. 370 .
Chinese Journal of Traumatology 2010; 13(6):370-376
Treatment of meniscal injury: a current concept review
GU Yang-lin 顾羊林 and WANG Yu-bin 王予彬 *
【Abstract】Meniscal injury is one of the most com-
mon injuries to the knee. The menisci are important for nor-
mal knee function. And loss of a meniscus increases the risk
of subsequent development of degenerative changes in the
knee. Now there are different techniques available for
meniscal injury. These techniques include expectant
treatment, meniscectomy, meniscal repair, meniscal
replacement, and meniscal tissue engineering. Expectant
treatment is the appropriate treatment for minor tears of the
menisci. Meniscectomy being favored at the beginning is
M
eniscus has an important role in load
transmission, shock absorption, stability,
congruence, lubrication and proprioception
of the knee joint. Meniscal injury is a common trau-
matic injury in the knee. And meniscal injury may lead
to long-term degenerative joint changes, such as os-
teophyte formation, articular cartilage degeneration, joint
space narrowing, and symptomatic osteoarthritis.1 In
this paper, we review current treatments of meniscal
injury including expectant treatment, total or partial
meniscectomy, meniscal repair, meniscal replacement,
and meniscal tissue engineering.
Anatomy and function of the menisci
The menisci of the knee are two crescentic wedges
of fibrocartilage, positioned between the tibia and the
femur in the medial and lateral compartments. Menisci
possess collagen fibers oriented circumferentially.
These circumferential fibers are bound by radially ori-
ented fibers. The menisci are centrally avascular, rely-
ing on diffusion from synovial fluid for their nutrition.
Peripherally, the menisci are nourished by a
perimeniscal capillary plexus originating in the knee’s
capsular and synovial tissues from the superior and
inferior medial and lateral geniculate arteries. Anterior
DOI: 10.3760/cma.j.issn.1008-1275.2010.06.009
Department of Sports Medicine, East Hospital, Tongji
University, Shanghai 200120, China (Gu YL and Wang YB)
*Corresponding author: Tel: 86-13301921073, E-mail:
wybdf@yahoo.com.cn
now obsolete. Meniscus repair has become a standard
procedure. Meniscal replacement and tissue engineering
are used to deal with considerable meniscal injuries. The
purpose of this paper is to provide current knowledge re-
garding the anatomy and function of the menisci, incidence,
aetiology, symptoms, signs, investigations and treatments
of meniscal injury.
Key words: Menisci, tibial; Knee injuries; Tissue
engineering; Review
Chin J Traumatol 2010; 13(6):370-376
and posterior horn-insertions contain types I and II
neuroreceptors with possible proprioceptive and mecha-
noreceptive capacities.
The flbrocartilage menisci have many important func-
tions in the knee joint. The menisci transmit 50% of
joint compressive forces in full extension and approxi-
mately 85% of the load in 90° of flexion.2 And they con-
tribute to shock absorption, augment lubrication, rota-
tion of the opposing articular surfaces, and joint nutrition.
The menisci also help the tibiofemoral joint stability and
overall joint congruency. A proprioceptive structure has
been found that provides a feedback mechanism for
joint position sense.3
Incidence and aetiology of meniscal injury
Meniscal injury is the most common injury of the
knee. The reported annual incidence of meniscal injury
is about 61 per 100 000 population. Medial meniscal
injuries are generally seen more frequently than inju-
ries of the lateral meniscus, to a ratio of approximately
2:1.4 Meniscal injuries may occur in acute knee inju-
ries in younger patients or as part of a degenerative
process in older individuals. The acute injuries frequently
result from sport injuries where there is a twisting mo-
tion on the partially flexed, weight-bearing knee. Acute
meniscal injuries may also occur as part of more major,
combined injuries to the knee.
Symptoms, signs and examinations
The classic symptoms of a meniscal injury are pain
around the affected side of the joint, possible locking of
Chinese Journal of Traumatology 2010; 13(6):370-376
the joint, and swelling. Ongoing symptoms include pain
around the joint line, clicking, giving way and locking.
McMurray’s test is commonly performed as part of the
routine knee examination in order to test for the pres-
ence of a meniscal injury. Plain anteroposterior and lat-
eral radiographs are used to determine meniscus width
and length. Spiral CT arthrography and MRI with proton
density, fast-spin-echo techniques may be used to evalu-
ate the status of the articular cartilage and subchon-
dral bone.5 But arthroscopy is infallible in the diagnosis
of meniscal injuries.6
Treatment
Expectant treatment Not all meniscal injuries
require surgery. Some of them have the ability to heal.
The meniscal tear pattern and the presence of adequate
vascularity are both key points. Tears within 3 mm of
the meniscosynovial junction usually have an adequate
blood supply that allows healing. Tears of 5 mm or more
from this junction are considered avascular and need
surgical intervention. The intervening area between
3 mm and 5 mm from the meniscosynovial junction
has variable vascularity, so the treatment depends on
clinical judgment.7 The decision of expectant treatment
must be considered by tear pattern, site, vascularity,
size, stability, patient’s age, tissue quality, and asso-
ciated pathology within the knee joint and the patient’s
goals.
Meniscectomy In the past, open total meniscec-
tomy was the appropriate treatment for tear of the
menisci. This technique could relieve the symptoms
effectively and improve the knee function fast. However,
some unhealthy changes after meniscectomy have been
showed in both short-term and long-term follow-up
studies. After total meniscectomy, the tibiofemoral con-
tact area decreases by approximately 50%, while con-
tact forces increase 2-to-3 folds.8 So poor results have
been reported following meniscectomy, including dis-
ruption of load-sharing and shock absorption, diminu-
tion of joint stability and nutrition, flattening of the femoral
condyle, development of osteophytes, narrowing of the
tibiofemoral joint space, and deterioration of articular
cartilage with progression to arthrosis. Roos9 reported
a 21 years’ follow-up and found 14% of patients having
radiographic signs of osteoarthritis after meniscectomy
as compared with controls.
Now adverse effects of total meniscectomy are
. 371 .
clearly demonstrated and universally accepted. And in
the more frequent cases with irreversible damage of
meniscal tissue, partial instead of total meniscectomy
is the treatment of choice to minimize loss of this im-
portant anatomical structure. So much interest has fo-
cused on the partial meniscectomy.
Universally, in the more frequent cases of extensive
tear of the posterior horn, not the loose central part of
the meniscal body, the risk of completely cutting
through the meniscal periphery or insertional ligament
in order to resect all damaged tissue, is high. And if the
meniscus is cut through its periphery, its load distribu-
tion function will probably be completely disrupted, de-
spite the fact that most of the meniscal body (central
region and horns) remains intact. Such a partial menis-
cectomy probably results in a similar increase of peak
stresses on the tibial plateau and therefore a potential
risk of the joint developing osteoarthrosis. Partial me-
niscectomies are thus in reality total ones.
In a biomechanical study of partial versus total
meniscectomy, Andersson-Molina10 showed that there
was a linear correlation between increase in peak stress
on the tibial joint surfaces and the amount of meniscal
tissue removed. In a review of patients undergoing ei-
ther partial or total meniscectomy, the function of the
knee was inversely related to the amount of meniscal
tissue excised.11 But there were still a significant num-
ber of complaints f rom patients af ter partial
meniscectomy.12 Until now we still do not know in the
individual case today if the so-called advancement in
therapy using partial instead of total meniscectomy
really means improvement of the long term prognosis
of knee function.
Meniscal repair Over the past two decades,
there has been great effort towards avoidance of
meniscectomy. Techniques to repair appropriate me-
niscus tears have been developed in a way to preserve
tissue and function.
Animal studies of the response of the menisci to
injury have shown that at its periphery, meniscal tissue
is capable of producing a reparative response. Cabaud13
performed transverse medial meniscal lacerations and
repaired with a single Dexon suture in 20 canine and
12 rhesus monkey knee joints. By four months, only
6% of the menisci had failed to heal. Newman14 per-
. 372 .
formed a complete midportion transaction of the me-
dial meniscus in 38 canine knees. He showed that the
response originated from the peripheral synovial tissues,
and that the menisci had completely healed by fibrovas-
cular scar within 10 weeks. Longitudinal incisions in
the inner, avascular portion of the meniscus failed to
heal.
Meniscal injuries are classified according to the lo-
cation of the injury relative to the blood supply of the
meniscus. In the ‘red–red’ region, both the peripheral
and inner margins of the injuries have an enough blood
supply, and these peripheral tears have the best prog-
nosis for healing. In the ‘red–white’ region, injuries have
vascularised tissue on the peripheral side and avascu-
lar tissue on the inner side. In the ‘white–white’ region,
injuries are completely in the avascular zone and are
least likely to heal.15
Various techniques have been described in an at-
tempt to facilitate healing of injuries in the inner, avas-
cular portion of the meniscus, including the creation of
vascular access channels, trephination, rasping of the
parameniscal synovium, and use of exogenous fibrin
clot or free synovial autografts, or even laser welding.
Techniques of open, inside-out, outside-in and all-
inside arthroscopic repair have been described, and
each has its merits.16 Open repair was first reported in
1885 by Annandale, 17 but was not widely used. An
arthroscopic inside-out meniscal repair was pioneered
by Henning in the early 1980s with later contributions
made by Clancy and Graf.18 The outside-in approach
was developed to decrease the risk of injury to poste-
rior neurovascular structures.19 Advances in technology
have led to all-inside techniques for posterior horn me-
niscus repair further reducing neurovascular injury and
decreasing operative time.20
A number of biomechanical studies have investigated
the properties of meniscal repairs using various differ-
ent techniques of suturing,21 and all have confirmed that
the vertical loop suture is the strongest, exhibiting the
greatest load to failure when compared with horizontal
or mulberry-knot sutures. Furthermore, numerous
meniscal repair devices, such as bioabsorbable arrows,
fasteners, and ‘T’-bar ended sutures, are now available
that may offer potential benefits compared with the tra-
ditional method of meniscal repair by suturing.22
Chinese Journal of Traumatology 2010; 13(6):370-376
Having tried many of the meniscal suturing devices
available, our preference is towards the use of the FasT-
Fix device. This is an all-inside suture repair system
comprising two 5 mm polymer suture bar anchors, with
a pre-tied self-sliding knot of 0# non-absorbable polyes-
ter suture. It allows easy and rapid insertion of strong,
tight horizontal or vertical loop sutures, which biome-
chanically remain the goldstandard.23 However, at the
same time the FasT-Fix avoids some of the potential
complications that have been observed with some of
the bioabsorbable arrows or dart-like devices, such as
foreign body reactions in the soft tissues due to migrat-
ing broken devices, or severe chondral damage from
broken or protruding implants within the knee.24 The re-
sults reported with the use of the FasT-Fix for meniscal
repair have been highly encouraging. Barber 25 reported
on the outcome of 41 meniscal repairs at an average
follow-up of 30.7 months, and observed that just over
83% of repairs were clinically successful, with absence
of joint-line tenderness, locking, or swelling, and a nega-
tive McMurray test. In another prospective case series
of 61 meniscal repairs using the FasT-Fix, Kotsovolos26
reported that patients (88%) had their results as good
or excellent at an average of 18-month follow-up.
Summarily, meniscal preservation has gained a high
level of awareness in the recent years. It is beneficial to
avoid the development of knee arthritis. So the surgeon
makes every attempt to repair tears in both the periph-
ery and central one-third avascular zone. meniscal re-
pair devices offer many advantages, including decreased
surgical time, less risk of injury to neurovascular struc-
tures and better cosmesis. Because of these advantages,
more and more meniscal repairs are being performed.
Self-adjusting suture devices (FasT-Fix and RapidLoc)
offer more flexibility in the repair construct and most
closely approximate the ‘‘gold standard’’ suture repair. 27
However, these repair devices have the disadvantages
of increased costs, retained polymer fragments, implant
migration, foreign body reactions, inflammation, a sig-
nificant learning curve, chondral injury, and concerns
over lower successful healing rates.
Meniscal replacement While many meniscus
injuries can be successfully repaired, not all of them
are salvageable, especially if considerable tissue dam-
age has occurred. A large proportion of meniscal inju-
ries remain irreparable, and partial, subtotal or total me-
Chinese Journal of Traumatology 2010; 13(6):370-376
niscectomy may still unavoidably be performed. In the
past, a number of different tissues or materials have
been used as an attempt to replace excised meniscal
tissue.28 These include the use of silastic, carbon fibre,
Dacron, and Teflon prostheses, patellar, Achilles or
semitendinosus tendon autograft, fat pad autograft, and
autologous rib perichondrial grafts. Few of them are avail-
able to relieve postmeniscectomy compartmental pain
or to reduce the likelihood of the subsequent develop-
ment of secondary arthritis.
As an alternative, the concept of meniscal allograft
transplantation has been developed. Meniscus allograft
transplantation represents a potential biological solu-
tion for the symptomatic meniscus-deficient patient who
has not developed advanced osteoarthritis. The indica-
tions for meniscus allograft transplantation are age of
50 years or less, prior total meniscectomy, clinical
symptoms of pain in the involved joint or articular carti-
lage degeneration, and 2 mm or more of tibiofemoral
joint space on 45° weight-bearing posteroanterior
radiographs.29 The contraindications for meniscus al-
lograft transplantation include diffuse subchondral bone
exposure, axial malalignment, and instability.30
The first published study describing meniscal al-
lograft transplantation in animals was a canine study in
1986 by Canham.31 Since this study, meniscal trans-
plantation has been described in sheep, rabbits, mice,
rats, goats, and monkeys. The first human meniscal
allograft transplantation was reported by Milachowski
in 1987,32 and again in 1989.33 Since then, numerous
clinical studies have reported results of meniscus
transplantation. Differences in tissue processing, sec-
ondary sterilization, preservation, operative techniques,
and rating schemes make comparisons between stud-
ies difficult.34 Clinical evaluation, using physical examina-
tion or subjective symptoms, may not reliably correlate
with the condition of the allograft.35 Both MRI and sec-
ond-look arthroscopy have been used to obtain objective
evaluation of the status of meniscal allografts post-
transplantation.36,37 Although more invasive, arthroscopy
may correlate better with outcome than MRI.37
The short-term results of meniscal allograft trans-
plantation are encouraging in terms of reduced knee
pain and increased function. Deie38 reported the largest
series of patients in 2007. The outcomes of 32 allografts,
performed in 29 patients at a mean follow-up of 3.3
. 373 .
years, showed good-to-excellent results in 96% of
cases. Although the published studies are often diffi-
cult to compare, meniscal allograft transplantation ap-
pears to have reliable results in pain relief and function
improvement. Most studies with mid-term follow-up
describe healing of the allograft to the periphery and
symptomatic improvement. Series with mid-term fol-
low-up are beginning to be published. Van der Wal 39
described 63 procedures and survival analysis showed
that pain relief and functional improvement persist in
approximate 71% of patients at 13.8 years follow-up.
An additional finding is that medial and lateral meniscal
transplantations have similar longevity unless the trans-
planted knee is lacking a functional anterior cruciate
ligament (ACL), in which the survival of medial implants
tends to be compromised.40
But long-term transplant function and chondroprotec-
tive effects remain unknown and require continued
investigation. Future research should determine if the
beneficial effects will persist in long-term follow-up. Ad-
ditional and long-term studies are needed to evaluate
the optimal timing of meniscal allotransplantation in hu-
mans and the actual function and condition of the
allografts. An ultimate question is whether or not this
procedure provides long-term prevention or delay of ar-
ticular cartilage degeneration and osteoarthritis.41
Although meniscal replacement is in its relative in-
fancy in China, several thousand procedures have been
performed in the USA and Europe. The future of meniscal
replacement probably lies with the field of tissue
engineering, and currently experimental work is directed
at the development of bioabsorbable scaffolds, cell cul-
ture and implantation, and gene therapy.
Tissue engineering Given the poor results fol-
lowing prosthetic meniscal replacement and the highly
variable results of autografting using alternative tissues,
now much interest and study is currently being directed
towards the field of tissue engineering. It may offer new
treatment modalities for the regeneration of meniscus
lesions or for the complete replacement of a degener-
ated (part of total) meniscus by the production of newly
synthesizing meniscal tissue, in part or in whole. Tis-
sue engineering is based on a smart and unique com-
bination of exogenous cells, matrix scaffold, specific
stimuli (growth factors, mechanical stress), in an in vitro
or in vivo environment. In terms of cell sources, three
. 374 .
basic cell types have been identified as potential
sources for the meniscal tissue engineering: the
meniscal fibrochondrocyte, the mesenchymal stem cell
and the pluripotential fibroblast. These cells could syn-
thesize appropriate extracellular matrices and restore
meniscal function. The future research should be di-
rected to the effect of using ideal matrix and growth
factors for their stimulation into an optimal phenotype
in combination with a mechanically loadable scaffold
material.42
The ideal matrix would allow cell proliferation, free
diffusion of nutrients, access to cytokines, and be me-
chanically durable and resorbable as the tissues own
extracellular matrix develops. So far, several growth
factors have been demonstrated to have an effect on
meniscus explants or on isolated meniscus cells in
culture. In particular, growth factors that stimulate syn-
thesis and inhibit degradation of extracellular matrix
production could be very useful to direct the cells into
an optimal phenotype. Transforming growth factor (TGF)-β
and platelet-derived growth factor (PDGF) are candi-
dates to stimulate proliferation of meniscus cells. A re-
cent study showed that both TGF- βand PDGF may
be involved in a shift of the chondrogenic or meniscus-
cell-like phenotype into a phenotype in which smooth
muscle actin is expressed. Alternatively, gene transfer
techniques are also very useful for the local up-regula-
tion of specific factors involved in the stimulation of an
optimal vascularity of tissue-engineered constructs.
Some experiments, vectors expressing therapeutic pro-
teins such as growth factors have been investigated to
assess their potential to improve remodeling and heal-
ing of meniscus allografts and tissue-engineered cells
or constructs.43
As regards to scaffold, an ideal scaffold material
should be biocompatible and biodegradable in the long
term. Moreover, it should permit unrestricted cellular
ingrowth, allow free diffusion of nutrients, may be used
as a carrier for stimulatory and inhibitory growth factors
and it should be strong enough to withstand the load in
the joint and maintain its structural integrity under these
loaded conditions. Furthermore, it should have a deg-
radation profile that allow ingrowth of new tissue and
thereafter allow remodeling of these tissues under the
influence of load.44 In the light of all these different
prerequisites, many scaffold materials of different cat-
egories may be considered for application for tissue
Chinese Journal of Traumatology 2010; 13(6):370-376
engineering of the meniscus.
Tissues have been used as natural scaffold
materials. Examples are periosteal tissue, perichon-
dral tissue, small intestine submucosa and meniscus
tissue itself. But the results of these whole tissues used
as scaffold material have met with poor results. Iso-
lated tissue components, for instance, collagens,
proteoglycans or elastin molecules, can be reconsti-
tuted into tailor-made scaffolds with optimal three-di-
mensional architecture. But the mechanical properties
of such scaffolds may be a problem, since they are
low for load-bearing applications in many cases. The
most popular reconstituted scaffold is based on iso-
lated collagen molecules. Thus, these new scaffolds
are very promising, optimising with respect to the initial
load-bearing capacity. The control of the creation of
pores for new tissue ingrowth and the biological turn-
over in the body may be subjected to further research.
The second option is to use completely synthetic
polymer-based scaffolds. Most polymers used currently
in tissue engineering are produced from the polyester
family of biomaterials and degraded by gradual
hydrolysis. 45 Polymers have been produced using
polyglycolic acid, polylactic acid, polyurethane and
combinations of these and of other copolymers. A great
advantage of polymers is that the porosity, the degra-
dation rate and the mechanical properties can be
adapted to the desired specifications. In this respect,
the biodegradable polyester urethanes based on l-
lactide/ ε-caprolactone might be particularly promis-
ing materials for tissue engineering of the meniscus .
To deal with tears located in the avascular, inner
one-third of the meniscus, a variety of techniques have
been developed to restore the structural integrity of these
menisci tears. Several studies in different animal mod-
els (rabbits, canines, sheep) have already showed that
particularly the porous and biodegradable polyurethane-
based polymers scaffolds can promote the formation of
fibrocartilage and can induce healing of the lesion.46
However, there are also problems with this technique.
In some cases integration between the polymer and
meniscus tissue is insufflcient, resulting in impaired
healing of the lesion.
In some cases, some patients have to take a total
meniscectomy. After that, they need an ideal implant
that could be used to replace their own menisci. Al-
Chinese Journal of Traumatology 2010; 13(6):370-376
lografts or synthetic menisci have been used with vary-
ing success to prevent early degenerative joint disease
in these cases. Problems related to reduced initial and
long-term stability, as well as immunological reactions,
prevent widespread clinical use so far. In a search for
alternatives for above-mentioned prosthesis, Further
work has recently been directed towards the role of
gene therapy for meniscal injury. In Sandmann’s study,
hum an meniscus sam ples were successf ully
acellularized using sodium dodecyl sulpfate (SDS) with-
out negatively affecting the main biomechanical
properties. These cell-free constructs could serve as
excellent scaffolds with a preserved extracellular ma-
trix maintaining the natural biomechanical properties.
Future research is necessary to evaluate the in vivo
consequences of SDS acellularization.47
The discipline of tissue engineering is in its relative
infancy. Many questions pertaining to tissue engineer-
ing of the meniscus still remain unanswered. But tech-
nological advances are enabling the application of new
techniques at a rapidly increasing rate, and instead of
merely being in the realms of science fiction, the pros-
pect of creating tailor-made replacement tissues by
order now seems even more likely to be a reality.
Conclusion
The principles of meniscal treatments have under-
gone considerable changes over the past years. Total
meniscectomy being favored in the beginning is now
obsolete. The importance of the meniscus has been
recognized and leads to the basis for the modern me-
niscus surgery. Then meniscus repair has become a
standard procedure. With the help of modern techniques
the healing of the meniscus can be enhanced even in
less vascularized areas of the meniscus. To deal with
the considerable meniscal injuries, the concept of
meniscal replacement and tissue engineering are
developed. Although both of them are in their relative
infancies. There is a great scope for further research.
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(Received March 16, 2010)
Edited by SONG Shuang-ming