Meniscal repair. Where do we go from here?

In summary, it has been the task of this article to try to forecast the future of meniscal surgery over the next decade. As we enter the twenty-first century, it becomes evident that a combination approach will be the most likely procedure. The code phrase will be, "Save as much meniscus as possible." The authors predict that accomplishing this objective will involve the use of adhesive materials, possibly autologous but more probably exogenous, supported by the insertion of a collagenous type material, which will serve as a scaffolding for the ingrowth of fibrocartilage, and the healing will be stimulated by hormonal methods. Whether this occurs through recombinant DNA techniques or better methods of precipitation remains an issue. Dose-specific mitogens and chemotactic agents will be placed in the area of injury to potentiate the vascular fibrous response of the host tissue. With earlier and more exuberant fibrous response and initial tissue adhesion from the fibrin adhesive, better stability will be established to allow for primary healing of meniscal tissues. This procedure will work well for longitudinal tears of the meniscus. A dilemma arises with more complex tears of the meniscus, however. Previously irreparable tears may be conducive to resection then replacement with cultured autologous fibrochondrocytes, either in a gel-type form or on scaffolds made of collagen or biodegradable materials. These scaffold/fibrochondrocyte replacements may be contoured to the defect present and bonded tightly with the fibrin adhesives previously discussed. Again, growth factors would be needed for ultimate success as the fibrochondrocytes mature into the appropriate morphologic subpopulations and begin to turn over their own extracellular matrix. The patient would have a neomeniscal autologous transplant with normal host cell turnover of matrix. A brave new era lies ahead for meniscal repair, and the journey promises to be a most exciting one.