Alright, good morning everyone. We're gonna talk about bucket handle meniscus tears. I have no disclosures. So typical case, 20 year old male wrestler, bucket handle tear, fixed it, high-fiving, get back to competition. First match, knee locked again. Retour. Eight months out. So these bucket handle tears could be very, very, you know, they make us rethink. So let's take a step back. These are longitudinal tears of meniscus separated from the peripheral remnant. Could have a fragment, displace, and notch. Presents as the inability to extend the knee. Patients kind of feel that the knee is locked in. These tears are five times more likely affect the medial rather than the lateral meniscus and more commonly seen with ACL tears. Common radiographic findings, you have your double PCL sign, which we've all seen, especially here on the sagittal T2 image. LaProd and his group did a pretty elegant study looking at the biomechanical consequences of a bucket handle tear in the context of an ACL. And what they found is when you have your ACL reconstruction with a medial meniscectomy, your significantly decreased contact areas and significantly increased mean and peak contact pressures in both your medial and lateral compartments while your meniscus repair restored it back to normal. So clinical characteristics, here's a respective review by Robson et al. They found that these bucket handle tears occur more significantly in younger age patients and these are usually traumatic events. All right, so there's a little bit of background. Let's get into a case. 27 year old female. She's a status post previous right knee ACL reconstruction with a hamstring autograph at age 17. Initially did extremely well. She was skiing, presented to your office, two days of knee pain, swelling, limited knee range of motion. She felt a pop, knee buckled on her. On exam, holding knee inflection, very large diffusion, knee range of motion 20 to 80 degrees. We thought that, hey, you know what, it's probably the swelling, so we aspirated, got about 60 cc's of blood, range of motion still limited to 15 to 90, still a block to motion. Significant tendinous palpation about the medial joint line. Grade 2B Lachman. The various valgus exam was kind of limited, but she did have some grade 1 opening on valgus stress at 30 degrees. Rest of the exam is normal. Here are her plain foam x-rays. This was done at an outside institution. Here's MRI. Classic bucket handle tear, right, double PCL sign. Complete ACL tear. That's just a meniscus fragment. All right, so here's our problem. She retore ACL graft, bucket handle tear, grade 2 MCL sprain. Let's talk about decision making. Here are the things that I want you guys to discuss, okay. Timing of surgery, all right. Is this something you send her a little bit of ACL prehab? Do you need to take it to the OR tomorrow? Is this urgent emergent? Schedule is a routine case. ACL graft will kind of minimize discussion of this, but do you use autograft, allograft? Do you use literature on this coming out from the MOON group? Here are the things I want you to really focus on now. Are you going to do a meniscectomy? Inside-out repair? All inside? Some kind of hybrid technique? How about MCL, right, non-op, internal brace? Is your role for LET or ALL? All right, let's discuss. All right guys, so the format's going to be, we're going to take about five minutes. I'm going to set a timer for five minutes and we'll discuss at the tables, okay. All right guys, hopefully you had a chance to kind of discuss, you know, what you guys would do. So here's what we did. All right, so she had a bucket handle tear. We were able to reduce it a little, agreed to damage there. You know, so synovial rasp to fix our tear. I did a hybrid, you know, type of technique. We did a all inside, you know, posteriorly. Then we did an inside-out repair on this meniscus. Thought we got a pretty good fixation. For the ACL, I did a BTB autograft. The initial graft was a hamstring. Tunnels were acceptable, so they were, you know, able to kind of reuse it with some minor adjustments, especially the tibial side. There she is. All right, so clinical outcomes. Here's a study, recent study, looking at ACL reconstruction with meniscus out repairs. What he finds is that bucket handle repairs leads to good outcomes and good long-term consequences versus a meniscectomy. The failure rate was about 19% at 35.2 months. In the multivariate analysis, they showed that younger patients with revision ACLs were more at risk for meniscus repair failure. Here's a systematic review out of a group from Colorado looking at bucket handle meniscus repairs. What they found is that all inside repair was found to have a 29.3% failure rate, which is no different than an inside-out repair. And there are no differences found in this study in terms of with or without concurrent ACL reconstruction. Longer term outcomes, here's a Canadian study. They found that isolated meniscus repairs had a 16.7 percentile failure rate, while ACL reconstruction plus meniscus out repair had a 9.7 rate. So, you know, ACL reconstruction, similar to what Dr. Rodeo discussed, had a lower rate of failure. At 10 years, the outcomes of meniscus repair with the ACL reconstruction had good, you know, survivorship, 89% at 10 years predicted. Be mindful of your equipment. You have a variety of different options. You could do an inside-out repair, which is zone-specific. You could do an all- inside anchor base, whether it's a peak anchor or the newer all suture anchor devices. We also have the intrameniscal repair devices as well. Don't forget about your outside-in technique, especially for the anterior horn, still quite effective. Dr. Rodeo spoke about, you know, different adjuvants as well. So meniscus repair results in good long-term functional outcomes and these tears that do heal. Failure rate, roughly about 30% can occur after two years, although similar to the initial case I presented, usually occurs within the first 12 months. Method of repair is less important. You have to be meticulous. So, you know, use all of the different tools that were discussed with using a synovial If it's isolated repair, consider a limited microfracture or, you know, marrow venting. Yeah, so that's an excellent question. It definitely affects decision-making. You know, fortunately, you know, this particular repair, this particular meniscus tear was repairable. Good blood supply. It was in a red-red zone, but you should definitely look to make sure it's not a complex tear. You could also get a couple of hints on your MRI, you know, as well to see if there is more of a, you know, complex nature to tear. Does it have, like, a horizontal cleavage feature associated with that longitudinal tear? Good question. Yeah, so that's an outstanding question. If she was a higher-level athlete, I definitely would have considered a modified lamere. She was not. She was just wanting to go to the office. Any other questions? You know, so I think you guys also discussed graft choices. The MOON study group showed that BTB had a lower rate of failure, you know, with these bucket handle tears versus soft tissue. So, and definitely lower than allograft, so definitely consider an autograft option. All right, thank you.

bucket handle meniscus tears

ACL injuries

surgery timing

graft choices

meniscus repair techniques