Simplified Arthroscopic Lateral Meniscal Root Repair Involving the Use of 2 Cinch-Loop Sutures  Patrick A. Smith, M.D., Jordan A. Bley, B.A.  Arthroscopy Techniques  Volume 6, Issue 1, Pages e73-e79 (February 2017) DOI: 10.1016/j.eats.2016.09.002 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Left knee magnetic resonance image, coronal view. The intact medial meniscal root (left) is attached to the tibia. The torn lateral meniscal root (right) is above the anatomic attachment point. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Left knee viewed through lateral portal, with patient lying supine. The torn lateral meniscal root is visualized arthroscopically (arrow). During anterior cruciate ligament reconstruction, it is important to probe the anatomic root to ensure proper attachment because lateral meniscal root tears often go undiagnosed with concomitant anterior cruciate ligament tears. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Left knee viewed through lateral portal, with patient lying supine. The PassPort Cannula (arrow), 8 mm in diameter and 20 mm long, is in place through the anteromedial portal. This allows for passage of meniscal root sutures and avoidance of troublesome portal soft-tissue bridges. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 Left knee viewed from lateral portal, with patient lying supine. The folded No. 0 FiberWire is passed through the attachment of the posterior horn root of the lateral meniscus with a Knee Scorpion device, which is delivered through the joint through a PassPort Cannula in the anteromedial portal. Squeezing the Knee Scorpion handles passes the needle with the No. 0 FiberWire suture through the lateral meniscal root as a loop to allow for the cinch configuration. The top jaw of the Knee Scorpion captures the suture in one step because it is self-retrieving (arrow). The Knee Scorpion, now with the attached suture loop, is then removed from the joint through the PassPort Cannula. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Left knee viewed from lateral portal, with patient lying supine. Outside the joint through the PassPort Cannula in the anteromedial portal, the 2 free ends of the No. 0 FiberWire suture are passed through the loop to create the cinch configuration. The cinch is then slid down to the posterior horn of the lateral meniscus by pulling on the free ends of the No. 0 FiberWire suture. This suturing process is repeated so that there are two No. 0 FiberWire cinch-loop sutures (arrows) in place in the lateral meniscal root. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 Left knee viewed laterally, with patient lying supine. The tibial anterior cruciate ligament aiming guide (Arthrex) is passed through the medial portal PassPort Cannula and positioned (arrow) at the anatomic attachment of the posterior root of the lateral meniscus off the posterior-central-lateral tibial plateau. This serves as a guide for the FlipCutter retrocutting device and allows drill entrance in the joint at the appropriate location to create the tibial bone socket for the lateral meniscal root repair. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 Left knee, with patient lying supine. The tibial anterior cruciate ligament aiming guide and guide sleeve (arrows) (Arthrex) are viewed from outside the knee. The knee is flexed to 60°, and the guide is passed through the medial portal and positioned arthroscopically at the anatomic insertion of the posterior root of the lateral meniscus. The 6.0-mm-diameter FlipCutter is drilled as a 3.5-mm guide pin through the guide sleeve across the tibia to the point of the aimer in the joint through the small medial tibia incision, which also will be used for creation of the anterior cruciate ligament tibial socket. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 Left knee viewed through lateral portal, with patient lying supine. (A) Once the FlipCutter is drilled across the tibia into the joint as a 3.5-mm pin (arrow), the button on the pin is depressed and slid forward. (B) This “flips” the pin into a 6.0-mm retrodrill (arrow). One should note that the shaver is passed through the medial portal to allow removal of bone fragments from the tibial reaming process. The socket is cut to the appropriate depth of 15 mm, delivered back into the joint and “unflipped” with the button on the device, and removed from the joint through the guide sleeve. Importantly, the guide sleeve is tapped 7 mm into the proximal-medial tibia, which provides a preserved conduit for later suture passage. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 Left knee viewed laterally, with patient lying supine. A No. 2 TigerStick suture (left arrow) (Arthrex) in its red sheath is passed through the guide sleeve that had been tapped in place in the proximal-medial tibia. This enters the joint in the created tibial socket, and the suture is retrieved through the anteromedial portal to shuttle back the two No. 0 FiberWire cinch-loop sutures (right arrow) placed in the torn lateral meniscal root. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 Left knee, with patient lying supine. The two No. 0 FiberWire lateral meniscal root sutures exiting out the small 3.5-mm tibial drill hole from the FlipCutter are passed through the eyelet of a 4.75-mm BioComposite SwiveLock anchor. A 2.4-mm drill pin is inserted into the proximal-medial tibia 1.5 cm distal to the hole with the 2 FiberWire cinch-loop sutures (arrow). This pin is then over-reamed to a depth of 20 mm with a 4.5-mm reamer. Next, with the knee flexed to approximately 60°, the SwiveLock anchor is gently tapped into the 4.5-mm reamed hole and then screwed in, holding the paddle handle until the anchor is flush to the tibial cortex to optimize fixation. This completes the lateral meniscal root repair. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 11 Left knee viewed laterally. Final arthroscopic confirmation of secure fixation for the posterior root repair of the lateral meniscus is performed. The two No. 0 FiberWire cinch sutures have been pulled down through the FlipCutter socket hole (arrow), pulling the meniscal root securely to its anatomic bony attachment. Arthroscopy Techniques 2017 6, e73-e79DOI: (10.1016/j.eats.2016.09.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions