Indications, Techniques, and Outcomes of Meniscus Centralization for Root Tears and Meniscus Transplantation: An International Expert Consensus Statement

PURPOSE: To develop an expert consensus statement on the biomechanics, diagnosis, surgical indications and techniques, rehabilitation protocols, and postoperative outcomes of centralization procedures in meniscus root pathology and meniscal allograft transplantation. METHODS: A working group generated 39 statements on meniscal centralization from previously published data for evaluation in a 3-round modified Delphi process. A panel of 22 international experts rated each statement on a 5-point Likert scale, and statements were retained, revised, or excluded according to predefined thresholds (≥75% agreement and <20% disagreement). Rounds 1 and 2 included both literature-derived items and open-ended responses, allowing panel members to propose additional statements. RESULTS: Ultimately, 35 statements were retained, with 100% participation across all rounds. The expert panel reached consensus that centralization may be considered in the setting of root repair and meniscal allograft transplantation to reduce meniscal extrusion (ME), improve joint contact mechanics, potentially enhance root healing, and limit displacement of the repair. The expert panel suggested that the degree of ME may help guide decision-making and that successful outcomes after medial meniscus posterior root repair with centralization may be evaluated by changes in ME and degenerative progression. Medial meniscus posterior root centralization should be considered when ME on magnetic resonance imaging exceeds 3 mm, and lateral centralization should be considered for lateral root tears with concomitant meniscofemoral ligament injury and >3 mm extrusion. Centralization was not recommended in advanced osteoarthritis. Panelists supported its use in symptomatic medial ME with varus deformity in combination with high tibial osteotomy. Transtibial tunnels, suture anchors, and hybrid constructs were all considered acceptable, provided that fixation is individualized to the location of ME and native meniscotibial anatomy and overtightening is avoided. The panel emphasized the need for long-term studies to confirm the durability and joint-protective benefits of centralization. CONCLUSIONS: The panel supported consideration of meniscal centralization when magnetic resonance imaging shows extrusion greater than 3 mm in medial meniscus posterior root tears and in selected lateral root tears with concomitant meniscofemoral ligament injury and extrusion greater than 3 mm. Its use was discouraged in the setting of advanced osteoarthritis, whereas a combined approach with high tibial osteotomy was supported in patients with symptomatic varus-associated medial ME. No single fixation construct was preferred; transtibial, anchor-based, and hybrid techniques were all considered acceptable. Emphasis was placed on individualized surgical decision-making and on avoiding overconstraint. LEVEL OF EVIDENCE: Level V, expert opinion.