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All-Inside Repair of Bucket-Handle Meniscal Tears: Clinical Outcomes and Prognostic Factors

Background: There is no consensus on technique of choice for repair of bucket-handle meniscal tears (BHMTs). Purpose: To determine factors that affect patient outcomes and failure rates in patients undergoing all-inside repairs of BHMTs. Study Design: Systematic review. Methods: A systematic review of 3 databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. All English-language literature from 1993 to 2019 describing clinical outcomes for patients undergoing all-inside BHMT repair with ≥12-month follow-up was reviewed by 2 independent reviewers. Patient characteristics (patient sex, age), intraoperative factors (laterality, concomitant procedures, surgical technique, implants utilized), and postoperative outcomes (failure rates) were analyzed. Study quality was evaluated with the Modified Coleman Methodology Score (MCMS). Results: Fifteen studies (1 level 1, 4 level 3, 10 level 4) with 763 total patients (64% male; average age, 26.4 years [range, 9-58 years]; average follow-up, 39.8 months [range, 12-120 months]) including 396 all-inside BHMT repairs were included. Six devices were used for repair including the Meniscal Repair System, FasT-Fix, Meniscus Arrow, Biofix Arrow, RapidLoc device, and PDS II suture, with failure rates of 13.5%, 22.4%, 27.1%, 42.9%, 45.2%, and 0%, respectively. The overall repair failure rate was 29.3% at an average of 13.0 months (range, 5.0-32.4 months), but 19.0% for devices still in use. The RapidLoc and Biofix Arrow had higher failure rates than other devices (P = .0003). Women (31%) were less likely to experience a failure than were men (69%) (P = .03). Longer follow-up duration resulted in higher failure rates (>30 months, 34.4%; <30 months, 23.4%; P = .016). In 4 studies reporting on both all-inside and inside-out repairs, no significant differences in failure rates were observed. No significant differences in failure rates were found between medial and lateral repairs nor repair with and without concurrent anterior cruciate ligament reconstruction (P > .05 for all). The overall average MCMS was 54.4 ± 12. Conclusion: The overall failure rate after all-inside repair of BHMTs is 29.3% at an average of 13.0 months, with no difference in failure rates between medial and lateral meniscal repairs. The variables shown to negatively affect the failure rates were the RapidLoc and Biofix Arrow, male sex, and longer follow-up duration.