MENISCAL REPAIR
In patients with ACL tear and meniscal tear, meniscal preservation should be considered to optimize joint health and function.

Rationale

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.