Bucket-handle Tear Research Articles

Both medial and lateral bucket-handle meniscus tears associated with chronic ACL injury: A rare presentation of triple-PCL sign

BackgroundSeveral types of meniscal tear could be presented in both acute and chronic anterior cruciate ligament injury. The incidence of bucket-handle meniscus tears can be up to 30% of the overall meniscus tears cases. The case of both compartment (medial and lateral) bucket-handle meniscus is rarely occurred.CaseA case of both medial and lateral bucket-handle meniscus tears was reported in a male of 21 years old. The patient also had a chronic anterior cruciate ligament injury. The magnetic resonance imaging also showed a rare presentation of the triple-PCL sign with the sagittal view. Arthroscopic surgery with a meniscus repair and anterior cruciate ligament reconstruction was performed on the patient.ConclusionsSeveral specific imaging signs including triple-PCL sign could be presented in a rare case of both medial and lateral bucket-handle meniscus tears. Recognition of this sign is important to have accurate preoperative diagnosis and proper treatment plan.

Association Between Meniscal Allograft Tears and Early Surgical Meniscal Allograft Failure

Background: Meniscal allograft transplantation (MAT) has become a viable treatment option for patients with symptomatic meniscal deficiency. Some patients experience early surgical meniscal allograft failure attributed to causes that have not yet been sufficiently clarified. Purpose: To evaluate the prevalence, types, and distribution of arthroscopically confirmed meniscal allograft tears and the associated effect on surgical meniscal allograft survival. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing MAT with a minimum 2-year follow-up were retrospectively reviewed. Descriptive and surgical data were collected. Type and location of arthroscopically confirmed meniscal allograft tears were recorded and compared between medial and lateral allografts and suture-only and bone block fixation. A survival analysis was conducted to evaluate the effect of meniscal allograft tears on surgical meniscal allograft survival. Results: This study included 142 patients (54% male; mean ± SD age, 29.6 ± 10.4 years) with a mean follow-up of 10.3 ± 7.5 years. The prevalence of meniscal allograft tears was 32%, observed at a median of 1.2 years (interquartile range, 2.8 years) after MAT. The posterior horns were most frequently affected, followed by the posterior roots, midbodies, anterior horns, and anterior roots. The most frequently observed tear types were root tears (43%), followed by longitudinal, horizontal, radial, complex, bucket-handle, and meniscocapsular separation tears. A statistically significant association was found between meniscal allograft tear types and fixation techniques (P = .027), with root tears predominant after suture-only as compared with bone block fixation (57% vs 22%). Patients with meniscal allograft root tears were a mean of 5.4 years (95% CI, 1.6-9.2 years; P = .007) younger than were patients without root tears. The 1-year surgical meniscal allograft survival rate was significantly lower for torn versus intact meniscal allografts (75% vs 99%; P < .001). Conclusion: Meniscal allograft root tears were predominant, associated with younger patient age, and more often observed when using the suture-only fixation technique versus the bone block fixation technique. Torn meniscal allografts were associated with early surgical graft failure when compared with intact meniscal allografts, resulting in a significantly lower 1-year survival rate.

Meniscal tears associated with complete vs partial anterior cruciate ligament injury

Purpose: To investigate the incidence and location of meniscal tears in relation to complete vs partial anterior cruciate ligament (ACL) injury.Subjects and Methods: We collected MRI of 114 patients (114 knees) diagnosed with combined ACL and meniscal injury at a follow up 3 months to 2 years of knee injury at our center in last 3 years. The subjects comprised 68 males and 46 females ranging in age from 20 to 55 years. The patients were divided into two groups: Meniscal tears with Partial ACL injury and Complete ACL injury and the results were compared between this two groups.Results: The incidence of complete ACL injury diagnosed with MRI was 52.63% (60 of 114 knees) and partial ACL injury was 47.36% (54 of 114 knees). Regarding the locations of meniscal tears, in complete ACL injury (60 knees), medial meniscal tear was found in 60% (36 of 60 knees), lateral meniscal tear in 31.66 % (19 of 60 knees), and bilateral meniscal tears in 8.33 % (5 of 60 knees). In Partial ACL injury (54 knees), medial meniscal tear was found in 46.29 % (25 of 54 knees) and lateral meniscal tear in 42.59 % (23 of 54 knees) and bilateral (including medial and lateral) meniscal tears in 11.11 % (6 of 54 knees). Bucket handle tear was observed in 11 knees (medial: 8 knees, lateral: 3 knees) in complete ACL injury, and 4 knees (medial: 3 knees, lateral: 1 knee) in partial ACL injury.Conclusion: Incidence of medial meniscus tear was more than 50% in complete ACL injury. Lateral meniscus tear was more associated with partial ACL injury compared to complete ACL injury.

Surgical Outcomes after Bucket Handle Meniscus Repairs: analysis of a large contained cohort study

Objectives:Comprising approximately 10% of all mensiscus tears, bucket-handle meniscus tears are large longitudinal vertical meniscus tears that have an attached fragment flipped into the intercondylar notch. Meniscectomy would often result in significant meniscal loss and increased joint loading. Alternatively, meniscus repair attempts to restore the function of the meniscus and aims to preserve joint mechanics. The objective of this observational data-only study is to evaluate the long-term risk of subsequent ipsilateral knee surgery in patients who underwent a bucket handle meniscus repair and assess risk factors associated with subsequent knee surgical intervention.Methods:We performed an electronic health records search for all patients who underwent arthroscopic knee meniscal repairs from 2011 to 2018. Natural language processing was used to search for terms of interest in the long operative notes to determine if these surgeries were performed for bucket handle meniscus tears. These patients comprised our initial cohort. Study subjects were followed for at least one year and up to five years with censoring at death, membership disenrollment, or 12/31/2019. Baseline patient characteristics and outcomes (i.e., subsequent operative procedures, deep surgical site infections, and deep venous thrombosis) were evaluated via a database review. Descriptive statistics were employed.Results:The median follow-up time was 4.2 years (interquartile range [IQR] 2.7-5.0 years). A total of 1353 patients underwent meniscus repair surgery for a bucket-handle meniscus tear. The median age was 24 years (IQR 17-34). During the follow-up period, 492 subsequent ipsilateral procedures were performed in 272 (20.1%) patients. 59 (4.3%) patients underwent a subsequent repeat meniscus repair and 164 (12.1%) patients underwent a subsequent meniscectomy. The median time to first procedure was 41.1 months (IQR 23.3-60 months). Younger age and lower BMI were significant risk factors for having subsequent surgery (adjusted odds ratio [aOR] 1.04, 95% Confidence Interval [95%CI] 1.02-1.05, and aOR 1.60, 95%CI 1.09-2.35, respectively). Patients undergoing concomitant ACL reconstruction had a lower risk of undergoing subsequent surgery (aOR 0.66, 95%CI 0.50-0.88).Conclusions:This is the largest reported contained patient cohort study on outcomes after bucket-handle meniscus repair. 20% of patients underwent repeat surgery during the follow-up time period with 4.3% experiencing a subsequent repeat meniscus repair and 12% experiencing a subsequent meniscectomy. Risk factors for subsequent surgery include younger age and lower BMI. Concomitant ACL reconstruction at time of bucket-handle meniscus repair reduced the risk of subsequent reoperation.

Functional outcome of arthroscopic meniscal repair in meniscal tears: a prospective study in tertiary care hospital in North India

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; A Meniscal injury can result in intra articular damage and which can eventually result in osteoarthritis if not treated on time and the objective should be to save the meniscus wherever possible. This study was done to analyse the functional outcome of arthroscopic meniscal repair done in different types of Meniscal tears.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study was conducted on a group of 28 patients with meniscal injury admitted in government medical college Jammu from November 2018 to October 2020. All the tears were located in the red-red and red-white zones. The functional outcome was assessed on the basis of Lysholm Tegner scoring. A standard rehabilitation protocol was followed post repair.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Twenty-eight patients were included in the study. Male patients outnumbered the females and the incidence of injury was more on the right side. Sports injuries were the most common mode of injury, followed by road traffic accidents and falls. Bucket handle tears were most commonly seen in the group of patients. ACL injury was the major associated injury to be noted. The functional outcome between pre and post operation was statistically significant (p&amp;lt;0.05). In one of the patient failures was seen. Two patients were lost to follow up and were not included in the study.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Arthroscopic meniscal repair is a has a very good functional outcome according to our study and should be preferred over meniscectomy (subtotal or total), as meniscus being a very important shock absorber present between the knee joint can lead to delay in osteoarthritis of knee joint. Therefore, our priority should be to save the meniscus and restore the normal anatomy of the knee joint for its biomechanical stability and normal function.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;

What Is the Failure Rate After Arthroscopic Repair of Bucket-Handle Meniscal Tears? A Systematic Review and Meta-analysis

Background: Meniscal repair has become the treatment of choice for meniscal tears, especially in the subset of bucket-handle meniscal tears (BHMTs). However, a comprehensive estimate of the corresponding failure rate is not available, thus maintaining doubts about the healing potential of these tears. Furthermore, a wide range of factors to predict high failure rates have been reported but with conflicting evidence. Purpose: To determine the failure rate after arthroscopic repair of BHMTs as reported in the literature, compare this with the failure rate of simple meniscal tears extracted from the same studies, and analyze the influence of factors previously reported to be predictive of meniscal repair failure. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search was conducted by 2 independent reviewers using principal bibliographic databases (PubMed, Scopus, Cochrane Library, and EMBASE). After a stepwise exclusion process, 38 articles met the inclusion criteria. Failure rate data were analyzed with a random-effects proportional meta-analysis (weighted for individual study size), and forest plots were constructed to determine any statistically significant differences between BHMTs versus simple tears (longitudinal, radial, or horizontal), medial versus lateral BHMTs, isolated procedures versus repairs with concomitant anterior cruciate ligament reconstruction, and tears in red-red versus red-white zones. Moreover, a meta-regression analysis was conducted to evaluate the effect of patient age and sex, suture technique (in-out or all-inside), time from injury to surgery, mean number of stitches, and length of follow-up on failure rates. Results: The pooled failure rate was 14.8% (95% CI, 11.3%-18.3%; I2 = 77.2%). A total of 17 studies provided failure rates of both BHMT repairs (46/311 repairs) and simple tear repairs (54/546 repairs), demonstrating a significantly higher failure rate for BHMT repairs (risk ratio [RR] = 1.50; 95% CI, 1.05-2.15; I2 = 0%; P = .03). Medial BHMT repairs (RR = 1.94; 95% CI, 1.25-3.01; I2 = 0%; P = .003) and isolated repairs (RR = 1.77; 95% CI, 1.15-2.72; I2 = 0%; P = .009) had statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. Among the other factors evaluated with meta-regression, only the mean number of stitches showed a statistically significant effect on failure rates. Conclusion: Based on the currently available literature, this systematic review provides a reasonably comprehensive analysis of failure rate after arthroscopic BHMT repair; failure is estimated to occur in 14.8% of cases. Medial tears and isolated repairs were the 2 major predictors of failure.

An Approach to Chronic and Displaced Bucket Handle Meniscal Tear—Assessment, Repair (Push-and-Pull Technique), or Salvage

Meniscal repairs are preferred to meniscectomies to preserve meniscal function and mitigate the risk of degeneration. However, repair of a chronic and displaced bucket handle tear of the meniscus can be technically challenging. We introduce a systematic method for assessment, reduction, repair, or salvage in this situation with an aim of reducing operating time and improving the chance of a favorable outcome. This technique describes repair of a bucket handle tear on the medial meniscus with displacement into the intercondylar notch. An arthroscopic probe is used for reduction and suture tension (push-and-pull technique) when using an all-inside suture device (FAST-FIX 360 repair system; Smith & Nephew) on the middle and posterior part of the tear. The anterior part of the tear is repaired with an outside-in method. If reduction is not possible, then a salvage reduction and hybrid repair is carried out instead. Postoperatively, patients will be nonweight-bearing on the operated limb, and range of motion restricted from 0 to 90° for 6 weeks, with the aim of resuming running by 6 months.

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.

Increased Construct Stiffness With Meniscal Repair Sutures and Devices Increases the Risk of Cheese-Wiring During Biomechanical Load-to-Failure Testing.

Background:Cheese-wiring, the suture that cuts through the meniscus, is a well-known issue in meniscal repair. So far, contributing factors are neither fully understood nor sufficiently studied.Hypothesis/Purpose:To investigate whether the construct stiffness of repair sutures and devices correlates with suture cut-through (cheese-wiring) during load-to-failure testing.Study Design:Controlled laboratory study.Methods:In 131 porcine menisci, longitudinal bucket-handle tears were repaired using either inside-out sutures (n = 66; No. 0 Ultrabraid, 2-0 Orthocord, 2-0 FiberWire, and 2-0 Ethibond) or all-inside devices (n = 65; FastFix360, Omnispan, and Meniscal Cinch). After cyclic loading, load-to-failure testing was performed. The mode of failure and construct stiffness were recorded. A receiver operating characteristic curve analysis was performed to define the optimal stiffness threshold for predicting meniscal repair failure by cheese-wiring. The 2-tailed t test and analysis of variance were used to test significance.Results:Loss of suture fixation was the most common mode of failure in all specimens (58%), except for the Omnispan, which failed most commonly because of anchor pull-through. The Omnispan demonstrated the highest construct stiffness (30.8 ± 3.5 N/mm), whereas the Meniscal Cinch (18.0 ± 8.8 N/mm) and Ethibond (19.4 ± 7.8 N/mm) demonstrated the lowest construct stiffness. The Omnispan showed significantly higher stiffness compared with the Meniscal Cinch (P < .001) and Ethibond (P = .02), whereas the stiffness of the Meniscal Cinch was significantly lower compared with that of the FiberWire (P = .01), Ultrabraid (P = .04), and FastFix360 (P = .03). While meniscal repair with a high construct stiffness more often failed by cheese-wiring, meniscal repair with a lower stiffness failed by loss of suture fixation, knot slippage, or anchor pull-through. Meniscal repair with a stiffness >26.5 N/mm had a 3.6 times higher risk of failure due to cheese-wiring during load-to-failure testing (95% CI, 1.4-8.2; P < .0001).Conclusion:Meniscal repair using inside-out sutures and all-inside devices with a higher construct stiffness (>26.5 N/mm) was more likely to fail through suture cut-through (cheese-wiring) than that with a lower stiffness (≤26.5 N/mm).Clinical Relevance:This is the first study investigating the impact of construct stiffness on meniscal repair failure by suture cut-through (cheese-wiring).

Bucket handle meniscus tears in low-resource settings can be successfully treated with a cost-effective technique.

In regions of the world where resources can limit medical care (limited-resource settings, LRS), most meniscal tears are often treated with meniscectomy. A simple, low-cost option for meniscal repair has been developed. We sought to evaluate patient reported outcomes (PROMs) and clinical failure rates of bucket handle meniscus tears (BHTs) treated with meniscal repair in a LRS. We prospectively enrolled patients over 18 who were treated for BHT with meniscal repair in a LRS. Meniscal repair was primarily accomplished using an outside-in technique. Pre-injury and final follow-up PROMs were recorded. Clinical failure was defined as the need for re-operation or symptoms that prevented the patient from returning to recreational activities or work responsibilities. Nineteen patients with a mean age of 25.4years were eligible. Two patients sustained a clinical failure (10.5%). At mean follow-up of 40.6months, there was significant improvement in all PROMs from baseline. Subgroup analysis revealed no significant difference in the failure group compared to the success group in number of knots used, pre-injury Tegner score, number of devices used, suture type, or technique. Bucket-handle meniscal tears can be repaired using a low-cost technique resulting in satisfactory healing rates and excellent outcomes.

Double bucket handle tear of the superior labrum in a young patient presented with shoulder instability treated with arthroscopic debridement: A case report.

Introduction and importanceThe two major etiologies of shoulder superior labral tears anterior to posterior (SLAP) are traumatic and degenerative processes. Bucket handle tears of the superior labrum represent one-third of labral lesions. However, in this article, we present a double bucket handle tear which has been reported once in the literature.Presentation of caseA 25-year-old male presented with complaint of chronic pain in his right shoulder with a remote history of traumatic dislocation. Physical examination revealed a positive apprehension test. Shoulder magnetic resonance imaging (MRI) showed a superior labral tear with a Hill-Sach lesion. Arthroscopy showed a double bucket handle tear of superior labrum and mild biceps tendonitis along with Bankart lesion. The tear was resected and the Bankart lesion was repaired followed by supervised physical therapy. Good clinical outcomes in form of resolution of pain and shoulder instability at six months were obtained.DiscussionSLAP tears are common shoulder lesion that is reported differently in the literature. Arthroscopic studies had reported the incidence between 3.9%-11.8. The diagnosis of such lesion relies on the clinical presentation and imaging. Knesek et al. classified SLAP lesions based on the integrity of the biceps anchor and the type of labral tear (Knesek et al., 2013). The standard treatment of symptomatic SLAP lesions is Arthroscopic debridement. However, non-operative management was described in the literature.ConclusionDouble bucket handle injuries of the superior labrum are reported in literature once. These lesions can be treated with arthroscopic debridement and Bankart repair and followed by supervised physical therapy.

Arthroscopic Diagnosis of Occult Posterolateral Meniscocapsular Separations: Another Hidden Lesion

PurposeThe purpose of this study was to describe the surgical findings and clinical outcomes in a series of patients with occult posterolateral meniscocapsular separations diagnosed arthroscopically after a negative magnetic resonance imaging (MRI) scan.MethodsA retrospective analysis of prospectively collected data of consecutive patients who underwent surgical arthroscopy with repair of an occult posterolateral meniscocapsular separation by 2 fellowship-trained orthopaedic sports medicine surgeons at a single institution was performed. All lesions were identified arthroscopically in the posterolateral aspect of the lateral compartment as a distinct pathologic separation between the posterolateral capsule and adjacent meniscal tissue with increased excursion on probing. Clinical examination notes, MRI scans, and operative reports were reviewed. Patient-reported outcome measures were assessed via patient questionnaire.ResultsA total of 6 patients were included for analysis. MRI evaluation of the lateral meniscus was unrevealing in 4 patients, suggesting a possible tear of the body of the lateral meniscus in one patient and demonstrating a parameniscal cyst abutting the anterior root of the lateral meniscus in another patient. Arthroscopic examination revealed meniscocapsular separations of the posterolateral meniscus in all 6 knees, with 2 knees demonstrating concomitant bucket-handle meniscus tears. Patient-reported outcomes were determined for 67% of study patients. The average reported International Knee Documentation Committee score was 63.8, the average Knee Outcome Survey Activities of Daily Living Scale score was reported as 63, the 12-Item Short Form Survey (SF-12) Physical score averaged 46.8 with an average SF-12 Mental score of 59.9.ConclusionsThe diagnosis of occult posterolateral meniscocapsular separations (MCS) could be missed on advanced imaging, such as MRI, so arthroscopic diagnosis may be required. This study indicates that arthroscopic diagnosis and repair of occult posterolateral MCS results in good functional and clinical outcomes.Level of EvidenceIV, therapeutic case series.

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.

Indirect Magnetic Resonance Arthrography May Help Avoid Second Look Arthroscopy for Assessment of Healing After Bucket Handle Medial Meniscus Repairs: A Prospective Clinico-Radiological Observational Study

The objectives were: (1) to analyze the MRI healing rates of bucket-handle meniscus repair; (2) to compare the accuracy of assessment ofmeniscus healing for conventional MRI and Indirect Magnetic Resonance Arthrography (IMRA); and (3) to identify patients who may requiresecond-look arthroscopy after meniscus repair. This is a prospective observational case series of thirty-seven patients with repaired bucket-handle medial meniscus tear with a minimum one year follow-up. Meniscus healing rates were assessed on direct MRI and IMRA using Henning's criteria. At the same time, patients' symptoms were evaluated according to Barrett's criteria and functional outcomes were recorded using International Knee Documentation Committee (IKDC) score, Knee Osteoarthritis and Outcomes Score (KOOS) and Tegner-Lysholm scores. A further clinical review was performed 18months after the imaging to assess the evolution of symptoms. At a mean of 22.3 ± 7.8months after the meniscus repair, 56.7% patients showed complete healing and 40.5% patients demonstrated incomplete repair healing on IMRA. 52% patients with complete healing and 40% patients with incomplete healing demonstrated meniscus symptoms. At the second clinical review, 19% patients with complete healing and 20% patients with incomplete healing had meniscus symptoms. There was no co-relation between symptoms, PROMs and healing on MRI. Indirect MR arthrography offers distinct advantages over direct MRIfor assessment of meniscus healing, especially in symptomatic patients. Patient-reported outcome measures and symptomatology are not co-related with the healing status of the meniscus and they resolve in the majority on longer follow-up. A more conservative approach guided by IMRA to assess meniscus healing will avoid early re-operations.

Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft: Challenges and Solutions of Medial Independent Femoral Tunnel Drilling

Background: As the main translational and rotatory stabilizer of the knee, the anterior cruciate ligament (ACL) plays a critical role in knee biomechanics. Anterior cruciate ligament ruptures generally require surgical attention for not only restoration of knee stability but also prevention of meniscal and chondral injuries. There are countless options for both the surgeon and the patient when contemplating graft choice and surgical technique for ACL reconstruction. However, the literature assessing the outcomes following various autografts has varied with some studies citing no significant difference in clinical and patient-reported outcomes, while others showing notable advantage when using bone–patellar tendon–bone (BPTB) autograft. In addition, there have been challenges associated with femoral tunnel placement using an anteromedial portal technique. Indications: In this study, we present a young female patient with a history of remote mid-substance ACL tear now presenting with worsening knee instability and a bucket-handle medial meniscus tear as a sequela of the incompetent ACL. After extensive discussion regarding the treatment options, patient had decided to proceed with surgical intervention with a BPTB autograft using the anteromedial portal technique for femoral tunnel placement and compression technique with bio-absorbable interference screw fixation. Results: Bone–patellar tendon–bone autograft has been noted to have lower risk of revision when compared with other graft options. Discussion: In this surgical technique study, we underline the importance of peritenon handling. We highlight the use of a 70-degree arthroscope to improve posterolateral wall visualization during femoral tunnel placement as well as for inspection of the reamed tibial tunnel. We also provide technique commentary and solutions for management of the medial femoral condyle (MFC) articular surface and femoral tunnel placement using an anteromedial portal technique. Last, we review graft-related outcomes, postoperative management, and rehabilitation protocol.

Management of a Lateral Meniscus Tear with Bucket-Handle Displacement in a Seven-Year-Old with Lateral Discoid Meniscus Morphology: A Case Report

Background: Lateral meniscus tears in patients less than ten years old are exceedingly rare. Displaced bucket handle tears of the lateral meniscus are even less commonly encountered. Hypothesis/Purpose: This case report details the presentation, treatment, and recovery of a seven year old female who presented with a bucket handle lateral meniscus tear and was found to have underlying discoid meniscus morphology. Methods: This case report details the pre-operative, arthroscopic findings, repair technique, and post-operative outcome of a single patient presenting with a rare injury pattern. Results: The lateral meniscus was torn along the periphery at the meniscocapsular junction involving zones I-III with displacement into the notch. The meniscal tissue appeared hypertrophied and was noted to be a Wrisberg type discoid variant. A saucerization and repair was performed using sutures utilizing a combination of all-inside and outside-in repair techniques. The patient regained full range of motion and returned to full unimpeded activity at three months post-operatively. Conclusions: This is a unique case of a pediatric patient less than ten years old presenting with a bucket-handle tear of a discoid lateral meniscus who underwent surgical repair. The case details the saucerization and repair technique with successful recovery of this pediatric patient to date. It highlights a technique for meniscus repair in lieu of partial meniscectomy which is of particular benefit in the pediatric population.

LATERAL MENISCUS TEARS IN ACL INJURED KNEE

Anterior cruciate ligament (ACL) tears can be associated with injuries to the lateral meniscus (LM) in about 20-30% cases. The lateral meniscus is more mobile than the medial and besides contributing to load transmission, it also stabilizes the knee in pivot-shift testing. The LM tears more often in the acute setting and its incidence does not rise in cases of chronic ACL instability. Lateral meniscus tears can be minor or major depending how severely the knee function gets impaired. Major tears are the complete radial tears, longitudinal bucket handle tears and posterior root tears. Male gender, high body mass index and contact injury mechanism are all risk factors for an LM tear. Anatomic factors which can contribute to LM tears include a high posterior tibial slope, varus malalignment and greater asymmetry between medial and lateral slopes. The lateral meniscus must be saved and repaired whenever possible to prevent residual knee instability and progressive lateral compartment arthritis, which can set in soon after a meniscectomy. The development of techniques and technology have rendered most tears amenable to repair. Longitudinal tears can be repaired by the all-inside or inside-out technique and the needles and devices must be inserted through a high anteromedial or transpatellar portal to prevent injury to the popliteal neurovascular structures. A lateral safety incision must always be used for inside-out repairs. Radial tears can be repaired by two horizontal sutures, a cross stich, a cross-tag or a hash-tag suture configuration. Lateral meniscus posterior root repairs are repaired by transtibial technique, either by drilling an independent anatomic tunnel or the sutures pulled out via the ACL tibial tunnel. The lateral meniscus has high healing rates and repairs yield improvement in functional outcome, beside delaying radiographic arthritis.

Technique for All-Inside Repair of Bucket-Handle Meniscus Tears

Bucket-handle meniscal tears (BHMT) remain a challenge to treat due to their complex pathology and technical difficulty. Subtotal meniscectomy has shown to improve symptoms early but leads to accelerated osteoarthritis in the affected compartment and poor long-term outcomes. BHMT repair and meniscal preservation is the preferred option. This can be performed with inside-out, all-inside, or hybrid meniscus repair techniques. All-inside meniscus repair avoids the need for additional safety incisions, trained assistants for suture passing, and reduce concerns of soft-tissue and neurovascular complications. In this Technical Note, we detail our all-inside technique for BHMT technique and share tips for a successful repair.

Arthroscopically assisted evaluation of frequency and patterns of meniscal tears in operative tibial plateau fractures: a retrospective study

BackgroundDespite tibial plateau fractures are often associated with meniscal tears, the association between meniscal tears and Schatzker classification remains unclear. The purpose of this study was to assess the frequency and patterns of meniscal tears in operatively treated tibial plateau fractures following immediate arthroscopic evaluation after internal fixation of tibial plateau fractures and to reveal the association between these concomitant meniscal tears and Schatzker classification.MethodsA total of 252 consecutive patients (166 males and 86 females, mean age 46.7 (19–80) years) with operatively treated tibial plateau fractures admitted to our hospital from January 2016 to May 2019 were performed. Arthroscopic examination for frequency and patterns of meniscal tears was evaluated and documented at the time of surgery, and the association between the frequency and patterns of meniscal tears with Schatzker classification was then analyzed.ResultsThe overall frequency of meniscal tears in TPFs was 67% (168 of 252) with 33% (84 of 252) of these being lateral meniscal tears, and 10% (26 of 252) medial meniscal tears, while 23% (58 of 252) had bilateral meniscal tears. Schatzker II was most commonly associated with meniscal tears, occurring in 72% (71 of 99) of our series. There is no significant difference between the frequency of meniscal tears and Schatzker classification (p > 0.05). The most common patterns of meniscal tears were longitudinal tears in 23% of tibial plateau fractures (59 of 252), and it occurred at a significantly higher frequency in Schatzker II with 43% (43 of 99). Schatzker IV had significantly higher prevalence of bucket-handle tears than other fracture patterns (p < 0.05), and Schatzker VI fractures had significantly higher prevalence of complex tears than other fracture patterns (p < 0.05). For other Schatzker classification, the patterns of meniscal tears demonstrated no statistical difference (p > 0.05).ConclusionThe results identified that meniscal tears are commonly seen in each Schatzker classification. Although various patterns of meniscal tears occurred in tibial plateau fractures, the most common patterns were longitudinal tears. Importantly, we suggest that the status of meniscal tears associated with TPFs should be considered at the time of surgery in addition to fracture fixation.

Numerical Investigation of the Effects of Bucket Handle Tears and Subtotal Medial Meniscectomies on the Biomechanical Response of Human Knee Joints

Understanding the complex biomechanical behaviour of the injured and meniscectomised knee joints is of utmost significance in various clinical circumstances. The objective of this study is to investigate the effects of bucket handle tears in the medial meniscus and subtotal medial meniscectomies on the biomechanical response of the knee joints belonging to multiple subjects. The three-dimensional (3D) finite element models of human knee joints including bones, cartilages, menisci, ligaments and tendons are developed from magnetic resonance images (MRI) of multiple healthy subjects. The knee joints are subjected to an axial compressive force, which corresponds to the force of the gait cycle for the full extension position of the knee joint. Three different conditions are compared: intact knee joints, knee joints with bucket handle tears in the medial meniscus and knee joints after subtotal meniscectomies. The bucket handle tear causes a considerable rise in the maximum principal stress at its tip compared to that at the same location in the intact meniscus. This would cause the total rupture of the meniscus resulting in cartilage damage. Subtotal meniscectomy causes a considerable reduction in the contact area along with a substantial increase in the contact pressure and maximum compressive stress in the cartilages in comparison with that in the intact knee. This could give rise to severe degenerative changes in the cartilage. The results of this study could help surgeons in making clinical decisions when managing patients with meniscal injuries.