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Technical Note

All-Inside Suture Technique Using Anterior Portals in PosteriorHorn Tears of Lateral Meniscus

Alejandro Espejo-Baena, M.D., Alejandro Figueroa-Mata, M.D., José Serrano-Fernández, M.D.,and Francisco de la Torre-Solís, M.D.

Abstract: Methods for the repair of meniscal tears include inside-out, outside-in, and all-insidetechniques. In this article an all-inside technique is proposed for the posterior horn of the lateralmeniscus that takes advantage of the capacious posterolateral recess when the knee is flexed. Adevice consisting of a large needle with a buttonhole in the tip (previously used for inside-out sutureof the medial meniscus) is used. This technique uses only anterior portals (anteromedial andanterolateral portals and an accessory lateral or transpatellar tendon portal). The arthroscope isinserted through the accessory portal. Once the tear has been located and its edges refreshed, thesuture device is placed anterolaterally. The tip of the needle is loaded with suture and passed throughboth sides of the tear and into the posterolateral recess of the knee (without exiting the capsule). Thesuture tail is recovered with the use of a suture retriever through the anteromedial portal. Next, thesuture retriever is inserted through the anterolateral portal to once again retrieve and shuttle the tailbefore completion of an arthroscopic knot. In addition to the ease of the technique, use of this simple,reusable device adds the benefit of low cost when compared with other techniques. Key Words:Lateral meniscus—Suture techniques—All-inside technique—Anterolateral portal.

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he preservation of the meniscus is a matter thathas given orthopaedic surgeons much cause for

oncern since the high risk of long-term meniscec-omy complications was discovered. Reconstructiveurgery methods used to repair meniscal tears includenside-out, outside-in, and all-inside suture techniquesnd even the use of bioabsorbable meniscal fixators.

From Servicio de Cirugia Ortopedica y Traumatologia, Hospitallinico Universitario Virgen de la Victoria, Málaga, Spain.The authors report no conflict of interest.Address correspondence and reprint requests to Alejandro

spejo-Baena, M.D., Paseo Reding, 9-1°C, 29016 Málaga, Spain.-mail: espejoreina@terra.es.© 2008 by the Arthroscopy Association of North AmericaCite this article as: Espejo-Baena A, Figueroa-Mata A, Serrano-

ernández J, de la Torre-Solís F. All-inside suture techniquesing anterior portals in posterior horn tears of lateral menis-us. Arthroscopy 2008;24:369.e1-369.e4 [doi:10.1016/j.arthro.007.06.017].

p0749-8063/08/2403-7167$34.00/0doi:10.1016/j.arthro.2007.06.017

rthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24,

Although the risk of neurovascular injury to theedial meniscus is low,1,2 the use of inside-out suture

echniques on the lateral meniscus carries a greaterisk of causing such lesions on the posterior side of thenee because of the proximity of the popliteal vesselsnd nerve in the middle zone and the external sciaticopliteal nerve in the lateral zone.3 Furthermore, aux-liary incisions are required, and this suture method is,echnically speaking, highly demanding.

For the reasons outlined previously, all-inside tech-iques are preferable when repairing the posteriororn of the lateral meniscus. Bioabsorbable meniscalxators are widely used, but these suffer from therawbacks of providing less resistance and carrying areater risk of synovitis and cartilage lesions.4,5 Otherll-inside suture techniques found in the literature,uch as those described by Morgan6 and Ahn andolleagues,7,8 are rarely used because they are techni-ally difficult to perform and require a posterolateral

ortal plus the use of a 70° arthroscope.

369.e1No 3 (March), 2008: pp 369.e1-369.e4

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369.e2 A. ESPEJO-BAENA ET AL.

This article proposes an all-inside suture techniqueor the posterior horn of the lateral meniscus that takesdvantage of the increased size of the posterior recesshen the knee is in flexion and the greater flexibilityf the lateral compartment9 (Fig 1). A device previ-usly used for inside-out suture of the medial menis-us is used.10 Because the technique in question usesnterior portals, it is easy to execute and carries min-mal risk of complications, as well as having thedditional benefit of the low cost of the materials usedn comparison to others such as all-inside fixators.

TECHNIQUE

The patient is placed in the supine decubitus posi-ion, with the lower limb secured by a leg-holder.eneral anesthesia is only given when the meniscal

esion is accompanied by a cruciate ligament injuryhat also requires reconstruction. In the case of ansolated tear, local anesthesia is administered via anntra-articular injection of 30 mL of bupivacaine at.5% by use of a vasoconstrictor and 15 mL of mepiv-caine at 1% for the portals. In this case the operations carried out without ischemia.

A device designed by the main author is used. Thisonsists of a large needle with a buttonhole in the tiphrough which the suture thread is passed. The tiptself is curved, which enables the suture to be di-ected. At the other end, the device features a handleith a carved depression that indicates the direction of

he curved tip (Fig 2). The suture material used is No.polyester.

FIGURE 1. Posterolateral recess.tp

The knee is bent to 90°, and the arthroscopic cameras placed in a central portal via the patellar tendon,hich provides easier access to the posterior recessesf the knee through the intercondylar notch. The su-ure device is introduced via a standard anterolateralortal. The meniscus is punctured, penetrating the tearFig 3). The end of the needle comes out through theecess described previously between the meniscus andhe posterior capsule, the curved tip making the ma-euver easier. A suture retriever is introduced through

FIGURE 2. Suture device.

IGURE 3. Piercing of meniscus. The tip of the needle passes

hrough both sides of the tear without exiting the capsule in theosterolateral recess of the knee.

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369.e3POSTERIOR HORN TEARS OF LATERAL MENISCUS

he anteromedial portal to recover the suture threads.nce the needle has been removed, the suture re-

riever is inserted again through the anterolateral por-al (Fig 4) to recover the suture, thus avoiding anyntrapment of the threads in the soft tissue of theortal without the need to use cannulas. With the aidf a knot-pusher, a vertical suture can be completedoth quickly and safely. The number of knots requiredill depend on the size of the tear; generally speaking,

wo or three are sufficient to repair the posterior hornf the lateral meniscus (Fig 5).

DISCUSSION

Although all-inside suture techniques and bioab-orbable meniscal fixators are more popular nowadays,hey generally provide less resistance than suture, yieldoorer results, and often suffer complications such asoss of fixation, synovitis, and chondral lesions.11-14

organ6 in 1991 and, more recently, Ahn and col-eagues7,8 described an all-inside suture technique thatses a posterolateral portal. We believe that thisethod has the disadvantages of being technicallyore difficult and requiring a 70° optical system.The increased flexibility afforded by the lateral

ompartment of the knee and the greater width pro-ided by the posterolateral capsule recess provideerfect visualization of the posterior horn of the lateraleniscus and easy access to it (even via the anterior

IGURE 4. Retrieval of suture threads with suture retriever tovoid entrapment of soft tissue.

ortals), enabling the suture to be performed with anppropriate instrument.

The all-inside suture technique for the lateral me-iscus outlined here provides a simple method ofarrying out repair that is practicable for most arthro-copists, guaranteeing strong fixation with a low riskf chondral damage. Because the method is all-insidend the tip of the device is controlled at all times, theisk of neurovascular complications is minimized.urthermore, it can be performed with a standardptical system of 30° and requires neither cannulasor auxiliary posterolateral incisions.

REFERENCES

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2. Fernández de Rota A, Mariscal J, Garcia-Herrera JM, AlvarezI, Amores F, Espejo Baena A. Sutura de menisco interno:Análisis del riesgo de lesión poplítea neurovascular medianteresonancia magnética dinámica. Cuad Artrosc 2006;13:35-39.

3. Fernández de Rota A, Morales Marcos V, Merino Ruíz ML,Mariscal Lara J. Sutura meniscal: Análisis del riesgo de lesióndel nervio ciático poplíteo externo. Rev Ortop Trauma 2006;50:91-232 (suppl 2).

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5. Gifstad T, Grontvedt T, Drogset JO. Meniscal repair with

IGURE 5. Completed repair. Two or, in this case, three suturesenerally suffice to repair a tear of the posterior horn of the lateraleniscus. The probe shows a stable tear.

biofix arrows: Results after 4.7 years’ follow-up. Am J SportsMed 2007;35:71-74.

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369.e4 A. ESPEJO-BAENA ET AL.

6. Morgan CD. The all-inside meniscus repair. Arthroscopy1991;7:120-125.

7. Ahn JH, Oh I. Arthroscopic all-inside lateral meniscus sutureusing posterolateral portal. Arthroscopy 2006;22:572.e1-572.e4. Available online at www.arthroscopyjournal.org.

8. Ahn JH, Kim SH, Yoo JC, Wang JH. All-inside suture tech-nique using two posteromedial portals in a medial meniscusposterior horn tear. Arthroscopy 2004;20:101-108.

9. Lubowitz JH, Rossi MJ, Baker BS, Guttmann D. Arthroscopicvisualization of the posterior compartments of the knee. Ar-throscopy 2004;20:675-680.

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