3°) after surgery.10 Cho et al.6 reported that arthroscopic surgery for adult DLM resulted in progression to valgus alignment and lateral compartment degeneration, compared with nonoperative treatment and arthroscopic surgery for adult non-DLM. In general, valgus malalignment increases the risk of knee osteoarthritis radiographic progression.11 Thus, DLM with valgus knees should be considered and treated. Takigami et al.12 report that the central meniscal shift of the DLM was a predictive factor for OCD of the lateral femoral condyle and that disappearance of the peripheral part of the meniscus, which indicates loss of meniscal load transmission, may be the main cause of OCD. Thus, preserving the peripheral rim of the meniscal repair is necessary to suppress the progression of valgus knees and heal OCD.

For valgus alignment, correcting lower-limb malalignment is necessary to improve the load environment in the lateral compartment. Temporary-guided growth using a tension band plate is a fixed bridging the physis using a plate and 2 screws. The interface between the screw heads and plate enables angular motion of the screws, which allows continued growth of the rest of the physis, thereby correcting angular deformities in a growing child. Compared with traditional osteotomy, this technique is technically easy, minimally invasive, and associated with less morbidity and fewer complications.13

Martay et al.14 described that a weight-bearing line ratio of 60% tibial width (3° valgus) causes minimal halved lateral compartment stress, and a weight-bearing line ratio of 50% tibial width (0° varus/valgus) causes minimal changes to lateral stress levels. Kumar et al.15 reported that the rate of deformity correction was the lateral distal femoral angle changed at 0.87°/month in patients younger than 10 years old. Ko et al.16 reported that the use of plates and faster correction speed were positively associated with the rebound phenomenon. Therefore, we recommend this technique during adolescence to prevent overcorrection or the rebound phenomenon.

This report is preliminary. Further follow-up assessments of clinical and radiologic outcomes are necessary to investigate the long-term effects of this technique. Nevertheless, this technique should be defined as the ideal method to preserve the meniscus and to correct knee deformity in patients with valgus DLM. This method maintains the meniscal status and decreases the pressure on the lateral compartment to prevent the progression of osteoarthritis. The advantages and limitations of our technique, as well as its advantages and disadvantages, are summarized in Tables 1 and 2, respectively.Table 1 Advantages and Limitations of the Procedure

Advantages	Limitations	
• Allows for the correction of the valgus knee for juvenile DLM with this plate.

• Compared with traditional osteotomy, this procedure is technically easy to perform, minimally invasive, and associated with less morbidity and fewer complications.

• Effective for OCD lesion of the lateral condyle.

• It can be used to treat a meniscal repair at the same time.

• A surgeon needs only standard meniscal repair skills and plating skills.

	• Need to use a specific plate.

• Only applicable for open physis.

• An additional skin incision is needed to put the plate.

• The plate needs to be removed after correcting the deformity.

• Possibility of rebound phenomenon.

• Possibility of reinjury after meniscal stabilization.

	
DLM, discoid lateral meniscus; OCD, osteochondritis dissecans.

Table 2 Pearls and Pitfalls of the Procedure

Pearls	Pitfalls	
• Careful evaluation of intraoperative plating.

• In the sagittal plane, the K-wire should be inserted into the center of the growth plate under fluoroscopic guidance.

• In the coronal plane, screws should be inserted into the metaphysis and epiphysis.

• For the meniscus, a reduction suture with Scorpion is needed.

• Firm stabilization is needed for the meniscus.

• Careful drilling is necessary to avoid perforating the physis for a stable OCD lesion.

	• Arthroscopy sometimes does not detect a stable OCD lesion.

• Fluoroscopic guidance is important for the drilling.

• Careful stabilization is needed between the meniscal body and capsule without gap.

• Anteriorization is avoided, which can lead to sagittal plane deformity (i.e., recurvatum).

• Careful observation for correcting deformity and adequate periods to remove the plate must be determined.

	
OCD, osteochondritis dissecans.

Disclosures

H.N. reports a relationship with Department of Orthopaedic Surgery, Osaka Metropolitan University. All other authors (Y.H., Ke.N., Ka.N., T.T., D.T., and H.K.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

We present a technique for simultaneous meniscal repair and temporarily guided growth by using a tension band plate to correct alignment in pediatric patients with discoid lateral meniscus (DLM) with valgus knees. In the anterolateral portal view of right knee, the meniscus is displaced centrally toward the intercondylar notch. A small volume of peripheral rims bridging the locked meniscus is visible. Softening of the cartilage surface without fissuring the lateral femoral condyle is confirmed by using a probe. After using arthroscopic rasping to freshen tear sites in the meniscus, the locked meniscus is reduced to an anatomic position by using a probe. It is an incomplete DLM. A reduction suture using the Scorpion suture passer is passed through the anterior meniscus via the anterolateral portal and viewed from the anteromedial portal. Dual meniscal repair needles loaded with 2-0 braided polyester sutures penetrate the unstable portion of the meniscus through a cannula positioned in the anteromedial portal. The suture needles are retrieved under direct visualization through a previously prepared lateral incision. The sutures are tied over the capsule; every 4 sutures are passed. The entire process is repeated. The stitching technique is administered at 3-mm intervals. After confirming instability of the anterior meniscus, sutures with 2-0 FiberWire sutures are passed through the anterior horn by using the Scorpion suture passer through the anterolateral portal. A suture hook is subsequently introduced through the anterolateral portal and penetrated the lower side of the capsule to reach the tibial side of the DLM. The grasper from the anterolateral portal retrieved the lower side of the suture and 2-0 PROLENE and suture relay is performed. After the sutures are tied using the sliding knot technique and secured using a knot pusher, the entire process is repeated. After stabilizing the entire meniscus, the location of osteochondritis dissecans is confirmed by using a 1.5-mm Kirschner wire (K-wire) under fluoroscopy in the lateral and anteroposterior (A-P) views to avoid perforating the physis. Under arthroscopy from anteromedial view, a K-wire is inserted through the anterolateral portal, and intra-articular drilling is performed on the osteochondritis dissecans lesion at 3-mm intervals. Blood flow from the bone marrow is confirmed with arthroscopy. A 2-cm surgical incision of the medial femoral side was made in the longitudinal direction. A 1.5-mm K-wire is inserted into the medial extent of the physis under A-P fluoroscopy, and the center of the growth plate is positioned under the lateral fluoroscopic view. A 2-hole guided growth plate is placed over the central K-wire. After 2 K-wires are placed on the proximal and distal holes, the final placement of the plate and the direction of the screws are confirmed under the C-arm in the A-P and lateral views, with the plate in the center of the lateral view to avoid any iatrogenic sagittal plane deformities. Solid screws are inserted and tightened to the plate in the metaphysis and epiphysis.
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References

1 Lee Y.S. Teo S.H. Ahn J.H. Lee O.S. Lee S.H. Lee J.H. Systematic review of the long-term surgical outcomes of discoid lateral meniscus Arthroscopy 33 2017 1884 1895 28655477
2 Diao Y.D. Vivekanantha P. Cohen D. Hoshino Y. Nagai K. de Sa D. Patients with discoid menisci have similar clinical outcomes to those without discoid menisci when undergoing surgical intervention: A systematic review Knee Surg Sports Traumatol Arthrosc 31 2023 3369 3380 37016177
3 Hashimoto Y. Nishino K. Reid J.B. 3rd Factors related to postoperative osteochondritis dissecans of the lateral femoral condyle after meniscal surgery in juvenile patients with a discoid lateral meniscus J Pediatr Orthop 40 2020 e853 e859 32658153
4 Campbell A.L. Pace J.L. Mandelbaum B.R. Discoid lateral meniscus. Short-term effects of discoid lateral meniscectomy on the axial alignment of the lower limb in adolescents Curr Rev Musculoskelet Med 16 2023 154 161 36920747
5 Wang J. Xiong J. Xu Z. Shi H. Dai J. Jiang Q. Short-term effects of discoid lateral meniscectomy on the axial alignment of the lower limb in adolescents J Bone Joint Surg Am 97 2015 201 207 25653320
6 Cho J.H. Nam H.S. Park S.Y. Ho J.P.Y. Lee Y.S. Arthroscopic meniscal repair and meniscectomy for adult discoid lateral meniscus result in progression to valgus alignment and lateral compartment degeneration compared with nonoperative treatment and nondiscoid lateral meniscus Arthroscopy 40 2024 1223 1233 37717929
7 Artioli E. Mazzotti A. Ramacci V. Indications and timing in isolated medial femoral hemiepiphysiodesis for idiopathic genu valgum: A systematic review Knee 40 2023 52 62 36410251
8 Hashimoto Y. Yamasaki S. Guttmann D. Surgical management of discoid lateral meniscus with anterior peripheral instability: Retaining an adequate residual meniscus volume Arthrosc Tech 11 2022 e1141 e1147 35936849
9 Su L. Bennett A. Combs K. Arthroscopic treatment of symptomatic discoid lateral meniscus and nondiscoid meniscus in adolescent patients Am J Sports Med 50 2022 3805 3811 36342468
10 Zhang P. Zhao Q. Shang X. Wang Y. Effect of arthroscopic resection for discoid lateral meniscus on axial alignment of the lower limb Int Orthop 42 2018 1897 1903 29770844
11 Felson D.T. Niu J. Gross K.D. Valgus malalignment is a risk factor for lateral knee osteoarthritis incidence and progression: Findings from the Multicenter Osteoarthritis Study and the Osteoarthritis Initiative Arthritis Rheum 65 2013 355 362 23203672
12 Takigami J. Hashimoto Y. Tomihara T. Predictive factors for osteochondritis dissecans of the lateral femoral condyle concurrent with a discoid lateral meniscus Knee Surg Sports Traumatol Arthrosc 26 2018 799 805 28197693
13 Masquijo J.J. Artigas C. de Pablos J. Growth modulation with tension-band plates for the correction of paediatric lower limb angular deformity: Current concepts and indications for a rational use EFORT Open Rev 6 2021 658 668 34532073
14 Martay J.L. Palmer A.J. Bangerter N.K. A preliminary modeling investigation into the safe correction zone for high tibial osteotomy Knee 25 2018 286 295 29395747
15 Kumar S. Sonanis S.V. Growth modulation for coronal deformity correction by using Eight Plates—Systematic review J Orthop 15 2018 168 172 29657461
16 Ko K.R. Shim J.S. Shin T.S. Jang M.C. Factors affecting rebound phenomenon after temporary hemiepiphysiodesis and implant removal for idiopathic genu valgum in adolescent patients J Pediatr Orthop 42 2022 e336 e342 35142715
