The modified cross-suture technique for unilateral pulled-out anchor during all-inside meniscal repair

Abstract

Background: Meniscal repair has received increasing attention, but for inexperienced doctors, unilateral suture anchor pulling out may occur during all-inside meniscal repair, and the treatment outcome may be affected. When the errors happened intraoperatively, how to minimize the loss under guaranteeing of treatment effectiveness is a topic worth studying.

Purpose: To explore the practicability and effectiveness of the modified cross-suture method for arthroscopic remediation of unilateral suture anchor pulling out of an all-inside meniscal repair system.

Methods: From May 2014 to May 2017, 28 patients diagnosed with injuries of the meniscus and anterior cruciate ligaments (ACL) from the First Department of Orthopaedics of the Second Affiliated Hospital of Xi'an Jiaotong University were enrolled in the study as the observation group, including 18 males and 10 females with an average age of 25.5 ± 2.3 years (range 18-42 years). All patients underwent ACL reconstruction concurrently. All meniscus injuries were repaired with an all-inside meniscal repair technique, and 1-3 needles of unilateral suture anchor pulling out occurred intraoperatively. The modified cross-suture method was used to remedy the error of anchor pulling out and to eventually complete an effective repair. Another 30 patients who underwent ACL reconstruction and all-inside meniscal concurrently without unilateral suture anchor pulling out, including 20 males and 10 females with an average age of 26.3 ± 1.9 years (range 19-45 years), were enrolled as the control group. During postoperative follow-up, range of motion, Lachman test and pivot shift test were performed during the physical examination. The clinical healing of the meniscus was evaluated according to the Barrett standard. The meniscus healing status was also confirmed with magnetic resonance imaging (MRI). The function of the knee joint was evaluated according to the IKDC, Lysholm and Tegner scores.

Results: Twenty-five patients in the observation group and 28 patients in the control group completed the follow-up, with an average follow-up of 18.4 ± 5.2 months. All operations were performed by the same surgeon. At the follow-up 1 year after the operation, the average knee ROM of the two groups was 125.2 ± 4.3 degrees and 124.7 ± 3.8 degrees, the clinical healing rate of the meniscus of the two groups was 92.0% (23/25) and 92.9% (26/28), the MRI healing rate of the menniscus of the two groups was 72.0% (18/25) and 71.4% (20/28), and the IKDC, Lysholm and Tegner scores of the two groups were 90.52 ± 2.8, 89.17 ± 3.1, and 6.81 ± 1.7 and 91.42 ± 1.9, 90.32 ± 3.4, and 7.02 ± 1.4, respectively. The differences were not statistically significant (P > 0.05).

Conclusions: The modified cross-suture method is practicable and effective for arthroscopic remediation of unilateral suture anchor pulling out in an all-inside meniscal repair system.

Keywords: All-inside repair; Arthroscopy; Cross-suture; Meniscus injury.

Fig. 1

Schematic diagram of the “modified cross-suture”: a: Vertical longitudinal tear at the posterior angle of the medial meniscus. The suture (red line) in the diagram represents the free end of the suture of the all-inside meniscal repair system after unilateral anchor pulling out. b: The two sutures (red line) in the diagram represent the two free ends of the suture of the all-inside meniscal repair system after unilateral anchor pulling out. c: The two all-inside meniscal repair systems were reinstalled into the torn meniscus. The free suture leg (blue line) was pulled until the suture was tight against the meniscus surface and the meniscal tear was closed. The two free ends (blue line) were left at the opposite side of the standby suture (red line), as shown in Fig b. d: The two sutures (red line) of the unilateral anchor pulling out and the other two sutures (blue line) of normal state were cross-knotted to reinforce the meniscal tear. e: The cross-suture was finished if there was only one suture of unilateral anchor pulling out. f: If the length of meniscal tear was less than 10 mm, the cross-suture was finished more easily if there was only one suture of unilateral anchor pulling out

Fig. 2

Typical case. The male patient was 33 years old and had an ACL rupture as well as a medial meniscal tear (a, c) in the right knee. The meniscus tear length was 2 cm. Two unilateral anchors of the all-inside meniscal repair system were pulled out intraoperatively (d, e, f). The modified cross-suture method (g) was used to remedy the error of unilateral suture anchor pulling out and to eventually complete an effective repair (h). According to the postoperative MRI 1 year postoperatively, meniscus healing was good (b)