Inside-Out Meniscal Repair: Medial and Lateral Approach.
ABSTRACT: Preservation of meniscal tissue has been proven to be the best approach in most cases of meniscal tears. Currently available techniques for treating a peripheral meniscal tear include inside-out, outside-in, and all-inside techniques. Each of these techniques present potential advantages and disadvantages. Despite technologic advances in all-inside devices, because of implant-related complications, cost concerns, and device availability, the inside-out technique is still the preferred method among many surgeons. Although the inside-out repair technique is considered more technically demanding and requires additional incisions, it has several advantages such as the possibility for an increased number of sutures, creating a stronger construct, and greater versatility in their placement. This article describes the inside-out meniscal repair technique with its corresponding posterolateral and posteromedial surgical approaches.
Project description:Posteromedial meniscocapsular separation of the knee has received renewed interest, with many articles describing a high incidence in association with anterior cruciate ligament injury. Various techniques have been described to address these lesions using all-inside meniscal repair sutures or using rotator cuff repair instruments through the posteromedial portal. Most orthopaedic surgeons are accustomed to using the "inside-out" meniscal repair technique with a double-armed suture. This technique is cost-effective and, in our opinion, more efficient in repairing such tears. We present our technique of repairing peripheral meniscocapsular lesions using an inside-out meniscal repair system. We believe that this technique is easily reproducible, is less time-consuming, and ensures a good "bite" of the capsular tissue, producing a robust repair.
Project description:Posteromedial meniscotibial ligament lesions, known as meniscal ramp lesions, are typically associated with ACL injuries, but frequently underdiagnosed. When correctly diagnosed, repair is mandatory in most cases. Retraction of the soft tissues makes it difficult to repair and leads to suture failure. Previously described techniques include all-inside and inside-out meniscal sutures, but do not ensure correct meniscotibial closure because of the soft tissue retraction. The purpose of this Technical Note is to describe a meniscal ramp lesion arthroscopic repair with an all-inside technique with the Fast-Fix 360 device, detailing the use of the accessory posteromedial portal, and the addition of an arthroscopic grasper that raises the retracted meniscotibial ligament, to allow correct fixation.
Project description:Three popular repair techniques for preserving the torn meniscus are the all-inside, outside-in, and inside-out techniques. Among these, the inside-out technique has shown low failure rates, and it therefore remains the gold-standard technique for repairing the torn meniscus. For extensive and chronic meniscal tears, proper use of this technique has become fundamental for knee surgeons. Nevertheless, challenges in using this technique include a higher risk of catching the neurovascular bundles on the posteromedial and posterolateral sides of the knee and difficulties in reducing and stabilizing chronically displaced meniscal fragments. In this article, the inside-out technique is revisited with an emphasis on anatomic details of how to avoid the neurovascular bundles while addressing extensive and chronic meniscal lesions.
Project description:Meniscal ramp lesions have been reported to be present in 9% to 17% of patients undergoing anterior cruciate ligament reconstruction. Detection at the time of arthroscopy can be accomplished based upon clinical suspicion and careful evaluation without the use of an accessory posteromedial portal. Options for surgical treatment include arthroscopic repair using an all-inside or inside-out technique. The purpose of this Technical Note is to detail our arthroscopic inside-out repair technique for meniscal ramp lesions.
Project description:The menisci are fibroelastic structures interposed between the articular surfaces of the femur and tibia. They absorb impact and transmit load. Meniscal injury may compromise function and cause rapid joint degeneration, leading to the development of secondary osteoarthritis. Surgical treatment of meniscal injury is usually performed by arthroscopy, and meniscectomy or meniscal suture may be associated with such treatment. Meniscal suture should be considered when the injury compromises the proper functioning of the meniscus to recover its anatomy and function. Different meniscal suture techniques exist; the most widely used are the inside-out, outside-in, and all-inside techniques. The gold-standard repair technique is the inside-out technique. A drawback of this technique is the need to alternate between intra- and extra-articular structures for every stitch, which makes it even more laborious. We describe the continuous meniscal suture technique, also called "meniscal stitching," for a medial meniscal bucket-handle injury. This technique is performed from the inside out and allows the surgeon to perform multiple stitches with the same thread quickly and effectively. This surgical technique is performed using a single meniscal suture device that was developed by our group, called the "Meniscus 4 A-II" device.
Project description:The meniscus is largely responsible for the health and longevity of the knee. It has diverse functions, being fundamental in load absorption and distribution and even in joint stability. To preserve meniscal functions and prevent the occurrence of osteoarthritis after meniscectomy, several meniscal repair techniques have been developed. To perform meniscal repair in anterior horn, the outside-in technique is the most used. There are few devices for performing them, with most of the surgical techniques described using needles. Our group uses a device capable of performing meniscal repair in different ways. Our objective is to describe a continuous outside-in meniscal repair technique, especially indicated for anterior horn and meniscus body tears, with the "Meniscus 4-All suture device." The continuous outside-in meniscal suture technique using this device is easy to perform, inexpensive, fast, and reproducible, minimizing the risk of soft-tissue entrapment. In addition, it allows the surgeon to perform meniscal repair in the posterior horn in extensive injuries with the same repair device, just switching to inside-out technique.
Project description:Since the role of the menisci has been better understood, there is a trend toward the meniscal repair rather than meniscectomy in the management of meniscal tears. Although numerous techniques of meniscal repair have been described and many authors advocate for and against each of them, no single method is universally accepted. The all-inside repair provides several advantages, such as a lower risk of neurovascular injury, the early introduction of exercises in passive range of motion, or the high strength of the repair. However, the all-inside meniscal repair with nonabsorbable suture is considered to be a technically demanding procedure with a long learning curve needed to perform it properly. The purpose of this Technical Note is to present the technique of lateral meniscus repair with nonabsorbable sutures and to provide surgical pearls to facilitate this procedure.
Project description:Meniscal injuries are common in the population, representing the major cause of functional impairment in the knee. Vertical longitudinal injuries of the meniscus can be stable or unstable. When extensive, they are commonly unstable and can lead to clinical signs of significant functional disability. Vertical longitudinal injuries have the best prognosis for repair, especially when occurring in the meniscal periphery, called the red-red zone. A recently developed type of meniscal suture device called Meniscus 4 A-II enables the surgeon to perform a meniscal suture from the inside-out continuously, reducing surgical time. Because it allows the surgeon to use a single and inexpensive device to repair the entire injury, costs are significantly reduced. Here, an approach to carry out continuous meniscal repair with vertical sutures is described. This technique warrants excellent stability to the meniscal repair, increasing the chances of a successful outcome. We believe that the popularization of the repair technique from the inside out using the Meniscus 4-All device will help many surgeons around the world save menisci that otherwise would have a great chance of being excised, since it is a cheap, reproducible, and easy-to-handle device.
Project description:The number of commercially available all-arthroscopic meniscal repair devices has increased in recent years. Although inside-out vertical mattress sutures have been considered the gold standard in the past, recent biomechanical studies have shown that some all-arthroscopic repair devices provide comparable strength. To successfully use these devices, surgeons must understand proper insertion technique. The purpose of this article is to demonstrate this technique for the Meniscal Cinch (Arthrex, Naples, FL).
Project description:Medial meniscus posterior root tear (MMPRT) is now attracting increased attention as a risk factor for the development of osteoarthritis. However, the healing rate after root repair by the suture anchor technique or the pull-out technique is still low. Here we report on a technique of MMPRT repair using suture anchor combined with arthroscopic meniscal centralization and open wedge high tibial osteotomy (OWHTO). The purposes of this technique are (1) to distribute the meniscal hoop tension between the root repair site and the centralization site and (2) to reduce the load on medial meniscus by OWHTO. The routine exposure for OWHTO with superficial medial collateral ligament release creates good visualization for arthroscopic root repair. The first anchor is inserted on the medial edge of the medial tibial plateau, and the second anchor is inserted on the root attachment through a posteromedial portal. After tying the knots, OWHTO could be performed without interference between the suture anchors and the screws of the plate for fixing the osteotomy. Although further follow-up is required, this technique could improve the outcomes after root repair, as well as have some technical advantages.