All-Inside Medial Meniscus Root Repair Improves Function With Results Comparable to Tibial Pullout Method, but Both...

To (1) synthesize available clinical data on medial meniscus posterior root tear all-inside repair, (2) compare biomechanical outcomes of all-inside and transtibial pullout repair technique, and (3) compare clinical outcomes of all-inside and transtibial pullout repair technique.

A systematic search was performed across PubMed, Embase, Scopus, and Web of Science through August 2025. All studies reporting the clinical outcomes of medial meniscus posterior root tear all-inside repair were included. Furthermore, all studies that compared clinical or biomechanical outcomes of all-inside versus pullout repair were included. A qualitative synthesis of the data including functional scores, meniscus healing, and extrusion along with heterogeneity and risk of bias assessments is provided.

Twelve studies (8 clinical, 4 biomechanical) met inclusion criteria. Four clinical studies (n = 153; mean follow-up, 23.7 months) directly compared the 2 techniques. Both repairs yielded significant postoperative improvements in patient-reported outcome measures. One study reported the proportions of patients achieving minimal clinically important difference to be higher in the all-inside group. The range of postoperative medial meniscal extrusion in the all-inside group was comparable with the pullout group (-2.2 mm to -0.6, vs -1.9 to +0.1). The change in Lysholm score ranged from 20.8 to 38.2 in all-inside and 11.0 to 45.8 in pullout repair. Complete meniscus healing rate ranged from 64.7% to 67.8% in all-inside and from 21.5% to 85.7% in pullout repair. There are only 4 studies that compared the biomechanical characteristics of all-inside versus transtibial pullout repair. All-inside repair showed higher failure loads in 2 studies, but overall results are contradictory; neither technique showed consistent superior biomechanics.

The all-inside repair, like the conventional pullout method, is a safe and effective method of medial meniscal root repair with reliable effects on joint's biomechanics, patients' function, minimal clinically important difference rates, and meniscus healing. Importantly, neither technique consistently restores meniscal position, because meaningful correction of extrusion remains unachieved. Given the substantial heterogeneity and predominantly nonrandomized nature of the available evidence, surgical decision-making should be individualized based on procedural context, concomitant procedures (e.g., osteotomy or additional tunnel requirements), and surgeon preference rather than presumed differences in efficacy.

All-inside and transtibial pullout meniscus root repair both can restore near-native joint biomechanics at time zero, with similar load to failure and both methods fail to correct extrusion. The persistent failure to correct extrusion highlights a fundamental limitation of current repair strategies and supports the need for adjunctive approaches, such as meniscal centralization, to optimize long-term joint preservation.