The evidence for non-surgical bucket handle meniscus tear repair
Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C
The evidence for non-surgical bucket handle meniscus tear repair
For many doctors and patients, arthroscopic repair is the treatment of choice for meniscal tears. Indeed in many cases, this is warranted. This article will discuss bucket handle tear surgery, realistic recovery expectations following an arthroscopic bucket handle procedure, and various non-surgical options.
Bucket handle meniscus tears come in many forms, each with a different challenge.
Here are some of the stories and medical histories we have heard from patients when they reach out to us with problems of bucket handle meniscus tears:
This time I could not unlock my knee
I had an MRI which revealed a “lateral meniscus bucket tear.” The reason I had the MRI was that after years of being able to “shake my knee loose,” I could no longer unlock my knee and my knee stayed locked.
I went to the orthopedic surgeon, surgery was recommended, I went to a chiropractor who was able to unlock my knee enough that I could walk with a slight limp. My knee is very unstable and painful. I have significant pain while sleeping and just about any movement. I am hesitant about surgery, the surgeon told me they would probably have to cut out some tissue. I do not think that will help me in the lo9ng-run.
Ortho surgeon recommends surgery: repair or cut determined during surgery. I feel surgery would leave me worse off in the long run, and perhaps is just addressing the symptom.
Bucket handle meniscus tear caused by successful ACL reconstruction
I had a very successful ACL reconstruction more than 5 years ago. My ACL is strong, the graft held well. Unfortunately, the ACL was so strong it leads to a degenerative meniscus condition including a bucket handle meniscus tear that my orthopedist said was unrepairable. The flap was ground down to nothing and there was nothing to suture. I have the typical symptoms of a meniscus problem, if I stand too long my knee locks up and I have to shake it free. I do not want to go in for surgery to remove my meniscus. I am kind of confused here.
Bucket handle meniscus tear surgery failure rates
23.5% to 34% confirmed by two different studies from surgeons
You go to the orthopedist. You have a bucket handle meniscus tear. A look at an MRI convinces the doctor to offer a recommendation to have suture repair surgery (the doctor will stitch up the tear) as opposed to meniscus tissue removal surgery. The doctor tells you that based on the research, the results from this type of procedure are satisfying. How satisfying? Let’s ask the surgeons.
In June 2018 German doctors at the University Medical Center Freiburg published these findings that they shared with orthopedic surgeons from around the world in the journal: Archives of Orthopaedic and Trauma Surgery: (1)
- A total of 38 patients (14 women, 24 men) with bucket handle tears underwent surgical meniscus repair.
- There were 27 isolated repairs and 11 that occurred within the context of an anterior cruciate ligament (ACL) reconstruction.
- There were 25 patients with a healed meniscus and 13 (34.2%) that sustained re-rupture and underwent either partial meniscectomy (8 patients) or re-suture (5 patients)
- Who is at risk for re-rupture and needs a second surgery?
- “Lower patient age, male gender, and higher activity level had the strongest impact to provoke re-rupture.”
- CONCLUSION: “Clinical outcome after meniscus bucket handle suture is satisfying. The re-rupture rate among this collective was 34.2%.” That is a quote.
The high reward, high risk factor of meniscal repair of bucket-handle tears
The above research study was followed up by a November 2021 study in the journal Knee surgery, sports traumatology, arthroscopy (10) which suggested “A high rate of clinical failure was observed after meniscal repair of bucket-handle tears. However, successful treatment led to lower rates of knee osteoarthritis development and better knee function, approximately 10 years postoperatively. Meniscal repair of bucket-handle tears is recommended to improve knee function and prevent knee osteoarthritis in young patients.”
One-fifth of patients underwent subsequent ipsilateral surgery during follow-up
Part of this high reward, high risk understanding of this procedure was shown by a June 2022 paper in The American journal of sports medicine (9) . The researchers of this study looked at 1359 patients with an average age being 24 years old, who underwent bucket handle meniscus repair for a bucket handle meniscus tear. During the follow-up period (average 50), 495 subsequent ipsilateral (same knee side) procedures were performed in 274 (20.2%) patients, and the average time to the first procedure was 10.6 months.
- An overall 59 (4.3%) patients underwent repeat meniscal repair, and 165 (12.1%) had a subsequent meniscectomy of the same knee.
- Significant risk factors for subsequent procedures included younger age.
Conclusion: “One-fifth of patients underwent subsequent ipsilateral surgery during follow-up, with 4.3% receiving a repeat meniscal repair and 12.1% experiencing a meniscectomy. Risk factors for subsequent surgery of the same knee included younger age and normal or overweight body mass index. Concomitant ACL reconstruction at time of bucket handle meniscus repair reduced the risk of subsequent reoperation.”
How about another opinion on this?
Doctors at the Department of Orthopaedic Surgery, Division of Sports Medicine, New York University Langone Medical Center, Hospital for Joint Diseases in New York released a May 2017 study (2) in which they investigated the failure rate for surgically repaired bucket-handle meniscus tears and compared the numbers in those clinical outcomes of bucket-handle meniscus repair failure versus those that did not fail at a minimum 2-year follow-up.
- Of the 51 patients that had a bucket-handle meniscal repair, 12 (23.5%) were defined as failures (return of symptoms alongside re-tear in the same zone of the repaired meniscus within two years of surgery).
- The researchers found a higher failure rate (23.5%) for bucket-handle meniscus repairs at two-year follow-up that has been cited in the literature, which is typically less than 20%.
- This is the first study to report these outcome scores solely for bucket-handle meniscus repairs, shedding light on the postoperative quality of life of patients with repair success or failure.
How about a third opinion on this? “What Is the Failure Rate After Arthroscopic Repair of Bucket-Handle Meniscal Tears?”
A June 2021 paper in The American Journal of Sports Medicine (3) explored a determination of patient failure rate after arthroscopic repair of Bucket-Handle Meniscal Tears. To make this determination doctors compared bucket-handle meniscal tears with the failure rate of simple meniscal tears extracted from the same studies, and analyze the influence of factors previously reported to be predictive of meniscal repair failure.
In other words, the doctors examined previous research in which meniscus tear failure rates were compiled. They also looked for research where a simple meniscus repair was performed to assess its failure rate against the bucket handle tear.
Results: The pooled failure rate was 14.8% (that is failure rates for bucket-handle meniscus tears across many studies). Bucket handle meniscus tears failure rates were significantly higher. Medial bucket-handle meniscus tear repairs and isolated repairs (the surgery fixed only the meniscus tear and did not address possible problems in other parts of the knee) had a statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. “Based on the currently available literature, this systematic review provides a reasonably comprehensive analysis of failure rate after arthroscopic BHMT repair; failure is estimated to occur in 14.8% of cases. Medial tears and isolated repairs were the 2 major predictors of failure.”
“Save as much meniscal tissue as possible.”
In December 2018, surgeons at the Freiburg University Hospital wrote in the journal BMC Musculoskeletal Disorders (4):
“The most important findings of this study were that isolated revision meniscal repair results in good to excellent knee function, high level of sports participation, and high patient satisfaction in patients with re-tears or failed healing after previous isolated meniscal repair. The failure rate of 25% is slightly higher compared to isolated primary meniscal repair, but still acceptable.”
They also noted: “Therefore, revision meniscal repair is worthwhile in selected cases in order to save as much meniscal tissue as possible.”
And another opinion: “Despite the fact that failure rate remains high for medial meniscus bucket-handle tears, suture repair of bucket-handle tears should be encouraged taking into account the long-term consequences of meniscectomy.” In other words, “Save as much meniscal tissue as possible.”
Here is the summary of a January 2020 paper with the title: “Clinical Outcome and Failure Analysis of Medial Meniscus Bucket-Handle Tear Repair,” published in the Archives of Orthopaedic and Trauma Surgery. (5)
- The failure rate of meniscal repair remains significant, especially for bucket-handle tears. This study aimed to evaluate the clinical outcomes, failure rate, and risk factors for failure of bucket-handle medial meniscal tear repairs performed during ACL reconstruction.
- Who was examined? Patients comprising ninety-six ACL reconstructions with meniscal arthroscopic suture of a bucket-handle tear of the medial meniscus with a minimum 2-year follow-up.
- The average entire group failure rate was 19% at final follow-up at about three years post-op.
- Analysis revealed that younger patients and a procedure of ACL revision (the meniscus will more likely fail when you go back for an ACL revision or second ACL Reconstruction).
- Despite the fact that the failure rate remains high for medial meniscus bucket-handle tears, suture repair of bucket-handle tears should be encouraged taking into account the long-term consequences of meniscectomy.
They took out a large piece of my meniscus
About two months ago I had knee surgery to remove a large piece of the meniscus in my right knee because of a bucket handle tear. The strength in my knee has returned, however, my mobility and flexibility in my right knee are now limited and although the pain is minor, I feel friction in my right knee continuously. If I wear a supporting brace it actually causes more pain than if I don’t wear one at all.
Is bucket handle meniscus tear surgery necessary for every patient?
The curious case of a 71-year-old patient that shows spontaneous healing is possible. Younger patients should pay attention to the lessons of spontaneous healing.
If you are a young athlete or a parent of a young athlete, pay close attention to this case of a 71-year-old man. It may save you from a surgery where one in three and one in four surgical failures are deemed acceptable.
Doctors at the Department of Orthopaedics and Rehabilitation, University of Miami Miller School of Medicine describe the case of a 71-year-old-patient with a bucket handle meniscus tear that healed spontaneously.
Here is what they wrote in the medical journal Geriatric Orthopaedic Surgery & Rehabilitation:(6)
“Displaced bucket-handle meniscal tears are usually treated operatively. Due to the rarity of these tears in elderly patients and conflicting evidence regarding the use of arthroscopy versus conservative treatment, it is valuable to report the clinical presentation, treatment, and outcome of these injuries in elderly patients.”
So something curious is happening here, something that can affect not only elderly patients by bucket handle injury patients as well.
This case history involves a 71-year-old man with acute, displaced, MRI-confirmed right medial meniscus bucket-handle tear with mild effusion and no signs of degenerative joint disease.
(Displaced bucket handle meniscus tears mean the flap of the tear has moved away from the tear and is pointing forward into the knee. This leads to the characteristic symptoms of knee locking and inability to straighten the knee.)
- On physical examination, the patient was unable to fully extend the right leg due to the locking of the knee.
- At a 2-month follow-up, MRI showed mild degenerative changes and an anatomically reduced tear.
- At a 6-month follow-up, the patient reported normal, pain-free knee function, and MRI showed the tear healing. He returned to his pain-free baseline level of physical activity.
This case suggests that in elderly patients with displaced medial meniscus bucket-handle tears that reduce spontaneously, the physician can safely and efficaciously use conservative, nonoperative management to achieve restoration of baseline knee function and anatomic meniscal healing while avoiding the risks of arthroscopic surgery.
We know what the athletes out there are saying – that took 6 months! Yes, but 6 months is less time than 1/3rd of you having to go through a second meniscus surgery. However, there can be a way to speed up and help this spontaneous healing.
The curious case of an 11-year-old patient that shows spontaneous healing is possible.
Here is a story reported by Korean doctors in the journal Knee Surgery & Related Research. (7)
- “An 11-year-old male patient complained of painful swelling and locking due to a displaced bucket-handle tear of the lateral meniscus. We recommended an arthroscopic surgery; however, the patient left the hospital without surgical treatment.
- Six weeks afterward, he returned without any complaint of pain and he regained full range of motion.
- The final follow-up magnetic resonance imaging showed a reduction of the torn meniscal fragment without any signal changes suggestive of a meniscal tear.”
Do these times spontaneously bucket-handle meniscus tears happen all the time? Both of the above-reported cases are considered “rare.” But is a spontaneous healing of a bucket handle meniscus tear without surgery that rare?
The evidence for Platelet Rich Plasma therapy and Prolotherapy for Meniscus Tears
In this section we will discuss Prolotherapy and PRP treatments: Here is a sample of the types of emails we get from people researching these treatments:
I have a bucket handle tear of the lateral meniscus. I have already had two arthroscopic knee surgeries to lavage and remove tissue. My doctor is recommended that I try PRP (Platelet-Rich Plasma Therapy) to see if I can avoid surgery. While they offer PRP, they never heard of Prolotherapy.
At our clinics, we are also very interested in spontaneous healing. All healing is spontaneous. As soon as you suffer a bucket handle meniscus tear your body is trying to heal it. Unfortunately, your body is usually not that successful at it and that is why you were off to a surgical consult.
In our clinics, one of the treatments we offer to help accelerate and augment non-surgical repair of meniscus injury is Platelet Rich Plasma Therapy combined with Prolotherapy. In the video below a general description and demonstration of the treatment is offered.
Writing in the Physical Medicine and Rehabilitation the Journal of Injury, Function, and Rehabilitation, (8) Jessica Urzen of the University of Louisville and Brad Fullerton of the Texas A&M’s College of Medicine, reported a case of a patient with a bucket-handle meniscus tear that resolved non-surgically with Platelet Rich Plasma injections.
They report the case of “a 43-year-old man with magnetic resonance imaging-confirmed medial bucket-handle meniscal tear who received 3 treatments of platelet-rich plasma injections in and around the meniscus within 7 months after the diagnosis of the tear. The patient reported resolution of pain with walking 8 months after the injury. Magnetic resonance imaging 10 months after the injury and arthroscopy 47 months after the injury showed complete resolution of the meniscal tear.”
I was just diagnosed with a bucket handle tear. I have had knee problems for decades. You name the treatment I have had. Physical therapy, hyaluronic acid, and yes even Prolotherapy did not work for me. How come Prolotherapy did not work for me?
The answer to the above question had something to do with the way Prolotherapy was given. Some doctors treat Prolotherapy as they would cortisone. One single injection into the knee and that is it. That is typically not the way Prolotherapy works. Prolotherapy requires many injections within the same treatment. Please see this video for a demonstration.
Platelet-Rich Plasma injections for meniscus tears
At this point, we are going to ask you to do one of two things. Continue on with your research at our companion articles on PRP and Prolotherapy for meniscus tears where we will explore research on Platelet Rich Plasma therapy for meniscus injury. This is an especially good article is for people exploring the possibility of meniscus arthroscopic surgery, meniscus arthroscopic surgery with PRP augmentation, or PRP injections for meniscus tears as an option. See Platelet-Rich Plasma injections for meniscus tears.
Or if you would like to explore these treatments, ask us your questions.
If you have questions about bucket handle meniscus tear repair and treatment options, get help and information from Caring Medical
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This article was updated June 30, 2021