This document discusses meniscus repair, including indications for repair such as longitudinal tears less than 3 cm within the vascular zone of the meniscus. It describes techniques for meniscus repair including inside-out, outside-in, all-inside, and hybrid techniques. Postoperative rehabilitation involves immobilization and restricted weight bearing followed by progressive range of motion and strengthening exercises.

1. Meniscus Repair
Dr.Avik Sarkar
KB Bhabha Municipal General Hospital, Bandra (West), Mumbai

2. Indications
• any peripheral non-degenerative longitudinal tears < 3 cm
• if tear is w/in 3 mm of the periphery, it is considered vascular
• unstable tears or tears within vascular zone that are > 7 mm are
repairable
• mobile, single, vertical, longitudinal tear of the meniscus limited to
vascular outer one-third of the meniscal substance;

3. Relative Contraindications
• tears greater than 3 cm do not seem to heal, following surgery
• transverse tears, even in the periphery
• do not repair flap tears, radial tears, cleavage tears, or vertical tears
with secondary lesions that extend into avascular inner 2/3 of
meniscus, except in young teenagers
• ligamentous instability (w/ ACL insufficiency, the rate or re-tearing
approaches 40%, especially in younger active individuals, and
therefore ACL reconstruction should be performed at the same
surgery; )

4. Principle for Repair
• Stimulation of the healing potential and Stabilization of
the defect [1]
• Stimulation is accomplished by perimeniscal synovial
abrasion and/or fibrin clot placement.
• Stability can be present inherently
on the basis of incompleteness
(the tear not extending the full
thickness of the meniscus) or short
tear length and can also be
augmented by suture approximation, immobilization,
and postoperative non-weight bearing.
1.Newman A, Daniels A, Burks R. Principles and Decision Making in Meniscal Surgery. Arthroscopy: The Journal of
Arthroscopic and Related Surgery. 1993;9(1):33-51.

5. Decision for Meniscal Repair
• Restore Function
• Maintain Load transmission
• Minimize Contact Stress
• Contribute to Stability
• Chondroprotection – Reduce Articular
Cartilage Wear

6. Meniscal Repair versus Resection
L—Location from capsule <2 mm 0
2-3 mm 1
4-5 mm 2
A—Age <20 0
20-30 y 1
>30 y 2
S—Size ≤2 cm 0
2-4 cm 1
>4 cm 2
T—Tissue quality Excellent 0
Good 1
Fair 2
Qualifiers Unstable 2
Malalignment 1
Chondromalacia grade III 1
Radial tear 2
ACL reconstruction or
fibrin clot
−1
Repair is Indicated if score ≤4

7. Zones
According to Miller, Warner and Harner, Zones of the
Menisci are classified based on the amount of blood supply
to the area
•The “red-red zone” is located on the very outer edge of the meniscus and
receives the most blood.
•The “red-white” zone is located in the middle 1/3 of the meniscus at the
junction between the vascular and avascular portions of the meniscus.
•The “white-white” zone is the innermost aspect of the meniscus and comprises
the avascular portion.
The further out the lesion, the more likely the meniscus will
heal
Poulsen M, Johnson D. Meniscal injuries in the young, athletically active patient. The Physician and sportsmedicine.
2011;39(1):123-130. doi: 10.3810/psm.2011.02.1870.

8. Types
O'Connor classified the patterns of meniscal tears into the
following categories:
(1) longitudinal tears;
(2) horizontal tears;
(3) oblique tears;
(4) radial tears
(5) Variations / complex,
flap tears,
complex tears,
degenerative meniscal tears.

9. Tear Patterns and their potential
to repair
Tear Pattern Potential to Repair
Horizontal tear Irreparable
Longitudinal tear Reparable
Radial tear Potentially Reparable
Bucket-Handle tear Reparable
Oblique tear Irreparable
Complex tear Irreparable

10. Technique
Arthroscopic repair techniques can be
divided into four categories:
•Inside-Out repairs
•Outside-In repairs
•All-Inside repairs
•Hybrid repairs, which combine the
previous techniques

11. Techniques Indications
Outside-in sutures Anterior horn tears,
mid-third tears,
radial tears,
complex tears,
reduction of bucket-handle tears
Inside-out sutures Posterior horn tears,
mid-third tears,
displaced bucket-handle tears,
peripheral capsular tears,
meniscal allografts
Fixator implants (first-generation
devices)
Posterior horn tears,
tears with >2-3 mm rim width,
vertical/longitudinal tears
Suture-based devices (second-
generation devices)
Posterior horn tears,
tears with >2-3 mm rim width,
vertical/longitudinal tears
From Sgaglione NA: Instructional course 206. The biological treatment of focal articular cartilage lesions in the
knee: future trends? Arthroscopy 19:154, 2003.

12. Inside-Out Technique
• The inside-out technique can be done
with double-lumen or single-lumen
zone-specific repair cannulas, with
absorbable or nonabsorbable sutures.
• The technique is rendered safe with the
use of an incision for exposure of the
capsule and placement of retractors for
safe retrieval of suture needles.

13. Outside-In Technique
• The outside-in technique, as described by Morgan
and Casscells and Johnson, is most suitable for
repairs of the midthird and anterior third of the
meniscus.
• The technique can be used to pass single sutures
through the superior and inferior surfaces of the
meniscus to be retrieved anteriorly and tied in a
Mulberry knot. The sutures are tied over the capsule
laterally. Preferably, a single-loop suture is passed
in a mattress fashion through the meniscus and is
tied laterally.

14. All-Inside Technique
• the all-inside technique, as described by
Morgan, uses a posterior cannula and
Linvatec spectrum suture hook (Largo, Fla)
to pass the suture through the posterior horn
for tying all inside.
• This technique is limited to posterior
meniscal tears within 2 mm of the joint
capsule and can be difficult because of the
size of the cannula and passing of the needle
through the tight joint space.

15. • All-Inside Fixator Technique (First Generation)
Arrows
Staples
Biostingers
Darts
• All-Inside Fixator Technique (Second Generation)
FasT-Fix
RapidLoc
MaxFire
Cinch

16. Rehabilitation
• For isolated meniscal repairs in cruciate-stable knees, immobilize the knee in
full extension for 7 to 10 days and allow weight bearing with crutches.
• When a meniscal repair is done in combination with an anterior cruciate
ligament reconstruction (bone–patellar tendon–bone auto graft), the knee is
immobilized for 2 weeks in full extension with immediate weight bearing.
• Active range of motion from 0 to 90 degrees of flexion twice daily for 20 minutes
can be started immediately postoperatively.
• After 2 weeks, progressive range of motion, bicycling, and thigh-strengthening
exercises are begun.
• Weight bearing and range of motion should not be done at the same time,
however, until about 4 weeks after surgery.