Editorial Commentary: The Reverse Suture Anchor Repair Technique for Posterior Medial Meniscus Root Tears Shows Promising Early Biomechanical Results but Clinical Results Are Still Unknown.

Injuries to the meniscal root attachments, specifically posterior medial meniscus root tears (PMMRT), result in meniscus extrusion, leading to impaired hoop stresses and devastating biomechanical and clinical consequences. Loss of the medial meniscus root attachment is associated with a biomechanical state mirroring that of a total meniscectomy. Over the past decade, the importance of repairing PMMRTs has been emphasized and demonstrated in multiple clinical studies, as nonoperative management is thought to be the underlying cause of subchondral insufficiency fractures and rapidly progressive osteoarthritis that can commonly necessitate a total knee arthroplasty. The most common root repair technique uses indirect fixation with a transtibial tunnel pull-through technique, whereas direct fixation methods using traditional suture anchors are technically challenging and less commonly used. The reverse suture anchor (RSA) technique is a newly described root repair approach that involves direct fixation by implanting a retensionable suture anchor into the tibial tunnel in a retrograde or "reverse" fashion, circumventing the difficulty with placing traditional suture anchors from a posteromedial portal. However, one concern with the RSA technique is the potential for diminished biological healing, as decortication of the bony meniscus anatomic root attachment is typically not recommended. The RSA repair technique, and those that model this mechanism, have demonstrated promising early biomechanical results in the laboratory; however, it is unknown whether the clinical healing will be as promising as these initial biomechanical strength studies. Our preferred repair technique for PMMRTs is a 2-tunnel transtibial pull-out repair.