Surgical treatment of complex meniscus tear and disease: state of the art

The meniscus is important for load distribution, shock absorption and stability of the knee joint. Meniscus injury or meniscectomy results in decreased function of the meniscus and increased risk of knee osteoarthritis. To preserve the meniscal functions, meniscal repair should be considered as the first option for meniscus injury. Although reoperation rates are higher after meniscal repair compared with arthroscopic partial meniscectomy, long-term follow-up of meniscal repair demonstrated better clinical outcomes and less severe degenerative changes of osteoarthritis compared with partial meniscectomy. In the past, the indication of a meniscal repair was limited both because of technical reasons and due to the localised vascularity of the meniscus. Meanwhile, it spreads today as the development of the concept to preserve the meniscus and the improvement of meniscal repair techniques. Longitudinal vertical tears in the peripheral third are considered the ‘gold standard' indication in terms of meniscus healing. Techniques for meniscal repair include ‘inside-out', ‘outside-in' and ‘all-inside' strategies. Surgical decision-making depends on the type, size and location of the meniscus injury. Meniscal root tears substantially affect meniscal hoop function and accelerate cartilage degeneration; therefore, meniscus root repair is necessary to prevent the progression of osteoarthritis change. For symptomatic meniscus defects after meniscectomy, transplantation of allograft or collagen meniscus implant may be indicated, and acceptable clinical results have been obtained. Recently, meniscus extrusion has attracted attention due to increased interest in early osteoarthritis. The centralisation techniques have been proposed to reduce the meniscus extrusion by suturing the meniscus-capsule complex to the edge of the tibial plateau. Long-term clinical outcomes of this procedure may change the strategy of treating meniscus extrusion. When malalignment of the lower leg is accompanied with meniscus pathologies, knee osteotomies are a reasonable option to protect the repaired meniscus by unloading the pathological compartment. Advancements in biological augmentation such as bone marrow stimulation, fibrin clot, platelet-rich plasma, stem cell therapy and scaffolds have also expanded the indications for meniscus surgery. In summary, improved repair techniques and biological augmentation have made meniscus repair more appealing to treat that had previously been considered irreparable. However, further research would be necessary to validate the efficacy of these specialised technique.