Hi, my name is Dr. Jennifer Beck, and I'm going to be talking to you today about outside end meniscus repair. I have no disclosures for this talk. In arthroscopy, we're typically used to using a lateral viewing portal, and you can see in these examples of a discoid meniscus, where your lateral viewing portal, especially if you're looking at anterior instability, doesn't show that anterior horn very well. You really have to look down, and in this extreme example, when you can see the probing of this severe anterior meniscus capsular junction tear in this discoid meniscus, it's quite obvious that the meniscus has torn away from the anterior horn, and you can see the tibial plateau deep to this. I think one of the biggest pearls, especially for lateral meniscus viewing, is switching your viewing portal to the medial portal and probing through the lateral portal so that you can really assess the instability of this anterior horn. These anterior horn tears are a great indication for outside end meniscus fixation, as well as ones that go over into the body for, say, a chronic bucket handle tear that you may want to get into the body of the meniscus. So there's a couple different techniques. Really one using spinal needles, a suture that's used through a grasper in your portal, and then a knot that's tied on top of the meniscus, or there are separate kits that can be done to help simplify this for a single surgeon user. When you're using just standard spinal needles, usually 18-gauge spinal needles are used, a strong, stout monofilament suture, typically a slowly absorbing, is used for this, and there's two different ways. As seen in this image, you can use a single spinal needle, pierce through the meniscus a single time, and then actually bring that same spinal needle through the meniscus or through the capsule a second time. It does require that you have a grasping technique in order to get these sutures out through a portal, and suture bridges and soft tissue bridges are the biggest thing that you need to worry about. Sometimes putting a cannula in to ensure that doesn't happen is important. In this technique, you can then tie a knot on top using a knot pusher, or if you use two separate spinal needles, you can pass two different sutures, then tie a knot on top and do a separate knot outside the capsule. I think the main concern about this is the soft tissue bridges, and so using that cannula inside your portal is going to be really critically important to avoid that complication. I think these get really nice fixation options. You can really tailor exactly the location of the tear with your fixation and get great visualization and repair. This is an example where you can see this technique using this stout, slowly absorbable suture. You can see a grasper that comes through, and you can see how both of those sutures in that top right-hand corner have come through that viewing portal, and that's where you need to be careful about any sort of soft tissue bridges. There's other techniques that have been done, more proprietary systems that use either straight or curved spinal needles through a small incision that you make after the sutures have been placed. You can see in this one, there's a lasso-type device where you can actually put that lasso around one of your needles. In this figure seven, you can see that curved needle with the lasso going around it. You pass the suture through that other spinal needle, and then you're able to use that lasso to pull it up against the meniscal tissue as you slowly withdraw both of the needles. The advantage of this technique is that you don't have to worry about soft tissue bridges with your sutures, and it was really better for a single operator not relying on any sort of assistance. This is my personal preferred technique with any sort of anterior body tears. Secondarily, you can use a similar system, and you can put lassos within both of the spinal needles. This can be a time when you want to be using any sort of braided, less stout suture material if you're concerned about irritation or allergy or any sort of other concern. You want to use a braided, softer-type suture. Passing the suture then through both of those lassos, and you can simultaneously pull them out. Then you would make a small incision over the lateral aspect or the aspect of the knee where the sutures are coming out, and you have to make sure and dissect down the capsule and tie these over the capsule. I think for these, the biggest tool is using your arthroscope in the medial viewing portal if you're going to be doing an anterior horn lateral meniscus repair so that your view is improved as well as making sure that you have adequate space for passing all of these needles and all these instruments. Sometimes you do need an accessory portal for using your passing suture depending on your aim and your trajectory. So hopefully this has given you some tips for how to do outside-in meniscus repairs. Here's my email if you have any other questions. Thank you very much.

outside end meniscus repair

lateral viewing portal

medial portal

discoid meniscus

anterior instability