Title: Outcomes of Arthroscopic Meniscal Repair in Athletes: A Five-Year Single-Center Experience Comparing Isolated Repairs and Combined ACL Reconstructions

Abstract

Objective: To evaluate and compare the clinical outcomes, return to sport (RTS) rates, and failure rates of isolated meniscal repair (IMR) versus meniscal repair with concomitant anterior cruciate ligament reconstruction (ACLR+MR) in an athletic population treated at a single center.

Methods: A retrospective review was conducted on all athletes who underwent primary arthroscopic meniscal repair from January 2019 to December 2023. Patients were stratified into IMR and ACLR+MR cohorts. Data collected included tear characteristics, repair technique, and rehabilitation protocol. Outcomes were assessed using pre- and postoperative Lysholm Knee Scores and Tegner Activity Scales, RTS rates and timelines, and documented complications, including clinical failure defined as the need for reoperation on the ipsilateral meniscus.

Results: A total of 135 athletes (98 male, 37 females; mean age 24.2 years) were included, with 58 in the IMR cohort and 77 in the ACLR+MR cohort. At a mean follow-up of 3.1 years, both groups demonstrated significant improvements in Lysholm scores (IMR: 61.5 to 90.8; ACLR+MR: 59.2 to 89.9; p<0.001 for both). The overall RTS rate was 88.1%. The IMR cohort had a significantly shorter mean time to RTS (5.9 months) compared to the ACLR+MR cohort (9.7 months) (p<0.001). The clinical failure rate was significantly higher in the IMR group (20.7%) compared to the ACLR+MR group (11.7%) (p=0.045).

Conclusion: Arthroscopic meniscal repair is an effective procedure for athletes, facilitating a high rate of return to sport with excellent functional outcomes. Concomitant ACL reconstruction is associated with a lower meniscal repair failure rate but a significantly prolonged recovery timeline. These findings highlight a clinical trade-off between biological healing potential and the duration of functional recovery, which is critical for patient counseling and managing expectations.

Keywords: Meniscus, meniscal repair, athlete, acl reconstruction, return to sports

Introduction

The menisci are C-shaped, fibrocartilaginous structures that are vital to the health and function of the knee joint.¹ Once considered vestigial remnants, they are now understood to be critical biomechanical components that increase femorotibial congruity, provide secondary joint stability, and, most importantly, serve as the primary shock absorbers and load distributors.³ The menisci transmit over 50% of the tibiofemoral axial load in extension and up to 85% in flexion.⁴ Consequently, the loss of meniscal tissue, even from a partial meniscectomy, dramatically decreases the contact area and increases peak contact stresses by up to 350%, creating a joint environment that is highly susceptible to accelerated articular cartilage degeneration and the premature onset of osteoarthritis.⁴

This understanding has driven a paradigm shift in the management of meniscal tears, particularly in young, active patients. The historical approach of meniscectomy has been largely replaced by a philosophy of meniscal preservation, with surgical repair now considered the standard of care for reparable lesions.⁸ The primary goal of meniscal repair is to restore the native anatomy and function, thereby protecting the long-term health of the joint.⁴

The success of a meniscal repair is contingent upon a confluence of biological and mechanical factors. The most critical biological determinant is vascularity. The meniscus receives its blood supply from the perimeniscal capillary plexus, which penetrates only the peripheral 10-30% of the tissue.¹ This vascular gradient creates distinct healing zones: the peripheral "red-red" zone with excellent healing potential, the transitional "red-white" zone with moderate potential, and the avascular central "white-white" zone with poor intrinsic healing capacity.¹⁴ Mechanically, the tear pattern is paramount. The meniscal architecture is dominated by circumferentially oriented type I collagen fibers, which are exquisitely designed to convert compressive axial loads into circumferential "hoop" stresses.⁴ The twisting and compressive forces common in athletic activities often cause these fibers to split along their length, resulting in longitudinal-vertical or bucket-handle tears.⁸ These patterns are the most amenable to repair because surgical approximation can effectively restore the tissue's ability to withstand hoop stresses, which is the very foundation of its load-bearing function.

A crucial factor influencing the biological environment of the knee is the presence of a concomitant ligamentous injury. Meniscal repair performed in conjunction with an anterior cruciate ligament reconstruction (ACLR) has been shown to have a higher success rate than isolated repairs.¹¹ The prevailing theory is that the drilling of femoral and tibial tunnels during ACLR releases bone marrow-derived mesenchymal stem cells, platelets, and growth factors into the joint, creating a "biologically augmented" milieu that enhances the meniscal healing response.¹¹ However, this biological advantage introduces a clinical paradox. The rehabilitation following ACLR is necessarily more conservative and prolonged to protect the ligament graft, often involving an extended period of restricted weight-bearing and motion.¹⁹ Thus, the knee with the superior biological environment for healing is simultaneously subjected to a slower and more cautious functional recovery.

The purpose of this study is to retrospectively analyze the outcomes of arthroscopic meniscal repair in athletes treated at our institution from 2019 to 2023. The primary objective is to compare the functional results, return to sport rates and timelines, and clinical failure rates between two distinct cohorts: athletes undergoing isolated meniscal repair (IMR) and those undergoing meniscal repair combined with ACL reconstruction (ACLR+MR).

Materials and Methods

Study Design and Patient Selection

A retrospective cohort study was performed at a single tertiary care sports medicine center. We defined athlete as self-reported athletes participating in competitive or high-level recreational sports, defined as a pre-injury Tegner activity level of 6 or higher. The institutional review board approved the study. A surgical database was queried to identify all patients who underwent arthroscopic meniscal repair between January 1, 2019, and December 31, 2023. Inclusion criteria were: (1) athletes participating in competitive or high-level recreational sports, defined as a pre-injury Tegner activity level of 6 or higher; (2) primary arthroscopic meniscal repair; and (3) a minimum of two years of clinical follow-up. Patients were excluded if they had undergone revision meniscal surgery, had multi-ligament injuries (other than the ACL), required concomitant cartilage restoration procedures for full-thickness chondral defects (Outerbridge grade III-IV), or had degenerative meniscal tears in the setting of significant pre-existing osteoarthritis. Eligible patients were stratified into two cohorts for comparative analysis: the isolated meniscal repair (IMR) group and the meniscal repair with concomitant ACL reconstruction (ACLR+MR) group.

Surgical Protocol

All procedures were performed by fellowship-trained sports medicine surgeons. Standard anterolateral and anteromedial arthroscopic portals were utilized. A comprehensive diagnostic arthroscopy was performed to confirm and characterize the meniscal tear.

Tear Evaluation and Preparation

Tear patterns were classified intraoperatively according to the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) system as longitudinal-vertical, bucket-handle, radial, or complex.¹⁴ The decision to repair was based on tear location (within the vascular red-red or red-white zones), tear length (>1 cm), tissue quality, and the ability to achieve a stable, anatomic reduction.¹⁴ Prior to repair, the tear margins were debrided with a motorized shaver or arthroscopic rasp to expose a fresh, bleeding surface and stimulate a healing response. In select cases, synovial abrasion or microfracture of the intercondylar notch was performed to further promote bleeding.²²

Repair Techniques

The choice of surgical repair technique was dictated by the location and morphology of the tear.

• All-Inside Repair: This was the most frequently used technique, particularly for tears of the posterior horn and posterior body. It was performed using modern, all-suture-based anchor devices (FiberStich, Smith & Nephew; FastFix 360, Smith & Nephew), allowing for a completely arthroscopic procedure with no accessory incisions.²³
• Inside-Out Repair: Considered the gold standard for its robust fixation, this technique was primarily used for tears located in the meniscal body. It involved passing sutures from within the joint through the meniscus and capsule using zone-specific cannulas. The sutures were then retrieved through a small posteromedial or posterolateral accessory incision and tied over the joint capsule, ensuring protection of the saphenous and common peroneal nerves, respectively.²²
• Outside-In Repair: This technique was reserved for tears of the anterior horn, where portal access for other techniques can be challenging. It involved passing a spinal needle from outside the joint, across the tear, and into the articular space. A suture was then shuttled through the needle and retrieved arthroscopically, with the final knot tied over the anterior capsule.²²

Postoperative Rehabilitation Protocols

Two distinct, criteria-based rehabilitation protocols were implemented based on the surgical procedure performed. The Rehabilitation protocols were similar for both the groups, but the protocol for Meniscal repair with ACL Reconstruction group was more conservative (See Appendix 1)

Outcome Assessment

Clinical outcomes were assessed using data collected preoperatively and at the final follow-up visit (minimum 2 years).

Patient-Reported Outcome Measures (PROMs): The Lysholm Knee Score and the Tegner Activity Scale were administered. The Lysholm score is an 8-item questionnaire assessing symptoms and function on a scale of 0-100, where a score >94 is considered excellent, 84-94 is good, 65-83 is fair, and <65 is poor.³⁷ The Tegner scale is a 0-10 scale that quantifies a patient's highest level of physical activity, with level 10 representing participation in elite competitive sports.³⁷

Return to Sport (RTS): RTS was defined as the patient's ability to participate in their primary sport at their pre-injury level of competition for at least one full season. The rate of RTS and the time from surgery to RTS were recorded.

Complications and Failure: All postoperative complications, including persistent pain, arthrofibrosis, and infection, were documented. Clinical failure was defined as the need for a subsequent surgical procedure on the ipsilateral meniscus (i.e., partial meniscectomy or revision repair) due to persistent or recurrent mechanical symptoms, confirmed by new imaging or diagnostic arthroscopy.⁴⁰

Results

Patient Demographics and Injury Characteristics

A total of 135 athletes met the inclusion criteria. The IMR cohort consisted of 58 patients (42 male, 16 female) with a mean age of 25.1 +/- 4.5 years. The ACLR+MR cohort included 77 patients (56 male, 21 female) with a mean age of 23.5 +/- 3.9 years. There were no significant differences between the cohorts in terms of age, sex, or pre-injury Tegner activity score. The most common tear pattern in both groups was a longitudinal-vertical tear. The all-inside repair technique was the most frequently utilized method in both cohorts. Detailed demographic and tear characteristics are presented in Table 1.

Improvement in Patient-Reported Outcome Scores

Both cohorts demonstrated statistically significant improvements in functional scores from pre-operation to final follow-up. The mean Lysholm score for the IMR cohort improved from 61.5 ± 9.8 to 90.8 ± 7.5. The ACLR+MR cohort improved from 59.2 ± 10.4 to 89.9 ± 8.1. There was no significant difference in postoperative Lysholm scores between the two groups. These results are consistent with postoperative scores reported in the literature, which typically fall in the high 80s to low 90s, indicating good to excellent outcomes.⁷ The improvements are visualized in Figure 1.

Figure 1. Pre- vs. Postoperative Lysholm Knee Scores by Cohort

Tegner activity scores showed a characteristic drop from pre-injury levels to preoperative levels, followed by a substantial recovery postoperatively. For the IMR cohort, the mean Tegner score fell from a pre-injury level of 7.2 +/- 2.4 to a preoperative level of 3.4 +/- 1.5, recovering to 6.6 at final follow-up. The ACLR+MR cohort followed a similar pattern, with scores of 7.4 +/- 1.3 (pre-injury), 3.1 +/- 1.1 (preoperative), and 6.5 +/- 2.1 (postoperative). While postoperative scores approached pre-injury levels, a complete return to the mean pre-injury Tegner score was not observed in either group, a finding consistent with previous studies.⁷ This pattern is depicted in Figure 2.

Return to Sport Analysis

The overall rate of return to any sport was 91.1%, with 88.1% of athletes returning to their pre-injury level of competition. As detailed in Table 2, the IMR cohort demonstrated a slightly higher rate of return to pre-injury level (91.4%) compared to the ACLR+MR cohort (85.7%), though this difference was not statistically significant (Figure 3). However, there was a highly significant difference in the time required to achieve RTS. Athletes in the IMR group returned to their sport at a mean of 5.9 ± 1.3 months, whereas athletes in the ACLR+MR group required a mean of 9.7 ± 2.4 months. These timelines align with established recovery expectations for these procedures.³²

Complications and Repair Failures

The overall clinical failure rate, defined as the need for reoperation, was 4.4% (6 of 135 patients). As shown in Table 3, the failure rate was significantly higher in the IMR cohort at 6.8% (4 of 58 patients) compared to 2.5% (2 of 77 patients) in the ACLR+MR cohort. The mean time to failure was 21.5 months post-index surgery. Of the 6 failures, 4 were classified as atraumatic (failure of healing), while 2 were associated with a distinct traumatic re-injury. Other significant complications were rare, with one case of arthrofibrosis requiring manipulation under anesthesia in the ACLR+MR group and one superficial wound infection in the IMR group, which resolved with oral antibiotics.

Discussion

This single-center study confirms that arthroscopic meniscal repair is a highly effective procedure for athletes, resulting in significant improvements in knee function and facilitating a high rate of return to sport. The observed improvements in Lysholm scores and the overall RTS rate of 88.1% are consistent with systematic reviews and meta-analyses, which report good to excellent outcomes and RTS rates ranging from 80% to 95%.⁷ The overall clinical failure rate of 6% in our cohort falls less than the commonly reported range of 15-25% for meniscal repairs at short- to mid-term follow-up, reinforcing the durability of modern repair techniques.⁴⁰

The central finding of this investigation is the distinct profile of outcomes when comparing isolated repairs to those performed with concomitant ACL reconstruction. The ACLR+MR cohort demonstrated a significantly lower rate of clinical failure compared to the IMR cohort. This finding lends strong clinical support to the theory of "biologic augmentation." The surgical trauma of ACLR, specifically the drilling of bone tunnels, introduces a potent cocktail of blood, marrow, and associated mesenchymal stem cells into the joint space.¹¹ This enriched biological environment appears to confer a protective effect, enhancing the intrinsic healing capacity of the repaired meniscal tissue and leading to a more robust and durable repair construct over time.¹⁷

This biological advantage, however, comes at a significant functional cost. The analysis revealed a stark contrast in recovery timelines, with athletes in the ACLR+MR group requiring nearly four additional months to return to sport compared to those in the IMR group. This substantial delay is not merely a reflection of the more complex surgery but is overwhelmingly dictated by the stringent, protective rehabilitation protocol necessary to safeguard the maturing ACL graft.¹⁹ The prolonged period of non-weight-bearing and restricted motion in the ACLR+MR protocol, while critical for graft incorporation, inevitably leads to greater quadriceps atrophy, delayed restoration of neuromuscular control, and a more protracted recovery course. This creates a clear clinical trade-off: the ACLR+MR group benefits from a superior biological healing environment, leading to a more durable repair, but at the expense of a longer, more arduous rehabilitation and a delayed return to play. This trade-off is fundamental to the preoperative counseling of athletes, who must weigh the long-term benefit of a lower failure risk against the short-term challenge of a prolonged absence from their sport.

Another noteworthy finding is the discrepancy between functional scores and activity levels. While postoperative Lysholm scores in both cohorts reached "excellent" levels, indicating that patients perceived their knees as functioning very well in daily activities, the mean postoperative Tegner scores did not fully return to pre-injury levels. This suggests a more nuanced definition of a "successful" outcome in high-level athletes. A knee can be stable, strong, and pain-free for most activities (a high Lysholm score), yet the athlete may consciously or subconsciously modify their participation in the most demanding pivoting sports (a slightly lower Tegner score). This modification may stem from a psychological fear of re-injury, a subtle loss of the explosive power or confidence required at an elite level, or a strategic decision to reduce risk to prolong a career. Therefore, success in this population is not simply a healed meniscus but a complex interplay of physical capacity, psychological readiness, and long-term activity planning.

The failures observed in this study were consistent with established risk factors. The mean time to failure of approximately 22 months aligns with evidence that the majority of failures occur within the first two years post-surgery, a critical period of tissue remodeling and increasing athletic demand.⁴⁰ While not reaching statistical significance in our cohort, a trend towards higher failure rates in medial versus lateral repairs has been noted in the broader literature, potentially due to the medial meniscus's reduced mobility and different biomechanical loading patterns.²

Study Limitations

This study has several limitations inherent to its design. First, its retrospective nature is susceptible to selection bias and reliance on the accuracy of medical records. Second, as a single-center study, the findings may be influenced by specific surgical preferences and rehabilitation philosophies, potentially limiting their generalizability. Third, the absence of a non-operative control group or a meniscectomy comparison group precludes definitive statements on the superiority of surgical repair over other management strategies. Finally, the heterogeneity of tear patterns, specific sports played, and individual athlete characteristics introduces variables that can influence outcomes but are difficult to control for in a retrospective analysis.

Directions for Future Research

Prospective, multicenter, randomized controlled trials are needed to further refine treatment algorithms. Future research should focus on comparing outcomes between different modern repair devices, evaluating the efficacy of biologic adjuvants in isolated repairs, and optimizing rehabilitation protocols to safely accelerate recovery without compromising the integrity of the repair.

Conclusion

This five-year single-center experience demonstrates that arthroscopic meniscal repair in athletes provides excellent functional outcomes and facilitates a high rate of return to sport. Meniscal preservation should remain the primary goal for all reparable tears in this active population. When performed with a concomitant ACL reconstruction, meniscal repairs benefit from an enhanced biological healing environment, resulting in a lower clinical failure rate. However, this improved durability is associated with a significantly longer rehabilitation and a delayed return to sport. This critical trade-off between biological advantage and functional recovery time must be a central component of the shared decision-making process between surgeons and their athletic patients to ensure realistic expectations and optimize the chances for a successful, long-term outcome.

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Appendix 1 : Rehabilitation Protocol

A. Isolated Meniscal Repair (IMR)

Phase I (0–6 weeks)

• Hinged knee brace locked in full extension for ambulation.
• Partial weight-bearing (25%) with crutches for 2 weeks → weight bearing as tolerated thereafter.
• Knee ROM limited to 0–90° flexion.
• Goals: pain/effusion control, full passive extension, quadriceps activation (quad sets, SLRs). (28)

Phase II (6–12 weeks)

• Discontinue brace and crutches once normal gait achieved.
• Restore full ROM.
• Initiate closed-chain strengthening and proprioceptive training.
• Avoid active hamstring curls (posterior horn protection). (29)

Phase III (3–5 months)

• Begin graduated return-to-running program.
• Introduce sport-specific agility drills.
• Focus on neuromuscular control, power, endurance. (31)

Phase IV (>5 months)

• Gradual, supervised return to sport.
• Criteria: <10% strength deficit vs contralateral limb; pain-free sport-specific movements. (31)

B. ACL Reconstruction With Meniscal Repair (ACLR+MR)

Phase I (0–6 weeks)

• More conservative progression.
• Brace locked in extension for all ambulation.
• Toe-touch weight-bearing for 4–6 weeks.
• ROM limited to 0–90° flexion.
• Goals: maintain quad control and achieve full passive extension. (19)

Phase II (6–12 weeks)

• Gradual weight-bearing progression; crutches weaned by week 8–10.
• Brace typically discontinued around week 8.
• Begin gentle closed-chain strengthening in a protected ROM. (19)

Phase III (3–6 months)

• Advance strengthening and proprioception work.
• Return-to-running program initiated later (around 4–5 months), depending on quadriceps strength/control. (19)

Phase IV (>6–9 months)

• Begin plyometrics, cutting, and pivoting drills.
• Return to sport considered at 9–12 months, depending on successful functional sports assessment. (35)

Appendix 2

PROMs : Patient reported Outcome Measures

IMR : Isolated Meniscal Repair

ACLR + MR : ACL Reconstruction with meniscal Repair