Long-term Outcomes and Survivorship of Meniscal Allograft Transplantation: A Systematic Review With Minimum 10-Year Follow-up

Abstract

Background:

Meniscal allograft transplantation (MAT) is an emerging treatment for patients with symptomatic meniscal deficiency.

Purpose:

To systematically evaluate the long-term clinical outcomes and graft survivorship of MAT with a minimum follow-up of 10 years.

Study Design:

Systematic review and meta-analysis; Level of evidence, 4.

Methods:

A review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and registered on Prospero. The PubMed, Cochrane Central Register of Controlled Trials, and Scopus databases were queried in January 2025. Studies assessing MAT patient-reported or objective outcomes with ≥10 years of follow-up were included. Non–English-language studies, case reports, non–peer-reviewed articles, editorials, commentaries, and reviews were excluded. The Lysholm score, Tegner Activity Scale score, visual analog scale (VAS) for pain score, Knee injury and Osteoarthritis Outcome Score (KOOS), and graft survivorship were extracted for analysis. MAT failure was defined by individual studies based on clinical, surgical, and/or radiographic criteria.

Results:

Thirteen studies, consisting of 619 patients and 632 MATs and performed from 1984 to 2012, met inclusion criteria. The mean patient age ranged from 24.5 to 43.5 years, with 47% to 87% males and a mean follow-up duration of 11.1 to 20.0 years. Fixation techniques included soft tissue (5 studies), bone plug (6 studies), and bone trough (4 studies). Statistically significant improvements were observed in the Lysholm score (7/9 studies), Tegner score (3/4 studies), VAS score (3/5 studies), and KOOS (1/1 studies). Two studies reported Patient Acceptable Symptom State rates ranging from 70.2% to 71% for Lysholm score and 58.5% to 82% for KOOS. Two studies also reported minimal clinically important difference rates, which ranged from 70.4% to 89.9% for the Lysholm score and 61% to 78.2% for the KOOS subscales. Ten-year MAT survival ranged from 45% to 100%. Most studies (5/9) demonstrated survivorship ≥73% at a minimum 10-year follow-up. MAT survival after ≥15 years ranged from 19% to 87%.

Conclusion:

MAT demonstrated favorable long-term clinical outcomes and variable graft survivorship beyond 10 years. Included studies varied based on graft type, fixation technique, and patient selection. Continued prospective, high-level studies are warranted to standardize surgical approaches, improve the durability of this joint-preserving intervention, and identify modifiable risk factors for inferior long-term outcomes.

Keywords

knee cartilage meniscus allograft transplant

The meniscus is a fibrocartilage structure within the tibiofemoral joint that plays a crucial role in knee joint stabilization and shock absorption.²³ Damage or deficiency of the meniscus can accelerate articular cartilage degeneration, leading to pain, mechanical symptoms, and early osteoarthritis.^11,23 Injuries to the meniscus are among the most common orthopaedic pathologies, with an annual incidence of 13.2 tears per 10,000 individuals.⁶ These injuries can occur as a result of sport, trauma, or degenerative processes, often severely limiting knee function and patient quality of life.²¹ Effective management of meniscal injuries is vital to alleviate pain, restore function, and prevent long-term joint deterioration, especially in young and active patients.^2,14

Meniscal allograft transplantation (MAT) is indicated in patients <50 years of age with symptomatic meniscal deficiency (usually after menisectomy), who have minimal to no existing osteoarthritis and correctable malalignment to optimize the success of the procedure.^7,12,20 MAT involves the transplantation of a donor (allograft) meniscus to restore functional knee biomechanics and potentially delay the progression of osteoarthritis. While the native meniscus has a well-established protective effect against osteoarthritis, the degree to which MAT confers similar chondroprotective benefits remains less certain.^2,20,31,37 Multiple fixation techniques for MAT have been described, including suture-only, bone plug, and/or bone bridge (trough) fixation. Recently, additional techniques such as meniscotibial ligament reconstruction have been increasingly used to secure the meniscal body to the tibia and reduce the risk of graft extrusion.^3,9 While fixation modalities remain mixed across the literature, previous studies have suggested that bone plug fixation may encourage improved allograft stability, a lower risk of graft failure, and a decreased reoperation rate compared with suture-only and bone bridge fixation methods.^1,20,28,44

Despite increasing utilization across specialized orthopaedic centers, MAT remains technically demanding and uncommon worldwide.^7,12,36 Previous literature has suggested that MAT demonstrates promise as a modality associated with improved patient-reported outcomes and survivorship rates of >70% at 10 years.^{4,12,25,38,43} While short- and midterm studies report improved clinical and functional outcomes, limited high-quality evidence assesses the long-term efficacy of MAT.^∥ Understanding the long-term outcomes and graft survivorship of MAT is critical for guiding surgical decision-making and patient counseling. As such, the purpose of this study was to systematically evaluate the long-term clinical outcomes and graft survivorship of MAT with a minimum follow-up of 10 years. We hypothesized that MAT provides sustained improvements in pain and function >10 years postoperatively.

Methods

This systematic review was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.²⁹ The protocol was prospectively registered in the PROSPERO database (registration ID: 42025640240), ensuring methodological transparency and adherence to established review standards.

Search Strategy

A systematic literature search was performed in January 2025 using the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus databases. The search strategy combined terms related to MAT and long-term outcomes, including “meniscus,”“allograft,”“transplantation,”“minimum 10-year,” and “long-term.” Detailed search strings for each database are provided in Table 1.

Table 1

Databases and Search Terms Utilized for Comprehensive Systematic Review

Database	Search Term
PubMed	(Long Term OR 10 year OR decade) AND (menisc*) AND (transplant OR allograft)
CENTRAL	1. (long term):ti,ab,kw OR (10 year):ti,ab,kw OR (decade):ti,ab,kw
	2. (menisc*):ti,ab,kw
	3. (transplant):ti,ab,kw OR (allograft):ti,ab,kw
	4. #1 AND #2 AND #3
Scopus	(TITLE-ABS-KEY ( long AND term ) OR TITLE-ABS-KEY ( 10 year ) OR TITLE-ABS-KEY ( decade ) AND TITLE-ABS-KEY ( menisc* ) AND TITLE-ABS-KEY ( transplant ) OR TITLE-ABS-KEY ( allograft ))

Eligibility Criteria

Included studies described patient-reported and functional outcomes associated with MAT at a minimum of 10 years after surgery. MAT failure was defined according to individual study criteria, including radiographic, surgical, or clinical endpoints. Studies were included if they involved human patients undergoing MAT for symptomatic meniscal deficiency. Exclusion criteria consisted of non–English-language publications, animal or cadaveric studies, case reports, editorials, commentaries, review articles, and studies lacking peer review. All studies that met inclusion and exclusion criteria were included regardless of year of publication, in order to maximize the capture of long-term outcomes after MAT.

Screening and Study Selection

All references were imported into Covidence (Veritas Health Innovation; www.covidence.org) for systematic screening. Two independent reviewers (J.D.K. and S.S.) screened titles and abstracts for relevance based on predefined inclusion and exclusion criteria. Full-text review was performed for studies meeting initial screening criteria. Discrepancies during study selection were resolved through consensus with a third reviewer (A.J.), a fellowship-trained orthopaedic sports medicine surgeon.

Data Extraction

A data extraction template was created in Microsoft Excel. Two blinded reviewers (J.D.K. and S.S.) independently performed data extraction. Information extracted included study design, level of evidence, sample size, study period, follow-up duration, patient demographics (age, sex, and body mass index [BMI]), surgical techniques, graft types, and concomitant cartilage procedures. Outcomes extracted included Lysholm score, Tegner Activity Scale score, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain score, MAT survival, and failure rates. Any discrepancies in the data extraction process were resolved by an independent third author (A.J.).

Quality Assessment

Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument.³⁵ This tool provides a maximum score of 16 for noncomparative studies and 24 for comparative studies. Studies scoring <14 were classified as poor quality, those scoring between 15 and 19 were considered moderate quality, and those scoring between 20 and 24 were categorized as high quality.³⁵ Two independent reviewers (J.D.K., S.S.) performed the scoring assessment, and discrepancies were resolved through consultation with a third reviewer (A.J.). A weighted Cohen kappa calculation was performed to assess the interrater reliability of MINORS scoring.⁸

Statistical Analysis

Review Manager (RevMan; Version 5.4; The Cochrane Collaboration) was used to assess heterogeneity in patient-reported outcomes reported in ≥3 studies that included preoperative and postoperative values with standard deviations. Additionally, 10- and ≥15-year implant survival were assessed using RStudio (Posit) with R software Version 4.5.0 (R Foundation for Statistical Computing) with the ‘meta’ package (Version 8.1-0; Guido Schwarzer). Study proportions were pooled using inverse variance weighting. Heterogeneity was quantified using the I² statistic, which measures the proportion of total variation across studies due to heterogeneity rather than chance. Between-study heterogeneity was assessed using the I² statistic, with values of 25%, 50%, and 75% representing low, moderate, and high heterogeneity, respectively.¹⁷ Statistical significance was defined as a P value <.05.

Results

Study Identification and Characteristics

A systematic search of the PubMed, Scopus, and CENTRAL databases identified a total of 1049 studies. After the removal of duplicates, titles and abstracts were screened for relevance. A total of 40 full-text articles were assessed for eligibility, of which 13 studies met the inclusion criteria and were included in the final analysis.^¶ The study selection process is detailed in the PRISMA flow diagram (Figure 1).

Figure 1.

Flowchart according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Study Characteristics and Demographics

Tables 2 and 3 summarize key study characteristics, including study design, level of evidence, study period, and patient demographics. Thirteen studies, consisting of 619 patients and 632 MATs, met inclusion criteria.^# The analyzed studies included 9 case series,^** 2 retrospective cohort studies,^40,43 and 2 prospective cohort study³¹; all were classified as level 3^37,45 or 4^{13,15,20,26,31,32,39-43} evidence. MINORS scores among included studies ranged from 9²⁰ to 19⁴⁵ (Figure 2). The weighted Cohen kappa demonstrated excellent interrater reliability of MINORS scoring (κ = 0.83).

Table 2

Study Characteristics and Design ^a

Authors (Year)	Study Design	LOE	MINORS Score	Study Period	MAT Type	MAT Fixation Technique
Grassi et al (2020)¹³	Case series	4	11 (comparative)	2006-2013	Fresh-frozen	Soft tissue
Hommen et al (2007)¹⁴	Case series	4	13	1991-1995	Cryopreserved	Medial: bone plug/soft tissue; lateral: trough/ bone plug/soft tissue
Lee et al (2025)²⁰	Case series	4	9 (comparative)	1996-2008	Fresh-frozen	Medial: bone plug; lateral: keyhole
Noyes and Barber- Westin (2016)²⁶	Case series	4	13 (comparative)	1995-2005	Cryopreserved	Bone plug
Paša et al (2021)³¹	Prospective cohort	4	13	NR	Deep-frozen	Transosseous fixation
Romandini et al (2024)³²	Case series	4	13	2004-2012	Fresh-frozen	Soft tissue
Torres et al (2023)³⁷	Case series	3	11	2001-2006	Fresh-frozen	Bone plug
van der Wal et al (2009)³⁹	Case series	4	12	1989-1999	Cryopreserved	Suture fixation
Verdonk et al (2006)⁴⁰	Retrospective cohort	4	17	1989-1993	Fresh (viable)	Soft tissue
von Lewinski et al (2007)⁴¹	Case series	4	11	1984-1986	Deep-frozen	Bone trough
Wagner et al (2023)⁴²	Case series	4	13	2001-2012	Fresh-frozen	Bone trough
Wang et al (2022)⁴³	Retrospective cohort	4	18 (comparative)	2005-2010	Fresh-frozen	Medial: soft tissue; lateral: bone plug
Wirth et al (2002)⁴⁵	Prospective cohort	3	19 (comparative)	1984-1986	17 lyophilized; 6 deep-frozen	Bone trough

LOE, level of evidence; MAT, meniscal allograft transplantation; MINORS, Methodological Index for Non-Randomized Studies.

Table 3

Study Characteristics ^a

Authors (Year)	Medial/ Lateral	Mean Age, y	No. of Patients	No. of MATs	Male Sex, %	BMI	Total Concomitant Procedures	Concomitant Procedures Performed	Follow-up, y
Grassi et al (2020)¹³	27/19	36.6 ± 10.6	46	46	78.26	24.0 ± 2.5	35	None: 21 (47%)1 procedure: 17 (38%)2 procedures: 8 (18%)ACL reconstruction: 9 (20%)Primary ACL: 4 (9%)Revision ACL: 5 (11%)High tibial osteotomy: 5 (11%)Distal femoral osteotomy: 2 (4%)Osteophyte removal: 4 (9%)Osteochondral autograft: 1 (2%)Osteochondral scaffold: 2 (4%)Microfracture: 3 (7%)	10.8 ± 0.8
Hommen et al (2007)¹⁵	14/8	32 (17-43)	22	22	59.10	NR	24	9 ACL reconstruction, 1 revision ACL reconstruction, 2 high tibial osteotomy, 3 lateral retinaculum release, 3 lysis of adhesions, 1 loose-body removal, 2 capsular plication, 3 chondroplasty of femoral condyle	11.75 (10-14)
Lee et al (2025)²⁰	10/22	32.6 ± 9.5	32	32	70.37	23.6 ± 2.9	17	13 ACL reconstruction, 3 cartilage procedure (OATS), 1 PCL reconstruction	17.5 ± 3.8
Noyes and Barber- Westin (2016)²⁶	41/31	30 (14-49)	69	72	47.83	NR	38	20 osteochondral autograft transfer on the femoral condyle, 6 primary knee ligament reconstruction, 2 revision knee ligament reconstruction, 4 stagedknee ligament reconstruction before meniscal transplant (6 ACL, 1 PCL), 4 staged ACLrevision, 13 staged high tibial osteotomy, 1 staged distal femoral osteotomy	11.9 ± 3.2
Paša et al (2021)³¹	36/13	37.2 (18-51)	46	49	60.90	NR	21	16 ACL reconstruction, 5 high tibial osteotomy	10.2 (112-161)
Romandini et al (2024)³²	26/21	43.5 ± 9	47	47	78.70	25.8 ± 4.3	45	2 meniscectomy, 4 primary ACL reconstruction, 2 ACL revision, 10 closed high tibial osteotomy, 2 open high tibial osteotomy, 4 closed distal femoral osteotomy, 1 open distalfemoral osteotomy, 9 microfracture, 2 shaving, 2 osteochondral scaffold implantation, 2 osteochondral allograft transplantation, 5 cheiloplasty for patellar osteophyte removal	11.1 ± 1
Torres et al (2023)³⁷	23/15	36.9 ± 8.5	38	38	65.80	NR	20	11 ACL reconstruction, 5 microfracture, 4 high tibial osteotomy	17.4 ± 2
van der Wal et al (2009)³⁹	23/40	39.4 ± 6.9	57	63	70.20	NR	2	2 ACL reconstruction	13.8 ± 2.8
Verdonk et al (2006)⁴⁰	27/15	35.4 ± 6.7	41	42	83.30	NR	Total: 15 (14 medial, 1 lateral)	Medial: 11 high tibial osteotomy, 3 ACL reconstruction; lateral: 1 femoral varus osteotomy	12.1 (10-14.8)
von Lewinski et al (2007)⁴¹	5/0	25 (24-26)	5	5	80	NR	6	5 concomitant ACL reconstruction, 1 temporary detachment of the MCL	20
Wagner et al (2023)⁴²	91/83	28.3 ± 10.1	174	174	47	25.7 ± 4.1	115	Most commonly osteochondral autograft transfer (34%), ACL reconstruction (14%), and autologous chondrocyte implantation (11%)	12.7 ± 2.7 (10-21)
Wang et al (2022)⁴³	I: 2/7; D: 4/6	I: 24.5 ± 8.7; D: 25.6 ± 5.9	19	19	I: 55.5; D: 80.0	I: 27.0 ± 7.3; D: 23.2 ± 3.6	Total: 7 (I: 4; D: 3)	I MAT: 4 concurrent ACL reconstruction; D MAT: 3 concurrent ACL reconstruction	I: 11.2 (10.2-14.1); D: 11.9 (10.0-14.3)
Wirth et al (2002)⁴⁵	23/0	29.6 (21-45)	23	23	87	NR	28	All 23 medial MATs were performed with combined ACL reconstruction. In cases of anterior instability (5 cases), the medial collateral ligament was split longitudinally, whereas in cases of anteromedial instability, the bony femoral insertion was detached with a chisel	14 (12-15)

Data are reported as mean ± SD, mean (range), number, or %. ACL, anterior cruciate ligament; BMI, body mass index; MAT, meniscal allograft transplantation; MCL, medial collateral ligament; NR, not reported; OATS, osteocondral autograf transfer system; PCL, posterior cruciate ligament.

Figure 2.

Comparison of initial Methodological Index for Non-Randomized Studies (MINORS) scoring and study quality assessment performed by Reviewer 1 (J.D.K; light blue) and Reviewer 2 (S.S.; dark blue). The weighted Cohen kappa demonstrated excellent interrater reliability of MINORS scoring between reviewers (κ = 0.83).

Study periods ranged from 1984^41,45 to 2013,¹³ with sample sizes varying from 5⁴¹ to 174⁴² total patients. The mean patient age ranged between 24.5 years⁴³ and 43.5 years,³² with male patients comprising 47%⁴² to 87%⁴⁵ of the study populations. BMI values were reported in 5 studies, ranging from 23.2 kg/m² to 27.0 kg/m².⁴³ The mean follow-up duration across all studies ranged from 11.1 years³² to 20 years.⁴¹

The meniscal allografts utilized varied in type and preservation method. Fresh-frozen allografts were most frequently reported and were used in 6 studies,^{13,20,32,37,42,43} whereas cryopreserved allografts were used in 3 studies.^15,26,39 Deep-frozen allografts were documented in 3 studies,^31,41,45 and lyophilized allografts were used in 1 study.⁴⁵ One study used fresh (viable) allografts.⁴⁰

The fixation techniques used exhibited considerable variability (Table 2). Soft tissue fixation was used in 5 studies,^{13,15,32,40,43} while bone plug fixation was reported in 5 studies,^{15,20,26,37,43} including 1 using a transosseous technique.³¹ Four studies utilized bone trough (bridge-in-slot) fixation.^15,41,42,45

Survivorship and Failure Rates

Graft survival was reported in 10 studies (Table 4).^†† Among these, 4 of 10 studies (40.0%) demonstrated 10-year survivorship rates exceeding 73%.^20,31,32,42 Reported 10-year MAT survival ranged from 45% to 100%, with the highest rates observed in lateral meniscus allograft cases.³¹ Five studies reported survival rates with a minimum of 15 years of follow-up.^{20,26,37,39,42} The MAT survival rate after a mean follow-up of ≥15 years ranged from 19% to 87%, with Lee et al²⁰ reporting an 87% survival rate at 17.5 years, Torres et al³⁷ 58% at 17.4 years, van der Wal et al³⁹ 52.5% at 16 years, Wagner et al⁴² 72% at 15 years, and Noyes and Barber-Westin²⁶ demonstrating a decline in survival from 45% at 10 years to 19% at 15 years.

Table 4

Survival and Failure Rates ^a

Authors (Year)	Survival Rate	Mean Follow-up	Medial vs Lateral	Failure Definition	No. of Failures	Reoperations Required	Conversion to TKA
Grassi et al (2020)¹³	73%	10 y	Logistic regression analysis identified lateral MAT as having a higher risk of surgical failure (OR, 10.5; 95% CI, 1.0- 110.3; P = .0495) and lower long-term survival rates (73%) compared with MMT (96%) (P = .0333)	Surgical failure: partial or total graft removalClinical failure: Lysholm score <65 at final follow-up	6 surgical failures14 clinical failures	17 subsequent surgical procedures wereperformed: partial graft meniscectomy (6), hardware removal (6), distal femoral osteotomy (2), arthroscopic arthrolysis (1), arthroscopic debridement (1), meniscal cyst removal (1)	0%
Hommen et al (2007)¹⁵	45%	10 y	25% of medial allografts and 50% of lateral allografts failed	Clinical: Lysholm score <65 or no improvement in pain scoreSurgical: >1/2 allograft menisectomyRadiographic: grade 3 signal	11 clinical + radiographic + surgical failures(7 medial, 4 lateral)	40 subsequent surgical procedures wereperformed	0%
Lee et al (2025)²⁰	87%	17.5 y	NR	Clinical: Lysholm score <65 or additional surgery required	7 clinical failures	NR	NR
Noyes and Barber-Westin (2016)²⁶	45%19%	10 y15 y	Mean time for failure was 8.2 ± 6.5 y for medial transplants and 7.7 ± 6.5 y for lateral transplants	Surgical: reoperation related to the transplantRadiographic: grade 3 MRI signal intensity, 50% extrusion of the meniscal transplant width, or loss of joint space in the tibiofemoral compartment	37 surgical failures + 21 radiographic failures	37 subsequent surgical procedures: transplant removal (15), transplant revision (6), TKA (10), UKA (4), osteotomy (2)	10 patients were converted to TKA 1.4-3.5 y after MAT (3), 9.7-13.9 y after MAT (7)
Paša et al (2021)³¹	100% (LM)83.6% (MM)	10 y	100% lateral MAT vs 83.6% MMT survival	NR	NR	Final assessmentafter 10 y showed that 38/46 patients completed thispostsurgery period without a new injury	0%
Romandini et al (2024)³²	89.40%	10 y	Multivariate analysis showed no significant difference in graft failure based on graft side (P = .799)	Surgical: required revision procedureClinical: Lysholm score <65	5 surgical failures15 clinical failures	3 patients (6.4%) underwent meniscal procedure andthe other2 patients (4.3%) underwent TKA	2 patients (4.3%) underwent TKA after 7 and 8 y, respectively
Torres et al (2023)³⁷	58%	17.4 y	There was no difference between medial and lateral MAT in time to failure, with means of 199.3 and 208.3 mo, respectively (P > .05)	Required revision in which the initial MAT was not maintained or reattached	16 surgical failures	6 TKA, 1 UKA, 9 MAT removals	6 patients underwent TKA and 1 patient had a UKA on the MAT side (all had grade 4 OA)
van der Wal et al (2009)³⁹	52.5%	16 y	Overall, 8 medial allografts (35%) and 10 lateral allografts (25%) failed	Complete resection of the graft, with or without placement of UKA or TKA	18 surgical failures (8 medial, 10 lateral)	12 patients were converted to TKA; 3 patients (5%) had a resection of the graft at a mean follow-up of 8.4 ± 4.8 y (range, 4.3-13.7 y)	12 conversions (21%) to TKA at a mean follow-up of 10.8 ± 4.1 y (range, 5.6-17.3 y)
Verdonk et al (2006)⁴⁰	NR	NR	NR	Conversion to TKA	7 surgical failures	4 MMTs (25%), 2 MMT+HTOs (18%), and 1LMT (7%) were converted to TKA during follow-up(mean, 6.5 ± 4.3 y)	With conversion to TKAas an endpoint, the overall failure rate was 18% (7/39 grafts)
Wagner et al (2023)⁴²	85%72%	10 y15 y	There were no significant differences in graft failure after medial vs lateral transplantation	Revision MAT or conversion to TKA	NR	65 patients (37%) underwent repeat MAT-associated intervention (meniscectomy, revision MAT, or TKA)	Most common criteria for failure were TKA (22), revision MAT (13), and UKA (5)

HTO, high tibial osteotomy; LM, lateral meniscus; LMT, lateral meniscus allograft transplantation; MAT, meniscal allograft transplantation; MM, medial meniscus; MMT, medial meniscus allograft transplantation; MRI, magnetic resonance imaging; NR, not reported; OA, osteoarthritis; TKA, total knee arthroplasty; UKA, unicompartmental knee arthroplasty.

A pooled analysis of 10-year survival data across 5 studies demonstrated a survivorship rate of 70.9% (95% CI, 48.0%-86.5%) with notable between-study heterogeneity (I² = 92.2%) (Figure 3).^{13,15,26,32,42} Similarly, pooled survival at ≥15 years was 58.4% (95% CI, 33.0%-80.0%) across a separate subset of 5 studies, again with substantial between-study heterogeneity (I² = 93%) (Figure 4).^{20,26,37,39,42}

Figure 3.

Forest plot of meniscal allograft survival proportions at 10 years postoperatively. Individual study survival estimates and 95% confidence intervals were calculated using a Wald-type method. The pooled survival proportion was 70.9% (95% CI, 48.0%-86.5%). Between-study heterogeneity was high (I² = 92.2%).

Figure 4.

Forest plot of meniscal allograft survival proportions at ≥15 years postoperatively. Individual study survival estimates and 95% confidence intervals were calculated using a Wald-type method. The pooled survival proportion was 58.4% (95% CI, 33.0%-80.0%). Between-study heterogeneity was high (I² = 93%).

Six studies assessing MAT survivorship before 2004 were found to have ≥10-year survival rates ranging from 45% to 87%.^{15,20,26,37,39,42} Alternatively, only 2 studies exclusively analyzed MATs performed from 2004 or later, reporting 73% to 89.4% survival.^13,32

Among different allograft types, fresh-frozen meniscal grafts demonstrated a 58% to 89.4% ≥10-year survival rate across 5 studies (3/5 studies ≥85% survivorship).^{13,20,32,37,42} Alternatively, 3 studies using cryopreserved allografts demonstrated survivorship ranging from 45% to 52.5%.^15,25,39 Only 1 study reported survivability in the context of deep-frozen allografts, underscoring an 83.6% survival rate for medial menisci and 100% survival for lateral menisci in a cohort of 49 total MATs.³¹

Failure criteria varied across studies and included surgical failure,^{13,26,32,37,39,40} clinical failure,^13,15,20,32 and radiographic failure.^15,26 The incidence of surgical failure ranged from 5 cases³² to 37 cases,²⁶ whereas clinical failure was observed in 7²⁰ to 15 cases,³² and radiographic failure in 11¹⁵ to 21²⁶ cases.

Graft survivorship and treatment failure rates among medial versus lateral MAT was analyzed among 8 reporting studies. The survivorship and failure rates associated with medial and lateral MAT were also notably variable. Studies from both Romandini³² and Wagner et al⁴² reported no significant differences in treatment failure based on graft laterality. Similarly, Torres et al³⁷ identified no significant difference in time to failure for medial or lateral MAT (199.3 vs 208.3 months, respectively). Inferior durability in lateral MAT was described by Noyes and Barber-Westin,²⁶ who reported a shorter time to failure (medial: 8.2 ± 6.5 years vs lateral: 7.7 ± 6.5 years), and Hommen et al,¹⁵ who highlighted poorer overall survivorship in lateral MATs (50% failure rate lateral, 25% failure rate medial). Furthermore, Grassi et al¹³ identified lateral MAT as having a higher risk of surgical failure (OR, 10.5; 95% CI, 1.0-110.3; P = .0495) and lower long-term survival rates (73%) compared with medial MAT (96%; P = .0333). In contrast, however, studies from van der Wal et al³⁹ (35% medial failure rate, 25% lateral failure rate) and Paša et al³¹ (100% lateral MAT vs 83.6% medial MAT survival) underscored superior lateral MAT durability.

Graft survivorship also varied by fixation technique. Bone plug fixation was the most commonly reported method, with 10-year survival rates ranging from 45% to 87%.^20,26,37 Two studies using soft tissue fixation reported survivorship between 73% and 89.4%.^13,32 One study using a bone trough (bridge-in-slot) technique reported 85% survivorship at 10 years.⁴² Suture-only fixation yielded a 52.5% survival rate at 10 years in 1 study,³⁹ while another using transosseous fixation demonstrated high survivorship, with 83.6% in medial and 100% in lateral allografts.³¹

Functional Outcomes

Postoperative functional outcomes were assessed using validated patient-reported outcome measures, including the Lysholm score, Tegner Activity Scale score, VAS for pain score, and KOOS subscales (Table 5).

Table 5

Patient-Reported Outcomes ^a

Authors (Year)	Preop Lysholm Score	Postop Lysholm Score	Preop Tegner Score	Postop Tegner Score	Preop VAS Score	Postop VAS Score	Preop KOOS	Postop KOOS
Grassi et al (2020)¹³	57 ± 19	82 ± 20 ^b	3 (2-5)	4 (3-6) ^b	6.8 ± 2.5	2.6 ± 3.2 ^b	NR	Symptoms: 81 + 20^bPain: 85 ± 20 ^b ADL: 90 ± 21 ^b Sport and Recreation: 63 ± 38 ^b QOL: 70 ± 24 ^b
Hommen et al (2007)¹⁵	53 (23-78)	75 (51-100)	NR	4.5 (1-9)	NR	NR	NR	NR
Lee et al (2025)²⁰	73.9 ± 17.5	86.4 ± 15.6 ^b	NR	NR	NR	NR	NR	NR
Noyes and Barber-Westin (2016)²⁶	NR	NR	NR	NR	NR	NR	NR	NR
Paša et al (2021)³¹	49.8 ± 24.4	78.2 ± 21.4 ^b	NR	NR	NR	NR	Symptoms: 49.35 ±20.94Pain: 54.79 ± 22.82ADL: 62.18 ± 24.47Sport and Recreation: 39.24 ± 24.14QOL: 28.51 ± 24.71	Symptoms: 74.69 ± 20.61 ^b Pain: 78.02 ± 22.24 ^b ADL: 85.35 ±16.70 ^b Sport and Recreation: 62.88 ± 27.09 ^b QOL: 59.67 ± 20.58 ^b
Romandini et al (2024)³²	46.4 ± 17.2	71.0 ± 23.3 ^b	2.4 ± 1.7	3.4 ± 1.7 ^b	72.5 ± 22.6	47.2 ± 30.7 ^b	NR	NR
Torres et al (2023)³⁷	61.5 ± 9.7	77.4 ± 11.5 ^b	3 (0-6)	4.5 (1-9) ^b	6.6 ± 1.7	2.5 ± 2 ^b	NR	Symptoms: 78.4 ± 10.7Pain: 80.5 ± 13.4ADL: 79.5 ± 13.5Sport and Recreation: 61.1 ± 25.2QOL: 68.71 ± 24.8
van der Wal et al (2009)³⁹	36 ± 18	61 ± 20 ^a	NR	NR	NR	NR	NR	NR
Verdonk et al (2006)⁴⁰	NR	NR	NR	NR	NR	NR	NR	Symptoms: 61.8Pain: 76.3ADL: 79.9Sport and Recreation: 49.3QOL: 45.9
Wang et al (2022)⁴³	I: 61.3 (18-84)D: 69.5 (51-98)	I: 87.7 (70-100)D: 78.0 (64-95)	I: 6 (0-7)D: 4.5 (4-6)	I: 7 (4-9)D: 3.5 (3-7)	I: 4.4 (2-7)D: 3.9 (2-7)	I: 0.2 (0-1)D: 1.5 (0-3)	NR	NR
Wirth et al (2002)⁴⁵	59 ± 11	75 ± 21	1	4.6	NR	NR	NR	NR

Data are reported as mean ± SD or mean (range). ADL, Activities of Daily Living; D, delayed; I, immediate; KOOS, Knee injury and Osteoarthritis Outcome Score; NR, not reported; postop, postoperative; preop, preoperative; QOL, Quality of Life.

Statistically significant (P < .05).

Lysholm scores were reported in 9 studies,^‡‡ with preoperative scores ranging from 36³⁹ to 73.9.²⁰ Postoperative scores ranged from 61.0³⁹ to 87.7.⁴³ Statistically significant improvements were reported in 7 of the 9 studies.^{13,15,20,31,32,37,39} The remaining studies showed numeric improvements but did not report P values.^43,45 A pooled analysis of standardized mean differences (SMDs) across 7 studies demonstrated a significant overall improvement in Lysholm scores after MAT, with a pooled SMD of 1.32 (95% CI, 1.14-1.50) and no observed between-study heterogeneity (I² = 0%) (Figure 5).

Figure 5.

Forest plot of standardized mean differences in pre- and postoperative Lysholm scores. Study estimates were pooled using inverse variance weighting to calculate the overall effect. The pooled standardized mean difference (1.32; 95% CI, 1.14-1.50) was statistically significant (P < .001), with no observed between-study heterogeneity (I² = 0%).

Tegner activity levels were assessed in 6 studies.^{13,15,32,37,43,45} Preoperative scores ranged from 1⁴⁵ to 6 (Wang et al,⁴³ immediate group), and postoperative scores ranged from 3.4³² to 7 (Wang et al,⁴³ immediate group). Significant postoperative improvements were documented in 3 studies^13,32,37; 2 studies did not report statistical significance.^43,45

VAS pain scores were reported in 4 studies.^13,32,37,43 Preoperative values ranged from 3.9 (Wang et al,⁴³ delayed group) to 7.25,³² and postoperative values ranged from 0.2 (Wang et al,⁴³ immediate group) to 1.5 (Wang et al,⁴³ delayed group). Three studies reported statistically significant reductions in pain (P < .05).^13,32,37 One study showed numeric improvements but did not report statistical significance.⁴³

Four studies reported postoperative KOOS values.^13,31,37,40 The range of postoperative scores for each KOOS domain across these studies was as follows: Pain: 76.3⁴⁰ to 85.0¹³; Symptoms: 61.8⁴⁰ to 81.0¹³; Activities of Daily Living: 79.5³⁷ to 90.0¹³; Sport and Recreation: 49.3⁴⁰ to 63.0¹³; and Quality of Life: 45.9⁴⁰ to 70.0.¹³ Of these, only Paša et al³¹ reported both preoperative and postoperative values, demonstrating significant improvements in all 5 domains (P < .05).

Clinically Significant Outcomes

The Patient Acceptable Symptom State (PASS) and/or minimal clinically important difference (MCID) were reported in 3 studies (Table 6). Grassi et al¹³ reported PASS achievement rates of 71% for Lysholm score and 60% to 82% for the KOOS subscales. Lee et al²⁰ found that 70.4% of patients met the MCID for Lysholm score. Furthermore, Wagner et al⁴² reported MCID achievement rates of 86.5% (Lysholm score) and 61% to 78.2% (KOOS subscales), with corresponding PASS rates of 70.2% (Lysholm score) and 56.2% to 79% (KOOS subscales) and substantial clinical benefit (SCB) rates of 47.8% (Lysholm score) and 46.2% to 61.9% (KOOS subscales).

Table 6

Clinically Significant Outcomes ^a

Authors (Year)	PRO	PASS	MCID	SCB
Grassi et al (2020)¹³	Lysholm score	71%	NR	NR
	KOOS
	Pain Symptoms ADL Sport and Recreation QOL	82%60%70%69%68%
Lee et al (2025)²⁰	Lysholm score	NR	38 (70.4)	NR
Wagner et al (2023)⁴²	Lysholm score	73/104 (70.2)	62/69 (89.9)	33/69 (47.8)
	KOOS
	Pain Symptoms ADL Sport and Recreation QOL	83/105 (79.0)62/106 (58.5)59/105 (56.2)67/105 (63.8)70/106 (66.0)	61/78 (78.2)50/82 (61.0)50/74 (67.6)47/63 (74.6)60/82 (73.2)	36/78 (46.2)45/82 (54.9)38/74 (51.4)39/63 (61.9)40/82 (48.8)

Data are reported as number or fraction of patients (%) meeting the threshold. ADL, Activities of Daily Living; KOOS, Knee injury and Osteoarthritis Outcome Score; MCID, minimal clinically important difference; NR, not reported; PASS, Patient Acceptable Symptom State; PRO, patient-reported outcome; QOL, Quality of Life; SCB, substantial clinical benefit.

Radiographic Progression of Osteoarthritis

Long-term progression of osteoarthritis after MAT was described variably across included studies (Table 7). Four studies measured the progression of preoperative joint space width (JSW) a decade after surgery. Lee et al²⁰ reported that the mean JSW narrowed from 4.96 ± 0.96 mm to 3.47 ± 1.62 mm, whereas Torres et al³⁷ reported a similar degree of narrowing from 3.3 ± 1.5 mm to 1.9 ± 1.5 mm. Changes in JSW were also analyzed by Verdonk et al,⁴⁰ who described a progression by 1 grade in 11 cases (34%), by 2 grades in 7 cases (22%), and by 3 grades in 1 case (3%). Similarly, Wang et al⁴³ identified a mean JSW narrowing of 0.35 ± 0.48 mm in immediate MATs and 0.71 ± 0.70 mm in delayed MATs.

Table 7

Radiographic Progression of Osteoarthritis 10 Years After MAT ^a

Authors (Year)	Preoperative JSW	Postoperative JSW	KL Grade	Other Descriptions of OA Progression
Grassi et al (2020)¹³	NR	NR	NR	Preoperative Outerbridge grade 0 or 1 (21; 46%), 2 or 3 (14; 30%), 4 (11; 24%)
Hommen et al (2007)¹⁵	NR	NR	NR	10/15 allografts showed radiographic joint space narrowing, and 12 had progression of degenerative joint disease
Lee et al (2025)²⁰	4.96 ± 0.96 mm	3.47 ± 1.62 mm	NR	Notable progression in joint space narrowing, OA, and cartilage degeneration were observed in objective assessment
Noyes and Barber-Westin (2016)²⁶	NR	NR	NR	Progression of OA as measured on standing PA radiographs was noted in 33 cases (57%), and retention of joint space was noted in 21 cases (36%)
Paša et al (2021)³¹	NR	NR	NR	Patients with a new injury or those without a new injury who underwent the control arthroscopy showed clear signs of improvement, on average, of 1 grade according to ICRS classification. In 2 patients with proven irreparable rupture of the medial meniscus posterior horn after the transplantation, the changes in cartilage deteriorated from grade 2 to 3a.
Romandini et al (2024)³²	NR	NR	Preoperative KL grade 2 (n = 30), preoperative KL grade 3 (n = 17) (no postoperative KL recorded)	No significant differences were observed in survivorship or clinical outcomes between KL grade 2 and KL grade 3 groups
Torres et al (2023)³⁷	3.3 ± 1.5 mm	1.9 ± 1.5 mm	All patients initially had a KL grade <3; final KL was a median of 3 (range, 10-4)	JSW remained almost unchanged from the initial evaluation (3.4 ± 1.5 mm) to the 5-y follow-up measurement (3.1 ± 1.7 mm) (n.s.). However, this joint space distance had decreased by the last evaluation in the long-term follow-up (1.9 ± 1.4 mm; P < .05).
Verdonk et al (2006)⁴⁰	NR	JSWN progressed by 1 grade in 11 cases (34%), by 2 grades in 7 cases (22%), and by 3 grades in 1 case (3%)	NR	Radiographical analysis revealed no further joint space narrowing in 13/32 knees (41%). MRI analysis showed no progression of cartilage degeneration in 6/17 knees (35%).
von Lewinski et al (2007)⁴¹	NR	NR	Increase of degenerative changes between 1 and 4 KL grades. Two patients had grade 2 (minimal), 2 patients grade 3 (moderate), and 1 patient severe degenerative changes (grade 4) according to the KL classification.	NR
Wang et al (2022)⁴³	NR	Mean JSW narrowing I: 0.35 ± 0.48 mm, mean JSW narrowing D: 0.71 ± 0.70 mm (P > .05)	Mean KL progression I: 0.6 (range, 0-2), mean KL progression D: 1.7 (range, 1-3) (P = .041)	Increase in CDI: I: femur 134 (range, 0-582), tibia 107 (range, 0-400), patella 11 (range, 0-93); D: femur 1367 (range, 336-5045), tibia 505 (range, 0-1855), patella 146 (range, 0-700)
Wirth et al (2002)⁴⁵	NR	NR	NR	Preoperatively, 8 patients had no degenerative changes, 13 patients had grade 1 degenerative changes, and 1 patient had grade 2 degenerative changes according to the criteria of Fairbank. At the 14-y follow-up, 6 patients had grade 2 degenerative changes and 5 patients had grade 3 degenerative changes.

CDI, cartilage degeneration index; D, delayed; I, immediate; ICRS, International Cartilage Regeneration & Joint Preservation Society; JSWN, joint space width narrowing; KL, Kellgren-Lawrence; MAT, meniscal allograft transplantation; MRI, magnetic resonance imaging; n.s., not significant; OA, osteoarthritis; PA, posteroanterior.

Three studies evaluated long-term changes in Kellgren-Lawrence (KL) grading after MAT. Wang et al⁴³ also examined KL grade, reporting a significantly greater KL progression in delayed MATs (1.7; range, 1-3) compared with immediate MATs (0.6; range, 0-2) (P = .041). An increase of degenerative changes from 1 to 4 KL grades was reported by von Lewinski et al,⁴¹ with 2 patients having grade 2 (minimal), 2 patients grade 3 (moderate), and 1 patient grade 4 (severe degenerative changes).

Discussion

The most important findings of this systematic review were as follows: (1) MAT led to sustained, meaningful improvements in patient-reported outcomes, including VAS pain scores, Lysholm scores, Tegner activity levels, and KOOS subscales; (2) survival rates were variable, ranging from 45% to 100% at 10 years and 17% to 87% at ≥15 years; and (3) failure rates increased over time, with declining survivorship beyond the 10-year mark. These findings suggest that while MAT is capable of providing significant improvements in pain and function for many patients, long-term graft survivorship is highly variable and may be influenced by a combination of patient selection, graft choice, and surgical technique.

While previous literature has established the short- and midterm efficacy of MAT, the present review demonstrates that MAT offers sustained, clinically meaningful improvements in pain and function after a decade.^25,34 Preoperative Lysholm scores improved significantly in 78% (7/9) of studies a decade after surgery. Furthermore, a pooled analysis of 7 studies highlighted consistent improvements in Lysholm scores after MAT, indicating greater postoperative knee function.^{13,15,20,31,32,37,39} Preoperative VAS scores also significantly decreased in 60% (3/5) of the included studies,^13,32,37 and Tegner activity levels improved in 75% (3/4).^13,32,37 KOOS subscales also demonstrated improvement in pain, activities of daily living, and quality of life.³¹ Given the sustained benefits across patient-reported outcomes, MAT remains a valuable joint-preserving treatment for young, active patients with significant meniscal deficiency. Nevertheless, future comparative studies should evaluate long-term MAT outcomes relative to the natural progression of untreated meniscal deficiency.^{11,20,24,30,33,37}

Graft survivorship at 10 years demonstrated substantial variability, ranging from 45% to 100% across studies.^§§ This review indicated that almost half the reporting articles demonstrated a survivability ≥83.6%,^20,31,32,42 and pooled analysis demonstrated an overall 10-year survivorship rate of 70.9% (95% CI, 48.0%-86.5%) with substantial between-study heterogeneity. It is likely that differences in surgical technique, graft type, fixation methods, and patient selection contributed to this variability. Survivorship was also defined variably between studies, with most studies using a combination of clinical, surgical, or radiographic failure criteria.

As expected, graft failure rates increased with longer duration of follow-up. Common causes of failure included persistent pain, mechanical symptoms, and osteoarthritis progression.^∥∥ Beyond a decade from surgery, ≥15-year survival varied greatly, with MAT survivability ranging from 19% to 87%.^{20,26,37,39,42} This was reinforced by the findings of our pooled analysis (58.4%; 95% CI, 33.0%-80.0%), which was heterogeneous (I² = 93%) and reinforced the inconsistencies in long-term MAT survivorship. Notable variability in implant survival supports the importance of patient counseling regarding the potential for long-term decline and additional revision surgery or conversion to arthroplasty. Furthermore, future investigations of MAT survivability at ≥15 years are warranted to maximize long-term outcomes and minimize osteoarthritis risk as patients age, especially considering the young age of MAT recipients.

Lydon et al²² reported that fresh allografts may address common complications associated with fresh-frozen MAT, such as graft shrinkage and extrusion. This review found that fresh-frozen meniscal allografts had a 73% to 89.4% survival rate (5 studies), which was comparable to the 1 study that used deep-frozen allograft (83.6% survival medial menisci, 100% survival lateral menisci). However, these survivorship rates were superior to those observed across 3 studies using cryopreserved allografts (45%-52.5% survivorship). Additionally, patient-specific factors such as axial alignment, cartilage status, and concomitant procedures (eg, osteotomy) may significantly influence MAT outcomes.^3,10,22,27

A recent meta-analysis examining different fixation techniques by Kakria et al¹⁸ identified comparable short- to midterm outcomes between suture and bony fixation, although long-term data remain limited. Kakria et al initially hypothesized that osseous graft fixation would result in superior long-term survivorship; however, 3 studies using bone plug or trough fixation reported survivability rates of 58% or worse after 10 years.^15,26,37 In contrast, Romandini et al³² reported an 89.40% survival rate using soft tissue fixation, suggesting that fixation methodology alone may not be the sole determinant of long-term success. Another plausible explanation for this discrepancy may be that the bone plug studies date back to 1991-1996, before more recent advancements in surgical technique, graft preparation, and postoperative rehabilitation.

Medial versus lateral MAT fixation also remains a significant topic of debate among sports surgeons. This systematic review identified 8 studies comparing long-term failure rates or implant survivorship based on graft laterality. Although comprehensive, these findings were variable. Both medial and lateral MAT have been shown to provide significant improvements in pain and function; however, some meta-analyses and cohort studies have reported that lateral MAT may be associated with superior pain relief and functional scores in the mid- to long-term.^5,19,46 Variability in cartilage status, concomitant procedures, and patient demographics may better explain differences in survival rather than graft laterality or the fixation method itself. Future studies directly comparing medial versus lateral fixation, surgical techniques, graft types, and biological augmentation strategies are warranted.

A prior systematic review by Novaretti et al²⁵ assessed long-term outcomes after MAT. While their work contributed important insights into survivorship and patient outcomes, their analysis included 3 studies with a mean follow-up period of <10 years.²⁵ In contrast, the present study focused exclusively on studies in which all patients had a minimum of 10 years of follow-up, offering a more homogeneous perspective on results after ≥10 years. This study also expands on the existing literature by incorporating clinically meaningful outcome measures such as the PASS, MCID, and SCB, providing greater context for evaluating patient-reported success. Finally, by including more recently published studies (2019-2025) and stratifying outcomes by graft type and fixation technique, our review offers a comprehensive update to the evolving body of literature surrounding MAT.

Limitations

This study has reportable limitations. First, the included studies were level 3 or 4 evidence, which carry risk of bias. It is also worth mentioning the significant heterogeneity in surgical techniques, patient populations, outcome measures, and definitions of failure; however, heterogeneity was shown to be zero for Lysholm score (I² = 0.00%; 95% CI, 0.00-0.43). Another important consideration is that while SCB, PASS, and MCID data were useful contributions provided by this review, these values were only present in 3 studies. Furthermore, this investigation analyzed all studies with sufficient long-term MAT follow-up, which included surgeries performed ≥2 decades ago. This may not be representative of long-term outcomes observed with advancements and techniques of the modern surgeon.

Additionally, graft survivorship criteria were inconsistently defined, complicating cross-study comparison. Definitions of treatment failure varied widely across studies; while some authors characterized return to the operating room for procedures such as a partial meniscectomy or chondroplasty as failure, others limited failure to revision MAT or conversion to arthroplasty. These inconsistencies complicate interpretation of long-term survivorship and call for standardized failure definitions in future research.

Although data on concomitant procedures such as osteotomy and cartilage restoration were extracted, substantial heterogeneity in reporting and the limited availability of viable patient-level data across studies precluded meaningful subgroup analyses of mechanical axis alignment or the impact of additional procedures on MAT survivorship. As a result, this review was unable to provide quantitative insight into whether outcomes differ by alignment, presence of osteotomy, or isolated versus combined MAT procedures despite the recognized importance of these factors in long-term success and osteoarthritis prevention. Prospective, multicenter trials with standardized definitions of outcomes and failure, as well as consistent reporting of alignment, concomitant procedures, and patient-level variables, are needed to better inform evidence-based indications in MAT.

Conclusion

Footnotes

Submitted August 4, 2025; accepted September 2, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: A.J. has received consulting fees from Smith ⩲ Nephew. 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.

ORCID iDs

Jacob D. Kodra

Michael S. Lee

Ronak Mahatme

Jay Moran

Andrew E. Jimenez

Notes

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