For a brief overview of knee anatomy, physiology, and biomechanics, please click here.

Please keep in mind that because this index page lists articles in reverse chronological order by publication date, the older "classic" articles appear at the bottom. However, keep in mind much of the pioneering work in the realm of meniscal repair was done in the 1990s and 1980s (and even earlier), by Dr. Frank Noyes and others. Meniscal repair is always the best route to pursue, because even a loss of a small portion of a meniscus can greatly increase the risk of future osteoarthritis. Regrettably, even today, many surgeons still perform partial menisectomies simply because they are easier, faster, and cheaper to do. If you have a meniscal tear and your surgeon is recommending "trimming" or "cleaning up" the meniscus, you might wish to peruse these articles first. (Note that meniscal repair via careful suturing is preferable to the use of "arrows" and "darts". Note, too, that even tears in the avascular central third of the menisci are amenable to repair.)

Midterm and Long-term Results After Arthroscopic Suture Repair of Isolated, Longitudinal, Vertical Meniscal Tears in Stable Knees, Martin Majewski et al.; American Journal of Sports Medicine, Baltimore; July 2006, Volume 34, pages 1072-1076. Comments: This study, with an impressive follow-up of a mean of 10 years (ranging from 5 to 17 years), looked at meniscal repair via suturing. The authors found that suturing brings excellent results, although they note that osteoarthritis remains a concern. They found a higher rate of osteoarthritis in meniscal-injured-and-repaired knees than in the never-injured contralateral knees. However, there is a catch here: the original meniscal injuries may have been accompanied by hidden damage, such as bone-bruising, which is a well-known harbinger of osteoarthritic degeneration. Remember, too, that in the past, bone-bruising was often unrecognized or unnoticed on knee examinations. So, what may have been recorded as "meniscal tear" may in fact have been a more complex injury involving multiple structures in addition to the meniscus. Subtle partial tearing of tensile structures (ligaments) may also have accompanied the meniscal tearing; such partial tearing may have affected overall knee motion and thus could have altered the loadings (compression and shear) which the compromised-and-repaired meniscus is subjected to over the long term.

Significance of the Arthroscopic Meniscal Flounce Sign -- A Prospective Study , Rick Wright and Dory Boyer; American Journal of Sports Medicine, Baltimore; February 2007, Volume 35, pages 242-244. Comments: This study shows that the little-known meniscal flounce sign is an important part of a rigorous meniscal evaluation. The only regrettable aspect is because the meniscal flounce can only be observed arthroscopically, this test cannot be done noninvasively.

Meniscal Tear Characteristics in Young Athletes With a Stable Knee -- Arthroscopic Evaluation, Ioannis P. Terzidis et al.; American Journal of Sports Medicine, Baltimore; July 2006, Volume 34, pages 1170-1175. Comments: This study provides good insight into meniscal injuries as a function of type of forcing in sport. The authors focus specifically on meniscal injuries in the absence of ligamentous injuries.

Prospective Evaluation of Allograft Meniscus Transplantation: A Minimum 2-Year Follow-up, Brian J. Cole et al.; American Journal of Sports Medicine, Baltimore; June 2006, Volume 34, pages 919-927. Comments: The authors found that meniscal allografting works well for relieving knee pain and improving knee function, but that long-term studies are needed. Ideally, a meniscal allograft transplant would bring an improvement that would last for the rest of the patient's life.

Human Meniscus Allografts’ In Vivo Size and Motion Characteristics -- Magnetic Resonance Imaging Assessment Under Weightbearing Conditions, Marc Rankin, Frank Noyes, Sue Barber-Westin et al.; American Journal of Sports Medicine, Baltimore; January 2006, Volume 34, pages 98-107. Comments: This study compared MRI images of normal and mensical-allografted knees under weightbearing conditions. The allografted menisci duplicated the motion of natural menisci remarkably well, although somewhat reduced motion at the horns was noted (albeit not statiscally confirmable due to the small sample size of 7).

Anterior Horn Tears of the Lateral Meniscus in Soccer Players, Nam-Hong Choi and Brian Victoroff; Arthroscopy: The Journal of Arthroscopic and Related Surgery; May 2006, Volume 22/5, pages 484-488. Comments: This very insightful study shows that the McMurray test and joint-line tenderness are not definitive when examining a knee for meniscal tears. MRI scans, which are extremely valuable for assessing meniscal damage, should be used too. (As for the manual-manipulation tests, note that other meniscal tests should also be in the orthopedist's toolbox, most notably Ege's test, as described in Akseki-AJARS-Nov04.shtml.) The authors note that longitudinal tears tend to be common in soccer players; in fact, such tears are probably common in all players of planting-and-twisting (also known as cutting-type or pivoting-type) sports.

Surgical Techniques: Meniscal Transplantation in Symptomatic Patients Less Than Fifty Years Old, Frank Noyes, Sue Barber-Westin et al.; Journal of Bone and Joint Surgery (American Edition); September 2005, Volume 87, Number 6, pages 149-165. Comments: The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1392-1404, July 2004 (and can be found here in the Knee Library as Noyes-JBJS-Jul04.shtml.). This September 2005 article describes and expounds on the actual surgical technique (the bone-bridge method) in great depth, and delves into the fine points essential to correct execution of the surgical technique (and therefore indispensable to optimal outcome for the patient). Meanwhile, the companion July 2004 article discusses the surgical technique in less detail, yet focuses on the underlying research and associated study results. Both articles constitute excellent reading for anyone who has lost a meniscus and is considering undergoing meniscal allografting. Both provide superbly penetrating insight, razor-sharp writing, and richly detailed illustrations.

Deteriorating Outcomes After Meniscal Repair Using the Meniscus Arrow in Knees Undergoing Concurrent Anterior Cruciate Ligament Reconstruction -- Increased Failure Rate With Long-term Follow-up, Gregory P. Lee et al.; American Journal of Sports Medicine, Baltimore; August 2005, Volume 33, pages 1138-1141. Comments: The authors, pursuing meniscal repair in conjunction with ACL reconstruction, found that using the Bionx Arrow brings disappointing results in the medium term, a finding which also applies in the case of meniscal repair without concurrent ligament reconstruction. (Note: The mean 6.6 year follow-up of this study makes it the longest to date, but when the yardstick is patient lifespan, then "long-term" arguably should be at least a decade.) Meniscal repair is best done with a careful inside-out (or vertical-mattress-style) suturing technique, a method pioneered by Dr. Frank Noyes and discussed in several articles involving numerous authors, for example Noyes-AJSM-Jul02.shtml, Rubman-AJSM-Jan98.shtml, McLaughlin-TO-Mar93.shtml.

Healing Potential of Meniscal Tears Without Repair in Knees With Anterior Cruciate Ligament Reconstruction, Kazuyoshi Yagishita et al.; American Journal of Sports Medicine, Baltimore; December 2004, Volume 32, pages 1953-1961. Comments: Meniscal injuries very often occur in conjunction with ACL tearing. This is not surprising, since planting-and-twisting is a major cause of both injury types. This study concludes that although some stable types of tears can be left unattended to while the ACL is reconstructed, major tears involving the medial meniscus should be repaired (ideally via suturing). And, because knee surgery is an involved procedure, it makes sense to combine meniscal repair with the ACL reconstruction. The fact that a meniscal tear might worsen if left unrepaired also makes repair very appropriate.

A new weight-bearing meniscal test and a comparison with McMurray's test and joint line tenderness, Devrim Akseki et al.; Arthroscopy: The Journal of Arthroscopic & Related Surgery; November 2004, Volume 20, pages 951-958. Comments: This intriguing study is a must-read for anyone with a suspected meniscal injury. The authors discuss the fine points of the joint-line tenderness (JLT) sign, as well as Ege's and McMurray's tests. All three tests should be done, since no one test is ideal for all meniscal tears. Unfortunately, many doctors are not familiar with Ege's test.

Kissing Cartilage Lesions of the Knee Caused by a Bioabsorbable Meniscal Repair Device: A Case Report, Robert F. LaPrade and Nicholas J. Wills; American Journal of Sports Medicine, Baltimore; October 2004, Volume 32, pages 1751-1754. Comments: This study shows that bioabsorbable meniscal-repair devices can have troubling side-effects. In the end, careful suturing (mattress-style or cross-stitching, also known as the Noyes method) is still the best, and will probably remain the best for quite some time. However, suturing makes the most demands on the surgeon's skill and time.

Histology of the Torn Meniscus -- A Comparison of Histologic Differences in Meniscal Tissue Between Tears in Anterior Cruciate Ligament–Intact and Anterior Cruciate Ligament–Deficient Knees, Keith Meister et al.; American Journal of Sports Medicine; September 2004, Volume 32, Number 6, pages 1479-1483. Comments: This superb study clearly shows the biomechanical importance of healthy menisci. The authors review the role of the menisci: shock absorption and load transmission (distribution of compressive and shear forces over the articular-cartilage bearing surfaces). The menisci are also important in helping the synovial fluid to lubricate the joint surfaces, and they contribute to overall joint stability as well. In ACL-deficient knees, erosion of the posterior edges of the menisci is observed. Meniscal damage is well-correlated with articular-cartilage deterioration, hence baleful osteoarthritis.

Meniscal Transplantation in Symptomatic Patients Less Than Fifty Years Old, Frank R Noyes, Sue D. Barber-Westin, et al; Journal of Bone and Joint Surgery: July 2004, Vol 86-A/7, pages 1392-1404. Comments: This study is essential reading for anyone who has undergone menisectomy, or who has early-stage knee arthrosis due to meniscal loss or damage. Dr. Noyes is renowned for his pioneering work in the field of meniscal repair; indeed, he was one of the first surgeons to both recognize and delve into the importance of preserving every ounce of meniscal tissue in the human knee. (This article includes a commentary by Scott Rodeo and a supplementary table.)

Prospective Evaluation of 1485 Meniscal Tear Patterns in Patients With Stable Knees, Michael H. Metcalf et al.; American Journal of Sports Medicine, Baltimore, April 2004, Volume 32, pages 675-680. Comments: This thought-provoking study reveals that whether or not the knee is stable has a substantial impact on the types of meniscal injuries that can be expected. Albeit meniscal damage can occur in the absence of ligamentous problems, complete ACL tearing (if unaddressed and if allowed to remain chronic, and especially if the knee is permitted to give way subsequent to the original injury incident) is a sure-fire way harbinger of abnormally rapid meniscal erosion and ensuing osteoarthritis. If an knee harbouring a torn meniscus is unstable due to the presence of a fully torn ACL, then the best treatment route is to promptly have the ACL reconstructed and also to have the meniscal tear repaired (preferably via cross-suturing or similar method).

Arthroscopic Repair of Meniscal Tears Extending into the Avascular Zone in Patients Younger Than Twenty Years of Age, Frank R. Noyes MD and Sue D. Barber-Westin; American Journal of Sports Medicine, Baltimore, July 2002, Volume 82, pages 711-715. Comments: An absolutely superb article. Frank Noyes and Sue Barber-Westin, both highly esteemed researchers in the realm of knee longevity, point out that a meticulous inside-out vertical divergent suture technique is well worth the extra time and effort on behalf of the surgeon. They recommend meniscal repair over partial menisectomy, particularly in cases where the patient is young. The article brilliantly illustrates how important the menisci are to proper knee functioning and overall joint longevity. Even a loss of a small portion of a meniscus is a recipe for serious problems (premature osteoarthritis) later on, and for this reason meniscal repair is far superior to partial menisectomy. Note that although this article focuses on people under 20 years of age, the profound value of meniscal repair applies to older people as well. Dr. Noyes is the pioneer in the world of meniscal repair, and his method of careful suturing the damaged meniscus remains the gold standard of meniscal repair surgery. Noyes and Barber-Westin make it unequivocally clear that tears to the avascular central third are very much amenable to repair.

A Biomechanical Analysis of Meniscal Repair Techniques, Christopher C. Rankin et al.; American Journal of Sports Medicine, Baltimore, July 2002, Volume 30, pages 492-497. Comments: This study, involving bovine menisci, compares the biomechanics of the various repair techniques. It found that suturing provides the strongest results. Other studies have also shown suturing to be superior to arrows (not only in strength but also in terms of success).

Long-term results of meniscal allograft transplantation, Carl Joachim Wirth; The American Journal of Sports Medicine, Baltimore; Mar/Apr 2002, Vol 30/2, p. 174. Comments: This article provides an excellent overview of results of meniscal-tissue transplantion (a procedure which was first performed in the early 1900s, but is still being refined). Wirth et al. have performed the longest-term study of meniscal transplantation to date, entailing a fourteen-year follow-up. Meniscal transplanation is indeed promising, although problems pertaining to the arthritis-type degeneration (of the knees in the study) remain. The major concern is that the knees which underwent the meniscal implantation were already somewhat deteriorated to begin with. As with all orthopedic surgeries, meniscal transplantation can be expected to yield the best results when performed on knees which harbour little in the way of preexisting degenerative changes. Currently, meniscal transplantation is often presented to the patient after the knee has been meniscus-less for an extended period. The paramount importance of the menisci (with regards to absorbing shock, distributing compression and shear forces, assisting in joint lubrication, contributing to joint stability, and maintaining joint alignment), and also the fact that the most prone-to-injury portions of the menisci tend to be those which are biomechanically most essential (and additionally, the fact that a loss of even a quarter of a meniscus can translate into the stresses on the articular cartilage increasing by a factor of two to eight), makes it clear that no knee should be left without an intact meniscus.

Meniscal Allograft Transplantation: Two- to Eight-Year Results, Ehud Rath et al; American Journal of Sports Medicine, Baltimore; July 2001, Vol 29/2, pages 410-414. Comments: This study shows that meniscal allografting is well worthwhile, even though it is technically demanding for the surgeon. Keep in mind that the menisci not only serve to absorb shock and distribute compressive and shear loadings over the vulnerable articular cartilage, but that they also contribute to overall knee stability and assist the synovial fluid in lubricating the joint. So, there are many reasons to have intact and fully functional menisci in the knee.

Tensile fixation strengths of absorbable meniscal repair devices as a function of hydrolysis time, Steven P Arnoczky et al; American Journal of Sports Medicine, Baltimore; Mar/Apr 2001, Vol 29/2, pages 118-123. Comments: This article provides good insight into how the strength of various bioabsorbable meniscal repair devices decreases after time. The concerns of structure failure, along with additional concerns unique to barbed meniscal-repair devices, mean that suturing (via the inside-out technique or similar painstaking method) remains the best option. Intriguingly, the product (Bionx Meniscus Arrow) from the firm which funded this study (Bionx Implants), proved to be the absolute worst meniscal-repair device. Anyone with a meniscal tear would be well-advised to seek out a surgeon who is willing to diligently and carefully repair the meniscus by suturing (instead of trying to cut corners by deciding beforehand to merely excise the damaged tissue).

Change in meniscal strain with anterior cruciate ligament injury and after reconstruction, J. Marcus Hollis; The American Journal of Sports Medicine, Baltimore; Sep/Oct 2000, Vol 28/5, p. 700. Comments: This article points out the importance of reliable and stable knee functioning to long-term meniscal integrity. Hollis makes it clear that in an unstable ACL-deficient knee, the menisci are at risk of tearing (or further tearing, if they have already incurred damage in conjunction with the ACL injury). Meniscal loss is well-correlated with articular-cartilage wearing; hence the imperative behind making every effort to preserve every ounce of meniscal tissue. (The menisci are responsible for absorbing shock, as well as distributing compressive and shear forces over the vulnerable bone-covering articular cartilage. The menisci also assist the synovial fluid in lubricating the joint, and contribute to overall knee stability. Regrettably, the central portions, which happen to be avascular and thus dependent upon diffusion for nutrient-supply purposes, are the most essential to articular cartilage longevity. Because these areas are also those which are most difficult to repair surgically, they are most likely to be excised. Note that even a 25% loss of a meniscus can result in a quadrupling of stress on the articular cartilage. Keep in mind that the knee is biomechanically the most-highly-stressed joint in the entire body, owing to the unique combination of enormous dynamic loadings it must contend with daily, the wrenching action of the long lever arms of the leg bones, and a complete lack of native bony stability. Chronic ACL deficiency is a well-known harbinger of osteoarthritis; by the time the chronically-ACLless person feels arthritic pain in the knee, the problem has often already progressed to the stage of irreversibility.)

See also the article "The Biomechanical Interdependence between the ACL graft and the Medial Meniscus" by Papageorgiou, in the Knee Biomechanics section

Results of anterior cruciate ligament reconstruction based on meniscus and articular-cartilage status at the time of surgery: Five- to fifteen-year evalutions, K. Donald Shelbourne; The American Journal of Sports Medicine, Baltimore; Jul/Aug 2000, Vol 28/4, p. 446. Comments: Shelbourne found that the long-term serviceability of the anterior-cruciate-ligament-reconstructed knee is affected by the status of the menisci and the condition of the articular cartilage. It was also found that having both menisci intact resulted in a significant improvement in KT-1000 arthrometer reading -- thus less knee laxity. This article again highlights the paramount importance of the menisci in overall knee functioning: not only to absorb shock, facilitate lubrication, and distribute compressive as well as shear forcing, but also to assist the ligaments in keeping the knee stable. Shelbourne emphasizes that successful return to pre-injury activities hinges most heavily on the condition of the articular cartilage and medial meniscus. He also points out that if the ACL reconstruction restores the stability of the knee, and if the articular- and meniscal-cartilage components are in good condition, then arthrosis will not be a problem within the 15 years or so after the injury. (Of course, one must keep in mind that modern ACL-reconstruction techniques have not been around for very long. Note that, in any case, since bone-bruising so often accompanies ACL injury, and because such damage results in permanent articular changes such as conversion of high-quality hyaline cartilage to biomechanically-suboptimal fibrocartilage, it is to be anticipated that the ACL-injury-history knee, even if reconstructed with the most stunning of successes, will retain an elevated probability of developing degenerative changes.)

Intermediate-term results of meniscal repair in anterior-cruciate-ligament-reconstructed knees, Shintaro Asahina et al; American Journal of Sports Medicine, Baltimore, Maryland: Sep/Oct 1998, Volume 26/5, pages 688-691. Comments: This article discusses meniscal repair in ACL-reconstructed knees. The authors make it clear that the somewhat different biomechanics/kinematics of an ACL-reconstructed knee (as compared to a knee with a natural, uninjured ACL) can compromise a meniscal repair. (But the biomechanics of an ACL-reconstructed knee are still far superior to the biomechanics of a chronically ACL-deficient knee.) The not-so-subtle difference between a natural and a reconstructed ACL arises from the fact that the former consists of several fibre bundles of varying orientation, whereas the latter is merely a single strand or simple rope-like bundle. The authors astutely write: "Even though an ACL reconstruction may make the Lachmann test or pivot shift test negative, the meniscus may still be exposed to excessive stress, even in those knees that are seemingly satisfactorily stabilized. More sophisticated testing may be needed, for example, loaded functional tests and sport-specific descriptions."

Arthroscopic Repair of Meniscal Tears that Extend into the Avascular Zone: A Review of 198 Single and Complex Tears , Marc H. Rubman, Frank R. Noyes, and Sue D. Barber-Westin; American Journal of Sports Medicine, Baltimore, Maryland: Jan/Feb 1998, Volume 26/1, pages 87-95. Comments: This excellent article, filled with deeply penetrating insight that remains undiminished by the passage of time, is a classic in the field of meniscal repair. Dr. Noyes is a pioneer in the realm of dealing with meniscal injuries, and this article makes the importance of preserving every ounce of meniscal tissue abundantly clear. Because losing even a small portion of a meniscus can increase the loadings (compression and shear) on the articular-cartilage surfaces many-fold, meniscal-injury patients should ask their surgeons specifically about meniscal repair (instead of partial menisectomy, i.e. "trimming" or "cleaning up" the meniscus). Sadly, since partial menisectomy is so easily done (no special skills are required) and quickly performed (thus much cheaper from the viewpoint of the surgeon), the vast majority of meniscal tears are still being dealt with via partial menisectomy, thus with the surgeon not making any effort to first repair the meniscal tear. (As with all articles in which Sue Barber-Westin is an author, this article has an extremely insightful discussion section. So, be sure to read the discussion thoroughly.)

Regeneration of Meniscal Cartilage with Use of a Collagen Scaffold. Analysis of Preliminary Data, Kevin R. Stone, J. Richard Steadman, et al.; Journal of Bone and Joint Surgery (American Edition): Dec 1997, Volume 79, pages 1770-1777. Comments (with additional points by Sue Barber-Westin): This very thought-provoking study involves a small group of 10 patients who underwent meniscus transplantation with tissue that had been regenerated using a collagen scaffold. Sue Barber-Westin, a gifted clinical researcher experienced with knee-cartilage issues, notes that these patients all had a good portion of their native meniscus intact, i.e. they had undergone only partial meniscectomies. She notes that someone with a complete or near-complete menisectomy, or with sectors extending from centre to edge of a meniscus missing, would probably not be a good candidate for this operation. The reason for this is that Stone's method apparently depends on the intact outer portions of the meniscus to provide structural-mechanical strength (and thereby provide some protection to the repaired portion, during the initial postoperative period), given the hoop stresses that naturally develop in the meniscus. (To conceptualize hoop stresses, imagine what would happen to a hypothetical meniscus if a small vertical cut were made in the outer edge. When the knee bears weight, the small cut would grow into a split extending towards the centre of the meniscus.) Results of Stone's collagen-scaffolding method showed good progress at 3 years postoperative. The method appears very promising, but the authors note that further research is needed. Also very promising is that this method appears to provide a good way to repair meniscal damage that affects the avascular central portions of the meniscus -- and said portions are exactly those which are most likely to be removed as a result of injury. This study dates from 1997. Regrettably, since then, no further study on this intriguing collagen-scaffolding concept seems to have been done. Stone's method would be especially desirable for people who have undergone partial menisectomy. This is especially the case today, given that partial menisectomy remains the most common way to deal with meniscal tears due to the fact that it makes little demand on the surgeon's time. Meniscal repair via careful inside-out suturing, a method pioneered by Noyes, is time-consuming and requires a skilled surgeon, but the long-term benefits makes it well worthwhile. (Incidentally, this repair method works well for splits that extend to the outer edge of the meniscus.) Stone's method would also be helpful in cases where the meniscal damage occurs in the form of irreparable shredding. So, the repair method of Noyes and the regrowth method of Stone complement each other. If all meniscal-tearing patients were to undergo these meniscal repair and regrowth techniques instead of merely undergoing partial menisectomy, then a lot of osteoarthritic degeneration would be averted. (Funding for this study was provided by California-based ReGen Biologics.)

Arthroscopic Meniscus Repair: Recommended Surgical Techniques for Complex Meniscal Tears, Jeffrey R. McLaughlin and Frank R. Noyes; Techniques in Orthopaedics, Raven Press, New York: March 1993, Volume 8/2, pages 129—136. Comments: This classic article is a must-read for anyone whose surgeon has recommended partial or full menisectomy. Please note that partial menisectomy is not much better than full menisectomy, as the first paragraph of the main text of this article makes clear. Losing even a small portion of a meniscus is a recipe for premature osteoarthritis, and so preserving every ounce of meniscal tissue should be a top priority. The value of meniscal repair, carefully done via suturing (using the techniques described in detail in this article), is clear. (Only if the meniscus has been shredded or otherwise extremely severely damaged is partial menisectomy appropriate. Few meniscal injuries fall into this category.) Dr. Noyes is considered a pioneer in the realm of meniscal-repair techniques; the suturing methods he devised in the 1980s are still the gold standard today. (It is interesting to note that the concept of meniscal repair is over a century old. Thomas Annandale, a British surgeon, foresightfully inaugurated the field in 1885.)

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