Overview
Meniscal repair aims to restore a stable, functional meniscus and preserve its load-sharing role. When a tear is repairable, preservation is favored over partial or total meniscectomy. The decision depends on tear location, configuration, reducibility and tissue quality, together with cartilage health, alignment, ligament stability and the patient's ability to follow rehabilitation (Campbell, Chapters 50 and 56).
A peripheral longitudinal tear is the classic indication, but selected radial, horizontal, ramp and root lesions may also be repairable. These patterns require specific constructs; they should not all be managed as a routine vertical tear (Campbell, Chapters 50 and 56).
Assessment and Patient Selection
Clinical assessment: distinguish true mechanical locking from pain-limited motion and review the injury mechanism, duration, activity demands and examination.
MRI: define tear configuration and associated ACL or cartilage injury. A negative study does not exclude a hidden posterior lesion; arthroscopic inspection and probing remain important.
Vascularity: red-red and red-white tears generally have better healing potential than tears entirely within the avascular region. Assess vascularity with the tourniquet deflated.
Tissue quality and reducibility: the displaced segment and peripheral rim should be sufficiently healthy to hold sutures and return to anatomic position. Fixed deformation and substantial degeneration reduce the likelihood of success.
Knee environment: address meaningful ligament instability when repairing a meniscus. Persistent laxity increases stress on the repair and the risk of recurrent tearing.
Patient factors: age contributes to selection but does not replace assessment of acuity, cartilage, tissue quality and expectations.
(Campbell, Chapters 50 and 56.)
Choosing a Repair Strategy
Method | Common applications | Principal considerations |
|---|---|---|
Inside-out | Body and posterior horn tears; long peripheral or bucket-handle tears | Versatile suture placement; requires protected extracapsular needle retrieval and an appropriate safety incision. |
Outside-in | Anterior horn and midbody tears; anterior portion of a long bucket-handle tear | Needle and shuttle passage from outside the joint; expose the capsule and protect adjacent nerves before tying. |
All-inside | Many body and posterior tears | Avoids a separate retrieval incision; deployment depth, device trajectory, implant-related damage and cost remain relevant. |
Hybrid | Long tears extending across regions with different access requirements | Combine methods to achieve safe, anatomic fixation rather than forcing one device to reach the whole tear. |
(Campbell, Chapter 56, Boxes 56.3–56.4 and repair techniques.)
Positioning and Setup
Position supine with a padded post or leg holder permitting controlled compartment opening. Establish anterior portals appropriate to the tear and confirm instrument trajectories with a spinal needle.
Complete the diagnostic survey and determine vascularity before inflating the tourniquet when feasible.
Prepare meniscal rasps, probes, cannulas, suture-passing and retrieval instruments, and the selected fixation system. For inside-out repair, prepare the appropriate posterior safety exposure and needle deflector.
For lateral posterior repairs, flexion near 90 degrees helps move the common peroneal nerve away from the joint line. Flexion alone does not replace direct protection of the needle exit path.
(Campbell, Chapter 56.)
Surgical Technique
Inspection, Reduction and Tear Preparation
Perform a complete arthroscopic examination and probe the entire tear. Inspect both surfaces and look for associated posterior horn, ramp, root or popliteal-hiatus pathology.
Reduce a displaced bucket-handle fragment gently. Confirm that the segment can sit anatomically without fixed distortion.
Prepare the opposing tear surfaces and adjacent synovium with a rasp to stimulate healing while retaining functional tissue. An acute vascular tear needs minimal preparation; do not remove the healthy peripheral rim.
For a chronic tear, freshen the surfaces conservatively. Technique 56.5 advises limiting meniscal tissue excision to approximately 0.5 mm where possible.
Choose the first stabilizing stitch to maintain reduction. A midbody or anterior stabilizing stitch can assist a difficult bucket-handle reduction, followed by fixation of the remaining tear.
(Campbell, Chapter 56.)
Inside-Out Repair: Medial Meniscus
Use a zone-specific cannula to direct needles across the tear and away from the posterior midline neurovascular structures.
Before advancing needles beyond the capsule, make the required posteromedial safety incision. Develop the plane between the posterior capsule and medial gastrocnemius, retract the muscle posteriorly and place a protective retractor for needle capture.
Pass a needle through healthy meniscal tissue, using it to help maintain anatomic reduction before advancing through the peripheral rim and capsule.
Pass its paired limb to form a stacked vertical or oblique mattress stitch. Technique 56.5 describes alternating superior and inferior vertical mattress sutures approximately 3–4 mm apart.
Retrieve and organize the paired sutures under protection. Keep the pes anserinus and saphenous nerve out of the needle path.
Tie over the capsule while viewing the repair arthroscopically. Obtain coaptation without folding or deforming the meniscus.
(Campbell, Chapter 56, Technique 56.5.)
Inside-Out Repair: Lateral Meniscus
With the knee near 90 degrees, establish the posterolateral safety exposure appropriate to the tear. Develop the interval between the iliotibial band and biceps femoris and carefully separate the lateral gastrocnemius from the capsule.
Place a needle deflector between capsule and gastrocnemius. Identify and protect the common peroneal nerve; ensure that the planned exit trajectory does not cross it.
Use the working portal and cannula that direct the needle safely across the tear. If posterior fixation is poorly reached from the contralateral portal, change the trajectory rather than advancing blindly.
Retrieve sutures through the protected exposure, maintain reduction and inspect the construct as the sutures are tied.
(Campbell, Chapter 56, Techniques 56.5 and 56.7.)
Outside-In Repair
Expose the capsule through a small incision opposite the tear; use a cannula for intraarticular suture management.
Under arthroscopic vision, pass an 18-gauge needle through the capsule, peripheral rim and reduced meniscal fragment.
Introduce a shuttle through the needle and retrieve it through the working cannula to pass one limb of the repair suture.
Pass a second needle approximately 3–4 mm away and shuttle the second limb to complete a mattress construct.
Tie over the exposed capsule and repeat as needed for stable fixation. Adapt knee position and the needle path to the tear location and nearby nerves.
(Campbell, Chapter 56, Technique 56.6.)
All-Inside Repair
Localize the working portal with a spinal needle to achieve a controlled trajectory across the prepared tear.
Measure and limit deployment depth for the chosen device and anatomy. Campbell describes stops of 14 or 16 mm for the devices discussed; this is not a universal setting for every implant or knee.
Direct the needle away from neurovascular structures and deploy fixation according to the selected system. Maintain reduction throughout passage.
Place mattress fixation to secure the tear, including superior and inferior surfaces as appropriate. Do not overtighten: excessive tension can cut through meniscal tissue.
Probe the repair for stability and verify that no implant or suture is abrading the articular surface.
(Campbell, Chapter 56, all-inside technique.)
Associated Lesions and Healing Adjuncts
ACL deficiency: perform stabilization with meniscal repair when indicated and feasible; concomitant reconstruction is associated with improved healing conditions.
Ramp lesions: a posteromedial view or portal may be necessary to identify and repair a lesion hidden from routine anterior inspection.
Radial and root tears: use a construct that restores the disrupted circumferential or root attachment function. A root lesion may require an anatomic transtibial pull-out repair rather than the techniques used for a peripheral longitudinal tear.
Biologic augmentation: rasping and marrow stimulation may support healing. Campbell discusses fibrin clot and other biologics, but the optimal strategy is unresolved; improved outcomes with PRP are not consistently demonstrated.
(Campbell, Chapters 50 and 56.)
Postoperative Care
There is no single accepted protocol for every meniscal repair. After an isolated repair, Technique 56.5 commonly permits early motion from 0–90 degrees and maintains touchdown or non-weight bearing for 4–6 weeks, particularly after bucket-handle, radial, ramp or root repair. Small vertical repairs may permit earlier loading. The chapter describes jogging around 3 months and squatting or sport at 4–6 months. Progression must reflect tear pattern, fixation and any concomitant operation; these intervals are the source's protocol, not a universal clearance schedule (Campbell, Chapter 56).
Complications and Outcomes
Persistent or recurrent tearing can follow inadequate reduction, poor tissue biology, unstable fixation, residual ligament laxity or excessive early loading.
Needle-related saphenous, peroneal and popliteal neurovascular injury are major technical concerns; protect the extracapsular path for inside-out sutures.
Device-related meniscal damage, cartilage abrasion, symptomatic sutures, stiffness, infection and venous thromboembolism may occur.
Both inside-out and contemporary all-inside techniques have good reported results. Chapter 50 cites a systematic review of bucket-handle repairs with success in 83% of inside-out and 81% of all-inside repairs; these are study-specific results and do not prove superiority of one method for all tears.
(Campbell, Chapters 50 and 56.)
References
Bernholt DL, Azar FM. Knee injuries. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 50, meniscal preservation and repair, pp. 2003–2006.
Bernholt DL, Mihalko MJ. Arthroscopy of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 56, pp. 2345–2354; Techniques 56.5–56.7 and all-inside repair.