The all-inside wrapping repair technique for lateral meniscus BHT resulted in a clinical healing rate of 94.1%. Postoperative MRI indicated a radiological healing rate of 64.7%. No complications were observed during the surgical procedure. At a mean follow-up of 4.2 years, the average postoperative IKDC score was 83.7. Notably, meniscus remodeling from an irregular to a triangular shape was observed on both MRI and second-look arthroscopy, highlighting the successful restoration of the meniscus.

The advantages of the all-inside wrapping repair technique are as follows: (1) the preservation of meniscal tissue as the meniscus is not pierced but instead wrapped circumferentially; (2) increased contact surface area with the suture, enabling better fixation and reduction of the meniscus; (3) significant reduction in the risk of neurovascular injury; (4) reduction in the need for avoidance of additional incisions, as the only additional portal used is a medial accessory portal for suture retrieval; and (5) absence of fixation devices, which eliminates associated costs.

However, critical comparisons with other meniscus repair techniques highlight some nuances. Inside-out repair, considered the gold standard, offers high biomechanical stability but requires additional incisions and carries a greater risk of neurovascular injury. Contemporary all-inside techniques using suture-based devices avoid these risks but may introduce implant-related complications, such as chondral damage or synovitis.

In contrast, the all-inside wrapping technique eliminates the need for fixation devices, reducing cost and potential implant-related complications. Nonetheless, it relies on suture hooks and non-absorbable sutures, which may share some limitations with other suture-based techniques. Incorporating insights from recent studies, such as Uchida et al. [28], could provide a more comprehensive understanding of how this technique compares in terms of biomechanical performance, complication rates, and long-term outcomes.

Further research is warranted to directly compare the all-inside wrapping technique with these alternatives, particularly in randomized controlled trials or large-scale prospective studies, to validate its relative efficacy and safety.

These benefits make the all-inside wrapping repair technique a favorable option for lateral BHTs. However, this technique still has some disadvantages of the all-inside circumferential suture hook technique, including: (1) the risk of chondral damage during suturing, particularly when performed by an inexperienced surgeon; (2) a relatively steep learning curve; and (3) the need for additional assistance during the procedure.

Several studies comparing the inside–out repair technique with the all-inside repair technique have demonstrated similar clinical failure rates. Grant et al., in a systematic review of 19 studies, reported no significant difference in clinical failure rates between the two techniques (17% for the inside–out repair technique vs. 19% for the all-inside repair technique) [14]. In a laboratory study by Marchetti et al., examining BHTs in cadaveric specimens, both the all-inside and inside–out repair techniques demonstrated comparable ability to restore native meniscus biomechanics to a near-intact level [20]. In a recent systematic review by Fillingham et al., comprising 27 studies, no significant differences in both clinical and anatomical failure rates were found between the inside–out and all-inside repair techniques (11% vs. 10%) [10]. Furthermore, the inside–out repair technique carries a risk of neurovascular injury, as highlighted in previous studies [4, 8]. However, in our study, no instances of neurovascular complications occurred. This can be attributed to our approach of using a suture hook and grasping only a partial capsule tissue during knee flexion, thereby reducing the risk of neurovascular injury. Given that comparable results can be achieved compared with the inside–out technique while decreasing the risk of neurovascular injury, favoring the all-inside wrapping technique seems reasonable.

Until now, various all-inside techniques using suture hooks have been developed for longitudinal meniscus tears; however, all of these techniques involve piercing the torn part of the meniscus. Ahn et al. introduced a technique that uses a suture passer hook to repair the meniscus through the posterolateral portal. However, this technique necessitates the creation of an additional posterolateral portal and involves piercing the torn part of the meniscus [2]. Fiorentino et al. described a similar technique that used standard anteromedial and anterolateral portals; however, it still involved piercing the torn part of the meniscus [11]. In cases of BHTs of the meniscus, the torn portion can be fragile, and penetrating it may compromise its structural integrity. Moreover, because of the mobility of the torn part, accurately penetrating the desired site for repair can be challenging, potentially leading to multiple penetrations. These factors increase the risk of iatrogenic injury to the meniscus during the repair procedure. The all-inside wrapping technique offers a method for repairing the meniscus by wrapping the torn part without compromising its structural integrity. By eliminating the need to penetrate the mobile torn portion of the meniscus, this wrapping technique also simplifies the reduction process, reducing the operative time while maintaining equivalent outcomes.

According to a systematic review by Ardizzone et al., the overall failure rate following all-inside repair of BHTs was 29.3% at an average follow-up of 13 months. Furthermore, no significant difference in the healing rate was observed between medial and lateral meniscus repairs [5]. Muench et al. conducted a study reporting a clinical healing rate of 83.3% and a radiological healing rate of 60.4% with a minimum follow-up of 2 years after repairing BHTs using either a meniscus fixation device or the inside–out technique. The study found that healing rates were not influenced by the laterality of the tear [23]. Goh et al. reported that repairing BHTs using a meniscus fixation device resulted in a healing rate of 90.4% on MRI and significant functional outcome improvement [12]. Uzun et al. reported the results of repairing lateral meniscus vertical longitudinal and BHTs of the lateral meniscus using the all-inside (meniscus fixation device) and hybrid (meniscus fixation device with inside–out) techniques. The results showed a success rate of 88.3% [29]. The aforementioned studies mostly featured the all-inside repair technique with suture devices; none purely looked at the all-inside repair technique with suture hooks. In this study, we introduced the all-inside wrapping repair technique, which has demonstrated comparable outcomes to existing methods but at a significantly lower cost. This approach could serve as a viable treatment alternative for lateral BHTs.

Generally, meniscal repair with concomitant ACL reconstruction has a higher healing rate than isolated meniscal tear repair. This is because of the growth factors and fibrin clots that originate from the bone tunnels in ACL reconstruction. Cannon et al. found only a 59% healing rate in isolated meniscal tears and a 94% healing rate when ACL reconstruction was performed in conjunction with meniscal repair [6]. In our study, we observed a similar failure rate, which agrees with the findings of Nepple et al. [24]. This similarity in results could be attributed to the fact that notchplasty was performed in all cases of isolated BHT repair, which could have induced bleeding and facilitated the healing process. Another factor that may have contributed to the comparable healing rates in our study is the younger age of the isolated BHT group, which was on average 4.7 years younger than the group undergoing concomitant ACL reconstruction.

Following the all-side wrapping repair, the repaired meniscus initially exhibited an irregular or round shape. However, an interesting observation was made during second-look arthroscopic surgery or follow-up MRI, where remodeling to a triangular cross-sectional configuration was observed. This finding is unique and has not been previously reported. However, one concern arising from this study is the quality of the remodeled meniscus once it has healed. Additional research is warranted to investigate the long-term effects of this observation.

This study had several limitations. First, the retrospective nature of the study introduces inherent risks of selection bias, which could influence the generalizability of the findings. Second, the relatively small sample size of 34 patients impacts the statistical power of the analysis and limits the ability to draw generalized conclusions. While the results provide valuable insights into the efficacy of the all-inside wrapping repair technique, they should be interpreted with caution due to the potential variability introduced by the sample size.

Third, the absence of a control group (e.g., patients treated with inside-out or other all-inside techniques) restricts the ability to directly compare the outcomes of this method to other established techniques. Additionally, postoperative second-look arthroscopy was not routinely performed in all patients because of ethical considerations, which may have underestimated the true rate of healing or complications.

Moreover, the postoperative IKDC score was used to assess function and sports activity, providing a reliable measure of patient-reported outcomes. However, additional functional scales, such as the Lysholm or Tegner Activity Scale, could have provided a more comprehensive assessment of patient outcomes, particularly in evaluating broader aspects of knee functionality and activity levels.

The decision to use only the IKDC score was based on its widespread acceptance and specific relevance to knee injuries. Nonetheless, the inclusion of other functional scales in future studies could offer valuable insights into various dimensions of patient recovery, such as daily activity levels and return to sports. Incorporating these scales would allow for a more holistic evaluation of the effectiveness of the all-inside wrapping repair technique.

Furthermore, this study was conducted by a single surgeon with substantial expertise in the wrapping technique, which introduces potential bias and limits the generalizability of the findings. A multicenter study involving surgeons with varying levels of experience could provide more balanced insights into the reproducibility and learning requirements of the technique.