Treatment of Meniscus Root Tears
Meniscus root tears require surgical repair in younger, active patients and those with minimal arthritis, while older patients with moderate-to-severe osteoarthritis should initially pursue conservative management with consideration for osteotomy or arthroplasty if nonoperative treatment fails.
Treatment Algorithm Based on Patient Characteristics
Young and Active Patients (Regardless of Age)
- Arthroscopic transosseous root repair is the treatment of choice for acute traumatic root tears in patients with normal or nearly normal cartilage 1
- Root repair demonstrates high satisfaction rates and superior outcomes compared to meniscectomy, as it restores meniscal function and prevents the biomechanical equivalent of a complete meniscectomy 1
- The all-inside repair technique using reduction sutures to re-tension the meniscus shows significant improvements in KOOS Pain, KOOS Symptoms, and Lysholm scores compared to observation 2
- Surgical repair reduces total knee arthroplasty conversion rates by 93.2% compared to nonoperative management (3.3% vs 33.3% conversion rate) 2
Middle-Aged Patients with Early or Minimal Arthritis
- Root repair is ideal to improve symptoms and restore meniscal function in patients with Kellgren-Lawrence grade 0-2 osteoarthritis 3
- Repair prevents meniscal extrusion and the dramatic increase in tibiofemoral contact pressures that accelerates arthritis progression 3
- Active patients in this category should be referred early for surgical consideration 1
Middle-Aged to Older Patients with Moderate-to-Severe Arthritis
- Begin with conservative management including medial unloader bracing or injections for patients with moderate or severe medial compartment arthritis 3
- When nonoperative treatment fails, proceed to high tibial osteotomy or arthroplasty rather than isolated root repair 3
- However, even in patients with moderate osteoarthritis (average Kellgren-Lawrence grade 2), all-inside root repair still shows significant functional improvements and dramatically reduced arthroplasty conversion rates compared to observation 2
Critical Distinguishing Features
Medial vs Lateral Root Tears
- Medial root tears typically occur in patients >50 years without adequate trauma, associated with obesity and varus deformities 4
- Lateral root tears occur in younger patients, often in combination with ACL rupture, requiring arthroscopic transosseous refixation combined with cruciate ligament surgery for type I and II lesions 4
Biomechanical Significance
- Root tears interrupt circumferential fiber continuity, causing failure of normal meniscal conversion of axial loads into transverse hoop stresses 1
- The biomechanical impact is equivalent to complete meniscectomy, with meniscal extrusion ≥3mm and dramatically increased joint contact pressures 3, 1
Surgical Technique Considerations
Transosseous Root Repair
- The transosseous technique allows reduction and fixation of the meniscal root to the broad anatomic footprint, maximizing healing potential 1
- Transtibial tunnels contribute to release of biological factors that enhance meniscal root repair healing 1
- All-inside sutures reduce the root back to its remnant (re-tensioning the meniscus), with additional mattress suture to posterior capsule for strengthening 2
Common Pitfalls to Avoid
- Do not treat root tears like degenerative meniscal tears - while degenerative tears should be managed conservatively per BMJ guidelines 5, 6, 7, root tears have distinct biomechanical consequences requiring different management
- Do not delay surgical referral in active patients with minimal arthritis - early repair prevents progression to meniscal extrusion and accelerated cartilage damage 3, 1
- Do not assume age alone contraindicates surgery - even older patients with moderate osteoarthritis benefit from root repair with 93% reduction in arthroplasty conversion 2
- Do not perform isolated meniscectomy for root tears - this provides inferior outcomes compared to repair and eliminates meniscal function entirely 1