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Lateral meniscus vertical tears are often seen with acute anterior cruciate ligament injuries. The inside-out technique of repairing the meniscal tear is currently the gold standard treatment. However, every technique has its own drawbacks. The inside-out technique has possible risk of infection and neurovascular complications. All-inside techniques are becoming increasingly popular. A novel all-inside technique and a variation of it for meniscus repair using an antegrade suture passer like a Knee Scorpion are described. These are cost effective using a 2-0 FiberWire for repair of vertical meniscal tears. This technique also provides a better control of reduction at tear site through tensioning the 2 suture limbs. It is cost effective, easy to use, and has less neurovascular complications as compared with the inside -out technique.
See video under supplementary data.
Lateral meniscus vertical tears are often seen with acute anterior cruciate ligament injury.
Knee-specific antegrade suture passers like the Knee Scorpion (Arthrex, Naples, FL) have been introduced that are more low profile to be used in tight spaces like the knee. They are used in repairing root tears of the menisci.
The described techniques are novel all-inside future repair techniques of lateral meniscus vertical tears using a knee scorpion and 2-0 FiberWire suture (Arthrex). There are 2 variations of the technique that have been described individually, depending on the location of the tear and the width of the meniscus. Technique A is used in tears that are in the red-white zone or where the posterior horn’s width is not greater than the length of the Knee Scorpion’s jaw. Technique B is used in cases in which the tear is in the red-red zone or the posterior horn width is more than the length of the Knee Scorpion’s jaw.
Technique A (With Video Illustration)
A standard anterolateral portal (portal A) of 1 cm in size is made in the soft spot and the arthroscope is introduced. The vertical tear in the lateral meniscus is identified. The joint space is opened up by giving a varus stress in a figure of 4 position on the operating table and the tear is visualized (Fig 1 A and B ). A 1-cm high horizontal medial portal (portal B) is made such that instruments can be introduced into the lateral compartment without scuffing the cartilage. The tear is freshened using a diamond rasp. A flexible PassPort Cannula (Arthrex) is introduced through portal B. The lower jaw of the Scorpion is loaded with a 2-0 FiberWire. The suture-loaded Knee Scorpion is then introduced through this portal. The jaws of the Knee Scorpion are opened and the meniscal tissue grasped till beyond the tear. The jaws are closed to secure the meniscal tissue and scorpion needle advanced to retrieve the FiberWire through the upper jaw (Fig 1 C and D). The scorpion is pulled back through the portal. The FiberWire is released from the scorpion. This secures the bite through the peripheral part of the meniscus beyond the tear (Fig 1 E and F). The Knee Scorpion is again loaded with the inferior arm of the FiberWire that passes under the meniscus. The meniscal tissue central to the tear is grasped again with the scorpion and jaws closed. The FiberWire is retrieved by advancing the needle of scorpion (Fig 1 G and H), and the scorpion is withdrawn. The FiberWire is released from the scorpion, leaving 2 ends of the FiberWire passing through near and far ends of the meniscal tissue around the tear (Fig 1I). Taking the peripheral part of the FiberWire as a post, a knot is tied in the peripheral part of meniscus with a knot pusher and a total of 3 knots tied (Fig 1 J and K). The FiberWire is cut flush with knot with the help of a suture cutter (Fig 1 L and M).
Technique B (With Video Illustration)
This technique is used when the jaws of the Knee Scorpion are not able to reach the peripheral portion of the meniscus tissue beyond the tear to pass the FiberWire through this tissue (Fig 2A). The jaws of the Knee Scorpion are opened and passed through the tear itself to grasp the peripheral part of the tear. The jaws are closed to secure the meniscal tissue and scorpion needle advanced to retrieve the FiberWire through the upper jaw (Fig 2 BandC).This leaves the upper arm of the FiberWire going through the peripheral meniscus tissue and lower arm coming out through the tear (Fig 2 D and E). The scorpion is pulled back through the portal. The FiberWire is released from the Knee Scorpion. A crochet hook is introduced through portal B and is passed under the near end of the meniscus into the tear to secure the lower arm of the FiberWire (Fig 2 F and G) and retrieve it (Fig 2 H and I). This is then pulled under the meniscus and out through the PassPort Cannula. The next steps are the same as Technique A.
The inside-out technique of repair is a gold standard technique, especially for unstable tears. However, every technique has its own drawbacks. Here it needs an extra incision and dissection down to the capsule with possible risk of infection and neurovascular complications.
It also leaves nonabsorbable suture knots outside the capsule that could irritate the patient later on. Other all-inside techniques also use implants that anchor to the capsule and are delivered by long beveled tip needles that can potentially injure vital structures in the posterior and posterolateral aspects of the knee. The all-inside technique described here has the advantage of less inventory and fewer chances of neurovascular complications with no implants in the capsule or beyond. The all-inside technique using suture anchors creates a fixed tension at the repair site, the technique described here provides better control of reduction through tensioning the 2 suture limbs. The length of the jaws of Knee Scorpion is 10 mm (Fig 3), and the average width of the posterior horn of lateral meniscus is 9.70 mm.
which is about the height the needle of the Knee Scorpion. However, these dimensions vary and have been determined via magnetic resonance imaging measurements. When the tear is very peripheral, the jaws of the knee scorpion may not pass beyond the tear to catch the meniscal tissue peripheral to the tear. Also, the needle that comes through the jaws has a curvilinear path and does not make use of the full jaw length and hence cannot grasp the peripheral meniscus tissue in tears that are very peripheral. Technique B describes a simple way to do the repair despite this problem, as bites through the periphery are taken through the tear. This is also a cost-effective technique of using a FiberWire only as compared with other devices used for all-inside fixation technique. The advantages and disadvantages as well as pearls and pitfalls are described in Tables 1 and 2. Techniques A and B are shown in Video 1.
Table 1Advantages and Disadvantages of This Technique
More cost-effective, as the Knee Scorpion is sterilizable. The only cost is the needle and 2-0 FiberWire. One 2-0 FiberWire can be used for up to 3 stitches.
More technically demanding with a longer learning curve as compared with other all-inside devices.
There is more control over tightening the knots, as it can be seen while tightening it.
In small tears of the posterior horn where the jaws of the Knee Scorpion cannot engage the peripheral part and Technique B is used, retrieving the lower end of the FiberWire from the tear to below the near end of the meniscus can be difficult, as the tear is not as mobile.
No implants in the capsule other than sutures.
Knots on the surface of the meniscus could potentially abrade the cartilage on the femoral side.
Less neurovascular complications, as no needle or implant is passed through the capsule into the posterior aspect of the knee where the popliteal artery or common peroneal nerve is.
Time taken is longer than other all-inside devices.
Inventory in operation room is less, as all that is needed in disposables is one Knee Scorpion needle and 2-0 FiberWires.
Needle used for multiple stitches could potentially lead to fatigue and can break.
Making a high medial working portal helps in reaching the lateral meniscus tear
Very low medial working portal can cause cartilage abrasion while introducing the Knee Scorpion and can be obstructed by the tibial spine preventing easy entry into the lateral compartment
Using a flexible cannula in the medial portal helps in maneuvering the Knee Scorpion intra-articularly
Using a hard cannula creates less maneuverability, and using no cannulas can cause a tissue bridge between the 2 ends of the meniscus
While loading the suture onto the Knee Scorpion, the loose end should be short so that it is easily delivered through the canula after the bite
Overzealously tightening the 2-0 FiberWire can potentially break it
Gently using the crochet to lift the meniscus up in Technique B makes the lower end of the suture more visible and easily deliverable below the near end of the meniscus
Not identifying the lower end of the suture passing through the far end of the meniscus can cause the suture to become entangled, preventing good knot security
Using a low-profile, smaller-diameter knot pusher helps, as it potentially has less chance of damaging the femoral condyle cartilage.
While delivering the lower end of the suture under the near end of the meniscus after taking a bite in the far end of the meniscus in Technique B, it is important that upper end of the suture is long enough and when the loop is pulled the correct arm of the loop is pulled as this could disengage the suture from the meniscus completely
Tying the knots more posteriorly on the meniscus potentially reduces damage on the articular cartilage
Simple knots are the preferred technique, with at least 3 knots, as they are easier to disengage if not secure enough, giving the surgeon another opportunity. This is not possible with a sliding knot, which needs to be cut completely if not satisfactorily tight
Depending on the location of the tear in the posterior horn of the lateral meniscus, the viewing and working portal may be interchanged
Technique A and B of repairing a bucket-handle tear of the lateral meniscus when the jaws of a Knee Scorpion can reach the periphery of the meniscus beyond the tear (Technique A) and when it cannot (Technique B).
The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.