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Outcomes of Combined All-Inside With Inside-Out or Outside-In Versus Inside-Out Meniscal Repair Techniques for Bucket-Handle Meniscal Tear

Mohamed Shakshak,S. Elghazaly,H. Diab,Amr H. Ahmed,Mahmoud M Abdelwahab

Published 2026 in Cureus

ABSTRACT

Bucket-handle meniscal tears (BHMT) are frequently encountered in young, physically active individuals and pose a unique clinical challenge due to their complex morphology and biomechanical implications. The inside-out meniscal repair technique has been regarded as the gold standard due to its robust fixation strength and reproducibility. However, advancements in arthroscopic technology have led to the development of all-inside and hybrid repair techniques, offering less invasive alternatives with comparable biomechanical outcomes and reduced surgical morbidity and time. The purpose of this study is to compare the short-term functional outcomes of different repair techniques of BHMT, comparing the inside-out meniscal repair technique as a gold standard with combined all-inside with outside-in and all-inside with inside-out hybrid techniques. During the period from 2019 to 2024, this prospective randomized controlled study evaluated the functional outcomes of 45 patients who underwent arthroscopic repair of BHMT using either the inside-out meniscal repair technique, combined all-inside with outside-in hybrid technique, or combined all-inside with inside-out hybrid technique. Patients were assessed preoperatively and at three, six, and nine months postoperatively using the Lysholm Knee Scoring Scale. Patients were selected and randomized to one of the three groups. Clinical evaluation was performed using the Lysholm score, as in patients treated with the inside-out technique, the preoperative score was 36.93 ± 12.13 which increased after three months to 75.33 ± 9.54, after six months to 86.57 ± 6.05, and after nine months to 96.07 ± 2.81 indicating fewer symptoms and higher levels of function. Likewise, in patients treated with combined all-inside plus outside-in, the preoperative score was 39.67 ± 10.37, which increased after three months to 77.57 ± 10.6, increasing after six months to 85.78 ± 5.33 and after nine months to 95.89 ± 3.44. In patients treated with combined all-inside plus inside-out, the preoperative score was 42.53 ± 12.94, which increased after three months to 72.13 ± 9.78, increasing after six months to 82.58 ± 8.18 and after nine months to 94.27 ± 4.58. The comparison between the three groups at each time point revealed no statistically significant difference. Except for one case treated with the combined all-inside plus outside-in which was lost to follow-up postoperatively, the mean improvement in Lysholm score was 58.47 ± 13.69 in patients treated with the inside-out technique, 52.43 ± 14.91 in patients treated with combined all-inside with outside-in, and 47.33 ± 15.62 in patients treated with combined all-inside plus inside-out which was not significantly different between the three groups. This finding emphasizes the validity and comparable results of various meniscal repair techniques.

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