AANA Lab Course 913 - Advanced Knee Course-All-Inside, Inside-Out, Outside-In_ How I Decide and How I Do It Faculty Lecture

All-Inside, Inside-Out, Outside-In_ How I Decide and How I Do It Faculty Lecture_ Kevin F. Bonner, MD

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Dr. Kevin F. Bonner discusses meniscus repair techniques—Inside-Out, Outside-In, and All-Inside—highlighting their indications, advantages, and limitations. Each method has unique applications depending on tear location, complexity, and surgical goals.

<strong>All-Inside Repair</strong> uses suture-based pledget implants inserted arthroscopically without posterior incisions. Its advantages include time savings, avoidance of additional incisions, no need for an experienced assistant, and potentially fewer complications. Contemporary devices provide reliable fixation strength. However, challenges include risk of device malfunction, difficulty in tight compartments, possible meniscal damage, higher initial costs, and concerns about neurovascular complications and cyst formation. All-inside is often ideal for smaller, posterior meniscal tears requiring 1-5 implants but may not be suitable for larger or complex tears.

<strong>Inside-Out Repair</strong> is the "gold standard," offering greater precision and versatility with the ability to place more sutures using smaller needles, thus causing less iatrogenic damage. It is preferred for larger, complex, or meniscocapsular tears. Disadvantages include the need for a posterior incision, more surgical time, an experienced assistant, and slightly higher technical demands, but it carries less risk of neurovascular injury when the anatomy is known. Studies comparing inside-out and all-inside repairs show similar failure and complication rates over medium-term follow-up, although evidence is limited and selection bias exists.

<strong>Outside-In Repair</strong> is optimal for anterior third meniscus tears, with safe application in the middle third but not recommended for the posterior third. Techniques include various knot-tying methods and use of non-absorbable sutures.

Dr. Bonner emphasizes the importance of maintaining proficiency in all three techniques to provide optimal, individualized care—not simply choosing the easiest option. He notes a concerning trend of younger surgeons favoring all-inside repairs exclusively, sometimes leading to increased meniscectomy when other repair options are feasible. Comprehensive knowledge and skill in all repair options enable better anatomic repairs, minimizing meniscal damage and improving outcomes.

In summary, successful meniscal repair relies on tailoring the approach to tear characteristics and patient anatomy, integrating inside-out, outside-in, and all-inside methods as appropriate to preserve meniscal function and joint health.

Keywords

meniscus repair

inside-out technique

outside-in technique

all-inside technique

meniscal tear

arthroscopic surgery

suture-based implants

neurovascular complications

meniscectomy

surgical proficiency