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Arthroscopic meniscus repair: Inside-out technique


OVERVIEW

Chapter synopsis

The inside-out technique for meniscus repair is the gold standard against which other repair modalities are compared. It is ideal for bucket handle tears and tears involving the posterior horn through the body of the meniscus. Once the exposure is performed, this technique allows the surgeon to efficiently place multiple sutures in a vertical mattress configuration to create a stable repair. The needles utilized are also smaller than those used in all-inside device delivery and therefore minimize the risk of iatrogenic injury to the meniscus. Patient selection remains critical to achieving acceptable outcomes.

Important points

  • Patient characteristics, chronicity of the tear, tear pattern, tear location, and concomitant ligament reconstruction are the most important factors that determine successful meniscus repair outcome.

  • Vertical mattress configuration provides the strongest repair because it is perpendicular to the circumferential collagen fibers of the meniscus.

  • Communication between primary surgeon and assistant during suture passage is important to minimize the risk of neurovascular injury to the patient, especially on the lateral side.

Clinical/surgical pearls

  • The use of double-ended 2-0 or 0 nonabsorbable sutures with long flexible needles is recommended.

  • Proper location of the posteromedial or posterolateral incision can facilitate needle capture, while improper positioning can hinder it. One third of the incision should be proximal to the joint line and two thirds distal to optimize ease of suture passage.

Clinical/surgical pitfalls

  • Beware of the saphenous nerve during medial meniscal repairs. Entrapment of this nerve is possible when tying the passed sutures. Injury to the nerve can be a cause of acute postoperative pain and formation of a neuroma.

  • Beware of the peroneal nerve during lateral repairs. This nerve can be pierced by suture needles or trapped by meniscal sutures if the deep retractor is not placed deep to the gastrocnemius. Confirm that the retractor sits directly behind the capsule before suture passage. The posterior capsule should be directly visualized before sutures are tied laterally.

  • Once the sutures have been passed, each suture should be sequentially tied (central to peripheral) with the leg in extension. This prevents tethering of the posterior capsule by the meniscal sutures and decreases the likelihood of a postoperative flexion contracture.

Introduction

Numerous studies have confirmed the biomechanical importance of the meniscus, thus meniscal repair is preferable to meniscectomy whenever feasible. Since the introduction of meniscus repair in 1885 by Annandale, multiple repair techniques have been developed, both open and arthroscopic. The development of inside-out repair techniques and devices revolutionized the management of repairable meniscus tears and use of such techniques and devices is currently the gold standard for meniscus repair. Such repair techniques are ideal for large and middle third meniscus tears and allow for the capture of multiple longitudinally-oriented collagen cables when a vertical suture technique is used. This chapter discusses the inside-out meniscus repair technique in detail.

Preoperative considerations

History

A detailed history remains critical to the accurate diagnosis of a meniscus tear. The timing of the injury, exact mechanism, associated injuries, duration of symptoms, previous treatments, and exacerbating and alleviating factors are important points of discussion at the time of the initial visit.

Signs and symptoms

The typical presentation of meniscal pathology includes the following:

  • Acute noncontact twisting injury to the knee.

  • Mild to moderate effusion that develops shortly after injury, as well as subsequent activity-related swelling. This can be differentiated from cruciate ligament injury in that patients are generally able to continue with activity.

  • Mechanical symptoms, such as catching, locking, or clicking, may be present.

  • Occasional episodes of giving way are often reported. These are due to effusion or pain causing quad weakness. However, it is important to consider symptoms of instability and perform a thorough ligamentous exam.

Physical examination

Typical physical examination findings of a meniscus tear include the following:

  • Gait is usually normal, although there may be an antalgic gait if the presentation is acute or a displaced or bucket handle tear is present.

  • Effusion is frequently present.

  • Range of motion can be limited if the patient is seen early with an effusion or with a displaced or bucket handle tear. Often this will manifest as a loss of extension or a flexion contracture if chronic in nature. Range of motion may be normal if the patient is seen late or after an initial course of physical therapy.

  • Posterior joint line pain with deep flexion.

  • Joint line tenderness is often noted.

  • A positive McMurray test may be present.

  • Ligamentous stability is tested to assess for concomitant injury (e.g., Lachman, posterior drawer, and pivot-shift tests).

  • Parameniscal cyst on the lateral side.

  • Mild quadriceps atrophy may be present.

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