Arthroscopy: The Journal of Arthroscopic and Related Surgery 9(1):33-51

Published by Raven Press, Ltd. 1993 Arthroscopy Association of North America

Principles and Decision Making in Meniscal Surgery

Alan P. Newman, M.D., A. U. Daniels, Ph.D., and Robert T. Burks, M.D.

Summary: This article provides a review of the basic science and clinical intbrmation available to the orthopedist on which a systematic approach to meniscal surgery can be based. Attitudes toward the meniscus have changed
dramatically in the last 50 years. Laboratory investigations show that the menisci participate in many important functions, including tibiofemoral load
transmission, shock absorption, lubrication, and passive stabilization of the
knee joint. Histologic/structural analyses reveal the menisci to be annular
structures, with the ability to transmit and properly distribute load over the
tibial plateau, primarily facilitated by the circumferential collagen fibers in the
peripheral third of the meniscus, in conjunction with their strong bony attachments at the anterior and posterior horns. Biologic studies demonstrate that
meniscal healing can occur through two pathways: an intrinsic ability of the
meniscal fibrochondrocyte to migrate, proliferate, and synthesize matrix (provided they are given the proper environment), and extrinsic stimulation
through neovascularization (when the meniscal injury occurs in the vascular
periphery). This review makes it clear that the menisci are essential components of the normal knee, and that techniques intended to preserve the menisci
are both possible and mandatory. As evidence has accumulated from both
animal and clinical studies of the frequent development of degenerative
changes following meniscectomy, surgeons have become increasingly aggressive in their efforts to conserve as much meniscal tissue as possible. Current
approaches to treatment of meniscal tears are based on a thorough understanding of meniscal structure, biology, and function, as well as familiarity with the
basic principles of meniscal repair and resection. To synthesize these principles, the article concludes with an algorithm intended to guide surgeons in
decision making when faced with a variety of meniscal lesions in different
clinical situations. Key Words: Meniscus--Meniscal healing--Meniscal function--Meniscal" repair--Meniscectomy.

Over the last 50 years, attitudes toward the menisci have evolved gradually from a perception of
them as inconsequential, functionless structures (I)
to the view that they are vital, integral components
of normal knee function. L a b o r a t o r y investigations
have shown that the menisci participate in many
important functions, including tibiofemoral load

transmission (2-6), shock absorption (7,8), lubrication (9), and passive stabilization (10,11) of the knee
joint. Both animal (12-14) and clinical (15-19) studies have d o c u m e n t e d the frequent development o f
degenerative changes within the knee following
meniscectomy.
This evidence of the importance of the menisci
has led clinicians to adopt an increasingly conservative approach to meniscal lesions, with the goal
literally to conserve as much meniscal tissue as possible. Partial meniscectomy (20-22) has replaced
complete excision as the treatment of choice for
most meniscal tears. Interest has been rekindled in
the topic of meniscal repair (23-32), and research

From the Division of Orthopedic Surgery, University of Utah

School Of Medicine, Salt Lake City, Utah, U.S.A.
Address correspondence and reprint requests to Alan P.
Newman, M.D., Division of Orthopedic Surgery, University of
Utah School of Medicine, 50 N. Medical Drive, Salt Lake City,
UT 94132, U.S.A.

33

34

A. P. N E W M A N E T A L .

efforts are under way to make meniscal replacement (either prosthetic; allograft, 33-36; or tendon
autograft, 37) a clinically useful procedure.
When faced with a spectrum of treatment options, it is important to base the management of a
particular meniscal lesion on fundamental biological
and mechanical principles. Subsequent sections of
this article cover meniscal nomenclature, mechanical and biological principles, and principles of repair and resection. In the final section we will
present a logical approach to decision making in the
diagnosis and treatment of meniscal injuries, based
on these principles.
STRUCTURE
Both menisci are a p p r o x i m a t e l y C-shaped
("semilunar") structures, with direct bony attachments to the tibia at the anterior and posterior horns
(Fig. 1). These attachments, in conjunction with the
collagen fibers in the peripheral third of the meniscus, are important for the generation of hoop
stresses (38) and are critical to the role the menisci
play in load transmission. The most peripheral aspect of the meniscus is the meniscosynovial junction, which extends from the anterior to the posterior horns. This is a transitional zone, with the
deeper collagenous tissue gradually shifting from
meniscal to capsular. The perimeniscai capillary
LAanlet,rtellnnwlal

_h I n r - f i n n

plexus (23,39,40) enters the meniscus through the

fringe of synovium covering this region and pro-.
vides vascularity to the peripheral 25-33% of the
meniscus (24,39,41).
The collagen in the central two thirds is a combination of radial (transverse) and circumferential fibers (38,42), while the peripheral one third has a
predominance of circumferential fibers. Some of
the transverse fibers act as "tie fibers" (42) between the circumferential bundles, resisting longitudinal splitting. The orientation of these fibers is
responsible for the tendency of menisci to tear with
rotational forces. Rotation (especially when augmented by axial compression, 43) can squeeze the
meniscus between the tibia and femur, generating
tensile forces in the body of the meniscus high
enough to damage either the transverse fibers (resulting in a longitudinal tear) or the circumferential
fibers (resulting in a radial tear).
The superior !femoral) and inferior (tibial) portions of both menisci are split into two lamina by a
collection of horizontally oriented (parallel to the
tibial plateau) fibers called "the middle perforating
bundle" (44,45), which traverses the inner two
thirds of the meniscus. Because the frictional forces
applied by the articular surfaces during flexionextension and axial rotation cause differential motion in the superior and inferior halves of the meniscus, a horizontally oriented plane of increased
shear stress appears, corresponding to the location
of the middle perforating bundle (46). Axial compression also results in generation of a shearing motion between the upper and lower lamina (43). This
region is essentially avascular with a weak healing
potential, and over time the shear stress can produce a degenerative horizontal cleavage along this
plane.
NOMENCLATURE

FIG. 1. Medial and lateral menisci. They are both attached peripherally through the meniscosynovial junction, and at their anterior and posterior extents through their respective horns. The
lateral meniscus is more circular (with the anterior horn attachment relatively more posteriorly) and wider than the medial meniscus. The meniscosynovial junction is the region where the
perimeniscal capillary plexus enters the body of the meniscus.

Arthroscopy, Vol. 9, No. l, 1993

Meniscal tears are specified by their plane of rupture, direction of propagation, location within the
meniscus, and shape. To improve communication
about different types of tears, as well as to facilitate
clinical documentation of tear patterns, Cooper et
al. (47,48) have devised a classification system for
the location of meniscal tears (Fig. 2). Each meniscus is divided into three radial zones (from anterior
to posterior) and four circumferential zones, including the meniscosynovial junction (from the peripheral attachment to the central free edge). Utilization

P R I N C I P L E S A N D DECISION M A K I N G I N M E N I S C A L S U R G E R Y
Anterior
C

i
,,K,,

FIG. 2. Zone classification of the meniscus (modified from Cooper et al., 47). The most anterior zone of the medial meniscus is
lettered C, while the most anterior zone of the lateral meniscus is
D. Zero is the meniscosynovial junction, while I is the outer
third, 2 the middle third, and 3 the inner third of each meniscus.

of this system should permit standardization of descriptions of meniscal tear locations.

Meniscal tears are also commonly defined according to the plane of rupture relative to the tibial
plateau (Fig. 3), either horizontal (parallel to the
plateau, Fig. 3A) or vertical (perpendicular to the
plateau). Vertical tears that travel directly in a radial direction from the central edge toward the meniscosynovial junction are called radial (or transverse) tears (Fig. 3B), while those that propagate
circumferentially along the anteroposterior extent
are termed longitudinal (Fig. 3C). Oblique vertical
tears also occur, travelling in a plane that is neither
circumferential nor radial. Vertical tears can also be
categorized as full-thickness (extending from the
tibial through to the femoral surface) and partialthickness lesions. Some common tear patterns have
been given specific descriptive names, such as
bucket-handle tears (Fig. 3D) and parrot-beak (or
flap) tears (Fig. 3E). Complex meniscal tears are
comprised of two or more tear patterns and are described by combining the terms provided earlier.
MECHANICAL PRINCIPLES
King (12) in 1936 was one of the first to document
experimentally the protective function of menisci
by demonstrating the degenerative changes that occurred in the canine stifle after meniscectomy. The
changes on the tibial articular surface developed
quickly and were proportional to the amount of me-

35

niscal tissue removed. More than 40 years later,

Cox et al. (13), in another canine study, verified
many of King's findings.
One of the first indications of the importance of
the meniscus in the human knee was provided by
Fairbank (15) in 1948. He described "adaptive" radiographic changes (formation of an anteriorposterior ridge, flattening at the margin of the femoral condyle, and narrowing of the cartilage space)
that occurred subsequent to meniscectomy and
speculated that these may predispose to degenerative arthritis. He hypothesized that the meniscus
must function as a load-bearing element in the knee,
accomplished by the generation of circumferential
tension within the collagenous fibers of the meniscus. Fairbank (15) believed that these fibers, much
like the metal hoops encircling a barrel, resisted the
extrusive forces on the meniscus during progressive
loading of the knee. Bullough et al. (42) and Aspden
et al. (49) supported this hypothesis by determining
that the principal orientation of collagen fibers
within the meniscal periphery was indeed circumferential. Since the menisci are not true annuli, the
circumferential fibers terminate in strong bony attachments at the anterior and posterior horns,
rather than on each other in a circular fashion.
Analysis of clinical results following complete
meniscectomy provides further evidence that these
hypotheses are correct. While earlier studies (50,51)
demonstrated excellent short-term results after
complete meniscectomy, subsequent authors (16-19,52) showed that these results tended to deteriorate over time. Patients had increasingly symptomatic and radiographically evident degenerative
changes with longer follow-up observation.
The menisci are now recognized to serve many
roles in the knee joint. These include passive stabilization, increased congruity, shock absorption, lubrication, prevention of synovial impingement, limitation of extremes of flexion and extension, increased contact area, and reduced contact stress. It
is believed, however, that their protective function
is conferred primarily by their ability to transmit
and properly distribute load over the tibial plateau.
This has been supported by numerous laboratory
studies.
Both menisci are contained within the contact
area between the femur and the tibia (2,3,53-55).
Following meniscectomy, total contact area significantly decreases (2,53,54,56), often by a factor of
two to three. Direct analyses (4,57,58) of compres-

Arthroscopy, Vol. 9,.No. 1, 1993

36

A. P. N E W M A N E T AL.

3A-C

)
3D,E

(
sire load displacements show that the medial meniscus facilitates transmission of 40-50% of the load
in the medial compartment, whereas the lateral meniscus may transmit as much as 65-75% of the load
on the lateral side. Kurosawa et al. (2) and Newman
et al. (59) further noted from dynamic loaddeformation data that the elastic energy stored in
the intact knee was significantly greater than in the
knee without menisci. These latter studies suggest
that in the intact knee, less energy is dissipated in
potentially destructive ways.
The menisci help to transmit and distribute load
over the tibial plateau by increasing the area of contact through which this load is transmitted, and this
contributes significantly to diminishing the peak
contact stresses seen by the articular cartilage. In
laboratory studies after meniscectomy, both indirect calculations (2,4,5,55) and direct measurements (54,56) of the average stress on the tibial ar-

Arthroscopy, VoL 9, No. 1, 1993

FIG. 3. Types of meniscal tears. A: Horizontal. B: Vertical: radial. C: Vertical:

longitudinal. D: Bucket handle. E: Flap.

ticular cartilage demonstrate that the area over

which pressure is distributed is significantly reduced. Within this area the peak pressures are
markedly increased, usually by more than a factor
of two. Interestingly, a torn meniscus may continue
to facilitate load transmission, provided the fragments remain in the normal position (55). This has
been shown in the laboratory for vertical longitudinal tears (22,55,56,60) and stable horizontal tears
(55,61).
The menisci also act as spacers (14,59,62), separating the tibia and femur at low loads. Initial tibiofemoral contact is thus through the structurally
more compliant meniscus, with direct tibiofemoral
contact (through the stiffer articular cartilage) occurring only at higher loads. This allows the intact
joint to be more compliant. The effect of the meniscus in the intact joint, through its improved energyhandling characteristics and overall decreased stiff-

P R I N C I P L E S A N D DECISION M A K I N G I N M E N I S C A L S U R G E R Y

ness, is to decrease the magnitude of vertical impulse loads encountered during walking, running,
jumping, and many other activities.
These intra-articular effects are mirrored by
changes in the mechanical behavior of the composite joint. Structural studies (2,59) confirm that the
compressive stiffness of postmeniscectomy joints is
increased relative to the intact knee. Alterations in
the internal architecture of the distal femur and
proximal tibia are to be expected as a consequence
of changes in the biomechanical stresses and functional demands on these tissues. Odgaard et al. (63)
reported an increase in the trabecular bone density
in the proximal medial tibia after medial meniscectomy, with more marked increases after complete
excision than following a partial meniscectomy.
Bourne et al. (64) demonstrated that in response to
the area of tibiofemoral contact shrinking and moving centrally after medial meniscectomy, the cortical strain in the medial tibia decreased proximally
and increased distally. Radin and Rose (65) introduced the concept of increased stiffness of the subchondral bone as possibly playing an important role
in the initiation and progression of articular cartilage damage. The increase in articular cartilage
peak stress and impulse loading, along with alterations in the strain pattern within the proximal tibia,
may directly be responsible for the increased articular wear and premature degeneration seen following meniscectomy.
Although the more central portion of the meniscus is of some importance in increasing the contact
area between the tibia and femur,, the integrity of

37

the circumferential collagen fibers (primarily located in the peripheral third) is essential for fulfilling the function of load transmission. As long as the
hoop stresses of the meniscal rim are maintained by
intact peripheral circumferential fibers, much of the
axial load is still borne by the anterior horn-collagen
fiber-posterior horn system (66). Seedhom and Hargreaves (55) found that the peripheral meniscal rim,
after excision of a bucket-handle segment, transmitted the same load as when the meniscus was intact
in some specimens, while in others it still transmitted a significant (although reduced) proportion of
the load. Radin et al. (22) reported only modest increases in stresses in the medial tibial plateau and
femoral condyle after removal of the central two
thirds of the medial meniscus, when compared to
the effect of a complete meniscectomy. Baratz et al.
(60) demonstrated that the contact stress on the articular cartilage tended to increase in direct proportion to the amount of meniscus removed.
The importance of the meniscal periphery in load
transmission is mirrored in its contribution to passive stability. The menisci (particularly the medial)
are secondary restraints to anterior translation, becoming more important in anterior cruciate deficiency (11,67,68). Shoemaker and Markolf (67)
showed that the peripheral third of the meniscus
(and its rim) provide the majority of that restraining
function. Thus, preservation of the peripheral zones
of the meniscus is functionally more important than
the central zones.
Grood (62) described two types of partial meniscectomies: a segmental meniscectomy (Fig. 4A, in-

4A,B

FIG. 4. Type of partial meniscectomies. A: Segmental meniscectomy: removing the entire width of
the meniscus, from the central
edge to the peripheral rim. B: Circumferential meniscectomy--removal of some length of the more
central portion of the meniscus,
leaving the peripheral portion intact.

Arthroscopy, Vol. 9, No. 1, 1993

38

A. P. N E W M A N E T A L .

volving the entire width of meniscus out to the capsular rim), and a circumferential meniscectomy
(Fig. 4B, which involves some length of the central
portion of the meniscus). A circumferential meniscectomy retains load transmission properties, the
extent of which is proportional to the width of peripheral meniscus retained, while a segmental meniscectomy destroys the ability to transmit load.
BIOLOGICAL PRINCIPLES
Interest in the ability of the meniscus to heal has
been sparked by laboratory studies documenting
the rich perimeniscal capillary plexus that supplies
the outer 25-33% of both menisci (Fig. 5) in adults
(39,47). The plexus penetrates relatively further
into the meniscal substance at both the anterior and
posterior horns and is a less prominent feature in
front of the popliteus tendon hiatus. Clark and Ogden (69) have shown that in young children virtually
the entire meniscus may be vascularized, and this
vascularity recedes with age.
There are two general pathways through which
meniscal healing can occur. The extrinsic pathway
is activated when the meniscus is injured within the
peripheral vascular region. A fibrin clot is formed
that acts as a scaffold for proliferation of the capillary plexus, attracting undifferentiated mesenchymal cells from the outside along with the nutrients

FIG. 5. Penetration of the perimeniscal capillary plexus to provide vascularity to the peripheral 25-33% of the meniscus. Although the plexus runs uninterrupted around the periphery of the
medial meniscus, there is a small segment of the lateral meniscus
(in front of the popliteus hiatus) that is not supplied by the
plexus.
Arthroscopy, Vol. 9, No. 1, 1993

necessary to accomplish healing (47,70). This fibrovascular tissue seals the defect and promotes
further neovascularization. Animal studies (23,24,
41,71) have confirmed that lesions that occur in this
vascular region of the meniscus do have the biologic
potential to heal.
Neovascularization can be stimulated by synovial
abrasion (30,31,72-74), creation of vascular access
channels (23,31), or excision of the peripheral rim
(28,31) (which allows apposition of a relatively
avascular central fragment with the synovial bed).
The increased healing rate seen in conjunction with
vascular access channels is under some question
(31), and some types of access channels may actually damage the important circumferential collagen
bundles they traverse. Excision of the peripheral
rim pulls the residual meniscus peripherally, leading
to a decrease in the width and cross-sectional area
of the meniscus. This also delays meniscal contact
with the femoral condyle (3 I) until higher joint loads
are reached. Thus, abrasion of the synovial fringe at
the meniscal periphery is by far the most widely
accepted clinical method of inducing neovascularization.
The second pathway is intrinsic to the meniscal
chondrocytes, and requires unlocking the inherent
capability of meniscal chondrocytes, even in the
avascular central region, to generate an adequate
healing response. Webber et al. (75,76) (in cell culture experiments) and Arnoczky et al. (70) (in animal studies) have both shown that these cells can
proliferate and synthesize matrix, without a blood
supply, if they are provided with the proper environment. Work is still under way to define precisely
the correct environment, but the fibrin clot (70,74)
appears to possess the requisite ingredients to nurture this intrinsic meniscal healing. It is thought that
the clot not only acts as a scaffold, but provides the
chemotactic and mitogenic stimuli (including platelet-derived growth factor and fibronectin) necessary
to support the requisite cellular response (47,70).
These factors probably entice synovial cells and migrating peripheral blood elements into the ~epair
site, but the cell culture experiments (75) imply that
the meniscal fibrochondrocyte itself is capable of
migrating from the surrounding matrix into an exogenous fibrin clot.
The need to provide extra stimulation to the tear
site is related to the inherent healing potential of
any tear. The more centrally a tear is located (the
further from the vascular periphery), the more we
need to add to the system to ensure an adequate

P R I N C I P L E S A N D DECISION M A K I N G I N M E N I S C A L S U R G E R Y

t Attempts
to I
~timu!,ate,I

"Distancefrom
I,, periphery I
FIG. 6. The further a tear is located from the vascular periphery,
the more we need to add to the system (synovial abrasion, fibrin
clo0 to stimulate the healing potential,

biological environment for healing (Fig. 6). This has

been recognized by clinicians, who have based their
decision to repair a particular meniscal lesion on
where the tear is located (47). Both red-red lesions
(peripheral detachments with vascular tissue on
both sides of the tear) and red-white lesions (vascular tissue on the capsular side and avascular tissue on the central side of the lesion) should heal,
provided adequate stability is achieved. A whitewhite lesion (completely within the avascular region) probably will not heal, unless stimulated sufficiently by synovial abrasion, use of a fibrin clot,
etc.
These concepts have greatly improved the results
of meniscal repair. Henning et al. provided the best
documentation of a large series of meniscal tears
and assessed the influence of a variety of methods
to stimulate healing. In a series (31) of predominantly longitudinal tears, they demonstrated a failure rate of meniscal healing of 9% when perimeniscal synovial abrasion was utilized, versus 22% failures without abrasion. In a subsequent review (77)
of 153 meniscal repairs, many of them in difficult
lesions (including radial, flap, and horizontal tears),
the failure rate was only 8% when an exogenous
fibrin clot was utilized, compared to a rate of 41%
with abrasion alone.
REPAIR PRINCIPLES
We often discuss the "repairability" of a particular meniscal lesion as if that was the only pertinent
factor to consider, when that only addresses one of
three important issues. Repairability is a question of
technique; do we possess the requisite surgical
skills to successfully coapt the edges of a meniscal
tear? A more fundamental question is that of the

39

healing potential, which is a question of biology

based on access to a vascular supply or stimulation
of the intrinsic pathway; does this particular tear
possess the ability to heal, given the proper environment? Finally, the most important question of
all concerns functional restoration, a question of
biomechanics; given the ability to repair and the
potential to heal, will this meniscus regain proper
mechanical function, after healing has occurred? If
the answer to the final question is no, then the answers to the first two are academic. In general,
there are two methods available to answer the question of functional restoration: laboratory studies
documenting restoration of mechanical function, or
long-term clinical studies documenting the prevention of the articular cartilage changes that occur after meniscectomy.
It is now accepted that in most clinical settings,
longitudinal tears in the vascular periphery of either
meniscus should be repaired. These have been
shown not only to heal in a high proportion of cases,
but animal studies (71) have demonstrated retention
of mechanical properties of load transmission. Recent long-term clinical studies have proven that the
protective effect of the meniscus is preserved following repair. DeHaven et al. (78) reported on a
series of 80 meniscal repairs with a 2-9 year followup time (average, 4.6 years) and documented a retear rate of 11%. Furthermore, they obtained
weight-bearing radiographs in 41 successful repairs
and found 40 of 41 medial compartments were normal. In another study, Sommerlath (79) reviewed a
matched pair of meniscal repairs and meniscectomies, with 50 patients in each group, at an average
follow-up time of 7 years (range, 6-9 years). She
found better overall knee function and radiographic
appearance after repair.
Questions still remain regarding the clinical efficacy of repairing tears outside this region. Although
the potential for healing can be extended thOughout virtually the entire meniscus by stimulation of
either the intrinsic or extrinsic pathway (30,77), it is
not known whether mechanical function is preserved in all these healed meniscal lesions. Healing
of radial lesions has been shown to occur in both
human studies and animal models. However, function was not retained in one animal study (71), and
the clinical series are too short to document maintenance of the protective function of the meniscus.
The conditions necessary to promote healing of a
meniscal lesion are similar to those that are fundamental to the repair of any of the musculoskeletal
Arthroscopy, Vol. 9, No. 1, 1993

40

A. P. N E W M A N ET AL.

tissues: stimulation of the healing potential and stabilization of the defect. Stimulation was discussed
in the preceding section and is generally 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. Stability can also be augmented
by suture approximation, immobilization, and postoperative non-weight bearing. Zhongnan et al. (80)
observed that external immobilization following
meniscal repair in rabbits was more important than
suturing. However, other canine studies (23,71)
have achieved 100% healing rates simply by suturing the meniscal tears, without postoperative immobilization or restriction of weight bearing. In general, the less inherent stability a tear possesses, the
more we need to add to the system (suturing, immobilization, etc.) to make it stable (Fig. 7).
If the meniscal repair is performed in the absence
of associated ligament surgery, some amount of
joint immobilization is usually employed. The suggested position of immobilization is 20 flexion,
since the posterior capsule is more closely applied
to the back of the meniscus in this position, relaxing
the sutures (27). The consensus is that most (isolated) meniscal repairs should be held immobile and
non-weight bearing for 4-6 weeks. However, there
are some reports (27,32) of decreased knee motion
(both flexion and extension) following meniscal repair, so many are now advocating more liberal protocols that allow early motion (74,78). Morgan and
Casscells (72) suggest immediate weight bearing in
full extension. Certainly, these early functional approaches demand suture techniques that confer adequate stability to the repair site without the addi-

Needto
stabilize[

Inherentstability I
partial tear
short tear

FIG. 7. The more stable a tear is inherently (partial or short

tear), the less we need to do to add stability (in terms of suture
fixation, immobilization, etc.).

Arthroscopy, Vol. 9, No. I, t993

tional protection of immobilization and/or nonweight bearing for extended periods. A return to
athletic endeavors (specifically, cutting and twisting
activities) is deferred for a minimum of 4 but more
commonly 6 months (78).
If a major ligamentous procedure is carried out
simultaneously with the meniscal repair and adequate meniscal stability is achieved by suture placement, then immobilization of the knee is abandoned
or minimized in favor of early motion for the joint
(47,48,78,81). The risk of stiffness after the ligament
reconstruction far outweighs the potential for failure of the meniscal repair, as the postoperative
hemarthrosis probably increases the likelihood of
meniscal healing (47). Buseck and Noyes (81), in a
series of anterior cruciate ligament (ACL) reconstructions with meniscal repairs managed by immediate postoperative motion, found only 6% of menisci failed to heal.
Another question to consider is what constitutes
the minimum size tear to warrant a surgical repair.
Some acute longitudinal tears under 1 cm may heal
spontaneously or go on to become asymptomatic
even in the absence of healing (82). It is the inherent
stability of these tears that results in neither extension of the tear nor symptoms. The treatment of
partial tears hinges on the same concept: stability.
If a partial-thickness tear is deemed unstable by
manual probing, then it requires treatment: either
resection or repair. If it is short enough to possess
inherent stability, it can be left alone.
Some controversy exists regarding the other end
of the length spectrum: what is the maximum length
tear that should be repaired? Most authors (30,77,
81,83) have stated that the length of a tear did not
influence the rate of healing. However, Stone and
VanWinkle (84) reported two failures in a series of
16 repairs, and both were in displaced buckethandle tears greater than 40 mm long. There may
have been other reasons for these failures (age of
tear, difficulty stabilizing the tear, malreduction of
deformed bucket-handle fragment, etc.). Clearly, if
a long tear is to be repaired, extra care must be
given to the proper stabilization (immobilization
along with sutures on both the femoral and tibial
sides, if repaired with horizontal mattress sutures)
and stimulation (use of a fibrin clot and/or synovial
abrasion).
The influence of the age of a tear on healing rates
has been evaluated by a number of investigators.
Buseck and Noyes (81), Scott et al. (30), and Barber
(85) did not observe any correlation between chro-

PRINCIPLES AND DECISION MAKING IN MENISCAL SURGERY

nicity and failure to heal. However, Henning et al.

(77), Cooper et al. (47), and Stone et al. (83) all
demonstrated higher healing rates in acute tears.
Henning et al. commented that this may have been
due to an increased number of complex tears in the
delayed group, as well as possible changes in the
histologic characteristics at the surface of the
chronic tear (77). Stone and Miller (86) have observed that fewer chronic tears may be amenable to
repair simply because of deformation of the fragments as well as secondary tearing, which may render either the fragment or the peripheral rim unsuitable for repair.
Most series (30,77,83) of meniscal repairs have
shown no effect of age of the patient on healing
rates, which is somewhat surprising in view of the
anatomic observation of receding meniscal vascularity with advancing age. Of more clinical relevance is the fact that there are generally fewer repairable tears in the older population due to the
presence of more horizontal degeneration and a different spectrum of tear patterns.
A special consideration is the presence of a "repairable" meniscal lesion in an anterior cruciatedeficient knee. The published studies (26,27,48,78,
85) document that the healing rates are lower and
the retear rates are higher when meniscal repair is
carried out in the unstable knee. The explanation
for this may be that the medial meniscus becomes a
significant restraint to anterior translation in the
ACL-deficient knee (11) and thus is more exposed
to higher, potentially injurious stresses than it is in
a stable knee. However, the situation may not be as
simple as the presence of a fu~actional ACL. Cooper
et al. (47) have observed a lower failure rate (5%)
following meniscal repair done at the time of ACL
reconstruction than in knees with an intact ACL
(23%). This difference may be due in part to the
large hemarthrosis that occurs after ACL reconstruction, effectively providing abundant stimulation to the repaired meniscal tissue.
Although the twin goals of stability and stimulation can be achieved by either open or arthroscopic
techniques, the methods most often employed are
arthroscopic. The surgical morbidity is generally
lower, suture placement is precise, and some tears
(more centrally located) are amenable to arthroscopic repair that could not be reached by open
methods. Advocates of open techniques point out
that for suitable lesions (within 2 mm of the meniscosynovial junction) open methods have proven to
be safe and effective, with a very low morbidity

41

(87). Open techniques include a small incision in the

posterior corner of the joint (posterior to the medial
collateral ligament medially and posterior to the
popliteus tendon laterally), preparation of the repair
site, and placement of either vertical (25,78) or horizontal (26) mattress sutures.
There are a variety of arthroscopic techniques,
divided generically into " o u t s i d e - i n , " "insideout," and combined open-arthroscopic approaches.
In general, the reason for the proliferation of different techniques has been the desire to find better
ways to avoid the potentially disastrous neurovascular complications that can occur with this procedure (77,88,89). The " i n s i d e - o u t " techniques
(27,85), in which needles are passed under arthroscopic visualization through both of the meniscal
fragments and then out the joint to exit percutaneously, were developed first. Because of a low but
troublesome rate of neurovascular complications
(86,88), most authors now advocate combining this
approach with adequate posteromedial or posterolateral incisions to assure safe passage of the needles.
The "outside-in" approaches (48,72,90) all share
in common the utilization of spinal needles to pass
percutaneous sutures in the opposite direction:
from outside the joint to inside, transfixing the meniscus tear with the needle under arthroscopic visualization. This technique allows safe passage of
the needles based on knowledge of certain anatomic
landmarks (e.g., on the lateral side, the site of needle entry is anterior to the biceps femoris tendon to
avoid the common peroneal nerve).
Henning (30,31,74,77) and others (73,86) have advanced the concept of the combined approach, in
which an open posterior corner dissection is carried
out and a popliteal retractor is placed deep in this
incision to protect the important neurovascular
structures from damage by the sutures, which are
placed with "inside-out" needles. A joint distractor
(30,74,77), although not necessary, is occasionally
employed with this method, using transosseous tibial and femoral pins.
Common to all these techniques is placement of
mattress sutures (usually horizontal or, less typically, vertical) that approximate the two surf'aces of
the torn meniscus. On the medial side the sutures
must be passed with the knee close to full extension
(48,72,88,90) to prevent obliteration of the deep recess between the posterior capsular wall and meniscus (present in flexion), which can limit extension. This also allows the needles to pass posterior
Arthroscopy, VoL 9, No. 1, 1993

42

A . P. N E W M A N E T A L .

to the sartorial branch of the saphenous nerve. On

the lateral side, the knee should be in flexion (27,
48,88) (toward 90 ) so that the needles pass anterior
to the biceps tendon.
There is much divergence of opinion with regard
to the type of suture employed. Many advocate a
nonabsorbable material, with the belief that absorbable sutures degrade too rapidly compared to the
slow time frame of meniscal healing. Barber and
Gurwitz (91) tested the breaking strength of various
suture materials implanted in rabbit knees. Polyglactin-910 (Vicryl) and polyglycolic acid (Dexon)
retained only minimal strength 3 weeks after implantation, while polydioxanone retained 40%
and braided polyester (Mersilene) virtually 100%
strength at 5 weeks after implantation. However,
others contend that the nonabsorbable sutures may
scuff the articular surfaces, and that the meniscal
"puckering" that occurs after suture placement
may cause permanent deformation. Therefore,
most advocate use of an absorbable suture, although one that will have adequate tensile strength
for at least 6 weeks.
Kohn et al. (37) analyzed the initial strength of
various meniscal suturing techniques in an in vitro
study. They demonstrated that a vertical mattress
suture is stronger than a horizontal mattress, as
more collagen fibers are contained within the loop,
and suggested this technique for open repairs. In
regard to the two most common arthroscopic methods of suture placement, they found that horizontal
mattress sutures had higher tearing stresses than
the knot-end technique described originally by Warren (90), and later by Morgan and Casscells (72).

junction; and whenever unsure, leave more meniscus than less.

To avoid removal of excess meniscal tissue, a
careful, progressive resection is carried out. First,
the major, mobile fragment is removed. Next, the
residual meniscus is inspected and probed to identify any unstable or hypermobile segments. This sequence of inspection, resection, and inspection is
continued until the objective of balancing is
achieved (93). A helpful guide is to visualize an
imaginary line on the tibial surface (94), corresponding to where the inner, central edge of the
normal meniscus (Fig. 8) can typically be translated. Further resection is necessary if the remaining meniscal tissue can be pulled centrally into the
area normally excluded to the meniscus, where it
can be caught between the femur and tibia during
axial rotation and retear. An alternative method of
envisioning meniscal stability is to reference the
meniscus relative to the femoral condyle. If part of
the meniscus can b~ pulled in front of the lowest,
most central portion of the femoral condyle, partial
meniscectomy is indicated. It is also important to
allow for the normally increased mobility of the lateral compared to the medial meniscus.
The distinction between stable and unstable meniscal tissue is a critical one. Recognizing that a
stable tear pattern can continue to function mechanically should make surgeons cautious about removing too much meniscus. To err in the direction of
leaving unstable tissue in place is also harmful. Displaceable fragments can not only cause persistent
.............

RESECTION PRINCIPLES
The goal of partial meniscectomy isto remove all
damaged, abnormal, or unstable meniscal tissue,
while preserving as much normal meniscus as possible. Some additional normal tissue usually must
be removed to prevent stress concentration at an
edge that could lead to tearing of the residual meniscus (66). This concept has been referred to as
"balancing" the residual meniscus.
Metcalf (92) outlined several important guidelines
for the successful performance of a partial meniscectomy: remove all mobile meniscal fragments;
leave no sudden changes in the contour of the meniscal rim; use a probe often to assess stability of
the residual meniscus; protect the meniscocapsular

Arthroscopy, VoL 9, No. I, 1993

FIG. 8. Visualization of an imaginary line on the tibia is helpful

as a guide to determining how much of the meniscus needs to be
removed, If meniscal tissue can be pulled beyond this line, it
could tear further by being caught between a rotating tibia and
femur, and should be removed.

PRINCIPLES AND DECISION MAKING IN MENISCAL SURGERY

symptoms, but also can precipitate articular damage. Such a fragment can generate direct chondral
erosions by increased local pressure and can cause
alterations in the normal instant centers of rotation.
These aberrant axes may lead to abnormal surface
joint motion, resulting in temporarily high local
compression forces on the articular cartilage (95).
Zamber et al. (96) have demonstrated a correlation
between the length of time an unstable meniscal
lesion is in place with eventual articular damage.
Dandy and Jackson (97) reported a higher incidence
of femoral chondromalacia in those patients with a
history longer than 3 months. However, these secondary lesions are generally superficial, and
Mankin (98) concluded that shallow, traumatic articular defects do not progress to osteoarthritis.
The issues involved in balancing a residual meniscus are obvious when dealing with a radial tear
(Fig. 9A). The presence of the right-angle edge of
each segment creates a stress concentration effect
such that each segment is prone to increased shear
stress in rotational motion between the femur and
tibia. The radial tear can then propagate peripherally, or turn anteriorly or posteriorly, creating a flap
tear. Enough meniscal tissue (unfortunately, norreal) needs to be excised to recreate a smooth, tapering C-shaped central edge (93).
Resection of a vertical, longitudinal tear not suitable for repair is straightforward. Exposure of the
anterior horn attachment may be required, accomplished by a partial synovectomy with motorized
instrumentation. The posterior attachment is in-

43

cised first (it is easier to cut the posterior attachment when there is still tension in the fragment from
the intact anterior attachment), followed by incision
of the anterior attachment. After removal of the
central fragment, the a n ~ i o r and posterior attachment sites are trimmed t0~ recreate a smooth, tapered inner margin (Fig. 9B). Care must be taken to
ensure that an occult second tear is not hidden behind the more central fragment (46,93). A second
longitudinal tear, horizontal degeneration, or even a
flap tear flipped underneath the coronary ligament
are all patterns that occur. Neglect of these residual
tears is responsible for some reported failures following arthroscopic meniscectomy (99).
A flap tear is resected following a combination of
the principles described earlier. The longitudinal
component is resected by cutting into the meniscus
at the axilla away from the radial or oblique component. The resultant anterior and posterior edges
are then contoured smoothly to prevent stress concentration (Fig. 9C).
Treatment of horizontal, degenerative tears is
somewhat different in that not all "torn" tissue is
removed; only the unstable tissue is r e s e c t e d
(46,93). This may require removal of enough meniscus to completely excise the separate tibial and femoral lamina and enter normal peripheral meniscus,
but this is not always required. Careful evaluation
with a probe during resection should allow assessment of mobility of the remaining meniscal rim.
Once again, the sequence of cutting, probing, and
cutting is beneficial in guiding the extent of resec-

9A-C

FIG. 9. Balancing meniscal resection. A: With a radial tear. B: With a longitudinal tear. C: With a flap tear.

Arthroscopy, Vol. 9, No. 1, 1993

44

A . P. N E W M A N E T A L .

tion (93). The mere presence of a horizontal cleavage alone is not sufficient to justify its removal.
Since the meniscal fragments may still participate in
load transmission, only that portion of each lamina,
judged to be unstable should be excised.
Some complex tears of the later meniscus (usually a combination of an oblique flap with peripheral
horizontal extension) are associated with development of a cyst at the level of the joint line. Although
the standard treatment for these lesions in the past
has been complete meniscectomy and open cyst removal, this is generally not necessary. A partial excision of the (usually anterolateral) horizontal
cleavage tear with decompression of the cyst contents is adequate in the majority of cases (I00). Taking the resection out to the vascular portion of the
meniscus is usually required to get back to stable
tissue and helps ensure that the horizontal cleft will
seal over with time. However, care should be taken
to still preserve as much peripheral tissue (including
the meniscocapsular junction) as possible. The cyst
can be emptied into the joint by external manipulation or by percutaneous needle puncture under arthroscopic visualization.
10A,B

Some partial meniscectomies (particularly those

involving the posterior aspect of the medial meniscus) are technically difficult to achieve. This can be
associated with increased operative time, less adequate resection, articular scuffing/damage, and potential complications such as instrument breakage
and medial collateral ligament sprains. To avoid
these pitfalls, the surgeon must be familiar with
multiple portals, instruments, and techniques (92,
101-103).
DECISION MAKING
Initial management
Based on the principles described earlier, we
have constructed an algorithm for diagnosis and
treatment of meniscal lesions (Figs. 10AD). As
with all codifications, there will be certain instances
in which it will not be easy to follow the decision
tree, but the principles to follow are still the same.
The first and mos( fundamental issue is whether to
treat the meniscal lesion surgically (Fig. 10A). Casscells (104) has pointed out that not all meniscus
tears cause symptoms. Furthermore, Weiss et al.

,(~ / Marked
f o pain/tenderness
c kk e~d
"[

t Treat conservatively x 4-6 I

weeks

MRI or

I +

~- .

arthrography ~ e x a m l

10C,D

Resect inner J
fragments,
repair
remainder

Longitudinalcomponentin,~
vascularperiphery?
Meniscectomy with

debridement

FIG. 10. Algorithm for treatment of meniscal lesions. A: Decision to proceed to arthroscopy. MRI, magnetic resonance imaging. B:
Management of vertical tears. C: Management of multiple tears. D: Management of horizontal tears. XR, roentgenogram.
Arthroscopy, VoI. 9, No. I, 1993

PRINCIPLES AND DECISION MAKING IN MENISCAL SURGERY

(82) have shown that the natural history of many

short (<~1 cm), longitudinal meniscal lesions is either spontaneous healing or resolution of symptoms
without extension of the tear. Since a stable,
asymptomatic tear can continue to participate in
load transmission, in certain situations it may be
prudent to observe a suspected tear for a period of
time rather than committing immediately to surgical
intervention. If symptoms subside, no further treatment is indicated. Most authors agree that a meniscal tear will not cause any secondary damage to the
neighboring articular cartilage (femoral chondromalacia, etc.), if it is treated within 3 months from the
onset of symptoms (17,97).
Some meniscal tears, in certain clinical settings,
do need to be treated right away. Although not an
emergency, a locked knee needs to be managed arthroscopically as soon as convenient for the patient.
Longer delays can cause cartilage damage by virtue
of the local increased pressure from the displaced
fragment, especially if weight bearing is attempted.
If a patient arrives with marked pain, joint line tenderness, and a large effusion, it is unlikely that complete resolution will follow (in addition to a higher
likelihood of associated injuries). These appearances speak for earlier operative intervention.
There are some other patients who may be served
best by considering arthroscopy prior to a trial of
nonoperative management. The professional, competitive, or highly motivated recreational athlete
may not want to invest the "down time" required
by observation to see if their symptoms resolve.
They may want to proceed with definitive diagnosis
and therapy to return to their vocation or avocation
as soon as possible. Although not usually considered in the same category as competitive athletes,
laborers who rely on their lower extremities for support in strenuous activities are also candidates for
more immediate therapeutic intervention. They
may have an even more pressing need to get back to
their livelihoods than athletes to return to their
sports.
A special case is a torn meniscus in a patient with
an acute ACL injury, whose ligament deficiency is
to be managed nonoperatively. The meniscal tear
also can be treated with an initial period of observation, provided the pain, swelling, and limitation
of motion all resolve shortly. However, Warren (48)
believes that meniscal tears in this clinical setting
should be treated immediately since the inherent
potential for these lesions to heal nonoperatively in
an unstable knee is probably compromised. If the

45

case does not fit the primary indications fov-anSmmediate ACL reconstruction and a meniscal tear is
suspected, Warren (48) advocates magnetic resonance imaging (MRI) to evaluate the menisci. If a
grade 3 tear is identified, then arthroscopy is performed, and the meniscal lesion is either resected or
repaired.
With conservative management of the (suspected) acute meniscus tear, the patient may see a
gradual resolution of symptoms over 6 weeks and
be back to normal activity without any problems by
3 months. If symptoms persist, such as pain, tenderness, effusion, or inability to perform certain activities, further treatment is indicated. If the clinical
appearance is clearly that of a meniscus tear, then
arthroscopy is the logical next step. If there is some
question as to what the actual diagnosis is, MRI or
arthrography may be a helpful intermediate step.
Use of MRI
Making the diagnosis of a meniscal tear on clinical grounds alone is often difficult (105). Arthrography (I06,107) has been useful in the past, but has
fallen out of favor in recent years due to the availability of MRI. Compared to arthrography, MRI has
greater sensitivity, better ability to demonstrate
other intra-articular (ligamentous, osteochondral)
pathologic conditions (108-110), and does not expose the patient to ionizing radiation or iodinated
compounds. Its accuracy for meniscal lesions is between 72-97% (109,111-I13). Its negative predictive value (the likelihood that a normal meniscus
will be correctly diagnosed by MRI) is 83-97%
(109-111,113), which is higher than its positive predictive value (the likelihood that a torn meniscus
will be correctly diagnosed). This reflects the
greater sensitivity than specificity of this technique;
it may pick up lesions that are asymptomatic (114),
or simply represent normal anatomic variants
(115,116) (false positives).
Lotysch et al. (117) and Crues et al. (108) utilized
a grading system for meniscal abnormalities as seen
on MRI. Grade 1 changes are irregular increases in
intrameniscal signal, while grade 2 represents linear
increased signal patterns. In both of these grades
the signal does not communicate with an articular
surface of the meniscus. Grade 3 changes are defined as linear signal intensity that abuts or communicates with an articular meniscal surface (the only
grade visible by arthroscopy, 113).
One of the reasons for many false-positive MRI
reports is overinterpretation of grade 2 signals. A
Arthroscopy, Vol. 9, No. l, 1993

46

A. P. N E W M A N E T A L .

study by Fischer et al. (112) demonstrated that only

17% of grade 2 signals were associated with meniscal tears as diagnosed by arthroscopy. This can be
-a significant pitfall in older patients. Negendank et
al. (118) reported that increased signal intensity occurs in most menisci by the age of 30 as a normal
part of the aging process, and the incidence increases with age.
Since MRI is a very expensive (although accurate) diagnostic test, its cost effectiveness must be
considered. Arthroscopy offers at least similar accuracy and greater specificity, as well as the opportunity to therapeutically manage the problem. Some
patients may require diagnostic arthroscopy in the
face of a negative MRI if they fail to respond to
conservative treatment. Other patients with MRIs
positive for meniscal tears may best be served by
deferring arthroscopy to avoid removal of asymptomatic tears or small/partial lesions that could go
on to become asymptomatic. For these reasons, it is
important to avoid indiscriminate use of MRI in all
patients with knee complaints. In view of its high
negative predictive value, it can be useful in avoiding unnecessary surgery in patients with chronic
and/or nonspecific complaints (119), or in high-risk
surgical candidates (I 13). Another potential indication for MRI is in the patient with an immediate
"need to know" (athlete, etc.), who cannot afford
an unsuccessful period of observation, nor the unnecessary recovery period following a negative arthroscopy.
If nonoperative treatment is to be attempted initially, then definitive diagnosis of the meniscal lesion won't change the approach, provided other injuries (ligamentous, osteochondral fractures, etc.)
have been ruled out. In this situation both MRI and
arthrography should be deferred until such time that
nonoperative treatment has provenunsuccessful
and it is deemed worthwhile to confirm a particular
diagnosis in question prior to arthroscopy. However, MRI is not indicated if there is a strong suspicion of a meniscal tear on clinical grounds alone
(Fig. 10A).
Operative management
At the time of arthroscopy, the assessment of stability is the first issue to be addressed. The goal is to
remove or repair all tissue that could cause either
subsequent symptoms or retear. The concept of
Metcalf and Rosenberg of the imaginary tibiat line
(94) (Fig. 8) inside of which meniscal tissue is at risk
is extremely helpful. In horizontal tears, often eiArthroscopy, Vol. 9, No. l, 1993

ther or both of the residual lamina have damage to

the radial tie fibers with decreased stiffness, allowing subluxation between the condyles. If it is possible to evert the torn edge of a partial-thickness
tear, it is at risk for further tearing, and needs treatment (repair or resection, depending on its length
and location) (47).
If arthroscopic evaluation reveals a small (~<1 cm)
longitudinal lesion or a stable partial tear, these either can be left alone (47,82,87) (in the acute setting)
or treated by perimeniscal synovial abrasion (48).
These are usually stable enough that they do not
require either suture fixation or immobilization (77).
Larger, full-thickness tears require more formal
treatment, either resection or repair, based on their
location, the presence of secondary tearing, ligamentous stability, etc. (Fig. 10B). Longitudinal
tears occurring in the vascular periphery and with
normal or near-normal inner fragments should be
repaired. Lesions located in the transitional redwhite region (3-5 mm from the meniscosynovial
junction) may be repaired, depending on the clinical
indications (age of patient, articular cartilage status,
etc.) and provided adequate stimulation is provided. Stone and Miller (86) advocate excision of
the fragment if the peripheral rim is significantly
damaged. Most surgeons favor partial excision for
any tear with a significant radial component (simple
radial or flap), or for longitudinal tears inside the
vascular periphery. Some chronically displaced
bucket-handle tears may unfortunately require partial meniscectomy. Besides frequently harboring
secondary tears or damage that renders the fragment irreparable (87), the central fragment may deform over time so that a congruous reduction adjacent to its peripheral bed cannot be obtained (84).
There is controversy regarding the repair of tears
that are not longitudinal and not in the vascular periphery. Scott et al. and Henning et al. (30,74)
championed the cause of repairing virtually all patterns of tears, and published relatively high healing
rates for many different types (radial, horizontal,
etc.) of meniscal lesions. However, successful healing without restoration of meniscal function does
not justify the morbidity of the procedure, compared to partial meniscectomy. Until further studies
document the restoration of function following repair and healing of these lesions, it is apparently the
consensus opinion to perform partial resections of
these lesions (87,120). Even longitudinal tears up to
30-40% of the meniscal width in from the central
edge customarily should be resected, when one bal-

P R I N C I P L E S A N D DECISION M A K I N G I N M E N I S C A L S U R G E R Y

ances the potential morbidity of meniscal repair

against the benefit of" retaining the mechanical function of a relatively small inner fragment.
Most of the difficult treatment decisions involve
menisci that have two or more tears within them,
with a combination of repairable and irreparable
patterns (Fig. 10C). In theory, the irreparable portion is resected and the remainder is repaired, if
justified. For example, a common pattern is a longitudinal tear in the vascular periphery with a second radial tear located in the central fragment. Another common tear pattern is the multiple longitudinal lesion, in which a series of two or three
concentric tears occurs. This is occasionally seen in
the lateral meniscus in conjunction with ACL injuries. If, following resection of the irreparable component and contouring of the edges, the remaining
fragment is still wide enough (a minimum of 3-4
mm) to justify the morbidity of repair (that is, significant mechanical benefit will derive from preservation of that fragment), then repair is carried out.
If the resultant central fragment after partial resection is only 1-2 mm wide at its narrowest portion,
repair would then yield little or no utility, and resection of the longitudinal tear should be performed.
A factor that has been given little attention in the
literature is patient preference for a particular treatment option. Meniscal repair is associated with a
longer recovery period (28,30,79) and a higher frequency of repeat surgery (26,30). Sommerlath (79)
reported that patient satisfaction (during an average
7-year follow-up period) was less in those undergoing meniscal repair than in those who had a partial
meniscectomy. It is our responsibility to educate
our patients as completely as possible about the
long-term benefits of meniscal preservation, realizing that that is not the only issue on which patients
will base their ultimate decision.
Although there is no substantial effect of patient
age on the likelihood of healing a particular meniscus lesion, age should certainly play a role in the
clinical decision of whether to repair a particular
lesion. The anticipated benefit of a particular procedure must always be balanced against the potential risk when counseling a patient preoperatively.
In the case of meniscal repair, the benefit we are
pursuing is the prevention of eventual osteoarthritis. The amount of benefit that one derives from this
aspect of meniscal repair is thus directly related to
one's life span. The risk of operative morbidity
(stiffness, thrombophlebitis, etc3 from repair in the

47

older population is also proportionately greater. Although there is no absolute cutoff in regard to age
and meniscal repair, the decision is based on a multitude of factors, including activity level, overall
health, status of the articular cartilage in the involved compartment, etc.
A number of investigators (27,48,84) have suggested that a repairable meniscus in an ACLdeficient knee is virtually a mandate for repair of
the meniscus and concomitant reconstruction of the
ACL. This is a reflection of the higher failure rates
encountered with meniscal repair in unstable knees.
Furthermore, since 6 weeks on crutches and 6
months of activity restriction (following meniscal
repair) are the better part of most ACL rehabilitation protocols, many advocate correcting the entire
spectrum of knee pathologic conditions for only a
little more investment in postoperative recovery
time. However, this reasoning can be used to promote inappropriate ACL reconstruction in patients
(older, less active, etc.) who might best be treated
by nonoperative management of their cruciate deficiency. More recent studies (32,78,121-123) have
shown that while the meniscal healing rate is decreased and the rerupture rate is increased for repairs in unstable knees, the results are still good
enough to warrant repair without cruciate reconstruction in certain selected patients. Sommerlath
(121) compared the prognosis of repaired and initially intact menisci in unstable knees, concluding
that a repaired meniscus has the same chance of
survival as an intact meniscus. Thus, rerupture may
simply reflect the recognized tendency of menisci in
unstable knees to tear, whether they were repaired
or intact to begin with.
The most critical statement that can be made
about meniscal tears in unstable knees is that treatment must be individualized (78). Most authors
claim that the results of ACL surgery are highly
dependent on patient selection, and it seems unwise
to let the single feature of a meniscal lesion drive
the entire decision-making process. Certainly the
meniscal pathologic condition should strongly influence the eventual course of action, but not to the
exclusion of other important criteria.
Although the principles of resecting horizontal
degenerative tears have already been discussed,
knowing whether to resect these types of tears is at
least as important as knowing how to resect them
(Fig. 10D). Degenerative tearing of menisci can be
seen as part of the normal aging process (124).
Many of these tears are secondary to concomitant
Arthroscopy, Vol. 9, No. t, 1993

48

A. P. N E W M A N E T A L .

osteoarthritis, with the meniscal tear contributing

few, if any, symptoms (124). Furthermore, some
horizontal degeneration can occur and be completely asymptomatic, continuing to facilitate load
transmission (55,61). MRI is not helpful in the older
population, since most studies would be abnormal
(due to normal age-related changes, 118; degenerative arthritis, 110, 111; or asymptomatic tears, 124),
and would provide no useful information on which
to base a therapeutic decision. It is important to
separate these patients with primarily articular
symptoms from those who truly have symptomatic
degenerative meniscal tears. Arthroscopically resecting tears in the former group of patients will not
provide any relief of symptoms, while arthroscopic
meniscectomy in the latter group is a successful
procedure. In general, if a patient has a relatively
short history of pain and swelling, precipitated by
some acute injury, and their radiographs show minimal degenerative articular changes and neutral axial alignment, then meniscectomy is an effective
treatment, despite age (125-127). The onset of acute
mechanical symptoms (true locking, 126, or catching) in this setting is also an indication for arthroscopy. Lacking these findings, arthroscopic meniscectomy/debridement will generally provide only a
transient response.
CONCLUSION

Currently, a spectrum of"modalities exists to treat

meniscal lesions that includes observation, resection, and repair. It is possible to base treatment
decisions on sound mechanical and biological principles. However, these principles always need to be
considered alongside individual patient issues such
as age, activity level, and associated injuries, as
well as socioeconomic and person/d factors. In the
future, we may have the opportunity to include the
alternatives of meniscal transplantation and/or
prosthetic replacement in our armamentarium, but
the same basic concepts will guide the application
of these methods.
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