All right. Let's talk about some tricks for the inside-out meniscus repair. Here's the plan. We'll go through some current concepts and the literature update. We'll talk about in today's times when you should consider an inside-out repair and some technical tips and tricks. Now, a inside-out repair has been the historical gold standard for a long time, but the literature is evolving. Here is a systematic review from 2017 that found no differences in failure rates, functional outcomes, scores, and complications between all inside techniques and inside-out. Here's another review that looked at more complex tears, these bucket handle tears that are considered sort of the mainstay for considering a inside-out repair. They also found no statistical difference between failure for inside-out versus all inside. So that makes us wonder, is the gold standard becoming just more of a historical dinosaur, or is it something that's been able to adapt and be used in today's times? And I think the answer is yes, we can adapt this technique and still consider it. So I consider a inside-out repair for larger bucket handle tears that require multiple sutures, complex tears that require multiple sutures, and these are obviously in the middle and posterior third of the meniscus. The benefits are that you only need one device to deliver down to the meniscus, and then you can shuttle multiple sutures through that guide more quickly, and it's easiest to fine-tune your tension as you tie with the inside-out approach. In younger patients where there's less working room, sometimes it's easier to get the cannulas down than some of the all inside guides, and certainly meniscal transplants where you have tons of sutures that need to be passed, you should consider this. So here's some tricks to help along the journey. To go inside-out, first start outside-in. So you can use a spinal neater while you're in the joint with your scope to localize and perfect your incision placement arthroscopically to be sure that you're going to make your incision in the exact right spot. Never forget what you're going to protect. So from the medial side, you have your saphenous nerve and vein. From your lateral side, you have your popliteal artery, vein, and perineal nerve. Your medial incision is just posterior to the MCL, and you want two-thirds of your incision below the joint line, one-third above. You progress your dissection down anterior to the sartorius, semimembranosus, and then deeper down to the medial gastroc. From the lateral side, your incision is just posterior to the LCL and anterior to the biceps, and that dissection should go down between the IT band and the biceps, and then anterior to your lateral gastroc. So some tricks to help you once you get down there, you should raid the hospital cafeteria and have a sterile bent spoon that you can use to help protect your structures and establish that safety zone. The concavity of the spoon is great for deflecting the needle, regardless of the zone of the meniscus in which you're passing it, and safely allowing for retrieval. Your assistant needs to know that their job is essential to make this case work. They have to visualize the needles as they exit the capsule, and they have to protect the structures. I have colleagues who have had a perfect dissection get ruined by an assistant that wasn't perfectly protecting the structures, and, you know, that's led to some short-term palsy. So you want to make sure that your assistant knows the importance of their role. You also want to consider upgrading your sutures. Proline has been classically described as a suture to consider, but it's a finicky stitch that's very easy to break when you're tying, which will add time to the case and require even more passes. So there's vendors that make these polyethylene core sutures with a braided outer layer. I'm sure you've heard of several of them. And there's also tape-type sutures, which you can consider. You also want to consider modernizing your cannulas. Here's a classic cannula set, but a lot of vendors now have these zone-specific repair sets that have a trigger on them that can let you, once you have the needle delivered down, controlled fashion, advance the needle through the meniscus and then carefully retrieve it. And those tend to be pretty helpful as well. Tie as you go. Remember the team approach. So one person is scoping and passing the needles. The other one is retrieving them and tying, and then gently dial in the tension, working and communicating as a team while you're viewing arthroscopically to ensure that you have satisfactory tension on that repair. Thanks.

inside-out meniscus repair

all-inside techniques

bucket handle tears

complex tears

one device for sutures