All-Inside Versus Inside-Out Suture Techniques in Athletes Undergoing Arthroscopic Meniscal Repair: A Systematic Review and Meta-analysis.

Background: Meniscal tears are a common knee injury in athletes, necessitating effective repair techniques. Despite the prevalence of meniscal tears, there is limited literature comparing the efficacy of the 2 primary suture methods-all-inside and inside-out-in the athletic population.

Purpose: To evaluate the postoperative outcomes and failure rates of the all-inside versus inside-out suture techniques in meniscal repairs among athletes.

Study design: Systematic review; Level of evidence, 4.

Methods: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive search was conducted across the PubMed, Cochrane, and Embase databases on July 26, 2023, yielding 245 studies, of which 7 were included in this review. Studies reporting postoperative outcomes and failure rates of both suture techniques were included. Failure was defined as the need for subsequent surgery due to a persistent meniscal tear. Outcome measures included the Tegner, Lysholm, and International Knee Documentation Committee scores. Differences between groups and subgroups were assessed using the Welch t test and the odds ratio. Wilcoxon tests were used as a sensitivity analysis to confirm the results of the Welch t tests. Heterogeneity was assessed with the I ² statistic and the Bartlett test. All statistical analyses were done using R.

Results: Seven studies-published between 2009 and 2023-met the inclusion criteria, including 469 operations in 458 patients. A total of 199 operations used the all-inside technique, and 270 operations used the inside-out technique. Of the 469 operations, 377 had documentation on laterality (medial meniscal repair versus lateral meniscal repair), with 167 patients undergoing medial meniscal repair and 210 patients undergoing lateral meniscal repair. Each all-inside repair was done with the Fast-Fix device. The all-inside technique showed a statistically significant increase in failure rate compared with the inside-out technique (23.1% vs 12.2%; P = .003). This trend was exaggerated in all-inside repairs for the medial meniscus versus the lateral meniscus (58.1% vs 11.8%; P = 2.6 × 10^-5). When excluding all radial tears, the all-inside technique again had an increased rate of failure compared with the inside-out repairs (20.7% vs 8.3%; P = .01). No significant difference was found in postoperative Tegner scores between all-inside and inside-out repairs (5.9 vs 6.5; P = 0.45).

Conclusion: Our review demonstrated that medial meniscal repairs with the all-inside technique using the Fast-Fix device had a higher failure rate compared with those with the inside-out technique; this trend is not seen for lateral meniscal repairs. Based on the findings of this study, surgeons should consider the inside-out technique first for athletic patients presenting with medial meniscal tears who want to return to their sport. Given the limited scope of existing studies combined with more recent utilization of novel all-inside meniscal repair devices that may not be captured in the present study, additional high-quality, prospective studies in this area are needed to validate these findings.