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Graft fixation depends on surgeon preference, graft selection and surgical technique. For bone block fixation several studies have found interference screw fixation provides the most rigid fixation. However, in some instances such as posterior wall compromise and graft-tunnel length mismatch, rigid interference screw fixation may not be possible. While conversion to a two incision technique is an option, endoscopic approaches require alternative fixation methods. These include suture post, endobutton, and cross pin fixation on the femoral side and suture post or staple fixation on the tibial side. These fixation methods have weaker biomechanical properties and should only be employed when rigid interference screw fixation cannot be achieved. In addition, when these methods are employed, a less aggressive postoperative rehabilitation will be necessary until biologic incorporation is achieved.

The menisci are important in many aspects of knee function, including load bearing, shock absorption, joint stabilization, joint lubrication, and proprioception. Total and partial meniscectomy significantly increase the load per unit area in the tibiofemoral joint and result in early osteoarthritis. Meniscus repair has generally been limited to the peripheral vascular area of the meniscus, but efforts have been made to promote the healing of tears in the avascular inner area. Recent studies have demonstrated the potential for cytokines to increase extracellular matrix synthesis by meniscal cells, suggesting the ability to improve meniscus healing. Meniscus allograft transplantation represents one of the few available treatment options after total meniscectomy. Novel strategies for meniscal repair using gene therapy techniques and engineered tissue are exciting options for the future. This review will discuss these basic aspects of the meniscus, focusing on meniscus biomechanics, the healing response of meniscal cells after injury and allograft transplantation, and future directions for meniscal repair and regeneration.