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Meniscal preservation in the age of biologics: toward a quantitative decision algorithm for personalized repair
Horacio Rivarola1, Camilo Helito2, Cristian Collazo1
1Traumatologist and Orthopedic Surgeon, Knee Specialist, Hospital Universitario Austral, Buenos Aires, Argentina.
Background:
Despite advances in arthroscopic repair and biologic augmentation, surgical indication for meniscal tears remains heterogeneous. No standardized framework currently integrates biomechanical, clinical, and biological determinants to guide repair versus resection.
Purpose:
To develop a quantitative decision model-the Meniscal Preservation Score (MPS)-that unifies biomechanical and biological evidence to stratify reparability potential and standardize treatment selection in meniscal surgery.
Methods:
A systematic evidence synthesis conducted in accordance with PRISMA 2020 reporting standards of studies published from 2000 to 2025 in PubMed, Embase, and Scopus identified key determinants of meniscal healing. Five consistent predictors-patient age, vascularity, tear morphology, associated pathology, and activity profile-were weighted through a two-round modified Delphi consensus among ten experienced knee surgeons. The resulting 0-9-point MPS was incorporated into a stepwise decision tree linking lesion morphology, biological context, and surgical strategy. Conceptual validation used 50 simulated cases and a retrospective cohort of 45 patients to test agreement between algorithm recommendations and expert surgical decisions.
Results:
The MPS achieved 86% concordance with expert judgment in simulation and 84% agreement in clinical validation. In this retrospective exploratory cohort, cases in which surgical management was concordant with MPS recommendations demonstrated higher mean IKDC scores at 24 months and lower observed reoperation rates. These findings should be interpreted as associative rather than causal, as treatment allocation was not controlled and discordant cases may have represented inherently more complex pathology.
Conclusion:
The MPS represents an evidence-informed decision-support framework designed to systematize reparability assessment. While exploratory analyses suggest structural coherence with expert reasoning, prospective implementation and external validation are required before clinical adoption as a predictive tool.
Level Of Evidence:
conceptual model with exploratory validation.
