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Bucket-handle injury to the triangular fibrocartilage complex is a rare and poorly described condition in the literature that is not included in the Palmer classification. A young man presented with right wrist torsional trauma while playing sports. He progressed with local pain and limited range of motion with a supination block. Magnetic resonance imaging revealed a bucket-handle injury to the central portion of the triangular fibrocartilage complex with a volar flap, measuring 0.6 cm × 0.6 cm. The patient underwent wrist arthroscopy with debridement, removal of a loose body, and resection of the bucket-handle lesion. In the postoperative period, pain alleviation and a considerable gain in range of motion occurred. The patient was able to resume his participation in sporting activities 3 months after surgery. There is no consensus about the treatment of bucket-handle injuries to the triangular fibrocartilage complex because of the small number of cases described in the literature.

Background: Meniscal repair has become the treatment of choice for meniscal tears, especially in the subset of bucket-handle meniscal tears (BHMTs). However, a comprehensive estimate of the corresponding failure rate is not available, thus maintaining doubts about the healing potential of these tears. Furthermore, a wide range of factors to predict high failure rates have been reported but with conflicting evidence. Purpose: To determine the failure rate after arthroscopic repair of BHMTs as reported in the literature, compare this 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. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search was conducted by 2 independent reviewers using principal bibliographic databases (PubMed, Scopus, Cochrane Library, and EMBASE). After a stepwise exclusion process, 38 articles met the inclusion criteria. Failure rate data were analyzed with a random-effects proportional meta-analysis (weighted for individual study size), and forest plots were constructed to determine any statistically significant differences between BHMTs versus simple tears (longitudinal, radial, or horizontal), medial versus lateral BHMTs, isolated procedures versus repairs with concomitant anterior cruciate ligament reconstruction, and tears in red-red versus red-white zones. Moreover, a meta-regression analysis was conducted to evaluate the effect of patient age and sex, suture technique (in-out or all-inside), time from injury to surgery, mean number of stitches, and length of follow-up on failure rates. Results: The pooled failure rate was 14.8% (95% CI, 11.3%-18.3%; I2 = 77.2%). A total of 17 studies provided failure rates of both BHMT repairs (46/311 repairs) and simple tear repairs (54/546 repairs), demonstrating a significantly higher failure rate for BHMT repairs (risk ratio [RR] = 1.50; 95% CI, 1.05-2.15; I2 = 0%; P = .03). Medial BHMT repairs (RR = 1.94; 95% CI, 1.25-3.01; I2 = 0%; P = .003) and isolated repairs (RR = 1.77; 95% CI, 1.15-2.72; I2 = 0%; P = .009) had statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. Among the other factors evaluated with meta-regression, only the mean number of stitches showed a statistically significant effect on failure rates. Conclusion: 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.

Meniscal repairs are preferred to meniscectomies to preserve meniscal function and mitigate the risk of degeneration. However, repair of a chronic and displaced bucket handle tear of the meniscus can be technically challenging. We introduce a systematic method for assessment, reduction, repair, or salvage in this situation with an aim of reducing operating time and improving the chance of a favorable outcome. This technique describes repair of a bucket handle tear on the medial meniscus with displacement into the intercondylar notch. An arthroscopic probe is used for reduction and suture tension (push-and-pull technique) when using an all-inside suture device (FAST-FIX 360 repair system; Smith & Nephew) on the middle and posterior part of the tear. The anterior part of the tear is repaired with an outside-in method. If reduction is not possible, then a salvage reduction and hybrid repair is carried out instead. Postoperatively, patients will be nonweight-bearing on the operated limb, and range of motion restricted from 0 to 90° for 6 weeks, with the aim of resuming running by 6 months., Technique Video Video 1 This shows the repair technique used on a medial meniscus chronic bucket handle tear in a right knee flexed to 90°. Assessment of adequate reduction is done with the scope in the anteromedial portal and the probe in the anterolateral portal. There should be no gap between the inner and outer meniscal segments, and the segment should remain reduced without the probe on it. The FAST-FIX 360 all-inside repair system is then used to place 2 suture anchors above and below the friable torn segment. The probe is used to push on the anterior part of the knot and below the tensioning length to counter the pull or tensioning of the suture, to control the tightening of the suture loop and reduce the risk of suture cut out. The same method is used to repair the posterior half of the tear. To perform an anterior repair, the scope is switched to the anterolateral portal. The repair position is determined and blunt dissection down the capsule is performed. One trocar needle is placed above and one below the torn segment. This is for the same reason to minimize the risk of further damage to a friable and thin torn segment. After passing the sutures, the meniscus reduction is optimized with the probe via the anteromedial portal.

In regions of the world where resources can limit medical care (limited-resource settings, LRS), most meniscal tears are often treated with meniscectomy. A simple, low-cost option for meniscal repair has been developed. We sought to evaluate patient reported outcomes (PROMs) and clinical failure rates of bucket handle meniscus tears (BHTs) treated with meniscal repair in a LRS. We prospectively enrolled patients over 18 who were treated for BHT with meniscal repair in a LRS. Meniscal repair was primarily accomplished using an outside-in technique. Pre-injury and final follow-up PROMs were recorded. Clinical failure was defined as the need for re-operation or symptoms that prevented the patient from returning to recreational activities or work responsibilities. Nineteen patients with a mean age of 25.4 years were eligible. Two patients sustained a clinical failure (10.5%). At mean follow-up of 40.6 months, there was significant improvement in all PROMs from baseline. Subgroup analysis revealed no significant difference in the failure group compared to the success group in number of knots used, pre-injury Tegner score, number of devices used, suture type, or technique. Bucket-handle meniscal tears can be repaired using a low-cost technique resulting in satisfactory healing rates and excellent outcomes.

The purpose of this study was to report the outcomes of concomitant bucket handle meniscal tear (BHMT) repair and anterior cruciate ligament (ACL) reconstruction and to compare the outcomes with those after isolated ACL reconstruction in patients aged ≤16 years. Patients in our database from 2013 to 2017 were retrospectively analyzed. Patients were assigned to one of two treatment groups based on the presence of BHMTs: no meniscal tear group (group A) and BHMT group (group B). All BHMTs were repaired using the combined inside-out with all-inside technique. This study included 64 knees divided into two groups: 47 knees in group A and 17 knees in group B. There was a significant difference in the interval between ACL injury and surgery between groups A and B (69 vs. 150 days, respectively; P0.001). Mean postoperative International Knee Documentation Committee and Lysholm scores in group A were slightly, although significantly, improved compared to those in group B (96.5 vs. 92.6, respectively; P0.05, and 98 vs. 95, respectively; P0.05). There were no significant differences in postoperative anteroposterior laxity and graft failure rate between the groups. In group B, four patients (23.5%) required surgery for incomplete meniscal healing. Postoperative International Knee Documentation Committee and Lysholm scores of patients with BHMTs were significantly lower than those of patients without any meniscal tear, although with significant improvement in the amount of instability. Level of evidence was Level III.

Arthroscopic treatment is the treatment of choice in bucket-handle meniscal tears (BHMTs). Following BHMT, however, surgery failure rates are approximately 20% in the literature. Achieving the healing of BHMT is difficult. This is worse in chronic situations because the torn meniscus is deformed, leading to nonanatomical reduction. Some authors have reported greater failure rates, especially in the early postoperative period. In isolated BHMTs, the failure rate is greater because of inadequate and incomplete repairs due to the tight medial compartment. Multiple techniques for possible reduction of failure rate have been described. We describe an arthroscopic technique for treating chronic isolated BHMT using the technique of subcutaneously releasing the posterior fibers of the medial collateral ligament to provide adequate space for arthroscopy, meniscal reduction, and repair. A combined inside-out and all-inside repair technique was used to enhance anatomic reduction, stable fixation, surface fixation (rather than the usual suture-points fixation), and biologic healing in repairable chronic BHMTs., Technique Video Video 1 Video demonstration of the arthroscopic procedure for chronic isolated bucket-handle meniscal tears.

Background and Aim: Meniscus plays an important role in the knee, and thus, is being an important research topic for years. There are three different methods available for the treatment of Bucket handle meniscal tears, which are meniscectomy, meniscal repair with or without the uses of augmentation technique and the meniscal reconstruction. The aim of the research paper is to compare the results of meniscus repair over meniscectomy in bucket handle tear of medial meniscus. Materials and methods: It was a retrospective review of the prospectively collected data between January 2015 and December 2016 on the patients having bucket handle tear of medial meniscus, undergoing the ACL reconstruction. For this study, 30 patients were selected on the basis of the exclusion and inclusion criteria, who were equally distributed in Group A (Meniscus repair) and Group B (Menisectomy). Results: In the present study it is found that the mean age of the patient was 25.38years, majority of the patients were male participants and sports injury is found to be the major reason for the meniscal tear. Further, there is no significant difference in the mean of tunnel diameter, Lachman test, overall grades and radiographic grades between Group A and Group B. Conclusion: The study concluded that the results of the tunnel widening were found to be higher when the patient is treated with meniscectomy, and the results of Lachman test shows that meniscal repair is effective. On comparing the after results of both the meniscal repair and meniscectomy with the help of applying the radiological analysing, it is being found that meniscal repair offers better outcomes as compared to the meniscectomy.

Highlights • The PCL angle in ACL-deficient knee might be false-negative in the presence of bucket handle tear. • There must be always high suspicious of ACL insufficiency in case of medial bucket handle tear. • Profound knowledge of clinical examination patient’s history is absolutely mandatory to examine ACL insufficiency., Introduction Chronic anterior cruciate ligament (ACL) tear might be difficult to diagnose on MRI. Indirect signs might be a typical meniscal or cartilage lesion, or a spontaneous anterior drawer visualized by a decreased angle of the posterior cruciate ligament (PCL). Presentation of case A 27-year-old former ballet dancer was admitted to the emergency department for a locked left knee, without never having experienced previous symptoms of giving way or locking. The MRI performed revealed a medial meniscus bucket handle tear, without traumatic bone marrow oedema or ligament injury. The PCL angle was 130°. A former MRI of her left knee performed 1 year previously to investigate on the recurrent catching of her left knee showed a grade III medial meniscal tear of the posterior horn, and buckling of the PCL angle of 100°, as a sign of chronic ACL rupture. During arthroscopy and medial meniscal repair, the ACL showed complete loss of tension, and was therefore reconstructed simultaneously to enable proper meniscal healing. Discussion and conclusion Chronic ACL insuffiency is a major risk factor for subsequent medial meniscus tear, especially bucket handle tear. The locked knee might unable proper pre-operative clinical examination. The preoperative MRI therefore being the only possibility to diagnose concomitant ligamentous injury. This is the first case reported in literature showing, that a positive PCL angle sign might be falsely negative due to a locked medial meniscus bucket handle tear.

Proximal tibiofibular dislocation (PTFD) is a rare injury. In this article, we report a case of a PTFD, complicated with an intraarticular injury, a bucket-handle tear of the lateral meniscus. A 37-year-old male patient presented to the emergency department with pain and swelling on the lateral side of his right knee due to lateral trauma to the fibula during external rotation of the leg while his foot was on the ground. Closed reduction was performed under sedation. The lateral meniscus was repaired, and the fibular head was fixed with a cannulated screw. The patient had no pain in the tibiofibular joint after eight weeks postoperatively. Results of magnetic resonance imaging for the diagnosis of PTFD should be kept in mind during the presentation of sports trauma patients that experience difficulty in bearing weight on the affected extremity.

Objective To assess if young military personnel who had sustained medial meniscal bucket handle/longitudinal tears could return to full, unrestricted active duty after meniscal repair by outside in/inside out technique. Methods 32 medial meniscal longitudinal/bucket handle tears were repaired by inside-out and outside in technique between Jul 01, 2017 and June 30, 2018 and followed up for at least 18 months. Results There were 03 failures of repair. The first 05 patients developed para-meniscal cyst due to irritation of soft tissue by PROLENE® suture hence the suture material was changed to ULTRABRAID® in next 27 patients and there was no occurrence of this complication. The mean IKDC, Lysholm and Tegner scores showed significant improvement till 12 months post op and thereafter there was marginal improvement in these scores. Most patients who had successful outcome at one year were able to carry out preinjury level of activities and join unrestricted active duty. Conclusion With more than 90% able to re-join active duty, we could demonstrate that inside out/outside in technique is an excellent method of reliably and economically repairing a torn meniscus even for very high demand military personnel.

Introduction Meniscal injuries are one of the most common musculoskeletal injuries around the knee affecting patients of different genders, ages and activity levels. These injuries could be acute or chronic tears that cause pain and mechanical symptoms based on the injury severity and whether it is displaced and entrapped in an abnormal location within the knee or not. Advances in magnetic resonance imaging (MRI) allowed us to have a better understanding of multiple bucket handle meniscal tear patterns with its specific MRI signs which have been reported in the literature. Case presentation This report presents a rare case of a 16-year-old boy with atypical bucket-handle tear of lateral meniscus and MRI showed a bucket-handle tear of lateral meniscus with a fragment entrapped behind and parallel to the anterior cruciate ligament (ACL) appearing as another ACL in sagittal views. Meniscus was repaired arthroscopically. Conclusion In our case, the unique and infrequent mechanism led to a bucket-handle tear involving lateral meniscus with a meniscal fragment entrapped in an unusual place intra-articularly behind ACL giving the appearance of a rare MRI sign “double ACL sign”. However, double ACL sign secondary to lateral meniscal tear has been reported only once previously up to the authors’ knowledge., Highlights • Radiologically, meniscal tears have multiple pathognomatic signs. • Double acl sign was reported twice only, one from medial meniscus and the other from lateral meniscus. • Double acl sign indicates huge bucket handle tear which displaced into the intercondylar notch.

Background: There is no consensus on technique of choice for repair of bucket-handle meniscal tears (BHMTs). Purpose: To determine factors that affect patient outcomes and failure rates in patients undergoing all-inside repairs of BHMTs. Study Design: Systematic review. Methods: A systematic review of 3 databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. All English-language literature from 1993 to 2019 describing clinical outcomes for patients undergoing all-inside BHMT repair with ≥12-month follow-up was reviewed by 2 independent reviewers. Patient characteristics (patient sex, age), intraoperative factors (laterality, concomitant procedures, surgical technique, implants utilized), and postoperative outcomes (failure rates) were analyzed. Study quality was evaluated with the Modified Coleman Methodology Score (MCMS). Results: Fifteen studies (1 level 1, 4 level 3, 10 level 4) with 763 total patients (64% male; average age, 26.4 years [range, 9-58 years]; average follow-up, 39.8 months [range, 12-120 months]) including 396 all-inside BHMT repairs were included. Six devices were used for repair including the Meniscal Repair System, FasT-Fix, Meniscus Arrow, Biofix Arrow, RapidLoc device, and PDS II suture, with failure rates of 13.5%, 22.4%, 27.1%, 42.9%, 45.2%, and 0%, respectively. The overall repair failure rate was 29.3% at an average of 13.0 months (range, 5.0-32.4 months), but 19.0% for devices still in use. The RapidLoc and Biofix Arrow had higher failure rates than other devices ( P = .0003). Women (31%) were less likely to experience a failure than were men (69%) ( P = .03). Longer follow-up duration resulted in higher failure rates (>30 months, 34.4%; .05 for all). The overall average MCMS was 54.4 ± 12. Conclusion: The overall failure rate after all-inside repair of BHMTs is 29.3% at an average of 13.0 months, with no difference in failure rates between medial and lateral meniscal repairs. The variables shown to negatively affect the failure rates were the RapidLoc and Biofix Arrow, male sex, and longer follow-up duration.

Objectives: Bucket handle meniscus tears often present concurrently with tears of the anterior cruciate ligament (ACL). However, little is known regarding the influence of demographic factors on surgical decision-making, or on outcomes following treatment of bucket handle meniscus tears in ACL-deficient patients. Furthermore, no study has compared outcomes in this population between patients undergoing meniscectomy versus repair. The purpose of this study was therefore to determine if there is a difference in outcomes between patients presenting with concomitant ACL and bucket handle meniscus tears treated with meniscal repair versus meniscectomy. A secondary aim of this study was to discover if there is an association between the decision to perform a meniscus repair or meniscectomy based on demographic factors. Methods: In this institutional review board-approved retrospective study, we evaluated 62 patients presenting with ACL tear who were found to have a bucket handle meniscus tear preoperatively or at the time of ACL reconstruction. Of those, 30 patients underwent partial meniscectomy, while 32 underwent meniscal repair. Primary outcome measures included ACL and meniscal retear rates, as well as patient-reported outcome measures (PROMs). Documented PROMs included the International Knee Documentation Committee (IKDC), Single Assessment Numeric Evaluation (SANE), and ACL-Return to Sport after Injury (ACL-RSI) scores. Demographic and patient-specific factors evaluated included age, body mass index (BMI), smoking status, and location of meniscus tear. Results: Of 62 patients presenting for ACL reconstruction with concomitant bucket handle meniscus tear, a total of 34 patients with greater than one year (mean 22.4 month) follow-up were included. 14 patients underwent repair, and 20 underwent meniscectomy. No significant differences were noted in IKDC (p = 0.36), delta IKDC (p = 0.18), SANE (p = 0.61), or ACL-RSI (p = 0.67) scores between the repair and meniscectomy groups at final follow-up. No significant differences were found in ACL (p = 1.00) or meniscus (p = 0.49) retear rates between the two groups. Younger age, lower BMI, and tear location (red-red zone) were significantly associated with the decision to perform meniscal repair over meniscectomy (p < 0.05). Conclusions: Among patients presenting with concomitant ACL and bucket handle meniscus tears, we found no difference in patient-reported outcomes or retear rates in patients undergoing meniscal repair versus meniscectomy. Demographic and patient-specific factors including age, BMI, and tear location may influence surgical decision-making when determining the optimal treatment of bucket handle meniscus tears in this population.

Bucket-handle meniscal tears are defined as vertical longitudinal tears of the meniscus with displacement of the torn inner fragment toward the intercondylar notch region. It is most commonly encountered in medial meniscus. Management of bucket handle tears is important to preserve knee function & preserving the meniscus will limit future osteoarthrosis. A series of 20 cases of bucket handle medial meniscus tears were treated by Arthroscopic repair: All-inside technique and were followed up regularly till 6months and evaluated using Lysholm Knee Scoring Scale. Most patients had Excellent score at 6th month follow-up. Our study suggests Arthroscopic repair: All-inside technique is an effective management of medial meniscus bucket handle tears.

Stages of healing for classic metaphyseal lesions (CMLs) are not well established. Follow-up skeletal surveys provide an opportunity to evaluate signs of healing CMLs. To evaluate the sequence of CML healing phases by comparing initial and follow-up skeletal surveys in children with distal tibial CMLs on the initial survey. Findings could assist in child abuse investigations. We identified all distal tibia CMLs with initial and follow-up skeletal surveys performed January 2009 through December 2018 at our institution. Two pediatric radiologists reviewed the surveys using Likert score from 1 (no CML) to 5 (definite CML). Only cases with score of 4 or 5 by both radiologists were selected for the study. The initial and 2-week follow-up skeletal surveys were reviewed in consensus for presence of the following signs: corner fracture, thin bucket handle fracture, thick bucket handle fracture, bucket handle fracture with endochondral bone filling the gap, subphyseal lucency, deformed corner, and subperiosteal new bone formation. We used the Kruskal–Wallis test to evaluate for significant difference in thickness among thin bucket handle fracture, thick bucket handle fracture, and bucket handle fracture with endochondral bone filling the gap. We included 26 children (12 girls) with age range 1–9.9 months who had a combined 34 distal tibia CMLs. Thin bucket handle fracture (n=13, 38.2%) was only seen on initial survey. On follow-up, six children had thick bucket handle fracture and four had bucket handle fracture with endochondral bone filling the gap. Fourteen thick bucket handle fractures (n=9) or bucket handle fractures with endochondral bone filling the gap (n=5) were noted on initial surveys; on follow-up, three (21.4%) had deformed corner, one (7.1%) had corner fracture, one (7.1%) had subphyseal lucency, and five (35.7%) were normal. None demonstrated thin bucket handle fracture on follow-up. Two of the nine (22.2%) thick bucket handle fractures became thicker, and 3/9 (33.3%) became bucket handle fractures with endochondral bone filling the gap. The metaphysis normalized in 8/34 (23.5%) CMLs on follow-up surveys. The thickness of thin bucket handle fracture was less than 1 mm (mean±standard deviation [SD] = 0.6±0.2 mm), which was significantly thinner (P

Meniscus tears are among the most common knee injuries in the general population and often are treated arthroscopically with a meniscus repair. Of the various meniscus repair techniques available, the inside-out meniscus tear is considered the gold standard due to its versatility and good clinical outcomes. The purpose of this Technical Note and accompanying video is to describe an inside-out bucket-handle meniscus repair using a single handed, self-advancing meniscus repair device with an interchangeable zone-specific multicannula system to decrease the technical difficulty and operative time of the repair.

Objectives: Comprising approximately 10% of all mensiscus tears, bucket-handle meniscus tears are large longitudinal vertical meniscus tears that have an attached fragment flipped into the intercondylar notch. Meniscectomy would often result in significant meniscal loss and increased joint loading. Alternatively, meniscus repair attempts to restore the function of the meniscus and aims to preserve joint mechanics. The objective of this observational data-only study is to evaluate the long-term risk of subsequent ipsilateral knee surgery in patients who underwent a bucket handle meniscus repair and assess risk factors associated with subsequent knee surgical intervention. Methods: We performed an electronic health records search for all patients who underwent arthroscopic knee meniscal repairs from 2011 to 2018. Natural language processing was used to search for terms of interest in the long operative notes to determine if these surgeries were performed for bucket handle meniscus tears. These patients comprised our initial cohort. Study subjects were followed for at least one year and up to five years with censoring at death, membership disenrollment, or 12/31/2019. Baseline patient characteristics and outcomes (i.e., subsequent operative procedures, deep surgical site infections, and deep venous thrombosis) were evaluated via a database review. Descriptive statistics were employed. Results: The median follow-up time was 4.2 years (interquartile range [IQR] 2.7-5.0 years). A total of 1353 patients underwent meniscus repair surgery for a bucket-handle meniscus tear. The median age was 24 years (IQR 17-34). During the follow-up period, 492 subsequent ipsilateral procedures were performed in 272 (20.1%) patients. 59 (4.3%) patients underwent a subsequent repeat meniscus repair and 164 (12.1%) patients underwent a subsequent meniscectomy. The median time to first procedure was 41.1 months (IQR 23.3-60 months). Younger age and lower BMI were significant risk factors for having subsequent surgery (adjusted odds ratio [aOR] 1.04, 95% Confidence Interval [95%CI] 1.02-1.05, and aOR 1.60, 95%CI 1.09-2.35, respectively). Patients undergoing concomitant ACL reconstruction had a lower risk of undergoing subsequent surgery (aOR 0.66, 95%CI 0.50-0.88). Conclusions: This is the largest reported contained patient cohort study on outcomes after bucket-handle meniscus repair. 20% of patients underwent repeat surgery during the follow-up time period with 4.3% experiencing a subsequent repeat meniscus repair and 12% experiencing a subsequent meniscectomy. Risk factors for subsequent surgery include younger age and lower BMI. Concomitant ACL reconstruction at time of bucket-handle meniscus repair reduced the risk of subsequent reoperation.

An object-tracking algorithm was used on computed tomography (CT) images of the thorax from six healthy participants and nine participants with chronic obstructive pulmonary disease (COPD) to describe the movement of the ribs between the static lung volumes of functional residual capacity (FRC) and total lung capacity (TLC). The continuous motion of the ribs during tidal breathing was also described using four-dimensional CT datasets from seven participants with thoracic esophageal malignancies. Rib motion was defined relative to a local joint coordinate system where rotations about the axes that predominantly affected the anteroposterior and transverse diameters of the rib cage were referred to as pump-handle and bucket-handle movements, respectively. Between TLC and FRC, pump-handle movements were 1.8 times larger in healthy participants than in participants with COPD, in line with their 1.6 times larger inspiratory capacities. However, when rib motion was normalized to the change in lung volume, pump-handle movements were similar for healthy participants and participants with COPD. We found no differences in bucket-handle movements between participant groups before and after normalization. Pump-handle movement was the dominant rib motion between FRC and TLC, on average four times greater than bucket-handle movement in healthy participants. For expiratory tidal volume, pump-handle movements were 20% smaller than bucket-handle movements. When normalized to tidal volume and compared with inspiratory capacity, pump-handle movements were smaller and bucket-handle movements were larger during tidal breathing. The findings suggest that the pump-handle and bucket-handle components of rib motion vary for small and large changes in lung volume.

Introduction and importance The two major etiologies of shoulder superior labral tears anterior to posterior (SLAP) are traumatic and degenerative processes. Bucket handle tears of the superior labrum represent one-third of labral lesions. However, in this article, we present a double bucket handle tear which has been reported once in the literature. Presentation of case A 25-year-old male presented with complaint of chronic pain in his right shoulder with a remote history of traumatic dislocation. Physical examination revealed a positive apprehension test. Shoulder magnetic resonance imaging (MRI) showed a superior labral tear with a Hill-Sach lesion. Arthroscopy showed a double bucket handle tear of superior labrum and mild biceps tendonitis along with Bankart lesion. The tear was resected and the Bankart lesion was repaired followed by supervised physical therapy. Good clinical outcomes in form of resolution of pain and shoulder instability at six months were obtained. Discussion SLAP tears are common shoulder lesion that is reported differently in the literature. Arthroscopic studies had reported the incidence between 3.9%-11.8. The diagnosis of such lesion relies on the clinical presentation and imaging. Knesek et al. classified SLAP lesions based on the integrity of the biceps anchor and the type of labral tear (Knesek et al., 2013). The standard treatment of symptomatic SLAP lesions is Arthroscopic debridement. However, non-operative management was described in the literature. Conclusion Double bucket handle injuries of the superior labrum are reported in literature once. These lesions can be treated with arthroscopic debridement and Bankart repair and followed by supervised physical therapy., Highlights • Superior labrum Anterior to posterior (SLAP) lesions are common cause of shoulder pain. • Various causes for SLAP lesions have been described including micro traumatic and non-traumatic (e.g., degenerative). • The incidence of SLAP tears varies among multiple arthroscopic studies. Snyder et al. reported an incidence of 3.9% to 11.8. • Most of patients with SLAP lesions present with concurrent shoulder injuries such as partial or complete rotator cuff tears. • MR arthrography is the best imaging Modality to evaluate the SLAP lesions. • Arthroscopic SLAP repair remains the gold standard treatment. However, management depends on patient age, functional status.

Bucket-handle meniscal tears (BHMT) remain a challenge to treat due to their complex pathology and technical difficulty. Subtotal meniscectomy has shown to improve symptoms early but leads to accelerated osteoarthritis in the affected compartment and poor long-term outcomes. BHMT repair and meniscal preservation is the preferred option. This can be performed with inside-out, all-inside, or hybrid meniscus repair techniques. All-inside meniscus repair avoids the need for additional safety incisions, trained assistants for suture passing, and reduce concerns of soft-tissue and neurovascular complications. In this Technical Note, we detail our all-inside technique for BHMT technique and share tips for a successful repair., Technique Video Video 1 The all-inside repair of the left knee medial meniscus BHMT is described in a stepwise manner. Five all-inside stitches are placed using the FAST-FIX 360 for the repair of the BHMT extending from posterior horn to midbody. After reduction, the first all-inside suture is placed in horizontal configuration at the junction of the posterior horn and body of the medial meniscus. Both horizontal and vertical configurations are used for subsequent all-inside sutures for the repair. The depth limiter of the device is set at 16 mm for the meniscus body and 18 mm for the posterior horn. The last all-inside vertical stitch is placed at the edge of the tear in the body of the meniscus to prevent tear propagation. Additional tips for reduction of stubborn BHMT are also presented. First, adequate release for the perimeniscal scar tissue, and the debridement of scar tissue between the BHMT fragment and the peripheral rim with VAPR radiofrequency wand and arthroscopic shaver can aid better BHMT reduction. Second, an inside-out horizontal reduction stitch can be placed using a zone-specific cannula into the mid-body of the medial meniscus and held in tension to assist with the reduction of the BHMT. The tips and techniques in this video can help achieve a successful all-inside BHMT repair. (BHMT, bucket-handle meniscal tear.)

The aim of this study was to evaluate the success of the all-inside repair technique for medial bucket-handle meniscus tear (BHMT) and the factors affecting healing. A total of 36 patients with BHMT who were operated between 2012 and 2018 and completed final follow-up examinations were included in the study. Functional evaluation was made with the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score. Healing was evaluated on magnetic resonance imaging (MRI) slices. The patients were evaluated with respect to the effect on healing of factors such as demographic data, body mass index (BMI), smoking status, anterior cruciate ligament tear reconstruction (ACLTR) applied at the same time as BHMT repair, and the tear being chronic or acute. The mean age of the patients was 28.6 ± 8.6 years (range,18–46 years), the mean follow-up period was 25.8 ± 13.9 months (range, 13–59 months), and BMI was mean 25.6 ± 3.5 kg/m2 (range, 20.1–30.5 kg/m2). The meniscus tears were acute in 16 (44.4%) patients and chronic in 20 (55.6%). ACLTR was applied together with BHMT repair in 25 patients. The hybrid technique, as the outside-in technique in addition to the all-inside technique, was applied to 12 (33.3%) patients, where there was seen to be extension to the anterior horn. The failure rate was determined as 27.8% according to the postoperative MRI evaluation and the Barrett criteria. No positive or negative statistically significant effect on healing was determined of chronic BHMT or of simultaneous application of ACLTR (p = 1.00 and 0.457, respectively). Cigarette smoking and high BMI were determined to have a statistically significant negative effect on healing (p = 0.026 and 0.007, respectively). In conclusion, it can be seen that the success of the all-inside technique for BHMT remains controversial. Due to the features of the application, it can be used in meniscus tears of the posterior horn only. In the current study, with the success rate of 72.2% of the all-inside technique in meniscus body tears, it was seen that a high success rate could not be achieved.

Teaching Point: Bicompartmental bucket handle meniscal tears are very rare occurrences that can result in menisci fragments superimposition in the intercondylar notch, referred to as the “triple posterior cruciate ligament sign”.

Purpose: Bucket handle tears of the meniscus are common and can lead to locking, extension deficit and functional impairment. The diagnosis is determined by a combination of physical examination and imaging, but in some cases the diagnosis may be challenging since specific clinical tests are lacking. The aim of the present study was to assess the value of a new clinical test, the elective pain at the anterior aspect of the joint line (defined as the “Rising Moon sign”) in the diagnosis of bucket handle tears of the medial meniscus. Methods: Forty patients treated for a bucket handle of the medial meniscus were enrolled as the study group and were compared to a matched group of 40 patients with a posterior horn tear of the medial meniscus and 50 healthy subjects. The following aspects were investigated in the groups: body mass index, extension deficit, pain at the posterior aspect of the joint line (PPJL), at the middle joint line (PMJL), at the anterior join line (PAJL) and at combined hyperflexion of the knee and external rotation of the foot (PHE). Pain at the anterior joint line (PAJL) was defined as the Rising Moon sign. Results: In the bucket handle group the average flexion contracture was 12° (0–30°). The average PPJL was one (0–2), the average PMJL was 1.6 (0–3), PAJL was 2.5 (1–3) and PHE was 1.6 (1–2). In the posterior horn tear group the average flexion contracture was 0.9° (−10 to 5°). The average PPJL was 2.2 (1–3), the average PMJL was 1.4 (0–3), PAJL was 0.6 (0–2) and PHE was 2.5 (1–3). The rising moon showed 95% sensitivity and 98% specificity in the diagnosis of bucket handle tears. In addition it showed a positive predictive value of 97.4% and negative predictive value of 96%. Finally it also demonstrated high inter-observer reliability (0.905). Conclusions: The “Rising Moon” sign has shown to be highly predictive for bucket handle tears of the medial meniscus with very high specificity and sensitivity. In addition it is easy to perform with very high inter-observer reliability. Level of evidence: Level IV.

Case A 16-year-old football player presented with chronic ACL deficiency along with bicompartmental bucket handle meniscal tears. Conclusion We present a "triple cruciate" sign in addition to the triple posterior cruciate ligament (PCL) sign seen on Magnetic Resonance Imaging (MRI) to aid in diagnosing this injury.

Purpose The purpose of this study was to evaluate our results of bucket handle meniscus tear (BHMT) repairs with an all-inside repair technique using postoperative radiological imaging to evaluate meniscus reduction and healing and use them as criteria for evaluation of repair success. Methods Prospective recruitment of 20 patients with 21 BHMT repairs performed with an all-inside technique over a period from 2013 to 2015. All patients had an International Knee Documentation Committee (IKDC) Subjective Knee Form (SKF), Lysholm Score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and Tegner Activity Level Scale obtained pre-operatively and at a minimum of 24 months after surgery. All patients had postoperative knee magnetic resonance imaging (MRI) performed between 18 and 24 months after surgery to assess the stability or failure of their repairs. At 5 years after surgery, the patients were assessed with regard to whether they had undergone repeat surgery or not. Results At 2 years, the mean postoperative SKF, Lysholm and KOOS grand scores were 78.9, 88.5 and 86.8, respectively. The mean pre-injury Tegner Activity Scale was 7.6 and postoperatively it was 6.0. There was a significant difference in all pre- and postoperative outcome scores (P The postoperative MRIs showed that 19 of the 21 BHMT repairs had stable reduction of the tear fragment and two patients had displacement of the torn bucket handle fragment. At 5 years, one patient had undergone revision surgery. Conclusion BHMTs can be repaired with all-inside techniques with good results and successful outcomes.

Case We report a case of a right knee lateral bucket-handle meniscal tear repair in a 25-year-old woman bilateral below-knee amputee. At the 4-year follow-up, the patient was ambulatory in a prosthesis with a successful outcome. Conclusion Meniscus repair in below-knee amputees requires careful evaluation and surgical management. Specific consideration should be given to evaluating limb alignment, maintaining the stump integrity, surgical technique, modified bracing, and rehabilitation. This case report demonstrates that bucket-handle meniscus repair can be successful in a below-knee amputee.

This study reported the outcomes of locked bucket-handle medial meniscal tear (BHMMT) repairs using an arthroscopic posterior approach during anterior cruciate ligament (ACL) reconstruction.Between 2011 and 2014, 48 patients with BHMMTs and ACL tears who met the eligibility criteria were enrolled in the present study. BHMMTs were assessed using a posterolateral transseptal portal and repaired using a posteromedial portal. Transportal ACL reconstruction was performed using hamstrings autograft. Patients were assessed based on their IKDC and Lysholm scores and Tegner activity level. Meniscal healing was clinically evaluated based on the absence of swelling, joint line tenderness, locking, and catching; McMurray test results; and the need for meniscectomy.According to follow-up assessments, the average IKDC and Lysholm scores improved significantly after 3-5 years (P 0.001) CONCLUSION: Excellent clinical outcomes were obtained when locked BHMMTs were repaired using an all-inside suture technique that employed posteromedial and posterolateral transseptal portals.IV.

Surgery failure rates average 20% following bucket-handle meniscal tears (BHMT) repairs in the literature. Achieving the healing of BHMT is difficult, how much more in revision cases. Some authors have reported higher failure rates especially in the early postoperative period and in younger patients. Multiple techniques and augmentations to enhance biologic healing and reduce failure rate have been described. We describe an arthroscopic technique for successfully revising a failed BHMT repair using the technique of percutaneously releasing the posterior fibers of the medial collateral ligament to provide adequate space for arthroscopy, refreshing of the torn surfaces, bed trephination before reduction and repair. We concluded that a combined double-level inside out vertical sutures with horizontal reinforcement and all-inside technique using fast fix give anatomic reduction, stable fixation, surface contact, and increased potential for biologic healing in failed BHMT repairs. Coupled with adequate rehabilitation programs, this technique has reduced the failure rate in revision cases and enhances early return to sport.

Concomitant meniscal injuries are common in patients with anterior cruciate ligament (ACL) insufficiency. Along with ACL reconstruction, meniscal repair offers better outcomes. This requires multiple incisions for both procedures. We present a novel technique of medial meniscus inside out repair using only the tibial tunnel wound without making an additional posteromedial incision. This is the first such description of this novel technique in a 21 year old male who underwent ACL reconstruction along with bucket handle medial meniscal repair.

Composite frontal scalp defects involving the frontal bone and full thickness scalp can pose a reconstructive challenge. Often, they necessitate the use of microsurgical free tissue transfer, which can be physiologically demanding in high-risk patients with multiple comorbidities, with exposure to prolonged general anesthesia time and increased surgical morbidity. The experience of a single surgeon was reviewed with reconstruction of composite frontal scalp wounds in 4 patients with structural framework and a bipedicled scalp advancement (ie, "bucket handle") flap, thus obviating the need for free tissue transfer. All 4 patients demonstrated complete wound healing by final follow-up, without need for further reoperations or ulcer recurrence. In face of composite frontal scalp defects in less than ideal candidates for lengthy microsurgical flap procedures, the bucket-handle flap can provide a simple and reliable reconstructive option.

Objective To define patient demographics, preoperative, and intraoperative surgical variables associated with successful or failed repair of bucket-handle meniscal tears. Design All patients who underwent arthroscopic repair of a bucket-handle meniscus tear at a single institution between May 2011 and July 2016 with minimum 6-month follow-up were retrospectively identified. Patient demographic, preoperative (including imaging), and operative variables were collected and evaluated. A Kaplan-Meier curve was generated to demonstrate meniscus repair survivorship. Results In total, 75 patients (78 knees) with an average age of 26.53 ± 10.67 years met inclusion criteria. The average follow-up was 23.41 ± 16.43 months. Fifteen knees (19.2%) suffered re-tear of the repaired meniscus at an average 12.24 ± 9.50 months postoperatively. Survival analysis demonstrated 93.6% survival at 6 months, 84.6% survival at 1 year, 78.4% survival at 2 years, and 69.9% survival at 3 years. There was significant improvement from baseline to time of final follow-up in all patient-reported outcome ( P < 0.05) except Marx score ( P = 0.933) and SF-12 Mental Subscale ( P = 0.807). The absence of other knee pathology (including ligament tear, contralateral compartment meniscal tear, or cartilage lesions) noted intraoperatively was the only variable significantly associated with repair failure ( P = 0.024). Concurrent anterior cruciate ligament reconstruction (vs. no concurrent anterior cruciate ligament reconstruction) trended toward significance ( P = 0.059) as a factor associated with successful repair. Conclusions With the exception of the absence of other knee pathology (including ligament tear, contralateral compartment meniscal tear, or cartilage lesions) noted intraoperatively, no other variables were significantly associated with re-tear. The results are relatively durable with 84.6% survival at 1 year. Surgeons should attempt meniscal repair when presented with a bucket-handle tear.

Bucket Handle tears occur most commonly in the medial meniscus. A typical Bucket Handle tear is a vertical tear from femoral surface of meniscus to tibial surface and extending longitudinally along the length of the meniscus from the anterior horn or body to the posterior part of the meniscus. The reported case is a rare one of horizontal cleavage tear of meniscus which developed bucket handle tear extending from anterior third of body to the posterior body in an ACL deficient knee and valgus deformity of lower limb and agenesis of 5th Metatarsal. The type of meniscal tear along with other contributory clinical findings makes this case unique. This has been successfully treated using outside in sutures and ACL reconstruction.

A connected topological space is said to be widely-connected if each of its non-degenerate connected subsets is dense in the entire space. The object of this paper is the construction of widely-connected subsets of the plane. We give a completely metrizable example that answers a question of Paul Erd\H{o}s and Howard Cook, while a similar example answers a question of Jerzy Mioduszewski., Comment: 15 pages, 5 figures

Background Several types of meniscal tear could be presented in both acute and chronic anterior cruciate ligament injury. The incidence of bucket-handle meniscus tears can be up to 30% of the overall meniscus tears cases. The case of both compartment (medial and lateral) bucket-handle meniscus is rarely occurred. Case A case of both medial and lateral bucket-handle meniscus tears was reported in a male of 21 years old. The patient also had a chronic anterior cruciate ligament injury. The magnetic resonance imaging also showed a rare presentation of the triple-PCL sign with the sagittal view. Arthroscopic surgery with a meniscus repair and anterior cruciate ligament reconstruction was performed on the patient. Conclusions Several specific imaging signs including triple-PCL sign could be presented in a rare case of both medial and lateral bucket-handle meniscus tears. Recognition of this sign is important to have accurate preoperative diagnosis and proper treatment plan.