Meniscal Repair

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CHAPTER 7 Meniscal Repair

Brian D. Shannon, Peter R. Kurzweil

In 1885, Thomas Annandale performed the first meniscal repair.1 Because of the lack of understanding regarding the role of the meniscus, this discovery went unheralded for many years. Over time, the major role that the menisci play in load distribution, shock absorption, secondary stabilization of the knee joint, and proprioception was better understood. The menisci transmit at least 50% of a compressive load with the knee in extension.2 This increases to 85% in 90 degrees of flexion. Following a meniscectomy, the contact area is decreased by 50%, which increases the load per unit area and leads to subsequent degenerative changes in the knee. Removal of 15% to 34% of a meniscus can increase contact pressure more than 350%, so even partial meniscectomy can significantly alter joint biomechanics.3

As our knowledge of the essential role that the meniscus plays in proper knee function increased, preserving its function became increasingly important. Arthroscopic inside-out repair techniques gained popularity in the early 1980s.4 Following that, outside-in procedures were developed to decrease the chance of neurovascular injury. Recently, all-inside methods are increasingly being performed because of ease of application, decreased operative times, and even lower risk to the neurovascular structures. These techniques have led to healing rates from 60% to 80% for isolated repairs and up to 90% with concomitant anterior cruciate ligament (ACL) reconstruction.5

The goal of this chapter is to provide a comprehensive overview of meniscal repair. Basic information about the menisci and their healing potential will be presented. We will review the process of proper patient selection, one of the most important aspects relating to success of the repair. Then, the different operative techniques will be presented in detail. Finally, the typical postoperative course, including rehabilitation, will be covered.

ANATOMY

The menisci are semilunar fibrocartilaginous structures that cover 50% of the medial and 70% of the lateral tibial plateaus.6 In cross section, their superior surface is concave and the inferior surface is convex to facilitate congruency with the femoral and tibial articular surfaces. The medial meniscus is shaped like a “C” whereas the lateral meniscus more closely resembles an incomplete “O” that is open medially. The coronary ligaments anchor both menisci to the tibia. Additionally, the medial meniscus has extensive peripheral attachments to the capsule and deep medial collateral ligament (MCL). Because of fewer capsular attachments, the popliteal hiatus, and no link to the neighboring collateral ligament, the lateral meniscus is more mobile and can displace up to 1 cm with knee range of motion.7 Its major connections to the posterior femur are through the ligaments of Humphrey and Wrisberg.

The solid microstructure of the menisci is 75% composed of collagen, with a 90% predominance of type I. The collagen is arranged in various patterns, but most of the fibers are aligned circumferentially.8 The orientation of these fibers permits absorption of the hoop stresses generated during natural movement. Radially oriented fibers provide a link between the circumferential bundles and add strength to the overall construct.9 Longitudinal or bucket handle meniscal tears disrupt these radial links between the circumferential collagen fibers. Repairing these tears may restore the biomechanical function of the native meniscus. Vertical mattress stitch configuration, which mimics the path of the radially oriented fibers, may secure more of the circumferential fibers and lead to greater repair strength more than other suture techniques.10

Thorough understanding of the meniscal microvasculature is necessary when considering repair of a tear because it plays a role in the potential for healing. Vessels from the superior and inferior branches of the medial and lateral genicular arteries perforate the menisci at the capsular attachments.11 In the area of the popliteal hiatus, the lateral meniscus lacks this peripheral supply and is an area of relative avascularity. The entire meniscus has a blood supply at birth but by 9 months, the inner third is avascular.12 By age 10, the menisci resemble those of an adult, with the outer 10% to 30% of the medial rim and 10% to 25% of the lateral rim vascularized. For clinical purposes, the menisci are often considered to have three zones, with the peripheral 3 mm considered vascular (red-red), more than 5 mm from the meniscocapsular junction, avascular (white-white), and between 3 and 5 mm, variable (red-white).13

PATIENT EVALUATION

History and Physical Examination

The diagnosis of a meniscal tear begins with a thorough initial evaluation in the office. Combining the patient’s history, physical examination, and plain radiographs can lead to a sensitivity of 88% to 95%, specificity of 72% to 92%, and positive predictive value of 58% to 85% for meniscal injuries.14 Meniscal tears in younger patients typically occur after an acute traumatic event, which often involves a twisting or hyperflexion mechanism. In the fourth decade and beyond, degenerative changes in the menisci often play a role in tears, so that less dramatic events, or even none at all, can results in a tear. Patients typically report pain, swelling, locking, catching, and giving out.

Physical examination begins with inspection of the knee for an effusion or focal joint line swelling, which may indicate a perimeniscal cyst. The presence of quadriceps atrophy may hint at the chronicity of the injury. One must determine whether range of motion loss is caused by a mechanical block. A bucket handle tear is a common cause for a locked knee. A complete ligamentous examination should be attempted to evaluate for concomitant pathology, although sometimes guarding from pain makes this impossible.

There are several tests described that focus directly on meniscal injuries. Unfortunately, no single physical examination finding can reliably predict the presence of a tear. A recent meta-analysis found a pooled sensitivity and specificity of 70% and 71% for McMurray’s test, 60% and 70% for Apley’s test, and 63% and 77% for joint line tenderness, respectively.15 Despite these findings, the authors concluded that none of the tests could accurately diagnose a tear based on the heterogeneity of study results. They could not explain the wide variation seen between each individual study’s results. Nevertheless, these tests are valuable to perform and help discern what is going on with the patient’s knee.

Diagnostic Imaging

Radiographic evaluation begins with weight-bearing x-rays of the knee, if possible. Standard views should include anteroposterior (AP), lateral, patellofemoral, and 45-degree posteroanterior (PA) images. Although the menisci are not visualized on radiographs, they provide valuable information regarding knee alignment and other possible pathologic sources of knee pain, such as degenerative arthritis.

Magnetic resonance imaging (MRI) has become the gold standard for meniscal imaging, although one must take into account that up to 13% of asymptomatic patients younger than 45 and 39% older than 45 years may have a “positive” scan.16 Benefits of MRI include providing additional information regarding associated injuries inside the knee, as well as tear location and configuration. A retrospective review following surgery for bucket handle meniscal tears has shown that whether a lesion was reparable or not could be accurately predicted 93% (26/28) of the time.17 The criteria created for this study included rim width less than 4 mm, tear length more than 1 cm, and isosignals of the peripheral rim and inner fragment with the normal contralateral meniscus in the same knee, indicating a nondegenerative process. Typically, contrast is not necessary to image the menisci properly, but should be used in cases involving a prior repair or if more than 25% of the meniscus has previously been resected to evaluate for a re-tear.18

TREATMENT

Indications and Contraindications

Once a patient has been diagnosed with a symptomatic tear of the meniscus and surgery is indicated, a number of factors play a role when considering whether the tear in this particular patient can and should be repaired. We typically explain to patients that much like real estate, location is the most important factor in addressing reparability. Adequate vascularity is a requirement for healing, so tears in the peripheral red-red zone have the best chance of healing. Tear configuration is the second most important factor, because longitudinal and vertical tears have a higher rate of healing than radial, horizontal cleavage, or degenerative tears. The third factor is size, or length, of the tear. Usually, a tear must be at least 1 cm long to be considered for repair, because smaller tears may be inherently stable and heal without surgery or be asymptomatic.19 Many of these factors are best judged arthroscopically. Acute tears also have a higher rate of healing than chronic injuries.20

Stability of the knee is another factor to consider when contemplating meniscal repair. Healing rates are less than 30% in an ACL-deficient knee that remains unreconstructed.5 It has been shown in several studies that simultaneous ACL reconstruction enhances the success of meniscal healing.21,22

In general, many surgeons consider patients younger than 40 years for meniscal repair. Although some studies have shown that older patients can heal following repairs,22 one has to weigh the risks and benefits versus a partial meniscectomy. Subjecting older patients to the risk of a possible second surgery if the tear doesn’t heal, as well as the difficulties of rehabilitation, may be unnecessary, considering that they might do just as well with a meniscectomy. In addition, older people are more likely to have articular cartilage changes and tissues with poorer healing qualities, which can jeopardize the success of a repair.

Conservative Management

Nonsurgical treatment may be considered for a select group of tears. Partial or small (less than 5 mm) complete tears located in the peripheral third may heal without operative intervention. This should only be considered for acute traumatic tears. Chronic and degenerative lesions are less likely to improve without surgery. In addition, meniscal tears generally do not heal in ligamentously unstable knees and nonoperative management is typically avoided.

The protocol for conservative management is surgeon-dependent. It may involve a temporary restriction of weight bearing and immobilization. Following resolution of the effusion and pain from the acute injury, a rehabilitation protocol, including strengthening and range of motion, is generally instituted. The treating physician may consider restricting deep knee flexion for a period of time. If the symptoms return after resuming unrestricted activity, surgical intervention should be discussed.

Arthroscopic Technique

It is essential to have an extensive discussion with the patient prior to surgery that includes the risks and benefits of surgery. The need for compliance with the postoperative rehabilitation protocol, as well as the possibility that a repair may fail and require an additional procedure in the future, should be discussed. These factors may be unacceptable to patients and may lead them to opt for a meniscectomy instead of a repair. Patients should also be warned that not all tears are reparable and that the ultimate decision about treatment occurs during surgery. Hence, patients should be aware that there remains the possibility of a meniscectomy. Finally, it is important to address the potential need for additional incisions with a repair so that they are not a surprise postoperatively. This is typically brought up when educating patients about the possibility of neurovascular injury during meniscal repair.

Patient Positioning

We typically perform our knee arthroscopies under a general anesthetic and prefer this over regional or local anesthetic. In our experience, complete relaxation allows the surgeon to enjoy a few extra millimeters of joint opening, which permits better visualization and instrumentation in the medial and lateral compartments. We inject a local anesthetic with epinephrine around our incision sites after prepping the leg to assist with perioperative pain control and hemostasis. A femoral nerve block can also be considered to assist with pain management, but we typically do not use one routinely unless an ACL reconstruction is performed concomitantly. We apply a nonsterile tourniquet to the upper thigh of the operative extremity, but make every attempt during the procedure to minimize inflating it. It is essential to make sure that it is not engaged when assessing the vascularity of the tear site. Most procedures can be done without ever increasing the tourniquet pressure. Electrocautery is useful to help maintain hemostasis during the procedure.

We prefer to position the patient supine on the operating room table. A lateral thigh post permits valgus stressing of the knee to open the medial compartment. Work in the lateral compartment is accomplished with the patient in the figure-of-four position, resting the leg on the contralateral shin.

Diagnostic Arthroscopy

We prefer gravity inflow of lactated Ringer’s solution to provide knee distention, and have found that a high-pressure pump can lead to extravasation of fluid into the surrounding soft tissues, which may contribute to increased postoperative swelling and pain. The cannula through which inflow is accomplished is placed in a standard anterolateral viewing portal. Using needle localization to make sure that the pathology can be reached, a medial working portal is established. We do not use a separate inflow-outflow portal.

Occasionally, it can be difficult to see the periphery of the posterior horn of the medial meniscus in tight knees. It is important not to force instruments into the compartment and risk scuffing of the articular cartilage. Usually, adjusting the knee angle, which is near full extension, and increasing the valgus load applied to the joint will open up the medial joint space sufficiently. Another option to aid visualization in this area is to use a 70-degree arthroscope through the intercondylar notch, although this is rarely needed in our experience. Posterolateral or posteromedial portals may also improve access to this area. In certain extremely tight knees, one may consider recessing the MCL by a “pie-crust” technique. We prefer to do this with a 14-gauge needle rather than a scalpel. Insert it into the joint through the MCL and, without removing it from the skin, repeatedly puncture the MCL multiple times while applying a valgus force. The joint space should slowly increase without creating a full-thickness iatrogenic tear of the ligament. If the knee joint opens excessively after this maneuver, we use a hinged knee brace postoperatively until the ligament tightens. When compared with the alternative of injury to the articular cartilage, the sequela of tearing the MCL seems to be fairly minor.

Meniscal Preparation

The meniscus tear site must be prepared properly prior to applying the fixation. We compare repairing the meniscus with treatment for nonunion of a bony fracture. Adequate blood flow to the area must be established, the two sides must be anatomically reduced, and stable fixation must be used to promote an environment conducive to healing. Failure at any of these stages can compromise the overall success.

First, fibrous tissue has to be removed from the meniscal edges to create surfaces conducive for healing. We typically accomplish this with a rasp, but one could also use a small motorized shaver. If a shaver is chosen, minimal or no suction should be used to avoid overly aggressive débridement.

There are multiple techniques to promote a vascular environment. Abrasion of the synovial fringes extending over the peripheral edges of the meniscus with a rasp can stimulate a proliferative response to enhance healing.23 In a rabbit model, this has been shown to improve the mechanical properties of the healed meniscus significantly.24 Another option is trephination of the peripheral meniscal rim. We prefer to do this by creating multiple perforations with an 18- or 20-gauge needle from outside-in. This technique creates conduits for vascular migration to the tear. It is important to minimize channel size to limit disruption of the collagen framework that provides the beneficial biomechanical properties of the meniscus.25 Rotational flaps of vascular synovial pedicles have also been shown to aid meniscal healing in animal models, but are rarely used in humans because of difficulties applying this technique arthroscopically.26

Similar to an unstable fracture pattern, temporary fixation is used to hold the reduction before final fixation is inserted. With unstable meniscus tears, a probe is used to reduce and hold the inner portion to the peripheral side while a small needle is introduced from outside-in across the tear. The probe can then be removed and permanent fixation applied.

Fixation

It is important to achieve fixation that is perpendicular to the tear to maximize compressive forces across it. We find that this is usually best achieved by viewing through the ipsilateral portal and placing instrumentation through the contralateral portal. For fixation of posterior tears near the root, the surgeon may sometimes find it beneficial to switch portals and place the instruments through the ipsilateral side while being mindful of avoiding injury to the neurovascular structures. In addition, most devices used to place the fixation come in varying degrees of curvature to aid in proper placement.

Vertical mattress orientation of the sutures is preferred whenever possible. These have been shown to be superior biomechanically to horizontal mattress and mulberry knot techniques.27 The number of fixation points used depends on the length and stability of the tear. Most surgeons tend to space fixators or sutures 5 to 8 mm apart. It is important to range the knee several times after final fixation has been applied. If subsequent gapping or displacement is noted, additional fixation or alternate methods must be added.

The choice regarding which fixation technique to use varies based on tear size, configuration, and location, as well as surgeon preference (Figs 1 to 6). It is also important to recognize that meniscal fixators cost significantly more than sutures. Typically, for tears located posteriorly, we prefer all-inside meniscal fixators to limit the risk of neurovascular injury. For anterior third tears, we typically use an outside-in technique. Once started, we often continue to use this technique into the middle third of the meniscus. It is not uncommon for us to achieve hybrid fixation with different techniques in the same tear.

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FIGURE 7-1 Biomet (Warsaw, Ind) MaxFire technique. A, Choose appropriate cannula and depth limiter. B, Deploy first anchor with the green lever. C, Retract green lever, reposition device, and deploy second anchor with red lever. D, Remove cannula and pull on loop until appropriate tension is achieved at repair site. E, Pull single strand to bring loop down to repair. F, Cut suture. G, Final view of repair.

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FIGURE 7-2 Outside-in spinal needle technique. A, Load suture into needle. B, Pass needle outside-in across tear. C, Withdraw needle, leaving intra-articular suture loop. D, Reload second suture into needle and pass across tear again. E, Pass second suture through loop and grasp it. F, Pull second suture out arthroscopic portal. G, Use first suture to shuttle second suture across tear. H, Tie second suture to complete the repair.

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FIGURE 7-3 Arthrex (Naples, Fla) Viper technique. A, Load suture on device. B, Place device over tear site. C, Deploy needle. D, Withdraw device. E, Secure with a racking hitch knot.

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FIGURE 7-4 Smith & Nephew (Andover, Mass) FasT-Fix technique. A, Deploy first anchor. B, Withdraw device from meniscus and advance second anchor with lever. C, Pierce tear to deploy second anchor. D, Remove device and pull on suture to advance knot. E, Cut knot after appropriate tension is obtained.

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FIGURE 7-5 Arthrex (Naples, Fla) Meniscal Cinch technique. A, Hold device like a syringe. B, Deploy first needle. C, Remove needle. D, Reposition device and fire second needle. E, Pull on single strand. F, Cut suture once tensioned appropriately.

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FIGURE 7-6 Smith & Nephew (Andover, Mass) Meniscus Mender II technique. A, Introduce both needles in desired position. B, Advance wire loop through needle. C, Advance suture through second needle after placing it through loop. D, Grasp suture and pull out through portal. E, Pull needle and wire loop out to shuttle suture across tear. F, Tie suture over capsule.

Inside-Out Repair.

Inside-out repairs are best suited for middle or posterior tears. Medially, the saphenous nerve is at risk. With the arthroscope in the anterolateral portal, it is brought up to the medial tear to transilluminate the skin where the planned incision is to be made. One can visualize the saphenous vein in this manner, knowing that the nerve lies immediately posterior and therefore can be avoided. Flex the knee 90 degrees also to let the nerve slide posteriorly, away from the area that is being manipulated. A 4-cm incision is made in line with the posteromedial border of the tibia, just posterior to the MCL. Place one third of the incision proximally and two thirds distally to the joint line. Dissect carefully through the subcutaneous tissues. Incise the fascia anterior to the sartorius muscle. Retract it posteriorly, along with the semitendinosus. Anteriorly, you will see the superficial MCL. Develop the interval between the joint capsule and the medial head of the gastrocnemius bluntly with a finger. Place a retractor or pediatric gynecologic speculum posteriorly to retract the gastrocnemius and semimembranosus.

The common peroneal nerve is at greatest risk laterally. Once again, flex the knee 90 degrees to let it drift posterior to the operative field. Make a 4-cm incision just posterior to the lateral collateral ligament. It should be centered just distally to the joint line, but should not extend beyond the level of the fibular head. This is the soft spot of the lateral knee, where posterolateral portals are made. After dissection through the subcutaneous tissues, identify the iliotibial band and biceps femoris. Retract the biceps posteriorly to protect the peroneal nerve. Elevate the lateral head of the gastrocnemius off the knee capsule and place a retractor or pediatric gynecologic speculum posteriorly.

The surgeon uses zone-specific cannulas to direct the sutures within the knee. These also aid in reducing slightly displaced tears while the sutures are passed. The cannula tips are fairly sharp to prevent slipping off the meniscus once placed; however, iatrogenic damage to the articular cartilage should be avoided as the cannulas are carefully inserted into the knee joint. Aim the cannula so that it is parallel or slightly inferior to the joint line. Use no. 2-0 nonabsorbable sutures on double-armed flexible needles. Reusable Nitinol needles are also cost-effective. An assistant holds the gastrocnemius retractor while waiting to retrieve the sutures. Excellent communication is essential to pass each stitch safely. The surgeon lets the assistant know when he or she begins passing the suture. The assistant watches intently for the needle while making sure to keep herself or himself safely away from the surgical field to avoid an accidental stick. Once it is visible, the assistant notifies the surgeon to stop passing it and grabs it with a needle driver or mosquito clamp. If the needle is not visible after passing it 2 to 3 cm, the surgeon should reassess the situation to make sure that it is being directed in the proper orientation. Pass the second arm of the suture in a similar fashion. Cut off the needles and tag each pair of sutures with a clamp. Repeat this process as necessary at the desired points along the tear. On the lateral side, we try not to capture the popliteus tendon.

Once all the sutures have been placed, apply tension to them to assess the adequacy of the repair while visualizing and probing arthroscopically. If satisfied, then tie the stitches from posterior to anterior. Make sure to tension the construct adequately, but pulling too hard will either break the sutures or have them pull through the meniscus. The surgeon should try to visualize tying the knots over the capsule directly to avoid entrapping any vital structures.

Outside-In Repair.

Although useful for tears in the anterior two thirds of the meniscus, it less useful for posterior third tears because of the inability to place sutures perpendicular to the tear. Typically, this technique permits a smaller incision than inside-out repairs. Sometimes, however, multiple passes through the meniscus are required until one is satisfied with placement; improper placement could damage the underlying collagen framework unnecessarily. The surgeon may initially consider intentionally passing the needle through the synovium superior to the meniscus to make sure that it has the proper orientation and location prior to perforating the meniscus itself.

One very simple and cost-effective technique was first described in 2004.28 Preload an 18-gauge needle with a suture that is at least 40 cm long. Roughly 10 cm of the stitch should extend beyond the needle tip. Transilluminate the skin to help identify where the needle should be placed. Pierce both the inner and outer portions on the meniscus across the tear. The needle should be directed so that it comes out on the superior surface of the inner meniscal rim. Use an arthroscopic grasper through the ipsilateral portal to hold the loop inside the knee joint while withdrawing the needle. Pull the needle out away from the skin approximately 15 cm without unloading the suture, or the surgeon may choose to reload the needle with a second suture. Tag the two suture limbs coming from the skin. Reinsert the needle through the same track and perforate the superior portion of the peripheral rim only in a vertical mattress fashion. Direct the needle so that it passes through the suture loop held by the grasper. Use the grasper to grab the suture from the needle tip and pull it out the ipsilateral portal. Pull on the two sutures held by the tag clamp to shuttle the suture from the second needle insertion through the path from the first insertion. Remove the needle and repeat the process as necessary.

Regardless of the method, make a small incision once all the sutures have been passed. Spread bluntly down to the level of the capsule and tie the stitches down. Make sure not to entrap any vital structures. As an alternative, the surgeon could also make the incision initially at the start of the repair and subsequently pass the needles through it.

All-Inside Repair.

A number of devices are on the market for all-inside repairs of meniscal tears. These have the benefit of less time needed to insert and the ability to be placed without the need of a surgical assistant. Also, accessory incisions may be avoided. Generally, these cost more than suture-based fixation methods.

The first generation of all-inside meniscal fixators consisted of rigid, bioabsorbable arrows, darts, and screws that could be placed across tears. Each device has a specific technique for insertion, but in general a curved cannula is used to place them in the proper location. After the tear is pierced with a trocar, the device is screwed or tapped into position. These fixators do not allow for the ability to tension the repair. In addition, several studies have demonstrated unacceptable failure rates and serious complications, including chondral scoring from the fixator’s head, implant breakage, insertion difficulties, and postoperative joint line irritation from the devices.29,30

A second generation of suture-based meniscal fixators has emerged. These bioabsorbable implants incorporate dual anchors connected by a pretied, sliding, self-locking knot. The first anchor is deployed through the meniscus and capsule. Depending on the specific implant design, the second anchor is designed to sit on the meniscal surface or to be placed though the meniscus and capsule in another area. The sliding knot can be tensioned appropriately to compress the tear site. Care must be taken during insertion not to plunge too deeply through the capsule to avoid neurovascular injury.

Adjuncts to Repair

As noted, simultaneous ACL reconstruction has been shown to enhance the ability of the meniscus to heal. One theory is that the tear is bathed postoperatively in cytokines and growth factors from the bone marrow released during tunnel drilling and notchplasty.19 This has led to the development of several methods to try and mimic this milieu. Intercondylar microfracture with an awl can simulate the environment created by a notchplasty, but the results have not been studied clinically.31 A fibrin clot can be made with the patient’s whole blood stirred in a container with a sintered glass rod. This should be placed in the tear prior to compressing it with the fixation. Studies have suggested that it may improve meniscal healing for red-white tears.32 Platelet-rich plasma derived from whole-blood centrifugation provides growth factors in higher concentrations than fibrin clot and has shown promise in promoting healing elsewhere in the body, but has not been studied for meniscal repair.19

PEARLS& PITFALLS

1. Treat a meniscus tear like a bony nonunion.
2. Proper patient selection is essential to maximize the healing potential of a repair.
3. Make sure that the tourniquet is not inflated when assessing the vascularity of the tear.
4. Use temporary fixation to hold a tear in a reduced position.
5. Test the fixation to ensure that it is stable by having the patient flex and extend the knee.
6. Apply fixation perpendicular to the tear to maximize compression.
7. Avoid injuring the articular cartilage; “pie-crust” the MCL if necessary to obtain adequate exposure.
8. Use a vertical mattress suture configuration when possible.
9. Consider the use of adjunctive healing factors, such as platelet-rich plasma.
10. Strict adherence to the postoperative rehabilitation protocol will decrease the risk of failure.

Postoperative Rehabilitation Protocol

We do not follow an aggressive rehabilitation protocol postoperatively. The patient is toe-touch weight bearing for the first 2 weeks in a knee immobilizer. Sitting or supine range of motion exercises begin at week 3. Progressive weight bearing in the immobilizer is allowed during weeks 3 and 4. Unrestricted walking out of the brace starts after 4 weeks. We also encourage the use of a stationary bike at that time. We discourage squatting until the patient is 4 months postoperative to reduce forces applied to the repair while it is healing. Patients are allowed to return to cutting sports 6 months after surgery. When an ACL reconstruction is done at the same time, our rehabilitation protocol for the meniscal repair takes precedence.

CONCLUSIONS

The meniscus serves several essential functions in the normal knee. When injured, every effort should be made to preserve as much of the meniscus as possible. Certain types of tears are more amenable to repair than others. Historically, arthroscopically assisted suture repairs through an accessory incision are the gold standard for treatment and can provide excellent outcomes. However, there has been a recent trend toward less invasive all-inside implants because of their ease of insertion. Newer designs for the all-inside fixators have emerged, with lower complications and improved healing rates. In addition to the advances in implant design, there is evidence that adjuncts such as platelet-rich plasma may enhance the ability of the meniscus to heal. More research needs to be done in this area, but early data are promising. Overall, repair of the meniscus can be a satisfying procedure with a high chance of a successful outcome if it is performed correctly, with adherence to accepted indications.

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