Skip to main content

Advertisement

SpringerLink
Log in

Inside-Out Approach to Meniscus Repair: Still the Gold Standard?

  • Meniscus (A Kyrch, Section Editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this review is to provide an up-to-date summary on the current literature and trends regarding use of the inside-out approach to meniscus repair. Additionally, the paper describes the authors preferred techniques for inside-out meniscus repair utilizing posteromedial and posterolateral exposures.

Recent Findings

There has been a substantial increase in recent publications regarding meniscus repair. However, comparisons regarding the optimal repair technique have not been conclusive. Despite the recent increase in use of all-inside devices, multiple investigations with short-to-mid-term follow-up have demonstrated similar rates of meniscus healing between inside-out and all-inside repair techniques. Similarly, current literature describes comparable failure rates of around 20%. There are variations in the profile of complications, with all-inside devices having more implant-related complications and inside-out techniques with higher neurovascular injuries.

Summary

Inside-out meniscus repair is a versatile, cost-effective technique that remains the gold standard for management of most meniscus tear patterns. Through a thoughtful approach, efficient suture retrieval and repair can be performed while protecting critical neurovascular structures. All-inside meniscus repair devices have increased in popularity and surgeon access, but this technique is not without limitations and comparisons to inside-out meniscus repair demonstrates equivocal outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bland-Sutton J. Ligaments; their nature and morphology. 2d ed. London: Lewis; 1897.

    Google Scholar 

  2. McNulty AL, Guilak F. Mechanobiology of the meniscus. J Biomech. 2015;48(8):1469–78. https://doi.org/10.1016/j.jbiomech.2015.02.008.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Mohamadi A, Momenzadeh K, Masoudi A, Walley KC, Ierardi K, Ramappa A, DeAngelis JP, Nazarian A. Evolution of knowledge on meniscal biomechanics: a 40 year perspective. BMC Musculoskelet Disord. 2021;22(1):625. https://doi.org/10.1186/s12891-021-04492-2.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Bhan K. Meniscal tears: current understanding, diagnosis, and management. Cureus. 2020;12(6):e8590. https://doi.org/10.7759/cureus.8590.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Jones JC, Burks R, Owens BD, Sturdivant RX, Svoboda SJ, Cameron KL. Incidence and risk factors associated with meniscal injuries among active-duty US military service members. J Athl Train. 2012;47(1):67–73. https://doi.org/10.4085/1062-6050-47.1.67.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Wasserburger JN, Shultz CL, Hankins DA, Korcek L, Martin DF, Amendola A, Richter DL, Schenck RC, Treme GP. Long-term national trends of arthroscopic meniscal repair and debridement. Am J Sports Med. 2021;49(6):1530–7. https://doi.org/10.1177/0363546521999419.

    Article  PubMed  Google Scholar 

  7. Jarraya M, Roemer FW, Englund M, Crema MD, Gale HI, Hayashi D, Katz JN, Guermazi A. Meniscus morphology: Does tear type matter? A narrative review with focus on relevance for osteoarthritis research. Semin Arthritis Rheum. 2017;46(5):552–61. https://doi.org/10.1016/j.semarthrit.2016.11.005.

    Article  PubMed  Google Scholar 

  8. Hagmeijer MH, Kennedy NI, Tagliero AJ, Levy BA, Stuart MJ, Saris DBF, et al. Long-term results after repair of isolated meniscal tears among patients aged 18 years and younger: an 18-year follow-up study. Am J Sports Med. 2019;47(4):799-806. 10.1177/0363546519826088. At a mean follow-up of 17.6 years, this investigation demonstrated good to excellent long-term clinical outcomes after isolated meniscal repair in an adolescent population, even for those requiring reoperation. Additionally, complex multiplanar tears had more failures at short-term follow-up, but, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears as compared with other tear types.

  9. Ow ZGW, Law MSN, Ng CH, Krych AJ, Saris DBF, Debieux P, Wong KL, Lin HA. All-cause failure rates increase with time following meniscal repair despite favorable outcomes: a systematic review and meta-analysis. Arthroscopy. 2021;37(12):3518–28. https://doi.org/10.1016/j.arthro.2021.05.033.

    Article  PubMed  Google Scholar 

  10. Yeo DYT, Suhaimi F, Parker DA. Factors predicting failure rates and patient-reported outcome measures after arthroscopic meniscal repair. Arthrosc J Arthrosc Relat Surg. 2019;35(11):3146-64.e2. 10.1016/j.arthro.2019.06.016.

  11. Schweizer C, Hanreich C, Tscholl PM, Ristl R, Apprich S, Windhager R, et al. Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: a systematic review and meta-analysis with a minimum follow-up of 5 years. Knee Surg Sports Traumatol Arthrosc. 2021. https://doi.org/10.1007/s00167-021-06770-x.

  12. Karia M, Ghaly Y, Al-Hadithy N, Mordecai S, Gupte C. Current concepts in the techniques, indications and outcomes of meniscal repairs. Eur J Orthop Surg Traumatol. 2019;29(3):509–20. https://doi.org/10.1007/s00590-018-2317-5.

    Article  PubMed  Google Scholar 

  13. Pace JL, Inclan PM, Matava MJ. Inside-out medial meniscal repair: improved surgical exposure with a sub-semimembranosus approach. Arthrosc Tech. 2021;10(2):e507-e17. 10.1016/j.eats.2020.10.032. This paper describes a modified inside-out medial meniscus repair technique in which the retractor is placed inferior to the semimembranosus, which puts it directly in line with the needles’ trajectory. This modification may provide changes to limit the risk of neurovascular injury during medial meniscal repair.

  14. Wu IT, Hevesi M, Desai VS, Camp CL, Dahm DL, Levy BA, Stuart MJ, Krych AJ. Comparative outcomes of radial and bucket-handle meniscal tear repair: a propensity-matched analysis. Am J Sports Med. 2018;46(11):2653–60. https://doi.org/10.1177/0363546518786035.

    Article  PubMed  Google Scholar 

  15. Farrell C, Shamrock AG, Kiel J. Anatomy, Bony Pelvis and Lower Limb. Treasure Island (FL): Medial Meniscus. StatPearls; 2022.

    Google Scholar 

  16. Fox AJ, Wanivenhaus F, Burge AJ, Warren RF, Rodeo SA. The human meniscus: a review of anatomy, function, injury, and advances in treatment. Clin Anat. 2015;28(2):269–87. https://doi.org/10.1002/ca.22456.

    Article  PubMed  Google Scholar 

  17. LaPrade RF, Floyd ER, Carlson GB, Moatshe G, Chahla J, Monson JK. Meniscal root tears: solving the silent epidemic. J Arthrosc Surg Sports Med. 2. 10.25259/JASSM_55_2020.

  18. Chahla J, Serra Cruz R, Cram TR, Dean CS, LaPrade RF. Inside-out meniscal repair: medial and lateral approach. Arthrosc Tech. 2016;5(1):e163–8. https://doi.org/10.1016/j.eats.2015.10.017.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Dandy DJ. The bucket handle meniscal tear: a technique detaching the posterior segment first. Orthop Clin North Am. 1982;13(2):369–85.

    Article  CAS  Google Scholar 

  20. Koh JL, Yi SJ, Ren Y, Zimmerman TA, Zhang LQ. Tibiofemoral contact mechanics with horizontal cleavage tear and resection of the medial meniscus in the human knee. J Bone Joint Surg Am. 2016;98(21):1829–36. https://doi.org/10.2106/JBJS.16.00214.

    Article  PubMed  Google Scholar 

  21. Kurzweil PR, Lynch NM, Coleman S, Kearney B. Repair of horizontal meniscus tears: a systematic review. Arthroscopy. 2014;30(11):1513–9. https://doi.org/10.1016/j.arthro.2014.05.038.

    Article  PubMed  Google Scholar 

  22. Bedi A, Kelly N, Baad M, Fox AJ, Ma Y, Warren RF, et al. Dynamic contact mechanics of radial tears of the lateral meniscus: implications for treatment. Arthroscopy. 2012;28(3):372–81. https://doi.org/10.1016/j.arthro.2011.08.287.

    Article  PubMed  Google Scholar 

  23. Bedi A, Kelly NH, Baad M, Fox AJ, Brophy RH, Warren RF, et al. Dynamic contact mechanics of the medial meniscus as a function of radial tear, repair, and partial meniscectomy. J Bone Joint Surg Am. 2010;92(6):1398–408. https://doi.org/10.2106/JBJS.I.00539.

    Article  PubMed  Google Scholar 

  24. Zhang AL, Miller SL, Coughlin DG, Lotz JC, Feeley BT. Tibiofemoral contact pressures in radial tears of the meniscus treated with all-inside repair, inside-out repair and partial meniscectomy. Knee. 2015;22(5):400–4. https://doi.org/10.1016/j.knee.2015.05.008.

    Article  PubMed  Google Scholar 

  25. Woodmass JM, LaPrade RF, Sgaglione NA, Nakamura N, Krych AJ. Meniscal repair: reconsidering indications, techniques, and biologic augmentation. J Bone Joint Surg Am. 2017;99(14):1222–31. https://doi.org/10.2106/jbjs.17.00297.

    Article  PubMed  Google Scholar 

  26. Buckland DM, Sadoghi P, Wimmer MD, Vavken P, Pagenstert GI, Valderrabano V, et al. Meta-analysis on biomechanical properties of meniscus repairs: are devices better than sutures? Knee Surgery, Sports Traumatology. Arthroscopy. 2015;23(1):83–9.

    Google Scholar 

  27. Fisher SR, Markel DC, Koman JD, Atkinson TS. Pull-out and shear failure strengths of arthroscopic meniscal repair systems. Knee Surg Sports Traumatol Arthrosc. 2002;10(5):294–9. https://doi.org/10.1007/s00167-002-0295-x.

    Article  PubMed  Google Scholar 

  28. Rankin CC, Lintner DM, Noble PC, Paravic V, Greer E. A biomechanical analysis of meniscal repair techniques. Am J Sports Med. 2002;30(4):492–7. https://doi.org/10.1177/03635465020300040801.

    Article  PubMed  Google Scholar 

  29. Samuelsen BT, Johnson NR, Hevesi M, Levy BA, Dahm DL, Stuart MJ, Krych AJ. Comparative outcomes of all-inside versus inside-out repair of bucket-handle meniscal tears: a propensity-matched analysis. Orthop J Sports Med. 2018;6(6):2325967118779045. https://doi.org/10.1177/2325967118779045.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Nelson CG, Bonner KF. Inside-out meniscus repair. Arthrosc Tech. 2013;2(4):e453–60. https://doi.org/10.1016/j.eats.2013.07.006.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Mow V. Structure and function relationships of the menisci of the knee. Knee meniscus: basic and clinical foundations. 1992.

  32. Ménétrey J, Seil R, Rupp S, Fritschy D. Chondral damage after meniscal repair with the use of a bioabsorbable implant. Am J Sports Med. 2002;30(6):896–9. https://doi.org/10.1177/03635465020300062301.

    Article  PubMed  Google Scholar 

  33. Tachibana Y, Sakaguchi K, Goto T, Oda H, Yamazaki K, Iida S. Repair integrity evaluated by second-look arthroscopy after arthroscopic meniscal repair with the FasT-Fix during anterior cruciate ligament reconstruction. Am J Sports Med. 2010;38(5):965–71.

    Article  Google Scholar 

  34. Smoak JB, Matthews JR, Vinod AV, Kluczynski MA, Bisson LJ. An up-to-date review of the meniscus literature: a systematic summary of systematic reviews and meta-analyses. Orthop J Sports Med. 2020;8(9):2325967120950306. 10.1177/2325967120950306. This systematic review provides a thorough summary of systematic reviews and meta-analyses pertaining to the meniscus. With respect to isolated meniscal repairs there has been no difference in clinical outcomes between all-inside versus inside-out repairs. Additionally, overall complications for inside-out and all-inside meniscal repairs were similar.

  35. Westermann RW, Duchman KR, Amendola A, Glass N, Wolf BR. All-inside versus inside-out meniscal repair with concurrent anterior cruciate ligament reconstruction: a meta-regression analysis. Am J Sports Med. 2017;45(3):719–24. https://doi.org/10.1177/0363546516642220.

    Article  PubMed  Google Scholar 

  36. Cannon WD Jr, Vittori JM. The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees. Am J Sports Med. 1992;20(2):176–81. https://doi.org/10.1177/036354659202000214.

    Article  PubMed  Google Scholar 

  37. Warren RF. Meniscectomy and repair in the anterior cruciate ligament-deficient patient. Clin Orthop Relat Res. 1990;252:55–63.

    Article  Google Scholar 

  38. Scott GA, Jolly BL, Henning CE. Combined posterior incision and arthroscopic intra-articular repair of the meniscus. An examination of factors affecting healing. J Bone Joint Surg Am. 1986;68(6):847–61.

    Article  CAS  Google Scholar 

  39. Steadman JR, Matheny LM, Singleton SB, Johnson NS, Rodkey WG, Crespo B, Briggs KK. Meniscus suture repair: minimum 10-year outcomes in patients younger than 40 years compared with patients 40 and older. Am J Sports Med. 2015;43(9):2222–7. https://doi.org/10.1177/0363546515591260.

    Article  PubMed  Google Scholar 

  40. Grant JA, Wilde J, Miller BS, Bedi A. Comparison of inside-out and all-inside techniques for the repair of isolated meniscal tears:a systematic review. Am J Sports Med. 2012;40(2):459–68. https://doi.org/10.1177/0363546511411701.

    Article  PubMed  Google Scholar 

  41. Vint H, Quartley M, Robinson JR. All-inside versus inside-out meniscal repair: a systematic review and meta-analysis. Knee. 2021;28:326–37. https://doi.org/10.1016/j.knee.2020.12.005.

    Article  PubMed  Google Scholar 

  42. Elmallah R, Jones LC, Malloch L, Barrett GR. A meta-analysis of arthroscopic meniscal repair: inside-out versus outside-in versus all-inside techniques. J Knee Surg. 2019;32(8):750–7. https://doi.org/10.1055/s-0038-1668123.

    Article  PubMed  Google Scholar 

  43. Fillingham YA, Riboh JC, Erickson BJ, Bach BR, Yanke AB. Inside-out versus all-inside repair of isolated meniscal tears: an updated systematic review. Am J Sports Med. 2017;45(1):234–42. https://doi.org/10.1177/0363546516632504.

    Article  PubMed  Google Scholar 

  44. Everhart JS, Higgins JD, Poland SG, Abouljoud MM, Flanigan DC. Meniscal repair in patients age 40 years and older: a systematic review of 11 studies and 148 patients. Knee. 2018;25(6):1142–50. https://doi.org/10.1016/j.knee.2018.09.009.

    Article  PubMed  Google Scholar 

  45. Petersen W, Karpinski K, Bierke S, Müller Rath R, Häner M. A systematic review about long-term results after meniscus repair. Arch Orthop Trauma Surg. 2021;142:835–44. https://doi.org/10.1007/s00402-021-03906-z.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Kang DG, Park YJ, Yu JH, Oh JB, Lee DY. A systematic review and meta-analysis of arthroscopic meniscus repair in young patients: comparison of all-inside and inside-out suture techniques. Knee Surg Relat Res. 2019;31(1):1–11. https://doi.org/10.5792/ksrr.17.078.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Monk P, Garfjeld Roberts P, Palmer AJ, Bayliss L, Mafi R, Beard D, et al. The urgent need for evidence in arthroscopic meniscal surgery. Am J Sports Med. 2017;45(4):965–73. https://doi.org/10.1177/0363546516650180.

    Article  PubMed  Google Scholar 

Download references

Funding

The authors would like to acknowledge the support from the Foderaro-Quattrone Musculoskeletal-Orthopaedic Surgery Research Innovation Fund.

This work was partially funded by the following: National Institute of Arthritis and Musculoskeletal and Skin Diseases for the Musculoskeletal Research Training Program (T32AR56950). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA

    Erick M. Marigi, Sara E. Till, Jory N. Wasserburger, Anna K. Reinholz, Aaron J. Krych & Michael J. Stuart

Authors
  1. Erick M. Marigi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sara E. Till
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jory N. Wasserburger
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Anna K. Reinholz
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Aaron J. Krych
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michael J. Stuart
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael J. Stuart.

Ethics declarations

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines.

Conflict of Interest

Authors EMM and JNW report no financial disclosures. Author AJK reports royalties, consulting, and personal fees from the Arthrex Inc., reports grant funding from the DJO, LLC, and reports royalties from the Responsive Arthroscopy LLC. Author MJS reports royalties, consulting fees, and personal fees from the Arthrex Inc., reports personal fees from the Gemini Inc. Authors SET and AKR received partial grant funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases for the Musculoskeletal Research Training Program (T32AR56950).

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Meniscus

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marigi, E.M., Till, S.E., Wasserburger, J.N. et al. Inside-Out Approach to Meniscus Repair: Still the Gold Standard?. Curr Rev Musculoskelet Med 15, 244–251 (2022). https://doi.org/10.1007/s12178-022-09764-5

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-022-09764-5

Keywords

Search

Navigation