Christian Stärke, M.D., Sebastian Kopf, M.D., Wolf Petersen, M.D., and Roland Becker, M.D.
Abstract: The meniscus plays an important role in preventing osteoarthritis of the knee. Repair of
a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with
concurrent anterior cruciate ligament reconstruction, and in younger patients. The probability of
healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Age
or extension of the tear into the avascular area are not exclusion criteria. Numerous repair techniques
are available, and suture repair seems to provide superior biomechanical stability. However, the
clinical success rate does not correlate well with the mechanical strength of the repair technique.
Biologic factors might be of greater importance to the success of meniscal repair than the surgical
technique. Therefore, the decision on the most appropriate repair technique should not rely on
biomechanical parameters alone. Contemporary all-inside repair systems have decreased the oper-
ating time and the level of surgical skill required. Despite the ease of use, there is a potential for
complications because of the close proximity of vessels, nerves, and tendons, of which the surgeon
should be aware. There is no clear consensus on postoperative rehabilitation. Weight bearing in
extension would most likely not be crucial in typical longitudinal lesions. However, higher degrees
of flexion, particularly with weight bearing, give rise to large excursions of the menisci and to shear
motions, and should therefore be advised carefully. Long-term studies show a decline in success rates
with time. Further studies are needed to clarify the factors relevant to the healing of the menisci.
Tissue engineering techniques to enhance the healing in situ are promising but have not yet evolved
to a practicable level. Key Words: Age—Growth factors—Healing—Meniscus—Rehabilitation—
men. Meniscectomy increases the risk of developing
osteoarthritis (OA) of the knee significantly after more
than 20 years.1The extent of resection relates to the
linical evidence supports the hypothesis that
meniscectomy leads to cartilage degeneration in
degree of radiologic OA.2These arguments suggest
that meniscal repair should lead to an improved clin-
ical outcome compared with meniscectomy. However,
the results found in the literature are equivocal. Some
authors have reported fewer radiologic symptoms of
OA in patients who had their meniscus repaired com-
pared with patients who underwent meniscectomy.3
Others failed to prove a substantial clinical benefit to
repairing a meniscus.4A number of case series re-
ported high rates of clinical success of meniscal re-
pair, but investigations with a strong study design are
rare. The available data indicate that meniscal repair
cannot reliably prevent the progression of degenera-
tive changes and clinical symptoms. A potential ex-
planation is that both meniscal lesions and cartilage
damage occur as different features of the same entity,
which is not cured by repairing the meniscus. Indeed,
there is evidence that meniscal pathology occurs not
From the Departments of Orthopaedic Surgery at Otto-von-
Guericke University Magdeburg (C.S.), Magdeburg, Germany, and
Pittsburgh University Medical Center (S.K.), Pittsburgh, Pennsyl-
vania, U.S.A.; the Department of Trauma Surgery, Martin Luther
Hospital (W.P.), Berlin, Germany; and the Department for Ortho-
paedic and Trauma Surgery, City Hospital Brandenburg (R.B.),
The authors report no conflict of interest.
Address correspondence and reprint requests to Roland Becker,
M.D., Department for Orthopaedic and Trauma Surgery, City
Hospital Brandenburg, Hochstrasse 29, 14776 Brandenburg an
der Havel, Germany. E-mail: firstname.lastname@example.org
© 2009 by the Arthroscopy Association of North America
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 25, No 9 (September), 2009: pp 1033-1044
only as a cause but also as a symptom of OA of the
knee.5It seems possible that the fate of a repaired
meniscal lesion depends largely on its nature: namely,
whether it is degenerative or traumatic in origin.
Nonetheless, meniscectomy is an irreversible proce-
dure. Neither replacement nor regeneration of the me-
niscus have yet evolved to a satisfactory level. It is
therefore reasonable to prefer repairing the meniscus
to removing it.
BLOOD SUPPLY AND TEAR LOCATION
In adults, only the peripheral 10% to 25% of the
meniscus is vascularized (Fig 1).6In normal tissue
repair, local bleeding provides cellular elements and
biochemical mediators that are essential for the repair
response. It is therefore generally believed that it is the
missing vascular supply that limits the healing capa-
bility of the central zones. However, it was shown in
animal explant culture models that meniscal tissue is
capable of a repair response in the absence of vascu-
larity.7In a clinical study of 198 meniscal repairs that
extended into the avascular zone, 80% remained
asymptomatic at follow-up.8Kalliakmanis et al.9did
not find a significant difference between tears located
in the red–red zone and tears in the red–white zone.9
Cannon and Vittori10found a substantial drop in the
healing rates if the rim width exceeded 4 mm in stable
knees. Tears located mainly in the central zone have
an inferior healing capability.11
So far, it has not been established if the locally
different healing response is solely a matter of the
vascular supply. Mechanical stress, for instance, may
influence the behavior of cells populating the menis-
cus. The chance of healing is increased if the tear
either is located in the vascularized area or if access to
blood elements is created. Therefore, most surgeons
limit repair to lesions located in the Cooper zones121
and 2 (Fig 2). Nevertheless, an extension of the tear
into the avascular area is not an exclusion criterion. In
select patients, such as young athletes, the chance of
healing probably outweighs the potential risks of the
Tear Pattern and Shape
Meniscal lesions are generally more common in
males.14Metcalf and Barrett15investigated tear pat-
terns in a large number of patients with stable
knees; 39% were peripheral tears (Cooper zone 1 or
2). The majority of tears occurred in the posterior
horns, with 73% being isolated medial tears and
19% isolated lateral tears. Horizontal tears were
most common in this study, followed by complex
and flap tears. Longitudinal and bucket-handle tears
were found in 19% of cases. In a similar study that
investigated patients with an anterior cruciate liga-
ment (ACL) rupture, the portion of lateral meniscal
tears increased to 50% in acute cases.16Again, most
tears were located in the posterior horns. Peripheral
tears (Cooper zones 1 and 2) were found in more
than 60% of cases. The probability of encountering
tears suitable for repair is substantially decreased in
stable knees compared with ligament injured knees.
If repaired, double longitudinal or complex tears
have a higher probability for failure.8Tears that
involve only the posterior segment seem to have an
inferior healing rate compared with lesions extend-
ing into the middle segments.17
the peripheral 10% to 25% of the meniscus is vascularized from the
Blood supply of an adult’s meniscus. Note that only
Zones 0 and 1 are considered peripheral and are associated with a
better healing capability.
Menisci with circumferential and radial Cooper zones.
C. STA¨RKE ET AL.
Horizontal cleavage tears are a frequent finding and
may exist without clinical symptoms.18There is little
information on the significance of this type of tear.
They can give rise to flap tears but are otherwise
mechanically stable. It has not been clarified yet
whether patients benefit from the repair of these tears.
It appears questionable if sutures could neutralize the
shear motion that is thought to be responsible for the
development of these tears. If horizontal tears are
encountered incidentally—during ACL surgery, for
example—they might be left alone. At times, those
tears are accompanied by meniscal cysts,19which are
thought to arise from the influx of joint fluid through
meniscal tears. Partial meniscectomy is often carried
out to drain the cyst. It has been suggested that aspi-
ration of the cyst and closure of the tear with sutures
could avoid the need for a meniscectomy.20
Controversy exists concerning radial tears. They
should be clearly distinguished between complete and
partial radial tears. Empirically, partial radial tears
often affect the central parts while the outer rim re-
mains intact. This has important mechanical implica-
tions: in partial radial tears, the important circumfer-
ential fiber bundles are mostly intact and the function
of the meniscus is retained. Further, those tears largely
extend into the avascular area, which limits the chance
of healing.21Therefore, particularly in small radial
tears, debridement of loose edges is usually sufficient.
In cases of a complete trans-section, however, the
effect can be similar to a complete meniscectomy.22If
left untreated, weight bearing would extrude the me-
niscus out of the joint space and most likely no func-
tionally sufficient healing would occur. Although it
has been found that lateral meniscal tears in conjunc-
tion with ACL tears seem to have good prognosis in
general,23some surgeons24including the authors of
this review, feel that it might be beneficial to approx-
imate and secure the tear margins of a complete tear
with sutures. In those cases, non–weight bearing ex-
ercise is warranted postoperatively because circumfer-
ential stress (so-called “hoop stress”) is induced in the
meniscus with tibiofemoral loads, which would dis-
tract the tear margins.
The influence of the tear length on the failure rate is
not entirely clear. Although some authors could not
prove an association between the failure rate and the
length of the tear,11others found that failures occurred
significantly earlier in larger tears.25In one study, the
healing rate was in excess of 90% if the length of the
tear was less than 2 cm, whereas it was only 50% with
tears larger than 4 cm.10
Medial Versus Lateral Lesions
In a series of 53 patients, no significant difference in
the healing rate was found by means of computed
tomographic arthrography for the medial and lateral
meniscus.17Cannon and Vittori10found lateral me-
nisci to have a better healing rate than medial menisci.
Another investigation into ACL-reconstructed knees
did not find different failure rates for lesions located in
the Cooper zones 1 and 2 of either the medial or lateral
meniscus.26It is not entirely clear whether or not the
healing potential in the medial and lateral meniscus
are different. Yet the potential sequelae of meniscec-
tomy are more serious in the lateral meniscus than in
the medial.2Therefore, in the decision-making pro-
cess, it matters which of the menisci is affected.
Influence of Age
It has been observed that meniscal tissue from pa-
tients over 40 years of age has a lesser cellularity and
a decreased healing response than tissue from younger
patients.27Eggli et al.28stratified their patients into
groups older and younger than 30 years and found
retears to be more frequent in older patients. Bach
et al.25analyzed failures in a series of 300 meniscal
repairs.25The average time to failure was 34 months
in this study. Older patients failed significantly later
than patients younger than 30 years of age. Other
investigators did not find a correlation between the
revision rate and patient age in 113 cases of an all-
inside repair using the Meniscus Arrow (Conmed Lin-
vatec, Largo, FL).29In a recent study, the results of
meniscal repair in patients with reconstructed ACLs
are reported, and in terms of failures, no difference
was found between patients older or younger than 35
years of age.9The rates of clinical success in repair
procedures, which involve the avascular area, seem
not to be worse in older patients (40 to 58 years)
compared with the younger population.8,30The out-
come of repair in young patients is not generally
favorable, as one might expect.31By means of ar-
thrography or magnetic resonance imaging, it was
shown that healing of repaired tears remained incom-
plete in a high fraction of young patients, even in the
absence of symptoms.31The same negative prognostic
factors as in older patients, such as a complex tear
configuration, large distance to the periphery, or lig-
amentous instability, apply to the younger patients.32
Obviously, the clinical results in younger patients are
in conflict with the better intrinsic healing capability
that the basic science suggests. First, there are no
randomized controlled studies in which the treatment
allocation is primarily based on patient age. Most
investigators will consider the macroscopic appear-
ance of the meniscus in their treatment decision and
would not repair tears in grossly degenerated menisci.
This results in a selection bias, which potentially ob-
scures the influence of the patient’s age. Further,
higher demands in sports and occupation in the young
population might compromise the outcome despite a
better intrinsic healing capability. The available data
suggest that age is not a general contraindication to
meniscal repair—it merely increases the likelihood of
encountering a tear that is not suitable for repair.15
CHOICE OF THE REPAIR TECHNIQUE
A central question for the surgeon is whether the
healing response and long-term outcome depends on
the technique that is used. Horizontal sutures usually
yield a lower failure load because they lie in between
the circumferential fiber bundles and are pulled
through those as they are loaded.33Vertical sutures are
commonly considered the gold standard in regard to
the strength, which was found to be in a range from
about 60 N to more than 200 N, depending on the
investigated model.34,35In the case of vertical sutures,
failure occurs mainly by rupture of the suture because
the strong circumferential fiber bundles of the menis-
cus are contained within the suture loop. Here, the
choice of the suture material determines the failure
load.36In general, vertical sutures are preferred to
horizontal stitches; the techniques are very similar, but
vertical sutures result in stiffer repairs. Variations,
with the limbs of the suture crossing each other,
further increase the failure load.37Conventional suture
techniques are afflicted with a relatively long operat-
ing time and problems to reach the far posterior re-
gions of the meniscus. Therefore, implants to be used
without the need for additional incisions (all-inside)
were developed. The first generation of those all-
inside systems were small rigid implants with barbs or
threads, usually made from absorbable polymers. In
addition to occasional mechanical complications,
most of the solid all-inside implants show a consider-
able inferior stiffness and failure load, partially less
than 10 N.38,39In an effort to provide the convenience
of the rigid implants while giving the strength of
suture repair, combinations of sutures and rigid parts
were developed (Table 1; Figs 3–5). While the FasT-
Fix (Smith & Nephew Endoscopy, Andover, MA)
implant was the first of its kind, all major suppliers of
arthroscopic equipment now offer devices with a sim-
ilar design. Table 2 shows the rates of clinical success
for a variety of repair techniques and implants. It
should be noted that partial healing or failure of heal-
Linvatec). (B) Meniscal Dart (Arthrex). (C) BioStinger (Conmed
Bioresorbable implants. (A) Meniscus Arrow (Conmed
Overview of Meniscal Repair Instruments
● Inside-out (generic
● Meniscus Arrow
● Meniscal Dart
● Meniscal Screw
● FasT-Fix (Smith &
● MaxFire (Biomet)
● Meniscal Cinch
● RapidLoc (DePuy
C. STA¨RKE ET AL.
ing does not necessarily cause clinical symptoms.8
Therefore, rates of so-called clinical healing do not
exactly reflect the healing status in a structural sense.
Further, the clinical success rates do not correspond
closely to the magnitudes of the mechanical strength
that is found for the different repair techniques38(Ta-
ble 2). The available data do not support the assump-
tion that stronger repair techniques are accompanied
by better outcomes. It must be acknowledged that
mechanical testing is usually done in the axis of in-
sertion, although it has not been shown conclusively
that substantial distraction forces do occur on repaired
lesions.40,41Shear forces might be more relevant but
are not addressed in most studies investigating the
stability of repair systems.
The success rates for the Meniscus Arrow and con-
ventional sutures seem to drop with time (Table 2).
Because there are no long-term studies for the newer
implants, the false impression might arise that those
are more successful than sutures or the Arrow. It is
possible that the same decline in the healing rate will
take effect with a longer follow-up of those systems.
COMPLICATIONS AND PITFALLS OF
Bleeding or pseudoaneurysms descending from
popliteal vessels are described with arthroscopic me-
niscal surgery. But those reports almost exclusively
pertain to the resection of the posterior horns,42,43not
meniscal repair. In a cadaver study, it was found that
the lateral genicular artery is at risk of being pene-
trated by the needle with inside-out and outside-in
sutures of the lateral meniscus (Fig 6). However, it has
not yet been established whether a laceration of this
vessel has detrimental effects on the healing meniscus.
Capture of branches of the peroneal nerve is possi-
ble when lateral meniscal lesions are sutured, but
seems to be rather seldom. Proper use of retractors can
largely avoid this complication.44In the case of medial
meniscal repair, the saphenous vein and nerve are at
risk of being affected.45Although transient neuro-
(Arthrex). (B) Prebent cannula, nitinol needle (Arthrex).
Instruments for suture repair. (A) Meniscal Viper
& Nephew Endoscopy). (B) MaxFire (Biomet). (C) Meniscal
Cinch (Arthrex). (D) RapidLoc (DePuy Mitek).
All-inside suture repair systems. (A) FasT-Fix (Smith
praxia was described in up to 22% of cases,46perma-
nent damage was found to occur in 0.4% to 1%.47,48
An anatomic study that investigated the placement
of the T-Fix (Smith & Nephew Endoscopy) device
showed that neurovascular structures seem not to be at
risk of being pierced with the insertion cannula.49In a
more recent investigation, the authors found that the
application cannula of a FasT-Fix device came within
3 mm of the popliteal artery under certain circum-
stances, whereas the RapidLoc (DePuy Mitek, Rayn-
ham, MA), with its shorter cannula, had a greater
distance to that vessel.50The use of the depth limiter
that comes with the FasT-Fix is therefore recom-
mended. However, Kalliakmanis et al.9reported no
neurovascular complications in a larger series of re-
pairs using the T-Fix and FasT-Fix implants.
In the case of solid implants, the depth of penetra-
tion can usually be controlled by choosing an implant
of appropriate length. Nevertheless, cases of nerve
damage have been described.51,52A complication that
is less dramatic than neurovascular damage and may
thus be under-recognized is accidental soft tissue te-
nodeses. Anatomic studies have shown, for example,
that the sartorius tendon, the deep medial collateral
ligament, and the popliteus tendon are at risk of being
penetrated by the application cannula (Fig 7).45,49Al-
Summary of Outcomes for Different Repair Techniques and Systems
Screw T-Fix FasT-Fix RapidLoc BioStingerSuture
Albrecht-Olsen et al.51
Pujol et al.17
Cannon and Vittori10
Kocabey et al.77
Barrett et al.87
Marinescu et al.88
Hürel et al.89
Kotsovolos et al.90
Frosch et al.76
Venkatachalam et al.91
Petsche et al.92
Haas et al.93
Tsai et al.94
Kalliakmanis et al.9
Barber et al.95
Gill and Diduch96
Spindler et al.97
Billante et al.98
Barber et al.99
Ellermann et al.100
Quinby et al.101
Barber and Coons102
Rubman et al.8
Kurzweil et al.103
Kurosaka et al.104
Gifstad et al.105
Koukoulias et al.106
Lee and Diduch107
Eggli et al.28
Majewski et al.108
NOTE. The criteria for success are heterogenous. Most authors shown in Table 2 define failure as the need for repeat arthroscopy or
symptoms of locking and catching. Table 2 is sorted by length of follow-up time, from the shortest amount of time at the top to the longest
amount of time at the bottom. Whether or not the anterior cruciate ligament was reconstructed is given and, if applicable, the impact on the
outcome. Numbers in parentheses give the outcome for the subgroup with unstable knees. It should be noted that there is a general trend of
increasing failure rates with time. Meniscal repairs in anterior cruciate ligament–reconstructed knees have better results than repairs in
primary stable knees or unstable knees.
Abbreviation: ACLR, anterior cruciate ligament reconstruction.
C. STA¨RKE ET AL.
though the results are not as severe as lacerations of
the nerves or vessels, increased postoperative pain
may compromise and slow down rehabilitation.
Complications specific to solid repair devices are
migration or breakage of the implant.53Parts of the
implants that surmount the surface of the meniscus
can also wear down the cartilage in the contact zones
and cause chronic synovitis.54Although this has been
addressed by changes in the design and resorption
time of the implants, it seems that these problems are
not fully eliminated.55
ENHANCEMENT OF THE HEALING
Biologic factors might be of greater importance to
the success of meniscal repair than the choice of the
surgical technique. The healing potential apparently
coincides with the vascular supply of the meniscal
tissue.56However, the local application of vascular
endothelial growth factor did not lead to improved
healing in a sheep model.57Exogenous fibrin clots
seem to improve the healing in animal models58and in
humans.59It is postulated that the clot serves as a
chemotactic and mitogenous stimulus. Some investi-
gators succeeded in enhancing the healing of meniscal
lesions with the application of mesenchymal stem
cells.60It is not clear whether this is a direct action of
the progenitor cells or is rather mediated by secretion
of certain stimulating factors. The behavior of menis-
cal fibrochondrocytes can be modulated when the cells
are exposed to certain growth factors.61The response
to mitogenic stimuli, however, seems not to be nec-
essarily the same for all regions.62Human menisci are
populated by cells of different phenotypes that might
respond differently to extrinsic stimuli, as was re-
ported by Verdonk et al.63
There are study findings showing that trephination
or rasping alone without suturing the meniscus might
be a reasonable option in stable tears. Shelbourne and
Heinrich23and Shelbourne and Rask64published clin-
ical studies investigating the fate of stable lesions in
the medial and lateral meniscus that were either left
alone or treated by rasping and trephination in con-
junction with an ACL reconstruction. They found that
only a minor proportion of their patients required
subsequent surgery for their meniscus. Fox et al.65
reported on a similar procedure with good or excellent
at the height of the tibiofemoral joint space. Structures potentially
at risk of being penetrated by a cannula or being caught by a suture
are shown. (LCL, lateral collateral ligament; MCL, medial collat-
Transverse magnetic resonance imaging slice of a knee
the close anatomic relationship of the inferior lateral genicular
artery (ILGA) and the lateral meniscus. The vessel is at risk when
passing needles/sutures inside-out or outside-in. (LCL, lateral col-
Coronal magnetic resonance imaging slice illustrating
results in about 90% of cases. Zhang and Arnold66and
Zhang et al.67have shown in animal studies that
trephination enhances the healing capacity of lesions
in the avascular zone with and without additional
INFLUENCE OF CONCURRENT INJURIES
An injury to the ACL is the most often described
entity encountered together with a meniscus tear.
While the classic description of the O’Donoghue triad
comprises a lesion of the medial meniscus together
with a rupture of the ACL and medial collateral lig-
ament, Barber68and Shelbourne and Nitz69have
pointed out that lesions of the lateral meniscus are
much more common in acute injuries. In chronic ACL
deficiency, the relation shifts toward the medial me-
niscus.16,70It has been shown that an abnormal an-
teroposterior laxity increases the resultant forces in the
medial meniscus.71The meniscus becomes a second-
ary stabilizer, a purpose for which it is not primarily
Accumulated microdamage explains the increasing
rates of medial meniscal lesions in the course of
untreated ACL deficiency. Conclusively, meniscal re-
pair should result in a better outcome if it is done in
conjunction with a stabilization of the knee. There
have been no randomized studies that have investi-
gated the outcome of meniscal repair in relation to the
ACL state. Usually, the anteroposterior instability will
be regarded as the primary problem, and randomiza-
tion in terms of the ACL reconstruction is not an
option. Nevertheless, there are some studies that com-
prise subgroups of patients with either ligamentous
intact, reconstructed, or unstable knees. In the major-
ity of these studies, it seems that the outcome of a
repair is better with concomitant reconstruction than
in knees that remain unstable72-74or even better than
knees without ACL injury.75-77
The fact that meniscal repair appears to be more
successful in combination with an ACL reconstruction
deserves some detailed reflection. The simplest expla-
nation is that, with the stabilization of the knee, the
inciting cause for the repeated microtrauma of the
menisci is eliminated, or at least diminished. More-
over, marrow elements are introduced into the joint
cavity with the ACL procedure that, as described
earlier, are thought to modulate the healing response
of meniscal fibrochondrocytes. Another potential ex-
planation for a seemingly improved healing rate with
concurrent ACL surgery is related to patient selection.
It must be assumed that in the subgroup of patients
with concomitant ACL reconstruction, the main rea-
son for the procedure is instability, and that conclu-
sively not only symptomatic but also clinically silent
lesions of the meniscus are identified and repaired.
However, in patients with stable knees, the cause for
the meniscal repair usually is meniscal symptoms,
such as locking or effusion. The possibility of a se-
lection bias must therefore be considered.
Patients should be informed in advance that menis-
cal repair is usually accompanied by much longer
periods of restricted motion and limitation of the knee
function than after a meniscectomy. It has been shown
that the reparability of meniscal tears can be predicted
reasonably well by magnetic resonance imaging stud-
ies,78which gives both the patient and surgeon the
opportunity to be prepared in advance.
A generally valid rehabilitation algorithm has not
been established. Rehabilitation plans need to be in-
dividually tailored and should take into consideration
the nature of the tear, concurrent injuries and proce-
dures, and the influence of specific exercises on the
repaired tear (Table 3).
There are both mechanical and biologic effects as-
sociated with postoperative weight bearing and mo-
tion of the knee. In repaired bucket-handle lesions,
weight bearing reduces the meniscus and stabilizes the
tear.40Flexion under tibiofemoral loads of the knee,
however, leads to increasing compressive and shear
loads in the posterior horn. It was reported that weight
bearing flexion from full extension to 90° increases
the pressure on the posterior horn by, roughly, a factor
of 4.79The menisci translate dorsally with knee flex-
ion. This motion depends not only on the flexion angle
but also on the weight bearing condition.80The mag-
Postoperative Rehabilitation Program for a
Typical Bucket-Handle Lesion
Early PhaseIntermediate Phase Late Phase
● Ice and analgesics
● Crutches as needed
● Brace to limit
● Partial or full
(60° to 90°)
● Aqua jogging
● Isometric strength
● Continue brace
● No squats for
● Regain full range
● Strength training
NOTE. Patients might need an individually tailored program.
C. STA¨RKE ET AL.
nitude of the posterior femoral rollback, and necessar-
ily the posteriorly directed translation of the menisci,
is substantially increased in the weight-loaded knee
compared with the unloaded state. Although this was
not directly proven by the cited study, motion exer-
cises of the knee without weight bearing might there-
fore be preferable during rehabilitation to limit the
stress on the repair. Weight bearing in extension most
likely does not pose a problem to repaired meniscal
lesions. An exception to this is complete transections
of circumferential fiber bundles of the meniscus, such
as radial tears that comprise the whole cross-section or
posterior root tears. In those cases, weight bearing
would be deleterious because the hoop stress distracts
the tear margins and healing is prevented.81
Tibial rotation causes large excursions of the me-
niscus within the first 30° of flexion.82Terminal flex-
ion is accompanied by a large dorsal translation of the
condyles and causes increased compressive stress of
the meniscus.79,80Therefore, deep squats and tibial
rotation should be avoided for at least 12 weeks.
Although the magnitude of the posterior translation
of the medial and lateral meniscus is different, no
significant difference in the pressure that arises on the
medial and lateral posterior horns was found by
Becker et al.79at up to 90° of flexion. So far, it is not
clear if medial and lateral meniscal repairs deserve
different rehabilitation protocols. Most investigations
about the biologic effects of immobilization found that
it impaired the healing of repaired menisci.83Limited
motion and weight bearing in full extension might
have stimulating effects on the healing response.84
There have been some clinical investigations re-
garding the effect of a more aggressive rehabilitation
of meniscal repair patients. Barber and Click46and
Barber85did not find any evidence that an accelerated
program compromises the result of the repair. Simi-
larly, Mariani et al.86failed to show deleterious effects
when patients with concomitant ACL surgery were
subjected to an accelerated rehabilitation program.
However, the design and case number of those studies
do not allow one to infer in general that restrictions
after meniscal repair are not necessary.
Meniscal preservation has gained a high level of
awareness in the recent years. The surgeon must con-
sider the nature of the tear in his decision of whether
or not to repair or resect. The prognosis of a meniscal
repair is better if it is possible to identify and treat an
underlying problem like an ACL deficiency. Contem-
porary all-inside repair systems have significantly de-
creased the level of technical skills required for a
successful repair. There is currently no scientifically
substantiated reason to believe that the choice of a
particular repair technique would improve the out-
come. It has not been shown thus far that a high failure
load is associated with better clinical results.
1. Roos H, Laurén M, Adalberth T, Roos EM, Jonsson K,
Lohmander LS. Knee osteoarthritis after meniscectomy:
Prevalence of radiographic changes after twenty-one years,
compared with matched controls. Arthritis Rheum 1998;41:
2. Englund M, Lohmander LS. Risk factors for symptomatic
knee osteoarthritis fifteen to twenty-two years after menis-
cectomy. Arthritis Rheum 2004;50:2811-2819.
3. Sommerlath KG. Results of meniscal repair and partial me-
niscectomy in stable knees. Int Orthop 1991;15:347-350.
4. Shelbourne KD, Carr DR. Meniscal repair compared with
meniscectomy for bucket-handle medial meniscal tears in
anterior cruciate ligament-reconstructed knees. Am J Sports
5. Englund M, Lohmander LS. Patellofemoral osteoarthritis co-
existent with tibiofemoral osteoarthritis in a meniscectomy
population. Ann Rheum Dis 2005;64:1721-1726.
6. Arnoczky SP, Warren RF. Microvasculature of the human
meniscus. Am J Sports Med 1982;10:90-95.
7. Hennerbichler A, Moutos FT, Hennerbichler D, Weinberg
JB, Guilak F. Repair response of the inner and outer regions
of the porcine meniscus in vitro. Am J Sports Med 2007;35:
8. Rubman MH, Noyes FR, Barber-Westin SD. Arthroscopic
repair of meniscal tears that extend into the avascular zone. A
review of 198 single and complex tears. Am J Sports Med
9. Kalliakmanis A, Zourntos S, Bousgas D, Nikolaou P. Com-
parison of arthroscopic meniscal repair results using 3 differ-
ent meniscal repair devices in anterior cruciate ligament
reconstruction patients. Arthroscopy 2008;24:810-816.
10. Cannon WD, Vittori JM. The incidence of healing in arthro-
scopic meniscal repairs in anterior cruciate ligament–recon-
structed knees versus stable knees. Am J Sports Med 1992;
11. Kimura M, Shirakura K, Hasegawa A, Kobuna Y, Niijima M.
Second look arthroscopy after meniscal repair. Factors affect-
ing the healing rate. Clin Orthop Relat Res 1995;314:185-
12. Cooper DE, Arnoczky SP, Warren RF. Meniscal repair. Clin
Sports Med 1991;10:529-548.
13. Noyes FR, Barber-Westin SD. Arthroscopic repair of menis-
cal tears extending into the avascular zone in patients
younger than twenty years of age. Am J Sports Med 2002;
14. Dandy DJ. The arthroscopic anatomy of symptomatic menis-
cal lesions. J Bone Joint Surg Br 1990;72:628-633.
15. Metcalf MH, Barrett GR. Prospective evaluation of 1485
meniscal tear patterns in patients with stable knees. Am J
Sports Med 2004;32:675-680.
16. Smith JP, Barrett GR. Medial and lateral meniscal tear pat-
terns in anterior cruciate ligament-deficient knees. A prospec-
tive analysis of 575 tears. Am J Sports Med 2001;29:415-419.
17. Pujol N, Panarella L, Selmi TAS, Neyret P, Fithian D, Beaufils
P. Meniscal healing after meniscal repair: A CT arthrography
assessment. Am J Sports Med 2008;36:1489-1495.
18. Noble J. Lesions of the menisci. Autopsy incidence in adults
less than fifty-five years old. J Bone Joint Surg Am 1977;59:
19. Barrie HJ. The pathogenesis and significance of menisceal
cysts. J Bone Joint Surg Br 1979;61:184-189.
20. Lu K. Arthroscopic meniscal repair and needle aspiration for
meniscal tear with meniscal cyst. Arthroscopy 2006;22:
21. Weiss CB, Lundberg M, Hamberg P, DeHaven KE, Gillquist
J. Non-operative treatment of meniscal tears. J Bone Joint
Surg Am 1989;71:811-822.
22. Lee SJ, Aadalen KJ, Malaviya P, et al. Tibiofemoral contact
mechanics after serial medial meniscectomies in the human
cadaveric knee. Am J Sports Med 2006;34:1334-1344.
23. Shelbourne KD, Heinrich J. The long-term evaluation of
lateral meniscus tears left in situ at the time of anterior
cruciate ligament reconstruction. Arthroscopy 2004;20:346-
24. Yoo JC, Ahn JH, Lee SH, Lee SH, Kim JH. Suturing com-
plete radial tears of the lateral meniscus. Arthroscopy 2007;
25. Bach BR, Dennis M, Balin J, Hayden J. Arthroscopic menis-
cal repair: Analysis of treatment failures. J Knee Surg 2005;
26. Kalliakmanis A, Zourntos S, Bousgas D, Nikolaou P. Com-
parison of arthroscopic meniscal repair results using 3 differ-
ent meniscal repair devices in anterior cruciate ligament
reconstruction patients. Arthroscopy 2008;24:810-816.
27. Mesiha M, Zurakowski D, Soriano J, Nielson JH, Zarins B,
Murray MM. Pathologic characteristics of the torn human
meniscus. Am J Sports Med 2007;35:103-112.
28. Eggli S, Wegmüller H, Kosina J, Huckell C, Jakob RP.
Long-term results of arthroscopic meniscal repair. An anal-
ysis of isolated tears. Am J Sports Med 1995;23:715-720.
29. Siebold R, Dehler C, Boes L, Ellermann A. Arthroscopic
all-inside repair using the Meniscus Arrow: Long-term clin-
ical follow-up of 113 patients. Arthroscopy 2007;23:394-399.
30. Noyes FR, Barber-Westin SD. Arthroscopic repair of menis-
cus tears extending into the avascular zone with or without
anterior cruciate ligament reconstruction in patients 40 years
of age and older. Arthroscopy 2000;16:822-829.
31. Accadbled F, Cassard X, Sales de Gauzy J, Cahuzac JP.
Meniscal tears in children and adolescents: Results of oper-
ative treatment. J Pediatr Orthop B 2007;16:56-60.
32. Krych AJ, McIntosh AL, Voll AE, Stuart MJ, Dahm DL.
Arthroscopic repair of isolated meniscal tears in patients 18
years and younger. Am J Sports Med 2008;36:1283-1289.
33. Rimmer MG, Nawana NS, Keene GC, Pearcy MJ. Failure
strengths of different meniscal suturing techniques. Arthros-
34. Dervin GF, Downing KJ, Keene GC, McBride DG. Failure
strengths of suture versus biodegradable arrow for meniscal
repair: An in vitro study. Arthroscopy 1997;13:296-300.
35. Rankin CC, Lintner DM, Noble PC, Paravic V, Greer E. A
biomechanical analysis of meniscal repair techniques. Am J
Sports Med 2002;30:492-497.
36. Post WR, Akers SR, Kish V. Load to failure of common
meniscal repair techniques: Effects of suture technique and
suture material. Arthroscopy 1997;13:731-736.
37. Abdelkafy A, Wlk M, Krasny C, Landsiedl F. The “cruciate
suture” for arthroscopic meniscal repair: A new technique.
38. Barber FA, Herbert MA, Richards DP. Load to failure testing
of new meniscal repair devices. Arthroscopy 2004;20:45-50.
39. Becker R, Schröder M, Stärke C, Urbach D, Nebelung W.
Biomechanical investigations of different meniscal repair im-
plants in comparison with horizontal sutures on human
meniscus. Arthroscopy 2001;17:439-444.
40. Richards DP, Barber FA, Herbert MA. Compressive loads in
longitudinal lateral meniscus tears: A biomechanical study in
porcine knees. Arthroscopy 2005;21:1452-1456.
41. Becker R, Brettschneider O, Gröbel K, von Versen R, Stärke
C. Distraction forces on repaired bucket-handle lesions in the
medial meniscus. Am J Sports Med 2006;34:1941-1947.
42. Jeffries JT, Gainor BJ, Allen WC, Cikrit D. Injury to the
popliteal artery as a complication of arthroscopic surgery. A
report of two cases. J Bone Joint Surg Am 1987;69:783-785.
43. Tawes RL, Etheredge SN, Webb RL, Enloe LJ, Stallone RJ.
Popliteal artery injury complicating arthroscopic menisec-
tomy. Am J Surg 1988;156:136-138.
44. Deutsch A, Wyzykowski RJ, Victoroff BN. Evaluation of the
anatomy of the common peroneal nerve. Defining nerve-at-
risk in arthroscopically assisted lateral meniscus repair. Am J
Sports Med 1999;27:10-15.
45. Espejo-Baena A, Golano P, Meschian S, Garcia-Herrera JM,
Serrano Jiménez JM. Complications in medial meniscus su-
ture: A cadaveric study. Knee Surg Sports Traumatol Ar-
46. Barber FA, Click SD. Meniscus repair rehabilitation with
concurrent anterior cruciate reconstruction. Arthroscopy
47. Small NC. Complications in arthroscopic surgery performed
by experienced arthroscopists. Arthroscopy 1988;4:215-221.
48. Small NC. Complications in arthroscopic meniscal surgery.
Clin Sports Med 1990;9:609-617.
49. Coen MJ, Caborn DN, Urban W, Nyland J, Johnson DL. An
anatomic evaluation of T-Fix suture device placement for
arthroscopic all-inside meniscal repair. Arthroscopy 1999;15:
50. Cohen SB, Boyd L, Miller MD. Vascular risk associated with
meniscal repair using RapidLoc versus FasT-Fix: Compari-
son of two all-inside meniscal devices. J Knee Surg 2007;20:
51. Albrecht-Olsen P, Kristensen G, Burgaard P, Joergensen U,
Toerholm C. The arrow versus horizontal suture in arthro-
scopic meniscus repair. A prospective randomized study with
arthroscopic evaluation. Knee Surg Sports Traumatol Ar-
52. Koukoulias N, Papastergiou S, Kazakos K, Poulios G, Parisis
K. Clinical results of meniscus repair with the meniscus
arrow: A 4- to 8-year follow-up study. Knee Surg Sports
Traumatol Arthrosc 2007;15:133-137.
53. Calder SJ, Myers PT. Broken arrow: A complication of
meniscal repair. Arthroscopy 1999;15:651-652.
54. Seil R, Rupp S, Dienst M, Mueller B, Bonkhoff H, Kohn
DM. Chondral lesions after arthroscopic meniscus repair
using meniscus arrows. Arthroscopy 2000;16:E17.
55. Sarimo J, Rantanen J, Tarvainen T, Härkönen M, Orava S.
Evaluation of the second-generation meniscus arrow in the
fixation of bucket-handle tears in the vascular area of the
meniscus. A prospective study of 20 patients with a mean
follow-up of 26 months. Knee Surg Sports Traumatol Ar-
56. Huang TL, Lin GT, O’Connor S, Chen DY, Barmada R.
Healing potential of experimental meniscal tears in the rabbit.
Preliminary results. Clin Orthop Relat Res 1991;267:299-
57. Petersen W, Pufe T, Stärke C, et al. The effect of locally
applied vascular endothelial growth factor on meniscus heal-
ing: Gross and histological findings. Arch Orthop Trauma
58. Arnoczky SP, Warren RF, Spivak JM. Meniscal repair using
an exogenous fibrin clot. An experimental study in dogs.
J Bone Joint Surg Am 1988;70:1209-1217.
59. Henning CE, Lynch MA, Yearout KM, Vequist SW, Stall-
C. STA¨RKE ET AL.
baumer RJ, Decker KA. Arthroscopic meniscal repair using
an exogenous fibrin clot. Clin Orthop Relat Res 1990;
60. Izuta Y, Ochi M, Adachi N, Deie M, Yamasaki T, Shinomiya
R. Meniscal repair using bone marrow-derived mesenchymal
stem cells: Experimental study using green fluorescent pro-
tein transgenic rats. Knee 2005;12:217-223.
61. Ishida K, Kuroda R, Miwa M, et al. The regenerative effects
of platelet-rich plasma on meniscal cells in vitro and its in
vivo application with biodegradable gelatin hydrogel. Tissue
62. Spindler KP, Mayes CE, Miller RR, Imro AK, Davidson JM.
Regional mitogenic response of the meniscus to platelet-
derived growth factor (PDGF-AB). J Orthop Res 1995;13:
63. Verdonk PC, Forsyth RG, Wang J, et al. Characterisation of
human knee meniscus cell phenotype. Osteoarthritis Carti-
64. Shelbourne K, Rask B. The sequelae of salvaged nondegen-
erative peripheral vertical medial meniscus tears with anterior
cruciate ligament reconstruction. Arthroscopy 2001;17:270-
65. Fox JM, Rintz KG, Ferkel RD. Trephination of incomplete
meniscal tears. Arthroscopy 1993;9:451-455.
66. Zhang Z, Arnold JA. Trephination and suturing of avascular
meniscal tears: A clinical study of the trephination procedure.
67. Zhang ZN, Tu KY, Xu YK, Zhang WM, Liu ZT, Ou SH.
Treatment of longitudinal injuries in avascular area of me-
niscus in dogs by trephination. Arthroscopy 1988;4:151-159.
68. Barber FA. What is the terrible triad? Arthroscopy 1992;8:
69. Shelbourne KD, Nitz PA. The O’Donoghue triad revisited.
Combined knee injuries involving anterior cruciate and me-
dial collateral ligament tears. Am J Sports Med 1995;19:474-
70. Cipolla M, Scala A, Gianni E, Puddu G. Different patterns of
meniscal tears in acute anterior cruciate ligament (ACL)
ruptures and in chronic ACL-deficient knees. Classification,
staging and timing of treatment. Knee Surg Sports Traumatol
71. Allen CR, Wong EK, Livesay GA, Sakane M, Fu FH, Woo
SL. Importance of the medial meniscus in the anterior cruci-
ate ligament-deficient knee. J Orthop Res 2000;18:109-115.
72. Strand T, Mølster A, Hordvik M, Krukhaug Y. Long-term
follow-up after primary repair of the anterior cruciate liga-
ment: Clinical and radiological evaluation 15-23 years post-
operatively. Arch Orthop Trauma Surg 2005;125:217-221.
73. Jensen NC, Riis J, Robertsen K, Holm AR. Arthroscopic
repair of the ruptured meniscus: One to 6.3 years follow-up.
74. Keene GC, Bickerstaff D, Rae PJ, Paterson RS. The natural
history of meniscal tears in anterior cruciate ligament insuf-
ficiency. Am J Sports Med 1993;21:672-679.
75. Asik M, Sen C, Erginsu M. Arthroscopic meniscal repair
using T-fix. Knee Surg Sports Traumatol Arthrosc 2002;10:
76. Frosch KH, Fuchs M, Losch A, Stürmer KM. Repair of
meniscal tears with the absorbable Clearfix screw: Results
after 1-3 years. Arch Orthop Trauma Surg 2005;125:585-
77. Kocabey Y, Nyland J, Isbell WM, Caborn DNM. Patient
outcomes following T-Fix meniscal repair and a modifiable,
progressive rehabilitation program, a retrospective study.
Arch Orthop Trauma Surg 2004;124:592-596.
78. Thoreux P, Réty F, Nourissat G, et al. Bucket-handle menis-
cal lesions: Magnetic resonance imaging criteria for repara-
bility. Arthroscopy 2006;22:954-961.
79. Becker R, Wirz D, Wolf C, Göpfert B, Nebelung W, Fried-
erich N. Measurement of meniscofemoral contact pressure
after repair of bucket-handle tears with biodegradable
implants. Arch Orthop Trauma Surg 2005;125:254-260.
80. Johal P, Williams A, Wragg P, Hunt D, Gedroyc W. Tibio-
femoral movement in the living knee. A study of weight
bearing and non-weight bearing knee kinematics using “in-
terventional” MRI. J Biomech 2005;38:269-276.
81. Gao J, Wei X, Messner K. Healing of the anterior attachment
of the rabbit meniscus to bone. Clin Orthop Relat Res 1998;
82. Tienen TG, Buma P, Scholten JGF, van Kampen A, Veth
RPH, Verdonschot N. Displacement of the medial meniscus
within the passive motion characteristics of the human knee
joint: An RSA study in human cadaver knees. Knee Surg
Sports Traumatol Arthrosc 2005;13:287-292.
83. Dowdy PA, Miniaci A, Arnoczky SP, Fowler PJ, Boughner
DR. The effect of cast immobilization on meniscal healing.
An experimental study in the dog. Am J Sports Med 1995;
84. Bray RC, Smith JA, Eng MK, Leonard CA, Sutherland CA,
Salo PT. Vascular response of the meniscus to injury: Effects
of immobilization. J Orthop Res 2001;19:384-390.
85. Barber FA. Accelerated rehabilitation for meniscus repairs.
86. Mariani PP, Santori N, Adriani E, Mastantuono M. Acceler-
ated rehabilitation after arthroscopic meniscal repair: A clin-
ical and magnetic resonance imaging evaluation. Arthroscopy
87. Barrett GR, Treacy SH, Ruff CG. Preliminary results of the
T-Fix endoscopic meniscus repair technique in an anterior
cruciate ligament reconstruction population. Arthroscopy
88. Marinescu R, Laptoiu D, Negrusoiu M. Outside-in meniscus
suture technique: 5 years’ follow-up. Knee Surg Sports Trau-
matol Arthrosc 2003;11:167-172.
89. Hürel C, Mertens F, Verdonk R. Biofix resorbable meniscus
arrow for meniscal ruptures: Results of a 1-year follow-up.
Knee Surg Sports Traumatol Arthrosc 2000;8:46-52.
90. Kotsovolos ES, Hantes ME, Mastrokalos DS, Lorbach O,
Paessler HH. Results of all-inside meniscal repair with the
FasT-Fix meniscal repair system. Arthroscopy 2006;22:3-9.
91. Venkatachalam S, Godsiff SP, Harding ML. Review of the
clinical results of arthroscopic meniscal repair. Knee 2001;8:
92. Petsche TS, Selesnick H, Rochman A. Arthroscopic meniscus
repair with bioabsorbable arrows. Arthroscopy 2002;18:246-
93. Haas AL, Schepsis AA, Hornstein J, Edgar CM. Meniscal
repair using the FasT-Fix all-inside meniscal repair device.
94. Tsai AM, McAllister DR, Chow S, Young CR, Hame SL.
Results of meniscal repair using a bioabsorbable screw. Ar-
95. Barber FA, Johnson DH, Halbrecht JL. Arthroscopic menis-
cal repair using the BioStinger. Arthroscopy 2005;21:744-
96. Gill SS, Diduch DR. Outcomes after meniscal repair using
the meniscus arrow in knees undergoing concurrent anterior
cruciate ligament reconstruction. Arthroscopy 2002;18:569-
97. Spindler KP, McCarty EC, Warren TA, Devin C, Connor JT.
Prospective comparison of arthroscopic medial meniscal re-
pair technique: Inside-out suture versus entirely arthroscopic
arrows. Am J Sports Med 2003;31:929-934.
98. Billante MJ, Diduch DR, Lunardini DJ, Treme GP, Miller MD,
Hart JM. Meniscal repair using an all-inside, rapidly absorbing,
tensionable device. Arthroscopy 2008;24:779-785.
99. Barber FA, Coons DA, Ruiz-Suarez M. Meniscal repair Download full-text
with the RapidLoc meniscal repair device. Arthroscopy
100. Ellermann A, Siebold R, Buelow JU, Sobau C. Clinical
evaluation of meniscus repair with a bioabsorbable arrow: A
2- to 3-year follow-up study. Knee Surg Sports Traumatol
101. Quinby JS, Golish SR, Hart JA, Diduch DR. All-inside
meniscal repair using a new flexible, tensionable device.
Am J Sports Med 2006;34:1281-1286.
102. Barber FA, Coons DA. Midterm results of meniscal repair
using the BioStinger meniscal repair device. Arthroscopy
103. Kurzweil PR, Tifford CD, Ignacio EM. Unsatisfactory clin-
ical results of meniscal repair using the meniscus arrow.
104. Kurosaka M, Yoshiya S, Kuroda R, Matsui N, Yamamoto
T, Tanaka J. Repeat tears of repaired menisci after arthro-
scopic confirmation of healing. J Bone Joint Surg Br
105. Gifstad T, Grøntvedt T, Drogset JO. Meniscal repair with
biofix arrows: Results after 4.7 years’ follow-up. Am J Sports
106. Koukoulias N, Papastergiou S, Kazakos K, Poulios G, Parisis
K. Mid-term clinical results of medial meniscus repair with
the meniscus arrow in the unstable knee. Knee Surg Sports
Traumatol Arthrosc 2007;15:138-143.
107. Lee GP, Diduch DR. Deteriorating outcomes after meniscal
repair using the Meniscus Arrow in knees undergoing con-
current anterior cruciate ligament reconstruction: Increased
failure rate with long-term follow-up. Am J Sports Med
108. Majewski M, Stoll R, Widmer H, Müller W, Friederich NF.
Midterm and long-term results after arthroscopic suture re-
pair of isolated, longitudinal, vertical meniscal tears in stable
knees. Am J Sports Med 2006;34:1072-1076.
C. STA¨RKE ET AL.