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Arthroscopic meniscus repair: Outside-in technique


OVERVIEW

Chapter synopsis

The outside-in technique of meniscus repair is useful for treating tears amenable to repair within the anterior horn and body. As our understanding of the biomechanical consequences of meniscal deficiency has improved, a detailed understanding of this surgical option is essential to preserve meniscal function. This chapter provides information on treatment indications, preoperative considerations, and surgical techniques that may be used when treating a meniscal tear with the outside-in technique.

Important points

  • Ideal candidate: Young, compliant patient with short history of pain.

  • Ideal tear type and location: Vertical, longitudinal tear in red-red zone of the anterior horn or anterior body of the meniscus

  • Contraindications (mostly relative): Older patients with unstable or anterior cruciate ligament (ACL)–deficient knee, horizontal cleavage tear, partial-thickness tear, stable tear, white-white zone (avascular) tear, osteoarthritic changes, posterior horn and root injury.

  • Classification: Arthroscopic surgical technique for addressing meniscal tears.

  • Symptoms: Often occur after a traumatic event, include locking or catching of the knee, effusion, focal tenderness, pain with meniscal compression (including hyperextension testing in setting of anterior meniscal pathology).

  • Surgical technique: Anesthesia determined by patient and anesthesiologist. We prefer regional anesthesia for ambulatory patients. Leg position should allow for access to posteromedial and posterolateral corners of the knee, and position may be modified depending on region(s) of meniscus being addressed.

Clinical and surgical pearls

  • Proper counseling is essential to ensure compliance with rehabilitation protocol.

  • Abrasion of the meniscal surface and adjacent synovium is recommended to stimulate healing response.

  • Marrow venting of the intercondylar notch can provide access to marrow-derived mesenchymal cells to augment healing of isolated meniscal repairs.

  • Vertically oriented sutures allow for improved biomechanical strength of the repair construct.

Clinical and surgical pitfalls

  • Tears in the posterior horn of the medial meniscus are difficult to repair with the outside-in technique due to difficult tear access; inside-out or all-inside repair is recommended in this location.

  • The saphenous nerve and associated branches may be at risk with medial meniscus repair. The nerve proper should be protected posteriorly, and its anterior branches protected with blunt dissection down to the capsule.

  • Compliance with a protected rehabilitation program and restriction of terminal flexion and hyperextension in the early postoperative period may be important to favorably influence healing.

The menisci play critical roles in load transmission, shock absorption, joint lubrication, and secondary knee stabilization. Numerous studies have demonstrated a progression to osteoarthritis (OA) associated with resection of increasing amounts of meniscal tissue, resulting in decreased femoral contact area and increases in contact stresses. , Meniscus preservation should be prioritized for all tears contingent on tissue quality and vascularity.

The evolution and advancement of arthroscopic surgical techniques have improved our ability to access and repair meniscal tears. The outside-in technique was first described by Warren as an alternative method to decrease the risk of neurovascular injury with repair ; whereas inside-out and all-inside techniques are particularly useful to address posterior horn and posterior- to mid-body lesions, the outside-in technique is a powerful and invaluable approach for repairable tears of the body and anterior horn. The outside-in technique is also useful to repair the anterior extension of bucket-handle tears and meniscus allograft transplants.

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