Biomechanical Properties of Posterior Meniscal Root Repairs: A Systematic Review

Neither All-Inside, nor Inside-Out, nor Outside-In Repair Demonstrates Superior Biomechanical Properties for Vertical Meniscal Tears: A Systematic Review of Human Cadaveric Studies

PURPOSE

To systematically review the literature regarding the biomechanical properties of different repair techniques and fixation methods for vertically oriented meniscal tears.

METHODS

Human cadaveric studies evaluating the biomechanical properties of different repair techniques for vertically oriented meniscal tears were identified using the PubMed, EMBASE, and Cumulative Index to Nursing & Allied Health databases. Primary outcomes included load to failure, displacement, stiffness, peak contact pressure, and contact area of repaired menisci. Repair techniques from included studies were reclassified into a total of 19 distinct all-inside (AI), inside-out (IO), or outside-in (OI) techniques.

RESULTS

Sixteen studies were included (420 total menisci). Contact pressure and area were restored to intact-state values across all 5 compressive load studies at low knee flexion angles but not at greater knee flexion angles (i.e., >60°). There were no significant differences in contact pressure or area between AI, IO, and OI techniques across all studies. Some studies demonstrated statistically significant advantages in tensile properties with IO techniques when compared with AI techniques, whereas others found AI techniques to be superior. No studies directly compared tensile properties of OI techniques with those of AI or IO techniques. Vertical mattress suture configurations resulted in significantly greater load to failure and decreased displacement compared with horizontal mattress configurations in 67% of studies comparing the 2 techniques. There was no difference in the rate of tissue failure in AI (66.97%), IO (60.38%), or OI (66.67%, χ2 = 0.83, P = .66) techniques.

CONCLUSIONS

Contact mechanics are reliably restored after repair of vertical meniscal tears at low flexion angles but inconsistently restored at greater flexion angles, regardless of technique. Vertical mattress configurations outperformed horizontal mattress configurations under tensile load. There are conflicting data regarding the comparison of tensile properties between AI and IO techniques. Ultimately, neither AI, IO, nor OI repair demonstrated superior biomechanical properties in the present literature.

CLINICAL RELEVANCE

Several repair techniques demonstrate favorable biomechanical properties for vertical meniscal tears under tensile and compressive loads. Neither AI, IO, nor OI repair techniques demonstrate superior biomechanical properties at this time.

A Reverse Suture Anchor Technique for Arthroscopic Medial Meniscus Root Repair

Injuries of the posterior root of the medial meniscus can be accompanied by damage to the anterior cruciate ligament or often occur independently in cases of degenerative meniscal injury in older individuals. Anchor suture repair can achieve favorable biomechanical effects and clinical outcomes. However, anchor placement is technically challenging and requires a posterior medial approach, which increases the risk of iatrogenic injury. To address these issues, we have utilized the reverse anchor technique to repair the posterior root of the medial meniscus. This technique offers advantages such as reduced surgical time, simplified operation, and reduced risk of the "bungee effect" and iatrogenic injury.

Knotless Re-tensionable Direct Fixation of Medial Meniscus Posterior Root Tears

Over the past decade, there has been an increased awareness of the recognition and treatment of medial meniscus posterior root tears. Recent systematic reviews and meta-analyses have shown that surgical repair of medial meniscus posterior root tears is effective in improving patient-reported outcome measures and decreasing the progression of osteoarthritis when compared with nonoperative treatment or meniscectomy. The available techniques currently consist of transosseous suture fixation and direct suture anchor fixation, with transosseous repairs being the most frequently performed. Transosseous fixation relies on indirect fixation on the anterior tibial cortex, which may predispose to gap formation at the repair site. On the other hand, suture anchor fixation is technically demanding with arthroscopic placement of the anchor perpendicular to the tibial plateau at the posterior medial root insertion. Furthermore, re-tensioning of the construct is not possible with the current techniques. In this technical note, we present a knotless re-tensionable direct fixation technique using an anterior tibial tunnel, which has the advantages of direct fixation, a rip-stop suture configuration, a reproducible surgical technique, and the possibility of re-tensioning of the repaired meniscal root.

Short-term results of tibial interference screw fixation for transtibial medial meniscus posterior root pull-out repair

Background

To evaluate the technique of transtibial pull-out repair with tibial interference screw fixation for medial meniscus posterior root (MMPR) tear by reporting on short-term outcomes and complications.

Methods

All MMPR repairs performed between January 2019 and August 2021 (n = 70) were retrospectively screened regarding demographic data and surgical parameters. The patients were questioned for performed revision surgery, symptoms and complications. The Numeric Rating Scale (NRS) for pain, Lysholm Knee Score and International Knee Documentation Committee Subjective Knee Form (IKDC) questionnaires were used to evaluate clinical outcome. In cases of revision surgery for re-tear the mode of failure was intraoperatively classified (patients with re-tear were excluded from the clinical follow-up examination). The influence of demographic and treatment parameters (surgical and rehabilitation) on the incidence and mode of re-tear and clinical scores was evaluated.

Results

After 2.3 ± 0.7 years, 62 patients (88.6 %) were available for follow-up. There were no direct intra- or postoperative complications. No revision was performed due to symptoms related to the tibial fixation material. The mean surgery time was 33.5 ± 10.8 min. The overall re-tear rate was 17.7 % (11 patients) of whom 10 were treated surgically and one conservatively. Primary mode of failure was suture cut-out from the meniscus (70 %). The NRS, Lysholm Knee Score and subjective IKDC were obtained in 38 patients and improved from 6.8 ± 2.4, 40.1 ± 23.9 and 32.8 ± 16.3 to 2.2 ± 2.2, 80.5 ± 16.3 and 63.0 ± 13.9, respectively (all p < 0.001). No influence was observed from demographic and treatment parameters on re-tear rates or clinical Scores.

Conclusions

Tibial interference screw fixation is a fast and promising technique for MMPR transtibial pull-out repair. In the presented technique, utilizing non-absorbable locking sutures alongside tibial interfenrence screw fixation, the primary mode of failure was suture cut-out from the meniscus.

Arthroscopic Lateral Meniscus Root Repair With Reverse Suture Anchor Technique

The stability of the knee joint is crucially dependent on the integrity of the lateral meniscus posterior root, which is often accompanied by anterior cruciate ligament injury. Anchor suture repair for lateral meniscus posterior root injury not only achieves better biomechanical effects but also ensures favorable prognosis. However, the placement of anchors often requires the establishment of a posterior approach, and the insertion of an anchor is a technical challenge. In light of this, we have applied the technique of reverse anchor fixation for repairing the lateral meniscus posterior root, which not only simplifies the procedure but also effectively reduces the "bungee effect."

The stability of repaired meniscal root can affect postoperative cartilage status following medial meniscus posterior root repair

BACKGROUND

Transtibial pullout repair yields beneficial clinical outcomes in patients with medial meniscus (MM) posterior root tear. However, the relationship between repaired meniscal root healing status and postoperative clinical outcomes remains unclear. We aimed to evaluate changes in articular cartilage damage and clinical scores after pullout repair using two simple stitches (TSS).

METHODS

Thirty-three patients who underwent pullout repair using TSS were assessed. Healing status was assessed by a semi-quantitative second-look arthroscopic scoring system comprising three evaluation criteria (width of bridging tissues, stability of the repaired root, and synovial coverage), 1 year postoperatively. MM medial extrusion (MMME) and cartilage damage were assessed preoperatively and 1 year postoperatively. The medial compartment was divided into 8 zones (A-H) for comparison of preoperative and 1-year postoperative cartilage damage. Clinical outcomes were evaluated using the Knee Injury and Osteoarthritis Outcome score, Lysholm score, International Knee Documentation Committee scores, and visual analogue scale pain score.

RESULTS

Although cartilage damage did not aggravate significantly in most medial compartment areas, MMME progressed at 1 year postoperatively. No statistical differences were observed in cartilage damage between the central-to-medial area of the medial femoral condyle and the medial tibial plateau area at 1 year postoperatively. Regarding semi-quantitative healing scores, the stability score was significantly correlated with the International Cartilage Repair Society grade at 1 year postoperatively. All 1-year and 2-year clinical scores significantly improved compared with the preoperative scores.

CONCLUSION

Regarding TSS repair, stability of repaired meniscal root negatively correlated with cartilage damage in the medial compartment loading area. All 1-year and 2-year clinical scores significantly improved than those of the preoperative scores. Achieving MM stability is crucial for suppressing cartilage degeneration.

LEVEL OF EVIDENCE

IV case series study.

Arthroscopic Transtibial Medial Meniscus Posterior Root Repair Using the "Meniscal Track" to Locate the Anatomical Footprint

The medial meniscus posterior root tears are a common problem in early elder patients. From a biomechanical study, the anatomical repair demonstrated a restored contact area and contact pressure than the nonanatomical repair. Nonanatomical repair of the medial meniscus posterior root resulted in decreased tibiofemoral contact area and increased contact pressure. Various surgical repair techniques were reported in the literature. However, there was no reported precise arthroscopic landmark to define the anatomical footprint of the posterior root attachment of the medial meniscus. We propose the "meniscal track", an arthroscopic landmark to guide the location of the anatomical footprint of the medial meniscus posterior root attachment.

The functional impact of home-based self-rehabilitation following arthroscopic meniscus root repair

BACKGROUND

Corona virus infectious pandemic makes outdoors rehabilitation a potential hazard. Patient education to perform simple home-based exercises seems to be an interesting and sometimes a mandatory option. This study provides a comparison between the conventional and home-based virtual rehabilitation after surgical repair of medial meniscus root tears.

METHODS

In this prospective study, all patients who underwent medial meniscus posterior root repair with a modified trans-tibial pull-out technique from March 2019 to March 2021 were evaluated. Those who underwent surgery after December 2019 were trained to perform self-rehabilitation. The rest had undergone outdoors specialized rehabilitation according to a unified protocol and these were used as a historical control group. All patients were followed up for a minimum of 2 year after surgery. Final Lysholm scores were utilized to compare functional outcomes after considering the effect of age, body mass index and time from surgery by multivariate linear regression analysis.

RESULTS

Forty-three consecutive patients with medial meniscal root tears were studied. Thirty-nine (90.7%) were women and 4 (9.3%) were men. The mean age of participants was 53.2 ± 8.1 years. The total Lysholm knee score, and all its items were significantly improved in both groups at a two-year follow-up (p < 0.05), except the "Using cane or crutches" item (p = 0.065). Nevertheless, the final Lysholm knee score improvement was higher in patients who performed outdoors specialized rehabilitation and in patients with shorter time-to-surgery.

CONCLUSION

Regardless of age and gender, home-based rehabilitation after meniscal root repair with the modified trans-tibial pull-out technique improved the patients' function at a two-year follow-up. Nonetheless, this effect was still significantly lower than that of the outdoors specialized rehabilitation. Future work is required to clarify basic protocols for home-based tele-rehabilitation programs and determine clinical, radiological and functional results.

LEVEL OF EVIDENCE

Level IV, therapeutic, historically controlled study.

Examining the Efficacy of Medial Meniscus Posterior Root Repair: A Meta-analysis and Systematic Review of Biomechanical and Clinical Outcomes

BACKGROUND

Medial meniscus posterior root (MMPR) injuries accelerate the progression of osteoarthritis. While partial meniscectomy was once considered the gold standard for treatment, meniscus root repair has become increasingly utilized with reported improvements in clinical and biomechanical outcomes.

PURPOSE

To perform a systematic review of biomechanical outcomes and a meta-analysis of clinical and radiographic outcomes after MMPR repair.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

The PubMed, Embase, and Cochrane databases were queried in August 2021 for studies reporting biomechanical, clinical, and radiographic outcomes after MMPR repair. Biomechanical studies were assessed for main results and conclusions. Data including study characteristics, cohort demographics, and outcomes were extracted. Included clinical studies were analyzed with a random-effects meta-analysis of proportions for binary outcomes or continuous outcomes for mean differences between preoperative and postoperative time points. Subgroup analysis for studies reporting repair outcomes with concomitant high tibial osteotomy (HTO) was performed where appropriate.

RESULTS

A total of 13 biomechanical studies were identified and reported an overall improvement in mean and peak contact pressures after MMPR repair. There were 24 clinical studies, consisting of 876 patients (877 knees), identified, with 3 studies (106 knees) reporting outcomes with concomitant HTO. The mean patient age was 57.1 years (range, 23-74 years), with a mean follow-up of 27.7 months (range, 2-64 months). Overall, clinical outcomes (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, visual analog scale for pain, Tegner, and Knee injury and Osteoarthritis Outcome Score scores) were noted to improve postoperatively compared with preoperatively, with improved Lysholm scores in patients undergoing concomitant HTO versus MMPR repair alone. Meniscal extrusion was not significantly improved after MMPR repair compared with preoperative measurements. The progression in Kellgren-Lawrence grades from grade 0 to grades 1 to 3 occurred in 5.9% (21/354) of patients after repair, with no patients progressing from grades 1 to 3 to grade 4.

CONCLUSION

MMPR repair generally improved biomechanical outcomes and led to improved patient-reported outcomes with greater improvements noted in patients undergoing concomitant HTO. Repair did not significantly improve meniscal extrusion, while only 5.9% of patients were noted to progress to low-grade osteoarthritis. The high level of heterogeneity in the included biomechanical and clinical investigations emphasizes the need for more well-designed studies that evaluate outcomes after MMPR repair.

Meniscal Root Repair Alone or Combined with Different Procedures After at Least 6 Months of Follow-Up: A Series of Cases

Purpose

To analyze clinical and functional outcomes of patients submitted to posterior meniscal root repair of the medial or lateral meniscus in different settings, with at least 6 months of follow-up.

Patients and Methods

Retrospective multicentric study assessing epidemiological characteristics and clinical-functional results of 22 patients who underwent meniscal root reinsertion (MRR) by transtibial technique. This study addressed different settings: isolated medial root repair, medial root repair associated with high tibial osteotomy (HTO) and lateral root repair associated with anterior cruciate ligament (ACL) reconstruction.

Results

Twelve patients had an isolated tear of the posterior root of the medial meniscus and underwent MRR alone. Six patients had a varus axis >5°, undergoing MRR in addition to HTO in the same surgical procedure. Four patients underwent repair of the posterior root of the lateral meniscus associated with simultaneous reconstruction of the ACL. The main results of the study were observed in the improvement of the IKDC score from 27.7% preoperatively to 69.8% in the postoperative period (p < 0.0001) and the Lysholm score of 44.4 points preoperatively to 88.4 points in the postoperative period (p < 0.0001). Significant clinical and subjective improvements were also reported.

Conclusion

Medial meniscal root repair, associated or not with valgus tibial osteotomy (when indicated) and lateral meniscal root repair associated with ACL reconstruction, improved clinical, functional, and subjective results of the patients presented in this case series in the short term.

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Midterm Outcomes of Posterior Medial Meniscus Root Tear Repair: A Systematic Review

BACKGROUND

Whereas there has been growing interest in surgical repair of posterior medial meniscus root tears (PMMRTs), our understanding of the medium- and long-term results of this procedure is still evolving.

PURPOSE

To report midterm clinical outcomes from PMMRT repairs.

STUDY DESIGN

Systematic review.

METHODS

A literature review for this systematic analysis was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified studies that reported the results of arthroscopic repair of PMMRTs. Functional and imaging outcomes were reviewed and summarized.

RESULTS

In total, 28 studies with a total of 994 patients (83% female) with an overall mean age of 57.1 were included in this review. Clinical outcomes (Lysholm, International Knee Documentation Committee, Hospital for Special Surgery, and Tegner scores) were improved at final follow-up in all studies. Of patients, 49% had radiographic progression of at least 1 grade in the Kellgren-Lawrence scale at a mean follow-up of 4.0 years in 11 studies. Cartilage degeneration had progressed at least 1 grade on magnetic resonance imaging scans in 23% of patients at a mean follow-up of 31.6 months in 4 studies.

CONCLUSION

PMMRT repairs provide a functional benefit with consistent improvements in clinical outcome scores. There is some evidence that PMMRT repair slows the progression of osteoarthritis but does not prevent it at midterm follow-up.

Arthroscopic Transtibial Pull-Out Repair for Meniscal Posterior Root Tear: The Slip Knot Technique

A meniscal root tear can increase the tibiofemoral contact pressure to approximate that of total meniscectomy and eventually lead to degenerative change. An anatomic and stable meniscal root repair is essential in restoring the tibiofemoral contact pressure back to that of a normal knee. Suture anchor technique and pull-out suture technique are the 2 main arthroscopic root repair procedures with equivalent success; nonetheless, there remains a lack of an optimal technique with a biomechanical property matching that of the intact root. This article presents a technically simple, fast, and robust pull-out suture construct that incorporates 2 slip-knot locking loops at the meniscus-suture interface. This technique can be used for both medial and lateral posterior root repair, as well as concomitantly with cruciate ligament reconstruction.

Arthroscopic Transtibial Pull-Out Repair for Meniscal Posterior Root Tear: The Slip Knot Technique

A meniscal root tear can increase the tibiofemoral contact pressure to approximate that of total meniscectomy, and eventually lead to degenerative change. An anatomic and stable meniscal root repair is essential in restoring the tibiofemoral contact pressure back to that of a normal knee. Suture anchor technique and pull-out suture technique are the two main arthroscopic root repair procedures with equivalent success; nonetheless, there remains a lack of an optimal technique with a biomechanical property matching that of the intact root. This article presents a technically simple, fast, and robust pull-out suture construct that incorporates two slip-knot locking loops at the meniscus-suture interface. This technique can be utilized for both medial and lateral posterior root repair as well as concomitantly with cruciate ligament reconstruction.

Repair of the Posterior Lateral Meniscal Root Tear: Suture Anchor Fixation Through the Outside-In Anterior Cruciate Ligament Reconstruction Femoral Tunnel

Posterior lateral meniscus root tears are defined as tears that occur within 9 mm of the posterior lateral meniscus insertion or as avulsions of the insertion. If root tears are left unrepaired, functional alterations and early degenerative changes occur in the affected compartment. Several surgical techniques have been described to reattach the posterior horn of the lateral meniscus, including transtibial pull-out technique and side-to-side repair technique. This surgical technique reports an alternative way to repair posterior lateral meniscus root tears that are associated with or without an anterior cruciate ligament graft tear. The technique involves the placement of a suture anchor on the lateral meniscus root footprint through the outside-in anterior cruciate ligament femoral tunnel, which minimizes the possibility of iatrogenic lesions and facilitates repair.

All-inside Techniques for Meniscal Radial Root Tear Repair

Meniscal radial root tears can disrupt the load-bearing function of the meniscus and worsen instability in anterior cruciate ligament-deficient knees. Paracentral radial tears adjacent to the root (types 1, 2, and 4) repaired with a transtibial pullout suture technique can lead to over-medialization of the meniscal root and a high-tension nonanatomic repair. We propose 2 all-inside techniques for anatomic repair of medial and lateral meniscal radial root tears with (1) an all-inside meniscal repair device and (2) an antegrade suture passer. We present the technical requirements and tips for these techniques. For lateral meniscal radial root repair with an all-inside meniscal repair device, ideal viewing is from an anterolateral portal with device entry from an anteromedial portal to reduce the risk of vascular injury. We recommend at least 2 stitches across the tear, with the depth setting limited to 18 to 20 mm for a central stitch and 16 mm or less for a peripherally placed stitch. For root repair with an antegrade suture passer, viewing should be from an anteromedial portal with the passer entering from an anterolateral portal. At least 2 stitches should be placed across the tear, with 1 central and 1 peripheral or 1 superior and 1 inferior.

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Background:

A large number of systematic reviews and meta-analyses regarding the meniscus have been published.

Purpose:

To provide a qualitative summary of the published systematic reviews and meta-analyses regarding the meniscus.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of all meta-analyses and systematic reviews regarding the meniscus and published between July 2009 and July 2019 was performed with PubMed, CINAHL, EMBASE, and the Cochrane database. Published abstracts, narrative reviews, articles not written in English, commentaries, study protocols, and topics that were not focused on the meniscus were excluded. The most pertinent results were extracted and summarized from each study.

Results:

A total of 332 articles were found, of which 142 were included. Included articles were summarized and divided into 16 topics: epidemiology, diagnosis, histology, biomechanics, comorbid pathology, animal models, arthroscopic partial meniscectomy (APM), meniscal repair, meniscal root repairs, meniscal allograft transplantation (MAT), meniscal implants and scaffolds, mesenchymal stem cells and growth factors, postoperative rehabilitation, postoperative imaging assessment, patient-reported outcome measures, and cost-effectiveness. The majority of articles focused on APM (20%), MAT (18%), and meniscal repair (17%).

Conclusion:

This summary of systematic reviews and meta-analyses delivers surgeons a single source of the current evidence regarding the meniscus.

Alternative Techniques for Lateral and Medial Posterior Root Meniscus Repair Without Special Instruments

Improved understanding and treatment of posterior medial and lateral meniscus root tears have attracted increasing interest. These lesions significantly compromise meniscal function, which can result in an outcome resembling total meniscectomy, and are also a potential cause of knee instability. Despite facilitating repair procedures and reducing the operative time for these lesions, all-inside meniscal repair devices are not available in all circumstances or registered for use in all countries worldwide. Furthermore, all-inside arthroscopic devices can be expensive. Therefore, low-cost alternatives for the treatment of these lesions must be identified. We present 2 efficient and safe techniques: an outside-in technique for repairing medial meniscus root tears and a technique using a simple needle inserted through the transtibial tunnel for lateral meniscal root repairs, neither of which requires the use of specific instruments, thus enabling appropriate treatment of posterior medial and lateral meniscus root tears.

AANA20: The 2020 Annual Meeting of the Arthroscopy Association of North America

Arthroscopy, Arthroscopy Techniques, and Arthroscopy, Sports Medicine, and Rehabilitation will be in attendance in force at the 2020 Annual Meeting of the Arthroscopy Association of North America (AANA20). Program highlights and innovations include surgery simulcasts, "Great Debates," award-winning papers, Feature Lectures, and sessions glimpsing what is On the Horizon-and perhaps over and beyond.

Different Suture Materials for Arthroscopic Transtibial Pull-out Repair of Medial Meniscal Posterior Root Tears: A Human Biomechanical Study

Background

Transtibial pull-out repair of the medial meniscal posterior root (MMPR) has been largely assessed through biomechanical studies. Biomechanically comparing different suture types would further optimize MMPR fixation and affect clinical care.

Purpose/Hypothesis

The purpose of this study was to determine the optimal suture material for MMPR fixation. It was hypothesized that ultra high-molecular weight polyethylene (UHMWPE) suture tape would be biomechanically superior to UHMWPE suture and standard suture.

Study Design

Controlled laboratory study.

Methods

The MMPR attachment was divided in 24 human cadaveric knees and randomly assigned to 3 repair groups: UHMWPE suture tape, UHMWPE suture, and standard suture. Specimens were dissected down to the medial meniscus, and the posterior root attachments were sectioned off the tibia. Two-tunnel transtibial pull-out repair with 2 sutures, as determined by the testing group, was performed. The repair constructs were cyclically loaded between 10 and 30 N at 0.5 Hz for 1000 cycles to mimic the forces experienced on the medial meniscus during postoperative rehabilitation. Displacement was recorded at 1, 50, 100, 500, and 1000 cycles. Ultimate failure load, displacement at failure, and load at 3 mm of displacement (clinical failure) were also recorded.

Results

UHMWPE suture tape had significantly less displacement of the medial meniscus when compared with standard suture at 1 (-0.22 mm [95% CI, -0.41 to -0.02]; P = .025) and 50 (-0.35 mm [95% CI, -0.67 to -0.03]; P = .029) cycles. There were no other significant differences observed in displacement between groups at any number of cycles. UHMWPE suture tape had significantly less displacement at the time of failure than standard suture (-3.71 mm [95% CI, -7.17 to -0.24]; P = .034). UHMWPE suture tape had a significantly higher load to reach the clinical failure displacement of 3 mm than UHMWPE suture (15.64 N [95% CI, 0.02 to 31.26]; P = .05). There were no significant differences in ultimate failure load between groups.

Conclusion

The meniscal root repair construct with UHMWPE suture tape may be stronger and less prone to displacement than that with standard suture or UHMWPE suture.

Clinical Relevance

UHMWPE suture tape may provide better clinical results compared with UHMWPE suture and standard suture.

Editorial Commentary: Save the Meniscal Root, Why Not?

The repair of the meniscal root in medial meniscal posterior root tears is receiving increasing interest as more and more research highlights the positive effects of this procedure on the biomechanical restoration of the meniscus. As a testament to the findings of these studies, an international consensus statement recently acknowledged, with several supporting findings from both biomechanical and clinical studies, the effectiveness of meniscal root repairs. Various root repair techniques have been developed with the overarching goal of restoring the structure and function of the meniscus. Yet several challenges such as obtaining robust and long-term healing of degenerative tissue and minimizing meniscal extrusion remain to be overcome.