What Is Inside Out Meniscus Repair
Arthrosc Tech. 2022 Feb; 5(1): e163–e168.
Within-Out Meniscal Repair: Medial and Lateral Arroyo
Jorge Chahla
aSteadman Philippon Research Establish, Vail, Colorado, United statesA.
Raphael Serra Cruz
aSteadman Philippon Research Found, Vail, Colorado, U.S.A.
Tyler R. Cram
bThe Steadman Clinic, Vail, Colorado, U.s.a.A.
Chase S. Dean
aSteadman Philippon Research Establish, Vail, Colorado, U.S.A.
Robert F. LaPrade
aSteadman Philippon Enquiry Institute, Vail, Colorado, U.S.A.
bThe Steadman Clinic, Vail, Colorado, U.S.A.
Received 2022 Jul 31; Accustomed 2022 Oct 29.
- Supplementary Materials
-
Video 1 Inside-out meniscal repair technique and corresponding posterolateral and posteromedial surgical approaches. The patient is positioned supine on the operating table, the foot of the bed is lowered, and the contralateral leg is abducted. The posterolateral approach is shown start. Then, the posteromedial approach is shown on a cadaver. Each approach begins with sharp dissection and is followed past blunt autopsy. Adhesions are released, and the posterior neurovascular structures are protected. Inside-out meniscal repair is then performed on the lateral meniscus in a left genu. A self-delivery gun fitted with a cannula (Sharpshooter; Ivy Sports Medicine, Montvale, NJ) is used to laissez passer double-loaded nonabsorbable sutures (No. 2.0 FiberWire; Arthrex) into the meniscus. To showtime passing the sutures, the knee is positioned in 20° to 30° of flexion and the meniscal needle is avant-garde through the superior or junior aspect of the meniscus, and the corresponding portion of the capsule is then penetrated with the 2nd needle of the suture. The human knee tin be flexed to 70° to 90° to help with retrieval of the needle. The needles are cut from the sutures, and the suture ends are clamped while slight tension is being maintained. The aforementioned process is repeated side by side to the previous suture, with sutures in both the superior and junior borders of the meniscus placed between three and 5 mm apart. On boilerplate, ten to 12 sutures are used to create a stronger construct. Lastly, with the knee in 90° of flexion, all sutures are tied, with the surgeon taking intendance not to over-tighten the tissue. When possible, a vertical suture pattern is preferred considering it allows for greater capture of the strong circumferential fibers of the meniscus; nonetheless, oblique and horizontal patterns tin can also be used if necessary to reduce the meniscal tear.
GUID: F9A050E1-9A0E-44C3-8100-F7DC0E9E0AAA
Abstract
Preservation of meniscal tissue has been proven to exist the best approach in most cases of meniscal tears. Currently bachelor 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, considering of implant-related complications, cost concerns, and device availability, the inside-out technique is withal the preferred method among many surgeons. Although the within-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.
The menisci play a key office in the articulatio genus. They contribute to load transmission and distribution, joint lubrication, proprioception, and cartilage nutrition and human activity every bit secondary stabilizing structures.1 Untreated meniscal tears tin can pb to deleterious furnishings on the human knee, predisposing the joint to early degenerative changes.ii Although meniscal repairs accept a college reoperation rate than meniscectomy, they likely outcome in better long-term patient-reported outcomes, better activity levels, and slower progression to osteoarthritis.three
Meniscal repair techniques can be divided into the inside-out technique, the exterior-in technique, and the more than recently described all-inside technique.4 Among these, the inside-out technique allows for fine precision, a greater number of sutures, and the advantage of not having a prominent intra-articular device. Indications and contraindications are listed in Table 1. The purpose of this article is to depict the surgical approaches and the arthroscopic procedure for lateral and medial meniscal repairs using an inside-out technique.
Table 1
Indications and Contraindications
| Indications |
| Posterior horn tears |
| Centre-third tears |
| Peripheral capsule tears |
| Saucepan-handle tears |
| Contraindications |
| Root tears |
| Severe degenerative meniscal changes |
| Avascular zone tears |
Surgical Technique
The patient is placed in the supine position on the operating table. After the consecration of general anesthesia, a bilateral knee joint examination is performed to appraise for range of move and evaluate for any concurrent ligament instability. A well-padded high-thigh tourniquet is subsequently placed on the operative articulatio genus, which is positioned into a leg holder. The contralateral human knee remains in an abduction holder with a pneumatic pinch device as a mechanical prophylaxis for deep venous thrombosis.
The anterolateral portal is created in a vertical fashion adjacent to the patellar tendon, and the articulation is initially inspected. With the assist of a spinal needle to assess location, the anteromedial portal is created in a similar manner. The meniscal margins are probed, and repair is considered for whatsoever unstable peripheral meniscal tears.
Posterolateral Approach
Palpable anatomic landmarks for this approach include the Gerdy tubercle, superficial layer of the iliotibial band (ITB), lateral aspect of the fibular caput, and lateral joint line. Afterward the joint line is located with the use of an arthroscopic probe, a transverse oblique incision is performed following the posterior border of the ITB down to the Gerdy tubercle centered over the lateral articulation line (Video i, Fig 1).
Anatomic landmarks for lateral approach in a cadaveric right knee joint: (A) Gerdy tubercle, (B) fibular head, and (C) marked transverse oblique–oriented incision.
The superficial layer of the ITB is then incised along its posterior attribute. Intendance must exist taken when making this incision to avoid injury to the fibular collateral ligament and deep lateral capsule. The incision through the ITB is positioned approximately 5 mm anterior to the posterior margin of the superficial layer of the ITB (Fig 2).
Cadaveric right knee showing (A) the subcutaneous tissue, (B) the iliotibial band (ITB) debrided from the subcutaneous tissue proximal and distally, and (C) the ITB incised 5 mm inductive to the posterior margin of the superficial layer of the ITB.
The inferior-lateral genicular artery overlies the popliteus musculotendinous junction and may exist injured if the dissection is performed too distally. It is also important to stay proximal to the long caput of the biceps circuitous during superficial dissection and anterior to the lateral gastrocnemius head during deep dissection to avoid iatrogenic injury to the mutual peroneal nerve. Blunt autopsy must be performed (from the ITB window accessed in the previous pace) toward the fibular caput and proximal to the long and short heads of the biceps tendon (Fig iii).
Cadaveric right knee showing edgeless dissection toward the fibular head through a transverse iliotibial ring window.
In one case a passage has been created, blunt finger dissection is performed, followed by use of a Cobb elevator, to release any adhesions betwixt the lateral gastrocnemius and the posterior capsule. According to the senior author's experience (R.F.L.), the adhesions between the lateral gastrocnemius and the posterolateral joint capsule are less dense than those on the medial side. Lastly, a tablespoon tin can exist placed in the interval (anterior to the lateral gastrocnemius and posterior to the posterolateral capsule) to protect the neurovascular package (Fig 4).
Cadaveric right knee with a metal spoon placed at the lateral interval (anterior to the lateral gastrocnemius and posterior to the posterolateral capsule [PLC]) to act as a retractor to protect the neurovascular bundle. (ITB, iliotibial band.)
Posteromedial Arroyo
Palpable landmarks should exist identified starting time. These include the adductor tubercle, posterior attribute of the tibial plateau, and medial articulation line. An arthroscopic probe is placed inside the joint to help locate the planned incision and place the joint line. An oblique vertical incision is performed from the adductor tubercle to the posterior attribute of the tibial plateau (ii cm distal to the articulation line). Care must exist taken not to make this incision also posteriorly because the saphenous nerve courses approximately 5 cm posteriorly to the adductor tubercle5 (Fig 5).
Anatomic landmarks for surgical approach in a cadaveric right knee: (A) adductor tubercle (AT) position, (B) posterior aspect of the medial tibial plateau, and (C) oblique vertically oriented incision centered on the tibiofemoral articulation line.
Subcutaneous sharp autopsy is performed down to the sartorial fascia, which is incised as proximally as possible to preserve the human foot anserine tendons. Later on blunt dissection from the sartorial fascia incision, an anatomic "triangle" tin can be observed. This triangle is formed past the posteromedial joint capsule anteriorly, the medial gastrocnemius posteriorly, and the semimembranosus inferiorly (Fig 6).
Right genu showing (A) the inductive incision to the sartorial fascia; (B) blunt dissection of the semimembranosus fascia; and (C) the anatomic triangle formed past the posteromedial capsule (PMC) as the anterior wall, semimembranosus tendon (SM) as the flooring, and medial gastrocnemius (MGT) as the posterior wall and roof. (sMCL, superficial medial collateral ligament.)
Careful dissection of the posteromedial joint capsule away from adhesions to the medial gastrocnemius complex is performed to permit for improved visualization and to permit passage of the neurovascular protector. Furthermore, a Cobb elevator is and so used to separate the medial gastrocnemius tendon and muscle from any posterior capsular adhesions. Lastly, a tablespoon or other device can be placed in this interval to act as a retractor, protecting the popliteal vessels (Fig vii).
(A) Targeted triangle interval (dashed outline) and (B) magnified image with a metallic spoon placed into the interval, protecting the popliteal vessels, in a right knee.
Meniscal Suture
Before the repair is attempted, a consummate evaluation of the lesion should be performed including size, stability, and state of the meniscus, as well as blazon and zone of the lesion. Typically, lesions that measure betwixt 1 and 4 cm and are located in the ruby-red zone or red-white zone can be repaired. The tear should be anatomically reduced, and the sutures should exist placed perpendicularly to the lesion to restore its anatomic position.
For an inside-out repair, a self-commitment gun fitted with a cannula (Sharpshooter; Ivy Sports Medicine, Montvale, NJ) is used to pass double-loaded nonabsorbable sutures (No. 2 FiberWire; Arthrex, Naples, FL) into the meniscus. To starting time passing the sutures, the articulatio genus is positioned in 20° to xxx° of flexion and the meniscal needle is avant-garde through the superior or junior aspect of the meniscus (Fig eight); the respective portion of the capsule is and so penetrated with the 2nd needle of the suture. To assistance the assistant retrieve the needle, the human knee tin can exist flexed to 70° to 90°. The needles are cut from the sutures, and the suture ends are clamped while slight tension is being maintained. The same procedure is repeated adjacent to the previous suture, with sutures in both the superior and inferior borders of the meniscus placed between iii and 5 mm autonomously. On average, 10 to 12 sutures are used to create a stronger construct (R.F.L., unpublished data, Dec 2022). Lastly, with the knee in 90° of flexion, the surgeon ties all sutures, being careful non to over-tighten the tissue (Fig 9). When possible, a vertical suture pattern is preferred because it allows for greater capture of the strong circumferential fibers of the meniscus; withal, oblique and horizontal patterns can also be used if necessary to reduce the meniscal tear6 (Fig ten, Fig 11, Fig 12).
(A) Arthroscopic paradigm of a left knee showing a suture needle penetrating the superior edge of the lateral meniscus equally viewed through the anteromedial parapatellar portal. (B) Intraoperative photograph of a left genu showing the utilise of a suture-passing device inserted through the lateral parapatellar portal, while the arthroscope is in the medial parapatellar portal. The banana is preparing to recollect the suture through the posterolateral portal for approach.
Intraoperative photograph of a left knee after the sutures take all been passed through the meniscus. The knee is flexed to 90°, and the sutures are tied, with care taken non to over-tighten the tissue.
Arthroscopic image of inside-out meniscal repair showing suture placement through the superior border of the medial meniscus and through the superior capsule (anteromedial portal) of the left knee. The same process is performed on the inferior edge of the meniscus and the inferior sheathing.
Arthroscopic images showing steps for meniscal suture placement in the left articulatio genus. (A) In xx° to 30° of knee flexion, a meniscal needle is advanced through the superior edge of the meniscus. (B) The inferior capsule is penetrated with the needle. (C) Final result of repaired meniscus (femoral side).
Arthroscopic epitome of the left knee showing the concluding result of the repaired medial meniscus (Thousand) with sutures on both sides of the meniscus going through the capsule.
Postoperative Rehabilitation for Isolated Meniscal Repairs
Postoperatively, all patients with an isolated meniscus tear remain non–weight bearing for 6 weeks. Physical therapy emphasizes early quadriceps musculus activation and genu flexion from 0° to xc°. Knee flexion is increased as tolerated starting ii weeks postoperatively. 6 weeks postoperatively, weight bearing is initiated. At this time, patients too may begin using a stationary bike with depression resistance settings and performing one-quarter–torso weight leg presses to a maximum of 70° of knee flexion. Boosted increases in low-impact knee joint exercises are permitted as tolerated starting 12 weeks postoperatively. We recommend that patients avoid deep squatting, sitting cantankerous-legged, or performing any heavy lifting or squatting activities for a minimum of 4 months subsequently surgery.
Discussion
The within-out meniscal repair technique has shown improved subjective and objective patient outcomes7 and remains the standard of intendance for meniscal repair.viii This technique is best used for posterior horn, heart-third, peripheral capsule, and bucket-handle tears.4 Advantages of the inside-out technique include the versatility of placing sutures, lower implant cost, and use of low-profile needles that permit for multiple sutures without compromising the structural integrity of the meniscus.7 The senior author uses 10 to 12 sutures on average (R.F.Fifty., unpublished data, Dec 2022) to create a stiff construct repair. Drawbacks of this technique include additional incisions, the gamble of neurovascular injury, the demand for an assistant, and theoretically, an increased process time.6, vii Pearls and pitfalls for this surgical technique are presented in Table ii, Table three.
Tabular array 2
Pearls
| Placement of sutures should begin through the most unstable portion of the meniscus. |
| Sutures should exist placed in both the superior and inferior aspects of the meniscus. |
| The distance between the sutures should be iii-5 mm. |
| The surgeon should utilize equally many sutures as necessary to stabilize the tear. |
Table 3
Risks and Pitfalls
| Risks and Pitfalls | Methods for Fugitive Risks and Pitfalls |
|---|---|
| Lesion of popliteal artery and its branches | The surgeon should perform conscientious dissection and use the heads of the gastrocnemius to protect the vascular structures. A spoon should be used to protect the exit of the needles. |
| Lesion of saphenous nerve | Attention should be given to avert placement of the medial incision as well posteriorly. |
| Lesion of common peroneal nerve | The surgeon should keep the dissection anterior to the biceps and lateral caput of the gastrocnemius tendons. |
| Flexion contracture or stiffness | The surgeon should not over-tighten the sutures. Early mobilization (0°-xc°) with an experienced physical therapist is recommended. |
| DVT | Intraoperative and postoperative prophylaxis should be used. |
A meta-analysis of 7 studies showed that meniscal repairs are probable to result in better long-term outcomes than meniscectomy, although they have a higher reoperation rate.three Grant et al.seven analyzed 19 studies comparing inside-out and all-inside meniscal repair techniques. They institute no differences in clinical failure rates (17% v xix%) or subjective outcomes. Complications are associated with both techniques. Nervus symptoms are more unremarkably associated with the inside-out repair, whereas implant-related complications (soft-tissue irritation, swelling, and implant migration or breakage) are more common with the all-inside technique. Stärke et al.9 reported that regardless of the repair technique used, there is a general trend of increasing failure rates with time (with success rates of 75% to 94% in the kickoff year of surgery but 59% to 76% beyond the fourth twelvemonth). Of note, the criteria for success and failure were heterogeneous amidst studies.
In conclusion, the inside-out meniscal repair technique needs to be a component of the armamentarium of the surgeon, especially when dealing with large tears. We recommend our approach for meniscal repair, which is easily performed with careful dissection. We encourage further studies by other groups to evaluate our surgical technique and the long-term subjective and objective patient outcomes.
Footnotes
The authors report the following potential disharmonize of interest or source of funding: Steadman Philippon Research Establish receives support from Arthrex, Ossur, Siemens, and Smith & Nephew. R.F.L. receives back up from Arthrex; Smith & Nephew; Ossur; Health East, Norway; and National Institutes of Wellness R13 grant for biologics.
Supplementary Data
Video 1:
Inside-out meniscal repair technique and respective posterolateral and posteromedial surgical approaches. The patient is positioned supine on the operating table, the pes of the bed is lowered, and the contralateral leg is abducted. The posterolateral approach is shown first. And then, the posteromedial approach is shown on a cadaver. Each arroyo begins with precipitous dissection and is followed by blunt dissection. Adhesions are released, and the posterior neurovascular structures are protected. Within-out meniscal repair is then performed on the lateral meniscus in a left knee. A self-delivery gun fitted with a cannula (Sharpshooter; Ivy Sports Medicine, Montvale, NJ) is used to laissez passer double-loaded nonabsorbable sutures (No. 2.0 FiberWire; Arthrex) into the meniscus. To start passing the sutures, the knee joint is positioned in twenty° to xxx° of flexion and the meniscal needle is avant-garde through the superior or inferior aspect of the meniscus, and the corresponding portion of the capsule is then penetrated with the 2nd needle of the suture. The knee tin exist flexed to lxx° to ninety° to assistance with retrieval of the needle. The needles are cutting from the sutures, and the suture ends are clamped while slight tension is being maintained. The aforementioned process is repeated adjacent to the previous suture, with sutures in both the superior and junior borders of the meniscus placed between 3 and 5 mm apart. On average, x to 12 sutures are used to create a stronger construct. Lastly, with the knee in xc° of flexion, all sutures are tied, with the surgeon taking care not to over-tighten the tissue. When possible, a vertical suture blueprint is preferred because information technology allows for greater capture of the potent circumferential fibers of the meniscus; nevertheless, oblique and horizontal patterns tin also exist used if necessary to reduce the meniscal tear.
References
i. Allen A.A., Caldwell G.L., Jr., Fu F.H. Anatomy and biomechanics of the meniscus. Oper Tech Orthop. 1995;v:two–9. [Google Scholar]
2. Hede A., Larsen Eastward., Sandberg H. The long term outcome of open total and fractional meniscectomy related to the quantity and site of the meniscus removed. Int Orthop. 1992;sixteen:122–125. [PubMed] [Google Scholar]
3. Xu C., Zhao J. A meta-analysis comparing meniscal repair with meniscectomy in the handling of meniscal tears: The more meniscus, the better outcome? Human knee Surg Sports Traumatol Arthrosc. 2015;23:164–170. [PubMed] [Google Scholar]
iv. Goodwillie A.D., Myers Thousand., Sgaglione N.A. Current strategies and approaches to meniscal repair. J Knee Surg. 2014;27:423–434. [PubMed] [Google Scholar]
5. Wijdicks C.A., Westerhaus B.D., Brand E.J., Johansen South., Engebretsen Fifty., LaPrade R.F. Sartorial co-operative of the saphenous nerve in relation to a medial knee ligament repair or reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;eighteen:1105–1109. [PubMed] [Google Scholar]
7. Grant J.A., Wilde J., Miller B.S., Bedi A. Comparing of within-out and all-inside techniques for the repair of isolated meniscal tears: A systematic review. Am J Sports Med. 2012;twoscore:459–468. [PubMed] [Google Scholar]
8. Laible C., Stein D.A., Kiridly D.N. Meniscal repair. J Am Acad Orthop Surg. 2013;21:204–213. [PubMed] [Google Scholar]
9. Stärke C., Kopf S., Petersen West., Becker R. Meniscal repair. Arthroscopy. 2009;25:1033–1044. [PubMed] [Google Scholar]
Articles from Arthroscopy Techniques are provided here courtesy of Elsevier
What Is Inside Out Meniscus Repair,
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4886039/#:~:text=For%20an%20inside%2Dout%20repair,%2C%20FL)%20into%20the%20meniscus.
Posted by: bergmanhison1971.blogspot.com
0 Response to "What Is Inside Out Meniscus Repair"
Post a Comment