All-Inside Arthroscopic Meniscal Repair With Meniscal Cinch

Vipool K. Goradia, M.D.

Abstract: The number of commercially available all-arthroscopic meniscal repair devices has increased in recent years.
Although inside-out vertical mattress sutures have been considered the gold standard in the past, recent biomechanical
studies have shown that some all-arthroscopic repair devices provide comparable strength. To successfully use these
devices, surgeons must understand proper insertion technique. The purpose of this article is to demonstrate this technique
for the Meniscal Cinch (Arthrex, Naples, FL).

recent systematic review of 91 studies suggests

better long-term outcomes with meniscal repairs
as compared with partial meniscectomies.1 Traditionally,
inside-out repair with braided polyethylene vertical
mattress stitches has been considered the gold standard.2,3
Less invasive all-inside meniscal repair devices have
become increasingly popular in the past 20 years. The
initial 2 generations of these devices showed lower
load to failure than inside-out vertical mattress
stitches. This led to the development of third-generation implants with self-adjusting ultrahighemolecular
weight polyethylene (UHMWPE) sutures, which have
been shown by Barber et al.3 to be biomechanically
comparable to inside-out vertical mattress stitches.
Several manufacturers produce their version of these
third-generation devices with their own technical
nuances. The purpose of this technical note is to
provide surgeons with pearls for appropriate use of the
Meniscal Cinch (Arthrex, Naples, FL) (Tables 1-3).

Surgical Technique
The Meniscal Cinch is packaged with 2 small PEEK
implants (polyetheretherketone) loaded onto small
needles. The implants are attached to No. 2-0 FiberWire
suture (Arthrex). The suture comes pre-tied with
a sliding, locking knot. The insertion device has a pistol-

From Go Orthopedics, Chester, Virginia, U.S.A.

The author reports the following potential conict of interest or source of
funding in relation to this article: Consulting for Arthrex, Naples, FL.
Received December 4, 2012; accepted January 22, 2013.
Address correspondence to Vipool K. Goradia, M.D., Go Orthopedics, 13225
Rivers Bend Blvd, Chester, VA 23836, U.S.A. E-mail: vic@goortho.net
2013 by the Arthroscopy Association of North America
2212-6287/12790/$36.00
http://dx.doi.org/10.1016/j.eats.2013.01.010

grip design, and one method for holding it that allows

for control during insertion is shown in Fig 1.
After identication and preparation of a meniscal tear
suitable for repair, the Meniscal Cinch is inserted into
the knee through an ipsilateral or contralateral portal.
The choice of portal is based on tear location. For
example, a tear along the body of a lateral meniscus in
a right knee may be best approached with the Meniscal
Cinch in the anteromedial portal.
After insertion into the joint, the depth stop (Fig 1) on
the Meniscal Cinch must be set to the desired distance
to prevent the needles from penetrating too far beyond
the capsule. The distance from the tear to the periphery
of the meniscus can be measured in 2-mm increments
by use of the black lines on the end of the Meniscal
Cinch cannula. Next, the rst needle is advanced just
a few millimeters beyond the cannula (Fig 2A) and
then inserted across the meniscus (Fig 2B). If resistance
is encountered, the hand can be rotated 30 to 40
clockwise and counterclockwise while the cannula is
allowed to slide back from the meniscus as only the
needle is advanced across it (Video 1). The surgeon will
have a tactile sensation as the needle penetrates the
meniscus and/or capsule. As this occurs, the cannula
will rest against the meniscus and the depth stop will
prevent further insertion of the needle.
After removal of needle 1, the second needle is locked
into place (Fig 3). The cannula is moved to the desired
location of the second implant for either a horizontal or
vertical mattress stitch. Needle 2 is then advanced just
beyond the cannula as was performed for needle 1. If
desired, the free suture end on the outside of the
delivery device can be gently pulled to remove suture
slack within the joint (Fig 4). If any resistance is felt, the
surgeon must stop pulling the suture; otherwise, it
could cause the PEEK implant to dissociate from needle
2. After the second needle and implant are inserted

Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e171-e174

e171

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V. K. GORADIA

Table 1. Key Steps to Use of Meniscal Cinch

Description
Step 1
Step 2
Step 3
Step 4
Step
Step
Step
Step
Step
Step

5
6
7
8
9
10

Step 11
Step 12
Step 13

Identify tear in body or posterior horn amenable to repair.

Remove nonviable tissue using arthroscopic rasp and/or
shaver.
Insert Cinch into knee over a probe.
Measure depth of tear from periphery using cinch
cannula.
Set depth stop.
Advance needle 1 beyond cannula into meniscus.
Advance needle across meniscus by rotating and pushing.
Remove needle 1.
Depress needle 2 into position.
Advance needle 2 across meniscus for vertical or
horizontal mattress repair.
Remove needle 2.
Pull tension on suture until pre-tied knot seats.
Use knot pusher/cutter for nal tensioning and then
cut suture.

Table 3. Advantages of Meniscal Cinch

1. The rigid metal cannula allows ease of insertion into the joint and
surgeon control of needle placement.
2. Small-diameter needles cause minimal damage to meniscal tissue.
3. The depth stop can be easily adjusted by the surgeon to prevent
excessive needle penetration.
4. No. 2-0 FiberWire is high-strength suture.
5. Suture slack can be removed to improve visualization.
6. The low-prole knot prevents chondral abrasion.

Table 2. Pearls for Proper Use of Meniscal Cinch

Challenge
Unable to advance needle

Visualization impaired by suture

slack in joint

Prevent premature cutting of

suture with non-disposable knot
pusher/cutter

Solution
Allow the metal cannula to slide
back; advance the needle while
rotating it clockwisecounterclockwise.
Gently pull on suture on the back
of the cinch (outside of knee).
Stop if any resistance is
encountered; otherwise, the
implant may dissociate from the
needle.
Advance the suture cutter in line
with suture.

across the meniscus, needle 2 and the cannula are

removed from the joint.
The knot is secured by pulling on the free suture end.
Final suture tension is applied by pushing the knot with

Fig 1. Meniscal Cinch with metal cannula showing black

markings in 2-mm increments (white arrow), depth stop with
white markings in 2-mm increments (black arrow), and
delivery needles 1 and 2 (stars). The ideal method for holding
the Meniscal Cinch is also shown.

either a disposable or non-disposable pusher/cutter

(Arthrex) (Fig 5). After the suture is cut, a probe is used
to assess security of the repair and the need for further
xation. Figure 6 shows the nal appearance of the
implants rmly against the capsule and the knot buried
in the meniscus.
The placement of vertical mattress sutures on the
superior and inferior surfaces of the meniscus can
provide excellent tear reduction and xation (Video 1).

Fig 2. Implant insertion. (A) The

delivery needle (arrow) is inserted beyond the metal cannula so
that it can pierce the meniscus.
(B) The needle and implant
penetrate the meniscus.

MENISCAL CINCH TECHNIQUE

e173

Fig 5. A disposable knot pusher/suture cutter is advanced in

line with the suture for nal tensioning.

posterolateral incision. The initial all-inside devices

were rigid and often resulted in chondral damage
because of prominence on the meniscal surface4 or pain
from penetration beyond the capsule. The next generation of all-inside repair devices used self-adjusting
braided polyester sutures attached to implants. These

Fig 3. After removal of delivery needle 1, the second needle is

locked into place by pushing directly down.

Discussion
Inside-out repair of meniscal tears has been the gold
standard in terms of biomechanical strength but has
had the disadvantage of requiring a posteromedial or

Fig 4. As needle 2 is advanced into the cannula, suture slack

within the joint can be removed by pulling on the suture in
the direction of the arrow.

Fig 6. Final appearance of vertical mattress stitch. (A) Both

implants are sitting securely on the capsule. (B) The knot is
buried in the meniscus and cannot be seen.

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V. K. GORADIA

reduced the risk of chondral abrasion and had pullout

strength similar to the gold standard but had a high rate
of breakage during biomechanical testing.5 The more
recent incorporation of UHMWPE suture in the selfadjusting devices has improved their pullout and cyclic
loading properties. The Meniscal Cinch is one of the
latest generation of these meniscal repair devices that
uses No. 2-0 UHMWPE suture (FiberWire). The
Meniscal Cinchs load to failure (mean, 70.9 N) and
displacement after 100 cycles (mean, 2.65 mm) have
been shown to be similar to inside-out vertical mattress
stitches with No. 2-0 Ethibond (Ethicon, Somerville,
NJ) (73.3 mm and 2.58 mm, respectively).2
The Meniscal Cinch contains a rigid curved cannula
that is low prole and gives the surgeon control when
inserting the delivery needle across the meniscus. The
resistance encountered during insertion is overcome by
rotating the hand (i.e., pronation-supination) as the
needle is advanced. The advantage of this natural
resistance is that it provides the surgeon with a clear
tactile sensation as the needle and implant penetrate
the meniscus and capsule. Other favorable properties of
the Meniscal Cinch include the ability to remove suture

slack within the joint, which improves visualization,

and the pre-tied knot, which consistently slides and
becomes buried in the meniscus, reducing the risk of
chondral abrasion. The Meniscal Cinch is designed for
repair of meniscal tears of the body and posterior horn
and cannot be used for anterior horn tears.

References
1. Paxton ES, Stock MV, Brophy RH. Systematic review with
video illustrations meniscal repair versus partial meniscectomy: A systematic review comparing reoperation rates
and clinical outcomes. Arthroscopy 2011;27:1275-1288.
2. Strke C, Kopf S, Petersen W, Becker R. Current concepts:
Meniscal repair. Arthroscopy 2009;25:1033-1044.
3. Barber FA, Herbert MA, Bava ED, Drew OR. Biomechanical testing of suture-based meniscal repair devices containing ultrahigh-molecular-weight polyethylene suture:
Update 2011. Arthroscopy 2012;28:827-834.
4. Ross G, Grabill J, McDevitt E. Chondral injury after
meniscal repair with bioabsorbable arrows. Arthroscopy
2000;16:754-756.
5. Barber FA, Herbert MA, Richards DP. Load to failure testing
of new meniscal repair devices. Arthroscopy 2004;20:45-50.