Bucket-handle Tear Of Medial Meniscus Research Articles

Arteriovenous fistula and pseudoaneurysm in a pediatric patient with persistent postoperative hemarthrosis: A rare complication following arthroscopic repair of a bucket handle medial meniscal tear

Arteriovenous fistula and pseudoaneurysm in a pediatric patient with persistent postoperative hemarthrosis: A rare complication following arthroscopic repair of a bucket handle medial meniscal tear

Using a Combined All-Inside, Inside-Out, and Outside-In Technique to Repair Bucket-Handle Medial Meniscal Tears Without a Safety Incision

We describe a combined all-inside, inside-out, and outside-in technique for the repair of unstable bucket-handle medial meniscal tears. Notably, a greater incidence of neurovascular complications has been associated with meniscal repair techniques that employ an accessory skin incision, especially when damage involves the body of the medial meniscus. However, with the operative knee in relative extension, passing inside-out needles anteromedial to the posterior horn and posterior to the semitendinosus tendon and saphenous nerve allows for the needles to exit the posteromedial knee through a “safe zone.” Therefore, we reduce iatrogenic damage by avoiding the necessity of a large safety incision while still maintaining suture placement versatility and meniscal fragment stabilization. Thus, the objective of this Technical Note is to outline an efficient technique for treating bucket-handle medial meniscal tears that yields a strong, durable repair while avoiding damage to adjacent neurovascular structures and eliminating the need for a posteromedial safety incision.

Long-term clinical results of using a posteromedial all-inside and anteromedial inside-out approach to repair unstable or irreducible bucket-handle medial meniscal tears

BackgroundIn irreducible bucket-handle medial meniscal tears (BHMMTs), the displaced central fragment is rotated 180° or more, meaning reduction is impossible without derotation of the tear. In chronic cases, the rotated meniscus is deformed and degenerated; thus, the issue of reproducibility and repairability arises. This study presents the clinical outcomes of chronic irreducible and unstable locked BHMMTs. Radiological outcomes were also evaluated using magnetic resonance imaging (MRI).MethodsThis is a retrospective study of 37 patients with 11 cases of irreducible BHMMT and 26 cases of reducible but unstable chronic BHMMT who underwent operations between 2011 and 2016. Posterior arthroscopy was performed after temporary meniscus fixation using a provisional needle fixation technique. After the posterior repair with vertical mattress sutures was completed using an all-inside technique, the classic outside-in technique was performed for the anterior third of the meniscus. The Lysholm, International Knee Documentation Committee (IKDC), and Tegner activity scores were obtained from all patients before surgery and at the latest follow-up. Radiological evaluations were performed using MRI before surgery and at 6 months postoperatively.ResultsBetween 2011 and 2016, a total of 37 consecutive patients with irreducible and chronic BHMMTs underwent surgery. The average postoperative follow-up was 7.2 ± 1.4 years (mean ± SD). Postoperative Lysholm (89.57 ± 2.7) and IKDC (87.22 ± 3.2) scores improved significantly at the last follow-up when compared with the pre-operative scores (38.44 ± 4.5 and 23.52 ± 7.8, respectively). According to the Tegner activity scale, patients’ postoperative activity levels remained unchanged compared to preoperative levels at the last follow-up.ConclusionPosterior knee arthroscopy with the all-inside posterior suture and inside-out anteromedial suture technique presented in this study yielded excellent clinical outcomes when used to repair chronic irreducible or unstable BHMMTs.Level of evidence: Level IV.

Failure Rates of Repaired Bucket-Handle Tears of the Medial Meniscus Concomitant With Anterior Cruciate Ligament Reconstruction: A Cohort Study of 253 Patients From the SANTI Study Group With a Mean Follow-up of 94 Months

Background: Failure rates of repaired bucket-handle medial meniscal tears (BHMMTs) concomitant with anterior cruciate ligament reconstruction (ACLR) are as high as 20%. The outcomes of posteromedial portal suture hook repair have not been compared with all-inside repair techniques for this subtype of meniscal lesion. Purpose/Hypothesis: The aim of this study was to evaluate the outcomes and failure rates of patients who underwent BHMMT repair concomitant with ACLR using an all-inside technique, suture hook + all-inside technique, or suture hook + outside-in technique. It was hypothesized that no significant differences in failure rates would be found between the groups. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis was performed on patients diagnosed with a BHMMT who underwent meniscal repair during primary ACLR and had a minimum follow-up of 2 years. Patients were grouped based on the meniscal repair technique used: all-inside repair, suture hook + all-inside repair, or suture hook + outside-in repair. At the end of the study period, secondary medial meniscectomy rates were determined. Results: The study population comprised 253 patients who underwent repair of a BHMMT with concomitant ACLR with a mean follow-up of 94.0 ± 47.6 months. A total of 114 patients (45.1%) underwent all-inside repair, 61 patients (24.1%) underwent suture hook + all-inside repair, and 78 patients (30.8%) underwent suture hook + outside-in repair. Overall, there were 36 failures. The failure rates were 20.2%, 14.8%, and 5.1%, respectively (P = .0135). All-inside repairs were >4 times more likely to fail than suture hook + outside-in repairs (hazard ratio [HR], 4.103; 95% CI, 1.369-12.296; P = .0117). Failure was also 3 times higher (HR, 2.943; 95% CI, 1.224-7.075; P = .0159) for patients <30 years of age compared with those aged ≥30 years. An additional anterolateral ligament reconstruction (ALLR) was also found to reduce the failure rate of repaired BHMMTs concomitant with ACLR. Conclusion: Combined suture hook + outside-in repair of BHMMTs resulted in significantly fewer failures than all other techniques. Furthermore, age <30 years and no additional ALLR were associated with higher failure rates.

Overview of posterior knee arthroscopy in the medial meniscal repair: Technical note

Preservation of the meniscus in bucket handle medial meniscal tears (BHMMTs) and posterior meniscocapsular (ramp) lesions is challenging. Current efforts are being made in the scientific community to (1) introduce new ways of gaining easier and better field of view over the repair site and (2) increase the chance of meniscal healing through effective augmentation procedures. The current note introduces a way to achieve good exposure of posterior knee compartments and proposes an augmentation technique that involves exposing the local non-articulating subchondral cancellous bone and making in situ clots.

Mid-term evaluation of clinical and functional outcomes after arthroscopic medial longitudinal and bucket-handle meniscus repair.

Objectives The aim of this study was to evaluate clinical and functional outcomes following the arthroscopic medial meniscal repair.Patients and methods A total of 50 patients (42 males, 8 females; mean age: 32.9±7.6 years; range, 17 to 48 years) who underwent arthroscopic repair for longitudinal and bucket-handle medial meniscal tears between March 2005 and October 2011 were retrospectively evaluated. The patients were divided into two groups as those having a longitudinal tear (patient group, n=31) and having a bucket-handle tear (control group, n=19). Preoperative and final follow-up functional outcomes were evaluated using the Lysholm Knee Score (LKS), International Knee Documentation Committee (IKDC) score, Tegner Activity Scale (TAS) score, and Knee Injury and Osteoarthritis Outcome Score (KOOS).Results The mean follow-up was 61.7±22.8 (range, 36 to 110) months. The mean preoperative LKS, IKDC score, TAS, and KOOS scores were significantly improved at the final postoperative follow-up (p<0.05). There was no significant difference in functional outcome scores between longitudinal and bucket-handle repairs (p>0.05), and isolated repairs and concomitant meniscal repair and anterior cruciate ligament reconstruction (p>0.05).Conclusion Arthroscopic meniscal repair provides similar mid-term functional and clinical outcomes for longitudinal and bucket-handle medial meniscal tears. Concomitant meniscal repair does not seem to affect meniscal healing.

Posterior knee arthroscopy facilitates the safe and effective all-inside repair of locked bucket-handle medial meniscal tear using a suture hook technique.

This study reported the outcomes of locked bucket-handle medial meniscal tear (BHMMT) repairs using an arthroscopic posterior approach during anterior cruciate ligament (ACL) reconstruction. Between 2011 and 2014, 48 patients with BHMMTs and ACL tears who met the eligibility criteria were enrolled in the present study. BHMMTs were assessed using a posterolateral transseptal portal and repaired using a posteromedial portal. Transportal ACL reconstruction was performed using hamstrings autograft. Patients were assessed based on their IKDC and Lysholm scores and Tegner activity level. Meniscal healing was clinically evaluated based on the absence of swelling, joint line tenderness, locking, and catching; McMurray test results; and the need for meniscectomy. According to follow-up assessments, the average IKDC and Lysholm scores improved significantly after 3-5years (P < 0.001) CONCLUSION: Excellent clinical outcomes were obtained when locked BHMMTs were repaired using an all-inside suture technique that employed posteromedial and posterolateral transseptal portals. IV.

Clinical outcome and failure analysis of medial meniscus bucket-handle tear repair: a series of 96 patients with a minimum 2year follow-up.

The failure rate of meniscal repair remains significant, especially for bucket-handle tears. This study aimed to evaluate the clinical outcomes, failure rate and risk factors for failure of bucket-handle medial meniscal tear repairs performed during ACL reconstruction. A retrospective analysis of prospectively collected data was performed on a consecutive series of 96 ACL reconstructions with meniscal arthroscopic suture of a bucket-handle tear of the medial meniscus with a minimum 2year follow-up. Preoperative and postoperative evaluation at last follow-up included objective IKDC rating, instrumented differential laxity and Tegner activity level. Functional outcome was evaluated with Lysholm score at last follow-up. Failure rate, survival curves and risk factor analysis using Cox proportional hazard ratio models were performed to analyze suture repair failure. At IKDC rating, all patients were C or D preoperatively, whereas they where all A or B at last follow-up. Instrumented differential laxity improved from 6.77mm (1.57) to 1.02mm (1.15) mm at last follow-up (p = 1.9 E-18). The mean Tegner score before injury was 6.79 (± 1.47) and 6.11 (± 1.75) at last follow-up (p = 0.0011). Mean Lyholm score at last follow-up was 91.53 (± 11.6). The average entire cohort failure rate was 19% at final follow-up of 35.2 ± 9.8months. Kaplan-Meier survival analysis demonstrated that the probability of the absence of failure decreased constantly over time. No significant difference in the objective IKDC, Lysholm or Tegner scores was observed between the failure group and the success group. Multivariate analysis revealed that younger patients and a procedure of ACL revision are more at risk for suture repair failure. In the majority of cases, the meniscal lesion observed at revision was equivalent or less extensive than the initial lesion. Despite the fact that failure rate remains high for medial meniscus bucket-handle tears, suture repair of bucket-handle tears should be encouraged taking into account the long-term consequences of menisectomy.

Influence of Medial Meniscus Bucket-Handle Repair in Setting of Anterior Cruciate Ligament Reconstruction on Tibiofemoral Contact Mechanics: A Biomechanical Study

To compare the impact of an inside-out repair versus meniscectomy of a medial meniscus bucket-handle tear in restoring native contact areas and pressures across the tibial plateaus in the setting of an anterior cruciate ligament (ACL) reconstruction (ACLR). Ten fresh-frozen cadaveric knees were tested in 6 knee conditions (1: intact; 2: ACL torn and bucket-handle tear of medial meniscus, flipped; 3: bucket-handle tear of medial meniscus, reduced; 4: bucket-handle tear of medial meniscus, repaired via inside-out vertical mattress suture technique; 5: ACLR with bone patella tendon bone autograft and bucket-handle repair; 6: ACLR and medial meniscus bucket-handle tear debridement) at 4 flexion angles (0°, 30°, 45°, and 60°), under a 1,000-N axial load. Contact area and pressure were measured with Tekscan sensors. ACLR with a concurrent medial meniscectomy for a medial meniscus bucket-handle tear resulted in significantly decreased contact area (P < .05) and increased mean and peak pressure in both the medial and lateral compartments across all tested flexion angles (P < .05). The ACLR with medial meniscectomy state also demonstrated significantly lower contact area than the bucket-handle repair state between 30° and 60° of flexion (all P < .05). Resection of a bucket-handle medial meniscus tear concurrent with an ACLR resulted in significant increases in mean and peak contact pressures in not only the medial but also the lateral compartment. Preservation of the medial meniscus in the face of a bucket-handle tear is essential to more closely restore native tibiofemoral biomechanics. The increased mean and peak tibiofemoral contact pressure seen with excision of a bucket-handle medial meniscus tear would over time result in increased cartilaginous degradation and resultant osteoarthritis. Decreasing both of these factors through concomitant ACLR and inside-out bucket-handle meniscal repairs should improve patient outcomes by restoring knee biomechanics and kinematics closer to that of the native state.

Biomechanical Comparison of Vertical Mattress and Cross-stitch Suture Techniques and Single- and Double-Row Configurations for the Treatment of Bucket-Handle Medial Meniscal Tears

Background: Given the variety of suturing techniques for bucket-handle meniscal repair, it is important to assess which suturing technique best restores native biomechanics. Purpose/Hypothesis: To biomechanically compare vertical mattress and cross-stitch suture techniques, in single- and double-row configurations, in their ability to restore native knee kinematics in a bucket-handle medial meniscal tear model. The hypothesis was that there would be no difference between the vertical mattress and cross-stitch double-row suture techniques but that the double-row technique would provide significantly improved biomechanical parameters versus the single-row technique. Study Design: Controlled laboratory study. Methods: Ten matched pairs of human cadaver knees were randomly assigned to the vertical mattress (n = 10) or cross-stitch (n = 10) repair group. Each knee underwent 4 consecutive testing conditions: (1) intact, (2) displaced bucket-handle tear, (3) single-row suture configuration on the femoral meniscus surface, and (4) double-row suture configuration (repair of femoral and tibial meniscus surfaces). Knees were loaded with a 1000-N axial compressive force at 0°, 30°, 60°, 90°, and 120° of flexion for each condition. Resultant medial compartment contact area, average contact pressure, and peak contact pressure data were recorded. Results: Intact state contact area was not restored at 0° (P = .027) for the vertical double-row configuration and at 0° (P = .032), 60° (P < .001), and 90° (P = .007) of flexion for the cross-stitch double-row configuration. No significant differences were found in the average contact pressure and peak contact pressure between the intact state and the vertical mattress and cross-stitch repairs with single- and double-row configurations at any flexion angles. When the vertical and cross-stich repairs were compared across all flexion angles, no significant differences were observed in single-row configurations, but in double-row configurations, cross-stitch repair resulted in a significantly decreased contact area, average contact pressure, and peak contact pressure (all P < .001). Conclusion: Single- and double-row configurations of the vertical mattress and cross-stitch inside-out meniscal repair techniques restored native tibiofemoral pressure after a medial meniscal bucket-handle tear at all assessed knee flexion angles. Despite decreased contact area with a double-row configuration, mainly related to the cross-stitch repair, in comparison with the intact state, the cross-stitch double-row repair led to decreased pressure as compared with the vertical double-row repair. These findings are applicable only at the time of the surgery, as the biological effects of healing were not considered. Clinical Relevance: Medial meniscal bucket-handle tears may be repaired with the single- or double-row configuration of vertical mattress or cross-stitch sutures.

Bucket-Handle Tear of the Medial Meniscus in a 2-Year-Old Child.

Bucket-handle meniscal tears are extremely rare injuries in the pediatric population. Given the known sequelae of meniscal tears and the development of osteoarthritis, early diagnosis and treatment of pediatric meniscal tears are essential. The communication barrier between physicians and pediatric patients, however, creates difficulties in making the correct diagnosis of meniscal pathology. Providers should have a low threshold for obtaining further confirmatory advanced imaging if patients present with prolonged knee pain and swelling, with associated locking mechanical symptoms. Good clinical outcomes following meniscal repair have been observed, likely a result of the increased residual vascularity found within pediatric menisci. The youngest reported case of an isolated traumatic bucket-handle medial meniscal tear is examined in this article. A 2-year-old girl presented with right knee pain after a heavy object fell onto the knee several weeks earlier. On examination, the patient walked with a limp but lacked full range of active knee motion. The McMurray test elicited pain without a mechanical or palpable click. After the patient continued to exhibit limitations following conservative management, magnetic resonance imaging of the right knee was obtained, which showed a bucket-handle tear of the right medial meniscus. The patient subsequently underwent meniscal repair and, on recovery, was able to regain normal functioning of the right knee without limitations. [Orthopedics. 2018; 41(4):e580-e582.].

Does meniscus removal affect ACL-deficient knee laxity? An in vivo study.

The purpose of the present study was to determine, in vivo, the effect of different types of meniscectomy on an ACL-deficient knee. Using a computer-assisted navigation system, 56 consecutive patients (45 men and 11 women) were subjected to a biomechanical testing with Lachman test (AP30), drawer test (AP90), internal/external rotation test, varus/valgus rotation test and pivot-shift test. The patients were divided into three groups according to the status of the medial meniscus. Group BH, 8 patients with bucket-handle tear of medial meniscus underwent a subtotal meniscectomy; Group PHB, 19 patients with posterior horn body of medial meniscus tear underwent a partial meniscectomy; and Group CG with isolated ACL rupture, as a control group, with 29 patients. A significant difference in anterior tibial translation was seen at 30 grades and in 90 grades between BH and PHB groups compared to the CG. In response to pivot-shift test, no significant differences in terms of AREA and POSTERIOR ACC were found among the three groups (n.s). Concerning the anterior displacement of the pivot shift a statistically significant differences among the three tested groups was found. The present study shows that meniscal defects significantly affect the kinematics of an ACL-deficient knee in terms of anterior tibial translation under static and dynamic testing.

The influence of the medial meniscus in different conditions on anterior tibial translation in the anterior cruciate deficient knee.

The purpose of this study was the evaluation of knee laxity in the ACL-deficient knee with combined meniscal tear, meniscal suture and partial medial meniscectomy. Kinematics of the intact knee were determined in 18 human cadaver specimens in response to a 134-N anterior tibial load (aTT) as well as a combined rotatory load of 10 Nm valgus and 4 Nm internal tibial rotation using a robotic/universal force moment sensor testing system. The anterior cruciate ligament was resected. Subsequently, a vertical bucket-handle medial meniscal tear was created followed by a standard meniscus repair using horizontal inside-out stitches or a partial medial meniscectomy. Knee kinematics were calculated following every sub-step. A significant increase of anterior tibial translation was found in the ACL-deficient knee compared to the intact knee at 30° and 90° of flexion (p = 0.001; p ≤ 0.001). Additional tear of the medial meniscus significantly increased anterior tibial translation (p = 0.01). In response to a simulated pivot shift, anterior tibial translation of the intact knee did not increase significantly after ACL resection (p = 0.067). However, ACL deficiency with an additional medial meniscus tear led to a significant increase compared to the intact knee at 0° of flexion (p = 0.009). Additional injury of the medial meniscus increased aTT as well as aTT under a combined rotatory load in the ACL-deficient knee whereas repair of the meniscus significantly decreased aTT. Therefore, the meniscus status does have a significant impact on knee kinematics in the ACL-deficient knee. The present biomechanical study further highlights the importance of preserving the meniscus especially in patients with additional ACL injuries.

Outcomes After Repair of Chronic Bucket-Handle Tears of Medial Meniscus

The purpose of this study was to determine the outcomes after repair of chronic bucket-handle medial meniscal tears by use of magnetic resonance imaging, clinical examination, and patient-reported outcomes. A retrospective review of patients with chronic bucket-handle medial meniscal tears that had been repaired with meniscal sutures was undertaken. The following criteria for inclusion were adopted: minimum tear length of 2cm and chronic medial meniscal tear identified at the time of arthroscopy. The tears were susceptible to dislocation with probing. Data collected included demographic, clinical, radiologic, and surgical data. Postoperative healing was assessed with the clinical criteria of Barrett etal. The International Knee Documentation Committee rating, Lysholm score, and Tegner activity level were determined, and postoperative magnetic resonance imaging was used to evaluate healing in accordance with the criteria of Henning etal. Twenty-four patients fulfilled the inclusion criteria. The mean time from injury to surgery was 10months (range, 2 to 60months). Sixteen patients underwent anterior cruciate ligament reconstruction, 1 patient underwent posterior cruciate ligament reconstruction, and 6 patients underwent meniscus repair only. A median of 5 sutures (range, 3 to 6 sutures) were used for repair. Four cases (all of which had undergone meniscus repair only) required revision. Complete healing was achieved in 83% of cases according to the criteria of Barrett etal. The mean follow-up time was 48months (range, 24 to 112months). An International Knee Documentation Committee rating of A or B was achieved in the 20 patients who did not require revision. The median Lysholm score was 95 (range, 92 to 100). The median Tegner activity level before injury was 7, and it remained unchanged after surgery in all cases. This study showed that repair of chronic bucket-handle meniscal tears can lead to good clinical outcomes and a relatively low (17%) failure rate. In addition, repairs of isolated meniscal tears had a significantly higher risk of failure than repairs performed in conjunction with anterior cruciate ligament reconstruction. Level IV, therapeutic case series.

Meniscal Injury After Adolescent Anterior Cruciate Ligament Injury: How Long Are Patients at Risk?

Delay of as much as 5 months between ACL injury and surgery is known to be associated with increased risk of a medial meniscal tear, but the risk of additional meniscal tear progression with a longer delay to surgery is unclear. We determined the (1) times of injury, MRI, and surgery in adolescents with ACL tears, and whether (2) timing of surgery, or (3) initial integrity of the meniscus seen on MR images predicted development of meniscal tears. We reviewed 112 adolescents who were 15 ± 1 years old (mean±SD) (range, 11-16 years) with a torn ACL. These patients underwent surgical repair from 2005 to 2011 in a Canadian city. We compared dates of injury, MRI, and surgery. A pediatric and musculoskeletal fellowship-trained radiologist reread the MR images, and meniscal injuries were graded according to severity. This was compared with surgical findings described in the operative report. Time after injury to MRI and surgery averaged 77 days (range, 1-377 days) and 342 days (range, 42-1637 days), respectively. Patients with new or worsened medial meniscal tears had waited longer for surgery (445 versus 290 days; p = 0.002). Bucket handle medial meniscal tears were more common in patients with surgery more than 1 year after injury than others (15 of 34 versus 14 of 75; p = 0.013). A medial meniscal tear observed on MR images was a significant covariate for a torn meniscus at surgery (relative risk, 5.7; 95% CI, 2.8-11.6). Medial meniscal survival continued to decline sharply greater than 1 year after injury. Medial meniscal tears, especially bucket handle tears, increased steadily in frequency more than 1 year after ACL injury. Timely ACL reconstruction may be warranted to reduce the risk of further medial meniscal damage even in patients whose original injury occurred more than 1 year before. Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Bucket-handle meniscal tear in a 5-year-old child

Bucket-handle meniscus tears are a common athletic injury that occur frequently in the adult population but are extremely rare in young children. A 5-year-old male patient presented with left knee pain after a minor fall to the ground. Complaints of pain with full weight-bearing, locking of the joint during walking, a significant limp, 45° flexion contracture of the knee, and an inability to bring the leg into full extension were noted during examination. MRI showed a large bucket-handle medial meniscal tear. The patient made a full recovery after undergoing arthroscopic repair surgery. Level of evidence Case report, Level IV.

Comparison of Contact Mechanics of Three Meniscal Repair Techniques and Partial Meniscectomy in Cadaveric Dog Stifles

To evaluate the biomechanical effect of horizontal, vertical, and cruciate suture repairs and partial meniscectomy on contact mechanics of dog stifles. Ex vivo experimental study. Cadaveric canine stifles (n=24). Simulated bucket handle medial meniscal tears were created in cadaveric dog stifles. Tears were treated with 1 of 3 suture repair techniques or partial meniscectomy. Instantaneous contact area (CA), mean contact pressure (MCP), and peak contact pressure (PCP) measurements were recorded with a pressure sensing system. CA, MCP, and PCP for intact stifles (control), stifles with simulated tears, and stifles after treatment were recorded and compared using 1-way repeated measures ANOVA. Stifles with bucket handle tears had significantly decreased CA, increased MCP and increased PCP when compared with control. All meniscal repair techniques reestablished normal contact mechanics. When comparing meniscal repair and partial meniscectomy, stifles with partial meniscectomy had approximately 35% lower CA, 57% higher MCP, and 55% higher PCP than stifles undergoing repair. Contact mechanics obtained from each repair technique were mechanically superior to partial meniscectomy. Performing meniscal repair instead of partial meniscectomy in dogs with select meniscal tears may mitigate the development of degenerative joint disease. Criteria for selection of candidates for meniscal repair should be confirmed with future studies. Based on this ex-vivo model, meniscal repair will restore normal contact mechanics. Consideration should be given to meniscal repair as treatment for peripheral meniscal tears located in the vascular zone if the meniscal parenchyma is normal.

Reply to the comments on our article “The fate of patellar tendon and infrapatellar fat pad after arthroscopy via central portal”

Dear Editor,We are pleased to read that more experience is beingshared about effects of Central Patellar (CP) portal onpatellar tendon, which was somehow an ignored topic inarthroscopic surgery until recently. We thank Dr Checa forthis important contribution and comments on our article[1], although these two studies are different in terms ofmethodology.We were also surprised to read about their study men-tioned in the letter, in which no echogenic abnormalities orthickening in the sagittal diameter of the tendon wasobserved four to 6 weeks after arthroscopy via CP portal.The authors had performed the arthroscopies for bucket-handle tears of medial meniscus, which was also theindication for the patients in our series. They stated that theprocedure was well tolerated by the majority of patientsand this finding was also similar to our study. None of ourpatients complained of anterior knee pain or had positiveclinical examination signs of patellofemoral joint pathol-ogy. However, our radiological findings were different.Most of the tendons in our study demonstrated the radio-logical sequela of the procedure about a mean of28 months after arthroscopy using CP portal. In addition toultrasonography, we had also performed MRI and furtherdelineated the radiological abnormalities. We have men-tioned in our manuscript that the lack of longitudinalobservations was a limitation for our study and a latercross-sectional evaluation to delineate whether the radio-logical findings would differ by time seems to beappropriate. Thus, we think that a cross-sectional study at4–6 weeks postoperatively would not be sufficient to besure that puncture of the tendon leaves nothing behind. Asfar as we know such prospective study is lacking and we donot clearly know the time of occurrence of fibrosis, scartissue, granulation tissue or mucoid degeneration within thetendon. On the other hand, the manner of use of the portalmight cause some difference. In our practice, we had usedthe portal interchangeably for holding and cutting instru-ments and the telescope: i.e. the tendon was penetrated afew times through this portal during the procedure. If thetendon was got across only once for the placement of aparticular instrument, the harm to the tendon might beexpected to be reduced.Finally, we had stated that use of CP portal and acci-dental violation of fat pad did not produce any clinicalproblems in a low demand group of patients. Although weagree with the authors of the letter that, interpretation ofchanges strictly as an abnormality in the tendon might beconfusing, the significant radiological sequela in ourpatients could not be overlooked. Rather than concludingthat the portal is unsafe, we preferred to state that it was notas safe as generally thought to be and we feel that untilthese changes were interpreted with biomechanical studiescaution should be held in patients who are or may becandidates for ACL reconstruction.Reference

Posterior double PCL sign: a case report of unusual MRI finding of bucket-handle tear of medial meniscus

Among the MRI signs of bucket-handle tears of medial meniscus, double posterior cruciate ligament (PCL) sign denotes a low signal band anterior and parallel to the PCL, which looks like another PCL in MR images. If the bucket-handle fragment subsequently tears at the anterior horn, the torn meniscal substance can be displaced to the posterosuperior region of the PCL, and looks like another PCL behind the original PCL. We propose the lesion be called the "posterior double PCL sign" in contrast to the ordinary double PCL sign. We present a case showing the posterior double PCL sign.

Resolução espontânea de lesão em alça de balde do menisco medial: relato de caso e revisão da literatura

Neste trabalho é relatado um caso de lesão do menisco medial do tipo em alça de balde, que se resolveu espontaneamente. O paciente torceu o joelho esquerdo durante jogo de futebol, evoluindo com dor e bloqueio articular. A ressonância magnética realizada após o trauma demonstrou uma lesão em alça de balde do menisco medial, com fragmento deslocado na incisura intercondilar. Após tratamento clínico, o exame de controle demonstrou que havia ocorrido resolução espontânea da referida lesão.