Bucket-handle medial meniscus tear: Experience in suture technique selection

BUCKET-HANDLE MEDIAL MENISCUS TEAR: EXPERIENCE IN REPAIR TECHNIQUE SELECTION

While meniscectomy was once indicated quite broadly, its indications are now increasingly restricted. Many studies have shown that although meniscectomy allows patients to undergo functional rehabilitation faster, it leads to an increased risk of early knee osteoarthritis later on (as I explained in the previous article).

In this article, I will share a case of a 39-year-old male patient who suffered a sports injury and presented with pain and instability in his right knee. Clinical examination and MRI clearly showed a complete anterior cruciate ligament (ACL) tear and a bucket-handle medial meniscus tear. The planned surgical strategy was arthroscopic ACL reconstruction and repair of the torn meniscus.

Intraoperative findings revealed a large bucket-handle tear of the medial meniscus, which was displaced and locked through the medial femoral condyle. (Figure 1)

Figure 1. Intraoperative medial meniscus tear

A: Medial meniscus bucket-handle tear, locked joint

B: Right medial femoral condyle

So, which repair technique should be chosen?

The answer is a bit tricky because medical facilities in Vietnam are not always fully equipped. Even when equipment is available, cost is also a factor to consider in order to fit the patient's economic conditions. My motto is naturally to "cut your coat according to your cloth," meaning choosing a method that ensures a secure repair while optimizing treatment costs.

In the schematic diagram below, let's divide the cross-section of the knee joint according to the hour positions on a clock face.

Figure 2. Bucket-handle meniscus tear from the 1 o'clock to 5 o'clock positions

For repairing the 1 o'clock and 2 o'clock corner positions, repair devices have the advantage because the entry angle is straight from the anteromedial portal to place the first stitches. In this case, I used the Fast-Fix 360 from Smith & Nephew. You can watch the technique video at this link:

https://www.smith-nephew.com/en/health-care-professionals/products/sports-medicine/fast-fix-360#surgicaltechniques

Figure 3. Direction of repairing the tear at the 1 o'clock and 2 o'clock positions from the anteromedial (AM) portal

Figure 4. Repair using Fast-Fix 360

A: Trocar

B: Right medial femoral condyle

C: Suture strand after the first stitch, preparing for the second stitch

Figure 5. After placing the second stitch

A: Suture strand after repair

B: Left medial femoral condyle

After completing the first two stitches, the remaining tear is located from the 3 to 6 o'clock positions. This is a more difficult area to access, and the appropriate technique must be chosen depending on the case.

To place the stitches at the 3 to 4 o'clock positions, there are two options. If you want to use Fast-Fix 360 or suture devices, access from the AM portal is very difficult. To make it easier, you can create an additional portal located more laterally than the anterolateral (AL) portal and insert the instruments. The second method is an inside-out repair using a long, hollow needle inserted perpendicularly from the outside (Figure 6).

Figure 6. Inside-out suture

For the final stitch at the 5 o'clock corner, we use the outside-in technique to ensure complete stability of the meniscus.

After successfully completing a secure meniscus repair, the anterior cruciate ligament was reconstructed using the standard "all-inside" technique. Below is the image of the meniscus postoperatively.

Figure 7. Meniscus after repair

With the development of modern knee arthroscopic techniques, an increasing number of bucket-handle meniscus tears, bucket-handle medial meniscus tears, or meniscus tears combined with ACL ruptures can be preserved. This helps maintain the biological function of the meniscus, reduces the risk of knee osteoarthritis, and provides better long-term outcomes for patients.

Read more about Bucket-Handle Meniscus Tears (Part 1):https://bsdovuanh.com/trai-nghiem/sun-chem-rach-quai-xo-quai-vali