Initially, we identify the adductor tubercle, the articular interline, and the posteromedial aspect of the tibial plateau and make a 6-cm long oblique incision, slightly anterior to the aforementioned anatomical points, extending 2 to 3 cm distal to the articular interline. After dissecting the subcutaneous tissue, we identify and incise the fascia from the sartorius tendon. Care must be taken with the saphenous nerve, which passes about 5 cm posterior to the adductor tubercle.

We seek to identify a triangle formed by the joint capsule, semimembranosus tendon, and medial head of the gastrocnemius muscle. We digitally dissect expanding this triangle to facilitate the passage of the meniscal suture device.

Depending on the location of the radial tear, we decide which portal to insert the camera. In injuries from the middle-third to anterior, we position the camera in the anteromedial portal. In injuries from the middle-third to posterior, we position the camera in the anterolateral portal.

The suture device must be previously loaded with a long nonabsorbable thread (preferably greater than 60 cm in length) through the lumen. We adjust the wire asymmetrically in the device, with its smaller end facing the angled device aspect, called the anterior region of the device (Fig 2A ). The device is introduced into the joint through the portal opposite to the camera, and it should penetrate the meniscus in its upper surface, 5 mm posterior to the radial tear, close to the capsule, in the red–red zone (Fig 2B and C). Through digital palpation through the previously performed approach, it is possible to feel the tip of the device before it crosses the joint capsule, minimizing the risk of iatrogenic injury.

Fig 2(A) The Meniscus 4 AII (Síntegra Surgical, Pompéia - SP, Brazil) is prepared, leaving the suture thread asymmetrical with the smallest end of the thread remaining in the anterior region of the device. (B) We perform a posteromedial approach, then introduce the device at the most posterior and upper edge of the radial tear. (C and D) With the aid of a probe, we pull the anterior (shorter) portion of the wire. (E) We return with the device into the joint. (F) We cross the lesion with the wire, introducing the device on the anterior and distal side of the radial tear. (G) We form the first extra-articular loop. (H) We hold the extra-articular loop with a probe. (I) We return with the device to the joint again. (J) We cross the tear horizontally, inserting the device in the posterior and distal side of the radial tear. (K) We form the second extra-articular loop, holding it with the aid of a probe, always holding the loop on the front side of it. (L) We return to the joint with the Meniscus 4 AII (Síntegra Surgical, Pompéia - SP, Brazil). (M) We cross the tear obliquely again, introducing the device on the anterior and proximal side of the radial tear. (N) We hold the third loop, with the aid of a probe, always holding the loop on the front side of it. (O) We return with the device, to the joint again. (P) We cross the tear horizontally, inserting the device in the posterior and proximal side of the radial tear. (Q) We pull the last loop formed, bringing the wire entirely to the extra-articular region. (R and S) We remove the wire from the inside of the lumen located at the device end and move the Meniscus 4 AII (Síntegra Surgical, Pompéia - SP, Brazil) back into the joint, removing it from the knee.

Fig 2(A) The Meniscus 4 AII (Síntegra Surgical, Pompéia - SP, Brazil) is prepared, leaving the suture thread asymmetrical with the smallest end of the thread remaining in the anterior region of the device. (B) We perform a posteromedial approach, then introduce the device at the most posterior and upper edge of the radial tear. (C and D) With the aid of a probe, we pull the anterior (shorter) portion of the wire. (E) We return with the device into the joint. (F) We cross the lesion with the wire, introducing the device on the anterior and distal side of the radial tear. (G) We form the first extra-articular loop. (H) We hold the extra-articular loop with a probe. (I) We return with the device to the joint again. (J) We cross the tear horizontally, inserting the device in the posterior and distal side of the radial tear. (K) We form the second extra-articular loop, holding it with the aid of a probe, always holding the loop on the front side of it. (L) We return to the joint with the Meniscus 4 AII (Síntegra Surgical, Pompéia - SP, Brazil). (M) We cross the tear obliquely again, introducing the device on the anterior and proximal side of the radial tear. (N) We hold the third loop, with the aid of a probe, always holding the loop on the front side of it. (O) We return with the device, to the joint again. (P) We cross the tear horizontally, inserting the device in the posterior and proximal side of the radial tear. (Q) We pull the last loop formed, bringing the wire entirely to the extra-articular region. (R and S) We remove the wire from the inside of the lumen located at the device end and move the Meniscus 4 AII (Síntegra Surgical, Pompéia - SP, Brazil) back into the joint, removing it from the knee.

The shortest wire is pulled out of the joint about 15 cm and secured with a Kelly clamp (Fig 2D). Then, we return with the Meniscus 4 A-II (Síntegra Surgical, Pompéia - SP, Brazil) to the joint (Fig 2E), and it is now inserted crossing obliquely the radial tear and penetrating the other side of the meniscus 5 mm anterior to the tear, far from the capsule, in the white or red–white area (Fig 2F). After the device exits through the posteromedial approach, we retract it about 0.5 cm, creating a loop with the suture thread (Fig 2G). We pull the loop formed at the posterior face of the device to gain extra-articular wire length. After we obtain a loop of an appropriate size, we pull the loop on the front face of the device, keeping it in that region of the device, making sure that the end of the wire that passes through the interior of the device, is the same that is passing through the arthroscopy portal. Then we hold that formed loop with a Kelly clamp (Fig 2H). Once again, the device returns to the joint (Fig 2I) and at this time, the point of entry into the meniscus must be 5 mm posterior to the radial tear, away from the capsule, crossing the tear horizontally, inserting the device posterior and distal to the radial tear (Fig 2J). After going through the capsule, we slightly retract the device, forming a loop again (Fig 2 K and L). We repeat the steps mentioned previously, forming a new loop on the anterior face of the device. We hold the second loop and move the device back into the joint again. The next step we cross the radial tear obliquely again (Fig 2M), introducing the device on the anterior and proximal side of the radial tear, 5 mm anterior to the radial tear, close to the joint capsule. Then, we repeat the aforementioned steps, forming the third loop (Fig 2N). Holding it, we retract the device into the joint again (Fig 2O). Finally, we cross the tear horizontally, inserting the device in the posterior and proximal side of the radial tear (Fig 2P). We pull the last loop formed (Fig 2Q), bringing the wire entirely to the extra-articular region, and then remove it from the lumen of the Meniscus 4 A-II (Síntegra Surgical, Pompéia - SP, Brazil) (Fig 2 R and S). We retract the device back into the joint, removing it from the knee.Then, we have 3 loops and 2 wire ends at the extra-articular medial incision. With the help of a scalpel or a scissors, we cut all the loops (Fig 3 A and B). We pull wire by wire to find which wire connects with the other, and tie each suture with 4 knots (Fig 3 C-G). At this moment, we verify arthroscopically the reduction of the radial tear and the repair configuration similar to an hourglass or a Roman numeral 10 (Fig 4 A and B).

Fig 3(A) With the help of a scalpel or a scissors, we cut all the loops. (B) With the help of a scalpel or a scissors, we cut all the loops. (C) We then perform the suture thread by thread. (D) We then perform the suturing thread by thread; at this moment, we observed the reduction of the radial tear. (E and F) We continue to perform the suture thread by thread. (G) Then the procedure is complete, and the surgery is finished.

Fig 4(A) Preoperative aspect of the radial tear on bovine model. (B) Meniscus 4 AII (Síntegra Surgical, Pompéia - SP, Brazil) crossing the posterior and proximal edge of the radial tear. (C) The device crosses the tear horizontally. (D) Meniscus 4 AII crosses the radial tear for the last time. (E) Postoperative aspect of the hourglass technique. (MFC, Medial Femoral Condyle.)