Over the past decade, we have developed a more complete understanding of meniscus pathophysiology, mechanical properties and functions, repair site healing, and performance and limitations of the evolving all-inside repair techniques (1,10). Arthroscopic meniscal repair technology continues to improve as does our knowledge of the meniscus itself. As new advances are made and research is continued, indications for repair will expand. Over the past few decades, research has stressed the importance of retaining as much functional meniscal tissue as possible in order to maintain normal contact stresses at the articular surface. The importance of a clear and thorough understanding of the indications as well as the technology and techniques involved in treating this subset of meniscus tears is paramount in decreasing the number of patients who develop significant life-long morbidity as a result of these injuries.

Historically, the inside-out method of suture fixation had been the treatment of choice for a repairable meniscus and remains the gold standard by which all new devices are measured. All inside approaches have become more common over the past decade because of their decreased associated risks, shorter operating time, decreased morbidity associated with a larger incision, less need for trained assistants, and often ability to repair tears in anatomic locations difficult to reach by open techniques. However, most studies continue to find that all-inside devices perform inferiorly to traditional suture repair techniques in biomechanical studies (2,4,11,15). The clinical relevance of this is still undetermined and all-inside devices are increasing in popularity.

Indications for meniscal repair are similar regardless of technique. It is generally agreed upon that factors that are favorable for fixation include acute symptomatic tears, longitudinal orientation, peripheral red-red/red-white tears, tears >7 to 10 mm in length, unstable tears with >3 mm excursion, concomitant reconstructive surgery (anterior cruciate ligament (ACL) or articular cartilage), and patients who prefer this procedure over continued nonoperative treatment. Contraindications may include degenerative tears in older patients, chronic tears >3 months, avascular tears in the white-white zone, complex tear patterns, stable/incomplete tears, patients unable to comply with weight-bearing and motion restrictions, and associated infectious/rheumatologic/collagen vascular diseases.

Many find that tears of the anterior one third are still most easily and predictably repaired with outside-in or open techniques with all-inside techniques being reserved for more posterior tears and those involving the body. Posterior one third tears are more difficult to reach using an inside-out technique, which also places the neurovascular structures, such as the saphenous nerve medially or peroneal nerve laterally, at risk. Also, all-inside devices are designed to be inserted perpendicular to the tear. An anterior anatomic location may make this difficult even by switching or using an additional accessory portal. In the case of bucket-handle tears displaced into the notch, some feel that traditional inside-out sutures placed in variable configurations are more preferable. It had been thought that the inside-out technique allows more reliable tensioning of the suture into a meniscus that has been torn. However, with the advent of suture-based fixators, bucket-handle tears may also be secured more reliably using the all-inside devices.

Some surgeons will allow immediate weight bearing in extension following repair with the thought that hoop stresses placed through the meniscus will not harm and in fact may aid in healing. However, many still maintain the traditional protocol of nonweight or partial weight bearing for up to 6 weeks. This conversation with the patient and their ability to comply with these restrictions is necessary prior to every planned arthroscopy with
the potential for repair. The patient must understand that a tear may be found irreparable at the time of surgery and a final decision may be made at that time.