Modified suture shuttle technique used for outside-in double-lasso loop meniscal repair
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Injuries to the meniscus are among the most common knee injuries and they are the most common reason for surgery performed by orthopedic surgeons.
The meniscus has well-established biomechanical properties that make it a critical structure in a normal functioning knee joint. The meniscus functions as a secondary stabilizer of the knee joint and contributes to load transmission, shock absorption, proprioception and joint lubrication. Several characteristics of the meniscal tear and a variety of patient factors must be considered when determining repair suitability and healing potential. Multiple studies have demonstrated that despite having higher reoperation rates, patients experience improved outcomes, including higher activity levels and slower progression of subsequent knee osteoarthritis, when meniscus tears are repaired as opposed to treated with partial or complete meniscectomy.
Given the essential biomechanical properties of the meniscus and the associated improved clinical outcomes that result when meniscal injuries are repaired, there has been a large emphasis on meniscal preservation and optimal repair techniques. Meniscal repair techniques have evolved in the past few decades. Commonly used techniques for meniscal repair include inside-out, outside-in and all-inside techniques. Of these techniques, outside-in repair is ideal for meniscal tears in the anterior horn to middle body segment of the meniscus because it allows for adequate access, stable fixation and avoids leaving prominent intra-articular material with a minimal approach. The purpose of this surgical technique description is to provide the unique steps relevant to the outside-in double-lasso loop technique as a distinct modification of previously published outside-in techniques for meniscal repair.
Surgical technique
To complete each meniscus repair, three basic and readily available materials are required: 18-gauge by 3.50-inch spinal needle, 0 polydioxanone (PDS) suture and nonabsorbable 2-0 FiberWire (Arthrex) (Figure 1). Additionally, if a curved needle is more appropriate for better access to the meniscus tear, the Meniscus Mender II (Smith & Nephew) may alternatively be used instead of the straight 18-gauge spinal needle.
Source: Ryan J. Urchek, MD
These basic materials can be pre-assembled on the back table to create the double lasso and set aside for later use during the meniscal repair. To assemble the double lasso, load the 0 PDS suture in the 18-gauge by 3.50-inch spinal needle and loop the 0 PDS suture around the heel of the bevel (point is opposite the tip of the bevel) so as not to cut the suture during percutaneous placement of the needle (Figure 2).
A complete diagnostic arthroscopy using standard portals is performed with meniscal tear evaluation, as well as preparation. An assessment is made to determine what the meniscal repair construct will look like (Figure 3), whether the tear pattern is more amenable to a vertical mattress vs. horizontal mattress repair, to one vs. multiple repair stitches, etc.
Create double-lasso suture
For this technique, we demonstrate repair of a horizontal tear within the mid-body lateral meniscus with a vertical mattress construct (Video). With the camera in the anteromedial portal, the first spinal needle with suture lasso is passed percutaneously through the inferior leaflet of the meniscus tear (Figure 4). Counterpressure on the inferior leaflet of the meniscus with a probe through the initial anterolateral (AL) portal can be used while passing the spinal needle so as not to place undue stress on the meniscus or propagate the tear. Alternatively, a separate spinal needle can be used to temporarily hold the inferior leaflet of the meniscus in place during passage of the first spinal needle with suture lasso. Once the first spinal needle with suture lasso is appropriately placed in the inferior leaflet of the meniscus, it is left in place while attention is turned to placing the second spinal needle with suture lasso to create the double lasso. The second spinal needle with suture lasso is percutaneously placed through the superior leaflet of the meniscus tear (Figure 5). The superior leaflet tends to be more stable secondary to the meniscocapsular attachment making utilization of a probe or accessory spinal needle for stabilization for counterpressure less important.
Once both spinal needles have been appropriately placed, an arthroscopic grasper is used to simultaneously retrieve the double-lasso 0 PDS sutures through the AL portal (Figure 6). By simultaneously retrieving the double-lasso 0 PDS sutures, a soft tissue bridge can be avoided, obviating the need for a cannula. To prevent the spinal needle from cutting the suture, the two spinal needles are removed prior to pulling the suture loops out of the AL portal. At this point, there are four free ends of 0 PDS out of the lateral aspect of the knee and two looped 0 PDS sutures (double lasso) out of the AL portal. The nonabsorbable 2-0 FiberWire repair suture is then placed through a single lasso of 0 PDS and shuttled through the inferior leaflet of the meniscus tear by pulling on the two corresponding free ends of 0 PDS exiting the lateral knee (Figure 7). Passage of the 2-0 repair suture should be visualized arthroscopically and assisted with the use of a probe, as needed, to ensure smooth shuttling of the suture. Next, the other end of the nonabsorbable 2-0 repair suture is placed through the second single-looped 0 PDS and similarly shuttled across the superior leaflet of the meniscus tear out the lateral incision (Figures 8 and 9). Next, a small incision can be made between the sutures on the lateral aspect of the knee. Dissection is carried down to the capsule with use of a hemostat so as not to injure sensory nerves or unintentionally violate the capsule. A probe can be used to retrieve the suture tails out of this lateral incision. A sliding or non-sliding knot is then tied on the outside of the exposed capsule and the stability of the repair is assessed with the arthroscopic probe (Figure 10). Additional repair sutures can be passed as needed, based on meniscal tear morphology, by repeating the aforementioned steps.
Conclusion
This technique provides several advantages when performing an outside-in meniscus repair. It is cost-effective as the materials required are readily available and inexpensive compared with other meniscus repair devices and instrumentation. This technique does not require cannula placement as both suture limbs are retrieved at the same time and a tissue bridge is avoided. The puncture holes from a spinal needle are smaller than typical “all-inside” devices. Lastly, this technique is relatively easy and reproducible for orthopedic surgeons to add to their armamentarium when treating specific meniscus tears.
- References:
- Allen AA, et al. Oper Tech Orthop. 1995;doi.org/10.1016/S1048-6666(95)80041-7.
- Menge TJ, et al. Arthrosc Tech. 2016;doi:10.1016/j.eats.2016.06.005.
- Peña E, et al. Clin Biomech (Bristol, Avon). 2005;doi:10.1016/j.clinbiomech.2005.01.009.
- Steiner SRH, et al. Arthrosc Tech. 2018;doi:10.1016/j.eats.2017.09.006.
- Xu C, et al. Knee Surg Sports Traumatol Arthrosc. 2015;doi:10.1007/s00167-013-2528-6.
- For more information:
- Dorsey R. Ek, MD, MS, is an orthopedic surgery resident at Summa Health Orthopedic Surgery. Alexander Malik, MD, is an internal medicine resident physician at Summa Health System. Blake R. Schach, MD, is an orthopedic surgery resident at Summa Health Orthopedic Surgery. Ryan J. Urchek, MD, is an orthopedic surgeon at Summa Health Sports Orthopedic Surgery. They can be reached at 525 East Market St., Akron, OH 44304. Ek’s email: dre16048@gmail.com. Malik’s email: malikal@summahealth.org. Schach’s email: schachb@summahealth.org. Urchek’s email: urchekr@summahealth.org.
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