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Arthroscopic lateral meniscal repair with fibrin clot and bone marrow aspirate using Smith and Nephew Fast Fix 360 system

    Overview

    Learn the Arthroscopic lateral meniscal repair with fibrin clot and bone marrow aspirate using Smith and Nephew Fast Fix 360 system surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Arthroscopic lateral meniscal repair with fibrin clot and bone marrow aspirate using Smith and Nephew Fast Fix 360 system surgical procedure.
    The meniscus is a vital component of the knee whose function is to transmit load over as wide an area as possible between the femur and tibia. Subject to injury in an increasingly sporting population and degenerative change in an increasingly ageing population, meniscal pathology is both common and usually symptomatic.
    From the advent of arthroscopic techniques, the meniscus has often been the site of surgical intervention, with meniscectomy or partial meniscectomy the mainstay historically. As arthroscopic techniques have improved, and an understanding of the sometimes deleterious longer term effects of menisectomy has become evident, surgical alternatives to menisectomy have begun to be explored.
    This shift in practice has been aided by the implant industry who have both developed devices and also standardised techniques to assist in the task of meniscal repair. The increasing focus on meniscal preservation has led to the recognition of different meniscal tear morphologies not previously recognised, such as the root tear or the meniscal ramp lesion.
    A variety of suture techniques are required for those carrying out meniscal repair, suture type being determined by the location of the pathology: For a posterior 1/3 meniscal tear “all inside” devices are ideal (eg The Smith and Nephew Fastfix 360 or the Arthrex Cinch II). The suture is usually an ultra-strong braided 2-0 suture such as Ultrabraid (Smith & Nephew) or 2-0 FiberWire (Arthrex) and the anchors on these devices are usually small (1mm x 2mm plastics (PEEK) or some manufacturers offer all suture anchors where the actual anchor is made of a suture knot. My current preference is for Smith and Nephew FastFix 360 for all inside due to small size of devices, strong suture and ease of use. The predecessor to this was the Smith and Nephew FastFix Ultra which I liked for its flexibility of use, but the anchor was larger and should an anchor come loose in the knee the smaller the better! For inside out sutures my preference is the Arthrex Meniscal Suture tape which allows a tape to be used with less risk of cut-out, and also this sits down flush with the meniscus.
    A mid-zone meniscal tear is easiest managed with inside to outside sutures. The anterior 1/3 meniscus often requires outside to inside techniques, to shuttle a suture across the tear. The suture ends are then retrieved through one of the portals anteriorly and tied down to the capsule under arthroscopic visualisation. The choice of suture is surgeon-specific. I have used both Ticron 2-0 (Smith and Nephew) sutures and more recently 2-0 Meniscal Suture Tapes (Arthrex).
    Remember always to assess the meniscal root (up to 10mm from the actual bony attachment) as this requires different techniques such as passing a meniscal tape (eg Ultra-tape from Smith and Nephew or FiberTape from Arthrex) with a passing device (eg the First Pass Mini from Smith & Nephew or the Knee Scorpion from Arthrex).
    Similarly it is important to assess for capsular detachment of the meniscus (particularly on the medial side) distal to the joint line (ie posterior to the tibia). This can be detected by probing and movement of the meniscus into the joint, or direct visualisation from a postero-medial portal.
    Readers will find the following OrthOracle surgical techniques also of interest: Meniscal repair using Smith and Nephew fast-fix 360 system and knee arthroscopy Trans-tibial meniscal root repair using Smith and Nephew Firstpass mini Knee arthroscopy and partial medial menisectomy

    Indications

    INDICATIONS
    All symptomatic meniscal injuries that are potentially repairable should be treated with arthroscopic meniscal repair. Overall failure rates of meniscal repair are around 10% (5-15%) with a better chance of repair succeeding with concomitant ACL Reconstruction (95%). However the decision making as to what is repairable is often subjective. I use the history (presence of a traumatic event), imaging (morphology and normal signal around the tear zone) and general condition of the knee (ie not arthritic) as the key decision-making factors. Increasing Age is often considered a relative contraindication to repair, but patients in their 60’s can have normal non-arthritic knees and may have repairable pathology. Equally patients in their 30’s may have degenerate knees where the meniscus is too badly damaged for a meaningful attempt at repair. The current thinking on the surgical priorities in knee joint preservation, clearly formulated by Al Getgood, is to address alignment first, correcting with osteotomy if necessary, then the stability of the knee (ligaments and menisci), before finally addressing any cartilage lesions in the joint. Thus an intact meniscus has a significant stability function for the knee and this must not be under-estimated.
    HISTORY
    There is usually a clear cut history of a traumatic event. The nature of this event varies, but there are common themes. Usually the patient has a healthy knee prior to the event and they are involved in a sudden weight bearing event during which they feel a ‘pop’ or ‘crack’ in the knee. The patient may have landed heavily on the leg for example during a change of direction, but in isolated meniscal injuries they do not describe the excruciating pain and visceral nauseation associated with an ACL injury. The patient is usually able to stand and bear weight, but does not normally continue playing. Swelling may come on quickly (similar to an ACL injury when the tear is peripheral and well vascularised) but usually the swelling starts later – up to 24 hours afterwards.
    Sub-acutely patients with meniscal injury complain of pain and swelling usually after deep flexion or twisting activities, or an inability to perform such activities and guarding the knee. Locking (an inability to fully extend the knee) may be permanent or intermittent, but is relatively rare. However mechanical symptoms where the patient feels something catching are much more common. It is worth being aware that certain meniscal tear morphologies
    Circumferential longitudinal tears: These often swell up quicker and are more obvious to the referring doctor. The most obvious of course is the bucket-handle tear.
    Radial tears: These usually present acutely with a heavy landing which drives the femoral condyle into the meniscus, splitting the meniscus to cause meniscal extrusion. The injury does not settle but the knee is not acutely locked and so referral can be delayed.
    Horizontal tears: These may be less acute in presentation as the remaining meniscus generally functions better and the patient may attempt returning to sport and suffer a second event.
    Root tears: These tend to occur as part of a serious acute knee, often multi-ligament, injury, or alternatively in an older population in isolation of any ligament injury. In the middle-aged population an injured meniscal root presents with a history of increased activity (squatting, twisting or dancing) immediately noticing something ‘going’ in the knee and then usually a slower presentation to the knee services because of self-management initially and then a medical resistance to image or refer because of age.
    EXAMINATION
    Weight bearing status depends on the chronicity, morphology and type of tear. Meniscal tear patients may be full weight bearing to completely non-weight bearing. Squatting usually shows a preference for the non-injured side.
    Inspection: Look for previous portals, the presence of swelling and in particular on the lateral side with the knee at 30 degrees, the presence of a lateral meniscal pseudo-cyst. This is an extrusion of meniscal tissue which mimics a cyst often from a radial lateral meniscal tear.
    Effusion: normally there a knee effusion which can be large initially, but most commonly a moderate effusion detected on sweep testing.
    Tenderness: the joint line on the side of the meniscal lesion is usually tender. In medial tears this is normally posteriorly whereas in lateral tears this is normally more anterior.
    Ligament examination: a full ligament assessment must be made of the ACL / PCL / MCL / LCL and posterolateral corner.
    Specific tests such as the McMurray and Thessaly may be appropriate.
    The McMurray test involves palpation of the joint line during passive flexion/extension of the knee joint with alternating internal and external rotation – a positive test equates to a palpable click on the joint line during the McMurray combined movement, usually with the medial joint on internal rotation and the lateral joint on external rotation.
    The Thessaly test is a variation of the McMurray but with the patient weight-bearing through the injured knee; the patient should be supported ( I ask the patient to support their weight on the back of a chair) and then squat to 30 degrees and rotated externally (lateral meniscal provocation with a positive test if painful on the lateral joint line) or internally rotated ( medial meniscal provocation with a positive test if there is medial joint line pain).
    IMAGING
    Simple AP and lateral Radiographs should be performed to rule out fractures. In non-acute cases there may be a role for long leg alignment views (for example if repair or root repair is being considered)
    MRI however is by far the most important investigation to confirm the tear site and morphology as well as concomitant ligament or chondral injury. Careful attention should be paid to the non-injured parts of the meniscus to give an idea on potential integrity of meniscal tissue to contemplate repair.
    The presence of peri-articular inflammation and cysts should also be noted.
    ALTERNATIVE OPERATIVE MANAGEMENT
    Partial meniscectomy should be discussed with the patient in case the meniscal lesion is not repairable.
    NON-OPERATIVE MANAGEMENT
    Analgesia, crutches, off-loader braces and physiotherapy.
    Occasionally if a non-repairable or questionably repairable meniscal tear is not settling down I instil low concentration local anaesthetic and steroid (Triamcinolone 40mg) around the tender joint line at the site of the maximal inflammation on MRI
    Contra-indications
    Non-repairable tears – avascular zone (very central white zone tears) degenerative tears (these have very high signal and look poorly defined on MRI), irreducible tears (despite operative attempts there is plastic deformation of the meniscus)
    Active infection in the knee or at other sites in the body.
    A patient who is unfit for anaesthetic
    Instability of the knee that is not corrected at the time of repair eg with ACL reconstruction.

    References:
    Getgood A, LaPrade RF, Verdonk P, Gersoff W, Cole B, Spalding T; IMREF Group. Am J Sports Med. 2017 May;45(5):1195-1205. Epub 2016 Aug 25.
    International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus Statement on the Practice of Meniscal Allograft Transplantation.

    Everhart JS, Higgins JD, Poland SG, Abouljoud MM, Flanigan DC. Knee. 2018 Dec;25(6):1142-1150. doi: 10.1016/j.knee.2018.09.009. Epub 2018 Nov 7.
    Meniscal repair in patients age 40 years and older: A systematic review of 11 studies and 148 patients.

    Setup


    The patient is positioned with feet over the end of the table

    I like to set up the patient without a tourniquet, feet over the end of the table and a side support.
    However remember that in the lateral joint this side support may reduce the ability to move into the classic ‘figure of 4’ position which is demonstrated later.
    Please remember the Gel pad on the corner of the table and a foot pump on the opposite limb.
    Also position the Monitor over the patient to avoid the surgeon twisting during the procedure.

    Skin preparation starting on the knee.
    I use 2% Chlorhexidine in Alcohol. This may be obtained through a proprietary brand as seen in this image (Chloraprep) or may be applied with a standard swab and Rampleys Forceps – please check the percentage is 2%.

    Operation – 1

    Coronal MRI of the lateral meniscal tear
    The lateral meniscal tear is marked with a ‘1’. There is a white line within a well demarcated black triangular structure which is extruded from the lateral margin of the knee between the femur and tibia.

    Saggital MRI of the Lateral Meniscal Tear
    The lateral meniscal tear is demarcated by a ‘1’ which is placed inferior to the posterolateral meniscal tear.

    Axial MRI of the Lateral Meniscal Tear showing good meniscal signal adjacent the tear
    The lateral plateau is marked with a ‘1’ which sits within the lateral meniscus. Notice how the lateral meniscus returns a ‘normal’ dark signal on this MRI which suggests it is of good integrity to repair.

    The patient is positioned with feet over the end of the tableI like to set up the patient without a tourniquet, feet over the end of the table and a side support.
    However remember that in the lateral joint this side support may reduce the ability to move into the classic ‘figure of 4’ position which is demonstrated later.
    Please remember the Gel pad on the corner of the table and a foot pump on the opposite limb.
    Also position the Monitor over the patient to avoid the surgeon twisting during the procedure.

    I use 2% Chlorhexidine in alcohol. This may be obtained through a proprietary brand as seen in this image (Chloraprep) or may be applied with a standard swab and Rampleys Forceps – please check the percentage is 2%.

    The foot is then prepared with Chlorhexidine

    Two gloves are applied to the foot allowing access to prepare the heel.

    The heel is then prepared with Chlorhexidine

    The top glove over the toes is then pulled around the heel

    The whole lower limb and knee are then prepared twice with Chlorhexidine

    An impervious U-Drap is applied around the thigh to cut-off the non-prepared area

    An additional large drape is then used to augment the U-drape and properly cover the table allowing for knee flexion intra-operatively

    An arthroscopic drape is then applied

    Local anaesthetic infiltration with adrenaline around the portals for analgesia and bleeding control

    The arthroscopic light lead is secured to the drapes.
    I like to use the same order with the light lead most lateral, then irrigation, then Radiofrequency device or shaver and suction.

    The irrigation system is then applied to the drape
    Here a squeezable chamber device is used which provides a burst of fluid by simple hand pressure from the operating surgeon or assistant.

    The radio-frequency ablation device is then secured on the drapes.
    This is a Flo-50 from Smith and Nephew which allows a variable power of radiofrequency and suction to be used within the knee.

    A suction tube is then passed through the drape holes for security

    White balance of the arthroscopic camera is performed
    The first anterolateral portal is generally in the same place in each arthroscopic procedure. This should be at the most superior aspect to the tibia-femoral joint line, but close to the patella.
    However additional portals need fine tuning depending on the particular arthroscopic procedure. In this case the medial portal will be higher (ie more superior) and more medial to allow access to the lateral joint from the medial side, not conflicting with the tibial spines.

    The anterolateral portal is made high and close to the patella / patella tendon.

    The arthroscope is introduced and a standard arthroscopic visualisation of the knee joint performedIt may be worth readers refreshing their memory about the mechanics of knee arthroscopy by reading Andrew Pearce’s OrthOracle technique Knee arthroscopy and partial medial menisectomy and also Faisal Hussain’s technique knee arthroscopy
    It is imperative to have a clear, standard arthroscopic sweep around the knee. This is covered in the linked techniques above, but my standard diagnostic sweep is:
    Supra-Patella Pouch
    Medial and Lateral Gutters
    Patellofemoral joint
    Notch including ACL / PCL
    Medial Joint – look for a Meniscal Flounce (as described by Peter Myers) which is a ‘wave’ or ‘ripple’ in the leading free edge of the meniscus indicating the meniscus is likely to be intact
    Lateral Joint
    Sometime it is necessary to perform posteromedial portals for posterior viewing / arthroscopic work eg as in PCL reconstruction or some Meniscal Ramp lesions.
    The working portal position will modified by what work is needed – this can be pre-determined for the imaging, but I find that an efficient diagnostic sweep is useful first.
    Once an additional portal is made, then the arthroscopic probe can be introduced and menisci probed.

    Fresh blood clot in the knee fits in with the acute history of lateral meniscal tear

    The second portal made is a high and medial anteromedial portal is made under direct arthroscopic vision.The reason to place the working anteromedial higher and more medial than ‘normal’ is because the pathology is in the lateral joint as identified on the MRI preoperatively and the first diagnostic sweep. By placing the portal ‘higher’ ie more superior relative to the joint line and more medial is to avoid the tibial eminences and allow better arthroscopic access to the mid-lateral joint for repair of the torn lateral meniscus.
    Once the anteromedial portal is made then the arthroscopic probe is introduced and any areas of concern on the first diagnostic sweep are revisited.
    Particular care should be given to:
    Documenting the complete joint chondral surface – eg posterior medial and lateral femoral condyles requires deep flexion whilst scoping.
    Meniscal roots – anterior and posterior, medial and lateral
    Meniscus tears – full visualisation – superior and inferior surfaces should be seen. Probing of the meniscus will exclude capsular detachments or longitudinal tears which are unstable.
    Meniscus tears – look for under-surface ‘tongue’ type tears where a flap of meniscus is extruded from the joint – usually in the medial gutter, but this can be posterior too. This can cause erosion of the tibial chondral surface.

    Once the meniscal tear is identified it needs to be probed to assist in determining repairability.A partial Lateral Meniscectomy was performed on the irreparable portion of the tear (‘1’). The healthy meniscus is seen lateral to the flap (labelled ‘3’)
    I use the Smith and Nephew Flo 50 (labelled ‘2’)which provides a variable power controlled from the hand piece. The resection tip is very precise which minimises the chance of iatrogenic injury to the chondral surfaces.
    The Chondral surface defect seen two slides later is obscured by the meniscal flap and the flexion angle of the knee.

    When assessing a tear for repairability I look for:
    If the meniscal tear reduces easily without tension across the tear then it makes a repair possible. If there is tension across the reduced meniscus then it is very likely that a repair will fail either by cut out of the suture or failure of the knot or breakage of the suture.
    The morphology of the meniscus. If the meniscus looks like a meniscus then it is far more likely to function like a meniscus after repair. Thus macerated, thickened meniscal tissue is far from ideal to repair.
    Plastic deformation – in more chronic tears the edges of the tear round off so that there is limited contact of meniscal tissue after a repair, which is not ideal. In these cases it is possible to remove some meniscal tissue and sometimes then repair.
    Integrity of meniscal structure – this is best assessed by the ‘feel’ fo the meniscus. Does the meniscus feel normal, but torn or does it feel macerated and lifeless! If it is the latter then meniscal repair is unlikely to work. This consistency of the meniscus is confirmed when a suture is passed – it should feel firm.

    Operation – 2

    Chondroplasty of the lateral femoral condyle (labelled 1) defect (labelled 2) using radio frequency (Smith and Nephew Wolf Flo 50 labelled as 3) at low power.

    20 ml of autologous blood is drawn for the patient and placed in a metal dish and a 10 minute timer startedIn order to form a fibrin clot we need an autologous blood sample from the patient. This takes time so remember to do this early in the operation.
    To form a reasonable size clot needs more blood than you might think – I use 20ml of autologous blood.
    To form a clot it is important to:
    Allow time – 7 minutes minimum standing time, although it is often 10 minutes allowing time to do other bits of the operation.
    Use a metal or glass container. Plastics do not work
    Agitate – stirring with glass (if you can find some) or metal from 7-10 minutes helps the fibrin clot form.
    Once the clot forms, dry it on a swab before suturing
    Arnoczky SP, Warren RF, Spivak JM. Meniscal repair using an exogenous fibrin clot. An experimental study in dogs. J Bone Joint Surg Am. 1988;70:1209–1217. [PubMed] [Google Scholar]

    The meniscal tear should be ‘stimulated’ to heal prior to repair and there are a number of techniques for this including using a green or white needle or a Venflon to traumatise the tear under direct vision and in a controlled fashion.Alternative ways to stimulate bleeding are:
    Diamond rasp – small rasps are very helpful to place inside the tears to remove ‘stable’ tissue and expose the underlying meniscal tissue
    Shavers and radiofrequency devices may also be used but caution must be exercised to prevent over-aggressive removal of meniscal tissue.

    The suture device in this case is the Smith and Nephew FAST-FIX 360.
    The next few slides are a “dry-run” example of a meniscal repair on a model, with a horizontal tear.
    The meniscal repair device consists of:
    A – needle (with a plastic safety sheath which is removed prior to use)
    B – white sheath to protect the soft tissues when manipulating the device in the knee
    C – sheath adjustment guide – pushing this forward advances the sheath to cover the needle – I retract it completely as I find the slotted cannula protects the soft tissue well enough
    D – grey trigger – pushing this forward deploys the suture anchors
    E – handle

    This image shows the slotted cannula resting on the model meniscus adjacent to the tear and planned entry of the needle

    The device is advanced along the groove of the slotted cannula with the tip of the needle point down.

    Once the tip of the needle is in the desired position the cannula can either be removed to allow greater ability to manoeuvre the device or left in situ to help hold an unstable tear.

    The needle is then advanced through the meniscus above the tear until it penetrates the capsule behind the meniscus. This is often felt as the resistance suddenly diminishes after exiting the meniscus. At this point the grey trigger is pushed forward until a palpable click is felt. The trigger then returns to its original retracted position on release. The first of the suture implants with a loop of Ultrabraid suture will be left behind outside the capsule.

    The process is repeated on the opposite side of the tear. (Note in this model case there is no suture loop).

    Insertion of the Smith and Nephew skid which prevents snagging of the meniscal needle or device.The Smith and Nephew Fastfix comes with a sheath to prevent the fixation device or sutures catching on the soft tissues of the arthroscopic portal. If this happens then the devices can be knocked off the introducer which is time-consuming and expensive so best avoided.
    I find that the metal ‘skid’ which comes with the knot pusher-cutter (Smith and Nephew) is an excellent introduction device. It is malleable so can be shaped to accommodate the required site of repair and accommodates the tip of the needle of the introducer so that the soft tissue of the portal do not touch the device.
    The best way to introduce the FastFix is with the needle angled towards the skid groove – ie in the centre of the ‘half-pipe’.

    A Fastfix 360 all inside meniscal fixation device is then used as part of the meniscal repair

    The FastFIx 360 is then passed across the tear and clicked to deploy the first anchor

    A white needle is used ‘outside in’ from the lateral side of the knee to manipulate the capsular portion of the lateral meniscal tear before insertion of the second fast fix device.

    A second fastfix 360 device is then used to restore the meniscus back to the capsule treating the longitudinal component of this complex tear.

    The second anchor of the 2nd fast fix is then deployed in the capsule.

    The second fast fix is tightened to close the tear gap.

    As the lateral meniscus is squeezed back to the capsule there is rush of blood from the stimulated bleeding within the tear.

    The harvested blood should by now have formed a clot which is collected from the metal plot. To form a clot it is important to:
    Allow time – 7 minutes minimum standing time, although it is often 10 minutes allowing time to do other bits of the operation.
    Use a metal or glass container. Plastics do not work
    Agitate – stirring with glass (if you can find some) or metal from 7-10 minutes helps the fibrin clot form.
    Once the clot forms, dry it on a swab before suturing

    The fibrin blood clot is secured with two 2-0 Vicryl sutures to allow introduction into the knee.I am using the Smith and Nephew skid as a holding device for the fibrin clot whilst I suture.

    Making the white needle suture snare
    A very cost-effective Suture Snare may be made with a white needle and a 2-0 Nylon suture with the needle removed. Fold the suture into half and cut off the suture needle leaving the suture thread ends equal. The ends are then fed down the white needle from the sharp end and withdraw from the ‘syringe’ end.

    The white needle with 2-0 nylon suture loop is then introduced from the lateral knee through the meniscal injury

    The nylon suture loop is then introduced into the knee

    By using the nylons suture loop the fibrin clot is then shuttled into the knee to sit in the meniscal tear zone

    The fibrin clot is pulled into the region of the meniscal repair from the outside-in suture loop.

    The Fibrin clot is introduced into the knee and manipulated into the lateral meniscal tear

    Operation – 3

    A modified short narrow bore suction catheter can be used as an access cannula if no dedicated cannualae or commercially available devices are available.
    Smith and Nephew supply zone specific cannula which are malleable.
    Arthrex supply a disposable zone Navigator with two different radius of curvatures for more posterior or anterior meniscal work respectively.

    An Arthrex Zone Navigator
    The different radius of curvature and shapes of the three ends allows the Zone Navigator to be used in different parts of the knee. There is one anterior ZN which is the most curved and then a left posterior/middle and a right posterior / middle.

    The Arthrex Zone Navigator in infographic
    These images are credit of Arthrex and demonstrate the Zone Navigator (ZN) introducing the second suture of a meniscal needle pair set to treat a longitudinal circumferential tear with a vertical mattress suture. The first suture was placed in the peripheral portion of the tear and has already been retrieved posteromedially. The second needle is just passing through the skin window posteromedially.
    The ZN allows the surgeon to introduce the needles by pressing down on the white switch and then advancing or withdrawing the needle. To withdraw the needle, advance the white switch towards the hilt of the ZN, then depress the switch and whilst depressing, retract the switch. This grasps the needle and withdraws.

    Inside-outside sutures are then introduced as paired suture needles to close down the meniscal tear gap.The first meniscal tape (1) is introduced down a malleable cannula (here I have used an ENT suction catheter. Once the suture needle is into the mobile segment of the meniscus (2) the cannula can be manipulated to reduce the meniscus and then the suture needle advanced out into the capsule and retrieved posteriorly (3)

    The first of the paired inside-outside suture needles is introducedAs the needle (directed anteriorly by the cannula or Zone Navigator) appears through the skin laterally, a small incision is made over the needle to create a skin window and then blunt dissection down to the capsule. The suture needle is then withdrawn though this skin window.

    The first inside outside suture needle is introduced into the posterior portion of the tear. The Fibrin clot can still be seen in the tear.

    The second of the paired inside-outside suture needles is introducedThe second needle of the pair is then introduced down the cannula or Zone Navigator and carefully retrieved through the same skin window. It is usually possible to manipulate the needle into the skin window, but if this is not possible then a needle holder or surgical clip (haemoastat) may be used to collect the needle from adjacent to the skin window and manipulate extracapsularly into the skin window.
    The suture needles are cut off and discarded.

    The second meniscal needle is retrieved externally to reduce the meniscal tape down over the initial repair.The Meniscal Tape is visible on the arthroscopic monitor. Notice that the tape is still slack. Once the needles are cut off and the suture tape pulled from the lateral side of the knee the intra-articular portion will go taught thus reducing the tear.
    Consequently it is important to watch this reduce under vision so that the tape is not over-tightened running the risk of cut-out for the meniscus. Tape is less likely to do this than suture, but it is still possible.

    The second Inside-outside sutures are then introduced as paired suture needle is then introduced and retrieved externally on the lateral side.

    Percutaneous retrieval of the second suture tape into the skin windowAlternatively it is possible to remove the needles and then retrieve the second meniscal suture end through the skin window by use of the arthroscopic probe – as in this image where I have retrieved the second suture tape through the skin window of the first needle. It is vital to stay close to the capsule doing this to reduce the risk of cutaneous nerve injury.
    The suture ends are then tied extracapsulalry, but with intra-articular visualisation from the Arthrosocope. The sutures are cut flush

    The suture ends are then tied extracapsulalry, but with intra-articular visualisation from the Arthrosocope. The sutures are then cut flush extra-capsularly through the skin window.

    A Jamshidi needle is ideal for harvesting bone marrow from the femoral notch

    The Jamshidi needle is introduced manually into the femoral canal via the femoral notch and then the central stylet is removed.Once the meniscal tear repair is secure final photographs are taken and then a Jamshidi needle is introduced into the femoral canal in the notch between ACL and PCL and a small volume of Bone Marrow withdrawn.

    Usually 6ml of bone marrow is harvested from the femoral canal via the femoral notch. The arthroscopic fluid is turned off and the BM aspirate introduced around the meniscal repair.

    The portals are then closed with 3-0 interrupted Monocryl as a deep dermal suture then cut flush.

    Steristrips are applied to the portals and then occlusive dressing, but I do not routinely use any bandaging with meniscal repairs.

    A range of motion brace, set at 0-60, is then applied to limit deep flexion when the patient is mobilising. I do not insist on this in bed or when not mobilising during the day to try and rest the soft tissues from compression.

    Post Operative

    Day case procedure
    The patient should remove the clear dressings at 2 weeks with any concern triggering an urgent review at the 2 week stage.
    Weight bearing status will depend on the morphology of the tear.
    For radial or root tears weight bearing is restricted for the first month to touch weight bearing.
    For longitudinal / circumferential meniscal tears I do not restrict weight bearing.
    In the second month I allow flexion 0-90 in the brace when weight bearing and this increased to full weight bearing as tolerates.
    From 8 weeks the brace is removed and the patient should be full weight bearing.
    However squatting (loaded deep flexion) and twisting should be avoided for 4 months

    Recommended Reading

    Getgood A, LaPrade RF, Verdonk P, Gersoff W, Cole B, Spalding T; IMREF Group.
    Am J Sports Med. 2017 May;45(5):1195-1205. Epub 2016 Aug 25.
    International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus Statement on the Practice of Meniscal Allograft Transplantation.
    Woodmass J.M., LaPrade R.F., Sgaglione N.A., Nakamura N., Krych A.J. Meniscal repair: Reconsidering indications, techniques, and biologic augmentation. J Bone Joint Surg Am. 2017;99:1222–1231. [PubMed] [Google Scholar]
    Yoon K.H., Park K.H. Meniscal repair. Knee Surg Relat Res. 2014;26:68–76. [PMC free article] [PubMed] [Google Scholar]
    Stein T., Mehling A.P., Welsch F., von Eisenhart-Rothe R., Jäger A. Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med. 2010;38:1542–1548. [PubMed] [Google Scholar]
    Feeley B.T., Liu S., Garner A.M., Zhang A.L., Pietzsch J.B. The cost-effectiveness of meniscal repair versus partial meniscectomy: A model-based projection for the United States. Knee. 2016;23:674–680. [
    Getgood A, LaPrade RF, Verdonk P, Gersoff W, Cole B, Spalding T; IMREF Group.
    Am J Sports Med. 2017 May;45(5):1195-1205. Epub 2016 Aug 25.
    International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus Statement on the Practice of Meniscal Allograft Transplantation.

    Everhart JS, Higgins JD, Poland SG, Abouljoud MM, Flanigan DC.
    Knee. 2018 Dec;25(6):1142-1150. doi: 10.1016/j.knee.2018.09.009. Epub 2018 Nov 7.
    Meniscal repair in patients age 40 years and older: A systematic review of 11 studies and 148 patients.

    Reference

    • orthoracle.com

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