Comparison of Inside-Out and All-Inside Techniques for the Repair of Isolated Meniscal Tears A Systematic Review

Background: Arthroscopic meniscal repair techniques are continuing to evolve. Most studies to date comparing the healing rate of inside-out to all-inside meniscal repair techniques are confounded by associated anterior cruciate ligament reconstruction or deficiency. Purpose: This review was conducted to compare the effectiveness and complications of the inside-out repair technique to that of the all-inside repair technique in isolated unstable peripheral longitudinal ("bucket-handle") meniscal tears. Study Design: Systematic review. Methods: Computerized keyword searches of MEDLINE, EMBASE, CINAHL, ACP Journal Club, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were performed. Two reviewers independently performed searches and article reduction. Studies that included stratified data for isolated unstable longitudinal meniscal tears in stable knees, repaired with either an inside-out or all-inside repair technique, were selected. Data on clinical failure, subjective outcome measures, and complications were summarized. Results: Nineteen studies included data specific to isolated meniscal tears. The rate of clinical failure was 17% for inside-out repairs and 19% for all-inside repairs. Lysholm scores and Tegner activity scores were similar between the 2 repair methods (87.8 vs 90.2 and 5.6 vs 5.5, respectively). The prevalence of nerve injury/irritation was higher with the inside-out technique (9% vs 2%). All-inside techniques had a higher rate of local soft tissue irritation, swelling, and implant migration or breakage. The use of older generation, rigid, all-inside implants is associated with chondral injury. Conclusion: There are no differences in clinical failure rate or subjective outcome between inside-out and all-inside meniscus repair techniques. Complications are associated with both techniques. More nerve symptoms are associated with the inside-out repair and more implant-related complications are associated with the all-inside technique. Clinical Relevance: Rates of structural healing and complications are comparable for inside-out and all-inside repair techniques for isolated meniscal injury. Differences in observed healing rates after meniscal repair may be more dependent on tear pattern and associated anterior cruciate ligament reconstruction rather than an inside-out versus all-inside surgical approach.