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January 2004 • Volume 20 • Number 1

Technical note
All-inside suture technique using two posteromedial portals in a medial meniscus posterior horn tear

Jin Hwan Ahn, M.D, Ph.D.^a ^* [MEDLINE LOOKUP]
Seung-Ho Kim, M.D.^a [MEDLINE LOOKUP]
Jae Chul Yoo, M.D.^a [MEDLINE LOOKUP]
Joon Ho Wang, M.D.^a [MEDLINE LOOKUP]

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Abstract

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Up to two thirds of patients with anterior cruciate ligament rupture have a combined medial meniscus posterior horn tear. Researchers have proven the importance of repairing this tear to enhance stability after anterior cruciate ligament reconstruction. However, repairing the meniscal tear can be sometimes cumbersome and difficult or even impossible in certain circumstances, especially in places such as the posterior horn of the medial meniscus. We devised a simple and easy method of all-inside suturing of medial meniscus posterior horn tears using a 2-posteromedial portal system. Furthermore, with a modification of our technique, a clinician can not only suture single but also double longitudinal medial meniscus posterior horn tears.

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Keywords: Medial meniscus posterior horn tear, Anterior cruciate ligament injury, Double posteromedial portal, Arthroscopic all-inside suture

Up to two thirds of patients with anterior cruciate ligament (ACL) rupture have combined medial meniscus posterior horn tear.^1,2 Repairing this torn meniscus anatomically allows the reconstructed ACL knee to be more stable than those with meniscectomized or unrepaired knees.³ However, many surgeons overlook this combined tear because of its concealing location and benign-looking appearance from the anterior portals (Fig 1). Furthermore, it is sometimes technically or structurally difficult or even impossible to repair the medial meniscus posterior horn tear.

Meniscal repairs are performed using inside-out, outside-in, and all-inside techniques.^4–10 However, inside-out and outside-in techniques all have several limitations in the meniscal suture at the posterior horn.

Figure 1. (A) The benign-looking appearance of the medial meniscus posterior horn tear seen by the standard anterior portal. (B) From the standard posteromedial portal, with a probe, the tear clearly seen.

Click on Image to view full size

Predominantly, this location is more difficult to access and includes a danger of major neurovascular injury, and fixing the meniscus together with the capsule restricts movement and causes pain. Among all-inside repair methods, bioabsorbable meniscal fixators have recently received great attention because of its simplicity in application. Despite the positive aspects, because frequently the medial meniscus posterior horn tear occurs near the meniscocapsular junction, especially in patients with ACL insufficiency, meniscal fixators are relatively contraindicated in this area because it has weak holding strength.

Conversely, all-inside meniscal suturing, which Morgan⁸ describes, allows placement of vertically oriented sutures, which have the strongest pullout strength.¹¹ Also, because the sutures are placed perpendicular to the tear without entrapment of the posterior capsule, the technique results in a balanced anatomic repair with good tissue approximation on the torn meniscal end. However, Morgan’s technique⁸ of all-inside suturing has several disadvantages,¹² mainly regarding the high technical demand.

We searched for alternatives, seeking easier and better ways of accomplishing an all-inside suture. We developed an all-inside suturing technique using 2 posteromedial portals. This technique is easier than Morgan’s technique⁸ and broadens the possible suture area for repair in the medial meniscus posterior horn tear. The ideal indication for this technique is medial meniscus posterior horn tear, which is within 3 mm from the peripheral meniscal rim (meniscocapsular junction). In addition, we introduced modification to our suturing technique for tears more than 3 mm from peripheral rim and double longitudinal medial meniscus posterior horn tears. This report introduces our surgical procedure.

Surgical technique

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Patient positioning

Allowing adequate room for placement of the posterior portals and space for maneuvering the intra-articular instruments is imperative when positioning the patient. The opposite healthy limb is elevated in a lithotomy position for further space security. The injured knee should be flexed 90°, which makes the posterior compartments roomy and enlarged. Also, this position permits manipulation of intra-articular instruments with relative ease and simultaneously protects the saphenous nerve by displacing it well posterior from the joint line.

Portal placement

The standard anterolateral and anteromedial portals are used for comprehensive examination with a 30° arthroscope and a probe. If medial meniscus posterior horn tear is suspected from preoperative magnetic resonance imaging (MRI) or scope examination, or if ACL ligament was torn concomitantly, the posterior compartment is approached by passing the 30° arthroscope from anterolateral portal through the intercondylar notch between the medial femoral condyle and the posterior cruciate ligament (PCL). This is first facilitated by placing the anterior portals close to the lateral margins of the patellar tendon.¹³ Afterward, a standard posteromedial portal is created under direct arthroscopic visualization.¹⁴ This initial standard portal is relatively small compared with the second posteromedial portal. This makes instruments such as the suture hook, easy to move and manipulate. Using a probe, the posterior compartment is examined thoroughly. Switching the scope to the posteromedial portal, the posterior horn is re-examined. After establishing a suture plan, a 70° arthroscope is reinserted to the anterolateral portal and placed through the intercondylar notch to view the posterior compartment.

The second posteromedial portal, which is a superior posteromedial portal, is marked 1 cm superior to the previous standard posteromedial portal. The entry point is then localized with an 18-gauge spinal needle while viewing from inside. After the proper position is confirmed, a skin incision and subcutaneous dissection are performed. A 5.5-mm diameter universal cannula (Linvatec, Largo, FL) is placed into this superior posteromedial portal (Fig 2).

Figure 2. (A) Schematic cross-section of the knee with 2 posteromedial portals. The drawing shows the location of the 2 posteromedial portals and the anterolateral viewing portal. (a, anterior portal; b, standard posteromedial portal; c, superior posteromedial portal.) (B) The portal with cannula is seen from the outside.

Click on Image to view full size

All-inside meniscal suture technique

A Linvatec suture hook loaded with a PDS No 0 (Ethicon, Somerville, NJ) is inserted through the standard posteromedial portal. The sharp hook tip first penetrates the meniscal peripheral rim tissue (meniscocapsular tissue first) from superior to inferior (Fig 3). Then it is advanced under and across the tear before penetrating the mobile central fragment from inferior to superior.

Figure 3. The suture hook loaded with PDS penetrates the torn meniscus from superior to inferior of the peripheral meniscal rim (meniscocapsular junction), and the tip is seen out of the torn hole.

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During this procedure, the surgeon must recognize that the peripheral rim of the torn meniscus is almost always displaced inferiorly relative to the mobile central fragment (Fig 4). Without caution, the entire thickness of the peripheral rim portion can be penetrated, which will result in a poor tissue approximation.

Figure 4. The relative position of the peripheral rim to the torn central meniscal fragment. (A) It generally lies below the central fragment. (B) This is also true for double longitudinal tears. These schematic figures show the relative location of the peripheral rim to the torn meniscus. Peripheral rim of the torn meniscus is almost always displaced inferiorly relative to the mobile central fragment.

Click on Image to view full size

The surgeon can essentially verify this with the suture hook by penetrating the whole thickness of the peripheral rim and making the tip of the hook come out of the torn interval before making additional sutures at the mobile central fragment.

Sometimes the portion of the torn central meniscus may be difficult to pierce because of its mobility, a probe was inserted into the universal cannula, aiding the suture. The probe holds the central fragment down to the tibial surface, and the suture hook penetrates from the inferior to superior side. Surgeons can use any other instruments that suit their convenience in aiding suturing. Using a suture retriever, both suture ends are brought out to the universal cannula. The SMC (Samsung Medical Center) knot¹⁵ is made externally and is slid inside toward the cannula with a knot pusher. An additional 2 or 3 half-hitch knots with alternating posts on reverse throws are made, and the procedure is carefully inspected arthroscopically. Because the capsular recess, which is the peripheral rim portion of the meniscocapsular junction, has sufficient space available, tied knots are placed toward this capsular recess. This can be performed more easily by making the capsular limb the post.

For good coaptation and stable fixation of the torn meniscus, we advise placing 3 to 4 sutures (Fig 5A; panel B shows complete healing of the same tear).

Figure 5. (A) Three to 4 sutures are made with the knots placed toward the capsular recess. (B) Complete healing is shown on the second-look arthroscopy at final follow-up evaluation.

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Firm suturing is re-examined with a probe. This all-inside suturing technique is ideal for medial meniscus posterior horn tears that are within 3 mm of the peripheral rim. However, we can also apply the technique to tears more than 3 mm from the peripheral rim and in double longitudinal tears with slight modification. We will also introduce the modified technique.

All-inside suturing of a single medial meniscus posterior horn tear that is more than 3 mm from the peripheral rim is identical to a double longitudinal tear, and we only introduce the double longitudinal tear suture technique in this article. In repairing this complex tear, a Shuttle-Relay (Linvatec, Largo, FL) was used to repair both tears with 1 suture. To make the description simpler, between the 2 longitudinal tears, we named the more peripheral tear site as the outer tear and the more central tear site as the inner tear (Fig 6A).

A suture hook loaded with PDS No. 0 is introduced to the standard posteromedial portal, and then a suture is made starting from the hole of the inner tear penetrating the most central fragment from inferior to superior (Fig 6B).

Figure 6. Suture sequence in medial meniscus posterior horn double longitudinal tear. (A) Schematic drawing of the double longitudinal tears on coronal plane. (B) The initial suture loaded with PDS is made on the far central mobile fragment from inferior to superior. (C) Both limbs of the suture material are drawn to the cannula. The first limb that was drawn out of the cannula is identified with a hemostat. (D) The second suture hook loaded with Shuttle-relay system is introduced through the standard PM portal to penetrate the peripheral rim of the meniscus from superior to inferior. The hook comes out of the inner torn hole, crossing the outer tear underneath. (E) The PDS, which is unmarked, is hooked to the shuttle-relay. (F) The shuttle relay is redirected to the standard PM portal. (G) A crochet hook is used to pull the limb through the cannula, and the SMC knot is made. (H) The complete suture is made, and the knot is placed toward the peripheral capsular recess.

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During this procedure, care must be taken not to damage the cartilage of the femoral condyle, because the hook is closest to the condyle during this procedure. A grasper through the universal cannula retrieves the forwarded suture limb, placing one end of the suture limb outside the universal cannula. Grasp this limb with a hemostat for identification. And then the other limb, which lies outside of the working standard portal, is also retrieved with a grasper or crochet hook to the cannula. Make sure to distinguish the 2 suture limbs because the suture limb that was in the standard portal (the limb that is coming out from the tear hole and the limb that is not marked with a hemostat) will be hooked to the Shuttle-Relay system (Fig 6C).

A second suture hook loaded with a Shuttle-Relay system was introduced via the standard posteromedial portal, and another suture is made piercing peripheral rim tissue from superior to inferior. The hook loaded with shuttle-relay crosses under the outer tear and comes out superiorly through the inner tear hole (Fig 6D). As the shuttle-relay is fed out of the hook, a grasper retrieves the relay through the universal cannula. The initial PDS suture limb is now hooked to the relay system and redirected to pass the peripheral rim of the meniscus (Fig 6E, F). Both ends of the suture are retrieved through the universal cannula with a suture retriever. A SMC knot is made and is slid with a knot pusher, with additional securing half-hitch sutures (Fig 6G, H). A firm repair is examined with a probe.

If the tear is extended to the midhorn, our modified inside-out technique or meniscal fixators are used in combination with all-inside suturing. If the patient has ACL insufficiency, ACL reconstruction is performed after the meniscal repair. For these patients, we repair the meniscus without tourniquet application and the ACL reconstruction with a tourniquet. This reduces the time needed for tourniquet application. Postoperative management includes a brace for 4 weeks, partial weight bearing after 2 weeks, and full weight bearing after 8 weeks.

Discussion

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Meniscal fixators, despite some early promising clinical results,^16–18 have been often reported as having several complications. The implant is too rigid and the knot is made in the articular surface of meniscus and is easy to break. Other complications include an inflammatory reaction combined with synovitis, possible cyst formation, possible migration, chondral injury, and insufficient tissue approximation.^{12,16,18–26} Most importantly, they are relatively contraindicated in tears near the meniscocapsular junction.

Morgan’s all-inside suture technique⁸ has several limitations. The limitations include (1) greater loss of fluid through the 8-mm cannula, which causes insufficient articular distention;¹² (2) a restricted area available for meniscus suture that consists of only approximately 3 mm of the meniscocapsular junction, (3) more technical difficulty in manipulating the suture hook through a single cannula, which is relatively rigid, and simultaneously suturing the highly mobile central torn fragment portion of the medial meniscus, and (4) a higher risk of articular cartilage damage because of the rigidity of the cannula during hook manipulation. Consequently, we were forced to limit usage of this technique.

To overcome these difficulties, we used a superior posteromedial portal to manipulate the instruments and reduced the torn fragment with a probe or other instrument during this suturing procedure. Advantages of this all-inside arthroscopic meniscus suture technique include (1) a smaller cannula (5.5 mm universal cannula), which minimizes water leakage and tissue damage; (2) greater ease in manipulating and maintaining reduction of the torn fragment with probe assistance, even for double longitudinal tears; (3) a lower rate of cartilage damage by the suture hook because of probe assistance; (4) expansion of the indicated area of repair; and (5) all other existing merits of all-inside sutures such as vertically oriented anatomic sutures, no posterior neurovascular injuries, no entrapment of the posterior capsule, and no additional posterior incision.^6,8 Overall, these advantages allow us to perform all-inside sutures with ease.

Furthermore, the standard portal without cannula greatly improves instrumentation. This freedom allows us to make more than 3 to 4 sutures to the torn meniscus, whereas Morgan’s technique⁸ only allows 1 or 2 sutures. This freedom also allows us to suture the far medial corner and tears more than 3 mm from the peripheral rim. Reigel et al.⁶ reported that only 15% of all medial meniscal tears are suitable for the all-inside repair. However, with this relative freedom of instruments, indication for all-inside techniques can be expanded to far medial corner tears and more central tears.

We have found that tears up to 5 mm from the meniscocapsular junction healed well with our suturing technique (Fig 7). Because the tear is located more than 3 mm from the peripheral meniscal rim, we had to modify our suturing method.

Figure 7. (A) The MRI findings show double longitudinal tears. (B) The standard posteromedial portal and a probe verify the lesion. (C) Complete suturing of the double longitudinal tear with our all-inside suture technique. (D) Follow-up MRI after 6 months shows complete healing of the posterior horn tear.

Click on Image to view full size

This was also true for double longitudinal tears in which the inner tear is probably 3 mm or more from the peripheral rim. If the suture is performed as previously described (from the peripheral side to central side), we have a greater chance of penetrating only a fraction of the mobile central fragment because of limited space available for hook manipulation. Therfore, reversed order was applied to ensure complete penetration of the meniscal thickness and to avoid the danger of cartilage injury.

From May 1997 to June 2001, the senior author (J.H.A.) performed this all-inside meniscal repair with ACL reconstruction in 78 knees in 78 patients, excluding lateral meniscal repair. For 39 of the 78 patients, it was possible to evaluate the healing of meniscal repair with second-look arthroscopy performed on average 19 months (range, 6 to 40 months) after meniscal repair with the ACL reconstruction. The success rate was 97.4% (38 of 39 patients) overall for all-inside suture healing.

The major drawback in our technique is the extended surgical time. However, all-inside suture techniques seem to be the optimal answer to medial meniscus posterior horn tears, because this is the only method that gives us vertically oriented sutures with good tissue approximation without concern about neurovascular injuries. Using this 2 posteromedial portal system, attempts to repair one of the most challenging tears in the posterior horn region of medial meniscus are promising, with expected optimal results.

Acknowledgements

The authors deeply thank Chan Hwa Park and Myung Ju Shin for their assistance with the drawings in this article.

References

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1. Indelicato PA, Bittar ES. A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases. Clin Orthop 1985;198:77-80.