The “Under, Over” Technique for Repair of a Peripheral Bucket-Handle Meniscus Tear With Circumferential Compression Stitches

The benefits of preserving the meniscus are well-established. Several arthroscopic meniscal repair techniques have been described, such as the inside-out, outside-in, and all-inside. All-inside self-retrieving suture devices can be used to repair vertical, horizontal, and radial tears. However, this technique becomes difficult with large tears, as the jaw of the device cannot reach the peripheral edge of the meniscal tear. We present an all-inside technique using circumferential compression stitches to address large peripheral meniscus tears.

T he meniscus functions to increase surface area for force transmission and shock absorption, as well as to provide stability for the knee joint in cases of cruciate ligament deficiency. 1,2 Without treatment, meniscal tears can lead to degenerative joint changes. 1,3,4 Meniscal repair has become increasingly common to prevent the early development of osteoarthritis that can occur after subtotal and partial meniscectomies. 4 Broadly, 3 types of arthroscopic techniques for meniscus repair have been well described: the insideout, the outside-in, and the all-inside. Although the inside-out remains the gold standard technique for meniscus repair, the all-inside technique is increasingly used for vertical, horizontal, and radial meniscal tears with the advances in suture implant technologies. 2 However, the traditional all-inside anchor-based technique for lateral meniscus posterior horn tears can place the popliteal neurovascular bundle at risk of injury. 5,6 Magnetic resonance imaging studies show that the popliteal artery lies lateral to the midline in approximately 94% of cases. 7,8 In addition, traditional allinside repair of the lateral meniscus places the popliteus tendon at risk of being captured by the anchor, which may lead to tissue irritation or injury. 9,10 Self-retrieving suture devices are available to perform the all-inside suture-based technique and reduce risk of injury to the posterior structures. In particular, selfretrieving devices are especially useful for circumferential stitches, which provide anatomic reduction and compression of tears with a high load to failure. [11][12][13] In order for self-retrieving devices to successfully reduce vertical tears, the jaw of the device must be able to fit between the femoral and tibial condyles as well as reach the peripheral side of the tear. If the meniscal tear is too large, the jaw of the device may have difficulty reaching the peripheral meniscal tissue. We present an all-inside technique to address large these peripheral meniscus tears.

Surgical Technique (With Video Illustration) Patient Setup
After the induction of general anesthesia, the patient is positioned in the supine position. A tourniquet is placed on the operative extremity and the thigh is positioned in a leg holder to allow 90 of knee flexion. Draping is performed in the standard sterile fashion.

Arthroscopic Access
A standard anterolateral arthroscopic portal is first created, and the anteromedial portal is created under direct arthroscopic visualization. An arthroscopic probe is used to fully evaluate the extent and nature of the meniscus tear. The tear edges are debrided with a combination of a motorized shaver and a round ball rasp. Meniscal trephination is performed with an 18gauge spinal needle.

Meniscal Repair
The repair is performed using the self-retrieving allinside NOVOSTITCH PRO device (Smith & Nephew, Andover, MA) (Video 1). The device is preloaded with a 2-0 high-strength, nonabsorbable suture before entering the joint through the working portal. The device is advanced in a low-profile configuration with the lower jaw retracted to minimize the risk of traumatic insertion. To maintain the low-profile configuration, the front trigger is squeezed while the device is advanced under the central component of the meniscus tear. Once at the site of the tear, the front trigger is released to lift the upper jaw of the device between the peripheral and central components of the tear. This will position the upper jaw above the femoral surface of the until the device is at the site of the tear. The upper jaw is extended through the tear above the femoral surface of the peripheral aspect of the meniscus tear (orange arrow). The first limb of suture is passed through the peripheral side of the tear from the lower to upper jaw of the device, which retains the suture (A, B). The lower jaw of the device is retracted to move the device centrally while the upper jaw retains the first limb of suture. The second limb of suture is then passed through the central side of the tear (blue arrow) to complete the suture construct (C, D). The lower jaw is retracted and the device is removed. The peripheral limb of suture is retrieved using an arthroscopic crab claw superior to both meniscal fragments (E, F). meniscus. The lower jaw is extended below the tibial surface of the meniscus by toggling the lever on the side of the device. The suture is passed through the peripheral side of the tear from the lower jaw to the upper jaw by squeezing the trigger (Fig 1 A and B). The lower jaw can be retracted at this time to allow better maneuverability. The device is moved centrally while the upper jaw retains the first limb of suture. The second limb of suture is then passed through the central side of the tear to complete the suture construct (Fig 1C  and D). Care is taken not to pierce the suture limb that is now below the meniscus. The device is removed from the joint. An arthroscopic crab claw is used to retrieve the peripheral suture limb superior to the meniscus (Fig 1 E and F). An arthroscopic knot is tied and cut using a suture cutter. The device can be reloaded with new suture cartridges to place additional circumferential sutures as needed.
Direct visualization of the peripheral tear can be helpful, especially with small residual meniscal tissue (Fig 2 A and B). This process is repeated until sufficient sutures are in place for adequate meniscus reduction (Fig 2C). It is advantageous to create an accessory portal to house the sutures and tie after passage of all sutures. Premature tying of the sutures can limit access to the peripheral meniscal tissue. After meniscus repair, a 2.0 Kirschner wire is used to make 3 to 6 holes on the lateral femoral notch anterior to the femoral anterior cruciate ligament footprint for biological augmentation.
The patient is braced and weight-bearing is performed as tolerated from postoperative day 0. From postoperative weeks 0-2, range of motion is limited to 0 to 70 . Range of motion is increased to 90 until week 6. From week 6 to 4 months, range of motion is increased to 130 , after which full range of motion is permitted. Hyperflexion and deep squatting are avoided for 4 months.

Discussion
Bucket-handle meniscus tears should be repaired, when possible, in order to prevent loss of meniscus volume and early development of osteoarthritis. Several studies have reported favorable functional outcomes and patient-reported outcomes after repair of a buckethandle tear. 14-16 Muench et al. 14 found that 83.3% of tears were healed at 2 years of follow-up, postoperative magnetic resonance imaging showed 69.4% were fully healed and another 25% were partially healed, and 87.5% of patients exceeded patient acceptable symptomatic state (PASS) criteria. Yuen et al. 17 described the use of a traditional all-inside anchor-based technique for bucket-handle tears and minimized potential complications compared with inside-out techniques.
Here, we describe a technique for repair of large peripheral bucket-handle meniscus tears using an allinside self-retrieving suture-based device. Early studies have demonstrated successful repair of other tear patterns using the NOVOSTITCH PRO device, including THE "UNDER, OVER" TECHNIQUE meniscal root tears, horizontal cleavage tears, and radial tears. 13,[18][19][20][21] All-inside techniques have also been shown to reduce operative time and lower the risk of nerve injury complications compared with inside-out repair. 22 Furthermore, the NOVOSTITCH PRO device can be used for circumferential compression sutures, which biomechanical studies show reduce gap formation at high cyclic loading and provide the highest load to failure of all repair techniques. 12,23,24 This technique is particularly useful for lateral meniscus posterior horn tears, where the popliteal artery is at significant risk of injury during the procedure (Table 1). 7,8 Using an anterolateral portal for traditional all-inside anchor-based repair of lateral meniscus posterior horn tears within 5-10 mm of the root can place the popliteal artery within the direct path of instruments. 5,6 Our technique does not violate the capsule, which reduces the risk of injury to the popliteal artery. Use of compression sutures also allows for repair of lateral meniscus tears without risk of capturing the popliteus tendon. 2 As with other all-inside repairs, this technique risks failure with improperly tensioned suture knots, and as the knots are tied on the mensicus, there is risk of chondral abrasion injury ( Table 2).
The technique presented here to successfully repair large peripheral vertical tears using circumferential compression sutures allows for the peripheral limb of the compression suture to be passed accurately through the peripheral side of the tear with minimal risk to surrounding structures. As compression sutures are increasingly used for various tear patterns, this technique provides a solution that can be applied to all tear patterns in which it is difficult to reach the peripheral meniscus.