Technical Note

All-Inside Suture Technique Using Two Posteromedial Portals

in a Medial Meniscus Posterior Horn Tear

Jin Hwan Ahn, M.D, Ph.D., Seung-Ho Kim, M.D., Jae Chul Yoo, M.D., and
Joon Ho Wang, M.D.

Abstract: Up to two thirds of patients with anterior cruciate ligament rupture have a combined
medial meniscus posterior horn tear. Researchers have proven the importance of repairing this tear
to enhance stability after anterior cruciate ligament reconstruction. However, repairing the meniscal
tear can be sometimes cumbersome and difficult or even impossible in certain circumstances,
especially in places such as the posterior horn of the medial meniscus. We devised a simple and easy
method of all-inside suturing of medial meniscus posterior horn tears using a 2-posteromedial portal
system. Furthermore, with a modification of our technique, a clinician can not only suture single but
also double longitudinal medial meniscus posterior horn tears. Key Words: Medial meniscus
posterior horn tear—Anterior cruciate ligament injury—Double posteromedial portal—Arthroscopic
all-inside suture.

U p to two thirds of patients with anterior cruciate

ligament (ACL) rupture have combined medial
meniscus posterior horn tear.1,2 Repairing this torn
side-out and outside-in techniques all have several
limitations in the meniscal suture at the posterior horn.
Predominantly, this location is more difficult to access
meniscus anatomically allows the reconstructed ACL and includes a danger of major neurovascular injury,
knee to be more stable than those with meniscecto- and fixing the meniscus together with the capsule
mized or unrepaired knees.3 However, many surgeons restricts movement and causes pain. Among all-inside
overlook this combined tear because of its concealing repair methods, bioabsorbable meniscal fixators have
location and benign-looking appearance from the an- recently received great attention because of its sim-
terior portals (Fig 1). Furthermore, it is sometimes plicity in application. Despite the positive aspects,
technically or structurally difficult or even impossible because frequently the medial meniscus posterior horn
to repair the medial meniscus posterior horn tear. tear occurs near the meniscocapsular junction, espe-
Meniscal repairs are performed using inside-out, cially in patients with ACL insufficiency, meniscal
outside-in, and all-inside techniques.4-10 However, in- fixators are relatively contraindicated in this area be-
cause it has weak holding strength.
Conversely, all-inside meniscal suturing, which
Morgan8 describes, allows placement of vertically ori-
From the Department of Orthopaedic Surgery, Sungkyunkwan
University School of Medicine, Samsung Medical Center, Seoul, ented sutures, which have the strongest pullout
Korea. strength.11 Also, because the sutures are placed per-
Address correspondence and reprint requests to Jin Hwan Ahn, pendicular to the tear without entrapment of the pos-
M.D., Ph.D., Department of Orthopaedic Surgery, Sungkyunkwan
University, School of Medicine, Samsung Medical Center, 50 terior capsule, the technique results in a balanced
Ilwon-Dong, Kangnam-Ku, Seoul, Korea 135-710. E-mail: jha@smc. anatomic repair with good tissue approximation on the
samsung.co.kr torn meniscal end. However, Morgan’s technique8 of
© 2004 by the Arthroscopy Association of North America
0749-8063/04/2001-3572$30.00/0 all-inside suturing has several disadvantages,12 mainly
doi:10.1016/j.arthro.2003.11.008 regarding the high technical demand.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 20, No 1 (January), 2004: pp 101-108 101
102 J. H. AHN ET AL.

FIGURE 1. (A) The benign-looking appearance of the medial meniscus posterior horn tear seen by the standard anterior portal. (B) From
the standard posteromedial portal, with a probe, the tear clearly seen.

We searched for alternatives, seeking easier and Portal Placement

better ways of accomplishing an all-inside suture. We
developed an all-inside suturing technique using 2 The standard anterolateral and anteromedial portals
posteromedial portals. This technique is easier than are used for comprehensive examination with a 30°
Morgan’s technique8 and broadens the possible suture arthroscope and a probe. If medial meniscus posterior
area for repair in the medial meniscus posterior horn horn tear is suspected from preoperative magnetic
tear. The ideal indication for this technique is medial resonance imaging (MRI) or scope examination, or if
meniscus posterior horn tear, which is within 3 mm ACL ligament was torn concomitantly, the posterior
from the peripheral meniscal rim (meniscocapsular compartment is approached by passing the 30° arthro-
junction). In addition, we introduced modification to scope from anterolateral portal through the intercon-
our suturing technique for tears more than 3 mm from dylar notch between the medial femoral condyle and
peripheral rim and double longitudinal medial menis- the posterior cruciate ligament (PCL). This is first
cus posterior horn tears. This report introduces our facilitated by placing the anterior portals close to the
surgical procedure. lateral margins of the patellar tendon.13 Afterward, a
standard posteromedial portal is created under direct
arthroscopic visualization.14 This initial standard por-
SURGICAL TECHNIQUE tal is relatively small compared with the second pos-
Patient Positioning teromedial portal. This makes instruments such as the
suture hook, easy to move and manipulate. Using a
Allowing adequate room for placement of the pos- probe, the posterior compartment is examined thor-
terior portals and space for maneuvering the intra- oughly. Switching the scope to the posteromedial por-
articular instruments is imperative when positioning tal, the posterior horn is re-examined. After establish-
the patient. The opposite healthy limb is elevated in a ing a suture plan, a 70° arthroscope is reinserted to the
lithotomy position for further space security. The in- anterolateral portal and placed through the intercon-
jured knee should be flexed 90°, which makes the dylar notch to view the posterior compartment.
posterior compartments roomy and enlarged. Also, The second posteromedial portal, which is a supe-
this position permits manipulation of intra-articular rior posteromedial portal, is marked 1 cm superior to
instruments with relative ease and simultaneously pro- the previous standard posteromedial portal. The entry
tects the saphenous nerve by displacing it well poste- point is then localized with an 18-gauge spinal needle
rior from the joint line. while viewing from inside. After the proper position is
 ALL-INSIDE SUTURE TECHNIQUE 103

FIGURE 2. (A) Schematic cross-section of the knee with 2 posteromedial portals. The drawing shows the location of the 2 posteromedial
portals and the anterolateral viewing portal. (a, anterior portal; b, standard posteromedial portal; c, superior posteromedial portal.) (B) The
portal with cannula is seen from the outside.

confirmed, a skin incision and subcutaneous dissec- ends are brought out to the universal cannula. The
tion are performed. A 5.5-mm diameter universal can- SMC (Samsung Medical Center) knot15 is made ex-
nula (Linvatec, Largo, FL) is placed into this superior ternally and is slid inside toward the cannula with a
posteromedial portal (Fig 2). knot pusher. An additional 2 or 3 half-hitch knots with
alternating posts on reverse throws are made, and the
All-Inside Meniscal Suture Technique procedure is carefully inspected arthroscopically. Be-
A Linvatec suture hook loaded with a PDS No 0 cause the capsular recess, which is the peripheral rim
(Ethicon, Somerville, NJ) is inserted through the stan- portion of the meniscocapsular junction, has sufficient
dard posteromedial portal. The sharp hook tip first space available, tied knots are placed toward this
penetrates the meniscal peripheral rim tissue (menis- capsular recess. This can be performed more easily by
cocapsular tissue first) from superior to inferior (Fig making the capsular limb the post.
3). Then it is advanced under and across the tear
before penetrating the mobile central fragment from
inferior to superior. During this procedure, the sur-
geon must recognize that the peripheral rim of the torn
meniscus is almost always displaced inferiorly relative
to the mobile central fragment (Fig 4). Without cau-
tion, the entire thickness of the peripheral rim portion
can be penetrated, which will result in a poor tissue
approximation. The surgeon can essentially verify this
with the suture hook by penetrating the whole thick-
ness of the peripheral rim and making the tip of the
hook come out of the torn interval before making
additional sutures at the mobile central fragment.
Sometimes the portion of the torn central meniscus
may be difficult to pierce because of its mobility, a
probe was inserted into the universal cannula, aiding
the suture. The probe holds the central fragment down
to the tibial surface, and the suture hook penetrates
from the inferior to superior side. Surgeons can use
FIGURE 3. The suture hook loaded with PDS penetrates the torn
any other instruments that suit their convenience in meniscus from superior to inferior of the peripheral meniscal rim
aiding suturing. Using a suture retriever, both suture (meniscocapsular junction), and the tip is seen out of the torn hole.
104 J. H. AHN ET AL.

FIGURE 4. The relative position of the peripheral rim to the torn central meniscal fragment. (A) It generally lies below the central fragment.
(B) This is also true for double longitudinal tears. These schematic figures show the relative location of the peripheral rim to the torn
meniscus. Peripheral rim of the torn meniscus is almost always displaced inferiorly relative to the mobile central fragment.

For good coaptation and stable fixation of the torn and in double longitudinal tears with slight modifica-
meniscus, we advise placing 3 to 4 sutures (Fig 5A; tion. We will also introduce the modified technique.
panel B shows complete healing of the same tear). All-inside suturing of a single medial meniscus
Firm suturing is re-examined with a probe. This all- posterior horn tear that is more than 3 mm from the
inside suturing technique is ideal for medial meniscus peripheral rim is identical to a double longitudinal
posterior horn tears that are within 3 mm of the tear, and we only introduce the double longitudinal
peripheral rim. However, we can also apply the tech- tear suture technique in this article. In repairing this
nique to tears more than 3 mm from the peripheral rim complex tear, a Shuttle-Relay (Linvatec, Largo, FL)

FIGURE 5. (A) Three to 4 sutures are made with the knots placed toward the capsular recess. (B) Complete healing is shown on the
second-look arthroscopy at final follow-up evaluation.
 ALL-INSIDE SUTURE TECHNIQUE 105

FIGURE 6. Suture sequence in medial meniscus posterior horn double longitudinal tear. (A) Schematic drawing of the double longitudinal
tears on coronal plane. (B) The initial suture loaded with PDS is made on the far central mobile fragment from inferior to superior. (C) Both
limbs of the suture material are drawn to the cannula. The first limb that was drawn out of the cannula is identified with a hemostat. (D) The
second suture hook loaded with Shuttle-relay system is introduced through the standard PM portal to penetrate the peripheral rim of the
meniscus from superior to inferior. The hook comes out of the inner torn hole, crossing the outer tear underneath. (E) The PDS, which is
unmarked, is hooked to the shuttle-relay. (F) The shuttle relay is redirected to the standard PM portal. (G) A crochet hook is used to pull
the limb through the cannula, and the SMC knot is made. (H) The complete suture is made, and the knot is placed toward the peripheral
capsular recess.

was used to repair both tears with 1 suture. To make end of the suture limb outside the universal cannula.
the description simpler, between the 2 longitudinal Grasp this limb with a hemostat for identification. And
tears, we named the more peripheral tear site as the then the other limb, which lies outside of the working
outer tear and the more central tear site as the inner standard portal, is also retrieved with a grasper or
tear (Fig 6A). crochet hook to the cannula. Make sure to distinguish
A suture hook loaded with PDS No. 0 is introduced the 2 suture limbs because the suture limb that was in
to the standard posteromedial portal, and then a suture the standard portal (the limb that is coming out from
is made starting from the hole of the inner tear pene- the tear hole and the limb that is not marked with a
trating the most central fragment from inferior to hemostat) will be hooked to the Shuttle-Relay system
superior (Fig 6B). During this procedure, care must be (Fig 6C).
taken not to damage the cartilage of the femoral con- A second suture hook loaded with a Shuttle-Relay
dyle, because the hook is closest to the condyle during system was introduced via the standard posteromedial
this procedure. A grasper through the universal can- portal, and another suture is made piercing peripheral
nula retrieves the forwarded suture limb, placing one rim tissue from superior to inferior. The hook loaded
106 J. H. AHN ET AL.

with shuttle-relay crosses under the outer tear and and reduced the torn fragment with a probe or other
comes out superiorly through the inner tear hole (Fig instrument during this suturing procedure. Advantages
6D). As the shuttle-relay is fed out of the hook, a of this all-inside arthroscopic meniscus suture tech-
grasper retrieves the relay through the universal can- nique include (1) a smaller cannula (5.5 mm universal
nula. The initial PDS suture limb is now hooked to the cannula), which minimizes water leakage and tissue
relay system and redirected to pass the peripheral rim damage; (2) greater ease in manipulating and main-
of the meniscus (Fig 6E, F). Both ends of the suture taining reduction of the torn fragment with probe
are retrieved through the universal cannula with a assistance, even for double longitudinal tears; (3) a
suture retriever. A SMC knot is made and is slid with lower rate of cartilage damage by the suture hook
a knot pusher, with additional securing half-hitch su- because of probe assistance; (4) expansion of the
tures (Fig 6G, H). A firm repair is examined with a indicated area of repair; and (5) all other existing
probe. merits of all-inside sutures such as vertically oriented
If the tear is extended to the midhorn, our modified anatomic sutures, no posterior neurovascular injuries,
inside-out technique or meniscal fixators are used in no entrapment of the posterior capsule, and no addi-
combination with all-inside suturing. If the patient has tional posterior incision.6,8 Overall, these advantages
ACL insufficiency, ACL reconstruction is performed allow us to perform all-inside sutures with ease.
after the meniscal repair. For these patients, we repair Furthermore, the standard portal without cannula
the meniscus without tourniquet application and the greatly improves instrumentation. This freedom al-
ACL reconstruction with a tourniquet. This reduces lows us to make more than 3 to 4 sutures to the torn
the time needed for tourniquet application. Postoper- meniscus, whereas Morgan’s technique8 only allows 1
ative management includes a brace for 4 weeks, par- or 2 sutures. This freedom also allows us to suture the
tial weight bearing after 2 weeks, and full weight far medial corner and tears more than 3 mm from the
bearing after 8 weeks. peripheral rim. Reigel et al.6 reported that only 15% of
all medial meniscal tears are suitable for the all-inside
DISCUSSION repair. However, with this relative freedom of instru-
ments, indication for all-inside techniques can be ex-
Meniscal fixators, despite some early promising panded to far medial corner tears and more central
clinical results,16-18 have been often reported as hav- tears.
ing several complications. The implant is too rigid and We have found that tears up to 5 mm from the
the knot is made in the articular surface of meniscus meniscocapsular junction healed well with our sutur-
and is easy to break. Other complications include an ing technique (Fig 7). Because the tear is located more
inflammatory reaction combined with synovitis, pos- than 3 mm from the peripheral meniscal rim, we had
sible cyst formation, possible migration, chondral in- to modify our suturing method. This was also true for
jury, and insufficient tissue approximation.12,16,18-26 double longitudinal tears in which the inner tear is
Most importantly, they are relatively contraindicated probably 3 mm or more from the peripheral rim. If the
in tears near the meniscocapsular junction. suture is performed as previously described (from the
Morgan’s all-inside suture technique8 has several peripheral side to central side), we have a greater
limitations. The limitations include (1) greater loss of chance of penetrating only a fraction of the mobile
fluid through the 8-mm cannula, which causes insuf- central fragment because of limited space available for
ficient articular distention;12 (2) a restricted area avail- hook manipulation. Therfore, reversed order was ap-
able for meniscus suture that consists of only approx- plied to ensure complete penetration of the meniscal
imately 3 mm of the meniscocapsular junction, (3) thickness and to avoid the danger of cartilage injury.
more technical difficulty in manipulating the suture From May 1997 to June 2001, the senior author
hook through a single cannula, which is relatively (J.H.A.) performed this all-inside meniscal repair with
rigid, and simultaneously suturing the highly mobile ACL reconstruction in 78 knees in 78 patients, ex-
central torn fragment portion of the medial meniscus, cluding lateral meniscal repair. For 39 of the 78 pa-
and (4) a higher risk of articular cartilage damage tients, it was possible to evaluate the healing of me-
because of the rigidity of the cannula during hook niscal repair with second-look arthroscopy performed
manipulation. Consequently, we were forced to limit on average 19 months (range, 6 to 40 months) after
usage of this technique. meniscal repair with the ACL reconstruction. The
To overcome these difficulties, we used a superior success rate was 97.4% (38 of 39 patients) overall for
posteromedial portal to manipulate the instruments all-inside suture healing.
 ALL-INSIDE SUTURE TECHNIQUE 107

FIGURE 7. (A) The MRI findings show double longitudinal tears. (B) The standard posteromedial portal and a probe verify the lesion. (C)
Complete suturing of the double longitudinal tear with our all-inside suture technique. (D) Follow-up MRI after 6 months shows complete
healing of the posterior horn tear.

The major drawback in our technique is the ex- good tissue approximation without concern about neu-
tended surgical time. However, all-inside suture tech- rovascular injuries. Using this 2 posteromedial portal
niques seem to be the optimal answer to medial me- system, attempts to repair one of the most challenging
niscus posterior horn tears, because this is the only tears in the posterior horn region of medial meniscus
method that gives us vertically oriented sutures with are promising, with expected optimal results.
108 J. H. AHN ET AL.

Acknowledgment: The authors deeply thank Chan Hwa 13. Mulhollan JS. Swedish arthroscopic system. Orthop Clin
Park and Myung Ju Shin for their assistance with the draw- North Am 1982;13:349-362.
ings in this article. 14. Ahn JH, Ha CW. Posterior trans-septal portal for arthroscopic
surgery of the knee joint. Arthroscopy 2000;16:774-779.
15. Kim SH, Ha KI. The SMC knot: A new slip knot with locking
mechanism. Arthroscopy 2000;16:563-565.
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