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Suture-based arthroscopic repair promotes healing and preserves the meniscus
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Nicholas A. Sgaglione
The natural history of the knee can be improved and knee function restored when meniscal tears are repaired in younger active patients. Therefore, having an effective, minimally invasive and technically reproducible suturing procedure at your disposal for managing these tears arthroscopically can prove invaluable.
Equally important, however, is using that technique when it is optimally indicated to promote more successful healing in select patients. Among my indications for all-inside and outside-in suture-based arthroscopic repair of meniscal tears are symptomatic unstable tears, tears greater than 7 mm to 10 mm long, vertical or longitudinal tears, red-red and red-white tears, and patients who will be compliant with the rather stringent post-surgical rehabilitation protocol.
Clinical profiling every case is essential, as is intraoperative assessment of the patient’s tear site tissue viability and reparability. For example, for a 35-year-old patient in whom I am performing an indicated ACL reconstruction I will consider repairing a concomitant meniscus tear if it looks repairable and the tissue is viable. On the other hand, I will resect rather than repair a torn meniscus in a 25-year-old patient whose tissue is deformed — not viable — and whose meniscus has a complex or irregular pathology and I am uncertain I can get it to heal.
Viability is the most important consideration in these cases in addition to the goals of the patient.
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Images: Sgaglione NA |
All outside-in technique
There are some key surgical pearls that make the all-arthroscopic outside-in procedure easy to complete, simple and cost-effective to perform at ambulatory surgical centers. An inside-out technique that requires multiple potential $400 all-inside suture repair devices is not always the only or best solution. I suggest learning outside-in repair, as well as all-arthroscopic methods, which is what I now use in most outpatient meniscal repairs.
Clinical and basic science work has demonstrated the importance of tear site preparation to promote a healing response, such as shaving any fragments as well as the surface of the meniscus, rasping it and abrading the meniscosynovial-capsular junction. Furthermore, trephination with an 18-gauge spinal needle, carried out to create vascular access channels, promotes a healing response based on results of second-look arthroscopy performed in the early postoperative period. If successful, the procedure creates an improved healing environment and is therefore effective at increasing the vascularity of a relatively hypovascular structure.
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Trephination and preparation
Trephination is performed inserting the spinal needle perpendicular to the meniscal circumferential band and requires that the surgeon always respect the ultrastructure of the meniscus. If you plan to trephinate and create vascular access channels, it is preferable to not carry out meniscal perforations in a perpendicular manner. A central Gilquist portal from the center and front of the knee may be a more effective approach.
The repair technique selected to ultimately perform the procedure depends on surgeon preference and choice regarding which all-arthroscopic suture device is used. There are six different proprietary systems now available, all of which allow all-arthroscopic suture placement that facilitates compression across the tear site. Gaining balanced compression allows you to optimize the suture construct so you can leave the operating room knowing you have done the best job possible with the most secure fixation. This not only translates into clinical success, but also enhances the progression of rehabilitation.
Shown on this page, is one all-arthroscopic suture device used for a posterior-horn lateral meniscus tear repair. In this case, you can place a vertical mattress suture using an all-arthroscopic device, but you must be cognizant of the depth of penetration of the needle delivery device and where the popliteal artery is at all times, with the depth stop set at 17 mm. This is particularly critical in the posterior horn of the lateral meniscus.
Use of a pre-tied tensioning knot is facilitated by the “pull-push” method of pulling on the suture tail while advancing a knot pusher to gain compression of the suture construct. Both steps enable creating a final meniscal construct that is optimal for healing.
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Attention to the tibial side
One goal of meniscal repair is to create a superior biomechanical result. During meniscal surgery, however, we tend to focus on the femoral side because the compartment may be tight and we typically struggle with it more. As a result, surgeons often place vertical mattress sutures on the femoral side of the meniscus. Placing a single vertical mattress suture on the femoral side of the meniscus may close down the femoral side and make that side of the meniscus the compressive side, but in turn, this may result in gapping, in which the tibial side becomes distracted.
At the conclusion of the procedure, if balanced compression is not achieved, then the meniscus puckers up and its inner taper lifts up, which is biomechanically inferior.
To address the gapping and resultant puckering, place a tibial suture on the tensile side to reduce the gap and balance out the compression across the meniscus. Alternate placement of vertical mattress sutures on the femoral and then the tibial sides results in a stronger, more optimal and anatomic repair.
My common indication for use of an all-arthroscopic suture device for repair is the non-displaced, non-deformed meniscus with associated ACL surgery. In certain cases where significantly displaced bucket handle tears tend to displace after reduction, I prefer using inside-out suture techniques.
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Outside-in suture techniques
There are advantages to outside-in suturing. It does not call for one or two assistants, as is the case with inside-out repairs. Furthermore, outside-in suturing supplies/devices can cost less than $100 per case.
One method that can be surgeon friendly uses two spinal needles and a proprietary needle kit for outside-in suturing. I have also used 3-0 stainless steel suture wire, essentially passing a wire loop down one of the 18-gauge spinal needles and advancing suture down the other. I then mate the two and then create either a vertical or a horizontal mattress configuration. In all, this takes about less than 15 minutes to complete, is cost-effective and works well for anterior horn and mid-horn third tears.
The patient’s anatomy and certain tear geometry usually dictate when I use outside-in suturing.
Meniscal repair should take into account the strength of suture and compression at the surgical site. Whatever technique you use, obtaining compression before you leave the operating room is important. I suggest studying and practicing with the available, proprietary arthroscopic systems in a laboratory setting to select the best one for you; keeping in mind they all have learning curves. Based on my experience, the learning curve should be conquered in the cadaver lab.
Individualized rehabilitation
Rehabilitation must be individualized and can be different when I carry out a repair compared to a resection. Therefore, I typically cite the 6-and-6 rule for patients: 6 weeks of recovery for partial meniscal resection without an associated ACL tear and a rehabilitation program after meniscus repair that may impact a patient’s life and activity level for 6 months following surgery.
Ultimately, you need a safe and reproducible method for doing meniscal repairs that preserves torn menisci in active young patients. The practical outside-in approach provides another technical option other than an all-arthroscopic repair and adds considerably to your armamentarium.
Reference:
- Sgaglione NA. Meniscal repair techniques: All inside and outside in suture-based techniques. Presented at Orthopedics Today Hawaii 2012. Jan. 15-18. Wailea, Hawaii.
For more information:
- Nicholas A. Sgaglione, MD, can be reached at University Orthopaedic Associates and the Department of Orthopaedic Surgery, North Shore – Long Island Jewish Medical Center, 611 Northern Blvd., Great Neck, NY 11021; 516-723-2663; email: nas@optonline.net.
- Disclosure: Sgaglione receives royalties from Biomet Sports Medicine.