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Meniscal repair

142 citationsUpdated Sep 2026

Overview¶

Meniscal tear is the most common knee injury necessitating surgery, with the medial meniscus affected approximately three times more often than the lateral meniscus [2, 3]. The primary goal of repair is to achieve healing and avoid the adverse effects of meniscectomy, which increases peak compartmental stresses and is associated with a higher rate of subsequent knee arthroplasty [1, 2, 3, 27]. Indications for repair include vertical tears between 1 and 4 cm, red-red tears, and meniscal root tears, particularly in patients younger than 40 years [2, 3]. However, age alone should not be a contraindication, as patient-reported outcomes at five years are satisfactory and similar to meniscectomy in patients aged 40 years and older [176]. Concomitant ACL reconstruction extends indications and improves results, with repair success rates reaching 90% in this setting compared to 60% in knees with an intact ACL and 30% in ACL-deficient knees [2, 3]. While most tears in the MOON cohort were not repairable, current standard indications offer repair potential for 34.9% of all meniscal injuries, rising to 55.6% when accompanied by ACL damage [38, 194].

Meniscal repair is a viable alternative to resection, with overall success rates exceeding 80% when performed with ACL reconstruction and approximately 80% in both men and women [20, 185]. In appropriately selected patients, repair delivers improved subjective outcomes with comparable reoperation rates and the potential for reduced osteoarthritis risk over time versus meniscectomy [9]. Both procedures are safe, with low adverse event rates of 0.95% for meniscectomy and 1.4% for repair, though complications are associated with medical comorbidities, older age, and longer operative times [21]. Meniscal repair is effective over the medium and long term in 70 to 80% of cases, and meniscectomy after repair is performed infrequently, supporting the long-term safety of the procedure [15, 25]. Surgical techniques continue to simplify and focus on biological environments, with the inside-out technique using vertical mattress sutures remaining the gold standard [2, 3, 25].

Rehabilitation following meniscus repair involves avoiding knee flexion beyond 90 degrees, while the level of allowed weight bearing remains controversial [2, 3]. Success depends on tear location, type, and chronicity, with the best results seen in acute peripheral tears in young patients undergoing concurrent ACL reconstruction [2, 3]. Although the failure rate may be greater in an unstable knee, meniscal repair is not contraindicated in ACL-deficient knees [45, 68]. For tears not amenable to repair, partial meniscectomy is the best treatment option [2, 3]. Meniscal surgery can be performed even in the presence of early osteoarthritis, taking into account the regenerative potential of the meniscus and surrounding cartilage [44].

Anatomy & Pathophysiology¶

Gross Anatomy and Composition¶

The menisci are wedge-shaped fibrocartilaginous structures with a triangular cross section situated between the femoral condyles and tibial plateaus [130, 154]. The medial meniscus is semicircular or C-shaped, wider in diameter than the lateral meniscus, and covers 50% to 60% of the medial tibial plateau surface [130]. Specific measurements indicate the medial meniscus is 10 mm wide and 3 to 5 mm thick, with a posterior horn approximately 11 mm wide [130, 154]. Conversely, the lateral meniscus is more circular, 12 to 13 mm wide and 3 to 5 mm thick, covering 84% of the condylar surface [130, 154]. The medial meniscus covers 64% of the condyle surface [154]. The anterior and posterior horns of the lateral meniscus are equally sized [130].

The substance of the menisci consists of a solid extracellular matrix and water, comprising 65% to 75% water [130, 154]. Fibrochondrocytes are the predominant cell type [130]. The extracellular matrix is composed predominantly of type I collagen, with types II, III, V, and VI collagen also present [130, 154]. Proteoglycans, such as aggrecan, constitute 1% of the dry weight of the meniscus [130, 154].

Microscopic Structure and Fiber Orientation¶

Collagen fibers are randomly oriented on the superficial aspects of the menisci, where type I collagen is most abundant to provide tensile strength [130]. In the deeper zones, collagen fibers adopt a circumferential orientation, stabilized by intermittent radially oriented tie fibers that present longitudinal splits [130, 154]. Larger concentrations of proteoglycans and water are found in these deeper zones to provide compressive strength [130].

Vascular Supply and Zones¶

The vascular supply derives from the superior, middle, and inferior geniculate arteries, specifically the superior medial and lateral, inferior medial and lateral, and middle genicular arteries [130, 154]. The peripheral 10% to 30% of the meniscus is well vascularized by synovial and capsular branches [130]. The anterior and posterior root attachments are also well vascularized by synovial branches [130].

The meniscus is divided into three zones based on vascularity: Red/Red Zone: The outer third, which is well vascularized [130]. Red/White Zone: The middle third, located at the border of the vascularized and avascular zones [130]. White/White Zone: The inner third, which is devoid of a vascular supply [130].

Vascularity decreases with advancing age; approximately 50% of the meniscus is vascularized at birth, whereas only 10% to 25% is vascularized in the adult [10, 154]. Poorly vascularized portions receive nutrition through diffusion [130]. Neural elements are found mostly in the periphery of the anterior and posterior horns [130].

Ligamentous Attachments and Stability¶

The medial meniscus is attached to the deep medial collateral ligament fibers and joint capsule, limiting its mobility [130, 154]. The inferior aspect of the posterior horn of the medial meniscus attaches to the tibia via the meniscotibial or coronary ligament [130]. The lateral meniscus has less continuous attachment to the capsule and greater mobility than the medial meniscus [130]. At the posterior lateral attachment, popliteomeniscal fascicles extend from the meniscus to the posterior capsule, and the popliteal hiatus is created as the popliteus tendon becomes intra-articular [130].

The meniscofemoral ligaments connect the posterior horn of the lateral meniscus to the medial femoral condyle: Anterior Meniscofemoral Ligament of Humphrey: Courses anterior to the posterior cruciate ligament [130]. Posterior Meniscofemoral Ligament of Wrisberg: Courses posterior to the posterior cruciate ligament [130].

The transverse intermeniscal ligament is the most common connection between the medial and lateral menisci, present in 60% to 94% of knees [130]. The medial and lateral menisci have anterior and posterior root attachments to the tibia that prevent meniscal extrusion during load bearing [154].

Biomechanical Function¶

The menisci provide proprioceptive feedback, load distribution during physiologic loading, joint lubrication during motion, and maintenance of tibiofemoral joint stability and congruity [130]. They distribute load, deliver congruency, enhance stability, and contribute to lubrication and nutrition [8]. The circumferential fiber orientation allows the menisci to absorb and dissipate hoop stresses from axial loading during weight bearing [130].

In knee extension, the menisci transmit 50% of joint loads [130, 154]. At 90° of knee flexion, the percentage of load-sharing by the meniscus increases to 90% [154]. In flexion, the menisci transmit as much as 85% of joint loads [130]. Beyond 90° of knee flexion, most of the force is transmitted to the posterior horns of the menisci [154]. The lateral meniscus provides more biomechanical protection to the joint than the medial meniscus [154].

When the meniscus is removed completely, articular cartilage contact stress increases by two to three times that experienced when the meniscus is intact [154]. Removal of the inner third of the meniscus results in a 10% reduction in contact area and a 65% increase in contact stress on the articular cartilage [154]. Peak contact articular cartilage stresses increase proportionally to the amount of meniscus removed [10].

Pathophysiology of Tears¶

Meniscal tears are the most common knee injury necessitating surgery [2, 3]. There is an increased rate of osteoarthritis in knees after meniscal tears and meniscectomy, particularly on the lateral side [2, 3]. Meniscal injury is identified on MRI in 31% of asymptomatic athletes and 91% of patients with knee osteoarthritis [13]. The relative risk of osteoarthritis after total meniscectomy is 14.0, associated with 4% cartilage loss per year [13]. The extent of subsequent joint degeneration is directly proportional to the amount of meniscal tissue removed [13].

Meniscal root tears are defined as a radial tear or avulsion of the meniscal root from the tibial plateau [2, 3]. These tears completely disrupt the circumferential fibers, resulting in a loss of hoop stresses and an increase in contact forces [2, 3]. Biomechanically, meniscal root tears are functionally equivalent to a total meniscectomy [2, 3]. Medial meniscus root tears result in peak articular cartilage contact pressure similar to that seen after a complete meniscectomy and have been associated with the progression of osteoarthritis [154]. Disruption of circumferential meniscal fibers leads to a loss of ability to transmit hoop stresses, with biomechanical effects approaching total meniscectomy [240]. Tears of the posterior medial meniscal root can increase contact pressure, external rotation, and lateral tibial translation [240]. A lateral root tear substantially decreases the contact area and increases contact pressure in the lateral compartment [240].

Radial tears perpendicularly transect meniscal fibers and impair the transmission of circumferential hoop stress, making them more biomechanically detrimental than longitudinal tears [281]. Radial tears of the posterior horn of the medial meniscus account for up to 28% of all meniscal tears, with posterior horn medial meniscus tears accounting for up to 53% of radial tear cases [281]. Unrepaired radial tears can result in increased joint contact stress, meniscal extrusion, meniscal root pathology, osteoarthrosis, and long-term cartilage damage [281].

A vertical tear of the medial meniscus causes increased contact area and maximum contact pressure in both the lateral and medial compartments [154]. A radial tear of the medial meniscus extending from the inner rim to the peripheral third but preserving the peripheral third has not been found to change maximum contact pressure and contact area [154]. A radial tear involving 90% of the medial meniscus results in a posterocentral shift in peak-pressure location [154]. The biomechanical consequences of a lateral meniscus root tear depend on the state of the meniscofemoral ligament [190]. The integrity of the posterior root of the medial meniscus plays an important role in maintaining normal tibial-femoral joint contact mechanics [204].

Meniscal status has a significant impact on knee kinematics in the ACL-deficient knee [123]. A longitudinal tear of the medial meniscus posterior horn in an ACL-deficient knee significantly influences anterior stability [169]. Meniscal tears are frequently unrecognized injuries that significantly alter knee biomechanics and kinematics, leading to accelerated degenerative changes [14].

The discoid meniscus is an uncommon variant, almost always lateral and extremely rare medially, that may present with symptomatic tearing and/or instability during childhood or adolescence [57]. The central area of a discoid meniscus is partially or completely filled in and may lack normal attachments to the surrounding capsule, distal femur, and proximal tibia [57]. Histopathology shows a disorganization of the circumferential collagen network at a molecular level [57]. Structural abnormalities compromise its ability to withstand normal stresses, predisposing it to tears [57]. The mechanical dysfunction of the discoid meniscus is associated with lateral femoral condyle osteochondritis dissecans lesions [57].

Cysts of the menisci are frequently associated with tears and are nine times more common on the lateral than on the medial side [76]. The most common cause is trauma that produces degeneration and secondary mucinous and cystic changes in the periphery of the meniscus [76]. Inflammatory changes following meniscal cyst formation may render the meniscus less mobile during flexion, extension, and rotary motions, making it more susceptible to additional longitudinal or radial tearing [76].

Meniscal mucoid degeneration is a degenerative lesion that may present as stromal mucoid degeneration or cystic parameniscal degeneration [88]. The cause is usually attributed to endogenous and/or exogenous trauma [88]. Accumulation of mucopolysaccharides in the meniscus is suggested to be a response to nutritional deficiency [88]. Intrameniscal stromal degeneration is a nonspecific reaction to injury and a physiological condition in all knees [88]. The degenerative process in the meniscus is secondary to a vascular disturbance initiated by trauma or other causes [88].

Classification¶

Tear Morphology and Nomenclature¶

O’Connor Classification: This system categorizes meniscal tears into longitudinal, horizontal, oblique, radial, and variations including flap, complex, and degenerative tears [6]. Longitudinal tears are vertically oriented, run parallel to the meniscus edge, and may be complete or incomplete [6]. A complete longitudinal tear that displaces the inner fragment into the intercondylar notch is referred to as a bucket-handle tear [6]. A longitudinal tear near the meniscocapsular attachment is referred to as a peripheral tear [6]. Horizontal tears involve a cleavage plane dividing the superior and inferior surfaces of the meniscus [6]. Horizontal tears are more common in older patients and frequently occur in the posterior half of the medial meniscus or the midsegment of the lateral meniscus [6]. Oblique tears are full-thickness tears running obliquely from the inner edge into the body of the meniscus [6]. Radial tears are vertically oriented, extending from the inner edge toward the periphery, and can be complete or incomplete [6]. Flap tears are similar to oblique tears but include a horizontal cleavage element [6]. Complex tears contain elements of multiple tear types and are more common in chronic lesions or older degenerative menisci [6]. Degenerative tears often refer to complex tears presenting with marked irregularity and complex tearing, most often seen in older patients [6].

Anatomic Distribution: The most common type of meniscal tear is the longitudinal tear, usually involving the posterior segment of either the medial or lateral meniscus [76]. Transverse, radial, or oblique tears more commonly involve the lateral meniscus and are usually located at the junction of the anterior and middle thirds [76]. The posterior root tear is a type of radial tear at the posterior root attachment of the meniscus [76]. The ramp lesion is a form of longitudinal tear at the menisco-capsular junction or the menisco-tibial attachment of the meniscus [76]. Tears within the meniscus can be complete or incomplete, with most involving the inferior rather than the superior surface [76]. Discoid menisci are abnormal and vulnerable to compression and rotary stresses due to hypermobility and tissue bulk [76].

Vascular Zones and Location¶

Vascular Zoning: A peripheral vertical tear in zone I is referred to as a red-red tear [6]. A tear between zone I and zone II is referred to as a red-white tear [6]. Red-red and red-white tears are located in the vascularized portion of the meniscus [6]. Tears posterior to the popliteal tendon may heal on their own or with local stimulation techniques [6].

Diagnostic and Assessment Criteria¶

Repair Indications: Classification of meniscal tear types during diagnostic arthroscopy is essential for planning subsequent resection or repair [6]. The most commonly accepted criteria for meniscal repair include a complete vertical longitudinal tear >10 mm long [17]. Meniscal repair criteria include a tear within the peripheral 10% to 30% of the meniscus or within 3 or 4 mm of the meniscocapsular junction [17]. Meniscal repair criteria include a tear that can be displaced by probing, demonstrating instability [17]. Meniscal repair criteria include a tear without secondary degeneration or deformity [17]. Meniscal repair criteria include a tear in an active patient [17]. Meniscal repair criteria include a tear associated with concurrent ligament stabilization or in a ligamentously stable knee [17]. Certain tears do not require treatment because they heal spontaneously or remain asymptomatic [17].

Assessment Reliability and MRI: Surgeons can reliably classify meniscal pathology and agree on treatment, which is important for multicenter trials [213]. A classification of tear type used in MRI studies categorizes tears by anatomic configuration as longitudinal, radial, horizontal cleavage, or degenerative [77]. Meniscal tear location in addition to type likely plays a crucial role in dictating the success of non-operative treatment [71]. The incidence of medial meniscal lesions and the complexity of tear types increased significantly with increasing time intervals between the index injury and ACL reconstruction [75].

Degeneration and Histology¶

Histological Degeneration: Traumatic meniscal tear tissue showed a higher degree of degeneration than intact menisci [56]. BMI is an independent risk factor for meniscal degeneration, with an increase of 0.21 points in histological score for each unit in BMI increase [56]. No clear association was observed between histological degree of degeneration and age, sex, or time interval between trauma and surgery [56]. Three degenerative lesions have been described in meniscal tissue: dystrophic or metastatic calcification, hyaline acellular degeneration, and mucoid degeneration [88]. Mucoid degeneration is the most frequent and clinically significant degenerative lesion in meniscal tissue [88]. Mucoid degeneration may present as stromal mucoid degeneration or cystic parameniscal degeneration [88].

MRI-Histology Correlation: Hyperintense signal zones adjacent to a tear on MRI correspond to histological anomalies such as fissures and degeneration [241]. The frequency of intrameniscal signal anomalies adjacent to the tear (grades 2–4) was significantly lower in stable knees than in ACL-deficient knees [241].

Imaging and Prediction¶

Diagnostic Accuracy: MRI sensitivity and specificity for diagnosing primary meniscal tears are high, but these values are lower for assessing healing status of repaired menisci [91]. A convolutional neural network model has the potential to be used in diagnosing the presence of meniscal tears and differentiating the types of meniscal tears [205]. A scoring system to predict the reparability of the meniscus based on MRI has limitations regarding MRI sensitivity, statistical details, and demographic data [67].

Clinical Presentation¶

History and Symptoms¶

Meniscal tears are unusual in patients younger than 10 years [19]. In adolescents and young adults, most tears occur with a twisting injury or a change in direction [19], whereas middle-aged and older adults often sustain tears from squatting or falling [19]. Patients with traumatic meniscal tears may report pain onset during a twisting mechanism or deep knee flexion [156], and occasionally describe an audible or palpable popping [156]. Approximately one-half to two-thirds of these patients report knee swelling [156]. Mechanical symptoms, including catching or frank locking, have been reported in 12% to 69% of patients with meniscal tears [156] and may suggest an unstable tear [156].

With an acute meniscal tear, an effusion often develops several hours after injury [19]. This delayed swelling distinguishes meniscal pathology from anterior cruciate ligament injury, in which swelling develops rapidly within the first few hours [19]. Patients typically localize pain to the joint line or posterior knee [19]. Chronic meniscal tears demonstrate intermittent effusions, often accompanied by mechanical symptoms [19]. Meniscal root tears are frequently unrecognized injuries that significantly alter knee biomechanics and kinematics [14] and lead to accelerated degenerative changes [14].

Physical Examination¶

Small joint effusions and joint line tenderness are common findings with meniscal tears [19]. Palpation of the joint line may elicit tenderness at the location of the tear [156], with the posterior joint line being a common site given the prevalence of posterior horn tears [156]. Range of motion is typically normal, though patients may report tightness in flexion if an effusion is present [19]. Longitudinal bucket-handle tears may block full extension of the knee joint [19].

Special Tests: * McMurray and Apley tests: Manipulative maneuvers may produce a palpable or audible click with localized tenderness [19]. However, these tests are not specific for meniscal pathology [19] and lose specificity in the presence of associated ligamentous or chondral injury [156]. In isolated meniscal tears, the McMurray test was accurate in 57% to 77% of patients [156]. * Thessaly test: The patient flexes the knee to 20° while standing on the affected extremity and twists in internal and external rotation [19]. This test often reproduces pain in patients with a meniscal tear [19] and was accurate in 61% to 80% of patients with isolated tears [156]. * Joint line tenderness: In isolated meniscal tears, this finding was accurate in 81% to 90% of patients [156].

Meniscus-specific tests should be interpreted for both pain and mechanical signs [156]. Clinical examination by an experienced examiner using multiple meniscus tests is sufficient for a diagnosis of a meniscal tear [113]. Several large studies have demonstrated the accuracy of the clinical diagnosis of meniscal tears to be 70% to 75% [19]. Pre-operative tests and clinical findings are not conclusive for identifying a meniscal tear in a symptomatic discoid meniscus [36].

Imaging¶

Standard knee radiographs should be obtained to evaluate for bone injuries or abnormalities [19]. A weight-bearing radiograph is necessary to evaluate for osteoarthritis [19]. A right-to-left difference of at least 2 mm on weight-bearing radiographs represents a significant difference that will be verified by articular cartilage chondrosis at the time of arthroscopy [19].

MRI remains the noninvasive diagnostic procedure of choice for confirming meniscal pathology [19]. In grade III MRI classification, increased signal intensity reaches the articular surface of the meniscus [19]. MRI has demonstrated a high negative predictive value for meniscal tears [19], and a well-performed MRI of a knee with no meniscal pathology will rarely demonstrate a tear [19]. The diagnostic validity of magnetic resonance imaging is similar for meniscal tears in acute knee trauma and in knee symptoms lasting over 6 months in young adults [59].

MRI Accuracy: * Medial meniscal tears: Sensitivity and specificity of 1.5-Tesla and 3.0-Tesla MRI, as confirmed with arthroscopy, were found to be 93% to 96% and 88% to 90%, respectively [156]. * Lateral meniscal tears: MRI was less sensitive (77% to 82%) but more specific (98% to 99%) [156]. * Posterior meniscal root tears: A study of 3.0-Tesla MRI found sensitivity of 77% and specificity of 73% [156]. The decreased accuracy for root tears may be attributable in part to the radial orientation of many posterior root tears, making them more difficult to visualize on MRI [156].

To be considered a relevant finding, a tear seen on MRI should correspond to the patient’s history and clinical examination findings [156]. The double ACL sign can be a supportive finding for diagnosis and preoperative planning for meniscus injury [135]. Anterior medial meniscus detachment combined with anterior cruciate ligament tear is relatively rare and difficult to diagnose via MRI [51].

Diagnostic Considerations¶

Consideration of treatment for meniscal tears relies heavily on patient history and clinical examination [13]. In nonarthritic knees, focal joint line tenderness, effusion, and positive meniscal signs on physical examination may indicate meniscal pathology as a symptomatic source worthy of surgical intervention [13]. In the presence of osteoarthritis, mechanical symptoms such as locking or catching in combination with unstable meniscal tears on MRI warrant intervention [13]. Débridement of stable meniscal tears in the presence of osteoarthritis is unlikely to provide lasting relief [13]. Not all meniscal tears cause symptoms, and many symptomatic tears become asymptomatic [10]. Management of meniscal tears is predicated on symptoms [10].

Investigations¶

Clinical Evaluation¶

Patients with meniscal injuries localize pain to the joint line or posterior knee and may describe mechanical symptoms of locking or catching [19]. Small joint effusions and joint line tenderness with palpation are common findings with meniscal tears [19]. Manipulative maneuvers, including the McMurray and Apley tests, may produce a palpable or audible click with localized tenderness, but they are not specific for meniscal pathology [19]. The accuracy of the clinical diagnosis of meniscal tears has been demonstrated to be 70% to 75% in several large studies [19]. Pre-operative tests and clinical findings are not conclusive for identifying a meniscal tear [36]. Surgeons should be vigilant in identifying and repairing tears at the time of surgery because pre-operative tests and clinical findings are not conclusive [36].

Imaging¶

MRI: Magnetic resonance imaging is not an effective or efficient predictor of reparability of meniscal tears with the current arthroscopic criteria [232]. MRI continues to be a poor predictor of meniscus tear reparability as assessed by arthroscopic criteria, even when using higher resolution 3-T scanners [262]. MRI is not always useful in predicting reparability of symptomatic isolated lateral semilunar meniscus tears [229]. Most symptomatic cases with normal MRI were reparable [229]. Confusion between meniscal fraying and small tears is a major source of discrepancy between MRI and surgical findings [264]. Precise description of meniscal tears on MRI should continue to improve its ability to assist with surgical planning [235]. Meniscal deformation or displacement observed on preoperative MR images suggests a higher risk of meniscal tears, even in menisci with signal changes other than grade 3 changes [243]. MRI is successful in determining the presence or absence of tears in discoid menisci [254]. The ability of MRI to determine the tear type in discoid menisci is questionable [254].

CT: Advanced imaging by 3-dimensional computed tomography may better allow preoperative planning for a safe approach to the posterior horn of the lateral meniscus using all-inside repair techniques [249].

Post-Repair Assessment¶

MRI: MRI contributes to enhancing the diagnostic accuracy of an unhealed meniscal repair when there are limited clinical signs of meniscal pathology [39]. The sensitivity and specificity of magnetic resonance imaging for the diagnosis of primary meniscal tears are high, but these values are lower for the assessment of healing status of repaired menisci [91]. Magnetic resonance imaging is unsuitable for diagnosis of the healing process of a repaired meniscus [251]. Magnetic resonance imaging is not suitable for interpretation of meniscal status ten years after arthroscopic repair [220]. Several abnormal vertical and/or horizontal hypersignals are present on MRI ten years after arthroscopic all-inside meniscal repair, without any subjective or objective clinical significance [220]. The meniscus fulfills its function as normal or nearly normal even though the MRI findings fail to prove healing [208]. Preservation of the integrity of the articular cartilage on quantitative MRI has been associated with healed meniscal repairs [12].

Ultrasound: Sonographic evaluation should be considered in patients presenting with ongoing knee pain after all-inside meniscus repair [94].

Treatment¶

Non-Operative¶

Management of meniscal tears is predicated on symptoms, as not all tears cause symptoms and many symptomatic tears become asymptomatic [10]. Nonsurgical management is indicated for stable longitudinal tears less than 10 mm in length with less than 3 to 5 mm of displacement, degenerative tears associated with significant osteoarthritis, short (<3 mm in length) radial tears, and stable partial tears [10]. It is also a consideration for stable peripheral tears shorter than 5 to 10 mm in length, some degenerative tears that do not cause mechanical symptoms, and tears in the setting of substantial osteoarthritis (Kellgren-Lawrence grade 3 or 4) [12]. Arthroscopic partial meniscectomy should not be proposed as a first-line treatment for degenerative meniscus lesions; non-operative treatment should always be started first, with surgery only envisaged after its failure [171]. The benefits of arthroscopic partial meniscectomy in adults with degenerative and nonobstructive meniscal symptoms are limited, with current evidence reporting similarity in outcomes between arthroscopic partial meniscectomy and physical therapy [173]. Initial nonoperative management of degenerative meniscal tears is worth a try [177]. We recommend nonoperative treatment of anterior horn tears noted on MRI among patients without mechanical symptoms and whose clinical examination is inconsistent with the presence of a pathologic meniscal condition [217]. Meniscal tear location in addition to type likely plays a crucial role in dictating the success of non-operative treatment of the menisci [71]. Patients with no meniscal damage at diagnosis should be aware that conservative management carries risks of further meniscal damage; if surgery is decided, delay should be no longer than 6 months from diagnosis [37]. Some pediatric meniscal tears, such as partial thickness tears comprising less than 50% of the total meniscal thickness, may be suitable for nonsurgical management [85]. An attempt at nonsurgical treatment also may be made for patients with small (<1 cm), stable, longitudinal tears in the peripheral red-red zone [85]. Although most meniscal tears require operative intervention, a small percentage may be observed, including partial-thickness split tears that arise from the femoral or tibial surfaces and are stable to probing, and short (<10 mm) vertical peripheral tears, which often heal sufficiently to resolve symptoms [11]. Nonsurgical management can include ice, NSAIDs, or physical therapy for range of motion and general strengthening of the lower extremities [10].

Operative¶

Indications: General indications for meniscal repair include a tear between 1 and 4 cm, a vertical tear, a red-red tear, a meniscal root tear, and a patient younger than 40 years [2]. Augmentation techniques such as fibrin clot, platelet-rich plasma clot, vascular access channels, and synovial rasping may extend the indications for repair [2]. According to current standard indications, 34.9% of all meniscal injuries offer the potential for repair, rising to 55.6% when accompanied by anterior cruciate ligament damage [38]. Meniscal removal should always be the last option, but is sometimes unavoidable; the author advocates for meniscal preservation with the plea to 'Repair Regularly, Resect Rarely' [167]. An integrated approach to meniscal surgery is required as part of an overall strategy to preserve and restore knee function, preserving meniscal tissue whenever possible [119]. The goal of meniscal repair is to provide the meniscus with structural support and the ability to heal, thereby preserving meniscus integrity and restoring its function [12]. In a pediatric meniscus, a surgeon may push the limits of a meniscus repair as a tear in the avascular zone, time from injury to surgery, or tear size may not be contraindication to a repair [11]. Indications for meniscal repair in pediatric patients include long (>10 mm) tears in the periphery without irreparable damage to the body of the meniscus [11]. The best results of meniscal repair in adults are achieved in tears within 3 mm of the periphery; however, in children it is likely that tears extending more than 3 mm from the periphery will have a good intermediate outcome [11]. Meniscal surgery can be performed with the correct timing and the proper indication even in the presence of early osteoarthritis, as there is a relevant regenerative potential of the meniscus and the surrounding cartilage that should be taken into account [44]. Older age is not a contraindication to meniscal repair in appropriately selected patients [9]. Acute meniscal root tears should be repaired early, while the treatment of chronic tears is more controversial [2]. Tear types appropriate for repair include vertical longitudinal tears in the vascular zone of the meniscus and displaced bucket-handle tears that remain in good condition once they are reduced [10]. In general, traumatic longitudinal tears occurring in the red/red (vascular) zone in patients younger than 30 years are believed to be most amenable to a successful repair [12]. Good results have also been demonstrated in red/white zone repairs in young patients [12]. Because of their blood supply, tears in the red/red zone are most likely to heal, followed by tears in the red/white zone [12]. White/white zone tears are avascular and thus have limited potential for healing [12]. Relative contraindications for meniscal repair include advanced degenerative articular cartilage damage, complex tears, poor meniscal tissue quality, and ACL deficiency [10]. Even though the failure rate of meniscus repair may be greater in an unstable knee, meniscus repair is not contraindicated in an anterior cruciate deficient knee [160]. Meniscal repair is effective over the medium and long term in 70 to 80% of cases, with indications extending to radial lesions and specific unstable knee scenarios [25]. If the meniscal tear complies with the criteria mentioned, with careful preparation of the suture site, correct surgical techniques and rehabilitation, we suggest the meniscus should be preserved, which could result in long-term benefits [23]. Meniscal repair has been shown to yield the lowest incidence of progressive osteoarthrosis when compared with total menisectomy, partial menisectomy, and nonoperative treatment of meniscal tears in stable knees [28]. The authors of the original systematic review maintain that meniscus repair should be adopted as the preferred initial intervention for medial meniscus root tears to prevent knee osteoarthritis [83]. Anatomical repair techniques, particularly pull-out and all-inside methods, appear to provide better functional outcomes for meniscal root tears than partial meniscectomy or conservative care [153]. The current level 3 and 4 evidence suggests that arthroscopic repair may result in slower progression of radiological deterioration compared with meniscectomy and nonoperative management for acute meniscus root tears [26]. Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared with nonoperative management and partial meniscectomy in a matched cohort based on patient characteristics [230].

Surgical Approach / Technique: Arthroscopic partial meniscectomy is indicated for radial, oblique, flap, horizontal cleavage, and complex tears, as well as for tears located in the white-white avascular zone [10]. The goal of arthroscopic partial meniscectomy is to débride degenerative or torn meniscal tissue, leaving a stable contoured rim and preserving as much tissue as possible [10]. During partial meniscectomy, the unstable portion of the meniscus is identified and excised, and the adjacent tissue is shaped into a smooth and stable contour leading into the excised segment [12]. It is critical to preserve as much meniscal tissue as possible and avoid creating a defect traversing the entire width of the meniscus during partial meniscectomy [12]. Irreparable unstable tears causing mechanical symptoms (locked knee); tears in the avascular zone, such as radial or flap tears; and degenerative tears without substantial osteoarthritis can be treated with partial meniscectomy [12]. Caution should be taken when considering surgical management of meniscal tears in patients with advanced radiographic osteoarthritis, even in those with frank mechanical symptoms [12]. Tears that are not amenable to repair (e.g., peripheral, longitudinal tears)—excluding those that do not necessitate any treatment (e.g., partial-thickness tears, those <5 to 10 mm in length, and those that cannot be displaced >1 to 2 mm)—are best treated with partial meniscectomy [2]. In general, complex, degenerative, and central/radial tears are treated with resection of a minimal amount of normal meniscus [2]. Open repair usually is reserved for peripheral tears in the posterior horn approached through a capsular incision [10]. Open repair has largely been replaced by arthroscopic techniques [12]. The inside-out meniscal repair technique remains the standard of care for meniscal repair, offering advantages such as versatility in suture placement and lower implant cost, though it carries risks of neurovascular injury and requires additional incisions [148]. Arthroscopic meniscal repair with the inside-out technique seems to be superior in comparison with the other methods because it offers a high rate of meniscus healing without prolonged operation time [155]. Arthroscopic inside-out repairs are performed using absorbable or nonabsorbable sutures placed using zone-appropriate cannulas; the sutures are retrieved and tied through a small capsular incision [10]. The arthroscopic outside-in technique usually is reserved for anterior horn tears [10]. The arthroscopic outside-in technique involves placing a suture through a needle placed across the tear, retrieved and tied outside the knee through an arthroscopic portal, with the knot pulled into the knee to reduce the tear when tied over the capsule [10]. Arthroscopic all-inside repairs involve absorbable stents or sutures tied to stents placed through arthroscopic portals [10]. All-inside repairs may offer reduced neurovascular risk [10]. Mechanical studies have investigated many all-inside devices and have demonstrated reasonable loads to failure, but no device improves on the load to failure of vertically placed inside-out sutures [10]. The all-inside repair does not require an additional skin incision, and the procedure is less [10]. Regardless of the technique used, it is essential that the saphenous nerve branches (anterior to both the semitendinosus and gracilis muscles and posterior to the inferior border of the sartorius muscle) be protected during medial repairs, and the peroneal nerve (posterior to the biceps femoris) during lateral repairs [2].

Other Considerations: Arthroscopic meniscectomy has been demonstrated to reduce surgical morbidity over open meniscectomy and to improve function [10]. Studies have demonstrated greater than 80% satisfactory function at minimum 5-year follow-up after arthroscopic partial meniscectomy, despite a 50% finding of Fairbank’s changes on radiographs [10]. Degenerative changes and a decrease in function occur more quickly in patients who have undergone arthroscopic lateral meniscectomy, probably due to the biomechanical protection effect of the lateral meniscus [10]. Factors that seem to predict better long-term function following arthroscopic partial meniscectomy include age younger than 40 years, normal lower extremity alignment, minimal arthritic changes noted at the time of arthroscopy, and a single fragment tear [10]. Clinical studies with long-term follow-up of partial meniscectomy for the treatment of meniscal tears found an increase in osteoarthritic changes within the affected compartment [12]. Partial meniscectomy for the management of radial tears that were within 1 cm of the posterior horn insertion led to progression of osteoarthritis in 35% of patients at a mean 77-month follow-up [12]. At 5- to 7-year follow-up of 46 patients, one-third had progression of Kellgren-Lawrence grade 0 to 2 osteoarthritis to grade 3 or 4 osteoarthritis after partial meniscectomy [12]. Although the modified Lysholm Knee Questionnaire score often significantly improved after partial meniscectomy, only 56% of patients reported pain improvement [12]. Partial meniscectomy offers pain relief and functional improvement for medial meniscus tear with intact posterior root [302]. Arthroscopic partial meniscectomy was not better than sham surgery for medial meniscal tear in a randomized controlled trial with 12 months of follow-up [285]. The failure and revision surgery rate was found to be higher for medial than lateral meniscal repairs at short-term and medium-term follow-up [12]. Concomitant ACL reconstruction positively correlated with healing [12]. Age younger than 30 years trended toward a positive correlation with healing [12]. Tears longer than 2 cm and smoking are negatively associated with healing rates [12]. In a systematic review of management for traumatic meniscal tears, both the short-term and long-term revision surgery rates were higher after meniscal repair than after meniscectomy (16.5% versus 1.4% and 20.7% versus 3.9%, respectively) [12]. There were no plain radiographic degenerative changes in 78% of knees after meniscal repair, compared with 64% of knees after meniscectomy [12]. Nearly 80% of patients with arthroscopic meniscal repair had no osteoarthritis progression compared with only 40% of patients with meniscectomy at 8- to 10-year follow-up [12]. Approximately 96% of the patients who underwent arthroscopic meniscal repair returned to their preinjury level of sports activity compared with only half of those who underwent a partial meniscectomy [12]. At 4-year follow-up, patients who underwent repair of a medial meniscal root tear had less progression of osteoarthritis and better clinical scores than those who underwent partial medial meniscectomy [12]. The risk for symptomatic osteoarthritis progression following meniscal repair is 25% to 50% lower than that following arthroscopic partial meniscectomy but remains approximately twice as high as the general population [12]. Both meniscectomy and meniscal repair are safe surgical procedures with low adverse event rates (0.95% and 1.4%, respectively), but complications are associated with medical comorbidities, older age, and longer operative times [21]. Complications of meniscal repair include failure to heal the tear, knee stiffness, and potential damage to the articular surface from mechanical devices used to repair the tear [10]. All-suture anchors most frequently failed by fracture of the device, rigid anchors with a capsular knot showed a unique susceptibility to device-device incompatibility, and rigid anchors with a meniscal knot were primarily associated with deployment-related errors [291]. Failure of meniscal repair was not altered with the administration of perioperative ketorolac [269]. In patients undergoing arthroscopic meniscal surgery, the chronicity of preoperative opioid intake and degree of knee osteoarthritis were found to have a significant effect on postoperative opioid use [303].

Complications¶

General Adverse Events and Safety: Arthroscopic meniscus repair and meniscectomy are safe surgical procedures with low overall adverse event rates of 1.4% and 0.95%, respectively [21]. Both procedures carry 30-day complication rates of less than 1% overall [321]. In patients aged over 40 years, the 30-day complication rate for both arthroscopic meniscus repair and meniscectomy remains below 1.3% [321]. Meniscal repair is associated with higher rates of early complications compared with meniscectomy [304]. Specifically, patients undergoing repair of horizontal cleavage tears experienced higher complication rates than those undergoing partial meniscectomy [322].

Neurovascular Injury: Peripheral nerve damage accounted for 0.6% of serious complications during arthroscopic meniscus repairs [247]. Common peroneal nerve injury caused by suture entrapment is a recognized complication of arthroscopic inside-out lateral meniscus repair [247]. Other possible neurovascular injuries associated with arthroscopy-assisted meniscal repair include peroneal nerve palsy, saphenous neuritis, and complex regional pain syndrome [258]. A partial peroneal nerve palsy following an open lateral meniscal repair by posterolateral arthrotomy spontaneously recovered 4 months after surgery [170]. Surgeons must protect the saphenous nerve branches during medial repairs and the peroneal nerve during lateral repairs [2, 3].

Infection: Possible complications associated with arthroscopy-assisted meniscal repair include infection [258]. Septic arthritis following meniscus repair can be successfully treated with sequential arthroscopic irrigation and debridements [339]. In one case, a patient developed septic arthritis postoperatively and underwent incision and drainage with antibiotic treatment [170]. Two other patients required repeat arthroscopic washouts for septic arthritis, with joint drainage that cleared after 4 weeks of intravenous antibiotics [108].

Repair Failure and Reoperation: The overall meniscal repair failure rate is 14.8% at a minimum follow-up ranging from 2 to 5 years [214]. Long-term studies with a minimum follow-up of 5 years report an overall meniscus repair failure rate of 19% [307]. Modern meniscal repair demonstrated an overall failure rate of 19.5% at a minimum of 5 years postoperatively [330]. Outcomes at a minimum 5 years postoperatively showed an overall failure rate of 21.8% [337]. In a large, population-based cohort, the 5-year reoperation risk after meniscal repair was 32.7% [255]. The reoperation rate following meniscus suture was 31.9% at 5 years [340]. The risk of any knee reoperation after meniscal repair is four-fold higher compared with partial meniscectomy [97]. The risk of same meniscus reoperations after meniscal repair is approximately 17-fold higher compared with partial meniscectomy [97]. One-fifth of patients underwent subsequent ipsilateral surgery during follow-up after bucket-handle meniscal repairs [30]. Of these patients, 4.3% received a repeat meniscal repair and 12.1% experienced a meniscectomy [30]. The failure rate of isolated revision meniscal repair is slightly higher than that of isolated primary meniscal repair but remains acceptable [86]. All-inside revision meniscal repair demonstrated a high failure rate of 50% at mid-term follow-up [314]. The meniscus repair failure rate after the staged procedure, preceding ACL reconstruction, was 36.7% at 3 years [332]. At 6-year follow-up, the overall meniscal failure rate defined by reoperation was 13% in the revision ACLR cohort [308, 309]. Meniscal repair in the revision ACLR setting has a 16% failure rate at 6 years [336]. More than 80% of all failures occurred during the first 3 postoperative years for arthroscopic all-inside repair using the Meniscus Arrow [334]. Nineteen percent of meniscus repairs are revised, with failures frequently occurring after the second postoperative year [307]. The clinical failure rate of the repair group was 22% in selected patients aged 60 years and older [318]. While a high proportion of patients required additional procedures on their operative knee at 8-year follow-up after transtibial medial meniscal root repair, few of these additional procedures were related to failure of the primary surgery [315].

Specific Implant and Technique Complications: Chondral injury from protruding implants has been reported as a complication of arthroscopy-assisted meniscal repair [258]. One case of foreign-body reaction with granuloma was reported following meniscus refixation with bioabsorbable arrows [253]. One case of a fresh meniscus tear after renewed trauma was reported in a patient with receding meniscus arrows and a chondral lesion [253]. The use of absorbable sutures leads to a lower incidence of additional tears than nonabsorbable sutures in patients undergoing meniscal repair with anterior cruciate ligament reconstruction [343]. No short-term or long-term postoperative complications were observed in a case series of revision meniscal repair, specifically no cases of infection, joint stiffness requiring intervention, neurovascular injury, or reoperation [207].

Other Considerations: Possible complications associated with arthroscopy-assisted meniscal repair include arthrofibrosis and deep venous thrombosis [258].

Recovery¶

Light activity (weeks): Basic science data indicate that meniscal healing is largely complete by 6 weeks [66]. During this period, weight bearing and range of motion are beneficial in a stable knee [66].

Full activity (months): A majority of isolated meniscal repair patients perform well on functional testing by 4 months post-operatively [293]. By 6 months post-operatively, isolated meniscal repair patients perform similarly to patients undergoing isolated ACL reconstruction on functional testing [293]. Meniscal repair in conjunction with ACL reconstruction does not significantly alter the recovery of limb symmetry in strength at 6 months postoperatively [324].

Complete recovery / outcome plateau (months): In the long term after meniscal repair, osteoarthritis is limited and meniscal function seems preserved [296]. The repaired meniscus maintains its biomechanical function regardless of the degree of healing [82].

Rehabilitation protocol: An international formal consensus established clear, updated, and structured recommendations for surgeons and physiotherapists treating patients after meniscus surgery [73]. Accelerated rehabilitation protocols after meniscal repair are safe and at least as effective as more conservative approaches, supported by limited short-term data [189]. Standard exercise therapy under the supervision of a physiotherapist improved the functional recovery of the knee after partial arthroscopic meniscectomy [178]. Of publicly available meniscal repair rehabilitation protocols, only 10.2% changed their protocol in relation to tear type, and there is a wide range of timeframes for each rehabilitation component across these protocols [161].

Functional milestones: Functional testing following isolated meniscus repair may help identify patients who need additional physical therapy prior to a return to activity [293]. Isolated repair of meniscal tears results in good to excellent sport-specific outcomes and a high return to sports rate in both recreational and professional athletes [70]. Most elite athletes can return to their preinjury level of activity following meniscal repair and healing [183].

Other Considerations: Meniscal repair is associated with a lower progression to knee osteoarthritis at approximately six years of follow-up compared to partial meniscectomy [4]. Arthroscopic meniscal repair offers significantly improved results for isolated traumatic meniscal tears regarding long-term follow-up in osteoarthritis prophylaxis and sports activity recovery compared with partial meniscectomy [233]. While 15% of meniscal repairs failed in professional soccer players, rates of subsequent surgery and 5- and 10-year professional sport participation did not differ significantly from those after partial meniscectomy [279]. Meniscal repairs performed concomitantly with an ACL reconstruction result in fewer reoperations [24]. The failure rate for isolated revision meniscal repair is slightly higher compared to isolated primary meniscal repair but remains acceptable [86]. Revision meniscal repair results in good to excellent knee function, high level of sports participation, and high patient satisfaction in patients with re-tears or failed healing [215]. Repeat repair of retorn menisci had a 72% survival rate with relief of symptoms and return to high levels of function [325]. Second-look arthroscopy confirmed complete healing in 92% of meniscal tears when performed for tears associated with tibial plateau fractures [95]. Complete healing of both menisci was confirmed arthroscopically 3 years postoperatively in a case of radial tears in the roots of the posterior horns combined with an ACL tear [7]. The FasT-Fix meniscal repair associated with an accelerated rehabilitation program resulted in clinically effective meniscal repair in 83% at the time of follow-up [196]. Concurrent medial meniscal posterior root repair during proximal tibial osteotomy appears to improve the arthroscopic appearance regarding healing of tears and cartilage regeneration during second-look arthroscopy [323].

Key Evidence¶

[L5] Meniscal repair aims to achieve healing and avoid the adverse effects of meniscectomy, with techniques largely depending on the type of tear and requiring precise assessment. [1] (10.1016/j.otsr.2017.04.016)
[L1] Meniscal repair is associated with a lower progression to knee osteoarthritis at approximately six years of followup compared to partial meniscectomy. [4] (10.1007/s00167-023-07600-y)
[L5] Meniscal repair should be considered whenever possible, with strategies specific to tear type and patient features. [5] (10.5435/jaaos-d-21-01153)
[Case_report] Complete healing of both menisci was confirmed arthroscopically 3 years postoperatively, and the restoration of a stable and functional knee joint testifies to the efficacy of the treatment strategy. [7] (10.1007/s00167-009-0839-4)
[L5] [8] (10.1177/0363546513498503)
[L5] In appropriately selected patients, meniscal repair can deliver improved subjective outcomes with comparable reoperation rates and the potential for reduced risk of osteoarthritis over time versus meniscectomy. [9] (10.1016/j.arthro.2024.11.058)
[L5] Meniscal root tears are frequently unrecognized injuries that significantly alter knee biomechanics and kinematics, leading to accelerated degenerative changes. [14] (10.1177/0363546514524162)
[L3] A meniscectomy after meniscal repair is performed infrequently, supporting the notion that repairing a meniscus is a safe and effective procedure in the long term. [15] (10.1177/0363546513503444)
[L5] [17] (10.5435/00124635-200205000-00003)
[L4] Meniscal repair is a viable alternative to resection in many clinical situations, with success rates exceeding 80% when performed with anterior cruciate ligament reconstruction. [20] (10.5435/00124635-200205000-00004)
[L5] Both meniscectomy and meniscal repair are safe surgical procedures with low adverse event rates (0.95% and 1.4%, respectively), but complications are associated with medical comorbidities, older age, and longer operative times. [21] (10.1016/j.arthro.2023.12.017)
[L4] If the meniscal tear complies with the criteria mentioned, with careful preparation of the suture site, correct surgical techniques and rehabilitation, we suggest the meniscus should be preserved, which could result in long-term benefits. [23] (10.1007/s00167-009-0926-6)
[L3] Meniscal repairs performed concomitantly with an ACLR result in fewer reoperations. [24] (10.1177/2325967120905529)
[L5] Meniscal repair is effective over the medium and long term in 70 to 80% of cases, with indications extending to radial lesions and specific unstable knee scenarios, while surgical techniques continue to simplify and focus on biological environments. [25] (10.1016/j.otsr.2009.09.004)
[L4] The current level 3 and 4 evidence suggests that arthroscopic repair may result in slower progression of radiological deterioration compared with meniscectomy and nonoperative management. [26] (10.1177/03635465211031250)
[L3] Patients treated with primary meniscectomy have over three times higher odds to undergo subsequent knee arthroplasty compared to those treated with meniscal repair. [27] (10.1002/ksa.12216)
[L5] Meniscal repair has been shown to yield the lowest incidence of progressive osteoarthrosis when compared with total menisectomy, partial menisectomy, and nonoperative treatment of meniscal tears in stable knees. [28] (10.1016/s0278-5919(05)70131-9)
[L4] One-fifth of patients underwent subsequent ipsilateral surgery during follow-up, with 4.3% receiving a repeat meniscal repair and 12.1% experiencing a meniscectomy. [30] (10.1177/03635465221101136)
[L3] Pre-operative tests and clinical findings are not conclusive for identifying a meniscal tear, and surgeons should be vigilant in identifying and repairing tears at the time of surgery. [36] (10.1007/s00167-020-06375-w)
[L3] Patients with no meniscal damage at diagnosis should be aware that conservative management carries risks of further meniscal damage; if surgery is decided, delay should be no longer than 6 months from diagnosis. [37] (10.1007/s00167-008-0622-y)
[L4] According to current standard indications, 34.9% of all meniscal injuries offer the potential for repair, rising to 55.6% when accompanied by anterior cruciate ligament damage. [38] (10.1016/j.arthro.2018.08.051)
[L3] The clinical relevance of this finding is that MRI contributes to enhancing the diagnostic accuracy of an unhealed meniscal repair when there are limited clinical signs of meniscal pathology. [39] (10.1007/s00167-019-05523-1)
[L4] Meniscal surgery can be performed with the correct timing and the proper indication even in the presence of early osteoarthritis, as there is a relevant regenerative potential of the meniscus and the surrounding cartilage that should be taken into account. [44] (10.1007/s00167-016-4069-2)
[L4] Medial meniscus repair in the ACL-deficient knee is not contraindicated. [45] (10.1007/s00167-006-0162-2)
[L4] This type of meniscus injury is relatively rare and difficult to diagnose via MRI; early ACL reconstruction is recommended to avoid progression of meniscal injury and facilitate repair. [51] (10.1007/s00167-006-0255-y)
[L4] [56] (10.1177/0363546520934766)
[L2] The diagnostic validity of magnetic resonance imaging is similar for meniscal tears in acute knee trauma and in knee symptoms lasting over 6 months in young adults. [59] (10.1177/0363546508329543)
[L5] Basic science studies suggest meniscal healing is largely complete by 6 weeks, with weight bearing and range of motion being beneficial in a stable knee. [66] (10.1016/j.csm.2004.03.001)
[L5] The authors appreciate the attempt to formulate a scoring system to predict the reparability of meniscus, limited to tears identifiable by MRI after testing the classification of zones and patterns of meniscal tear based on MRI, but highlight limitations regarding MRI sensitivity, statistical details, and demographic data. [67] (10.1007/s00167-019-05825-4)
[L3] Although the failure rate of meniscus repair may be greater in an unstable knee, meniscal repair is not contraindicated in a knee with a deficient ACL. [68] (10.1007/s00264-004-0616-4)
[L4] Meniscal repair in ACL reconstructed knees with expanded indications achieved a healing rate (including incomplete healing) of 75%. [69] (10.1016/j.arthro.2019.04.009)
[L4] This systematic review suggests that isolated repair of meniscal tears results in good to excellent sport-specific outcomes and a high return to sports rate in both recreational and professional athletes. [70] (10.1007/s00167-017-4463-4)
[L5] Meniscal tear location in addition to type likely plays a crucial role in dictating the success of non-operative treatment of the menisci. [71] (10.1007/s00167-018-5090-4)
[L1] This international formal consensus established clear, updated and structured recommendations for both surgeons and physiotherapists treating patients after meniscus surgery. [73] (10.1002/ksa.12674)
[L5] Positive outcomes for meniscal allograft transplantation are most likely to be achieved when performed in appropriately selected patients, with studies reporting long-term graft survivorship as high as 89% at 10 years and significant improvements in multiple patient reported outcome measures. [74] (10.1007/s00167-020-06058-6)
[L4] The incidence of medial meniscal lesions and the complexity of tear types increased significantly with increasing time intervals between the index injury and ACL reconstruction. [75] (10.1177/03635465231216364)
[L3] [77] (10.1177/03635465990270040601)
[L5] The authors argue that evaluating the usefulness of meniscectomy is flawed due to insufficient stratification of meniscal tear characteristics, and that clinical practice guidelines may be flawed if they recommend against treatments that benefit specific patient subgroups despite Level I evidence showing safety and efficacy. [80] (10.1016/j.arthro.2014.03.016)
[L2] The repaired meniscus, whatever its healing may maintain its biomechanical function. [82] (10.1016/j.arthro.2013.07.142)
[L5] The authors of the original systematic review maintain that meniscus repair should be adopted as the preferred initial intervention for medial meniscus root tears to prevent knee osteoarthritis, despite the additional evidence presented regarding nonoperative management. [83] (10.1177/0363546518783958)
[L4] The failure rate is slightly higher compared to isolated primary meniscal repair, but still acceptable. [86] (10.1186/s12891-018-2368-0)
[L4] [88] (10.1007/s00167-003-0412-5)
[L2] [91] (10.1177/0363546520904680)
[L4] Sonographic evaluation should be considered in patients presenting with ongoing knee pain after all-inside meniscus repair. [94] (10.1177/2325967116664882)
[L4] Second-look arthroscopy confirmed complete healing in 92% of meniscal tears when performed. [95] (10.1177/0363546512457552)
[L3] The risk of any knee reoperation after meniscal repair had a four-fold increase compared with partial meniscectomy, and for same meniscus reoperations about 17-fold. [97] (10.1002/ksa.12791)
[L3] [108] (10.1007/s00167-010-1286-y)
[L2] Clinical examination by an experienced examiner using multiple meniscus tests is sufficient for a diagnosis of a meniscal tear. [113] (10.1007/s00167-011-1636-4)
[L4] An integrated approach to meniscal surgery is required as part of an overall strategy to preserve and restore knee function, preserving meniscal tissue whenever possible. [119] (10.1016/j.csm.2019.08.012)
[L5] The meniscus status does have a significant impact on knee kinematics in the ACL-deficient knee. [123] (10.1007/s00264-014-2581-x)
[L5] This sign can be a supportive finding for diagnosis and preoperative planning for meniscus injury. [135] (10.1007/s00167-011-1441-0)
[Paper] The inside-out meniscal repair technique remains the standard of care for meniscal repair, offering advantages such as versatility in suture placement and lower implant cost, though it carries risks of neurovascular injury and requires additional incisions. [148] (10.1016/j.eats.2015.10.017)
[L2] Anatomical repair techniques, particularly pull-out and all-inside methods, appear to provide better functional outcomes for meniscal root tears than partial meniscectomy or conservative care. [153] (10.1186/s12891-026-09704-1)
[L2] Arthroscopic meniscal repair with the inside-out technique seems to be superior in comparison with the other methods because it offers a high rate of meniscus healing without prolonged operation time. [155] (10.1007/s00167-006-0094-x)
[L4] Even though the failure rate of meniscus repair may be greater in an unstable knee, we conclude that meniscus repair is not contraindicated in an anterior cruciate deficient knee. [160] (10.1177/036354659001800609)
[L4] Of publicly available meniscal repair rehabilitation protocols, a small percentage (10.2%) changed their protocol in relation to tear type and there was a wide range of timeframes for each rehabilitation component. [161] (10.1016/j.asmr.2020.10.004)
[L5] Meniscal removal should always be the last option, but is sometimes unavoidable; the author advocates for meniscal preservation with the plea to 'Repair Regularly, Resect Rarely.' [167] (10.1016/j.csm.2019.10.002)
[L5] This study shows that an MMPH longitudinal tear in an ACL-deficient knee alters the knee kinematics, particularly the anterior-posterior tibial translation. [169] (10.1177/0363546511416597)
[L4] [170] (10.1177/2325967119843355)
[L5] Arthroscopic partial meniscectomy should not be proposed as a first-line treatment for degenerative meniscus lesions; non-operative treatment should always be started first, with surgery only envisaged after its failure. [171] (10.1007/s00167-017-4458-1)
[L1] The benefits of APM in adults with degenerative and nonobstructive meniscal symptoms are limited, with current evidence reporting similarity in outcomes between APM and physical therapy. [173] (10.1007/s00167-022-07040-0)
[L3] In patients aged 40 years and older, patient-reported outcomes at an average of 5 years postoperatively were satisfactory and similar in patients undergoing meniscal repair and meniscectomy, indicating that age alone should not be a contraindication to meniscal repair. [176] (10.1007/s00167-020-06299-5)
[L5] Initial nonoperative management of degenerative meniscal tears is worth a try. [177] (10.1016/j.arthro.2019.11.128)
[L1] This prospective, randomised, partially blinded study showed that standard exercise therapy under the supervision of a physiotherapist improved the functional recovery of the knee after partial arthroscopic meniscectomy. [178] (10.1007/s001670050181)
[L4] The authors consider meniscal repair a successful option and recommend increasing the rate of meniscal suture. [181] (10.1177/2325967117s00010)
[L4] Meniscal repair and healing are possible, and most elite athletes can return to their preinjury level of activity. [183] (10.1177/0363546508330138)
[L5] Knee meniscal repair has a success rate of approximately 80% in both men and women, and meniscal repair is a critical procedure for maintaining long-term knee health. [185] (10.1016/j.arthro.2019.12.017)
[Paper] Accelerated rehabilitation protocols after meniscal repair are safe and at least as effective as more conservative approaches, supported by limited short-term data. [189] (10.1016/j.csm.2011.08.010)
[L5] The biomechanical consequences of a lateral meniscus root tear depend on the state of the meniscofemoral ligament. [190] (10.1007/s00402-013-1716-7)
[L3] Although meniscal preservation is generally accepted in the treatment of meniscal tears, most tears in this cohort were not repairable, despite contemporary methods. [194] (10.1055/s-0030-1247746)
[L3] Meniscus repair in the revision setting is a successful treatment choice when appropriate. [195] (10.1177/2325967117s00239)
[L4] The FasT-Fix meniscal repair associated with an accelerated rehabilitation program resulted in clinically effective meniscal repair in 83% at the time of follow-up. [196] (10.1016/j.arthro.2008.08.001)
[L3] The menisci should be repaired if at all possible, especially in the setting of anterior cruciate ligament reconstruction, for optimal functional outcome and patient satisfaction. [200] (10.1177/03635465020300061501)
[L5] The integrity of the posterior root of the medial meniscus plays an important role in maintaining normal tibial-femoral joint contact mechanics. [204] (10.1186/s12891-022-06069-z)
[L4] Our study showed that the CNN model has the potential to be used in diagnosing the presence of meniscal tears and differentiating the types of meniscal tears. [205] (10.1186/s12891-022-05468-6)
[L4] [207] (10.1177/23259671261451781)
[L3] The meniscus fulfills its function as normal or nearly normal even though the MRI findings fail to prove healing. [208] (10.1177/2325967114s00132)
[L4] Surgeons can reliably classify meniscal pathology and agree on treatment, which is important for multicenter trials. [213] (10.1177/0363546504264586)
[L4] This meta-analysis on close to 4000 patients demonstrates an overall meniscal repair failure rate of 14.8% at a minimum follow-up from 2 years up to 5 years. [214] (10.1177/03635465231158385)
[L4] In patients with re-tears or failed healing after previous isolated meniscal repair, revision meniscal repair results in good to excellent knee function, high level of sports participation, and high patient satisfaction. [215] (10.1177/2325967119s00223)
[L4] We recommend nonoperative treatment of anterior horn tears noted on MRI among patients without mechanical symptoms and whose clinical examination is inconsistent with the presence of a pathologic meniscal condition. [217] (10.1177/03635465020300020701)
[L3] Several abnormal vertical and/or horizontal hypersignals are present on MRI ten years after arthroscopic all-inside meniscal repair, without any subjective or objective clinical significance. [220] (10.1007/s00264-013-2039-6)
[L3] MRI is not always useful in predicting reparability of symptomatic isolated lateral semilunar meniscus tears, and most of the symptomatic cases with normal MRI were reparable. [229] (10.1007/s00167-002-0280-4)
[L3] Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared with nonoperative management and partial meniscectomy in a matched cohort based on patient characteristics. [230] (10.1177/0363546519888212)
[L3] Magnetic resonance imaging is not an effective or efficient predictor of reparability of meniscal tears with the current arthroscopic criteria. [232] (10.1177/0363546510387507)
[L3] Arthroscopic meniscal repair offers significantly improved results for isolated traumatic meniscal tears regarding the long-term follow-up in osteoarthritis prophylaxis and sports activity recovery compared with partial meniscectomy. [233] (10.1177/0363546510364052)
[L4] Precise description of meniscal tears on MRI should continue to improve its ability to assist with surgical planning. [235] (10.1016/j.csm.2013.03.005)
[L3] [241] (10.1007/s001670050163)
[L4] Meniscal deformation or displacement observed on preoperative MR images suggests a higher risk of meniscal tears, even in menisci with signal changes other than grade 3 changes. [243] (10.1016/j.arthro.2011.08.300)
[L4] [247] (10.1055/s-0030-1247723)
[L5] Advanced imaging by 3-dimensional computed tomography may better allow preoperative planning for a safe approach to the posterior horn of the lateral meniscus using all-inside repair techniques, solving limitations of cadaveric and MRI studies. [249] (10.1016/j.arthro.2019.02.038)
[L3] The long-term survival rate of repaired menisci was 91%, and magnetic resonance imaging is unsuitable for diagnosis of the healing process of a repaired meniscus. [251] (10.1177/03635465990270011001)
[L4] [253] (10.1007/s00167-002-0283-1)
[L4] MRI is successful in determining the presence or absence of tears in discoid menisci; however, its ability to determine the tear type is questionable. [254] (10.1007/s00167-013-2371-9)
[L3] In this large, population-based cohort, the 5-year reoperation risk after meniscal repair was 32.7%. [255] (10.1002/ksa.70144)
[L5] [258] (10.1016/j.csm.2011.09.002)
[L2] MRI continues to be a poor predictor of meniscus tear reparability as assessed by arthroscopic criteria, even when using higher resolution 3-T scanners. [262] (10.1177/03635465211052526)
[L3] Confusion between meniscal fraying and small tears is a major source of discrepancy between MRI and surgical findings. [264] (10.1007/s00402-007-0318-7)
[L3] Failure of meniscal repair was not altered with the administration of perioperative ketorolac. [269] (10.1177/2325967114529537)
[L3] While 15% of meniscal repairs failed, rates of subsequent surgery and 5- and 10-year professional sport participation did not differ significantly from those after partial meniscectomy. [279] (10.1177/03635465251362504)
[L1] [281] (10.1016/j.arthro.2016.03.029)
[L1] [285] (10.2106/jbjs.9616.ebo521)
[L4] All-suture anchors most frequently failed by Fracture of the device, rigid anchors with a capsular knot showed a unique susceptibility to Device-Device Incompatibility, and rigid anchors with a meniscal knot were primarily associated with deployment-related errors. [291] (10.1002/arj.70453)
[L3] A majority of isolated meniscal repair patients perform well on functional testing by 4 months post-operatively and similar to patients undergoing isolated ACL reconstruction at 6 months post-operatively. [293] (10.1016/j.jisako.2024.04.007)
[Paper] In the long-term after meniscal repair, osteoarthritis is limited and meniscal function seems preserved. [296] (10.1016/j.otsr.2016.12.014)
[L4] Partial meniscectomy offers pain relief and functional improvement for medial meniscus tear with intact posterior root. [302] (10.1007/s00167-019-05634-9)
[L3] In patients undergoing arthroscopic meniscal surgery, the chronicity of preoperative opioid intake and degree of knee osteoarthritis were found to have a significant effect on postoperative opioid use. [303] (10.1016/j.arthro.2018.10.122)
[L3] Meniscal repair leads to significantly lower rates of reoperation and higher rates of early complications with a higher total cost compared with meniscectomy in a large database study. [304] (10.1177/0363546520935453)
[L1] The overall meniscus repair failure rate remains nineteen percent in long-term studies. [307] (10.1007/s00167-021-06770-x)
[L3] At 6-year follow-up, overall meniscal failure rate as defined by reoperation was 13% in this revision cohort. [308] (10.1177/2325967124s00001)
[L3] At 6-year follow-up, overall meniscal failure rate as defined by reoperation was 13% in this revision cohort. [309] (10.1177/2325967124s00274)
[L3] All-inside revision meniscal repair demonstrated a high failure rate of 50% at mid-term follow-up. [314] (10.1002/ksa.70503)
[L4] While a high proportion of patients required additional procedures on their operative knee at 8‐year follow‐up, few of these patient's additional procedures were related to failure of their primary surgery. [315] (10.1002/ksa.12321)
[L2] The clinical failure rate of the repair group was 22%, supporting meniscal repair in selected patients aged 60 years and older. [318] (10.1177/23259671221117491)
[L3] Arthroscopic meniscus repair and meniscectomy are both low-risk procedures with 30-day complication rates < 1% overall and < 1.3% among patients aged > 40 years. [321] (10.1007/s00167-023-07507-8)
[L4] Patients undergoing repair had higher complication rates than those undergoing partial meniscectomy. [322] (10.1007/s00167-019-05557-5)
[L3] Concurrent medial meniscal posterior root repair during proximal tibial osteotomy appears to improve the arthroscopic appearance regarding healing of tears and cartilage regeneration during second-look arthroscopy. [323] (10.1016/j.arthro.2020.04.038)
[L3] Generally, meniscal repair in conjunction with ACLR does not significantly alter the recovery of limb symmetry in strength at 6 months postoperatively. [324] (10.1007/s00402-020-03347-0)
[L4] Repeat repair of retorn menisci had a 72% survival rate with relief of symptoms and return to high levels of function. [325] (10.1177/03635465030310062401)
[L1] Modern meniscal repair had an overall failure rate of 19.5% at a minimum of 5 years postoperatively. [330] (10.2106/jbjs.21.01303)
[L4] The meniscus repair failure rate after the staged procedure was 36.7% at 3 years. [332] (10.1002/ksa.12593)
[L4] More than 80% of all failures occurred during the first 3 postoperative years, suggesting that the initial refixation potential of the Meniscus Arrow is low. [334] (10.1016/j.arthro.2006.11.027)
[L2] Meniscal repair in the revision ACLR setting has a 16% failure rate at 6 years. [336] (10.1177/03635465251387333)
[L1] The outcomes of meniscal repair at a minimum 5 years postoperatively had an overall failure rate of 21.8%. [337] (10.1177/2325967121s00421)
[L4] Septic arthritis following meniscus repair can be successfully treated with sequential arthroscopic I&Ds. [339] (10.1007/s00167-018-4890-x)
[L3] The reoperation rate following meniscus suture was 31.9% at 5 years. [340] (10.1016/j.jisako.2025.100655)
[L3] The use of absorbable sutures leads to comparable healing rates to and lower incidence of additional tears than nonabsorbable sutures in patients undergoing meniscal repair with anterior cruciate ligament reconstruction. [343] (10.1016/j.arthro.2019.08.045)

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[254] Comparison of magnetic resonance imaging findings with arthroscopic findings in discoid meniscus. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2371-9

[255] One‐third of meniscal repairs undergo reoperation within five years: Incidence and predictors in a retrospective study of 2390 cases. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70144

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[285] Arthroscopic Partial Meniscectomy Was Not Better Than Sham Surgery for Medial Meniscal Tear. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.9616.ebo521

[291] All‐Inside Meniscus Repair Systems Failure Analysis Shows Device‐Related Adverse Events Differ by Device Design Type and Show Varied Reporting Delays by Manufacturer. Arthroscopy. 2026. DOI: 10.1002/arj.70453

[293] Functional testing following isolated meniscus repair may help to identify patients who need additional physical therapy prior to a return to activity. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.04.007

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[315] Clinical outcomes following transtibial medial meniscal root repair are maintained at long‐term follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12321

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[339] Meniscus repairs can be saved in the event of postoperative septic arthritis. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-4890-x

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Meniscal repair

Overview¶

Anatomy & Pathophysiology¶

Gross Anatomy and Composition¶

Microscopic Structure and Fiber Orientation¶

Vascular Supply and Zones¶

Ligamentous Attachments and Stability¶

Biomechanical Function¶

Pathophysiology of Tears¶

Classification¶

Tear Morphology and Nomenclature¶

Vascular Zones and Location¶

Diagnostic and Assessment Criteria¶

Degeneration and Histology¶

Imaging and Prediction¶

Clinical Presentation¶

History and Symptoms¶

Physical Examination¶

Imaging¶

Diagnostic Considerations¶

Investigations¶

Clinical Evaluation¶

Imaging¶

Post-Repair Assessment¶

Treatment¶

Non-Operative¶

Operative¶

Complications¶

Recovery¶

Key Evidence¶

See Also¶

References¶