EXPERIMENTAL STUDY

Biomechanical evaluation of different suture materialsfor arthroscopic transtibial pull-out repair of posterior meniscusroot tears

Matthias J. Feucht • Eduardo Grande • Johannes Brunhuber •

Nikolaus Rosenstiel • Rainer Burgkart • Andreas B. Imhoff •

Sepp Braun

Received: 3 May 2013 / Accepted: 24 August 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract

Purpose To evaluate the biomechanical properties of four

different suture materials for arthroscopic transtibial pull-

out repair of posterior meniscus root tears, with special

focus on the meniscus–suture interface.

Methods Forty fresh-frozen lateral porcine menisci were

used. The posterior meniscus root was sutured in a stan-

dardized fashion with a simple stitch using four different

suture materials: group A, No. 2 PDSTM; group B, No. 2

EthibondTM; group C, No. 2 FiberWireTM; and group D,

2-mm FibertapeTM. Meniscus–suture constructs were sub-

jected to cyclic loading followed by load-to-failure testing

using a servo-hydraulic material testing machine.

Results During cyclic loading, group D showed a sig-

nificantly higher displacement after 100, 500, and 1,000

cycles compared to group A (p \ 0.001, p = 0.001, and

p = 0.001), and a significantly higher displacement after

100 and 500 cycles compared to group B (p = 0.010 and

p = 0.045). Group C showed a significantly higher dis-

placement compared to group A after 100 cycles

(p = 0.008). The highest maximum load was observed in

group D, with significant differences compared to group A

(p = 0.013). Group B showed a significantly higher stiff-

ness compared to group A (p = 0.023), and both group C

and group D showed a significantly higher stiffness com-

pared to group A and group B (p \ 0.001).

Conclusion None of the evaluated suture materials pro-

vided clearly superior properties over the others during

both cyclic loading and load-to-failure testing. Based on

the results of this study, FiberWireTM may be the preferred

suture material for transtibial pull-out repair of posterior

meniscus root tears because of comparably low displace-

ment during cyclic loading and high values for maximum

load and stiffness. In the clinical setting, FiberWireTM may

improve healing rates and avoid progressive extrusion of

the meniscus after transtibial pull-out repair of posterior

meniscus root tears.

Keywords Meniscus root � Root repair � Pull-out

repair � Suture material � FiberWire � FiberTape

Introduction

The meniscus roots are the ligamentous attachments of the

anterior and posterior meniscal horns to the tibial plateau

[22, 29, 39]. These structures are crucial for preserving

circumferential hoop tension and preventing extrusion of

the meniscus during axial loading [19, 39, 45]. Biome-

chanical in vitro studies have shown that both posterior

medial and posterior lateral meniscus root tears lead to

decreased tibiofemoral contact area and consequently to

increased tibiofemoral contact pressure [5, 15, 23, 38, 49].

Clinical in vivo studies have found an association between

posterior root tears and meniscus extrusion, high-grade

chondral lesions, osteonecrosis, and rapid progression of

osteoarthritis [12, 17, 25, 47, 52].

Because of the deleterious consequences of these inju-

ries, root repair techniques have gained increasing interest

M. J. Feucht � J. Brunhuber � N. Rosenstiel �A. B. Imhoff (&) � S. Braun

Department of Orthopaedic Sports Medicine, Technical

University Munich, Ismaninger Straße 22,

81675 Munich, Germany

e-mail: a.imhoff@lrz.tum.de; A.Imhoff@lrz.tu-muenchen.de

E. Grande � R. Burgkart

Department of Orthopaedics, Biomechanic Lab, Technical

University Munich, Ismaninger Straße 22,

81675 Munich, Germany

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-013-2656-z

[2, 28, 37, 43, 53]. The most commonly used technique for

refixation of the posterior medial or posterior lateral

meniscus root is a transtibial pull-out suture [3, 4, 11, 16,

18, 27, 32, 33, 40, 50]. Various methods using different

suturing techniques and different suture materials have

been described in recent years [3, 4, 16, 18, 27, 32, 40, 50].

Whereas few studies have evaluated the biomechanical

properties of different suture techniques for transtibial pull-

out repair [26, 30, 48], the influence of different suture

materials has not been reported so far.

The most commonly used suture materials for transtibial

pull-out repair are absorbable monofilament polydioxanone

sutures (PDSTM) [3, 11, 25, 32, 40, 44, 50] and braided

nonabsorbable polyester sutures (EthibondTM) [4, 16, 24,

27, 33, 50]. Other authors, however, used high-strength

sutures composed of ultra-high molecular weight polyeth-

ylene (UHMWPE) [18, 42, 53], which have been reported

to be stronger and stiffer compared to conventional sutures

[1, 6, 9, 13, 31, 36, 54, 55]. These high-performance

materials are also available as suture tapes, which may

provide additional advantages because of load transmission

over a wider area [10]. However, no recommendation

concerning the choice of suture material for transtibial pull-

out repair of meniscus root tears is available so far.

The purpose of this study was to evaluate the biome-

chanical properties of four different suture materials com-

monly used for arthroscopic transtibial pull-out repair of

posterior meniscus root tears in an in vitro porcine model,

with special emphasis on the suture–meniscus interface.

The study hypothesis was that UHMWPE sutures (Fiber-

WireTM, FiberTapeTM) provide superior biomechanical

properties compared to PDSTM and EthibondTM.

Materials and methods

Forty fresh-frozen lateral porcine menisci without any

macroscopic signs of degeneration were used to compare

four different suture materials for pull-out repair of pos-

terior meniscus root tears. Using porcine menisci to eval-

uate meniscus repair techniques is a common and

established practice in orthopaedic research [20, 34, 48,

58]. Porcine menisci have shown to provide more consis-

tent mechanical properties compared to elderly cadavers

and are anatomically and functionally comparable to young

adult human menisci [21, 41, 46].

Specimen preparation

Forty intact porcine knee joints were obtained from a local

butcher. The lateral meniscus was dissected free and

detached from the tibial plateau by cutting the anterior and

posterior meniscotibial ligament at 5 mm medial to the

margin of the anterior and posterior meniscus horn,

respectively. The menisci were fresh-frozen at -20 �C

immediately after harvesting and thawed for 8 h at room

temperature before biomechanical testing.

The posterior root of all specimens was sutured in a

standardized fashion with a single simple stitch using a �circle conventional cutting needle (FCP-6, Ethicon, Som-

erville, NJ, USA). The meniscus was penetrated at 5 mm

lateral to the medial edge and 5 mm centrally to the pos-

terior edge of the posterior meniscal horn (Fig. 1). The

menisci were assigned randomly to one of four different

suture materials: Group A, No. 2 PDSTM (Ethicon, Som-

erville, NJ, USA); group B, No. 2 EthibondTM (Ethicon,

Somerville, NJ, USA); group C, No. 2 FiberWireTM

(Arthrex, Naples, FL, USA); and group D, 2-mm Fiber-

TapeTM (Arthrex, Naples, FL, USA). Ten menisci were

tested in each group, which is congruent with other bio-

mechanical in vitro studies on meniscus–suture techniques

[48, 56–58].

Biomechanical testing

All tests were performed at room temperature, and the

menisci were kept moist with saline solution. A servo-

hydraulic material testing machine (Zwick Amsler HC10,

Zwick/Roell AG, Ulm, Germany) equipped with a dynamic

load cell (Huppert 1010-AF, Huppert GmbH, Herrenberg,

Germany) was used for tensile testing. The material testing

machine uses a linear variable differential transformer

(RDP 192028, RDP Electronics Ltd, Wolverhampton, UK)

with an accuracy of 0.20 lm. The testing machine presents

an accuracy class of ±0.5 %. The peripheral section of the

meniscus was placed in a tissue clamp (2,5 KN screw grip,

Zwick/Roell AG, Ulm, Germany) attached to the testing

machine, so that the distance between the suture in the

meniscus and the end of the clamp was 1 cm. The free ends

of the suture were tensioned and tied with a stack of three

half-hitches followed by three consecutive half-hitches on

alternating posts (‘‘surgeon’s knot’’ [36]) over a hole in a

metal plate fixed to the platen of the material testing

machine (Fig. 2a). The menisci and the metal plate were

positioned so that load was applied in line with the cir-

cumferential fibres of the posterior meniscus horn

(Fig. 2b). The distance between the suture in the meniscus

and the upper border of the hole in the metal plate was

3.5 cm. This distance was chosen on the basis of intraop-

erative measurements during root repair in three patients.

After preloading the menisci with 2 N, all specimens

were subjected to 1,000 cycles of a load between 5 and

20 N at a rate of 0.5 Hz. Subsequently, the specimens were

loaded to failure at a rate of 0.5 mm/s. This testing protocol

has been adopted from other studies evaluating repair

techniques for meniscus root tears or radial meniscus tears

Knee Surg Sports Traumatol Arthrosc

123

and is thought to simulate in vivo loads to which repaired

menisci are subjected during the early post-operative per-

iod [20, 30, 34, 48].

The number of cycles and displacement was recorded

continuously during cyclic loading by use of data-acqui-

sition software (testXpert, Zwick/Roell AG, Ulm, Ger-

many). During load-to-failure testing, load–displacement

graphs were generated. To compare the biomechanical

properties of the suture materials, the following parameters

were evaluated: displacement after 100, 500, and 1,000

cycles (defined as the difference in cross-head position

from the peak of the first cycle to the peak of cycle number

100, 500, and 1,000), maximum load-to-failure, yield load,

stiffness (calculated as the steepest slope of the load–

deformation curve spanning 30 % of the data points col-

lected between load initiation and the maximum load at

failure), and displacement at failure (measured as the total

elongation at ultimate failure). Additionally, the mode of

failure (suture pull-out of the meniscus, suture breakage,

and knot failure) was determined by visual inspection.

The study was approved by the Ethics Committee of the

Technical University of Munich.

Statistical analysis

A post hoc power analysis using the G*Power 3.1.3 soft-

ware (Franz Paul, Kiel, Germany) was used to determine

the power of the present study. Based on the results of

maximum load-to-failure, stiffness, and displacement after

1,000 cycles, an effect size of 0.55, 2.19, and 0.67 was

calculated. With the corresponding effect size and an a of

0.05, a power of 0.85, 1.00, and 0.95 was calculated with

10 samples per group.

Further statistical analysis was done using SPSS soft-

ware version 20.0 (IBM-SPSS, New York, USA). The

Kolmogorov–Smirnov test revealed normal distribution of

all test variables. Therefore, one-way analysis of variance

(ANOVA) and a post hoc Tukey’s honest significant dif-

ference test were used to evaluate group variable differ-

ences. The level of significance was set at p \ 0.05.

Fig. 1 Representative

photographs of the different

testing groups. a No. 2 PDSTM

(group A); b No. 2 EthibondTM

(group B); c No. 2 FiberWireTM

(group C); d: 2-mm

FiberTapeTM (group D)

Fig. 2 Biomechanical testing

set-up (a) and detailed view of

the clamped meniscus (b)

Knee Surg Sports Traumatol Arthrosc

123

Results

Displacement during cyclic loading

No specimen failed during the cyclic loading protocol. The

group data and the corresponding p values in the case of

significant differences between two groups are shown in

Table 1. Group A showed significantly less displacement

after 100 cycles compared to group C (p = 0.008), and

significantly less displacement after 100, 500, and 1,000

cycles compared to group D (p \ 0.001, p = 0.001, and

p = 0.001) (Fig. 3). Group B showed significantly less

displacement after 100 and 500 cycles compared to group

D (p = 0.010, p = 0.045) (Fig. 3). No significant differ-

ences were found between group A and group B, and

between group C and group D.

Maximum load and mode of failure

The group results for maximum load are shown in Table 2.

Group D showed a significantly higher maximum load

compared to group A (p = 0.013) (Fig. 4). No other sig-

nificant group differences were observed. In group C and

group D, the mode of failure was suture pull-out of the

meniscus in all specimens. In group A and group D, two

specimens each failed by suture breakage away from the

knot, whereas the other specimens failed by suture pull-out.

No knot failure was observed.

Yield load

Table 2 shows the results for yield load. No significant

differences were found between the four groups.

Stiffness

The detailed group results for stiffness are shown in

Table 2. Group B showed a significantly higher stiffness

compared to group A (p = 0.023) (Fig. 5). Both group C

and group D showed a significantly higher stiffness com-

pared to group A and group B (p \ 0.001) (Fig. 5). No

significant differences were found between group C and

group D.

Table 1 Displacement during cyclic loading

Displacement after

100 cycles (mm)

Displacement after

500 cycles (mm)

Displacement after

1,000 cycles (mm)

Group A (PDSTM) 0.2 ± 0.1a,b

(0.1–0.2)

0.4 ± 0.2b

(0.3–0.6)

0.6 ± 0.2b

(0.4–0.7)

Group B (EthibondTM) 0.3 ± 0.1c

(0.3–0.3)

0.6 ± 0.1c

(0.5–0.7)

0.8 ± 0.1

(0.7–0.8)

Group C (FiberWireTM) 0.3 ± 0.1

(0.2–0.4)

0.7 ± 0.3

(0.4–0.9)

0.8 ± 0.3

(0.6–1.0)

Group D (FiberTapeTM) 0.5 ± 0.2

(0.4–0.6)

0.8 ± 0.2

(0.7–1.0)

1.0 ± 0.2

(0.9–1.2)

Data are shown as mean ± standard deviation (95 % CI)a Group A showed significantly less displacement compared to group C (p = 0.008)b Group A showed significantly less displacement compared to group D (100 cycles: p \ 0.001; 500 cycles: p = 0.001; 1,000 cycles:

p = 0.001)c Group B showed significantly less displacement compared to group D (100 cycles: p = 0.010; 500 cycles p = 0.045)

Fig. 3 Displacement during cyclic loading (mean values with

standard deviations). a Group A showed significantly less displace-

ment compared to group C after 100 cycles (p = 0.008); b group A

showed significantly less displacement compared to group D after 100

(p \ 0.001), 500 (p = 0.001), and 1,000 cycles (p = 0.001); c group

B showed significantly less displacement compared to group D after

100 (p = 0.010) and 500 cycles (p = 0.045)

Knee Surg Sports Traumatol Arthrosc

123

Displacement at failure

Group B, group C, and group D showed significantly less

displacement at failure compared to group A (p = 0.004,

p \ 0.001, and p \ 0.001) (Table 2). Group C additionally

showed significantly less displacement at failure compared

to group B (p = 0.003).

Discussion

The most important finding of this laboratory study was that

none of the evaluated suture materials showed clearly

superior biomechanical properties over the others during

both cyclic loading and load-to-failure testing. FiberTapeTM

and FiberWireTM provided favourable characteristics

compared to PDSTM and EthibondTM during load-to-failure

testing, but showed a slight tendency towards higher dis-

placement during cyclic loading.

Tensile strength of transtibial pull-out repair is deter-

mined by the suture technique and the suture material. The

ideal suture material should provide low displacement, high

stiffness, and high maximum load to keep the reattached

meniscus root in place during the healing process. In other

fields of arthroscopic surgery, there has been a shift from

conventional sutures, such as braided polyester sutures

(EthibondTM) and monofilament PDSTM to newer high-

strength sutures composed either totally or partially of

UHMWPE [6, 55]. These high-performance sutures have

Table 2 Maximum load-to-failure, yield load, stiffness, and displacement at failure

Maximum load (N) Yield load (N) Stiffness (N/mm) Displacement at failure (mm)

Group A (PDSTM) 133.2 ± 35.4

(107.8–158.5)

119.8 ± 40.3

(91.0–148.7)

8.6 ± 1.2

(7.8–9.4)

17.0 ± 3.8

(14.3–19.7)

Group B (EthibondTM) 146.1 ± 20.6

(131.3–160.8)

130.8 ± 21.8

(115.3–146.4)

13.6 ± 0.8b

(13.0–14.2)

12.8 ± 2.0e

(11.4–14.3)

Group C (FiberWireTM) 169.0 ± 43.4

(138.0–200.1)

142.0 ± 30.4

(120.2–163.7)

26.9 ± 2.4c

(25.2–28.6)

8.5 ± 2.5f

(6.8–10.3)

Group D (FiberTapeTM) 195.6 ± 62.1a

(151.2–240.1)

162.9 ± 55.2

(123.4–202.3)

26.6 ± 6.8d

(21.7–31.5)

10.5 ± 1.3g

(9.6–11.5)

Data are shown as mean ± standard deviation (95 % CI)a Group D showed a significantly higher maximum load compared to group A (p = 0.013)b Group B showed a significantly higher stiffness compared to group A (p = 0.023)c Group C showed a significantly higher stiffness compared to group A and group B (p \ 0.001 and p \ 0.001)d Group D showed a significantly higher stiffness compared to group A and group B (p \ 0.001 and p \ 0.001)e Group B showed significantly less displacement at failure compared to group A (p = 0.004)f Group C showed significantly less displacement at failure compared to group A and group B (p \ 0.001 and p = 0.003)g Group D showed significantly less displacement at failure compared to group A (p \ 0.001)

Fig. 4 Maximum load-to-failure (mean values with standard devia-

tions). a Group D showed a significantly higher maximum load

compared to group A (p = 0.013)

Fig. 5 Stiffness (mean values with standard deviations). a Group B

showed a significantly higher stiffness compared to group A

(p = 0.023); b group C showed a significantly higher stiffness

compared to group A and group B (p \ 0.001 and p \ 0.001);

c group D showed a significantly higher stiffness compared to group

A and group B (p \ 0.001 and p \ 0.001)

Knee Surg Sports Traumatol Arthrosc

123

also improved the biomechanical properties of all-inside

meniscus repair devices [8]. FiberWireTM suture is made of

a multi-strand, long-chain UHMWPE core with a braided

jacket of polyester and UHMWPE. Compared to Ethi-

bondTM and PDSTM, FiberWireTM of the same calibre has

been shown to provide significantly higher load-to-failure

and stiffness [1, 7, 9, 13, 31, 36, 54, 55]. FiberTapeTM is a

2-mm-wide tape with a similar structure as FiberWireTM.

Because of its larger surface area, this suture material may

distribute loads over a broader area and may therefore

increase the load required for tissue pull-through. Burgess

et al. [10] compared FiberTapeTM, FiberWireTM, and nylon

leader line used as suture loops in an in vitro biomechanical

study. In this study, FiberTapeTM was the strongest and

stiffest material tested. Testing the suture material in iso-

lation, however, might not reflect the biomechanical prop-

erties when used for tissue refixation. Several studies have

shown that improved suture strength has resulted in the

most common site of failure being the suture–tissue inter-

face, leading to cut-out failures [9]. Our study therefore

aimed to specifically evaluate the biomechanical behaviour

of the suture–meniscus interface. FiberTapeTM and Fiber-

WireTM both failed by suture pull-out of the meniscus root,

whereas suture breakage was the mode of failure in two

specimens after repair with PDSTM and EthibondTM. The

highest maximum load was achieved with FiberTapeTM;

however, statistical significance was only achieved when

compared to PDSTM. These findings reveal that the ultimate

suture strength does not determine maximum load-to-fail-

ure of root repair since the weakest link is the suture–

meniscus interface. Both FiberTapeTM and FiberWireTM

showed a significantly higher stiffness compared to PDSTM

and EthibondTM. Stiffness is an important parameter, as it

describes the ability of the meniscus–suture complex to

avoid deformation under loading conditions [35].

In a similar biomechanical study, Bisson et al. [9]

compared simple suture fixation of bovine infraspinatus

tendons using three different No. 2 UHMWPE sutures and

No. 2 EthibondTM. Load-to-failure testing showed no sig-

nificant difference between any suture materials with

respect to maximum load-to-failure. Comparable to our

results, all FiberWireTM specimens failed as a result of

suture pulling through the tendon at loads much lower than

their ultimate tensile load, whereas suture breakage was

observed in some EthibondTM specimens. Tendon fixation

with FiberWireTM was stiffer than fixation with Ethi-

bondTM, which also confirms the finding of our study.

Displacement of the meniscus–suture complex during

the early post-operative period might result in nonanatomic

(more peripheral) healing of the meniscus root, leading to

diminished function of the meniscus [51]. In this study

UHMWPE sutures, especially FiberTapeTM, showed a

slight tendency towards higher displacement during cyclic

loading. One explanation for this finding might be that the

high stiffness of UHMWPE predisposes to higher dis-

placement during cyclic loading by suture cutting through

the meniscus tissue. Furthermore, FiberTapeTM might have

created greater damage of the meniscus tissue during suture

passage because of its wider diameter. It should be noted,

however, that the overall displacement during cyclic

loading was relatively low, with a maximum of 1.46 mm.

The clinical consequence of this small amount of dis-

placement is currently unknown.

In general, the functional results after arthroscopic

transtibial pull-out repair are encouraging [24, 25, 33, 40].

Nevertheless, studies using magnetic resonance imaging

and second-look arthroscopies reported poor healing rates

and progressive meniscal extrusion after transtibial pull-out

repair of posterior medial meniscus root tears [40, 50]. In

all of these patients, PDSTM or EthibondTM was used as

suture material. In our study, PDSTM and EthibondTM

showed inferior characteristics during load-to-failure test-

ing compared to UHMWPE. Whether these high-strength

sutures enhance meniscus healing has to be the subject of

future clinical studies.

This study has several limitations. As with all in vitro

biomechanical models, only the time zero stability is

evaluated. Since porcine menisci were used, our results

may not reflect the true impact of the suture materials in

human menisci. However, the use of porcine menisci is an

established and widely used model to evaluate meniscus

repair techniques, because porcine menisci provide more

consistent tissue quality compared to human cadaveric

specimens [20, 35, 48, 58]. In our test set-up, load on the

sutured PMMR was applied parallel to the fibres of the

meniscus root, simulating a worst-case scenario. This may

not reflect the in vivo forces on the meniscus–suture con-

struct, since the angle between the transtibial tunnel and the

meniscus root serves as a pulley, which could alter the

resulting forces. Furthermore, shear and compression for-

ces are neglected in this test scenario. Nevertheless, the

worst-case scenario is a commonly used practice in

orthopaedic research. Besides different suture materials,

also different suture techniques are currently used for root

repair [3, 14, 16, 18, 27, 32, 42]. Since the focus of this

study was to evaluate the biomechanical properties of

different suture materials, a simple stitch was chosen to

minimize the influence of more complex suture techniques.

However, the results of this study may not be entirely

extrapolated to other suture techniques. Further studies

using human specimens and more complex suture tech-

niques are necessary to determine the optimal suture

material for arthroscopic transtibial pull-out repair of

meniscus root tears.

Regarding the clinical relevance of this study, the

favourable biomechanical characteristic of FiberWireTM

Knee Surg Sports Traumatol Arthrosc

123

may be beneficial for meniscus healing and restoration of

meniscus function after transtibial pull-out repair of pos-

terior meniscus root tears. However, further clinical studies

are necessary to prove this hypothesis.

Conclusion

None of the evaluated suture materials showed clearly

superior biomechanical properties over the others during

both cyclic loading and load-to-failure testing. UHMWPE

sutures provided favourable characteristics compared to

PDSTM and EthibondTM during load-to-failure testing, but

showed a slight tendency towards higher displacement

during cyclic loading. Of the four evaluated suture mate-

rials, FiberWireTM may be the preferred suture material for

transtibial pull-out repair of posterior root tears because of

comparably low displacement during cyclic loading, high

values for maximum load and stiffness, and low displace-

ment at failure.

References

1. Abbi G, Espinoza L, Odell T, Mahar A, Pedowitz R (2006)

Evaluation of 5 knots and 2 suture materials for arthroscopic

rotator cuff repair: very strong sutures can still slip. Arthroscopy

22(1):38–43

2. Ahn JH, Lee YS, Yoo JC, Chang MJ, Park SJ, Pae YR (2010)

Results of arthroscopic all-inside repair for lateral meniscus root

tear in patients undergoing concomitant anterior cruciate liga-

ment reconstruction. Arthroscopy 26(1):67–75

3. Ahn JH, Wang JH, Lim HC, Bae JH, Park JS, Yoo JC, Shyam AK

(2009) Double transosseous pull out suture technique for tran-

section of posterior horn of medial meniscus. Arch Orthop

Trauma Surg 129(3):387–392

4. Ahn JH, Wang JH, Yoo JC, Noh HK, Park JH (2007) A pull out

suture for transection of the posterior horn of the medial menis-

cus: using a posterior trans-septal portal. Knee Surg Sports

Traumatol Arthrosc 15(12):1510–1513

5. Allaire R, Muriuki M, Gilbertson L, Harner CD (2008) Biome-

chanical consequences of a tear of the posterior root of the medial

meniscus. Similar to total meniscectomy. J Bone Jt Surg Am

90(9):1922–1931

6. Barber FA, Herbert MA, Coons DA, Boothby MH (2006) Sutures

and suture anchors–update 2006. Arthroscopy 22(10):1063–1069

7. Barber FA, Herbert MA, Richards DP (2003) Sutures and suture

anchors: update 2003. Arthroscopy 19(9):985–990

8. Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Sutker MJ

(2009) Biomechanical testing of new meniscal repair techniques

containing ultra high-molecular weight polyethylene suture.

Arthroscopy 25(9):959–967

9. Bisson LJ, Manohar LM, Wilkins RD, Gurske-Deperio J, Eh-

rensberger MT (2008) Influence of suture material on the bio-

mechanical behavior of suture-tendon specimens: a controlled

study in bovine rotator cuff. Am J Sports Med 36(5):907–912

10. Burgess R, Elder S, McLaughlin R, Constable P (2010) In vitro

biomechanical evaluation and comparison of FiberWire, Fiber-

Tape, OrthoFiber, and nylon leader line for potential use during

extraarticular stabilization of canine cruciate deficient stifles. Vet

Surg 39(2):208–215

11. Cho JH (2012) Modified pull-out suture in posterior root tear of

the medial meniscus: using a posteromedial portal. Knee Surg

Relat Res 24(2):124–127

12. Choi SH, Bae S, Ji SK, Chang MJ (2012) The MRI findings of

meniscal root tear of the medial meniscus: emphasis on coronal,

sagittal and axial images. Knee Surg Sports Traumatol Arthrosc

20(10):2098–2103

13. Deakin M, Stubbs D, Bruce W, Goldberg J, Gillies RM, Walsh

WR (2005) Suture strength and angle of load application in a

suture anchor eyelet. Arthroscopy 21(12):1447–1451

14. Feucht MJ, Minzlaff P, Saier T, Lenich A, Imhoff AB, Hin-

terwimmer S (2013) Avulsion of the anterior medial meniscus

root: case report and surgical technique. Knee Surg Sports

Traumatol Arthrosc. doi:10.1007/s00167-013-2462-7

15. Forkel P, Herbort M, Schulze M, Rosenbaum D, Kirstein L,

Raschke M, Petersen W (2013) Biomechanical consequences of a

posterior root tear of the lateral meniscus: stabilizing effect of the

meniscofemoral ligament. Arch Orthop Trauma Surg 133(5):

621–626

16. Forkel P, Petersen W (2012) Posterior root tear fixation of the

lateral meniscus combined with arthroscopic ACL double-bundle

reconstruction: technical note of a transosseous fixation using the

tibial PL tunnel. Arch Orthop Trauma Surg 132(3):387–391

17. Han SB, Shetty GM, Lee DH, Chae DJ, Seo SS, Wang KH, Yoo

SH, Nha KW (2010) Unfavorable results of partial meniscectomy

for complete posterior medial meniscus root tear with early

osteoarthritis: a 5- to 8-year follow-up study. Arthroscopy 26(10):

1326–1332

18. Harner CD, Mauro CS, Lesniak BP, Romanowski JR (2009)

Biomechanical consequences of a tear of the posterior root of the

medial meniscus. Surgical technique. J Bone Jt Surg Am

91(Suppl 2):257–270

19. Hein CN, Deperio JG, Ehrensberger MT, Marzo JM (2011)

Effects of medial meniscal posterior horn avulsion and repair on

meniscal displacement. Knee 18(3):189–192

20. Herbort M, Siam S, Lenschow S, Petersen W, Zantop T (2010)

Strategies for repair of radial tears close to the meniscal rim–

biomechanical analysis with a cyclic loading protocol. Am J

Sports Med 38(11):2281–2287

21. Jaspers P, de Lange A, Huiskes R, van Rens TJ (1980) The

mechanical function of the meniscus, experiments on cadaveric

pig knee-joints. Acta Orthop Belg 46(6):663–668

22. Johannsen AM, Civitarese DM, Padalecki JR, Goldsmith MT,

Wijdicks CA, Laprade RF (2012) Qualitative and quantitative

anatomic analysis of the posterior root attachments of the medial

and lateral menisci. Am J Sports Med 40(10):2342–2347

23. Kim JG, Lee YS, Bae TS, Ha JK, Lee DH, Kim YJ, Ra HJ (2012)

Tibiofemoral contact mechanics following posterior root of

medial meniscus tear, repair, meniscectomy, and allograft trans-

plantation. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/

s00167-012-2182-4

24. Kim JH, Chung JH, Lee DH, Lee YS, Kim JR, Ryu KJ (2011)

Arthroscopic suture anchor repair versus pullout suture repair in

posterior root tear of the medial meniscus: a prospective com-

parison study. Arthroscopy 27(12):1644–1653

25. Kim SB, Ha JK, Lee SW, Kim DW, Shim JC, Kim JG, Lee MY

(2011) Medial meniscus root tear refixation: comparison of

clinical, radiologic, and arthroscopic findings with medial men-

iscectomy. Arthroscopy 27(3):346–354

26. Kim YM, Joo YB (2013) Pullout failure strength of the posterior

horn of the medial meniscus with root ligament tear. Knee Surg

Sports Traumatol Arthrosc 21(7):1546–1552

27. Kim YM, Rhee KJ, Lee JK, Hwang DS, Yang JY, Kim SJ (2006)

Arthroscopic pullout repair of a complete radial tear of the tibial

Knee Surg Sports Traumatol Arthrosc

123

attachment site of the medial meniscus posterior horn. Arthros-

copy 22(7):7951–7954

28. Koenig JH, Ranawat AS, Umans HR, Difelice GS (2009) Men-

iscal root tears: diagnosis and treatment. Arthroscopy 25(9):

1025–1032

29. Kohn D, Moreno B (1995) Meniscus insertion anatomy as a basis

for meniscus replacement: a morphological cadaveric study.

Arthroscopy 11(1):96–103

30. Kopf S, Colvin AC, Muriuki M, Zhang X, Harner CD (2011)

Meniscal root suturing techniques: implications for root fixation.

Am J Sports Med 39(10):2141–2146

31. Lawrence TM, Davis TR (2005) A biomechanical analysis of

suture materials and their influence on a four-strand flexor tendon

repair. J Hand Surg Am 30(4):836–841

32. Lee DW, Jang SH, Ha JK, Kim JG, Ahn JH (2013) Meniscus root

refixation technique using a modified Mason-Allen stitch. Knee

Surg Sports Traumatol Arthrosc 21(3):654–657

33. Lee JH, Lim YJ, Kim KB, Kim KH, Song JH (2009) Arthro-

scopic pullout suture repair of posterior root tear of the medial

meniscus: radiographic and clinical results with a 2-year follow-

up. Arthroscopy 25(9):951–958

34. Lee YH, Nyland J, Burden R, Caborn DN (2012) Cyclic test

comparison of all-inside device and inside-out sutures for radial

meniscus lesion repair: an in vitro porcine model study.

Arthroscopy 28(12):1873–1881

35. Lee YH, Nyland J, Burden R, Caborn DN (2013) Repair of

peripheral vertical meniscus lesions in porcine menisci: in vitro

biomechanical testing of 3 different meniscus repair devices. Am

J Sports Med 41(5):1873–1881

36. Lo IK, Burkhart SS, Chan KC, Athanasiou K (2004) Arthroscopic

knots: determining the optimal balance of loop security and knot

security. Arthroscopy 20(5):489–502

37. Marzo JM (2012) Meniscus root avulsion. Clin Sports Med

31(1):101–111

38. Marzo JM, Gurske-DePerio J (2009) Effects of medial meniscus

posterior horn avulsion and repair on tibiofemoral contact area

and peak contact pressure with clinical implications. Am J Sports

Med 37(1):124–129

39. Messner K, Gao J (1998) The menisci of the knee joint. Ana-

tomical and functional characteristics, and a rationale for clinical

treatment. J Anat 193(Pt 2):161–178

40. Moon HK, Koh YG, Kim YC, Park YS, Jo SB, Kwon SK (2012)

Prognostic factors of arthroscopic pull-out repair for a posterior

root tear of the medial meniscus. Am J Sports Med 40(5):

1138–1143

41. Nakano T, Aherne FX (1992) Morphology and water and lipid

contents of stifle menisci of growing swine. Can J Vet Res

56(2):165–167

42. Nicholas SJ, Golant A, Schachter AK, Lee SJ (2009) A new

surgical technique for arthroscopic repair of the meniscus root

tear. Knee Surg Sports Traumatol Arthrosc 17(12):1433–1436

43. Papalia R, Vasta S, Franceschi F, D’Adamio S, Maffulli N, De-

naro V (2013) Meniscal root tears: from basic science to ultimate

surgery. Br Med Bull. doi:10.1093/bmb/ldt002

44. Park YS, Moon HK, Koh YG, Kim YC, Sim DS, Jo SB, Kwon

SK (2011) Arthroscopic pullout repair of posterior root tear of the

medial meniscus: the anterior approach using medial collateral

ligament pie-crusting release. Knee Surg Sports Traumatol

Arthrosc 19(8):1334–1336

45. Petersen W, Tillmann B (1998) Collagenous fibril texture of the

human knee joint menisci. Anat Embryol (Berl) 197(4):317–324

46. Post WR, Akers SR, Kish V (1997) Load-to-failure of common

meniscal repair techniques: effects of suture technique and suture

material. Arthroscopy 13(6):731–736

47. Robertson DD, Armfield DR, Towers JD, Irrgang JJ, Maloney

WJ, Harner CD (2009) Meniscal root injury and spontaneous

osteonecrosis of the knee: an observation. J Bone Jt Surg Br

91(2):190–195

48. Rosslenbroich SB, Borgmann J, Herbort M, Raschke MJ, Peter-

sen W, Zantop T (2013) Root tear of the meniscus: biomechanical

evaluation of an arthroscopic refixation technique. Arch Orthop

Trauma Surg 133(1):111–115

49. Schillhammer CK, Werner FW, Scuderi MG, Cannizzaro JP

(2012) Repair of lateral meniscus posterior horn detachment

lesions: a biomechanical evaluation. Am J Sports Med

40(11):2604–2609

50. Seo HS, Lee SC, Jung KA (2011) Second-look arthroscopic

findings after repairs of posterior root tears of the medial

meniscus. Am J Sports Med 39(1):99–107

51. Starke C, Kopf S, Grobel KH, Becker R (2010) The effect of a

nonanatomic repair of the meniscal horn attachment on meniscal

tension: a biomechanical study. Arthroscopy 26(3):358–365

52. Sung JH, Ha JK, Lee DW, Seo WY, Kim JG (2013) Meniscal

extrusion and spontaneous osteonecrosis with root tear of medial

meniscus: comparison with horizontal tear. Arthroscopy

29(4):726–732

53. Vyas D, Harner CD (2012) Meniscus root repair. Sports Med

Arthrosc 20(2):86–94

54. Wright PB, Budoff JE, Yeh ML, Kelm ZS, Luo ZP (2006)

Strength of damaged suture: an in vitro study. Arthroscopy

22(12):1270–1275

55. Wust DM, Meyer DC, Favre P, Gerber C (2006) Mechanical and

handling properties of braided polyblend polyethylene sutures in

comparison to braided polyester and monofilament polydioxa-

none sutures. Arthroscopy 22(11):1146–1153

56. Zantop T, Eggers AK, Musahl V, Weimann A, Petersen W (2005)

Cyclic testing of flexible all-inside meniscus-suture anchors:

biomechanical analysis. Am J Sports Med 33(3):388–394

57. Zantop T, Eggers AK, Weimann A, Hassenpflug J, Petersen W

(2004) Initial fixation strength of flexible all-inside meniscus-

suture anchors in comparison to conventional suture technique

and rigid anchors: biomechanical evaluation of new meniscus

refixation systems. Am J Sports Med 32(4):863–869

58. Zantop T, Temmig K, Weimann A, Eggers AK, Raschke MJ,

Petersen W (2006) Elongation and structural properties of men-

iscal repair using suture techniques in distraction and shear force

scenarios: biomechanical evaluation using a cyclic loading pro-

tocol. Am J Sports Med 34(5):799–805

Knee Surg Sports Traumatol Arthrosc

123