No randomized trials comparing surgical vs. non surgical treatment of symptomatic meniscus injuries are present in the literature, however not all meniscal tears are symptomatic. Furthermore MRI has greater sensitivity then specificity, and meniscal anomalies identified using MRI may not represent meniscal tear. Therefore, not all meniscal lesions need to be managed surgically. The extent, duration, and location of the injury will influence the choice of treatment but also influential is the opportunity allowed by diagnostic arthroscopy to extend this to surgical treatment. The main factors in the decision making of conservative Vs surgical management are the nature of the patient's symptoms and whether the patient can afford a period of observation (patient's occupation, hobbies) ₂ .

Partial Vs Total: Compared with total meniscectomy, partial meniscectomy is associated with shorter operating times, a faster recovery, superior post operative functional scores, and better subjective assessment of outcome. No reduction in the incidence of post operative osteoarthritis has been demonstrated in the short term. The only prospective randomized long term follow up comparing partial and total meniscectomy showed better functional results of partial resection. However it did not show better results with regards to the development of radiological OA ₃ . In a long term follow up study of arthroscopic partial Vs total meniscectomy, Andersson and Karlson ₄ report that the frequency of radiographic changes 14 years after meniscectomy is related to the size of the meniscus removed, but the grades of these changes are low and have little influence on activity and knee function. Burks et al reported 88% good to excellent results of arthroscopic meniscal resection in 146 patients with isolated meniscal injury. Results were based on the Lysholm score, satisfaction index at an average follow up of 15 years.

Open Vs Arthroscopic: With regards to the surgical route, there is insufficient evidence available from randomised trials to establish whether arthroscopic surgery is better then open surgery. The choice of method depends on a surgeons' experience and patient preference with the two methods, but the potential of a skilled application of arthroscopy to limit the damage to knee structures and enhance the rate of recovery makes arthroscopy an attractive option. Several investigations have directly compared the results of arthroscopic and open technique for meniscal resection showing that outcome with the former is better than with both open partial and total meniscectomy.

With better understanding of the benefits of preservation of intraarticular structures, the new measuring stick for interpretation of results after arthroscopic meniscectomy is meniscal repair.

The approach to meniscal repair has significantly evolved in the past 10 years and continues to expand. Recent advances and continuing work have contributed to a greater understanding of the anatomic structure, biomechanical function, and importance of meniscal tissue in joint load distribution, stability, and congruence as well as cartilage homeostasis and proprioception ₅ . The indications for meniscal repair include the position and pattern of the tear, the age of the tear, the age of the patient, their expected compliance with postoperative instructions and their activity levels and occupation. Traditionally meniscal repair is reserved for young, compliant patients with acute (< 8 weeks) peripheral longitudinal tears which lie within the vascular zone of the meniscus and occur in otherwise stable or concomitantly reconstructed knees. Repaired meniscal tears heal if there is adequate blood supply. Recent studies have demonstrated that meniscal repair can be successfully achieved with tears in less vascular zones (White-White tears), more complex geometric configurations, and isolated tears in younger patients (discoid variants) ₆ . The potential to biologically augment these at risk repairs has been reported and continues to increase. A stable knee is also important and increased healing rates have been seen with repairs done at same time as ACL reconstruction ₇ . The location of the tear in the knee can also influence the outcome of meniscal repair. There is a higher rate of healing in the medial meniscus then in the lateral meniscus. This is likely because the lateral meniscus is more mobile then the medial meniscus. In addition, there is less vascularity in the periphery of the lateral meniscus because of the presence of the popliteal hiatus ₈ . There is currently no reliable treatment option that addresses tears located in the inner two third of the meniscus, although repair of tears in this area have been attempted ₉ . Kocabey et al ₁₀ repaired 29 menisci in the red-red zone and 26 in the red-white zone with excellent results at 12 months. Some authors ₁₁ have reviewed the healing potential of tears extending into the avascular zone in patients age 40 years or older and in patients aged 20 years and younger. In the older cohort, 93% of tears were asymptomatic for tibio femoral joint symptoms. On second look arthroscopy, only one out of 6 tears was completely healed, two were partially healed, and three had failed. Comparable results were obtained with the younger patient cohort. Post operative protocols vary but the majority of patients will be asked to follow a strict physiotherapy regime and avoid contact sports for 6 months, as opposed to partial meniscectomy when patients can resume normal activities after 2 weeks.

Although many meniscus tears can be successfully repaired, not all are salvageable, especially if considerable tissue damage has occurred. Meniscus transplantation has been shown to be an acceptable procedure for younger patients. The primary candidate is a patient younger then age 50 years who has had a total meniscectomy and who either has pain in the tibiofemoral component, arthroscopic evidence of articular cartilage deterioration or both. Contraindications are advanced knee joint arthrosis, with flattening of the femoral condyle, concavity of the tibial plateau and osteophytes that prevent anatomic seating of the meniscus allograft; axial malalignment, knee joint instability; knee arhtrofibrosis; muscular atrophy; and prior joint infection. In a recent paper, Noyes et al ₁₂ prospectively evaluate the results of meniscal transplantation in a consecutive series of young patients treated for pain in the tibio-femoral compartment following a previous meniscectomy. 89% of the 38 patients rated the knee condition as improved. 76% of patients returned to light low-impact sports without problems. Some authors have shown that there is a significant difference in the clinical results between lateral and medial meniscal transplants. In fact, the cumulative survival rate of the lateral, medial and combined allograft in the same knee was 76%, 50% and 67% respectively ₁₃ .