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

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.