Failure Rates of Repaired Bucket-Handle Tears of the Medial Meniscus Concomitant With Anterior Cruciate Ligament Reconstruction: A Cohort Study of 253 Patients From the SANTI Study Group With a Mean Follow-up of 94 Months

BACKGROUND

Failure rates of repaired bucket-handle medial meniscal tears (BHMMTs) concomitant with anterior cruciate ligament reconstruction (ACLR) are as high as 20%. The outcomes of posteromedial portal suture hook repair have not been compared with all-inside repair techniques for this subtype of meniscal lesion.

PURPOSE/HYPOTHESIS

The aim of this study was to evaluate the outcomes and failure rates of patients who underwent BHMMT repair concomitant with ACLR using an all-inside technique, suture hook + all-inside technique, or suture hook + outside-in technique. It was hypothesized that no significant differences in failure rates would be found between the groups.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis was performed on patients diagnosed with a BHMMT who underwent meniscal repair during primary ACLR and had a minimum follow-up of 2 years. Patients were grouped based on the meniscal repair technique used: all-inside repair, suture hook + all-inside repair, or suture hook + outside-in repair. At the end of the study period, secondary medial meniscectomy rates were determined.

RESULTS

The study population comprised 253 patients who underwent repair of a BHMMT with concomitant ACLR with a mean follow-up of 94.0 ± 47.6 months. A total of 114 patients (45.1%) underwent all-inside repair, 61 patients (24.1%) underwent suture hook + all-inside repair, and 78 patients (30.8%) underwent suture hook + outside-in repair. Overall, there were 36 failures. The failure rates were 20.2%, 14.8%, and 5.1%, respectively (P = .0135). All-inside repairs were >4 times more likely to fail than suture hook + outside-in repairs (hazard ratio [HR], 4.103; 95% CI, 1.369-12.296; P = .0117). Failure was also 3 times higher (HR, 2.943; 95% CI, 1.224-7.075; P = .0159) for patients <30 years of age compared with those aged ≥30 years. An additional anterolateral ligament reconstruction (ALLR) was also found to reduce the failure rate of repaired BHMMTs concomitant with ACLR.

CONCLUSION

Combined suture hook + outside-in repair of BHMMTs resulted in significantly fewer failures than all other techniques. Furthermore, age <30 years and no additional ALLR were associated with higher failure rates.

Long-term Natural History of Unrepaired Stable Ramp Lesions: A Retrospective Analysis of 28 Patients With a Minimum Follow-up of 20 Years

BACKGROUND

There is a lack of consensus about whether stable ramp lesions associated with anterior cruciate ligament (ACL) injuries need to be repaired.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate how many stable ramp lesions left in situ during ACL reconstruction (ACLR) have subsequently failed after >20 years of follow-up. We hypothesized that ACL-reconstructed knees with ramp lesions left in situ without repair have a high risk of meniscal failure over the long term.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients who underwent arthroscopic ACLR by a single experienced surgeon between January 1998 and December 2000 were evaluated retrospectively. Included were all cases of longitudinal tears in the meniscocapsular junction or the red zone of the posterior horn of the medial meniscus that were left in situ and identified through the anterior portals. Successful anterior probing confirmed a meniscal tear of the posterior segment. A lesion was considered stable if it was ≤2 cm and did not extend beyond the lower pole of the femoral condyle. The following data were collected preoperatively and at the last follow-up: demographics, time to surgery, side-to-side laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner activity scale, and meniscal failure rate. We defined 2 groups based on our findings: medial meniscal failure versus no medial meniscal failure.

RESULTS

A total of 716 knees underwent primary ACLR during this period. The 39 (5.4%) stable unrepaired ramp lesions identified were included in the case series. Mean ± standard deviation follow-up was 262.1 ± 10.5 months. Eleven patients (28%) were lost to follow-up. Of the remaining patients, 8 (28.6%) had a medial meniscal failure, of which 6 (21.4%) were bucket-handle tears. The average time elapsed before complications was 87.8 ± 52 months (range, 6-156 months). The medial meniscal survival rate was 93% at 5 years, 75% at 10 years, and 71% at 15 and 20 years. The failure event mainly happened between 96 and 120 months (8 and 10 years) after ACLR. No risk factors for failure were found, but some trends appeared, such as older age, higher body mass index, and preoperative rotational instability. All postoperative scores were significantly improved at the last follow-up (P < .0001); 16 patients (57%) returned to their sport of choice.

CONCLUSION

With nearly one-third of patients developing meniscal complications, including a large share of bucket-handle tears and mostly occurring 8 years after the ACLR, it may not be wise to leave stable ramp lesions unrepaired.

[Clinical observation of arthroscopic all-inside combined with outside-in "suture loop" repair for meniscus bucket-handle tear]

OBJECTIVE

To investigate the effectiveness of arthroscopic all-inside combined with outside-in "suture loop" repair for meniscus bucket-handle tear (BHT).

METHODS

Between August 2016 and May 2019, 44 case of meniscus BHT were treated with arthroscopic all-inside combined outside-in "suture loop". There were 29 males and 15 females with an average age of 26.6 years (range, 18-42 years). The causes of injury included sports injury in 31 cases, falling injury in 7 cases, and sprain in 6 cases. There were 32 cases of medial meniscus posterior horn tears and 12 cases of lateral meniscus posterior horn tears. The disease duration ranged from 6 weeks to 3 months. Thirty-three cases were complicated with anterior cruciate ligament rupture. All patients had normal lower limb alignment. The preoperative Lysholm score was 42.1±9.1. According to the evaluation criteria of MRI and Barrett et al., the healing of meniscus was evaluated, and the effectiveness was evaluated by Lysholm score.

RESULTS

All the 44 patients were followed up 8-36 months with an average of 16.8 months. At last follow-up, according to the evaluation criteria of Barrett et al., 39 cases were clinically healed, 5 cases were not healed, the clinical healing rate was 88.6%; according to MRI evaluation, 32 cases were completely healed, 7 cases were partially healed, and 5 cases were not healed, the total healing rate was 88.6%, and the complete healing rate was 72.7%. Lysholm score was 87.8±4.8, which was significantly different from that before operation ( t=31.060, P=0.000).

CONCLUSION

Arthroscopic all-inside combined with outside-in "suture loop" repair is a reliable and effective method for the meniscus BHT, which can obtain good joint function.

Biomechanical Comparison of Vertical Mattress and Cross-stitch Suture Techniques and Single- and Double-Row Configurations for the Treatment of Bucket-Handle Medial Meniscal Tears

BACKGROUND

Given the variety of suturing techniques for bucket-handle meniscal repair, it is important to assess which suturing technique best restores native biomechanics.

PURPOSE/HYPOTHESIS

To biomechanically compare vertical mattress and cross-stitch suture techniques, in single- and double-row configurations, in their ability to restore native knee kinematics in a bucket-handle medial meniscal tear model. The hypothesis was that there would be no difference between the vertical mattress and cross-stitch double-row suture techniques but that the double-row technique would provide significantly improved biomechanical parameters versus the single-row technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten matched pairs of human cadaver knees were randomly assigned to the vertical mattress (n = 10) or cross-stitch (n = 10) repair group. Each knee underwent 4 consecutive testing conditions: (1) intact, (2) displaced bucket-handle tear, (3) single-row suture configuration on the femoral meniscus surface, and (4) double-row suture configuration (repair of femoral and tibial meniscus surfaces). Knees were loaded with a 1000-N axial compressive force at 0°, 30°, 60°, 90°, and 120° of flexion for each condition. Resultant medial compartment contact area, average contact pressure, and peak contact pressure data were recorded.

RESULTS

Intact state contact area was not restored at 0° ( P = .027) for the vertical double-row configuration and at 0° ( P = .032), 60° ( P < .001), and 90° ( P = .007) of flexion for the cross-stitch double-row configuration. No significant differences were found in the average contact pressure and peak contact pressure between the intact state and the vertical mattress and cross-stitch repairs with single- and double-row configurations at any flexion angles. When the vertical and cross-stich repairs were compared across all flexion angles, no significant differences were observed in single-row configurations, but in double-row configurations, cross-stitch repair resulted in a significantly decreased contact area, average contact pressure, and peak contact pressure (all P < .001).

CONCLUSION

Single- and double-row configurations of the vertical mattress and cross-stitch inside-out meniscal repair techniques restored native tibiofemoral pressure after a medial meniscal bucket-handle tear at all assessed knee flexion angles. Despite decreased contact area with a double-row configuration, mainly related to the cross-stitch repair, in comparison with the intact state, the cross-stitch double-row repair led to decreased pressure as compared with the vertical double-row repair. These findings are applicable only at the time of the surgery, as the biological effects of healing were not considered.

CLINICAL RELEVANCE

Medial meniscal bucket-handle tears may be repaired with the single- or double-row configuration of vertical mattress or cross-stitch sutures.

Outcomes After the Operative Treatment of Bucket-Handle Meniscal Tears in Children and Adolescents

Background:

Bucket-handle meniscal tears (BHMTs), which we define as vertical longitudinal tears of the meniscus with displacement of the torn inner fragment toward the intercondylar notch region, are a well-recognized tear pattern. Optimizing the management of BHMTs in younger patients is important, as preserving meniscal tissue may limit future joint degeneration.

Purpose/Hypothesis:

The purpose of this study was to review the patient demographics, clinical presentation, operative details, outcomes, and risk factors for a reoperation associated with operatively treated BHMTs in a pediatric population. We hypothesized that the repair of BHMTs in adolescents would yield a higher reoperation rate than meniscectomy in our population.

Study Design:

Case-series; Level of evidence, 4.

Methods:

A departmental database was queried to identify all patients 19 years or younger who presented with a BHMT and underwent surgery between October 2002 and February 2013. Clinical, radiological, and surgical data were retrospectively collected, and risk factors for a reoperation and persistent pain were assessed in all patients with longer than or equal to 6 months of follow-up.

Results:

A total of 280 BHMTs were treated arthroscopically by 1 of 8 sports medicine fellowship–trained surgeons. The mean age at surgery was 15.5 ± 2.5 years (range, 2.1-19.2 years), and most patients were male (177/280; 63%). Most injuries occurred during sports (203/248; 82%) and involved the medial meniscus (157/280; 56%). Concurrent anterior cruciate ligament (ACL) surgery was performed in 103 cases (37%). Meniscal repair was performed in 181 cases (65%) and was more common in younger patients (P = .01) and for the lateral meniscus (P < .001). Among 185 (66%) cases with longer than or equal to 6 months of adequate follow-up data (which included 126 meniscal repairs [68%]), a meniscus-related reoperation occurred in 45 (24%) cases. A reoperation related to the original BHMT injury or surgery was more common after meniscal repair than after meniscectomy (40/126 [32%] vs 5/59 [8%], respectively) (P = .001) and less common with concurrent ACL surgery (P = .07), although this was not statistically significant. Among patients injured during sports and with adequate follow-up, all but 1 patient (176/177; 99%) returned to sports; a slower rate of return was seen in those undergoing meniscal repair (P = .002) and concurrent ACL surgery (P < .001). At final follow-up, 170 of 185 patients (92%) were pain free. For the 15 patients with persistent pain at final follow-up, no identifiable risk factors for persistent pain were identified.

Conclusion:

Most BHMTs in younger patients occurred in males and during sports and affected the medial meniscus. Concurrent ACL surgery was indicated in approximately one-third of cases and was associated with a lower reoperation rate and slower return to sports. Two-thirds of patients underwent meniscal repair, over two-thirds of whom did not require a reoperation during the study period, despite the high activity levels in this age group.

Comparative Outcomes of Radial and Bucket-Handle Meniscal Tear Repair: A Propensity-Matched Analysis

BACKGROUND

Full-thickness radial meniscal tears render the meniscus nonfunctional and have historically been treated with partial meniscectomy. As preservative techniques evolve for radial repair, comparisons with other tear patterns are necessary to evaluate repair efficacy and prognosis.

PURPOSE

To assess clinical outcomes and reoperation rates of radial meniscal repair and to compare them to bucket-handle meniscal repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Radial and bucket-handle meniscal tears without concurrent root injuries undergoing surgical repair at a single institution between 2007 and 2015 were analyzed, including both all-inside and inside-out suturing techniques. Propensity matching was performed on the basis of age at surgery, sex, meniscus laterality, body mass index (BMI), and concomitant anterior cruciate ligament reconstruction (ACLR) using a comparison pool of 70 bucket-handle repairs. Reoperation-free survival rates and Tegner, visual analog scale (VAS) for pain, and International Knee Documentation Committee (IKDC) scores were analyzed.

RESULTS

Twenty-four patients (18 male, 6 female; mean age, 22.8 ± 11.9 years) who underwent repair of a radial meniscal tear were followed for a mean of 3.5 years (range, 2.0-6.3 years). Significant postoperative improvements in VAS scores at rest and with use and IKDC scores were noted postoperatively ( P < .001). Five patients (20.8%) required a reoperation. Subsequently, 18 patients with radial tears (mean age, 19.1 ± 9.1 years; 12 male; mean BMI, 27.0 ± 6.2 kg/m²; 3 medial; 11 ACLR) were propensity matched to 18 patients with bucket-handle tears (mean age, 20.8 ± 5.1 years; 13 male; mean BMI, 25.0 ± 3.5 kg/m²; 3 medial; 11 ACLR). The matched radial and bucket-handle groups demonstrated similar ( P = .17) reoperation-free survival rates at 2 years (88.9% and 94.4%, respectively) and 5 years (77.8% and 87.7%, respectively). VAS and IKDC scores improved significantly after surgery ( P < .001), with no difference noted between the groups ( P ≥ .17). Patients with radial and bucket-handle meniscal repairs achieved mean postoperative Tegner scores (6.6 and 6.6, respectively) not significantly different from their preinjury levels (6.9 and 6.7, respectively) ( P ≥ .32).

CONCLUSION

Satisfactory clinical outcomes are achievable for radial meniscal tear repair at short-term follow-up. In a robustly matched comparison, radial and bucket-handle meniscal tears demonstrate similar improvements in VAS and IKDC scores, restoration of preoperative Tegner scores, and acceptable reoperation rates. Full-thickness radial meniscal tears should be considered for repair.

Double Posterior Cruciate Ligament Sign on Magnetic Resonance Imaging: Imaging Variants, Mimics, and Clinical Implications

Introduction

Double posterior cruciate ligament (PCL) sign is a sign on magnetic resonance imaging (MRI) which is suggestive of a bucket- handle tear (BHT) of the meniscus. We undertook this study to assess the presence of a double PCL sign and its correlation with arthroscopic findings. We also discussed the various mimics and variants of the double PCL sign.

Case Report

All the patients with a double PCL sign on the MRI and who underwent knee arthroscopy between January 2012 and December 2016 (total of 5 cases, 4 males and one female) were included in the study. A correlation between the imaging findings and the MRI findings was done. All these young patients were aged between 22 and 41 years. Two patients underwent arthroscopic partial meniscectomy, and three patients underwent arthroscopic meniscal repair using all inside technique.

Conclusion

It is necessary for the sports physician to understand and recognize this important and subtle sign on MRI which is suggestive of a BHT of the meniscus. It is also important to identify the mimics of this sign and its variants for better management planning and patient prognostication.

The Influence of Medical Insurance on Patient Access to Orthopaedic Surgery Sports Medicine Appointments Under the Affordable Care Act

Background:

The goal of the Patient Protection and Affordable Care Act (PPACA) was to expand patient access to health care. Since the rollout of the PPACA, Medicaid patients have demonstrated difficulty obtaining appointments in some specialty care settings.

Purpose:

To assess the effect of insurance type (Medicaid and private) on patient access to orthopaedic surgery sports medicine specialists for a semiurgent evaluation of a likely operative bucket-handle meniscus tear. The study was designed to determine whether disparities in access exist since the PPACA rollout.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

The design was to call 180 orthopaedic surgery sports medicine specialists in 6 representative states (California, Ohio, New York, Florida, Texas, and North Carolina) between June 2015 and December 2015. An appointment was requested for the caller’s fictitious 25-year-old-brother who had suffered a bucket-handle meniscus tear. Each office was called twice to assess the ease of obtaining an appointment: once for patients with Medicaid and once for patients with private insurance. For each call, data pertaining to whether an appointment was given, wait times, and barriers to receiving an appointment were recorded.

Results:

A total of 177 surgeons were called within the study period. Overall, 27.1% of offices scheduled an appointment for a patient with Medicaid, compared with 91.2% (P < .0001) for a patient with private insurance. Medicaid patients were significantly more likely to be denied an appointment due to lack of referral compared with private patients (40.2% vs 3.7%, P < .0001), and Medicaid patients were more likely to experience longer wait times for an appointment (15 vs 12 days, P < .029). No significant differences were found in patients’ access to orthopaedic surgery sports medicine specialists between Medicaid-expanded and -nonexpanded states. Medicaid reimbursement for knee arthroscopy with meniscus repair was not significantly correlated with appointment success rate or patient waiting periods.

Conclusion:

Despite the passage of the PPACA, patients with Medicaid have reduced access to care. In addition, patients with Medicaid confront more barriers to receiving appointments than patients with private insurance and wait longer for an appointment.

[Clinical efficacy of arthroscopic simultaneous treatment for anterior cruciate ligament injury combined with meniscus bucket-handle tear]

Objective

To explore the clinical efficacy of arthroscopic simultaneous both anterior cruciate ligament (ACL) reconstruction and suture of the meniscus bucket-handle tear (BHT).

Methods

Between January 2013 and April 2014, 22 patients (22 knees) with ACL injury and BHT, who accorded with the inclusion criteria, were studied. There were 14 males and 8 females with a mean age of 30.68 years (range, 15-44 years). The left side was involved in 10 cases and the right side in 12 cases. Injury located at the medial meniscus in 14 patients, and at the lateral meniscus in 8 patients. The median of interval from injury to operation was 40 days (range, 9 hours to 4 years). BHT was sutured, and then single bundle reconstruction of ACL was performed under arthroscopy.

Results

All incisions healed by first intention, and there were no serious complications such as infection, vascular injury, and nerve injury. The patients were followed up for 26.7 months on average (range, 12-42 months). At 6 weeks after operation, one patient had limited motion of the knee, the function was recovered after release under anesthesia; and one patient had joint space tenderness, which was relieved after conservative treatment. The total effective rate was 90.9% (20/22). At last follow-up, the anterior drawer test, Lachman test, and McMurray test were negative in all the cases. The visual analogue scale (VAS), Tegner activity level score, and Lysholm score were significantly improved at 12 months after operation when compared with preoperative scores ( P<0.05). At 6-12 months after operation, complete healing was obtained in 7 cases, and partial healing in 11 cases, and nonunion in 4 cases based on MRI evaluation criteria by Crues et al. There was no rupture of reconstruc-tive ligament during follow-up.

Conclusion

Arthroscopic simultaneous both ACL reconstruction and suture of BHT can improve the symptoms, reduce the risk of re-tear of sutured meniscus effectively, delay degeneration of articular cartilage, and maintain the stability of the knee joint.

[Medium-term clinical outcome of encircled suture for repair of medial meniscus bucket-handle tear]

Objective

To investigate the medium-term clinical outcome of encircled suture for repair of medial meniscus bucket-handle tear (BHT).

Methods

Between March 2011 and June 2013, 78 patients (78 knees) with medial meniscus BHT were treated with encircled suture under arthroscopy. There were 57 males and 21 females with a mean age of 28.3 years (range, 16-39 years). The causes included sports injury in 61 cases, traffic accident injury in 12 cases, and other trauma in 5 cases. Of 78 cases, 35 were acute injury and 43 were chronic injury; 65 cases had combined injury of anterior cruciate ligament rupture. International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score were 48.2±6.3, 43.6±4.7, and 2.5±0.6, respectively. Barrett's assessment standard, MRI, and arthroscopy examination were used for assessment of meniscus healing. IKDC score, Lysholm score, and Tegner score were used for assessment of knee function.

Results

Primary healing of incisions were achieved in all patients, and no complications occurred. All patients were followed up 26-63 months (mean, 42.8 months). BHT recurrence was observed in 2 patients within 1 year. Clinical healing of meniscus tear was obtained in 72 cases (92.3%) according to Barrett's assessment standard. The IKDC score, Lysholm score, and Tegner score were significantly improved to 81.5±5.1, 86.9±3.9, and 6.2±0.5 respectively ( t=-14.598, P=0.000; t=-18.478, P=0.000; t=-3.362, P=0.002). MRI results showed complete healing in 56 cases, incomplete healing in 15 cases, and unhealing in 7 cases at last follow-up, with a total healing rate of 91.0% (71/78) and a complete healing rate of 71.8% (56/78). In 21 cases undergoing arthroscopy at 18-49 months after operation, complete healing and incomplete healing were observed in 17 cases and 4 cases respectively, with a total healing rate of 100% (21/21) and a complete healing rate of 81.0% (17/21). No re-tear occurred.

Conclusion

Encircled suture for repair of medial meniscus BHT owns the advantage of firm suturing and good blood supply which can obtain satisfactory medium-term clinical results.