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).
• 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).