Arthroscopic Matrix-Based Meniscus Repair Surgical Technique With “Goat” Instrument

• Published in: Arthroscopy techniques (Amsterdam) Vol. 12; no. 8; pp. e1417 - e1422
• Main Authors: Ciemniewska-Gorzela, Kinga, Piontek, Tomasz, Naczk, Jakub, Bąkowski, Paweł, Murray, James
• Format: Journal Article
• Language: English
• Published: Elsevier 01.08.2023
• Subjects: Technical Note
• ISSN: 2212-6287; 2212-6287
• DOI: 10.1016/j.eats.2023.04.011

Human meniscal treatment with an arthroscopic matrix-based meniscal repair technique is a promising procedure. Heretofore, the procedure has required a skilled surgeon with a great amount of experience in knee arthroscopic surgery and meniscal suturing. A surgical technique using a “goat” delivery clamp has been developed. Technique development followed extensive review and the application of earlier arthroscopic matrix-based meniscal repair techniques, along with cadaveric refinement of the proposed arthroscopic technique. The presented technique includes preparation of the meniscus with initial stabilization of the damaged fragments, preparation of the collagen matrix and placement of this matrix into the open jaws of the goat delivery clamp, introduction of the collagen matrix into the knee and placement of this matrix on the meniscus, suturing of the collagen matrix to the meniscus, and bone marrow blood aspirate injection between the collagen matrix and meniscus. Video 1 Surgical technique of arthroscopic matrix-based meniscal repair (AMMR) with goat instrument. The patient is anesthetized and is placed in the supine position on the operating table with an Esmarch tourniquet on the operative leg. A knee examination is performed, including range-of-motion and ligamentous integrity testing. Medial and lateral arthroscopic parapatellar portal incisions are made, and a comprehensive diagnostic arthroscopy is performed. The meniscal tear is identified and probed. An assistant prepares the collagen matrix as follows: The matrix, usually 20 or 30 mm in size, is folded in half with its dense surface directed outward and is placed into the open jaws of the goat delivery clamp. The small needle at the top of each jaw pierces the border part of the appropriate half of the collagen matrix. The surgeon inserts the goat delivery clamp with the matrix through the enlarged medial portal into the knee. The surgeon opens the jaws of the goat delivery clamp to insert the matrix on the meniscal body in the correct position. The matrix covers the meniscus in the meniscal tear area from both sides (femoral and tibial). While the goat delivery clamp is held in this position by the assistant, the surgeon places the first suture anchor. The curved delivery needle is aimed to enter posterior one third-width of the collagen matrix implant with the inner curve of the needle pointed toward the femoral surface of the posterior horn. The needle tip is then advanced and penetrates the full thickness of the collagen matrix implant and the meniscus. When the needle tip penetrates the meniscal rim, the first anchoring device is deployed. After deployment, the needle is withdrawn, and the second anchoring device is deployed from the tibial surface of the posterior horn in the same fashion. Once both anchors are deployed, the suture stitch is tightened via its sliding knot. A knot pusher is used when advancing the knot and cinching it down. Once the stitch is knotted, the suture is cut, leaving a 2- to 3-mm suture tail. At this time, the goat delivery clamp is removed from the knee and the collagen matrix is safety placed on the meniscus. The second stitch is a vertical suture stitch placed into the anterior border of the collagen matrix. A horizontal mattress repair is also accomplished by orienting the suture passes on the meniscus approximately 5 mm posterior to the first suture pass. After this procedure, the meniscus is wrapped in the collagen matrix on both sides and is fixed into the meniscus in a stable way. At the same time, sutures stabilize the meniscal tear. An arthroscopic probe is used to confirm that the meniscus is well stabilized. GALL-BM11/10 equipment is used to collect blood from the bone marrow of the femoral distal epiphysis. The cortical layer is pierced with the needle on the lateral side of the femoral notch anterior to the femoral anterior cruciate ligament attachment. After passage through the cortical layer of the femoral bone with the use of a hammer, the internal mandrin of the cannula is removed, and a 50-mL syringe is attached to the needle. Then, approximately 5 mL of liquid bone marrow is aspirated. The knee is dried with a shaver-suction system. The entire aspirated liquid bone marrow is injected with a long needle between the collagen matrix and the meniscus using direct arthroscopic visualization with a dry arthroscopy technique. The tourniquet is then deflated, and wound closure is performed.