Inside-Out Meniscal Repair: Medial and Lateral Approach

Abstract

Preservation of meniscal tissue has been proven to be the best approach in most cases of meniscal tears. Currently available techniques for treating a peripheral meniscal tear include inside-out, outside-in, and all-inside techniques. Each of these techniques present potential advantages and disadvantages. Despite technologic advances in all-inside devices, because of implant-related complications, cost concerns, and device availability, the inside-out technique is still the preferred method among many surgeons. Although the inside-out repair technique is considered more technically demanding and requires additional incisions, it has several advantages such as the possibility for an increased number of sutures, creating a stronger construct, and greater versatility in their placement. This article describes the inside-out meniscal repair technique with its corresponding posterolateral and posteromedial surgical approaches.

Fig 1

Anatomic landmarks for lateral approach in a cadaveric right knee: (A) Gerdy tubercle, (B) fibular head, and (C) marked transverse oblique–oriented incision.

Fig 2

Cadaveric right knee showing (A) the subcutaneous tissue, (B) the iliotibial band (ITB) debrided from the subcutaneous tissue proximal and distally, and (C) the ITB incised 5 mm anterior to the posterior margin of the superficial layer of the ITB.

Fig 3

Cadaveric right knee showing blunt dissection toward the fibular head through a transverse iliotibial band window.

Fig 4

Cadaveric right knee with a metal spoon placed at the lateral interval (anterior to the lateral gastrocnemius and posterior to the posterolateral capsule [PLC]) to act as a retractor to protect the neurovascular bundle. (ITB, iliotibial band.)

Fig 5

Anatomic landmarks for surgical approach in a cadaveric right knee: (A) adductor tubercle (AT) position, (B) posterior aspect of the medial tibial plateau, and (C) oblique vertically oriented incision centered on the tibiofemoral joint line.

Fig 6

Right knee showing (A) the anterior incision to the sartorial fascia; (B) blunt dissection of the semimembranosus fascia; and (C) the anatomic triangle formed by the posteromedial capsule (PMC) as the anterior wall, semimembranosus tendon (SM) as the floor, and medial gastrocnemius (MGT) as the posterior wall and roof. (sMCL, superficial medial collateral ligament.)

Fig 7

(A) Targeted triangle interval (dashed outline) and (B) magnified image with a metal spoon placed into the interval, protecting the popliteal vessels, in a right knee.

Fig 8

(A) Arthroscopic image of a left knee showing a suture needle penetrating the superior border of the lateral meniscus as viewed through the anteromedial parapatellar portal. (B) Intraoperative photograph of a left knee showing the use of a suture-passing device inserted through the lateral parapatellar portal, while the arthroscope is in the medial parapatellar portal. The assistant is preparing to retrieve the suture through the posterolateral portal for approach.

Fig 9

Intraoperative photograph of a left knee after the sutures have all been passed through the meniscus. The knee is flexed to 90°, and the sutures are tied, with care taken not to over-tighten the tissue.

Fig 10

Arthroscopic image of inside-out meniscal repair showing suture placement through the superior border of the medial meniscus and through the superior capsule (anteromedial portal) of the left knee. The same procedure is performed on the inferior border of the meniscus and the inferior capsule.

Fig 11

Arthroscopic images showing steps for meniscal suture placement in the left knee. (A) In 20° to 30° of knee flexion, a meniscal needle is advanced through the superior border of the meniscus. (B) The inferior capsule is penetrated with the needle. (C) Final result of repaired meniscus (femoral side).

Fig 12

Arthroscopic image of the left knee showing the final result of the repaired medial meniscus (M) with sutures on both sides of the meniscus going through the capsule.