Arthroscopic Transtibial Pullout Suture Repair Versus Suture Anchor Repair in Posterior Root Tear of the Medial Meniscus: An Open-Label, Blinded-Endpoint, Randomized, Controlled Trial.
Phase: NA
Conditions: Posterior Root Tear of the Medial Meniscus, Arthroscopic Transtibial Pullout Suture Repair, Suture Anchor Repair
Sponsor: Al-Azhar University

Arthroscopic Transtibial Pullout Suture Repair Versus Suture Anchor Repair 
in Posterior Root Tear of the Medial Meniscus, open-label blinded endpoint 
randomized controlled trial. 
NCT Number: Not yet registered 
Study Date: August 2025  
 
 
 
 
 
 
 
 
 
 
 
 
 

Introduction 
The menisci play a fundamental role in maintaining normal knee biomechanics by 
distributing load, absorbing shock, providing stability, and facilitating joint lubrication. Damage 
to the meniscus, particularly root tears, disrupts hoop tension and leads to altered joint loading 
patterns. This condition accelerates cartilage degeneration and predisposes patients to early-onset 
osteoarthritis, especially when untreated or inadequately managed. (Kim et al., 2025) 
Posterior root medial meniscus tears (PRMMTs) have gained increasing clinical attention 
in the past two decades. These injuries are biomechanically equivalent to a total meniscectomy 
because they cause extrusion of the meniscus and loss of its load- sharing capacity. PRMMTs 
typically affect middle-aged and older patients, often associated with degenerative changes, but 
can also occur in younger populations following trauma or high-impact activities. (Kumar et al., 
2024) 
The clinical presentation of PRMMTs is often subtle, with patients experiencing posterior 
knee pain, mechanical symptoms, and joint line tenderness. Magnetic resonance imaging (MRI) 
remains the gold standard for diagnosis, with characteristic findings such as the “ghost sign” and 
meniscal extrusion beyond 3 mm. However, diagnosis is frequently delayed, contributing to the 
progression of cartilage degeneration by the time of surgical intervention. (Monson et al., 2025) 
Several risk factors have been identified, including female gender, obesity, varus 
malalignment, and increased posterior tibial slope. These factors not only predispose patients to 
PRMMTs but also influence the prognosis following surgical repair. Given the high prevalence of 
these risk factors, especially in populations with rising obesity and osteoarthritis incidence, 
effective treatment strategies have become essential. (Furumatsu et al., 2023) 

Surgical repair techniques have evolved significantly to restore hoop stresses and 
improve long-term outcomes. Two widely practiced arthroscopic methods are the transtibial 
pullout suture repair and the suture anchor repair. Both aim to reattach the meniscal root to its 
anatomical footprint, thereby restoring biomechanics and delaying degenerative progression. 
(Furumatsu et al., 2022) 
The transtibial pullout technique involves creating a tibial tunnel through which sutures 
are passed and tied over a bone bridge or fixation device. This method is technically reproducible, 
cost-effective, and provides strong fixation. However, concerns have been raised regarding 
potential tunnel widening, loss of fixation strength over time, and non-anatomic placement in 
some cases.(Briese et al., 2025) 
On the other hand, the suture anchor technique employs specialized anchors inserted into 
the tibial plateau, securing sutures directly to the meniscal root. This method provides anatomic 
fixation and avoids tibial tunnels but is technically demanding and may carry a higher cost. 
Additionally, anchor placement near the root attachment site poses a risk of cartilage damage if 
improperly executed.(Cuéllar et al., 2017) 
Recent comparative studies have reported conflicting outcomes regarding healing rates, 
functional recovery, and complication profiles between these two techniques. Some trials suggest 
that transtibial pullout repairs provide comparable clinical outcomes to anchor-based repairs, 
whereas others highlight superior biomechanical stability and healing with suture anchors. These 
inconsistencies underscore the need for further evaluation of both methods in comparable patient 
populations.(Kumar et al., 2024)  

The goal of surgical intervention is to preserve meniscal function, alleviate symptoms, 
and prevent osteoarthritis progression. Therefore, selecting the optimal repair technique for 
PRMMTs is critical in orthopedic practice. Evaluating and comparing these approaches may 
help establish evidence-based recommendations and improve patient outcomes. (Moon et al., 
2023) 
This study aims to evaluate the results of arthroscopic transtibial pullout suture versus anchor 
repair in patients with a tear of the posterior root of the medial meniscus using Lysholm and 
International Knee Documentation Committee [IKDC] scores. 
 Methodology 
This study will be designed as a prospective, open-label, blinded-endpoint, randomized, 
single-center clinical trial conducted at Al-Zahraa University Hospital, Faculty of Medicine for 
Girls, Al-Azhar University (Cairo, Egypt). The study period extended from August 2023 to 
February 2026, during which patients will be consecutively recruited and followed up for at least 
12 months postoperatively. The study was approved via the Institutional Review Board of Al-
Zahraa University Faculty of Medicine, and it was given the following code: 1971/4-7-2023 The 
study followed the CONSORT guidelines for reporting the results(Hopewell et al., 2025). 
Randomization  
Randomization will be performed using a computer-generated random sequence, and allocation 
will be concealed in sealed opaque envelopes. The operations will be performed by the same 
senior orthopedic surgical team to minimize inter-surgeon variability. Neither the patients nor the 
surgeons will be blinded to the procedure; however, the outcome assessors will be blinded to the 
intervention type to reduce bias. 

 Sample Size 
The sample size will be calculated using the Kelsey method with data derived from previous 
literature that reported differences in Lysholm and IKDC scores between the two techniques. 
Assuming an effect size of 0.8, a significance level (α) of 0.05, and a power (1-β) of 0.8, a 
minimum of 18 patients per group will be required. To account for potential dropouts, the sample 
will be increased to 20 patients per group (40 total). 
Eligibility criteria 
Inclusion Criteria 
Patients aged between 20 and 50 years, who had an acute or degenerative posterior root tear of 
the medial meniscus, confirmed by MRI, will be included. Patients should have an isolated 
medial meniscus root tear or a tear associated with anterior cruciate ligament (ACL) injury. 
Exclusion Criteria 
On the other hand, we will exclude patients who refused to participate or had Knee joint 
malalignment (varus/valgus) confirmed clinically and radiologically. Also, patients with 
Osteoarthritis grade III or IV according to Kellgren–Lawrence classification, inoperable or 
severely degenerated, crushed meniscus. We excluded patients with prior ipsilateral knee 
fracture, infection, or tumor, and patients were deemed unfit for surgery or anesthesia. 
Preoperative Evaluation 
All patients underwent: 
• Detailed history taking with emphasis on trauma, mechanical symptoms, and functional 
limitations. 

• Clinical examination, including general examination and specific knee tests (McMurray 
test, Apley grinding test, joint line tenderness, and Akmese sign test). 
• Radiological imaging:  
✓ Weight-bearing X-ray of the affected knee in anteroposterior (AP) and lateral 
(LAT) views.  
✓ The degree of pre-existing osteoarthritic changes was classified using the 
Kellgren–Lawrence grading system, and results were presented as Kellgren–
Lawrence Grade, n (%). 
✓ Long-leg alignment views were performed if malalignment was suspected. 
✓ Magnetic resonance imaging (MRI) of the knee (sagittal, coronal, axial views) 
was considered the gold standard for diagnosing meniscal root pathology. 
Operative Technique 
All procedures were performed under spinal anesthesia with the patient in the supine 
position and a tourniquet applied to the proximal thigh. The operative field was prepared 
and draped in a standard sterile fashion. 
A diagnostic arthroscopy was carried out through anterolateral and anteromedial portals. 
The tear pattern, tissue quality, and concomitant intra- articular pathology were evaluated 
Transtibial Pullout Suture Repair 
Arthroscopic Examination 
Standard diagnostic arthroscopy was performed using anterolateral (viewing) and 
anteromedial (working) portals. 

The posterior horn of the medial meniscus was carefully probed to confirm the presence, 
type, and extent of the posterior root tear. 
The articular cartilage of the medial femoral condyle and tibial plateau was inspected to 
assess the degree of chondral damage, and associated pathologies were recorded 
Preparation of the Root Footprint 
The anatomic footprint of the posterior medial meniscus root was identified just anterior 
to the posterior cruciate ligament (PCL) insertion. 
Fibrotic tissue and remnants were debrided using a curette and motorized shaver until 
bleeding cancellous bone was exposed, creating a biological bed for tendon-to-bone 
healing  
Suture Passage Through Meniscal Root 
Using a suture-passing device (Arthrex Knee Scorpion™ or Suture Lasso™), No. 2 
FiberWire sutures were passed through the substance of the torn meniscal root  
Two separate sutures were placed, usually in a Mason–Allen or luggage-tag 
configuration, to enhance fixation strength and tissue capture 
Each pass was confirmed arthroscopically to ensure adequate tissue bite and avoidance of 
suture cutout or tissue cut through. 
  

A low-profile ACL C- guide was introduced through the anteromedial portal and its tip 
positioned at the center of the root footprint. 
Under direct arthroscopic visualization, a passing pin was advanced from the 
anteromedial tibial cortex to the root attachment site  
A 4.5-mm cannulated drill bit was used over the passing pin to create a tibial tunnel 
directed toward the root footprint. 
Care was taken to avoid tunnel convergence in cases of concomitant cruciate ligament 
reconstruction  
Suture Retrieval Through Tibial Tunnel 
The suture limbs were retrieved through the tibial tunnel using a suture- shuttling 
technique with a passing wire using a nonabsorbable suture (PDS, FiberWire, or Prolene 
No. 2) as a loop. 
All suture ends were exteriorized from the tibial cortex exit point to allow extracortical 
fixation  
Fixation on Tibial Cortex 
The sutures were tensioned under direct arthroscopic visualization to reduce the meniscus 
to its anatomic footprint. 
Fixation was performed over the proximal tibial cortex using one of the following 
devices: 

Adjustable Button System (ABS) (extracortical suspensory fixation), EndoButton 
(extracortical fixation device), Screw and washer construct (for cost-effective secure 
fixation). 
Small plate and screw and tie sutures o it through plate holes. 
The fixation method was chosen according to surgeon preference and intraoperative 
availability. 
  Final Arthroscopic Assessment 
The repair site was probed to confirm anatomic reduction, firm fixation, and absence of 
gapping. The knee was taken through full cycles of flexion and extension to ensure that 
the repair remained stable under physiological motion  
Postoperative Radiography 
Standard anteroposterior and lateral radiographs of the knee were obtained to confirm the 
position of the tibial tunnel and fixation device.  
Suture Anchor Repair 
Arthroscopic Examination 
Arthroscopy was performed through anterolateral and anteromedial portals. 
The posterior medial meniscus root tear was visualized and probed to confirm diagnosis 
and evaluate tissue quality  
Associated intra-articular lesions were documented. 

Preparation of the Root Footprint 
The anatomic tibial attachment of the meniscal root was identified. 
The footprint was debrided using a curette and shaver until a bleeding cancellous bone 
bed was created to promote tendon-to-bone healing  
Anchor Tunnel Preparation 
An ACL C guide was inserted through the anteromedial portal and positioned at the root 
footprint. 
Under direct arthroscopic visualization, a tibial tunnel was created. The passing pin was 
advanced and retracted repeatedly to debride the tunnel walls, ensuring a smooth internal 
surface and achieving the desired concentric diameter. Drilling was performed carefully 
to avoid breaching the joint or damaging adjacent structures. 
  anteromedial portal, positioning its tip at the anatomic footprint of the meniscal root. B. 
drilling tunnel by passing pin advanced and retracted repeatedly toward the posterior 
tibial cortex to accommodate the suture anchor. 
Anchor Insertion 
Insertion of a nonabsorbable suture (PDS, FiberWire, or Prolene No. 2) into the tibial 
tunnel as a loop and retrieval through the anteromedial portal  
A 2.9-mm all-suture anchor (ASA) was prepared. One limb of the suture was marked at 
20 mm from the anchor using a sterile marker  

A pulling suture was applied at the kink point of the ASA, and the anchor was pulled into 
the joint and guided into the drilled tunnel 
reaches the drill hole at the meniscal root footprint. 
By retracting on the suture, the anchor was deployed and locked beneath the tibial 
cortical bone, providing stable fixation  
Suture Passage Through the Meniscus 
The sutures of the anchor were passed through the meniscal root using a Scorpion™ or 
Lasso™ device. Simple or mattress sutures were performed to ensure secure fixation of 
the meniscal tissue 
Knot Tying 
Arthroscopic sliding knots were tied sequentially, with knot pushers used to advance the 
knots onto the meniscal root. 
 Adequate tension was maintained to ensure firm apposition of the root to its prepared 
footprint without over-constraining the meniscus  
Final Arthroscopic Assessment 
After knot were tied and suture ends were cutted the repair was probed to check stability, 
anatomic reduction, and absence of displacement under tension. 
The knee joint was cycled through flexion and extension to verify repair integrity 
throughout the range of motion of the anchor repair. 

Postoperative Radiography 
Standard anteroposterior and lateral radiographs were obtained to confirm anchor 
placement and tunnel integrity  
General Steps for Both Groups 
Accessory portals: Posteromedial or posterolateral portals were created if needed for 
suture passage or anchor placement, ensuring safe passage by transillumination and 
careful blunt dissection to avoid saphenous nerve or vein injury. 
Associated procedures: In cases with concomitant ACL tears, ACL reconstruction was 
performed in the same sitting, with tunnel planning adjusted to avoid convergence. 
Closure: Hemostasis was achieved, arthroscopic fluid was drained, and portals were 
closed with proline sutures. Sterile dressings and compressive bandages were applied. 
Postoperative Rehabilitation 
• Patients will be kept non–weight-bearing on crutches for 6 weeks. 
• A hinged knee brace will be applied in extension for the first 2 weeks. 
•  
Quadriceps 
setting and 
straightleg 
raise 
exercises were initiated 
immediately postoperatively. 
• Range of motion should be increased gradually by 30° every 2 weeks, reaching 135° by 
10 weeks. 
• Partial weight bearing will be started at 6 weeks, with progression to full weight bearing 
by 10–12 weeks. 

• Deep knee flexion and squatting will be avoided until 3 months postoperatively. 
• Return to full sports activities will be permitted at 6 months. 
Compliance with rehabilitation was supervised by the same physiotherapy team, and adherence 
was documented. 
Outcomes 
The primary outcomes are subjective functional improvement assessed via 1/ Arabic validated 
form of the Lysholm score(Ahmed et al., 2019) and the Arabic validated form of the 
International Knee Documentation Committee (IKDC) 2000 score. (Ahmed et al., 2019) These 
outcomes were assessed at 3, 6, and 12 months postoperatively. 
The secondary outcomes included meniscal evaluation tests,  Pain relief, return to activity, and 
operative complications 
Statistical Analysis 
Data will be entered into SPSS software (version [28]). Quantitative variables will be expressed 
as mean ± standard deviation (SD), while categorical variables will be expressed as frequencies 
and percentages. An independent t-test or Mann–Whitney U test will be used to compare 
continuous data between groups, while the Chi-square test (or Fisher’s exact test) will be used 
for categorical variables. 
Repeated measures ANOVA will be applied to compare preoperative and postoperative scores 
within groups. A P-value < 0.05 was considered statistically significant. Finally, Multivariable 
logistic regression was performed to assess the predictors of the poor outcomes defined as 
Lysholm score < 80 or IKDC score < 80% at 12- month follow-up 

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