Bucket Handle,Inside-Out Medial Meniscal Repair: A Technique Video

Abstract

Background:

Bucket-handle medial meniscal tears represent a common subset of meniscal injuries, particularly among younger athletes. In cases requiring operative intervention, the inside-out technique for medial meniscal repair remains the gold standard.

Indications:

We present a technique video for the repair of a bucket-handle medial meniscal tear in a young athlete who sustained a meniscal injury while playing soccer, resulting in mechanical symptoms. The tear was noted to remain within the peripheral vascular zone of the meniscus, making him a favorable candidate for operative repair.

Technique Description:

The bucket-handle medial meniscal injury was confirmed with a diagnostic arthroscopy. The identified tear was subsequently reduced, debrided, and repaired via an inside-out technique using a mechanized suture passer. After appropriate repair, a femoral notch microfracture—a marrow stimulation procedure—was performed.

Results:

After the operation, the patient was expected to recover without complications and achieve return to sports and full recovery within 4 to 6 months. Surgical intervention was anticipated to result in symptom resolution, improved functional outcomes, and high patient satisfaction.

Discussion/Conclusion:

While the inside-out technique remains the gold standard for medial meniscal repair, the documented relative rate of failure for this procedure is not insignificant in high-level athletes. This technique video addresses some potential pearls and pitfalls to maximize the likelihood of success. It is imperative to accurately assess the extent of the injury during diagnostic arthroscopy and to strongly consider the regenerative capacity of the meniscus in establishing the appropriate treatment plan. Passing vertical mattress sutures with a mechanized device may obviate the need for a second surgical assistant. When finalizing the repair, sutures should be tied in full extension with the assistance of an arthroscopic knot pusher; direct visualization should be maintained to ensure adequate meniscal reduction and appropriate tension of both the knots tied and the tissues secured. Lastly, we advocate a femoral notch microfracture procedure to introduce marrow elements, platelets, growth factors, and cells into the articular space to provide a biologically favorable healing environment.

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

We present our technique for mechanized inside-out medial meniscal repair.

Background

Meniscus Anatomy

The medial and lateral menisci are 2 crescent-shaped, fibrocartilaginous structures that attach to the tibial plateau. Although they share common functions, there are also distinguishing features between the 2. The medial meniscus has a larger radius, is more static, and covers a smaller articular surface, while the lateral meniscus has a smaller radius, greater mobility, and covers a larger articular surface.^3,8

The medial meniscus primarily acts as a load transmitter, distributing stress across the tibiofemoral joint, but also has some shock-absorbing properties and contributes to stability throughout the knee range of motion. Because of its limited mobility, it is more susceptible to tearing and injury compared with the lateral meniscus. ³ This case demonstrates the application and clinical value of mechanized medial meniscal repair in the context of an inside-out technique.

Function

During weightbearing activities, the meniscus distributes stress across the knee joint and minimizes friction forces associated with femorotibial articulation. The meniscus also enhances the stability of this articulation and facilitates rotatory movements during knee flexion and extension.

Meniscal Tears

The meniscus is susceptible to tears when rotational or shearing forces are placed across the tibiofemoral joint and frequently occur in the setting of trauma or chronic attrition.^3,7 These tears typically occur in patterns that coincide with the direction of biomechanical forces imparted upon the meniscal tissue.

Tears may also be differentiated by their location relative to the existing blood supply. Red-red tears occur within the vascular outer one-third of the menisci, red-white tears extend from the red zone into the avascular white zone comprised of the inner two-thirds of the meniscus, and white-white tears remain exclusively within the avascular zone.^7,11

Current Trends

The inside-out technique has historically been considered the gold standard for medial meniscal repair. However, all-inside and outside-in approaches are also used, depending on the tear location and available instrumentation, at the discretion of the attending surgeon. ¹ Recent literature by Fillingham et al ⁵ suggests there is no significant difference in clinical or anatomic failure rates between inside-out and modern all-inside suture repair techniques for isolated meniscal tears. ² While all-inside repairs may offer advantages such as reduced operative time and a lower risk of postoperative nerve injury, ¹⁴ Grant et al ⁹ have reported a higher incidence of implant-related complications with the all-inside technique compared with inside-out repairs. ⁵ Although inside-out repairs remain the standard, they can present logistical challenges, as they typically require 2 assistants for suture passage and retrieval. As a result, some surgeons prefer all-inside techniques for their minimally invasive nature, reduced operative time, and decreased need for surgical personnel or open wound closure. The use of mechanized inside-out devices may mitigate some of these limitations by reducing the need for a second operative assistant.

Case Presentation

We present the case of a 15-year-old male soccer player who sustained an injury while planting his right foot to kick a soccer ball. He reported feeling a pop in his right knee, followed by transient locking in slight flexion. Two days later, he experienced a second injury while planting and pivoting on the same leg, resulting in an inability to bear weight and persistent symptoms.

Physical Examination

On physical examination, the right knee demonstrated soft tissue swelling and tenderness along the medial joint line. He was unable to extend the knee beyond 30° of flexion. The McMurray test was positive.

Radiograph and Magnetic Resonance Imaging (MRI)

The patient's radiographs and MRIs are shown here, which demonstrate a bucket-handle medial meniscal tear in a patient nearing skeletal maturity.

Treatment Options

There are several treatment options available for managing bucket-handle medial meniscal tears— including a variety of operative and biologic interventions.

Indications

Indications and Contraindications

Indications and relative contraindications for a meniscal repair in this patient are listed here. Partial or subtotal meniscectomy may have been considered in the setting of an irreparable tear pattern in a nonperfused region of the meniscus (eg, white-white zone), or complex bucket-handle tear patterns with radial or flap components. Significant delays to operative intervention may render initially repairable tears irreparable.

Treatment Plan

In this case, we chose to perform an inside-out medial meniscal repair using a mechanized suture passer as well as a femoral notch microfracture or a marrow-stimulation technique to facilitate healing.

Technique Description

Pictures of Surgery

We prefer to perform this procedure in the supine position, with a lateral post in place to provide a lever point for valgus force application. A nonsterile thigh tourniquet is also placed for hemostasis to improve intra-articular visualization. After a preoperative examination under anesthesia is performed, standard anterolateral and anteromedial portals are established, and a diagnostic arthroscopy is completed, confirming stable cruciate ligaments and chondral surfaces.

Video of Surgery

We then made a 4-cm longitudinal incision along the posteromedial aspect of the joint line. One-third of the incision is superior to the joint line, and two-thirds is below the joint line. Dissection is carried down to the sartorial fascial plane, with care taken to protect the saphenous nerve and vein. The fascia is then incised in line with the skin incision. The interval between the medial gastrocnemius and the joint capsule is then identified and exploited bluntly before a Henning retractor is placed within this interval, posterior to the joint capsule.

In this patient, the bucket-handle medial meniscal tear was found to extend from the posterior horn to the anterior horn, and fell within the peripheral one-third (red-red zone). This was reduced with pressure from a switching stick while a valgus force was applied. Next, an arthroscopic rasp was used to gently debride the torn meniscal margins. Given the aforementioned indications for meniscal repair in this setting, this tear was deemed repairable.

We then performed an inside-out meniscal repair using a Stryker SharpShooter mechanized suture passer to place vertical mattress sutures sequentially from posterior to anterior, spaced approximately 5 mm apart. The posterior 4 vertical mattress sutures in this case were placed utilizing the midbody cannula device. The anterior 2 vertical mattress sutures were placed with the anterior cannula device. Sutures are retrieved by an assistant from the posteromedial knee, and pairs of sutures are sequentially clamped together against the drape. Once all sutures are passed, the knee is brought into full extension, and the sutures are sequentially tied with 5 alternating half-hitches utilizing an arthroscopic knot pusher. The arthroscope is maintained within the joint to confirm the reduction and tension during knot tying.

After completion of the meniscal repair, a microfracture awl is utilized to penetrate the subchondral plate 2 times, just proximal to the anterior cruciate ligament (ACL) insertion on the medial aspect of the lateral femoral condyle within its nonweightbearing portion. The tourniquet is let down to confirm a gentle egress of marrow elements entering the joint space. A standard layered closure is performed.

Tips and Tricks

Some Tips

• - Assessment of the residual meniscal rim should be performed before reducing the displaced bucket-handle tear to confirm that the tear location lies within a perfused segment of the meniscus.

• - Percutaneous release of the medial collateral ligament via a pie-crusting technique can be employed in the case of inadequate visualization or to facilitate instrumentation without causing iatrogenic cartilage damage.

• - Careful suture management should be performed when retrieving sutures from the posteromedial knee.

• - Intercondylar notch microfracture can provide favorable biology for healing of the meniscal tear, providing a source of marrow elements—cells, platelets, and growth factors.

Pitfalls

• - Failure to directly visualize the reduction or tension of the inside-out repair with the arthroscope when tying knots.

• - Failure to utilize blunt dissection during the posteromedial approach to the knee can result in injury to the saphenous vein or nerve.

Results

Postoperative care after bucket-handle medial meniscal repair aims to protect the repair while restoring function. Continuous passive motion (CPM) is initiated immediately and continued until 90° of flexion is achieved to maintain joint mobility. CPM is continued for 4 to 6 weeks postoperatively, or until the machine reaches maximum flexion at 110°. Weightbearing as tolerated is typically allowed from 1 week postoperatively. Early weightbearing is supported by modern fixation techniques that provide sufficient stability for joint loading, while also promoting meniscal healing. Running is generally reintroduced around 3 months postoperatively, with return to sports permitted at approximately 4 months.

Discussion/Conclusion

Nepple et al ¹² published a systematic review and meta-analysis of 27 studies that assessed >1630 meniscal repairs. The overall failure rate was 22.6%, with medial meniscal repairs more likely to fail than lateral repairs. The failure rate of either tear was 23.9% versus 12.6%, respectively. They also found that failure rates were similar between an inside-out suture repair and a modern all-inside technique.

Kalifis et al ¹⁰ published an 11-year retrospective cohort analysis to assess long-term outcomes in younger patients (<40 years) who underwent bucket-handle meniscal repairs with or without concomitant ACL reconstruction. All-inside, outside-in, and inside-out repairs were included. Overall, they reported a high rate of failure, around 33%, at a median time of 19 months, with higher rates observed among patients with osteoarthritis (OA) (defined by Kellgren-Lawrence classification). Other predictors for increased risk of failure included medial meniscal repair (odds ratio, 4.8). Despite high failure rates, they found that successful repairs were associated with significantly improved Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee, and Lysholm scores compared with failed repairs at 10-year follow-up, suggesting successful repairs may improve long-term function and decrease OA risk. ⁶

When indicating meniscal repair procedures, operative success rates must be carefully considered. Numerous studies^3,4,13 have demonstrated failure rates ranging from 15 to 33%. Bucket handle tears confer an even higher risk, nearly twice that of simple tear patterns.^3,13 Importantly, much of the existing literature has reported aggregate outcomes, which may obscure clinically relevant subgroups.

Alhamdi et al ¹ studied failure rates in patients undergoing repair of isolated bucket-handle tears of the medial meniscus in otherwise stable knees. They elected to include reducible tears >2 cm located within the red-red or red-white regions, and even with the listed exclusion criteria, failure rates approached 70%. The key takeaway remains that careful patient selection and shared decision-making are paramount in optimizing postoperative success. Factors such as patient age, activity level, tear location, morphology, vascularity, and tissue quality should be considered when selecting the appropriate repair technique.

Meniscal tears are a common injury in athletes who experience severe rotational or shearing forces during activity. The inside-out suture repair technique is considered the historical gold standard for treating bucket-handle meniscal tears, although recent literature shows failure rates similar to those of more modern, all-inside repair devices. Lastly, compared with meniscectomy, meniscal repair may decrease the risk of progression to OA and improve long-term functional outcomes.