Abstract
Background:
Repair of meniscal tears should be chosen whenever possible. Posterior tears are usually repaired by suture and meniscal anchors. To avoid the pitfalls associated with the use of anchors, as well as for cost-saving and environmental reasons, we describe an alternative suture technique that is all-inside and without anchors.
Indications:
All posterior, vertical, and horizontal meniscal tears, including ramp lesions.
Technique Description:
For meniscal tears affecting the posterior horn of the medial or lateral meniscus, we perform meniscal repair using a size 1 monofilament polydioxanone (PDS; Ethicon) suture. This is an all-inside suture technique performed through an anterior arthroscopy portal. We introduce a large bevel epidural needle (Tuohy needle 1.3 × 150 mm), passing under the meniscus and piercing through the meniscotibial ligament. The PDS thread is passed through, and the limb exiting from the needle is retrieved through the posteromedial (PM) arthroscopy portal. The other limb of the thread, which is still in the needle, is passed over the meniscus and then retrieved through the PM portal. The limbs are then knotted through the PM portal. The procedure can be repeated, often 3 times, as far as the mid-body, resulting in 3 separate suture stitches.
Results:
This technique has a number of advantages over the usual techniques: economical: a cost saving is made with every single suture stitch compared to the usual method using an anchor; environmental: lower consumption of individually packaged implantable products; reproducible/safe: use of a large epidural needle means that all posterior meniscal tears can be sutured under arthroscopic guidance, with visualization of the needle entry and exit points above and below the meniscus; and fewer risks: lower risk of secondary meniscal tear by the suture (Tachibana effect) as the thread used is absorbable, as well as lower risk of cartilage lesions caused by migration of meniscal implants.
Discussion/Conclusion:
The meniscal repair technique described here, using only a monofilament absorbable suture and an epidural needle, is an innovative alternative that is reliable, reproducible, low cost, and low risk.
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.
This is a visual representation of the abstract.
Video Transcript
All-inside meniscal suture without anchor: the Artics technique presented by Dr Frank Wein and coauthors.
The disclosures for the senior author are listed on this slide.
Background
Meniscal surgery is performed more often throughout the world than any other type of bone and joint intervention. For example, over 1,000,000 meniscal interventions are performed every year in the United States: 850,000 primary meniscal tears 1 + tears concomitant with anterior cruciate ligament injuries = 200,000 (>50% of 400,000).5,7
The role of meniscectomy has been called into question1,2 in recent years, as it can lead to joint pain and compromised joint function, and it can encourage the onset of osteoarthritis. This means that there has been a growing interest in meniscal repair.1,3,6 However, outcomes with sutures are not yet good enough, with a repeat intervention rate ranging from 10% to 30%.3,4
Indications
There are various causes for these repeat interventions:
a. Failure of the suture repair to heal can occur in 45% of cases. 8
b. Onset of secondary meniscal tears in methods when every suture creates new holes in the meniscal tissue, which can then be the site where a new tear forms: “Tachibana effect.” 10
c. Onset of cartilage lesions due to migration of the anchors, especially when made from polyether ether ketone. 1
Technique Description
Our technique makes use of specific technical elements that aim to reduce the risk of repeat surgery. First, it aims to improve meniscal healing, while also offering better control of reduction at the tear site through tensioning the 2 suture limbs. Our technique also reduces the risk of secondary meniscal tear (Tachibana effect) because the meniscus is not perforated and an absorbable thread is used, meaning shear stresses of the suture over the meniscus are reduced. Finally, our technique lowers the risk of secondary cartilage damage, as it is only an absorbable thread that is implanted.
In addition, when using meniscal repair techniques other than the usual all-inside techniques, there is the potential risk of neurovascular complications. 1
Our technique reduces the risk of neurovascular complications due to the visualization and control of the needle entry and exit points above and below the meniscus.
Because only an epidural needle and absorbable threads are used, our suture technique means lower usage of materials and packaging. As a result, the economic 9 and environmental impacts of the surgery are reduced.
The patient is a 42-year-old woman who had trauma to the knee 3 months previously. Despite physical therapy, she experiences persistent symptoms of instability and medial pain.
On examination, joint mobility was complete; the Lachman test was positive with a differential laxity of 7 mm compared to the contralateral limb (11 vs 4 mm). Pain was elicited on palpation of the medial meniscus without increasing lateral rotation to 20° or 90° of flexion.
Magnetic resonance imaging found a vertical posterior meniscal tear, with fissures and no ramp lesion. We also found an anterior cruciate ligament tear and lateral compartment bone bruising, which is pathognomonic for the ligament involvement.
Three months of conservative therapy have failed at this point, and knee arthroscopy with meniscal suture and anterior cruciate ligament reconstruction is indicated.
Results
Reconstruction of the anterior cruciate ligament can then be performed, and closure can then begin layer by layer.
Discussion/Conclusion
Physical therapy can then be offered in line with the usual protocol for meniscal repair. In our practice, we do not restrict weightbearing or mobility.
Footnotes
Submitted July 15, 2024; accepted January 23, 2025.
One or more of the authors has declared the following potential conflict of interest or source of funding: F.W. received consulting fees from ARTHREX; A.J. received consulting fees from ARTHREX and STRYKER. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
