I do have some disclosures. I am a consultant for Smith & Nephew, which is a company that is important in this talk. So all inside is my talk, and it's not for every tear, and actually no single technique is good for every tear. So all inside is best for middle and posterior third tears. It's not good for anterior third tears. So this is the fight against the inside-out, which the next speaker will talk about. My problem with the inside-out, which I used to do a lot before newer technology was available, is that it requires two separate needle passes that you pass through the meniscus and through the capsule. So any structure that lies between the path of these two needles is at risk. And this has resulted in the need for posterior incisions, and in some studies on average about a 9% neurovascular injury rate. So because of those reasons, I rarely do them anymore. So all inside has a lot of benefits, besides eliminating the posterior incisions and the neurovascular complications, it's much faster. One recent study showed it was more than twice as fast to perform a complete meniscus repair. So now in the United States, 80% of all meniscus repairs are done all inside. So it's important to know whether all inside is as good as inside-out. And biomechanically, the answer is yes. When you compare sutures and fixators, both techniques restored meniscus biomechanics to near intact levels. How about clinically? Well, there's been meta-analyses and systematic reviews that show that the failure rate is about the same, with a slightly higher complication rate using inside-out suture. Now meniscus fixators, while safe, are not 100% safe, because they rely on a deployed anchor and a thin person where it's subcutaneous. You can get foreign body reactions and subcutaneous irritation. And especially at the posterior horn of the lateral meniscus, Mark Miller showed us you're very close to that popliteal artery. And there have been cases of that. When we talk about all inside, in the 1990s and 2000s, we were talking about meniscal fixators. But this decade has brought a new advancement in all inside repair. We now have instruments that give the arthroscopic placement of sutures that are perpendicular to the meniscus. This evenly compresses both the tibial and femoral surfaces and does not rely on piercing the capsule for fixation. So it eliminates all those extra capsular risks. Not only that, it opens the possibility of repairing more tear patterns. So all inside circumferential sutures, is it biomechanically as good or better than fixators and inside-out sutures? And the answer is yes. Higher loads to failure with vertical tears, lower gap formation than inside-out sutures, and with radial tears, improved biomechanics than inside-out sutures. This has led to a changing approach in horizontal cleavage tears, which we've been traditionally taught, if you're old enough, to leave alone with benign neglect or to resect one of the leaflets. Why repair this? You can't. They're degenerative. They're partly avascular. And we've been told that repair is really not an option as late as 2014. I did a systematic review in that year and looked at nine studies that showed actually a 78% success rate. Many of them open techniques. Now with the circumferential stitch, there's been renewed interest in horizontal cleavage repair. And since 2017, you can see five articles listed about that. We're doing a prospective, non-randomized, multi-center investigation of all suture-based repair of horizontal tears. These are often degenerative tears. These are non-traumatic tears. We're including patients that are up to age 60, our oldest is 57, and we're going to be carrying it out for two years. And the six-month data shows marked improvement in all knee scores. We'll hopefully present that when we have the two-year data. Exciting thing about the newer techniques of all-inside suturing is that we're able to consider repair of white-on-white tears, which, as Dr. Gallagher noted, meniscal repair of avascular tears is controversial, and some would say inappropriate. And yet he had a 68% success rate, and that's isolated without an ACL reconstruction, while Noyes found a 75% success rate in 71 tears. And he concluded that vascularity is not needed for a successful repair. We're being bombarded in our literature and in the media that meniscectomies are not effective and unnecessary. So meniscal repair is something that's going to be more important for us. All-inside techniques allow us to address previously irreparable tears, white-on-white, degenerative, like the one I just showed, not only because potential future insurance company pressure of not paying for a meniscectomy, but probably because it's the best for our patients. Thank you.

meniscus repair

all inside technique

inside-out technique

neurovascular injury

meniscal biomechanics