Arthroscopic Meniscal Repair with Use of the Outside-in Technique*†

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Abstract
The well established importance of the meniscus in load transmission across the knee joint has led to the development of techniques to repair meniscal tears. Advances in our understanding of the basic biology and the healing of the meniscus have improved our ability to select appropriate tears for repair and to design methods to enhance meniscal healing. Both open and arthroscopic repair techniques have been found to be effective for meniscal suturing. The outside-in technique of arthroscopic repair of the meniscus was developed by Warren as a method to decrease the risk of injury to the peroneal nerve during arthroscopic repair of the lateral meniscus37. This technique is especially useful for repairing tears in the anterior portion of the meniscus, for suturing a meniscal replacement (such as an allograft or a collagen meniscal implant), and for inserting a fibrin clot into a repair site. This paper reviews the technique, indications, and results of meniscal repair with use of the outside-in method. The indications for meniscal repair have been well defined. The important factors for consideration include the location of the tear, the type of tear, the quality of tissue, chronicity, the age of the patient, and the stability of the knee. The most important factor in determining repairability is the location of the tear, as tears in the vascular periphery of the meniscus can mount a healing response. The ideal tear is an acute, vertical, longitudinal tear in the peripheral one-third of the meniscus in a young patient who has a stable knee or will have concomitant reconstruction of the anterior cruciate ligament. Because of the importance of the meniscus, repair can be considered for tears that extend into the central, avascular zone of the meniscus in younger patients. In support of invasive attempts to repair such tears, Rubman et al. reported that 159 (80 percent) of 198 knees in which a tear in the central, avascular zone had been repaired had no symptoms at the time of follow-up28. Most bucket-handle tears are repairable as long as the handle fragment is not extensively deformed. Flap tears and horizontal cleavage tears generally are not repairable. Radially oriented tears in the posterior horn of the meniscus may be repaired because of the rich blood supply in this region, but radial tears in the middle portion of the meniscus have a poorer potential for healing7. However, an attempt at repair of a large, radial split tear should be considered in a young patient, as a radial tear through the entire width of the meniscus may effectively render the meniscus nonfunctional because of the loss of the ability to transmit hoop stresses. Because clinical studies have demonstrated that the rates of healing after repairs of the lateral meniscus are better than those after repairs of the medial meniscus, there are broader indications for repair of the lateral meniscus7,20,21,35. Similarly, studies have demonstrated the highest rates of healing after concomitant reconstruction of the anterior cruciate ligament, with these rates having been better even than those for knees with a stable cruciate ligament7,20,21; thus, more intensive attempts at repair may be indicated if reconstruction of the anterior cruciate ligament is also being performed. Although both acute and chronic tears can be successfully repaired, Henning et al.13 as well as Tenuta and Arciero31 reported better rates of healing after acute repairs. Many studies have demonstrated higher rates of failure after meniscal repairs performed in knees with an injury of the anterior cruciate ligament, and thus concomitant reconstruction of the anterior cruciate ligament is recommended5,26,27.

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