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Inclusion Of The Popliteal Tendon In A Lateral Meniscus Repair Does Not Affect The Viability Of The Repair-A Cadaveric Study Using An Experimental Knee Simulator

 Xavier Pelfort*, Marc Tey**, Francisco Reina#, Lluís Puig*, Enric Càceres**, Rafael Iñigo Pavlovich***, Joan Carles Monllau*,**

* The Department of Orthopaedics and Traumatology. IMAS - Hospital del Mar and Hospital de l’Esperança. Universitat Autònoma de Barcelona. Barcelona. Spain.

** The Institut Catala de Traumatologia y Medicina de L'Esport (ICATME). Institut Universitari Dexeus. Universitat Autònoma de Barcelona. Barcelona. Spain.

# The Department of Morphological Sciences. Medicine Faculty. Universitat Autònoma de Barcelona. Bellaterra. Spain.

*** The Institute of Orthopaedic Surgery, Arthroscopy and Sports Medicine. Hermosillo. Sonora. Mexico.

Address for Correspondence:  

Xavier Pelfort, M.D.
IMAS – Hospital del Mar. Passeig Marítim 25-29. 08003 Barcelona. Spain.
Tel: +34/ 932483196
Fax: +34/ 932483201


Introduction: Repairing lateral meniscal injuries has some controversial aspects that still have not been well-responded to. The indications for lateral meniscus repair have been well defined and avoiding the placement of sutures crossing the popliteal hiatus is usually recommended. The purpose of our work is to evaluate the reliability of including the popliteal tendon in an lateral meniscus repair. Methods: An experimental work on lateral meniscal repair including or not including the popliteal tendon was designed using an experimental knee-simulator. Six fresh frozen human cadaveric knees were used. A lateral condile osteotomy and a bucket handle tear of the lateral meniscus were created in a reproducible manner.  The knees were divided into three groups: group A: the meniscus was repaired with five vertical stitches avoiding the popliteal hiatus (control group), Group B: an additional suture was placed including the popliteal tendon and in Group C: the same additional suture including the popliteal tendon as well as the joint capsule was done. After a one thousand gait cycles, we macroscopically evaluated the condition of the popliteal tendon, the lateral meniscus and the sutures. Thereafter, the osteotomy was again fixed and the knees were tested with external and internal tibial rotation for five hundred cycles more in each position and finally the last macroscopic evaluation was performed. Results: No differences were observed between the distinct groups. Conclusion: Repairing the lateral meniscus along with the popliteal tendon does not seem to cause any damage to either structure and thus suggests that lateral meniscus can be safely repaired using this method.

J.Orthopaedics 2008;5(4)e14


Popliteal tendon; Lateral meniscal repair; Meniscus suture; Posterolateral corner; Knee.


The posterolateral corner of the knee has received great attention over the past decade [4, 10]. Some of its anatomical structures are thought to play an important role as restraints on the external rotation of the tibia [12, 25]. The popliteus tendon (PT) is one of the main contributors to static stabilization of the particular area [7, 14, 19].

The lateral meniscus’ (LM) plays a protective effect in preventing degenerative changes in the knee joint [1, 3]. Although the connections between the PT, fibular head, and the LM have been well established [13, 20], its dynamic interaction is not completely understood.

In clinical practice, indications for LM repair are well defined [8, 9, 22-23]. However, there is no consensus with regard to repairing the LM when the rupture involves its posterolateral zone. The main doubt being when the tears involve the popliteal hiatus. Avoiding the placement of sutures through the PT is usually recommended. However, no evidence has been published about the effects of including the PT in an LM repair, to our knowledge.

The purpose of this study is to ascertain the reliability of including the PT in an LM repair.

Material and Methods :

Twelve fresh frozen human knees (8 left, 4 right) were obtained from donors with a mean age of 47 years (range, 28-67 years). After the specimens were thawed overnight at room temperature, arthroscopy of the knees was performed to identify any previous pathology. Six knee joints had to be excluded from the study because of LM tears, ACL insufficiency or cartilage degeneration Outerbrigde grades III or IV. In the end, 6 cadaveric knees (4 left and 2 right) were included in this study.

Preparation of the cadaveric knees and Lateral Meniscus 

Each knee was prepared by transecting the femur and tibia approximately 25 cm from the joint line. An anatomical dissection to the capsular plane, preserving quadriceps as well as biceps tendons, was performed. A non-absorbable suture was used on the quadriceps and biceps tendons to improve the attachment in the experimental knee simulator. The lateral compartment was approached using a lateral femoral condyle osteotomy previously described by Dienst et al [6]. This osteotomy was planned as a vertical cut starting directly lateral to the femoral origin of the ACL aiming towards the lateral transition of the femoral diaphysis and metaphysis (Fig.1). After the osteotomy, a bucket handle tear in the LM was made. To achieve this in a reproducible manner, the LM was divided into 3 parts starting from the meniscal wall to the free margin. The bucket handle tear was always made at the junction between the two-thirds medial point and the external third (Fig.2). Afterwards, the knees were randomly divided into three groups. In group A, the tear was repaired with five 00 vertical non-absorbable stitches. The repair was performed combining inside-out and outside-in techniques using 18 gauge curved spinal needles. Two vertical stitches were placed posterior to the popliteal hiatus and three anterior to it. This first group was used as a control. In group B, an additional vertical suture including the LM and the PT was added. In group C, this additional stitch included the LM, the PT and the knee joint capsule. Subsequently, reduction and fixation of the femoral condyle was done with two 6.5mm cancellous screws. The bone defect created by the saw was compensated for with a thin rubber film.

The bone ends of the tibia and femur were then solidly mounted using a high resistance epoxy resin in a 15cm diameter PVC tube. To improve the fixation of the tibia and fibula in the simulator, some screws were added to the distal part of the tibia. Finally, two additional Steimann rods were drilled through the construct to improve rotational stability.

The femur was assembled in a cylindrical stainless steel piece and fixed with three additional shafts. The knees were then prepared for mounting in the experimental knee simulator. 

Fig.1 Technique for the lateral condile osteotomy described by Dienst


Fig.2 Lateral meniscus preparation previous to create a bucket-handle tear


Fig.3 Type I experimental knee simulator

Fig.4 A normal curve of a human gait cycle that reproduces the simulator


Fig.5 Macroscopic evaluation of LM, PT and sutures before and after one thousand gait cycles and “rotational test”

Experimental Knee-Simulator 

For this experimental study, we used a type I knee-simulator (Fig.3). In the aforementioned simulators, the forces were externally applied to the bones and musculotendinosus structures. The simulator includes five hydropneumatical cylinders that allow for the reproduction of the human gait cycle. These cylinders are able to control the flexo-extension movement of the knee during a gait cycle (Fig.4), the ground reaction forces and its mediolateral component as well as the extension and flexion forces of quadriceps and femoral biceps muscles, respectively. After putting the knees in the simulator, we were able to reproduce the gait cycle as many times as was needed as well as control tibial rotation.

As in previous works, the forces applied to the knees were approximately 20% of the physiological strength [16]. This allowed for simulating a greater number of cycles without damaging the tendon attachments.

After a careful preparation of the specimens, they were mounted on the simulator and one thousand gait cycles were carried out on each one. The screws of the lateral osteotomy were then removed and a second macroscopic look was taken in order to evaluate the situation of the LM repair, the PT and the sutures. In order to evaluate the viability of the repair under rotational movements, we added as a “rotational test” of five hundred cycles with 20º external rotation and five hundred more with 20º internal rotation. Finally, the indemnity or breakages of the LM, the PT as well as the stiches were evaluated using a digital calliper (ProMax, Fowler; USA, range 0-150mm, resolution 0.02mm).

Results :

Each was evaluated after one thousand cycles. The digital calliper was used in order to measure any disruption of the LM or the PT. If a breakage was greater than 1mm it was considered as a re-tearing of the LM or a partial rupture of the PT.

With regards to the LM repair evaluations, there were no signs of re-tearing in any of the groups and there were no differences in them (Table I).










No rupture





No rupture





No rupture





No rupture





No rupture





No rupture


Furthermore, the PT was not damaged by the non-absorbable 00 stitches when they were included in the repair (Fig.5).

We were also able to prove that there were not any ruptures of the stitches in the three groups.

Furthermore there were no differences between the three groups before or after the “rotational test.”

Discussion :

There is much mention in recent literature about the posterolateral corner of the knee and lateral meniscal repair. Most of the material covers anatomical descriptions or biomechanical studies of some of the structures in this particular area [4, 7, 10, 12, 14, 19, 25]. It is well known that the entire periphery of the LM is not fused to the capsule. The posterior margin of the meniscus is adjacent to the articular recess that separates the LM from the tendon. This is confirmed in other works, using late-stage human fetuses, with arthroscopical and also histological evaluation [13, 20]. It is also known that popliteus muscle inserts into a triangular area along the posteromedial aspect of the proximal tibia and has some static and dynamic functions such as the “unlocking” of the knee joint and preventing forward dislocation of the femur from the tibia during initial flexion. Ricklin et al. [18] described “two thin tissue bridges” attaching the LM to the joint capsule and the synovial membrane of the PT around the popliteal hiatus. Using 10 fresh frozen human knee specimens in 1979, Conh et al. [5], considered the popliteomeniscal fascicles to be the superior and inferior limits of the popliteal hiatus. They emphasized that the anatomy of the popliteal hiatus is constant.

Nowadays, there is a relative consensus with regard to the necessity to repair the popliteomeniscal fascicles in cases of posterolateral instability of the knee [11].

Furthermore, the role of LM stabilizers was well-studied during the flexo-extension movement of the knee. Minowa et al. described solid PT attachments to the fibula and LM in late-stage fetuses [13]. Sussmann et al. [20] hypothesized a retractor function of the PT and popliteofibular ligament of the LM during knee flexion. All these physiological actions on the LM are very important in order to better understand the effect of a lateral meniscectomy or a LM repair.

On the other hand, the long-term effects of the meniscectomy are well-known. Kimura et al., obtained better results after a subtotal meniscectomy or an LM repair rather than with a partial meniscectomy in an analysis of the knee functional scores [10]. This was thought to be due to the fact that the LM was forcefully pulled back by the popliteal muscle when the knee was flexed. After a partial meniscectomy, this force was not transmitted to the portion where the residual meniscus and synovial membrane meet.

Stäubli et al. [19] performed a dynamic study with videoarthroscopic control in order to gain a better undertanding of the PT’s work. They found the PT was covered by synovial tissue. The superior and inferior popliteal fascicles control the play of the LM. With increased flexion of the knee, the tendon progressively glided into the popliteal sulcus, which was angled at 30º to the saggital plane of the femoral shaft. The PT clearly changed position and orientation between the extended and the flexed positions. Furthermore, the tension in the tendon gradually increases when the knee extends.

In a cadaveric study, Tria et al. [21] reported that the PT in 7 out of 40 knees had strong dual attachments to the LM and the lateral femoral condile. More recently, Bozkurt et al. [4] described the importance of the PT and meniscofibular ligament in LM movement during flexo-extension of the knee. They hypothesized that all these solid attachments to the LM may be one of the causes of repeating LM tears.

Our results suggest that the inclusion of the PT in a lateral meniscal repair does not appear to cause excessive tension on all these structures. Consequently, there is no significant repercussion on the LM’s or PT’s functioning. The closure of the popliteal hiatus may have a similar effect on the LM, more so than all the ligaments previously mentioned. Including the PT in the repair and the closure of the popliteal hiatus with an additional stitch can probably improve the stability and the strength of the repair without significantly changing the kynematics of the posterolateral corner of the knee. 

We are aware that this work has some limitations that we should take into account. In the first place, in spite of the number of cycles, we cannot simulate the popliteal muscle contraction. This might be one of the reasons why the “rotational test” does not affect the viability of the repair.  To our knowledge, there is no exact measurement of the force that the popliteal muscle exerts and we do not know its repercussion on the kynematics of the knee.

Moreover, the experimental simulator worked within the range of infra-physiological forces [16] and the relation of 1000 cycles corresponded approximately to a distance of 1500 meters. A greater number of cycles might be necessary to come to a definitive conclusion.

Notwithstanding, to our knowledge there are no works in the literature dealing with lateral meniscal repair that include the PT. In conclusion, repairing the LM along with the PT does not seem to cause any damage to either structure and this suggests that the LM can be safely repaired using this method. More research and clinical series are needed to confirm these preliminary findings.

Reference :


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This is a peer reviewed paper 

Please cite as :Xavier Pelfort : Inclusion Of The Popliteal Tendon In A Lateral Meniscus Repair Does Not Affect The Viability Of The Repair-A Cadaveric Study Using An Experimental Knee Simulator

J.Orthopaedics 2008;5(4)e14





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