Inside-Out Meniscal Repair: Still a Useful Technique

Abstract

Background:

New generation of all-inside meniscal repair devices are now the preferred repairing method for most orthopedic surgeons. The economic considerations in low-income countries make routine use of these devices very difficult. The inside-out technique described by Charles Henning in the 1980s, which is considered as the gold standard by many expert surgeons, can solve this problem with equal results.

Indications:

Indications are large and unstable tears localized in the middle and posterior thirds of both menisci.

Surgical Technique:

We introduced a slight modification to the original technique, allowing the use of a resorbable suture thread. After a good exposition of the lesion and debridement of the margins, a canulated needle with curved tip (Menghini needle) is introduced through the opposite portal to the repaired meniscus. The first passage of the needle is done on the peripheric side of the tear to protect neurovascular structures; posteromedial or posterolateral security approaches are made to control the capsular exit of the needle. A popliteal retractor is placed to keep the articular capsule exposed. A polydioxanone (PDS) suture thread is passed through the needle and retrieved by the assistant. The needle is then pulled out in the joint and reintroduced on the inner part of the tears producing a vertical mattress suture. The second limb of the PDS is retrieved by the assistant, and a knot is tied on the capsular side of the knee. Sutures are placed on the femoral and the tibial side of the meniscus to produce a good reduction and a stable fixation of the lesion. Full range of motion of the knee is allowed at 6 weeks postoperatively.

Results:

Between January 2017 and June 2020, 33 bucket-handle meniscal tears were repaired. Associated anterior cruciate ligament reconstruction was done in 17 cases. The average International Knee Documentation Committee (IKDC) score jumped from 49.6 to 86.2. We had a short-term success rate of 91%. Recent literature review showed equivalent results with new all-inside repairing devices.

Conclusion:

Despite some disadvantages as being time-consuming, the need of security approaches, and the need of a trained assistant, inside-out meniscal repair remains a reliable technique offering good results.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In this video, we will demonstrate the inside-out technique for meniscal repair which is still a useful technique.

This surgical technique was first described by Charles Henning in the early 1980s. It is still considered as the gold standard for many surgeons. It is as efficient as fourth-generation all-inside meniscal repairing devices, with a much lower cost.

This technique is indicated for large meniscal tears in which we will need more than 4 knots. It can be very useful for the lesions localized in the posterior two-thirds of both menisci, and it can be used for most types of tears.

The classical instrumentation consists of a set of malleable tubes with double-loaded suture and a specific popliteal retractor called the Henning retractor.

In our practice, we have introduced a slight modification of the original technique. We use a long cannulated needle with a curved tip and a small spoon as a popliteal retractor. This instrumentation is cheap and reusable.

The patient will be set in supine position under general or spinal anesthesia. A tourniquet is placed at the base of the limb. We don’t use arthrostress to keep the knee free. To open the medial compartment, we use a classical thigh post. For lateral meniscal repair, we use a lateral leg holder on which we put the leg. This allows to put the knee in figure-of-4 position. This setup allows the trained assistant to be in comfortable position for the entire procedure.

Our case is a 23-year-old man, a recreational soccer player. He has a history of right knee trauma 3 months ago. Since then, he has been suffering of recurring episodes of locked knee. The magnetic resonance imaging (MRI) showed a large medial meniscal longitudinal tear.

The arthroscopic aspect confirmed the MRI findings, with this large peripheral bucket-handle tear. The exposure is improved by superficial medial collateral ligament (MCL) pie crusting which is a useful and harmless trick.

We start by aggressively debriding the lesion with the rasper. Afterward, we start the repair. The needle is inserted through the opposite approach to the repaired meniscus. For this case, the repaired meniscus is medial, while the needle is inserted through the lateral approach.

The first knot is crucial as it will affect the whole procedure. To do a vertical knot, the needle is first inserted in the upper side of the tear, exiting the articular capsule posteromedially.

At this point, it is essential to keep in mind all the anatomical structures at risk. If we are in the medial side, we need to pay attention for the saphenous nerve and vein. If it is the lateral side, then the common peroneal nerve must be kept in mind. The popliteal artery is only at risk when we repair the posterior horn of the lateral meniscus. To have these anatomical structures under control, security approaches must be made.

These approaches were well described by Nelson in 2013 and Chahla in 2016. We will describe both approaches. Anatomical landmarks for the medial approach form a triangle, delimited by the semimembranosis in the lower side, the medial head of the gastrocnemius posteriorly, and the articular capsule anteriorly. After delimiting this triangle, we can put our retractor.

Surgically, this anatomical space can be reached with a small cutaneous incision of 3 to 4 cm. The lower 2/3 of the incision is below the joint line. The subcutaneous tissue is opened to expose the sartorius fascia which is opened longitudinally. The space under the sartorius fascia is developed. We use our finger to make a blunt dissection until we expose the posteromedial articular capsule.

For the postero-lateral approach, common peroneal nerve must be kept in mind, which is hopefully protected by the biceps femoris. The anatomical landmarks form a rectangle which is composed of biceps femoris in the lower base, lateral head of the gastrocnemius posteriorly, the articular capsule anteriorly, and the tensor fascia lata (TFL) superiorly. As previously shown, the spoon must be put in that space to control the needle exit.

The landmark for the cutaneous incision is mainly the fibular head. We start the incision in the fibular head, and we go posteriorly for around 3 to 4 cm. The subcutaneous tissue is opened. After a blunt dissection with the finger, we will find the previously described anatomical landmarks. Once the rectangle is identified, we can put our spoon.

Coming back to our case and after keeping all these precautions in mind, first step of the knot consists of passing the needle in the femoral side of the meniscus on the peripheral part of the tear.

The exit of the needle is controlled by the assistant through the surgical security approach. A polydioxanone (PDS) suture thread is passed through the needle, and the thread is retrieved by the assistant.

The needle is pulled back in the articular side and then reintroduced in the femoral side of the meniscus. The entry point can be precisely controlled by the surgeon making a perfect vertical knot on the femoral side of the meniscus.

The needle exits again. The second limb of the suture is retrieved by the assistant.

Both sides of the suture are now outside the articular capsule. The knot is tightened on the capsular side. The effect of the knot can be controlled arthroscopically. We will then be able to repeat these simple steps as much as we need quite easily. We can place knots every 5 to 7 mm on the femoral side of the meniscus.

After doing the number of sutures needed using these steps, we will start to notice that the meniscus is starting to bend upward, producing a partial reduction interesting only the femoral side, and thus opening the tibial side of the tear.

To nullify this effect, same knots have to be done on the tibial side of the meniscus. This will create a balance in the repair, and the meniscus will be completely applied in both sides of the articular capsule.

You can see the difference after this very important step. In the left, the meniscus is bending upward. On the right, the meniscus is perfectly horizontal and balanced and, more importantly, applied to both sides of the articular capsule. Keep in mind that these inferior knots are technically more difficult to make, so we’ll make just the necessary number of knots to produce this effect.

This is the final aspect of the repair of a large medial meniscal bucket-handle tear. This technique allows to put in place as many knots as you need.

We can apply this technique for other types of tears like radial tears, especially posterior two-thirds of both menisci as for this case. We can do a tie grip repair as described by Nakata et al, using an association of horizontal and vertical knots, producing a solid repair with good opposition of both sides of the tear.

Large horizontal tears in young active people can be a good indication for this technique as for this case.

And finally are meniscal cysts. After draining the cyst, we can do the sutures to close the cavity.

After the surgery, the patient is allowed to have an early weight-bearing. The use of a knee brace and crutches is strongly advised during the first 3 weeks. It is allowed to have a range of motion from 0° to 60° in the first 3 weeks and up to 90° between the third and sixth week. Starting from 6 weeks, full range of motion will be allowed progressively. Return to sports is not authorized before 4 months to protect the meniscal suture.

This technique is cheap. It is used with reusable instruments. It allows solid repair of meniscal lesions, and we can put as many sutures as we want.

Unfortunately, need of a trained assistant is a must to make the repair go smoothly. It needs also security incisions. This technique can also be time-consuming.

We used this technique for 33 bucket-handle meniscal tears between January 2017 and June 2020. About 52% of the cases had a concomitant anterior cruciate ligament (ACL) tear. IKDC score average jumped from 49.6 to 86.2 postoperatively. Postoperative Lysholm score average is 87.8. We had a success rate of 91% with only 3 fails. Note that these 3 fails happened with tears with an ACL efficient knee.

Our results are quite similar to those we find in the literature. In fact, the most recent studies about the outcomes of meniscal sutures show success rates between 80% and 91%. Postoperative Lysholm scores are between 85 and 92, which is encouraging toward meniscal suture.

For many experienced surgeons, in-out meniscal suture is still the gold standard for meniscal tears especially for the posteromedial side. This technique can be applied quite easily for large meniscal tears. It is a cheap and reliable technique but needs a trained assistant.