The Position of the Popliteal Artery and Peroneal Nerve Relative to the Menisci in Children: A Cadaveric Study

Abstract

Background: Meniscal injury in skeletally immature patients is increasingly reported. During meniscal repair, all-inside devices may protrude beyond the posterior limits of the meniscus, putting the neurovascular structures at risk. Purpose: The purposes of this study were (1) to examine the relationship between the popliteal artery and the posterolateral and posteromedial aspects of the menisci, (2) to examine the relationship of the peroneal nerve to the posterolateral meniscus, and (3) to develop recommendations for avoiding neurovascular injury during posterior meniscal repair in pediatric patients. Study Design: Descriptive laboratory study. Methods: A total of 26 skeletally immature knee cadaveric specimens (7 females and 19 males) were included. Specimens were divided into age groups: 2-4, 5-8, and 9-11 years. The most posterior extent of the lateral and medial menisci was identified via sagittal and axial views on computed tomography (CT) scans. The shortest distance from the most posterior aspect of the lateral and medial menisci to the popliteal artery and the shortest distance from the posterior aspect of the lateral menisci to the anterior rim of the peroneal nerve were measured, and 3-dimensional models of representative specimens were re-created through use of CT scans. Results: For the age groups 2-4, 5-8, and 9-11 years, the mean minimum distance from the posterolateral meniscus to the popliteal artery was 5.2, 6.7, and 8.2 mm, respectively, and the mean minimum distance from the posteromedial meniscus to the popliteal artery was 12.7, 15.4, and 20.3 mm, respectively. In all groups, the distance between the posteromedial meniscus and the popliteal artery was greater than that between the posterolateral meniscus and the popliteal artery. The mean distance from the peroneal nerve to the lateral meniscus was 13.3, 15.0, and 17.9 mm for the respective groups. Conclusion: Many all-inside meniscal repair devices have sharp tips that penetrate posterior to the meniscus and capsule. This study demonstrated that the distance between the posterior meniscus and popliteal artery is relatively small in pediatric patients, especially for the lateral meniscus region. Clinical Relevance: Because of the higher potential for meniscal healing, meniscal repair is more likely to be performed in pediatric patients. The data in this study regarding the proximity of the lateral meniscus and neurovascular structures may be used to guide safe surgical repair of posterior meniscal tears during the use of all-inside meniscal repair devices in these patients.

The Risk of Iatrogenic Peroneal Nerve Injury in Lateral Meniscal Repair and Safe Zone to Minimize the Risk Based on Actual Arthroscopic Position: An MRI Study

“…An all–inside meniscal repair device can endanger the peroneal nerve when the repair involves damage close to the medial and/or lateral borders of the PT and the tear type warrants meniscocapsular repair because the peroneal nerve is located at the posterolateral aspect of the knee joint. There have been several cadaveric and MRI-based studies that evaluated the risk of iatrogenic peroneal nerve injury during lateral meniscal repair 2,5,6,12,13,18,21 ; however, the results of these studies may not have accurately represented the true operative situation. The cadaveric studies may have been inaccurate because they all used midleg to midthigh cadaveric sections, which would have less than normal muscle and neurovascular tensions, and also were not evaluated in the actual surgical figure-of-4 arthroscopic position.…”

“…However, all previous cadaveric studies on meniscal repairs evaluated the peroneal nerve and/or posterior neurovascular structure of this area using midfemoral to midtibial knee joint specimens. 2,5,6,12,13,18,21 Several factors can influence the outcome of arthroscopic lateral meniscal repair, which could lead to inaccurate results from such cadaveric studies. First, when using a midthigh to midleg section, the tension from the various neurovascular structures, muscles, and tendons around the knees will be lower than the tension in a living person or a full-body cadaver.…”

Pediatric Ramp Lesions

“…For example, the average distance from the posteromedial meniscus to the popliteal artery is 20.3mm in children 9-11 years old and decreases with age and child size. 65 This should be considered with any ramp or posteromedial meniscus repair technique chosen in children.…”

No risk of iatrogenic peroneal nerve injury in all-inside lateral meniscal repair with either 14- or 18-mm needles through the popliteus tendon in the standard arthroscopic knee conditions

“…However, with this technique, there are concerns of potential iatrogenic injury to the peroneal nerve (PN), which is located in close proximity to the lateral joint line in the posterolateral knee compartment [9]. Cadaveric and magnetic resonance imaging (MRI) studies have been conducted to evaluate the risk of injury to the posterolateral neurovascular structures of the knee [1, 4, 7, 8, 12, 14–16, 18, 21, 23, 24, 26]; however, none of these studies focussed on the surgical technique of placing an anchor through the PT or simulated their repairs in knees in the standard arthroscopic lateral meniscal repair position. (see Fig.…”