Systematic Review

Treatment Outcomes of Meniscal Root Tears:

A Systematic Review
Jonah M. Stein, B.S., Michael Yayac, M.D., Evan J. Conte, M.D., and
Joshua Hornstein, M.D.

Purpose: To report changes in outcomes for these 3 treatment options for meniscal root tears. Methods: We system-
atically searched databases including PubMed, SCOPUS, and ScienceDirect for relevant articles. Criteria from the National
Heart, Lung, and Blood Institute was used for a quality assessment of the included studies. A meta-analysis was performed
to analyze changes in outcomes for meniscal repair. Results: Nineteen studies, 12 level III and 7 level IV, were included in
this systematic review, with a total of 1086 patients. Conversion to total knee arthroplasty (TKA) following partial
meniscectomy ranged from 11% to 54%, 31% to 35% for nonoperative, conservative treatment, and 0% to 1% for
meniscal repair. Studies comparing repair with either meniscectomy or conservative treatment found greater improve-
ment and slower progression of KellgreneLawrence grade with meniscal repair. A meta-analysis of the studies included in
the systematic review using forest plots showed repair to have the greatest mean difference for functional outcomes
(International Knee Documentation Committee and Lysholm Activity Scale) and the lowest change in follow-up joint
space. Conclusions: In patients who experience meniscal root tears, meniscal repair may provide the greatest
improvement in function and lowest risk of conversion to TKA when compared with partial meniscectomy or conservative
methods. Partial meniscectomy appears to provide no benefit over conservative treatment, placing patients at a high risk of
requiring TKA in the near future. However, future high-quality studiesdboth comparative studies and randomized
trialsdare needed to draw further conclusions and better impact treatment decision-making. Level of Evidence: Level
IV, systematic review of level III and level IV evidence

T ears or avulsions of the meniscal root, whether

occurring acutely or as a result of chronic degen-
eration of the meniscus, have been shown to occur less
Although many developments in orthopaedic surgery
have broadened treatment options, data regarding the
clinical indications for one treatment over another are
frequently than tears of the meniscal body or meniscal limited. A recent classification system for MRTs was
horns and are often more difficult to diagnose. Never- developed by LaPrade et al.,3 which is based on the
theless, early diagnosis and treatment of meniscal root morphology and location of the tear. By this system,
tears (MRTs) are crucial in minimizing meniscal tears are grouped into 1 of 5 types, with type 2, com-
extrusion, which can disrupt normal biomechanics in plete radial tears, having 3 subtypes based on the dis-
the knee, result in increased instability and tibiofemoral tance between the tear and root attachment. While
contact pressure, and increase cartilage degeneration.1,2 such a classification system is certainly a useful aid
when describing meniscal tears, the utility of such a
system, especially in determining the prognosis of a root
From the Rothman Orthopaedic Institute (M.Y., E.J.C., J.H.) at Thomas tear and in guiding treatment, is not yet known.4
Jefferson University (J.M.S.), Philadelphia, Pennsylvania, U.S.A. It has been recommended that the decision regarding
The authors report that they have no conflicts of interest in the authorship treatment modality should be based on the degree of
and publication of this article. Full ICMJE author disclosure forms are pre-existing osteoarthritis and the chronicity of the
available for this article online, as supplementary material.
Received July 15, 2019; accepted February 11, 2020.
tear.5 However, the paucity of literature guiding sur-
Address correspondence to Michael Yayac, M.D., Rothman Institute at geons toward one treatment over another has proved it
Thomas Jefferson University, 125 S. 9th St., Suite 1000, Philadelphia, difficult to create a set algorithm for the treatment of
PA 19107. E-mail: [email protected] MRTs. Moreover, several comparative studies have
Ó 2020 by the Arthroscopy Association of North America. Published by drawn contradictory conclusions about the superiority
Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
or noninferiority of the aforementioned nonoperative,
2666-061X/19859 operative, and repair treatment options with regards to
https://doi.org/10.1016/j.asmr.2020.02.005 frequently used outcome scores.4,6-8 While 2 relatively

Arthroscopy, Sports Medicine, and Rehabilitation, Vol -, No - (Month), 2020: pp e1-e11 e1

e2 J. M. STEIN ET AL.

recent systematic reviews focused on reporting out- Institute for study quality assessment.10 If ratings
comes of meniscal repair, the goal and novelty of this differed between reviewers, then the article was dis-
study is to systematically compare a broader range of cussed to reach consensus. The questions asked in the
treatment options for MRTs, including repair, partial quality assessment cover a variety of biases, including
meniscectomy, and conservative treatment.9 The pri- selection bias, detection bias, attrition bias, and report-
mary focus of this study was to report changes in ing bias, as well as other questions to judge the quality
functional outcome scores between these 3 treatment and methodology of the included studies. The scores
options for MRTs. We hypothesized that meniscal have been totaled for both the comparative studies and
repair would result in the greatest improvement in case series in Table 14,6,7,11-19 and Table 2,20-26 respec-
these outcomes measures. tively, and can be used both qualitatively and quanti-
tatively as a measure of bias within this systematic
review.
Methods
Outcome Measures
Search Strategy
The primary outcomes of our study were clinical and
A systematic literature review was performed under
radiologic improvement or progression of MRTs be-
the Preferred Reporting Items for Systematic Reviews
tween the various treatments of MRTs. Assessment of
and Meta-Analysis statement to identify and select
clinical improvement or worsening associated with
studies in this review. A systematic search was con-
operative or nonoperative treatment of MRTs used In-
ducted in PubMed, SCOPUS, and ScienceDirect data-
ternational Knee Documentation Committee (IKDC)
bases on December 10, 2018 for all English-language
score and Lysholm Activity Scale. Radiologic improve-
literature using the following terms and Boolean op-
ment or worsening of MRTs was quantified by changes
erators in the title and abstract: [Meniscus] AND [“root
in medial meniscus extrusion and changes in the width
tear”] OR [avulsion]; [meniscus] AND [“root tear”
of medial joint space using magnetic resonance imaging
meniscectomy]; [meniscus] AND [“root tear” transtibial
and KellgreneLawrence (K-L) grade on plain radio-
suture repair]; [meniscus] AND [“root tear”] AND
graphs. Progression of the tear site gap and need for
[“suture anchor repair”]; [meniscus] AND [“root tear”]
subsequent arthroplasty also were included for an
AND [non-operative] OR [Non-surgical].
assessment of treatment success. A meta-analysis using
Studies were systematically reviewed if they met the
forest plots was performed for functional outcomes of
following inclusion criteria: (1) English-language
MRT repair: IKDC, Lysholm Activity Scale, meniscal
studies and (2) level I through IV clinical studies of
extrusion, and joint space. Statistical analysis was per-
operative and nonoperative treatment options for MRT
formed using R (R Foundation for Statistical
and avulsion. The exclusion criteria included (1) level V
Computing, Vienna, Austria). Results were reported as
studies, including technique articles, biomechanical
standardized mean difference and 95% confidence in-
studies, and narrative review articles; (2) studies lacking
terval. Statistical significance was set at P < .05
data on clinical outcomes, failure, or reoperation rate;
(3) non-English language; and (4) publication
before 2010. Results
Our literature search identified 406 unique studies for
Data Extraction review. Nineteen studies were selected for full-text re-
Two reviewers independently screened all titles and view, all of which satisfied our inclusion and exclusion
abstracts to determine suitability for a full-text review. criteria (Fig 1); 5 studies included conservative groups,
Search criteria and filtering was completed in line with 5 studies included partial meniscectomy groups, and 15
a checklist of inclusion and exclusion criteria. Covi- studies included meniscal repair groups. Of the 19
dence systematic review software (Veritas Health included studies, 12 had a level III evidence (1 pro-
Innovation, Melbourne, Australia; available at www. spective case-control, 2 prospective comparative, 9
covidence.org) was used for study review and data retrospective) (Table 3),4,6,7,11-19,27 and 7 had a level IV
extraction. Data extracted from the studies included evidence (one prospective therapeutic case series, 6
year of publication, study design, study population de- retrospective case series) (Table 4).20-26
mographics, interventions, and all clinical and radio- For the primary outcome of identifying differences in
graphic data. various quantitative variables between treatment op-
tions for MRT, 1142 tears were included: 968 were
Quality Assessment medial and 174 were lateral; 155 were in the conser-
Two reviewers independently assessed the quality of vative treatment group, 408 were in the meniscectomy
each included study according to the 14 criteria out- group, and 579 were in the repair group. The study
lined for observational studies and 9 criteria for case population had an average reported age range of 15 to
series studies by the National Heart, Lung, and Blood 85 years and was more likely to be female (55%).
Table 1. Quality Assessment of Comparative Studies

Question Ahn et al., LaPrade et al., Krych et al., Lee et al., Kim et al., Keyhani et al., Chung et al., Chung et al., Kim et al., Furumatsu et al., Lee et al.,
No. 201511 201712 20177 Ma 201513 201414 201115 201816 201717 20156 20114 201918 201919
1 Y Y Y Y Y Y Y Y Y Y Y Y

TREATMENT OUTCOMES OF MENISCAL ROOT TEARS

2 Y Y Y Y Y Y Y Y Y Y Y Y
3 NA NA NA NA NA Y NA Y NA NA NA NA
4 Y Y Y Y N Y N Y Y Y N Y
5 N N Y N N Y N Y Y Y Y Y
6 Y Y N Y Y Y Y Y Y Y Y Y
7 Y Y Y Y Y Y Y Y Y Y Y Y
8 Y Y Y Y Y Y Y Y Y Y Y Y
9 Y Y Y Y Y Y Y Y Y Y Y Y
10 Y Y N Y Y Y Y Y Y Y Y Y
11 Y Y Y Y Y Y Y Y Y Y Y Y
12 N N N N N N N N N N N N
13 Y Y Y Y Y Y N Y N Y Y Y
14 Y N N N Y N N N N N N N
Total 11 10 9 10 10 12 8 12 10 11 10 11
1. Was the research question or objective in this paper clearly stated? 2. Was the study population clearly specified and defined? 3. Was the participation rate of eligible persons at least 50%?
4. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified
and applied uniformly to all participants? 5. Was a sample size justification, power description, or variance and effect estimates provided? 6. For the analyses in this paper, were the exposure(s)
of interest measured prior to the outcome(s) being measured? 7. Was the time frame sufficient so that one could reasonably expect to see an association between exposure and outcome if it
existed? 8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured
as a continuous variable)? 9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? 10. Was the
exposure(s) assessed more than once over time? 11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study par-
ticipants? 12. Were the outcome assessors blinded to the exposure status of participants? 13. Was loss to follow-up after baseline 20% or less? 14. Were key potential confounding variables
measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
N, no; NA, not available; Y, yes.

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e4 J. M. STEIN ET AL.

Table 2. Quality Assessment of Case Series

Question Han et al., Ahn et al., Lee et al., Krych et al., Chung et al., Tjoumakaris et al., Alaia et al.,
No. 201020 201021 201822 201723 201824 201525 201726
1 Y Y Y Y Y Y Y
2 Y Y Y Y Y N N
3 Y Y Y Y Y CD CD
4 Y N Y N Y CD CD
5 Y Y Y Y Y Y Y
6 Y Y Y Y Y Y Y
7 Y N Y Y Y Y Y
8 Y Y Y Y Y N N
9 Y Y Y Y Y Y Y
Total 9 7 9 8 9 5 5
1. Was the research question or objective in this paper clearly stated? 2. Was the study population clearly and fully described, including a case
definition? 3. Were the cases consecutive? 4. Were the subjects comparable? 5. Was the intervention clearly described? 6. Were the outcome
measures clearly defined, valid, reliable, and implemented consistently across all study participants? 7. Was the length of follow-up adequate? 8.
Were the statistical methods well-described? 9. Were the results well-described?
CD, cannot determine; N, no; Y, yes.

Results of quality assessment are summarized in of 1.15. Sources of bias in these studies included:
Tables 1 and 2. Of the 14 questions assessing the quality outcome assessors not being blinded to the participants’
of the 12 included comparative studies, the average exposure status (question 12), lack of power description
score was 10.3 of 14 (73.8%) with a standard deviation or sample size justification (question 5), and the

Fig 1. Systematic review algo-

rithm using Preferred Reporting
Items for Systematic Reviews and
Meta-Analyses (PRISMA).
Table 3. Level III Studies

Study Intervention Mean Follow-up Laterality Radiographic Outcomes Clinical Outcomes Comments
Ahn et al., 201511 Pull-out repair (25) vs 18 mo Medial Severe varus alignment Significantly greater IKDC, Increased MA angle, tibia vara
Conservative (13) and Outerbridge 3 or 4 Tegner, and Lysholm scores angle cartilage grade
associated with poorer at final follow-up with correlated with poor IKDC,
outcomes in patients meniscal repair Tegner, and Lysholm scores
undergoing meniscal
repair
LaPrade et al., 201712 Pull-out repair of lateral (14) 24 mo Both Not reported Significant improvement in Lateral tear had 8 times the
vs medial (31) (minimum) Lysholm, WOMAC, SF-12, odds of undergoing
and Tegner with both concomitant ACL
groups reconstruction
No significant difference All failures (6.7%) occurred
between groups with medial meniscal tears

TREATMENT OUTCOMES OF MENISCAL ROOT TEARS

and in patients <50 years
old
Krych et al., 20177 Meniscectomy (26) vs 66 mo Medial No significant difference in No significant difference in Female sex, BMI >30, and
conservative (26) progression of K-L grade follow-up Tegner or IKDC meniscal extrusion greater
between groups scores than 3mm associated with
worse outcomes
Ma et al., 201513 Pull-out repair (31) vs Lateral Significantly worse ICRS dSignificant improvement in All patients underwent
conservative (31) score with conservative Lysholm and IKDC scores in concomitant ACL
treatment both groups reconstruction
dNo significant difference
between groups
Lee et al., 201414 Mason-Allen stitch repair (25) 25 mo Medial dSignificantly greater Significant improvement in dSignificant improvement in
vs simple stitch repair (25) progression of joint space IKDC, Lysholm, and Tegner effusion, range of motion,
narrowing, progression scores in both groups joint line tenderness, pain of
of K-L grade, and No significant difference flexion, locking, giving way,
arthrosis grade with between groups and McMurray test in both
simple stitch but not groups
Mason-Allen stitch dNo significant difference
between groups
Kim et al., 201115 Suture anchor repair (22) vs 25.9 mo Medial Suture anchor repair dSignificant improvement in Incomplete healing associated
pull-out suture repair (23) associated with greater IKDC, Lysholm, and HSS with progression of cartilage
progression to grade 3 K- scores in both groups degeneration
L grade, cartilage dNo significant difference
degeneration, and between groups
incomplete healing
Keyhani et al., 201816 Suture anchor repair (40) vs 24 mo Lateral No significant difference in dNo significant difference in All patients underwent
conservative (33) (minimum) Lachman test s-IKDC or Lysholm score concomitant ACL
dSignificantly greater reconstruction
proportion returned to
previous level of activity
following repair
(continued)

e5
Table 3. Continued

e6
Study Intervention Mean Follow-up Laterality Radiographic Outcomes Clinical Outcomes Comments
Chung et al., 201717 Meniscus repair- increased Medial dNo significant Significantly higher postop No significant difference in
extrusion (23) vs decreased progression of K-L grade Lysholm and IKDC score in meniscal healing between
extrusion (16) in patients with patients with decreased groups
decreased extrusion extrusion
dSignificantly greater
progression of OA in
patients with increased
extrusion
Chung et al., 20156 Partial meniscectomy (20) vs 60 months Medial Significantly greater Significantly greater Lysholm, Significantly greater
pull-out repair (37) (minimum) progression of joint space IKDC, and Tegner scores at conversion to TKA rate with
narrowing and K-L final follow-up with partial meniscectomy (35%
grade with partial meniscal repair than vs 0%)
meniscectomy over meniscectomy
repair
Kim et al., 20114 Partial meniscectomy (28) vs 46.1-48.5 mo Medial Significantly less joint Significant improvement in 3/28 progressed to TKA in
pull-out repair (30) space narrowing and IKDC and Lysholm for both meniscectomy group while
progression of K-L grade groups, repair more than none progressed to TKA in
in repair group meniscectomy repair group
Furumatsu et al., 201918 Repair, FasT-Fix vs FasT-Fix 12 mo Medial F-MMA had better second- Significant improvement in Second-look arthroscopic

J. M. STEIN ET AL.
Modified Mason Allen look arthroscopic score Lysholm, IKDC, and VAS for score defined by same
(F-MMA) (7.2 vs 6.0) both groups. F-MMA group authors in alternate study27
had better postoperative
(VAS) pain score, KOOS
pain, and sports/rec scores
Lee, 201919 Progression to TKA post- 60 mo Medial Varus alignment, presence Older age and greater BMI Patients with no TKA still had
meniscectomy vs no (minimum) of radiographic arthritis, associated with significantly significant progression of
progression to TKA post- and greater K-L grade at greater progression to TKA radiographic arthritis 2 years
meniscectomy baseline (2-3) and at last follow-up (mean
significantly more 8.9 y)
associated with
progression to TKA post-
meniscectomy
ACL, anterior cruciate ligament; BMI, body mass index; HSS, Hospital for Special Surgery; ICRS, International Cartilage Repair Society; IKDC, International Knee Documentation Committee;
K-L, KellgreneLawrence; KOOS, Knee Injury and Osteoarthritis Outcome Score; MA, mechanical axis; OA, osteoarthritis; SF-12, Short Form-12; TKA, total knee arthroplasty; VAS, visual
analog scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
Table 4. Level IV Studies

Mean
Study Intervention Follow-up Laterality Radiographic Outcomes Clinical Outcomes Comments
Han et al., 201020 Partial meniscectomy (46) 78 mo Medial 35% showed progression of K-L Significant improvement in 56% improvement in pain
grade modified Lysholm score 67% patient satisfaction
19% underwent

TREATMENT OUTCOMES OF MENISCAL ROOT TEARS

reoperation
Ahn et al., 201021 Repair, all inside (27) 18 mo Lateral Significant improvement in Improvement in IKDC and dAll patients underwent
extrusion in sagittal plane only Lysholm scores concomitant ACL
reconstruction
d8 of 9 patients showed
complete healing on second-
look arthroscopy
Lee et al., 201822 Repair, pull-out (56) 40.6 mo Medial e23% Progression of K-L grade Improved Lysholm, IKDC, Significant prognostic factors
dNarrowed medial joint space: and HSS functional were age, BMI, K-L grade,
3.52 to 3.17 mm scores medial joint space width,
meniscal extrusion, type of
tear, grade 3 or greater
chondral lesion
Krych et al., 201723 Conservative (52) 62 mo Medial Significant progression of K-L 13% with abnormal IKDC, Female sex associated with
grade 56% had severely worse outcomes
abnormal score
Chung et al., 201824 Repair, pull-out (91) 84.8 mo Medial All failures were K-L grade I and Significant improvement in All failures were female
Outerbridge grade 2 or 3 Lysholm score
Tjoumakaris et al., 2015*,25 Repair, pull-out (9) Unknown Medial Mean meniscal extrusion: 1.5 mm Mean Lysholm: 81.6 dRecurrence of tear in 4
Mean WOMAC: 11.2 patients
Alaia et al., 2017*,26 Repair, transtibial (18) 24.9 mo Medial dSignificantly worsened ICRS Significant improvement in Only 1/18 achieved complete
grades IKDC (45.9-76.8) and healing
dMeniscal extrusion increased: Lysholm (50.9-87.1)
4.74 to 5.98
ACL, anterior cruciate ligament; BMI, body mass index; HSS, Hospital for Special Surgery; ICRS, International Cartilage Repair Society; IKDC, International Knee Documentation Committee;
K-L, KellgreneLawrence; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
*Abstract presentation.

e7
e8 J. M. STEIN ET AL.

Table 5. Studies Reporting Conversion to TKA Grouped by Intervention

Level of Mean Time to Conversion

Intervention Authors Study Type Evidence No. of Tears Mean Age, y Failure, mo to TKA (%)
Partial meniscectomy Krych et al., 20177 Retrospective comparative III 26 54.7 54.3 53.85%
Chung et al., 20156 Retrospective comparative III 20 55.0 NR 35.00%
Kim et al., 20114 Retrospective comparative III 28 57.4 17.8 10.71%
Lee et al., 201919 Retrospective comparative III 60 60.8 84.0 20.83%
Repair Chung et al., 20156 Retrospective comparative III 37 55.5 e 0.00%
Chung et al., 201717 Retrospective case series IV 91 66 47 1.10%
Kim et al., 20114 Retrospective comparative III 30 55.2 e 0.00%
Conservative Krych et al., 201723 Retrospective case series IV 52 58 30 30.77%
Krych et al., 20177 Retrospective comparative III 26 55.8 30.2 34.62%
NR, not reported; TKA, total knee arthroplasty.

potential for confounding variables (question 14). Of with repair was significantly greater in the 1 study
the 9 questions assessing the quality of the 7 included comparing it with conservative treatment of medial
studies that were case series, the average quality MRTs, but no difference in improvement was noted in
assessment score was 7.43 of 9 (82.5%) with a standard the 2 studies comparing repair with conservative
deviation of 1.81. The largest sources of bias came from treatment of lateral meniscal tears.11,13,16 The 1 study
the subjects not being comparable (question 4) and the comparing partial meniscectomy with repair of medial
statistical methods within the studies not being well root tears suggests that repair results in better outcomes
described (question 8). Overall, we believe the bias in with a slower progression of osteoarthritis.8 Meniscec-
this systematic review is due to the availability of low- tomy appears to provide no benefit over conservative
level studies and the reliance on level III and level IV treatment in medial MRTs.
studies to draw conclusions. Of the 7 level IV studies included in this systematic
Of the 12 level III studies included in this review, 3 review, 6 looked at medial MRT (1 meniscectomy, 1
compared meniscal repair with conservative treatment, conservative, and 4 repair) and 1 looked at lateral
1 compared meniscectomy with conservative treat- MRT (repair).20-26 Six of the studies showed
ment, 2 compared repair with meniscectomy, and 4 improvement in clinical outcomes for MRT, whereas
compared distinct repair groups, such as medial versus Krych et al.23 found 13% abnormal and 56% severely
lateral tears or repair techniques.4,6,7,11-19 One study abnormal IKDC scores in patients who underwent
compared patients with primary meniscectomy and conservative treatment of MRT, as well as an 87%
conversion to total knee arthroplasty (TKA) with pa- failure rate. Thirty-one percent of patients underwent
tients who did not need subsequent TKA.19 Meniscal TKA at mean 30 months’ postdiagnosis. In patients
repair resulted in significant improvement in functional undergoing treatment of a lateral MRT repair with
outcomes scores in all studies. Functional improvement concomitant anterior cruciate ligament reconstruction,

Fig 2. IKDC forest plot of meniscal repair studies. (CI, confidence interval; IKDC, International Knee Documentation Committee;
IV, inverse variance; SD, standard deviation.)
 TREATMENT OUTCOMES OF MENISCAL ROOT TEARS e9

Fig 3. Lysholm Score forest plot of meniscal repair studies (CI, confidence interval; IV, inverse variance; SD, standard deviation.)

Ahn et al.21 showed significant improvement in both Repair of the meniscal root significantly increased
radiographic and clinical outcomes with 8 of 9 pa- functional outcomes scores in 14 of 14 studies and the
tients, displaying complete healing on second-look rate of conversion to TKA was considerably less than
arthroscopy. Lee et al.24 identified age, body mass in- those observed following conservative treatment or
dex, K-L grade, medial joint space width, meniscal partial meniscectomy. Studies comparing repair with
extrusion, and degree of cartilage damage as worse either meniscectomy or conservative treatment found
prognostic factors for medial MRT repair.24 Krych et al. greater improvement and slower progression of K-L
and Chung et al. showed a greater degree of failure grade with meniscal root repair. A single study
and worse functional outcomes in women for conser- compared partial meniscectomy with conservative
vative treatment and repair, respectively.23,24 Alaia treatment and found no significant difference in
et al.26 and Tjoumakaris et al.25 showed that wors- outcomes.
ening in radiographic outcomes (such as meniscal
extrusion and K-L grade) was not always correlated Meta-Analysis of Meniscal Repair Groups
with functional outcome scores. Meniscal repair resulted in a significant and consistent
Nine studies reported incidence of K-L grade improvement in IKDC scores (mean difference [MD] ¼
progression, 27.8% for conservative, 34.8%-100% for 34.19, 95% confidence interval [CI] 33.14-35.24, P 
meniscectomy, and 8.7%-67.6% for repair. Six studies .001; Fig 2). Similar findings were found for Lysholm
reported rates of conversion to TKA (Table 5). Three of scores (MD 31.04, 95% CI 29.24-32.84, P  .001; Fig
these studies included patients treated by partial 3). Changes in meniscal extrusion were not as consis-
meniscectomy with failure rates ranging from 10.77% tent however, with an MD of e0.80 mm (95% CI
and 53.85% with mean time to failure ranging from e1.80 to 0.20, P ¼ .117; Fig 4).
17.8 to 84.0 months.4,6,7,17,19,23 For the 2 groups who
were treated conservatively, there were similar rates of Discussion
conversion of 30.77% and 34.62% with similar mean The primary and secondary outcomes of this study
time to failure of 30 months.10,25 However, in the 3 were to review changes in functional outcomes and the
groups who underwent repair, rates of failure were rate of conversion to TKA for the various treatments of
considerably lower, with only 1 of the 158 total patients MRTs. Based on a systematic review of the literature on
(0.6%) requiring conversion to TKA.4,6,17 the treatment of medial and lateral MRTs, it is clear that

Fig 4. Meniscal extrusion forest plot of meniscal repair studies. (CI, confidence interval; IV, inverse variance; SD, standard
deviation.)
e10 J. M. STEIN ET AL.

although many prognostic factors may play a role, status at baseline (K-L grade I and Outerbridge grade 2
repair of an MRT has the best clinical and radiographic or 3) was associated with worse outcomes for repair of a
outcomes when compared with partial meniscectomy medial MRT. For meniscectomy, poor cartilage status at
and conservative treatment. To our knowledge, this baseline (K-L grade II or III), presence of radiographic
review is the first of its kind to pool and review out- arthritis, and varus alignment were show by Lee et al.19
comes and prognostic factors between the meniscal to be poor prognostic factors and more likely to require
repair, meniscectomy, and nonoperative management subsequent TKA. When comparing meniscectomy and
in the hopes of determining which might be the most repair, Chung et al.6 showed the former to be more
appropriate for a given patient. associated with joint space narrowing and K-L grade
Comparative analysis of clinical and radiologic out- progression on follow-up imaging.
comes for the treatment of medial and lateral MRTs Other studies concluded that demographic and social
revealed the best results with surgical repair over factors, such as sex and body mass index, play a role in
meniscectomy and conservative groups. For the medial determining which treatment will have the best out-
meniscus, the available data showed improved func- comes for a specific patient.7,19,23-25 Although many
tional outcome scores for patients undergoing surgical have associated older age with worsened outcomes of
repair of medial MRT whereas the data for lateral MRT MRT repair, LaPrade et al.12 found no statistically sig-
show similar results, although the limited data avail- nificant difference in the clinical and radiologic im-
ability minimizes the generalizability of similar con- provements in patients older than 50 and younger than
clusions. A surface-level comparison of the treatment of 50 years of age. Lastly, in analyzing patients with poor
medial MRT versus lateral MRT revealed the minimal baseline cartilage status, Kim et al.15 discovered that the
use of surgical meniscectomy for the treatment of pullout suture repair technique had significantly worse
lateral MRT, and several studies have found that lateral progression of cartilage status dmore follow-up K-L
meniscectomy has a greater risk of subsequent osteo- grade 3 or 5 and more incomplete healingdand a
arthritis when compared with medial meniscec- greater degree of cartilage degeneration (more patients
tomy.28,29 Despite the minimal number of studies with grade 3) at follow-up than suture anchor repair of
directly comparing the treatment of lateral MRT by the meniscus.
repair versus conservative options, the available data do
not appear to show any significant difference in out- Limitations
comes between the 2 approaches to lateral MRT man- There were several limitations to this study. First, this
agement. One confounding variable may be that lateral systematic review included only level III and level IV
MRTs almost exclusively occur in conjunction with evidence studies. There was no high-quality evidence in
anterior cruciate ligament tears. Therefore, this is likely the form of randomized controlled trials or controlled
a different demographic group that medial MRTs and clinical trials, and this played a role in the level of bias
their outcomes are not generalizable to the medial MRT within our systematic review as analyzed in our quality
group. In addition, the anatomy of the medial and assessment (Tables 1 and 2). Second, varying tech-
lateral meniscal root complexes differ, and the degree to niques were used for meniscal root repair, which pre-
which they carry the compartment load of the knee sents a potential source of confounding. Third, the
differs.27 The medial attaches to the adjacent bone only, measured outcomes and follow-up period were not
whereas the lateral attaches both to bone and via the consistent between studies, nor were statistical data
posterior meniscofemoral ligaments, which are often universally reported by all studies, making direct com-
preserved during injury and may confer some stability parison difficult and precluding us from using all studies
the avulsed lateral root. in the meta-analysis of outcomes. Finally, the biggest
This systematic review identified a number of prog- limitation of the study was that the 3 treatment groups
nostic factors associated with lower outcomes of the had significantly different numbers of patients, and
various procedures, as well as some insight into the both between the groups as well as within each group
specific prognostic factors favoring surgical repair over there were different indications for MRT treatment.
conservative treatment and meniscectomy. Overall,
most studies concluded that the status of the articular Conclusions
cartilage, K-L grade, and meniscal extrusion were In patients who experience MRTs, meniscal repair
associated with worse clinical outcomes. For example, may provide the greatest improvement in function and
Chung et al.17 showed that increased meniscal extru- lowest risk of conversion to TKA when compared with
sion on follow-up magnetic resonance imaging was partial meniscectomy or conservative methods. Partial
associated with a greater progression of osteoarthritis meniscectomy appears to provide no benefit over con-
and worse clinical outcomes for patients undergoing servative treatment, placing patients at a high risk of
MRT repair than patients with decreased extrusion. It requiring TKA in the near future. However, future
was also identified by Chung et al.24 that poor cartilage high-quality studiesdboth comparative studies and
 TREATMENT OUTCOMES OF MENISCAL ROOT TEARS e11

randomized trialsdare needed to draw further con- 15. Kim J-H, Chung J-H, Lee D-H, Lee Y-S, Kim J-R, Ryu K-J.
clusions and better impact treatment decision-making. Arthroscopic suture anchor repair versus pullout suture
repair in posterior root tear of the medial meniscus: A pro-
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