Updated: 10/18/2016

Meniscal Repair - Inside Out

Review Topic

Preoperative Patient Care


Outpatient Evaluation and Management


Obtains focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • evaluate for
  • knee pain
  • mechanical symptoms
  • pain or swelling with ADLs and sports
  • joint line tenderness
  • knee effusion
  • associated with decreased quadriceps strength
  • positive McMurrays, Apley grind and Thesaly tests


Interprets basic imaging studies

  • standing radiographs
  • 30 degree flexion lateral
  • AP weightbearing in extension
  • 45 degree PA flexion weightbearing views
  • identify fairbanks changes
  • discoid meniscus on radiograph
  • tibial spine hypoplasia, widening of the lateral joint line or flattening of the lateral femoral condyle on AP view.


Prescribes and manages non-operative treatment

  • Injects/aspirates knee
  • guides trial of medical managment
  • attempts trial of physical therapy
  • quad strength closed chain


Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention


Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • prescribe Nsaids
  • remove sutures
  • diagnose and management of early complications
  • limit range of motion to 90° for the first three weeks for nondisplaced meniscus tears and six weeks for displaced bucket handle tears
  • postop: 4-6 week postoperative visit
  • discontinue crutches
  • return to pivoting sports when full range of motion is present, no effusion, and can show full extension and painless terminal flexion
  • usually at 4-6 months
  • diagnosis and management of late complications
  • postop: 1 year Postoperative Visit

Advanced Evaluation and Management


Appropriately orders and interprets advanced imaging studies

  • MRI
  • 3-T gives excellent visualization on pathology.
  • useful in distinguishing tear, location and morphology
  • MRI abnormality of thickened "bow tie" on coronal view on greater than 3 cuts with continuity of the anterior horn and posterior horn on 5 mm thick saggital view cut is diagnostic for discoid meniscus
  • MRI classification of tears
  • grade one small: focal area of increased signal not extending to the joint surface
  • grade two: linear area of increased signal not extending to the joint surface
  • grade three: linear area of increased signal extending to the joint surface


Provides complex nonoperative treatment

  • concomitant injuries
  • ligament
  • fractures


Modifies and adjusts post-operative treatment plan as needed

  • knee arthrofibrosis
  • continued pain

Preoperative H & P


Obtain history and perform basic physical exam

  • history
  • Age
  • Gender
  • HPI
  • PMHx
  • identify medical co-morbidities that might impact surgical treatment
  • Social history
  • physical exam
  • ROM
  • joint effusion
  • joint tenderness
  • complete neurovascular exam of extremity.


Order basic imaging studies

  • order triplanar standing radiographs of the knee


Perform operative consent

  • describe complications of surgery including
  • pain
  • infection
  • neurovascular injury
  • loss of motion
  • degenerative joint disease [DJD])

Operative Techniques


Preoperative Plan


Determine pathology using MRI

  • radial tear
  • horizontal cleavage tear
  • displaced bucket handle tear
  • meniscal root tear
  • discoid meniscus


Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical Instrumentation

  • standard knee arthroscopy setup
  • double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles


Room setup and Equipment

  • standard OR table with choice of leg holder or post
  • patient is supine on bed
  • tourniquet may be used

Scope Insertion


Mark out the anatomy of the knee

  • draw out the patella, patellar tendon, medial and lateral joint lines and the posterior contours of the medial and lateral femoral condyles
  • mark future portals as well as the incision for the medial / lateral meniscus repair


Place anterolateral portal

  • an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella
  • insert the blunt trocar at the same angle as incision
  • place scope in the trocar after removing the inner cannula


Place anteromedial portal

  • created under direct visualization once the medial compartment is entered
  • use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal
  • the medial portal should be located just superior to the medial meniscus and able to provide access to the medial meniscal root if needed

Diagnostic Arthroscopy



  • suprapatellar pouch
  • undersurface of the patella and trochlear groove
  • lateral and medial gutters
  • medial compartment
  • visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment
  • the foot will be positioned on your opposite hip for control
  • medial meniscus, medial femoral condyle, and medial tibial plateau
  • once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage
  • intercondylar notch – ACL/PCL
  • use the probe to assess the ACL and PCL
  • Lateral compartment
  • the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment
  • lateral meniscus, lateral femoral condyle, and lateral tibial plateau
  • a probe is used to assess the lateral meniscus and cartilage

Meniscal Tear Evaluation and Preparation


Diagnose tear and determine configuration if present

  • investigate superior and inferior portion of the meniscus with the probe
  • check the capsule attachment of the meniscus by pulling the meniscus from the posterior capsule gently
  • assess the meniscal root


Check location of tear if present

  • assess the zone of tear and decide if the tear is repairable


Check stability, size and extent of tear

  • extent
  • partial or complete



Make incision posteriomedially or posterolaterally for needle capture

  • posteromedial incision
  • place the knee in 20 to 30 degrees of flexion
  • make a 4 to 6 cm incision just posterior to the medial collateral ligament
  • the incision should be one third above and two thirds below the joint
  • incise longitudinally through the sartorial fascia and continue the dissection anterior to the semimembranosus deep to the head of the gastrocnemius without violating the capsule.
  • posterolateral incision
  • place knee in 90° of flexion
  • this allows the peroneal nerve, popliteus and lateral inferior geniculate artery to fall posteriorly
  • make a 4 to 6 cm incision just posterior to the lateral collateral ligament anterior to the biceps femoris tendon
  • the incision should be one third above and two thirds below the joint
  • incise longitudinally through the iliotibial band and continue the dissection staying superior and anterior to the biceps tendon to protect the peroneal nerve.
  • proceed deep and anterior to the lateral head of the gastroc without violating the capsule.

Inside-Out Repair


Place a popliteal retractor "Henning retractor" against the capsule

  • a needle driver can be clamped to the retractor and held secure to the leg with a sterile coban to help hold the retractor in place


Place a single or double lumen cannula through the arthroscopic portals

  • the long flexible needles can be passed through the cannula by an assistant and slowly progressed at 1 cm increments until visualized at the medial or lateral incision through the retractor


Capture the needles one at a time as they pass through the capsule and cut the suture free from the needles.

  • be sure not to pull either suture all the way through until both needles are passed
  • keep each pair of sutures together for later repair with the knee in full extension.


Tension then tie the sutures over the capsule

  • the sutures are tensioned to simulate the tying. the knee is then brought into extension during the suture tying so that the capsule is not tightened.
  • ensure that the sutures are directly on the capsule prior to suture tying.

Treats Intraoperative and Immediate Postoperative Complications


Treat any intraoperative complications


Treat any immediate postoperative complications


Wound Closure


Use 3-0 and 4-0 biosyn for closure


Apply steristrips


Cover with tegaderm and occlusive dressings

Postoperative Patient Care


Perioperative Inpatient Management


Discharges patient appropriately

  • pain meds
  • schedule follow up in 2 weeks
  • outpatient physical therapy
  • place in a knee immobilizer or hinged brace locked in extension
  • partially weight-bearing with crutches for one month
  • passive range of motion starting postop day one
  • limit range of motion to 90°

Complex Patient Care


Treat complex complications


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