Meniscus Repair Technique Must be Determined on a Tear-by-Tear Basis: Hybrid Techniques Plus Biologics are Optimal

Bucket-handle meniscus tears alter knee biomechanics and significantly elevate the risk of osteoarthritis when the tissue is not preserved. Consequentially, meniscus repair is preferred whenever possible to optimize load distribution and knee stability, with the overall goal of joint preservation. Bucket-handle meniscus tears have a higher rate of repair failure compared to many other tear patterns, and both the inside-out (IO) and all-inside (AI) techniques are acceptable options, each with distinct advantages and disadvantages. Both have demonstrated improved clinical outcomes with similar failure rates. IO is cost-effective and allows less meniscal trauma due to small diameter needles, while risks include increased surgical time, increased risk of infection, and need for 1 or more skilled assistants. AI avoids an extra-incisions and extra assistants and shows decreased surgical time, while complications can include hardware irritation, chondral and neurovascular injury (particularly for posterolateral repairs), and motion loss. Hybrid repair using AI for posterior tears, and IO for middle-third, and outside-in for the anterior meniscus is cost-effective and efficacious. Biologics to promote healing through mechanical stimulation of tear, notch marrow venting, trephination, and/or platelet-rich plasma is an essential adjunct.