Overview
Partial meniscectomy gives better function than total meniscectomy, but results remain suboptimal. Fairbank changes and functional deterioration are much more frequent after meniscectomy than after meniscal repair. Joint deterioration after meniscectomy is accelerated by femoral or tibial chondromalacia, grade II–III ACL instability, or malalignment at the time of surgery. Partial lateral meniscectomy does worse than medial. The lateral meniscus carries about 70% of the load in its compartment, the medial about 50%. (Campbell)
Indications and Patient Selection
Repairable tears. Classically only 10%–15% of tears are repairable, often those associated with ACL injury. Healing correlates with a narrow peripheral rim (<4 mm) and repair within 8 weeks of injury. More than half of tears longer than 4 cm fail to heal. Fibrin clot or marrow stimulation increases healing. (Campbell)
Tears that can be left alone. Peripheral tears of 7 mm or less heal without sutures. Probe to confirm less than 3 mm of displacement, then rasp the tear and meniscal synovium. (Campbell)
Tears that definitely can be repaired. Single vertical tears in the peripheral vascular portion: the red–red zone at the meniscosynovial junction, or the red–white zone within 3 mm of it. They are displaceable, longer than 1 cm and have minimal damage to the meniscal body. (Campbell)
Repairable under certain circumstances. Tears 3 to 5 mm from the meniscosynovial junction, evaluated with the tourniquet deflated to judge vascularity. Success is most likely in young, active patients with minimal body damage and preserved cartilage (less than Outerbridge II), particularly when ACL reconstruction is performed at the same time. (Campbell)
Resect. Menisci with several tears, tears with body damage or deformation, and tears clearly in the avascular white–white zone. (Campbell)
Radial tears. Complete radial tears disrupt all circumferential fibers. Those near the posterior horn origin of the lateral meniscus can heal, but their biomechanical function is in doubt. Long-term results of repair may still be better than subtotal meniscectomy, especially in young patients. (Campbell)
Repair is seldom done over age 40, but tear acuity, tissue quality, cartilage status and patient expectations decide. If the ACL is deficient and the meniscus is repairable, reconstruct and repair at the same time. (Campbell)
Repair techniques and when to use them (Campbell Box 56.3)
Inside-out. Posterior horn tears, midthird tears, displaced bucket-handle tears, peripheral capsular tears, meniscal allografts.
Outside-in. Anterior horn tears, midthird tears, radial and complex tears, reduction of bucket-handle tears. Often part of a hybrid repair of a bucket-handle tear, allowing more anterior stitches.
All-inside (fixator implants). Tears 2 to 4 mm from the periphery: posterior horn, vertical/longitudinal, midthird and radial tears. Secure fixation with less chondral injury and lower morbidity.
Hybrid. Combines the above.
Campbell's preferences (Box 56.4): all-inside devices for body tears, inside-out for meniscocapsular tears, all-suture anchors for anterior root tears, and simple sutures with a transtibial tunnel and button fixation for posterior root tears.
Technique 56.5: Inside-to-Outside Repair (Campbell)
Preparation
Perform a complete systematic diagnostic arthroscopy and probe the meniscus to be sure no further damage is present.
If the lesion is repairable, exsanguinate and inflate the tourniquet. Use a leg holder to open the compartment.
For the medial meniscus, view with a 30-degree scope from the anterolateral portal and probe the tear.
Acute tear in the red zone: prepare the rim minimally. Do not resect peripheral to the tear, which decompresses the meniscus and acts like a partial meniscectomy.
Chronic tear: freshen the torn surfaces, especially peripherally, removing no more than about 0.5 mm of tissue. Use baskets, a shaver, curved meniscal knives or small angled rasps through the anteromedial, accessory medial or posteromedial portal. A small rasp is preferred to abrade the meniscal surfaces and the superior and inferior parameniscal synovium.
Choose a zone-specific cannula that angles the needle away from posterior midline structures and perpendicular to the tear.
Medial meniscus exposure
For peripheral tears beyond the posteromedial corner, use an all-inside device or the inside-out method.
For inside-out repair, make a 5- to 7-cm posteromedial incision and dissect to the posteromedial corner.
Identify the interval between the medial head of the gastrocnemius and the posterior capsule, and retract the gastrocnemius posteriorly.
Place a popliteal retractor in this interval to protect the popliteal vessels and catch the needles.
Suture passage
Pass the cannula through the anterolateral portal, tip near the posterior limit of the tear. Remove the needle cradle and have an assistant load the first needle.
Enter the meniscus 3 to 4 mm from the edge, angled slightly vertically so the needle exits at or above the center of the torn edge. Watch the needle pass through the outer meniscus. Use the needle to align the meniscus anatomically before advancing, then drive it 1 cm further.
Pass the second needle peripheral to the first to make a stacked vertical or oblique mattress suture. Stacked vertical sutures hold better than horizontal mattress sutures.
Pass the needles out through the capsule with the knee flexed 15–20 degrees, retracting the pes anserinus and saphenous nerve posteriorly. Clamp the paired sutures.
Place vertical mattress sutures alternating from both meniscal surfaces every 3 to 4 mm. In a bucket-handle tear that is hard to hold reduced, place the first mattress suture anteriorly.
Suture choice: no study shows harm from absorbable sutures with long tensile life or from nonabsorbable sutures. Campbell prefers nonabsorbable suture for larger, more central tears because of prolonged healing time.
For a tear mainly in the middle third of the medial meniscus when the capsule has not been opened posteriorly, incise over the medial joint line before pushing the first needle through the capsule.
Expose the capsule along the length of the tear before passing sutures through it, which lessens the chance of cutting them.
Tie the sutures over the capsule while watching arthroscopically to confirm reduction without deformation.
Lateral meniscus (Technique 56.7)
Place the knee near 90 degrees of flexion (or figure-four). The peroneal nerve falls inferiorly and is protected. Needles must enter and exit the capsule anterior to the biceps femoris tendon.
Make a 3- to 4-cm posterolateral incision just anterior to the fibular tip, two thirds of it distal to the joint line.
Develop the interval between the iliotibial band and biceps, retract the biceps posteriorly and reflect the lateral gastrocnemius head off the posterior capsule. Place a hip skid or needle deflector between capsule and gastrocnemius.
If the tear extends near the posterior midline, protect the popliteal vessels with a wide retractor. The common peroneal nerve lies just behind the biceps tendon, so expose the area before bringing sutures through the posterior capsule.
Place stacked vertical mattress sutures about 3 mm from the edge, every 4 to 5 mm, inside-out or outside-in. If the posterior horn cannot be reached from the contralateral portal, pass needles from the ipsilateral portal, directed away from the neurovascular bundle.
Tie sutures to each other over the posterolateral capsule with the knee in full extension. Immobilize in a knee immobilizer in extension.
Technique 56.6: Outside-to-Inside Repair (Johnson) (Campbell)
Used for midbody and anterior horn tears of either meniscus. Prepare the meniscus and parameniscal tissue with a rasp first. Nerve-safe knee positions: posteromedial repairs 10–20 degrees of flexion, anteromedial repairs 40–50 degrees, lateral repairs 90 degrees.
Make a small skin incision down to the capsule opposite the tear.
Under arthroscopy, pass an 18-gauge needle from outside to inside through the meniscal rim and the fragment.
Remove the stylet and pass a doubled 20-gauge wire or No. 0 PDS into the joint. Retrieve it through a 5-mm cannula in the ipsilateral portal.
Use the wire or suture as a shuttle to pass one end of a nonabsorbable suture through the meniscus.
Place a second needle 3–4 mm from the first and shuttle the second limb, forming a vertical mattress suture.
Tie over the capsule. Repeat as often as needed.
For a large displaced peripheral medial bucket-handle tear, combine inside-out and outside-in methods. First place a single horizontal mattress suture with a cannula technique in the midportion of the tear, anterior to the posteromedial corner. This stabilizes the fragment while spinal needles carry suture through the posterior and anterior horns.
Postoperative Care
No universally accepted protocol exists. After isolated meniscal repair, early motion is accepted, and Campbell often allows 0 to 90 degrees.
Touchdown or non-weight bearing is often kept for 4 to 6 weeks, particularly for bucket-handle, root, ramp or radial repairs. Early weight bearing can be considered for small vertical repairs.
For lateral repairs, partial weight bearing on crutches for 4 to 6 weeks, depending on tear stability and distance from the blood supply.
Jogging at 3 months. Squatting and return to sport at 4 to 6 months. (Campbell)
Complications
Nerve injury. Saphenous and peroneal nerve injuries are reported with open-assisted repairs and have fallen dramatically with all-inside techniques. (Campbell)
Vascular injury. Popliteal vessels at risk posteriorly. Use protective retractors and keep needles clear of the neurovascular bundle. (Campbell)
Failure to heal. More likely with long tears, wide peripheral rims and delayed repair. Concomitant ACL reconstruction and healing enhancement (rasping, trephination, fibrin clot, PRP, marrow stimulation) improve healing. (Campbell)
Arthrofibrosis and infection. More frequent when meniscal repair is combined with ACL reconstruction. (Campbell)
References
Bernholt DL, Mihalko MJ. Arthroscopy of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 56, Arthroscopic repair of torn menisci, Techniques 56.5–56.7.