Anatomical repair of bucket-handle medial meniscal tears combined with a ramp lesion: a case report and surgical technique

Introduction

Background

The menisci are crescent-shaped fibrocartilaginous structures essential for knee joint biomechanics, including load transmission, shock absorption, joint lubrication, and proprioception (1). The medial meniscus (MM), semi-circular in shape, covers approximately 50–60% of the medial tibial plateau’s articular surface (2). It significantly contributes to knee joint stability by limiting anterior tibial translation, especially in the presence of an anterior cruciate ligament (ACL) deficiency (3,4). The unique morphology and biomechanical properties of the menisci are critical for maintaining joint homeostasis and preventing degenerative changes. Several studies have shown the importance of the menisci for joint cartilage protection and prevention of early onset osteoarthritis (OA) (5-11). Anatomically, the MM is divided into five zones based on distinct characteristics: zone 1 (anterior root), zones 2a and 2b (anteromedial zone), zone 3 (medial zone), zone 4 (posterior zone), and zone 5 (posterior root) (Figure 1) (12).

Figure 1 Medial meniscus zonal anatomy described by Robert Śmigielski. Schematic representation of the medial meniscus with zonal subdivision: zone 1 (anterior root), zones 2a–2b (anteromedial), zone 3 (body), zone 4 (posterior horn), zone 5 (posterior root).

Rationale and knowledge gap

Bucket-handle medial meniscal tears (BHMMTs) are defined as oblique or vertical tears that extend along the meniscal body from the posterior horn (zone 4) to the anterior horn (zone 2). The inner fragment might displace into the intercondylar notch, causing mechanical knee symptoms (i.e., locking) (13). Meniscal repair is preferred over meniscectomy as it aims to restore a functional meniscus while preventing the early degenerative changes caused by meniscectomy (14,15). The co-existence of ACL injury and MM tears is relatively common, reported as high as 61% in the literature (16,17). Among these, ramp lesions, tears at the posterior meniscocapsular attachment or meniscotibial ligament detachment, are present in approximately 16.6% of ACL-deficient patients (18). Ramp lesion repair is highly recommended, as it significantly reduces joint laxity and improves knee stability (19). Combining repair of BHMMTs with ACL reconstruction has shown improved outcomes by restoring knee kinematics and minimizing degenerative risks (20). Despite advancements in arthroscopic techniques and improved understanding of meniscal anatomy, diagnosing and managing ramp lesions remain challenging due to their subtle presentation and posterior location (21,22). No previous study has described an anatomical dual repair of BHMMT and ramp lesion performed in a single stage in the setting of an ACL-deficient knee.

Objective

This study aims to describe a surgical technique for the anatomic treatment of BHMMT combined with a ramp lesion and an ACL tear, considering pertinent anatomical and biomechanical characteristics of each zone of the MM and to report early clinical outcomes. We present this article in accordance with the SUPER reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-20/rc).

Case summary

An 18-year-old male semi-professional soccer player presented to our clinic with a history of recurrent left knee injuries. Ten months prior, he sustained a twisting injury while playing soccer, resulting in a partial ACL tear and a posterior horn MM lesion diagnosed via magnetic resonance imaging (MRI). At that time, he was managed conservatively with physiotherapy [brace 6 weeks, progressive range of motion (ROM), quadriceps strengthening; return to sport (RTS) criteria: pain-free full ROM and single-leg hop symmetry >90%]. He returned to sports but experienced a similar injury, leading to immediate pain, swelling, and inability to fully extend his knee.

Clinical examination

On examination, the patient had a limited ROM (10–120°) with an extension deficit. Medial joint line tenderness was noted, and the anterior drawer and Lachman tests were positive, indicating ACL insufficiency. There was no evidence of ligamentous laxity in the collateral ligaments.

Imaging studies

MRI revealed a displaced BHMMT with the inner fragment flipped into the intercondylar notch and a complete ACL tear (Figure 2). The BHMMT extended from the posterior horn (zone 4) through the body (zone 3) to the anterior horn (zone 2b) of the MM. Additionally, signs suggestive of a ramp lesion were observed, characterized by abnormal signal intensity at the posterior meniscocapsular junction.

Figure 2 Double PCL sign. Preoperative MRI documenting BHMMT and ACL rupture. Sagittal PD/T2-FS image showing displaced bucket-handle fragment (asterisk) with “absent bow-tie” sign, and the posterior cruciate ligament (red arrow). ACL, anterior cruciate ligament; BHMMT, bucket-handle medial meniscal tear; MRI, magnetic resonance imaging; PCL, posterior cruciate ligament; PD/T2-FS, proton density/T2-fat-suppressed.

Preoperative preparations and requirements

The study was approved by the Institutional Review Board of Casa di Cura Caminiti (IRB #2025-ORM-156, 12 May 2024) and was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of the case, images and videos. A copy of the written consent is available for review by the editorial office of this journal.

The procedure was performed in a Class I laminar-flow operating theatre at a tertiary sports medicine center. The surgical team included a lead surgeon performing over 150 ACL reconstructions annually, a senior resident, scrub nurse, anesthetist, and circulating nurse. Pre-operative optimization included electrocardiogram (ECG), complete blood count (CBC), coagulation profile, coronavirus disease 2019 (COVID-19) screening, and cardiology clearance when indicated. Patients fasted for at least 6 hours and took a chlorhexidine shower the night before surgery. Anesthesia was provided via spinal block combined with femoral nerve block. The patient was positioned supine with a leg holder, lateral post, and pneumatic tourniquet. Prophylaxis included 2 g intravenous (IV) cefazolin at induction and 40 mg subcutaneous low-molecular-weight heparin for 14 days. Key instruments included a 30° arthroscope, FiberStitch^® device, 25° SutureLasso™, polydioxanone suture (PDS) 2-0 sutures, outside-in spinal needles, and a hamstring tendon harvesting set.

Operating-room set-up

The operating room was arranged to optimize workflow and efficiency for arthroscopic knee surgery. The patient was positioned supine with the operative leg secured in a leg holder and a lateral post to allow full ROM. A pneumatic tourniquet was applied proximally on the thigh. The Arthrex^® arthroscopy tower was placed on the contralateral side of the operative leg, ensuring direct line of sight for the surgeon and unobstructed access to instrumentation. The camera system, shaver, fluid management system, and 4K monitor were integrated for seamless control. Instrument tables were arranged on the ipsilateral side, with the scrub nurse positioned for easy handoff of devices. A Mayo stand was prepared with key tools, including arthroscopic probes, graspers, suture passers, and the FiberStitch^® and SutureLasso™ devices. Clear marking of portals and orientation ensured a smooth surgical flow.

Surgical planning

Considering the patient’s age, activity level, and desire to return to competitive sports, surgical intervention was recommended. The surgical plan included arthroscopic repair of the BHMMT, repair of the ramp lesion, and ACL reconstruction using hamstring autograft.

Step-by-step description

Diagnostic arthroscopic examination

The patient was placed supine on the operating table. A well-padded thigh tourniquet was placed on the operative extremity, which was then secured in a leg holder. Routine diagnostic arthroscopic examination of the knee joint was performed through standard anterolateral and anteromedial portals. The diagnosis of a displaced BHMMT was confirmed, with the tear involving zones 2b, 3, and 4. Provisional reduction was achieved by combined extension of the knee and external rotation of the foot in valgus stress with the aid of a lateral post and manipulation of the torn meniscal fragment with an arthroscopic probe. Trans-notch visualization of the posteromedial compartment was performed with the knee in 90° of flexion and a double lesion (meniscocapsular ramp lesion and meniscal lesion) was detected (Figure 3). Total skin-to-skin time: 100 minutes.

Figure 3 Diagnostic examination: displaced bucket-handle fragment and concomitant ramp lesion. (A) View of the medial compartment through the anterolateral portal showing displaced medial meniscus (asterisk) and MFC. (B) Trans-notch view at 90° flexion through the anterolateral portal showing a ramp lesion: meniscocapsular separation (arrow) at the posterior horn (asterisk) of the medial meniscus. MFC, medial femoral condyle.

All-inside repair with meniscal fixators

First, an all-inside suturing of the MM was performed using FiberStitch™ (Arthrex^®, Naples, FL, USA), with the suture placed on the border between zones 4 and 3, to fix the bucket-handle tear and to reduce the meniscus for the remainder of the procedure. The all-inside repair can be performed in vertical or horizontal mattress configurations, although the vertical mattress is still considered the gold standard (14,15,22).

All-inside ramp lesion repair

Trans-notch visualization of the posteromedial compartment was performed with the knee in 90° of flexion. The arthroscope was then introduced through the anterolateral portal in the triangle limited by the medial femoral condyle, posterior cruciate ligament, and medial tibial spine. To open the ramp area, the authors recommend using the so-called “R.S. maneuver”: a varus force is applied to the ankle with the limb hanging out of the operating table (Video 1). In this position, a posteromedial approach is easier to establish. According to Thaunat et al. (23), transillumination allows the surgeon to observe the veins and nerves that must be avoided (Figure 4). With the leg brought back on the operating table and the knee flexed to 90° to avoid the popliteal structures, the needle has to be introduced from outside to inside in the direction of the lesion, above the hamstring tendon and 1 cm posterior to the joint line. The authors performed a single incision approach using a no. 11 scalpel and without a cannula. A right curved 25° hook (QuickPass™ SutureLasso™-Arthrex^®, Naples, FL, USA) loaded with absorbable monofilament suture n° 2-0 (PDS-Ethicon, Somerville, NJ, USA) was used for this step of the procedure. With the foot positioned in maximal internal rotation, the suture hook was introduced through the posteromedial portal and used to penetrate the peripheral meniscal wall from outside to inside. The suture was performed in two steps depending on movements of surgeon’s hand: the first movement is up-twist-down to cross the capsular wall; the second is directed proximally to the tibia to pass through the MM in zone 4 with a twisting movement. The free end of the suture was grasped and pulled out of the posteromedial portal. A sliding and self-locked knot was tied to the meniscus with the help of a knot pusher. If you are able to do the above, you can proceed to the next step of procedure; differently, it is necessary to place one or more all-inside sutures to repair the meniscal lesion in zone 4.

Figure 4 Transillumination of the medial compartment with the knee flexed at 90°: identification of the entry point for the posteromedial arthroscopic portal between the femur (F) and tibia (T).

Outside-in repair

In the next step, repair of the BHMMT in zones 3 and 2b was performed. A spinal needle with a free-end absorbable suture was placed inside the knee, crossing the meniscal wall and the tear at the border of zones 3 and 2b. A second spinal needle with an end-loop non-absorbable suture was then placed anteriorly and inferiorly in the same way, in zone 2b (Figure 5A). The first suture was taken up to the second end-loop suture by using arthroscopic forceps (Figure 5B); from the outside, pulling out the second suture, the first was taken out, and the suture was then tied on the capsule (Figure 5C).

Figure 5 Outside-in repair of the medial meniscus in zone 3/2b (step-by-step). (A) Arthroscopic image showing the medial compartment of the knee, MFC, MTP and MM. Two spinal needles with endoloop pass absorbable sutures across the meniscal wall at the 3/2b border. (B) Second spinal needle with end-loop suture retrieves the first suture (shuttling). (C) Arthroscopic image of the suture after extra-capsular knot tying over the capsule, completing the outside-in construct. MFC, medial femoral condyle; MTP, medial tibial plateau; MM, medial meniscus.

The procedure is summarized in Video 2.

Postoperative considerations and tasks

As the final step of the surgery, a routine ACL reconstruction with hamstring autograft was performed according to our recently described technique (24). Physical therapy began on post-operative day 1 with a focus on pain control, reducing edema, and knee motion. After the procedure, the patient was allowed weight bearing as tolerated with the use of crutches for a minimum of 2 weeks and may discontinue crutches once able to walk without a limp. Six weeks after the surgery, closed kinetic chain exercises were started with a focus on recovery of muscular endurance, strength and power. Five months after the surgery, the patient was allowed to run in a straight line without pivoting or twisting.

Tips and pearls

• Avoid over-tension: test excursion after each suture;
• Protect popliteal neuro-vascular bundle by keeping knee >90°;
• Convert to inside-out if hook passage fails or tear >3 mm from capsule.

Follow-up schedule & success criteria

Success criteria: International Knee Documentation Committee (IKDC) >80, MRI-verified healing. Failure: re-tear on MRI, revision surgery, IKDC <60.

Results

At the 6-month follow-up, the patient demonstrated excellent clinical outcomes:

• Pain-free function: the patient reported no episodes of pain, swelling, or discomfort during daily activities;
• ROM: physical examination revealed full knee extension and flexion (0–135°), matching the contralateral side;
• Stability tests: the anterior drawer and Lachman tests were negative with a firm endpoint, indicating restored ACL function. The pivot-shift test was also negative;
• Objective functional outcomes: the patient achieved a Lysholm Knee Scoring Scale score of 95 out of 100, indicating excellent knee function. The IKDC subjective knee evaluation score was 92 out of 100. The Italian-validated WOMET score (25) was 8 out of 100. These findings indicate high patient satisfaction and satisfactory knee performance, accompanied by a notably positive recovery index;
• Rehabilitation adherence: he patient adhered strictly to the prescribed rehabilitation protocol (Table 1). He attended all scheduled physiotherapy sessions and performed home exercises as recommended. Progression through the rehabilitation phases was smooth, with no setbacks or delays;
• Complications: no postoperative complications were observed. There were no signs of infection, neurovascular injury, or graft failure. The surgical wounds healed uneventfully.

By 6 months post-operatively, the patient resumed non-contact sports activities, including jogging and strength training. At 9 months, he returned to competitive soccer without any limitations. At the 1-year follow-up, he remained symptom-free with no recurrence of instability, mechanical symptoms, or functional deficits. Imaging studies, including MRI, confirmed the integrity of the meniscal repair and the reconstructed ACL (Figure 6).

Figure 6 Postoperative MRI at 6 months. (A) Sagittal PD/T2-FS image demonstrating complete healing of medial meniscus, relocated within the joint space (white arrow). (B) Coronal PD/T2-FS image showing ACL graft intact (asterisk). ACL, anterior cruciate ligament; MRI, magnetic resonance imaging; PD/T2-FS, proton density/T2-fat-suppressed.

Discussion

Surgical highlights

This study describes a novel surgical technique for the anatomical repair of a BHMMT combined with a ramp lesion in an ACL-deficient knee. Meniscal tears are common injuries (26,27). Several long-term follow-up studies showed increased arthritic changes after meniscectomy when compared to the healthy contralateral knee (28-30). The load transmitted across the knee joint increases with the increase in the amount of meniscus removed (31,32). Chronic meniscal tears are often unsuitable for suturing because of decreased vascularity or deformation of the fragments (33,34). In order to restore function and avoid early arthritic changes caused by meniscectomy, meniscal repair is preferred for specific tears, such as those in the red-red/red-white zones (21,34,35). The major vascular support to the meniscus comes from the branches of superior and inferior geniculate arteries that make a subsynovial and perimeniscal capillary network infiltrating the periphery of the meniscus. Anterior (zone 2) and posterior horn (zone 4) are the best perfused areas. Zone 3 is also called the white zone, and the peripheral rim is called the red zone (34,36,37). BHMMTs are often displaced and unstable, requiring surgical intervention. In the case we presented, the suture in zone 4 was performed with an all-inside repair technique using FiberStitch™ (Arthrex^®, Naples, FL, USA), and a vertical mattress suture was placed. This kind of suture repair is considered the gold standard because it surrounds the longitudinal peripheral meniscal fibers perpendicularly, supporting up to 200 N (38,39). Using this particular device also helps reduce the surgical time. Ramp lesion is defined as a tear in the posterior horn (zone 4) meniscocapsular attachment of the MM, or as a menisco-tibial ligament detachment as described by several studies (40-45). Śmigielski’s anatomical studies revealed that the superior part of the posterior horn has no capsular insertion, while the inferior part is attached to the tibia via the meniscotibial ligament (12). These fixed points reduce the mobility of the MM, making it prone to tearing in maximum flexion and rotation. It has been demonstrated that a ramp lesion increases anteroposterior and rotatory laxity in a knee with a torn ACL; in particular, the increase in anterior translation and pivot shift is massive when a meniscotibial ligament lesion is present (46). The classification of ramp lesions proposed by Thaunat et al. (23) describes different types of lesions of the ramp area but doesn’t provide indications for their treatment. In the event of an isolated meniscal lesion, it is possible to repair it with an all-inside device from the AM portal and after that verify its strength from trans-notch view (47-49). In addition to biomechanical restoration, this study emphasizes the clinical significance of preserving meniscal tissue. Our results demonstrate that the dual-repair technique not only improves functional outcomes but also mitigates the mechanical symptoms associated with meniscal displacement, such as knee locking. Instead, suture hooks need to be used when the lesion also involves the meniscocapsular attachment (23). Interestingly, there’s a rare case where these two lesions are associated, and it is necessary to use both suturing techniques, all-inside devices and suture hooks. We recommend repairing the ramp lesion because the MM has a crucial role in knee stability.

During ACL reconstruction, every effort must be made to properly diagnose and treat these lesions. In the literature, the gold standard to repair a meniscal tear is an inside-out suture technique; the rationale for this method of repair is that it permits accurate reduction, stabilization, and coaptation of the tear edges (50). The disadvantages of using an inside-out suture repair are the need for additional skin incisions either posterolaterally or posteromedially with a risk of common peroneal nerve or saphenous nerve injury. Overall risk of infections or neurovascular complications has been reported to be as high as 21% (47). The authors don’t recommend inside-out suture repair in zones 2b and 4; considering the attachment of the MM in zone 2a, the inferior vertical suture technique is recommended in order to restore the meniscotibial ligament attachment. This is slightly different in zone 2b, because of the attachments of the inferior and superior parts of the meniscus periphery (12). In zone 4, an inside-out suture approximates the capsule to the meniscus superiorly which isn’t anatomical. For these reasons, we prefer the outside-in suture technique as it is nearly anatomical and also less expensive. Finally, it has to be underlined that a BHMMT combined with a ramp lesion in the setting of an ACL-deficient knee is very uncommon. In their study, Keyhani et al. (51) found that the incidence of a ramp lesion in patients with an ACL tear is about 9.1% while it is about 20% in patients with an ACL and meniscus tears.

The proposed technique uses an all-inside meniscal device to restore and maintain anatomic reduction of BHMMT, followed by an all-inside suture to repair the ramp lesion, and finally an outside-in suture to repair the BHMMT. To the best of our knowledge, the combined use of these techniques for BHMMT repair has not been previously described. It potentially avoids the risks of conventional inside-out repair and helps to restore knee stability.

Strengths & limitations

The present report offers several strengths: (I) a fully anatomic reduction of both the bucket-handle fragment and the posteromedial ramp lesion, restoring hoop tension and meniscocapsular continuity; (II) avoidance of a posteromedial incision, which lowers the risk of saphenous-nerve injury and wound problems reported in up to 21% of inside-out series (52); (III) a reproducible set-up that combines all-inside and outside-in sutures without specialised equipment beyond a suture-hook; (IV) objective confirmation of healing by 6-month MRI and return-to-sport testing.

Conversely, limitations include the inherent level-IV evidence of a single case, a relatively short 12-month follow-up that cannot capture chondroprotective effects or late failures, the absence of second-look arthroscopy or quantitative laxity measurement, and a learning curve that may lengthen operative time for low-volume surgeons. Clinical outcomes for the proposed technique have not been studied, due to the relative infrequency of this kind of complex lesion. The authors believe that most BHMMTs are good candidates for an all-inside repair as they usually extend to zone 3, where other techniques pose the risk of injuring the popliteal neurovascular structures; however, a comparison of different techniques is out of the scope of this study. Future prospective studies on the failure rates, biomechanical assessment, functional outcomes, and complication rates will better clarify the outcomes of this combined procedure. Finally, we strongly believe that further studies are necessary to provide a comprehensive classification of ramp lesions in order to guide surgeons to the most appropriate treatment.

Comparison with existing evidence

Biomechanical data consistently demonstrate that combined repair of a ramp lesion and BHMMT in ACL-deficient knees restores anterior stability and reduces pivot-shift to values comparable with the intact knee. DePhillipo et al. reported a 46% reduction in anterior tibial translation versus isolated ACL reconstruction. Early clinical cohorts echo these findings: a recent multicentre study comparing all-inside versus inside-out BHMMT repair at ≥5 years found similar healing rates (88% vs. 82%) but fewer neuro-vascular complications with all-inside devices (40). Systematic reviews further indicate shorter operative time (14 min on average) and lower nerve-injury risk for all-inside approaches compared with inside-out, without compromising survivorship (52). Our patient’s negative pivot-shift, IKDC 92 and MRI-proven union at 6 months are therefore in line with, although not superior to, the current body of evidence.

Implications & economic cost

From a hospital perspective, the index procedure required two FiberStitch^® implants (€500 each) and two outside-in sutures (€25), for an added material cost of ≈ €1050 relative to a pure inside-out construct. However, inside-out techniques typically prolong operative time by 10–15 min and mandate a posteromedial approach associated with higher rates of nerve paresthesia and re-operation costs (52,53). A U.S. claims-database analysis identified implant selection and OR time as the major cost drivers of meniscal repair, with every additional 10 minutes adding ≈ €320 to the overall charge (54). Moreover, decision-analytic modelling suggests that meniscus preservation is ultimately cost-saving over the patient’s lifetime by reducing the incidence of post-meniscectomy OA and subsequent arthroplasty (55). When these downstream savings and the lower risk of neuro-vascular injury are factored in, the upfront €1,050 premium of the hybrid all-inside/outside-in technique appears justifiable, especially in young athletes.

Conclusions

The technique here proposed for the repair of a BHMMT combined with a ramp lesion in the setting of an ACL-deficient knee offers several advantages compared to the other techniques described: (I) anatomical reconstruction of the ramp area and repair of the BHMMT; (II) reduced risk of neurovascular damage; and (III) reduced surgical time. We strongly encourage the use of this technique in the treatment of such complex lesions. Surgeons should actively probe for concomitant ramp lesions in every BHMMT to avoid residual laxity.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-20/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-20/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-20/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the Institutional Review Board of Casa di Cura Caminiti (IRB #2025-ORM-156, 12 May 2024) and was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of the case, images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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