Abstract
Meniscus is an important structure within the knee to maintain stability and load gravity distribution. Compared with meniscectomy, timely meniscal repair can reduce the risk of knee regression and laxity. Various methods have been studied to repair the meniscus. Among them, the outside-in technique is appropriate to repair anterior and middle segments of the meniscus. A number of modifications of this technique have been described in previous literatures. However, it still has disadvantages, such as complex intra-articular maneuvers, requiring extra devices sometimes. Therefore, we have developed the modified outside-in technique using thin steel wire to introduce the suture from the outside to the inside and then to the outside. We then make a knot outside the capsule. The advantages of our technique are that it is easy to perform, is reproducible, and avoids making multiple intra-articular suture loops.
Technique Video
The meniscus is an important structure between the tibial plateau and condyles of the femur, which could provide load transmission, reduce the impact of exercise on the knee, and ensure knee stability.1 Recently, an enormous amount of evidence has concluded that meniscal repair could decrease the risk of osteoarthritis and knee laxity, as well as even reduce the risk of graft rupture following ligament reconstruction of knee.2, 3, 4 Therefore, meniscal repair has gained massive importance, becoming the focus of meniscal treatment.
Various meniscal repair techniques have been described in the literature, including all inside, inside out, and outside in.5 The outside-in technique, which is mainly used to repair the tears in the anterior horn and body of the meniscus, is extremely cost-effective and has high patient satisfaction.6,7 Many authors have applied this technique and given their own modifications.8, 9, 10, 11, 12 However, some limitations still exist, such as complex intra-articular maneuvers of suture winding, which require extensive experience for doctors and need auxiliary tools or instruments. In addition, sensing the relative position of the spinal needle and capsule is difficult, especially for newbies.8,9,11,12 Thus, we report our meniscus repair technique, which avoids making multiple intra-articular suture loops and does not need extra equipment assistance. It is uncomplicated and suitable for beginners. The technique presented in our article differs from the conventional outside-in technique because the steel wires pass from outside the joint to inside the joint, then pull out again and bring the suture outside the capsule to make a knot. Hence, this technique is an outside-in-outside repair technique or modified outside-in repair technique (Video 1).
Surgical Technique
The patient is anesthetized with spinal anesthesia or general anesthesia and placed in the supine position (Fig 1). After standard anteromedial and anterolateral portals are created, a shaver blade (Smith & Nephew) is used to debride the synovium, and a probe is used to check the type and scope of meniscus tear (Fig 2). A meniscal rasp and shaver blade are used to freshen the torn edges of the meniscus and capsule to enhance the healing potential.
Fig 1.
The patient is placed in the supine position and the right leg is maintained by a lateral post.
Fig 2.
With the knee dangling in 90° of flexion, an arthroscopic view of the lateral compartment of the right knee shows a petaloid tear (red arrow) of the lateral meniscus.
After locating the puncture position through the center point of the brightest part of the skin under arthroscopy (Fig 3), a 16-gauge spinal needle is inserted into the joint cavity from outside to inside and passed through the upper surface of the meniscus tear (Fig 4). For a medial meniscus tear, we observe from the anterolateral portal and operate from the anteromedial portal. For a lateral meniscus tear, we change the position. We fold a steel wire with a diameter of 0.2 mm (Arthrex) in half (Fig 5) and send it to the joint cavity through the external opening of the spinal needle (Fig 6), then fix the steel wire using mosquito forceps and pull out the spinal needle (Fig 7). The spinal needle is inserted again through the same skin puncture point, changing the direction subcutaneously to ensure the spinal needle passes between the lower surface of the meniscus tear and tibial plateau (Fig 8). We fold another steel wire with a diameter of 0.2 mm in half and send it into the joint cavity (Fig 9). We grasp 2 steel wires using the same mosquito forceps and pull them out from the joint (Fig 10). The steel wires are pulled out from the anteromedial portal for a medial meniscus tear and the anterolateral portal for a lateral meniscus tear. A No. 2-0 nonabsorbable suture (Johnson & Johnson) is introduced between the 2 steel wires (Fig 11). The 2 steel wires along with the suture are pulled from outside to inside and then outside. A knot is made to the outside capsule after a straining suture (Fig 12), and then surgical scissors are used to cut the subcutaneous tail. A probe is used to adjust the position of the tear edge of the meniscus. The repair starts from the posterior aspect of the tear and advances forward. Several repair sutures can be placed 3 to 5 mm apart according to the length of the tear.
Fig 3.
The figure shows the skin puncture position (right leg) through the center area of the brightest part after arthroscopy.
Fig 4.
(A) A right knee is shown with the spinal needle being inserted (red arrow). (B) Arthroscopic view from an anteromedial portal shows a 16-gauge spinal needle passing through the superior surface and taking partial tissue of the synovial edge of the meniscus (red arrow).
Fig 5.
The figure displays double-folded steel wire with a diameter of 0.2 mm and a length of 15 to 25 cm.
Fig 6.
A right knee is shown. The figure shows the steel wire enters the joint cavity through the external opening of the spinal needle.
Fig 7.
A right knee is shown. Arthroscopic view from the anteromedial portal shows a mosquito forceps is used to fix steel wire from the anterolateral portal.
Fig 8.
A right knee is shown. Arthroscopic view from the anteromedial portal shows the spinal needle passing from the lower surface (red arrow) through the same skin puncture point.
Fig 9.
A right knee is shown. The figure displays another steel wire entering the joint cavity through the external opening of the spinal needle.
Fig 10.
(A) Arthroscopic view from the anteromedial portal shows the mosquito forceps are used to grasp 2 steel wires from the anterolateral portal. (B) The figure shows 2 steel wires are pulled out from the joint cavity through the anterolateral portal (right knee).
Fig 11.
A right knee is shown. The figure indicates a suture thread is introduced between the 2 loops of steel wires.
Fig 12.
(A) Arthroscopic view from the anteromedial portal shows repaired meniscus shape after the straining suture (red arrow). (B) The figure indicates a Samsung Medical Center knot is made outside the capsule (right knee).
We examine the meniscus again under arthroscopy to ensure the repaired site is stable and effective (Fig 13). Last, we suture the incision, cover it with a sterile dressing, wrap the knee with an elastic bandage, and fix it with a brace.
Fig 13.
A right knee is shown. Arthroscopic view from the anteromedial portal shows a probe is used to check the stability and efficiency of the repaired site.
Discussion
The meniscus plays an essential role in ensuring knee stability and reducing the impact of exercise on the knee.1 Considering the importance of the meniscus, the treatment choice for meniscal injury has shifted from meniscectomy to meniscal preservation.13,14 The repair techniques mainly include inside-out repair, all-inside repair and outside-in repair, and combined repair techniques.5 The all-inside repair is suitable for the posterior horn and body tears, but the application of this technique has the limitations, such as high cost and occasional neurovascular complications.15 The inside-out repair is suitable for posterior horn tears, while requiring specialized devices and large safety incisions when necessary.5 The outside-in repair is convenient, is inexpensive, and does not require special instruments, which is mainly suitable for anterior and body tears.7 Several studies have developed modifications of the outside-in technique.8,9,11,16 However, we still encounter difficulty in sensing the relative position of the spinal needle and capsule when replicating these techniques. In addition, repeatedly making wire loops under arthroscopy is technically demanding. In contrast, our technique uses 2 steel wires to introduce the suture from the outside to the inside and then to the outside. Last, we make a knot outside the capsule. Therefore, our technique is an outside-in-outside repair technique or modified outside-in repair technique.
The advantages of our technique are as follows. First, this technique is easy to perform. The huge limitation of the conventional outside-in technique is that surgeons have to sense the relative position of the spinal needle and capsule when replicating, which is technically demanding for beginners. We use steel wire to introduce the suture, avoiding complex intra-articular maneuvers of suture passing. Second, this technique is highly cost-effective. Spinal needle, steel wire, and suture are all easily available and inexpensive. Third, this technique is reproducible, without needing extra suture devices. Last, this technique can be used for various types of meniscal injuries, such as longitudinal and horizontal tears. The surgeons can use the spinal needle to pass through partial tissue of the synovial edge of the meniscus when crossing the upper surface of meniscal tears, especially longitudinal tears. Moreover, we can make a lateral auxiliary incision to accurately locate the position of the lateral collateral ligament, reducing the risk of nerve and vessel injury.
There are some disadvantages of this outside-in-outside technique. The spinal needle could lead to puncture point pain and probable cartilage and soft tissue injury, which are common problems of the outside-in technique. In addition, there is a possibility of cracking the steel wires when they are pulled. We suggest the operator not to repeat applying the steel wire and to use pliers to make the folded end of the steel wire narrow. The handling procedure should be gentle and sequential, avoiding violent operation. Technical pearls and pitfalls along with advantages and disadvantages of our technique are summarized in Table 1.
Table 1.
Advantages, Disadvantages, and Pearls and Pitfalls of This Technique
| Advantages | Disadvantages | Pearls and Pitfalls |
|---|---|---|
| Simple and easy to perform, avoiding repeatedly making the suture loop and knot | The risk of puncture point pain | The spinal needle should pass through partial tissue of the synovial edge of the meniscus when crossing the upper surface of meniscus tears |
| Highly cost-effective and low cost, gaining as much anatomic reduction as possible | Possibility of fracturing the steel wire | Spinal needle should be as close as possible to the tibial plateau when crossing the lower surface of meniscus tears |
| Not needing extra suture devices, except spinal needle and steel wire | Pie-crusting is almost always required for medial meniscus tears | Lateral auxiliary incision is available to protect nerve and vessel for beginners |
| Reproducible | Not suited for the posterior part of the meniscus | A probe could be used to reduce the torn inner edge of the meniscus, which makes needle pass easier |
| Can be used for various types of meniscus injuries | Spinal needle may damage cartilage and meniscal tissue, especially for multiple punctures | Arthroscopic observation is necessary when making a knot to prevent overtightening of the knot |
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This work is supported by the National Natural Science Foundation of China (82104896) and the Project of Science and Technology of Henan Province. All authors (G.C., X.S., X.W., L.Y., H.T.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
The video shows the complete suture process of the lateral meniscus through our techniques. We view from the anteromedial portal and perform from the anterolateral portal. The patient is placed in the supine position. This is a right knee. After standard anteromedial and anterolateral portals are created, a shaver blade is used to debride the synovium, and a probe is used to check the type and scope of the meniscus tear. We find that this is a petaloid tear of the lateral meniscus. Basket pliers are used to trim the shape of the meniscus and remove excess tissue. A shaver blade is used to freshen the torn edges of the meniscus and capsule to enhance the healing potential. We locate the puncture position through the center point of the brightest part of the skin under arthroscopy. A spinal needle is inserted into the joint from outside to inside and passed through the upper surface of the meniscus tear. A steel wire is sent into the cavity through the external opening of the spinal needle. We fix the steel wire using mosquito forceps and pull out the spinal needle. The spinal needle is inserted again through the same skin puncture point, passing through the lower surface of the meniscus tear. A suture is introduced between the 2 steel wires. We repeat the puncture process using the spinal needle and steel wire. We fix the steel wire using mosquito forceps. The 2 steel wires along with the suture are pulled from outside to inside and then outside. A knot is made outside the capsule after the straining suture. We make a Samsung Medical Center knot outside the capsule. A probe is used to adjust the position of the tear edge of the meniscus. We examine the meniscus again under arthroscopy to ensure the repaired site is stable and effective.
References
- 1.Makris E.A., Hadidi P., Athanasiou K.A. The knee meniscus: Structure-function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials. 2011;32:7411–7431. doi: 10.1016/j.biomaterials.2011.06.037. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Barenius B., Ponzer S., Shalabi A., et al. Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: A 14-year follow-up study of a randomized controlled trial. Am J Sports Med. 2014;42:1049–1057. doi: 10.1177/0363546514526139. [DOI] [PubMed] [Google Scholar]
- 3.Cristiani R., Rönnblad E., Engström B., et al. Medial meniscus resection increases and medial meniscus repair preserves anterior knee laxity: A cohort study of 4497 patients with primary anterior cruciate ligament reconstruction. Am J Sports Med. 2018;46:357–362. doi: 10.1177/0363546517737054. [DOI] [PubMed] [Google Scholar]
- 4.Robb C., Kempshall P., Getgood A., et al. Meniscal integrity predicts laxity of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015;23:3683–3690. doi: 10.1007/s00167-014-3277-x. [DOI] [PubMed] [Google Scholar]
- 5.Turman K.A., Diduch D.R. Meniscal repair: Indications and techniques. J Knee Surg. 2008;21:154–162. doi: 10.1055/s-0030-1247812. [DOI] [PubMed] [Google Scholar]
- 6.Migliorini F., Pilone M., Bell A., et al. Outside-in repair technique is effective in traumatic tears of the meniscus in active adults: A systematic review. Knee Surg Sports Traumatol Arthrosc. 2023;31:4257–4264. doi: 10.1007/s00167-023-07475-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Raoulis V Sr, Fyllos A., Baltas C., et al. Clinical and radiological outcomes after isolated anterior horn repair of medial and lateral meniscus at 24 months’ follow-up, with the outside-in technique. Cureus. 2021;13 doi: 10.7759/cureus.17917. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Joshi A., Basukala B., Singh N., et al. Outside-in repair of longitudinal tear of medial meniscus: Suture shuttle technique. Arthrosc Tech. 2020;9:e407–e417. doi: 10.1016/j.eats.2019.11.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Kim B.R., Kim D.H., Lee G.C., et al. Modified outside-in plus suture technique for repair of the anterior and middle segments of the meniscus: Technical note. Arthrosc Tech. 2023;12:e1803–e1807. doi: 10.1016/j.eats.2023.06.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Kucharik M.P., Eberlin C.T., Cherian N.J., et al. Using a combined all-inside, inside-out, and outside-in technique to repair bucket-handle medial meniscal tears without a safety incision. Arthrosc Tech. 2023;12:e1065–e1073. doi: 10.1016/j.eats.2023.02.044. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Laddha M.S., Shingane D. Modified outside-in repair technique for chronic retracted, unstable bucket-handle anterior horn lateral meniscal tear. Arthrosc Tech. 2022;11:e1747–e1752. doi: 10.1016/j.eats.2022.06.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Rocha de Faria J.L., Pavão D.M., Padua V.B.C., et al. Outside-in continuous meniscal suture technique of the knee. Arthrosc Tech. 2020;9:e1547–e1552. doi: 10.1016/j.eats.2020.06.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Di Matteo B., Moran C.J., Tarabella V., et al. A history of meniscal surgery: From ancient times to the twenty-first century. Knee Surg Sports Traumatol Arthrosc. 2016;24:1510–1518. doi: 10.1007/s00167-015-3717-2. [DOI] [PubMed] [Google Scholar]
- 14.Phillips M., Rönnblad E., Lopez-Rengstig L., et al. Meniscus repair with simultaneous ACL reconstruction demonstrated similar clinical outcomes as isolated ACL repair: A result not seen with meniscus resection. Knee Surg Sports Traumatol Arthrosc. 2018;26:2270–2277. doi: 10.1007/s00167-018-4862-1. [DOI] [PubMed] [Google Scholar]
- 15.Cuéllar A., Cuéllar R., Garcia-Alonso, et al. The effect of knee flexion angle on the neurovascular safety of all-inside lateral meniscus repair: A cadaveric study. Arthroscopy. 2015;31:2138–2144. doi: 10.1016/j.arthro.2015.04.100. [DOI] [PubMed] [Google Scholar]
- 16.Abdelkafy A. Meniscus-side-knot-tying technique instead of capsular-side-knot-tying in arthroscopic outside-in meniscal repair: A small but meaningful modification. Arthrosc Tech. 2024;13 doi: 10.1016/j.eats.2023.09.031. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The video shows the complete suture process of the lateral meniscus through our techniques. We view from the anteromedial portal and perform from the anterolateral portal. The patient is placed in the supine position. This is a right knee. After standard anteromedial and anterolateral portals are created, a shaver blade is used to debride the synovium, and a probe is used to check the type and scope of the meniscus tear. We find that this is a petaloid tear of the lateral meniscus. Basket pliers are used to trim the shape of the meniscus and remove excess tissue. A shaver blade is used to freshen the torn edges of the meniscus and capsule to enhance the healing potential. We locate the puncture position through the center point of the brightest part of the skin under arthroscopy. A spinal needle is inserted into the joint from outside to inside and passed through the upper surface of the meniscus tear. A steel wire is sent into the cavity through the external opening of the spinal needle. We fix the steel wire using mosquito forceps and pull out the spinal needle. The spinal needle is inserted again through the same skin puncture point, passing through the lower surface of the meniscus tear. A suture is introduced between the 2 steel wires. We repeat the puncture process using the spinal needle and steel wire. We fix the steel wire using mosquito forceps. The 2 steel wires along with the suture are pulled from outside to inside and then outside. A knot is made outside the capsule after the straining suture. We make a Samsung Medical Center knot outside the capsule. A probe is used to adjust the position of the tear edge of the meniscus. We examine the meniscus again under arthroscopy to ensure the repaired site is stable and effective.