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A Novel and Cheap Method of Outside-In Meniscal Repair for Anterior Horn Tears

Open AccessPublished:March 17, 2014DOI:https://doi.org/10.1016/j.eats.2013.11.001

      Abstract

      Outside-in meniscal repair techniques can involve the use of expensive passing devices that may not be readily available to all orthopaedic surgeons. There are many different ways to repair a meniscus, and we describe a quick and simple technique that requires no special equipment.

      Technique Video

      See video under supplementary data.

      Outside-in meniscal repair techniques can involve the use of passing devices that are expensive and may not be readily available to all orthopaedic surgeons.
      • Rodeo S.A.
      Arthroscopic meniscal repair with use of the outside-in technique.
      There are many different ways to repair a meniscus; we describe a quick and simple technique that does not require special equipment.
      • Yoon J.R.
      • Muzaffar N.
      • Kang J.W.
      • Lim H.C.
      • Bae J.H.
      • Nha K.W.
      A novel technique for arthroscopic reduction and repair of a bucket-handle meniscal tear.
      • Cho J.H.
      Arthroscopic all-inside repair of anterior horn tears of the lateral meniscus using a spinal needle.
      • Lee C.K.
      • Suh J.T.
      • Yoo C.I.
      • Cho H.L.
      Arthroscopic all-inside repair techniques of lateral meniscus anterior horn tear: A technical note.
      • Ahn J.H.
      • Wang J.H.
      • Yoo J.C.
      • Kim S.K.
      • Park J.H.
      • Park J.W.
      The modified outside-in suture: Vertical repair of the anterior horn of the meniscus after decompression of a large meniscal cyst.

      Technique

      The surgeon passes a green needle (BD Microlance 3, 21 gauge × 1.5-inch needle; Becton Dickinson, Franklin Lakes, NJ) through the skin, capsule, and meniscus, aiming for it to exit at the preferred site of the meniscal suture. We recommend using the green needle before the white needle because many passes of the larger-bore needle may cause unnecessary soft-tissue damage.
      The surgeon then uses 2 white needles (BD Microlance 3, 19 gauge × 2-inch needles; Becton Dickinson) prethreaded with a braided No. 2-0 Ethibond suture (Ethicon, Somerville, NJ). Outside-in repairs are most commonly used to complete repairs of large bucket-handle tears; however, in this situation, the remnants of suture material from an all-inside passing device (e.g., FastFix [Smith & Nephew, Andover, MA]) provide a more-than-adequate quantity of suture material.
      The suture is prethreaded through the needle barrel (Fig 1) in a retrograde direction and looped back on itself on the side of the needle opposite the sharp tip (at the “lowest” point of the bevel). The first needle is then placed along the track of the removed green needle. The surgeon grasps the needle and the free end of the suture at the same time. The needle is placed 10 mm beyond the meniscus and withdrawn to leave a loop of suture material in the knee (Fig 1).
      Fig 1
      Fig 1Suture setup inside 21-gauge needle with placement of loop in knee.
      Once the first suture loop has been placed, a 10-mm transverse incision is made immediately adjacent to it. The second prethreaded white needle is passed through this incision, exiting through the capsule adjacent to the previously placed meniscal suture loop, under arthroscopic guidance. The needle is once again withdrawn to leave 2 loops in the knee and 4 suture strands outside (Fig 2).
      Fig 2
      Fig 2Both loops are vertically stacked. The first loop is pulled through the second loop through the arthroscopic portal with a grasper or clip.
      An arthroscopic grasper or clip is passed through the most appropriate arthroscopic portal to gain access to the loops. The instrument is placed through the first loop and grasps the second loop (Fig 2). While the surgeon is holding onto 1 of the free ends of this second loop, the other end is pulled out through the arthroscopic portal (Fig 3).
      Fig 3
      Fig 3One limb of the suture loop is pulled completely out through the arthroscopic portal. The other limb remains through the meniscus and capsule.
      The surgeon then withdraws both free ends of the first loop while maintaining his or her hold on the free strand of the second loop (Fig 4). This leaves a simple vertical suture across the meniscal tear. The free ends are then tied over the capsule in approximately 30° of knee flexion to avoid tethering of the anterior soft tissues (Fig 5). The technique is demonstrated in Video 1.
      Fig 4
      Fig 4The loop still in the knee is pulled out completely through the meniscus, bringing the portal limb back through and creating a vertical mattress suture.
      Fig 5
      Fig 5The suture is in place and is ready to be tied externally over the capsule.

      Discussion

      Our technique is a technically straightforward, quick, and cheap method of outside-in meniscal repair. Other techniques have used larger needle gauges and are technically more involved, requiring multiple passes of a suture and needle.
      • Laupattarakasem W.
      • Sumanont S.
      • Kesprayura S.
      • Kasemkijwattana C.
      Arthroscopic outside-in meniscal repair through a needle hole.
      This technique is far simpler than those previously described in the literature and uses easily obtainable devices found in the operating theater. We advocate the use of a vertical mattress suture where possible because of the stronger biomechanical advantage offered in meniscal repair.
      • Post W.R.
      • Akers S.R.
      • Kish V.
      Load to failure of common meniscal repair techniques: Effects of suture technique and suture material.

      Supplementary Data

      References

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        Arthroscopic meniscal repair with use of the outside-in technique.
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        • Yoon J.R.
        • Muzaffar N.
        • Kang J.W.
        • Lim H.C.
        • Bae J.H.
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        A novel technique for arthroscopic reduction and repair of a bucket-handle meniscal tear.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 1332-1335
        • Cho J.H.
        Arthroscopic all-inside repair of anterior horn tears of the lateral meniscus using a spinal needle.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 683-686
        • Lee C.K.
        • Suh J.T.
        • Yoo C.I.
        • Cho H.L.
        Arthroscopic all-inside repair techniques of lateral meniscus anterior horn tear: A technical note.
        Knee Surg Sports Traumatol Arthrosc. 2007; 15: 1335-1339
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        • Wang J.H.
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        The modified outside-in suture: Vertical repair of the anterior horn of the meniscus after decompression of a large meniscal cyst.
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        Arthroscopic outside-in meniscal repair through a needle hole.
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