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and Meniscal Repair
A Matched Cohort Analysis Utilizing
a National Insurance Database
Kyle R. Sochacki,
MD, Kunal Varshneya,
BS, Jacob G. Calcei,
MD, Marc R. Safran,
Geoffrey D. Abrams,
MD, Joseph Donahue,
MD, and Seth L. Sherman,
Investigation performed at Department of Orthopaedic Surgery,
Stanford University Medical Center, Palo Alto, California, USA
Background: Meniscal repair leads to improved patient outcomes compared with meniscectomy in small case series.
Purpose: To compare the reoperation rates, 30-day complication rates, and cost differences between meniscectomy and
meniscal repair in a large insurance database.
Study Design: Cohort study; Level of evidence, 3.
Methods: A national insurance database was queried for patients who underwent meniscectomy (Current Procedural Terminol-
ogy [CPT] code 29880 or 29881) or meniscal repair (CPT code 29882 or 29883) in the outpatient setting and who had a minimum
2-year follow-up. Patients without confirmed laterality and patients who underwent concomitant ligament reconstruction were
excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication
rates were assessed using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The cost of the
procedures per patient was calculated. Propensity score matching was utilized to create matched cohorts with similar character-
istics. Statistical comparisons of cohort characteristics, reoperations, postoperative complications, and payments were made. All
Pvalues were reported with significance set at P\.05.
Results: A total of 27,580 patients (22,064 meniscectomy and 5516 meniscal repair; mean age, 29.9 615.1 years; 41.2% female)
were included in this study with a mean follow-up of 45.6 621.0 months. The matched groups were similar with regard to char-
acteristics and comorbidities. There were significantly more patients who required reoperation after index meniscectomy com-
pared with meniscal repair postoperatively (5.3% vs 2.1%; P\.001). Patients undergoing meniscectomy were also
significantly more likely to undergo any ipsilateral meniscal surgery (P\.001), meniscal transplantation (P= .005), or total
knee arthroplasty (P= .001) postoperatively. There was a significantly higher overall 30-day complication rate after meniscal repair
(1.2%) compared with meniscectomy (0.82%; P= .011). The total day-of-surgery payments was significantly higher in the repair
group compared with the meniscectomy group ($7094 vs $5423; P\.001).
Conclusion: Meniscal repair leads to significantly lower rates of reoperation and higher rates of early complications with a higher
total cost compared with meniscectomy in a large database study.
Keywords: meniscectomy; meniscal repair; reoperations; database
The meniscus functions to provide joint stability, congruency,
proprioception, and force distribution across the knee by con-
verting compressive forces into hoop stresses.
injury is one of the most common conditions treated by ortho-
paedic surgeons, with up to 61% of patients demonstrating
meniscal pathology on imaging.
Once the meniscus is
injured, the patient’s loss of meniscal integrity leads to
altered mechanics and joint forces with resultant increased
contact pressures on the articular cartilage.
ifests as pain, swelling, locking, or other mechanical symp-
toms. After the failure of nonoperative treatment, the
historical treatment of choice has been arthroscopic partial
meniscectomy to improve symptoms in these patients. How-
ever, biomechanical studies have shown that meniscectomy
can lead to increased contact pressures of up to 80% to 90%
with increasing amounts of meniscus resected.
tionally, partial meniscectomy can also lead to changes in
gait kinematics that place even more stress on the tibiofe-
This results in the majority of these patients
The American Journal of Sports Medicine
Ó2020 The Author(s)
demonstrating articular cartilage degenerative changes and
osteoarthritis less than 10 years after surgery.
Now that the long-term morbidities associated with par-
tial meniscectomy have been identified, meniscal preserva-
tion has been increasingly emphasized.
studies have demonstrated that meniscal repair restores
the tibiofemoral contact pressures to levels similar to those
of an intact meniscus, while partial meniscectomy leads to
significantly higher values.
Clinical studies have
also found there to be significantly improved patient-reported
outcomes and decreased progression to osteoarthritis rate
after meniscal repair, but with a relatively high reopera-
However, there are very few studies that
directly compare meniscectomy with meniscal repair.
The purpose of this study was to compare the reopera-
tion rates, 30-day complication rates, and cost differences
between meniscectomy and meniscal repair in a large
insurance database. The authors hypothesized that there
would be (1) significantly higher reoperation rates for
meniscal repair, (2) no difference in 30-day complications
rates between groups, and (3) significantly higher cost in
patients undergoing meniscal repair.
The MarketScan Commercial Claims and Encounters data-
base (Truven Health Analytics) from January 1, 2007, to
December 31, 2016, was used for this study. This database
is a collection of commercial inpatient, outpatient, and phar-
maceutical claims of more than 75 million employees, retir-
ees, and dependents representing a substantial portion of
the U.S. population covered by employer-sponsored insur-
ance. MarketScan contains 53 million inpatient records,
40 million with employer-sponsored insurance, 3.7 million
with Medicare Part B, and 6.8 million on Medicaid, for
a total of more than 28 billion patient records. Only outpa-
tient records in MarketScan were queried for this study.
The MarketScan database contains International Classifica-
tion of Diseases, 9th Revision, Clinical Modification (ICD-9-
CM) and 10th Revision, Clinical Modification (ICD-10-CM),
Current Procedural Terminology (CPT), and Diagnosis
Related Group codes, as well as National Drug Codes.
Patients who underwent meniscectomy (CPT code
29880 or 29881) or meniscal repair (CPT code 29882 or
29883) in the outpatient setting with a minimum 2-year
follow-up were queried in the database. Records of the
index surgery were reviewed for analysis. Patients without
a CPT modifier for laterality (left or right) were excluded.
Patients who had both procedures were excluded, thus
making the cohorts mutually exclusive. Additionally,
patients undergoing concomitant ligament reconstruction
procedures were excluded. Patient-level variables, includ-
ing age at time of surgery, sex, and comorbidities (obesity,
myocardial infarction, congestive heart failure, peripheral
vascular disease, cerebrovascular disease, dementia,
chronic pulmonary disease, rheumatic disease, peptic ulcer
disease, liver disease, diabetes, hemiplegia, renal disease,
malignancy, AIDS/HIV, tobacco use), were recorded based
on claims data (Table 1).
The primary outcome measure was rate of ipsilateral
reoperation. Reoperation was defined by ipsilateral menis-
cectomy (CPT code 29880 or 29881), meniscal repair (CPT
code 29882 or 29883), meniscal allograft transplantation
(CPT code 29868), synovectomy (CPT code 29875 or
29876), chondroplasty (CPT code 29877), manipulation
under anesthesia (CPT code 27570), lysis of adhesions
(CPT code 29884), arthroscopic loose body removal (CPT
code 29874), debridement for infection (CPT code 27301,
27303, 27310, or 29871), osteotomy (CPT code 27457 or
27450), partial knee replacement (CPT code 27446), or
total knee replacement (CPT code 27447) that occurred
after the index surgery date. Ipsilateral reoperation was
queried using CPT codes and the CPT modifiers for later-
ality to ensure that the procedures were reoperations and
not contralateral procedures. The time period for potential
reoperation was up to 9 years postoperatively, depending
on when the index surgery was performed.
The 30-day postoperative complication rates were also
assessed for both cohorts using the ICD-9-CM codes. These
included bursitis, anemia, knee dislocation, infection, nerve
injury, neurologic complications, cardiac complications, het-
erotopic ossification, sepsis, wound complications, deep vein
thrombosis, pulmonary embolus, hematoma, pulmonary
complications, urinary tract infection, and delirium.
The cost of the procedure per patient was calculated
using the Diagnosis Related Group system. This included
the entire reimbursement by the insurer on the day of sur-
gery. The cumulative cost of the procedure per patient was
also calculated at 9 months and 2 years postoperatively,
including the cost of reoperations.
Address correspondence to Kyle R. Sochacki, MD, Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street MC
6342, Redwood City, CA 94063, USA (email: email@example.com).
Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA.
Submitted January 6, 2020; accepted April 27, 2020.
One or more of the authors has declared the following potential conflict of interest or source of funding: M.R.S. holds stock or stock options in Biomi-
medica; receives royalties from DJ Orthopaedics, Smith & Nephew, and Stryker; has received consulting fees from Medacta; and has received research
support and speaking fees from Smith & Nephew. G.D.A. has received consulting fees from Cytonics Inc, Fidia Pharma, RubiconMD, and Sideline Sports
Doc; other financial or material support from Arthrex Inc and Stryker; and holds stock or stock options in Cytonics Inc. J.D. holds stock or stock options in
Stabilynx; and has received education payments from Arthrex, consulting fees from DePuy Synthes, and hospitality payments from Evolution Surgical,
Medical Device Business Services, and Stabilynx Inc. S.L.S. has received consulting fees from Arthrex Inc, Ceterix Orthopaedics, CONMED Linvatec, Flex-
ion Therapeutics, GLG Consulting, JRF Ortho, Moximed, Olympus, and Vericel; research support from Arthrex Inc; and education payments from Elite
Orthopedics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation
on the OPD and disclaims any liability or responsibility relating thereto.
2Sochacki et al The American Journal of Sports Medicine
To minimize the effect of potential confounding on the
direct comparison of patients undergoing the 2 procedures,
a propensity score match procedure was utilized. A greedy
nearest-neighbor algorithm was employed to match
patient cohorts with a 2:1 meniscectomy to repair ratio.
A caliper of 0.01 was utilized in the match, and replace-
ment of patients in the algorithm was not allowed. All
baseline characteristics were input into the algorithm,
leading to the matched covariates having no statistically
A propensity score is the probability a patient may be
placed in a group (meniscal repair or meniscectomy) based
on the patient’s characteristics and comorbidity status (all
covariates from Table 1).
When patients are matched on
their propensity scores (based on the covariates incorpo-
rated into the scores), patients will have statistically insig-
nificant differences in their likelihood to be placed in either
group (in this case, to receive a meniscectomy or meniscal
A greedy nearest-neighbor algorithm was
employed to match patient cohorts with a 2:1 meniscec-
tomy to repair ratio. Although there are many algorithms
available to match with, greedy nearest neighbor is pre-
ferred as it matches patients based on closest, ‘‘nearest’’
propensity scores within the caliper (maximal difference
allowed between a patient’s propensity scores to match).
Statistical comparisons of cohort characteristics, reoper-
ations, postoperative complications, and payments were
made. The significance of differences in means of continu-
ous variables between the 2 groups was determined using
the Student ttest. The differences in categorical variables
between groups was determined using the chi-square test.
Percentages in this study were a representation of propor-
tion of the cohort. All Pvalues were reported with signifi-
cance set at P\.05.
As this study includes only analysis of secondary de-
identified data, it was not considered human subject
research and was given exempt status approval by our
institutional review board at our institution.
A total of 27,580 patients (22,064 meniscectomy and 5516
meniscal repair; mean age, 29.9 615.1 years old; 41.2%
female) were included in this study with a mean follow-up
of 45.6 621.0 months (Table 1). Before matching, patients
in the meniscectomy cohort were significantly older, more
often female, and had significantly more comorbidities (P\
.001 for all) (Table 1). After matching, the groups were simi-
lar with regard to characteristics and comorbidities.
There were significantly more patients who required
reoperation after index meniscectomy compared with
meniscal repair postoperatively (5.3% vs 2.1%; P\.001)
(Table 2). Patients undergoing meniscectomy were also sig-
nificantly more likely to undergo any ipsilateral meniscal
surgery (P\.001), meniscal transplantation (P= .005),
or total knee arthroplasty (P= .001) up to a maximum of
9 years postoperatively compared with those undergoing
There were significantly higher overall 30-day compli-
cation rates after meniscal repair (1.2%) compared with
meniscectomy (0.82%; P= .011) (Table 3). Patients under-
going meniscal repair had significantly higher infection
(0.4% vs 0.2%; P= .016) and deep vein thrombosis (0.3%
vs 0.1%; P\.001) rates compared with those undergoing
The total day-of-surgery payments were significantly
higher in the repair group compared with the meniscec-
tomy group ($7094 vs $5423; P\.001) (Table 4). This trend
occurred at all time points in the study, with a total 2-year
cost of repair at $15,203. This is compared with the 2-year
cost of meniscectomy of $12,594 (P\.001).
Our data showed that meniscal repair leads to significantly
lower reoperation, meniscal surgery, meniscal transplanta-
tion, and total knee arthroplasty rates compared with
Non–Propensity Score Matched Propensity Score Matched
(n = 562,251)
(n = 13,780) PValue
(n = 22,064)
(n = 5516) PValue
Age, mean 6SD 49.1 611.6 29.6 614.5 \.001
30.0 615.2 29.9 614.8 .784
Female 256,861 (45.7) 5439 (39.5) \.001
9107 (41.3) 2245 (40.7) .437
Hypertension 209,795 (37.3) 1670 (12.1) \.001
2839 (12.9) 702 (12.7) .780
Diabetes 70,828 (12.6) 541 (3.9) \.001
823 (3.7) 227 (4.1) .181
Hyperlipidemia 183,636 (32.7) 1480 (10.7) \.001
3415 (15.5) 608 (11.0) .870
Cerebrovascular accident 18,374 (3.3) 155 (1.1) \.001
232 (1.1) 64 (1.2) .483
Tobacco use 46,060 (8.2) 801 (5.8) \.001
1113 (5.0) 296 (5.4) .332
Tissue disorder 3796 (0.7) 43 (0.3) \.001
39 (0.2) 13 (0.2) .367
Obesity 73,402 (13.1) 840 (6.1) \.001
1129 (5.1) 286 (5.2) .838
Mean CCI 0.37 0.14 \.001
0.12 0.13 .112
Mean follow-up, mo 25.2 623.3 23.4 622.9 \.001
45.6 620.9 45.4 621.1 .413
Data are presented as n (%) unless otherwise indicated. CCI, Charlson Comorbidity Index.
AJSM Vol. XX, No. X, XXXX Meniscectomy Has Higher Reoperation Rate Than Repair 3
meniscectomy at final follow-up. However, there were higher
rates of complications and a higher total cost with meniscal
repair compared with meniscectomy. This partially confirms
the authors’ hypotheses.
Before matching, patients in the meniscectomy cohort
were significantly older and had significantly more comor-
bidities (P\.001 for all). This is likely because of a long-
held belief that older patients have worse outcomes
compared with younger patients after meniscal repair.
However, more recent studies have suggested that age
may not play as significant a role in outcomes as previously
Additionally, the role of obesity in meniscal
repair outcomes has conflicting results in the literature,
with a study by Brophy et al
showing significantly worse
outcomes and higher rates of subsequent surgery rates in
obese patients undergoing posterior medial root repairs.
Meniscectomy (n = 22,064) Meniscal Repair (n = 5516) PValue
Overall reoperation rate 1175 (5.3) 116 (2.1) \.001
Meniscectomy 832 (3.8) 0 (0.0) ..999
Meniscal repair 0 (0.0) 120 (2.2) \.001
Meniscal transplantation 40 (0.2) 1 (0.0) .005
Synovectomy 321 (1.5) 74 (1.4) .595
Chondroplasty 102 (0.5) 27 (0.5) .791
Manipulation under anesthesia 27 (0.1) 7 (0.1) .932
Lysis of adhesions 21 (0.1) 13 (0.2) .008
Loose body removal 26 (0.1) 9 (0.2) .398
Debridement for infection 8 (0.0) 1 (0.0) .791
Osteotomy—HTO 7 (0.0) 1 (0.0) .596
Osteotomy—DFO 7 (0.0) 3 (0.1) .429
UKA 16 (0.1) 5 (0.1) .662
TKA 321 (1.5) 49 (0.9) .001
Data are presented as n (%). DFO, distal femoral osteotomy; HTO, high tibial osteotomy; TKA, total knee arthroplasty; UKA, unicom-
partmental knee arthroplasty.
Meniscectomy (n = 22,064) Meniscal Repair (n = 5516) PValue
Any complication 181 (0.82) 68 (1.2) .011
Bursitis 8 (0.0) 4 (0.1) .248
Deficiency anemia 72 (0.3) 20 (0.4) .716
Infection 45 (0.2) 21 (0.4) .016
Nerve injury 1 (0.0) 1 (0.0) .289
Sepsis 4 (0.0) 1 (0.0) ..999
Wound complication 12 (0.1) 1 (0.0) .267
Deep vein thrombosis 27 (0.1) 17 (0.3) \.001
Pulmonary embolus 0 (0.0) 0 (0.0) ..999
Hematoma 17 (0.1) 5 (0.1) .749
Data are presented as n (%).
Meniscectomy (n = 22,064) Meniscal Repair (n = 5516) PValue
Day-of-surgery payments $5423 $7094 \.001
9 mo $8348 $10,898 \.001
2 y $12,594 $15,203 \.001
4Sochacki et al The American Journal of Sports Medicine
However, a study by Sommerfeldt et al
found that obese
patients did not have a higher risk of failure compared
with normal weight patients when considering all menis-
cus tear patterns. This leads the current authors to believe
that tear location, tear pattern, tear size, concomitant sur-
geries, and preexisting joint degeneration may play a larger
role in patient outcomes than patient characteristics or
After controlling for these patient characteristic con-
founders and creating matched cohorts, patients undergo-
ing meniscectomy were significantly more likely to
undergo reoperation (5.3% vs 2.1%) compared with those
undergoing meniscal repair. However, previous non-
matched studies found that meniscal repair leads to signif-
icantly higher reoperation rates in both the short and the
long term, with some studies reporting reoperation rates
of 20.7% versus 3.9%.
This is surprising given the fact
that patients undergoing meniscectomy had worse patient-
reported outcome scores and were more likely to progress
to knee osteoarthritis compared with those undergoing
It is also important to note that the revi-
sions and/or reoperation rates would likely be even higher if
there had been a longer follow-up.
The difference in reoperation rates from those reported
in previous studies is likely because of the lack of matched
cohorts and the resultant inability to control for confound-
ing variables. Additionally, the number of patients
included in these studies likely plays a large role. Most of
the studies included in the review by Paxton et al
small case series, with the largest study including 198
patients. This is compared with the current study of
27,580 patients. These small case series represent selec-
tion bias in which the majority of the peer-reviewed litera-
ture is from meniscus experts who work at tertiary referral
centers, making them likely to encounter more complex
tear patterns. Additionally, patients with complications
or poor outcomes are more likely to return for follow-ups
than patients who are doing well, leading to a higher pro-
portion of patients with unfavorable outcomes meeting the
minimum follow-up requirement for publication.
Patients undergoing meniscectomy were also signifi-
cantly more likely to undergo meniscal transplantation
(0.2% vs 0.0%; P= .0049) and total knee arthroplasty
(1.5% vs 0.9%; P= .0011) up to a maximum of 9 years post-
operatively compared with those undergoing meniscal
repair. This further illustrates the need for meniscal pres-
ervation at index surgery whenever possible, with both
meniscal transplantation and knee arthroplasty consid-
ered salvage procedures in this young population. Once
the patient becomes meniscus-deficient, the outcomes after
meniscal transplantation are worse than if the patient
underwent meniscal repair at their index procedure.
The increased rate of knee arthroplasty after meniscec-
tomy further confirms the results of previous studies, with
up to 51.5% of patients requiring knee arthroplasty after
meniscectomy compared with 33.5% after meniscal repair
at the 10-year follow-up.
Abram et al
National Health Service database of England to determine
that 0.67% of patients who underwent meniscectomy
between the ages of 20 and 39 years required subsequent
knee arthroplasty. This is similar to the current study,
with 1.5% requiring total knee arthroplasty in similar
aged patients with similar follow-up. However, Abram
et al did not compare the differences in arthroplasty rates
between meniscectomy and meniscal repair in this young
patient population. It is also possible that meniscectomy
was perhaps not indicated at the time of surgery and the
patient may have been better managed with nonoperative
care or knee arthroplasty at the time of the index proce-
dure. This is supported by previous studies demonstrating
that patients undergoing meniscectomy did no better than
control groups, especially in degenerative knees.
Despite a higher reoperation rate, meniscectomy was
associated with lower 30-day complication rates compared
with meniscal repair (0.82% vs 1.2%). These rates are simi-
lar to the previously reported complications after meniscec-
tomy and meniscal repair.
A recent systematic
review demonstrated that patients undergoing meniscal
repair had higher complication rates than those with menis-
cectomy (12.9% vs 1.3%).
This was because of the inclusion
of knee pain and revision surgery as complications. Knee
pain was not a codable complication and may not have
been identified in the present study, while reoperation was
considered separate from complications. After removing
these confounders, the complication rates become more sim-
ilar between groups. Additional complications specific to
meniscal repair include device failure, device breakage, or
reactive synovitis to the repair material.
are also not codable complications and may lead to an under-
estimation of the complication rate after meniscal repair.
The total day-of-surgery, 9-month, and 2-year payments
were significantly higher in the repair group compared
with meniscectomy. The higher cost in the meniscal repair
group is likely because of initial differences in implant cost
and higher surgeon reimbursement for the procedure.
Meniscal repair also demonstrated a higher day-of-surgery
cost in previous studies investigating the cost-effectiveness
of meniscectomy versus repair.
However, at 10 and 30
years postoperatively, meniscal repair became more cost-
effective because of reduced rates of total knee arthro-
plasty in a Markov model.
It is likely that the current
study failed to follow this same trend because of the
shorter follow-up and a younger patient population. This
leads to a relatively low incidence of knee arthroplasty
compared with older patients undergoing meniscectomy
or meniscal repair in other studies.
There are some limitations to this study that are inher-
ent to all studies that use large databases. The analysis is
dependent upon the accuracy of the ICD and CPT codes
reported. As such, inaccuracies, miscoding, or noncoding
by physicians is a potential source of error. Additionally,
patients can change insurance providers and, therefore,
leave the database. However, this was controlled for
through inclusion of patients with a minimum 2-year fol-
low-up. However, this minimum follow-up likely excluded
a large number of patients who changed or lost their insur-
ance, creating a potential population bias. It is also possi-
ble that the database is not a true representation of the
population receiving health care in the United States.
However, through the inclusion of outpatient records
AJSM Vol. XX, No. X, XXXX Meniscectomy Has Higher Reoperation Rate Than Repair 5
from patients with commercial insurance, Medicare, and
Medicaid, the current study is more inclusive. Addition-
ally, the database only included records during a 9-year
period from January 1, 2007, to December 31, 2016, so pro-
cedures (index or reoperation) that occurred outside that
time frame may have been missed. The current study
also only identified complications that occurred within 30
days of the index procedure to increase the likelihood
that the complications identified were related to the post-
operative course after meniscal repair or meniscectomy
and not another medical condition that arose. Thus, late
complications that occurred outside the 30-day window
were not captured in the present study. Cost analysis is
based on the average, per-patient total insurer payout
per diagnosis at the time of surgery and
follow-up time points. This may not be representative of
all institutions. There is also the limitation of not perform-
ing a formal chart review. Inherent to this type of study,
there are multiple unknown confounding variables, such
as no direct physical contact, patient-reported outcomes,
or medical record access to determine previous procedures,
alignment, cartilage status, meniscal tear pattern, amount
of meniscus resected, type of meniscal repair, and concom-
In conclusion, meniscal repair leads to significantly lower
rates of reoperation and higher rates of early complication
with a higher total cost compared with meniscectomy in
a large database study.
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