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Atlas of meniscal repair
ATLAS OF MENISCAL REPAIR MARK D. MILLER, MD To clarify the various techniques for meniscal repair, a brief atlas is included in this issue of Operative Techniques in All examples illustrate suturing techniques for a right knee; the first two examples are for a medial meniscus, and the second two, a lateral meniscus. For all techniques, the importance of adequate dissection and protection of important neurovascular structures cannot be overemphasized.
Orthopaedics.
A
B
Fig 1. Open medial meniscal repair is accomplished through a 4- to 5-cm vertical incision centered on the joint line behind the medial collateral ligament. (A) Care is taken to retract the posterior structures, including the infrapatellar branch of the saphenous nerve, before making the capsular incision. (B) The rim of the meniscus is reattached to the synovial bed using vertical mattress sutures placed at 3- to 4-mm intervals.
B
Fig. 2. Outside-in medial meniscal repair using the "Mulberry knot" technique. (A) A 2- to 3-cm vertical incision is made adjacent to the tear, and a spinal needle is introduced from outside the capsule and through the tear under arthroscopic visualization. The suture is then passed through the needle and grabbed with an instrument placed in the ipsilateral portal. (B) Knots are tied in the ends of the suture before pulling it back into the knee adjacent to the tear. Pairs of sutures are then tied directly over the capsule, coaptating the edges of the tear. 70
Operative Techniques in Orthopaedics, Vol 5, No 1 (January), 1995: pp 70-71
A
I
Fig 3. Inside-out lateral meniscal repair using a curved canula system. (A) The canula is placed through the contralateral portal, and arthroscopic needles are placed through the tear. Sutures are retrieved with a needle holder by a qualified assistant who is also responsible for retracting important neurovascular structures. (B) Sutures can be placed in vertical orientation providing better coaptation of the repair.
A
B
Fig 4. All-inside technique of meniscal repair is suitable for peripheral tears. (A) A cannulated hook is introduced through a 7-ram canula, and the suture is passed through the instrument. (B) Knots are tied outside the canula and "pushed" into place under arthroscopic visualization. ATLAS OF MENISCAL REPAIR
71
Orthopaedics.
A
B
Fig 1. Open medial meniscal repair is accomplished through a 4- to 5-cm vertical incision centered on the joint line behind the medial collateral ligament. (A) Care is taken to retract the posterior structures, including the infrapatellar branch of the saphenous nerve, before making the capsular incision. (B) The rim of the meniscus is reattached to the synovial bed using vertical mattress sutures placed at 3- to 4-mm intervals.
B
Fig. 2. Outside-in medial meniscal repair using the "Mulberry knot" technique. (A) A 2- to 3-cm vertical incision is made adjacent to the tear, and a spinal needle is introduced from outside the capsule and through the tear under arthroscopic visualization. The suture is then passed through the needle and grabbed with an instrument placed in the ipsilateral portal. (B) Knots are tied in the ends of the suture before pulling it back into the knee adjacent to the tear. Pairs of sutures are then tied directly over the capsule, coaptating the edges of the tear. 70
Operative Techniques in Orthopaedics, Vol 5, No 1 (January), 1995: pp 70-71
A
I
Fig 3. Inside-out lateral meniscal repair using a curved canula system. (A) The canula is placed through the contralateral portal, and arthroscopic needles are placed through the tear. Sutures are retrieved with a needle holder by a qualified assistant who is also responsible for retracting important neurovascular structures. (B) Sutures can be placed in vertical orientation providing better coaptation of the repair.
A
B
Fig 4. All-inside technique of meniscal repair is suitable for peripheral tears. (A) A cannulated hook is introduced through a 7-ram canula, and the suture is passed through the instrument. (B) Knots are tied outside the canula and "pushed" into place under arthroscopic visualization. ATLAS OF MENISCAL REPAIR
71