Meniscal Repair

Definition/Description[edit | edit source]

A meniscal repair or arthroscopic meniscectomy is a surgical procedure to repair a torn meniscus via keyhole surgery. It involves removal of some or all of a meniscus from the tibio-femoral joint of the knee using arthroscopic (keyhole) surgery. The procedure can be a complete meniscectomy where the meniscus and the meniscal rim is removed or partial, where only a section of the meniscus is removed. This may vary from a minor trimming of a frayed edge to anything short of removing the rim. It is a minimally invasive procedure often undergone as an outpatient in a one-day clinic and is performed when a meniscal tear is too large to be corrected by a surgical repair of the meniscus. [1] .  Factors affecting success include tear age, location and pattern, age of the patient, as well as any associated injuries.

Clinically Relevant Anatomy[edit | edit source]

The menisci of the knee are crescent-shaped fibrocartilaginous structures which add to the tibio-femoral joint congruency while also dispersing friction and body weight.[1]

A difference exists between the medial and the lateral meniscus:

  • The medial meniscus is larger and has a C-type shape. It blends with the medial collateral ligament [2]
  • The smaller lateral meniscus has an O shape. This is more mobile than the medial meniscus and blends with the popliteus muscle. [2]

The major meniscal functions are to:

  • Distribute stress across the knee during weight bearing
  • Provide shock absorption
  • Serve as secondary joint stabilizers (in an anterior cruciate ligament deficient knee, menisci will serve as joint stabilizers [3]
  • Provide articular cartilage nutrition and lubrication
  • Facilitate joint gliding
  • Prevent hyperextension and
  • Protect the joint margins.

During knee flexion, the femoral condyles glide posteriorly on the tibial plateau in conjunction with tibial internal rotation. The lateral meniscus undergoes twice the anteroposterior translation of the medial meniscus during knee flexion. This translation prevents the femur from contacting the posterior margin of the tibial plateau.[4] 

Zones of the meniscus[edit | edit source]

The meniscus is divided into three zones: the red-red, the red-white and the white-white. The zones are divided by vascularization and thus healing potential.

  1. The red-red zone is the peripheral zone of the meniscus. It is very well vascularized and has a good healing rate. Patients differ in vascularization of the medial and lateral meniscus, varying between 20-30 and 10-25 % width.
  2. The red-white zone is the middle third with less vascularization but can heal through sometimes.
  3. The white-white zone has no blood capillaries at all and therefore cannot heal.

Epidemiology[edit | edit source]

Meniscal lesions are one of the most common intra-articular knee injury in the United States and second most common to the knee, with an incidence of 12% to 14% and a prevalence of 61 cases per 100,000 persons [5][6][7] . It is the most frequent cause of surgical procedures performed by orthopaedic surgeons. The mean annual incidence of meniscal lesions is 0.066 %. There are more male patients (59,5%) undergoing an isolated meniscal repair compared with female patients (40,5%). This is the same compared with male patients (60%) undergoing a concomitant meniscal repair and anterior cruciate ligament. So most of the patients undergoing meniscal repair are males. [8][9] 

Football and rugby, followed by skiing, are the sports with an increased risk of acute meniscal injuries. Amongst injuries affecting the knee, it is suggested by Majewski et al (2006) that most involve the anterior cruciate ligament (ACL), the medial and lateral meniscus. In the same study it was also observed that 85% of patients with meniscal and ACL injuries require arthroscopic treatment [9].
In general, meniscal tears frequently occur in middle-aged and elderly patients and are caused by long term degeneration.

One third of the lesions in young patients are caused by sports-related injuries, because of the cutting or twisting movements, hyperextension or actions with great force. In more than 80%, meniscus tears are accompanied by anterior cruciate ligament (ACL) injury.

Meniscal lesions in children are different than those in adult patients. In children, more than 70% are isolated meniscal lesions caused most of the time by sport-related twisting of the knee. [10]

For degenerative meniscal tears, there is strong evidence that age (greater than 60 years,), gender (male), work-related kneeling and squatting and consistently climbing stairs of greater than 30 flights are risk factors for meniscal tears. There is also strong evidence that sitting for longer than 2 hours a dacey may reduce the risk of degenerative meniscal tears [11]. Barbara et al suggest that waiting more than 12 months between ACL injury and reconstructive surgery is a risk factor for developing a tear of the medial meniscus [12] [13].

Clinical Presentation[edit | edit source]

  • Joint line tenderness and effusion.
  • Complaints of 'clicking', 'locking' and 'giving way' are common.
  • Functionally unstable knee[14]A list of special tests for assessing knee stability can be found on the Physiopedia page of the Knee.
  • Symptoms are frequently more intense by flexing and loading the knee, with activities such as squatting and kneeling being poorly tolerated because of stiffness and pain [15]

Differential Diagnosis[edit | edit source]

  • Joint line tenderness may present a false positive as other diagnosis' may be; osteoarthritis, osteochondral defects, collateral ligament injury or fractures. [16] [17]Effusion may also occur when there are problems with the cruciate ligaments, bones or the articular cartilage.
  • Symptoms are frequently worsened by flexing and loading the knee; activities such as squatting and kneeling are poorly tolerated. But it’s the same with patients suffering from other pathologies like chondromalacia patellae, fractures and Sinding Larsen Johansson Syndrome.

• Complaints of 'clicking', 'locking' and 'giving way' are common. Patients also complain about ‘giving way' when there are suffering from anterior cruciate ligament injury. The feeling of instability and locking is also common with osteochondritis dessecans.

Diagnostic Tests and Procedures[edit | edit source]

When making a diagnosis, relevant patient history, physical examination, and appropriate imaging studies are required.[17] 

  • Joint line tenderness has been reported to be the best common test for meniscal injury [18]
  • McMurray's test positive if a pop or a snap at the joint line occurs while flexing and rotating the patient's knee.
  • Apley's test performed with the patient prone, and with the examiner hyper-flexing the knee and rotating the tibial plateau on the condyles.
  • Steinman's test performed on a supine patient by bringing the knee into flexion and rotating.
  • Ege's Test is performed with the patient squatting, an audible and palpable click is heard/felt over the area of the meniscus tear. The patient's feet are turned outwards to detect a medial meniscus tear, and turned inwards to detect a lateral meniscus tear.
  • Thessaly Test.
  • Meniscal Imaging is an essential tool in decision-making for surgical management of meniscus tears. Accurate imaging of the meniscus is essential to evaluate the damaged area and to select the most appropriate treatment. Imaging is also an important tool for postoperative management and treatment, follow up, and identification of any further injury. Currently, magnetic resonance imaging (MRI) scans are the preferred imaging technique. Other techniques are Radiography, Computed Tomography (CT) scan, Computed Tomography (CT) arthrography and Magnetic Resonance Arthrography. [3] 
    The advantages of MRI in the diagnosis of a meniscus lesion are: grade-I and grade-II tears are detected earlier, extra-articular structures are also visible, no radiation and MRI is a non-invasive imaging technique. [19] 

Grading of meniscal tears are as follows:

Grade I: Discrete central degeneration - an intra-meniscal lesion of increased signal without connection to the articular surface [22]

Grade II: Extensive central degeneration - a larger intra-meniscal area of increased signal intensity, again without connection to the articular surface. May be horizontal or linear in orientation [22]

Grade III: Meniscal tear - increased intra-meniscal signal intensity with contour disruption of articular surface. May be associated with displacement of meniscal fragments or superficial step formation [22]

Grade IV: Complex meniscal tear - multiple disruption of meniscal surfaces

The presence of tears in the red area versus the white areas of the meniscus is crucial as long term positive prognosis for the repair of tears is only good within the vascularized red areas.

Outcome measures[edit | edit source]

Medical Management[edit | edit source]

Indication for surgery[edit | edit source]

The decision as to whether a lesion is treated surgically or non-surgically is the first decision made after definitively diagnosing a meniscal tear.  

Other factors which may weigh into the decision of whether to operate include:

  1. Patients factors (e.g. age, co-morbidities and compliance)
  2. Tear characteristics (e.g. location of the tear, age of the tear and pattern of the tear) and the fact whether the tear is stable or unstable. When the tear is unstable surgery is necessary.[24] [25]

Definitive indications for surgery include a complete or large incomplete longitudinal tear of the media and lateral meniscus close to the base, large flap tear, so-called bucked-handle tear. [26]

It must be noted that nonoperative treatment is rarely successful in treating meniscal tears in young athletes and repair of the torn menisci is often required[17]

Degenerative or non-degenerative tears which are asymptomatic or stable are treated non-surgically, but treated surgically in symptomatic cases. [27] It has then to be determined whether a meniscal repair or a meniscectomy is appropriate. Where none of the normal surgical treatments are appropriate total meniscectomy is the option. The factors taken in consideration are:

  • The clinical evaluation
  • Related lesions
  • The exact type, location, and extent of the meniscal tear [28]  


Degenerative meniscal tissue. Unstable knee joint without concomitant surgical stabilization. Complex meniscal tears or radial tears, tear in the central avascular region, gonoarthrosis, joint infection and local skin disorders. [26] 

Tenuta JJ et al. also found that rim width is an important factor as no repair with a width greater than 4 mm healed.[29]

If a meniscal repair is performed with concomitant ACL reconstruction the success rate has reported to have been elevated in several studies [30][31][32][33]

Small, degenerative meniscal tears are often treated conservatively with rest, NSAIDS, reducing load bearing on the joint through activity modification and treating with physical therapy. Where a non-surgical approach is taken it is essential that a good level of strength is achieved and maintained in the affected leg and activities requiring pivoting or sudden changes of direction are avoided. If the tear is large, in a low vascularised region or if conservative management fails to alleviate the associated pain and joint dysfunction then surgery is the next step [34].

Repair of a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with concurrent Anterior Cruciate Ligament (ACL) reconstruction, and in younger patients. The probability of healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Numerous repair techniques are available.[24] Preservation of meniscal tissue is recommended, regardless of age - in active patients- whenever possible.[35] 
Meniscal tears amenable to repair include unstable tears > 1 cm in length and occurring in the outer 20% to 30% toward the periphery, or in the so-called red-red zone. Those tears occurring more toward the junction of the red-white zone may also heal, and the decision to repair should be made based on the clinician's judgment. Ideal candidates for repair are vertical, longitudinal tears occurring within 3 mm of the peripheral rim.

Outcome Measures[edit | edit source]

An overall meniscal repair success rate of 85-90% has been found by R.P.Walter et al. [35] 
Patients undergoing con concomitant anterior cruciate ligament reconstruction enjoyed significantly improved outcomes of meniscal repair. (91%), while those with a past history of anterior cra uciate ligament reconstruction had significantly worse meniscal repair success rate (63%). Bohnsack found a healing rate of 86-95%. The overall success rate for healing menisci with meniscal repair is high.[36] 
In most of the studies they took a second MRI to confirm whether the lesion is healed. A patient is considered as being healed when there is no lesion on the second MRI and the patient is able to resume his normal life/activities.

Locked bucket-handle, meniscal tears heal at a high rate when repaired as an isolated surgery; even when full weight bearing and activity before reconstruction is allowed and when the tear is in the white-on-white zone.[8] 
Age or time between injury and surgery don’t affect the amount of people that were healed by meniscal repair.[10] 

Surgical Techniques[edit | edit source]

The type of surgery employed is largely dependent on the type of tear and its location. The most common surgical lesion in the knee is a torn meniscus[19] [37] The goal of the surgery is to save as healthy tissue as possible.[35]

Long term, the surgical repair of the meniscus gives a better result than a partial meniscectomy. But the rehabilitation is longer.[36] This is something that the athlete must consider: whether he wants to resume the sport quickly or not. Meniscal repairs can be performed by open, inside-out, outside-in and all-inside techniques. But not all meniscus tears have the ability to heal, the meniscal tear pattern and the presence of adequate vascularity are both key. [38] 

Types of Surgical Repair[edit | edit source]

There are 4 types of surgical repair:

  1. Open
  2. Inside-out
  3. Outside-in
  4. All-inside.

Whether meniscus repair is carried out under arthroscopic visualization, as an inside-out, or outside-in or even the all-inside technique, some common steps, have to be followed. There have to be arthroscopic set-up, tear debridement and fixation. [39] For each operation they have to remove the loose parts, both surfaces of the tear should be sanded and the vascularity should be encouraged.[36]
The all-inside techniques are attractive because of the decrease in operative time and ease of the technique. Short-term results are positive for the all-inside technique; however, good long-term data on these techniques are lacking.[3] 

Patients who have repairs of peripheral meniscus tears are generally progressed more rapidly than those who have repairs of tears extending in the central one-third region or those who undergo meniscal transplantation. [24] 

The advantage of meniscectomy is that only the damaged tissue is removed. Important is that the circular collagen fibers may not be cut. [36][8] When that happens, the meniscus will lose his function as distributor of weight and then there is an increased risk of Osteoarthritis.
A disadvantage of meniscectomy is that there is a prolonged conservative aftercare. There needs to be a period of maximum prognosis to obtain the best possible healing.

Patients who have had an arthroscopic partial meniscectomy often initially experience knee swelling, pain, and loss of range of motion (ROM), and they may have increased joint laxity and osteoarthritis in the long term. [10]

Meniscal injuries are often accompanied by injuries to the anterior cruciate ligament, the collateral ligaments or the joint cartilage. [40][4] Such associated injuries also influence functional recovery after an arthroscopic meniscectomy. [17][24][35][3]

Open technique[edit | edit source]

This technique offers the advantage of better preparation of the tear side. However, only the most peripheral of tears in the red-red zone are amenable to this technique and the main disadvantage of this technique is the risk of neural damage. Nowadays this technique isn’t frequently used anymore.

The capsule is incised posterior to the collateral ligament and the synovium is opened to give direct access to the posterior segment of the meniscus and the tear, provided that it is a vertical peripheral longitudinal tear. In case of a horizontal tear, the meniscosynovial rim needs to be dissected in order to expose the peripheral meniscal rim and the horizontal cleavage. [39] [41] 

Inside-out technique[edit | edit source]

This technique has been used commonly for tears in the posterior horn or the body of the meniscus and the tears have to be in the red-red zone or in the red-white zone. [39][42][43] 
Absorbable or nonabsorbable 2-0 or 0 sutures are passed from inside the knee to a protected area on the outside of the joint capsule, using long flexible needles. The sutures are retrieved through an extra-articular posteromedial or posterolateral incision. The posterior neurovascular structures are protected with a large retractor. The knots are tied outside the joint over the capsule. [39][41] 
This technique has been considered the gold standard in meniscus repair because of the proven long term results, but there is still a risk of neurovascular complications. [39] [43][44] 

Outside-in technique[edit | edit source]

This technique is used in the anterior horn of the meniscus and was initially designed to decrease the risk of neurovascular complications. [39] [45] 
A cannulated 18-gauge spinal needle is passed across the tear from the outside-in. Once the sharp tip of the needle is in view, the suture is passed through the arthroscopic ipsilateral portal. An interference knot is tied in the end of the suture and the suture is pulled back. The process is repeated and the free ends are tied two by two over the capsule through an accessory skin incision until the tear is stabilised. Sutures may be placed alternately on the femoral and tibial surface of the meniscus in order to balance the repair. [39] 

All-inside technique[edit | edit source]

This technique can be used for repairing extreme posterior horn tears. All-inside repairs have been traditionally carried out using several devices, such as staples, tacks and screws. Most of these devices are bioabsorbable and composed of rigid poly-L-lactic acid (PLLA). [39] 
[38] [44] [46] 
The newest devices are the self-adjusting suture devices. They are based on the same principle as the other devices. An anchor is positioned behind the capsule and a suture compresses and holds the axial meniscal part by using a sliding knot. These implants share the potential ability to deform and move with the meniscus during weight bearing and carry a lower risk of chondral abrasion. The devices are RapidLoc, FasT-Fix and the Meniscal Cinch. [39] 
The advantages of all-inside repair include ease of use, avoidance of an accessory incision, shorter operation time, less risk to neurovascular structures and especially for the suture devices better strength. [39] 
[38] [46] 

Complications[edit | edit source]

Small et al. [47]studied the complications of 10,262 patients undergoing meniscal repair. Of the 10,262 patients 1,68% had complications. These complications were: Hemarthrosis, infection, thromboembolic disease, anesthetic complications, instrument failure, reflex sympathetic dystrophy, ligament injury, fracture and neurologic injuries. With hemarthrosis being the most common complication and neurologic injuries being least common. No vascular injuries were reported. And there was emphasized 7% incidence of saphenous neuropathy by Austin et al.[48] 

Physiotherapy Management[edit | edit source]

Pre-Operative[edit | edit source]

During the pre-operative phase of total knee replacement and anterior cruciate ligament reconstruction, it is proven that quadriceps strength training leads to improved knee function and a better quality of life after the operation.[10][40][4]
It is also proven that neuromuscular electrical stimulation improves quadriceps muscle strength in subjects with Knee Osteoarthritis Most patients who choose for meniscal repair are operated within a short period of time, because of that there is seldom pre-operative physical therapy. But if a quick operative intervention is not possible for any reason, we assume that quadriceps training is also beneficial for patients undergoing meniscal repair.

Neuromuscular electrical stimulation (NMES) causes muscle contraction by applying transcutaneous current to terminal branches of the motoneuron. In subjects with knee osteoarthritis, NMES can increase quadriceps strength and improve functional performance, and has been found to be as effective as exercise therapy. NMES has also a beneficial effect on muscle mass. Other benefits of the therapy are a reduction in postoperative muscle atrophy with exercise rehabilitation [49]

Pre-operative risk factors[edit | edit source]

Meniscectomy is a safe procedure even in older patients. However, regardless of age, patients with an increased comorbidity and those with a history of smoking are at increased risk of adverse events and/or readmission after the procedure.

Post-Operative[edit | edit source]

Supervised rehabilitation after surgery has been advocated and studied as part of short- and long-term follow-up after arthroscopic partial meniscectomy. [10]

The goal of rehabilitation is to restore patient’s function based on individual needs. It is important to consider the type of surgical procedure, which meniscus was repaired, the presence of coexisting knee pathology (particularly ligamentous laxity or articular cartilage degeneration), the type of Meniscus rupture, the patient's age, preoperative knee status (including time between injury and surgery), decreased range of motion or strength, and the patient's athletic expectations and motivations. [19][36][8]

Exercise has been suggested to be an efficient treatment for patients with knee degeneration in order to improve knee function and limit joint pain. There is strong evidence that physical training plays an important role in order to reduce symptoms, improve muscle strength and physical ability.[10]

In the first week after surgery rehabilitation treatment consists of a progressive loading with crutches. Early objectives after surgery are: control of pain and swelling, maximum knee range of motion (ROM) and a full weight bearing walking. There is no load limitation, with weight bearing being as tolerated by the patient.

In the subsequent 3 weeks the goal is to normalise gait and to increase knee ROM, led by the patient’s tolerance. Intensive muscle strengthening, proprioceptive and balance exercises are carried out around the third week.

Return to sport/activities is recommended only when the quadriceps’ muscle strength is at least 80% of the contralateral limb. Competitive level sport is, however, not recommended until muscle strength in the affected limb is at least 90%.

Patients generally return to work after 1 to 2 weeks, to sporting activities after 3 to 6 weeks and to competition after 5 to 8 weeks [50]

Phases of Rehabilitation[edit | edit source]

Phase 1: The Acute Phase (1-10 days post-op)

Goals are to decrease inflammation, restore the range of motion and the neuromuscular re-education of the quadriceps. Recommended exercises in the first phase are: long arc quadricep, short arc quadricep, hamstring curls (open chain exercises), cycling and leg presses (Closed chain exercises).

• Phase 2: The Subacute Phase (10 days-4 weeks post-op)

Goals are to restore muscle strength and endurance, to re-establish full and pain free ROM, a gradual return to functional activities and to minimise normal gait deviations. More concentric/eccentric exercises for the hip and the knee should be added to the open chain exercises from phase 1. Closed chain exercises in phase 2 could be resisted terminal knee extension, partial squats (not complete), step up/down progressions, toe raises, functional and agility training.

Phase 3: The Advanced Activity Phase (4-7 weeks post-op)

The goals of the final phase are to enhance muscle strength and endurance, maintain full ROM and a return to sports or full functional activities. This phase is based on progression to dynamic single leg stance, plyometrics, running, and sport specific training.

General points in the therapy:[edit | edit source]

  • Control the pain and inflammation - Cryotherapy, analgaesics, NSAIDs. As rehabilitation progresses, continued use of modalities may be required to control residual pain and swelling
  • Regain good knee control [10]
  • Restore ROM (Range of motion) [10]- ROM exercises within any limits in range that the consultant has requested [19]
    • Restore the flexibility [10]
    • Restore muscle function [10]- specific strengthening exercises including quadriceps (A medial meniscus lesion influences the strength of the M. Vastus medialis.[40]), hamstrings, calf, hip.
  • The exercise program should consist of both concentric and eccentric exercises to receive muscular hypertrophy as well as neuromuscular function. [10]
  • Optimize neuromuscular coordination - proprioceptive re-education
  • Progress weight bearing - weight bearing and joint stress are necessary to enhance the functionality of the meniscal repair so should be progressed as indicated by the consultant. Excessive shear forces may be disruptive and should be avoided initially.
  • After meniscectomy, rehabilitation protocol can be aggressive, because the knee joint anatomical structures should not be overly protected during the healing phase. The rehabilitative treatment consists of ice-ultrasound therapy, friction massage, joint mobilization, calf raises, steps-ups, extensor exercise and cycling.[51] Treatment under water cannot begin until the wounds have properly closed in order to prevent increased risk of infection.

The use of electromyographic biofeedback in the early stages of rehabilitation, after meniscal repair, helps patients to control their muscles. It can help accomplish physical activities that require better neuromuscular coordination and control. For these reasons one may consider electromyographic biofeedback as an important component of rehabilitation after meniscal repair. Electromyographic Biofeedback is not responsible for the degrees in pain, swelling, or other post-operative symptoms. This technique is a painless, non-invasive method that can be used in muscle recovery. This technique can be used in all phases of rehabilitation. [3] 

Physical exercise three times weekly during 4 months could lead to more than 35% improvement of knee function.[10] Any rehabilitation program should be written on the patient’s body, every patient is different and will react differently to the rehabilitation. The results are for a large part depended on the speed and exactness of how the diagnosis is confirmed.

Unresisted open chain exercises should be given to patients who underwent meniscal repair. Because the study of David L. et al. supports that it does not place undue stress on meniscal repairs.[36]

The findings of many studies support weight-bearing limitations during the initial 4 to 8 weeks after meniscal repair. In theory, weight bearing alone should not disrupt healing meniscal tissue, because the hoop stresses are primarily absorbed at the periphery of the meniscus. However, weight bearing in conjunction with tibiofemoral rotation during knee flexion, could produce shear forces capable of disrupting healing meniscal tissue.[4]
Standard ‘cookbook’ protocols should be avoided and individualized programs - based on the type of surgical procedure, which meniscus was repaired, the presence of coexisting knee pathology (ligamentous laxity or OA), meniscal tear type, the patient’s age, preoperative knee status (including the time between injury and surgery), loss of ROM and strength, and the patient’s athletic expectations and motivations – should be encouraged.
Accelerated meniscal repair rehabilitation programs that permit full knee ROM and full weight bearing are becoming more common, with return to full activity as early as 10 weeks after surgery.[4]

References[edit | edit source]

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