# Meniscal Tear Management Associated with ACL Reconstruction
## 2 Therapeutical Options for Meniscal Lesions with Concomitant ACL Reconstruction
### Meniscectomy Associated with ACL Reconstruction  
Meniscectomy (partial, total) was the preferred treatment for many years because of its benefits, namely the fact that a low rate of early complications and no short or medium-term re-arthroscopy is required (such as in failed sutured menisci lesions) [1; 26; 27]. After meniscectomy, patients generally require significant less time for recovery than after meniscus repair [28].  
Unfortunately, meniscectomy is associated with disadvantages such as inferior results in terms of patient satisfaction with long-term pain, episodes of joint effusion, and a higher risk of OA [18; 26; 29]. Partial meniscectomy is better tolerated and has superior clinical results compared to total meniscectomy with a superior quality of life [18; 30; 31; 32; 33; 34].  
The meniscus has an important biomechanical role being the secondary stabilizer to the anterior translation and rotatory stability, after the ACL [35; 36; 37; 38; 39]. Therefore, in ACL deficient knees, meniscectomy can alter the loading patterns, increase the focal contact pressures, and accentuate the symptoms of instability [26; 39].  
Fortunately, in the treatment of meniscal lesions, partial meniscectomy decreased in frequency as our knowledge progressed and as the repair techniques improved. However, there is still room for improvement [40].  
Partial meniscectomy in association with an ACL reconstruction can still be considered if other meniscal preservation techniques have a reduced chance of success [40; 41]. Usually, meniscectomy is reserved for degenerative meniscal tears, ruptures in the white-white region of the meniscus, complex ruptures, and chronic displaced ruptures with plastic deformation [40].  
Meniscectomy without ACL reconstruction should be performed only as an exception if all four of the following criteria are met: (1) symptomatic meniscal tear; (2) irreparable meniscal tear; (3) no significant knee laxity on clinical examination; and (4) elderly or inactive patient or refuses ACL reconstruction [40].  
Lateral meniscus meniscectomy is associated with a higher risk of OA than medial meniscus meniscectomy, mainly due to the difference in the concavity of the two tibial plateaus [20; 42; 43]. Furthermore, the progression of OA depends on the amount of meniscal tissue that has been removed [44; 45]. The Moon and Mars Groups studies showed that meniscectomy of more than 33% of the lateral meniscus at the time of ACL reconstruction determined a 17\(\times\) increase in the damage progression of the lateral compartment articular cartilage [43]. This increased risk is significantly lower after a similar loss of the medial meniscus [21; 42].  
Worse results have been reported after lateral than after medial meniscectomy. [43]. This is due to anatomical and biomechanical reasons: the lateral meniscus carries more load in the lateral compartment than the medial meniscus does in the medial compartment (70% vs. 50%) and the lateral knee compartment is less congruent than the medial one [44].  
In professional athletes who underwent partial lateral meniscectomy, a significantly delayed return to sports has been noted along with more adverse events such as persistent pain and joint effusion than those undergoing partial medial meniscectomy. This has led to a higher likelihood of further arthroscopic procedures and a higher rate in resuming sporting activity [45; 46; 47]. Radiographic deterioration and faster knee osteoarthritis progression were more frequent after lateral than medial meniscectomy [48; 49; 50; 51].  
Due to the high rate of OA progression after meniscectomy and ACL reconstruction, preserving the meniscus should be the first option when treating these knees and, if meniscectomy cannot be avoided, the minimal amount of meniscal tissue should be removed [52; 53; 54; 55].