Bucket‐handle and medial meniscal tears exhibit higher failure rates after all‐inside repair with concomitant ACL reconstruction

PURPOSE: To evaluate failure rates across specific meniscal tear morphologies in patients undergoing all-inside meniscal repair with anterior cruciate ligament reconstruction (ACLR), and to identify factors associated with failure. METHODS: This retrospective cohort included 1355 patients who underwent all-inside meniscal repair during ACLR between 2015 and 2022 at Capio Artro Clinic, Stockholm, Sweden. Failure was defined as reoperation within 3 years. Tear morphology, meniscal laterality, age and sex were recorded. Kaplan-Meier (KM) analysis assessed survival, and Cox regression identified factors associated with failure. RESULTS: The 3-year failure rate was 12.3%. Medial repairs failed significantly more than lateral repairs (17.7% vs. 5.3%; p < 0.001) with lower medial survival on KM analysis (log rank p < 0.001). Bucket handle tears had the highest failure rate (18.6%), followed by undersurface (15.6%) and longitudinal tears (11.2%). Root (6.1%) and radial tears (RTs) (5.6%) had the lowest. In multivariable analysis, medial repair was the strongest predictor of failure (hazard ratio [HR] 3.08, 95% confidence interval [CI] 2.03-4.67, p < 0.001). Longitudinal tears had lower failure risk than bucket handle tears (HR 0.67, 95% CI 0.57-0.95, p = 0.03). Female sex increased failure risk (HR 1.38, 95% CI 1.02-1.88, p = 0.03), while age >30 years was not associated with failure. CONCLUSION: Meniscal repair performed during ACL reconstruction demonstrated a 12.3% failure rate at 3 years. Failure risk differed by tear morphology and meniscal side, with medial repairs and bucket‑handle tears showing the highest risk, while root and RTs showed the lowest. Female sex was independently associated with increased failure, whereas age was not. LEVEL OF EVIDENCE: Level III, retrospective cohort study.