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Meniscal suture: a simple method
Injury (1992)23, (S), 553-554
553
Printed inGreat Britain
Meniscai suture: a simple method D. W. Murray
and J. Wilson-Macdonald
The Nuffield Orthopaedic
Centre, Oxford, UK
A simple technique of meniscal suture is described. It avoids the main problem with most other outside-to-inside suture techniques, which is that knots either have to be left inside the joint or have to be pulled out through the meniscus. These knots often come undone or damage either the joint surfnce or meniscw. Essentially, a suture is inserted from outside to inside through the meniscus, using a cannulated needle. The end of this suture is then pulled back out through a separate hole in themeniscus, wing a suture loop inserted with another cannulated needle. The two ends of the first suture are then tied together.
Introduction Many authors believe that the ideal treatment for acute and some chronic peripheral vertical men&al tears is arthroscopit suture (Scott et al., 1986; Sisk, 1987; Henning et al., 1988; Amoczky, 1990; Kalenak et al., 1990). Arthroscopic meniseal suture is, however, not practised universally. This is partly because it is thought to be a technically demanding procedure requiring specialized equipment. We describe a technique that we find simple and quick, and which does not require special instruments. Arthroscopic meniscal suturing can be either inside-tooutside or outside-to-inside. Inside-to-outside techniques require long cannulas and with posterior sutures may put the neurovascular structures at risk (Clancy and Graf, 1983; Hendler, 1984; Jakob et al., 1988; Johannsen et al., 1988; Salisbury and Nottage, 1989). In contrast, outside-to-inside techniques do not necessarily require special instruments and are not so hazardous (Morgan and Casscells, 1986). With outside-to-inside techniques, either large knots have to be tied in the ends of the sutures inside the knee, or the sutures have to be pulled back out through separate holes in the meniscus so that the sutures grip the meniscus (Warren, 1985; Morgan and Casscells, 1986). The latter technique is better as sutures knotted on the inside are not as strong as those pulled back out, and the knots may damage the articular surface (Kahn and Siebert, 1989). A suture may be pulled back through the meniscus either with a wire loop, or by applying suction to a cannula into which the suture is threaded, or by tying to another suture (Johnson, 1986; Cameron, 1990).The first method requires special cannulas and wire loops. Both the first and second methods require considerable dexterity to thread a suture arthroscopically through a loop or into a cannula. The third method is simpler, but the knots may undo or break, and they are likely to damage the meniscus as they are pulled through. Because of these difficulties we have developed a new method of outside-to-inside suturing. 0 1992 Butteworth-Heinemann 0020-1383/92/080553-02
Ltd
Method Following standard methods of patient selection, arthroscopit assessment, tear reduction and debridement preparations are made for suturing. Two needles are loaded with sutures, one of which is in the form of a loop. We have used standard white (19G) needles, but other types of needle, for example spinal needles, could be used, providing the loop can be pushed through the needle. Before loading, the plastic ends are cut off the two white (19G) needles (Figtrre I), so that the sutures can easily be pushed through the needles. One needle is then loaded with I gauge nylon suture and the other with a loop of 00 gauge nylon suture. In order to load a 00 suture loop, both ends of a 00 suture are inserted into the sharp end of a needle. The ends are then carefully withdrawn from the blunt end until the loop has just disappeared into the sharp end. (A trial is carried out to make sure that the 00 loop can be pushed back out of the needle; if it cannot, then more plastic must be cut off the needle.) The 1 gauge suture is inserted into the other needle so that its tip just does not appear from the sharp end. The needle loaded with the 1 gauge suture is inserted from outside to inside, through the meniscus under arthroscopic control. It should cross the tear and then, ideally, it should exit from the inferior surface of the meniscus. (Should the suture fall out of the needle it can be rethreaded with the needle in the knee.) The suture is advanced through the needle into the knee, and grasped with arthroscopic grabbers (Figure ,?a). The needle is then withdrawn and the suture is pulled out through the arthroscopic portal. The two ends of the suture are clipped together and held out of the way. The needle loaded with the 00 loop is inserted parallel to and about 5 mm away from the first suture. The loop is then advanced into the knee, grabbed and withdrawn through the same portal as the first suture (Figure.87). The second needle is removed. After removal of the clip about 10 cm of the I gauge suture is passed through the 00 loop outside the CUT 1 LPL__
v-==
A
T CUT
Figure 1. Preparation of the needles.
554
Injury: the British Journal of Accident Surgery (1992)Vol. 23/No. 8
Figure 2. Meniscal suture.
knee. The two free ends of the oo suture are then firmly pulled, thereby pulling the I gauge suture back into the knee and out through the meniscus (Figure 2~). A small incision is made where the I gauge suture enters and exits the knee. The two ends of this suture are tied over the capsule, avoiding underlying vital structures, while viewing the meniscus arthroscopically (Figrtreti). Other sutures are inserted as necessary by the same technique. Meniscal stability is then confirmed with a probe.
Hendler R. C. (1984) Arthroscopic meniscal repair. C/in. Or&p. 190,163. Henning C. E., Clark C. E., Lynch M. A. et al. (1988) Arthroscopic meniscus repair with a posterior incision. In: American Academy of Orthopaedic Surgeons. Instructional Course Lectures. St Louis: C. V. Mosby, 209. Jakob R. B., Staubli H. LJ.,Zuber K. et al. (1988) The arthroscopic meniscal repair. Techniques and clinical experience. Am. J Sports Med. 16, 137. Johannsen H. V., Fruensgaard S., Holm A. et al. (1988) Arthroscopit suture of peripheral men&al tears. Int &hop. 12,287. Johnson L. L. (1986) F'rucfice ofArfhroscopic&pry, 3rd Ed. St Louis: C. V. Mosby. Kalenak A., Hanks G. A. and Sebastianelli W. J. (1990) Arthroscopy of the knee. In: McCollister Evarts (ed.) Surgery of the Mtc.culosk&ful System. New York: Churchill Livingstone, 3377. Kohn D. and Siebert W. (1989)Meniscus suture techniques: a comparative biomechanical cadaver study. Arthroscopy 5,324. Morgan C. D. and Casscells S. W. (1986) Arthroscopic meniscal repair: a safe approach to the posterior horns. Arthroscopy ~3. Salisbury R. B. and Nottage W. M. (1989) A simple method of meniscal repair. Arthroscopy 5,346. Sisk T. D. (1987) Arthroscopy of knee and ankle. In: Crenshaw A. H. (ed.) Campbell’s Operative Orfhopuedics. St Louis: C. V. Mosby, 2547. Scott G. A., Jolly B. L. and Henning C. E. (1986) Combined posterior incision and arthroscopic intra-articular repair of the meniscus. 1. BoneJoint Surg. 68A, 847. Warren R. F. (1985) Arthroscopic meniscal repair. Arthroscopy 1, 170.
References Amoczky S. P. (1990) Modem trends in meniscal surgery. Surgery 2012.
Cameron H. (1990) A simple method of men&al suture. Orthop. Rev. 19, 103. Clancy W. G. and Graf B. K. (1983) Arthroscopic meniscai repair. Orfhopaedics 6,1125.
Paper accepted
14 April 1992.
Reqtrests for reprints should be aakfressed to: D. W. Murray MD FRCS, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7 LD, UK.
553
Printed inGreat Britain
Meniscai suture: a simple method D. W. Murray
and J. Wilson-Macdonald
The Nuffield Orthopaedic
Centre, Oxford, UK
A simple technique of meniscal suture is described. It avoids the main problem with most other outside-to-inside suture techniques, which is that knots either have to be left inside the joint or have to be pulled out through the meniscus. These knots often come undone or damage either the joint surfnce or meniscw. Essentially, a suture is inserted from outside to inside through the meniscus, using a cannulated needle. The end of this suture is then pulled back out through a separate hole in themeniscus, wing a suture loop inserted with another cannulated needle. The two ends of the first suture are then tied together.
Introduction Many authors believe that the ideal treatment for acute and some chronic peripheral vertical men&al tears is arthroscopit suture (Scott et al., 1986; Sisk, 1987; Henning et al., 1988; Amoczky, 1990; Kalenak et al., 1990). Arthroscopic meniseal suture is, however, not practised universally. This is partly because it is thought to be a technically demanding procedure requiring specialized equipment. We describe a technique that we find simple and quick, and which does not require special instruments. Arthroscopic meniscal suturing can be either inside-tooutside or outside-to-inside. Inside-to-outside techniques require long cannulas and with posterior sutures may put the neurovascular structures at risk (Clancy and Graf, 1983; Hendler, 1984; Jakob et al., 1988; Johannsen et al., 1988; Salisbury and Nottage, 1989). In contrast, outside-to-inside techniques do not necessarily require special instruments and are not so hazardous (Morgan and Casscells, 1986). With outside-to-inside techniques, either large knots have to be tied in the ends of the sutures inside the knee, or the sutures have to be pulled back out through separate holes in the meniscus so that the sutures grip the meniscus (Warren, 1985; Morgan and Casscells, 1986). The latter technique is better as sutures knotted on the inside are not as strong as those pulled back out, and the knots may damage the articular surface (Kahn and Siebert, 1989). A suture may be pulled back through the meniscus either with a wire loop, or by applying suction to a cannula into which the suture is threaded, or by tying to another suture (Johnson, 1986; Cameron, 1990).The first method requires special cannulas and wire loops. Both the first and second methods require considerable dexterity to thread a suture arthroscopically through a loop or into a cannula. The third method is simpler, but the knots may undo or break, and they are likely to damage the meniscus as they are pulled through. Because of these difficulties we have developed a new method of outside-to-inside suturing. 0 1992 Butteworth-Heinemann 0020-1383/92/080553-02
Ltd
Method Following standard methods of patient selection, arthroscopit assessment, tear reduction and debridement preparations are made for suturing. Two needles are loaded with sutures, one of which is in the form of a loop. We have used standard white (19G) needles, but other types of needle, for example spinal needles, could be used, providing the loop can be pushed through the needle. Before loading, the plastic ends are cut off the two white (19G) needles (Figtrre I), so that the sutures can easily be pushed through the needles. One needle is then loaded with I gauge nylon suture and the other with a loop of 00 gauge nylon suture. In order to load a 00 suture loop, both ends of a 00 suture are inserted into the sharp end of a needle. The ends are then carefully withdrawn from the blunt end until the loop has just disappeared into the sharp end. (A trial is carried out to make sure that the 00 loop can be pushed back out of the needle; if it cannot, then more plastic must be cut off the needle.) The 1 gauge suture is inserted into the other needle so that its tip just does not appear from the sharp end. The needle loaded with the 1 gauge suture is inserted from outside to inside, through the meniscus under arthroscopic control. It should cross the tear and then, ideally, it should exit from the inferior surface of the meniscus. (Should the suture fall out of the needle it can be rethreaded with the needle in the knee.) The suture is advanced through the needle into the knee, and grasped with arthroscopic grabbers (Figure ,?a). The needle is then withdrawn and the suture is pulled out through the arthroscopic portal. The two ends of the suture are clipped together and held out of the way. The needle loaded with the 00 loop is inserted parallel to and about 5 mm away from the first suture. The loop is then advanced into the knee, grabbed and withdrawn through the same portal as the first suture (Figure.87). The second needle is removed. After removal of the clip about 10 cm of the I gauge suture is passed through the 00 loop outside the CUT 1 LPL__
v-==
A
T CUT
Figure 1. Preparation of the needles.
554
Injury: the British Journal of Accident Surgery (1992)Vol. 23/No. 8
Figure 2. Meniscal suture.
knee. The two free ends of the oo suture are then firmly pulled, thereby pulling the I gauge suture back into the knee and out through the meniscus (Figure 2~). A small incision is made where the I gauge suture enters and exits the knee. The two ends of this suture are tied over the capsule, avoiding underlying vital structures, while viewing the meniscus arthroscopically (Figrtreti). Other sutures are inserted as necessary by the same technique. Meniscal stability is then confirmed with a probe.
Hendler R. C. (1984) Arthroscopic meniscal repair. C/in. Or&p. 190,163. Henning C. E., Clark C. E., Lynch M. A. et al. (1988) Arthroscopic meniscus repair with a posterior incision. In: American Academy of Orthopaedic Surgeons. Instructional Course Lectures. St Louis: C. V. Mosby, 209. Jakob R. B., Staubli H. LJ.,Zuber K. et al. (1988) The arthroscopic meniscal repair. Techniques and clinical experience. Am. J Sports Med. 16, 137. Johannsen H. V., Fruensgaard S., Holm A. et al. (1988) Arthroscopit suture of peripheral men&al tears. Int &hop. 12,287. Johnson L. L. (1986) F'rucfice ofArfhroscopic&pry, 3rd Ed. St Louis: C. V. Mosby. Kalenak A., Hanks G. A. and Sebastianelli W. J. (1990) Arthroscopy of the knee. In: McCollister Evarts (ed.) Surgery of the Mtc.culosk&ful System. New York: Churchill Livingstone, 3377. Kohn D. and Siebert W. (1989)Meniscus suture techniques: a comparative biomechanical cadaver study. Arthroscopy 5,324. Morgan C. D. and Casscells S. W. (1986) Arthroscopic meniscal repair: a safe approach to the posterior horns. Arthroscopy ~3. Salisbury R. B. and Nottage W. M. (1989) A simple method of meniscal repair. Arthroscopy 5,346. Sisk T. D. (1987) Arthroscopy of knee and ankle. In: Crenshaw A. H. (ed.) Campbell’s Operative Orfhopuedics. St Louis: C. V. Mosby, 2547. Scott G. A., Jolly B. L. and Henning C. E. (1986) Combined posterior incision and arthroscopic intra-articular repair of the meniscus. 1. BoneJoint Surg. 68A, 847. Warren R. F. (1985) Arthroscopic meniscal repair. Arthroscopy 1, 170.
References Amoczky S. P. (1990) Modem trends in meniscal surgery. Surgery 2012.
Cameron H. (1990) A simple method of men&al suture. Orthop. Rev. 19, 103. Clancy W. G. and Graf B. K. (1983) Arthroscopic meniscai repair. Orfhopaedics 6,1125.
Paper accepted
14 April 1992.
Reqtrests for reprints should be aakfressed to: D. W. Murray MD FRCS, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7 LD, UK.