# Meniscal Tear Management Associated with ACL Reconstruction
## 2 Therapeutical Options for Meniscal Lesions with Concomitant ACL Reconstruction
### Meniscal Repair Associated with ACL Reconstruction  
When deciding what meniscal ruptures should be repaired, we must consider both rupture characteristics (size, appearance, acute vs. chronic, location) as well as general factors (age, activity level, knee stability, alignment) [1]. Although the repair rate is still low and there is a mismatch between the repairable meniscal tears (30%) and the number of performed repairs (4-10%), there is a visible trend toward surgical repair in the last 15-20 years [1; 64; 65; 66]. The best indication for suturing is an unstable, vertical, longitudinal rupture located in the peripheral region (red-red zone) of the meniscus. Since the tissue is of good quality and well-vascularized, the healing rates are higher and the benefit the greatest [41; 67]. The vertical longitudinal ruptures can be easily reduced and are ideal for the placement of vertical sutures [67]. Meniscal repair has significantly higher success rates in early stabilized knees if performed early after trauma (<12 weeks). A repaired meniscus also provides better outcomes in ACL reconstructed knees. When repair is required, surgery should be performed as soon as possible to maximize the suture success rate and reduce secondary damage [1; 68; 69; 70]. Therefore, the general rule is to perform reconstruction of the ACL and the meniscal suture simultaneously. A possible exception/alternative could be a non-reducible bucket handle tear in an inflamed knee with a subacute ACL tear. A two-step approach may be the best option to reduce the risk of orthofribrosis if one-stage surgery cannot be performed [71; 72; 1]. If the two-stage approach is chosen, the ACL reconstruction should be performed as soon as possible (weeks) after full ROM is obtained and the knee is no longer inflamed due to the increased risk of re-rupture of the repaired meniscus (1% for each month after the first surgery) [1; 73]. Arthroscopic meniscus repairs have become part of the routine, open surgery being performed exceptionally for specific cases. Initially, the inside-out technique has been considered the gold standard for meniscal repair [74], till outside-in and all-inside techniques were developed. Currently, the newer generation meniscal repair devices exhibit biomechanical properties similar to inside-out sutures [74; 75; 76]. First-generation all-inside repair devices were rigid and had high failure rates and produced articular cartilage damage. Therefore, they became unsuitable for meniscal repair [77; 74]. The presently preferred all-inside systems are the flexible suture- and anchor-based repair devices which are used for the management of tears located at the posterior horn and body of both menisci. They are built with dual anchors connected by a pre-tied, sliding, and self-locking knot, allowing for appropriate tensioning across the meniscal tear The anterior horn is better approached with an outside-in technique [78]. The ideal suture for meniscal repair should have a high load to failure to prevent detachment, high stiffness to prevent deformation, and low displacement to avoid suture elongation [79; 80]. New biomaterials are better engineered to provide optimum strength and absorption profile [80]. Meniscal sutures have a higher load to failure and greater stiffness properties than meniscal repair devices [81]. With respect to the suture material, the top suture repairs were vertical sutures performed with PDS 0, Orthocord 00, Ethibond 0, FiberWire(r) and FiberTape(r). FiberTape seems to be the strongest and stiffest material with the lowest elongation rate [79; 82]. With regard to the devices, second-generation devices were significantly stronger and stiffer than first-generation devices (Meniscal Viper (Arthrex, Munich, Germany), MaxFire (Biomet, Warsaw, IN, USA), and FasT Fix (Smith&Nephew, London, UK)) [74; 75]. Modern meniscal suture devices make repairs more feasible by increasing accuracy, speed and reproducibility. Newer devices with a backstop may be used in tears that are more peripheral [83].