Viewed for many years as just vestigial organs, a lack of appreciation of the importance of the menisci led to the widespread practice of total meniscectomy. The realization that removal of these important structures leads to accelerated arthritis took some time. It is now recognized that the menisci play an important role in load distribution, joint stability and lubrication, protecting the joint surfaces from degenerative change. As awareness of the true importance of these important structures has increased, and so has the understanding of different patterns of meniscal injury and the interaction of additional factors, such as alignment and ligamentous stability, in determining long-term meniscal and knee function. This has led to an integrated approach to meniscal surgery as part of an overall strategy to preserve and restore knee function, incorporating a shift towards meniscal preserving surgery whenever possible. This article will review knee anatomy and biomechanics as a basis for understanding the mechanism and classification of meniscal tears and associated injuries. Assessment, surgical decision-making and repair techniques, including the role of biological augmentation to increase the scope of repairable injuries, will also be reviewed. Options to reconstruct the meniscus using meniscal allograft transplantation for patients with symptomatic meniscal deficiency will be discussed.