All‐Inside Arthroscopic Technique for Repairing Radial Meniscus Tears at the Anterior Horn–Body Junction

Abstract

Radial meniscus tears are a common tear pattern that, if left untreated, can ultimately lead to accelerated degenerative changes and disability. There is well‐established evidence that supports meniscal preservation in patients with radial meniscus tears. Various surgical techniques are used to repair radial tears, including inside‐out, outside‐in, and all‐inside methods. Self‐retrieving all‐inside devices are a safe option when repairing radial tears. However, radial tears at the junction of the anterior horn and body present a unique surgical challenge, as surgeons may have difficulty maneuvering the jaws of the self‐retrieving suture device around the anterior limb of the meniscal tear. We describe an all‐inside repair technique using a suture shuttle for junctional anterior horn and body tears.

Radial meniscus tears are a common tear pattern of the meniscus that disrupt the circumferential fibers that aid in absorbing forces in the knee. If left untreated, these tears expose the articular surface of the knee to increased force transmission, leading to accelerated degenerative changes. With advancements in surgical techniques, meniscal repair has become a more common practice. ¹ , ² , ³ , ⁴ Various arthroscopic surgical techniques are employed for radial tears, including inside‐out, outside‐in, and all‐inside methods.

For radial tears, an all‐inside meniscal repair technique has gained popularity. This approach is favored because it reduces neurovascular risk, maintains physiological meniscal excursion by compressing meniscus‐to‐meniscus rather than tethering to the capsule, and potentially decreases operative time. ² , ⁵ , ⁶ , ⁷ One study indicated that although both all‐inside and inside‐out techniques are effective, inside‐out approaches showed higher clinical and arthroscopic failure rates (up to 62%) compared with all‐inside (up to 40%). ⁸ Although all‐inside techniques generally yield good outcomes, their usage is often limited by factors such as tear location.

Radial meniscus tears located at the junction of the anterior horn and body pose a unique challenge for surgical correction. ¹ , ⁹ , ¹⁰ Visualization and instrument angulation toward the anterior meniscal limb are often limited because the anterior horn prevents access to this location. Our objective is to describe an all‐inside repair technique to address such tears, using the Novostitch Pro Meniscal Repair Device (Smith & Nephew, Andover, MA) in conjunction with the ACCU‐PASS Suture Shuttle (Smith & Nephew, Andover, MA).

SURGICAL TECHNIQUE

Patient Setup

After inducing general anesthesia, the patient is positioned supine. A tourniquet is applied to the operative extremity, and the thigh is then placed in a leg holder, which allows for approximately 90° of knee flexion. Standard sterile draping is then performed.

Arthroscopic Access

Portal access is established starting with the anterolateral portal. For the anteromedial portal, a spinal needle is used under direct visualization to confirm the optimal entry point.

Meniscal Repair

After clearly identifying the tear at the junction of the anterior horn and body of the lateral or medial meniscus (Figure 1A), the tear edges are debrided to create a stable rim (Video 1). This is typically done with a shaver, an arthroscopic biter, and a round‐ball rasp (Figure 1B). Next, meniscal trephination is performed using an 18‐gauge spinal needle to promote healing. The tear's posterior limb, which often appears retracted, is carefully manipulated using a grasper to ensure it can be reduced back into its anatomical position with the final fixation construct.

FIGURE 1.

Meniscal tear debridement. (A) Arthroscopic visualization of a left knee via the anteromedial portal, displaying a radial tear at the junction of the anterior horn and body of the lateral meniscus. This tear disrupts the circumferential fibers, which are essential for the meniscus's function in absorbing forces. (B) The tear edges have been debrided using an arthroscopic biter and shaver. This process creates a stable rim, which is essential to promote a robust healing response. (LMT, lateral meniscus tear; LMAH, lateral meniscus anterior horn; LMB, lateral meniscus body.)

VIDEO 1.

Download video file ^{(28.6MB, mov)}

This video shows an all‐inside arthroscopic technique for repairing radial meniscus tears at the anterior horn‐body junction. We are operating on the left knee repairing a radial lateral meniscus tear at the junction of the anterior horn and body. We showcase our method for preparing the tear, inserting multiple 2‐0 sutures through the posterior limb using the Novostitch Pro device (Smith & Nephew, Andover, MA), and then addressing the challenging anterior leaflet. This is accomplished using a 45° angled suture shuttle device (ACCU‐PASS; Smith & Nephew, Andover, MA) introduced through the anterolateral portal, with suture retrieval facilitated by an accessory transpatellar portal. The video details suture shuttling, subsequent suture placement to ensure a stable repair, and the use of a 2.0 mm Kirschner wire for biological augmentation. We also highlight key pearls for avoiding suture cutout and ensuring an anatomic reduction. Video content can be viewed at https://doi.org/10.1002/atn2.70069.

For suture placement, a self‐retrieving all‐inside Novostitch Pro device (Smith & Nephew, Andover, MA) preloaded with a 2‐0 high‐strength, nonabsorbable suture is introduced through the anteromedial or anterolateral portal (Figure 2A,B). The first pass of the device is made through the posterior limb of the meniscus, with the needle moved from the undersurface toward the curved upper jaw on the superior aspect. Upon deployment, 1 suture limb will reside on the superior aspect of the posterior limb of the meniscus, while the other limb will be on its inferior aspect.

FIGURE 2.

Suture insertion in posterior limb of lateral meniscal tear. Arthroscopic views of the left knee. The Novostitch Pro device (Smith & Nephew, Andover, MA) is used to pass a suture through the posterior limb of a radial tear at the anterior horn‐body junction. (A) The device is introduced through the anterolateral portal, passing the needle from the undersurface toward the superior aspect of the posterior limb. (B) The same maneuver can be performed with the device introduced through the anteromedial portal. For the posterior limb of this specific meniscal tear, either portal can be used to achieve an optimal pass. Initial suture placement should be along the outer periphery of the tear (closer to capsule), so subsequent sutures can be placed more centrally. (LMB, lateral meniscus body.)

Next, a suture shuttle device with a 45° curve (ACCU‐PASS, Smith & Nephew, Andover, MA) is introduced through the anterolateral portal (Figure 3A). The device is selected with the appropriate left or right‐angled curve based on the operative extremity and tear location (medial or lateral). The angulation of the device facilitates a peripheral starting point with a central trajectory as the device moves inferiorly. The anterior limb of the meniscus is pierced with the shuttle device, moving from the superior to the inferior aspect (Figure 3B). Then, the device is deployed, releasing the monofilament passing loop on the inferior aspect of the meniscus, between the anterior and posterior limbs (Figure 3C). An accessory transpatellar portal is created in the mid‐substance of the patellar tendon just superior to the joint line using a No. 11 blade after needle localization. Through the accessory transpatellar portal, the inferior limb of the 2‐0 suture and the shuttle device's monofilament passing loop are retrieved out of the transpatellar portal with a crab‐claw grasper (Figure 4A). The 2‐0 suture is placed through the monofilament passing loop. After this, the shuttle device is removed from the joint, and the 2‐0 suture is pulled from the inferior aspect of the posterior limb through to the superior aspect of the anterior limb (Figure 4B). Once the suture is shuttled, both limbs of the suture are regrasped through the portal closest to the repair site to ensure there is no soft tissue bridge between the suture limbs.

FIGURE 3.

Suture shuttling to the anterior limb. Arthroscopic views of a left knee, via the anteromedial portal. (A) A suture shuttle device with a 45° curve (ACCU‐PASS; Smith & Nephew, Andover, MA) is introduced into the joint. For this left knee radial lateral meniscus tear at the junction of the anterior horn and body, the device is angled to the left to ensure penetration is directed toward the compartment and not the capsule. (B) The optimal entry location is selected on the anterior limb to match the suture depth from the posterior limb. Initial suture placement on the anterior limb should be along the periphery of the tear (closer to capsule) to allow subsequent sutures to follow with a more central position. (C) A monofilament loop is passed through the anterior limb, and the ACCU‐PASS device is held still to avoid injuring the meniscus or scuffing the cartilage. (LMAH, lateral meniscus anterior horn; LMB, lateral meniscus body.)

FIGURE 4.

Suture retrieval, tying, and final repair. Arthroscopic views of a left knee, via the anteromedial portal. (A) An accessory transpatellar portal is created, and a crab‐claw grasper is introduced to grab both the inferior suture limb and the monofilament shuttling loop. The suture is passed through the loop. (B) The inferior suture limb is then shuttled through to the superior aspect of the anterior limb. Both suture limbs are then regrasped via the portal closest to the tear (anterolateral in this case), to ensure there is no soft tissue bridge. (C) The sutures are tied with the knee at 20° of flexion. The meniscus is now anatomically reduced and stable.

With 1 suture limb now positioned on the superior aspect of the posterior limb and the other on the superior aspect of the anterior limb, the suture is tied arthroscopically with the knee at 20° flexion or near extension to prevent suture cut‐out when the knee is in full extension (Figure 4C). This process is typically repeated 1 to 2 times for additional suture placement (Figure 5A,B). Finally, a 2.0 mm Kirschner wire is used to make 3‐4 holes in the intercondylar notch just anterior to the anterior cruciate ligament for biological augmentation.

FIGURE 5.

Achieving stable repair with subsequent sutures. Arthroscopic views of the left knee through the anteromedial portal. (A) Subsequent sutures are passed via the described technique, with the subsequent suture being placed in a more central position. Care is taken not to violate or cut the old sutures during this process. (B) A total of 3 sutures are placed, spaced appropriately to achieve a stable repair. (C) The final construct shows a well‐fixed meniscal repair with good coaptation of the torn edges.

Wound Closure

After confirming the stability of the repair and performing a final diagnostic arthroscopy (Figure 5C), the arthroscopic portals are closed. The skin incisions are closed with 4‐0 Monocryl sutures, Steri‐Strips, and a sterile dressing is then applied.

POSTOPERATIVE INSTRUCTIONS/RESTRICTIONS

Postoperatively, the patient is placed in a Bledsoe knee brace, locked in extension for ambulation. The patient is nonweight bearing for the initial 6 weeks, followed by progressive weight‐bearing during weeks 6 to 8. Range of motion is restricted for the initial 6 weeks, with flexion limited to 0°‐70° for weeks 0 to 2. Flexion then advances to 0°‐90° for weeks 3 to 6. Flexion will subsequently advance to 0°‐130° for weeks 7 through month 4 postoperatively. For the initial 4 months, the patient is restricted from hyperflexion, isolated hamstring activation, deep squatting, and cross‐leg sitting. The goals of these restrictions are to protect the surgical repair, resolve the joint effusion, and safely restore full range of motion.

DISCUSSION

Arthroscopic all‐inside repair of radial meniscal tears has become increasingly popular among surgeons. These techniques are associated with lower nerve injury rates, shorter operative times, and a more physiological meniscal repair without capsule dissection and tethering (Table 1). ² , ⁵ , ⁶ , ⁷ Furthermore, these techniques allow for the appropriate reduction of the posterior fragment, which often retracts posteriorly. This supports the use of all‐inside techniques when the anatomy permits. However, the choice to use an all‐inside technique can be complicated by factors such as tear location.

TABLE 1.

Advantages & Disadvantages

Advantages	Disadvantages
Improved access to anterior meniscal tissue	High cost of devices 2 , 9
All‐inside reduces neurovascular risk	Potential for device issues
Avoids capsule tethering	Risk of iatrogenic cartilage damage with device
Preserves meniscal excursion by compressing meniscus‐to‐meniscus	Requires creation of transpatellar portal
No accessory lateral incision

For entirely anterior radial tears, surgeons typically favor an outside‐in technique, as the location restricts access for an inside device and offers less potential for neurovascular compromise. ¹¹ For more posterior radial tears, surgeons can effectively use all‐inside devices designed to address both sections of the tear, such as the Novostitch Pro.

However, radial tears at the junction of the anterior horn and body of the meniscus present a unique and technically challenging tear pattern for arthroscopic repair. In such cases, a surgeon can often only effectively penetrate the posterior piece of the meniscus with a single use inside device. The anterior portion is difficult to pierce with the Novostitch Pro from the portal of the same compartment; the jaw of the Novostitch Pro is also blocked by the anterior horn when coming across the joint. Conversely using outside‐in or inside‐out capsular based approach for these tears risk tethering the meniscus to capsule in a nonreduced, gapped position leading to accelerated cartilage wear. ² , ¹² , ¹³ An in‐vitro study showed that leaving radial tears gapped shifted peak contact pressure from the meniscal body to a cartilage‐on‐cartilage area. This study additionally confirmed that inside‐out repair had limited ability to prevent the radial tear from gapping as the inner rim could not be effectively restored. ¹³ Hybrid strategies have been described that combine all‐inside posterior fixation with outside‐in or inside‐out anterior stitches, solving the all‐inside access problem for radial tears located at the junction of the anterior horn and body. Additionally, hybrid strategies have been described which address the gapping problem by placing reduction/traction sutures to reduce gapping before fixation to capsule. ¹ , ² , ¹² Ultimately however, these techniques sacrifice the purely all‐inside advantage, reintroduce capsular tethering, and increase incision‐related morbidity and neurovascular risks when compared with all inside technique. ⁵ , ¹⁴ , ¹⁵

Given the inherent benefits of all‐inside repair, there have been recent attempts to improve techniques to allow for broader usage of all‐inside devices. For instance, other described techniques use a combination of Novostitch Pro for the posterior aspect and a grasper device for the anterior, maintaining the benefits of an all‐inside repair. However, previous authors note, and clinical experience shows, that manipulating a rigid grasper within the tight anterior interval is technically challenging and risks anterior leaflet laceration or cartilage damage. ⁹

Our technique directly addresses these problems and aims to help reduce potential iatrogenic complications by substituting a rigid suture grasper for a low‐profile suture‐shuttle (ACCU‐PASS). This device deploys a passing wire immediately on penetration, minimizing intra‐articular manipulation. Drawing on principles from accessory‐portal suture management used in other meniscal repairs, a transpatellar portal is utilized to capture both the suture and passing wire, reducing the incidence of a soft‐tissue bridge. Although the portals described are typical for a lateral meniscal tear, this technique can be effectively adapted for a medial meniscal tear. In the setting of a left knee lateral tear, a left ACCU‐PASS would be used, oriented to face centrally, with the inverse approach for a medial tear or a right‐sided lateral tear. Advantages and disadvantages, as well as pearls and pitfalls of the presented technique are summarized in Tables 1 and 2. In essence, our suture‐shuttle approach maintains an all‐inside construct while simplifying anterior capture and suture management through a central portal, allowing for excellent reduction of the often‐retracted posterior fragment, which can be a challenge for in‐situ outside‐in repairs.

TABLE 2.

Pearls & Pitfalls

Pearls	Pitfalls
Release and mobilize all free meniscal edges before passing sutures.	Cartilage scuffing or anterior limb cut through when levering bulky devices
Pass and park in posterior limb first with all inside device; control reduction while addressing anterior limb.	Soft tissue bridge when limbs are not grasped together
Advance low‐profile suture shuttle through anterior limb; deploy suture grasping loop immediately on inferior aspect of meniscus to minimize intraarticular manipulation.	Device misfire or stump laceration on penetration.
Retrieve the passing suture loop and the inferior suture limb through a small central transpatellar portal.

DECLARATION OF GENERATIVE AI AND AI‐ASSISTED TECHNOLOGIES IN THE WRITING PROCESS

During the preparation of this work the author(s) used ChatGPT (GPT‐5, OpenAI, September 14, 2025 version) to assist in title edits and grammatical proofreading. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article.

DISCLOSURES

The authors (B.O.B., R.M.W., H.A.V., F.J.C.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.