Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145

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Review article

Meniscal repair: Technique

P. Beaufils ∗ , N. Pujol
Service d’orthopédie traumatologie, centre hospitalier de Versailles, 78150 Le Chesnay, France

a r t i c l e i n f o a b s t r a c t

Article history: Meniscal repair aims to achieve meniscal healing, avoiding the adverse effects of meniscectomy. Longi-
Received 8 January 2017 tudinal vertical tears in a vascularized area are the reference indication. The technique generally uses
Accepted 16 April 2017 hybrid all-inside implants. The outside-in technique has other indications in more anterior tears. Healing
has been demonstrated on CT-arthrography and arthroscopy. Specific techniques have been developed
Keywords: for other pathological situations. Posterior meniscosynovial lesions in a context of chronic anterior laxity
Meniscus are identified by exploration of the posterior compartment, and fixed by all-inside hook suture. Hori-
Meniscal repair
zontal lesions in young athletes can be treated by open meniscal suture. Radial tears, when deep, can be
Longitudinal vertical tear
Meniscocapsular lesion
repaired. Root tears, when traumatic, can be treated by transosseous pullout reinsertion.
Ramp lesion © 2017 Elsevier Masson SAS. All rights reserved.
Horizontal cleavage
Root tear

Meniscal repair aims to achieve meniscal healing, avoiding the
adverse effects of meniscectomy.
Meniscal repair techniques largely depend on the type of tear,
presupposing precise pre- and intra-operative assessment. The
present paper does not deal with results or indications, including
the essential choice between abstention, repair and meniscectomy.
Suffice it to say that attitudes need inversing the paradigm, consid-
ering the possibility of meniscal preservation before even partial
meniscectomy.
Rather than describing the various techniques, the presentation
will be based on various clinical situations, seeking to answer the
following questions:
• which kind of repair in longitudinal vertical tears in stable knee
or with anterior cruciate ligament (ACL) tear?
• in ACL tear, do meniscocapsular (ramp lesions) lesions require a
specific technique?
• is open suture still indicated in certain cases, such as horizontal
cleavage, notably of the lateral meniscus, in young patients?
• how should radial tears be repaired?
• how should meniscal root tears be repaired?
and a biological process of cicatrization, which requires prior abra-
sion.
1.1. Fixation must be solid
Fixation uses knotted sutures, whatever the support. The
sutures may be non-absorbable (ultra-high-molecular-weight
®
polyethylene: UHMWPE) or with slow absorption (e.g., PDS ), to
maintain solid fixation throughout the healing process, which takes
several months. Absorbable and non-absorbable anchors, arrows
and staples have all been abandoned, due to poor solidity and car-
tilage impingement [1,2].
Hybrid systems, associating suture (usually UHMWPE) and an
absorbable or PEEK (polyether ether ketone) anchor, combine the
qualities of a minimally invasive implant and biomechanical prop-
erties comparable to those achieved with simple suture (considered
as the gold-standard) [1]. Fixation points are close together, every
5 to 7 mm, and preferably vertical rather than oblique or horizontal
(Table 1); the most resistant part of the meniscus is composed of
horizontally distributed collagen fibers, so that a vertical suture has
a better hold than a horizontal one [4].

1. Basics common to all techniques 1.2. Abrasion is an essential step, and consists in abrading the
fibrous tissue on the two edges of the meniscus to obtain bleeding
Successful meniscal repair depends on a healing process, which tissue that is able to heal over. Such is the theory; what is the
is based on two fundamental principles: a solid primary fixation, evidence?

Ochi [5] demonstrated the role of freshening in an animal study.

∗ Corresponding author. Uchio [6] reported better clinical results with suture-
E-mail address: pbeaufils@ch-versailles.fr (P. Beaufils). freshening-trephination than with suture alone.

https://doi.org/10.1016/j.otsr.2017.04.016
1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.
S138 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145

Table 1 2.1. Patient positioning

Key-points of all-inside meniscal repair (from Pujol and Seil [3]).

Abrasion “Aggressive” True peripheral partial Meniscal repair can be carried out on an ordinary table or with
resection of all meniscectomy the thigh clamped in a knee-holder. In the former case, a support
fibrous tissue
under the lateral side of the thigh facilitates valgus decoaptation
Suture placement Every 5–7 mm Inter-anchor interval > 5 mm
Orientation As much meniscal Vertical > oblique > horizontal
of the medial compartment, although it may hinder flexion-varus
tissue as mposible Double row > Single row (“Figure-4”) positioning to access the lateral meniscus.
involved in suture
Number of stitches 2 to 8 Add more at will 2.2. Anterior arthroscopic portals

The portals are standard: inferolateral and inferomedial. The

Fig. 1. Diagram explaining radial shortening by abrasion, with a true peripheral
partial meniscectomy.
instrument portal location, however, is more difficult than for
meniscectomy: repair instruments are flexible and cannot be forced
through, so the portal has to be directly over the lesion to avoid
bending the instruments. This is especially true for access to the
posterior segment of the medial meniscus. To ensure this “ideal”
portal position, especially early in the learning curve, vertical inci-
sions, which can be extended proximally or distally to optimize
instrument orientation, are recommenced.
Good visual and instrumental access to a posterior meniscal
lesion involves passing under the convexity of the condyle for
the portal ipsilateral to the compartment and crossing the tibial
spines for the contralateral portal. For example, to reach the pos-
terior segment of the medial meniscus, the lateral portal has to be
high enough and the medial portal low enough, each performed
under visual arthroscopic control against the femoral edge of the
meniscus.
If the tibiofemoral compartment is tight, it is often useful
to release the medial collateral ligament by “pie-crusting” with
multiple percutaneous needle perforations [12] (Video 2). Two
techniques have been described:

• under valgus stress, a needle is passed through the medial capsule

And finally, Pujol [7], in a CT-arthroscopy assessment of menis-
cal repair, showed that healing in the posterior segment of the
medial meniscus correlated with radial shortening of the meniscus
(Fig. 1), caused by abrasion of the edges.
Thus, the principle of abrasion as a first step in successful menis-
cal repair is well-founded!
Abrasion may be performed using a punch (Video 1), motorized
shaver or dedicated rasps.
to above or below the mid-part of the meniscus, perforating the
deep layer of the ligament;
• a needle is introduced at the distal insertion of the superficial
bundle of the medial collateral ligament, to “scrape” the ligament
from the posterior edge of the tibia forward.
This maneuver opens the compartment sufficiently to be able to
work under good visualization, and does not alter the rehabilitation
program.

2.3. Reparability assessment

1.3. Can extrinsic biological factors (fibrin clot, synovial flap,
growth factors, platelet-rich plasma, mesenchymal cells) promote
healing?
This is of theoretical importance, especially in repairs in which
vascular conditions are not favorable. Without going into all the
detail of the many experimental studies, with their conflicting
results [8], the situation is that clinical studies are lacking, and only
preliminary series have as yet been reported [9].
2. Repair of longitudinal vertical tear in vascularized zone
Longitudinal vertical tears run parallel to the peripheral rim of
the meniscus in red-red or red-white zones, sparing a peripheral
wall of meniscal tissue available for suture. This is the indication of
choice, and also the most frequent situation [10,11].
Repair can be performed in a stable knee, in which case all
repairable symptomatic tears should be treated, or in situations
of laxity. During ACL reconstruction, even stable medial menis-
cal lesions are systematically repaired, as are lateral lesions when
unstable or symptomatic; otherwise, abstention is indicated.
Reparability is assessed during arthroscopy, on 3 criteria:
• peripheral location in a vascularized area (Fig. 2); a hemorrhagic
stippled surface is a good sign;
• anteroposterior lesion extension, assessed by meniscal instability
found and measured on hook maneuver; a simple method is to
look at the segments, to distinguish 1-, 2- and 3-segment tears;
• meniscal tissue macroscopically remodeled or not; partial radial
tear associated with peripheral tear is frequent, and does not in
itself contraindicate repair.
2.4. Anterior all-inside repair: the standard technique [13,14]
There are two principal techniques: all-inside, for posterior
tears, and outside-in for more anterior locations.
“Hybrid” implants, introduced in the late 1990s, have com-
pletely replaced the old anchors, harpoons, arrows and staples. . .
®
The first hybrid device to come on the market was the FastTfix
(Smith &Nephew, Andover, MA, USA) (Fig. 3), with two bars car-
rying pre-tied non-absorbable sutures introduced successively.
Several devices are now available (Fig. 4). The free suture is
 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
Fig. 2. a: preoperative MRI: longitudinal vertical tear of the posterior segment of
the medial meniscus in vascularized zone. Note remaining peripheral meniscal wall,
supporting the anchors of the hybrid system; b: arthroscopic aspect: peripheral wall
vascularization.
extracted beyond the joint with a suture-passer/cutter and fed
into the retrocapsular bars (gentle traction); the knot is tightened
(strong traction), and the suture cut. The range of curvatures and
orientations of the needles makes these devices very easy to handle,
with good access to the meniscus.
2.4.1. Posterior segment
The needle is introduced into the knee via the ipsilateral portal
by sliding it along a metallic gutter, which:
• directs the tip of the needle onto the meniscus, without damaging
the cartilage;
• can either lie on the superior surface of the meniscus or else lift
up the inferior surface, to enhance exposure of the region;
S139
®
Fig. 3. Meniscal repair by FastTFix (Smith & Nephew).
Fig. 4. Main all-inside hybrid fixation systems.
®
Fig. 5. Steps in setting up a hybrid system (FasTFix Smith & Nephew): a–c: posi-
tioning first anchor; d–f: positioning second anchor and tying knot.
• can be used to widen the tibiofemoral space, by twisting it along
its axis.
The first suture is always the most posterior, except in unstable
bucket-handle tear (see below).
The needle is first positioned with the concavity toward the
meniscus (Fig. 5) (pointing downward to attack the superior surface
of the meniscus), so as to achieve a perforation as perpendicular
as possible; then, in a “Métaizeau effect”, (Video 3), it is turned
S140 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
Fig. 6. Sutures should be at 5–7 mm intervals: example of horizontal, vertical and
oblique stitches.
through 180◦ so as to lie in the radial axis of the meniscus, and is
then pushed.
A stop, usually set at 16–20 mm depending on the size of the
knee, prevents the needle being pushed too far. A first bar is then
pushed behind the capsule. The needle is gently withdrawn, but
without leaving the joint space. The system is reloaded for the sec-
ond bar, and the needle is reintroduced for about 5 mm into the
meniscus as before, and the second bar is delivered. The needle is
withdrawn completely from the knee, leaving the traction suture
visible.
The running knot is tightened manually on the suture outside
the portal, with counter-pressure either using a palpation hook on
the meniscus or directly using a knot-pusher. The traction suture is
then sectioned against the knot, using the dedicated suture-cutter.
The knots should not be too tight, to avoid plicature reducing
the width of the meniscus.
The stitches are then made, from the back forward, with a suf-
ficient number to ensure solid primary fixation: i.e., one every
5–7 mm (Fig. 6). They may be vertical (Video 4) (with one entry
point in the meniscus, one entry point in the adjacent synovial
membrane or horizontal (Video 5) on the surface of the menis-
cus, or oblique). Especially in the lateral meniscus, it is a good idea
to alternate sutures on the superior and on the inferior surface
(Fig. 7). Those on the inferior surface use the inverted curvature
of the needle.
2.4.2. Mid-segment or pars intermedia
The portals are inverted, to allow the needle to be introduced as
perpendicularly as possible to the meniscus (Fig. 8).
The all-inside technique generally enables the posterior half of
the mid-segment to be reached. In the anterior half, the needle is
not oblique enough to be perpendicular to the meniscus.
2.4.3. Intra operative complications
What are the risks of injuring, for example, a neurovascular
structure or other peri-articular structure with this technique?
As well as the rich anastomotic vascular network around the
joint, we need to bear in mind:
®
Fig. 7. FasTFix (Smith & Nephew) with inverted curve for meniscal repair via the
inferior side of the meniscus. (Formerly Fig. 6).
Fig. 8. a: the posterior segment is approached via the ipsilateral instrument portal;
b: the middle segment is approached via the contralateral instrumental portal.
• the position of the popliteal neurovascular bundle, pushed out
behind the lateral meniscal horn, close to the tibia, even in flexion,
being fixed by the soleus arcade;
• and the position of the saphenous nerve adjacent to the junction
between the posterior and mid-segments of the medial meniscus.
In actual practice, this risk of injuring peri-articular neural or
vascular structures when “blindly” introducing the bars does not
seem to arise [7]. In the 2003 SFA series [15], there were no neural
or vascular complications.
On the other hand, a subcutaneous protrusion of the bar may be
troublesome and require secondary resection.
2.5. Outside-in suture
Outside-in suture is indicated for tears of the anterior part of the
middle segment and anterior segment lesions, and is usually asso-
ciated to posterior all-inside suture, but may be isolated in some
rare cases of isolated lesions of the anterior segment of the lateral
meniscus.
The principle consists in passing two needles from outside
inward, under arthroscopic control, one carrying a loop of thread
or metal (suture passer) and the other the suture. This technique
was originated by Warren [16].
A test needle is used to check the exact location and direction of
the needle, perpendicular to the meniscus.
 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
Fig. 9. Outside-in repair. (Coll. Franck Jouve).
A short incision is made, to try to locate and spare the infrapatel-
lar branches of the saphenous nerve in the medial compartment.
Two large-diameter 19-gauge needles are prepared, the first being
used to introduce the monofilament relay loop. The second is pre-
®
pared with non-absorbable or slow-absorption suture (PDS 0 or
1) (Fig. 9). It is recommended to use sutures of different colors. The
first needle is passed through the capsule, the meniscal rim and the
meniscal tear, and emerges from the superior surface of the menis-
cus (Video 6). The loop is pushed into the joint. The second needle
is passed in the same manner. By manipulating the two needles,
the suture is positioned in front of the loop and pushed inside so as
to feed several centimeters of suture into the joint. If problems are
encountered, suture and loop can both be extracted via the instru-
ment portal and the suture can be passed through the loop outside
the joint. The needle carrying the suture is withdrawn, so that in
the subsequent maneuver the suture will not be sectioned by the
cannula. The loop is retracted to block the suture. By pulling on the
needle carrying the loop, the free end of the suture is extracted and
tied to itself subcutaneously. Stitches may be vertical or horizontal.
Fig. 11. Eighteen year-old athlete with medial knee pain: a: CT-arthrography: normal; b: MRI: grade 2 intrameniscal cleavage tear, typical of overuse in young athletes.
S141
Fig. 10. Meniscocapsular lesion of the posterior segment of the medial meniscus on
posteromedial approach (left knee).
Single-use needles, with various forms (straight or curved:
®
Mender , Smith & Nephew, Andover, MA), facilitate passage within
the meniscus, and have a metal loop to facilitate holding the suture
by pulling it into the needle.
2.6. Is there still a role for inside-out meniscal repair? [17]
Inside-out repair is less and less used in Europe, as it involves
a posterior counter-incision, which may entail neurologic com-
plications, especially in the medial compartment. Absorbable or
non-absorbable sutures are passed from inside out by long flexi-
ble needles, allowing vertical or horizontal stitches. The sutures are
picked up outside the joint via the posteromedial or posterolateral
counter-incision, tied and applied on the capsule.
Paradoxically, the risk of neurovascular lesion is greater than
with all-inside techniques. In the lateral compartment, the peroneal
nerve has to be protected, by approaching from behind the lateral
collateral ligament but anteriorly to the femoral biceps tendon; in
the medial compartment, the saphenous nerve and saphenous vein
have to be protected and left in the posterior lip of the incision.
S142 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
Fig. 12. Open repair of horizontal cleavage of the posterior segment of the medial meniscus; a: after meniscosynovial release, cleavage revealed in the peripheral wall: b:
®
PDS 0 suturing; c: aspect after suture.
Fig. 13. PRP injection in horizontal cleavage before tying sutures. (Coll. N. Pujol).
2.7. Specific cases
2.7.1. Displaced bucket-handle in the notch [10]
The first step is necessarily reduction of the bucket-handle, and
only then can the feasibility of repair be assessed. This reduction
is not always easy, especially in case of long-standing dislocation.
Decoaptation combined to direct pushing on the displaced meniscal
fragment usually enables reduction.
What are the feasibility criteria for repair?:
• lesion extension is not a criterion of unfeasibility. The chances
of success may be smaller, but the risk should be taken, having
warned the patient [18];
• peripheral tear is obviously a very important factor, often involv-
ing two elements. Firstly, remodeling of meniscal tissue damaged
by iterative passage under the condyle: except in complex tears,
we do not see this as a contraindication, especially in the common
case of small partial radial tear within the displaced fragment.
Secondly, a horizontal cleavage in the meniscal wall is more or
less systematic, and not a contraindication;
• a more difficult question is that of lesion instability. A meniscus
with a tendency for recurrent intraoperative dislocation indicates
a variable degree of retraction of the meniscal tissue and thus
excessive traction on the sutures. If repair is decided on, the cen-
tral area should be fixed first, to stabilize the meniscus, before
continuing repair as described above;
• in rare cases when the bucket-handle is irreducible but repair is
nevertheless envisaged (e.g., in the lateral meniscus in a child),
the anterior horn can be detached, to allow the meniscus to repo-
sition and then be fixed: this technique leaves an anterior void,
which is probably better than a total void.
2.7.2. Lateral meniscus
Three points need highlighting:
• the most posterior fixation incurs a risk of neurovascular damage.
Suture via the contralateral instrument portal, if possible, reduces
this risk by making the suture oblique;
• the anterior segment of the lateral meniscus has no real capsu-
lar insertion, but is in direct contact with the fat pad, to which
its attachment is very slack; thus, it does not need suturing in
extensive lesions;
• in discoid meniscus, morphologic dysplasia is very often associ-
ated with meniscal instability [19], which may be posterior or
anterior. After meniscoplasty, the stability of the residual menis-
cus should be tested and fixation performed if necessary.
2.8. To sum up
Meniscal repair for traumatic peripheral longitudinal vertical
tears is a well-established procedure, as regards both technique
and outcome. The risk of failure is worth taking, and repair should
be suggested whenever possible. Functional results are good, and
correlate with complete or partial meniscal healing. They are bet-
ter in the lateral meniscus. Any associated ACL tear should usually
be treated by reconstruction. Meniscal repair ensures long-term
cartilage protection [20], but cicatrization does not allow normal
meniscal tissue to be restored, as seen in the very frequent long-
term MRI signal abnormalities.
3. Is there a specific technique for medial meniscus
meniscocapsular (ramp) lesions?
Posterior meniscocapsular tears are associated with 15% to
30% of ACL tears [3], and consist in very posterior tears that are
uncicatrized or badly cicatrized. They do not necessarily show up
on anterior arthroscopy [21], or visually or even on palpation, and
may cause extensive secondary meniscal tears, even after ligament
reconstruction, contributing to rotational laxity [22].
They are revealed by exploration of the posteromedial compart-
ment (Fig. 10), either by direct visualization or by the collapse of a
poor-quality cicatricial synovial curtain (Video 7) [23].
They cannot be treated by hybrid implants on an anterior
approach. Rather, repair consists in passing sutures through the
posteromedial instrument portal, using a hook [24–26] through
the posterior wall then the posterior capsule. These suture-passer
 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
Fig. 14. Hybrid system repair of deep radial lesion of middle segment of lateral
meniscus (left knee): a: lesion aspect; b: first suture; c: final aspect.
hooks are curved, leftward or rightward, to a greater or lesser
degree.
Sutures can be passed in a single step but, in the early learn-
ing curve, we recommend a two-step approach using a Shuttle
Relay Suture Passer. A posteromedial cannula is useful for manag-
S143
ing sutures and tying knots, as in rotator cuff surgery. The technique
is difficult and requires a long learning curve.
4. Is open repair still an option?
Open repair is no longer indicated for vertical lesions, but may
still be used in some very particular circumstances, notably in
horizontal lesions in young athletes. Such lesions are admittedly
degenerative from the histological point of view, but should be
seen as an overuse syndrome, different from degenerative meniscal
lesions in older subjects. They are found in both the medial (Fig. 11)
and lateral meniscus, often in association with a meniscal cyst.
We consider open repair [3,12,27] for the following reasons:
• grade 2 intra-meniscal lesions can only be debrided via a periph-
eral approach;
• primary fixation by vertical sutures through the two meniscal
leaves seems more robust than oblique suture via an arthroscopic
portal.
4.1. Technique
The procedure begins with arthroscopy, to analyze the macro-
scopic status of the meniscus: normal in grade-2 lesions, and with a
fissure in grade 3, in which case partial axial meniscectomy is per-
formed, resecting all the unstable meniscal tissue and leaving the
deep horizontal cleavage.
How arthrotomy is performed depends on the location of the
lesion. The knee is placed in 90◦ flexion. Arthrotomy is gener-
ally on a medial (Video 8) or lateral retro-ligamentous approach,
although the approach may also be adjacent to the pars intermedia
or anterior segment, especially in the lateral meniscus. In the lateral
meniscus, the approach is hindered by the lateral collateral liga-
ment and popliteal tendon; if the lesion continues forward, these
should be identified.
Any meniscal cyst is resected in the approach.
Supra-meniscus vertical arthrotomy moves distally with a ver-
tical incision adjacent to the meniscal wall and down to the edge
of the tibia. Meniscocapsular release moves forward and backward,
creating two capsular flaps, which are pushed to a greater, or lesser
degree depending on the extent of the lesion.
The release reveals the horizontal cleavage in the meniscal wall
(Fig. 12), which is freshened using small curettes.
Suturing proceeds backward and forward in the posterior lip of
®
the incision, passing absorbable PDS 0 sutures on a small needle
through the superior surface of the meniscus, crossing the cleavage
and coming out on the inferior surface and then passing through
the joint capsule.
The sutures are passed one after the other, without being tied,
at 5 mm intervals. They are then tightened, so that the knot lies on
the superior surface of the meniscus-capsule junction.
The knee is placed in extension to check against undue tighten-
ing, and the arthrotomy is closed.
Adding a fibrin clot [28] or platelet-rich plasma (PRP) [9] (Fig. 13)
may be a promising way of improving results, injected in the cleav-
age and menisco-capsular junction after the sutures have been
passed and before they are tied. This is the only indication in which
we use this adjuvant; preliminary results seem to show improved
function and healing.
5. Radial tears
Radial tears, if extending to the meniscocapsular junction,
should be repaired, as they break the meniscal belt, inducing menis-
cal extrusion.
S144 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
Fig. 15. Acute traumatic lesion of lateral meniscus root (right knee): a: lesion aspect; b: UHMWPE suture passed into the meniscus; PDS relay loop (deep blue) emerges
from transtibial tunnel (guide still in place); c: final aspect.
After freshening the edges, two sutures are made on either side
of the lesion, one peripheral (Fig. 14) and the other axial near the
free edge, using an all-inside (hybrid implants, or hook technique)
or outside-in technique [3,11–20], depending on location (Video 9).
6. Recognizing and repairing meniscal root tears
Meniscal root tears are poorly known and ambiguously defined,
including both true bone insertion avulsions and, for some authors
[26], any radial lesion within one centimeter of the meniscal horn;
this gives rise to varying estimates of prevalence. They lead to
meniscal extrusion by breaking the peripheral meniscal belt, and
in some cases require repair.
Medial lesions are generally degenerative, located in the
meniscal tissue. Repair has been suggested, but efficacy remains
unproven.
Lateral horn lesions are traumatic in origin [29], associated with
ACL tear. True avulsions may not be immediately visible and need
exploring by hook palpation, lifting the posterior segment of the
lateral meniscus in continuity with the meniscofemoral ligament.
For lesions a few millimeters away from the root, repair is as for
a radial tear (see above).
For true avulsion, reinsertion is transosseous (Fig. 15) [24,30]:
the tibial insertion zone of the horn is located and freshened
(curette, motorized tool, rasp). A ligamentoplasty-type aimer is
introduced and pointed toward the insertion zone. A 4–5 mm tun-
nel is drilled from outside in, from the ipsilateral tibial epiphysis.
One or, preferably, two cross sutures (on the Mason-Allen suture
bridge principle) are passed by hook into the meniscus and picked
up in the tunnel by a Shuttle Relay device. Tensioning is on an
®
extra-cortical button. UHMWPE sutures are preferable, for solid and
lasting fixation (Video10). Kodama [31] recommended the hybrid
®
FastTFix system to fix the meniscus, with the free suture serving
for traction in extra-cortical fixation.
7. Rehabilitation after meniscal repair
There is no scientific evidence to guide rehabilitation after
meniscal repair; the following represent expert opinion:
• repair of peripheral longitudinal vertical lesions is followed by
immediate resumption of full weight-bearing and immediate
passive mobilization, except in case of particular difficulty or
repair under strong tension, in which case cast immobiliza-
tion is prescribed. Notably, meniscal repair associated to ACL
reconstruction does not alter the reconstruction rehabilitation
program;
• repair of tears (radial, root) breaking the meniscal belt is followed
by 4–6 weeks’ non-weight-bearing, to limit extrusion forces.
• repair of horizontal cleavage can be followed by full weight-
bearing, but with 4 weeks’ immobilization;
• in all cases, resumption of pivot sport is not allowed before
6 months.
8. Conclusion
Meniscal repair is a well-established procedure, mainly con-
cerning peripheral longitudinal vertical tears in vascularized zones.
Technical progress, especially in the form of hybrid implants, has
improved results, which are good in terms of healing, function and
 P. Beaufils, N. Pujol / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S137–S145
cartilage protection, with a low rate of secondary meniscectomy
[20,32,33].
Received wisdom thus needs turning on its head: seek preser-
vation before meniscectomy [34].
Other indications have emerged, with specific techniques;
results have been promising, even over the long-term [35].
Save the meniscus!
Disclosure of interest
P. Beaufils: occasional educational consultant for Smith &
Nephew and Zimmer/Biomet. Editor-in-Chief, OTSR-RCOT.
N. Pujol: occasional educational consultant for Smith & Nephew
and Zimmer/Biomet.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi/10.1016/j.otsr.2017.04.016.
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Further reading
The Meniscus, P Beaufils, R Verdonk, eds. Berlin Heidelberg:
Springer Verlag; 2010.
Techniques en Arthroscopie du membre inférieur, C Hulet, JF
Potel, eds. Cahiers d’Enseignement de la SoFCOT, D Huten ed. Paris:
Elsevier; 2014.
L’Arthroscopie, JF Potel, C Hulet, eds. Paris: Elsevier; 2015.
Surgery of the Meniscus, C Hulet, H Pereira, G Peretti, M Dentied,
eds. Berlin Heidelberg: Springer Verlag; 2016.