Dr. Brian Lau:

Welcome, everyone. I'm Dr. Brian Lau from Duke University. Today I have the privilege of speaking with Dr. Sachin Allahabadi, who is a clinical assistant professor at Houston Methodist Hospital. He was an author on the paper titled "All-Inside and Inside-Out Repair Techniques for Bucket-Handle Meniscus Tears Both Result in Improved Patient Outcomes and a Broad Range of Failure Rates: A Systematic Review," which was published in the February 2024 article in Arthroscopy Journal.

Welcome, Sachin, thanks for joining us this morning and I appreciate you taking the time.

Dr. Sachin Allahabadi:

Yeah, thanks so much for having me. I love talking about the meniscus, so I'm excited to be here and really grateful to be invited to join you all.

Dr. Brian Lau:

Yeah. Well, bucket handle meniscus tears are obviously one of those cases in sports medicine where there's a sense of urgency in getting to them but how we repair them may have evolved a little bit over time. I thought your paper was very interesting and timely. But before we get into results, I want to get a sense of how it came to be. Was there something clinically in the OR or clinic that kind of prompted you guys to look into this question?

Dr. Sachin Allahabadi:

Well, it's a great question and in today's society there's a big push towards meniscal preservation. If you're on social media, which I know you are, I'm sure you see all the hashtags, #savethemeniscus, and it's out there largely for a good cause. We know that meniscal preservation when possible can improve our ability to resist loads in the lateral compartment in the long-term and limit progression to ultimate degenerative changes in osteoarthritis. There's been many studies recently increasingly looking at how to optimize repair techniques and success in multiple different types of tears that were traditionally felt to be less reparable, including those horizontal cleavage tears, radial tears. We know that each type of tear in this case behaves quite differently. Bucket handle tears, as you alluded to, are really their own unique entity. If they're not able to be repaired or not repaired, they can often have really substantial consequences given their extended involvement and often require as much as a subtotal meniscectomy in the case of a debridement.

This study really comes about from our group's and my mentor, Jorge Chahla's, work and trying to really preserve the meniscus and just trying to figure out what we can do to continue to optimize our technique.

We also know that even if we do try to repair bucket handle tears, the failure rates in literature have been cited to be higher than failure rates for other types of repairs. That can be for really many reasons and that can be due to the extent of tearing, the number of points of stability necessary to achieve a robust repair. The question really becomes is as our meniscal repair techniques evolve, do still require the historical gold standard approach of an inside-out repair technique for this unique entity of tears or if it's safe to transition to a more of a quicker, less invasive all-inside approach. In the study, what we really did was try to seek to compare if isolated treatment of bucket handle tears with a completely all-inside technique or totally an inside-out technique were different in terms of PROs, failure rates, risks of failure, and complication profiles.

Dr. Brian Lau:

Yeah, I think you're definitely right. There's a bigger push to preserve the meniscus and coming up with the best ways we can do that. Also the evolution of our all-inside devices has changed a lot since the first initial studies were out. I think this, like you said, very timely and I think you guys address a little bit of that in your article now. Just briefly, just so our readers understand what the methodology was for the study and just a couple, few pointers of how you guys did that.

Dr. Sachin Allahabadi:

Yeah, well this was a systematic review study and we looked at studies primarily in the last decade that were level one to four human clinical studies. We sought to evaluate those with at least a minimum of two-year mean follow up. We collected multiple outcomes. We assessed the study quality, collected article-level data study characteristics including information on patients, follow-up, the types of devices and surgical technique that was utilized. Then also we sought to evaluate the effect of concomitant procedures and augmentation procedures for the meniscal repair, and looking at all this data together to try to come up with conclusions or at least broad comparisons of different rates of the success or failure and risk factors for failure from these repairs. Given the heterogeneity in the available literature, we didn't really pull any data, but really it's more of a summary of the available data and what the current literature is showing.

Dr. Brian Lau:

Sure. Yeah, I think it's hard, like you mentioned there's a lot of heterogeneity in the literature. I'm curious as you're going through it, because you guys didn't quite mention it was when you were reviewing the different articles, was it easy to find ones were all-inside and all-inside-out versus some that were hybrid? Was that something you guys had to address during review of the articles?

Dr. Sachin Allahabadi:

Yes, certainly. There are certainly many techniques where people describe using a hybrid technique, so sorting out which ones were just isolated to all-inside or inside-out did require some filtering. I think that's a really good point is that this article really is seeking to compare an isolated approach with an all-inside approach compared to an isolated inside-out approach. Certainly a hybrid technique is very valid and important tool to have. Really the focus of this study in particular is isolating the two to see if one may be superior to another or what the outcomes are when you look at the techniques themselves.

Dr. Brian Lau:

What are some of the big key takeaways that you and your co-authors kind of took away from this study after you guys did the big systematic review?

Dr. Sachin Allahabadi:

Well, I think firstly to me, one thing I would say is we are definitely continuing to improve in our meniscal repair techniques over time. I think number one, when you look at ... There's a reason an inside-out technique has been traditionally considered the gold standard and it's biomechanically very strong and allows for multiple points of fixation. But with modern all-inside devices, really the failure rates are really not substantially different even for these bucket handle meniscus tears. I think with modern all-inside devices, it's important to know that if we do get an adequate repair, they probably function if not the same or very similar to an inside-out repair.

Certainly another thing to take away is that the risk and complication profiles really are inherent to each surgical technique. We know that for the all-inside devices there's not really the same risks with the inside-out approaches. Most of the inside-out complications related to the additional incision including infections or complications that we found related to the actual sutures or knots themselves on the external asset of the capsule. But overall really there is, to me, I take away from the study that there's validity to using either approach, there's reasons to use each, and that surgeons who feel comfortable with one or the other should feel confident they can use whichever technique they feel is appropriate at the time of surgery and understand that there's just a different risk or complication profile, but that the failure rates may not be that substantially different.

Dr. Brian Lau:

I think you mentioned a little bit here kind of the difference of complication profile. Maybe you could highlight a little bit of what you mean by that so that we just can weigh the differences between the two techniques.

Dr. Sachin Allahabadi:

Yeah. Well, in the study we found firstly the most common complication in both groups is really decreased range of motion or adhesions or scarring. This has to do with the fact that many meniscal repair devices, of these all-inside devices, are capsular-based. There's an anchor point or fixation from the menaces to the capsule and certainly an inside-out technique does the same thing. That's the number one most common complication we saw both in both groups. In the all-inside the group, I would've expected more complications related to the actual implants themselves, but in this study, in the studies that were included, there were no reported complications related to the actual device implants themselves.

On the other hand, in the inside-out group, there were suture complications. There were those few small infections that were noted, likely related to the additional incision, additional surgical time, and knot issues including an adjacent parameniscal cyst that was felt to be due to a knot and others. Really I summarize it in my head as the inside-out approach has basically complications related to adding the extra incision and tying external knots in the capsule that the all-inside approach does not have.

Dr. Brian Lau:

Gotcha. Yeah, that makes sense. I think one of the things that you guys also did really well and highlighted with one of your figures was comparing the modern all-inside versus the older all-inside, which I think a lot of our previous literature was based on. Just kind of get your takeaway from that and maybe just the key takeaway from that and if you guys did a direct comparison to that and how you guys thought about it.

Dr. Sachin Allahabadi:

Yeah, and that's honestly I think another really key point of this study and another thing to be looking for moving forward in future studies is that a lot of our literature is based on implants and devices that we don't even really use anymore. The development and progression of these all-inside devices has been honestly incredible. I used a device the other day that I swear I bent it 180 degrees and it still worked. They allow for much greater access, they have better fixation than prior devices. Yeah, in the study we tried to look a little bit at is there a difference between using the older all-inside devices versus a more modern all-inside device? This study with its study design can only include so much, but one thing that I would note is that the rate of failure, the range of failure was less using modern implants.

The older implants, you look at them in the studies that use more older implants, the range was much wider in terms of the failure rates reported versus when you have the newer implants, the range is much lower. This likely suggests that our modern implants are doing much better at being successful, providing better fixation, and providing better access to repair the tears. Also in addition to those things, they're easier to use and the more easier they are to use, the more likely people are to put in more fixation points, which is likely necessary for these bucket handle meniscus tears.

Dr. Brian Lau:

Yeah, I think that's really valid points. I think the technology has advanced so much and makes it really easier to use, but one other thing to consider with that technology is cost. As we get newer techniques, new implants, there's an added cost to that. If you get a bucket handle meniscus tear and you're thinking about taking care of it, are there other factors? I think primarily we would hope that everything that matter's about outcome, but just similar as you highlighted, are there other factors such as cost or assistance, or assistance being help in the OR, that drive you one way or another that may be variable based on each person's individual practice?

Dr. Sachin Allahabadi:

Yeah, and that's a great point. I think cost is always something we should have in the back of our mind and being cost-conscious surgeons can help our overall health system and it's very important. There's no doubt that the cost of the surgical materials or implants is less with an inside-out and outside repair technique relative to using numerous all-inside devices. But the other part of cost I think that we should also remember is that there's increased time in the OR with using an inside-out technique, with including performing the exposure, getting optimal and safe retractor placement and wound closure. There's a balance that, but yes, probably from most of the data I'm familiar with, the inside-out and outside-in techniques are more cost-effective. But that being said, for me, my primary goal still is getting an adequate repair and I don't typically consider cost as directly while I'm deciding my fixation method.

I think you also mentioned the importance of having an assistant available and I've learned to plan to have help available for any meniscus repair case. There's just so many different types of flavors of tears and plans can change quickly after a drop-in evaluation. I think preparing for all possible scenarios with assistance available and also having a broad spectrum of equipment ready to go is critical. Whenever I have a complex meniscus tear or a known bucket handle tear, I'm marking out the inside-out approach and incisions at the beginning of the case so that I'm ready to go right away if I need it. I think just really being prepared to do anything and having the assistant available if you can, is really critical for these meniscus repair cases.

Dr. Brian Lau:

Yeah, I agree with that. Planning for something like this is really important. Your study also mentions a little bit about the difference of medial and lateral. I'd say when you're planning out your surgery for a medial or lateral, are there different considerations or techniques that you're thinking about?

Dr. Sachin Allahabadi:

Yeah, certainly. Medial and lateral repairs, they really behave very differently and we know that as well that the medial side is more prone to failure than the lateral side. I don't think that's just because we are inherently better at repairing lateral meniscus tears in the medial side. I think that in our review here and in other literature on meniscus tears in general and not just bucket handle tears, the medial meniscus tends to have a higher failure rate than the lateral meniscus, and that's looking at all tear types. I think a lot of this comes down to anatomy. We know that the medial and lateral meniscus are structurally very different. The medial meniscus has more attachments to the adjacent deep MCL and capsule and has less inherent mobility than the lateral meniscus.

The lateral meniscus has fewer attachments to surrounding capsule and plateau. Likely when we're repairing the lateral side, we can get away with more because the greater mobility maybe gives us a little bit more forgiveness and tolerance to stress than the medial side after repair.

I think when I'm thinking about approaching each of these, firstly, there may be more points of fixation and stability necessary for an adequate medial sided repair. That's number one. Number two I think is improving access on the medial side. I routinely trephinate the MCL to improve my access ability to work and see and to make sure that I can really get around to every part of the meniscus that I possibly can while also minimizing chondral damage. But in general, I think those are the main considerations about medial and lateral repairs. We also know that medial-sided repairs, when they're isolated relative to a medial-sided repair with an ACL reconstruction, is its own higher risk of failure.

Dr. Brian Lau:

Right. Yeah, and I think your study does a good job of highlighting both those points that you made, that the medial side fails more and so maybe you want to consider more points of fixation, which may lean more one way or another. But we're kind of running up on time here, but I wanted to ask you, so run-of-the-mill bucket handle meniscus tear in a 20-year-old comes in, it's on a medial side. When you're planning, what's your technique, how are you going to do it?

Dr. Sachin Allahabadi:

Yeah, well this question is really timely for me because it seems to be raining bucket handle meniscus tears in my clinic here in Houston. I've done four in the last two weeks and I have another two I just signed up this weekend and I have another guy coming to my clinic tomorrow.

Dr. Brian Lau:

It's great for your practice, but obviously your patients must be having a tough time.

Dr. Sachin Allahabadi:

Yeah. But right now my preferred personal technique is still a hybrid of methods and that really is based on location, the extent of the tear, assume we're talking about vertical, longitudinal, or displaced bucket handle tears. For the posterior horn, I'm primarily using all-inside techniques and then as I get to the posterior horn to body junction, I'll start to transition to an inside-out approach. I use that throughout the body and using an alternating vertical mattress suture on the superior and inferior aspects of the tear. Then as I get more anterior towards the anterior horn, I utilize an outside-in technique.

For me, this combination of techniques works well, allows me to have some versatility, and if I find sort of at the end of the repair there are gaps in any location, whether that's the body, the posterior horn, or the anterior horn, then I typically will go back in with an all-inside device to see if I can get the right angle to fill the gap or get an additional area of fixation that I felt that I missed. Again, like I was mentioning, I think a lot of these modern all-inside devices really allow you to get angles that we didn't really think we could ever get before.

In your scenario, you mentioned a medial-sided tear. I just add again that I routinely perform an MCL trepanation to improve access in those cases and that's how I'm currently doing it. I also would add that I will typically add some sort of bone marrow stimulation marrow venting or notch micro-fracture to an isolated case. In the case of an concomitant ACL reconstruction or a case where I'm drilling tunnels, I don't find that necessary, but I'm trying to do whatever I can to improve the healing environment for these tears.

I think the healing environment is another big area of conversation as to what can we do to stimulate healing because we can get a great repair at the time of surgery, you can use hybrid techniques, all-inside techniques, all-inside-out techniques, whatever you'd like. But then if you get stability and there's no healing, then ultimately we don't win the game that we're trying to win. Getting the right clinical environment with marrow venting or adding biologics or if it's just remembering to use a rasp to freshen up the edges of the tear all can be really valuable and is another area that I think is becoming more and more exciting and more literature will hopefully allow us to determine the best way to get the right environment for these to also heal.

Dr. Brian Lau:

Yeah, Sachin, that was a great kind of overview and I think you hit a lot of really good points. One is making sure you have great visualization of the trephination or releasing a pie crust on the MCL, kind of go up and superior and inferior aspects to get that balanced repair. I also preferred doing the hybrid technique from the medial side, particularly for the scenario is I'm going to try to start in the middle of the tear and work my way posterior and see how far I can get, how much struggle my assistants is having in terms of getting to it. If I can get it all through inside-out, then I will try. But often the last couple there in the posterior, I'm doing an all-inside then in the front doing outside-in, as you mentioned. Creating the biological environment, I agree with that too. I also do a little venting. There's obviously balance, to have too much blood into the joint can affect things too.

You mentioned so many different things about and there's more to it than just how you fix it in the environment. I think I wanted to step back a little bit because one of the points that came up in your study and also on how you describe your practice is timing and how quickly you get to it. Does that change what your approach is and maybe how your repair is going to be and your thought process with it?

Dr. Sachin Allahabadi:

Yeah, timing is critical. In our study and in other studies on meniscus tears, it does seem to be that the quicker we can get to these, especially these bucket handle tears, there is a better chance of healing. Certainly a couple of the patients who I mentioned I'm seeing, I'm booking as soon as possible, within a couple of weeks. But you also have some of the cases that, one of the ones I was referring to is two years out from the injury and had been managed non-operatively for many other reasons. In a young patient, if I look at the tear and even if it's been a longer time, a greater chronicity of injury, I'm still trying to repair it if I can, as long as the tear looks that it's still reparable. But ideally, in my practice, I would get to it sooner than later just to enhance the potential for healing. I think that's, especially with this bucket handle-pattern tears, that can be really critical because they involve so much of the meniscal surface and if we can't get them to heal, it really is a salvage procedure at a later time. They can really lead to really rapid degenerations in that compartment.

As soon as we can get to them, the better. We think that the healing response biological environment is better for those tears earlier on. But if you can't, I still think it's oftentimes worth trying, especially in a young patient, to repair given that the consequences otherwise are so drastic.

Dr. Brian Lau:

Yeah, I agree with you. I think out there you have those meniscus savers or meniscus killers and I'm on the same boat as you. If it's a young patient, I'm going to try to do whatever I can to try to save it. In those chronic scenarios and in the case that you're describing, what are some tips and tricks for people, chronic bucket tears can be very difficult to reduce and keep reduced. Are there certain tips and tricks you give to our listeners and readers that they can use in the operating room?

Dr. Sachin Allahabadi:

Well, I would say actually firstly, one of the big tips I would give is it starts before the operating room, and that's with patient counseling and really explaining to them scenario that they're in and the consequences of a bucket handle tear. I talk to all my patients about repair, what the rehab means if I were able to do that and the real possibility of re-tear. The failure rates are not small, they're not terrible, but they definitely exist, and it's something that we need to keep in mind. I think that's firstly, it starts off with preoperative counseling and also describing to the patient that there is a chance that it's not reparable, especially in the chronic setting. I may have to perform debridement because it's just the right thing to do and to not put the patient under multiple surgeries if I know it's going to fail. I think that's number one.

Number two, as you mentioned in the operating room, I think to be able to reduce these, a couple things. Number one, if it's on the medial side, trephinating and opening up the medial compartment as much as possible can be helpful. There are multiple techniques I can describe about releasing various parts of meniscus from the capsule to try to see if that can help reduce the tear. I've found that oftentimes when we're looking at a meniscus, we'll use a small three to four-millimeter probe to push and pull on a meniscus. I've found I use a blunt trocar that I use to enter the joint space initially to help push the meniscus. I've found that to be really helpful. It's wider, you get a better contact on the meniscus, and it's a little bit sturdier and can allow you to push it back in more easily. But I think the other key is just to be persistent because oftentimes you can get it reduced with some patients and also being willing to manipulate the position of the knee in different angles throughout the attempt at reduction.

Dr. Brian Lau:

Yeah. I think your point about a counseling patient is really, really critical. We obviously did not touch on that, but that's a great, great point. I find that, like you said, so the releases in the very front and the back to help if it's chronic and then I use a circumferential stitch around the meniscus rather than trying to do a vertical mattress through it, actually do a circumferential. That's where I think the inside-out can be very powerful because you can actually pull through your sutures of the inside-out and see where it needs to reduce and add them before you tie it down. I think in those chronic ones, I think inside-out tends to be a little bit more powerful and more versatile in the chronic ones.

But Sachin, I wanted to thank you for joining us this morning. I know it's early where you're at and all your insights I think is really, really valuable. Any final comments or takeaways you want for our listeners to have maybe in a 10-second, 15-second rundown? What's the final takeaway you want for everyone to have?

Dr. Sachin Allahabadi:

Well, thanks again for having me and it's been an honor to be on this with you. I think the main things that I would take away from the study and when you think about bucket handle meniscus tears is that they can come in a variety of different flavors and cases, and there are reasons to use multiple different techniques. I think for any surgeon who is approaching these, he or she should be ready to use a variety of techniques and be armed with the ability to be flexible in the approach depending on the style of repair. There are reasons that each different technique are valid and you can have great success no matter what approach you use as long as we get the right fixation.

Dr. Brian Lau:

All right, well thanks, Sachin. Thank you everyone else for joining us today. Again, this is Dr. Sachin Allahabadi, Houston Methodist, and his article, if you want to read up more on it, is in the February 2024 Journal of Arthroscopy and is titled "All-Inside and Inside-Out Repair Techniques for Bucket-Handle Meniscus Tears Both Result in Improved Patient Outcomes and a Broad Range of Failure Rates." I just wanted to also remind everybody that the views and comments made on this Arthroscopy podcast are not represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thanks again everyone and Sachin, again, thanks so much.

Dr. Sachin Allahabadi:

Thank you very much.

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