Rethinking meniscal repair in patients over 40: Extending the boundaries of joint preservation

Abstract

This article provides a comprehensive overview of current perspectives on meniscal repair, with a particular focus on the evolving situation for patients over 40. In the past, meniscectomy was the most common treatment for meniscal tears in this group due to presumptions about its poor capacity for healing. The paradigm has shifted in favor of meniscal preservation, thanks to recent developments in arthroscopic procedures, a deeper understanding of meniscal biology, and the crucial recognition of the role that meniscal tissue plays in long-term knee health. Results from important primary studies, meta-analyses, and recent systematic reviews are summarized in this article. We address the advantages of meniscal repair over meniscectomy in terms of long-term results and functional preservation, considering conflicting data and the significance of a patient’s unique evaluation. In addition to the substantial influence of biologic augmentation methods like platelet-rich plasma and bone marrow aspirate concentrate in accelerating healing rates, the role of conservative management for degenerative tears is examined. Additionally, we compare all-inside and inside-out repair methods and look at the crucial elements of patient and tear selection, surgical methods, and technological advancements. Future research directions are paved by highlighting unresolved issues, such as the standardization of terminology and outcome definitions. Overall, the findings indicate that meniscal repair is no longer strictly contraindicated based solely on age, with careful patient selection and the strategic application of innovative techniques providing older patients with improved long-term outcomes and significant chondroprotective benefits.

Key Words: Meniscal repair; Meniscectomy; Degenerative meniscal tears; Over 40 years old; Biological augmentation; Chondroprotection; Outcomes

Core Tip: Age alone should not preclude meniscal repair in patients over 40. Careful tear selection and modern arthroscopic techniques can yield outcomes comparable to younger cohorts while preserving chondroprotection and potentially slowing osteoarthritis progression. Emerging biologic augmentation, such as platelet-rich plasma and bone marrow aspirate concentrate, and structured rehabilitation broaden indications. This review synthesizes current evidence, clarifies patient and tear selection, outlines repair tactics and augmentation, and highlights unresolved risks and research priorities shaping joint-preserving care in the middle-aged knee.

INTRODUCTION

The menisci of the knee are crucial fibrocartilaginous structures that play a vital role in joint health and function. These crescent-shaped tissues, which are situated between the tibial plateau and the femoral condyles, serve the primary purposes of deepening the tibial plateau, enhancing articulation, and distributing compressive loads throughout the knee joint[1,2]. They greatly improve knee stability, proprioception, and lubrication by acting as shock absorbers and lowering stress on the articular cartilage[1,3]. Preventing degenerative changes and preserving long-term knee function depend on the complex biomechanical processes of the menisci.

Meniscal injuries are a common orthopedic problem, affecting a wide range of individuals from athletes to older adults. Every year, there are roughly 61 cases of meniscal tears for every 100000 people[4]. A second peak in incidence is seen in people over 40, where degenerative tears are more common, although they are frequently linked to sports-related trauma in younger, active people[4,5]. Body mass index, athletic participation, and specific occupations are modifiable risk factors for meniscal injury[6]. Recognizing the importance of meniscal preservation techniques, which are receiving more and more attention in orthopedic practice, requires an understanding of the anatomy, function, and epidemiology of meniscal injuries.

We will explore the evolution of treatment paradigms, the role of long-term outcomes and functional preservation, comparison with conservative management, the impact of biologic augmentation, and the importance of careful patient and tear selection. Lastly, we will outline future directions in this developing field by talking about surgical techniques, technological advancements, and unsolved challenges.

LITERATURE REVIEW

This article synthesized existing literature on meniscal repair with a focus on patients over 40 by searching PubMed, Scopus, and Web of Science using terms such as “meniscal repair”, “meniscectomy”, “meniscus tear”, “elderly”, “older patients”, “degenerative meniscus”, “biologic augmentation”, and “long-term outcomes” on August 2025. Studies were included if they addressed meniscal tear management, surgical techniques, conservative treatment, or outcomes in adult populations, with particular relevance to older patients. In contrast, case reports, animal studies, and non-English articles were excluded. The resulting papers were used to identify prevailing themes, controversies, and advances that underpin the discussions presented in this review. Given the narrative and integrative nature of this review, a formal quality assessment using standardized tools was not employed. Instead, a critical perspective was maintained throughout the literature appraisal, and heterogeneity of studies, whenever possible, is discussed through narrative explanation. Meniscectomy and partial meniscectomy: Historical context and evolving perspectives historically, partial meniscectomy was frequently used to treat meniscal tears, particularly in patients over 40, under the assumption that degenerative tears in this population had limited healing potential[7,8]. This method was thought to be a simple surgical fix and provided immediate symptom relief. Because of age-related biological changes and decreased vascularity, the traditional surgical dogma frequently advised meniscectomy for older patients with degenerative tears, which are common in this population[9,10]. However, this conventional wisdom has been increasingly called into question by recent developments in arthroscopic procedures, a better comprehension of meniscal biology, and a growing understanding of the long-term consequences of meniscal tissue removal[11,12]. Although partial meniscectomy can successfully reduce mechanical symptoms, it invariably results in the removal of essential meniscal tissue, which is essential for shock absorption, load transmission, and joint stability. Osteoarthritis advances more quickly when meniscal tissue is removed because it increases contact pressures on the articular cartilage[13,14]. Recent research has highlighted the importance of meniscal preservation whenever possible, even in older patients, due to the critical role of the meniscus in maintaining knee joint homeostasis. Research has indicated that the primary goals of meniscal preservation, rather than merely providing short-term symptom relief, are to preserve long-term knee function and prevent or slow the progression of osteoarthritis[15,16]. The general trend in orthopedic surgery is to preserve meniscal tissue to protect long-term joint health, even though some studies still report favorable results for partial meniscectomy, especially in particular patient cohorts or tear patterns[17]. Even in populations that were previously thought to be unsuitable, this paradigm shift calls for a thorough reevaluation of the role of meniscectomy and a greater emphasis on meniscal repair techniques.

LONG TERM OUTCOMES AND FUNCTIONAL PRESERVATION

In addition to providing short-term symptom relief, meniscal preservation aims to preserve long-term knee function and prevent or slow the progression of osteoarthritis[15,16]. The chondroprotective benefits of an intact meniscus, which distributes load and absorbs shock in the knee joint, are consistently highlighted by research[1,2]. Meniscectomy reduces tibiofemoral contact area (approximately of 50%) and raises contact stresses, accelerating cartilage wear and osteoarthritis risk[1]. Comparative studies and meta-analyses generally suggest better long-term function and slower osteoarthritic progression with repair vs meniscectomy, but direct head-to-head evidence in ≥ 40 cohorts is limited and heterogeneous[18-20]. According to Cabarcas et al[3], for example, meniscal preservation significantly reduces the risk of osteoarthritis progression by maintaining native knee kinematics, and meniscal repair is strongly supported by long-term clinical data for maintaining overall knee function and longevity. Similarly, in a meta-analysis that directly compared meniscal repair and meniscectomy in patients aged 40 and older, Barustan et al[8] discovered that meniscal repair improved clinical outcomes, particularly in Lysholm score and International Knee Documentation Committee score. It is important to highlight that the difference, although better with meniscal repair, is not statistically significant and may be limited by only 3 studies for 220 knees total in their review[8]. It is crucial to recognize studies that show favorable results for partial meniscectomy in particular situations, even though the trend tends towards meniscal preservation. For example, Olivotto et al[17] looked into the relationship between cartilage lesions, symptoms, and macroscopic synovial inflammation in patients having arthroscopic partial meniscectomy. Their results showed a correlation between the degree of cartilage pathology and synovitis and pre-operative and post-operative symptoms. This implies that, when properly indicated, partial meniscectomy can still result in favorable outcomes by treating the symptomatic mechanical problems in cases with significant synovial inflammation and cartilage defects. Clinical results after meniscal surgery, whether repair or meniscectomy, can be greatly impacted by the presence of cartilage defects and synovial inflammation. These can negatively impact the healing potential of the meniscus, leading to pain, failure to heal and ultimately progression of osteoarthritis, hence treatment needs to consider the whole knee joint environment[17,21]. While numerous studies suggest that meniscal repair yields superior long-term results compared to meniscectomy[18-20], conflicting evidence exists, notably from Choudhary et al[7]. This study had a substantial and diverse patient cohort and an impressive 14.5-year follow-up, offering a robust analysis of long-term outcomes, including reoperation rates following meniscus repair. However, it has several limitations typical of database studies, lacking crucial patient-specific factors such as alignment and chondrosis, as well as long-term imaging data for evaluating degenerative or alignment changes. Additionally, factors such as the type and location of meniscal tears, surgical technique, implant selection, and postoperative rehabilitation protocols were not taken into consideration. A statistically significant difference in reoperation rate, favoring meniscectomy (13% vs 10%), was the study’s main finding. Despite being statistically significant, this difference’s clinical significance merits careful evaluation. Furthermore, there was no significant difference in the incidence of meniscal repair and subsequent ipsilateral meniscectomy between the groups. Given that the study included older studies (some as early as 2006), where methods, equipment, and device technology have since improved, this calls into question the study’s capacity to make significant inferences about the impact of age on meniscal tear repairability. Future reviews should priorities more recent literature to reflect contemporary practices. Recent systematic reviews and meta-analyses provide a clearer picture of meniscal repair outcomes, particularly in older patients. For instance, Sedgwick et al[22] reported a meniscal repair failure rate of 12% (95% confidence interval: 7.3%-19.4%) in older patients (age ≥ 40 years). A systematic review and meta-analysis by Nepple et al[23] provided important insights into the durability of meniscal repair, reporting an overall failure rate of 19.5% for 1630 meniscal repairs at 5 years, with failure defined as either lack of symptom improvement or re-operation. While the mean patient age in this comprehensive review was 26.4 years, the included studies encompassed a broad age range, with patients up to 70 years old[23]. This suggests that age alone may not be a contraindication for meniscal repair. Further adding on to this, despite showing medial-sided repairs were more likely to fail, medial meniscus root tears in Ro et al[19] observed a substantially lower reoperation rate for meniscal repair as opposed to partial meniscectomy. Similarly, the most recent systematic review to date, involving 316 meniscal repairs across 13 studies in older patients (over 40), by Jaibaji et al[24], revealed an overall failure rate of 15.5%. They found no discernible difference between patients over 40 and those under 40 in terms of failure rates or functional outcomes. Age should not be a barrier to meniscal repair, as these results indicate that meniscal repair in carefully chosen older patients can achieve acceptable failure rates, between about 12% and 19.5%[2,22,24], and functional outcomes comparable to younger patients. This supports the notion that, in patients over 40, meniscal repair is a feasible and successful treatment option with the potential for better long-term results than meniscectomy, provided that patients are carefully chosen.

COMPARISON WITH NON-OPERATIVE MANAGEMENT

For meniscal tears, non-operative management is preferable to surgical intervention, especially in older patients, as degenerative tears may not always exhibit mechanical symptoms that call for surgery. Elsenosy et al[25] compared arthroscopic meniscal surgery (including meniscectomy) with conservative treatment for degenerative meniscal tears in patients average age of 52 years to 61 years old. Based on a number of postoperative outcome measures, they only focus on short-term benefits in pain and function between the two strategies, but this does not extend into the long term. This implies that a conservative management trial could be a reasonable first line of treatment for some degenerative tears, especially those without noticeable mechanical symptoms, especially in older populations. Elsenosy et al[25] concentrated on arthroscopic surgery in general rather than comparing meniscal repair with conservative management in particular. They also did not look into the factors that would cause a higher risk of failure of treatment, as previously discussed, such as synovial inflammation, cartilage defects or the presence of concurrent anterior cruciate ligament injury. As a result, even though it offers insightful background information regarding the efficacy of non-surgical treatments for degenerative tears, it does not lessen the significance of meniscal repair in carefully chosen situations where preservation is thought to be advantageous for chronic joint health.

THE ROLE OF BIOLOGICAL AUGMENTATION

One of the most significant advancements in raising the success rates of meniscal repair, particularly in older patients with potentially compromised healing capacities, is the introduction of biologic augmentation. These strategies seek to decrease failure rates and speed healing by improving the biological environment at the repair site. Numerous modalities, including platelet-rich plasma (PRP), bone marrow aspirate concentrate, and other growth factors, have been studied to support the natural healing process[26,27]. The mechanism behind this improvement is believed to be the concentrated growth factors and cytokines of biologic agents, which stimulate cellular proliferation, angiogenesis, and extracellular matrix synthesis at the repair site[28,29]. Zaffagnini et al[12] have demonstrated that biologic augmentation, particularly PRP, is safe and effective in boosting the survival rate of meniscal repair. Six comparative studies with 128 patients that focused on PRP augmentation (with 180 controls) that had only meniscus suture repair were included. The results showed that the PRP augmentation group had a much lower failure rate (9.9%) than the control group (25.7%; P < 0.0005). Although this meta-analysis offers convincing evidence for PRP’s effectiveness, it is crucial to remember that the included studies differed in terms of methodology and patient populations. To validate these results and create the best practices for PRP application, more research is required, especially large-scale randomized controlled trials. Zaffagnini et al[12] have also highlighted the role of fibrin clot augmentation as well as mesenchymal stem cell augmentation. The number of patients is significantly smaller compared to PRP, with 32 patients and 11 patients, respectively. They have shown improved clinical outcome measures, but the fibrin clot augmentation group had a 25% failure rate at mid-term follow-up, whilst the mesenchymal stem cell group had none[12]. We have summarized the key findings of studies with biological augmentation of meniscal repairs from 2015 to highlight up-to-date research only in Table 1[29-49]. Although findings across the board support the use of biological augmented repair with good outcomes, particular research around older adults (> 40 years) are lacking, with only 2 studies in the last 10 years being done. Overall, the evidence level is low with 2 randomized controlled trials, and selection bias of the studies is prevalent, given majority of patients are young (below 40), with the healing potential would be better in this group inherently. It is therefore uncertain to show any benefit over standard repair, and therefore, no clear recommendation can be made[50]. As healing potential is reduced, some evidence has shown supportive improvements in healing rates based on arthroscopy and improvements in patient-reported outcome measurements and reduction in inflammatory cytokines[31,44]. Further trials in this area would significantly improve understanding and help draw firm conclusions where it is needed most.

Table 1 Summary of key biological augmented meniscal repairs, their demographics, outcomes and study design.

Ref.	Year	Study design	Average age	Follow-up	Biological augmentation	Number of patients	Method to determine success/failure	Outcome	Evidence level
Pujol et al[30]	2015	Case-control study	< 40 years old	12 months	PRP	34	KOOS and IKDC 2000 scores, MRI	Clinical outcomes slightly improved with PRP	3
Ahn et al[31]	2015	Retrospective case series	> 40 years old	45 months	Marrow-stimulating technique	32	Clinical assessment, second-look arthroscopy	91% healed clinically. 73% showed complete healing on second-look arthroscopy	4
Griffin et al[32]	2015	Retrospective cohort	< 40 years old	4 years	PRP	35	Reoperation rate, IKDC score, Tegner Lysholm Knee Scoring Scale	No difference in reoperation rate or functional outcome measures between PRP and non-PRP groups	3
Whitehouse et al[33]	2017	Case series	Not reported	24 months	MSC	5	Clinical improvement, MRI, subsequent meniscectomy	3/5 asymptomatic at 24 months. 2/5 required meniscectomy	4
Nakayama et al[34]	2017	Case series	< 40 years old	20 months	Autogenous fibrin clot	46	Return to original sports activities, re-tear rate	80% returned to sports. 8.7% re-tear rate	4
Dean et al[35]	2017	Prospective cohort	< 40 years old	12 months	Marrow venting procedure	109	Subjective questionnaire, survivorship, failure rates	No difference in outcomes between MVP and ACL reconstruction groups	3
Kemmochi et al[36]	2018	Non-randomized controlled cohort	< 40 years old	24 months	PRP	17	Clinical outcomes (Tegner Activity Level Scale, Lysholm Knee Scoring Scale, and IKDC scores) and changes in MRI findings	Meniscal repair surgery using PRP/PRF is an effective treatment option for improving knee function in patients with knee deformity. MRI findings showed no regeneration of the repaired meniscus; nevertheless, none of them worsened	3
Kaminski et al[37]	2018	Randomized Controlled Trial	< 40 years old	30 months	PRP	37	Meniscus healing rate assessed during a second-look arthroscopy. Changes in IKDC score, KOOS, WOMAC, and VAS	Meniscus healing rate was significantly higher in the PRP-treated group (85% vs 47%). Functional outcomes were significantly better in the BMVP-treated group	1
Dai et al[38]	2019	Retrospective cohort	< 40 years old	20 months	PRP	29	Lysholm score, Ikeuchi grade, VAS for pain, failure rate	No difference in failure rate or clinical scores between PRP and non-PRP groups	4
Kaminski et al[39]	2019	Randomized controlled trial	< 40 years old	30 months	Marrow venting	40	Meniscus healing rate assessed during a second-look arthroscopy. Changes in IKDC score, KOOS, WOMAC, and VAS	Meniscus healing rate was significantly higher in the BMVP-treated group (100% vs 76%). Functional outcomes were significantly better in the BMVP-treated group	1
Everhart et al[40]	2019	Prospective cohort	< 40 years old (mean age, 28.8 ± 11.2 years)	3 years	PRP	550	Meniscal repair failure within 3 years	PRP reduces failure risk for isolated meniscal repairs but provides no benefit for meniscal repairs with ACL reconstruction	2
Yang et al[41]	2021	Retrospective cohort	< 40 years old	24 months	PRP	61	Subsequent meniscal repair, meniscectomy, knee arthroplasty, IKDC changes	Similar functional outcome and healing rate compared to non-PRP group	4
Ciemniewska-Gorzela et al[42]	2021	Retrospective cohort	< 40 years old	60 months	Collagen matrix wrapping and bone marrow blood injection	54	Subjective scores, clinical criteria, MRI, survival analyses	Significant improvement in subjective scores. 88% survival rate at final follow-up	4
Kale et al[43]	2022	Prospective cohort	Not reported	24 months	Autologous fibrin clot	35	Clinical criteria, Lysholm Knee Scoring Scale system, and MRI	Clinical improvement in 29 out of 30 patients (96.6%). Mean Lysholm score improved significantly. Follow-up MRI revealed complete healing except in 1 case	2
Yi et al[44]	2023	Retrospective cohort	> 40 years old	3 months	PRP	56	VAS, WOMAC, Lysholm score, lequesne index, ROM, BGP, IGF-1, MMP-1	PRP group showed more improvement in all scores and reduced BGP, IGF-1, and MMP-1	4
Dancy et al[29]	2023	Retrospective cohort	Not reported	48 months	PRP or BMAC	3420	Revision meniscus surgery	No association between augmentation and revision rate for isolated repair	3
Massey et al[45]	2019	Retrospective case series	< 40 years old	36 months	BMAC	17	Lysholm scores, IKDC, Tegner scale	Improved outcomes in both pain and function at minimum follow-up of 12 months. 100% of patients had improvement above the MCID and 88% met patient acceptable symptomatic state	4
Skarpas et al[46]	2024	Prospective cohort	Not reported	6 months	ArthroZheal® (autologous bioactive fibrin scaffold)	110	IKDC score, Tegner Activity Level Scale, MRI, 2nd-look arthroscopy	Excellent results, significant improvement in Tegner and IKDC scores	3
Chrysanthou et al[47]	2024	Prospective cohort	< 40 years old	12 months	Exogenous fibrin clot	24	TLKSS, MCRSQ, MRI	Fibrin clot showed significant advantage in early clinical assessment	3
Kemmochi et al[48]	2024	Non-randomized controlled cohort	< 40 years old	24 months	PRP	35	Clinical outcomes (Tegner Activity Level Scale, Lysholm Knee Scoring Scale, and IKDC scores) and changes in MRI findings	Meniscal repair surgery using PRP/PRF is an effective treatment option for improving knee function in patients with knee deformity. MRI findings showed no regeneration of the repaired meniscus; nevertheless, none of them worsened	3
Demir et al[49]	2024	Retrospective cohort	< 40 years old	18 months	Bone marrow venting with stem cells	83	Lysholm, WOMAC, IKDC, and VAS scores. Surgical success evaluated based on Barrett’s criteria	Significant improvement in postoperative 18-month Lysholm, WOMAC, and IKDC values in all three groups. BMVP and ACLR repair groups yielded better results compared to isolated meniscus repair	3

PRP: Platelet-rich plasma; MSC: Mesenchymal stem cell; BMAC: Bone marrow aspirate concentrate; KOOS: Knee Injury and Osteoarthritis Outcome Score; IKDC: International Knee Documentation Committee; MRI: Magnetic resonance imaging; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; VAS: Visual Analogue Scale; ROM: Read-only memory; BGP: Border gateway protocol; IGF-1: Insulin-like growth factor-1; MMP-1: Matrix metallopeptidase 1; TLKSS: Tegner Lysholm Knee Scoring Scale; MCRSQ: Modified Cincinnati Rating System Questionnaire; MVP: Meniscus vascularized periosteum; ACL: Anterior cruciate ligament; PRF: Platelet-rich fibrin; BMVP: Biological meniscus vascularized periosteum; MCID: Minimal clinically important difference; ACLR: Anterior cruciate ligament reconstruction.

MENISCAL TEAR PATTERNS AND PATIENT SELECTION

Meniscal repair success depends on careful patient and tear selection, particularly in the older adult. Not all meniscal tears can be fixed, and the best outcomes necessitate a thorough understanding of the location, shape, and associated knee pathology of the tear. Even though age is no longer considered an absolute contraindication, the decision-making process is still guided by the tear’s characteristics as well as patient-specific factors[17]. With their classification system that considers the tear pattern, biomechanical effects, technical difficulty, and prognosis, Simonetta et al[51] offer a useful framework for treating meniscal tears. “The good”, “the bad”, and “the ugly” lesions are the three categories into which meniscal tears fall. Unless they are larger than 15 mm or involve the posterior horn, “good” lesions, such as stable longitudinal tears or tiny flap tears, have less of an impact on knee biomechanics. For small lesions in the avascular zone, either partial meniscectomy or arthroscopic repair is advised because of their good healing potential, regardless of the surgical technique used. Examples of “bad” lesions that drastically change knee biomechanics and impair meniscus function include degenerative tears, bucket handle tears, ramp lesions, and lateral posterior root tears. Finally, “ugly” lesions like anterior root tears, medial posterior root tears, and radial tears have the worst prognosis. The authors strongly advise preserving meniscal tissue while repairing and considering limb alignment, as this may necessitate corrective osteotomy[51]. When choosing a patient, comorbidities, activity level, and overall knee health are considered, in addition to tear characteristics[51].

SURGICAL TECHNIQUES AND TECHNOLOGICAL ADVANCES

The development of meniscal repair techniques has allowed for the expansion of the indications for meniscal repair in older patients. Numerous surgical techniques, including open and arthroscopic procedures, modern all-inside implants, and inside-out and outside-in techniques, have been documented for meniscus repair, according to Cabarcas et al[3]. While inside-out repairs are still frequently regarded as the best choice for posterior horn tears, all-inside repairs are effective for mid-body tears[52]. Nonetheless, an increasing number of systematic reviews and meta-analyses have demonstrated that there is no discernible difference between inside-out and all-inside approaches about long-term clinical outcomes, failure rates, or overall complications[52-54]. For example, Vint et al[52] revealed that failure rates were not significantly different between inside-out and all-inside meniscal repair, despite the latter being linked to shorter operating times and a lower risk of nerve injury complications. Comparable success rates between these techniques have also been reported in other studies, indicating that careful patient and tear selection, as well as the surgeon’s preference and experience, may be more important factors than the specific technique employed[53,54]. Therefore, device and/or approach should reflect the tear pattern, the surgeon’s expertise, and neurovascular safety, as pooled analyses show broadly similar failure and complication rates.

CONCLUSION

The recent literature supports meniscal repair to be done in patients over 40, contending traditional orthopedic dogma in favor of joint preservation. By maintaining natural knee kinematics and reducing the risk of developing osteoarthritis, meniscal preservation provides substantial chondroprotective advantages over meniscectomy. Successful outcomes are now more likely due to novel techniques, instrumentation, as well as implants and biological augments, but more importantly, with an improved understanding of meniscal tear patterns and careful patient selection. The literature needs standardized measures for failure, as well as success, and given body of literature is mainly of lower quality, it would benefit greatly from trials not just for outcomes for repair, but also specifically outcomes with biologically augmented repairs.