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 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