Transtibial Pull-Out Repair of a Chronic Medial Meniscal Posterior Root Tear With All-Suture Knotless Centralization

Background: Medial meniscus posterior root tears (MMPRTs) are a common form of meniscal tear and are increasingly recognized as one of the most detrimental insults to knee health. Root repairs have mainly focused on reestablishing the biomechanics of the medial knee compartment and preventing joint deterioration; however, meniscal extrusion persists even after the best root repairs and remains an independent risk factor for knee degeneration. Furthermore, chronic MMPRTs are more likely to be associated with significant extrusion, chondromalacia, and fibrotic changes, which make successful repair more challenging. Careful meniscal mobilization and centralization can provide consistent, repeatable results. Indications: This technique is indicated for patients with chronic MMPRTs, meniscal extrusion of at least 3 mm, minimal arthritic changes, minimal-to-no varus knee alignment, and the ability to be nonweightbearing for 6 weeks postoperatively. Technique Description: The following technique demonstrates the senior author's method of repairing a chronic MMPRT in an anatomic fashion using a 2-tunnel transtibial pull-out repair and footbed anchor fixation. An all-outside centralization is performed using 2 all-suture knotless anchors to address meniscal extrusion and reestablish the biomechanics of the meniscotibial ligament by approximating the posteromedial joint capsule with the rim of the tibial plateau. Results: By repairing a chronic root tear and addressing meniscal extrusion, the native biomechanics of the medial compartment are restored, and the meniscus's ability to withstand hoop stress is preserved. Centralization has been shown to lead to favorable improvements in patient-reported and functional outcomes during short-term follow-up and may significantly reduce strain on the root repair construct, thereby improving healing of the meniscal root attachment. Discussion/Conclusion: We present our preferred technique for augmenting a chronic MMPRT repair with centralization using all-suture knotless anchors. This method mobilizes fibrotic adhesions and reduces the medial meniscus and peripheral capsule to the rim of the tibial plateau. The advantages include eliminating intra-articular knot-related issues, avoiding the need for an additional tibial tunnel—thereby reducing the risk of tunnel coalition—and offering a streamlined, reproducible approach to minimize meniscal extrusion, with favorable short-term outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.