Question: I injured my knee when I was checked into the boards during a college game and have a bucket-handle tear of my meniscus. Should I have it repaired or should I have it taken out so I can return back to playing hockey right away?
Answer: A bucket-handle tear of a meniscus happens when the meniscus is detached from its normal position in the back of the knee and flips to the front. Essentially, it looks like the handle on a bucket, whereas instead of the main portion of the meniscus being on the back of the bucket, it is flipped to the front of the bucket. Because the meniscus is quite wide, when it does flip to the front, it prevents the knee from being able to be straightened out. Thus, athletes who have an injury and cannot straighten out their knee have to be concerned about whether they have a bucket-handle tear of their meniscus.
The meniscus is the most important structure in the knee to prevent arthritis. It is essential for proper joint health. The meniscus acts both as a cushion to prevent the knee from being overloaded, and also helps to make the knee more stable, especially if there is a concurrent ligament tear.
There are two menisci within the knee. The medial meniscus is on the inside part of the knee and provides 50 percent of the cushioning for the inside part of the knee, whereas the lateral meniscus is on the outside of the knee and provides 70 percent of the cushioning for the lateral compartment of the knee. When one loses either their medial meniscus or lateral meniscus, there is a very high risk for the development of arthritis, sometimes within as early as a few years. Thus, it is essential in all but very unusual circumstances that patients, such as you, have a bucket-handle tear of their meniscus repaired. This is especially important for younger athletes or in high-level professional athletes because the lack of a meniscus not only leads to arthritis, it has also been shown in published studies to shorten one’s athletic career.
Meniscus repair techniques have greatly improved over the past decade. While historically many athletes would have their meniscus taken out to get back to play sooner, this has been shown to be very short-sighted because it not only leads to arthritis but also has been shown to shorten an athlete’s career. Thus, when a young or professional athlete has a bucket-handle tear of their meniscus, it should be repaired.
The best way to repair a bucket-handle tear is by using inside-out vertical mattress sutures. We have found that using the more sutures, the better it is to be able to have the athlete return back to competition sooner and safely. Supplementing a meniscus repair with biologic healing factors, such as making holes in the middle of the knee to release stem cells (called a marrow venting procedure) or adding in platelet-rich plasma (PRP) or bone marrow aspirate concentrate (BMAC) has also been felt to increase the healing potential of a meniscus repair. In general, isolated meniscus repairs are kept nonweightbearing for 6 weeks to allow the meniscus to heal around the periphery where it is sewn and then athletes usually can start to resume full activities anywhere from 4 to 6 months after a bucket-handle meniscus tear repair.
Thus, in your case, it would be strongly indicated to perform a meniscus repair so you have your knee at a high level of functioning ability for the rest of your life. Taking out a bucket-handle tear would not be indicated because of the much higher risk of arthritis. As we understand more about the knee, a crusade to “save the meniscus” is being advocated by most surgeons to prevent the development of osteoarthritis.
Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado. He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it to firstname.lastname@example.org.