Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-015-3717-2
KNEE
A history of meniscal surgery: from ancient times to the
twenty‑first century
B. Di Matteo1 · C. J. Moran2 · V. Tarabella1 · A. Viganò3 · P. Tomba3 · M. Marcacci1 ·
R. Verdonk4 
Received: 24 April 2015 / Accepted: 13 July 2015
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
Abstract  The science and surgery of the meniscus have
evolved significantly over time. Surgeons and scientists
always enjoy looking forward to novel therapies. How-
ever, as part of the ongoing effort at optimizing interven-
tions and outcomes, it may also be useful to reflect on
important milestones from the past. The aim of the present
manuscript was to explore the history of meniscal surgery
across the ages, from ancient times to the twenty-first cen-
tury. Herein, some of the investigations of the pioneers in
orthopaedics are described, to underline how their work
has influenced the management of the injured meniscus in
modern times.
Level of evidence V.
Keywords  History of surgery · Meniscus · Meniscal
treatments · Meniscectomy · Scaffold · Allograft
Introduction
One hundred and thirty-one years have passed since the
first reported operative treatment on the meniscus [14].
* B. Di Matteo
berardo.dimatteo@gmail.com
1 derived from the greek “μηνίσκος, a diminutive form of
II Orthopaedic Clinic and Biomechanics Laboratory,
Rizzoli Orthopaedic Institute, Via di Barbiano n. 1/10,
40136 Bologna, Italy
2
Trinity College and Sports Surgery Clinic, Dublin, Ireland
3 [21]. It was many years later that surgeons and physicians
Donazione Putti, Biblioteche Scientifiche Istituto Ortopedico
Rizzoli, Rizzoli Orthopaedic Institute, Via Pupilli n. 1,
40136 Bologna, Italy
4
Orthopaedics and Traumatology, Gent State University,
Ghent, Belgium
Since that time there have been many important contribu-
tions to the knowledge of its biology and biomechanics.
This knowledge, along with the development and refine-
ment of new surgical techniques, has led to a range of
novel treatment options and improvements in patient care
[10, 20, 42]. Each year a growing number of publications
can be documented that continue to shape the state of the
art in meniscus surgery [1, 31, 38, 43, 46]. Surgeons and
scientists always enjoy looking forward, but it may also
be useful to look back, question and reflect on important
milestones from the past [27]. The aim of the present man-
uscript is to explore the history of meniscal surgery across
the ages, from ancient times to the twenty-first century.
A historical perspective
The ancient times: from poetry to arthrotomy
Sappho (ca 630–570 BC) has been linked to the first
recorded use of the word “Meniscus”, as the name of the
mourning father of a fisherman, in a poem entitled “The
Fisherman’s Tomb” [34]. In keeping with custom around
that time, it is possible to speculate that the name was
derived from the moon phase on the day of his birth, as
the word meniscus, meaning “crescent-shaped body”, was
“μήνη”, moon. The first use of the term meniscus in a sci-
entific context was by Johannes Kepler when describing a
lens in his book “Dioptrice”, which was published in 1611
started to adopt the term for the use we are accustomed to.
Instead, for centuries, the most common way to describe
the knee meniscus was “semilunar cartilage” or, in the orig-
inal Latin, “cartilago semilunaris”.
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 Knee Surg Sports Traumatol Arthrosc

When looking specifically at the history of relevant

medical literature, we should first consider “On Fractures”,
one of the few works inside the so-called Hippocratic Cor-
pus that scholars really consider as a genuine writing by
Hippocrates himself (ca 460–370 BC) [19]. These writings,
dating back at around 400 BC, described injuries of the
long bones and joints of the body. Hippocrates presented
the clinical features of fractures and how to heal them, and
in doing so, he left the first written medical account on the
difficulty of repairing the knee joint, and the first (and for
many years the only one) brief mention of something called
“cartilage”. The Hippocratic experience and the following
writings by Galen of Pergamon (129–216 BC) were, for
more than a 1000 years, the only recognized and approved
“know-how” about human anatomy, due to the fact that
anatomical dissections were largely forbidden in late Clas-
sical Age and for the most part of the Middle Ages. For a
very long time, the shadow of the Dark Ages provided a
complete shutdown for anatomical research, a shroud that
started to lift just at the end of thirteen century with the
works of Mondino de’ Liuzzi and then Jacopo Berengario
da Carpi. The writings of these authors resurrected classical
Greek and Roman teachings, reporting them with reverence
and without critical thinking, still full of awe for the ancient
auctoritas (i.e. authority) and entangled with mediaeval
religion and astrology. To find a real step forward towards
modern times, we need to proceed forward to the Renais-
sance and in particular to the work of Andreas Vesalius
and his “De Humani Corporis Fabrica” published in 1543 Fig. 1  Frontispiece from “De Humani Corporis Fabrica” by Andreas
(Fig. 1). This work provides a complete description of the Vesalius (1543)
human body based on dissections made by the author [44].
By introducing the world to a modern view of anatomy,
Vesalius was the father of several important discoveries and nineteenth century saw other fascinating writings appear:
legitimately coined new anatomical terms. Among these, the beautifully illustrated meniscus (Fig. 4) inside the
he proposed to his peers the definition of “cartilago semi- “Icones Anatomicae” by Floriano Caldani [7]; a large sam-
lunaris” to name the cartilaginous structures located on the ple of clinical cases, including the “internal derangement
tibial plateau (Fig. 2). Following the path opened by “De of the knee joint” and “loose cartilaginous substance in the
Humani Corporis Fabrica”, many anatomists and physician joints”, described by William Hey [18]; and a monography
began even deeper examinations of the body. In 1706, Gio- on dislocations and fractures of the joints by Astley Cooper
vanni Battista Morgagni published the “Adversaria Ana- (Fig. 5) [9].
tomica Prima” [29], a six-volume work aimed at improving From a surgical point of view, all meniscus history
and clarifying the knowledge about anatomy (Fig. 3). since Hippocrates to Cooper focused on conservative
In 1731, Heinrich Bass was one of the first physicians treatment. The turning point in the approach to this par-
to combine anatomical analysis with surgical teaching in ticular pathology is embodied by the achievements of
his book [4] entitled “Observationes Anatomico Chirurgico Scottish surgeon Sir Thomas Annandale, and his revolu-
Medicae”. A whole chapter considers the anatomy of the tionary procedure performed in 1883: the first meniscal
knee and also describes a meniscal luxation case occur- repair in medical history [14]. In his milestone paper, Sir
ring in a 40-year-old woman and being treated by manual Thomas wrote: “it is a clinical fact that one of the semilu-
reduction. nar cartilage, usually the internal one, does occasionally
“The Chirurgical Observations and Cases” of William become loosened from its attachments; and, in conse-
Bromfield, published in 1773, described a case of “tem- quence, this body is liable to be displaced either forwards
porary lameness from one of the semilunar cartilages of or backwards, and so to interfere with the proper move-
the joint flipping out of its place” [6]. The first half of the ments of the knee joint”. A 30-year-old miner came to

13
Knee Surg Sports Traumatol Arthrosc
Fig. 2  Close-up of the menisci
from “De Humani Corporis
Fabrica” by Andreas Vesalius
(1543)
Dr. Annandale’s attention complaining of “acute pain in
certain movements of the joint, which frequently became
locked in the flexed position […] and also the movements
of the joint were interfered with by something ‘slipping’
in the knee”. The surgeon, after unsuccessful conservative
approach, devised and performed the first meniscal repair
procedure in history: “…the semilunar cartilage was com-
pletely separated from its attachments and was displaced
backwards about half an inch. The anterior edge of this
cartilage was seized by a pair of artery catch forceps, and
it was drawn forwards into its natural position, and held
there until three stitches of chromic catgut were passed
through it and through the fascia and periosteum covering
the margin of the tibia. The forceps were then withdrawn,
the cartilage remaining securely stitched in position
(Fig.  6)”. Six months after surgery, the patient reported
complete healing and recovery of the knee function.
Annandale was also the first surgeon to perform, a few
years later (1889), the first meniscectomy ever described,
in a patient suffering for a massive, irreparable lesion
[14]. Annadale performed meniscal surgery throughout all
his career, establishing a pioneering procedure that over-
turned all the accepted theories about the possible treat-
ment options for meniscal pathologies. A new era started
thanks to Annandale’s contribution, the era of the surgical
management of meniscal injuries.
Modernity: from arthrotomy to arthroscopy
In 1908, Moritz Katzenstein published the first case series
regarding meniscus surgery, his report appearing in a Ger-
man medical journal [30]. This study was on a series of
seven meniscal repairs with a follow-up of up to 7 years.
He treated very different patients, including a 6-year-old
girl and a 27-year-old man, by using silk suture to repair
the torn meniscus. The rehabilitation protocol consisted of
3 weeks of bracing associated with early isometric mus-
cular strengthening. Results were overall very positive up
to middle term evaluation, thus suggesting the beneficial
effects of meniscal repair compared with meniscectomy.
Based on these findings, Katzenstein also reviewed the lit-
erature on meniscal resection and stated that initially good
results deteriorated over time because of the development
of a varus deformity and loss of normal function associated
with pain. He also pointed out that long-term follow-up is
critical for judging clinical results. He believed that only
“in a minority of cases (1 of 10) resection of the meniscus
results in permanently good function”. In all other cases,
residual deficits and complaints remained. He stated that
“this was not astonishing, since with resection of the menis-
cus, an important part of the joint is removed”. Katzen-
stein was also aware of the limitations of meniscal repair.
He stated that “it does not make sense to try to suture a
severely degenerated or misformed meniscus, in all other
cases I would strongly advise repairing a torn meniscus”.
The insight and information provided in Katzenstein’s arti-
cle is remarkable considering how long it has taken since
then for meniscal repair to become the procedure of choice
when possible.
In 1936, Don King reported on a series of experiments
in dogs and concluded that the menisci do protect hyaline
cartilage, improve joint congruity, increase its stability and
enhance lubrication [23]. He also noted that the meniscec-
tomy site was filled with fibrocartilage that appeared indis-
tinguishable from meniscal tissue but which did not prevent
degenerative change in the articular surface. King also went
13

Fig. 3  Close-up of the menisci
from “Adversaria Anatomica
Prima” by Giovanni Battista
Morgagni (1706)
on to investigate healing and found that “tears limited to the
semilunar cartilage probably never heal” but that “a torn
meniscus can be healed […] if the tear communicates with
the synovial membrane […]”. Despite the importance of
these data, which remain relevant to this day, the first sig-
nificant paper demonstrating the clinical effects of meniscal
removal was published by Sir Thomas Fairbank in 1948.
The author showed a dramatic degeneration of articular
cartilage over time after meniscectomy [16]. However, a
few years later, the prominent Scottish surgeon Ian Smil-
lie suggested that “[…] the importance of the lesion on
the medial side is not only the loss of function but also
the future welfare of the joint, in terms of rupture of the
anterior cruciate ligament from interference with the
screw-home movement and destruction of the articular
13
Knee Surg Sports Traumatol Arthrosc
cartilage of the femoral condyle from direct pressure. […]
Once the diagnosis is established the sooner meniscec-
tomy is performed the quicker the recovery and the better
the long-term result […]” [37]. The understanding of the
meniscus evolved further over the late 1960s and 1970s as
new data became available to demonstrate their important
role. In 1969, Edward Tapper reported that, at 10–30 years
of follow-up, there was evidence of degenerative changes
in the post-meniscectomy knee and that there were bet-
ter results when the rim was left intact [40]. He also noted
worse results at follow-up in women and also in patients
less than 20 years of age (who had traumatic meniscal rup-
ture and prolonged physical participation with respect to
patients affected by more degenerative type tears). It was
also reported in 1976 that the meniscus played an essential
Knee Surg Sports Traumatol Arthrosc

Fig. 4  Close-up of the menisci

from “Icones Anatomicae” by
Leopoldo Caldani (1813)

Fig. 6  Close-up of the meniscus from the paper “Excision of the

internal semilunar cartilage, resulting in perfect restoration of the
joint-movements” by Thomas Annandale (1889)

and quantifiable part in “[…] energy absorbing and load

Fig. 5  Close-up of the menisci from “Treatise on dislocations and
fractures of the joints” by Astley Cooper (1826)
transmission functions across the knee joint […]” [24].
The same study also noted that the compressed meniscus
was deformed rather than pushed away during loading at
the knee, demonstrating the presence and role of “hoop
stresses” in its function [22, 25].
A history of meniscal surgery must also focus on the
achievements made in surgical techniques around this time,
with Japanese surgeons playing a major role in the devel-
opment of arthroscopy. Masaki Watanabe (1921–1994) is
regarded as the father of arthroscopy, and he is believed to

13

Fig. 7  Microvasculature of meniscus (republished by courtesy of
Sage Publication, in accordance with the STD Guidelines “Opt out”
policy—originally published on the Am J Sports Med 1982;10:90–
95)
have performed the first arthroscopic meniscectomy around
1962 [2]. The first reported arthroscopic meniscal repair
was performed by Hiroshi Ikeuchi in 1969. Robert Jackson
is credited with introducing arthroscopic meniscal surgery
in the USA in 1968, following his visit to Watanabe and
Ikeuchi in the mid-1960s. The following years saw fur-
ther understanding of the importance of the meniscus and
the role of meniscal surgery, with the work of people such
as Lanny L. Johnson, David J. Dandy, Ward S. Casscells,
Carl-Joachim Wirth and Kenneth E. DeHaven [8, 11, 13,
35, 47]. Charles Henning pioneered an inside-out arthro-
scopic repair technique in the early 1980s using postero-
medial and lateral incisions to retrieve suture needles and
tie the sutures over the intact capsule [36]. He later intro-
duced rasping and fibrin clot to enhance healing. Much of
this work was later continued by Dilworth Cannon, focus-
ing on stratified outcomes following meniscal surgery [5].
In the early 1980s, the microvasculature of the various
zones of the meniscus was illustrated by Steven Arnoc-
zky and Russell Warren (Fig. 7), again enhancing the
understanding of the ability of meniscal repair depending
on the affected zone [3]. Long-term results of meniscal
repair also started to appear around the early 1990s, based
on the work of DeHaven and others [12]. This coincided
with an increased understanding of the knee as a complex
organ consisting of multiple interdependent components. It
was noted by Scott Dye that “purpose” of the knee is to
accept, transfer and dissipate loads generated at the ends
of the long mechanical lever-arms of the femur and tibia
[15]. In this analogy, the various ligaments represented
adaptive linkages, the articular cartilages represented a
static bearing, and the menisci represented mobile bearings
within the trasnmission. Dye identified that this thinking
13
Knee Surg Sports Traumatol Arthrosc
would facilitate a more rational clinical approach to treat-
ing patients with knee injuries and other orthopaedic condi-
tions, something which further enhanced appropriate man-
agement of the injured meniscus.
The current era and future developments…
The concept of the meniscus being a “vestigial” structure
has now been refuted, and the integrity of the semilunar
cartilage is instead respected as being of great importance.
In the modern diagnosis of meniscal injury and planning
of the appropriate intervention, a good patient history and
clinical examination have been supplemented with precise
non-invasive imaging. However, a common denomination
of similar meniscal injury findings remains difficult. Only
recently international committees have come to an agreed
denomination of the several pathologies at hand [2]. It is
the orthopaedic surgeons’ responsibility to combine clini-
cal information, imaging data and experience in an effort
to appropriately tailor treatments in individual patients.
Long-term results have now clearly shown the importance
of both functioning menisci and stable ligamentous struc-
tures as being of complimentary importance to preserve
the articular cartilage surface of the knee. Furthermore,
once primary meniscal surgery leads to (often necessary)
significant resection, the “slippery slope” [33] concept
comes into play. It is now widely recognized that ligament
replacement represents the standard of care in the ligament-
deficient knee joint. Given the improved understanding of
the function of meniscus, it is likely that loss of this struc-
ture should similarly be replaced when indicated, with the
aim of continuing to optimize long-term patient outcomes.
Although adequate resection is the current standard of care
whenever appropriate, repair and replacement of the menis-
cus must remain a major focus for surgeons. The concept
of meniscus replacement is not entirely new, as studies of
autogenic fat interposition arthroplasty have been reported
by Erich Lexer in 1916 and Karl Gebhardt in 1933, as well
as the first proximal tibial replacement by David Zukor and
Allan Gross in 1972. Wirth performed the first free menis-
cal allograft transplantation, and data from both pre-clinical
and clinical studies published by his group in 1989 demon-
strated the potential efficacy of this procedure [45]. When
considering the symptoms that may follow total resec-
tion, meniscal replacement by allograft transplantation has
proven to be a useful intervention with satisfactory long-
term outcomes. This is supported by the clinical reports
from Dieter Kohn, Ewoud Van Arkel and Herman de Boer,
as well as René Verdonk and others in the 1990s and 2000s
[26, 28, 43, 45, 46]. Deep-frozen, cryo-preserved and
viable allografts tend to provide 70 % of near-satisfactory
results, independently from the preservation technique
Knee Surg Sports Traumatol Arthrosc
Fig. 8  Cartilage tissue ingrowth after implantation of the polyurethane meniscus scaffold (republished by courtesy of Sage Publication, in
accordance with the STD Guidelines “Opt out” policy—originally published on the Am J Sports Med 2012;40:844–853)
used. This is particularly true for the lateral compartment
of the knee. Survival analysis from these studies hold in
Europe has recently been supported by survival analysis
from the work of Brian Cole and others in the USA [28].
Given the limitations on solely relying on allograft as a
source of meniscus tissue replacement, as well as the desire
to retain functional remaining meniscal tissue when pos-
sible, partial meniscal replacements are also desired. The
first of these, the collagen meniscus implant, has been in
use for over 30 years, after being first introduced by Wil-
liam Rodkey, Richard Steadman, Kevin Stone and others
[39]. In more recent times, a second synthetic substitute
has become available, the polyurethane meniscus scaffold
(Fig. 8) [17, 41]. Despite evidence that points to the safety
and efficacy of these implants, their application remains
inhibited by variations in regional regulation. Tissue engi-
neering and scaffolds augmentation with biological factors
can hopefully further assist the process of a search for a
biologically active replacement structure [32]. In an ideal
scenario, it is likely that these implants should be resorb-
able yet strong enough to allow time for initial migration
of host “meniscal” cells, originating from the synovia, that
could replace the implanted scaffold with a newly woven
collagen-based construct. Given the current focus on these
strategies, it is possible that soon additional progress will
be reached and new historical landmarks set, with enhanced
treatment options over the coming years.
Conclusion
The present historical note reveals that the interest towards
meniscal pathology and treatment has increased dramati-
cally over the past 130 years. Conservative approach has
moved, with the correct indication, towards surgical treat-
ment. Interestingly, the very first treatment for meniscal
lesions was repair and not resection, suggesting that keep-
ing the meniscus in place was the right approach all along.
From the origins of meniscal repair and throughout the
twentieth century, a better definition of therapeutic indi-
cations and relevant improvements in surgical techniques
have led to a wide range of treatment options, whose choice
should be based on patient’s specific features.
The work and the ingenuity of these precursors will pro-
vide the inspiration required to continue the huge effort
of improving orthopaedics practice for the benefit of the
patients.
Acknowledgments  The authors would like to thank Liliana
Draghetti (Donazione Putti, Biblioteche Scientifiche, Rizzoli Ortho-
paedic Institute), Keith Smith (Rizzoli Orthopaedic Institute), Davide
Puppini and Linda Accorsi for their help. The present paper was sup-
ported by the following funds granted to Rizzoli Orthopaedic Insti-
tute: “5 ‰ (5 per mille), anno 2011”.
Authors’ contribution statement  R. Verdonk was responsible for
conceiving the structure and the organization of the present manu-
script. B. Di Matteo, C. J. Moran and V. Tarabella were responsible
13

for writing the paper. They should be considered “first authors” due
to their equal contribution to the present manuscript. A. Viganò and P.
Tomba were responsible for the research of the iconographic material
and for collecting the papers that were used to create the Reference
List. M. Marcacci and R. Verdonk were responsible for the critical
revision of the paper. R. Verdonk was responsible for the final editing
of the manuscript.
Compliance with ethical standards  23. King D (1936) The function of semilunar cartilages. J Bone Joint
Conflict of interest  The authors declare that they have no conflict of
interest with respect to the contents of the present manuscript.
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