Horizontal cleavage meniscus tears are a common orthopedic injury ^[1]. Horizontal cleavage tears (HCT) of the meniscus are treated with debridement of the flaps, rasping the edges, and closure of the flaps with sutures to achieve stable repair. Various methods are used to accomplish the repair, including an all-inside device [2, 3] or using a suture passing device [4, 5] and taking a bite through both flaps of the meniscus, using a sliding knot and half hitches. We used a modification of the racking hitch knot for repair of horizontal cleavage tear of the meniscus.

The patient is supine under spinal anesthesia with lateral thigh support applied at the level of the tourniquet. Standard arthroscopy portals are created for meniscus repair. Pie crusting of the medial collateral ligament is done to prevent the scuffing of the cartilage. The portals are switched to get a proper trajectory for the passage of the suture passing device. After debridement of the horizontal cleavage tear (Fig. 1a), a single bite is taken through both the flaps with a no. 0 fiber wire using the antegrade suture passing device (Fig. 1b). The fiber wire loop is then delivered through the working portal (Fig. 1c).

Then, the surgeon places the thumb and index finger down to up through the loop, and the same strands of thread are held to make a double loop (Fig. 2a, b, and c). The loop should look similar to what is shown in Fig. 2d. Both suture tails are passed through the double loop in opposite directions to each other (Fig. 2e, f, and g). The two ends of the suture are pulled, drawing a knot into the joint (Fig. 1d and Fig. 2h). This maneuver closes the meniscus flaps on each other (Fig. 1e and Fig. 2i). The knot is self-locking and gets tightly secured by making the suture tails rock in a “To and Fro” fashion. With the help of a suture cutter, the remaining threads are cut (Fig. 1f and Fig. 2j). This procedure is repeated multiple times as per the extent of tear (Fig. 1h and i).

Clinical reports on horizontal cleavage tear repair had shown good results [6, 7]. Kurzweil et al. in their systematic review reported a 78% healing rate ^[7]. Options available for fish mouth closure of horizontal cleavage tear of medial meniscus are either take one superior and one inferior capsular bite by inside out or all inside device such as fast fix or pass fiber wire through both the flap of the meniscus using suture passing device and tie the knot manually. Though it is time-saving, there is always a cost concern for using all inside devices. The inside-out technique needs the use of a safety incision, which adds to the operative time ^[8]. Passing fiber wire through the meniscus flap and manually tying the knot is cost-effective, but it needs multiple knots to secure it. Hence, it adds time to operative procedures, especially in tight joints. Furthermore, the final knot could be bulkier. Sanada et al. ^[9] used a raking hitch knot [10, 11] for all-inside repair for a radial tear at the posterior horn of the lateral meniscus. They recommended multiple half hitches to secure the knot, which adds to the time of the procedure. We tried modifying the racking hitch knot to take advantage of all the methods, i.e., cost-effectiveness and saving operative time. Our modified racking hitch knot (HP knot) is self-locking. The knot is complete in one step, it does not need a cannula as only a single bite is taken, saving operative time, especially in tight joints. We have confirmed the stability of the knot on the model as well as intraoperatively by pulling the knot with the probe. Furthermore, the knot is relatively less bulky, so concern about rubbing it against the femoral condyle is minimized. It is cost-effective as well.

Our modification of the racking hitch knot (HP knot) for fish mouth closure of horizontal cleavage tear of the meniscus is cost-effective and time-saving. The final knot is less bulky.

Modified racking hitch knot is a time-saving and cost-effective solution for closure of horizontal cleavage tear of the meniscus.