Revista de Medicina Desportiva (English) July 2018 | Page 30

time. The needle is placed about
10mm beyond the meniscus under
arthroscopic control and then with-
drawn while controlling the loop a
clamp placed through the accessory
arthroscopic portal, so that the loop
of Ethibond remains inside the knee
(Figure 2).
Once the first loop is placed,
the second pre-prepared needle is
passed through the same incision,
coming out through the capsule
adjacent to the first suture wire
(Figure 3). The needle is once again
removed, leaving two laces (or, alter-
natively, only a wire in loop and the
second without loop) in the knee (in
each side of the tear) and the suture
wires on the outside (Figure 4). A
grasper is passed through the more
appropriate arthroscopic portal to
reach the wires. The instrument is
placed through the first Loop and
grabs the second loop or wire (Figure
4). While the surgeon holds one of
the free ends of this second wire,
the other end is pulled out through
the first needle loop leaving the wire
immediately prepared for suture
(Figures 5 and 6). Using both ends of
the same wire, it is possible to test
the stability of the stitch and then
tighten the knot that will be sup-
ported at the joint capsule. Depend-
ing on the relative orientation of
both needles, there will be a simple
suture that can be horizontal or
vertical (Figure 7).
Discussion
The aim of this work is to describe a
surgical technique that we consider
to very useful and simple for knee
and sports trauma surgeons. There
are no reports in the literature of the
specific results of this technique and
the results are scarce on Outside-
In meniscus repair techniques in
general.
Morgan and Casscels et al. were
the first authors to report their
results with an outside-in meniscus
suture technique. 5 They evaluated
74 meniscus repairs (50 of medial
meniscus and 24 lateral) with a
second-look arthroscopy and related
the arthroscopic findings with symp-
toms. With an average of 18 months
of follow-up, in 84% of patients there
was an asymptomatic healing, with
28 july 2018 www.revdesportiva.pt
65% completely healed and 19%
with incomplete healing. The failure
rate was of 16%. All patients with
unhealed ruptures were sympto-
matic, while all patients with full
or partially healed rupture were
asymptomatic. All failure cases had
an associated anterior cruciate liga-
ment (LCA) tear. A minimum period
of four months was necessary to
observe healing of the meniscus.
Van Trommel et al, did a second-
look arthroscopy, arthrography and
MRI in 51 patients that underwent
meniscus repair with an outside-in
technique. 6 41 medial and 10 lateral
menisci were analyzed. The average
follow-up was of 15 months (3 to
80). Complete healing was observed
in 23 menisci (45%), partial on 16
(32%) and absence of healing in 12
(24%).
Mariani et al. reported favorable
results in 17 out of 22 patients who
underwent this type of repair associ-
ated with ACL reconstruction. 7 Vari-
ous authors studied this association
and their publications reinforce that
a meniscus repair associated with
ACL reconstruction increases the
chances of clinical success. 8-10
Shelbourne and Dersam et al.
published a study comparing par-
tial meniscectomy with meniscus
repair in bucket handle tears of the
external meniscus on patients who
underwent previous ACL reconstruc-
tion in the same knee. 11 With 67
repairs and 24 meniscectomies, they
obtained a statistically significant
difference in terms of pain score, but
no significant difference has been
recorded in the global subjective
score (IKDC).
The success rate of meniscus
repair, in the short and medium
term, is consistent in the literature
and, regardless of the technique
used, it is common to find suc-
cess rates around 90% in the larger
series. 12-17
Rockborn and Messer compared
the long-term results (13-year follow
up), between meniscus repair and
meniscectomies. 18 They evaluated
30 patients submitted to repair and
30 submitted to partial or subtotal
meniscectomy, both functionally
and radiologically. In the meniscus
repair group, four menisci did not
heal and three suffered re-rupture
(23%). The authors did not find,
significative functional differences
between groups, at 13 years follow-up,
although 90% of patients in both
groups did not complain during
their daily activities. Knee osteoar-
thritis was found in 50% of patients
in both groups, but the reduction of
the articular space was significantly
higher after meniscectomy (P < 0.05).
However, the incidence and severity
of osteoarthritis showed no signifi-
cant difference between groups. 18
Based on our experience, and
although no comparative study
between surgical techniques (menis-
cus repair and meniscectomy) was
performed, we understood the clini-
cal and functional success of menis-
cal sutures. We also realize that
with the outside-in method, com-
plications are rare, if the surgeon
has attention to the surgical tech-
nique and respect for the anatomy.
Injury to the peroneal nerve may
be avoided by performing the repair
with a knee flexion of over 90° and
by inserting the needle anterior to
the biceps tendon. A careful dissec-
tion, combined with trans-illumina-
tion, decreases this risk. 19
Conclusion
The described outside-in suture
method is technically simple, fast
and inexpensive. It allows to per-
form vertical and / or horizontal
sutures and does not require a big
surgical incision. Other techniques
using needles or other devices of
larger caliber are technically more
complex and require several suture
and needle passages. We believe
that this technique is easier and
more reproducible than others
previously described in the litera-
ture, requiring only few steps and
low-cost material that is readily
available in most operating rooms.
It should also be noted that thi s
technique does not require specific
training and is intuitive for surgeons
with arthroscopic practice. We
advocate the use of an Ethibond®
wire and vertical sutures, whenever
possible, by the strong biomechani-
cal advantages that both offer in
meniscal repair. 5, 6