Bucket Handle Medial Meniscal Tears Anatomy
The meniscus, a C-shaped piece of tough, rubbery cartilage, acts as a shock absorber between your shinbone and thighbone. Each knee has two menisci, one at the outer edge (lateral) and one at the inner edge (medial). A bucket handle tear is a particular type of meniscal tear that occurs in the medial meniscus and resembles the handle of a bucket.
Presentation
Patients with a bucket handle medial meniscal tear often present with symptoms of a locked knee. This condition is characterized by an inability to fully straighten the knee, causing difficulty in walking. Other symptoms may include pain, swelling, and instability.
Findings on MRI
On an MRI scan, a bucket handle tear is often recognized by a specific sign called the “double PCL sign”. This sign is seen when the torn fragment of the meniscus flips into the middle of the knee joint, giving the appearance of two posterior cruciate ligaments (PCLs) instead of one.
Repair Techniques
There are two common techniques for repairing a bucket handle medial meniscal tear: all-inside sutures and inside-out suture techniques. The all-inside technique uses special devices to place sutures entirely within the knee joint, while the inside-out technique involves passing sutures from inside the joint to the outer surface of the knee. Both techniques aim to restore the normal anatomy of the meniscus and its function.
Results
Evidence suggests that meniscal repair provides good clinical outcomes, with successful restoration of knee function and low rates of complications (Paxton et al., 2011). Furthermore, there is growing interest in the potential role of augmentation with bone marrow aspirate or platelet-rich plasma to enhance healing and improve outcomes (Griffin et al., 2015).
Postoperative Rehabilitation
Following surgery, the knee is typically immobilized in a brace to allow full weight bearing. The brace is locked for the first six weeks, but can be unlocked to allow knee movement from 0-90 degrees. Gradual return to walking is usually possible after six weeks, with a return to impact activities at around four months. Full recovery can be expected around 4-6 months post-surgery.
Dr. Gilmer’s Take
We know that meniscal tears heal better when we do an ACL surgery at the same time. So in cases of meniscal repairs without an ACL injury I will generally harvest bone marrow aspirate at the same time to mimic the release of these bone marrow contents. This in injected into the repair site at the end of surgery. I will generally use all-inside technique along the back of the meniscus (posterior horn) and inside out sutures moving forward (body and anterior horn). We call this a ‘hybrid’ approach. Sometimes a small portion is removed (meniscectomy) if the area is badly damaged and unlikely to heal successfully. Like many parts of knee surgery, I am seeking to balance the benefits of getting complete healing against the risk of needing to return for a second surgery. Results in a relatively large database were consistent with good results for our meniscal repairs that were in line with experts from the Arthroscopy Association of North America. My repeat surgery rate is around 5%. Age is not necessarily a strict criteria and in general I tend to be more aggressive than some surgeons as far as attempting repairs. Nonetheless, the patient age, goals, alignment, specific activities, and ability to rehab, as well as concomitant procedures all factor into this decision. It is important to treat these bucket handle tears acutely to improve the chance of healing before the meniscus is too deformed by the repetitive forces on it while it is flipped over.
References
- Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy. 2011;27(9):1275-1288.
- Griffin JW, Hadeed MM, Werner BC, Diduch DR, Carson EW, Miller MD. Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes? Clin Orthop Relat Res. 2015;473(5):1665-1672.
