Prior CPG recommendations in 2014 presented limited evidence for concomitant meniscus repairs in conjunction with an ACL reconstruction. However, it supports that practitioners might consider meniscus repair because it improves patient outcomes. In this updated CPG, four low quality evidence studies favor meniscus repair due to improved healing (Hayatama 2020), revision surgery (Pullen 2016), osteoarthritis progression (Pan 2015), and return to sports (Keyhani 2018). No study favors improvement in function in meniscus repair compared to no repair while performing an ACL reconstruction. There is one high quality (McCarthy 2017), one moderate quality (LaPrade 2015), and four low quality studies (Lord 2020, Hoshino 2021, Eken 2020 Cristiani 2020) that address meniscus repair versus resection. The high quality study (McCarthy 2017) notes that a meniscus repair has a higher rate of future knee procedures in the short term, particularly medial meniscus repairs, which was also supported by a low quality study (Lord 2020). Three low quality studies demonstrate conflicted opinions regarding meniscus repair vs. resection (Hoshino 2021, Eken 2020, Cristiani 2020).
Notable is that no study in the recent series demonstrated long term outcome or OA progression favoring meniscus repair vs. no repair vs. resection. All studies presented had 2-3 year follow up. Long term studies are lacking.
Benefits/Harms of Implementation
The theoretical benefit of performing a meniscus repair is for long term knee preservation, however, evidence has not yet supported meniscus repairs to minimize or delay the rate of osteoarthritis. A meniscus repair may be associated with higher rates of subsequent knee surgery, but no additional adverse events were noted.
Outcome Importance
With the improvement in device design, meniscus repairs are becoming more common as compared to technically easier meniscal resection or no repair. To date, there is not significant evidence to support meniscus repair, however, the potential substantial long-term benefit should still be considered.
Cost Effectiveness/Resource Utilization
Meniscus repair is notably more costly (time and value of implants) than a meniscus resection or no repair.
Acceptability
Early data will likely not sway the importance of meniscus repair as historical data has suggested meniscal resection clearly advances osteoarthritis progression in the long term. Patient factors such as age, BMI and activity level may be important considerations that affect the value of meniscal preservation.
Feasibility
The impact of this recommendation will not likely change practice.
Future Research
Long term studies that focus on meniscus repair and the rates of osteoarthritis progression are required in order to determine the value of this procedure.
- Hatayama, K., Terauchi, M., Saito, K., Takase, R., Higuchi, H. Healing Status of Meniscal Ramp Lesion Affects Anterior Knee Stability After ACL Reconstruction. Orthopaedic Journal of Sports Medicine 2020; 5: 2325967120917674
- Pullen, W. M., Bryant, B., Gaskill, T., Sicignano, N., Evans, A. M., DeMaio, M. Predictors of Revision Surgery After Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine 2016; 12: 3140-3145
- Pan, F., Hua, S., Ma, Z. Surgical treatment of combined posterior root tears of the lateral meniscus and ACL tears. Medical Science Monitor 2015; 0: 1345-9
- Keyhani, S., Mardani-Kivi, M., Sharafat Vaziri, A. Root avulsion and para-root tear of the posterolateral meniscus: Repair versus untreated. Current Orthopaedic Practice 2018; 2: 144-150
- McCarthy, M., Mallett, K., Abola, M., Vassallo, S., Nguyen, J. Hospital for Special Surgery ACL Registry: 2-Year Outcomes Suggest Low Revision and Return to OR Rates. HSS Journal 2017; 2: 119-127
- LaPrade, C. M., Dornan, G. J., Granan, L. P., LaPrade, R. F., Engebretsen, L. Outcomes After Anterior Cruciate Ligament Reconstruction Using the Norwegian Knee Ligament Registry of 4691 Patients: How Does Meniscal Repair or Resection Affect Short-term Outcomes?. American Journal of Sports Medicine 2015; 7: 1591-7
- Lord, L., Cristiani, R., Edman, G., Forssblad, M., Stalman, A. One sixth of primary anterior cruciate ligament reconstructions may undergo reoperation due to complications or new injuries within 2 years. Knee Surgery, Sports Traumatology, Arthroscopy 2020; 0: 29
- Hoshino, T., Nakagawa, Y., Inomata, K., Ohara, T., Katagiri, H., Otabe, K., Hiyama, K., Katagiri, K., Katakura, M., Ueki, H., Hayashi, M., Nagase, T., Sekiya, I., Ogiuchi, T., Muneta, T., Koga, H., Tokyo, Medical, Dental University Multicenter Arthroscopic Knee Surgery, Group Effects of different surgical procedures for meniscus injury on two-year clinical and radiological outcomes after anterior cruciate ligament reconstructions. -TMDU MAKS study. Journal of Orthopaedic Science 2021; 0: 18
- Eken, G., Misir, A., Demirag, B., Ulusaloglu, C., Kizkapan, T. B. Delayed or neglected meniscus tear repair and meniscectomy in addition to ACL reconstruction have similar clinical outcome. Knee Surgery, Sports Traumatology, Arthroscopy 2020; 0: 13
- Cristiani, R., Mikkelsen, C., Edman, G., Forssblad, M., Engstrom, B., Stalman, A. Age, gender, quadriceps strength and hop test performance are the most important factors affecting the achievement of a patient-acceptable symptom state after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy 2020; 2: 369-380