Reproductable approach of medial meniscus bucket handle repair with anterior cruciate reconstruction

Carlos Mesquita Queirós; Fábio Fernandes; Alexandre Castro; Levi Reina Fernandes; Alcindo Silva

Abstract

Background: Bucket-handle medial meniscal tears (BHMTs) are severe injuries frequently associated with anterior cruciate ligament (ACL) rupture. Meniscal preservation through repair is preferred over meniscectomy to prevent early degenerative changes; however, failure rates remain variable and may depend on repair configuration and biomechanical stability.Purpose: To evaluate the clinical outcomes, failure rate, and survivorship of a standardized hybrid meniscal repair technique for BHMTs performed concomitantly with ACL reconstruction, and to provide independent evidence regarding the reproducibility of this repair configuration.Methods: A consecutive cohort of patients with BHMTs associated with ACL rupture treated between 2018 and June 2023 was retrospectively reviewed. All patients underwent arthroscopic meniscal repair using a standardized hybrid configuration combining posteromedial suture-hook stitches, one all-inside device at the posteromedial meniscocapsular junction, and outside-in sutures for the meniscal body, in conjunction with ACL reconstruction and an anterolateral reinforcement procedure. Clinical outcomes were assessed using the Lysholm score and Tegner activity scale. Failure was defined as reoperation on the repaired meniscus. Kaplan–Meier survival analysis was performed.Results: Forty-three patients (31 men, 12 women; mean age 30.9 ± 8.1 years) were included, with a mean follow-up of 40.7 months (minimum 24 months). The mean Lysholm score at final follow-up was 83 ± 8, and the mean Tegner activity level was 6.3 ± 0.5. Three repair failures (7.0%) occurred at 16 to 23 months postoperatively, all following new traumatic events, and were treated with partial meniscectomy. No ACL graft failures were observed. No significant associations were found between failure and sex, graft type, anterolateral procedure, or number of sutures (p > 0.05). Minor complications were infrequent and resolved spontaneously.Conclusion: This standardized hybrid repair technique for BHMTs associated with ACL reconstruction provides satisfactory functional outcomes, low failure rates, and a favorable safety profile at mid-term follow-up. The configuration offers reliable biomechanical stability and supports accelerated rehabilitation without motion restriction.What this study adds: This study provides independent evidence that a standardized hybrid meniscal repair configuration, combining suture-hook, all-inside, and outside-in techniques, achieves low failure rates and good functional outcomes in bucket-handle medial meniscal tears repaired concomitantly with ACL reconstruction, even when minor technical variations are applied.How this study might affect research, practice or policy: These findings support the routine use of biomechanically complementary hybrid repair constructs for complex medial meniscal tears, encourage meniscal preservation strategies over meniscectomy, and may inform future comparative studies and surgical guidelines aimed at optimizing repair durability and rehabilitation protocols.Study Design: Retrospective cohort studyLevel of Evidence: Level IV evidenceKeywords: Bucket-handle meniscal tear; Meniscal repair; Anterior cruciate ligament reconstruction; Hybrid repair; Knee arthroscopy.https://doi.org/10.70885/hmsj.2026.05.001

References

  1. Kushwaha S, Singh S, Khan FA, R C, Kumar P. Meniscal and Chondral Injury Patterns in Athletes With Anterior Cruciate Ligament Tear. Cureus. 2023 Nov 23;15(11).
  2. Saltzman BM, Rice R, Cole BJ, Manning BT, Verma NN, Wang KC, et al. Arthroscopically Repaired Bucket-Handle Meniscus Tears: Patient Demographics, Postoperative Outcomes, and a Comparison of Success and Failure Cases. CARTILAGE. 2018 June 29;11(1):77–87.
  3. Magnussen RA, Mansour AA, Carey JL, Spindler KP. Meniscus status at anterior cruciate ligament reconstruction associated with radiographic signs of osteoarthritis at 5- to 10-year follow-up: a systematic review. J Knee Surg. 2009 Jan 1;22(4):347–357.
  4. Lee WQ, Gan JZW, Lie DTT. Save the meniscus - Clinical outcomes of meniscectomy versus meniscal repair. J Orthop Surg (Hong Kong). 2019 May 1;27(2):230949901984981.
  5. Xu C, Zhao J. A meta‐analysis comparing meniscal repair with meniscectomy in the treatment of meniscal tears: the more meniscus, the better outcome? Knee surg sports traumatol arthrosc. 2013 May 14;23(1):164–170.
  6. Petersen W, Karpinski K, Bierke S, Müller Rath R, Häner M. A systematic review about long-term results after meniscus repair. Arch Orthop Trauma Surg. 2021 Apr 28;142(5):835–844.
  7. Wright RW, Parker RD, Berg JH, Cooper DE, Johnson DC, Steven J Svoboda L, et al. Meniscal Repair in the Setting of Revision Anterior Cruciate Ligament Reconstruction: Results From the MARS Cohort. Am J Sports Med. 2020 Aug 21;48(12):2978–2985.
  8. Kalifis G, Raoulis V, Panteliadou F, D’Ambrosi R, Hantes M, Liantsis A. Long-term follow-up of bucket-handle meniscal repairs: chondroprotective effect outweighs high failure risk. Knee surg sports traumatol arthrosc. 2021 Nov 6;30(7):2209–2214.
  9. Westermann RW, Duchman KR, Amendola A, Glass N, Wolf BR. All-Inside Versus Inside-Out Meniscal Repair With Concurrent Anterior Cruciate Ligament Reconstruction: A Meta-regression Analysis. Am J Sports Med. 2016 July 20;45(3):719–724.
  10. Ardizzone CA, Vidal AF, Houck DA, Mccartney DW, Frank RM. All-Inside Repair of Bucket-Handle Meniscal Tears: Clinical Outcomes and Prognostic Factors. Am J Sports Med. 2020 Mar 20;48(13):3386–3393.
  11. Gousopoulos L, Sonnery-Cottet B, Haidar I, Hopper GP, Grob C, Thaunat M, et al. Suture Hook Versus All-Inside Repair for Longitudinal Tears of the Posterior Horn of the Medial Meniscus Concomitant to Anterior Cruciate Ligament Reconstruction: A Matched-Pair Analysis From the SANTI Study Group. Am J Sports Med. 2022 June 6;50(9):2357–2366.
  12. Gousopoulos L, Grob C, Ahrens P, Levy Y, Vieira TD, Sonnery-Cottet B. How to Avoid Iatrogenic Saphenous Nerve Injury During Outside-In or Inside-Out Medial Meniscus Sutures. Arthroscopy Techniques. 2022 Jan 13;11(2):e127–e132.
  13. Getgood A, Kuroda R, Helito CP, Karlsson J, Inderhaug E, Musahl V, et al. The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee surg sports traumatol arthrosc. 2018 July 25;27(1):166–176.
  14. Solheim E, Inderhaug E, Hegna J. Long-term outcome after all-inside meniscal repair using the RapidLoc system. Knee Surg Sports Traumatol Arthrosc. 2015 May 14;24(5):1495–1500.
  15. Wu IT, Dahm DL, Stuart MJ, Krych AJ, Levy BA, Desai VS, et al. Comparative Outcomes of Radial and Bucket-Handle Meniscal Tear Repair: A Propensity-Matched Analysis. Am J Sports Med. 2018 Aug 2;46(11):2653–2660.
  16. Costa GG, Fanzone G, Russo A, Grassi A, Lauria M, Graceffa A, et al. What Is the Failure Rate After Arthroscopic Repair of Bucket-Handle Meniscal Tears? A Systematic Review and Meta-analysis. Am J Sports Med. 2021 June 23;50(6):1742–1752.
  17. Dzidzishvili L, Berreta RS, Jackson GR, Mowers CC, Cotter EJ, Allahabadi S, et al. All-Inside and Inside-Out Repair Techniques for Bucket-Handle Meniscus Tears Both Result in Improved Patient Outcomes and a Broad Range of Failure Rates: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2024 Feb 2;40(9):2477-2490.e1.
  18. Spalding T, Damasena I, Lawton R. Meniscal Repair Techniques. Clinics in Sports Medicine. 2019 Nov 22;39(1):37–56.
  19. Uzun E, Misir A, Kizkapan TB, Ozcamdalli M, Akkurt S, Guney A. Evaluation of Midterm Clinical and Radiographic Outcomes ofArthroscopically Repaired Vertical Longitudinal and Bucket-Handle LateralMeniscal Tears. Orthopaedic Journal of Sports Medicine. 2019 May 1;7(5):232596711984320.
  20. Alhamdi H, Foissey C, Vieira TD, Sonnery-Cottet B, Rajput V, Bahroun S, et al. High failure rate after medial meniscus bucket handle tears repair in the stable knee. Orthopaedics & Traumatology: Surgery & Research. 2023 Oct 28;110(4):103737.
  21. Dean CS, Mitchell JJ, Laprade RF, Matheny LM, Chahla J. Outcomes After Biologically Augmented Isolated Meniscal Repair With Marrow Venting Are Comparable With Those After Meniscal Repair With Concomitant Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017 Feb 1;45(6):1341–1348.
  22. Robinson JR, Davies H, Murray JRD, Porteous AJ, Howells NR, Bruce D. Single-stage repair of displaced bucket-handle meniscal tears with anterior cruciate ligament reconstruction leads to good meniscal survivorship : a retrospective cohort study. The Bone & Joint Journal. 2022 June 1;104-B(6):680–686.
  23. Seo SS, Kim CW, Kim CK, Kim OG, Lee CR, Kwon YU, et al. Second-look arthroscopic findings and clinical outcomes of meniscal repair with concomitant anterior cruciate ligament reconstruction: comparison of suture and meniscus fixation device. Arch Orthop Trauma Surg. 2019 Dec 14;140(3):365–372.
  24. Kang HJ, Chun CH, Kim SH, Kim KM. A ganglion cyst generated by non-absorbable meniscal repair suture material. Orthopaedics & Traumatology: Surgery & Research. 2012 Aug 1;98(5):608–612.
  25. Yoon KH, Park JY, Kwon YB, Lee YJ, Kim EJ, Kim SG. Inside-Out Repair of the Meniscus in Concomitant Anterior Cruciate Ligament Reconstruction: Absorbable Versus Nonabsorbable Sutures. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020 Jan 14;36(4):1074–1082.
  26. Jesani S, Getgood A. Modified Lemaire Lateral Extra-Articular Tenodesis Augmentation of Anterior Cruciate Ligament Reconstruction. JBJS Essential Surgical Techniques. 2019 Jan 1;9(4):e41.
  27. Firth A, Metcalfe A, Bardana D, O’Neill L, Chan D, Macdonald PB, et al. Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience. Am J Sports Med. 2022 Jan 20;50(2):384–395.
  28. Getgood A, Macdonald PB, Metcalfe A, Peterson D, Chan D, O’Neill L, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020 Jan 15;48(2):285–297.

Full text PDF