Failure rates increase over time and are higher following medial arthroscopic bucket-handle meniscal repair: A systematic review and meta-analysis.

Abstract

Purpose: Bucket-handle meniscal tears (BHMTs) constitute a technically demanding form of meniscal injury. However, the incidence of repair failure and the factors influencing outcomes remain incompletely characterised. This study aimed to estimate the pooled failure rate after bucket-handle meniscal repair (BHMR) and to identify variables associated with unsuccessful healing.

Methods: A systematic review and meta-analysis (SRMA) was performed to identify studies published from January 2005 through 2026 evaluating arthroscopic BHMR. Eligible designs included randomised trials, cohort studies and case series with at least 15 patients. Random-effects or fixed models were used to calculate pooled failure proportions and odds ratios. Subgroup analyses and meta-regression were conducted to explore potential predictors of failure.

Results: The pooled BHMR failure rate was 21.5% (95% CI: 16.3%-27.8%; I ² = 79.2%). Failure rates increased with longer follow-up (β = 0.12, p < 0.01). Medial repairs had significantly higher failure odds than lateral repairs (OR = 2.20, p < 0.001, pooled failure rate: 18.9% vs. 12.1%). No significant differences were observed for tear zone (red-red vs. white-red), sex or isolated (pooled rate: 24.3%) versus concomitant ACLR (pooled rate: 14.9%). Publication bias was suggested by Egger's test (p = 0.02).

Conclusion: BHMRs carry a substantial 21.5% failure rate that increases over time, with medial tears at significantly higher risk than lateral tears. Concomitant ACL reconstruction and tear vascularity did not significantly impact failure odds. High-quality prospective studies are needed to optimise patient selection and long-term counselling.

Level of evidence: Level II.