Meniscal Repair

This is a failed meniscal repair occurring in approximately 15-25% of red-white zone repairs, and it presents a challenging decision tree. Let me provide a systematic assessment: (1) The initial repair was appropriate - bucket handle tear, concurrent ACL reconstruction, young patient, red-white zone. The 65-75% healing rate for red-white zone means 25-35% failure rate is expected. This is not a technical failure but rather biological failure of the repair to heal. (2) The patient achieved 9 months of successful function before re-tearing, suggesting the repair did initially heal to some degree but has subsequently failed. The failure at 18 months with return to sport is consistent with inadequate biological incorporation allowing re-tear under sporting loads. (3) I need to determine if this is a true re-tear of healed meniscus versus failure of the repair to heal. The MRI showing recurrent tear at the same location suggests the repair never fully healed and has pulled apart. Management options and my recommendation: Option 1 - Repeat meniscal repair: This is technically possible but has significantly worse outcomes than primary repair. Revision meniscal repair success rates are only 40-50% (compared to 65-75% for primary red-white zone repair). The reasons for lower success include: compromised biology from first repair, scar tissue reducing vascular access, potentially worse tissue quality. However, for a 26-year-old active patient, preservation of meniscal tissue remains critical to prevent early arthritis. If I pursue revision repair, I would need to counsel that success rates are lower, there may be 50-60% chance of failure requiring subsequent meniscectomy, and she may be accepting multiple surgeries. I would only consider revision repair if: (1) The tissue quality is excellent on arthroscopy, (2) The tear is still in a repairable location/pattern, (3) The patient accepts the lower success rate and is committed to prolonged protected rehabilitation again. Option 2 - Partial meniscectomy: This involves arthroscopic resection of the unstable torn portion while preserving as much stable meniscal rim as possible. This definitively addresses the mechanical symptoms and pain. The downside is loss of meniscal tissue which increases contact stress and arthritis risk. For a 26-year-old, meniscectomy means potential arthritis in her 40s-50s. However, this provides symptom relief and allows return to activity without the prolonged rehab and uncertainty of revision repair. Option 3 - Meniscal transplant (future consideration): If she undergoes meniscectomy and later develops arthritis, meniscal allograft transplantation is a salvage option. This is a major procedure with mixed outcomes but represents a potential future option if she loses her meniscus. My recommendation: I would recommend attempting arthroscopic assessment first with a low threshold for revision repair IF the tissue quality is good. If the tissue is poor quality, scarred, or degenerative, I would proceed with partial meniscectomy preserving maximum meniscal rim. The decision should be made intraoperatively based on tissue quality. I would counsel the patient: (1) The initial repair was appropriate and had 65-75% chance of success - this is an expected failure rate, not a technical error. (2) Revision repair is possible but success rate only 40-50%, may require multiple surgeries, prolonged rehab again (12 months to return to sport). (3) Partial meniscectomy provides symptom relief and quicker return to activity but increases arthritis risk. (4) For a 26-year-old, I favor attempting tissue preservation if quality permits, but if tissue poor then meniscectomy is reasonable. (5) Regardless of choice, she should understand this complicates her long-term knee health and may need further interventions. Patient decision-making: This requires shared decision-making balancing the desire for tissue preservation against the risks of multiple surgeries and prolonged rehab with uncertain success. Some patients opt for meniscectomy to achieve symptom resolution, others pursue revision repair accepting the risks. The key is informed consent with realistic expectations.