CONSENSUS RECOMMENDATION The most recent meta-analysis and systematic review (Schweizer C/Nepple) on all inside versus inside out repair showed no significant difference in pooled failure rates between all inside versus inside out repair. Another low-level study (Borque) demonstrated a higher rate of failure of medial meniscus tears treated with the all inside technique versus inside out technique, but this may be limited by the study population and tear morphology. Biomechanical studies (Rosso) have demonstrated similar responses to cyclic loading with all inside versus inside out repairs.
Benefits & Harms:
All inside meniscal repair has the potential to decrease operative time as well as morbidity by avoiding additional incisions and dissection. All inside devices do not eliminate the risk for neurovascular injury however and present a risk for iatrogenic cartilage injury and can break or malfunction. Inside out repair has risks of iatrogenic nerve injury and additional surgical dissection.
Outcome Importance:
The relative risk of complications and retear likely depends on tear and patient specific variables. Determining the ideal indication for various repair techniques could optimize outcomes.
Cost Effectiveness/Resource Utilization:
Cost of increased OR time with an inside out repair versus increased cost of all inside implants should be weighed.
Acceptability:
Both techniques are accepted treatment modalities for meniscal repair with the inside out repair being the historical gold standard.
Feasibility:
Both techniques are widely available for use.
Future Research:
Future research should investigate how tear and patient specific variables relate to the impact of meniscal repair technique on outcomes, complications, and cost in the treatment of acute meniscal tears.
Additional References:
- Schweizer C, Hanreich C, Tscholl PM, Blatter S, Windhager R, Waldstein W. Meniscal Repair Outcome in 3829 Patients With a Minimum Follow-up From 2 Years Up to 5 Years: A Meta-analysis on the Overall Failure Rate and Factors Influencing Failure. Am J Sports Med. 2023 Apr 6:3635465231158385. doi: 10.1177/03635465231158385. Epub ahead of print. PMID: 37022676
- Borque KA, Laughlin MS, Webster E, Jones M, Pinheiro VH, Williams A. A Comparison of All-inside and Inside-out Meniscal Repair in Elite Athletes. Am J Sports Med. 2023 Mar;51(3):579-584. doi: 10.1177/03635465221147058. Epub 2023 Feb 6. PMID: 36745037.
- Nepple JJ, Block AM, Eisenberg MT, Palumbo NE, Wright RW. Meniscal Repair Outcomes at Greater Than 5 Years: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am. 2022 Jul 20;104(14):1311-1320. doi: 10.2106/JBJS.21.01303. Epub 2022 Apr 19. PMID: 35856932.
- Rosso C, Kovtun K, Dow W, McKenzie B, Nazarian A, DeAngelis JP, Ramappa AJ. Comparison of all-inside meniscal repair devices with matched inside-out suture repair. Am J Sports Med. 2011 Dec;39(12):2634-9. doi: 10.1177/0363546511424723. Epub 2011 Oct 13. PMID: 21997730.