At what point would you proceed with a meniscectomy versus a meniscal repair?

Meniscectomy versus Meniscal Repair: Decision-Making Algorithm

Meniscal repair should be prioritized over meniscectomy whenever possible due to better long-term patient outcomes, improved activity levels, and lower rates of osteoarthritis development. 1

Factors Favoring Meniscal Repair

Tear Characteristics

• Location: Tears in the peripheral/vascular "red zone" or "red-white zone" (outer 1/3 to middle 1/3)
• Type: Vertical longitudinal tears (especially in vascularized zones) 2
• Length: Any length can be considered (even longer tears previously thought irreparable) 3
• Timing: Acute tears (repair should be performed as early as possible) 3
• Special cases:
  • Posterior root tears 4
  • Ramp lesions (especially with ACL tears) 2
  • Radial tears 2
  • Horizontal cleavage tears in young athletes 2

Patient Factors

• Younger patients (higher healing potential)
• Active lifestyle
• No or minimal osteoarthritis
• Stable knee or concomitant ACL reconstruction

Factors Favoring Meniscectomy

• Location: Tears in the avascular "white zone" (inner 1/3)
• Type: Complex, degenerative, or severely fragmented tears
• Tissue quality: Poor quality meniscal tissue that cannot hold sutures
• Chronicity: Long-standing degenerative tears in older patients
• Associated conditions: Advanced osteoarthritis
• Special case: Parameniscal cysts with horizontal cleavage tears (partial meniscectomy with cyst decompression) 5

Evidence-Based Decision Algorithm

1. First assessment: Determine if tear is traumatic or degenerative

   • Traumatic tears: Consider repair as first option 2
   • Degenerative tears: Consider non-operative treatment first 2

2. For traumatic tears:

   • If in vascular zone (red/red-white): Proceed with repair
   • If stable and asymptomatic (especially lateral meniscus during ACL reconstruction): Consider leaving in situ 2
   • If in avascular zone but patient is young and active: Consider repair with biological augmentation 4

3. For degenerative tears:

   • First-line: Non-operative treatment 2
   • Consider meniscectomy only after failed conservative management or with "considerable" mechanical symptoms 2

4. Special considerations:

   • Meniscal tears with parameniscal cysts: Arthroscopic partial meniscectomy with cyst decompression is recommended, especially for large horizontal cleavage tears 5
   • Horizontal cleavage tears in young athletes: Repair to avoid extensive meniscectomy 2

Clinical Outcomes and Evidence Quality

The evidence strongly supports meniscal repair over meniscectomy when possible. A review of observational studies showed that meniscal repairs have:

• Better long-term patient-reported outcome measures
• Better activity levels
• Lower failure rates compared to meniscectomy 1

However, it's important to note that the overall quality of evidence for meniscal procedures is relatively low. Of the studies examining meniscal treatments, most received grades of C (low level of scientific support) or D (expert opinion) 3.

Surgical Technique Considerations

• Repair techniques include "inside-out," "outside-in," and "all-inside" approaches 4
• Success rates: Outside-in technique shows approximately 74% success rate at 3.5 years follow-up 6
• Biological augmentation (bone marrow stimulation, fibrin clot, PRP) may expand indications for repair, though evidence for enhancement techniques is still limited 4, 3

Pitfalls and Caveats

1. Higher reoperation rates: While meniscal repair has better long-term outcomes, it does have higher reoperation rates compared to meniscectomy 4

2. Timing matters: Delayed repair may reduce healing potential; surgery should be performed as early as possible when repair is indicated 3

3. ACL deficiency: While stable ACL-deficient knees can have good meniscal repair outcomes without ACL reconstruction, individual factors like age and activity level must be considered 6

4. Conservative approach for degenerative tears: For middle-aged or elderly patients with degenerative meniscal lesions, non-operative treatment should be first-line, with arthroscopic meniscectomy reserved for treatment failures 2