Revision Repair of a Locked Bucket-Handle Medial Meniscal Tear with Concomitant Anatomic Medial Collateral Ligament Reconstruction

Abstract

Background:

Bucket-handle medial meniscal (BHMM) tears are a complex injury commonly found in young athletes. The literature reports that, on average, 85% of BHMM repairs are successful 1 year postoperatively. When failure occurs, a revision repair is optimal to prevent long-term arthritic changes and further stress on other knee ligaments.

Indications:

A revision repair of BHMM tears in adolescents is preferred compared with a meniscectomy due to a higher likelihood of the revision fully healing compared with older patients, and a higher chance of preventing the effects of increased joint contact stresses. The literature has reported that grade 3 medial collateral ligament (MCL) reconstructions may be indicated in symptomatic patients when medial compartment gapping exceeds 3 mm on stress x-rays.

Technical Description:

A reconstruction of the superficial medial collateral ligament (sMCL) with a locked BHMM revision repair was performed. Dissection of significant scarring surrounding the semitendinosus and gracilis tendons was performed for graft harvesting. Tibial suture anchors were placed 6 cm distal to the joint line at the distal tibial attachment of the sMCL. A Beath pin was passed through the femoral sMCL attachment site anterolaterally, over reamed with a 7-mm reamer, and placed into the femoral tunnel with a passing suture. A medial meniscal retear was confirmed through arthroscopy. Twelve vertical mattress inside-out sutures were used to repair the BHMM tear. The sMCL graft was fixed with a slight varus force with the knee flexed to 20° in the femoral tunnel. Lastly, another suture anchor was placed at the proximal tibial sMCL attachment 15 mm distal to the joint line and sewn into the sMCL graft.

Results:

BHMM tears in the adolescent population have demonstrated a higher healing rate than similar tears in adults. Therefore, a revision BHMM tear repair is indicated, especially in the setting of a concomitant grade 3 sMCL tear.

Discussion/Conclusion:

One risk involved in BHMM tears and MCL reconstruction is damage to the posterior neurovascular structures. The technique presented attempts to restore the native contact pressures and biomechanics within the knee through a revision BHMM repair with an anatomic sMCL reconstruction.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video presentation depicts a revision repair of a locked bucket-handle medial meniscus (BHMM) tear with concomitant anatomic medial collateral ligament (MCL) reconstruction.

Background/Indications

BHMM tears are a common injury that presents a challenge to surgeons due to their complexity. BHMM tears are often seen in younger male athletes and occur during rapid, sudden twisting during loading. This creates a vertical longitudinal tear in the meniscus, leading to a detached segment that flips upon itself, resembling a bucket handle. ⁵ Meniscal tears, such as BHMM tears, have a higher likelihood of healing when repaired in pediatric patients compared with those in adults due to increased vascularity. A study ⁷ reported that the 1- and 2-year survival rates after arthroscopic repair of BHMM tears are approximately 80%. For young athletes with BHMM tears, repairs have been associated with very high rates of successful rehabilitation. One study found that 66% of athletes returned to sports within 6 months, and 95% within 12 months. Given that BHMM tears can increase joint contact stresses by roughly 65%, revision repair of a BHMM tear is often indicated, especially in the setting of a concomitant MCL tear. ²

We present the case of a 16-year-old male patient with a history of BHMM repair 2 years prior, who injured the medial side of his right knee. Before reinjury, the patient was without symptoms. During a baseball swing, he pivoted, felt a pop, and subsequently developed immediate pain and swelling with persistent mechanical symptoms 1 week before his clinic visit.

Upon physical examination, the patient's right knee was tender to palpation at the medial joint line and meniscofemoral MCL attachment. The injured knee demonstrated 3 cm heel height to 130^o of flexion compared with 5 cm heel height to 140^o of flexion in the uninjured knee. Valgus stress testing at 30° demonstrated a grade 2 or 3 MCL injury.

Radiographs of the right knee demonstrated slight bilateral valgus mechanical alignment and 2.3 mm of increased side-to-side valgus opening, but the stress radiographs were limited due to guarding. Magnetic resonance imaging of the right knee demonstrated a BHMM retear with an intrasubstance superficial medial collateral ligament (sMCL) tear. The patient and his family elected to pursue a revision repair of a locked BHMM tear with concomitant anatomic reconstruction of the sMCL.

Technique Description

The patient was induced under general anesthesia, and a tourniquet was placed. Examination under anesthesia demonstrated 5 cm heel height to 135° knee flexion and a 3+ valgus stress test at 30° in the right knee. Fluoroscopic valgus stress testing demonstrated 4 mm of increased side-to-side gapping with valgus stress of the right knee, consistent with a complete sMCL tear.

The procedure started with a standard anteromedial incision over the vastus medialis oblique musculature and extended 7 cm distal to the joint line, splitting the distance between the anterior and posteromedial aspect of the tibia. The knee was further dissected to expose the pes anserine bursa, and the semitendinosus and gracilis tendons were both identified to be used for the MCL reconstruction. Adhesions were removed from both tendons, and they were harvested with an open hamstring harvester, then left attached distally. A prolonged, meticulous dissection was required due to profuse scarring from the previous BHMM repair.

Next, a spinal needle was placed at the joint line, and the sMCL distal tibial attachment was identified 6 cm distal from the joint line with a ruler. One Q-Fix anchor (Smith & Nephew) was then placed along the most posterior aspect of the anteroproximal medial tibia, and another was placed approximately 7 to 8 mm more lateral in relation to the first anchor. The grafts were then sutured down to reconstruct the distal tibial attachment site of the sMCL. The adductor magnus tendon and adductor tubercle were then identified on the femur. A ruler was used to measure 12.6 mm distally and 8.3 mm anteriorly from the adductor tubercle to identify the medial epicondyle and the sMCL femoral attachment site. A Beath pin was then drilled anterolaterally across the thigh using a femoral guide, directly at the sMCL femoral attachment site. This location was then reamed with a 7-mm reamer to a depth of 40 mm, and a passing stitch was placed.

The grafts were then passed under the remaining sartorius fascia and whipstitched so that 30 mm of each graft fit within the reconstruction tunnel. The remaining grafts were amputated.

Arthroscopy then began, and the suprapatellar pouch demonstrated mild scarring. A chondral fissure was also present, which created catching in the joint when the patella glided over the proximal trochlea. A gentle trochlear chondroplasty was performed. A wide-open drive-through sign was present in the medial compartment, and a BHMM tear was visualized and determined to be repairable. The medial meniscal tear edges were then rasped and gently shaved to stimulate blood flow and provide further reduction of the meniscus.

The meniscal repair zone was then dissected posteriorly, and a retractor was placed anterior to the medial head of the gastrocnemius. This was difficult due to the scarring from the previous BHMM repair. Twelve inside-out vertical mattress sutures were then placed carefully, alternating on the superior and inferior surfaces. After every 3 to 4 sutures were placed, the sutures were tied extra-articularly to ensure the meniscus was reduced to the anatomic position and to determine the best placement for the next sutures. To avoid placing sutures through the MCL graft, a blunt obturator was placed along the path of the MCL graft for visualization.

A microfracture awl was then used to place 4 awl holes in the lateral aspect of the intercondylar notch for a marrow venting procedure to help promote healing.

The sMCL graft was then dunked into the femoral tunnel. A 7 × 20 mm bioabsorbable screw was used to fixate the MCL in the femoral tunnel with the knee flexed to 20° with a slight varus reduction force. This eliminated the patient's valgus gapping.

Next, a spinal needle was placed at the joint line, and a ruler was used to measure 15 mm distally, marking a site for a Q-fix anchor (Smith & Nephew) to secure the sMCL graft at its proximal tibial attachment and complete the reconstruction.

Deep and superficial closure was performed, followed by the application of steri-strips, and the patient was placed in a knee immobilizer in full extension.

Potential complications must be acknowledged. To protect the posterior neurovascular structures, it is recommended to place a retractor behind the posteromedial capsule before suture placement to prevent potential nerve damage. Inside-out sutures were used in this surgery because of the smaller delivery needle, which allowed for more sutures and less meniscal tissue damage. ⁸ The more precise suture placement that the inside-out technique provides is also important when paired with an MCL reconstruction, as it is important to avoid suture placement through the MCL graft, possibly damaging the graft, and preventing healing. ⁶ Another potential complication is damage to the semitendinosus and gracilis tendons while harvesting them. Especially in a revision case, scarring may occur in the tendons, making their harvesting much more challenging and time-consuming. In this case, it is best to dissect carefully to avoid premature graft amputation.

Results

Postoperatively, the patient was instructed to be nonweightbearing for 6 weeks with knee flexion limited to 90° for the first 2 weeks, and then increasing knee range of motion as tolerated. Quadriceps activation, edema control, and knee motion were initiated in physical therapy on postoperative day 1. The patient would be transitioned to a CTi brace (Ossur) once able to bear weight and instructed to wear it for all activities for the following 4 months.

Discussion/Conclusion

Although the MCL has been shown to have sufficient healing capacity to warrant nonoperative treatment, ⁴ in grade 3 tears, a reconstruction is recommended. A study of cadaveric knees reported that sMCL reconstructions and repairs show no major difference in restoration of knee laxity. ⁹ A systematic review by Floyd et al ¹ revealed improved healing for patients with grade 3 MCL tears who underwent total reconstruction compared with repair. MCL reconstructions demonstrated significantly less stiffness and range of motion loss in the knee compared with repairs, with 11.6% of repairs resulting in arthrofibrosis compared with 5.4% in reconstructions. A randomized study between patients who received either sMCL repairs or reconstructions indicated that patient-reported outcomes were more favorable after reconstruction than repair. ³ Saltzman et al ⁷ reported that the majority of BHMM repairs had successful outcomes, with 84.6% of patients maintaining a successful repair 1 year postoperatively. On average, patients who underwent BHMM repairs reported high satisfaction rates with their procedures and stated that they would have the procedure again should the situation arise.

Postoperative day 1 radiograph demonstrated stable hardware fixation. At the patient's 6-month postoperative visit, strength testing showed a quadriceps limb symmetry index of 104%. Range of motion on both knees demonstrated 2 cm of heel height to 140° of flexion. All joint spaces appeared preserved, and the right knee demonstrated 0.6 mm of increased valgus gapping compared with the left knee.