Abstract
The outside-in technique is widely preferred for anterior horn tears because of its direct access. However, conventional methods require manipulation of multiple instruments in a limited working space. We introduce a specialized needle with a bidirectional groove at its tip, allowing single-handed antegrade and retrograde suture passage. This simplifies the procedure and reduces operative time. The device is also applicable to bucket-handle tears via a hybrid approach that combines all-inside suture passage and outside-in retrieval, achieving fixation comparable with that of the inside-out technique.
Technique Video
Because the outside-in repair provides optimal access to the anterior horn of the meniscus, the technique is adequate for anterior horn tears, ensures secure fixation, and avoids unnecessary intra-articular material.1, 2, 3
Reliable devices for the outside-in technique remain scarce. In most cases, the suture shuttle or lasso-loop techniques are used.4,5 However, these approaches present several technical challenges, including the need to manipulate multiple instruments in a confined joint space, which is often difficult to access with both hands, especially with an assistant holding the arthroscope. This Technical Note and accompanying video describes an outside-in meniscus repair technique using a meniscus repair device equipped with a bidirectional groove, allowing controlled suture passage in both directions with a single hand to simplify the procedure and reduce operative time.
Moreover, this device can be applied to bucket-handle tears, where the inside-out technique has been considered the gold standard.6 Currently, numerous studies are ongoing comparing the all-inside technique with the inside-out technique because of the risk of saphenous or peroneal nerve palsy and deep infection. Some studies have demonstrated that there is no significant difference between the 2 techniques.7 However, many surgeons repair large or challenging tears using the inside-out technique because of its superior structural integrity, especially in cases accompanied by ACL tear.8,9
Using this device, we performed a hybrid technique using an all-inside passer with outside-in needle retrieval. This technique integrates the biomechanical advantages of the inside-out method while minimizing the risk of nerve injury and infection, offering a reliable option for bucket-handle tear repair.
Surgical Techniques
A specialized needle (Fixone Single-arm Needle; Aju Pharm Co., Ltd., Gyeonggi-do, Republic of Korea) featuring a bidirectional groove near the tip is used to apply the suture (Fig 1). A soft braided material (e.g., ETHIBOND; Ethicon, Somerville, NJ) or a stiffer monofilament (e.g., polydioxanone) is used for suturing.10 With the bidirectional groove, the suture can be manipulated for both pulling and pushing. By hooking onto the distal end of the groove, it can be transported into the joint. By hooking onto the proximal end, it can be retrieved from the joint.
Fig 1.
(A) Magnified view of the groove of the needle. The proximal end (open arrow) allows retrieval of the suture from the joint (B), whereas the distal end (black arrow) enables delivery of the suture into the joint (C).
The specialized needle, with the suture looped onto it, is passed through the inner portion of the meniscal tear (Fig 2). The penetration site should be carefully determined. Once the suture loop is passed through the first preloaded needle, adjusting its location can be difficult because of the risk of damaging the remaining meniscal tissue. To prevent the suture from tangling, gently advance it into the joint. During penetration, using an arthroscopic hook is helpful for reducing the tear and controlling the meniscus. The needle is carefully advanced further to ensure the loop remains within the joint, facilitating easier manipulation. It is then cautiously withdrawn from the joint to unload the suture (Fig 3).
Fig 2.
(A) Anatomic model. (B) Arthroscopic view of anteromedial segment of medial meniscus from anterolateral portal in left knee. The specialized needle (black arrows) with the suture anchored onto it, is passed through the inner portion of the meniscal tear (open arrows).
Fig 3.
(A) Anatomic model. (B) Arthroscopic view of anteromedial segment of medial meniscus from anterolateral portal in left knee. The specialized needle is carefully advanced further to ensure the loop remains within the joint (black arrows), facilitating easier manipulation, and then it is cautiously withdrawn from the joint to unload the suture.
We reinsert the empty needle into the predetermined suture site, usually in the outer segment (Fig 4). Penetrating the inner segment first and then withdrawing the suture through the outer facilitates anatomic reduction of the meniscus. While applying slight tension to the suture material, it becomes easier to anchor the suture onto the distal end of the groove. Using just one device, a single surgeon can hold both the arthroscope and the needle simultaneously. Once the suture is hooked onto the groove, gently retrieve the suture (Fig 5). To ensure the suture remains in place during retrieval, the initially placed strand should be securely held.
Fig 4.
(A) Anatomic model. (B) Arthroscopic view of anteromedial segment of medial meniscus from anterolateral portal in left knee. The specialized needle is reinserted into the planned second point (black arrows), either vertically or horizontally, without a suture loop, to create the desired suture configuration. The suture is engaged onto the distal end of the groove (open arrow).
Fig 5.
(A) Anatomic model. (B) Arthroscopic view of anteromedial segment of medial meniscus from anterolateral portal in left knee. The suture, anchored to the distal end of the groove (black arrow), is pulled out of the joint to complete the suture passage (open arrow).
In addition, this device can be used to repair a bucket-handle tear using a hybrid technique that combines an all-inside suture passer with outside-in needle retrieval. First, the suture is passed through the inner segment of the bucket-handle tear using a Scorpion Suture Passer (Arthrex, Naples, FL) (Fig 6 A and B). Next, a needle with bidirectional groove is inserted at the planned suture exit point from outside the joint capsule, through the skin and soft tissue, and into the joint under arthroscopic guidance. The suture limbs are sequentially retrieved using the distal groove: the femoral-side limb is retrieved first (Fig 6C), followed by the tibial-side limb (Fig 6D). Once both limbs are retrieved, they are tied outside the joint capsule, securing the meniscus in its anatomic position (Fig 6E).
Fig 6.
Arthroscopic view of a bucket-handle tear of the medial meniscus in the left knee. A suture is passed through the inner segment of the bucket-handle tear using an all-inside passer (black arrow) (A, B). A needle with bidirectional groove is inserted at the planned suture exit point from outside the joint capsule under arthroscopic guidance. The suture limbs are sequentially retrieved using the distal end of the groove: the femoral-side limb (open arrow) is retrieved first (C), followed by the tibial-side limb (arrowhead) (D). Both suture limbs (curved arrow) are then tied outside the joint capsule to secure the meniscus in its anatomic position (E).
Discussion
Several techniques for meniscus repair are discussed in the vast body of literature. The choice of technique depends on the size, location, and pattern of the meniscal tear. These techniques are generally classified into 4 groups: all-inside, inside-out, outside-in, and the hybrid technique.4
The all-inside repair does not require an additional skin incision, and the procedure is less demanding with the use of various specialized fixators, resulting in a shorter operation time. This technique is particularly suited for the posterior horn of the meniscus.10
Unlike the all-inside technique, both the inside-out and outside-in techniques inevitably necessitate a further skin incision. Inside-out technique, in particular, has been demonstrated to be a reliable option for repairing tears in the posterior horn and body of both the medial and lateral menisci.11
It is challenging to access the anterior horn using the all-inside or inside-out techniques. Therefore, many surgeons have employed the outside-in technique using suture shuttle or lasso-loop methods.4,5 However, 3 devices must be manipulated—1 arthroscope for viewing and 2 instruments for suture handling—and an assistant is usually required to hold the arthroscope in the anterior compartment, which has limited space. To overcome this limitation, we invented a bidirectional groove needle that can pass the suture into or retrieve it from the joint. This is a cost-effective and reproducible technique for meniscal repair that does not require specific arthroscopic instrumentation and reduces the number of surgical steps.
In addition to anterior horn repairs, this device is also effective in bucket-handle tears, where the inside-out technique has traditionally been regarded as the standard.6 Extensive research has compared the all-inside and inside-out techniques, especially as a variety of innovative, commercially available all-inside repair systems have been developed. However, some surgeons still prefer the inside-out technique for complex and large tears.7
The inside-out technique provides strong structural stability but is technically demanding and carries a risk of neurovascular injury and deep infection. When accompanied by an anterior cruciate ligament tear, it has been shown to be biomechanically superior to the all-inside method. However, performing inside-out repair alongside ACL reconstruction can be challenging.8,9
In our technique, the suture is passed through the inner segment of the bucket-handle tear using an all-inside passer and retrieved using a needle with bidirectional groove. This method can accomplish stability comparable with the inside-out technique while minimizing the risk of nerve injury and the need for an extensive skin incision. Nevertheless, the outside-in technique is not suitable for posterior meniscal tears due to the proximity of neurovascular structures.5 It is most effective for anterior to mid-body tears, particularly bucket-handle type lesions. This technique allows for both horizontal and vertical suturing, using any suture material preferred by the surgeon. The slim profile of the device enables its use in the wrist as well as other small joints, including the ankle and elbow.
Soft-tissue entrapment may occur at the groove site; however, this can usually be resolved by slightly retracting the needle and readvancing it in the opposite direction. To avoid cartilage injury, the needle should be inserted at a shallow depth, and careful handling is essential, as incorrect trajectory may lead to tissue damage. All relevant aspects of this technique—including its advantages, disadvantages, pearls, and pitfalls—are fully described in Table 1 and Table 2. Future biomechanical studies are warranted to validate the tensile strength and fixation stability of this technique compared to the inside-out or all-inside techniques
Table 1.
Advantages and Disadvantages
| Advantages | Disadvantages |
|---|---|
| No requirement for proprietary arthroscopic instruments | Not applicable to posterior horn tear |
| Simplified suture steps | Potential neurovascular injury |
| Applicable to anterior/midbody tears including bucket-handle types | Requires precise needle placement and careful handling |
Table 2.
Pitfalls and Pearls
| Pitfalls | Pearls |
|---|---|
| Tissue entrapment at groove site | Repositioning the needle can resolve suture entrapment |
| Incorrect needle trajectory may cause tissue damage | Shallow needle angle to avoid cartilage injury |
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: J-B.K. has patent #30-0788098 licensed to J-B.K and is the holder of a registered patent (No. 30-0788098) for the specialized needle used in this study. The device was manufactured by Aju Pharm Co., Ltd., on the basis of his design. The company had no involvement in the study design, data collection, analysis, interpretation, or manuscript preparation. All other authors (N.J.B., J.Y.Y., J.P.) 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
A medial-compartment view of the left knee is visualized through the anterolateral portal. The patient presented with left knee pain that began during a squatting-to-standing motion, accompanied by a popping sensation. Preoperative magnetic resonance imaging revealed a bucket-handle tear of the medial meniscus. On the coronal view, the displaced meniscal fragment was noted within the intercondylar notch. The sagittal view demonstrated the characteristic “double posterior cruciate ligament sign.” Pass a suture through the inner segment of the bucket-handle tear using a Scorpion suture passer. Then, insert a specialized needle from outside the joint. Retrieve the suture limbs sequentially—first the femoral-side limb, followed by the tibial-side limb. Tie both limbs extracapsularly to anatomically reduce the meniscus. For the anterior portion of the tear, complete the repair using an outside-in technique. Carefully pass the specialized needle, preloaded with a suture loop at the proximal end of the groove, through the inner portion of the meniscal tear. Then, gently withdraw the needle, taking care to maintain the loop in place without displacing it. Reinsert the needle into the outer segment and hook the suture limb onto the distal end of the groove. Gently retrieve the suture limb and tie it through a small incision at the external capsule.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
A medial-compartment view of the left knee is visualized through the anterolateral portal. The patient presented with left knee pain that began during a squatting-to-standing motion, accompanied by a popping sensation. Preoperative magnetic resonance imaging revealed a bucket-handle tear of the medial meniscus. On the coronal view, the displaced meniscal fragment was noted within the intercondylar notch. The sagittal view demonstrated the characteristic “double posterior cruciate ligament sign.” Pass a suture through the inner segment of the bucket-handle tear using a Scorpion suture passer. Then, insert a specialized needle from outside the joint. Retrieve the suture limbs sequentially—first the femoral-side limb, followed by the tibial-side limb. Tie both limbs extracapsularly to anatomically reduce the meniscus. For the anterior portion of the tear, complete the repair using an outside-in technique. Carefully pass the specialized needle, preloaded with a suture loop at the proximal end of the groove, through the inner portion of the meniscal tear. Then, gently withdraw the needle, taking care to maintain the loop in place without displacing it. Reinsert the needle into the outer segment and hook the suture limb onto the distal end of the groove. Gently retrieve the suture limb and tie it through a small incision at the external capsule.