Technical Note

Meniscal Radial Tears: A Classification System Based

on Tear Morphology
Jorge Chahla, M.D., Ph.D., Derrick M. Knapik, M.D., Harkirat Jawanda, B.S.,
Felicitas Allende, M.D., Horacio Rivarola, M.D., Johnathon R. McCormick, M.D.,
Robert F. LaPrade, M.D., Ph.D., and Garrett R. Jackson, M.D.

Abstract: Appropriate management of radial meniscal tears is complex, with continued efforts focused on optimizing
diagnostic methods for identification to help dictate treatment, especially as surgical indications for repair have expanded,
coupled with improvements in surgical techniques and instrumentation. Currently, no standardized classification system
for radial meniscal tears exists, limiting the ability to accurately characterize injury patterns and guide surgical decision-
making.

M eniscal tears remain one of the most common

knee injuries, affecting patients of all ages and
activity levels.1,2 The menisci play a crucial role in
reported to restore biomechanical load distribution
within the affected compartment,5,6 decreasing the risk
for early chondral wear and degeneration.10,11 As such,
maintaining homeostasis within the knee joint, preser- the popularity of meniscal repair procedures has
ving tibiofemoral congruency, joint stability, dynamic increased when compared to meniscal debridement in
load distribution, and proprioception.3,4 As a result, appropriately selected patients.12
operative intervention is often recommended in patients Radial tears of the meniscus are unique due to their
with meniscal tears and continued symptoms following perpendicular orientation to the meniscal axis, effec-
a trial of nonoperative management. Despite providing tively disrupting the circumferential collagenous fibers
short-term pain relief, debridement of meniscal tears, at the periphery of the menisci. Arising from the central
especially those involving >60% of the meniscal width,4 region and extending to a variable extent to the pe-
results in inferior biomechanical effects,5,6 perpetuating riphery, radial tears may occur in all zones within the
a meniscal-deficient state and increasing the risk for medial and lateral menisci secondary to acute traumatic
early osteoarthritis (OA) development.7-9 Meanwhile, or chronic degenerative processes.4 When present,
tissue preservation through meniscal repair has been radial tears lead to increased joint contact pressures,

From the Department of Orthopaedic Surgery, Rush University Medical Arthrex, Linvatec, and Smith & Nephew. J.C. is on the speakers bureau or
Center, Chicago, Illinois, U.S.A. (J.C., H.J., F.A., J.R.M., G.R.J.); Department has received paid presentations from Smith & Nephew. All other authors
of Orthopaedic Surgery, Washington University and Barnes-Jewish Ortho- (D.M.K., H.J., F.A., H.R., J.R.M., G.R.J.) declare that they have no known
pedic Center, Chesterfield, Missouri, U.S.A. (D.M.K.); Department of Ortho- competing financial interests or personal relationships that could have
paedic Surgery, Hospital Universitario Austral, Buenos Aires, Argentina appeared to influence the work reported in this paper. Full ICMJE author
(H.R.); and Twin Cities Orthopedics, Edina, Minnesota, U.S.A. (R.F.L.). disclosure forms are available for this article online, as supplementary
The authors report the following potential conflicts of interest or sources of material.
funding: J.C. is a board member/owner/officer or has committee appointments Received August 24, 2023; accepted November 4, 2023.
with the American Orthopaedic Society for Sports Medicine, Arthroscopy Address correspondence to Jorge Chahla, M.D., Ph.D., Rush University
Association of North America, and International Society of Arthroscopy, Knee Medical Center, 1611 W Harrison St., Chicago, IL 60612, U.S.A. E-mail:
Surgery, and Orthopaedic Sports Medicine and is a paid consultant or [email protected]
employee for Smith & Nephew, CONMED Linvatec, and Ossur. R.F.L. is a is a Ó 2023 THE AUTHORS. Published by Elsevier Inc. on behalf of the
board member/owner/officer or has committee appointments with the Amer- Arthroscopy Association of North America. This is an open access article under
ican Orthopaedic Society for Sports Medicine, American Journal of Sports the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
Medicine, Arthroscopy, and the International Society of Arthroscopy, Knee 4.0/).
Surgery, and Orthopaedic Sports Medicine; receives royalties from Smith & 2212-6287/231202
Nephew and Arthrex; is on the speakers bureau or has received paid pre- https://doi.org/10.1016/j.eats.2023.11.016
sentations from Smith & Nephew; is a paid consultant or employee for Smith
& Nephew and Ossur; and receives research or institutional support from

Arthroscopy Techniques, Vol -, No - (Month), 2023: 102888 e1

e2 J. CHAHLA ET AL.

resulting in a higher risk for chondral damage, as well Treatment Algorithm

as the potential for increased meniscal extrusion rela- The senior author’s preferred approach to the man-
tive to longitudinal and horizontal meniscal tears.13,14 agement of each tear type is illustrated in Figure 2 and
As such, proper identification and treatment for radial Table 2.
meniscal tears are essential to preserve knee function
and ensure the longevity and health of the knee. When Patient Positioning and Preparation
indicated, decision-making during operative manage- Following the induction of general anesthesia, the
ment is dictated based on several patient-specific (pa- patient is placed in the supine position, ensuring that all
tient age, activity level, compliance, weight, lower bony prominences are well padded. A nonsterile
extremity mechanical alignment) and tissue-specific pneumatic tourniquet is placed on the upper thigh. A
(meniscal tissue quality, extent of degenerative lateral post is positioned to allow for effective valgus
changes to chondral surfaces) factors. There remains a positioning of the knee to improve visualization of the
substantial degree of heterogeneity in the reporting of medial compartment. The patient is given appropriate
outcomes in patients with radial tears of the meniscus, antibiotics for prophylaxis against infection. Examina-
limiting the ability to pool results between in- tion under anesthesia is performed on the bilateral
vestigations to better understand optimal indications knees to assess the range of motion, patellar mobiliza-
and techniques for surgical repair. To improve homo- tion, and knee stability in the anterior/posterior and
geneity in the reporting of outcomes in patients with medial/lateral planes. The operative leg is then prepped
radial tears, establishing a standardized classification of and draped in a standard sterile fashion. The leg is
tear morphology is essential to ensure consistency in exsanguinated using an Esmarch and the tourniquet is
nomenclature and treatment. inflated.
The aim of the current article is to introduce a A standard anterolateral portal is created, and a 30-
comprehensive classification system to better charac- degree arthroscope (Smith & Nephew) is inserted. An
terize radial tears of the menisci, along with the senior anteromedial portal is then created under arthroscopic
author’s (J.C.) preferred approach to the management visualization using a spinal needle. Diagnostic arthros-
of each tear type. copy is then performed, evaluating the integrity of the
chondral surfaces of the patellofemoral as well as
medial and lateral tibiofemoral joint spaces. The
Classification menisci are visualized, and an arthroscopic probe is
The proposed classification system based on radial used to inspect the meniscus and determine the pres-
tear morphology is illustrated in Figure 1 and Table 1. ence of any tearing or instability (Table 3). If a tear is

Fig 1. Illustrations of the left knee depicting meniscal radial tear patterns based on morphology: partial stable radial tear
extending to the white-white zone (type I), partial unstable radial tear extending to the red-white zone (type II), complete radial
tear without gapping (type III), complete radial tear with
3 mm of gapping (type IV), and complete radial tear with >3 mm of
gapping (type V).
 MENISCAL RADIAL TEARS CLASSIFICATION e3

Table 1. Classification of Radial Tears of the Medial and Type II: Partial Tear in the Red-White Zone
Lateral Meniscus Based on Tear Morphology Type II tears consist of incomplete radial tears that
Type Description extend from the inner border to the red-white zone of
I Partial radial tear extending to the white-white zone the meniscus. As the red-white zone of the meniscus
II Partial radial tear extending to the red-white zone possesses a viable blood supply, increasing the potential
III Complete radial tear with no gapping for successful healing, meniscal repair is suggested for
IV Complete radial tear with
3 mm of gapping type II tears in the absence of degenerative tissue
V Complete radial tear with >3 mm of gapping
tearing or advanced chondral changes (modified Out-
erbridge 3) within the affected compartment. The
identified, the location (posterior root, posterior horn, borders of the torn meniscus are gently debrided to
midbody, anterior horn, anterior root), size, and type remove any frayed tissue using an arthroscopic shaver,
(radial, horizontal, vertical, degenerative, etc.) of the and meniscal edges may then be rasped. Based on the
tear are determined and recorded. For radial tears, tear location of the meniscal tear (posterior horn, midbody,
morphology is classified based on the proposed classi- anterior horn), an outside-in, all-inside, or inside-out
fication system. approach can be used for meniscal repair. For an all-
inside repair, the implant (Fast Fix Flex; Smith &
Type I: Partial Radial Tear in the White-White Zone Nephew) is inserted into the joint carefully using a skid
Type I tears are characterized as incomplete radial and placed perpendicularly across the tear in a hori-
tears, representing stable, partial tears that originate zontal mattress fashion. After removing the device from
from the inner border of the meniscus and extend the joint, a knot pusher is used to tension the knot,
peripherally to the white-white zone. In the presence of ensuring the meniscal edges re-establish continuity,
a type I tear, partial meniscectomy is recommended after which the suture is cut. Additional implants are
secondary to the low healing potential and avascular placed in an identical manner parallel to the first
nature of the torn meniscus. The free margins of the implant to create a stable horizontal mattress configu-
menisci are gently debrided using a combination of an ration. Inside-out and outside-in repairs have been
arthroscopic shaver and biter until a smooth border and previously described with their respective
stable rim are achieved (Video 1). approaches.15-17

Fig 2. Illustrations of the left knee showing the senior author’s preferred repair configurations based on radial tear patterns. Type
I: Partial meniscectomy. Type II: Side-to-side repair stitches. Type III: Hashtag repair. Two vertical “rip-stop” mattress sutures and
multiple side-to-side repair stitches. Type IV: Reduction stitch to approximate the leaflets followed by a hashtag repair. Type V:
Release of the anterior and posterior meniscocapsular attachments to aid in further mobilization and then a reduction stitch,
followed by a hashtag repair. A transtibial tunnel can be used for type III, IV, and V tears involving the medial meniscus.
e4 J. CHAHLA ET AL.

Table 2. The Senior Author’s Preferred Approach to the meniscal repair implant is then used to reduce the
Management of Each Tear Type fragment edges to their anatomic position. The needle is
Type Tear Treatment inserted in one of the meniscal ends without passing
I Partial radial tear extending to Partial meniscectomy through the capsule. The needle is used as a “joystick”
the white-white zone to mobilize the fragment into an anatomic position,
II Partial radial tear extending to Side-to-side repair after which the needle or the implant is inserted
the red-white zone through the capsule to secure the meniscus in an
III Complete radial tear with no Hashtag repair*
appropriate position along both the anterior and pos-
gapping
IV Complete radial tear with Reduction stitch and terior leaflets.

3 mm of gapping hashtag repair* The suture is then tensioned using the knot pusher
V Complete radial tear with Release, reduction stitch, and cut and/or tied on the capsule (inside-out). Then
>3 mm of gapping and hashtag repair* the hashtag configuration can be performed as previ-
* For any complete medial meniscus radial repairs (types III, IV, and ously described. Two vertical mattress rip-stop sutures
V), a transtibial tunnel can be created to centralize the meniscus. are then inserted (and tied to the opposite rip-stop su-
ture on the capsule), followed by the appropriate
number of horizontal mattress sutures to create a stable
Type III: Complete Radial Tear With No Gapping construct.
Type III tears are characterized by the presence of
complete radial tears that reach the meniscocapsular Type V: Complete Radial Tear With >3 mm of
junction, effectively dividing the meniscus into separate Gapping
anterior and posterior fragments, without any Type V tears are characterized by the presence of a
displacement or gapping between fragments. complete radial tear with a gap measuring greater than
Similar to type II tears, the senior author’s preferred
treatment for type III tears in the absence of degener-
ative meniscal edges or advanced chondral degenera- Table 3. Pearls and Pitfalls
tion is surgical repair. The meniscal edges are debrided, Pearls
and a rasp is used to prepare the torn edges. Repair is  Appropriate portal placement is vital for sufficient visualization, and
performed with either an all-inside or inside-out repair if necessary, accessory portals should be created to improve visu-
technique consisting of a horizontal mattress configu- alization and accuracy for implant placement.
ration with 2 vertical rip-stop sutures (hashtag config-  Appropriate visualization is necessary to allow accurate tear iden-
tification and classification to ensure the appropriate repair tech-
uration). The vertical mattress sutures are placed first, nique is used.
tensioned, and then cut, effectively avoiding cutting  In the case of a tight medial compartment obscuring visualization, a
through the horizontal mattress sutures by serving as a percutaneous superficial medial collateral ligament lengthening
“rip-stop.” The horizontal mattress sutures are then procedure should be performed.
placed, beginning at the more posterior leaflet, ensuring  Vertical mattress sutures placed parallel to the tear are vital to
ensure an appropriate “rip-stop” is placed for sutures placed hori-
the sutures are placed further from the tear than the zontally across the torn meniscal edges to minimize the risk of su-
vertical mattress sutures. The horizontal mattress su- ture cut-out, especially in poorer-quality meniscal tissue.
tures are then tensioned, avoiding over-reduction, and  Rasping of the torn edges should be used to prepare the tear site for
then cut. Additional horizontal mattress sutures are repair by removing scar tissue and stimulating the vascularity in the
then placed in parallel to secure the repair construct. peripheral aspect of the tear.
 When meniscal edges are separated, as in the case of type IV and V
tears, mobilization of the anterior and posterior fragment should be
Type IV: Complete Radial Tear With £3 mm of performed along the meniscocapsular junction of the tear to ach-
Gapping ieve anatomic compression to optimize healing.
Type IV tears are described based on the presence of a Pitfalls
complete radial tear to the meniscocapsular junction  Insufficient evaluation of the tear may lead to misclassification of
with fragment gapping no greater than 3 mm. In pa- the tear and inappropriate selection of the repair technique.
 Failure to adequately release a tight medial compartment via
tients without degenerative meniscal fraying or medial collateral ligament lengthening may result in iatrogenic
advanced chondral changes, meniscal repair is recom- injury to the chondral surfaces during implant passage.
mended. The proposed treatment for type IV lesions  For type IV and V tears, failure to release the anterior and posterior
begins by ensuring the meniscal fragments can be fragments along the meniscocapsular junction may result in mal-
reduced to their anatomic position. Scarring for type IV reduction or inability to achieve compression across the tear site,
increasing the potential for repair failure.
tears is often not encountered due to the limited degree  In the event of a concomitant anterior cruciate ligament recon-
of displacement, as such releasing along the menisco- struction, use of a transtibial tunnel for type III, IV, and V medial
capsular junction is often not necessary. An arthro- meniscus repairs may result in tunnel convergence.
scopic rasp or shaver may be gently used to prepare the  Premature weightbearing postoperatively may lead to failure with
torn meniscal edges. An all-inside or inside-out displacement and damage to the repair site.
 MENISCAL RADIAL TEARS CLASSIFICATION e5

Table 4. Advantages and Disadvantages placed within the ipsilateral compartment portal, and a
Advantages self-capture suture-passing device (FirstPass; Smith &
 The proposed repair techniques focus on an easily identifiable set of Nephew) is used to place a 2-0 nonabsorbable meniscal
tear patterns, with reproducible repair techniques aimed at suture (FiberWire; Arthrex) in a horizontal mattress
anatomic restoration and compression along the extent of the tear
to optimize repair healing.
fashion through the posterior and anterior fragments of
 For type III, IV, and V tears, vertical mattress sutures positioned the radial tear near the periphery. The sutures are then
parallel to the meniscal tear are crucial to improve loads to failure shuttled down through the transosseous tunnel using a
for sutures placed perpendicular to the tear, acting as a “rip-stop” looped passing wire, and appropriate tensioning is
and decreasing the potential for tear displacement and failure. visually confirmed. The sutures are then fixed to the
Disadvantages
 Using an inside-out repair technique may inadvertently lead to
anteromedial tibial cortex using a suture anchor
injury to nearby neurovascular structures (saphenous nerve (FootPrint Suture Anchor; Smith & Nephew). Once
medially, peroneal nerve laterally), while necessitating a larger satisfactory reduction is achieved, a hashtag technique,
incision, increasing the potential for infection and wound-healing as detailed above, can be used.
complication. For these reasons, the senior author prefers an all-
inside repair technique when appropriate.
Discussion
While multiple types of meniscal tears have been
observed, radial tears represent a unique subtype that
3 mm. In appropriately selected patients and compart- has traditionally been associated with a poor prog-
ment conditions amenable to healing, meniscal repair is nosis.13,18 Radial tears are often encountered in the
recommended. Due to fragment displacement, release acute traumatic setting in young patients or as a result
of the anterior and posterior fragments along the of degenerative processes in older patients, especially
meniscocapsular junction is necessary to achieve an involving the medial meniscus.13 As a result of damage
optimal reduction. When indicated, an arthroscopic sustained to the circumferential fibers in radial tears, a
scissor may be used to release the meniscus along the substantial loss of meniscal function occurs, leading to
meniscocapsular junction. Care must be taken to avoid decreased contact area and increased dynamic contact
injury to the deep capsule or meniscal tissue. Meniscal pressures,19,20 resulting in a functionally meniscal-
excursion is checked using an arthroscopic grasper to deficient state.21-23 With resultant meniscal extrusion
reapproximate the meniscal fragments to their and the potential for tear progression, radial tears
anatomic position, after which, the meniscal edges are possess a high risk for subsequent chondral damage
gently debrided and rasped. A reduction stitch is then and early OA development.13,14,24
used to approximate the edges of the meniscus, and the As radial tears were originally believed to not be
construct is reinforced with a hashtag configuration in amendable to repair, partial meniscectomy was tradi-
the same fashion as that described for type IV tears. tionally regarded as the preferred surgical technique in
patients with symptomatic radial tears of the
Transtibial Tunnels for Medial Meniscus Tear Types meniscus.10,25,26 However, debridement of radial tears
III, IV, and V has been shown to result in inferior biomechanical
When addressing type III, IV, and V tears on the outcomes,5,6 perpetuating a meniscal-deficient state
medial side, transtibial drill tunnels and suture fixation and leading to early OA development.7,9 Using a 3-
may be used to aid in reducing meniscal extrusion. For dimensional model, Zhang et al.27 observed a signifi-
type IV and V tears, once the fragments are appropri- cant increase in compressive and shear stresses in the
ately mobilized and positioned in their native anatomic knee following meniscectomy, especially in cases in
location, and the edges have been debrided and rasped, which radial tears were present. As such, with recent
a curved ring curette may be used to ensure removal of advancements in surgical techniques, equipment, and
the cartilage under the inferior leaflet at the periphery understanding of meniscal function following menis-
of the tear. A meniscal root aiming guide (Smith & cectomy in the setting of radial tears, increased
Nephew) is then positioned through the ipsilateral emphasis has been placed on preserving meniscal tissue
compartment (anteromedial portal for medial tears) through repair, when clinically indicated.
and a 2-cm incision is created along the anteromedial Operative repair is indicated in patients sustaining
aspect of the proximal tibia, positioned midway be- acute, traumatic tears, as well as in the setting of
tween the tibial tubercle and the posteromedial border chronic, degenerative tearing in which adequate
of the tibia. A 2.4-mm drill pin is then passed using a meniscal tissue remains and advanced degenerative
cannula through the tibia and chondral surface at the changes are absent. Specifically, relative contraindica-
level of the tear, near the meniscocapsular junction. tions to radial meniscal repair include patients with
The metal cannula is gently malleted into place, the drill joint space narrowing (<3 mm), as well as the presence
pin is removed, and a passing suture is placed through of Kellgren-Lawrence grade 3 or modified Outer-
the transtibial tunnel. An arthroscopic cannula is then bridge grade >3 chondral degeneration, especially
e6 J. CHAHLA ET AL.

along both the femoral and tibial cartilage.28 As such, in when compared to inside-out repairs. While mid- and
appropriately indicated cases, the repair of radial tears long-term clinical outcomes studies following radial
has shown promising outcomes, with healing rates meniscal tears are lacking, incorporation of transtibial
ranging from 60% to 86%.4 In a recent systematic re- pullout augmentation has revealed the ability to
view evaluating 12 studies, consisting of 243 tears in reduce gapping at the site of the tear, improving load
241 patients, Milliron et al.18 reported improved out- to failure and displacement.38,39
comes in Lysholm, International Knee Documentation Diagnostic classification for radial tears is important
Committee, and Western Ontario and McMaster’s as successful healing is largely dependent on the
University scores, with complete healing reported in extent of peripheral tearing and the intrinsic ability for
62% of cases at a mean follow-up of 35 months (range, meniscal healing when repair is performed in the
12-75.6 months). Meanwhile, the systematic review by appropriately indicated patient. Nakata et al.40 previ-
Moulton et al.29 evaluating 6 studies in 55 patients ously proposed a classification system for radial
observed improvements in subjective outcome scores at meniscal tears based on tear morphology. Type A tears
a minimum 2-year follow-up. Additional investigations were classified as split tears extending <50% of the
have further revealed that repair of radial tears allows width of the peripheral rim. Type B1 tears included
for effective return to function and activity through radial split tears extending greater than 50% of the
improvements in Tegner activity scores.30,31 meniscal width, with B2 tears consisting of a radial
Optimal repair technique for radial meniscus tears split and flap component. Type C included complete
remains largely unknown, with studies reporting radial split tears extending to the peripheral rim, while
satisfactory repair achieved using multiple techniques type D tears consisted of a radial split and associated
and approaches. In their review of 6 studies examining bucket-handle component closer to the peripheral rim.
repair characteristics for the treatment of radial tears in Our currently proposed classification system builds on
the midbody of the lateral meniscus, Alentorn-Geli the classification system by Nakata et al.,40 but
et al.32 reported no significant differences in load to focusing on the peripheral extent of the tear, impera-
failure when comparing all-inside vs inside-out (P ¼ tive for successful healing,41 as well as the presence of
.45) techniques, with significantly greater repair stiff- gapping, which may result in inferior outcomes if not
ness following all-inside repair (P ¼ .0009). Accordant properly identified and reduced.42 Further in-
with the senior author’s preferred technique, the use vestigations examining clinical outcomes and meniscal
of all-inside implants has gained popularity, owing to healing based on the proposed classification system are
improvements in implant design and technique, with warranted to better understand and formulate an
repairs being less technically demanding, while optimal treatment algorithm for patients with radial
avoiding the need for a separate incision, minimizing meniscal tears.
the risk for injury to the surrounding neurovascular
structures.33 Additional investigations have shown all-
inside repair to possess comparable biomechanical References
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