Ten Pearls for Bucket Handle Medial Meniscus Repair

Abstract

Bucket-handle medial meniscus tears are complex injuries that represent approximately 10% of all meniscal lesions. Because of their vascular location, mainly being in the red-red zone, these injuries often have a favorable prognosis when properly treated. Surgical repair is the gold standard to preserve meniscal function and prevent osteoarthritis. This Technical Note outlines a 10-step technique for the effective evaluation and repair of medial bucket-handle medial meniscus tears using both inside-out and all-inside suturing techniques. Key surgical pearls include proper patient positioning, portal placement, and medial collateral ligament pie-crusting and knee-stressing technique to optimize access to the medial compartment. Meniscal wall reduction and preparation are followed by anatomic fixation using a mixed suture approach: inside-out for the meniscal body, all-inside sutures for the posterior horn and outside-in repair if the anterior horn is involved. Vertical suture configurations are preferred for their superior biomechanical strength, with undersurface stitches added to obtain anatomic reduction. This technique is safe, reproducible, and minimizes neurovascular risk while ensuring a stable, anatomic repair.

Meniscal repair represents one of the most common knee surgeries, and bucket-handle meniscal tears (BHMTs) account for 10% of all meniscal injuries. These have good healing potential after a repair procedure, especially if they occur at the level of the red-red zone, which is rich in vascularization.¹

It is now proven that meniscal repair should always be attempted, whenever possible, for the best clinical outcomes and the lowest risk of developing osteoarthritis.²

This Technical Note discusses the 10 steps to perform a proper repair of a BHMT of the medial meniscus (MM) requiring the use of a mixed meniscal suture technique. An inside-out technique is used for the body, whereas an all-inside technique is preferred to repair the posterior horn. If the anterior horn is involved, an outside-in technique is necessary to fix the tear. This combined technique is illustrated in Video 1.

Surgical Technique

Preoperative Magnetic Resonance Imaging

This is an injury that usually affects young, athletic individuals, who presents with pain, swelling, and mechanical symptoms like joint locking when the fragment engages the intercondylar notch. The McMurray and Apley tests represent reliable clinical tests, but the gold standard for the diagnosis of meniscal injury is magnetic resonance imaging, which in the case of BHMT can show the double posterior cruciate ligament sign in the sagittal view and the dislocation of the fragment in the intercondylar notch in the coronal view (Fig 1).

Fig 1.

Preoperative magnetic resonance of the right knee of a patient in the supine position. (A) Sagittal view of the right knee: the blue arrow shows the double PCL sign with the fragment of MM BHMT displaced in the intercondylar notch. (B) Coronal view of the right knee: the blue arrow shows the fragment of the MM BHMT displaced in the intercondylar notch. (BHMT, bucket-handle medial meniscus tear; MM, medial meniscus; PCL, posterior cruciate ligament.)

Patient Positioning

Spinal anesthesia is preferred for postoperative pain management. Two grams of intravenous cefazolin is administered as antibiotic prophylaxis. The patient is placed in a supine position on the operating table with a tourniquet applied at the level of proximal thigh. A lateral support is placed slightly distal to the tourniquet to allow applying intraoperative valgus stress and another support on the contralateral iliac crest to avoid the patient sliding out of the table during stress maneuvers. A roll is placed distally on the operating table to support the knee at 90° of flexion (Fig 2). A step is used by the surgeon during surgery to stress the knee in valgus in order to expose the medial compartment (Fig 3): the knee is held at 30° of flexion while the surgeon applies valgus stress with his thigh and the assistant holds the foot in slight extra-rotation while pushing on the femur (Fig 4).

Fig 2.

Patient positioning. (A) Lateral view of the patient positioned supine with the right knee flexed at 90°: a lateral holder is placed slightly distal the tourniquet (green arrow), a roller (yellow arrow) is placed distally to flex the knee at 90°. (B) Anterior view of the patient positioned supine with the right knee flexed at 90°: a lateral holder is placed at the level of the tourniquet (green arrow), a roller (yellow arrow) is placed distally to flex the knee at 90°, another holder (red arrow) is placed on the contralateral iliac crest to avoid patient lateral shifting.

Fig 3.

Patient positioning. Lateral view of the patient positioned supine, right knee. A lateral holder is placed at the level of the tourniquet (green arrow) and a bench (yellow arrow) is used by the surgeon to stress the knee in valgus in order to expose the medial compartment.

Fig 4.

Patient positioning. Anterior view of the patient positioned supine with the right knee flexed at 30°. To expose the medial compartment, the knee is held at 30° of flexion while the surgeon applies valgus stress with his thigh and the assistant holds the foot in slight extra-rotation while pushing on the femur.

Portal Placement

Standard anterolateral and anteromedial (AM) portals with a 30° arthroscope are used (Fig 5). A no. 11 blade is used to make 2 stab incisions and then trocars are inserted into the portals. An arthroscope is inserted in the anterolateral portal to perform a complete diagnostic arthroscopy and visualize the BHMT (Fig 6). A no. 11 blade is used to create the anteromedial portal under direct visualization taking care to not damage the anterior horn of the medial meniscus.

Fig 5.

Portal placement landmarks on the right knee. Blue arrow: anterolateral portal; yellow arrow: anteromedial portal; green star: tibial tuberosity; asterisk: patella.

Fig 6.

Arthroscopic view through the anterolateral portal, right knee. The green star indicates the bucket-handle tear displaced inside the intercondylar notch. Yellow arrow: femur; blue arrow: tibial plateau.

Evaluation of the Tear and Preliminary Reduction of the Lesion

A probe is introduced to determine the extent of the lesion and to determine whether it is a suitable candidate for repair. This depends on the complexity of the tear, the quality of the tissue and the zone of the lesion. Then, using a blunt trocar from the AM portal, the bucket-handle tissue is reduced while applying a valgus stress and taking the knee at 30° of flexion (Fig 7).

Fig 7.

Arthroscopic view through the anterolateral portal, right knee. A blunt trocar (blue arrow) introduced from the anteromedial portal is used to reduce the bucket-handle medial meniscus tear (green star). Yellow arrow: femur; asterisk: tibial plateau.

Medial Collateral Ligament (MCL) Pie-Crusting

Pie-crust release of the MCL is crucial to improve access, aid reduction, and to allow an optimal placement of stitches, especially for better visualization of the MM posterior horn.³ A spinal needle, 16 to 18 gauge, is used to perform multiple percutaneous punctures of the posteromedial part of MCL while an assistant applies valgus stress with the knee at 30° of flexion to better open the medial compartment (Fig 8).

Fig 8.

Medial collateral ligament pie crusting of the right knee. While the assistant is applying a valgus stress, the surgeon performs multiple percutaneous punctures of the medial collateral ligament with a spinal needle (green arrow).

Meniscal Wall Cruentation

Before performing MM tear repair, the margins of the lesion need to be prepared by debridement of perimeniscal synovial tissue with the shaver. Scar tissue around the displaced tear fragment and between the meniscal wall and the tear fragment can prevent healing; for this reason, it must be debrided well with a basket or a shaver. Then, meniscal wall cruentation by mechanical rasping is performed to promote healing (Fig 9).

Fig 9.

Arthroscopic view through the anterolateral portal, right knee. Meniscal wall cruentation: mechanical rasping (blue arrow) of the meniscal wall (asterisk) is performed to promote healing.

Bucket Handle Tear Reduction

Once BHMT debridement is completed, the displaced tear fragment is reduced using a blunt trocar from the AM portal, the BHMT is reduced while applying a valgus stress and maintaining the knee to 30° of flexion. The trocar has to be blunt to avoid damaging the anterior horn of the MM. A probe is used to check the anatomic reduction of BHMT.

Inside-Out Sutures of the Meniscal Body

The first step in the inside-out repair is to switch the arthroscopic visualization portal to the anteromedial portal with the knee flexed at 30° and a cannula is introduced through the anterolateral portal to reach the body of the medial meniscus (Fig 10). In this position, the saphenous nerve and its infrapatellar branches are anterior to the semitendinosus tendon at joint line level.⁴ A vertical pattern suture is performed superiorly to fix the meniscus to the superior capsule and another suture is performed on the undersurface.

Fig 10.

Arthroscopic view through the anteromedial portal, right knee. In-out sutures of medial meniscus body. (A) A cannula introduced from the anterolateral portal is used to pass a needle, loaded with a No. 0 FiberWire, through the medial meniscus body. (B) Then the needle is loaded with the free end of the FiberWire and passed through the superior part of the knee capsule.

A needle loaded with a #0 FiberWire suture (Arthrex, Naples, FL) is advanced by an assistant through the top of the fragment of MM body and then through the superior aspect of the knee capsule and then pulled out with a needle driver from the posteromedial knee. Then, the free end of the FiberWire is loaded on the needle and passed superiorly only through the capsule, in this way an in-out suture in a vertical pattern is delivered. The same technique is used to fix the inferior part of the meniscal body to the inferior knee capsule, so that the meniscus remains adhered to the tibial plateau. The same suturing pattern is then repeated to repair the entire extent of meniscal body tear. Transillumination of the medial compartment and the introduction of the cannula from anterolateral portal allow for suture passing posterior to the semitendinosus tendon in the safe zone.⁴

All-Inside Sutures of the Posterior Horn

An all-inside technique is preferred to address the posterior horn tear. The arthroscope is switched back to the AL portal for better visualization. The all-inside technique is chosen because of the lower risk of injury of the neurovascular popliteal bundle and better access to MM posterior horn viewing through AL portal and working from AM portal.^4,5 It is important to place the AM portal as close as possible to the patellar tendon to better reach the MM posterior horn. Meniscal sutures should be placed perpendicular to the tear: a vertical configuration is preferred because it is biomechanically stronger. This vertical configuration tends to flip the meniscus upwards, so an undersurface stitch should be placed to flip the meniscus down.^5,6

A cannula is used to introduce a FAST-FIX 360 meniscal repair suture system (Smith & Nephew, Watford, England) from the AM portal into the knee joint, it allows to clean the portal from soft tissues and to guide the fast fix safely past the condyle, reducing the risk of chondral injury (Fig 11). The first stitch should be placed in the peripheral region to prevent propagation of the lesion. The following stitches are placed in the BHMT unstable fragment and then through the posterior capsule. The push-knot technique is used to reduce the unstable fragment back to the periphery and to tie and cut the knot. The same procedure is repeated to place an undersurface stitch to flip the meniscus down and to make it stick to the tibial plateau. To achieve a satisfactory repair, the stitches should be placed 3 to 5 mm apart. Once meniscal repair is completed, stability of the repair is checked with a probe.

Fig 11.

Arthroscopic view through the anterolateral portal, right knee. All-inside sutures of MM posterior horn. (A) A cannula (blue arrow) is introduced from the anteromedial portal and used to guide the FAST-FIX (yellow arrow) to the medial meniscus (asterisk). (B) A push-knot (green arrow) is used to tie and cut the stitch.

Tying of In-Out Sutures

With the knee flexed at 90°, the suture limbs are gently tensioned to assess stability and approximate the meniscal edges. At this flexion angle, the saphenous nerve lies posterior to the joint line, along the posterior border of the sartorius tendon, reducing neurovascular risk. A 3- to 4-cm longitudinal incision is made posteromedially, posterior to the semitendinosus tendon, centered at the level of the joint line. The incision is carried through the subcutaneous tissue to identify and retract the sartorius fascia. Blunt dissection is used to create a safe window to the capsule. Transillumination from the arthroscope aids identifying the needle exits. A hemostat or curved clamp is used to retrieve the paired suture ends from within the soft-tissue tunnel. Each suture is tied securely over the capsule, taking care to avoid overtensioning which may causa meniscal elevation or extrusion (Fig 12). Once knots are secured, excess suture is trimmed and layered closure is performed.

Fig 12.

Tying of in-out sutures, right knee. (A) With the knee flexed at 90°, a small incision is made at the exit point of in-out sutures. The incision is deepened to the capsule and suture threads are retrieved with a Clemmer. (B) Then the sutures are knotted on the joint capsule.

Discussion

BHMTs often are complex, and their repair can prove to be challenging. This Technical Note describes a 10-step list to follow when addressing these types of lesions. The checklist includes inside-out repair of the meniscus body, for its cost effectiveness and an all-inside repair of the posterior horn to avoid posterior neurovascular bundle injury. Meniscal sutures should be perpendicular to the tear and a vertical configuration should be used because it is biomechanically stronger.⁶ Patient positioning and MCL pie-crusting are crucial for correct opening of the medial compartment during surgery (Table 1). Lesion margin cruentation is essential to improve healing. It is worth mentioning that the medial compartment is exposed to greater forces and hence MM repairs tend to fail more often than in the lateral compartment; therefore, the MM repair has to be very stable to avoid the risk of rerupture. In terms of advantages (Table 2), this technique provides excellent anatomic reduction and stable fixation by combining the strength of inside-out sutures for the meniscal body with the mini-invasive fixation of the posterior horn with an all-inside technique.

Table 1.

Pearls and Pitfalls of Our Mixed Surgical Technique For Medial Meniscus Bucket Handle Repair.

Pearls	Pitfalls
Perform pie-crusting of the medial collateral ligament to open the medial compartment	Inadequate medial collateral ligament pie-crusting can limit access
Use vertical mattress sutures for biomechanical strength	Overtensioning sutures may cause meniscal extrusion
Place anteromedial portal close to patellar tendon for posterior horn access	Portal misplacement can limit instrument mobility
Use transillumination to identify safe needle exit zones	Blind suture retrieval risks neurovascular injury

Table 2.

Advantages and Disadvantages of Our Mixed Surgical Technique for Medial Meniscus Bucket Handle Repair

Advantages	Disadvantages
Anatomic reduction with high stability	Requires mastering multiple techniques
Reduced neurovascular injury risk using all-inside technique for the posterior horn	The cost of all-inside suturing devices
Enhanced healing through lesion cruentation and stable fixation	Inside-out approach requires accurate posteromedial dissection
Cost-effective technique for meniscal body	Increased operative time in complex tears

The inside-out technique allows to the surgeon a controlled suture passage and precise placement under direct visualization, whereas the all-inside technique reduces the risk of neurovascular injury in the posterior compartment. One limitation is the fact that the surgeon must manage both inside-out and all-inside techniques. Moreover, the in-out technique exposes to potential risks including saphenous nerve injury if dissection is inadequate. In fact, another disadvantage is that posteromedial dissection can be technically demanding for a less-experienced surgeon. Moreover, the cost of the devices used for the all-inside technique to repair the posterior horn of MM must be considered. In conclusion, this Technical Note presents a mixed technique that is safe, reproducible, and minimizes neurovascular risk while ensuring a stable, anatomic repair.

Disclosures

All authors (J.C., Z.A.T., A.D.M.M.C., F.P., F.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

This video shows our surgical technique for bucket-handle medial meniscus tear repair. Surgical technique is described in ten step, comprehensive of arthroscopic and external videos of the procedures. Preoperative magnetic resonance imaging is the gold standard for the correct diagnosis of medial meniscus tear. On the sagittal view on the left, you can see the “double posterior cruciate ligament sign,” whereas on the right you can see the displaced fragment into the intercondylar notch. Patient positioning is extremely crucial: we place a distal roll to support the knee at 90° of flexion and a lateral support to allow for valgus stress on the knee during surgery. Standard anterolateral and anteromedial portals are used with a 30° arthroscope: the margins of the patella and tibial tuberosity are marked and then two stab incisions are performed. Diagnostic arthroscopy is then performed to rule out any other lesions. The first step in this surgery is the preliminary reduction and evaluation of the lesion. While maintaining valgus stress at 30° of flexion, a 18-gauge needle is used to perform percutaneous outside-in pie-crusting from the posterior aspect to the anterior part of medial collateral ligament fibers. This is done to open the medial compartment and improve access to medial meniscus. Before attending the repair, the margins of the lesion must be debrided from all soft tissues that might prevent reduction, this is done using a rasp and a shaver. Valgus stress is applied to the knee during this step to make sure that all the lesion is visualized and completely debrided. The displaced fragment is reduced using a blunt trocar to avoid damaging of the anterior horn of the meniscus. The first step is to fix the anatomic reduction of the meniscal body using inside-out sutures: with the knee flexed at 30° the anteromedial portal is used as the visualizing portal and a cannula is introduced from the anterolateral portal to reach the body of the meniscus. A needle loaded with a No. 0 FiberWire suture is advanced by an assistant to the top fragment medial meniscus body, then the freehand of the FiberWire is loaded on the needle and passed to the superior capsule. This completes the first stitch, then the second stitch is done in the same fashion but to the undersurface of the meniscus and the inferior capsule. This procedure is then repeated to repair the entire extent of the meniscal body tear. To address the posterior horn, an all-inside technique is preferred due to the lower risk of injury to the neurovascular popliteal bundle and better access to the posterior horn. The first stitch should be placed in the periphery to allow for a more stable repair and prevent for the propagation of the lesion. The same procedure is then repeated to place an undersurface stitch to flip the meniscus downward and make it stick to the tibial plateau. With the knee at 90° of flexion the suture limbs are paired and separated. A skin incision of approximately 3 to 4 cm is made at the exit point of the in-out sutures, then the incision is deepened until it reaches the joint capsule. The free ends of the suture threads are retrieved with forceps and the suture ends are tied on the joint capsule. Then a plane suture is performed at the level of the incision. On final inspection, the bucket handle medial meniscus repair is stable.