Avoiding Injury to the Popliteal Neurovascular

Bundle in All-Inside Suturing of the Posterior Horn of

the Lateral Meniscus: An MRI Assessment of Portal
Selection and Safety
Ron Gilat, M.D., Gabriel Agar, M.D., Noam Shohat, M.D., Moshe Dahan, M.D.,
Yiftah Beer, M.D., and Dror Lindner, M.D.

Purpose: We assessed the risk of injury to the popliteal neurovascular bundle (PNVB) while suturing the posterior horn
of the lateral meniscus (PHLM). Methods: We simulated all-inside suturing of the PHLM using magnetic resonance
imaging of 60 knees. Lines were drawn from the medial and the lateral edges of the patellar tendon to the PHLM at
increasing distances from the posterior cruciate ligament (PCL) to simulate suturing device trajectory. Distance from each
line to the PNVB was measured (d). A similar analysis was performed using lines drawn from 1 cm medial and 1 cm lateral
to the patellar tendon. We compared the average “d” at increasing distances from the PCL, between the different simulated
portal entry points. We have also analyzed the association between different demographic characteristics and the shortest
distance from the PVNB to the PHLM. Results: Of 1200 measurements performed, the simulated suturing trajectory
transected the PNVB 343 times (28.6%). At 0 mm from the PCL, the safest portal was the 1-cm lateral portal (P < .001),
with an average “d” of 2.7 mm. At 3 mm, 6 mm, 9 mm, and 12 mm from the PCL, the safest portal was the 1-cm medial
portal (P < .001), with average “d” of 3.8 mm, 6.9 mm, 10.1 mm, and 13.5 mm, respectively. Average distance between
the PHLM and the PNVB was 7.8 mm. Shorter distance between the PHLM and the PNVB was associated with younger
age and female sex (P ¼ .014 and .001, respectively). Conclusions: All-inside suturing of the PHLM at 0 mm from the
PCL is safer with a more lateral portal. Beyond 3 mm from the PCL, a more medial portal carries a lower risk to the PNVB.
Young and female patients have a shorter distance between the PHLM and the PNVB, suggesting a greater risk for injury to
the PNVB. Careful preoperative magnetic resonance imaging assessment may assist in safer portal selection when plan-
ning repair of the PHLM. Clinical Relevance: This study describes a magnetic resonance imagingebased risk assessment for
injury of the PVNB while suturing the PHLM. It allows the orthopaedic surgeon a better understanding of the anatomic
relationship between the popliteal neurovascular bundle and the lateral meniscus and can assist in portal selection and safety.

preservation.2 Meniscal repair using all-inside suturing

A rthroscopic knee surgery is the most common
orthopaedic procedure performed in the United
States, with a meniscal tear encountered in more than
half of knee arthroscopies.1 The ideal treatment in the
management of meniscal tears is meniscal
From the Department of Orthopaedic Surgery, Yitzhak Shamir Medical
Center (R.G., G.A., N.S., M.D., Y.B., D.L.), Zriffin, Israel, and Tel Aviv
University (R.G., G.A., N.S., M.D., Y.B., D.L.), Tel Aviv, Israel.
Dr. Gilat and Dr. Agar have contributed equally to this article and share
first authorship.
The authors report that they have no conflicts of interest in the authorship
and publication of this article. Full ICMJE author disclosure forms are
available for this article online, as supplementary material.
Received March 7, 2019; accepted August 14, 2019.
Address correspondence to Ron Gilat, M.D., Assaf Harofeh Medical Center,
Zriffin, Israel. E-mail: ron.gilat@gmail.com
Ó 2019 by the Arthroscopy Association of North America
0749-8063/19272/$36.00
https://doi.org/10.1016/j.arthro.2019.08.041
devices is on the rise.3 Extensive use of all-inside su-
turing of the meniscus is also being used in increasing
frequency in meniscal allograft transplantations.4
The risk for damaging the popliteal neurovascular
bundle (NVB) with meniscal repair has been demon-
strated in several cadaveric and imaging studies, as well as
numerous case reports and series.5-13 Injury to the popli-
teal NVB, although rare, may have grave consequences
for patients who choose to undergo this elective proced-
ure. Complications include massive bleeding and pseu-
doaneurysm and fistula formation and may consequently
result in revision surgery and amputation.6,10,12 Studies
reporting on the risk of injury to the popliteal NVB while
suturing the posterior horn of the lateral meniscus
(PHLM) are limited, and most lack emphasis on the effect
of portal selection, the suture location on the PHLM, and
demographic characteristics of this risk assessment.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2019: pp 1-7 1
2 R. GILAT ET AL.

Fig 1. Axial proton density magnetic resonance imaging (MRI) of the knee at the level of the menisci with measurements of
the knee cross-section area in mm2 and of the distance between the posterior horn of the lateral meniscus (PHLM) and the
popliteal neurovascular bundle (NVB). Popliteal artery and vein and tibial nerve are encircled in red, blue, and yellow,
respectively.(A) Right knee of a 21-year-old female patient with cross-section area of 11,789 mm2 and a very short PHLM to
popliteal NVB distance (white line and the letter D), measuring 1.8 mm. (B) Right knee of a 54-year-old male patient with
cross-section area of 11,669 mm2 and a relatively long distance from the PHLM to the popliteal NVB (white line and the letter
D), measuring 11.3 mm.

The purpose of this study is to assess the risk of injury
to the popliteal NVB while suturing the PHLM. We
hypothesize that there will be no difference in the
average shortest distance between suturing device tra-
jectory and the popliteal NVB using different portals.
We also hypothesize that there will be no association
between the distance from the PHLM to the popliteal
NVB and demographic characteristics.
Methods
The study was approved by the Institutional Review
Board before initiation. Patients included in the study
underwent magnetic resonance imaging (MRI) of the
knee at a single institution throughout August 2018. We
excluded (1) patients younger than 18 years old, (2) pa-
tients who underwent prior knee surgery, (3) those with
an acquired knee deformity (such as prior fracture of the
distal femur or proximal tibia), (4) cases in which the
quality of MRI was low and did not allow measurements,
and (5) incidental findings affecting the position of the
NVB (such as arteriovenous malformations, large gan-
glion cysts, and other space-occupying lesions).
A Siemens Magnetom Skyra 3 Tesla (Siemens
Healthcare Diagnostics, Inc, Tarrytown, NY) MRI scan-
ner was used for all knee scans. MRI was performed with
the patient at rest in a supine position with the index
knee in extension. A dedicated coil was placed around
the knee, and a standard U-shaped ankle cushion was
placed under the patient’s ankle to minimize leg motion
and patient discomfort. Axial plane cross-section slices of
the knee were acquired using proton density fat
suppression sequencing. All measurements were per-
formed using the PACS software (Centricity; GE
Healthcare System Inc., Amersham, United Kingdom).
First, an anthropometric measurement of the knee
cross-section area was performed at the level of the
menisci (Fig 1A-B). Then the popliteal NVB was
located and encircled. The shortest distance between
the posterior border of the PHLM and the most ante-
rior point of the popliteal NVB was measured in mil-
limeters (Fig 1A-B). We simulated all-inside suturing
of the PHLM using a similar technique to the methods
described by Espejo-Baena et al.11 and Sanz-Perez
et al.14 Confirmation of the most superior axial slice
through the lateral meniscus was performed with
concurrent localization on sagittal and coronal views.
The medial and lateral edges of the patellar tendon
were used as the simulated entry points of the ante-
romedial and anterolateral portals, respectively.6,11,14
Trajectory lines were drawn from the anteromedial
and anterolateral portals to the PHLM at increasing
distance from the posterior cruciate ligament (0 mm,
3 mm, 6 mm, 9 mm, and 12 mm). The distance from
each of these lines to the popliteal NVB was measured
(d). A similar analysis was performed for simulated
portal entry points 1 cm medial to the edge of the
patellar tendon and 1 cm lateral to the edge of the
patellar tendon (Fig 2A-D). We then compared the
average “d” at increasing distance from the PCL
between the different simulated portals.
All measurements were performed using PACS soft-
ware (Centricity; GE Healthcare System Inc.).
 SAFE PORTALS FOR LATERAL MENISCUS REPAIR 3

Interobserver and intraobserver reliability were evalu-
ated using repeat measurements performed by 2 or-
thopaedic surgery residents (R.G., N.S.), and a senior
orthopaedic surgeon specialized in orthopaedic sports
medicine (M.D.). Intraobserver measurements were
performed more than a month apart by a single
investigator (R.G.).
We evaluated a total of 75 consecutive patients who
underwent knee MRI. Fifteen patients were excluded
from the study; 7 had poor-quality MRI scans pre-
cluding reliable measurements, 3 were status post
anterior cruciate ligament reconstruction, 3 were
younger than age 18, 1 had a giant ganglion cyst, and 1
had a massive prepatellar bursa effusion. Overall, 60
knee MRIs were evaluated in 40 males (67%) and 20
females (33%), with an average age of 44 years (range,
18-79). Patients’ demographic characteristics are pre-
sented in Table 1.
organized using Microsoft Excel (2013; Microsoft, Red-
mond, WA). We used the 1-way repeated measures
analysis of variance to compare the distance from the
popliteal NVB to the all-inside device trajectory, among
all different portals. We have also performed an analysis
comparing each portal with each of the other 3 portals at
each distance from the posterior cruciate ligament (PCL)
separately, using the paired Student t-test. We used
multivariate linear regression analysis to assess the
association between demographic characteristics (inde-
pendent variables; age, sex, laterality and knee cross-
section area) and the distance of the PHLM to the
popliteal NVB (dependent continuous variable; D).
Interobserver and intraobserver reliability was assessed
using intraclass correlation coefficient. Statistical signif-
icance was determined with a P value <.05. Statistical
analysis was performed using Stata v.13.0 (StataCorp,
College Station, TX).

Statistical Methods
A power analysis was performed, assuming 80%
power and an a level of 0.05, which indicated 44 patients
will allow the detection of a difference >0.5 mm with a
standard deviation of 1. Data were collected and
Results
The simulated suturing trajectory transected the
popliteal NVB 343 times out of a total of 1200 mea-
surements (28.6%). Average distances of simulated

Fig 2. Simulation of all-inside

suturing device trajectories to
the posterior horn of the
lateral meniscus (PHLM) at
increasing distance from the
posterior cruciate ligament
(0 mm, 3 mm, 6 mm, 9 mm,
and 12 mm). Red simulated
trajectories signify transection
of the popliteal NVB, whereas
green simulated trajectories
signify safe passage. (A and B)
Simulated trajectories from
medial and 1-cm medial por-
tals, respectively. Shortest dis-
tance between a 6-mm
trajectory, and the popliteal
neurovascular bundle (NVB) is
represented by the white line
and the letter d. (C and D)
Simulated trajectories from
lateral and 1-cm lateral portals,
respectively. Shortest distance
between a 0-mm trajectory
and the popliteal neuro-
vascular bundle (NVB) is rep-
resented by the white line and
the letter d.
4 R. GILAT ET AL.

Table 1. Demographic characteristics of the study participants
No. of patients 60
Age, mean (range) 44 (18-79)
Sex
Female 20 (33%)
Male 40 (67%)
Laterality
Right 30 (50%)
Left 30 (50%)
Knee cross-section area,* 11,369 (8451-16,336)
mean (range) in mm2
Distance from PHLM to popliteal NVB,* 7.8 (1.5-13)
mean (range) in mm
PHLM, posterior horn of lateral meniscus; NVB, neurovascular
bundle.
*As measured by axial cross-section magnetic resonance imaging of
the knee.
trajectories to the popliteal neurovascular bundle,
stratified by different portals and by increasing distances
from the PCL, are detailed in Table 2.
At 0 mm from the PCL, the safest portal was the
1-cmelateral portal with an average distance of 2.7 mm
from the simulated suture trajectory and the popliteal
NVB (P < .001). The 1-cmemedial portal was the safest
portal at 3 mm, 6 mm, 9 mm, and 12 mm from the PCL
with average distances from the simulated suture tra-
jectory to the popliteal NVB of 3.8 mm, 6.9 mm,
10.1 mm, and 13.5 mm, respectively (P < .001). Of
note, at 0 mm from the PCL, there was no significant
difference between the 1-cmemedial and the lateral
portals (P ¼ .681), and, at 6 mm from the PCL, there
was no significant difference between the lateral and
the 1 cmelateral portals (P ¼ .144). All other separate
portal comparisons showed a statistically significant
difference. Intraclass correlation coefficient for inter-
observer and intraobserver reliability were 0.81 (95%
confidence interval 0.58-0.9) and 0.89 (0.84-0.92),
respectively. Interobserver and intraobserver measure-
ments are reported in Table 3.
The average distance between the PHLM and the
popliteal NVB was 7.8 mm (range, 1.5-13). Average
distance between the PHLM and the popliteal NVB for
female patients was 6.3 mm, whereas for male
patients the average distance was 8.5 mm. Shorter
distance between the PHLM and the popliteal NVB
was found to be significantly associated with younger
age and female sex (P ¼ .014 and 0.001, respectively).
The association between knee cross-section area and
distance between the PHLM and the popliteal NVB
was not statistically significant (P ¼ .98). The associ-
ation between laterality and distance between the
PHLM and the popliteal NVB was also not statistically
significant (P ¼ .632) (Table 4).
Discussion
Our study demonstrates that, when aiming at the
PHLM, almost one-third of the simulated all-inside su-
ture device trajectories transect the popliteal NVB. Our
analysis indicates that a more-lateral portal is safer
when suturing the PHLM in close proximity to the PCL,
whereas a more medial portal is safer when planning to
suture the PHLM in a distance 3 mm lateral to the
PCL. We have also found the distance between the
popliteal NVB and the PHLM to be shorter in young and
female patients independently, suggesting an increased
risk for injury to the popliteal NVB in young and female
patients.
The anatomy of the popliteal vessels and tibial nerve
crossing the knee has been well described in anatomy
books and previous literature. At the height of the knee
joint, the popliteal artery is medial to the popliteal vein,
and both vessels lie medial in respect to the tibial
nerve.15-17 There are also some known anatomic vari-
ations because a bifurcation of the popliteal may arise at
or above the knee joint in 1.2% of the population.17
Studies reporting on the relationship of the popliteal
NVB to the posterior aspect of the knee joint capsule
and posterior horns of the menisci are limited. A
couple of studies have reported that the localization of
the popliteal NVB was lateral to the central axis of the
knee in z94% of knees examined on MRI axial
cross-section.14-18 They have found no significant
effect of sex and side.18 Yoo et al.19 have examined
MRIs of 30 knees of young Korean males in different
degrees of flexion. They have reported that, at the
joint line, the distance between the popliteal artery
and the posterior capsule is 3.9 mm in extension and
7.6 mm in flexion.19 Our study reports an average

Table 2. Average distances of simulated trajectories to the popliteal neurovascular bundle, stratified by different portals and
increasing distances from the PCL

Distance of simulated trajectory to PCL 1-cm medial portal Medial portal Lateral portal 1-cm lateral portal P
0 mm (SD) 1.4 (2.0) 0.5 (1.5) 1.6 (1.8) 2.7 (2.4) <.001
3 mm (SD) 3.8 (2.9) 1.9 (2.5) 0.3 (0.8) 0.7 (1.4) <.001
6 mm (SD) 6.9 (3.4) 4.7 (3.2) 0.4 (1.2) 0.3 (0.7) <.001
9 mm (SD) 10.1 (3.5) 8.2 (3.6) 1.7 (2.3) 1.1 (1.9) <.001
12 mm (SD) 13.5 (3.5) 11.8 (3.7) 4.7 (3.0) 3.6 (3.0) <.001
PCL, posterior cruciate ligament; SD, standard deviation.
 SAFE PORTALS FOR LATERAL MENISCUS REPAIR 5

Table 3. Interobserver and intraobserver measurements device trajectory is difficult to obtain because it
depends on the curvature of the device, the pene-
0 mm 3 mm 6 mm 9 mm 12 mm
tration depth, and the rotation of the tip of the device.
Interobserver
Observer 1 Further studies are warranted to address this issue.
Mean 1.5 1.7 3.1 5.3 8.4 Miller et al.22 have advised avoiding the use of
SD 2.1 2.5 3.7 4.9 5.5 straight devices when suturing the PHLM near its root.
Observer 2 A maximum 15-mm penetration depth was also
Mean 1.8 2.0 3.3 5.5 8.3
advised.5,22 The surgeon should be aware that, when
SD 2 2.2 3.5 5.1 6.1
Observer 3 using a curved all-inside device, the trajectory will be
Mean 1.7 1.9 3.5 5.7 8.9 affected. Therefore, when possible, the surgeon can use
SD 2.2 2.4 4 5.2 6 the MRI axial cross-section to plan how to divert the
Intraobserver curved end of the device away from the postulated
First measurement
location of the NVB. Moreover, preoperative planning
Mean 1.5 1.7 3.1 5.3 8.4
SD 2.1 2.5 3.7 4.9 5.5 using the MRI axial cross-section can help in defining
Second measurement the distance to the popliteal NVB and, accordingly,
Mean 1.6 1.7 3.4 6.1 9 assist in adjusting the depth limiter that is available in
SD 1.9 2.7 3.9 5 5.8 some devices.
SD, standard deviation.

Limitations
distance of 7.8 mm from the posterior edge of the The main limitation of our study is that suturing of
PHLM to the popliteal NVB in knee extension. We the PHLM is usually done in a figure-of-four position
found that shorter distance between the PHLM and (hip abducted and externally rotated with the knee
the popliteal NVB was associated with younger age flexed), whereas standard knee MRI is performed with
and female sex. the patient in a supine position. Knee flexion will
Beck et al.6 have also reported a significant associa- increase the distance between the popliteal NVB and
tion between younger age and female sex and the the PHLM.9,19 However, applying pressure to the PHLM
popliteal NVB location in the pediatric population. with the all-inside suturing device will, it is assumed,
While assessing the safe zone of the PHLM at the bring the NV bundle closer and increase the risk of
meniscocapsular junction, they reported an average injury. Also, other variables such as the exact portal
distance between the popliteal tendon and popliteal entry point, the varus force applied by the assistant if
NVB of 18 mm in adolescent males and 15 mm in needed, and the force of gravity acting on the knee in
adolescent females.6 the figure-of-four position may also play a role. Finally,
Although the risk of damaging the popliteal NVB has many surgeons use curved devices in which the
been well documented in several studies,8,10,12 Coen trajectory of the device will be deflected according to
et al.20 have documented the location of T-fix suture the curvature of the device, the penetration depth, and
devices (Acufex Microsurgical, Mansfield, MA) placed the rotation of the tip of the device.
in 6 cadaveric knees, and none of the 50 total devices
were placed near neurovascular structures.
Nishimura et al.21 assessed 100 knee MRIs and Conclusions
evaluated the distance between the popliteal artery All-inside suturing of the PHLM at 0 mm from the
and the posterior tibial cortex. They concluded that PCL is safer with a more lateral portal. Beyond 3 mm
all-inside suturing of the PHLM is safer from the from the PCL, a more-medial portal carries a lower risk
anteromedial portal than the anterolateral portal.
They have also suggested that, when using curved or
Table 4. Association between demographic characteristics
reverse-curved devices to suture the PHLM nearest to
and distance from the PHLM to the popliteal NVB
the PCL, the tip of the device should be turned in a
lateral direction. However, our results suggest that, Standard
when suturing the PHLM nearest to the PCL, a 1-cm Variable Coefficient error P 95% CI
lateral portal is safer, and thus the tip of a curved or Knee cross-section 0 0.0002 .979 0.0004
area to 0.0004
reverse curved should be turned toward the PCL if
Age 0.058 0.023 .014 0.012-0.103
suturing from a lateral portal (Fig 3A and B). Also, Sex 2.812 0.774 .001 4.363
the PHLM near its root is sometimes hard to approach to 1.262
from an anteromedial portal because the anterior Laterality 0.318 0.659 .632 1.638 to 1.003
cruciate ligament and tibial eminence may interfere in CI, confidence interval; NVB, neurovascular bundle; PHLM, poste-
the device passage. An exact assessment of the curved rior horn lateral meniscus.
6 R. GILAT ET AL.
to the PNVB. Young and female patients have shorter
distance between the PHLM and the PNVB, suggesting a
greater risk for injury to the PNVB. Careful preopera-
tive MRI assessment may assist in safer portal selection
when planning repair of the PHLM.
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