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Arch Orthop Trauma Surg

DOI 10.1007/s00402-015-2351-2


Surgical interventions for meniscal tears: a closer look
at the evidence
Eduard L. A. R. Mutsaerts1 • Carola F. van Eck2 • Victor A. van de Graaf1
Job N. Doornberg3 • Michel P. J. van den Bekerom1

Received: 7 October 2015
Ó Springer-Verlag Berlin Heidelberg 2015

Introduction The aim of the present study was to compare the outcomes of various surgical treatments for
meniscal injuries including (1) total and partial meniscectomy; (2) meniscectomy and meniscal repair; (3) meniscectomy and meniscal transplantation; (4) open and
arthroscopic meniscectomy and (5) various different repair
Materials and methods The Bone, Joint and Muscle
Trauma Group Register, Cochrane Database, MEDLINE,
EMBASE and CINAHL were searched for all (quasi)
randomized controlled clinical trials comparing various
surgical techniques for meniscal injuries. Primary outcomes of interest included patient-reported outcomes
scores, return to pre-injury activity level, level of sports
participation and persistence of pain using the visual analogue score. Where possible, data were pooled and a metaanalysis was performed.
Results A total of nine studies were included, involving a
combined 904 subjects, 330 patients underwent a meniscal
repair, 402 meniscectomy and 160 a collagen meniscal
implant. The only surgical treatments that were compared
in homogeneous fashion across more than one study were
the arrow and inside-out technique, which showed no

& Carola F. van Eck

Department of Orthopaedic Surgery, Joint Research, Onze
Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands


Department of Orthopaedic Surgery, University of Pittsburgh
Medical Center, 3471 Fifth Avenue, Kaufmann building suite
1011, Pittsburgh, PA, USA


Department of Orthopaedic Surgery, Academic Medical
Centre, Amsterdam, The Netherlands

difference for re-tear or complication rate. Strong evidence-based recommendations regarding the other surgical
treatments that were compared could not be made.
Conclusions This meta-analysis illustrates the lack of
level I evidence to guide the surgical management of
meniscal tears.
Level of evidence Level I meta-analysis.
Keywords Meniscus  Meniscectomy  Meniscal repair 
Meniscal transplant  Meta-analysis  Clinical outcomes

Meniscal tears are one of the most common injuries in
orthopaedic sports medicine with an incidence of 24 per
100,00 per year [1]. They show a bimodal distribution with
a first peak in the young, athletic population and the second
peak in middle-aged patients with degenerative joint disease [1]. Surgical procedures involving the meniscus are
performed in close to one million patients are year in the
United States alone [2, 3].
Surgical treatment of meniscal injuries has undergone
several developments over the past two decades [4, 5],
moving from open to arthroscopic surgery, from total to
partial meniscectomy and adding novel treatments such as
repair using a variety of devices/techniques, transplant,
collagen implants and xenografts [6–9]. The indications for
some is these treatment options overlap and consensus
about the best treatment option is lacking. For example, the
efficacy of arthroscopic meniscectomy for the treatment of
degenerative meniscal tears has recently come under
scrutiny [10, 11].
The aim of the present meta-analysis was to compare the
outcomes of (1) total and partial meniscectomy; (2)


Arch Orthop Trauma Surg

This meta-analysis was designed, conducted and reported
using the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines and
according the Cochrane methodology [12, 13].

searched for ongoing/uncompleted studies. To ensure no
potentially relevant studies were missed, the reference list
of all included studies was searched manually for potential
additional publication. In addition, experts in the field were
contacted and abstracts from subspecialty organization
meetings [including European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), International Society of Arthroscopy, Knee Surgery and
Orthopaedic Sports Medicine (ISAKOS), European Federation of National Associations of Orthopaedics and
Traumatology (EFORT) and American Academy of
Orthopaedic Surgeons (AAOS)] websites were searched.

Eligibility criteria

Assessment of risk of bias of included studies

All randomized and quasi-randomized controlled clinical
trials comparing two or more surgical treatments for
meniscal injuries were eligible for inclusion. Quasi randomization could include allocation by date of birth,
patient number or alternating. Surgical procedures could
include partial and total meniscectomy and any form of
meniscal repair, replacement or transplantation. Studies
were excluded if they compared one of these surgical
treatments to non-operative management alone. Studies
were also excluded if they focused on the skeletally
immature population or animals.

The risk of bias of the included studies was independently
assessed by two authors using the Cochrane Risk of Bias
Tool (Table 3 in ‘‘Appendix’’) [13]. Items graded with this
tool include selection bias, performance bias, detection
bias, attrition bias, reporting bias and ‘‘other’’. ‘‘Other’’
includes imbalances in baseline characteristics between
groups and risk of bias from systematic differences in the
care provided. Disagreement was resolved by consensus or
third party adjudication.

Types of outcomes

Two authors independently evaluated all the abstracts from
the list of studies generated by the search to identify
potentially relevant articles. Full text manuscript from
these articles was then obtained and this was evaluated by
two independent reviewers for eligibility. Disagreement
was resolved by consensus or third party adjudication.
Prior to submission of the current manuscript, the search
was updated by one of the authors.
Two authors independently extracted data from the
included articles using a piloted data extraction sheet.
Disagreement was resolved by consensus or third party
adjudication. If data regarding certain outcome measures
were missing, an attempt was made to contact the corresponding author of the study in question.

meniscectomy and meniscal repair; (3) meniscectomy and
meniscal transplantation; (4) open and arthroscopic
meniscectomy and (5) various different repair techniques
for the treatment of meniscal injuries.


Primary outcomes of interest included various functional
and patient-reported outcomes instruments such as the
Lysholm Score (LKSS) [14], Tegner Activity Scale (TAS)
[15], Cincinnati Knee Scale (CKS) [15], Knee injury and
Osteoarthritis Outcome Score (KOOS) [16], International
Knee Documentation Committee score (IKDC) [17], return
to pre-injury activity level, level of sports participation and
persistence of pain using the visual analogue score. Secondary outcomes included swelling, stiffness, range of
motion, muscle atrophy, objective muscle weakness, subjective instability, recurrent tears, revision surgery or
reoperation, development or progression of osteoarthritis,
complications, surgical time, length of hospital stay and
time off work.
Literature search and information sources
The Bone, Joint and Muscle Trauma Group Register,
Cochrane Database, MEDLINE, EMBASE and CINAHL
were searched from inception to June 25th of 2015. No
language restrictions were applied. Details of the search
strategy can be found in Table 2 in ‘‘Appendix’’. In addition the World Health Organization (WHO) Clinical Trials
Registry Platform and Current Controlled Trials were


Study selection and data collection

Statistical Analysis
All dichotomous outcomes were expressed as risk ratios
with 95 % confidence intervals (95 % CI) and all continuous outcomes as mean differences with 95 % CI. The
outcomes of similar treatments were pooled where possible. This was done using a random effects model.
Heterogeneity of these data was determined using the I2.
An I2 greater than 50 % was considered moderate heterogeneity and above 75 % as severe heterogeneity [18]. If the
I2 was greater than 50 %, data were deemed to

Arch Orthop Trauma Surg

heterogeneous to validate pooling. The statistical analysis
was performed using Review Manager (RevMan version
5.2, Nordic Cochrane Center, Copenhagen, Denmark).

A total of nine studies were included in this meta-analysis,
involving a combined 904 subjects (Fig. 1) [19–27]. Study
size ranged from 40 to 311 participants. Three hundred
thirty patients underwent a meniscal repair, 402 meniscectomy and 160 a collagen meniscal implant.
Characteristics of the included studies
The characteristics of the included studies are shown in
Table 1. The majority of the included studies focused on
longitudinal tears only [19–21, 23, 25, 26]. In three studies,
the tear had to be in the red–red or red-white zone for
patients to be included [19, 21, 25]. Two studies only
included patients with a meniscal tear greater than 10 mm
[19, 23].

Risk of bias of included studies
This risk of bias assessment of the included studies is
shown in Fig. 2.
The risk of allocation bias was graded as high in one
study [20] due to quasi-randomization and rated as unclear
in two studies [19, 26] which did not provide sufficient
details regarding randomization methods.
Performance bias was deemed high in two studies [21,
27] due to lack of blinding of both patient and surgeon, and
unclear in six studies [19, 20, 22–25] due to lack of
reporting on blinding.
Detection bias was unclear in five studies as they did
not report if outcome assessment was blinded [19, 20,
22, 23, 27].
Attrition bias was graded as high in three studies due to
low follow-up percentages, lack of detail about late
exclusions, presentation of incomplete outcome data and
missing explanations on how data analysis was corrected
for missing data [21, 23, 24].
Potential reporting bias was identified in three studies.
In one study muscle strength was stated to be an outcome

Fig. 1 Search results from date June 25th, 2015


Study design







et al. [19]


Biedert [20]

Bryant et al.

et al. [22]

Hanteset al.

O: 28.5I:
28A: 25

AP: 46.9AT:

A: 25.1I: 25.7


A: 26.5I: 25.5

Mean age

Table 1 Characteristics of included studies













23 months (17–37)

At least 8 weeks

28.0 ± 8.4 months

26.5 months

3–4 months

Mean follow-up

Allinside technique
(n = 20)

Inside-out technique
(n = 20)

Outside-in technique
(n = 17)

Open total meniscectomy
(n = 10)

Open partial meniscectomy
(n = 10)

Arthroscopic total
meniscectomy (n = 10)

Arthroscopic partial
meniscectomy (n = 10)

Inside-out suture technique
(n = 49)

Arrow suturing (n = 51)

Minimal resection followed
by suture repair (n = 7)
APM (n = 11)

Suture repair (n = 10)

Conservative (n = 12)

Insideout suture repair
(n = 34)

Arrow suturing (n = 34)


Longitudinal full thickness
tear [10 mm in
length, \6 mm from the
meniscocapsular junction

Horizontal cleavage or flap
tears of the posterior horn
of the medial meniscus

Reducible vertical meniscal
tear in the red–red or redwhite zone) [10 mm in
length and not [3 mm
displaced into the joint

Medial intra substance
meniscal lesion

Complication rate

rupture [10 mm in
length, \6 mm from the

Complication rate

arthrometer laxity

Meniscus healing

IKDC knee

Number of visits

Muscle strength


Return to sport

Operation time

Length of sick leave

Knee range of



Re-tear rate

Complication rate


Complication rate

Control MRI




Meniscal healing

Outcome measures

Type of tear

No differences
techniques in
complication rate

Inside-out is
superior to outsidein or all-inside

Arthroscopic partial
meniscectomy is
superior to other

No statistically
between sutures
and arrows

MRI is not superior
to clinical

should be
performed for
meniscal lesions

Better healing in
arrow repair group

Main findings

Arch Orthop Trauma Surg





Hedeet al.

Jarvela et al.

Kise et al.

et al. [27]


B: 26.9F:

S: 30A: 32


Mean age











59 months (16–92)

24 months

27 months ± 9

12 months

Mean follow-up

Collagen implant for
recurrent medial meniscus
injury (n = 85)

APM for recurrent medial
meniscus injury (n = 69)

Collagen implant for acute
meniscus injury (n = 75)

APM for acute medial
meniscus injury (n = 82)

FasT-fix all-inside sutures
(n = 25)

Biofix all-inside meniscal
arrows (n = 21)

Bioabsorbable meniscus
arrow (n = 21)

Bioabsorbable Trinion
meniscal screw (n = 21)

Open total meniscectomy
(n = 100)

Open partial meniscectomy
(n = 100)


Irreparable injury of the
medial meniscus with or
without previous partial

Vertical longitudinal
meniscal tears eligible for
arthroscopic all-inside
meniscal repair

Traumatic longitudinal
unstable meniscal tear in
a red–red zone or in the
red–white zone of the

Symptomatic tear in the
central three-quarters of
the meniscus

Type of tear

Complication rate

Osteoarthritis (outer

Re-operation rate

Persistent pain



Re-operation rate

MRA evaluation

IKDC score


Clinical examination

mineral changes


Long term change of

Length of time off


Outcome measures

The collagen
implant had no
positive effects in
patients with acute

The collagen
implant was
superior in the
recurrent group

No difference
between groups for

Lower reoperation
rate with FasT-Fix
sutures compared
to Biofix arrows

More chondral
damage with arrow

Similar outcomes for
all-inside repair
with bioabsorbable
screws and arrows

Preservation of the
peripheral rim of
the meniscus

meniscectomy is
superior to open

Main findings

A arrow suturing, ACL anterior cruciate ligament, APM arthroscopic partial meniscectomy, B biofix, F female, FF fast-fix; I inside-out suture repair, IKDC International Knee Documentation
Committee, KOOS Knee Injury and Osteoarthritis Outcome Score, LKSS Lysholm Knee Scoring Scale, M male, Mo months, MRA/MRI magnetic resonance angiography/imaging, QOL quality
of life, RCT randomized controlled trial, TAS Tegner Activity Scale, VAS Visual Analogue Scale, WOMET Western Ontario Meniscal Evaluation Tool

Study design


Table 1 continued

Arch Orthop Trauma Surg


Arch Orthop Trauma Surg
Fig. 2 Risk of bias graph:
review author’s judgement of
each risk of bias item presented
as percentage across all
included studies

in the method section, but was subsequently not reported in
the results section [22]. This was also true for KT
arthrometer test results in the study by Hantes et al. [23] In
the study by Rodkey et al. the authors reported on LKSS,
but they only provided means without range, standard
deviation or standard error of means [27].
An ‘other source of bias’ was identified in one study,
where one patient’s result was excluded from the sick
leave analysis due to the fact this person was an outlier.
Although no validation for this late exclusion was provided [22].

On radiographic evaluation after 12 months, a [1 mm
decrease in joint space was seen in 27 % of patients who
underwent partial meniscectomy as compared to 24 % in
the total meniscectomy group (NS) [24]. No differences
were found for subjective instability (4.4 vs. 8.9 %, RR
2.04; 95 % CI 0.64–6.66, p = NS), complication rate and
re-operation rate [24].
Meniscectomy versus meniscal repair
Only one study reported on this comparison [20]. Biedert
et al. found a lower re-operation rate and higher functional
outcomes after arthroscopic partial meniscectomy when
compared to arthroscopic suture repair [20].

Results of the included studies
Meniscectomy versus meniscal transplant
Partial versus total meniscectomy
Two studies reported on the comparison between partial
and total meniscectomy, however, the heterogeneity
between them was too high to validate pooling of the data
[22, 24]. Hamberg et al. found no difference in LKSS
between the two treatments. Hede et al. did find a difference with a better functional outcome at 1-year follow-up
in the partial meniscectomy group (91 vs. 80 % of patients
symptom free, p = 0.029).
With regards to return to work, Hamberg et al. found a
shorter period of sick leave in the partial meniscectomy
group (1.5 week for arthroscopic and 2.6 weeks for open
partial meniscectomy vs. 3.4 weeks for both arthroscopic
and open total meniscectomy, p \ 0.05) [22]. Hede et al.
reported no significant differences (22 days for partial and
27 days for total meniscectomy, p = NS) [24].
Surgical time was shorter for arthroscopic partial
meniscectomy (28 ± 14 min) than arthroscopic total
meniscectomy (52 ± 16 min, p \ 0.05), but not for open
partial versus total meniscectomy (43 ± 8 vs. 39 ± 5 min,
p = NS) [22].


There are no level I studies reporting on meniscal transplant, but one study describes a collagen meniscal implant
[27]. Rodkey et al. reported on 311 patients with either an
irreparable meniscal tear or prior partial meniscectomy and
randomized these patients to either a collagen meniscal
implant or arthroscopic meniscectomy. At 2-year follow-up
they found no significant difference for patient-reported
physical function, LKSS, patient satisfaction, pain scores
and complications [27]. However, they did find that there
were fewer unplanned re-operations as a results of disabling or persistent pain or mechanical symptoms in the
collagen implant group when compared to the meniscectomy group (89 versus 74 % survival rate, p = 0.04) [27].
Open versus arthroscopic approach
There were no studies that specifically focused on this
comparison. However, as reported earlier, Hamberg et al.
studied both an open and arthroscopic approach to partial
and total meniscectomy, the results of which can be read in
the ‘‘Partial versus total meniscectomy’’ paragraph [22].

Arch Orthop Trauma Surg

Different surgical techniques

Arrow versus screw

A total of five studies compared various meniscal repair
techniques [19, 21, 23, 25, 26].

Jarvela et al. compared arrow with screw fixation for
meniscal repair [25]. They found no difference in LKSS,
IKDC and re-tear rate [25]. However, there was significantly more chondral damage in the arrow repair group (30
vs. 0 %, p = 0.018).

Arrow versus meniscal sutures
Albrecht-Olsen et al. [19] and Bryant et al. [21] compared
the arrow technique to inside-out meniscal sutures, whereas
Kise et al. [26] compared arrow with all-inside suturing.
Kise et al. [26] was excluded from pooling due to heterogeneity. The pooled results of the studies by AlbrechtOlsen et al. [19] and Bryant et al. [21] are displayed in
Figs. 3 and 4. Kise et al. found a 3.6 times higher risk for
re-operation after treatment with arrows as compared to allinside sutures, but no difference in functional outcomes as
measured with KOOS [26].
Different suture techniques
Hantes et al. compares inside-out, outside-in and all-inside
suture techniques and found a healing rate of 100, 95 and
65 %, respectively, (p = 0.009 and p = 0.044) [23].

The most important finding of this systematic review and
meta-analysis is that there is a lack of level I evidence on
the surgical treatment options for meniscal injuries. Only
the outcome of the arrow technique versus inside-out
sutures was evaluated in more than one level I study with
good homogeneity. Pooling of these data showed that
there was no difference in outcome for recurrent tears,
minor complications and major complications. The other
comparisons between treatment strategies were either only
found in one level I study, or the studies were too
heterogeneous to allow for pooling of the results. Therefore the aim of the present meta-analysis to compare the

Fig. 3 Forest plot of the comparison arrow versus suture repair, outcome: recurrent tear

Fig. 4 Forest plot of the comparison arrow versus suture repair, outcome: complications


Arch Orthop Trauma Surg

outcomes of (1) total and partial meniscectomy; (2)
meniscectomy and meniscal repair; (3) meniscectomy and
meniscal transplantation; (4) open and arthroscopic
meniscectomy and (5) various different repair techniques
for the treatment of meniscal injuries did not result in a
cohesive body of level I evidence to provide strong
treatment recommendations.
Two prior meta-analyses are available in existing literature with a similar focus to the present study. A metaanalysis by Xu et al. [28] comparing meniscal repair to
meniscectomy included six observations studies and one
quasi-randomized trial and a meta-analysis by Paxton et al.
[29] comparing meniscal repair to partial meniscectomy
included three observational studies and one quasi-randomized trial. Both studies concluded a higher subjective
functional outcome after meniscal repair. Xu et al. found a
lower failure rate after repair, whereas Paxton et al. found a
higher re-operation rate after repair [28, 29]. No data to
support either finding could be found in the present metaanalysis of exclusively level I studies. Similar to the present study, Paxton et al. did conclude a lack of high-quality
evidence on various surgical treatments for meniscal injuries [29]. They described finding a total of 92 studies in
2010 of which only 3 % were level I evidence and 86 %
level IV evidence [29].
A meta-analysis by Ayeni et al. comparing the arrow
and suture repair techniques included two observational
and two randomized trials [30]. Similar to the present
meta-analysis, they found that neither technique was
superior over the other with regards to healing rate
[30]. A systematic review by Grant et al. compared the
inside-out and all-inside suture technique [31]. They
included two randomized trials, one retrospective
cohort study and 16 case series. They found no difference in healing rate, IKDC and LKSS, but more soft
tissue irritation, implant failure and nerve injuries in
the inside-out group [31]. This was different from the
present meta-analysis which suggests that the all-inside
technique has a lower healing rate. Lorenzo et al.
summarized all available evidence for various devices
for all-inside meniscal repair and found a higher failure
rate with the arrow technique [32]. However, similar to
the present study, due to the lack of high-quality evidence they were unable to make strong recommendations for clinical practice.
Myers et al. performed a systematic review on meniscal
transplantation, however, this included only non-randomized studies [33]. The authors concluded that meniscal
allograft transplantation could be considered in patients
with unicompartmental pain after previous meniscectomy
with a stable and well-aligned knee.


Strong points of this systematic review/meta-analysis are
that every attempt was made to minimize error and bias
during the review process by performing each step by at
least two authors independently. In addition, none of the
authors were involved in any of the included studies. There
was no restriction in language for the search or inclusion of
studies. The references list of all included studies was
carefully reviewed, meeting abstracts were searched and
experts in the field were contacted for potentially missed
studies. However, this study does have limitations. There is
a chance that publication bias has resulted in unpublished
trials with negative results. Some of the included studies
had a low sample size. In addition, various studies showed
heterogeneity which impaired pooling of the results. Some
of the predefined primary and secondary outcomes of
interest were not reported in literature such as swelling,
stiffness, range of motion, muscle atrophy, muscle weakness and length of hospital stay. All these aforementioned
factors affect the quality of evidence presented in the metaanalysis.
Clinical implications and recommendations
for the future
With the recent scrutiny of the efficacy of arthroscopic
partial meniscectomy for degenerative meniscal tears [10,
11], it is more important than ever to critically assess
current orthopaedic practice. This meta-analysis illustrates
the lack of level I evidence to guide the surgical management of meniscal tears. Large, possibly multi-center, double-blinded, randomized clinical trials comparing the
various treatment options are necessary to ensure strong
treatment recommendations founded on evidence-based

The aim of the present meta-analysis was to compare the
outcomes of (1) total and partial meniscectomy; (2) meniscectomy and meniscal repair; (3) meniscectomy and
meniscal transplantation; (4) open and arthroscopic meniscectomy and (5) various different repair techniques for the
treatment of meniscal injuries. The only surgical treatments
that were compared in homogeneous fashion across more
than one study were the arrow and inside-out technique,
which showed no difference for re-tear or complication rate.
This meta-analysis illustrates the lack of level I evidence to
guide the surgical management of meniscal tears.

Arch Orthop Trauma Surg
Compliance with ethical standards

Table 3 Cochrane risk of bias descriptions

Conflict of interest The authors did not receive any outside funding
or grants directly related to the research presented in this manuscript.
The authors state that this manuscript is an original work only submitted to this book. The authors hold the rights to all the material
presented in this manuscript. All authors contributed to the preparation of this work. Author Job Doornberg has received a research grant
from the Marti-Keuning-Eckhardt Foundation for his post-doctoral
research. The remaining authors declare that they have no conflict of

Type of bias


Relevant domains
in the ‘risk of bias’


Systematic differences between
baseline characteristics of the
groups that are compared


Systematic differences between
groups in the care that is
provided, or in exposure to
factors other than the
interventions of interest

Blinding of
participants and


Systematic differences between
groups in how outcomes are

Blinding of
Other potential
threats to validity

Attrition bias

Systematic differences between
groups in withdrawals from a
Systematic differences between
reported and unreported

outcome data


See Tables 2 and 3.

Table 2 Search strategy

Menisci, tibial/


Soft tissue injuries/


‘‘Sprains and strains’’/


Athletic Injuries/


Knee injuries/or knee/or knee joint/









1 or 9


Randomized controlled


Controlled clinical










11 or 12 or 13 or 14 or 15 or 16 or 17


Animals/not (humans/and animals/)


18 not 19


10 and 20



Other potential
threats to validity

Selective outcome

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