All-inside suture meniscal repair using suture passer

Introduction

The menisci are fibrocartilaginous, crescent-shaped wedges located in the femoral condyle and tibial plateau of the knee joint that enable load transmission, stability, and lubrication.

Despite these important roles, the meniscus is relatively avascular structure with limited blood supply and thus it’s healing potential is poor. Therefore, treatment option for meniscus tear, including meniscus repair, should take into account vascularity as well as the other various factors including patient background. In addition, several suture techniques must be selected for repair. This paper provides a review of relatively recent all-inside suture (AIS) repair technique using suture passer.

History of treatment for meniscus tear

Looking back on the history of treatment for meniscal tear, until 1970s, total menisectomy was the gold standard, but Fairbank (1) was the first to document long-term degenerative changes after subtotal menisectomy. Since then, partial menisectomy and meniscal repair have been developed. The meniscal repair techniques have evolved from open repairs to all-inside arthroscopic repairs. There are three basic options for meniscal repair, inside-out (IO), outside-in (OI), and all-inside techniques. Many surgeons still consider IO technique to be the gold standard of meniscal repair even though this technique has a risk for neurovascular injury with accessory posterior incisions (2). For indication, tears of the posterior and middle thirds of the meniscus are suitable for IO technique, while OI techniques are more suitable for repair of the anterior and middle thirds. All-inside techniques with implants have been developed because it is easy to use without additional incision. Morgan et al. (3) introduced first-generation all-inside technique with accessory posterior portal and only curved suture hooks without implant. This technique was applied for only posterior horn meniscus tear. Then, the suture-based device with anchor such as T-Fix (Smith & Nephew, Andover, MA, USA) and rigid bioabsorbable implants including Meniscus Arrow (ConMed Linvatec, FL, USA), BioStinger (ConMed Linvatec, FL USA), Mensical Dart (Arthrex, Naples, FL, USA) and RapidLoc (DePuy Mitek, Raynham, MA, USA), were developed. However, the Meniscal Arrow and other rigid bioabsorbable devices quickly fell out of favor because longer-term studies demonstrated both higher rate of failure and complications (4,5). The complications were inflammatory reaction, transient synovitis, cyst formation, device failure/breakage, device migration and chondral damage (6-8). On the other hand, suture-based device with anchor, T-Fix, was improved, and a large number of similar new devices, FasT-Fix (Smith & Nephew, Andover, MA, USA), Omnispan (DePuy Mitek, Raynham, MA, USA), and Meniscul Cinch (Arthrex, Naples, FL, USA), have been widely spread. However, the number of reports of complication by these devices has been increasing, such as device misfire, implant breakage or migration, entrapment of the collateral ligament, popliteal tendon, and subcutaneous tissues and neurovascular injury (9,10). Additionally, all-inside repair techniques with only suture anchors have been developed for repair at the meniscal root (11). Apart from these all-inside repair techniques with implant or anchor, recently, new suture passers for all-inside techniques with only suture have been developed. This all-inside technique can avoid interposition of extra-articular soft tissues including the capsule compared to IO/OI techniques and conventional all-inside techniques with anchor or implants.

Classification of meniscal repair techniques

Conventionally, meniscal repair techniques were classified by the direction of suture/device as you can image the name of techniques such as “inside-out”, “outside-in” and “all-inside”. But, from the perspective of suture with penetrating capsule, IO/OI techniques and conventional all-inside techniques with implant/anchor can be classified as trans-capsular (TC) repair.

On the other hand, recent all-inside repair technique with only suture using suture passer and first-generation all-inside technique with suture hook described by Morgan (3) were classified as AIS repair (Figure 1).

Figure 1 New classification of meniscal repair. In middle column, there are illustrations showing different repair techniques and suture/implant location of each technique. Left column shows conventional “all-inside repair” technique including both all-inside techniques with implants and suture passer as well as suture hook. On the other hand, right column shows two repair techniques, trans-capsular and all-inside suture repair techniques, newly classified from the perspective of suture with penetrating capsule.

In TC repair, suture penetrates not only meniscus but also capsule, while, in AIS repair, only meniscus to meniscus sutures across the tear without interposition of soft tissues including the capsule between suture and meniscus. Therefore, AIS with only intra-meniscus suturing can directly close a gap between torn edges. In this respect, AIS repair is considered to be “anatomical meniscus repair”.

In the following text, to distinguish from AIS repair using suture passer, the conventional all-inside repair technique with implant/anchor is abbreviated to TC all-inside (TC-AI) repair. In a recent report, the AIS and TC-AI repair were similarly classified as “meniscus based repair” and “capsular based repair”, respectively (12).

Meniscal tear patterns

Generally, type of meniscus tears has been classified by tear depth, pattern, length, location and rim width, as well as quality of meniscal tissue (13,14). A recent review article demonstrated that tear patterns were divided according to the treatment option (15). Their new classification is more practical and helpful for surgeon to treat meniscal tears.

According to the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification (14), there are various tear patterns, longitudinal (extension would be a “bucket-handle tear”), horizontal, radial, flap, and complex tears (Figure 2). Longitudinal tear is commonly associated with twisting injury in young patients, including anterior cruciate ligament (ACL) injuries (16). Longitudinal tear exhibits a vertical axis and runs parallel to the circumference of the meniscus and perpendicular to the tibial plateau. Isolated radial tear in young patients is the most common in the middle segment of lateral meniscus (17). In middle-aged patients, this tear represents medial meniscus posterior root degenerative tear (18). Radial tear extends from the inner free edge of the meniscus, running perpendicular to the tibial plateau as well as long axis of the meniscus (19). Most horizontal tears are commonly degenerative tear. Horizontal tear runs parallel to the tibial plateau and appear as a horizontal line. This horizontal line separates the meniscus into upper and lower parts (20).

Figure 2 Meniscal tear patterns. Illustrations showing appearances of different meniscal tears.

AIS repair for various types of meniscal tears

The number of reports on biomechanical (Table 1) and clinical study (Tables 2,3) of AIS repair has been increasing. According to the tear type, there were few reports of AIS repair for horizontal or complex tears (31,34), while some reports of AIS repair for radial and longitudinal tears were published. The following section will present a review of AIS repair for each type of tear.

AIS for longitudinal tear

Biomechanical studies for longitudinal tear

For longitudinal tear, there have been two biomechanical studies using porcine knee of AIS repair compared both IO and TC-AI repairs. Compared with TC-AI repair, Masoudi et al. (22) showed higher failure load after AIS repairs using NovoStitch Pro (Smith & Nephew, Andover, MA, USA), while Chang et al. (21) presented lower failure load after AIS repair using Meniscal Viper (Arthrex, FL, USA). These are contradictory. Regarding stiffness and gap after cyclic loading, there were no differences between AIS and TC-AI repairs in both reports. Compared with IO repair, Masoudi et al. (22) showed only smaller gap after cyclic loading in AIS repairs but no differences in failure load and stiffness. On the other hand, Chang et al. (21) presented inferior biomechanical properties with lower failure load and stiffness and larger gap after cyclic loading in AIS repair. Consequently, for longitudinal tear, the biomechanical superiority of AIS repair is controversial. All values in the biomechanical studies were shown in Table 1.

Clinical studies for longitudinal tear

Clinically, AIS is often adopted for repair of longitudinal tear with concomitant ACL injury, especially tear at posterior horn (28,30,32,33,35,38-40). Of these reports, there were three comparative studies between AIS and TC repairs for longitudinal meniscal tears combined with ACL reconstructions. First, Choi et al. (39) compared AIS and TC-AI repairs for lateral and medial meniscus tear in postoperative clinical score and meniscus healing on magnetic resonance image (MRI). In their paper, most patients had longitudinal tears. There were no significant differences in clinical score and meniscus healing between AIS and TC-AI repairs. Second, Seo et al. (40) also compared AIS and TC-AI repairs for lateral and medial meniscus longitudinal tear in postoperative clinical score and meniscus healing on second-look arthroscopy. No significant difference was found in postoperative clinical score between AIS and TC-AI, while better healing was found after AIS repair compared that after TC-AI. Third, Choi et al. (38) also reported a comparative study between AIS and IO repairs for longitudinal tear. No significant differences in clinical score and healing on MRI between AIS and IO repairs similarly to the aforementioned report of comparative studies between AIS and TC-AI repairs (39). Our unpublished data also showed AIS repair brought better healing and smaller lateral meniscal extrusion than those after IO repair significantly (42).

For longitudinal tear, the biomechanical superiority of AIS repair was not clear, Moreover, postoperative clinical score and healing on MRI after AIS repair were equivalent to those after TC repair. However, second-look arthroscopy showed better healing after AIS repair for longitudinal tear, compared to both TC repairs, TC-AI and IO repairs.

AIS for radial tear

Biomechanical studies for radial tear

The mechanical properties after AIS and TC repairs for radial tears have been compared in several reports (23-27). Doig et al. (26) described the biomechanical superiority after AIS repair for radial tear with significantly greater failure load and stiffness as well as significantly smaller gap after cyclic loading than those after TC-AI repair. Beamer et al. (23) also found the biomechanical superiority after AIS repair with significantly greater failure load and stiffness as well as significantly smaller gap after cyclic loading than those after IO repair. Additionally, Hang et al. (27) compared the mechanical properties of repaired meniscus by three repair techniques, AIS, IO, and Hybrid (combination with AIS and IO repairs) repairs. As a result, in failure load and stiffness, AIS repair was equivalent to Hybrid repair, and these two repair techniques were superior to IO repair. In a cadaveric study comparing the AIS and IO repairs for radial tear, results varied by suture technique, but AIS repair with a particular suture technique (figure-of-8 plus horizontal construct) showed superior mechanical properties to IO repair (24).

Regarding the failure mode, cadaveric study presented that failure mode in all specimens was meniscal tissue suture pull-through (tissue failure), regardless of repair techniques, AIS or IO repairs (24). Considering the age of the cadaveric knees, this failure mode may be attributed to the fragility of the meniscal tissue due to age-related degenerative changes. In the aforementioned report using porcine knee, tissue failures were most in 78% of specimen after IO repair, while suture failures were most in 75% of specimen after AIS repair (23).

For radial tear, the previous biomechanical studies (23,24,26,27) showed the superiority of AIS repair in failure load, stiffness, and gap after cyclic loading regardless of porcine or cadaveric knee, compared to TC repair. Focused on failure mode in porcine knee, most menisci after AIS repair showed suture failure, while most those after TC repair showed tissue failure. AIS technique could hold meniscal microarchitecture of whole meniscus layer more strongly compared to IO technique. Additionally, the resulting reactive force of the stitch of AIS is made directly opposite to the direction of displacement, whereas an TC repair stitch is made oblique to it.

Clinical studies for radial tear

Clinically, there were a few reports of case series associated with AIS repair for radial tear that revealed satisfactory clinical outcomes (29,36,37). In only our comparative study, both successful clinical score and poor healing rate after AIS repair for isolated radial tear of lateral meniscus were equivalent to those after IO repair (41). But lower failure rate and smaller lateral meniscal extrusion after AIS repair for radial tear of lateral meniscus was found compared to those after IO repair.

Supposedly, AIS repair could apply only direct compressive force against the torn edges, while there could be not only compressive force against the torn edges but also tensile force to the periphery by the sutures tied on the capsule after TC repair. For radial tear, higher stability at repair site after AIS repair without soft tissue interposition can be also sustaining than that after TC repair.

Characteristics of AIS

AIS technique has advantages as follows: (I) stitch of AIS penetrates meniscus vertically in full thickness and (II) stitch can be tied perpendicular to tear regardless of tear type, (III) only meniscus to meniscus suturing without soft tissue interposition. Owing to these advantages of AIS techniques, tear site of meniscus can be closed by only compressive force and postoperative extrusion could be minimized after AIS repair. As a result, AIS repair would have benefit in biomechanical properties. Moreover, second-look arthroscopy revealed that better healing for longitudinal tear and lower failure rate for radial tear after AIS repair compared those after TC repair (40-42).

AIS repair has some disadvantages. First, AIS repair has application limits. Suture passers for AIS repair can be broadly classified into two types, “hook type” and “needle type”. Hook type includes suture hook (ConMed Linvatec, FL, USA), Micro SutureLasso (Arthrex, FL, USA), while needle type includes Knee Scorpion (Arthrex, FL, USA), FIRSTPASS Mini (Smith & Nephew, Andover, MA, USA), NovoStitch Pro (Smith & Nephew, Andover, MA, USA). Hook-type suture passer can be used for whole lateral meniscus and anterior segment and posterior horn of medial meniscus. Needle type suture passer cane be used for only posterior half of lateral meniscus and posterior horn of medial meniscus. Application limits of hook type is smaller than that of needle type. Repairing the middle and posterior segments of medial meniscus, TC repair techniques should be applied. However, the usage region of suture passers in medial meniscus could be expanded by the medial collateral ligament (MCL) pie-crusting (43), or MCL resection or release during medial open wedge high tibial osteotomy.

Second, AIS technique has few chances to stimulate soft tissues with abundant vascularity surroundings meniscus, because, in AIS repair, only meniscus is penetrated by devices or suture. On the other hand, TC repair can provide a vascular access channel due to penetration of abundant vascularity surroundings meniscus (44). This disadvantage can be compensated by additional procedures such as fibrin clot and/or bone marrow stimulation including microfracture. The hybrid repair—that is, the combination of AIS and IO repairs—can also have provides a vascular access channel, which would potentially promote meniscal healing. In an aforementioned report of biomechanical report, Hybrid repair was superior to IO repair and equivalent to AIS repair (27).

Third, AIS has potential of intra-articular knot impingement. After rotator cuff repair, knot impingement and mirror lesion of erosive change of acromion was found (45). In case of AIS repair for radial lateral meniscus tear, Tanaka et al. (46) reported the cartilage damage because of suspected impingement by a residual suture knot was observed. This complication would be prevented If a knotless suturing technique is developed in the future. At present, considering the complication of knot impingement and mirror chondral lesion, careful observation should be needed in patients after AIS repair.

Finally, AIS cannot promote meniscus healing in avascular zone. To promote healing of tear in avascular zone, additional procedures including biologic augmentation, such as stem cell therapies, might be needed.

Conclusions

AIS repair can be “anatomical suture repair” because, using this repair technique, torn edges can be repaired directly by intra-meniscus suturing without penetrating of capsule. But there is limited evidence in clinical practice. Moreover, there are some disadvantages for AIS repair. Further studies, and development of new devices and surgical techniques for AIS should be required.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-4/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-4/coif). T.O. serves as an unpaid editorial board member of Annals of Joint from August 2023 to July 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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