Chief Complaint/Injury

25 year-old female with prior ACL injury treated conservatively and new onset functional instability resulting in bucket-handle medial meniscal tear with loss of both flexion and extension.  In ideal cases, particularly in young patients, these tears are treated with arthroscopic medial meniscal repair.

Workup/Images

MRI confirms displaced bucket-handle medial meniscal tear.

Surgery

We discussed the risks and benefits of a staged approach.  Given her loss of flexion and extension, a combined repair of her bucket-handle medial meniscal tear and ACL reconstruction would have an unacceptably high risk of arthrofibrosis (stiffness after surgery that can be a serious condition requiring additional procedures and compromised outcome).  As a result, we decided to proceed with an acute arthroscopic inside-out repair of her bucket-handle medial meniscal tear followed by a course of rehabilitation and subsequent ACL reconstruction with hamstring autograft.

The outpatient procedure is performed with a combined regional and lighter general anesthetic.  The tear is reduced (placed back into position) and multiple sutures placed with a suture passing device through the meniscus and capsule.  An incision is made on the medial or lateral side of the knee to carefully dissect down to the capsule, retrieve the needles and tie knots to complete the repair.  We often incorporate a notch-pasty and microfracture which facilitates meniscal healing through recruitment of additional bleeding with stem cells and an enhanced healing response.

Meniscal tears are incredibly common and can be a source of not only pain and mechanical symptoms, but progressive degeneration of the knee.  The fibrocartilage rings serve as shock-absorbing protectors of the hyaline articular cartilage which lines the tip of the femur and the top of the tibia. Physical therapy can often be successful in the treatment of degenerative meniscal tears.  Acute traumatic tears in younger athletes such as the example shown in this case study typically require surgical intervention.

Dr. Rudzki uses several different arthroscopic techniques to treat meniscal tears including an all-inside approach demonstrated in this video:

Dr Rudzki Video Demonstrates new orthopaedic implant for all inside arthroscopic meniscal repair

This brief presentation summarizes the fundamental principles of meniscal tear treatment. Tears are categorized as:

  • acute vs degenerative
  • location (relevant for blood supply and healing)
  • type (radial, horizontal, vertical, parrot-beak, bucket-handle)
  • potential reparability (very difficult to ascertain from MRI)