Saving the meniscus through early intervention: The impact of primary ACL repair on tear complexity and repairability

Purpose To compare the proportion of repairable meniscal tears between patients undergoing primary anterior cruciate ligament (ACL) repair and those receiving ACL reconstruction; secondary aims were to compare tear morphology/location and assess the association between injury‐to‐surgery interval and repairability. Methods This retrospective cohort study evaluated patients who underwent ACL surgeries between 2014 and 2024. Patients were grouped by surgical technique: ACL repair and ACL reconstruction. Meniscal tears were classified intraoperatively by type (longitudinal, bucket‐handle, radial, root, horizontal, complex) and location, and judged repairable using prespecified criteria. Group comparisons used Chi‐square/Fisher′s tests. A multivariable logistic regression adjusted for age, sex, and injury‐to‐surgery interval evaluated independent associations with repairability. Results 283 patients were included (repair 106; reconstruction 177). Groups were similar in age, sex, and side; the injury‐to‐surgery interval was shorter in the repair group (20.4 ± 10.2 vs. 83.8 ± 18.6 days; p < 0.001). Meniscal tear incidence was comparable (43.3% vs. 44.6%; p = 0.45). Among tear‐positive patients, repairability was higher in the repair group (89.1% vs. 48.1%; p < 0.001), including both compartments. Vertical tears (defined as longitudinal/bucket‐handle) were more frequent and less often repairable in the reconstruction group (both p < 0.01). Complex tears occurred only in the reconstruction group (8/79 vs. 0/46; p = 0.027). In adjusted analysis, the treatment group was not independently associated with repairability (aOR 1.05; 95% CI 0.14–7.73; p = 0.964), whereas each 10‐day increase in the interval was associated with lower odds of repairability (aOR 0.74; 95% CI 0.56–0.96; p = 0.024). Conclusions Primary ACL repair was associated with higher meniscal repairability and fewer complex patterns than delayed reconstruction; however, these differences appear related to earlier timing, not an independent technique effect. Findings underscore surgical timing as a potential factor in meniscal preservation; causal inference about technique cannot be made. Level of Evidence Level III, retrospective comparative study.