Arthroscopic procedure for revision of failed isolated bucket-handle meniscal tear repair

Abstract

Surgery failure rates average 20% following bucket-handle meniscal tears (BHMT) repairs in the literature. Achieving the healing of BHMT is difficult, how much more in revision cases. Some authors have reported higher failure rates especially in the early postoperative period and in younger patients. Multiple techniques and augmentations to enhance biologic healing and reduce failure rate have been described. We describe an arthroscopic technique for successfully revising a failed BHMT repair using the technique of percutaneously releasing the posterior fibers of the medial collateral ligament to provide adequate space for arthroscopy, refreshing of the torn surfaces, bed trephination before reduction and repair. We concluded that a combined double-level inside out vertical sutures with horizontal reinforcement and all-inside technique using fast fix give anatomic reduction, stable fixation, surface contact, and increased potential for biologic healing in failed BHMT repairs. Coupled with adequate rehabilitation programs, this technique has reduced the failure rate in revision cases and enhances early return to sport.

1. Introduction

Meniscal repair is desirable over resection to prevent post meniscectomy arthritis, especially among young and active patients.¹ The failure rate of meniscal repair remains significant, especially for bucket-handle tears.² Krych et al. found out that 21% of cases of revision of BHMT had documented failure of revision repairs and underwent subsequent partial meniscectomy and that younger patients may be at higher risk of failure of the revision meniscus repair.³ Most failures occur within a year of repair as Saltzman et al. found out that 19.2% of patients that had repair suffered re-tear of the repaired meniscus at an average of 12.24 ± 9.50 months postoperatively.⁴ Most failures are the result of an acute re-injury within 1 year, and nearly half will require debridement of the re-torn meniscus.⁵ Complete healing can be achieved in as high as 82.7% of cases of BHMT in the red-red and the red-white zones.⁶

All the aforementioned underlines the need for a stable fixation that can maintain the integrity of the meniscus pending the attainment of complete biologic healing especially in young patients. Biological enhancement of healing has been attempted using varieties of modalities including mechanical stimulation, supplemental bone marrow stimulation, platelet-rich plasma, stem cell therapy, and scaffolds and membranes.⁷ Our procedure is aimed at preventing failures that often characterize the revision of failed repairs of BHMT by ensuring a complete and stable repair that gives surface contact rather than suture point contacts, and cost-effective biologic augmentation through the stimulation of patient's own potentials for healing.

2. Clinical and radiologic diagnosis

Patients with failed BHMT are often males, young athletic individuals with prior meniscal surgery, and may have mild to moderate osteoarthritis.¹ One-in-five patients suffer a re-tear of the affected meniscus at a mean of 20.94 months postoperatively.⁸ Displacement of the free segment can lead to significant pain and disability, necessitating reduction, and surgical treatment.⁹ In our setting, patients complain of locking and inability to achieve full extension. History of sharp pain and other symptoms often follow an active sporting or rigorous activities. Other symptoms that patients may experience with a bucket handle tear include stiffness, tightness and swelling. Joint line tenderness can be elicited in the affected compartment when chondral damage is involved.¹⁰ In this index case, an attempt at full extension was excruciatingly painful (Fig. 1a–h).

Fig. 1.

fig.(a): incomplete extension. Fig. 1b–d: Bucket Handle meniscal tear (in the notch).Figure e–h: Double delta sign(e); double PCL (f); meniscus in the notch (g); normal lateral meniscus (h).

Preoperatively, plain radiograph (anteroposterior, lateral, and skyline views) are done to rule out osteochondral pathology. MRI when analyzed often gives the following findings: the absence of bow tie sign, presence of double posterior cruciate ligament (PCL) sign, double anterior horn sign, flipped meniscus sign, disproportional posterior horn sign, and fragment within the intercondylar region.¹¹ The findings in this index case was similar (Fig. 1b–c). The earlier arthroscopic findings and the repair done is always reviewed if surgery was done in our facility or when made available by the patient (Fig. 2a–c). Pre-operatively, the international knee documentation committee (IKDC) score and Tegner-Lysholm score activity level are determined and recorded.

Fig. 2.

(a): initial injury. Figure 2b: medial repair then. Fig 2c: posterior repair then.

3. Patient position

Following a regional or general anesthesia (according to anesthetists' decision from the patient's preference), the patient is positioned supine with the affected limb hanging over the edge of the operating table and the contralateral leg is placed in an abduction stirrup (Fig. 3). This position allows a wide range of motion during fixation without interference from the contralateral limb. A well-padded high thigh pneumatic tourniquet is applied and inflated after surgical site preparation and exsanguination.

Fig. 3.

a &b: Patients in a supine position with index leg hanging and the contralateral leg in abduction.

4. Arthroscopic examination

A routine arthroscopic examination is performed through a standard anterolateral and anteromedial portal to confirm the integrity of other intra-articular structures: anterior cruciate ligament, posterior cruciate ligament and osteochondral injuries that are commonly associated with meniscal injuries. Arthroscopic diagnosis of a re-tear for bucket-handle meniscal tear is easily diagnosed as the torn segment is often seen in the intercondylar notch (Fig. 4). There may be need for initial debridement if significant degenerative changes are found.

Fig. 4.

a, b: torn meniscus in the intercondylar notch.

5. Releasing the medial collateral ligament

Arthroscopic treatment of tears in the middle and posterior parts of the medial meniscus can be difficult when the medial tibiofemoral compartment is tight.¹² In cases of revision of isolated medial BHMT with tight medial compartment despite positional maneuvers, there is a need to deliberately open up the medial compartment. Iatrogenic chondral lesions (which may result in working in such a condition) might cause serious morbidity, and residual tears (from inadequate view in a tight knee) may result in inadequate symptom relief.¹³,¹⁴ Visualization and surgery of tears in the posterior medial meniscus are difficult if the joint space is tight.

In cases where the medial compartment is tight as in this index case, the posterior fibers of the medial collateral ligament are released percutaneously using a size 18G needle at a magic point. This is done with the knee flexed to 20° while applying valgus deformation to the knee and external rotation to open the medial compartment and tense the posterior fibers of the MCL (Fig. 5a–f). The outside-in, percutaneous release of the medial collateral ligament (MCL) is a technique used to increase the medial tibiofemoral joint space during arthroscopy to facilitate the use of instrumentation and improve visualization without causing iatrogenic cartilage damage.¹⁵

Fig. 5.

a: maximal valgus position Fig. 5b: palpate tensed fibres Fig. 5c release tensed fibres, Fig 5d: before MCL release Fig. 5e: post MCL release Fig. 5f: good access to the bed.

6. Preparation of the soft tissue bed

In this index case and most of our revisions, it was observed from the bed that the previous repair gave more of suture points contact rather than surface contact (Fig. 6a). The bed and the torn surface of the meniscus are refreshed using a 4.5mm arthroscopic shaver. Trephinations are made into the bed using 1.8mm Kirschner wire to a debt of about 2–4mm and 2mm apart to stimulate fresh bleeding, fibrin clot formation, and release of progenitors that will enhance biologic healing (Fig. 6b and c).

Fig. 6.

a: the bed from the previous repair. Fig. 6b: Refreshing the bed. Fig. 6c: Trephination being done.

7. Reduction and repair of the torn meniscus

The torn and usually flipped meniscal segment is then reduced into its anatomic position gently using a probe (Fig. 7a–d). Through an anterolateral portal, a zone-specific single lumen cannula is placed on the upper surface of the meniscus (Fig. 8a). A number 2 Ethibond carrying needle is loaded into the cannula to pass the suture through the upper part of the meniscus. The needle is then reloaded with the other arm of the same suture to be passed just above the upper surface of the meniscus into the bed and to the exterior (Fig. 8b). This process is repeated for the undersurface as well (Fig. 8b–d). Thus, giving a double (upper and lower) vertical sutures at a point.

Fig. 7.

a–d: The reduction of the torn meniscus.

Fig. 8.

a–d: showing vertical upper and lower sutures being passed.

Subsequently, 5 to 6 double vertical sutures are placed from the anterior part of the tear towards the posteromedial corner to give a surface contact repair (Fig. 9a). Series of horizontal sutures were then passed over the vertical sutures on the upper surface to give a Mason-Allen suture effect. This effectively compresses the meniscus back into its anatomic shape and further enhances surface contact repair (Fig. 9b–c).

Fig. 9.

a: vertical sutures. Figure 9b, c: when horizontal sutures were added gradually.

In the posterior part of the meniscus, further trephinations are done to provoke more bleeding leading to fibrin clot formation that will enhance biologic healing. Previous sutures are removed from the meniscus (Fig. 10a–c). All inside technique repair was used using a fast fix meniscal repair tool (by Smith & Nephew) with vertical mattress in the upper surface and the lower surface of the meniscus (Fig. 10d–g). sutures were cut very low to avoid possible irritation of the articular surfaces. These reduced the risk of failure, restore surface contact (rather than suture point contacts) and enhance biologic healing. The pictorial cross-sectional representation and the surface value of our repair is as shown in (Fig. 11a–c).

Fig. 10.

a–c: more trephinations of the posterior bed and removal of previous stitches. Figure 10d–g: various stages of all-inside repair of the posterior part.

Fig. 11.

a–c: shows final repair, and the pictorial cross-section and the surface value of our repair is as shown below.

On the skin medially, a small incision is made between the two rows of sutures as they emerge on the skin surface, from the upper and the lower arm of each of the sutures respectively (Fig. 12a). Blunt dissection is done using artery forceps down to the external surface of the joint capsule, care taken not to damage the saphenous vein and branches of the saphenous nerve (Fig. 12b–c). The knots are tied directly over the capsule (Fig. 13a–c). Wound is apposed and dressed. The patient leaves the suit in a brace locked in extension.

Fig. 12.

a–c: small incision, blunt dissection, and retrieval of sutures through the wound.

Fig. 13.

a–e: sutures are tied on the capsule to protect saphenous vein and branches of the saphenous nerve, and to ensure a firm repair.

8. Post-operative rehabilitation

Isometric exercises are commenced immediately the patient recovers from anesthesia. The patient is allowed to do protected weight-bearing with the knee immobilized in full extension with the brace mentioned above and discharged home by the third day of the postoperative period. Follow up is done at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year at the surgical outpatient department. Passive range motion begins after 2 weeks (Fig. 14a). For this index case, Mc Murray's test was negative at 3 months (Fig. 14b), active rehabilitation exercise was commenced at 6 months (Fig. 14c) and he returned to active sporting activity after 9 months of the postoperative period (Fig. 15a–c).

Fig. 14.

a: (a)Range of motion exercise at 2 weeks. (b) negative McMurray test at 3 months,⁶ the patient commenced active rehabilitation exercises at 6 months.

Fig. 15.

a–d: Returned to sport at 9 months.

MRIs were obtained at the 6 months and 12-months postoperatively. MRI at 6 months and 12 months were essentially the same and both confirmed that the meniscus has healed with no re-tear despite the return to sport (Fig. 16a–d). IKDC and Tegner-Lysholm score activity level showed a sudden rise of scores in the first three months of the postoperative period and increased steadily to 98.9% and 98% respectively at the end of 12 months after surgery (Fig. 17).

Fig. 16.

a–d: repaired meniscus healed well and remained in its proper position.

Fig. 17.

Comparing pre-operative and post operative ikdc and lysholm score for 12months.

9. Discussion

The demographic features of patients coming with failed repair of isolated BHMT are those of young, athletic, usually male who sustained re-tears during an energetic sporting or rigorous activities. Most cases of failure occur in the early postoperative period. These demographic findings are in keeping with what was found by Shieh et al. who evaluated revisions of BHMT in children and adolescents.¹⁶ Krych et al. in their retrospective study also alluded to the fact that younger patients may be at higher risk of failure of the revision meniscus repair.³

The higher failure rate in isolated BHMT is not unconnected with the limited exposure of the medial compartment leading to incomplete and inadequate repair that subsequently resulted in the high failure rate in the early stages and osteochondral damage.¹⁵ This may explain why isolated meniscal tears had a significantly higher risk of failure than repairs performed in conjunction with anterior cruciate ligament reconstruction.¹⁷ Percutaneous release of the posterior fibers of the MCL is done to improve the exposure of the medial compartment for better visualization, anatomic reduction of the torn meniscus, and the complete repair of the tear. This maneuver ensures a complete stable repair with good surface contact instead of the suture points contacts in poorly visualized joints. This is similar to those of Moran TE, Javidan P et al. and Hinton MA.^15,18,19

Fakioglu et al. and Moran et al. found out that controlled release of the MCL in tight knees allowed easier handling in posterior medial meniscus tears and a better understanding of tear configurations, avoiding iatrogenic chondral damage and the MCL injury healed uneventfully.¹³,¹⁵ In this index case, percutaneous release was done in the first surgery that failed. At the revision surgery, it was repeated as the previous release healed completely without any residual valgus instability. Although, Lons A et al. found out that valgus laxity was present at 6 weeks post-pie-crusting of the MC, the main procedure carried out by the team was meniscectomies (33 out of 40 meniscal surgeries).²⁰ In a more recent publication, Lons A et al. recorded a similar outcome as in this index case.¹⁵

Combined inside-out and all-inside techniques with double vertical suturing and horizontal suturing techniques on the medial side, and fast fix on the upper and lower surfaces of the posterior part respectively are used to ensure stable and adequate fixation. Combining inside-out and all-inside techniques were supported as being appropriate by many researchers⁹,21, 22, 23, 24, 25, some authors have however recorded better outcomes with all inside repairs when compared to inside-out repairs,²¹,²⁶ This technique of adding horizontal sutures to give Mason-Allen suture effect has prevented early post-operative failure commonly seen in repairs of BHMT repair failures.

Various modalities have been used by various authors to enhance biologic healing. S. Rodeo used exogenous fibrin clot.²⁷ Some biological therapies that tried to enhance meniscal repair success (but their efficacy needs further research) include mechanical stimulation, supplemental bone marrow stimulation, platelet-rich plasma, stem cell therapy, and scaffolds and membranes.⁷ Our debridement of the bed and the torn surface of the meniscus refreshes them. Trephination of the bed before repair further produces bleeding leading to fibrin clot formation and possible release of progenitor cells that aid in biologic healing. This gives a similar biologic-augmentation effect as those derived from exogenous sources, and at no extra cost to the patient.

Muckenhirn KJ et al. also allows immobilization, physical therapy, and weight-bearing as appropriate.⁹ Lons et al. will allow immediate postoperative full weight-bearing while Brett W et al. expect painless full weight-bearing at 2 weeks of the postoperative period.¹⁴,²⁰ Early protected weight-bearing is allowed postoperatively, with the knee kept in extension using a brace locked in extension. The meniscus is stable and locked in extension. Thus, the repaired meniscus is further protected in extension. Allowing protected weight-bearing also promotes condylar remodeling of the newly repaired meniscus. Maintaining the knee in extension will prevent motion and twisting that could disrupt the healing process of the meniscus in the early postoperative period. Full weight-bearing is commenced 2 weeks postoperatively.

The patient recorded an excellent functional outcome as depicted in the combined chat for IKDC score and Tegner-Lysholm score activity level (Fig. 17). This corresponds well with the radiologic outcome recorded in the MRI at 6 and 12months. These findings is in line with the conclusion of other authors that combine inside-out and all-inside techniques, and good rehabilitation protocols produce good to excellent outcome in bucket-handle meniscal tear repairs.^28,29 The advantages and the disadvantages of this technique is as stated in Table 1.

Table 1.

Advantages, disadvantages of this arthroscopic technique for revision of failed isolated BHMT repairs.

Advantages:
Gives adequate exposure during repair.
Does not require hardware removal
Ensures complete repair of meniscal tears
It gives surface contact rather than suture-points contact
Enhance biologic healing
No risk of cartilage damage
It is cost-effective
Does not involve the use of exogenous substance
Disadvantages:
May need more than the primary arthroscopic anterolateral portal.
Risk of damaging the saphenous nerve in inexperience hands
Takes a longer time than single rows of vertical sutures only.

10. Conclusion

A combined double-level inside out vertical sutures with horizontal reinforcement and all-inside technique using fast fix give anatomic reduction, stable fixation, surface contact and increased potential for biologic healing in failed BHMT repairs. Coupled with adequate rehabilitation program, this technique has reduced the failure rate in revision cases and enhances early return to sport.

CRediT author statement

Ibrahim Abolaji Alabi: Conceptualization, Methodology, Software, Data Curation, writing the original draft, Visualization, reviewing and editing.

Assoc. prof. Bancha. Chernchujit: conceptualization, Data curation, editing and reviewing.

Artha Arrisna: Visualization, Investigation.

Chanont Kanokvaleewong: Supervision reviewing.

Reneil Jay Pena: Software, Validation.

Declaration of competing interest

No conflict of interest.

Appendix A. Supplementary data

The following is the Supplementary data to this article: