From the Guidelines
Meniscal repairs are currently indicated for peripheral tears in younger patients, particularly vertical longitudinal tears greater than 10mm in length, and are typically performed arthroscopically using one of three main techniques: inside-out, outside-in, or all-inside repair. The decision to perform a meniscal repair is based on the tear pattern and location, as well as the patient's age and activity level. Repairs are also considered for unstable tears, bucket-handle tears, and meniscal root tears to preserve meniscal function 1.
Indications for Meniscal Repair
- Peripheral tears (within the vascular "red zone" or red-white junction) in younger patients
- Vertical longitudinal tears greater than 10mm in length
- Unstable tears
- Bucket-handle tears
- Meniscal root tears
Surgical Techniques
- Inside-out technique: uses long needles passed through arthroscopic cannulas to place sutures across the tear, requiring a posterior incision to protect neurovascular structures
- Outside-in technique: involves passing sutures from outside the joint through the meniscus
- All-inside technique: uses specialized implantable devices that deploy anchors or sutures entirely within the joint, reducing surgical exposure and operative time
Post-Repair Rehabilitation
- Limited weight-bearing for 4-6 weeks
- Avoiding deep flexion
- Gradual return to activities over 4-6 months
Preserving the meniscus is crucial as it serves important functions in load distribution, joint stability, and cartilage protection. Meniscectomy leads to increased contact pressures and predisposes patients to early osteoarthritis, making repair preferable when the tear pattern and location are amenable to healing 1.
From the Research
Current Indications for Meniscal Repairs
- Meniscus tears that occur in the periphery may be repaired using a variety of operative procedures with high success rates 2
- Complex multiplanar tears that extend into the central one-third avascular zone can also be successfully repaired using a meticulous vertically divergent suture technique 2
- Meniscal repair is superior to partial meniscectomy with better functional outcomes and less severe degenerative changes over time 3
- Meniscal transplantation is a valid treatment option for patients who have undergone meniscectomy and have related tibiofemoral joint pain, or in whom articular cartilage deterioration in the meniscectomized compartment is present 2
Surgical Techniques for Meniscal Repairs
- Inside-out repair remains the gold standard and is most appropriate for a bucket-handle type tear of the medial or lateral meniscus 4
- All-inside technique has gained in popularity recently and has outcomes that approach those of the inside-out repair with decreased morbidity but increased cost 4
- Outside-in repair can also be employed and is preferred for anterior horn tears 4
- Hybrid technique that incorporates all techniques can be used in some challenging cases 4
- Biological augmentation techniques, such as meniscus wrapping with extracellular matrix materials, trephination, synovial rasping and abrasion, fibrin/blood clot placement, and platelet-rich plasma injections, are being devised to enhance the likelihood and rate of healing in meniscus repair 5
- Biologic augmentation typically aims to improve cellular incorporation to the wound site, vascularization in the inner zones, matrix deposition, and inflammatory relief 6
Considerations for Meniscal Repairs
- Tear location is one aspect which determines the endogenous healing response; tears that occur in the peripheral densely vascularized zone of the meniscus have the potential to heal while the healing capacity is more limited in the less vascularized inner zones 5
- Vascular zones and biomechanical classifications of meniscal tears should be thoroughly understood by surgeons to best determine the most appropriate treatment 3
- Failed repair is not without consequences and can negatively impact patient outcomes 3