disclosed to this talk. So most of us know what a bucket handle is. It's five times more common in the medial meniscus compared to the lateral meniscus, and it's more commonly seen with ACL ruptures. We know what the MRI looks like. Typically, we see a double PCL sign, but there are a lot of variations of this. And here's the case, a 26-year-old pro-MMA person with a bucket handle tear. And we can discuss whether you'd fix this or not, but I ended up fixing this. And there's a variety of techniques you could use. We could also discuss that at the tables. What's your preferred technique? And in this case, I used an all-inside technique. And as you continue through, vertical mattress sutures above and below the meniscus. And as we just continue here, I just want to show you the final product. And then one below to balance it out. I did not use any biological augments on this, and we can discuss whether that was right or wrong, but this was the finished product. He returns to fighting at eight months, wins the fight, but his knee starts to lock during the fight, and this is what we have. And so the question is, what to do next on this 26-year-old individual? So we're going to take five minutes or so at the tables. So let's discuss this case. I'm sorry? Oh yeah, can we get more people up? We've got some faculty here that are feeling a little left out. So there's people at the back. Matt's got several spots at his table. And if we're uneven, why don't you come up? Matt's got there. Yeah. But we're going to just take five minutes. All right. Okay, guys. So at the discussion of the tables, everyone at the initial case, would they have repaired it? Is that fair to say? I think so. Anyone not, would have not repaired the initial presentation? Okay. What about this? Anyone, would anyone re-repair this? Okay. We got some. Go ahead, Lee. Maybe a little bit. I mean, that inner leaflet definitely looks irreparable, but maybe there's some purple tissue that's fixable. I don't know. It depends on how it seals on that probe. The other thing that came up at the table, inside out versus all inside, anyone would have gone with an inside out instead? Okay. That was a couple. I agree. I probably should have done that. You know, the needles less, you know, less of a smaller bore when you're passing them. So I think that's reasonable. So this is what I ended up doing a partial minisectomy on him and not repairing it. Six months later is right knee. Not as bad as the other side. Maybe not a true bucket, but an undersurface, unstable. How many are fixing it? Got a lot of fixing. How many are taking it out? Yeah. He's still an MMA guy. So we ended up taking it out. So he's gone back and he's competing at the professional level and he's happy. Anyone have experience within these MMA jiu-jitsu guys with fixing their meniscus and actually getting them to successfully heal? I want to make one comment now. So the knee jerk reaction is we're going to have a poor score in the marathons. And the reason you took that out might have been more related to the fact that he failed his first one than it had to be in the second one. So I just think that's one of the challenges in this area where we have big room is that there are reasons to excise a tear that you think has a chance. That you put stitches in it and make it look great and you think it's going to be healed. So it's a consensual decision making that can be challenging. When you're dealing with two, five, sometimes three, five chances for you to tear in the cost of an athlete like this, I think always having to have that conversation about whether your knee jerk goes up. Obviously we all know what the consequences are, but we'll hear from the scores. But yeah, all of us can put stitches in a fix like you can see. I think the hardest part is making that decision with someone where, yes, people are prepared There's also a likelihood of it not healing. And what are the consequences of that? So I think everyone has to be prepared to have that conversation with patients. You know, we're shocked when, I always use the analogy we were talking about of a rotator cuff tear. You fix a degenerative rotator cuff and a year later they re-tear. Of course, you know, they still have the same degenerative dystrophic problem that led to their tear in the first place. So why should we be shocked a year later if it re-tears? Similarly, there's some research that looks at the meniscal capsular junction that goes back to the 80s where that's not normal tissue in a person who has an isolated bucket. Like Don Shelborn used to say, there's no such thing as an isolated bucket tear. You don't see them. You do see them. And I think those are probably very different tears than those that happen with ACLs, and not because an ACL gives all the vascularity and the stem cells and everything else that people talk about, because those are probably more likely than not more healthy tissue in some instances versus isolated where it wasn't healthy to begin with. And we shouldn't be shocked if they re-tear, even though we do a great repair. So I'm just putting it out there for the tables to think about what are the sort of psychosocial, athletic, professional, academic scenarios where you know it might heal, but you also know it may not, and what are the consequences of coming back and doing it again after four months out or six months out from their trade or their craft or their school? So just things that I often think about. That's a great point. That's why I brought up these cases. I think our knee-jerk reaction is fix, fix, fix. And I think there are issues when you fix this. Fortunately, this guy didn't have any implant-related issues. Sometimes when these implants fail, those plastic buttons or whatever you decide to use can start wearing down the cartilage, and they can be worse off after we fix them sometimes. Lathe, can I just ask one question that was a good segue that came up at our table was you had a secondary tear pattern in that failure. Did you feel that was through one of the iatrogenic perforations with your All-Inside device? I mean, you were there. You know that case best. Absolutely. And I get nervous. I've started to use less, and I've started to go into more inside-out. Like, I saw a lot of people raise their hands because I think those needles are smaller. And we don't, you know, even with our meniscus transplants, we don't see as often that tear pattern. So it's a balance. We all know the biomechanical consequences of bucket-handle tears. And when you take it out, you're going to have a higher chance of getting arthritis. In this retrospective review, they concluded that meniscus repairs had less arthritis associated with them compared to meniscectomy. But I think when you start to hone in on what are failure rates, and this was a review of bucket-handle tears, their failure rate was almost 30%. And they looked at, honed in, and there was no difference compared to inside-out repairs compared to All-Inside. And they also added that there was no difference in failure rates compared to Medially Unlateral. And also, it didn't matter whether they reconstructed the ACL or not. Now, this is just this isolated paper, but it just, you know, makes you pause and think. In this study out of Canada, 16% failure rate, almost 17% failure rate, versus about a 10% failure rate when they reconstructed the ACL. And again, 10-year follow-up, if you can get the meniscus to heal, you're going to have a better outcome in terms of KUS scores and progression of arthritis. Here's another one, long-term outcome bucket-handle repairs. Yes, you get this chondroprotective effect if it heals, but the failure rate in this group was very high, over 30%, and it was higher as age increased. If meniscus heals, yeah, best outcomes, but we've got to get it to field. And not all failed meniscus repairs are benign, secondary to implant-related morbidity. Scott talked about biological augmentation. This is a tough one. This systematic review looked at 4,000 articles with PRP, fibrin-clot, marrow stimulation. Minimal improvement, if any, compared to controls with essentially similar failure rates. Granted, there was significant heterogeneity in these prep methods, delivery, and post-op rehab protocols in this study. So, in conclusion, good long-term functional outcome if you can get the meniscus to heal. Progression of OA is less than in the meniscectomy. Failure rates can be as high as 30% and can occur after two or more years, with most failures occurring in the first 12 months. Be prepared to use multiple repair techniques for bucket-handle, outside-in type of repair for the anterior aspect of the bucket. And I think, most importantly, the method of repair is probably less important than being meticulous and the stability of the repair. And I'm thinking more about the inside-out and the smaller needle bore that's created that will lead to less failure rates in the future. Thank you.

bucket handle tears

knee

MMA fighter

meniscus tear repair

decision making