<i>Editorial Commentary</i> : Suture Anchor Fixation for Posterior Medial Meniscus Root Repair Continues to Show Biomechanical Favorability, but It Is Not Yet Time to Toss the Tibial Tunnel

Meniscal root tears are defined as a disruption or avulsion within 1 cm of the tibial root attachment. Posterior medial meniscus root tears (PMMRT) represent a distinct injury pattern, typically affecting sedentary, middle-aged patients through degenerative mechanisms. These injuries produce biomechanical consequences similar to total meniscectomy, including increased medial compartment peak contact pressures and decreased tibiofemoral contact area. The biomechanical and clinical consequences have led to PMMRT's being labeled as a "silent epidemic." By restoring hoop tension, PMMRT repair improves clinical symptoms and slows osteoarthritis progression. PMMRT repair can be accomplished with transtibial pull-out or suture anchor (SA) techniques. Transtibial pull-out remains the most common technique and has showed excellent healing rates, though concerns over laxity and meniscal extrusion remain. SA repairs obtain fixation directly beneath the root footprint and minimize suture length, potentially preventing initial displacement and suture elongation. SA repairs of PMMRT traditionally presented the technical challenge of inserting anchors through a posteromedial portal, though contemporary SA techniques frequently utilize anterior transosseous tibial tunnels for anchor deployment, which may increase familiarity and ease of use. Recent comparative biomechanical studies between transtibial pull-out and SA techniques show superior performance in displacement, load, stiffness, contact area, and extrusion with SA repairs. Suture cutout remains the most common complication for both procedures. While there is increasing biomechanical rationale for SA repair, further clinical and second-look data are required to determine the optimal technique.