Inside-Out Meniscal Repair: Still a Useful Technique

New generation of all-inside meniscal repair devices are now the preferred repairing method for most orthopedic surgeons. The economic considerations in low-income countries make routine use of these devices very difficult. The inside-out technique described by Charles Henning in the 1980s, which is considered as the gold standard by many expert surgeons, can solve this problem with equal results.

Indications are large and unstable tears localized in the middle and posterior thirds of both menisci.

We introduced a slight modification to the original technique, allowing the use of a resorbable suture thread. After a good exposition of the lesion and debridement of the margins, a canulated needle with curved tip (Menghini needle) is introduced through the opposite portal to the repaired meniscus. The first passage of the needle is done on the peripheric side of the tear to protect neurovascular structures; posteromedial or posterolateral security approaches are made to control the capsular exit of the needle. A popliteal retractor is placed to keep the articular capsule exposed. A polydioxanone (PDS) suture thread is passed through the needle and retrieved by the assistant. The needle is then pulled out in the joint and reintroduced on the inner part of the tears producing a vertical mattress suture. The second limb of the PDS is retrieved by the assistant, and a knot is tied on the capsular side of the knee. Sutures are placed on the femoral and the tibial side of the meniscus to produce a good reduction and a stable fixation of the lesion. Full range of motion of the knee is allowed at 6 weeks postoperatively.

Between January 2017 and June 2020, 33 bucket-handle meniscal tears were repaired. Associated anterior cruciate ligament reconstruction was done in 17 cases. The average International Knee Documentation Committee (IKDC) score jumped from 49.6 to 86.2. We had a short-term success rate of 91%. Recent literature review showed equivalent results with new all-inside repairing devices.

Despite some disadvantages as being time-consuming, the need of security approaches, and the need of a trained assistant, inside-out meniscal repair remains a reliable technique offering good results.