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The “all-inside” meniscus repair
Arthroscopy: The Journal of Arthroscopic Published by Raven Press, Ltd. 0 1991
and Related
Surgery
7(1):120-125 America
Arthroscopy Association of North
Technical
The
‘
‘All-Inside’
’
Note
Meniscus Repair
Craig D. Morgan, M.D.
Summary: The arthroscopic “all-inside” meniscus suturing technique offers the arthroscopist a way of placing vertically oriented sutures through peripheral posterior horn tears located posterocentral without the risks of nerve, vessel, or posterior capsular entrapment inherent in both the “outside-in” and the “inside-out” arthroscopic methods. This technique introduces new instrumentation that allows the surgeon to both place sutures and tie suture knots intraarticularly under arthroscopic control. Key Words: Meniscus repairPosterior horn-Intraarticular knot tying.
Due largely to the work of DeHaven (l-3) and others (4), peripheral meniscus suture repair by open arthrotomy popularized the concept of meniscus preservation. The classic report of Arnoczky and Warren (5) demonstrated a peripheral meniscal blood supply limited to the outer 25-30% of the meniscus, which defined a vascular basis for potential healing of repaired meniscus tears in this location. Historically, open suture repairs of the meniscus by either posteromedial or posterolateral arthrotomy were the first to appear in the literature (l-4). These repairs placed multiple vertically oriented sutures into the detached meniscus and adjacent capsule, which resulted in an anatomic balanced peripheral repair at the meniscocapsular junction with both the meniscotibial and meniscofemoral portions of the coronary ligament complex firmly apposed to the meniscus at the repair site. Due to difficulties with open exposure, particularly when approaching the posterior horns, meniscus repair by arthrotomy was largely limited to tears located at the meniscocapsular junction or within l-2 mm from the meniscocapsular junction. Substance tears located 2-4
mm central to the meniscocapsular junction were difficult if not impossible to suture by open means. With the development of meniscus suturing methods performed under arthroscopic control, these problems related to exposure were overcome, allowing for more centrally located outer third tears to be repaired (6-12). As arthroscopic “inside-out” repairs became popular in the mid 198Os, the incidence of associated posterior neurovascular injury caused by posterior needle exit became an issue (3,13). In 1986, Small (13) reported 30 saphenous nerve, six peroneal nerve, and three popliteal artery injuries in a review of 3,034 percutaneous inside-out arthroscopic meniscus repairs. In a subsequent report in 1988, Small (14) noted no serious neurovascular injuries when “inside-out” meniscus suturing was done in combination with an open posterior capsular exposure to protect the posterior neurovascular anatomy. In an attempt to avoid posterior neurovascular injury with a percutaneous arthroscopic approach to meniscus suture repair, Warren (11) developed the “outside-in” method, which directs absorbable suture percutaneously through the lumen of a spinal needle placed from a known safe area outside the knee across the tear intraarticularly under arthroscopic control. Morgan and Casscells (12) reported clinical experience with this method and defined the details of safe needle passage. Subsequently, Morgan et al. (15) reported 85% good to excellent results in 75 second looks at “outside-in”
From Sports Medicine, Alfred I. duPont Institute and Delaware Orthopaedic Center, Wilmington, Delaware, and Orthopaedie Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A. Address correspondence and reprint requests to Dr. C. D. Morgan at 2501 Silverside Road, Wilmington, DE 19810. U.S.A. The technique described in this article will be demonstrated in a forthcoming Video Supplement to Arthroscopy.
120
“ALL-INSIDE” repairs. In a larger clinical series, Morgan et al. (IS) noted a 3.4% clinical failure rate, with only one saphenous nerve injury in over 350 “outside-in” repairs. It has been this author’s experience that the most posterocentral peripheral portion of the posterior horns (posterior root) cannot be both anatomically and safely sutured by either the “inside-out” or the “outside-in” methods. With either method, avoidance of the posterior neurovascular structures necessitates suture placement at a high oblique angle in reference to these vertical longitudinal tears located far posterocentral. For this reason, these repairs tend to be nonanatomic and lack the vertical suture orientation felt to be important by DeHaven (3). Also, with regard to posterior horn tears, these arthroscopic methods tie sutures over the posterior capsule rather than directly suturing the meniscus tear. This results in entrapping the posterior capsule, which may lead to the development of a flexion contracture. For these reasons, coupled with the fact that 90% of repairable meniscus tears are located in the posterior horns, this author sought to develop a safe approach to peripheral posterior horn tears that would produce a vertically oriented anatomic suture repair which sutures meniscus to meniscus and excludes the posterior capsule from the repair. OPERATIVE TECHNIQUE In general, the arthroscopic “all-inside” suturing technique recreates the open method of vertical su-
MENISCUS
121
REPAIR
ture placement for the posterior horn under arthroscopic control. In addition, this technique introduces a new concept of arthroscopic intraarticular knot tying whereby, subsequent to suture placement, the suture tails are tied in the posterior compartment apposing meniscus to meniscus with an arthroscopic knot pusher. This method takes advantage of the rather large posterior compartment space that exists where the meniscotibial attachment to the posterior horn of the meniscus forms a large recess posteroinferior to the posterior horn of the meniscus as it becomes confluent with the posterior capsule. This posterior capsular space or recess enlarges with knee flexion and becomes smaller with knee extension. Circumferentially, in the axial plane, the posterior capsular space or recess ends at the posterior meniscocapsular corners. For this reason, the “all-inside” suturing method is only indicated for peripheral posterior horn tears and cannot be used for tears located anterior to either the posterolateral or posteromedial meniscus corners due to lack of space for instrument placement. The “all-inside” meniscus repair requires visualizing the pathology from the posterior compartment with a 70” foreoblique arthroscope placed through the intercondylar notch. This is best accomplished with the knee in flexion to enlarge the posterior compartment space. In this position, the optical lens is rotated 90” (medial or lateral), which gives the surgeon a good view of the posterior compartment including the posterior meniscocapsular junction and posterior capsular recess (Figs. IA and
lA,B
FIG. 1 A: Right knee with a 70” arthroscope through the intercondylar notch from an anterolateral portal and an operative cannula placed in the posteromedial compartment from a posteromedial approach made above the pes anserinus group tendons with the knee flexed 90”. B: Arthroscope placement through the intercondylar notch and suture placement using a suture hook from a posterolateral operative cannula during peripheral lateral meniscal repair.
Arthroscopy.
Vol. 7. No. I. 1991
122
C. D. MORGAN
2A-D). In this author’s experience, peripheral posterior horn tears up to 4 mm central to the meniscocapsular junction can be visualized much better with this approach than from a standard anterior approach. Furthermore, the status of the posterior
peripheral meniscal rim can be better assessed for secondary tears, giving the surgeon more information as to the repairability of a given tear. Once the tear has been visualized, a 7-mm inner diameter operative cannula with semiblunt trochar
FIG. 2. A: Peripheral posterior horn tear of a left lateral meniscus as seen with a 70” arthroscope placed through the intercondylar notch with the tear being probed through a posterolateral cannula. B: Same tear as A seen with suture hook spanning both sides of the tear with suture being threaded through the lumen of the suture hook. C: Same tear as A following suture hook removal leaving a vertical oriented suture through both sides of the tear. D: Same tear as B showing completed repair following intraarticular knot tying. Note apposition of meniscus to meniscus at the tear site with two suture knots evident.
Arthroscopy, Vol. 7, No. I, 1991
“ALL-INSIDE” (Acufex Microsurgical, Norwood, MA, U.S.A.) is placed into the posterior compartment in question from either a posterolateral or posteromedial approach with the knee flexed 90”. The entry point posterior is first localized with an 1%gauge spinal needle that facilitates posterior triangulation in the surgeon’s “minds eye.” The operative cannula’s entrance through the posterior capsule is visualized under direct arthroscopic control while maintaining maximum fluid distention. In order to avoid the peroneal nerve on the lateral side during posterolateral cannula placement, the entry point outside is made well above the palpable biceps femoris tendon slightly above and posterior to the joint line at the posterolateral corner with the knee flexed a90”. On the medial side, the saphenous nerve is avoided by making the posteromedial cannula entry point above the pes group tendons slightly above and behind the posterior joint line at the posteromedial corner, also with knee flexed 290” (Fig. IA). Once proper operative cannula placement posterior is confirmed, the tear region is probed and debrided of all abortive healing response with instruments placed through the operative cannula (Fig. 2A). The local synovium is excoriated using either hand-held rasps or motorized instrumentation. In chronic tears, autogenous clot, as advocated by Arnoczky and Warren (16), may also be placed into the tear region through the posterior operative cannula. Following adequate preparation of the tear region to stimulate a vascular fibrous response, vertically oriented sutures are placed across the tear using a
MENISCUS
REPAIR
tool called a “suture hook” (Concept Inc., South Cleat-water, FL, U.S.A.), which is delivered down the operative cannula. The suture hook is a modified hook-shaped 18-gauge needle with a specialized roller device incorporated into its handle, which facilitates suture delivery through the lumen of its hook-shaped terminal end (Fig. 3A and B). By hand manipulation and rotation of the suture hook, its sharp tip penetrates the peripheral meniscal rim first, then the mobile meniscal fragment second, in a vertical orientation in reference to the body of the meniscus (Figs. 1B and 2B). Following this, suture (“0” PDS; Ethicon, Sommerville, NJ, U.S.A.) is delivered through the lumen of the suture hook, and the suture hook is withdrawn. The terminal end of the suture that has crossed the meniscus repair site is then grasped and brought out the posterior operative cannula. At this point, a vertically oriented suture spans the tear intraarticularly with suture tails that go up the posterior cannula outside the knee (Fig. 2C). The last step is tying the intraarticular knot through the operative cannula. This is accomplished by using an arthroscopic knot pusher (Arthrex; Arthroscopy Instruments Inc., Winooski, VT, U.S.A.). The knot pusher is a metal rod with a cup-shaped terminal end with two holes (one for each suture tail) at 45” from the terminal end (Fig. 4A and B). Using the knot pusher, four to six sequential throws are advanced down the operative cannula, which produce a double or triple “stacked” square knot respectively, which completes the suture repair by coapting meniscus to meniscus at the tear site (Fig. 4C and D). The tails of
3A,B
FIG. 3. A: Concept suture hook (Concept, Inc., South Clearwater, FL, U.S.A.) with monofilament suture threaded from handle through lumen of shaft and terminal hooked end. B: Terminal hooked needle end of a suture hook with monofilament suture threaded out the sharp tip.
Arthroscopy.
Vol. 7, No. I. 1991
124
C. D. MORGAN
4A,B
FIG. 4. A: Terminal end of the Arthrex knot pusher. (Arthrex Arthroscopy Instruments, Inc. Winooski, VT, U.S.A.). B: Terminal end of Arthrex knot pusher with suture present advancing first throw of a square knot. C: Use of the knot pusher through a posterolateral operative cannula during peripheral posterolateral meniscus repair in a left knee.
the completed knot are cut with scissors through the posterior cannula, and this entire process is repeated two or three additional times until the posterior horn is stabilized (Fig. 2D). Advantages of the “all-inside” arthroscopic meniscus repair technique include (a) safe suture placement far posterocentral in the posterior horn, (b) a vertical orientation of the sutures, which facilitates an anatomic repair, (c) meniscus to meniscus coaptation by suture, which excludes entrapment of the posterior capsule, and (d) avoidance of extracapsular posterior neurovascular injury by suture since sutures are tied intraarticularly and avoid entrapping the posterior capsule. Disadvantages of this technique are that it is technically demanding and requires visualization in the posterior compartArthroscopy,
Vol. 7, No. I, 1991
ment with a 70” scope placed through the intercondylar notch, which requires a learning curve for the uninitiated. A second disadvantage is that it requires posterior operative cannula placement, which carries some potential risk of posterior complications. CONCLUSION The arthroscopic “all-inside” meniscus suturing technique offers the arthroscopist a way of placing vertically oriented sutures through peripheral posterior horn tears far posterocentral without the risks of nerve, vessel, or posterior capsular suture entrapment inherent in both the “outside-in” and the “inside-out” arthroscopic methods. This technique
’ ‘ALL-INSIDE”
MENISCUS
introduces new instrumentation that allows the surgeon to both place sutures and tie knots intraarticularly under arthroscopic control.
8. DiStefano VJ, Bizzle P. A technique of arthroscopic meniscoplasty. Orrhopaedics
REFERENCES Il. 12.
1985:198:31-5. vs. arthroscopic. Ar3. DeHaven KE. Meniscus repair--open rhroscopy 1985;1:173~. 4. Hamberg P. Gillquist J, Lysholm J. Suture of new and old peripheral meniscus tears. f Bone Joint Surg [Am] 1983; 65: 193-7.
13. 14. 15.
5. Amoczky
SP. Warren RF. The microvasculature of the human meniscus. Am I Sports Med 1982;10:90-5. arthroscopic 6. Barber FA. Stone RG. Meniscus repair-an technique. .I Bone Joinf Surg [Br] 1985;67:39-41. 7. Clancy WG, Graf BK. Arthroscopic meniscus repair. Orrhopaedics 1983:6: 1125-9.
1983;6: 1135-9. repair of meniscus tears. Ortho-
9. Henning CE. Arthroscopic 10.
I. DeHaven KE. Peripheral meniscus repair: an alternative to meniscectomy. J Bone Joint Surg [Br] 1981;63:463. 2. DeHaven KE. Meniscus repair in the athlete. CORR
12.5
REPAIR
16.
paedics l983;6: 1130-2. Rosenberg T, Scott S, Paulos L. Arthroscopic surgery: repair of peripheral detachment of the meniscus. Contemporary Orrhopaedics 1984;10:43-50. Warren RF. Arthroscopic meniscus repair. Arthroscopy 1985;1:170-2. Morgan CD, Casscells SW. Arthroscopic meniscus repair: a safe approach to the posterior horns. Arthroscopy 19&X6:2:312. Small NC. Complications in arthroscopy: the knee and other joints. Arthroscopy 1986;2:253-8. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arrhroscopy 1988:4:215-21. Morgan CD. Wojtys EM, Casscells CD, Casscells SW. Arthroscopic meniscus repair evaluated by second look arthroscopy: proceedings of the International Knee Society. Am J .S&ts Med 1989;17:724-5. Arnoczky SP, Warren RF. Spivak JM. Meniscus repair using an exogenous fibrin clot. J Bone Joint Surg [Am] 1988:70:1209-16.
Arthroscopy. Vol. 7, NO. I, 1991
and Related
Surgery
7(1):120-125 America
Arthroscopy Association of North
Technical
The
‘
‘All-Inside’
’
Note
Meniscus Repair
Craig D. Morgan, M.D.
Summary: The arthroscopic “all-inside” meniscus suturing technique offers the arthroscopist a way of placing vertically oriented sutures through peripheral posterior horn tears located posterocentral without the risks of nerve, vessel, or posterior capsular entrapment inherent in both the “outside-in” and the “inside-out” arthroscopic methods. This technique introduces new instrumentation that allows the surgeon to both place sutures and tie suture knots intraarticularly under arthroscopic control. Key Words: Meniscus repairPosterior horn-Intraarticular knot tying.
Due largely to the work of DeHaven (l-3) and others (4), peripheral meniscus suture repair by open arthrotomy popularized the concept of meniscus preservation. The classic report of Arnoczky and Warren (5) demonstrated a peripheral meniscal blood supply limited to the outer 25-30% of the meniscus, which defined a vascular basis for potential healing of repaired meniscus tears in this location. Historically, open suture repairs of the meniscus by either posteromedial or posterolateral arthrotomy were the first to appear in the literature (l-4). These repairs placed multiple vertically oriented sutures into the detached meniscus and adjacent capsule, which resulted in an anatomic balanced peripheral repair at the meniscocapsular junction with both the meniscotibial and meniscofemoral portions of the coronary ligament complex firmly apposed to the meniscus at the repair site. Due to difficulties with open exposure, particularly when approaching the posterior horns, meniscus repair by arthrotomy was largely limited to tears located at the meniscocapsular junction or within l-2 mm from the meniscocapsular junction. Substance tears located 2-4
mm central to the meniscocapsular junction were difficult if not impossible to suture by open means. With the development of meniscus suturing methods performed under arthroscopic control, these problems related to exposure were overcome, allowing for more centrally located outer third tears to be repaired (6-12). As arthroscopic “inside-out” repairs became popular in the mid 198Os, the incidence of associated posterior neurovascular injury caused by posterior needle exit became an issue (3,13). In 1986, Small (13) reported 30 saphenous nerve, six peroneal nerve, and three popliteal artery injuries in a review of 3,034 percutaneous inside-out arthroscopic meniscus repairs. In a subsequent report in 1988, Small (14) noted no serious neurovascular injuries when “inside-out” meniscus suturing was done in combination with an open posterior capsular exposure to protect the posterior neurovascular anatomy. In an attempt to avoid posterior neurovascular injury with a percutaneous arthroscopic approach to meniscus suture repair, Warren (11) developed the “outside-in” method, which directs absorbable suture percutaneously through the lumen of a spinal needle placed from a known safe area outside the knee across the tear intraarticularly under arthroscopic control. Morgan and Casscells (12) reported clinical experience with this method and defined the details of safe needle passage. Subsequently, Morgan et al. (15) reported 85% good to excellent results in 75 second looks at “outside-in”
From Sports Medicine, Alfred I. duPont Institute and Delaware Orthopaedic Center, Wilmington, Delaware, and Orthopaedie Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A. Address correspondence and reprint requests to Dr. C. D. Morgan at 2501 Silverside Road, Wilmington, DE 19810. U.S.A. The technique described in this article will be demonstrated in a forthcoming Video Supplement to Arthroscopy.
120
“ALL-INSIDE” repairs. In a larger clinical series, Morgan et al. (IS) noted a 3.4% clinical failure rate, with only one saphenous nerve injury in over 350 “outside-in” repairs. It has been this author’s experience that the most posterocentral peripheral portion of the posterior horns (posterior root) cannot be both anatomically and safely sutured by either the “inside-out” or the “outside-in” methods. With either method, avoidance of the posterior neurovascular structures necessitates suture placement at a high oblique angle in reference to these vertical longitudinal tears located far posterocentral. For this reason, these repairs tend to be nonanatomic and lack the vertical suture orientation felt to be important by DeHaven (3). Also, with regard to posterior horn tears, these arthroscopic methods tie sutures over the posterior capsule rather than directly suturing the meniscus tear. This results in entrapping the posterior capsule, which may lead to the development of a flexion contracture. For these reasons, coupled with the fact that 90% of repairable meniscus tears are located in the posterior horns, this author sought to develop a safe approach to peripheral posterior horn tears that would produce a vertically oriented anatomic suture repair which sutures meniscus to meniscus and excludes the posterior capsule from the repair. OPERATIVE TECHNIQUE In general, the arthroscopic “all-inside” suturing technique recreates the open method of vertical su-
MENISCUS
121
REPAIR
ture placement for the posterior horn under arthroscopic control. In addition, this technique introduces a new concept of arthroscopic intraarticular knot tying whereby, subsequent to suture placement, the suture tails are tied in the posterior compartment apposing meniscus to meniscus with an arthroscopic knot pusher. This method takes advantage of the rather large posterior compartment space that exists where the meniscotibial attachment to the posterior horn of the meniscus forms a large recess posteroinferior to the posterior horn of the meniscus as it becomes confluent with the posterior capsule. This posterior capsular space or recess enlarges with knee flexion and becomes smaller with knee extension. Circumferentially, in the axial plane, the posterior capsular space or recess ends at the posterior meniscocapsular corners. For this reason, the “all-inside” suturing method is only indicated for peripheral posterior horn tears and cannot be used for tears located anterior to either the posterolateral or posteromedial meniscus corners due to lack of space for instrument placement. The “all-inside” meniscus repair requires visualizing the pathology from the posterior compartment with a 70” foreoblique arthroscope placed through the intercondylar notch. This is best accomplished with the knee in flexion to enlarge the posterior compartment space. In this position, the optical lens is rotated 90” (medial or lateral), which gives the surgeon a good view of the posterior compartment including the posterior meniscocapsular junction and posterior capsular recess (Figs. IA and
lA,B
FIG. 1 A: Right knee with a 70” arthroscope through the intercondylar notch from an anterolateral portal and an operative cannula placed in the posteromedial compartment from a posteromedial approach made above the pes anserinus group tendons with the knee flexed 90”. B: Arthroscope placement through the intercondylar notch and suture placement using a suture hook from a posterolateral operative cannula during peripheral lateral meniscal repair.
Arthroscopy.
Vol. 7. No. I. 1991
122
C. D. MORGAN
2A-D). In this author’s experience, peripheral posterior horn tears up to 4 mm central to the meniscocapsular junction can be visualized much better with this approach than from a standard anterior approach. Furthermore, the status of the posterior
peripheral meniscal rim can be better assessed for secondary tears, giving the surgeon more information as to the repairability of a given tear. Once the tear has been visualized, a 7-mm inner diameter operative cannula with semiblunt trochar
FIG. 2. A: Peripheral posterior horn tear of a left lateral meniscus as seen with a 70” arthroscope placed through the intercondylar notch with the tear being probed through a posterolateral cannula. B: Same tear as A seen with suture hook spanning both sides of the tear with suture being threaded through the lumen of the suture hook. C: Same tear as A following suture hook removal leaving a vertical oriented suture through both sides of the tear. D: Same tear as B showing completed repair following intraarticular knot tying. Note apposition of meniscus to meniscus at the tear site with two suture knots evident.
Arthroscopy, Vol. 7, No. I, 1991
“ALL-INSIDE” (Acufex Microsurgical, Norwood, MA, U.S.A.) is placed into the posterior compartment in question from either a posterolateral or posteromedial approach with the knee flexed 90”. The entry point posterior is first localized with an 1%gauge spinal needle that facilitates posterior triangulation in the surgeon’s “minds eye.” The operative cannula’s entrance through the posterior capsule is visualized under direct arthroscopic control while maintaining maximum fluid distention. In order to avoid the peroneal nerve on the lateral side during posterolateral cannula placement, the entry point outside is made well above the palpable biceps femoris tendon slightly above and posterior to the joint line at the posterolateral corner with the knee flexed a90”. On the medial side, the saphenous nerve is avoided by making the posteromedial cannula entry point above the pes group tendons slightly above and behind the posterior joint line at the posteromedial corner, also with knee flexed 290” (Fig. IA). Once proper operative cannula placement posterior is confirmed, the tear region is probed and debrided of all abortive healing response with instruments placed through the operative cannula (Fig. 2A). The local synovium is excoriated using either hand-held rasps or motorized instrumentation. In chronic tears, autogenous clot, as advocated by Arnoczky and Warren (16), may also be placed into the tear region through the posterior operative cannula. Following adequate preparation of the tear region to stimulate a vascular fibrous response, vertically oriented sutures are placed across the tear using a
MENISCUS
REPAIR
tool called a “suture hook” (Concept Inc., South Cleat-water, FL, U.S.A.), which is delivered down the operative cannula. The suture hook is a modified hook-shaped 18-gauge needle with a specialized roller device incorporated into its handle, which facilitates suture delivery through the lumen of its hook-shaped terminal end (Fig. 3A and B). By hand manipulation and rotation of the suture hook, its sharp tip penetrates the peripheral meniscal rim first, then the mobile meniscal fragment second, in a vertical orientation in reference to the body of the meniscus (Figs. 1B and 2B). Following this, suture (“0” PDS; Ethicon, Sommerville, NJ, U.S.A.) is delivered through the lumen of the suture hook, and the suture hook is withdrawn. The terminal end of the suture that has crossed the meniscus repair site is then grasped and brought out the posterior operative cannula. At this point, a vertically oriented suture spans the tear intraarticularly with suture tails that go up the posterior cannula outside the knee (Fig. 2C). The last step is tying the intraarticular knot through the operative cannula. This is accomplished by using an arthroscopic knot pusher (Arthrex; Arthroscopy Instruments Inc., Winooski, VT, U.S.A.). The knot pusher is a metal rod with a cup-shaped terminal end with two holes (one for each suture tail) at 45” from the terminal end (Fig. 4A and B). Using the knot pusher, four to six sequential throws are advanced down the operative cannula, which produce a double or triple “stacked” square knot respectively, which completes the suture repair by coapting meniscus to meniscus at the tear site (Fig. 4C and D). The tails of
3A,B
FIG. 3. A: Concept suture hook (Concept, Inc., South Clearwater, FL, U.S.A.) with monofilament suture threaded from handle through lumen of shaft and terminal hooked end. B: Terminal hooked needle end of a suture hook with monofilament suture threaded out the sharp tip.
Arthroscopy.
Vol. 7, No. I. 1991
124
C. D. MORGAN
4A,B
FIG. 4. A: Terminal end of the Arthrex knot pusher. (Arthrex Arthroscopy Instruments, Inc. Winooski, VT, U.S.A.). B: Terminal end of Arthrex knot pusher with suture present advancing first throw of a square knot. C: Use of the knot pusher through a posterolateral operative cannula during peripheral posterolateral meniscus repair in a left knee.
the completed knot are cut with scissors through the posterior cannula, and this entire process is repeated two or three additional times until the posterior horn is stabilized (Fig. 2D). Advantages of the “all-inside” arthroscopic meniscus repair technique include (a) safe suture placement far posterocentral in the posterior horn, (b) a vertical orientation of the sutures, which facilitates an anatomic repair, (c) meniscus to meniscus coaptation by suture, which excludes entrapment of the posterior capsule, and (d) avoidance of extracapsular posterior neurovascular injury by suture since sutures are tied intraarticularly and avoid entrapping the posterior capsule. Disadvantages of this technique are that it is technically demanding and requires visualization in the posterior compartArthroscopy,
Vol. 7, No. I, 1991
ment with a 70” scope placed through the intercondylar notch, which requires a learning curve for the uninitiated. A second disadvantage is that it requires posterior operative cannula placement, which carries some potential risk of posterior complications. CONCLUSION The arthroscopic “all-inside” meniscus suturing technique offers the arthroscopist a way of placing vertically oriented sutures through peripheral posterior horn tears far posterocentral without the risks of nerve, vessel, or posterior capsular suture entrapment inherent in both the “outside-in” and the “inside-out” arthroscopic methods. This technique
’ ‘ALL-INSIDE”
MENISCUS
introduces new instrumentation that allows the surgeon to both place sutures and tie knots intraarticularly under arthroscopic control.
8. DiStefano VJ, Bizzle P. A technique of arthroscopic meniscoplasty. Orrhopaedics
REFERENCES Il. 12.
1985:198:31-5. vs. arthroscopic. Ar3. DeHaven KE. Meniscus repair--open rhroscopy 1985;1:173~. 4. Hamberg P. Gillquist J, Lysholm J. Suture of new and old peripheral meniscus tears. f Bone Joint Surg [Am] 1983; 65: 193-7.
13. 14. 15.
5. Amoczky
SP. Warren RF. The microvasculature of the human meniscus. Am I Sports Med 1982;10:90-5. arthroscopic 6. Barber FA. Stone RG. Meniscus repair-an technique. .I Bone Joinf Surg [Br] 1985;67:39-41. 7. Clancy WG, Graf BK. Arthroscopic meniscus repair. Orrhopaedics 1983:6: 1125-9.
1983;6: 1135-9. repair of meniscus tears. Ortho-
9. Henning CE. Arthroscopic 10.
I. DeHaven KE. Peripheral meniscus repair: an alternative to meniscectomy. J Bone Joint Surg [Br] 1981;63:463. 2. DeHaven KE. Meniscus repair in the athlete. CORR
12.5
REPAIR
16.
paedics l983;6: 1130-2. Rosenberg T, Scott S, Paulos L. Arthroscopic surgery: repair of peripheral detachment of the meniscus. Contemporary Orrhopaedics 1984;10:43-50. Warren RF. Arthroscopic meniscus repair. Arthroscopy 1985;1:170-2. Morgan CD, Casscells SW. Arthroscopic meniscus repair: a safe approach to the posterior horns. Arthroscopy 19&X6:2:312. Small NC. Complications in arthroscopy: the knee and other joints. Arthroscopy 1986;2:253-8. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arrhroscopy 1988:4:215-21. Morgan CD. Wojtys EM, Casscells CD, Casscells SW. Arthroscopic meniscus repair evaluated by second look arthroscopy: proceedings of the International Knee Society. Am J .S&ts Med 1989;17:724-5. Arnoczky SP, Warren RF. Spivak JM. Meniscus repair using an exogenous fibrin clot. J Bone Joint Surg [Am] 1988:70:1209-16.
Arthroscopy. Vol. 7, NO. I, 1991