Original Article

Comparison of the Radiologic, Arthroscopic, and Clinical

Outcomes between Repaired versus Unrepaired Medial
Meniscus Posterior Horn Root Tear During Open Wedge
High Tibial Osteotomy
O-Sung Lee, MD1 Seung Hoon Lee, MD2 Yong Seuk Lee, MD, PhD1

1 Department of Orthopaedic Surgery, Seoul National University
College of Medicine, Bundang Hospital, Seongnam, Seoul, Korea
2 Department of Orthopaedic Surgery, Incheon Metropolitan City
Medical Center, Seongnam, Korea
J Knee Surg
Address for correspondence Yong Seuk Lee, MD, Department of
Orthopaedic Surgery, Seoul National University College of Medicine,
Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si,
Gyeonggi-do 463-707, South Korea
(e-mail: smcos1@daum.net; smcos1@snu.ac.kr).

Abstract The efficacy and outcomes for the concurrent repair of medial meniscus posterior horn

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root tear (MMPHRT) during open wedge high tibial osteotomy (OWHTO) are unclear.
This study compared the radiologic, arthroscopic, and clinical outcomes between
repaired and unrepaired MMPHRT during OWHTO. Fifty-seven patients were prospec-
tively enrolled from 2014 to 2016. The radiologic, arthroscopic, and clinical outcomes
were compared between 25 patients who underwent OWHTO with all-inside repair of
MMPRT using FasT-Fix (repaired group) and 32 patients who underwent OWHTO
without repair of MMPRT (unrepaired group) with a mean 2-year follow up in both
groups. The meniscal healing status was classified as complete, partial, or no healing,
according to second-look arthroscopic findings. The medial meniscal extrusion (MME)
was evaluated using magnetic resonance imaging. The width of medial joint space,
joint line convergence angle (JLCA), posterior tibial slope (PTS), Kellgren–Lawrence (KL)
grade, hip-knee-ankle angle, and weight-bearing line ratio was evaluated on simple
standing. The clinical outcomes were evaluated using the Knee Society score and the
Western Ontario and McMaster University score. Healing rates (partial and complete)
of the MMPHRT showed a statistical difference between the two groups (repaired
group vs. unrepaired group, 19/25 (76%) vs. 13/32 (40.6%), p ¼ 0.008). The post-
Keywords operative MME showed no statistical differences between groups (repaired versus
► knee unrepaired group: 4.5  1.3 mm vs. 4.5  2.1 mm, p ¼ 0.909). The postoperative
► open wedge high width of medial joint space, JLCA, PTS, and KL grade all showed no statistical differences
tibial osteotomy between groups after 2 years of OWHTO. Other radiologic parameters and clinical
► meniscus posterior outcomes showed no statistical differences between groups. Repair of the MMPHRT
horn root tear during OWHTO showed a superior healing rate to the unrepaired MMPHRT. However,
► repair repair of the MMPHRT was not related to the radiologic and clinical outcomes.
► healing Therefore, there is no clear evidence of the need for the MMPHRT repair during
► outcome OWHTO.

received Copyright © by Thieme Medical DOI https://doi.org/

October 28, 2018 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-1692992.
accepted after revision New York, NY 10001, USA. ISSN 1538-8506.
May 19, 2019 Tel: +1(212) 584-4662.
Efficacy and Outcomes of MMPHRT Repair Lee et al.
Open wedge high tibial osteotomy (OWHTO) is a well-estab-
lished treatment option for medial compartment arthritis of
the knee joint. This procedure could provide the medial
compartment with a favorable mechanical environment for
better healing of the articular cartilage by reducing the load.1–4
During OWHTO, medial meniscus posterior horn root tear
(MMPHRT) is commonly observed in the osteoarthritic knee.
The incidence of MMPHRT has been frequently reported and
this accounts for 80% of patients with osteoarthritis and 27.8%
of medial meniscal tear injuries.5,6
MMPHRT is considered to be a radial tear or avulsion at the
insertion of the medial meniscus.7,8 A radial tear of the medial
meniscus posterior root can result in a total meniscectomized
knee due to the loss of hoop tension by disrupting the critical
circumferential fibers.9,10 This pathology may cause meniscal
extrusion, loss of articular cartilage, joint space narrowing, and
eventually, progressive osteoarthritis.7,8,11–14 Recently, non-
operative treatment and partial meniscectomy for MMPHRT
has shown unsatisfactory results.15,16 Therefore, surgical
repair of the MMPHRT has been increasingly performed.17–22
Although the surgical treatment of the MMPHRT is increas-
ingly being attempted, reports of how it should be treated
during OWHTO are rare. In one study, MMPHRT showed a high
rate of healing after OWHTO without attempted repair, and
clinical and radiologic outcomes were not different between
healed and nonhealed groups.8 Additionally, it was recently
supposed that alignment correction is more important than
repair itself for the healing of MMPHRT, and it is recommended
to correct alignment if patients show varus alignments with
MMPHRT.12,15,23 This could imply that MMPHRT could be
a secondary change of the osteoarthritis, and that there might
be questionable clinical relevance for its repair.
Therefore, this study compared the radiologic, arthro-
scopic, and clinical outcomes between repaired and unre-
paired MMPHRT during OWHTO to evaluate the necessity of
MMPHRT repair during OWHTO. The hypotheses of this study
were that (1) there are no differences in the healing rate
between the repaired and unrepaired MMPHRT during
OWHTO, and (2) other radiologic and clinical outcomes do
not differ between the groups.
Materials and Methods
Patients Selection
Between March 2014 and February 2016, 179 patients who
underwent OWHTO were retrospectively reviewed. All patients
underwent preoperative 3-T magnetic resonance imaging
(MRI) scans (Ingenia, Philips Healthcare, Best, the Netherlands),
and an MMPHRT was defined as a radial tear at the posterior
attachment of the medial meniscus by a radial linear defect at
the posterior insertion in the axial plane, a vertical linear defect
at the root on the coronal plane, and a ghost sign in the sagittal
plane.24–26 During OWHTO, it was confirmed by concomitant
arthroscopy. From March 2014 to February 2015, 32 cases
among a total of 96 OWHTOs were diagnosed as MMPHRT,
and a simple debridement on the site of meniscal tear was
performed to promote the healing of the MMPHRT. From
March 2015 to February 2016, 30 cases among a total of 83
The Journal of Knee Surgery
OWHTOs were diagnosed as MMPHRT, and arthroscopic all-
inside repair using FasT-Fix (Smith & Nephew Endoscopy,
Andover, MA) was attempted on MMPHRT. However, four cases
of MMPRT among the cases in which repair were initially
attempted were not suitable for repair with FasT-Fix, and as
a result, only debridement and partial meniscectomy were
performed (►Fig. 1). All patients were recommended to
undergo locking plate removal with second-look arthroscopy
at approximately 2 years after OWHTO. This study obtained the
approval of the institutional review board of our hospital.
Surgical Technique
A single-surgeon performed all surgical procedures. The
target mechanical axis was the weight-bearing line passing
through 62.5% of the width of the tibial plateau, correspond-
ing to a postoperative mechanical valgus of 2 to 4 degrees. An
approximately 5-cm incision was made longitudinally at the
anteromedial aspect of the proximal tibia. After release of the
superior border of the pes anserinus and the anterior border
of the medial collateral ligament, horizontal osteotomy was
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performed along guiding pins. Biplanar anterior osteotomy
was then performed. The distraction was performed gradu-
ally at the most posterior gap until the target mechanical axis
was obtained.27 The osteotomy site was fixed with a long
locking plate (DWLP, TDM, Seongnam, Korea).
A concomitant arthroscopy during OWHTO was per-
formed on all patients included in this study. Diagnosis of
MMPHRT was confirmed when that could be raised easily on
probing and showed no true meniscal continuity between
the tibial attachment site and posterior horn of the medial
meniscus. Other types of meniscal tears, rather than root
tears, were excluded from this study, even if they had been
diagnosed as a MMPHRT on preoperative MRI. In the repaired
group, the meniscal tear was reduced anatomically close to
the origin of the meniscal root using the tip of the FasT-Fix
360 curved needle delivery system (Smith & Nephew Endo-
scopy, Andover, MA).20 When the meniscus was adequately
reduced, the first and second implants were positioned
sequentially in the most suitable location to maintain the
hoop of the meniscus. The knot was then snugged down to
form the suture construct. Finally, we trimmed the free end
of the suture materials. If necessary, for the effective repair,
multiple sutures were performed. In the unrepaired group, a
simple debridement was performed to refresh the degen-
erative site of meniscal tear and promote the healing of the
MMPHRT. In cases of MMPHRT in which repair was initially
attempted but was found to be unsuitable for FasT-Fix repair,
a simple debridement was performed to promote the spon-
taneous healing of the MMPHRT. No intra-articular drains
were inserted in either group.
Postoperative Rehabilitation
For the repaired group, weight bearing was delayed until
2-weeks postoperatively, and only then was partial weight
bearing with crutches was permitted. Full weight-bearing was
permitted beginning at 4 weeks postoperatively, only if the
patient could tolerate it. Lifestyle modifications were recom-
mended to avoid deep flexion of the knee. For the unrepaired

Fig. 1 Flow diagram of the study based on Consolidated Standards of Reporting Trials (CONSORT) guidelines. MMPHRT, medial meniscus
posterior horn root tear; OWHTO, open wedge high tibial osteotomy.
group, tolerable weight bearing with crutches was encouraged
immediately postoperation, and full weight-bearing was
permitted, if the patient was able. All patients performed
isometric exercises and passive range of motion (ROM) exer-
cises with the operated knee 2 days after surgery until a
maximum flexion angle of 130 degrees or more was achieved.
For both groups, squatting with weight was avoided for
3 months, and patients were instructed to exercise caution
when rising from a seated position.
Evaluation of MMPHRT Healing
The healing status of MMPHRT was classified as complete,
partial, or no healing, according to second-look arthroscopic
findings.8,19,28 Complete healing was defined as meniscal
continuity with no cleft, no lifting on probing, and normal
meniscal tension at the repair site. Partial healing included both
lax healing and scar tissue healing, as defined by Seo et al.28 Lax
healing was defined as apparent increases in meniscus lifting
and mobility on probing with good meniscal continuity. Scar
tissue healing was defined as a meniscus that could be easily
raised on probing, and showed no true meniscal continuity
except for some connecting scar tissue fibers between the tibial
attachment site and the posterior horn of the medial meniscus.
No healing was defined as no meniscal continuity, without any
evidence of meniscal healing at the repair site.
Evaluation of Radiologic Outcomes
Radiographic evaluations were performed preoperatively and
at the time of second-look arthroscopy. The INFINITT version
Efficacy and Outcomes of MMPHRT Repair Lee et al.
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5.0.9.2 (INFINITT, Seoul, South Korea) was used for the all
radiographic measurements. Medial meniscal extrusion
(MME) was defined as the amount of meniscus displacement
from the medial edge of the tibial plateau to the periphery of
the meniscal body, at the level of the medial collateral ligament
in the coronal view using the 3-T MRI scans (Ingenia, Philips
Healthcare, Best, the Netherlands).24,25,29 The width of the
medial joint space was measured from the center of the medial
femoral condyle to the center of the medial tibial plateau on
standing posteroanterior view with 45-degree knee flexion
(Rosenberg’s view).22,30,31 The joint line convergence angle
(JLCA), posterior tibial slope (PTS), weight-bearing line (WBL)
ratio, and hip-knee-ankle (HKA) angle were measured pre-
operatively, and at the time of second-look arthroscopy on full-
length standing anteroposterior radiographs. The JLCA was
measured as the angle between the line connecting the distal
femur and the proximal tibial articular surfaces. The PTS was
defined as the angle formed between the proximal tibial
plateau and a line perpendicular to the anatomical axis of
the tibial shaft on a lateral radiograph. The WBL was drawn
from the center of the femoral head to the center of the
superior articular surface of the talus. To calculate the WBL
ratio, the denominator was the width of the tibia, measured
using a ruler, and the numerator was the tibial intersection of
the WBL in the knee joint (with the medial tibial edge at 0%).
The HKA angle was measured as the angle between the line
from the center of the femoral head to the center of the knee
joint, and the line from the center of the knee joint to the center
of the ankle joint.
The Journal of Knee Surgery
Efficacy and Outcomes of MMPHRT Repair Lee et al.

The Kellgren–Lawrence (KL) grade was used for the eva-
luation of the radiologic severity of osteoarthritis on full-
length standing anteroposterior radiographs (grade 0, no
degenerative change; grade 1, questionable osteophytes and
no joint space narrowing; grade 2, definitive osteophytes
with possible joint space narrowing; grade 3, definitive joint
space narrowing with moderate multiple osteophytes and
some sclerosis; and grade 4, severe joint space narrowing
with cysts, osteophytes, and sclerosis). Additionally, the
articular cartilage status of the medial femoral cartilage
was evaluated according to the International Cartilage Repair
Society (ICRS) grade by an arthroscopic examination during
OWHTO at the time of metal removal (ICRS 0, a macrosco-
pically normal cartilage without notable defects; ICRS 1, a
cartilage with a fibrillated, slightly softened surface or super-
ficial fissures; ICRS 2, a defect < 50% of the cartilage thick-
ness; ICRS 3, a defect > 50% of the cartilage thickness; and
ICRS 4, a full-thickness osteochondral injury).
Evaluation of Clinical Outcomes
in the unrepaired group (OWHTO without repair of MMPRT),
with a mean follow-up of 2 years. There were no statistical
differences between groups for preoperative demographics.
Additionally, no statistical differences between groups were
observed with respect to preoperative ROM, WOMAC scores,
and knee scores (►Table 1).
The healing of the MMPHRT was observed in 76.0% (19/25)
of the patients in the repaired group, whereas it was observed
in 40.6% (13/32) of the patients in the unrepaired group. There
was a statistically significant difference between the groups for
healing rate (p ¼ 0.008) (►Table 2). Among the patients
whose MMPHRT was healed, complete healing was observed
in 40% (10/25) of patients in the repaired group, and in 15.6%
(5/32) of patients in the unrepaired group (p ¼ 0.038). Partial
healing was observed in 36% (9/25) of patients in the repaired
group, and in 25% (8/32) of patients in the unrepaired group
the MMPHRT (p ¼ 0.368; ►Table 2). ►Fig. 2 shows a patient
who achieved complete healing of MMPHRT at 2-year follow-
up after OWHTO with MMPHRTrepair (►Fig. 2). ►Fig. 3 shows
a patient with a good postoperative alignment and clinical

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Flexion contracture and active maximal flexion were mea- outcomes, although she did not achieve a healing of the
sured in the supine position using a goniometer preopera-
tively and at the time of the second-look arthroscopy. The
clinical status of each patient was assessed using the Western
Table 1 Comparison of preoperative demographics and
Ontario and McMaster University (WOMAC) score and the
measurements
Knee Society (KS) knee and functional scores.
Repair Unrepaired p-Value
Analysis of Possible Variables Affecting Healing Status group group
Repair of MMPHRT, undercorrection and overcorrection Patients number 25 32 –
compared with acceptable correction, preoperative KL grade,
Age (y) 58.1  4.2 59.8  5.3 0.240a
preoperative degree of meniscus extrusion, age, body mass
index (BMI), and sex were subjected to multivariate logistic Sex (male/female) 8/18 10/24 0.865b
analysis to identify independent predictors of healing status Side (left/right) 11/15 20/14 0.239b
for MMPHRT after OWHTO. The criteria for undercorrection Height (cm) 158.8  7.7 155.6  8.4 0.189a
and overcorrection of WBL ratio were 50 and 70%, respec- Weight (kg) 68.6  10.5 64.9  10.3 0.240a
tively.32 Preoperative KL grade was divided into grades 3 and
Body mass index 27.1  3.2 26.8  3.7 0.744a
4. Preoperative extrusion of the medial meniscus was (kg/m2)
divided by 3 mm based on the previous study.33 The cut-
Onset of symptom 25.4  14.0 28.5  22.7 0.780a
off values of age and BMI were 60 and 25, respectively. (mo)
Follow-up (y) 1.9  2.4 2.2  2.1 0.120a
Statistical Analysis
Flexion contracture 4.2  4.1 2.7  2.1 0.097a
All statistical analyses were performed with SPSS version
(degrees)
22.0 statistical package (IBM Corp., Armonk, NY). Mean and
Active flexion 129.5  8.1 127  7 0.077a
standard deviation (SD) are presented for continuous vari-
(degrees)
ables. The differences in continuous variables were analyzed
WOMAC Total 41.4  8.4 40.2  10.5 0.158a
with Student’s t-test. The differences in other categorical
scores
variables were analyzed with Pearson’s Chi-square test or by Pain 8.7  2.4 8.8  3.9 0.314a
linear association. Independent risk factors for nonhealing Stiffness 6.6  2.1 4.1  2.0 0.070a
were examined using a multivariable logistic regression Function 26.2  6.3 27.3  12.7 0.317a
model with a backward stepwise procedure. Results are
Knee Knee 46.6  11.9 53.2  18.2 0.169a
expressed using odds ratios (OR) and their 95% confidence scores scores
intervals (CI). Statistical significance was set at p < 0.05. Function 57.6  7.7 57.6  10.9 0.988a
scores

Results Abbreviation: WOMAC, Western Ontario and McMaster University.

Note: the values are presented as mean  standard deviation.
Among a total of 55 patients included in this study, 25 patients a
Derived with Student’s t-test.
were included in the repaired group (OWHTO with all-inside b
Derived with Pearson’s Chi-square test. The statistical significance was
repair of MMPRTusing FasT-Fix) and 32 patients were included set at p < 0.05.

The Journal of Knee Surgery


Table 2 Comparison of the healing of MMPHRT between
repaired group and unrepaired group
Repaired Unrepaired p-Value
group group
(n ¼ 25) (n ¼ 32)
Total number of 19 (76.0) 13 (40.6) 0.008a
MMPHRT healing (%)
Complete healing (%) 10 (40) 5 (15.6)
Partial healing (%) 9 (36) 8 (25)
No healing (%) 6 (24) 19 (59.4)
Abbreviation: MMPHRT, medial meniscus posterior horn root tear.
Note: the values are presented as mean  standard deviation.
a most patients (84.4%). Despite the differences in the healing
The comparison was performed between the healing (n ¼ 19, 76%)
and no healing (n ¼ 13, 40.6%) using the Pearson’s Chi-square test. The
statistical significance was set at p < 0.05.
MMPHRT at 2 years after OWHTO without MMPHRT repair
(►Fig. 3).
The preoperative and postoperative MMEs of the repaired
group were 4.6  1.9 mm and 4.5  1.3 mm, respectively.
The preoperative and postoperative MMEs of the unrepaired
group were 4.3  1.6 mm and 4.5  2.1 mm, respectively.
There were no statistically significant differences between
the preoperative and postoperative MMEs between groups
(p ¼ 0.195 and p ¼ 0.909, respectively). The preoperative
width of the medial joint space were not statistically differ-
ent between groups (repaired vs. unrepaired, 3.4  1.0 mm
vs. 3.7  1.2 mm, p ¼ 0.095), and the postoperative width of
the medial joint space was also not statistically different
between groups (repaired vs. unrepaired, 3.7  1.3 mm vs.
3.8  1.3 mm, p ¼ 0.943; ►Table 3).
There were no statistically significant differences in the
preoperative and postoperative JLCA, PTS, WBL ratio, and
HKA angle between groups. Moreover, the severity of
osteoarthritis indicated by the KL grade was not statistically
different between groups preoperatively, and at the time of
the second-look arthroscopy (p ¼ 0.243 and p ¼ 0.789,
respectively). In addition, the preoperative and postopera-
tive cartilage status of the medial femoral condyle assessed
by the ICRS grade was also not statistically different between
groups (p ¼ 0.426 and p ¼ 0.497, respectively; ►Table 3).
In terms of the clinical outcomes, there were no statistically
significant differences in the preoperative and postoperative
values of flexion contracture and active maximal flexion. All
clinical scores improved at the 2-year follow-up after OWHTO
in both groups. There were no statistically significant differ-
ences in the postoperative values of KS knee and functional
scores, or WOMAC scores between groups (►Table 4).
Multivariable logistic regression analysis revealed that the
following three factors were significant independent predic-
tors of healing status of MMPHRT after OWHTO: no repair
(OR ¼ 36.35, 95% CI: 2.78–475.88, p ¼ 0.006), undercorrec-
tion of WBL ratio (< 50%; OR ¼ 24.51, 95% CI: 1.64–367.37,
p ¼ 0.021), and preoperative KL grade 4 (OR ¼ 43.75, 95% CI:
3.78–506.57, p ¼ 0.002). Overcorrection of WBL ratio (> 70%),
preoperative large extrusion of meniscus (> 3 mm), age over
Efficacy and Outcomes of MMPHRT Repair Lee et al.
60, BMI over 25 kg/m2, and sex were not associated with the
healing status of MMPHRT after OWHTO (►Table 5).
Discussion
The most important finding of the present study was that
repair of MMPHRT using FasT-Fix during OWHTO signifi-
cantly increased the healing rate of MMPHRT compared with
the unrepaired treatment; however, it was not related to the
postoperative radiologic and clinical outcomes. Although
complete healing of the MMPHRT was achieved in some of
the patients (15.6%) after OWHTO without repair of the torn
meniscus, healing was either incomplete or not obtained in
rates, patients who underwent OWHTO showed similar
radiologic and clinical results, regardless of repair of the
concurrent MMPHRT. Additionally, no repair, undercorrec-
tion of WBL ratio (< 50%), and preoperative KL grade 4 rather
than grade 3, were significant predictors of no healing of
MMPHRT after OWHTO.
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MMPHRT can lead to loss of the hoop strain by disrupting
the critical circumferential fibers.5,34 The subsequent per-
ipheral displacement of the meniscus weakens its capacity to
protect the articular cartilage, and, as a result, progresses
medial compartment osteoarthritis.10,35 With regards to the
fate of MMPHRT without surgery, Krych et al36 reported that
nonoperative management resulted in poor clinical out-
comes, worsening arthritis, and a relatively high rate of
arthroplasty at 5-year follow-up. The arthroscopic partial
meniscectomy (the traditional surgical option of the
MMPHRT) has been known to provide satisfactory clinical
outcomes.16,37 However, although it may improve clinical
symptoms of patients with MMPHRT, there has been concern
about the worsening of osteoarthritis after partial menis-
cectomy.16,37–39 Han et al reported that 16 of 46 patients
(35%) showed radiographic progression of osteoarthritis at a
mean follow-up of 77 months, and, in addition, only 56% of
patients had improvements in pain.38 Chung et al16 also
reported that refixation of the MMPHRT slowed the progres-
sion of osteoarthritis compared with partial meniscectomy,
although it did not completely prevent the progression of
arthritis.
Contrary to nonoperative management and partial menis-
cectomy of the MMPHRT, repair of MMPHRT improved
clinical scores and restored tibiofemoral contact pressures
to a more favorable level.40,41 Additionally, surgeons can
expect good healing after the repair of MMPHRT because the
anterior and posterior horns of the menisci have been known
to have good vascular supply.42 Clinically, many authors have
reported better outcomes for repair of MMPHRT compared
with partial meniscectomy and nonoperative manage-
ment.15,36,37 Kim et al37 reported that arthroscopic pullout
repair of a medial MRT achieved better clinical and radiologic
results, and good healing with restoration of hoop tension of
the meniscus on MRI and second-look arthroscopy, com-
pared with partial meniscectomy at a mean follow-up of
48.5 months. In a recent systematic review of 172 patients,
arthroscopic transtibial pullout repair improved functional
The Journal of Knee Surgery
Efficacy and Outcomes of MMPHRT Repair Lee et al.

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Fig. 2 (A) A 58-year-old woman shows a medial meniscus posterior horn root tear (MMPHRT) on MRI; (B) arthroscopic view of repaired MMPHRT
at the time of open wedge high tibial osteotomy; (C) second-look arthroscopy showing complete healing of MMPHRT at postoperative 2 years;
(D) comparison between preoperative and postoperative limb alignments.

scores and prevented the progression of osteoarthritis in
most patients, at least during a short-term follow-up
(30.2 months).43 However, the long-term results of the
MMPHRT repair are still unclear because healing of
the torn root after repair would be disturbed by the low-
healing potential of degenerative meniscal tissues, and
remaining medial extrusion would be a biomechanical factor
impeding healing of the repaired MMPHRT.5,23,44,45 Indeed,
in a study with a midterm follow-up (mean, 72 months,
range, 60–110 months), KL grade progressed in 67% of the
patients with refixation of MMPHRT.16
Surgeons have introduced several techniques for better
healing of MMPHRT. Lee et al46 reported that only one (4.8%)
among 20 knees treated with pullout refixation using simple
stitches showed a progression of KL grade, and the articular
cartilage of 10 knees which underwent second-look arthro-
scopy healed completely at a minimum of 2-years follow-up.
Kim et al37 reported that pullout suture of an MMPHRT
showed better clinical and radiologic outcomes compared
with partial meniscectomy. Among 14 patients treated with
pullout suture, 64.3% showed normal fixation strength,
71.4% had normal hoop strain, and only 6.7% had retears of
the meniscus on second-look examinations at a mean follow-
up of 48.5 months. Seo et al28 reported that pullout refixa-
tion using double-loop sutures showed significant improve-
ment in clinical outcomes and KL grade progression occurred

The Journal of Knee Surgery

 Efficacy and Outcomes of MMPHRT Repair Lee et al.

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Fig. 3 (A) A 55-year-old woman performed open wedge high tibial osteotomy without repair of medial meniscus posterior horn root tear.
(MMPHRT); (B) second-look arthroscopy showing the unhealed MMPHRT at postoperative 2 years; (C) MRI showing the MMPHRT at
postoperative 2 years; (D) comparison between preoperative and postoperative limb alignments.

in only one of 21 patients. The suture anchor technique has
been introduced as another repair option, with the advan-
tages of avoiding tibial tunnel and additional incision. Jung
et al18 reported that the suture anchor technique showed
significant improvements in clinical outcomes, meniscal
extrusion, and a healing rate of 90% at a mean follow-up of
30.8 months. Additionally, Kim et al17 reported that both
suture anchor refixation and pullout refixation showed
similar improvements in clinical outcomes and progression
of KL grade. In our study, MMPHRT was repaired with a
method using a Fast-Fix 360 (Smith & Nephew Endoscopy,
Andover, MA) similar to the all-inside method, which
Thompson and Pinczewski20 introduced. The technique
was dramatically simpler in terms of reduction and manip-
ulation of torn meniscus compared with previous techni-
ques, such as pullout refixation and the suture anchor
technique. Although direct comparisons with other methods
were not possible because it was performed concurrently
with OWHTO in our study, the healing rate with our
technique was comparable to those of previous studies.
Several prognostic factors leading to poor outcomes after
the refixation of MMPHRT have been reported.12,15,23
Previous studies commonly reported that concomitant
high grade chondral lesions and varus alignment were
poor prognostic factors for clinical outcomes.12,15,23 Similar
to previous literature, multivariable logistic regression ana-
lysis in our study revealed that no repair, undercorrection of
WBL ratio (< 50%), and preoperative KL grade 4 rather than

The Journal of Knee Surgery

Efficacy and Outcomes of MMPHRT Repair Lee et al.

Table 3 Comparison of radiologic and arthroscopic results between repaired group and unrepaired group

Repaired group (n ¼ 25) Unrepaired group (n ¼ 32) p-Value

Medial meniscal extrusion
Preoperative 4.6  1.9 4.3  1.6 0.195a
Postoperative 4.5  1.3 4.5  2.1 0.909a
Width of medial joint space (mm)
Preoperative 3.4  1.0 3.7  1.3 0.095a
Postoperative 3.7  1.2 3.8  1.3 0.943a
Joint line convergence angle (degrees)
Preoperative 3.3  1.2 3.0  1.6 0.072a
Postoperative 2.5  1.2 2.4  1.5 0.331a
Posterior tibial slope (degrees)
Preoperative 8.7  1.4 8.6  1.6 0.451
Postoperative 9.1  1.8 9.3  1.5 0.348
WBL ratio (percent)
Preoperative 21.9  9.7 22.2  12.6 0.928a

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Postoperative 64.1  10.6 62.0  11.6 0.192
Hip-knee-ankle angle (degrees)
Preoperative Varus 6.3  2.2 Varus 6.4  2.3 0.808a
Postoperative Valgus 1.9  1.2 Valgus 1.8  1.4 0.755a
Kellgren–Lawrence grade
Preoperative (grade 1/2/3/4) 0/0/16/9 0/0/25/7 0.243b
Postoperative (grade 1/2/3/4) 0/5/16/4 0/2/28/2 0.789b
ICRS grade of medial femoral condyle
Preoperative (grade 0/1/2/3/4) 0/0/4/9/12 0/1/8/12/14 0.426b
Postoperative (grade 0/1/2/3/4) 1/3/6/9/6 2/6/9/11/7 0.497b

Abbreviations: ICRS, International Cartilage Repair Society; WBL, weight-bearing line.

Note: the values are presented as mean  standard deviation.
a
Derived with Student’s t-test.
b
Derived by linear by linear association. The statistical significance was set at p < 0.05.

Table 4 Comparison of postoperative clinical results between repaired group and unrepaired group

Repaired group Unrepaired group p-Value

Flexion contracture (degrees) 1.1  2.1 1.0  1.6 0.976
Active flexion (degrees) 137.1  7.5 133.1  8.9 0.063
WOMAC scores Total 6.4  5.5 9.2  5.3 0.158
Pain 1.5  1.9 1.4  1.4 0.958
Stiffness 0.9  1.1 1.1  1.5 0.543
Function 4.0  3.4 6.6  4.0 0.317
KS Scores KS knee scores 46.6  11.9 53.2  18.2 0.278
KS function scores 91.8  7.1 89.0  9.9 0.511

Abbreviations: KS, Knee Society; WOMAC, Western Ontario and McMaster University.
Note: the values are presented as mean  standard deviation derived with Student’s t-test. The statistical significance was set at p < 0.05.

grade 3 were significant predictors of no healing of MMPHRT reported as possible factors leading to arthritic progres-
after OWHTO. Additionally, older age, preoperative large sion.12,15,23,39,47 All patients included in our study had
meniscus extrusion ratio, incomplete reduction of meniscal knee osteoarthritis of KL grade 3 or 4 combined with varus
extrusion, and loose healing after refixation were also alignment. Other prognostic factors, except for the varus

The Journal of Knee Surgery


Table 5 Multivariate logistic regression models for the possible
variables affecting the healing status of MMPHRT after OWHTO
OR (95% CI) p-Value
No repair 36.35 (2.78–475.88) 0.006
WBL ratio 24.51 (1.64–367.37) 0.021
Undercorrection (< 50%)
Overcorrection (> 70%) 4.72 (0.55–40.16) 0.156
Preoperative Kellgren– 43.75 (3.78–506.57) 0.002
Lawrence grade 4
Preoperative meniscal 1.74 (0.22–13.75) 0.599
extrusion (> 3 mm)
Body mass index 2.05 (0.32–13.22) 0.451
(kg/m2)  25.0
Age  60 (y) 5.46 (0.94–31.91) 0.059
Sex (male) 0.21 (0.03–1.47) 0.116
Abbreviations: CI, confidence interval; MMPHRT, medial meniscus
posterior horn root tear; OR, odds ratio; OWHTO, open wedge high
tibial osteotomy; WBL, weight bearing line.
The statistical significance was set at p< 0.05. CI: confidence intervals.
alignment, could not be corrected by a surgeon at the time of
surgery. Therefore, proper realignment of lower extremities
would be a better treatment for the patients with the
MMPHRT combined with osteoarthritis.
There are several limitations in this study. First, this study
was a retrospective case-control study in which both groups
were divided over time. Therefore, a selection bias could have
occurred. However, the influence of potential confounders was
minimized because a single surgeon performed all surgeries in
a single institution and his skill regarding the OWHTO and
arthroscopic procedure was already mature at the beginning of
this study. Second, the follow-up period was only 2 years after
surgery. A long-term study is necessary to determine whether
healing of the MMPHRT affects the progression of arthritis and
survival after OWHTO. Third, results of the MMPHRT repair
method in this study were not yet established when the
method was used alone, without OWHTO. Finally, it was not
possible to include all preoperative and postoperative variables
in the analysis for the multivariate analysis concerning healing
status. We had to select and categorize some continuous
variables, considering their clinical significance, to overcome
the limitations of the statistical analysis method. We analyzed
the categorical data with a backward stepwise procedure to
maintain the statistical adequacy of the regression analysis.
Conclusion
Repair of the MMPHRT during OWHTO showed a superior
healing rate to the unrepaired MMPHRT. However, repair of
the MMPHRT was not related to the postoperative radiologic
and clinical outcomes. Therefore, there is no clear evidence of
the need for the MMPHRT repair during OWHTO.
Conflict of Interest
None declared.
Efficacy and Outcomes of MMPHRT Repair Lee et al.
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