The gold standard for repair of bucket-handle tears in the red-white or red zone of the meniscus has been inside-out repairs, but increasingly all-inside techniques have been used with mixed results. A 2021 systematic review and meta-analysis revealed an overall failure rate of 14.8% for arthroscopic repairs of bucket-handle tears, and identified only medial-sided tears and tears performed in isolation rather than with ACL reconstruction as relative risks for failure of repair.⁹ The overall failure rate is far less than reported in a prior systematic review of bucket-handle repairs that was limited to all-inside implants and did not include inside-out repairs, which found a 29.3% failure rate. The higher failure rate may be due to inclusion of older all-inside implant types that had a high failure rate.¹⁰ Although a significant difference was not detected for failure rate between all-inside versus inside-out repairs in the 2021 meta-analysis, a trend toward more failures in the all-inside repairs was noted. Additionally, bucket-handle tears had a significantly
higher failure rate than simple longitudinal repairs, but a similar rate when compared with simple radial or horizontal repairs.⁹ A 2019 review of factors predictive of failure of meniscus repair that included bucket-handle tears as well as simple repairs found concomitant ACL reconstruction to be a protective factor for meniscal healing, but it is unclear how generalizable these findings are to bucket-handle tears.¹¹

Additionally, a systematic review of studies comparing inside-out with all-inside repairs included both bucket-handle and simple repairs, but excluded meniscal arrows and screws, thus including only modern all-inside implants.¹² This study found no difference in outcomes between all-inside repair and inside-out repair including clinical and anatomic failure rates, functional outcome scores, and complication rates. Clinical failure was noted to be 11% versus 10% and anatomic failure to be 13% versus 16% for inside-out versus all-inside repairs, respectively. A 2021 MRI follow-up study looking at a series of all-inside bucket-handle repairs 2 years postoperatively found 90% healed and 10% had recurrent bucket-handle tears. The authors suggest that 90% healing on MRI with 10% anatomic failure is similar to results attained with inside-out repair.¹³ High-quality studies are particularly lacking for comparisons of all-inside and inside-out repairs of bucket-handle tears.

Meniscal root tears have become an increasing area of interest. Medial and lateral meniscal root tears present differently. Medial tears occur more often in older patients, with a higher body mass index, and with more evidence of baseline osteoarthritis.¹⁴ Lateral meniscal root tears are more likely to occur in the setting of concomitant ligament injury and demonstrate less extrusion on MRI.¹⁴ The meniscus root is an essential component in maintaining the hoop stresses. There is increasing evidence that meniscal root repair in patients should be the standard of care. In the absence of subchondral collapse, greater than 2 cm² grade 3+ chondral defects, Kellgren-Lawrence grade of 3 to 4, malalignment greater than 5°, and instability, meniscal root repair has been found to be effective at avoiding progression to TKA. In a 2020 study, control patients matched by age, sex, and Kellgren-Lawrence grade reported 60% of meniscectomies progressed to TKA at an average of 74 months, compared with 26.7% of nonsurgical treatment and zero meniscal root repairs.¹⁵ This study also showed less progression of arthritis. A 2021 systematic review found that repair improves functional outcomes scores (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, and Tegner) and slows progression, but does not prevent osteoarthritis.¹⁶