Review Article

Meniscus Repair Part 1: Biology, Function, Tear

Morphology, and Special Considerations

Justin W. Arner, MD
Joseph J. Ruzbarsky, MD
Armando F. Vidal, MD
ABSTRACT
Rachel M. Frank, MD Knowledge of anatomy and physiology of the meniscus is essential for
appropriate treatment. The unique anatomy of the medial and lateral
meniscus and blood supply play an important role in decision making.
From the Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Controversy exists regarding the optimal treatment of meniscal tears
Pittsburgh, PA (Arner), the The Steadman Clinic
and Steadman Philippon Research Institute,
including débridement, repair, root repair, and transplantation. The
Aspen, CO (Ruzbarsky), the The Steadman Clinic unique tear location and morphology thus plays an essential role in
and Steadman Philippon Research Institute, Vail,
CO (Vidal), and the Department of Orthopaedic determination of appropriate treatment. Repair is generally advised in
Surgery, University of Colorado, Denver, CO
(Frank). tear types with healing potential to preserve meniscal function and
Arner or an immediate family member serves as a joint health.
board member, owner, officer, or committee
member of the American Orthopaedic Society for
Sports Medicine and the American Shoulder and
Elbow Surgeons. Vidal or an immediate family
member is a member of a speakers’ bureau or

has made paid presentations on behalf of
Arthrex, Inc, Smith & Nephew, and Vericel;
serves as a paid consultant to Arthrex, Inc; has
received research or institutional support from
Arthrex, Inc; serves as a board member, owner,
officer, or committee member of the American
Orthopaedic Society for Sports Medicine; and
serves and on the editorial or governing board of
the Video Journal of Sports Medicine. Frank or an
immediate family member is a member of a
speakers’ bureau or has made paid
presentations on behalf of Allosource, Arthrex,
Inc, JRF, and Ossur; serves as a paid consultant
to the AAOS, Arthrex, Inc, and JRF; has received
research or institutional support from Arthrex,
Inc, and Smith & Nephew; serves as a board
member, owner, officer, or committee member of
the AAOS, American Orthopaedic Society for
Sports Medicine, American Shoulder and Elbow
Surgeons, Arthroscopy Association of North
America, International Cartilage Restoration
Society, International Society of Arthroscopy,
Knee Surgery, and Orthopaedic Sports
Medicine; and serves on the editorial or
governing board of the Journal of Shoulder and
Elbow Surgery. Neither Dr. Ruzbarksy nor any
immediate family member has received anything
of value from or has stock or stock options held
in a commercial company or institution related
directly or indirectly to the subject of this article.
J Am Acad Orthop Surg 2022;30:e852-e858
DOI: 10.5435/JAAOS-D-21-00993
Copyright 2022 by the American Academy of
Orthopaedic Surgeons.
T
he importance of meniscal preservation has been appreciated in recent
years due to its essential functions of load bearing, shock absorption,
joint stability, lubrication, nutrition, and proprioception.1,2 Paralleling
the understanding of function, the management of meniscus injuries has also
evolved from open meniscectomy to meniscal preservation. Meniscectomy
has been shown to decrease contact area by 75%.3 This is particularly
evident in the lateral compartment that is uniquely sensitive to meniscal
deficiency with often rapidly progressive degeneration in meniscus-deficient
states.4 Meniscal preservation surgery has been shown to restore joint
congruity and loading forces, with both short-term and long-term studies
displaying improved outcomes and decreased joint degeneration compared
with partial meniscectomy.5 Healing capacity, biology, and patient-specific
factors must be taken into account to determine the best individualized
treatment regimen.
Meniscus Biology, Anatomy, and Function
The meniscus is 72% water, with the rest being composed primarily of col-
lagen and glycosaminoglycans.6 Collagen type I predominates in the
peripheral meniscus, whereas more type II (60%) exists in the more central
region.7 These allow the meniscus to resist compression, which permits its
important roles of shock absorption and stability, with the circumferential
fibers being essential to transmit hoop stresses. In addition to load distri-
bution, the meniscus also provides important proprioception and nutrition to
the knee.

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 Justin W. Arner, MD, et al

Review Article
Figure 1

Normal meniscal anatomy is seen here with the medial meniscus roots attaching more anterior and posterior, respectively, whereas the
lateral meniscus is more c shaped with greater coverage of the lateral tibial plateau.31

Understanding of meniscal anatomy is essential for
appropriate treatment (Figure 1). The medial meniscus
can be broken up into five anatomic zones, which
include the anterior root that attaches at the anterior
intercondylar crest of the anterior slope of the tibia. The
posterior root attaches posterior to the medial tibial
eminence apex and anteromedial to the tibial attachment of
the posterior cruciate ligament. The anteromedial meniscus
has no attachment to the capsule, whereas the region near
the MCL is the only portion fully attached to the joint
capsule. This is also known as the deep medial collateral
ligament made up by the meniscofemoral and meniscoti-
bial ligaments. The posterior horn is most commonly
injured and only has attachments to the tibia, also known
as the meniscotibial or coronary ligaments.
The lateral meniscus is more c shaped, covers more of
the articular surface, and is more mobile than the medial
meniscus. The anterior horn is the most mobile portion
due to its lack of capsular attachments. The anterior root
inserts beneath the anterior cruciate ligament (ACL),
whereas the lateral meniscus has a unique attachment at
the popliteus hiatus via the meniscofibular ligament that
passes anterior to the popliteus tendon. Two distinct
ligaments attach the lateral meniscus to the medial fem-
oral condyle, with the ligament of Humphrey going
anterior to the PCL and the ligament of Wrisberg going
posterior to it. The posterior root attaches anterolateral
to the medial meniscus posterior root.8 Bony morphol-
ogy also plays an important role as the medial plateau is
more concave and the lateral convex which likely con-
tributes to the lateral side being more meniscus
dependent.
Blood supply to the meniscus is unique in that its
vascularity comes from the peripheral perimeniscal cap-
illary plexus originating from the capsular and synovial
tissues. The meniscus is typically split into three zones
based on blood supply: red-red, white-red, and white-
white with the more central meniscus historically
having less healing potential while the red-red zone has
more blood supply and thus greater healing (Figures 2
and 3).9
Meniscal preservation has been determined to be
essential as it restores joint congruity and loading, which
prevents osteoarthritis. Healing rates of tears in the red-
white zone have been quoted to be around 83%. How-
ever, complication rates have been reported to be 4.6%
to 5.1%.10 Short- and long-term outcome studies have
reported improved outcomes and decreased radio-
graphic degeneration with meniscal repair when com-
pared with partial meniscectomy; however, a higher
revision surgery rate is seen typically due to issues with
healing.5,11,12 Predictors of poor outcomes after partial
meniscectomy are shown in Table 1, whereas Table 2
shows the comparison of partial meniscectomy with
repair.13
Figure 2
Cross section of the medial knee showing the peripheral to
central meniscal vascularity with the perimensical capillaries
(PCP). T = tibia, F = femur32

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Meniscus Repair

Figure 3

Meniscal zones are separated by anterior, middle, and posterior horns with further distinction from peripheral to central based on blood
supply and healing potential.32

cumferential fibers, therefore maintaining the ability to

Meniscal Tear Morphology
Meniscus tears are also classified by their pattern based on
the direction of the tear (Figures 4 and 5). Longitudinal or
vertical meniscal tears are typically traumatic and
observed in young patients, commonly with a concomi-
tant ACL tear. These tears disrupt the superficial radial
fibers and are in line with the circumferential fibers.
Radial meniscal tears represent a unique pathology as
they are perpendicular to the circumferential fibers and
can be partial or complete. If these fibers are completely
disrupted, this leaves the meniscus essentially nonfunc-
tional.14 Horizontal tears are parallel to that of the cir-
Table 1. Predictors and Nonpredictors of Poor
Outcomes
resist hoop stresses despite their injury (Figure 6). Typi-
cally seen in more chronic conditions, this pattern usually
does not cause mechanical symptoms or degeneration of
the knee. Historically, this type has been thought to be
degenerative with little healing capacity. However, recent
studies have shown a significant increase in compartment
pressures with removal of one leaflet and more promising
healing capacity than initially appreciated.15
Meniscocapsular tears or ramp lesions have gained
focus recently with debate regarding their incidence and
the fact that they commonly may be overlooked. Studies
are mixed regarding if close preoperative MRI evaluation
is sufficient for identification or if direct visualization
using the Gillquist view or if a posteromedial portal is
required (Figure 7).16 Initial studies voiced concern
regarding the possibility of high ACL reconstruction

Predictors Nonpredictors
Female Age
Table 2. Comparison of Partial Meniscectomy Versus
Low preoperative Lysholm score Tear pattern Meniscal Repair
Lateral meniscus (versus medial Smoking
meniscus) Partial Meniscectomy Meniscal Repair
Lower revision surgery rate Increased improvement on
Extensive resection (total or Preoperative activity
clinical outcomes (IKDC,
subtotal meniscectomy .50%) level
Lysholm Tegner)
Focal chondral injuries Duration of symptoms
Better outcomes with the Less revision surgery rate for
High BMI Traumatic (versus medial meniscus versus lateral meniscal tears versus
atraumatic) lateral meniscus medial meniscus
Incompetent ACL — Osteoarthritis—no difference Osteoarthritis—no
Lower extremity malalignment — with repair at average 6.6 yr differences with
meniscectomy at average
ACL = anterior cruciate ligament, BMI = body mass index, 6.6 yr
Outcomes measured include Lysholm score and Visual Analog
Scale for Pain IKDC = International Knee Documentation Committee

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 Justin W. Arner, MD, et al

Review Article
Figure 4

Typical meniscal tear types are shown with (A) being an oblique flap tear, (B) a complex tear, (C) a complete radial tear, (D) a horizontal
tear, and (E) a longitudinal tear.13

failure rates if a ramp lesion is left untreated.17 More
recent studies, however, have cited that stable tears may
only require trephination with some believing repair
may over constrain the knee.18,19
There has been a recent focus on the importance of
meniscal root tears (Figure 8). Similar to complete radial
tears, root tears lead to complete loss of the hoop
stresses resisted by the circumferential fibers.14 Meniscal
extrusion occurs, which leads to significant increases in
tibiofemoral contact forces and predictable progression
to arthritis. For this reason, repair is typically recom-
mended in those with minimal arthritis.20
Appropriate diagnosis based on history, examination,
and MRI is essential. Risk factors for medial root tears
are higher body mass index, increased age, female sex,
and malalignment.21 Lateral meniscal root tears typi-
cally occur in younger males with lower body mass
index and normally have healthier cartilage and more
commonly occur with ligamentous injuries. Thus, lat-
eral meniscal root tears are a distinctly different injury
than medial root tears, which are more commonly seen
in female patients with higher body mass indexes. For
these reasons, outcomes have been reported to be
superior in lateral root repairs.22
Medial Versus Lateral Meniscus
Considerations
Although the medial and lateral menisci serve similar
functions, they are unique in their motion and size, and
each responds differently to treatments (Figures 3 and 4).

Figure 5

Arthroscopic examples of (A) a radial tear, (B) a flap tear, and (C) a horizonal tear are shown.13

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Meniscus Repair
Figure 6
Magnetic resonance image showing a horizontal tear of the
posterior medial meniscus with a large parameniscal cyst.
A better understanding how each differs is important
for a knee surgeon’s algorithm when each scenario is
encountered. Evidence suggests that the lateral side of
the knee is much more sensitive to loss of meniscus tissue
than the medial side.23 A possible explanation is that in
the setting of a partial lateral meniscectomy under
compressive loads, the peak contact and shear stresses
experienced on the lateral articular cartilage are 200%
more than under the same conditions of partial menis-
cectomy on the medial side.24 This distinction is a
function of the differing anatomy between the medial
and lateral sides.
This biomechanical evidence has manifested clinically
in several important but distinct outcomes. In a clinical
comparative study looking at professional soccer play-
ers, lateral meniscectomies had both a strikingly lower
return to play rate (5· lower), took longer to return, and
had both more pain and swelling and a higher revision
rate.25 Another study, also looking at professional
athletes, found that even if athletes return to sport after
partial lateral meniscectomies, a high proportion go on
Figure 7
MRI and arthroscopic image of a 27-year-old rugby player with a meniscocapsular separation (ramp) lesion. MRI (A) shows a high-
intensity signal in the posterior medial meniscus capsular region (arrow). Image (B) shows a Gillquist view where the lesion is
appreciated. MFC = medial femoral condyle, PC = posterior capsule, PHMM = posterior horn, medial meniscus
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to significant radiographic joint space narrowing at
mean 6-year follow-up.23 In longer-term follow-up
comparative studies, radiographic narrowing of the
lateral compartment joint space in the setting of partial
lateral meniscectomy progressed more rapidly than the
medial compartment in the setting of partial medial
meniscectomy.25
Although the above evidence indicates that partial
lateral meniscectomy should be avoided, it is unclear
whether a repair should always be done. For instance,
despite evidence that lateral meniscus tears occurring
concomitant with an ACL injury that are left in situ
have a tendency to enlarge with or without a functioning
ACL,26 there is also evidence that leaving the tears
in situ can lead to spontaneous healing good outcomes.
Several studies have demonstrated that lateral periph-
eral longitudinal tears, when left in situ, have low rates
of becoming symptomatic,27 high rates of healing,28 and
low revision surgery rates.29 Even lateral meniscus root
tears when left unrepaired at the setting of ACL
reconstruction have good radiologic and patient-
reported outcomes at long-term follow-up.30 Given
the progression of osteoarthritis after lateral menis-
cectomy, whether through repair or leaving the tears
in situ, the lateral meniscus tissue should be preserved
whenever possible.
Summary
The meniscus is a complex and vital structure, with me-
niscal preservation being critical to long-term joint
health. Knowledge of meniscal biology, physiology, and
patient factors is essential to determine the most appro-
priate intervention. The medial and lateral menisci have
unique characteristics and thus have different injuries
requiring individual treatment. Substantial evidence ex-
ists, finding that lateral meniscal tears may heal without
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Figure 8
Magnetic resonance images of a posterior medial meniscus root tear on both the coronal (A) and sagittal views (B).
treatment. More recent data have shown that some tears,
including horizontal tears, may have more propensity to
heal than previously thought. Meniscal preservation
should be attempted whenever possible to optimize the
chance of maintenance of optimal knee health.
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Justin W. Arner, MD, et al
Review Article
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