All-Inside Repair of Complex Posterior Horn Meniscus Tears

Abstract

Background:

Due to difficult-to-access location and complex tear patterns, the management of meniscus injuries in isolation and in conjunction with anterior cruciate ligament injury may be challenging. The aim of this video is to present techniques and tips that may help surgeons perform arthroscopic all-inside repair of complex meniscus tears.

Indications:

Indications for the presented repair techniques are young patients with high activity demands, symptomatic lateral and medial meniscus lesions, ligamentous knee instability, chondral changes grade 2 or less, neutral joint alignment, and body mass index below 35 kg/m².

Technique Description:

High anterolateral, low anteromedial, and accessory anterolateral portals are used for the arthroscopic assessment of meniscus tear quality and pattern, and to ensure adequate access to the lesion. Horizontal mattress, vertical mattress, and cerclage sutures are passed using a range of all-inside devices to approximate tear edges with the aim of restoring native hoop stresses along the circumferential meniscus collagen fibers. Tear edges are abraded to enhance healing potential. Two separate cases and complex tear configurations are presented to illustrate these all-inside meniscus repair techniques.

Results:

Meniscus repair yields superior long-term outcomes compared with partial meniscectomy. Improvements in subjective knee function and lower rates of progression to long-term knee osteoarthritis are reported in patients treated with meniscus repair versus resection. Advantages of all-inside meniscus repair include the reduced risk of iatrogenic neurovascular lesions, decreased operative time, restoration of native contact surfaces, and repair without fixation of the menisci to the surrounding soft tissue.

Discussion/Conclusion:

Arthroscopic all-inside meniscus repair enables the safe and efficient management of complex meniscus tears in active patients with symptomatic meniscus pathology, and can be performed concurrent with knee ligament surgery. Consequently, all-inside meniscus repair techniques are a versatile addition to the toolkit of complex knee surgeons.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This is a presentation for “All-Inside Repair of Complex Posterior Horn Meniscus Tears” by Sahil Dadoo, Bálint Zsidai, Laura Keeling, and Volker Musahl from the University of Pittsburgh and UPMC Freddie Fu Sports Medicine Center.

The disclosures are listed.

This is a very brief introduction to the topic. The meniscus is an important weight-bearing structure in the knee and needs to be preserved whenever possible,^2,8 as meniscectomy is associated with adverse long-term outcomes compared with repair. ⁹

This first patient is a 17-year-old female high school field hockey player. She had a non-contact pivoting injury during a game and presented with immediate pain and swelling. On examination, there was limited range of motion (ROM) and a positive Lachman test. Her magnetic resonance imaging (MRI) showed a complete anterior cruciate ligament (ACL) tear, which is not relevant for this particular presentation, and a complex 1-cm radial and complete longitudinal tear of the posterior horn of the lateral meniscus.

The operative setup for all-inside meniscus repair includes a side post and an L-bar so that the knee can be positioned at 90° knee flexion. We use a high anterolateral portal above the inferior pole of the patella, sometimes accessory low anterolateral portals, and an anteromedial portal. Therefore, this is a 3, and sometimes 4, portal technique. For preoperative planning, I recommend using some sort of graphic to better understand the tear pattern and the necessary operative approach. Although this picture is complex, we will have it superimposed on the upper side of the arthroscopic video for ease of visualization. This particular tear is a radial split, and the remaining lateral side of the posterior horn is also split horizontally and vertically. The planned repair will start with horizontal mattress sutures to approximate the radial split, followed by further horizontal sutures to approximate the more peripheral part of the radial split. Then, a cerclage suture will be placed at the end.

Here is the arthroscopic video for our first case—the patient has normal chondral surfaces as seen here. The knee has already been placed in varus stress, which is best achieved using manual traction. Our first all-inside device is used to approximate the inferior, or tibial-sided, portion of the radial split to restore the hoop stresses of the meniscus. A second suture is placed also on the tibial surface of the meniscus, which allows for further tension to be taken off the tear side. Now that the tear is better approximated, an additional femoral surface stitch is placed. This is then anchored to the root of the meniscus, and one can even place this suture through some of the fibers of the posterior cruciate ligament to have better purchase. Though this suture is under quite some tension, it will in turn take the tension off of the previously passed 2 stitches that are inferiorly placed.

Now the mid-body of the meniscus can be appreciated, and you can see that the hoop stresses are nicely recreated, whereas without repair this would be equal to a total meniscectomy. An additional (fourth) horizontal mattress suture is then placed on the tibial surface of this tear, to further solidify and approximate the repair side. Finally, at the very end, a cerclage suture is placed around the meniscus from the femoral surface to the tibial surface in a “non-anatomic” fashion; however, this will relieve some of the tension that is otherwise across the construct. This approach is synonymous to a “gift-wrapping” approach across the entire construct. Now the meniscus is fully approximated, and these lateral meniscus tears have very good healing potential.

A second case is demonstrated here. This is a 13-year-old boy who had an injury during trampoline jumping 6 weeks prior to presentation. He felt a pop in his knee and had medial-sided tenderness and pain. On examination, he had loss of terminal extension, which is very common with medial meniscus and ACL tears. On MRI, he had an ACL tear as well as a vertical longitudinal tear of the medial meniscus posterior horn and body. Although this tear is much more straightforward to treat, it actually has much less healing potential than the lateral tear shown previously. Our graphic demonstrates a long vertical tear approximately 4 to 5 cm long in the red-white zone of the meniscus, going from the posterior horn all the way to the anterior part of the mid-body. The planned sutures for this repair will all be placed in vertical mattress fashion along the length of the tear.

Here is the arthroscopic video for our second case—again, the patient had normal chondral surfaces. The camera is placed in the high anterolateral portal, and the instrument is placed in the anteromedial portal. A small radial component of the meniscus was trimmed so that no further stress riser exists, but otherwise no meniscectomy is done. An awl is used to prepare vascular access channels, and the surface can then be further abraded using a shaver without suction to better receive the sutures and hopefully have better healing potential. Vertical mattress sutures are the most important sutures for this tear type as they capture the circumferential collagen fibers of the meniscus, and therefore help to restore the hoop stresses the best. Two vertical mattress sutures are placed in the midbody and posterior horn junction, followed by a third suture placed posteriorly. The meniscus is now a little bit flipped up, so a fourth suture can be placed on the tibial-sided portion of the meniscus to better balance the meniscus. A final vertical mattress suture is then placed on the femoral side.

Potential complications for meniscus repair include chondral damage, if the device is inserted too aggressively, and device failure, which can lead to chondral lysis if the plastic floats in the joint. ⁷ Superficial or deep wound infections and nerve injuries are rare but can occur, and one needs to respect the fact that the posterior compartments contain the neurovascular structures within them.^10,12

Rehabilitation in the first weeks following all-inside meniscus repair includes non-weight bearing with a hinged knee brace and initiation of ROM exercises from 0° to 90°. After 6 weeks, full weight-bearing and ROM can occur without restrictions.

Return to sport (RTS) timing can vary based on the tear pattern. Complete radial splits and root tears are treated a little bit slower than a clean vertical split, especially if in the red zone of the meniscus. However, RTS generally occurs in 3 phases: Phase 1, comprising the first 6 weeks, was demonstrated on the slide prior. Phase 2 occurs from 7 to 12 weeks postoperatively, and includes baseline strength and gait training. Finally, Phase 3 occurs after 3 months and includes multi-directional and sports-specific activities. Full return to play can be expected to occur around 4 to 6 months postoperatively. ¹¹

Outcomes following all-inside meniscus repair are generally good. Patient-reported outcomes are overall improved postoperatively, and the failure rate is low at approximately 10% to 15% at 5 years.^1,3-5 MRI demonstrates strong healing potential of all-inside repair at 2 years postoperatively, with about 70% of meniscus tears fully healed. ⁶

Here is our literature list for reference.

We hope you enjoyed this presentation—thank you very much.