Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 1, pp 153–165 | Cite as

Popliteal neurovascular bundle is safe during inside-out repair of medial meniscus without a safety incision

  • Himanshu GuptaEmail author
  • Rohini Gupta Ghasi
  • Himanshu Kataria
  • Vineet Jain
  • Vivek Shankar
  • Rakesh Kumar Daripa
  • Ashish Datt Upadhyay



There is a theoretical risk of injury to neurovascular structures during inside-out meniscal repair without a safety incision, although there are limited studies assessing this risk. This simulation study on archival MRI films was performed to assess the risk for the popliteal neurovascular bundle and the peroneal nerve during passage of needles for inside-out meniscus repair without a “safety incision”, thereby defining a “safe zone” of the menisci that can be safely repaired using this technique.


Archival MRI scans (n = 50) were retrieved and axial sections through the menisci were used for simulation. The needle passage was simulated for different points on the posterior horn and body of lateral and medial menisci at “half-hour” intervals using clock method (15° intervals) with three different portals and two different needle cannulas, resulting in six different scenarios of needle passage for each point on the meniscus. The distance of the needle in each scenario was measured from popliteal vessels (n = 50) and peroneal nerve (n = 10). The value “mean-3SD” was calculated for positive means and “Mean + 3SD” was calculated if the mean was negative. An additional 2 mm was defined as “safe distance”. Thus, simulation models in which the mean − 3SD was less than 2 mm (or mean + 3SD was greater than − 2 mm for negative means) were labelled as “unsafe”.


Needle passage through medial meniscus at and medial to 1 o’clock position for a right knee (or 11 o’clock position for a left knee) was safe, irrespective of the portal and needle type. For the lateral meniscus, only the equatorial region was found to be safe with this method.


The popliteal neurovascular bundle is safe during the inside-out medial meniscal repair without a safety incision. For the terminal-most part of the posterior horn, the AM portal and the straight cannula should be avoided. However, this method without safety incision cannot be recommended for lateral meniscus because of the risk to the popliteal vessels and the peroneal nerve. Instead, the inside-out method with a safety incision, or an all-inside method should be used for lateral meniscus.

Level of evidence



Meniscus Repair Inside out Popliteal vessels Peroneal nerve 


Author contributions

HG conceived the study, designed the study, was involved in performance of simulation study and data collection, coordination, statistical analysis, and drafted the manuscript. RGG was involved in design of study, performance of simulation and data collection, and performed critical review of the manuscript. HK was involved in design of study, data collection, and performed critical review of the manuscript. VJ was involved in design of study, data collection, and performed critical review of the manuscript. VSh was involved in design of study, and performed critical review of the manuscript. RKD was involved in performance of simulation study and data collection, and performed critical review of the manuscript. ADU was involved in design of study, statistical analysis, and performed critical review of the manuscript. All authors approved the final manuscript.


There was no source of funding.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

Prior ethical approval was obtained from Institutional Ethics Committee (approval no. IEC/SJH/VMMC/Project/May-2016/583).

Informed consent

Waiver for informed consent was obtained from the Institutional Ethics Committee as the study was performed on archival MRI data.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.Sports Injury CentreVMMC and Safdarjung HospitalNew DelhiIndia
  2. 2.Department of RadiodiagnosisVMMC and Safdarjung HospitalNew DelhiIndia
  3. 3.Department of OrthopaedicsAll India Institute of Medical SciencesNew DelhiIndia
  4. 4.Department of BiostatisticsAll India Institute of Medical SciencesNew DelhiIndia

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