Review Article
Meniscus Repair Part 2: Technical Aspects, Biologic
Augmentation, Rehabilitation, and Outcomes
Justin W. Arner, MD
Joseph J. Ruzbarsky, MD
Armando F. Vidal, MD
ABSTRACT
Rachel M. Frank, MD Multiple meniscal repair techniques exist, and successful healing and
excellent patient outcomes have been reported with a variety of all-
inside and open techniques. Increased awareness and recognition of
root tears and meniscocapsular separations are topics of recent
interest. The ideal treatment of these injuries remains uncertain, and
definitive recommendations regarding their treatment are lacking.
Postoperative protocols regarding weight bearing and range of motion
are controversial and require future study. The role of biologics in the
augmentation of meniscal repair remains unclear but promising. An
evidence-based individualized approach for meniscal repair focusing
on clinical outcomes and value is essential.
M
eniscal repair should be considered whenever possible. Repair
strategies are specific to the tear type and patient features that may
influence outcomes. The quality of the meniscus also plays an
important role in determining appropriate treatment because complex
degenerative tear patterns may not be amendable to repair. A systematic
review in 20111 compared revision surgery rates and clinical outcomes
between repair versus partial meniscectomy and found that patients
undergoing repairs had higher Lysholm scores and less radiographic
degeneration at the 10-year follow-up; however, those patients undergoing
repair did have a higher revision surgery rate. Unfortunately, however, most
studies investigating repair versus meniscectomy are retrospective, thus di-
minishing the strength of the conclusions.2 Another important consideration
and discussion with the patient is the time missed and a possible psycho-
logical effect on those who undergo repair and require future meniscectomy.
From the Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center,
Given the improved clinical outcomes with meniscus repair, meniscus
Pittsburgh, PA (Arner), The Steadman Clinic and preservation is a priority. With improved instrumentation, repair techniques,
Steadman Philippon Research Institute, Aspen,
adjunctive procedures, and biologic augmentation, the goal is to improve
CO (Ruzbarsky), The Steadman Clinic and
Steadman Philippon Research Institute, Vail, CO outcomes for meniscus healing and knee preservation in the future.
(Vidal), and the Department of Orthopaedic
Surgery, University of Colorado, Denver, CO
(Frank).
Types of Repairs
J Am Acad Orthop Surg 2022;30:613-619
DOI: 10.5435/JAAOS-D-21-01153 When a meniscus tear is encountered, various options exist regarding treat-
Copyright 2022 by the American Academy of
ment. The tear type, chronicity, location, and articular cartilage status are the
Orthopaedic Surgeons. primary factors that influence the optimal technique. However, given the
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Meniscus Repair
versatility of newer repair styles, there is some degree of Meniscal root repairs are unique and require special
overlap that requires individual decision making. The attention. They involve another repair iteration when
benchmark of meniscus repair is the inside-out technique, either the anterior or posterior meniscus root is avulsed
which was first described by Scott in 1986.3 This com- from its bony insertion. The approach for root repairs is the
bined arthroscopic and open technique involves passing same for both the medial and lateral sides: Prepare a
sutures with needles arthroscopically through the bleeding bony bed in the anatomic insertion of the root, and
meniscus which are then retrieved through an open then, anchor the meniscus root tissue back to its footprint.
incision outside the capsule and are subsequently tied. Several methods have been described, but the most com-
This technique is the workhorse for large tears that are monly used methods involve the use of transosseous su-
located in the posterior and midbody of the meniscus. tures or suture anchors at the aperture of the repair tunnel.
One drawback is that access to the anterior horn is Other more unique meniscal repairs are used by some
limited using this technique. Although the inside-out for specific pathologies. The first is the instance of ramp
repair requires an open incision by a skilled assistant and lesions or medial mensicocapsular separation commonly
is technically demanding, this technique has the advan- encountered in the setting of anterior cruciate ligament
tages of only creating small punctures in the meniscus, the (ACL) tears.7,8 For these tears, several options for repair
ability to pass multiple repair stitches across the tear, and exist including inside-out or all-inside techniques, but
the versatility to repair a variety of complex tear patterns. some advocate for repair through a posteromedial portal
A second technique for meniscus repair is the outside- using suture passage methods and knot tying analogous
in approach, first described by Warren in 1985.4 This to methods used in the shoulder.9 All-inside looped su-
technique involves passing spinal needles from the skin tures around the meniscus that are then tied may be used
through the meniscus with passage of a shuttling suture for horizontal tears. Radial tears are typically sutured in a
that can be used to pass a braided suture, which can be side-to-side all-inside fashion.10 Outside-in bone tunnels
tied over the capsule through a small incision. This have also been described to improve stabilization of these
technique is most advantageous in the anterior horn but tears.11
is also useful for midbody tears. Its use is limited in the More recently, the issue of meniscal extrusion has
posterior meniscus. This can be easily done without the been attempted to be addressed by meniscal fixation.
help of a skilled assistant. One unique circumstance is meniscotibial ligament tears.
The most recent and a very common technique in In this circumstance, a combination of arthroscopic and
meniscus repair has involved the development of all-inside open approaches is used to pass sutures, which are then
devices, which allows for repair using anchor devices repaired to the bone using suture anchors with the goal of
without the need for an accessory skin incision.5 These anchoring the meniscotibial ligaments to prevent or
techniques, although also not requiring a skilled assistant, decrease extrusion.12 Centralization sutures in the tibia
have the disadvantages of increased cost, often larger have also been described using the above-described
perforations in the meniscus, and risk of vascular injury, technique with bone tunnels or suture anchors.11
particularly when placed from the lateral portal into the
posterior lateral meniscus. Access is also limited in ante-
rior horn tears. When comparing inside-out and all-inside
techniques, numerous studies have shown equivalent Repair Techniques by Tear Type
healing rates and outcomes. Owing to this and their ease Longitudinal Tears
of use and no need for a skilled assistant, this technique Although inside-out repairs have historically been the
has become a treatment of choice for many surgeons.6 repair technique of choice in these typically traumatic
Arner or an immediate family member serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports
Medicine and American Shoulder and Elbow Surgeons. Vidal or an immediate family member is a member of a speakers’ bureau or has made paid
presentations on behalf of Arthrex, Smith & Nephew, and Vericel; serves as a paid consultant to Arthrex; has received research or institutional support
from Arthrex; serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports Medicine; and is on
editorial or governing board of the Video Journal of Sports Medicine. Frank or an immediate family member is a member of a speakers’ bureau or has
made paid presentations on behalf of AAOS, Allosource, Arthrex, JRF, and Ossur; serves as a paid consultant to Allosource, Arthrex, and JRF; has
received research or institutional support from Arthrex and Ossur; serves as a board member, owner, officer, or committee member of AAOS, American
Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, International Cartilage
Restoration Society, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; and is on editorial or governing board of the
Journal of Shoulder and Elbow Surgery and Orthopedics Today. Neither Dr. Ruzbarksy nor any immediate family member has received anything of value
from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.
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Justin W. Arner, MD, et al
Review Article
tears in young people, inside-out or all-inside repair Horizontal Tears
techniques have been shown to be successful when su- These tears have historically been considered to be more
tures are placed 3 to 5 mm apart.6 Stacked vertical su- degenerative in nature, with treatments typically being
tures are proposed to be superior because more meniscectomy of a single leaflet. However, recent studies
circumferential fibers are able to be incorporated into have shown a notable increase in compartment pressures
the repair.13 In more chronic longitudinal tears or those with this partial meniscectomy technique with a more
in the central two-thirds, less propensity to heal exists. promising healing capacity than initially appreciated.18
However, meniscectomy in large bucket-handle tears Therefore, some advocate for circumferential sutures
can result in a nearly complete meniscectomy and can around the tear, which has been reported to lead to
cause the contact pressures to nearly triple.14 successful outcomes.10,18 Tissue quality and patient age
Revision surgery rates after repair range from 3.2% play an important role in this decision making.
to 11.5%, with tears greater than 10 mm resulting in a
higher rate of repeat surgery.15 Bogunovic et al16
Meniscocapsular Tears
evaluated all-inside repair outcomes at a minimum 5-
Repair techniques range from an all inside repair uti-
year follow-up and found that 16% required revision
lizing a suture tying technique, an all inside repair using
surgery after repair. Management of repeat tears and
a speical device, or an inside out technique (Figure 2).10
fairly substantial revision surgery rates include
Recent studies have noted that stable tears treated only
meniscectomy and the removal of implants and
with trephination during an ACL reconstruction have
suture. The physical and psychological effect of time
no difference in outcomes, and a biomechanical study
missed in work, activities, and/or sport after initial
showed fixation may overconstrain the meniscus.19,20
repair, continued symptoms, and need for revision
Additional work is required regarding a consensus
surgery should be appreciated and discussed with the
treatment of this pathology.
patient.
Radial Tears Root Tears
If substantial radial fibers are disrupted, this essentially Two distinct populations typically sustain root tears. In
leads to a nonfunctional meniscus.17 For this reason, an the United States, medial meniscal root tears occur
attempt at repair in those with good-quality tissue is commonly in middle-aged patients who are overweight
recommended. Different techniques exist to help deal and may already have degenerative changes. Treatment
with this difficult problem, with most data being limited is individualized in these patients based on the extent of
to biomechanical studies.11 These techniques include chondrosis, body mass index (BMI), and activity. In
crossed sutures combined with both vertical and hori- those with a high BMI and degenerative changes, root
zontal mattress sutures, which can be done all-inside, repair is not typically recommended. Meniscectomy in
partially inside-out, and with suture anchors or tibial this patient population has also not shown to produce
bone tunnels (Figure 1).10,11 A robust repair is essential, desirable outcomes. Root tears also occur in a young
given the alternative is commonly a near-complete athletic individual who sustains an ACL tear. In this
meniscectomy. population, repair of the medial root is recommended,
Figure 1
Photographs showing (A) preoperative and (B) postoperative images of a near-complete radial tear of a lateral meniscus in a young
female patient. A combination of two rip-stop sutures was used on either sides of the repair with four crossing stitches, all of which were
done in an inside-out manner. Preparation of the tear with rasping and other means and marrow venting are recommended.
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Meniscus Repair
Figure 2
MRI and arthroscopic images showing a 27-year-old rugby player with a meniscocapsular separation (ramp) lesion. MRI image (A)
shows the torn ACL, with (B) showing a high-intensity signal in the posterior medial meniscus capsular region (arrow). Image (C) shows
the arthroscopic view from the standard anterolateral portal where no obvious tear is seen, while (D) shows a Gillquist view where the
lesion is appreciated and (E) shows this region being probed. Image (F) shows a repair of this tear with an all-inside meniscal repair
device.34
while some studies report excellent outcomes in those In the young athletic population or those with minimal
with untreated lateral root tears, making the lateral side to no arthritis, repair is typically recommended to restore
more controversial. the meniscal function with multiple described techniques
Figure 3
Diagram showing the schematic depiction of meniscal root repair techniques, including the use of suture anchors and transtibial tunnel
techniques. Options for fixation to the meniscal tissue include (A) a simple suture, locking loop, or simple cinch suture configurations (B).35
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Justin W. Arner, MD, et al
Review Article
Figure 4
Arthroscopic images showing a posterior medial meniscus root tear (A). The footprint is prepared (B), and a tunnel is drilled (C). Sutures
are passed through the meniscal root (D), and they are then passed through the tunnel in the tibia (E). A final picture (F) of the root repair
is shown.23
(Figure 3).21 Analysis has also shown root repairs, typi- There is a paucity of literature focusing on how lower
cally done with sutures through bone tunnels, to be cost- extremity alignment predisposes one to meniscus injury
effective in preventing osteoarthritis (Figure 4).22,23 and how alignment affects meniscus repair. However,
Meniscal extrusion, however, has not been consistently given the effect of alignment on compartment contact
shown to be improved or prevented after root repair. For pressures, it is likely that alignment plays an important role
this reason, techniques including centralization tunnels not only in predisposing to a meniscus injury but also in
with suture or anchor techniques have been described as meniscus repair success.25 Unloading braces and realign-
has tenodesis of the meniscotibial ligaments in an attempt ment procedures may be investigated as another modality
to prevent or improve extrusion.24 Few high-quality in increasing the success rates of meniscus repair.
outcome studies have yet reported on these techniques. Another consideration for enhancing meniscus healing
rates includes those improving the biologic environment.
One of the strongest known factors that improve meniscal
healing is when performed with a concomitant ACL
Other Considerations in Meniscal Repair reconstruction. Much of the literature does not separate the
Potential strategies exist to improve meniscal healing, outcomes in the very different clinical scenarios of those
which may optimize mechanics and biology. Lower undergoing meniscal repair with or without ACL recon-
extremity alignment is a more recently appreciated factor struction. It is important for the surgeon to portray the
affecting the success of various operations in the knee, inferior healing rates and outcomes in those undergoing
including meniscus healing, ligament reconstruction, and isolated repairs when appropriately educating patients. The
cartilage restoration.25 Lower extremity biomechanical hypothesized reason for this success is the theory that the
studies26 and finite-element modeling studies focusing on bone tunnels allow for access to the tibial and femoral
the gait cycle of the human knee have demonstrated that marrow elements and postoperative hemarthrosis, which
mechanical alignment has a tremendous role in the may promote healing through mesenchymal stem cells,
amount of force experienced by both compartments of the growth factors, or a combination of both.
knee in addition to the load seen by each meniscus.27 Other described techniques and strategies for improv-
Unfortunately, in many studies examining mid-term to ing the biology of meniscus repair include meniscus
long-term outcomes of meniscus repair, few have taken trephination, local mechanical synovial abrasion, marrow
lower extremity alignment into account. venting, fibrin clots, platelet-rich plasma, and bone
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Meniscus Repair
marrow aspirate with or without scaffolds.28,29 Preparing making regarding postoperative symptomatology
the potential healing environment with techniques such difficult. Additional investigation is needed to deter-
as rasping and trephination is important. Not all groups mine what constitutes a healed meniscus.
have found biologic augments to be beneficial in meniscal
repair, with some even citing possible negative effects.
One study found that PRP use in meniscal repair during Summary
ACL reconstruction did not improve outcome scores, Proper identification of tear morphology and knowl-
performance, or return to play and may have negative edge of repair strategies with utilization of the appro-
consequences regarding postoperative motion.30 priate technique are crucial. Furthermore, optimization
Although a detailed discussion of all investigatory of alignment and biology is vital for the best outcomes,
methods is beyond the scope of this review, biology with marrow venting currently exhibiting the most
certainly plays a notable role in meniscus healing, and compelling literature when doing a meniscal repair in
more preclinical, translational, and clinical randomized isolation. Preparing the potential healing location with
controlled human trials are needed to determine the techniques such as rasping and trephination is impor-
optimal method or a combination of methods to conduct. tant. Future studies and developments are necessary to
optimize the repair and healing environment, with bi-
ologics showing promise. The same is required to
Rehabilitation and Return to Activities determine the best postoperative treatment.
No consensus currently exists regarding appropriate
and optimal weight-bearing and range of motion re- References
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Justin W. Arner, MD, et al
Review Article
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