Arthroscopic All-Inside Meniscal Repair

Matthew H. Blake

Darren L. Johnson

Indications

• Timing

• Acute traumatic meniscal tear

• Chronic tear without complex geometry

• Tear patterns

• Vertical longitudinal tears >1 cm

• Horizontal tears

• Bucket-handle tears (may be best repaired using inside-out techniques)

• Radial tears are difficult to repair with an all-inside technique

• Location

• Posterior horn

• Body

• Anterior horn best repaired by outside-in technique

• Red-red zone

• Red-white zone in patients younger than 40 years

• Stability

• Must be done in a ligamentously stable knee

• Can be done with concomitant ligament reconstruction

Equipment

• Tower

• Light source

• Monitor and recording device

• 4-mm 30- and 70-degree arthroscope with cannula

• Shaver system

• Irrigation

• Gravity or high-pressure pump system

• Suction

• Draping

• Knee arthroscopy pack with sterile drapes

• Impervious stockinette and 6-in elastic bandage wrap for the leg and foot

• Accessory

• Well-leg holder or lateral post

• ±Tourniquet

▪ Performing surgery without a tourniquet may allow better visualization of bleeding from the prepared meniscal tissue.

• Instruments

• All-inside suture passing device of surgeon’s choosing

• Various angled meniscal graspers and biters

• Meniscal shaver

• Probe

• Rasp

• 18-gauge spinal needle

• Microfracture awls

Anesthesia

• General with laryngeal mask airway (LMA) or sedation and local anesthesia

• 0.5% ropivacaine at the portal sites

• ±Regional block

• Weight-based dose of third-generation cephalosporin

• ±Anticoagulation: stratified by risk factors such as prior deep venous thrombosis (DVT) or clotting disorder

Positioning

• The patient is positioned supine.

• A bump can be placed underneath operative hip.

• Leg support must allow the knee to achieve full range of motion including application of varus and valgus stress and should be positioned to allow circumferential access to the knee.

• Leg holder:

▪ Placed perpendicular to the femur at mid- to upper thigh to allow placement of varus and valgus forces on the knee.

▪ The leg should be internally rotated before the holder is secured so that the patella is en face.

▪ The end of the table is lowered past 90 degrees from horizontal to allow the leg to hang freely (Fig. 35-1).

Figure 35-1 | Patient positioned with a leg holder to allow circumferential access to the knee.

• Lateral post:

▪ Placed midthigh and angled to allow a valgus force on the knee.

▪ The surgeon may leave the end of the table up or drop the end of the table.

• The contralateral leg with a sequential compression device (SCD) is placed in a padded well-leg holder of surgeon’s choosing.

Surgical Approach

• Overview

• Portals are created using no. 11 blade.

• Standard portals are the anterolateral and anteromedial portals.

• Accessory portals can be used depending on tear patterns and repair strategies (Fig. 35-2).

Figure 35-2 | Standard anterolateral and anteromedial portals shown with possible accessory portals (right knee).

• Portals

• The anterolateral portal is created 5-10 mm lateral to and at the level of the inferior pole of the patella in the anatomic “soft spot.”

• The arthroscope is introduced to the notch, and the fat pad is swept anteriorly.

• The anteromedial portal is established under direct vision by localizing the entry point with a spinal needle.

▪ If the lateral meniscus is to be repaired, then the portal should be 3-5 mm superior to the anteromedial horn of the meniscus so that the suture passage device can be advanced over the tibial eminence and underneath the femoral condyle (Fig. 35-3).

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