[ clinical commentary ]

FRANK R. NOYES, MD1 • TIMOTHY P. HECKMANN, PT, ATC2 • SUE D. BARBER-WESTIN, BS3

Meniscus Repair and Transplantation:

A Comprehensive Update

T
he menisci provide several vital mechanical functions in the ies focused on repair of simple longitudi-
knee joint. They act as a spacer between the femoral condyle nal tears located in the periphery or outer
one-third region of the meniscus, many
and tibial plateau and, when there are no compressive weight-
studies have now been published on the
bearing loads across the joint, limit contact between the outcome of repair of complex multiplanar
articular surfaces. The menisci provide shock absorption to the knee tears that extend into the central third
joint during walking and are believed to assist in overall lubrication avascular region, and have reported en-
of the articular surfaces.36,75 Following meniscectomy, the tibiofemoral couraging success rates.40
Unfortunately, not all meniscus tears
contact area decreases by approximately Preservation of meniscal tissue and can be repaired, especially if considerable
50%, while the contact forces increase function is paramount for long-term joint tissue damage has occurred. In appropri-
2-fold to 3-fold.2,32,74 Meniscectomy fre- function, especially in younger patients ate patients, meniscus transplantation
quently leads to irreparable joint damage, who are athletically active. Since early offers the potential to restore partial
including articular cartilage degenera- reports of meniscus repair in the 1980s, load-bearing meniscus function, decrease
tion, flattening of articular surfaces, and considerable attention has been made to symptoms, and provide chondropro-
subchondral bone sclerosis.26,49,66,79 Poor improve surgical techniques, understand tective effects.20,73,77 Transplantation of
long-term clinical results have been re- appropriate indications, and enhance human menisci is no longer considered
ported by many investigators following postoperative rehabilitation to restore experimental, as over 30 clinical studies
partial and total meniscectomy.3,34,54,57,58,61 normal joint function. While early stud- involving hundreds of patients have been
published.41 While the results of this op-
TTSYNOPSIS: Preservation of meniscal tissue is
eration vary, studies continue to justify
high compressive and shear forces can disrupt
paramount for long-term joint function, especially healing meniscus repair sites and transplants. the procedure in young patients who have
in younger patients who are athletically active. Immediate knee motion and muscle strengthening undergone meniscectomy and have pain
Many studies have reported encouraging results are initiated the day after surgery. Variations are or articular cartilage damage in the men-
following repair of meniscus tears for both simple built into the rehabilitation protocol according to iscectomized tibiofemoral compartment.
longitudinal tears located in the periphery and the type, location, and size of the meniscus repair, In the 5 years since our last update
complex multiplanar tears that extend into the if concomitant procedures are performed, and if
on this topic in the JOSPT,22 further
central third avascular region. This operation articular cartilage damage is present. Meniscus re-
pairs located in the periphery heal rapidly, whereas longer-term data have been published
is usually indicated in active patients who have
tibiofemoral joint line pain and are less than 50 complex multiplanar repairs tend to heal more supporting both meniscus repair30,48,62
years of age. However, not all meniscus tears are slowly and require greater caution. The authors and meniscus transplantation.63,69,73,76,77
repairable, especially if considerable damage has have reported the efficacy of the rehabilitation The operative techniques and rehabilita-
occurred. In select patients, meniscus transplanta- programs and the results of meniscus repair and tion programs remain relatively similar,
tion may restore partial load-bearing meniscus transplantation in many studies. J Orthop Sports
as do the indications and contraindica-
function, decrease symptoms, and provide Phys Ther 2012;42(3):274-290, Epub 4 September
2011. doi:10.2519/jospt.2012.3588 tions. Newer magnetic resonance imag-
chondroprotective effects. The initial postoperative
TTKEY WORDS: knee rehabilitation, meniscus
ing (MRI) techniques, including use of a
goal after both meniscus repair and transplanta-
tion is to prevent excessive weight bearing, as repair, meniscus transplant 3-T scanner with cartilage-sensitive pulse
sequences and T2 mapping, have provid-

1
Chairman and Medical Director, Cincinnati SportsMedicine & Orthopaedic Center, Cincinnati, OH; President, Cincinnati SportsMedicine Research and Education Foundation,
Cincinnati, OH. 2Director of Rehabilitation, Cincinnati SportsMedicine & Orthopaedic Center, Cincinnati, OH. 3Director of Clinical and Applied Research, Cincinnati SportsMedicine
Research and Education Foundation, Cincinnati, OH. Address correspondence to Sue D. Barber-Westin, Cincinnati SportsMedicine Research and Education Foundation, 10663
Montgomery Rd, Cincinnati, OH 45242. E-mail: [email protected]

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 Axial lower-limb alignment is measured
Indications and Contraindications
TABLE 1 using full standing, hip-knee-ankle
for Meniscus Repair
weight-bearing radiographs in knees that
Indications
demonstrate varus or valgus alignment
• Meniscus tear with tibiofemoral joint line pain
on physical examination. Varus or val-
• Patients younger than 50 years of age or patients in their fifties who are athletically active
gus malalignment is also a contraindica-
• Concurrent knee ligament reconstruction or osteotomy
tion to meniscus transplantation (unless
• Meniscus tear reducible, good tissue integrity, normal position in the joint once repaired
corrected with a high tibial or femoral
• Peripheral single longitudinal tears: red-red, 1 plane; reparable in all cases, high success rates
osteotomy). MRI is obtained using a pro-
• Middle-third region: red-white (vascular supply present) or white-white (no blood supply); often reparable with
ton-density-weighted, high-resolution,
reasonable success rates
fast spin-echo sequence18,50 to determine
• Outer-third and middle-third regions, longitudinal, radial, horizontal tears: red-white, 1 plane; often reparable
the status of the articular cartilage and
Contraindications
menisci. As viewed on MRI, advanced
• Meniscus tears located in inner-third region
knee joint arthrosis, with flattening of the
• Chronic degenerative tears in which the tissue is of poor quality and not amenable to suture repair
femoral condyle, concavity of the tibial
• Longitudinal tears less than 10 mm in length
plateau, and osteophytes, is a contraindi-
• Incomplete radial tears that do not extend into the outer-third region
cation for meniscus transplantation.
• Patients older than 60 years of age
• Patients unwilling to follow postoperative rehabilitation program
MENISCUS REPAIR
Reprinted from Noyes and Barber-Westin,40 with permission.
Indications

T
he indications and contraindi-
ed advanced, noninvasive insight into the popping, clicking, or catching) during cations for meniscus repair are
ultrastructure of hyaline cartilage. This joint compression and flexion and exten- shown in TABLE 1 and have been
allows detection of early degenerative sion, lack of full extension, and a positive described in detail elsewhere.40,44 Can-
changes before discernible loss of carti- McMurray test.33 The clinical examina- didates are active patients who have
lage thickness is visible on conventional tion may reveal tenderness on palpation tibiofemoral joint line pain and usually
MRI. Use of this technology allows for a at the posterolateral aspect of the joint, at less than 50 years of age, or in their fif-
better assessment of the chondroprotec- the anatomic site of the popliteomeniscal ties and athletically active.62 The patient
tive effects of these operations and the attachments. The McMurray test is per- must be willing to follow the rehabilita-
integrity of the repair site or transplant formed in maximum flexion, progressing tion program, including protected weight
tissue. from maximum external rotation to in- bearing for up to 6 weeks. Those in whom
ternal rotation, then back to external ro- complex tears are repaired must agree to
CLINICAL EVALUATION tation. With maximum internal rotation, avoid strenuous activities and deep knee
this test may produce a lateral, palpable flexion for 4 to 6 months to prevent tear-

A
thorough history is taken and snapping sensation, representing an an- ing and failure of the repair. Meniscus
questionnaires are used to rate terior subluxation of the posterior horn of tears are classified at arthroscopy accord-
symptoms, functional limitations, the lateral meniscus. ing to location, type of tear, and integrity
sports and occupational activity levels, In all patients, radiographs are taken and damage to meniscal tissue and the
and patient perception of the overall during the initial examination. These meniscus attachment sites. This classi-
knee condition according to the Cincin- include an anteroposterior view of both fication and a meticulous arthroscopic
nati Knee Rating System.6 A compre- knees in full extension, a lateral view at inspection of the tear site determine if
hensive knee examination is performed 45° of flexion, and an axial view of the a tear is repairable. The meniscus tis-
that includes assessment of knee motion, patellofemoral joint. The anteroposterior sue should appear nearly normal, with
patellofemoral indices, tibiofemoral pain and lateral radiographs are used for siz- no secondary tears or fragmentation. A
and crepitus, muscle strength, ligament ing assessment for meniscus allografts.41 complex multiplanar tear located in the
subluxation tests, and gait abnormali- The tibiofemoral joint spaces (medial and middle-third region or in multiple planes
ties. The presence of tibiofemoral joint lateral) are assessed with weight-bearing may have a success rate of approximately
line pain on joint palpation is a primary posteroanterior (PA) views taken at 45° 50%, and the repair of these more diffi-
indicator of a meniscus tear. Other clini- of knee flexion. A tibiofemoral joint space cult tears is usually performed in young
cal signs include pain on forced flexion, of at least 2 mm on standing PA views is patients in an attempt to preserve some
obvious meniscal displacement (such as required for meniscus transplantation. meniscal function.

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 [ clinical commentary ]
Operative Techniques
Several studies have analyzed the biome-
chanical properties of suture techniques
and meniscus repair devices.5,9,17,35,78,80,81
Vertical sutures are superior to both
horizontal sutures and meniscus arrows
in mean load-to-failure values.4,16,52,78 The
superior strength of vertical sutures is hy-
pothesized to be due to the perpendicular
orientation to the circumferential colla-
gen bundles of the meniscus.52
We have previously described the op-
erative techniques for meniscus repair of
various types of tears in detail.40 Diag-
nostic arthroscopy is first performed and
the meniscus tear analyzed according to
its location, type, and size. The meniscus
tissue and synovial junction are rasped
to stimulate bleeding at the meniscus-sy-
novial border. Loose, unstable meniscus
fragments are removed. Our preferred
inside-out repair procedure uses mul-
tiple 2-0 braided polyester nonabsorb-
able sutures (Ti-cron; Davis & Geck
Co, Danbury, CT; or Ethibond; Ethicon
Inc, Somerville, NJ). The neurovascular
structures are protected throughout the
procedure with the appropriate exposure
and a Henning retractor (FIGURE 1).
The location of sutures is dependent
on the tear pattern. For single longitudi-
FIGURE 1. Cross-section showing popliteal retractor between the posterior capsule and medial gastrocnemius for a
nal tears, vertical divergent sutures are
medial meniscus repair. The suture cannula is placed through the lateral or medial portal, with care taken to angle
the needle away from the neurovascular structures. This figure was published in Noyes’ Knee Disorders: Surgery, placed at 3- to 4-mm intervals along the
Rehabilitation, Clinical Outcomes, Noyes FR, Barber-Westin SD, Meniscus tears: diagnosis, repair techniques, length of the tear in alternating fashion,
clinical outcomes, 733-771, Copyright Saunders, 2009.40 first on the superior surface to reduce the
meniscus, then on the inferior surface to
close the inferior tear (FIGURE 2).The su-
tures are brought out through the acces-
sory incision and tied directly over the
posterior meniscal attachment and cap-
sule. The tension in each suture is con-
firmed arthroscopically after the knot is
tied (FIGURE 3). Double-longitudinal me-
niscus tears require an additional set of
sutures (FIGURE 4). The peripheral tear is
repaired in the same manner as a single
longitudinal tear with superior and infe-
rior sutures. The longitudinal tear located
FIGURE 2. Double-stacked vertical suture pattern used in the repair of longitudinal meniscus tears. (A) The
superior sutures are placed first to close the superior gap and to reduce the meniscus to its bed. (B) Then, the in the middle body is repaired with 2 or 3
inferior suture is placed through the tear to close the inferior gap. This figure was published in Noyes’ Knee additional superior and inferior sutures.
Disorders: Surgery, Rehabilitation, Clinical Outcomes, Noyes FR, Barber-Westin SD, Meniscus tears: diagnosis, Radial tears are repaired with hori-
repair techniques, clinical outcomes, 733-771, Copyright Saunders, 2009.40 zontal sutures placed at 2- to 4-mm in-

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 tervals along the tear site (FIGURE 5). The
inner sutures are placed first and securely
tied, followed by sutures located in the
periphery. Three to four sutures are used
on the superior surface and 1 or 2 sutures
are used on the inferior surface. Flap
tears require 2 sets of sutures (FIGURE 6).
Tension sutures are inserted first through
the flap and then into the intact menis-
cal rim to anchor and reduce the flap into
its anatomic bed. With the meniscus re-
duced, the remaining tear is repaired in
the same fashion as a longitudinal tear,
with superior and inferior vertical diver-
gent sutures.

MENISCUS
TRANSPLANTATION
Indications

T
he indications and contraindi-
cations for meniscus transplantation
FIGURE 3. A longitudinal meniscus tear site demonstrating some fragmentation inferiorly. This tear required
are shown in TABLE 2.41 The results of multiple superior and inferior vertical divergent sutures to achieve an anatomic reduction. The final version of this
this operation are more favorable when paper has been published in Am J Sports Med, 30, 2002 by SAGE Publications Ltd, All rights reserved. © 2002.37
it is performed before the onset of ad-
vanced tibiofemoral joint arthritis. Nor-
mal axial alignment and a stable joint are
required, as untreated varus lower-limb
malalignment and anterior cruciate liga-
ment (ACL) deficiency increase the risk of
transplant failure.12,67,68 At least 2 mm of
tibiofemoral joint space should be visible
on 45° weight-bearing PA radiographs.
Prophylactic meniscus transplantation is
not recommended in asymptomatic pa-
tients who do not have articular cartilage
damage, because predictable long-term
success rates are not available.

Operative Techniques
We have previously described in detail FIGURE 4. Double-stacked repair technique for double longitudinal tears. (A) The peripheral tear is repaired first
with superior and inferior vertical divergent sutures, followed by (B) repair of the inner tear in the same fashion.
the operative techniques for lateral and
This figure was published in Noyes’ Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes, Noyes FR, Barber-
medial meniscus transplantation.41 The Westin SD, Meniscus tears: diagnosis, repair techniques, clinical outcomes, 733-771, Copyright Saunders, 2009.40
central bone-bridge technique is our
preferred method for both transplants, after the initial operative exposure and the medial tibia and that the attachment
because this procedure maintains the measurement of the anteroposterior and locations are anatomically correct. If the
meniscus and bone in normal anatomic mediolateral dimensions required for transplant must be adjusted to either fit
attachments and secures the meniscus the transplant. The central bone-bridge to the medial tibial plateau (by attach-
in the desired position in the knee joint. procedure is selected if the surgeon de- ing the anterior horn placement further
However, in some cases, medial meniscus termines that the transplant will fit in laterally) or to avoid compromising the
transplantation is accomplished using the proper position adjacent to the ACL ACL tibial attachment, then the 2-tunnel
2 bone tunnels.41 The decision is made tibial attachment without overhang over technique is used.

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 [ clinical commentary ]
A variety of allograft sterilization
techniques are available, including ir-
radiation, cryopreservation, proprietary
chemicals, and fresh-frozen. We have
used all types of sterilization techniques
in our clinical studies. At present, no
scientific data exist to recommend one
over another. Others have discussed the
implications of different graft-process-
ing methods, allograft-harvesting tech-
niques, and disease testing.7,14,70,71
The patient is placed in a supine posi-
tion on the operating room table, with a
tourniquet applied with a leg holder, and FIGURE 5. Repair technique for radial meniscus tears. (A) The inner sutures are placed first, followed by (B) the
the table adjusted to allow 90° of knee peripheral sutures. The first suture needle is placed midway through the meniscus body and then used to apply
flexion. After examination under anes- a circumferential tension to reduce the tear gap, and is then advanced through the posterior meniscus bed. The
second suture needle is placed in a similar manner. This reduces the radial gap, allowing subsequent sutures to
thesia, diagnostic arthroscopy confirms
be placed. Usually, sutures are placed superiorly and two sutures are placed inferiorly. (C) Occasionally, superior
the preoperative diagnosis and articular vertical divergent sutures are placed along the tear site to help stabilize the repair. This figure was published in
cartilage changes. A meniscus bed of 3 Noyes’ Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes, Noyes FR, Barber-Westin SD, Meniscus tears:
mm is retained when possible, except at diagnosis, repair techniques, clinical outcomes, 733-771, Copyright Saunders, 2009.40
the popliteal tendon region, where the
native meniscus rim is removed. The
meniscus bed and adjacent synovium are
rasped to aid in revascularization of the
transplant.
For lateral meniscus transplants, a
limited 3-cm lateral arthrotomy is made
just adjacent to the patellar tendon and
a second 3-cm posterolateral incision is
made just behind the fibular collateral
ligament.40 A popliteal retractor is placed
directly behind the lateral meniscus bed
and anterior to the lateral gastrocnemius
muscle. The width of the transplant is
determined as described elsewhere.41 A FIGURE 6. Repair technique for flap tears. (A) The tear is identified and reduced. (B) Horizontal tension sutures
rectangular bone slot is prepared at the are placed to anchor the radial component of the tear. (C) The longitudinal component is sutured using the
double-stacked suture technique. This figure was published in Noyes’ Knee Disorders: Surgery, Rehabilitation,
anterior and posterior meniscus tibial at-
Clinical Outcomes, Noyes FR, Barber-Westin SD, Meniscus tears: diagnosis, repair techniques, clinical outcomes,
tachment sites to match the dimensions 733-771, Copyright Saunders, 2009.40
of the prepared transplant. The anterior
and posterior horns of the transplant ed, and rotated to confirm that correct 4-cm skin anteromedial incision is made
are placed into their normal attachment placement of the transplant has been adjacent to the patellar tendon and a sec-
locations, adjacent to the ACL. The obtained. Sutures are placed into the ond 3-cm vertical posteromedial incision
transplant is inserted into the slot and anterior one third of the meniscus, at- is made, as previously described.40 In the
the bone portion of the graft is seated taching it to the prepared meniscus rim central bone bridge technique, the trans-
against the posterior bone buttress to under direct visualization. Two sutures plant is prepared using either a rectangu-
achieve correct anterior-to-posterior are placed retrograde into the tibial slot lar or dovetail technique. The meniscus is
placement of the attachment sites (FIG- over the central bone bridge and tied to a passed into the joint as described previ-
URE 7A). A vertical suture in the posterior tibial post. The arthrotomy is closed, and ously and positioned in the medial joint.
meniscus body is passed posteriorly to the inside-out meniscal repair completed The meniscus fixation is similar to that of
provide tension and facilitate transplant with multiple vertical divergent sutures the lateral transplant.
placement. The suture is tied later in the (FIGURE 7B). If it is determined that the central
procedure. The knee is flexed, extend- For medial meniscus transplants, a bone bridge technique is not acceptable,

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 Indications and Contraindications
TABLE 2
for Meniscus Transplantation

Indications
• Prior meniscectomy
• Patients 50 years of age or younger
• Pain in the meniscectomized tibiofemoral compartment
• No radiographic evidence of advanced joint deterioration, 2 mm of tibiofemoral joint space on 45° weight-bearing
posteroanterior radiographs
• No or only minimal bone exposed on tibiofemoral surfaces
• Normal axial alignment
Contraindications
• Advanced knee joint arthrosis with flattening of the femoral condyles, concavity of the tibial plateau, and osteophytes FIGURE 8. Two-tunnel technique for medial meniscus
that prevent anatomic seating of the meniscus transplant allografts showing insertion of transplant, including
• Uncorrected varus or valgus axial malalignment the posteromedial suture placed to facilitate
meniscus reduction. The anterior and posterior bone
• Uncorrected knee joint instability, anterior cruciate ligament deficiency
attachments of the medial meniscus transplant
• Knee arthrofibrosis are fixed into separate tibial tunnels. This figure
• Significant muscular atrophy was published in Noyes’ Knee Disorders: Surgery,
• Prior joint infection with subsequent arthrosis Rehabilitation, Clinical Outcomes, Noyes FR, Barber-
• Symptomatic, noteworthy patellofemoral articular cartilage deterioration Westin SD, Meniscus transplantation: diagnosis,
operative techniques, clinical outcomes, 772-805,
• Obesity (body mass index >30 kg/m2)
Copyright Saunders, 2009.41
• Prophylactic procedure (asymptomatic patients with no articular cartilage damage)
Reprinted from Noyes and Barber-Westin,41 with permission.

FIGURE 7. (A) A lateral meniscus transplant is ready to be placed into the tibial slot using the central bone bridge
technique. Reprinted with permission from Noyes FR, Barber-Westin SD, Rankin M. Meniscal transplantation in
FIGURE 9. Final anterior and posterior tunnel fixation
symptomatic patients less than fifty years old. J Bone Joint Surg Am. 2005;87 suppl 1 pt 2:149-165.47 (B) A lateral
appearance of medial meniscus transplant and
meniscus graft in place and sutured. This figure was published in Noyes’ Knee Disorders: Surgery, Rehabilitation,
vertical divergent sutures. This figure was published
Clinical Outcomes, Noyes FR, Barber-Westin SD, Meniscus transplantation: diagnosis, operative techniques,
in Noyes’ Knee Disorders: Surgery, Rehabilitation,
clinical outcomes, 772-805, Copyright Saunders, 2009.41
Clinical Outcomes, Noyes FR, Barber-Westin SD,
Meniscus transplantation: diagnosis, operative
separate anterior and posterior tibial medial approaches are performed as al- techniques, clinical outcomes, 772-805, Copyright
Saunders, 2009.41
bone attachments are prepared for the ready described. A tibial tunnel is drilled
medial meniscus transplant, which are over the guide wire. The graft is passed
secured to the normal anatomic attach- through the anteromedial arthrotomy. A the posteromedial approach to guide the
ment sites (FIGURE 8). Two sutures are guide wire is passed retrogradely through meniscus.
passed retrograde through each bone at- the tibial tunnel, and the sutures attached The posterior meniscus bone attach-
tachment, with 2 additional locking su- to the posterior bone are retrieved. A ment sutures are tied over the tibial post
tures placed in the meniscus for secure second suture is placed into the poste- to provide tension to the posterior bone
fixation. The anteromedial and postero- rior horn and passed inside-out through attachment. A 12-mm rectangular bone

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 [ clinical commentary ]
TABLE 3 Rehabilitation Protocol Summary for Meniscus Repairs and Transplants*

Postoperative Weeks Postoperative Months

1-2 3-4 5-6 7-8 9-12 4 5 6 7-12
Brace
Long-leg postoperative C, A, T C, A, T C, T
Range-of-motion minimum goals
0° to 90° X
0° to 120° X
0° to 135° X
Weight bearing
Toe touch: half body weight P
Three-quarters to full P
Toe touch: one-quarter body weight C, T, A
Half to three-quarters body weight C, T, A C, A
Full T C, A
Patellar mobilization X X X
Stretching
Hamstring, gastroc-soleus, iliotibial band, quadriceps X X X X X X X X X
Strengthening
Quadriceps isometrics, straight leg raises, active X X X X X X X X X
knee extension
Closed-chain: gait retraining, toe raises, wall sits, P C X X X X X
minisquats
Knee flexion hamstring curls (90°) P C X X X X X
Knee extension quadriceps (90°-30°) X X X X X X X
Hip abduction-adduction, multihip X X X X X X X
Leg press (70°-10°) P P X X X X X
Balance/proprioceptive training
Weight shifting, minitrampoline, BAPS, BBS, P X X X X X X X X
plyometrics
Conditioning
Upper-body ergometer X X X
Bike (stationary) X X X X X X
Aquatic program X X X X X
Swimming (kicking) P, C X X X X
Walking X X X X X
Stair-climbing machine P, C P, C P, C P, C X
Ski machine P P P C X
Running
Straight† P P C X
Cutting
Lateral carioca, figure-of-eight† P P X
Full sports† P P X
Abbreviations: A, all-inside meniscus repairs; BAPS, Biomechanical Ankle Platform System; BBS, Biodex Balance System; C, complex inside-out meniscus
repairs extending into middle third region; P, peripheral meniscus repairs; T, transplants; X, all meniscus repairs and transplants.
*Modified from Heckmann et al,22 with permission.
†
Return to running, cutting, and full sports based on multiple criteria. Patients with noteworthy articular cartilage damage are advised to return to light
recreational activities only.

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 attachment is fashioned in the tibia to
Postoperative Signs and Symptoms
correspond to the anterior bone attach- TABLE 4
Requiring Prompt Treatment*
ment of the meniscus graft. The sutures
are passed through the bone tunnel, and
Postoperative Sign/Symptom Treatment Recommendations
the anterior horn is seated. Full knee
Continued pain in the medial or lateral tibiofemoral Physician examination: assess need for refixation or
flexion and extension are performed to
compartment of the meniscus repair or transplant rerepair
determine proper graft placement and fit.
Tibiofemoral compartment clicking or a subjective Physician examination: assess need for refixation or
The anterior arthrotomy is closed
sensation by the patient of “something being loose” rerepair
and the suture cannula is inserted into
within the tibiofemoral joint
the lateral portal for the meniscal repair.
Failure to meet knee extension and flexion goals Overpressure program: early gentle manipulation under
The meniscal repair is performed in an
anesthesia if 0° to 135° not met by 6 wk after surgery
inside-out fashion, with multiple vertical
Decreased patellar mobility (indicative of early Aggressive knee flexion, extension overpressure program,
divergent sutures both superiorly and in-
arthrofibrosis) or gentle manipulation under anesthesia to regain full
feriorly (FIGURE 9). After final inspection
ROM and normal patellar mobility
of the graft with knee flexion and exten-
Decrease in voluntary quadriceps contraction and muscle Aggressive quadriceps muscle strengthening program,
sion and tibial rotation, the operative
tone, advancing muscle atrophy EMS
wounds are closed in a routine fashion.
Persistent joint effusion, joint inflammation Aspiration, rule out infection, close physician observation

POSTOPERATIVE Abbreviations: EMS, electrical muscle stimulation; ROM, range of motion.

*Modified from Heckmann et al,22 with permission.
REHABILITATION
Clinical Concepts nique allows for a more progressive reha- Immediate Postoperative Management

T
he postoperative program for bilitation program and that the efficacy of Important early postoperative signs for
meniscus repair and transplanta- early full weight bearing after all-inside the therapist to monitor after meniscus
tion is shown in TABLE 3 and has suture repairs is not established. repair and transplantation include effu-
been described elsewhere in detail.23 Ex- Other modifications to the postopera- sion, pain, gait, knee flexion and exten-
cessive weight bearing is prevented early tive exercise program may be required if sion range of motion (ROM), patellar
postoperatively, as high compressive and noteworthy articular cartilage deteriora- mobility, strength and control of the
shear forces can disrupt healing menis- tion is found during the operative pro- lower extremity, lower extremity flexibil-
cus repair sites (especially radial repairs) cedure. This rehabilitation program has ity, and tibiofemoral symptoms indicative
and transplants. Variations are built into been used at our institution in hundreds of a meniscal tear (TABLE 4). Early control
the protocol according to the type, loca- of meniscus transplant and repair recipi- of postoperative effusion is essential for
tion, and size of the meniscus repair, and ents, and the results of clinical investiga- pain management and early quadriceps
whether concomitant procedures, such tions37,38,46,59 demonstrate its safety and re-education. Compression and cryother-
as ligament reconstructions, have been effectiveness in restoring normal knee apy are critical during this time. Patients
performed. motion, muscle, and gait characteristics. are instructed to maintain lower-limb el-
Meniscus repairs located in the pe- Patients receive instructions regarding evation as frequently as possible during
riphery (outer one-third region) heal the postoperative protocol before surgery the first week. A portable neuromuscu-
rapidly, whereas complex multiplanar so that they have a thorough understand- lar electric stimulator may be helpful for
repairs that extend into the central one- ing of what is expected after surgery. Pa- quadriceps re-education and pain man-
third region tend to heal more slowly and tients are warned that an early return to agement.27 This device is used 6 times
require greater caution. In addition, all- strenuous activities, including impact per day, 15 minutes per session, until the
inside meniscus repair techniques that loading, jogging, deep knee flexion, or patient displays an excellent voluntary
use only a few sutures require a delay in pivoting, carries a definite risk of a repeat quadriceps contraction.
achieving full weight bearing and protec- meniscus tear or tear to the transplant. The patient’s initial response to sur-
tion to prevent separation at the menis- This is particularly true in the first 4 to gery and progression during the first 2
cus repair site. It is imperative that the 6 months after surgery. The supervised weeks set the tone for the initial phase
therapist have knowledge of the type of rehabilitation program is supplemented of rehabilitation. Common postoperative
meniscus repair procedure that was per- with home exercises to be performed complications include excessive pain or
formed to institute the preferred post- daily. The therapist routinely examines swelling, quadriceps shutdown or loss of
operative program. We believe that the the patient in the clinic to implement and voluntary isometric contraction, limita-
multiple vertical divergent suture tech- progress the appropriate protocol. tion of ROM, and saphenous nerve irri-

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 [ clinical commentary ]
from 0° to 90° of flexion. Patients who
Range of Motion, Flexibility,
have had complex or all-inside repairs
TABLE 5 and Modality Usage Following
or meniscus transplantation may be re-
Meniscus Repair and Transplantation
quired to limit knee motion to 0° to 90°
for the first 2 weeks. Hyperextension is
Electrical Muscle
Postoperative Extension/ Flexibility Stimulation Cryotherapy
avoided in individuals who have had ante-
Time, Frequency Flexion Limits Patellar Mobilization (5 Reps × 20 s) (20 min) (20 min) rior horn meniscus repairs. Knee motion
1 to 2 wk, 3 to 0° to 90° Medial/lateral, Hamstring, Yes Yes exercises are accompanied by patellar
4 times per superior/inferior gastroc-soleus mobilization (in the superior, inferior,
day, 10-min medial, and lateral directions), which is
sessions paramount to achieve full knee motion.
3 to 4 wk, 3 to 0° to 120° Medial/lateral, Hamstring, Yes Yes Flexibility exercises, beginning with ham-
4 times per superior/inferior gastroc-soleus string and gastroc-soleus muscle stretch-
day, 10-min es, are begun the first day after surgery.
sessions If 0° to 90° of knee motion are not
5 to 6 wk, 3 times 0° to 135° Medial/lateral, Hamstring, Yes Yes easily achieved by the end of the first
per day, 10- superior/inferior gastroc-soleus postoperative week, the patient may be
min sessions at risk of a knee motion complication.
7 to 8 wk, 2 times 0° to 135° If required Hamstring, No Yes Individuals who develop such a limita-
per day, 10- gastroc-soleus, tion are placed into a specific treatment
min sessions quadriceps, program, which has been previously de-
iliotibial band scribed in detail.43 Overpressure exercises
9 to 52 wk, 2 Should be normal None Hamstring, No Yes and modalities are usually successful in
times per gastroc-soleus, achieving the last few degrees of exten-
day, 10-min quadriceps, sion if initiated within the first few weeks
sessions iliotibial band after surgery. The goal is to produce a
Abbreviation: reps, repetitions. gradual stretching of posterior capsular
*From Heckmann et al,22 with permission. tissues, but not to induce soft tissue tear-
ing and further injury, as this could lead
to an inflammatory response. One effec-
tation for medial meniscus repairs. It is routinely used after repair of a periph- tive exercise consists of propping the foot
important to monitor patient complaints eral meniscus tear unless added protec- and ankle on a towel or other object to
of posteromedial or infrapatellar burn- tion is desired following surgery using an elevate the posterior aspect of the lower
ing, posteromedial tenderness along the all-inside fixator with only a few sutures. extremity off the table, which allows the
distal pes anserine tendons, tenderness The use of crutches with partial weight knee to drop toward full extension. This
of Hunter’s canal along the medial thigh, bearing is recommended for the time pe- position is maintained for 10 to 15 min-
hypersensitivity to light pressure, or hy- riods shown in TABLE 3. Weight bearing utes and repeated at least 8 times per day.
persensitivity to temperature change. is gradually progressed and patients are Initially, a 4.5-kg weight, which may be
These abnormal symptoms or signs occur encouraged to use a normal gait pattern, progressed up to 11.4 kg, is applied over
in the early stages of complex regional avoiding a locked knee and using normal the distal thigh to provide overpressure to
pain syndrome60 and require immediate flexion motion throughout the gait cycle. stretch the posterior aspect of the knee. If
treatment. these treatment measures are not effec-
Knee Motion and Flexibility tive, a dropout (bivalved) cast (FIGURE 10)
Brace and Crutch Support Passive knee flexion and passive and is used to provide continuous extension
A long-leg postoperative brace is applied active/active-assisted knee extension overpressure. The advantage of this tech-
immediately after surgery following com- exercises are begun the first day post- nique is that the patient, having greater
plex meniscus repairs or transplants. operatively for all patients who undergo control of the process, can apply or re-
The brace allows from 0° to 90° of mo- meniscus repair or transplantation (TABLE move wedge material as tolerated and
tion, but is locked at 0° of extension at 5). Active knee flexion is avoided to pre- bathe. When indicated, the cast is used
night for the first 2 weeks. The brace is vent hamstring strain to the postero- within the first 4 weeks for cases resis-
used for 6 weeks for complex meniscus medial joint. Knee motion exercises are tant to the other overpressure extension
repairs and transplants. A brace is not performed in the seated position initially modalities. Casting is not recommended

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 FIGURE 10. Dropout cast. This figure was published
in Noyes’ Knee Disorders: Surgery, Rehabilitation,
Clinical Outcomes, Noyes FR, Barber-Westin SD,
Prevention and treatment of knee arthrofibrosis,
1053-1095, Copyright Saunders, 2009.43

in knees with greater than a –12° exten-

sion deficit with a hard block to terminal
extension.
Flexion exercises are performed in the
seated position, using the opposite lower FIGURE 11. Knee flexion overpressure device. This
figure was published in Noyes’ Knee Disorders:
extremity to provide overpressure. Chair
Surgery, Rehabilitation, Clinical Outcomes, Noyes
rolling, wall sliding, passive quadriceps FR, Barber-Westin SD, Prevention and treatment of
stretching, and commercial knee motion knee arthrofibrosis, 1053-1095, Copyright Saunders,
devices (FIGURE 11) are helpful in regaining 2009.43
full knee flexion. The goal of these exer-
cises and modalities is to gradually and surgical and contralateral limbs, hip and
passively stretch tissues in a controlled knee flexion, quadriceps control during
manner, while not inducing pain or the midstance, hip and pelvic control dur- FIGURE 12. Cup walking is used early after surgery
tearing of tissues. Patients who have diffi- ing midstance, and adequate gastroc- to develop symmetry between limbs, hip and knee
culty achieving 90° by the third to fourth soleus control during push-off. Tandem flexion, quadriceps control during midstance, hip
and pelvic control during midstance, and adequate
week may require a gentle ranging of stance balance is also initiated to assist
gastrocnemius-soleus control during pushoff. This
the knee under anesthesia (not a force- with position sense and balance. Patients exercise also facilitates quadriceps control to prevent
ful manipulation), by which full flexion perform single-leg balance exercises by knee hyperextension from occurring during gait.
is typically obtained with only light loads pointing the foot straight ahead, flexing This figure was published in Noyes’ Knee Disorders:
applied. Close supervision and additional the knee to 20° to 30°, extending the Surgery, Rehabilitation, Clinical Outcomes, Noyes
FR, Barber-Westin SD, Prevention and treatment of
exercises may be required in patients who arms outward to horizontal, and position-
knee arthrofibrosis, 1053-1095, Copyright Saunders,
undergo combined procedures to suc- ing the torso upright with the shoulders 2009.43
cessfully restore normal knee motion. above the hips and the hips above the an-
kles. This position is held until balance is System (Biodex Medical Systems, Shir-
Balance and Proprioceptive Training perturbed. A minitrampoline makes this ley, NY) and Neurocom’s Balance System
Patients with peripheral meniscus re- exercise more challenging after it has (NeuroCom, Clackamas, OR).
pairs begin balance and proprioception been mastered on a hard surface.
exercises when partial weight bearing Many devices are available to assist all Strengthening
has been achieved, which is usually 1 patients with balance and gait retraining, Quadriceps isometrics, straight leg rais-
week after surgery. Those with complex including styrofoam half rolls and whole es, and active-assisted knee extension
meniscus repairs or transplants begin rolls, and the Biomechanical Ankle Plat- from 90° to 0° of knee flexion are begun
these exercises 3 to 4 weeks after surgery. form System (Dynatronics Corporation, the first day after surgery (TABLE 6). The
Crutch support is maintained during Salt Lake City, UT). Patients walk (unas- only exception is for patients with an-
these exercises until full weight bearing sisted) on styrofoam half rolls to develop terior horn meniscus repairs, in whom
is achieved. a center of balance, quadriceps control active-assisted knee extension is limited
All patients begin balance training in midstance, and postural positioning. from 90° to 30°. Straight leg raises are
by performing weight shifting from side More sophisticated commercial devices performed in the flexion plane only un-
to side and front to back. Then, walking are also available that provide visual feed- til the patient demonstrates a sufficient
over cups or cones (FIGURE 12) is encour- back to assist with a variety of balance quadriceps contraction to eliminate any
aged to develop symmetry between the activities, including Biodex’s Balance extensor lag. Then, straight leg raises in

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 [ clinical commentary ]
Muscle-Strengthening Exercises Following
TABLE 6
Meniscus Repair and Transplantation*

Quadriceps Isometrics
PO Time, Frequency (Active, 90°-0°) Straight Leg Raises Knee Extension Toe Raises Wall Sits (to Fatigue)
1 to 2 wk, 3 times per 1 set of 10 reps every h Flexion, 3 sets of 10 reps Active-assisted, 90° to 0° all
d, 15 min but anterior horn repairs,
90° to 30°, 3 sets of 10
reps
3 to 4 wk, 2 to 3 times Multiangle (0°, 60°), 1 set of Flexion, extension, adduction, Active-assisted, 90° to 0° all Meniscus repairs only, 3 sets Meniscus repairs only, 3 sets
per d, 20 min 10 reps each 3 sets of 10 reps but anterior horn repairs, of 20 reps
90° to 30°, 3 sets of 10
reps
5 to 6 wk, 2 times per Multiangle (30°, 60°, 90°), Add ankle weight, 10% Active, 90° to 30°, 3 sets All; meniscus repairs: add Transplants start, 3 sets
d, 20 min 2 sets of 10 reps of body weight, 3 sets of 10 reps heel raises, 3 sets of 10
of 10 reps reps
7 to 8 wk, 2 times per Add abduction, 3 sets of Active, 90° to 30°, 3 sets Transplants: add heel raises, 3 sets
d, 20 min 10 reps of 10 reps 3 sets of 10 reps
Add rubber tubing, 3 sets
of 30 reps
9 to 12 wk, 2 times per 3 sets of 10 reps Active, 90° to 30°, 3 sets 3 sets
d, 20 min Rubber tubing, 3 sets of 30 of 10 reps
reps
13 to 26 wk, 2 times Rubber tubing, high-speed, Active, 90° to 30° with resis-
per d, 20 min 3 sets of 30 reps tance, 3 sets of 10 reps
27 to 52 wk, 1 time per Rubber tubing, high speed, Active, 90° to 30° with resis-
d, 20 to 30 min 3 sets of 30 reps tance 3 sets of 10 reps
Table continued on page 285.

the other 3 planes (abduction, adduction, exercises. Care should be taken to avoid ripheral meniscus repairs. The ROM is
and extension) are added. hyperextension, which places tension on limited to 60° to 10° to protect against
Closed-kinetic-chain weight-bearing the posterior capsule. This exercise is de- excess loading of the posterior horn of the
exercises begin during postoperative layed until at least 7 to 8 weeks after a meniscus, which occurs at knee flexion
weeks 3 to 4. The program incorporates complex meniscus repair, and until 9 to angles greater than 60°, and high forces
toe raises, wall sits, and minisquats when 12 weeks after meniscus transplantation. on the patellofemoral joint. This limita-
patients are 50% weight bearing. These Isolated resisted hamstring curls are lim- tion of motion is also advantageous be-
activities are limited from 0° to 60° of ited in complex medial meniscus repairs cause it requires increased control from
flexion to protect the posterior horn of and medial meniscus transplants, due to the quadriceps musculature. For com-
the meniscus. the medial hamstring insertion along the plex meniscus repairs, exercise on the leg
Open-kinetic-chain non–weight- posteromedial joint capsule. This exercise press is delayed until week 6 to allow for
bearing exercises begin 5 to 6 weeks after is also delayed in lateral meniscus trans- sufficient healing of the repair. This exer-
surgery. Knee extension progressive re- plant patients, as a greater pull of the lat- cise is initiated between weeks 9 and 12
sistive exercises are initiated from 90° to eral portion of the hamstrings compared for meniscus transplants.
30° to protect the patellofemoral joint.19 to the medial portion may increase tibial
By keeping the quadriceps exercises in rotation. This limitation is designed to Conditioning
this protected ROM, minimal forces will lessen potential traction forces being A cardiovascular program may be initi-
be placed along peripheral and midsub- imposed onto the repair and transplant ated as early as 3 to 4 weeks after surgery
stance repair sites. sites. Patients are monitored as they per- if the patient has access to an upper-body
Hamstring curls from 0° to 90° are form this exercise, to ensure that a neu- ergometer (TABLE 7). Stationary bicycling
initiated in patients who had peripheral tral pull and no tibial rotation occur. begins 7 to 8 weeks after surgery. The
meniscus repairs at the same time as Exercise on the leg press machine is seat height is adjusted to its highest level
the knee extension progressive resistive initiated as early as 4 weeks after pe- based on the patient’s body size, and a

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 Muscle-Strengthening Exercises Following
TABLE 6
Meniscus Repair and Transplantation* (continued)

Lateral Step-ups Multihip Flexion, Extension,

PO Time, Frequency Minisquats (5- to 10-cm Block) Hamstring Curls (0°-90°) Abduction, Adduction Leg Press (70°-10°)
1 to 2 wk, 3 times per
d, 15 min
3 to 4 wk, 2 to 3 times Meniscus repairs only, 3 sets
per d, 20 min
5 to 6 wk, 2 times per Transplants start, 3 sets Peripheral repairs only, active, 3 sets of 10 reps Peripheral meniscus repairs
d, 20 min 3 sets of 10 reps only, 3 sets of 10 reps
7 to 8 wk, 2 times per 3 sets 3 sets of 10 reps All meniscus repairs only, 3 sets of 10 reps Peripheral meniscus repairs
d, 20 min active, 3 sets of 10 reps only, 3 sets of 10 reps
9 to 12 wk, 2 times per Add rubber tubing, 0° to 40°, 3 sets of 10 reps Transplants. start active, 3 3 sets of 10 reps Transplants, start 3 sets
d, 20 min 3 sets of 20 reps sets of 10 reps of 10 reps
13 to 26 wk, 2 times 3 sets of 20 reps Add resistance, 3 sets of 3 sets of 10 reps 3 sets of 10 reps
per d, 20 min 10 reps
27 to 52 wk, 1 time per 3 sets of 20 reps With resistance, 3 sets of 3 sets of 10 reps 3 sets of 10 reps
d, 20 to 30 min 10 reps
Abbreviations: PO, postoperative; reps, repetitions.
*Exercises done by recipients of either meniscus repair or transplantation unless otherwise indicated. From Heckmann et al,22 with permission.

low resistance level is used. A recumbent eratively in patients who had complex of the running and functional training
bicycle may be substituted for patients meniscus repairs, and until at least 1 year programs. Muscle and functional test-
who have damage to the patellofemoral postoperatively in patients who had a ing should be within normal limits, and
joint articular cartilage or anterior knee meniscus transplant. Patients begin with a trial of function is encouraged, dur-
pain. Water walking may be implement- a walk-run combination program, using ing which the patient is monitored for
ed during this time frame. To protect running distances of between 18 and 91 symptoms. The majority of patients who
the healing meniscus, swimming with m. Initially, patients run at 25% to 50% undergo meniscal transplantation have
straight-leg kicking and dry-land walk- of their normal speed. Once they are able noteworthy articular cartilage deteriora-
ing programs are initiated between 9 and to run straight ahead at full speed, lat- tion and are not candidates for strenu-
12 weeks after surgery. Protection against eral and crossover maneuvers are added. ous plyometric training or heavy-impact
high stresses to the patellofemoral joint Short distances, such as 18 m, are used sports activities.
is required in patients with symptoms or to work on speed and agility. Side-to-side
articular cartilage damage. The cardio- running over cups, figures-of-eight, and CLINICAL OUTCOME STUDIES
vascular program should be done at least carioca running drills may be used to fa-
3 times a week for 20 to 30 minutes, and cilitate agility and proprioception. Meniscus Repair

W
the exercise performed to at least 60% to Progressive plyometric training is ini- e have summarized the re-
85% of maximal heart rate. tiated in select patients upon successful sults of meniscal repair from a
completion of the running program, as variety of studies published over
Running, Plyometric Training, and Return- described in detail elsewhere.23 These the last 10 years.40 Most investigations
to-Sport Activities activities are typically incorporated after have focused on vertical meniscus suture
A running program is begun at approxi- 6 months postoperatively in patients who repair techniques; few have reported on
mately 20 weeks postoperatively in pa- have had a large peripheral tear or com- the outcome of horizontal suture repair
tients who have had peripheral meniscus plex repair. In patients who had a radial or all-inside fixators. Failure rates of
repairs and who have an average peak meniscus repair, this program may be suture repairs vary greatly, as do corre-
torque deficit of no more than 30% for delayed until 9 months postoperatively, lations with side of meniscus tear, con-
the quadriceps and hamstrings with iso- due to the disruption that occurred in the current ACL reconstruction, location of
metric testing performed on an isokinetic hoop stresses of the meniscus. meniscus tear, age, and gender. Investiga-
dynamometer. This program is delayed The clearance for return to athlet- tions of newer all-inside suture systems
until approximately 30 weeks postop- ics is based on successful completion have reported acceptable failure rates

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 [ clinical commentary ]
Aerobic-Conditioning Exercises Following
TABLE 7
Meniscus Repair and Transplantation*

PO Time, Frequency Upper-Body Ergometer Bicycle (Stationary) Water Walking Swimming Walking
3 to 4 wk, 1 to 2 times per d 10 min
5 to 6 wk, 2 times per d 10 min
7 to 8 wk, 1 to 2 times per d 15 min 15 min
9 to 12 wk, once per d (select 1 activity per session) 15 min 15 min 15 min 15 min
13 to 26 wk, 3 times per wk, (select 1 activity per session) 20 min 20 min 20 min 20 min
20 wk, 3 times per wk (peripheral meniscus repairs only)†
27 wk and beyond, 3 times per wk (select 1 activity per session) 20 to 30 min 20 to 30 min 20 to 30 min 20 to 30 min
30 wk and beyond
12 mo and beyond
Table continued on page 287.

between 9% and 13%.8,21,25,28,29,51 However, symptomatic patients). loss of joint space on radiographs, and 3
long-term, clinical follow-up reports are We assessed the results of meniscus that were asymptomatic failed according
required of these systems. Most authors repairs in a subgroup of patients 40 to MRI criteria. There was no significant
use an average of 2 sutures, and there years of age and older.38 At follow-up, 26 difference in the mean T2 scores in the
is concern regarding the expected infe- repairs (87%) had no tibiofemoral joint menisci that had not failed between the
rior fixation strength of these techniques symptoms and had not required further involved and contralateral tibiofemo-
compared to the multiple vertical diver- surgery, demonstrating that repair of ral compartments. We concluded that
gent suturing procedure. complex tears in older adults is feasible the ability to provide long-term menis-
We have published a series of stud- and that the majority are asymptomatic cus function with an inside-out verti-
ies11,37-39,59 that provide the outcomes of for tibiofemoral joint symptoms an aver- cal divergent suture technique appears
198 complex meniscus repairs that ex- age of 3 years postoperatively. to warrant this procedure over resec-
tended into the central-third avascular Another study was conducted in a tion, which has a well-documented poor
region in 177 patients aged 9 to 53 years. subgroup of 58 patients under the age of outcome.3,34,54,57,58,61
These repairs were performed with the 20.37 Skeletal maturity had been reached In the future, tissue engineering may
inside-out vertical divergent suture tech- in 54 knees (88%). ACL reconstruction provide increased success rates of me-
nique described previously. Patients un- was done either with or staged after the niscus repair, especially for tears that
derwent either a clinical examination a meniscus repair in 47 knees (81%). At extend into the avascular region.1,10,13,15,65
minimum of 2 years postoperatively or follow-up, 53 meniscal repairs (75%) had Cell-based therapy using meniscal fibro-
follow-up arthroscopy. ACL ruptures no tibiofemoral symptoms and had not chondrocytes, articular chondrocytes,
were present in 128 of the patients, of failed on follow-up arthroscopy. or mesenchymal stem cells seeded onto
whom 126 underwent ACL reconstruc- A long-term study was completed on scaffolds offers promise,56,64 as does the
tion. We found that, for all 198 repairs, a subgroup of 29 meniscus repairs done introduction of growth factors into re-
the reoperation rate for tibiofemoral in patients under the age of 20.48 The pair sites.
compartment pain symptoms was 20%. mean follow-up was 16.8 years (range,
Statistically significant differences were 10.1-21.9 years). Eighteen repairs were Meniscus Transplantation
found in the rates of meniscus repair evaluated by follow-up arthroscopy, 19 Since 1984, over 30 clinical investigations
healing for 3 factors: tibiofemoral com- by clinical evaluation, 17 by MRI, and have reported results of meniscus trans-
partment of the meniscus repair (higher 22 by weight-bearing PA radiographs. plant surgery, and the results of these re-
healing rate in lateral meniscus repairs A 3-T MRI scanner with cartilage-sen- ports have been summarized elsewhere.41
compared to medial meniscus repairs), sitive pulse sequences and T2 mapping Differences in tissue processing, second-
time from repair to follow-up arthrosco- was used. The results showed a clinical ary sterilization, preservation, operative
py (higher healing rate in patients evalu- success rate (asymptomatic patients) of technique, and rating schemes make
ated at 12 months or less compared to 79% and a biologic success rate of 62%. comparisons between studies difficult;
those evaluated at more than 12 months Using strict criteria, 18 (62%) of the however, others have performed lengthy
postoperatively), and the presence of tib- meniscus repairs had normal or nearly reviews of these investigations.14,31,55 Al-
iofemoral symptoms (higher healing rate normal characteristics. Six repairs (21%) though results are mixed, long-term
in asymptomatic patients compared to required arthroscopic resection, 2 had studies have shown enough benefits to

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 Aerobic-Conditioning Exercises Following
TABLE 7
Meniscus Repair and Transplantation* (continued)

Stair Climbing Machine Ski Machine (Short

(Low Resistance, Low Stride, Level, Low
PO Time, Frequency Stroke) Resistance) Running (Straight) Cutting Functional Training
3 to 4 wk, 1 to 2 times per d
5 to 6 wk, 2 times per d
7 to 8 wk, 1 to 2 times per d
9 to 12 wk, once per d (select 1 activity per Meniscus repairs only, Meniscus repairs
session) 15 min only, 15 min
13 to 26 wk, 3 times per wk (select 1 activity per Meniscus repairs only, Meniscus repairs
session) 20 min only, 20 min
20 wk, 3 times per wk (peripheral meniscus Jog one-quarter mile, Lateral, carioca, figure- Plyometrics: box hops,
repairs only)† walk one-eighth mile, of-eight, 20 yd level, double-leg, 15 s, 4
backward run 20 yd to 6 sets
Sport-specific drills, 4 to
6 sets
27 wk and beyond, 3 times per wk (select 1 activity 20 to 30 min 20 to 30 min
per session)
30 wk and beyond Complex meniscus Complex meniscus Complex meniscus repairs,
repairs, start 30 wk repairs, start beyond start beyond 35 wk
postoperatively 35 wk postopera- postoperatively
Advance program as tively Advance program as
needed Advance program as needed
needed
12 mo and beyond Transplants start, with
precautions
Abbreviation: PO, postoperative.
*Exercises done by recipients of either meniscus repair or transplantation unless otherwise indicated.
†
Begin running program when no more than 30% deficit is present on isokinetic testing; begin cutting program when no more than 20% deficit is present on
isokinetic testing.

justify the procedure in appropriately in- function. The cumulative survival rates mal characteristics, 12 (30%) had altered
dicated patients.68,69,72,77 at 10 years were 74.2% for medial trans- characteristics, and 11 (27.5%) failed, ac-
To date, 2 survival-analysis investiga- plants and 69.8% for lateral transplants. cording to strict criteria from follow-up
tions of meniscus transplantation have Medial meniscus transplants done con- arthroscopy, MRI, and patient symptoms.
been published. van Arkel and de Boer68 currently with high tibial osteotomy had There was a correlation between the ar-
followed 63 consecutive cryopreserved a cumulative survival rate of 83.3%. thritis rating on MRI and the transplant
meniscal transplants 4 to 126 months af- We previously described the results characteristics (P = .01). Before surgery,
ter surgery. Persistent pain or mechanical of 40 consecutive cryopreserved and 27 patients (77%) had moderate to severe
damage (detached or torn transplant) de- 96 fresh-frozen irradiated medial and pain with daily activities; but at follow-
termined transplant failure. The cumu- lateral meniscus transplants.42,45,46,53 A up, only 2 patients (6%) had pain with
lative 10-year survival rates of lateral, 100% follow-up was obtained in these daily activities (P<.0001).
medial, and combined transplants in the prospective studies. The cryopreserved The results of the irradiated trans-
same knee were 76%, 50%, and 67%, re- transplants were followed a mean of 40 plants included a failure rate of 6% (1
spectively. Verdonk et al72 followed 100 months (range, 24-69 months) postop- of 18) in knees with normal or only mild
fresh meniscus transplants a mean of eratively and the irradiated transplants arthritis on MRI, 45% (14 of 31) in knees
7.2 years postoperatively. End points for a mean of 44 months postoperatively with moderate arthritis, and 80% (12
failure were moderate or severe pain, oc- (range, 22-111 months). In the cryopre- of 15) in knees with advanced arthritis.
casional or persistent pain, or poor knee served transplants, 17 (42.5%) had nor- The relationship between the meniscus

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 [ clinical commentary ]
transplant failure rate and increasing be required. Postoperative rehabilitation cine. J Cell Physiol. 2007;213:341-347. http://
dx.doi.org/10.1002/jcp.21200
severity of joint arthritis was significant for both operations includes immediate
14. Cole BJ, Carter TR, Rodeo SA. Allograft
(P<.001). The role of low-dose irradiation knee motion, patellar mobilization, and meniscal transplantation: background, tech-
(2.0-2.5 Mrad) in terms of increasing the quadriceps strengthening exercises that niques, and results. J Bone Joint Surg Am.
failure rate is not scientifically known. do not appear to be harmful. Precautions 2002;84:1236-1250.
15. Evans CH, Ghivizzani SC, Robbins PD. The 2003
The increase in failure rate was due, we are required in limiting high-loading ac-
Nicolas Andry Award. Orthopaedic gene therapy.
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including minimal cellular repopulation a clinical and biomechanical literature review.
Arthroscopy. 2004;20:273-286. http://dx.doi.
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http://dx.doi.org/10.1016/j.arthro.2006.10.009 medium-term subjective, clinical, and radio-
72. Verdonk PC, Demurie A, Almqvist KF, Veys EM, graphical outcome evaluation. Am J Sports WWW.JOSPT.ORG

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