Current Orthopaedics (2008) 22, 193e201

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/cuor

BASIC SCIENCE

Biomechanics of the menisci of the knee

Ian D. McDermott a,b,*, Spyridon D. Masouros c,d, Andrew A. Amis d,e

a
Northwood Sports Orthopaedics, 166 Northwood Way, Northwood, Middlesex HA6 1RB, UK
b
The Centre for Sports Medicine and Human Performance, Brunel University School of Sport & Education, Heinz Wolff
Building, Uxbridge, Middlesex UB8 3PH, UK
c
Department of Bioengineering, Imperial College London, Exhibition Road, London SW7 2AZ, UK
d
Biomechanics Group, Department of Mechanical Engineering, Imperial College London, Exhibition Road,
London SW7 2AZ, UK
e
Musculoskeletal Surgery, Imperial College London, Charing Cross Hospital, London W6 8RF, UK

KEYWORDS Summary
Menisci; The menisci of the knee are complex structures with various important functions within the
Knee; knee. Loss of the menisci leads to a significantly increased risk of developing degenerative
Biomechanics changes in the long term. To fully understand the role of the menisci it is necessary to have
an appropriate understanding of their anatomy, microstructure, material/mechanical proper-
ties and biomechanical function. This review will give a brief outline of both the underlying
principles involved as well as giving some detail explaining the behaviour in-vivo of these com-
plex and important structures.
ª 2008 Elsevier Ltd. All rights reserved.

Introduction considered to be the functionless remains of a leg muscle.1

The menisci are two crescent-shaped cartilages that are
found within each knee between the femoral condyles and
the tibial plateaux. For many years the menisci were
* Corresponding author. Mr Ian McDermott MB, BS, MS, FRCS(Orth),
FFSEM(UK), Consultant Orthopaedic Surgeon, Honorary Professor
Associate, Brunel University School of Sport & Education. Northwood
Sports Orthopaedics, 166 Northwood Way, Northwood, Middlesex
HA6 1RB, UK.
E-mail address: ian.mcdermott@doctors.org.uk (I.D.
McDermott).
Indeed, in his paper in 1942 McMurray stated that ‘‘When
the knee-joint is opened on the anterior aspect, and the
suspected cartilage appears normal, its removal can be
undertaken with confidence if the diagnosis of a posterior
tear has been arrived at (clinically) prior to operation. A
far too common error is shown in the incomplete removal
of the injured meniscus.’’ 2
Attitudes towards the menisci have changed dramati-
cally, and since King’s pivotal paper in 1936,3 numerous
studies have shown that the menisci do in fact play impor-
tant roles in load bearing4e8 and shock absorption within
the knee,9e11 and that they are also secondary stabilisers
of the joint.12e15 Further roles in joint lubrication and

0268-0890/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cuor.2008.04.005
194
nutrient distribution,16 and sensory function and proprio-
ception17 have been proposed. Meniscal tears are probably
the most common intra-articular injury of the knee,18 and it
is now fully appreciated that meniscectomy leads to a large
increase in the risk of subsequently developing
degenerative changes within the joint.19
The responses of the menisci to loads applied to the
tibiofemoral joint result from their macro-geometry, their
fine structure and the nature of their insertional ligaments.
The menisci are fibrocartilagenous structures primarily
composed of an interlacing network of collagen fibres (pre-
dominantly type I collagen) interposed with cells, with an
extracellular matrix of proteoglycans and glycoproteins.
The collagen composition varies between the surface
layer of the menisci and the deeper tissue. The collagen
bundles of the surface layer are randomly orientated with
a compositional similarity to articular hyaline cartilage.20
This relates to its function, which is to allow low-friction
motion between the meniscal tissue and the femur and
tibia as the femoral condyles slide against the meniscus
and move it over the tibial plateau during knee motion.
Within the bulk of the meniscal tissue, beneath the
surface layers, there are two structurally distinct regions
where the orientation of collagen fibres is different: in the
innermost third the collagen bundles predominantly lie in
a radial pattern, whereas in the outer two-thirds the
collagen bundles are orientated circumferentially (Fig. 1).
This suggests that the inner third may function in compres-
sion and that the outer two-thirds function in tension.
Further, less-frequent, radially-orientated collagen fibres
can also be found within the bulk of the meniscal tissue
and these may act as tie fibres, resisting longitudinal split-
ting of the circumferential collagen bundles.21
To fully understand the functioning of the menisci of the
knee, it is first essential to have a firm grasp of the basic
underlying principles of biomechanics as they relate to
meniscal tissue. These principles will be outlined and then
expanded upon in the following sections.
The basic biomechanics of tension
When a force is applied to any material or tissue that is not
completely free to move, there will be a resultant
Figure 1 Diagrammatic representation of the collagen fibre
orientations within the meniscus. Taken from Bullough et al.21
I.D. McDermott et al.
deformation. The behaviour of tissue as a stretching force
is applied is referred to as its tensile properties.
As a stretching force is applied to a sample of tissue,
such as mensical tissue, the sample will show a resultant
elongation. Equally, as a tissue is stretched, a force will
develop within the tissue, opposing its elongation. Tissue
extension can be plotted graphically against the measured
resultant force, to give a load-elongation curve (Fig. 2).
The first region of the load-elongation curve is referred
to as the ‘toe region’. Little force is required to elongate
the tissue initially, and the elongation at this stage occurs
as the wavy pattern of relaxed collagen fibres within the
meniscal tissue becomes straighter.22
The second region of the curve is linear, and during this
stage the collagen fibres themselves become stretched and are
parallel, having lost their wavy appearance. During this phase,
there is a linear relationship between elongation and load.
Towards the end of the linear phase of the curve, small
dips representing force reductions can be seen. These are
caused by the early sequential failure of some individual fibre
bundles.23 Eventually, major failure of fibre bundles occurs
and complete failure ensues. The point at which this begins
to occur is referred to as the yield point for the tissue, and
represents a change from elastic (reversible) to plastic (irre-
versible) deformation. The maximum load attained is re-
ferred to as the ultimate tensile load of the specimen.
The stiffness of the testing sample can be defined by
load DF
stiffnessZ ; kZ
elongation DL
and can be determined by calculating the gradient of the
linear portion of the graph. The stiffness of the sample is
a structural property of the specific tissue sample tested.
This means that the stiffness value is dependent upon the
material properties of the tissue itself and the dimensions
of the sample. In order to make comparisons between dif-
ferent tissues or materials, measures which are indepen-
dent of sample dimensions are used; these are termed
material properties.
To adjust for specimen cross-sectional area, a measure-
ment of stress is used. This is defined as
load F

stressZ ; sZ MPaZN=mm2
cross-sectional area A
Load (N)
Elongation (mm)
Figure 2 Typical Load versus Elongation curve for tensile
testing of fibrous soft-tissue samples.
Biomechanics of the menisci of the knee 195

To adjust for specimen length, a measurement of strain

is used. This is defined as B
elongation DL
strainZ

Extension
; 3Z
original length L

The original length of the test sample is referred to as the A

gauge length. Strain is often multiplied by 100 to give per-
cent strain, and has no units.
Using the definition of stress and strain given above,
a new ‘stress-strain’ curve can be plotted. This has the
Time
same shape as the load-elongation curve. Calculating
the gradient of the linear portion of this curve by dividing Figure 3 Plot of Compression against time for a constant
the change in stress by the change in strain, now gives compressive load. An initial near-linear portion is seen (A), fol-
a value referred to as the Young’s modulus of the material: lowed by a curved section of diminishing rate of compression
stress s (B), representing creep of the tissue as water is extruded.
Young0 s modulusZ ; EZ
strain 3
Similarly, when meniscal tissue is compressed and then
The modulus is a material property and can be used as held, and the load required to maintain that compression is
a measure of comparison of the material stiffnesses of measured, it can be seen that the load diminishes with
various tissues of different size and shape. time. If load is plotted against time, then a characteristic
curve is seen. As fluid is expelled from the meniscal tissue,
The basic biomechanics of compression the tissue relaxes and the required load to maintain any
given compression decreases with time. The resulting curve
In 1980, Mow et al. investigated the behaviour of articular is known as a stress relaxation curve (Fig. 4).
cartilage and showed that it could be described as a biphasic Creep and stress-relaxation are related characteristics
material; composed of a solid matrix phase and an in- of viscoelastic behaviour; this is a time dependent behav-
terstitial fluid phase.24 Favenesi et al., in 1983, examined iour. The water content and permeability of meniscal tissue
the behaviour of bovine menisci and concluded that menis- are responsible for the viscoelastic response of the tissue. It
cal tissue also followed the expected behaviour of a biphasic is important to note, however, that the permeability of
material.25 They demonstrated that the water content of meniscal tissue is very low when compared to articular
the meniscus was freely exchangeable with the surrounding cartilage, so that the menisci effectively maintain their
fluid by mechanical means. The meniscal water content volume under load, otherwise they would soon become
could be extruded either by compression or by direct appli- functionless within the knee.
cation of a pressure differential. Favenesi et al. showed,
however, that the meniscal tissue was only half as stiff, The material properties of meniscal tissue
and one sixth as permeable as articular cartilage.
Spilker et al. used computer finite element analysis to Tensile material properties
model meniscal properties, and found that the biphasic
representation, whereby the tissue was described as a mix- As far back as 1949, Mathur et al. took fresh meniscal tissue
ture of solid and fluid components, was crucial, and that the from amputated limbs, held the tissue in metal clamps,
fluid phase carried a significant part of the applied load.26
Thus, when a load is applied to meniscal tissue the solid
phase, consisting predominantly of circumferentially orien-
tated collagen bundles, shows an elastic response. How-
ever, simultaneously, the fluid pressure carries the
compressive load while the fluid component of the tissue
is very slowly extruded at a rate dependent on the
permeability of the tissue and the viscosity of the fluid.
The tissue therefore exhibits viscoelastic behaviour.
Load

If a constant compressive load is applied to a sample of

meniscal tissue, there is an initial compression that is near-
linear, and which predominantly represents the solid phase
of the material, i.e. the elastic behaviour of the collagen
bundles and the matrix material. This immediate phase is
followed by a curved phase where there is a continued
compression of the tissue, but at a diminishing rate. This
second stage is where the fluid-phase predominates, and
Time
fluid is moving within and being expelled from the meniscal
tissue. The continued but diminishing compression is Figure 4 Stress-relaxation curve, showing the behaviour of
referred to as creep, and can be seen when extension is meniscal tissue when it is compressed to a set value of
plotted against time (Fig. 3). displacement.
196 I.D. McDermott et al.

suspended the tissue within a three foot high frame, and

then hung weights on the samples, measuring the ‘stretch-
ing’ of the tissue and the load necessary to cause the tissue
to ‘fracture’.27
However, in order to measure the material properties of
meniscal tissue, samples of clearly-defined geometry are
necessary. The standard shape of tissue sample used by
most investigators is based on the basic materials testing
dumbbell (Fig. 5). This has expanded sections at the ends
for clamping the tissue, and a narrower gauge length in
between. The cross-sectional area in this section is uni-
form, thus allowing calculation of stress. However, al-
though this is appropriate for the testing of non-fibrous
materials, dumbbell shaped test samples should be used
with care for fibre-reinforced composites because they
tend to split in the region where the width changes.28
Whipple et al. studied the tensile properties of bovine
menisci using dumbbell-shaped samples, 400 micrometers
in thickness.29 They compared the properties of the tissue
from samples taken either circumferentially or radially to
the circumferentially-orientated collagen fibres (Fig. 6)
and demonstrated that in the surface layer of the menisci,
where the collagen fibres are randomly orientated, there
were no differences between samples taken in different
orientations. However, in the deeper, main bulk of the
meniscal tissue, samples taken circumferentially had
a much greater modulus (198.4 MPa) compared to radi-
Figure 6 Orientation of tensile testing dumbbells. Taken
ally-orientated samples (2.8 MPa). Similar findings have
from Whipple et al., 1985.29
been observed by other authors.21,30,31 This directional
variation of material properties within the tissue is referred
to as anisotropy, and the tissue is described as anisotropic. In a more recent and highly comprehensive study,
Whipple et al. also observed differences in the material Lechner et al. observed that the posterior and middle
properties of circumferentially sampled meniscal tissue regions of human medial menisci had a higher tensile
depending on the depth of the samples: tissue from the modulus than the anterior region.33 They also noted that
surface layer had a modulus of 48.3 MPa compared to as the circumferential collagen fibres are continuous
a value of 198.4 MPa for the middle zone and 139.0 MPa through the meniscus from the anterior to the posterior tib-
for the deepest layer sampled. ial attachments, and the anterior horn of the medial menis-
Other investigators have demonstrated regional varia- cus is not as wide in the radial direction as the central or
tions in the material properties of meniscal tissue. Fithian posterior regions, the same number of collagen fibres
et al. found that the tensile modulus was significantly must be packed into a smaller cross-sectional area of tissue
reduced in the posterior two-thirds of the medial meniscus, anteriorly. This would increase the ratio of collagen fibres
compared to the anterior third of the medial meniscus or to matrix tissue anteriorly, and might explain the increased
the entire lateral meniscus.32 They inspected the meniscal stiffness of the tissue anteriorly.
tissue under polarised light to determine collagen fibre ori- Lechner et al. also showed that the modulus of meniscal
entation, and found that whereas in the rest of meniscal tissue varies inversely with test specimen thickness.33 They
tissue the fibres were highly orientated in the circumferen- noted that standard materials testing assumes that the
tial direction, in the posterior two-thirds of the medial tissue being tested is actually homogenous. Meniscal tissue,
meniscus the fibre bundles were orientated obliquely with however, is composed of collagen fibre bundles, ranging
respect to each other. Fithian et al. felt that the capsular from 50 to 400 micrometers in diameter, embedded within
attachments in the posterior two-thirds of the medial me- weak matrix tissue (Fig. 7).34 Thus, thinner samples may
niscus may interrupt the circumferential fibre organisation, consist predominantly of matrix tissue. Lechner et al. found
and stated that this might explain in part the frequency of that 28% of 0.5 mm thickness samples either failed prema-
tears observed in the posterior horn of the medial turely, or could not even be tested. Only 17% of thicker,
meniscus. 3 mm samples were untestable. Thus with thinner samples,
the samples that could be tested were likely to be those
that contained a significant amount of collagen fibre tissue,
as opposed to just mainly weak matrix. Hence the thinner
samples that could be tested had an apparent higher
mean modulus than the thicker samples.
The above issues emphasize how complicated it is to try
to define the biomechanical properties of mensical tissue.
Figure 5 Materials testing dumbbell. Thus, attempts to try to quantify absolute values for
Biomechanics of the menisci of the knee
A B
Figure 7 Diagram representing how sample thickness may
affect material properties. Sample A (thin) contains 2 collagen
bundles. Sample B (thin) contains only matrix and is untest-
able. Therefore of the thin samples successfully tested, there
appear to be 2 bundles per slice thickness. Sample A þ B (thick)
contains 2 collagen bundles and is testable. The mean collagen
bundle count per slice thickness is 1. Therefore, the thicker
slice has a lower tensile modulus.
material properties probably have little meaning unless
taken within the context of the overall macrostructure of
this highly complex organ.
However, for general comparison, if a value in the region
of 150 MPa is taken as an approximation of the tensile mod-
ulus of meniscal tissue, Young’s modulus for the anterior
cruciate ligament is approximately 200e300 MPa, and the
modulus of high-density polyethylene is approximately
1000 MPa. The ultimate stress to failure of meniscal tissue
is in the region of 20 MPa. The ultimate stress of ligament
tissue is typically 50 MPa, and of mild steel is approximately
250 MPa.
Compressive material properties
Favenesi et al. examined the compressive material prop-
erties of bovine menisci using confined compression creep
testing and direct permeability measurement.25 They found
that the water content of the menisci was 73.9%. The mean
hydraulic permeability of the tissue was 6.4  1016 m4/
NS, and the mean compressive modulus was 0.41 MPa.
The water content, hydraulic permeability and compressive
197
modulus were noted to vary according to the depth of the
sample location (superficial vs deep) and also the location
of the sample (anterior vs central vs deep).
Proctor et al. also investigated the compressive behav-
iour of bovine menisci to determine the compressive
modulus and permeability of the tissue.31 Proctor et al.
found a mean water content of 73.8%, with a mean perme-
ability of 0.81  1015 m4/NS, and a mean compressive
modulus of 0.41 MPa. They found that values were uniform
within the surface layer and did not differ according to
location. However, for the deeper tissue, Proctor et al.
did observe that the measured compressive material prop-
erties differed significantly according to sample location.
The posterior deep specimens had a significantly higher
modulus. No significant regional variations were observed
in the permeability coefficients of the tissue, but the poste-
rior specimens were found to have a significantly higher
water content.
Functional biomechanics
Load transmission
The menisci transfer forces between the femoral and tibial
joint surfaces by the development of hoop (circumferen-
tial) stresses within the meniscal tissue.11 These are tensile
stresses transferred along the circumferential collagen fi-
bres of the meniscus between insertions. As the near-
circular femoral condyles bear down onto the meniscal
tissue, the menisci have a tendency to be extruded periph-
erally.9 This extrusion is prevented by the firm attachments
of the anterior and posterior horns to the tibia via the ante-
rior and posterior insertional ligaments, because an
increase of the radius of the circle of meniscus simulta-
neously increases the circumference. Thus, a circumferen-
tial tension develops within the menisci, opposing further
displacement. This is referred to as ‘hoop stresses’.35
Thus the compression force across the knee, as it is trans-
mitted from the femur through the meniscus to the tibia,
causes tension along the circumferential collagen fibres
within the meniscal tissue (Fig. 8).
A number of different experimental techniques have
been used to determine intra-articular contact areas and
pressure distribution. By loading cadaver knees in
Figure 8 Conversion of axial load into meniscal hoop
stresses.
198
a materials testing machine and using pressure transducers
within the joint, Seedhom showed that on the lateral side
the meniscus carries 70% of the load in the lateral
compartment, and that the medial meniscus carries 50%
of the load in the medial compartment.36
Walker et al. used methylmethacrylate casting and
showed that under no load, contact across the knee
occurred primarily on the menisci.8 With loads of 1472N,
the menisci were shown to cover between 59 to 71% of
the joint contact surface area.
Using a casting method employing silicone rubber,
Fukubayashi and Kurosawa found that under a load of
1000N, the menisci occupied 70% of the total contact area.5
Removal of the menisci more than halved the contact area
and led to a doubling of the peak contact pressures.
The importance of the menisci in load bearing was
further shown by Baratz et al., who, using pressure-sensitive
film in knees loaded by a materials testing machine, showed
that after total meniscectomy, joint contact areas de-
creased by approximately 75%, and peak local contact
stresses increased by approximately 235% (Fig. 9).37
Shock absorption
As has been described above, axially directed energy across
the knee during loading of the joint is converted into hoop
stresses within the circumferential collagen fibres.9
Furthermore, as well as energy being absorbed into the
collagen fibres (solid phase of the meniscus), as the tissue is
compressed energy is further absorbed by the expulsion of
the joint fluid (fluid phase of the meniscus) out of the tissue.
The shock absorbing capacity of the menisci has been
measured by registration of bone vibrations resulting
from gait, and it has been shown that without the menisci,
shock absorption within the knee is reduced by approxi-
mately 20%.11
Meniscal motion
The menisci are dynamic structures, and to effectively
maintain an optimum load-bearing function over a moving,
incongruent joint surface, they need to be able to move as
Figure 9 Increase in peak local contact pressures after
meniscectomy.
I.D. McDermott et al.
the femur and tibia move, to maintain maximum
congruency.
Thompson et al. were the first to describe meniscal
movements through a full flexion-extension arc in the
intact knee using MRI of cadaver knees.38 They showed
that from full extension to full flexion, there was posterior
excursion of the medial meniscus of 5.1 mm, and of the lat-
eral meniscus of 11.2 mm, with the anterior horns moving
more than the posterior horns. However, these observations
were made in unloaded cadaver knees, and may therefore
not be representative of the in-vivo weight bearing situa-
tion. Furthermore, Thompson et al. failed to comment on
the medio-lateral movement of the meniscal tissue.
More recent technical advances in the field of radio-
graphic imaging have lead to the development of so-called
‘open’ magnetic resonance scanners. These scanners allow
a subject to lie, stand, sit or squat within the imaging field,
and thus permit imaging of the intact in-vivo knee under
load in all positions. Using such a scanner, Vedi et al.
described the details of meniscal motion in the normal
knee in both the weight-bearing and non-weight-bearing
situations.39 They found that the menisci moved less than
had been reported by Thompson et al. However, in common
with the findings of Thompson et al., Vedi et al. observed
that the menisci do move posteriorly as the knee flexes.
The anterior horns were noted to be more mobile than
the posterior horns, and the lateral meniscus to be more
mobile than the medial (Fig. 10). The posterior horn of
the medial meniscus was found to be the least mobile.
Vedi et al. also showed that there was significant move-
ment of the bodies of the menisci peripherally with flexion.
Vedi et al. compared the observed values in the
unloaded knee with those found in the weight-bearing
situation. They showed that statistically there was signif-
icantly greater movement in the anterior horn of the lateral
meniscus when the knee was weight-bearing, but no
significant differences were seen in the other meniscal
movements observed.
Joint stabilisation
The role of different anatomical structures in the stability
of the knee has been studied extensively, both in cadaveric
work and in-vivo. Tapper and Hoover reviewed 113 patients
at between 10 to 30 years after meniscectomy (84% medial,
16% lateral) and found that 24% showed evidence of
instability of the knee.40 In this study all patients that
had evidence of collateral or cruciate ligamentous injuries
during initial surgery were excluded. It was therefore pos-
tulated that the group of patients showing instability at fol-
low-up either had unrecognised injuries, were re-injured
later, had laxity due to degenerative changes, or that
perhaps the loss of the meniscal mass might have
caused a relative laxity of the ligaments.
Levy et al. showed that anterior-posterior laxity and
coupled rotation were unaffected by medial meniscectomy
in the anterior cruciate-intact knee.13 However, after sec-
tion of the anterior cruciate ligament subsequent further
resection of the medial meniscus led to an additional
increase in anterior laxity. In a further study, Levy et al.
also showed that lateral meniscectomy after resection of
the anterior cruciate ligament resulted in a small but
Biomechanics of the menisci of the knee
Figure 10 Diagram showing the mean movement (mm) in each meniscus from extension (shaded) to flexion (hashed) in (A) the
weight-bearing and (B) the unloaded knee. Taken from Vedi et al.39
significant further increase in anterior translation.12 The
smaller increase in anterior laxity associated with removal
of the lateral meniscus compared to that seen with the
medial meniscus may well be related to the fact that the
lateral meniscus is more mobile than the medial. The rela-
tively immobile posterior horn of the medial meniscus,
however, most probably acts as a ‘chock block’ resisting
posterior translation of the medial femoral condyle.
Further work by Allen et al. confirmed that the actual
forces within the medial meniscus in response to an
anterior tibial load increased by up to 197% after section
of the anterior cruciate ligament.41 It was also shown that
after medial meniscectomy in the anterior cruciate defi-
cient knee there was a significant further increase in in-
duced anterior tibial translation of up to 5.8 mm.
It can therefore be considered that the medial meniscus
does appear to be a significant secondary stabiliser to
anterior drawer, of particular importance in the ACL-
deficient knee, and this may well be a factor contributing
to the poor prognosis that is seen in those patients with
combined ACL tears plus medial meniscal deficiency.
Associated ligaments
To further complicate the issue of accurately describing the
biomechanical properties of the menisci of the knee, there
Figure 11 The transverse ligament on a cadaveric specimen,
being held with a pair of forceps.
199
are various associated ligaments which, although variable
in their presence, can have significant influence on the
behaviour of the menisci.
The anterior intermeniscal ligament, also known as the
transverse geniculate ligament, connects the anterior
fibres of the anterior horns of the medial and lateral
menisci (Fig. 11). In a cadaveric study of ninety-two knees
performed by Kohn and Moreno, a transverse ligament was
found to be present in 64% of specimens.42 However, the
functional relevance of this ligament has not yet been
determined.
Two ligaments have also been identified joining the
posterior horn of the lateral meniscus to the lateral side of
the medial condyle of the femur in the intercondylar notch.
These are known as the meniscofemoral ligaments. One
ligament runs anterior to the posterior cruciate ligament,
and is known as the ligament of Humphrey. The other runs
posterior to the posterior cruciate ligament, and is known
as the ligament of Wrisberg (Fig. 12). The ligament of
Humphrey has been found to be present in 74% of knees,
the ligament of Wrisberg in 69% of knees, and both
ligaments together in 50% of knees.43 The relevance and im-
portance of these ligaments has been demonstrated by
Gupte et al., who showed in a cadaveric study that the
Figure 12 The meniscofemoral ligaments. LM Z lateral
meniscus. PCL Z posterior cruciate ligament. AMFL Z anterior
mensicofemoral ligament (Ligament of Humphrey).
PMFL Z posterior meniscofemoral ligament (Ligament of
Wrisberg).
200
meniscofemoral ligaments contributed 28% to the total
force resisting posterior drawer at 90 degrees of flexion in
the intact knee, and 70.1% in the PCL-deficient knee.44
It should, therefore, perhaps be of some concern that
such little, if any, consideration is currently given to
the associated ligaments of the menisci during surgery of
the knee and when undertaking mensical repair or
replacement.
Conclusion
This brief review has described how the morphology and
structure of the menisci are adapted to their mechanical
load-transmitting function. In particular, the circumferen-
tial collagen fibres allow meniscal radial extrusion under
axial joint forces to be resisted by the build-up of hoop
stresses. The anisotropic material properties are adapted
to this role, but at the expense of the tissue being weak in
the radial direction, which allows the meniscus to be torn
relatively easily by splitting along the lines of the circum-
ferential fibres. Meniscal surgery should aim to maintain
continuity of the circumferential structure in order to
ensure the load-bearing performance; without this, the
articular joint surfaces are subjected to excessive contact
stresses, resulting in premature onset of osteoarthrosis.
The true structural complexity of the menisci, with their
material inhomogeneity, their anisotropy and their various
associated ligaments, emphasizes just how specialised they
in fulfilling their various roles within the knee. It also
explains how complicated a task it is to try and model them
accurately. However, a detailed and comprehensive un-
derstanding of the structural and biomechanical character-
istics of the menisci is vital for future work such as the
tissue engineering of meniscal replacements.
References
1. Sutton JB. Ligaments: their nature and morphology. London:
M.K. Lewis & Co.; 1897.
2. McMurray TP. The semilunar cartilages. Br J Surg 1942;29:
407e14.
3. King D. The function of the semilunar cartilages. J Bone Joint
Surg Br 1936;18:1069e76.
4. Ahmed AM, Burke DL. In-vitro measurement of static pressure
distribution in synovial joints e part I: tibial surface of the
knee. J Biomech Eng 1983;105:216e25.
5. Fukubayashi T, Kurosawa H. The contact area and pressure dis-
tribution pattern of the knee. A study of normal and osteoar-
thritic knee joints. Acta Orthop Scand 1980;51:871e9.
6. Seedhom BB. Loadbearing function of the menisci. Physiother-
apy 1976;62:223.
7. Shrive NG, O’Connor JJ, Goodfellow JW. Load-bearing in the
knee joint. Clin Orthop Relat Res 1978;131:279e87.
8. Walker PS, Erkman MJ. The role of the menisci in force trans-
mission across the knee. Clin Orthop Relat Res 1975;109:
184e92.
9. Krause WR, Pope MH, Johnson RJ, Wilder DG. Mechanical
changes in the knee after meniscectomy. J Bone Joint Surg
Am 1976;58:599e603.
10. Kurosawa H, Fukubayashi T, Nakajima H. Load-bearing mode of
the knee joint: physical behavior of the knee joint with or
without menisci. Clin Orthop Relat Res 1980;149:283e90.
I.D. McDermott et al.
11. Voloshin AS, Wosk J. Shock absorption of meniscectomized and
painful knees: a comparative in vivo study. J Biomed Eng 1983;
5:157e61.
12. Levy IM, Torzilli PA, Gould JD, Warren RF. The effect of lateral
meniscectomy on motion of the knee. J Bone Joint Surg Am
1989;71:401e6.
13. Levy IM, Torzilli PA, Warren RF. The effect of medial meniscec-
tomy on anterior-posterior motion of the knee. J Bone Joint
Surg Am 1982;64:883e8.
14. Markolf KL, Mensch JS, Amstutz HC. Stiffness and laxity of the
knee e the contributions of the supporting structures. A quan-
titative in vitro study. J Bone Joint Surg Am 1976;58:583e94.
15. Shoemaker SC, Markolf KL. The role of the meniscus in the an-
terior-posterior stability of the loaded anterior cruciate-defi-
cient knee. Effects of partial versus total excision. J Bone
Joint Surg Am 1986;68:71e9.
16. Renstrom P, Johnson RJ. Anatomy and biomechanics of the me-
nisci. Clin Sports Med 1990;9:523e38.
17. Messner K, Jizong DL. The menisci of the knee joint. Anatom-
ical and functional characteristics, and a rationale for clinical
treatment. J Anat 1998;193:161e78.
18. McDermott ID. Meniscal tears. Curr Orthop 2006;20:85e94.
19. McDermott ID, Amis AA. The consequences of meniscectomy.
J Bone Joint Surg Br 2006;88:1549e56.
20. Beaupre A, Choukroun R, Guidouin R, Garneau R, Gerardin H,
Cardou A. Knee menisci. Correlation between microstructure
and biomechanics. Clin Orthop Relat Res 1986;208:72e5.
21. Bullough PG, Munuera L, Murphy J, Weinstein AM. The strength
of the menisci of the knee as it relates to their fine structure.
J Bone Joint Surg Br 1970;52:564e7.
22. Viidik A. Functional properties of collagenous tissues. Int Rev
Connect Tissue Res 1973;6:127e215.
23. Butler DL, Grood ES, Noyes FR, Zernicke RF. Biomechanics of
ligaments and tendons. Exerc Sport Sci Rev 1978;6:125e81.
24. Mow VC, Kuei SC, Lai WM, Armstrong CG. Biphasic creep and
stress relaxation of articular cartilage in compression? Theory
and experiments. J Biomech Eng 1980;102:73e84.
25. Favenesi JA, Schaffer JC, Mow VC. Biphasic mechanical proper-
ties of knee meniscus. Orthop Trans 1983;8:264.
26. Spilker RL, Donzelli PS, Mow VC. A transversely isotropic
biphasic finite element model of the meniscus. J Biomech
1992;25:1027e45.
27. Mathur PD, McDonald JR, Ghormley RK. A study of the tensile
strength of the menisci of the knee. J Bone Joint Surg Am
1949;31:650e4.
28. Sekaran SV, Hull ML, Howell SM. Nonanatomic location of the
posterior horn of a medial meniscal autograft implanted in a ca-
daveric knee adversely affects the pressure distribution on the
tibial plateau. Am J Sports Med 2002;30:74e82.
29. Whipple RR, Wirth CJ, Mow VC. Anisotropic and zonal varia-
tions in the tensile properties of the meniscus. Orthop Trans
1985;10:367.
30. Tissakht M, Ahmed AM. Tensile stress-strain characteristics of
the human meniscal material. J Biomech 1995;28:411e22.
31. Proctor CS, Schmidt MB, Whipple RR, Kelly MA, Mow VC. Mate-
rial properties of the normal medial bovine meniscus. J Orthop
Res 1989;7:771e82.
32. Fithian DC, Schmidt MB, Ratcliffe A, Mow VC. Human meniscus
tensile properties: regional variation and biochemical correla-
tion. Orthop Trans 1989;14:205.
33. Lechner K, Hull ML, Howell SM. Is the circumferential tensile
modulus within a human medial meniscus affected by the
test sample location and cross-sectional area? J Orthop Res
2000;18:945e51.
34. Kelly MA, Fithian DC, Chern KY, Mow VC. Structure and function
of the meniscus: basics and clinical implications. In: Biome-
chanics of diarthrodial joints. New York: Springer-Verlag;
1990. p. 191e211.
Biomechanics of the menisci of the knee
35. Jones RS, Keene GC, Learmonth DJ, Bickerstaff D, Nawana NS,
Costi JJ, Pearcy MJ. Direct measurement of hoop strains in the
intact and torn human meniscus. Clin Biomech 1996;11:
295e300.
36. Seedhom BB, Dowson D, Wright V. Proceedings: functions of
the menisci. A preliminary study. J Bone Joint Surg Br 1974;
56:381e2.
37. Baratz ME, Fu FH, Mengato R. Meniscal tears: the effect of
meniscectomy and of repair on intraarticular contact areas
and stress in the human knee. Am J Sports Med 1986;14:
270e4.
38. Thompson WO, Thaete FL, Fu FH, Dye SF. Tibial meniscal dy-
namics using three-dimensional reconstruction of magnetic
resonance images. Am J Sports Med 1991;19:210e5.
39. Vedi V, Williams A, Tennant SJ, Spouse E, Hunt DM,
Gedroyc WM. Meniscal movement. An in-vivo study using dy-
namic MRI. J Bone Joint Surg Br 1999;81:37e41.
201
40. Tapper EM, Hoover NW. Late results after meniscectomy.
J Bone Joint Surg Am 1969;51:517e26.
41. Allen CR, Wong EK, Livesay GA, Sakane M, Fu FH, Woo SL.
Importance of the medial meniscus in the anterior cruciate
ligament-deficient knee. J Orthop Res 2000;18:109e15.
42. Kohn D, Moreno B. Meniscus insertion anatomy as a basis for
meniscus replacement: a morphological cadaveric study. Ar-
throscopy 1995;11:96e103.
43. Gupte CM, Smith A, McDermott ID, Bull AM, Thomas RD,
Amis AA. Meniscofemoral ligaments revisited. Anatomical
study, age correlation and clinical implications. J Bone Joint
Surg Br 2002;84:846e51.
44. Gupte CM, Bull AM, Thomas RD, Amis AA. The meniscofemoral
ligaments: secondary restraints to the posterior drawer. Anal-
ysis of anteroposterior and rotary laxity in the intact and pos-
terior-cruciate-deficient knee. J Bone Joint Surg Br 2003;85:
765e73.