The circumferential compression stitch for meniscus repair

Abstract

Over the past 30 years, many patients have benefited from arthroscopically assisted meniscus repair surgery and its ability to preserve a healthy knee. Although techniques have evolved, the basic premise of central-to-peripheral needle penetration across the tear with fixation into the capsular region immediately peripheral to the meniscus has remained. Suture repair techniques that involve encircling the tear have been discussed but have remained largely impractical because of the anatomic constraints of the arthroscopic knee. A suture-passing technology designed to function within these constraints was recently made available from Ceterix Orthopaedics (Menlo Park, CA). It allows surgeons to arthroscopically place circumferential sutures around meniscus tears to provide uniform, anatomic compression of the tear edges through an all-inside technique. This stitch is likely to improve healing rates and safety, as well as to enable repair of tears that were previously considered difficult or impossible to sew. The purposes of this note and accompanying video are to show the feasibility of placing all-inside circumferential compression stitches to treat tears of the knee meniscus and to discuss the potential benefits of such techniques.

Figures

Fig 1

Peripheral vertical tear before repair (A), after traditional all-inside repair (B), and after circumferential compression stitch all-inside repair (C). Note that with the circumferential compression stitch, the entire tear surface is uniformly compressed from top to bottom and that the capsule remains untethered.

Fig 2

Profile view of Ceterix meniscus suture passer. The orange trigger controls the upper jaw; when compressed, the upper jaw flexes forward so that it can be brought in line with the shaft during insertion into the knee. The black trigger has dual functionality: lower jaw protraction and needle drive. When compressed the first time, the lower jaw protracts forward, and when compressed a second time, the needle passes the suture from the lower jaw to the upper jaw, where it is self retained. The lower jaw can then be retracted back into the shaft by use of downward pressure on the thumb trigger so that the device can be atraumatically removed. The device is designed for use with 1 hand. The surgeon can place multiple stitches with 1 disposable device.

Fig 3

(A, B) The Ceterix suture passer is inserted through the working portal and advanced until the upper jaw is between the superior surface of the meniscus and the articular surface of the femoral condyle. (C) The lower jaw is then protracted forward so that it moves under the meniscus and the needle trigger is actuated to complete the peripheral pass of the suture from the lower jaw to the upper jaw, where it is atraumatically self retained. (D) The lower jaw is retracted and the device removed. (E) The lower jaw is then loaded with the opposite end of the suture while leaving the first end retained within the upper jaw. A gentle pull on the trailing suture during re-insertion ensures that there is not a tissue bridge. (F, G) The suture is passed evenly spaced on the other side of the tear, and then the lower jaw is again retracted and the device removed. (H) The knot is tied at the peripheral femorosynovial junction. Also shown are arthroscopic photos of the Ceterix Novostitch device passing suture to repair a vertical tear of the medial meniscus (I) in a 37-year-old woman. Note that in this case the 2 suture strands were shuttled to the tibial side (J) so that the knot could be placed within the tibial gutter (K) and that uniform tear compression was obtained. Video 1 shows this repair.

Fig 4

Suture repair of a bucket-handle lateral meniscus tear in a 16-year-old boy with a small intact peripheral rim. This tear would be difficult to treat with traditional inside-out or all-inside techniques because of the presence of the popliteal hiatus and the proximity of neurovascular structures. (A) The first of multiple peripheral stitches is placed around the remnant at the region of the popliteal hiatus. (B) The Ceterix device is re-inserted to pass the central limb of the second stitch. (C) The first 2 stitches have been placed and tied at the region of the popliteal hiatus. At 6 months' follow-up, clinical healing had been obtained.

Fig 5

Radial meniscus tears can be repaired with the Ceterix device by placing circumferential stitches in any combination that best reduces and compresses the tear. (A) The central third of the meniscus can be excised, and the central and peripheral thirds can be repaired with side-to-side or figure-of-8 sutures. The photographs show a radial tear of the posterior horn of the medial meniscus (B) in a 55-year-old man with completely healthy tricompartmental articular surfaces. (C) Photograph taken after passage of the first stitch, showing the device being removed with the suture after it has been self retained in the upper jaw. (D) In this case the central 2 sutures were used to shuttle polydioxanone, and a third stitch was placed more peripherally and left as No. 2-0 nonabsorbable suture to back up the repair. Polydioxanone is sometimes used in radial tear repairs because the more central knots cannot be peripheralized like they can with circumferential compression stitches that are placed in the central to peripheral vector. Video 1 includes excerpts from this repair.

Fig 6

Horizontal cleavage tear of lateral meniscus in a 28-year-old woman before repair (A), after passage of the first stitch around the back of the meniscus at the level of the popliteal hiatus (B), and after repair (C). (D) Drawing showing resected and repaired regions relative to popliteal hiatus. (E) Coronal magnetic resonance images of lateral compartment at level of popliteal hiatus obtained preoperatively (Pre-op) and 6 weeks postoperatively (6 wks post-op), showing excellent early healing of the lateral meniscus horizontal cleavage tear. The postoperative magnetic resonance image was obtained to guide rehabilitation. The preoperative and postoperative MRI scans were obtained from different facilities with slightly different protocols explaining the difference in contrast within the bone.

Fig 7

Medial meniscus root tear repair in a 50-year-old woman. Four passes through the meniscus were made, including an inverted mattress stitch, and the sutures were brought through a bone tunnel and tied over a tibial washer. The bone tunnel was created with a FlipCutter device (Arthrex, Naples, FL), as shown in Video 1. Pictured is (A) Ceterix device removal after passage of the first stitch, (B) the meniscal root after passage of the above mentioned suture patterns, and (C) following reduction of the root into the prepared trough.