Arthroscopic meniscus repair: All-inside technique

OVERVIEW

Chapter synopsis

All-inside meniscal repair offers many advantages over traditional inside-out or outside-in meniscal repairs. Benefits include decreased operative times, avoidance of the risks associated with secondary incisions, and ease of use of the implants.
Implant designs have evolved since their introduction, which has allowed for safe and reliable all-inside meniscal repairs with results that compare favorably with those of more traditional open methods.

Important points

Need to identify meniscal tears that are amenable to repair
Need to be familiar with the specific features of each device used for all-inside meniscal repair, including possible suture configuration, deployment mechanism, tensioning method, and location of knots and backstops

Clinical and surgical pearls

Use a portal that affords the most perpendicular approach to the tear.
Change portals as necessary.
Vertical mattress suture configurations are optimal for strength and healing.
Leave suture attached to implants until all implants are in to allow repeated tensioning.
Consider percutaneous release of the medial collateral ligament with a “pie-crusting” technique, if needed, for access to the medial meniscus; placement of vertically oriented sutures is key.
Newer, suture-based fourth-generation devices offer definite advantages over previous devices, including adjustable tension, lower profile, and lower chondral risk.

Clinical and surgical pitfalls

The lack of a meniscal rim can compromise holding ability for devices used at the meniscocapsular junction.
Access is a potential problem for tears that affect the anterior horn.
Know the specifics of each device, including deployment mechanism, possible configurations of suture placement, and type and location of implants to prevent device misfire, breakage, or injury to patient.
Care should be taken to avoid damage to the neurovascular bundle when deploying an all-inside suture, particularly near the posterior root of the lateral meniscus.

Morgan first described all-inside meniscal repair in 1991, when he used curved suture hooks and accessory posterior portals. Although these initial results demonstrated that all-inside meniscal repairs could be highly successful, they were technically difficult and required accessory incisions. Since this initial description, there has been a significant evolution with regard to surgical techniques and implant designs.

There are many advantages of an all-inside meniscal repair compared with the more traditional open procedures, including the avoidance of secondary incisions and their associated risks, decreased operative times, and the technical ease of insertion. However, to be considered successful, an all-inside meniscal repair must be able to restore the normal anatomy and must have outcomes that compare favorably with those of the more traditional and current gold standard inside-out meniscal repair technique.

In this chapter we will discuss the preoperative evaluation of patients with meniscal pathology, indications for all-inside meniscal repair, and techniques for fixation. Additionally, we will briefly describe the evolution of the all-inside meniscal repair and more specifically concentrate on the surgical techniques and implants associated with the latest fourth-generation devices.

Preoperative considerations

History

Meniscal injury commonly occurs with a twisting injury to the knee and is at times seen in conjunction with a ligamentous knee injury. Frequently there are joint line tenderness and mechanical symptoms that include catching, locking, and giving way. Swelling typically occurs overnight in the acute setting and on an intermittent, activity-related basis with a chronic tear.

Physical examination

Perform full knee evaluation bilaterally.
Rule out any hip, pelvic, or back disease that may be contributing to “knee” pain.
Key examination elements for meniscal tears include:
- Presence of an effusion
- Extension deficit (which may indicate a locked meniscal fragment)
- Joint line tenderness
- Positive results of McMurray and Apley tests

Imaging

Radiography

Plain radiographs are helpful in assessing for arthrosis as well as limb alignment.

Standing anteroposterior and posteroanterior flexed views
Lateral and sunrise views

Other imaging modalities

Magnetic resonance imaging can be more than 96% accurate in identifying meniscal lesions and can be used to help confirm their presence. However, it has not yet been shown to be helpful in predicting whether a tear is reparable. The decision for repair versus partial resection usually requires arthroscopic assessment.

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