Biologic augmentation strategies in meniscus repair: A Delphi study

To establish international expert consensus on the indications, terminology, clinical decision-making, outcome assessment and research priorities for biological augmentation techniques used in meniscus repair.

A Delphi study was conducted in accordance with the latest Delphi guidance. A scoping review informed statement generation. An international multidisciplinary expert panel (n = 33) was objectively selected and participated in three rounds of anonymised surveys, with optional 'out-of-expertise' responses, and free-text comment boxes. Consensus thresholds were defined a priori: Rounds one and two required ≥70% agreement and <20% disagreement; whereas round three required ≥75% and <10%, respectively.

All invited experts completed all three rounds (100% response rate). Ninety-eight initial statements were included in round one. Consensus was achieved for 66/67 (98.5%) in the final round. The panel agreed that biologic augmentation should be defined as the modification of the local healing environment rather than presumed regeneration. Consensus supported the selective use of simple, low-cost augmentation strategies (e.g., trephination/rasping, marrow venting procedures, fibrin clot) for meniscal repairs with increased failure risk, including radial, complex and horizontal cleavage tear morphologies. Evidence was considered inconclusive for routine use of autologous blood products (e.g., platelet-rich plasma [PRP]) and cell-based therapies (e.g., mesenchymal stromal cells, bone marrow aspirate concentrate). Routine postoperative magnetic resonance imaging to confirm healing in asymptomatic individuals was not recommended, but that imaging should be interpreted alongside clinical findings. For higher-cost, cell-based therapies, ethical concerns were highlighted, specifically regarding direct-to-consumer marketing, false claims and inconsistent reporting.

This Delphi study provides pragmatic, tear-specific recommendations for the use of biological augmentation strategies in meniscal repair, prioritising low-cost strategies for higher-risk tear morphologies, while cautioning against the routine use of PRP and cell-based therapies without robust comparative evidence. Standardised terminology, outcome reporting and targeted comparative trials are priorities for future research to optimise repair outcomes.

Level V.