See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/360198804

Meniscus tears in professional soccer athletes: Resect or repair?

Article · April 2022

DOI: 10.1016/j.jcjp.2022.100051

CITATION READS

1 110

5 authors, including:

Georgios Kalifis Theodorakys Marín Fermín

Hull and East Yorkshire Hospitals NHS Trust Aspetar - Qatar Orthopaedic and Sports Medicine Hospital
10 PUBLICATIONS   53 CITATIONS    34 PUBLICATIONS   31 CITATIONS   

SEE PROFILE SEE PROFILE

Vasilios Raoulis Akash Shakya

General Hospital Of Karditsa ESI Hospital Mumbai
40 PUBLICATIONS   230 CITATIONS    20 PUBLICATIONS   7 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Spine Injury In India View project

spine disease and Diabetes View project

All content following this page was uploaded by Theodorakys Marín Fermín on 23 May 2022.

The user has requested enhancement of the downloaded file.

JID: JCJP
ARTICLE IN PRESS [m3GeSsc;May 15, 2022;12:25]
®
Journal of Cartilage & Joint Preservation xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Cartilage & Joint Preservation®

journal homepage: www.elsevier.com/locate/jcjp

Meniscus tears in professional soccer athletes: Resect or repair?

Georgios Kalifis a,b, Theodorakys Marín Fermín c, Vasilios Raoulis a, Akash Shakya b,
and Michael Hantes a,∗
a
Department of Orthopedic Surgery, Faculty of Medicine, University of Thessaly, Larissa, Greece
b
Department of Trauma and Orthopaedics, Hull Royal Infirmary, Hull, United Kingdom
c
Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar

a r t i c l e i n f o a b s t r a c t

Keywords: Introduction: Meniscal tears in professional soccer players, may lead to decreased game time and
meniscus tear: meniscus repair potentially affect their career and quality of life in the long term. Advancements in surgical tech-
meniscus resection niques and increased duration of many elite soccer players’ career may necessitate re-evaluation
soccer player
of the treatment strategies.
return to play
Objectives: To review the current literature regarding surgical management of meniscal tears in
professional soccer players.
Methods: A comprehensive search of PubMed has been conducted. Studies in English, reporting
results of surgical management of meniscal tears or meniscal deficiency in professional soccer
players were included. Studies not mentioning return to play (RTP), not examining professional
soccer players or not published in English were excluded.
Results: Following meniscus repair, an 82% to 90% RTP is reported. Mean time to RTP has been
reported from 4.3 to 5.5 months. The outcomes of a single study reporting partial meniscectomy
results in professional soccer athletes were 100% RTP at a mean of 1.5 months. Successful results
with RTP 92.3 to 100% after salvage procedures such as meniscal allograft transplantation or
collagen meniscal implant has been reported, Mean time to RTP stood at 10 to 11.8 months. In
addition, knee osteoarthritis is more common after lateral meniscectomy in comparison to medial
meniscectomy in the long-term follow-up.
Conclusion: Surgical management of meniscal lesions in professional soccer players is the mainstay
of treatment. Partial meniscectomy may offer temporary relief and fast RTP. Meniscal repair
requires a longer rehabilitation period but may have a chondroprotective effect on the knee.
Explicit player consultation and individualized approach may lead to optimal outcomes.

Introduction

Professional soccer players are at increased risk of sustaining a knee injury during their careers.1 Although there is limited data
available for this specific patient group, traumatic meniscal injuries may constitute up to 8% of total soccer injuries in a single season.2
Noncontact high-velocity pivot, cutting movements, or contact injuries are often the cause of meniscal injuries at the competitive
soccer level. Typically, rapid transition from hyperflexion to full knee extension combined with torsional or axial loading forces
may result in compression of the meniscus and eventually in meniscal tears.3 In addition, meniscal tears tend to occur 6 to 9 times
more frequently during competitive soccer matches than routine practice.4 Lavoie-Gagne et al5 in their study on RTP after traumatic
meniscal tears in elite European soccer players reported that age younger than 30 years, more goals scored preinjury and surgical

∗
Department of Orthopedic Surgery, Faculty of Medicine, University of Thessaly, 41500 Larissa, Greece.
Email address: hantesmi@otenet.gr (M. Hantes).

https://doi.org/10.1016/j.jcjp.2022.100051
Received 25 February 2022; Revised 11 April 2022; Accepted 20 April 2022
Available online xxx
2667-2545/© 2022 The Author(s). Published by Elsevier B.V. on behalf of International Cartilage Regeneration and Joint Preservation Society.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Please cite this article as: G. Kalifis, T.M. Fermín, V. Raoulis et al., Meniscus tears in professional soccer athletes: Resect or repair?
Journal of Cartilage & Joint Preservation® , https://doi.org/10.1016/j.jcjp.2022.100051
JID: JCJP
ARTICLE IN PRESS [m3GeSsc;May 15, 2022;12:25]

G. Kalifis, T.M. Fermín, V. Raoulis et al. Journal of Cartilage & Joint Preservation® xxx (xxxx) xxx

Table 1
Operative management of meniscal tears in professional soccer players.

Study Number of patients Operative technique RTP rate (%) Mean time of RTP (months)

Heath et al11 33 Meniscal repair 83.7 5.5

Alvarez-Diaz et al12 29 Meniscal repair 89.6 4.3 (for IMT)
Steibacher et al13 45 Meniscal repair 82 –
Nawabi et al9 90 Partial meniscectomy 100 1.5
Marcacci et al20 12 MAT 92.3 10.3
Bonanzinga et al21 10 MAT 100 11.8
Marcheggiani-Muccioli et al37 1 CMI 100 10

Abbreviations: CMI, collagen meniscal implant; IMT, Isolated meniscal tears; MAT, Meniscal allograft transplantation; RTP, Return to play.

management had a positive effect on RTP. Management of these injuries can be challenging in the elite-level soccer setting, mainly due
to immense pressure on players to return to preinjury status as soon as possible. Meniscectomy may alleviate mechanical symptoms
and allow a faster return to play for the athletes compared to the prolonged rehabilitation period and varying healing rates of meniscal
repair. However, there is plenty of data suggesting that meniscal deficiency may predispose the patients to persistent pain, residual
symptoms, and early knee osteoarthritis (OA) related to a negative long-term impact on their quality of life.1 , 6-8
Depending on the timing of the injury during the season and athletes’ career stage, the treatment plan may be based on a more
individualized approach.9 The purpose of this study is to present an update of the current literature in the surgical management of
meniscal injuries or meniscal deficiency exclusively in professional soccer players, focusing on comparing the outcomes of meniscal
repair and meniscectomy. Key factors such as return to play (RTP), long-term consequences, and meniscal deficiency management
were examined.

Methods

A search in PubMed using the terms (meniscus OR meniscal AND tear OR injury) AND (soccer OR football OR athletes) was
conducted. All studies were identified and reviewed independently by 2 authors (G.K. and T.M.F.) Studies published in the English
language, reporting results after operative management of traumatic meniscal lesions or management of meniscal deficiency in soccer
players were included (Table 1). Studies that included soccer players as a part of a group of athletes were examined, however, they
were excluded if soccer players’ postoperative outcomes were not reported separately. Studies not reporting RTP, lacked follow-up
time data and did not specify the type of operative management were also excluded. Studies including only patients or not reporting
separate results for patients with multiligamentous injuries or concomitant fractures were also excluded.

Meniscal repair

The importance of meniscal tissue preservation is being increasingly highlighted in the literature. Additionally, factors previously
considered as contraindications such as chronicity of the tear and Cooper zone 3 tears have been re-evaluated, not precluding suitable
candidates from meniscal repair.10 Heath et al11 in their case-control study including 33 Major League Soccer professional players
following medial meniscus repair after sustaining isolated medial meniscus injuries, found an 83.77% RTP rate at an average of 5.53
months. Lower performance and decreased play time was observed 1-year postoperatively compared to uninjured controls. However,
all players returned to the preinjury level at 2 years after the repair. Players from the repair group had a 3.8 years shorter career length
than the control group. In their study, Alvarez-Diaz et al12 including 29 professional soccer players following all-inside meniscal repair
of longitudinal posterior horn tears, at a minimum of 5 years follow-up, reported a RTP rate of 89.6%. Fourteen of 29 (48%) were
isolated repairs while 15 of 29 (52%) were combined with anterior cruciate ligament reconstruction (ACLR). In addition, normal or
mild grade I cartilage lesions of the affected joint compartment were reported in 26 (90%) patients as three patients had grade II or
III cartilage lesions.
All players returned to the preinjury level, while the average RTP time was 4.3 months for isolated repairs. Revision arthroscopy
and partial meniscectomy was performed in 2 patients (6.7%) due to repair failure. Three patients (10.3%) experienced persistent
symptoms after RTP, while in 2 cases, symptoms resolved with conservative management. However, one player had to retire from
professional soccer and continue playing at a recreational level. It has also been reported that these three patients were the only
patients diagnosed with grade II-III focal cartilage lesions during arthroscopy. All but the 2 patients who required reoperation were
satisfied with the postoperative outcome and would undergo this operation again. On the other hand, the 2 unsatisfied patients
were content with the concept of meniscal preservation and would have made the same choice for their treatment despite failure.
Steinbacher et al13 in their study in 45 professional soccer players following arthroscopic all-inside meniscal repair for hypermobile
lateral meniscus, reported 82% RTP at a mean 43 months follow-up. It has also been reported that 59% of the players returned to
the preinjury level. Sixty nine percent (69%) of the patients did not experience any symptoms during sports activity, while 15%
experienced pain during maximum flexion and/or extension and 38% had mild decrease in maximal flexion. Re-operation rate
stood at 6.5%. The reason for reoperation was persistent knee pain, due to failure of the fixation in one case, treated with revision
repair and finally returned to preinjury level. Two patients sustained new meniscal tears and were managed operatively with partial
meniscectomy, one returning to preinjury level and one retiring.

2
JID: JCJP
ARTICLE IN PRESS [m3GeSsc;May 15, 2022;12:25]

G. Kalifis, T.M. Fermín, V. Raoulis et al. Journal of Cartilage & Joint Preservation® xxx (xxxx) xxx

Partial meniscectomy

Partial meniscectomy is one of the most common sports orthopedic procedures, primarily because of its fast postoperative reha-
bilitation and early return to sports.14-16 In a cohort study by Nawabi et al,9 including ninety professional soccer players, time of
return to preinjury level, incidence of adverse events in the early recovery and the need for reoperation after isolated partial medial
or lateral meniscectomy were evaluated. Players undergoing partial medial meniscectomy had 6 times more chances to return to
play (P < .001). On the other hand, players who underwent partial lateral meniscectomy had a significantly delayed return to sports
(7 weeks vs 5 weeks, P < .001) and more adverse events such as persistent pain and joint effusion (69% vs 8%, P < .001) than
those undergoing partial medial meniscectomy. Additionally, the players undergoing lateral partial meniscectomy showed a higher
likelihood of further arthroscopic procedures. (7% vs 0%, P = .098) at an average of 10 weeks. A larger proportion of the medial
meniscal tissue was excised (27.6%) in comparison with the lateral meniscus (19.2%). The majority of the lateral meniscus tears were
complex (50%), while in the medial meniscus the majority was vertical (50%).

Management of meniscal deficiency

Partial or total meniscectomy may be performed either as a first-line treatment for meniscal tears or as a secondary procedure
after meniscal repair failure.17 , 18 It is well established in the current literature that meniscal deficiency may predispose to post-
meniscectomy persistent pain and early knee osteoarthritis.1 , 6 , 8 , 19 Modern treatment options such as meniscal allograft transplanta-
tion (MAT) and meniscal scaffolds may be offered as a salvage option to address meniscal deficiency.18 , 20 Marcacci et al20 in their
study, including 12 professional soccer players following arthroscopic MAT reported 92% RTP at an average of 10.3 months. Only
75% returned at the same preinjury level. Concomitant procedures or focal cartilage lesions or laterality of the meniscus involved
did not significantly affect the outcome. The reoperation rate was 25%; however, authors report that in most cases, patients returned
to sports after reoperation and the reason that led to subsequent surgical intervention was not related to MAT. Bonanzinga et al21
reported a 100% RTP at an average of 11.8 months after MAT in his study, including 10 professional soccer players. Marcheggiani-
Muccioli et al22 reported a case of a high-level professional soccer player having undergone arthroscopically lateral Collagen Meniscus
Implant (CMI) surgery, with RTP at 10 months postoperatively. The player returned to his pre-injury level, played for 3 soccer seasons
at that level, and was still performing at a semi-professional level at 10 years follow-up.

Discussion

The most important element of this review is that it is solely focused on published data regarding professional soccer players. Elite
soccer players have been included in the majority of previous studies on meniscal injuries management in elite athletes, however,
most of the times their outcomes were not examined separately.23-25 Professional soccer specific data are extremely limited in current
literature. The aim of this study is to examine the impact of meniscal surgical treatment or operative treatment for meniscal deficiency
on professional soccer players’ careers and contribute to the establishment of more evidenced based data and guidelines regarding
management of meniscal tears in this highly demanding group of athletes. Therefore, despite conducting a non-systematic search,
articles not including RTP rate, follow-up, and type of surgical management were excluded.
Return to play is a key factor following every injury in elite soccer players. The ultimate goal of meniscal tears management in this
group is to achieve a fast RTP to the preinjury level. High RTP rate has been reported following meniscal repairs in professional football
players, ranging from 83.7% to 89.7%. In addition, all players returned to preinjury level at an average of 4.3 to 5.5 months.11-13
Recent systematic reviews on isolated meniscal repairs in athletes, report 83% to 89% RTP at the preinjury level at 4.3 to 8.7 months
on average.26 , 27 Eberbach et al26 in their systematic review reporting sport-specific outcomes after isolated meniscal repair, also
reported that similarly successful outcomes were observed in both recreational and professional level athletes. Fried et al28 in their
systematic study on RTP and rehabilitation after isolated meniscal repairs, found a RTP rate ranging from 71.2% to 100%, while 53.9%
to 92.6% returned to the preinjury level. Additionally, they found that 44% had returned to play within 4 months after surgery and
up to 97% RTP within 6 months postoperatively. Tachibana et al29 in their study on 15 young soccer players, at 16.7 years old on
average, following repair of medial meniscus anterior and middle segment bucket-handle tears, reported 100 RTP to the preinjury
level at 1-year follow-up. They also reported that 4 of 15 (26%) had second-look arthroscopy performed, confirming healing of the
tear. Based on the aforementioned data, a similarly high RTP rate has been observed both in professional soccer players as well as
professional or recreational athletic population in general. Time of return to play results may be more variable, however, studies
reporting longer RTP time, also include older surgical techniques such as open meniscal repairs. In addition, rehabilitation protocols
are not mentioned in the majority of studies. As a consequence, considering that open meniscal repair, (as less advanced meniscal
surgical technique and delayed aggressive rehabilitation protocols) may be the reason for longer RTP time and variable outcomes
reported in the current literature.
Alvarez-Diaz et al12 reported a 6.7% failure rate following meniscal repair in professional soccer players. Two recent systematic
reviews including athletes who sustained meniscal repair, reported failure rates from 8.4% to 22%.26 , 27 Logan et al23 reported that
lateral meniscal repairs were significantly more successful in elite athletes compared to medial lesions at a minimum of 5 years
follow-up. Eberbach et al. reported 9% failure rate for professional athletes compared to 22% for recreational ones. Kang et al30 in
their review on arthroscopic meniscal repair on young population, reported failure rates ranging from 6.7% to 29.8%. They also did
not find significant differences between repair techniques. Petersen et al31 reported failure rates from 22.3% to 30.1% for meniscal
repairs in the long-term follow-up. Although failure rates after meniscal repair vary significantly in the literature, the majority of the

3
JID: JCJP
ARTICLE IN PRESS [m3GeSsc;May 15, 2022;12:25]

G. Kalifis, T.M. Fermín, V. Raoulis et al. Journal of Cartilage & Joint Preservation® xxx (xxxx) xxx

studies includes patients from all age groups and may report mid-term to long-term follow-up as well. Professional soccer players are
young, fit and well patients with high demands and high healing potential. In that group, short-term and mid-term results may be
highly important as their career is short-lived in nature.
The role of concurrent ACLR with meniscal repair has been controversial. While plenty of studies suggesting significantly more
successful repairs with less failures,17 , 32-34 other studies do not corroborate those findings.6 , 35 , 36 Alvarez-Diaz et al12 did not report
statistically significant difference of combined ACLR with meniscal repairs in professional soccer players compared to isolated repairs.
Menisci have been shown to provide secondary knee joint stability, especially in the setting of ACLR, while it has been suggested
that meniscal integrity may be predictive of laxity and ACL graft survivorship following ACLR.37-40 Inconclusive results from pre-
vious studies regarding the effect of ACLR in meniscal repair success rate, suggest that strong recommendations may be taken into
consideration cautiously. However, the highly successful rates of meniscal repairs both in isolated and combined repairs with ACLR,
as well as the important role of menisci as a secondary stabilizer, our personal belief is that in professional soccer players meniscal
repair combined with ACLR should be performed.
Partial meniscectomy has shown a faster return to sports and the highest return to sports rate, especially when performed on the
medial meniscus.9 , 41 In a cohort study by Nawabi et al,9 professional football soccer players undergoing partial medial meniscec-
tomy had 6 times more chances to return to play (P < .001). However, players who underwent partial lateral meniscectomy had
a significantly delayed return to sports (7 weeks vs. 5 weeks, P < .001) and more adverse events such as persistent pain and joint
effusion (69% vs 8%, P < .001) than those undergoing partial medial meniscectomy. Additionally, the players undergoing lateral
partial meniscectomy showed a higher likelihood of further arthroscopic procedures. (7% vs 0%, P = 0.098). A systematic review by
Lee et al,41 comprising 11 studies on athletes from different disciplines after meniscus surgery, revealed a similar return to sports at
the pre-injury level at an average of 7 to 9 weeks after partial meniscectomy. On the contrary, Kim et al42 in their study on stable
knees following partial meniscectomy, reported that young patients and patients sustaining lateral meniscectomy had a statistically
significant shorter RTP. Bonneux et al43 in their study including competitive level athletes following partial lateral meniscectomy
at an average of 8 years follow-up, reported that 50% of the athletes had not satisfying functional outcomes and the average level
decreased from competitive to recreational. They also reported that degenerative changes were noted in 93%. Ekhtiari et al24 in their
systematic review on elite athletes undergoing meniscal surgery, reported a rate of 80.2% RTP to the preinjury level at an average of
4.3 months following meniscectomy. Borque et al17 in their evidence-based study on meniscal lesions management in athletes, argue
that although partial meniscectomy may predispose to rapid knee osteoarthritis, especially in lateral meniscus tears, this is far less
common in the setting of medial side lesions and usually occurs after the end of their professional career.
It is widely accepted that long-term post-meniscectomy consequences may be devastating.1 , 17 , 31 Especially when lateral menis-
cectomy is performed in athletes, may lead to increased contact forces and subtle rotatory instability resulting in rapid chondrolysis
of the lateral compartment.8 Prien et al in their study including retired elite soccer players, reported 50% knee OA at 10 years after
retirement. They also report that meniscal lesions were highly associated with the presence of knee degeneration.44 Turner et al in
their study examining the long-term health impact of soccer on retired professional soccer players in the United Kingdom, reported
that patients suffering from post-traumatic knee OA had a significantly lower quality of life compared to controls.1 Development of
early onset knee osteoarthritis should be taken into consideration when making decisions regarding management of meniscal lesions
in professional soccer players. It is fairly reasonable that players, managers and soccer organizations focus on short-term results and
rapid RTP and partial meniscectomy may be effective in terms of symptoms alleviation. However, knee OA development, need for
re-operations and knee arthroplasty at an early stage ought to be discussed explicitly with the player.
It is well established that resection of meniscal tissue may lead to postoperative limitation of knee function and early knee
osteoarthritis.6 , 10 , 45 Meniscal scaffolds and MAT have increasingly being used for meniscal deficiency management. Marcacci et al
and Bonanzinga et al reported 92% RTP at an average of 10.3 months and 100% RTP at an 11.8 months average respectively, following
MAT in professional soccer players.20 , 21 Alenton-Geli et al46 in their study including 14 lower division soccer players following MAT,
reported a RTP rate of 85.7% at an average of 7.6 months follow-up. They also found that MAT had a similarly positive effect in both
patients with focal cartilage lesions (grade I-IV) and patients without chondral lesions. Recent systematic reviews report promising
RTP rates after MAT, especially for recreational sports, however, cautious interpretation of successful results is suggested as there is
not sufficient evidence to support sports involvement at professional level.47-49 Borque et al17 suggest that the role of MAT in elite
athletes is still limited and should be considered only when the athlete is completely unable to perform.
Historically, professional soccer players with symptomatic meniscal tears have been treated with meniscectomy in order to RTP,
free of symptoms, as soon as possible.50-52 Partial meniscectomy may allow early RTP at 6 to 8 weeks at the preinjury level in the
majority of professional athletes.9 , 24 Resection of meniscal tissue, besides having established long-term consequences predisposing
patients to early knee osteoarthritis,6 , 10 in the setting of lateral partial meniscectomy may lead to rapid chondrolysis of the lateral
compartment.8 , 53 Additionally, it has also been suggested that lateral meniscal repair in athletes may be more successful than medial
repairs.23 For the aforementioned reasons, as previous evidence-based studies have also suggested,17 we suggest that meniscal repair
should be performed in all symptomatic reparable tears of the lateral meniscus, even in complex patterns regardless the zone of the
tear. In case that tears are unsalvageable, degenerative or if repair has failed (first or multiple times) as limited resection as possible is
recommended. Medial meniscectomy has been shown to lead in earlier RTP compared to lateral side in professional soccer athletes.9
It has also been suggested that rapid chondrolysis of the medial compartment occurs rarely in comparison to lateral compartment
following partial meniscectomy and has successful mid-term outcomes.17 On top of that, authors argue that in professional athletes
that want a fast RTP and especially in the middle or end of their career, partial medial meniscectomy should be the treatment of
choice. They suggest that meniscal repair may be reserved for young athletes in their early twenties. However, recent studies on
professional and recreational soccer players and athletes in general reported successful outcomes, constantly around 83% RTP at

4
JID: JCJP
ARTICLE IN PRESS [m3GeSsc;May 15, 2022;12:25]

G. Kalifis, T.M. Fermín, V. Raoulis et al. Journal of Cartilage & Joint Preservation® xxx (xxxx) xxx

4 to 8 months’ time while the majority of players return to preinjury level, following both isolated and combined medial meniscal
repair with ACLR.11 , 12 , 26 , 28 Professional soccer players are young healthy patients with great healing potential in the majority of
cases. Additionally, modern arthroscopic techniques and biological augmentation of the meniscal repairs may play a role in the
outcome and failure rates. Sports-specific, modern rehabilitation protocols may also positively affect RTP and lead to earlier RTP
to the preinjury level. It is also important that in modern professional soccer, more and more elite athletes follow state-of-the-art
training, rehabilitation programs and adapt their lifestyle in a way that allows them to perform in the highest level for more years
than in the past. Having said that, age of the player may be interpreted in a different way in terms of indication of medial meniscal
tears management and treatment should be more individualized. Saving the meniscal tissue should be a priority for this group of
patients, and therefore, further studies including combination of meniscal repairs with biological augmentation in comparison with
control group and/or partial meniscectomy group may provide more evidence-based information regarding medial meniscal tears
management in professional soccer players.
This study has several limitations. Our review has not been done in a systematic fashion. In addition, very small number of articles
related to the topic can be found in the literature and thus included in our study. The level of evidence of our study is strongly affected
by the evidence of include studies, the majority being case series or case reports. Another limitation of our study is that the type of
meniscal injuries is not reported for a significant number of patients. Thus there is no sufficient information regarding decision making
between repair and partial meniscectomy and how this factor may influenced postoperative outcome. Additionally, all studies except
from one11 do not specify the exact league of participation of the athletes and use generic terms such as “professional”, “competitive”,
“elite-level”, “high-level” athlete. On top of that, the findings of our study should be taken into consideration with caution.

Conclusions

Surgical management of meniscal lesions in professional soccer players is the mainstay of treatment. Partial meniscectomy may
offer temporary relief and fast RTP. Meniscal repair requires a longer rehabilitation period but may have a chondroprotective effect
on the knee. Explicit player consultation and individualized approach may lead to optimal outcomes.

Ethics approval

The manuscript entitled “Meniscus tears in professional soccer athletes: resect or repair?” is a literature review and therefore
no patient informed consent or IRB approval, is required or needed.

Authorship contribution

The main concept, design and final review of the study can be attributed to MH, who was the senior author. GK and TMF searched
the literature separately and proceeded with data collection and analysis. GK contributed to the development of the concept and design
of the study, as he was the main manuscript author too. TMF had a major contribution to the manuscript and also was involved in
reviewing and revising the manuscript. VR and AS were involved in manuscript writing and revision as well.

Declaration of competing interest

All authors declare that there is no conflict of interest regarding this manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

REFERENCES

1. Turner AP, Barlow JH, Heathcote-Elliott C. Long term health impact of playing professional football in the United Kingdom. Br J Sports Med. 2000;34(5):332.
doi:10.1136/bjsm.34.5.332.
2. Chomiak J, Junge A, Peterson L, Dvorak J. Severe Injuries in Football Players. Am J Sports Med. 2000;28(5_suppl):58–68. doi:10.1177/28.suppl_5.s-58.
3. Frizziero A, Ferrari R, Giannotti E, Ferroni C, Poli P, Masiero S. The meniscus tear. State of the art of rehabilitation protocols related to surgical procedures.
Muscles Ligaments Tendons J. 2013;2(4):295–301. https://pubmed.ncbi.nlm.nih.gov/23738313.
4. Mitchell J, Graham W, Best TM, et al. Epidemiology of meniscal injuries in US high school athletes between 2007 and 2013. Knee Surg Sports Traumatol Arthrosc.
2016;24(3):715–722. doi:10.1007/s00167-015-3814-2.
5. Lavoie-Gagne OZ, Korrapati A, Retzky J, et al. Return to play and player performance after meniscal tear among elite-level european soccer players: a matched
cohort analysis of injuries from 2006 to 2016. Orthop J Sports Med. 2022;10(1):23259671211059540. doi:10.1177/23259671211059541.
6. Kalifis G, Raoulis V, Panteliadou F, Liantsis A, D’Ambrosi R, Hantes M. Long-term follow-up of bucket-handle meniscal repairs: chondroprotective effect outweighs
high failure risk. Knee Surg Sports Traumatol Arthroscopy. 2021 Published online. doi:10.1007/s00167-021-06787-2.
7. Arliani GG, Lara PS, Astur DC, Cohen M, Gonçalves JPP, Ferretti M. Impact of sports on health of former professional soccer players in Brazil. Acta Ortop Bras.
2014;22(4):188–190. doi:10.1590/1413-78522014220400954.
8. Mariani PP, Garofalo R, Margheritini F. Chondrolysis after partial lateral meniscectomy in athletes. Knee Surg Sports Traumatol Arthroscopy. 2008;16(6):574–580.
doi:10.1007/s00167-008-0508-z.
9. Nawabi DH, Cro S, Hamid IP, Williams A. Return to play after lateral meniscectomy compared with medial meniscectomy in elite professional soccer players. Am
J Sports Med. 2014;42(9):2193–2198. doi:10.1177/0363546514540271.
10. Kopf S, Beaufils P, Hirschmann MT, et al. Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthroscopy.
2020;28(4):1177–1194. doi:10.1007/s00167-020-05847-3.

5
JID: JCJP
ARTICLE IN PRESS [m3GeSsc;May 15, 2022;12:25]

G. Kalifis, T.M. Fermín, V. Raoulis et al. Journal of Cartilage & Joint Preservation® xxx (xxxx) xxx

11. Heath D, Momtaz D, Ghali A, et al. Medial meniscus repair in major league soccer players results in decreased performance metrics for one year and shortened
career longevity. Open Access J Sports Med. 2021;12:147–157. doi:10.2147/oajsm.s337251.
12. Alvarez-Diaz P, Alentorn-Geli E, Llobet F, Granados N, Steinbacher G, Cugat R. Return to play after all-inside meniscal repair in competitive football players: a
minimum 5-year follow-up. Knee Surg Sports Traumatol Arthroscopy. 2016;24(6):1997–2001. doi:10.1007/s00167-014-3285-x.
13. Steinbacher G, Alentorn-Geli E, Alvarado-Calderón M, Barastegui D, Álvarez-Díaz P, Cugat R. Meniscal fixation is a successful treatment for hypermobile lateral
meniscus in soccer players. Knee Surg Sports Traumatol Arthroscopy. 2019;27(2):354–360. doi:10.1007/s00167-018-5080-6.
14. Chatain F, Adeleine P, Chambat P, Neyret P. A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-Year minimum
follow-up. Arthroscopy. 2003;19(8):842–849. doi:10.1016/S0749-8063(03)00735-7.
15. Beaufils P, Pujol N. Management of traumatic meniscal tear and degenerative meniscal lesions. Save the meniscus. Orthop Traumatol Surg Res. 2017;103(8,
Supplement):S237–S244. doi:10.1016/j.otsr.2017.08.003.
16. Lee YS, Lee OS, Lee SH. Return to sports after athletes undergo meniscal surgery: a systematic review. Clin J Sport Med. 2019;29(1).
https://journals.lww.com/cjsportsmed/Fulltext/2019/01000/Return_to_Sports_After_Athletes_Undergo_Meniscal.6.aspx.
17. Borque KA, Jones M, Cohen M, Johnson D, Williams A. Evidence-based rationale for treatment of meniscal lesions in athletes. Knee Surg Sports Traumatol
Arthroscopy. 2021 Published online. doi:10.1007/s00167-021-06694-6.
18. Dangelmajer S, Familiari F, Simonetta R, Kaymakoglu M, Huri G. Meniscal transplants and scaffolds: a systematic review of the literature. Knee Surg Relat Res.
2017;29(1):3–10. doi:10.5792/ksrr.16.059.
19. Kopf S, Sava MP, Stärke C, Becker R. The menisci and articular cartilage: a life-long fascination. EFORT Open Rev. 2020;5(10):652–662.
doi:10.1302/2058-5241.5.200016.
20. Marcacci M, Marcheggiani Muccioli GM, Grassi A, et al. Arthroscopic meniscus allograft transplantation in male professional soccer players: a 36-month follow-up
study. Am J Sports Med. 2013;42(2):382–388. doi:10.1177/0363546513508763.
21. Bonanzinga T, Grassi A, Altomare D, Vitale ND, Zaffagnini S, Marcacci M. Long sports career and satisfactory clinical outcomes after meniscal allo-
graft transplantation (MAT) in young professional athletes involved in strenuous sports. Knee Surg Sports Traumatol Arthroscopy. 2021 Published online.
doi:10.1007/s00167-021-06779-2.
22. Marcheggiani Muccioli GM, Lullini G, Cammisa E, Leardini A, Zaffagnini S. A professional athlete functionally active 10 years after an arthroscopic lateral collagen
meniscus implant. Knee Surg Sports Traumatol Arthroscopy. 2021;29(1):117–119. doi:10.1007/s00167-020-05876-y.
23. Logan M, Watts M, Owen J, Myers P. Meniscal repair in the elite athlete: results of 45 repairs with a minimum 5-year follow-up. Am J Sports Med. 2009;37(6):1131–
1134. doi:10.1177/0363546508330138.
24. Ekhtiari S, Khan M, Kirsch JM, Thornley P, Larson CM, Bedi A. Most elite athletes return to competition following operative management of meniscal tears: a
systematic review. J ISAKOS. 2018;3(2):110–115. doi:10.1136/jisakos-2017-000181.
25. Tucciarone A, Godente L, Fabbrini R, Garro L, Salate Santone F. Chillemi C. isolates. Arch Orthop Trauma Surg. 2012;132(3):349–356.
doi:10.1007/s00402-011-1391-5.
26. Eberbach H, Zwingmann J, Hohloch L, et al. Sport-specific outcomes after isolated meniscal repair: a systematic review. Knee Surg Sports Traumatol Arthroscopy.
2018;26(3):762–771. doi:10.1007/s00167-017-4463-4.
27. Blanchard ER, Hadley CJ, Wicks ED, Emper W, Cohen SB. Return to play after isolated meniscal repairs in athletes: a systematic review. Orthop J Sports Med.
2020;8(11) 2325967120962093-2325967120962093. doi:10.1177/2325967120962093.
28. Fried JW, Manjunath AK, Hurley ET, Jazrawi LM, Strauss EJ, Campbell KA. Return-to-play and rehabilitation protocols following isolated meniscal repair—a
systematic review. Arthroscopy Sports Med Rehabil. 2021;3(1):e241–e247. doi:10.1016/j.asmr.2020.07.023.
29. Tachibana Y, Tanaka Y, Amano H, et al. Isolated peripheral longitudinal tears in the anterior-middle segment of medial meniscus among young soccer players: a
case series. Int J Surg Case Rep. 2021;89:106630. doi:10.1016/j.ijscr.2021.106630.
30. Kang DG, Park YJ, Yu JH, Oh JB, Lee DY. A Systematic review and meta-analysis of arthroscopic meniscus repair in young patients: comparison of all-inside and
inside-out suture techniques. Knee Surg Relat Res. 2019;31(1):1–11. doi:10.5792/ksrr.17.078.
31. Petersen W, Karpinski K, Bierke S, Müller Rath R, Häner M. A systematic review about long-term results after meniscus repair. Arch Orthop Trauma Surg. 2021
Published online. doi:10.1007/s00402-021-03906-z.
32. Melton JTK, Murray JR, Karim A, Pandit H, Wandless F, Thomas NP. Meniscal repair in anterior cruciate ligament reconstruction: a long-term outcome study.
Knee Surg Sports Traumatol Arthroscopy. 2011;19(10):1729. doi:10.1007/s00167-011-1501-5.
33. Ahn JH, Lee SH, Choi SH, Lim TK. Magnetic Resonance imaging evaluation of anterior cruciate ligament reconstruction using quadrupled hamstring tendon
autografts: comparison of remnant bundle preservation and standard technique. Am J Sports Med. 2010;38(9):1768–1777. doi:10.1177/0363546510368132.
34. Hupperich A, Salzmann GM, Niemeyer P, et al. What are the factors to affect outcome and healing of meniscus bucket handle tears? Arch Orthop Trauma Surg.
2018;138(10):1365–1373. doi:10.1007/s00402-018-2989-7.
35. Steadman JR, Matheny LM, Singleton SB, et al. Meniscus suture repair: minimum 10-year outcomes in patients younger than 40 years compared with patients 40
and older. Am J Sports Med. 2015;43(9):2222–2227. doi:10.1177/0363546515591260.
36. Noyes FR, Chen RC, Barber-Westin SD, Potter HG. Greater than 10-year results of red-white longitudinal meniscal repairs in patients 20 years of age or younger.
Am J Sports Med. 2011;39(5):1008–1017. doi:10.1177/0363546510392014.
37. Zhang Y, Huang W, Yao Z, et al. Anterior cruciate ligament injuries alter the kinematics of knees with or without meniscal deficiency. Am J Sports Med.
2016;44(12):3132–3139. doi:10.1177/0363546516658026.
38. Vindfeld S, Strand T, Solheim E, Inderhaug E. Failed meniscal repairs after anterior cruciate ligament reconstruction increases risk of revision surgery. Orthop J
Sports Med. 2020;8(10):2325967120960538. doi:10.1177/2325967120960538.
39. Parkinson B, Robb C, Thomas M, Thompson P, Spalding T. Factors that predict failure in anatomic single-bundle anterior cruciate ligament reconstruction. Am J
Sports Med. 2017;45(7):1529–1536. doi:10.1177/0363546517691961.
40. Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral meniscectomy on the stability of the anterior cruciate ligament-
deficient knee. Am J Sports Med. 2010;38(8):1591–1597. doi:10.1177/0363546510364402.
41. Lee YS, Lee OS, Lee SH. Return to sports after athletes undergo meniscal surgery: a systematic review. Clin J Sport Med. 2019;29(1).
https://journals.lww.com/cjsportsmed/Fulltext/2019/01000/Return_to_Sports_After_Athletes_Undergo_Meniscal.6.aspx.
42. Kim SG, Nagao M, Kamata K, Maeda K, Nozawa M. Return to sport after arthroscopic meniscectomy on stable knees. BMC Sports Sci Med Rehabil. 2013;5(1):23
doi:10.1186/2052-1847-5-23.
43. 12415937.
44. Prien A, Boudabous S, Junge A, Verhagen E, Delattre BMA, Tscholl PM. Every second retired elite female football player has MRI evidence of knee
osteoarthritis before age 50 years: a cross-sectional study of clinical and MRI outcomes. Knee Surg Sports Traumatol Arthroscopy. 2020;28(2):353–362.
doi:10.1007/s00167-019-05560-w.
45. Wiley TJ, Lemme NJ, Marcaccio S, et al. Return to play following meniscal repair. Clin Sports Med. 2020;39(1):185–196. doi:10.1016/j.csm.2019.08.002.
46. Alentorn-Geli E, Vázquez RS, Díaz PÁ, Cuscó X, Cugat R. Arthroscopic meniscal transplants in soccer players: outcomes at 2- to 5-year follow-up. Clin J Sport Med.
2010;20(5). https://journals.lww.com/cjsportsmed/Fulltext/2010/09000/Arthroscopic_Meniscal_Transplants_in_Soccer.4.aspx.
47. Ahmed AF, Rinaldi J, Noorzad AS, Zikria BA. Return to sports following meniscal allograft transplantation is possible but remains questionable: a systematic
review. Arthroscopy J Arthroscop Relat Surg. 2021 Published online. doi:10.1016/j.arthro.2021.11.003.
48. Hurley ET, Davey MS, Jamal MS, et al. High rate of return-to-play following meniscal allograft transplantation. Knee Surg Sports Traumatol Arthroscopy.
2020;28(11):3561–3568. doi:10.1007/s00167-020-05956-z.
49. Barber-Westin SD, Noyes FR. Low-impact sports activities are feasible after meniscus transplantation: a systematic review. Knee Surg Sports Traumatol Arthroscopy.
2018;26(7):1950–1958. doi:10.1007/s00167-017-4658-8.

6
JID: JCJP
ARTICLE IN PRESS [m3GeSsc;May 15, 2022;12:25]

G. Kalifis, T.M. Fermín, V. Raoulis et al. Journal of Cartilage & Joint Preservation® xxx (xxxx) xxx

50. Jorgensen U, Sonne-Holm S, Lauridsen F, Rosenklint A. Long-term follow-up of meniscectomy in athletes. A prospective longitudinal study. J Bone Joint Surg Br
Vol. 1987;69-B(1):80–83. doi:10.1302/0301-620X.69B1.3818740.
51. Muckle DS. Factors affecting the prognosis of meniscectomy in soccer players. Br J Sports Med. 1983;17(2):88. doi:10.1136/bjsm.17.2.88.
52. Muckle DS. Factors affecting the prognosis of meniscectomy in soccer players. Br J Sports Med. 1983;17(2):88. doi:10.1136/bjsm.17.2.88.
53. Sonnery-Cottet B, Archbold P, Thaunat M, Carnesecchi O, Tostes M, Chambat P. Rapid chondrolysis of the knee after partial lateral meniscectomy in professional
athletes. Knee. 2014;21(2):504–508. doi:10.1016/j.knee.2014.01.001.

View publication stats