0363-5465/98/2626-0087$02.
00/0
THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 26, No. 1
© 1998 American Orthopaedic Society for Sports Medicine
Arthroscopic Repair of Meniscal Tears that
Extend into the Avascular Zone
A Review of 198 Single and Complex Tears
Marc H. Rubman, MD, Frank R. Noyes,* MD, and Sue D. Barber-Westin
From the Cincinnati Sportsmedicine and Orthopaedic Center and the Deaconess Hospital,
Cincinnati, Ohio
ABSTRACT
We assessed the results of 198 meniscal tears that
had a major segment in the central avascular region
repaired with an arthroscopically assisted inside-out
technique. There were 177 patients whose mean age
was 28 years. Eighty-two percent were injured during
sports, and 71% also required anterior cruciate liga-
ment reconstruction. The menisci were evaluated by
clinical examination (180 repairs) a mean of 42 months
postoperatively, by follow-up arthroscopic evaluation
(91 repairs) a mean of 18 months postoperatively, or
both. At followup, 159 (80%) of the 198 tears were
asymptomatic for tibiofemoral joint symptoms, and 39
(20%) required repeat arthroscopic surgery for these
symptoms. Of the 91 repairs evaluated arthroscopi-
cally, 23 (25%) were classified as healed, 35 (38%) as
partially healed, and 33 (36%) as failed. We recom-
mend repair of meniscal tears that extend into the
avascular region for select patients, including those in
their 20s and 30s and highly competitive athletes. This
study’s reoperation rate of 20% should not be inter-
preted as the rate of meniscal healing, but as the
incidence of tibiofemoral joint symptoms. Even though
this is a higher rate than that reported for the repair of
peripheral meniscal tears, we believe the benefits of a
potentially functional meniscus outweigh the risks of
reoperation.
It is well known that the meniscus provides vital load-
bearing and shock-absorbing functions that are important
for the integrity and preservation of the articular cartilage
* Address correspondence and reprint requests to Frank R. Noyes, MD,
Cincinnati Sportsmedicine and Orthopaedic Center, Deaconess Hospital, 311
Straight Street, Cincinnati, OH 45219.
No author or related institution has received any financial benefit from
research in this study. See “Acknowledgment” for funding information.
87
in the knee joint. The increased risk for tibiofemoral joint
arthrosis after meniscectomy has been demonstrated in
several long-term clinical studies.16, 31, 34, 51
Various meniscal repair techniques have been developed
in an effort to preserve meniscal function.4, 23, 29, 33, 40, 49, 53
Most investigators have advocated repair of single longitu-
dinal tears located in the outer-third region, or the periph-
ery, of the meniscus. Tears that extended into the central-
third region were presumed to have poor healing potential
because of the limited vascularity in these areas.10, 17, 22, 46
This reasoning was supported by the work of Arnoczky
and Warren,1 who demonstrated that a direct blood sup-
ply was present in only the most peripheral 10% to 25% of
the adult meniscus, and that of King,32 who reported that
untreated meniscal tears located in the central-third re-
gion in a canine model failed to heal when isolated from
the peripheral vessels. Therefore, the recommended treat-
ment of meniscal tears that extended into the avascular
region was excision rather than repair.10, 17, 22 Addition-
ally, tears that contained multiple components in more
than one plane (complex meniscal tears) were also be-
lieved to be poor candidates for repair.
Although there have been limited reports in the English
literature describing repair techniques and results of re-
pairs for tears in the central avascular zone,8, 24 –26, 38, 49
no study, to our knowledge, has evaluated the results of
meniscal repair in a large group of patients with exclu-
sively avascular tears. Scott et al.49 presented results of
26 meniscal repairs for central tears evaluated a mean of
100 weeks after repair by arthrographic (medial meniscal
repairs) and arthroscopic (lateral meniscal repairs) eval-
uation. Nineteen of the 26 (73%) repairs were considered
healed or partially healed and 7 (27%) were classified as
failed. Subsequent reports showed improved healing of
tears in the avascular zone using new techniques such as
rasping of the parameniscal synovium, addition of a fibrin
clot to the repair, and covering the tear and clot with a
fascial patch.24 –27 Buseck and Noyes8 reported the results
of 28 meniscal repairs for tears that extended into the
88 Rubman et al.
central-third region evaluated with follow-up arthroscopic
evaluation an average of 12 months after repair. Complete
or partial healing was seen in 24 of these 28 (86%) repairs.
Based on their findings, the authors recommended that
repair of tears in the central-third region be considered in
cases in which the alternative of partial meniscectomy
would result in considerable loss of meniscal tissue and
function.
One problem in interpreting the results of meniscal
repairs is the differing methods used to assess the healing
of the meniscus after repair. These have included patient
history and clinical examination, diagnostic tests such as
arthrography or magnetic resonance imaging (MRI), and
follow-up arthroscopic evaluation. The least specific of
these methods, a physical examination, has been widely
used to determine the results of repair.12, 15, 21, 30, 48 Un-
fortunately, physical examination can only evaluate tib-
iofemoral joint symptoms and not the amount of meniscal
healing that has occurred. Theoretically, a meniscal repair
that has healed only partially, or failed to heal, may not
produce tibiofemoral joint symptoms. Arthrography or
MRI have limited sensitivity in determining tear patterns,
the portion of the tear that did not heal, actual tear size,
or general degeneration in a meniscus after repair.5, 7, 11, 35
In addition, these tests increase the cost of treatment and,
in the case of arthrography, are invasive. Follow-up ar-
throscopic evaluation has been used to evaluate the heal-
ing of meniscal repairs.8, 9, 24, 27, 28, 39, 41, 46, 52 Arthroscopy
is an invasive procedure and is not justified for clinical
research purposes alone. It thus remains problematic to
accurately assess the results of meniscal repairs and usu-
ally a combination of assessment methods is required.
In 1982, we began repairing meniscal tears, including
single and complex tears located in the central, avascular
zone of the meniscus. The purpose of this study was to
assess the results of these repairs in a large population
evaluated by either clinical examination at a minimum of
2 years after the initial repair, follow-up arthroscopic eval-
uation, or both. This is the first study that we are aware of
in the English literature that reports the results of menis-
cal repairs in a large group of patients who underwent
arthroscopic repair of single and complex tears in the
central, avascular zone.
MATERIALS AND METHODS
Subjects
From January 1982 through July 1995, 266 consecutive
meniscal tears (in 244 patients) that extended into the
central-third region of the meniscus, or had a rim width of
4 mm or greater, were repaired by one of us (FRN). To be
included in the study, a patient had to have had either an
arthroscopic examination after the initial repair or a clin-
ical examination at a minimum of 2 years after the repair.
One hundred ninety-eight meniscal repairs in 177 pa-
tients met the inclusionary criteria and composed the
study group. Of these, 180 meniscal repairs (91%) in 161
patients were evaluated with a clinical examination a
mean of 42 months (range, 23 to 116) postoperatively.
American Journal of Sports Medicine
Additionally, 91 meniscal repairs (46%) in 79 patients
were evaluated with follow-up arthroscopic evaluation a
mean of 18 months (range, 2 to 81) after the initial repair.
All follow-up arthroscopic examinations were done at least
6 months after the meniscal repair, except for four that
were required between 2 and 5 months postoperatively for
meniscal symptoms. These four repairs failed and were
included in the calculation of the reoperation and failure
rates.
One hundred six medial and 92 lateral menisci were
repaired. A single meniscus was repaired in 157 patients,
medial and lateral meniscal repairs were done in 18 pa-
tients, and 5 patients required repeat arthroscopic repairs
for previous repairs that had failed. There were 138 male
and 39 female patients whose mean age was 28 years
(range, 9 to 53). Seventy-six acute and 122 chronic menis-
cal tears were repaired. One hundred forty-six patients
(82%) sustained the injury during sports activities.
One hundred twenty-eight (72%) patients also had rup-
tures of the ACL. Of these, 126 had ACL reconstructions
performed either concurrently with the meniscal repair
(96 patients) or after the meniscal repair (30 patients).
The delayed reconstructions were performed a mean of 22
weeks (range, 2 to 208) after the meniscal repairs. Seven-
ty-two reconstructions were done with allogenic tissues
and 54 with autogenous bone-patellar tendon-bone grafts.
Surgical Procedures
The arthroscopic technique at the initial and follow-up
arthroscopic evaluation consisted of a comprehensive ex-
amination of the entire knee using 0° or 30° and 70°
arthroscopes. All injuries to the menisci and intraarticular
ligaments were identified. All articular cartilage surfaces
(femoral condyles, tibial plateaus, patella, and trochlea)
were examined and graded according to our previously
described classification system.44 The articular cartilage
was considered to be abnormal if fissuring and fragmen-
tation of more than half of the involved articular surface
was present or if any subchondral bone was exposed. Any
meniscal tear that was identified was probed to determine
the location within the meniscus and the pattern of the
tear. The tear was considered a candidate for repair if the
tear edges could be brought together without any major
gapping and no significant deformation or degeneration of
the meniscal tissue had occurred in the interval between
the tear and the repair. Repairs of single and complex
tears were performed in the cases where excision of the
tear would remove a large portion of the meniscus and
render that meniscus nonfunctioning. Cadaveric studies
have shown that even small partial meniscectomies in-
crease articular cartilage stresses and decrease load-bear-
ing surface area.2, 50 No tears in the inner-third region
were repaired.
A 0° or 30° arthroscope allowed complete visualization
of the anterior and suprapatellar compartments. Exami-
nation of the posteromedial meniscal region from an an-
terior portal with a 70° arthroscope was an important
component of the diagnostic arthroscopic procedure be-
cause the periphery of the posterior horn of the medial
Vol. 26, No. 1, 1998
meniscus could not be seen from the anterior aspect of the
knee.6, 17, 18 The 70° arthroscope allowed inspection of the
meniscosynovial junction, peripheral edge of the medial
meniscus, opening to the semimembranosus bursa, and
posterior articular surface of the medial femoral condyle.
The authors’ preferred method for repair of peripheral
and central meniscal tears was an arthroscopically as-
sisted inside-out technique, which has been previously
described.23, 38, 49 An accessory posteromedial or postero-
lateral incision was used in all cases for suture retrieval
and knot tying. An appropriately sized popliteal retractor
(Stryker Co., Kalamazoo, Michigan) was used to protect
the soft tissues during suture passage. Regardless of loca-
tion or tear pattern, 2– 0 coated polyester nonabsorbable
sutures (Ticron, Davis and Geck Co., Wayne, New Jersey;
or Ethibond, Ethicon Inc., Sommerville, New Jersey) on a
10-inch straight cutting needle were used to repair all
meniscal tears. Sutures were placed every 3 to 4 mm along
the tear length with a single-barrel arthroscopic cannula
(Richard Wolf Medical, Vernon Hills, Illinois) to rigidly
secure the meniscal tear. A straight or curved cannula
was used, depending on the location of the tear. A double-
barrel suture cannula was usually not used because the
distance between the barrels was insufficient to allow both
throws of the suture to be in good quality tissue. In some
cases, the double-barrel cannula was used if the surgeon
could move the cannula after the first suture and success-
fully increase the width of the meniscal tissue sutured.
Tension was placed on the loop of the suture after the first
needle was passed to decrease the likelihood of cutting the
suture by passage of the second needle. We favored the
single-barrel cannula because it allowed for accurate
placement of the sutures along the tear edge in tissue that
held the stitch to produce a meticulous repair, opposing
the tear edges.
The placement of the sutures along the tear depended
on the tear pattern. Single longitudinal tears were re-
Figure 1. Double-stacked vertical suture pattern used in the repair of single-longitudinal meniscal tears. A, the superior sutures
are placed first close to the superior gap and to anchor the meniscus to it bed. B, the inferior sutures can then be placed without
displacing the tear.
Arthroscopic Repair of Meniscal Tears in the Avascular Zone 89
paired with a double-stacked vertical suture every 3 to 4
mm along the length of the tear (Fig. 1). Vertical sutures
placed perpendicular to the circumferential collagen fibers
of the meniscus have a higher failure strength than do
horizontally placed sutures.45 The sutures were placed
initially in the superior (femoral) surface of the meniscus
and then into the inferior (tibial) surface. The superior
sutures were always placed first to restore the meniscus to
its bed and to ensure that the superior surface did not
displace when the suture cannula was placed beneath the
meniscus. Sutures were required on both surfaces to com-
pletely close the tear. The first pass of the double-armed
suture was placed into the peripheral portion of the tear,
and the second pass was placed vertically through the
central tissues. The sutures were brought out through the
posteromedial or posterolateral incision and tied directly
over the posterior meniscal attachment and capsule. The
sutures were tied as they were passed to determine the
apposition of the tear surfaces, regardless of tear pattern
or concurrent surgical procedures. The tension in the
suture was confirmed arthroscopically after the knot
was tied.
Double and triple longitudinal tears required additional
sutures for each tear (Fig. 2). The peripheral tears were
repaired first, followed by the central tears, both in the
same fashion as the described above for single tears. Ra-
dial tears, as well as the radial portions of the flap and
complex multiplanar tears, were repaired with horizontal
sutures placed perpendicular to the tear at 2- to 4-mm
intervals as described previously.38
Postoperative Rehabilitation
The protocol for postoperative rehabilitation followed
guidelines similar to those the senior author has advo-
cated for rehabilitation after ligamentous reconstruction
of the knee, which have remained consistent.13, 14, 36, 37
90 Rubman et al.
Figure 2. Repair technique for multiple longitudinal tears.
The peripheral tear is repaired first with superior sutures,
followed by repair of the inner tear in the same fashion.
The goal of this program was to decrease joint compressive
forces that could be disruptive to the complex meniscal
repair. We empirically selected a period of 4 weeks in
which maximal protection was used against weightbear-
ing and compressive forces. Immediate knee motion was
instituted, with the goal of achieving 0° to 90° of knee
motion within the first 7 to 10 days postoperatively and 0°
to 125° by the 3rd postoperative week. Any conditions
such as effusion or pain that limited full extension or knee
motion were addressed early in the postoperative peri-
od.43 Squatting, or deep flexion, greater than 125° was
restricted for at least 4 to 6 months after repair because
this could have produced a large disruptive force across
the repair site and risked a possible retear. Patients were
also restricted for 6 months from sports that required
jumping, cutting, or twisting maneuvers.
Crutches were used for the first 4 weeks postoperatively
to protect the repair site and to prevent the hoop stresses
that accompany full weightbearing. Patients who had sin-
gle or multiple longitudinal meniscal repairs were allowed
to begin full weightbearing by the 4th postoperative week.
Patients who had horizontal, radial, or complex multipla-
nar repairs were kept nonweightbearing for the first 4
weeks postoperatively and thereafter slowly advanced to
full weightbearing by the 6th postoperative week.
Classification of Tears
All meniscal tears were classified during the initial ar-
throscopic procedure. Rim width, tear pattern, and the
number of tear components were determined. Seven dis-
tinct tear patterns were identified. Single tears occurred
in one plane and were classified as either longitudinal,
radial, or horizontal. Multiple component, or complex,
tears were identified as 1) double longitudinal, two tears
occurring in the vertical plane; 2) triple longitudinal, three
tears occurring in the vertical plane; 3) flap, a combined
longitudinal and radial tear; or 4) complex multiplanar,
American Journal of Sports Medicine
multiple tear components in more than one plane, typically
involving longitudinal, horizontal, and radial components.
Follow-up Arthroscopic Evaluation and Determination
of Healing
The indications for follow-up arthroscopic evaluation per-
formed on the 91 meniscal repairs were 1) diagnostic,
either in conjunction with removal of tibial hardware or
for evaluation of previous ACL reconstruction or meniscal
repair, 39 menisci; 2) continuing meniscal symptoms with-
out a reinjury, 29 menisci; 3) a new injury with or without
meniscal symptoms, 15 menisci; 4) ACL reconstruction, 6
menisci; and 5) neurectomy and diagnostic, 2 menisci. A
complete arthroscopic evaluation was performed and the
site of the initial meniscal repair identified. An arthro-
scopic probe was used to evaluate the repair site, deter-
mine the stability of the remaining meniscus, and esti-
mate the percentage of healing using criteria previously
described.25 Healing was considered complete when full-
thickness apposition of the original tear occurred with no
more than 10% of the original tear remaining. The re-
paired tear was considered partially healed if at least 50%
of the original tear was healed, it was stable when probed,
and the meniscal body was in a normal position in the
tibiofemoral joint. The repair was classified as failed if
more than 50% of the original tear was present. Any
unstable segments that were displaceable into the joint
were either excised or re-repaired. Tears that were unsta-
ble and required additional sutures were classified as
failed.
Follow-up Physical Examination
The comprehensive examination of the affected knee was
performed at a minimum of 2 years after the meniscal
repair to determine range of knee motion and presence of
tibiofemoral joint pain and tibiofemoral and patellofemo-
ral crepitus. Joint line pain was determined by palpation
and by joint line compression with a McMurray test. Pa-
tients who had persistent palpable joint line pain accom-
panied by functional limitations had follow-up arthro-
scopic examinations.
Patients who had ACL reconstructions had arthromet-
ric testing (KT-2000, MEDmetrics Inc., San Diego, Cali-
fornia) to measure total anterior-posterior (AP) displace-
ment at 89 and 134 N of force. All arthrometer testing was
performed by the same examiner.54 The difference in the
measurements of the AP displacement between the in-
volved knee and the contralateral, noninvolved knee was
used for all analyses. Thirteen patients who had ACL
ruptures in the contralateral knee were excluded from
arthrometric testing. Pivot shift testing was performed on
both the involved and contralateral knee in all patients.
RESULTS
Reoperation Rate
In the group of 198 meniscal repairs, 159 (80%) were
asymptomatic for tibiofemoral joint symptoms at followup.
Vol. 26, No. 1, 1998 Arthroscopic Repair of Meniscal Tears in the Avascular Zone 91

TABLE 1 excision and 16 (46%) were stable. Of the 33 meniscal

Reoperation Rates of Meniscal Repairs for Tibiofemoral repairs that failed to heal, 20 (61%) were treated with
Joint Symptoms
partial meniscectomy, 10 (30%) with a second repair, and
Repeat arthroscopic procedure 3 (9%) with resection and subsequent replacement with a
Type of meniscal tear
N (%) meniscal allograft.
The effect of 6 factors on the healing of the 91 meniscal
Single longitudinal (N ⫽ 92) 11 (12)
Double longitudinal (N ⫽ 40) 11 (28) repairs that had follow-up arthroscopic evaluation are
Complex multiplanar (N ⫽ 26) 7 (27) shown in Table 4. Statistically significant differences were
Radial (N ⫽ 15) 4 (27) found for three factors: tibiofemoral compartment of me-
Horizontal (N ⫽ 14) 4 (29) niscal repair, time from repair to follow-up arthroscopic
Flap (N ⫽ 9) 2 (22)
evaluation, and the presence of tibiofemoral joint symp-
Triple longitudinal (N ⫽ 2) 0 (0)
toms. A trend was observed (P ⫽ 0.06) for the factor of
Total (N ⫽ 198) 39 (20)
time from original injury to initial repair. No statistically
significant difference was found for the factors of timing of
ACL reconstruction or patient age.
Repeat arthroscopic procedures were required because of
We evaluated these same 6 factors in the 43 single
subsequent tibiofemoral joint symptoms in 39 (20%) me-
longitudinal tears to remove the influence of tear pattern.
nisci in 33 patients (Table 1). Two of these 39 menisci were
A similar correlation was seen for all factors except the
classified as healed, 13 as partially healed, and 24 as
interval from repair to follow-up arthroscopic evaluation,
failed (Table 2). Of the 13 menisci classified as partially
where no significant relationship was found.
healed, 11 had limited resections of 10% to 30% of the
meniscus at the site of the initial repair, and 2, which were
stable to probing, were not treated. Of the 24 repairs
Articular Cartilage Surface Conditions
classified as failed, 8 had second repairs; 13 had partial
meniscectomies performed, in which up to 50% of the Abnormal cartilaginous surfaces were found during the
meniscal body was removed; and 3 had total meniscecto- initial meniscal repair procedure in 51 (65%) of the 79
mies and subsequent implantation of whole meniscal patients who had follow-up arthroscopic evaluation. Dur-
allografts.42 ing the follow-up arthroscopic procedure, eight patients
In the entire group of 198 meniscal repairs, 166 repairs who had normal cartilage surfaces during the initial op-
were performed in knees determined to have functional or eration showed deterioration in the medial tibiofemoral
partially functional ACLs at followup (⬍5 mm of increased compartment. Five patients who had normal cartilaginous
AP displacement on arthrometer testing or pivot shift of surfaces during the initial operation had deterioration in
grade 0 or 1). Thirty-two repairs were performed in knees the lateral tibiofemoral compartment. Eleven patients
where the ACL was ruptured or the reconstruction was had deterioration of the patellofemoral compartment
not functional at followup (Table 3). Functional status of surfaces compared with that seen during the initial
the ACL did not affect the incidence of tibiofemoral joint operation.
symptoms.

Arthroscopic Determination of Healing Physical Examination

Of the 91 meniscal repairs that were evaluated arthro-
scopically, 23 (25%) were classified as completely healed,
35 (38%) as partially healed, and 33 (36%) as failed. The
overall rate of meniscal retention (repairs healed or par-
tially healed) was 64% (58 of 91). Of the 35 meniscal
repairs that partially healed, 19 (54%) required partial
At followup, 160 of the 161 patients examined had no or
only a mild joint effusion. A moderate effusion was present
in one. A full normal range of knee motion (0° to 135°) was
found in 150 (94%) patients. The other 11 patients had
either a mild loss of extension (1° to 5°) or a mild loss of
flexion (less than 10° from 135°). Nine of these patients

TABLE 2
Healing Rates of 91 Meniscal Repairs That Had Follow-up Arthroscopy
Healed Partially healed Failed
Type of meniscal tear
a a
All TF symptoms All TF symptoms All TF symptoms a

Single longitudinal (N ⫽ 43) 13 1 19 2 11 8

Double longitudinal (N ⫽ 20) 5 0 7 4 8 7
Complex multiplanar (N ⫽ 14) 3 0 4 3 7 4
Radial (N ⫽ 5) 1 0 3 3 1 1
Horizontal (N ⫽ 5) 1 1 1 1 3 2
Flap (N ⫽ 2) 0 0 0 0 2 2
Triple longitudinal (N ⫽ 2) 0 0 1 0 1 0
Total (N ⫽ 91) 23 2 35 13 33 24
a
Menisci that had follow-up arthroscopy because of tibiofemoral compartment symptoms.
92 Rubman et al.
TABLE 3
Reoperation Rates According to ACL Function
Menisci that required follow-up
arthroscopic procedures for
a
ACL function tibiofemoral joint symptoms
N (%)
Functional (N ⫽ 166) 32 (19)
Not functional (N ⫽ 32) 7 (22)
Total (N ⫽ 198) 39
a
Functional ⫽ ⬍5 mm of increased AP displacement on ar-
thrometer testing or pivot shift grade of 0 or 1 for patients with
bilateral ACL ruptures; nonfunctional ⫽ ⬎5 mm of increased
displacement or pivot shift grade of 2 or 3.
had also had ACL reconstructions. No patient had a loss of
both flexion and extension.
Before the initial meniscal repair, no or only mild pal-
pable tibiofemoral crepitus was found in 160 of the 161
knees, and moderate crepitus was found in 1. At followup,
three other patients had moderate palpable crepitus. Be-
fore the initial meniscal repair, moderate patellofemoral
crepitus was present in seven patients. At followup, 15
(9%) had moderate crepitus. Twelve of these 15 patients
had ACL reconstructions performed with the meniscal
repairs.
At followup, moderate tibiofemoral joint line pain was
found in three patients, all of whom had subsequent fol-
low-up arthroscopic evaluation.
The results of arthrometric testing performed in 113
patients showed that 74 (65%) patients had less than 3
mm of increased AP displacement, 26 (23%) patients had
3 to 5.5 mm, and 13 (12%) patients had 6 mm or more
increased displacement at 89 N. Only two patients in the
autograft bone-patellar tendon-bone group had more than
6 mm of increased displacement. Similar findings were
noted at 134 N.
Postoperative Complications
Eleven patients (15 meniscal repairs) sustained new inju-
ries to their knees postoperatively and had follow-up ar-
throscopic evaluation, during which time 2 of these re-
pairs were classified as healed, 3 as partially healed, and
10 as failed. The mechanisms or causes of the reinjuries
were motor vehicle accident 6 weeks postoperatively, 1
patient; fall 4 months postoperatively, 1 patient; sports
twisting injuries 4 to 8 months postoperatively, 2 patients;
fall during daily activities 2 years postoperatively, 2 pa-
tients; sports twisting injuries 4 years postoperatively, 5
patients; sports injury 5 years postoperatively, 1 patient;
activities of daily living twisting injury 5 years postoper-
atively, 2 patients; and work injury 6 years postopera-
tively, 1 patient. Seven of the 10 failed repairs occurred at
the site of the initial repair and 3 were at sites other than
that of the initial repair. These latter three repairs had
healed at the site of the initial meniscal repair, but they
were classified as failed because of the loss of meniscal
tissue and function.
One patient (one meniscal repair) became infected with
a low virulent staphylococcus bacteria that resolved with
American Journal of Sports Medicine
arthroscopic irrigation, debridement, and antibiotic treat-
ment. Another patient developed an infrapatellar neu-
roma and required subsequent arthroscopic treatment
and neurectomy.
DISCUSSION
This investigation represents the first report in the En-
glish literature to critically evaluate arthroscopic menis-
cal repairs in a large group of patients with exclusively
single or complex tears that extended into the avascular
zone. We found that 159 of the 198 meniscal repairs (80%)
were asymptomatic a minimum of 2 years postoperatively
and that only 39 repairs (20%) required reoperation for
symptoms consistent with a possible meniscal tear. We
interpret these findings to be encouraging in light of the
complexity of the procedure and the potential benefits
achieved from not performing an extensive partial menis-
cectomy. The reoperation rates for tibiofemoral joint
symptoms were 12% for single longitudinal tears, 28% for
double longitudinal tears, and 27% for the most difficult
complex multiplanar tears.
The results of this investigation allow recommendation
of repair of meniscal tears that extend into the avascular
central zone for select patients. These include young pa-
tients, especially those in the 2nd and 3rd decades of life,
and highly competitive athletes who desire to participate
in strenuous activities. Additionally, the preservation of
meniscal tissue is especially warranted in patients with
varus or valgus lower extremity malalignment that pro-
duces high medial or lateral tibiofemoral compartment
loads. These patients require a functional, load-sharing
meniscus to prevent early articular cartilage degenera-
tion. Excision of a meniscal tear that extends into the
central zone usually requires removal of a large portion of
the meniscus, severely limiting its function.
This study’s overall reoperation rate of 20% should not
be interpreted to be the rate of meniscal healing, but
rather the incidence of tibiofemoral joint symptoms that
occurred in our group of 198 meniscal repairs. The reop-
eration rate is used to allow patients to understand the
potential for future symptoms and surgery if they under-
go a repair of an avascular meniscal tear. Although this
rate represents a lower clinical success rate than that
reported for the repair of peripheral-third longitudinal
tears,3, 8, 12, 15, 41 we believe that in the properly selected
patient the benefits of a potentially functional meniscus
outweigh the risks of reoperation. Our complication rate
was low, and only 11 patients had slight limitation of knee
motion at followup. Nine of these patients had undergone
ACL reconstructions in addition to the meniscal repair. It
has been shown in previous reports that the risk of post-
operative motion complications increases with additional
procedures.19, 43
The meniscal repairs in this study were performed by
one surgeon and were evaluated with either follow-up
arthroscopic evaluation, a comprehensive physical exam-
ination at least 2 years after the repair, or both. Although
no clinically proven method or diagnostic test is currently
available to determine the true function of a repaired
Vol. 26, No. 1, 1998 Arthroscopic Repair of Meniscal Tears in the Avascular Zone 93

TABLE 4
Effect of Various Factors on Healing Rates of Meniscal Repairs That Had Follow-up Arthroscopy
Healed Partially healed Failed
Factor
N (%) N (%) N (%)

Tibiofemoral compartment of menisal repair a

Medial (N ⫽ 47) 8 (17) 15 (32) 24 (51)
Lateral (N ⫽ 44) 15 (34) 20 (45) 9 (20)
Time from meniscal repair to follow-up arthroscopy b
ⱕ12 months (N ⫽ 61) 18 (30) 27 (44) 16 (26)
⬎12 months (N ⫽ 30) 5 (17) 8 (27) 17 (57)
Timing of ACL reconstruction
With meniscal repair (N ⫽ 39) 12 (31) 18 (46) 9 (23)
After meniscal repair (N ⫽ 27) 9 (33) 11 (41) 7 (26)
Presence of tibiofemoral compartment symptoms c
Symptomatic (N ⫽ 39) 2 (5) 13 (33) 24 (62)
Asymptomatic (N ⫽ 52) 21 (40) 22 (42) 9 (17)
Time from original knee injury to meniscal repair d
ⱕ10 weeks (N ⫽ 33) 13 (39) 10 (30) 10 (30)
⬎10 weeks (N ⫽ 58) 10 (17) 25 (43) 23 (40)
Patient age
⬍25 years (N ⫽ 44) 13 (30) 17 (39) 14 (32)
ⱖ25 years (N ⫽ 47) 10 (21) 18 (38) 19 (40)
a
P ⫽ 0.008.
b
P ⫽ 0.02
c
P ⫽ 0.0001.
d
P ⫽ 0.06.

meniscus in terms of its load-sharing abilities, clinical
examination and follow-up arthroscopic evaluation can
give an indication of meniscal function. With careful ar-
throscopic evaluation, meniscal tissue integrity can be
determined and all repair sites or tears identified and
assessed. Displacement of the meniscus out of the tib-
iofemoral joint can also be evaluated. Unfortunately, fol-
low-up arthroscopic evaluation is an invasive procedure
that exposes the patient to an additional period of recu-
peration and risk, even though limited. These issues, plus
cost-containment concerns prevalent in health care today,
have made follow-up arthroscopic evaluation unsuitable
for clinical research purposes alone. The cost of noninva-
sive diagnostic procedures such as MRI also precludes
their use in a large series. This leaves clinical examination
as the only method for assessing meniscal function after
repair in a large group of patients.
We believe that a comprehensive clinical examination
performed at least 2 years after meniscal repair will detect
a failure in the majority of patients. In this investigation,
159 of the 198 repairs resulted in the patient having no
symptoms related to meniscal failure, such as tibiofemoral
joint pain, locking, or clicking. Nine of these 159 patients
(6%) had follow-up arthroscopic procedures for reasons
other than tibiofemoral joint pain, and they had repairs
that were classified as failed (Table 2). The indications for
arthroscopic procedures in these patients were new inju-
ries in two, symptoms related to the ACL tibial fixation in
four, ACL allograft reconstruction in two, and neurectomy
for saphenous neuritis symptoms in one. We considered
these nine repairs as false-negative results, which brought
to light the limitation of physical examination as a truly
reliable method of assessing healing. On the other hand,
two meniscal repairs that required follow-up arthroscopic
evaluation because of tibiofemoral joint symptoms had
menisci that were observed to be completely healed.
Therefore, we did not calculate an overall failure rate for
the entire group of 198 repairs because of the limitations
of physical examination in determining meniscal healing.
A limitation of this study was the small number of
meniscal tears in many of the individual classification
categories. Specific conclusions could not therefore be ob-
tained on the success of our repairs for each tear classifi-
cation. The pattern of meniscal tears has been previously
presumed to have an effect on healing, with the more
complex tears hypothesized to have a lower rate of heal-
ing. Our findings indicated that the tear pattern may have
had an effect on meniscal healing, but the differences were
not statistically significant, in part, because of the limited
numbers available. For all 198 repairs, we identified 3
factors that had an effect on meniscal healing. These were
the presence of tibiofemoral symptoms, the time interval
from repair to follow-up arthroscopic evaluation, and the
tibiofemoral compartment of the meniscal repair.
The time interval from the initial repair to follow-up
arthroscopic evaluation correlated with meniscal healing.
Menisci examined more than 1 year after a repair had a
higher rate of tibiofemoral joint symptoms and failed re-
pairs than those examined less than 1 year postopera-
tively. The mean time from the repair to the follow-up
arthroscopic evaluation in the 39 menisci with tibiofemo-
ral symptoms attributed to a failed repair was 24 months
(range, 3 to 81). Of these 39, 25 (64%) had an interval
longer than 12 months. Twenty-one (64%) of the 33 re-
pairs that were proven failed by follow-up arthroscopic
evaluation occurred more than 1 year after the repair: 15
between 1 and 3 years, and 6 between 3 and 5 years after
repair. These data indicate that over half of the meniscal
repairs may have functioned normally for up to 5 years
before the onset of symptoms. The causes of the late symp-
94 Rubman et al.
toms in the cases where no reinjury occurred are unknown
and demonstrate the importance of long-term followup of
all meniscal repair procedures.
In this study, the results showed that the lateral me-
niscal repairs had a significantly higher rate of retention
than the medial meniscal repairs, regardless of tear pat-
tern. This finding is similar to other reports that showed
higher rates of failure of medial meniscal repairs when
compared with lateral meniscal repairs for reasons that
are currently unknown.41, 46, 49
In the present study, no statistical difference was noted
between the reoperation rate and the function of the ACL
as determined by arthrometer and pivot shift testing.
Previous studies have reported that meniscal repairs in
cruciate-deficient knees had a higher rate of failed repairs
because of the presence of abnormal motion lim-
its.9, 20, 41, 46, 52 We also found no statistical difference in
the rate of meniscal healing, or in the percentage of me-
nisci that required follow-up arthroscopic evaluation,
when an ACL reconstruction was performed concurrently
with the meniscal repair (96 patients) or after the repair
(30 patients).
Our current protocol for repair of meniscal tears relies
on several technical details that the authors consider to be
essential for the successful repair of simple and complex
meniscal tears extending into, or solely located in, the
avascular central-third region. A careful examination is
required to determine the integrity of the meniscal tissue
and assess chronic changes, such as deformation or degen-
eration. The meniscus must contain a reducible tear with
good tissue integrity that will maintain its position in the
joint once repaired. Degenerative, poor quality meniscal
tissue is not strong enough to hold the sutures and should
not be considered for repair. Stable fixation of the menis-
cal tear decreases the possibility of motion between the
meniscal fragments and allows a postoperative reha-
bilitation program that emphasizes early motion and
weightbearing.
Multiple, nonabsorbable sutures, vertically stacked in
both the superior and inferior surfaces of the meniscus,
are placed every 3 to 4 mm to ensure the repair will be
held in position to allow healing to occur.38, 47 A recent
report of the results of repair of longitudinal meniscal
tears evaluated arthroscopically found that no tear with a
rim width of greater than 4 mm healed.52 The sutures in
that study were placed at least 4 mm apart. It is the
authors’ opinion that complex tear patterns and meniscal
tears in the central region are subjected to higher stresses
than those incurred in single longitudinal tears located in
the periphery and, therefore, require sutures to be placed
at closer intervals. Because the location of the tear within
the meniscus is not a primary consideration for which
tears are amenable to repair, we no longer measure the
rim width at the time of repair. All tears that undergo
repair, regardless of pattern or location, are held in place
with multiple sutures placed at 3- to 4-mm intervals.
The tear patterns and locations found in the patients in
the current study are not uncommon and, when they occur
in young or active patients, represent a treatment di-
lemma. Partial meniscectomy for complex tear patterns or
American Journal of Sports Medicine
tears that extend into the avascular zone require removal
of a large portion of the meniscus and may render it
nonfunctional. If meniscal repair is performed, the short-
term data in our study show that at 2 years after surgery,
a majority of the patients will be asymptomatic. The long-
term function of these menisci needs to be determined in
future studies.
ACKNOWLEDGMENT
This research was funded by the Cincinnati Sportsmedi-
cine Research and Education Foundation.
REFERENCES
1. Arnoczky SP, Warren RF: Microvasculature of the human meniscus.
Am J Sports Med 10: 90 –95, 1982
2. Baratz ME, Fu FH, Mengato R: Meniscal tears: The effect of meniscec-
tomy and of repair on intraarticular contact areas and stress in the human
knee. A preliminary report. Am J Sports Med 14: 270 –275, 1986
3. Barber FA: Meniscus repair: Results of an arthroscopic technique. Arthros-
copy 3: 25–30, 1987
4. Barber FA, Stone RG: Meniscal repair. An arthroscopic technique. J Bone
Joint Surg 67B: 39 – 41, 1985
5. Bonamo JJ, Shulman G: Double contrast arthrography of the knee. A
comparison to clinical diagnosis and arthroscopic findings. Orthopedics
11: 1041–1046, 1988
6. Boytim MJ, Smith JP, Fischer DA, et al: Arthroscopic posteromedial
visualization of the knee. Clin Orthop 310: 82– 86, 1995
7. Bronstein R, Kirk P, Hurley J: The usefulness of MRI in evaluating menisci
after meniscus repair. Orthopedics 15: 149 –152, 1992
8. Buseck MS, Noyes FR: Arthroscopic evaluation of meniscal repairs after
anterior cruciate ligament reconstruction and immediate motion.
Am J Sports Med 19: 489 – 494, 1991
9. Cannon WD Jr, Vittori JM: The incidence of healing in arthroscopic me-
niscal repairs in anterior cruciate ligament-reconstructed knees versus
stable knees. Am J Sports Med 20: 176 –181, 1992
10. Cooper DE, Arnoczky SP, Warren RF: Meniscal repair. Clin Sports Med
10: 529 –548, 1991
11. Daniel D, Daniels E, Aronson D: The diagnosis of meniscal pathology. Clin
Orthop 163: 218 –224, 1982
12. DeHaven KE, Lohrer WA, Lovelock JE: Long-term results of open menis-
cal repair. Am J Sports Med 23: 524 –530, 1995
13. DeMaio M, Mangine RE, Noyes FR, et al: Advanced muscle training after
ACL reconstruction: Weeks 6 to 52. Orthopedics 15: 757–767, 1992
14. DeMaio M, Noyes FR, Mangine RE: Principles for aggressive rehabilita-
tion after reconstruction of the anterior cruciate ligament. Orthopedics 15:
385–392, 1992
15. Eggli S, Wegmüller H, Kosina J, et al: Long-term results of arthroscopic
meniscal repair: An analysis of isolated tears. Am J Sports Med 23:
715–720, 1995
16. Fairbank FJ: Knee joint changes after meniscectomy. J Bone Joint Surg
30B: 664 – 670, 1948
17. Fu FH, Baratz M: Meniscal injuries, in DeLee JC, Drez DJ (eds): Ortho-
paedic Sports Medicine. Second edition. Philadelphia, WB Saunders,
1994, pp 1146 –1162
18. Gillquist J, Hagberg G, Oretorp N: Arthroscopic visualization of the pos-
teromedial compartment of the knee joint. Orthop Clin North Am 10:
545–547, 1979
19. Graf B, Uhr F: Complications of intra-articular anterior cruciate reconstruc-
tion. Clin Sports Med 7: 835– 848, 1988
20. Hanks GA, Gause TM, Handal JA, et al: Meniscus repair in the anterior
cruciate deficient knee. Am J Sports Med 18: 606 – 613, 1990
21. Hanks GA, Gause TM, Sebastianelli WJ, et al: Repair of peripheral
meniscal tears: Open versus arthroscopic technique. Arthroscopy 7: 72–
77, 1991
22. Hendler RC: Arthroscopic meniscal repair. Surgical technique. Clin Orthop
190: 163–169, 1984
23. Henning CE: Arthroscopic repair of meniscus tears. Orthopedics 6: 1130 –
1132, 1983
24. Henning CE, Clark JR, Lynch MA, et al: Arthroscopic meniscus repair with
a posterior incision. Instr Course Lect 37: 209 –221, 1988
25. Henning CE, Lynch MA, Clark JR: Vascularity for healing of meniscus
repairs. Arthroscopy 3: 13–18, 1987
26. Henning CE, Lynch MA, Yearout KM, et al: Arthroscopic meniscal repair
using an exogenous fibrin clot. Clin Orthop 252: 64 –72, 1990
Vol. 26, No. 1, 1998
27. Henning CE, Yearout KM, Vequist SW, et al: Use of the fascia sheath
coverage and exogenous fibrin clot in the treatment of complex meniscal
tears. Am J Sports Med 19: 626 – 631, 1991
28. Horibe S, Shino K, Nakata K, et al: Second-look arthroscopy after menis-
cal repair. Review of 132 menisci repaired by an arthroscopic inside-out
technique. J Bone Joint Surg 77B: 245–249, 1995
29. Jakob RP, Stäubli HU, Zuber K, et al: The arthroscopic meniscal repair.
Techniques and clinical experience. Am J Sports Med 16: 137–142, 1988
30. Jensen NC, Riis J, Robertsen K, et al: Arthroscopic repair of the ruptured
meniscus: One to 6.3 years follow up. Arthroscopy 10: 211–214, 1994
31. Johnson RJ, Kettelkamp DB, Clark W, et al: Factors affecting late results
after meniscectomy. J Bone Joint Surg 56A: 719 –729, 1974
32. King D: The healing of semilunar cartilages. J Bone Joint Surg 18: 333–
342, 1936
33. Lindenfeld TN: Arthroscopically aided meniscal repair. Orthopedics 10:
1293–1296, 1987
34. Lynch MA, Henning CE, Glick KR Jr: Knee joint surface changes. Long-
term follow-up meniscus tear treatment in stable anterior cruciate ligament
reconstructions. Clin Orthop 172: 148 –153, 1983
35. Manco LG, Berlow ME: Meniscal tears— comparison of arthrography, CT,
and MRI. Crit Rev Diagn Imaging 29: 151–179, 1989
36. Mangine RE, Noyes FR, DeMaio M: Minimal protection program: Ad-
vanced weight bearing and range of motion after ACL reconstruction—
Weeks 1 to 5. Orthopedics 15: 504 –515, 1992
37. McLaughlin J, DeMaio M, Noyes FR, et al: Rehabilitation after meniscus
repair. Orthopedics 17: 463– 471, 1994
38. McLaughlin JR, Noyes FR: Arthroscopic meniscus repair: Recommended
surgical techniques for complex meniscal tears. Tech Orthop 8: 129 –136,
1993
39. Miller DB Jr: Arthroscopic meniscus repair. Am J Sports Med 16: 315–320,
1988
40. Morgan CD, Casscells SW: Arthroscopic meniscus repair: A safe ap-
proach to the posterior horns. Arthroscopy 2: 3–12, 1986
Arthroscopic Repair of Meniscal Tears in the Avascular Zone 95
41. Morgan CD, Wojtys EM, Casscells CD, et al: Arthroscopic meniscal repair
evaluated by second-look arthroscopy. Am J Sports Med 19: 632– 638,
1991
42. Noyes FR, Barber-Westin SD: Irradiated meniscus allografts in the human
knee. A two to five year follow-up study, Orthop Trans 19: 417, 1995
43. Noyes FR, Mangine RE, Barber SD: The early treatment of motion com-
plications after reconstruction of the anterior cruciate ligament. Clin Or-
thop 277: 217–228, 1992
44. Noyes FR, Stabler CL: A system for grading articular cartilage lesions at
arthroscopy. Am J Sports Med 17: 505–513, 1989
45. Rimmer MG, Nawana NS, Keene GCR, et al: Failure strengths of different
meniscal suturing techniques. Arthroscopy 11: 146 –150, 1995
46. Rosenberg TD, Scott SM, Coward DB, et al: Arthroscopic meniscal repair
evaluated with repeat arthroscopy. Arthroscopy 2: 14 –20, 1986
47. Rubman MH, Noyes FR, Barber-Westin SD: Technical considerations in
the management of complex meniscus tears. Clin Sports Med 15: 511–
530, 1996
48. Ryu RKN, Dunbar WH IV: Arthroscopic meniscal repair with two-year
follow-up: A clinical review. Arthroscopy 4: 168 –173, 1988
49. Scott GA, Jolly BL, Henning CE: Combined posterior incision and arthro-
scopic intra-articular repair of the meniscus: An examination of factors
affecting healing. J Bone Joint Surg 68A: 847– 861, 1986
50. Seedhom BB, Hargreaves DJ: Transmission of the load in the knee joint
with special reference to the role of the menisci. Part II. Experimental
results, discussion, and conclusions. Eng Med 8: 220 –228, 1979
51. Sommerlath K, Gillquist J: The long-term course of various meniscal
treatments in anterior cruciate ligament deficient knees. Clin Orthop 283:
207–214, 1992
52. Tenuta JJ, Arciero RA: Arthroscopic evaluation of meniscal repairs. Fac-
tors that effect healing. Am J Sports Med 22: 797– 802, 1994
53. Warren RF: Arthroscopic meniscus repair. Arthroscopy 1: 170 –172, 1985
54. Wroble RR, Van Ginkel LA, Grood ES, et al: Repeatability of the KT-1000
arthrometer in a normal population. Am J Sports Med 18: 396 –399,
1990