Bucket handle tears represent displaced longitudinal vertical tears, commonly seen in young active individuals. These tears often compromise knee stability and necessitate timely intervention to preserve meniscal function and prevent degenerative changes (Canton et al., 2021). Magnetic resonance imaging is considered the gold standard for diagnosing these injuries, offering high sensitivity and specificity in detecting the presence, location, and complexity of meniscal lesions, including associated pathologies (Idrissi et al., 2021). While arthroscopic surgery, using standard anteromedial and anterolateral portals, is the established procedure for managing meniscal tears, particularly those in the midbody and posterior horn, bucket-handle tears are distinct in their presentation and management (Chen et al., 2017) Unlike typical meniscal tears, bucket-handle lesions are characterized by a longitudinal and full-thickness tear where the inner part migrates centrally, often presenting as a "bucket-handle like tear" (Kouzelis et al., 2022). This distinct morphology, which accounts for approximately 8.2% of all meniscal tear patterns, often results in significant mechanical symptoms such as locking, catching, and instability, thereby necessitating surgical intervention (Zhang, 2022). These tears, although more prevalent in adults, can occur in the pediatric and adolescent populations, frequently affecting the medial meniscus and often occurring in conjunction with other knee injuries such as anterior cruciate ligament tears (Combs et al., 2021). The presence of concomitant injuries, such as anterior cruciate ligament tears, further complicates the clinical picture, often necessitating a comprehensive surgical approach to restore knee stability and function. The displacement of the meniscal fragment, often depicted accurately by computed tomography, significantly contributes to the mechanical symptoms experienced by patients (Manco et al., 1988).

Given their size and instability, these tears traditionally require multiple repair devices, increasing cost significantly in resource-constrained settings. This study therefore introduces and evaluates a novel, cost-effective arthroscopic repair technique that utilizes a single all-inside device to achieve circumferential compression and stability through seven continuous sequential stitches, aiming to mitigate these financial burdens without compromising clinical outcomes. This approach seeks to provide a viable alternative to conventional meniscoplasty techniques, which often involve multiple implants and thus higher costs, while still maintaining the crescent shape of the meniscus and avoiding complications such as abnormal lower-limb biomechanical axes (Zhang et al., 2025). The objective is to restore the natural anatomy and biomechanics of the meniscus to prevent further degeneration and the onset of osteoarthritis, which has been linked to meniscal extrusion (Koga et al., 2012) (Mameri et al., 2022). Therefore, the optimization of meniscal repair techniques, particularly for bucket handle tears, is critical for both short-term symptomatic relief and long-term joint health, especially in light of recent advancements in all-inside repair devices that aim to enhance outcomes while minimizing invasiveness (Ozeki et al., 2023). Moreover, preserving the meniscus is crucial for its chondroprotective properties, as its removal or damage can lead to the development of osteoarthritis (Ozeki et al., 2023). Consequently, innovative repair strategies that facilitate healing while minimizing extrusion are essential to preserve its crucial load-bearing and shock-absorbing functions (Leafblad et al., 2020).

With the evolution of flexible suture-passing all-inside devices, a continuous stitching technique allows multiple suture passes with one device. This study presents outcomes from using a single all-inside repair device to place 7 continuous locking stitches,

MATERIALS AND METHODS

Design: Prospective clinical study

Setting: Hosmat Hospital, Bangalore

Study Duration: 2022–2024

Sample Size: 150 patients

Follow-Up: Minimum 12 months

Inclusion Criteria:

- Age 18–45

- MRI and arthroscopic confirmed bucket handle tear (medial or lateral)

- Tear length ≥ 2.5 cm

- Stable knees or ACLR performed simultaneously

Exclusion Criteria:

- Complex, degenerative tears

- Severe OA or K-L grade ≥3

- Previous meniscus surgery offering both biomechanical stability and reduced implant cost.

- Multi-ligament injuries

Surgical Technique:

Diagnostic arthroscopy confirmed reducible BHT. Tear was reduced using a probe and graspers. Using a single all-inside suture-passing device (e.g., Novostitch or similar), 7 sequential locking stitches were placed along the tear from posterior horn to anterior horn without removing the device. Stitch tensioning and final cut were done after all passes.

Rehabilitation Protocol:

- Hinged brace with ROM 0–90° for 4 weeks

- Partial weight-bearing at 4 weeks

ivity at 12–16 weeks

RESULTS

Charts and Graphs – Bucket Handle Meniscus Repair (150 Patients)

Figure 1: Lysholm Score Progression (150 Patients)

Figure 2: IKDC Score Comparison (150 Patients)

Figure 3: VAS Score Comparison (150 Patients)

Statistical analysis and visualisations- Bucket Handle Meniscus Repair(150 patients)

Summary statistics and T- tests

The following sections summarize descriptive statistics and paired t-test results comparing preoperative and 12-month postoperative scores for Lysholm, IKDC, and VAS.

Descriptive statistics

Correlation matrix

T – Test results

Visualisations

Figure 1:Lysholm Score Comparison (Pre op  vs 12M)

Figure 2 : IKDC Score Comparison (Pre op Vs 12M)

Figure 3 : VAS Score Comparison (Preop Vs 12M)

Figure 4 :MRI Healing Distribution at 6 months

Figure 5 : Scatter plot – Preop VAS vs 12M Lysholm  score

DISCUSSION

The results of this study demonstrate the efficacy and cost-effectiveness of a novel arthroscopic meniscal repair technique utilizing a single all-inside device for bucket-handle tears.

This approach provides significant financial savings compared to conventional methods requiring multiple implants, while achieving comparable clinical outcomes (Ramos et al., 2019). Furthermore, this method maintains the structural integrity of the meniscus, crucial for preventing long-term degenerative changes within the knee joint (Wang et al., 2025). This technique also safeguards the anterior cruciate ligament graft in cases of concomitant ACL reconstruction, by ensuring mechanical stability of the meniscus, thereby reducing overall stress on the knee joint and averting the need for extensive rehabilitation .The observed improvements in Lysholm and IKDC scores, coupled with low VAS pain scores and a high MRI healing rate, underscore the robust clinical efficacy of this single-device repair method, validating its potential for widespread adoption in resource-constrained surgical environments. The high rate of meniscal healing observed in postoperative MRI further supports the effectiveness of this technique in promoting tissue regeneration and functional recovery, consistent with findings from other studies on meniscal root repairs (Krych et al., 2021). This is particularly relevant given the challenges associated with meniscal repair, such as limited vascularity in certain zones and the biomechanical complexities of tear patterns (Patel, 2022). The innovative single-device approach not only addresses these challenges through a continuous stitching mechanism that enhances load distribution but also mitigates residual valgus laxity, which is crucial for overall knee stability and protection of concurrently reconstructed ligaments like the anterior cruciate ligament . This approach therefore minimizes the risk of ACL graft overload and potential failure, promoting faster and more complete rehabilitation  (Inoue et al., 1987).

Using a single all-inside device to repair bucket handle tears with 7 sequential stitches provides:

- Strong circumferential compression

- Minimized cost and hardware burden

- Reduced surgical time and suture adjustment

- Avoidance of posterior dissection or inside-out complications

MRI-confirmed healing in over 93% of patients shows this technique does not compromise outcomes despite economic savings. This efficacy is particularly significant given the challenges associated with meniscal repair, such as limited vascularity in certain zones and the biomechanical complexities of tear patterns. Furthermore, the continuous stitching mechanism employed in this technique enhances load distribution across the repair site, fostering a more robust healing environment compared to traditional methods that might involve discrete fixation points. This continuous repair, by providing more uniform compression across the tear, may also contribute to reducing meniscal extrusion, an important indicator of successful repair and reduced risk of degenerative arthritis (Yanagisawa et al., 2020). Future research should focus on long-term outcomes to validate the sustained clinical and radiographic superiority of this approach, especially in diverse patient populations and activity levels. Further studies could also explore the biomechanical properties of the repaired meniscus under various loading conditions to ascertain the long-term resilience and functional integrity of the repaired tissue.

This method is particularly beneficial in high-volume centers and public health systems.

CONCLUSION

Arthroscopic repair of bucket handle tears using 7 continuous sequential stitches with a single all-inside device is:

- Clinically effective

- Safe

- Highly cost-efficient

It is a valuable technique in resource-conscious settings without compromising patient outcome. This innovative approach represents a significant advancement in meniscal repair strategies, offering a sustainable and effective solution for a broad range of patients. It addresses the challenges of both surgical complexity and economic constraints, paving the way for improved accessibility to high-quality meniscal repair. Further research is warranted to assess its long-term durability and applicability across a wider spectrum of meniscal tear patterns, including complex ramp lesions or root avulsions that may necessitate alternative repair strategies (Siboni et al., 2022) (Koga et al., 2021). Further investigations into advanced biomaterials and bio-scaffolds may also enhance the regenerative potential of such repairs, potentially leading to even more favorable outcomes in complex meniscal injuries (Li et al., 2024). This ongoing research could further refine surgical techniques and material science for improved meniscal healing (Ansari et al., 2024), ultimately broadening the applicability and success rates of minimally invasive repairs like the single all-inside device method (Rilk et al., 2023). The implications of this technique extend beyond immediate repair, offering promise for mitigating the long-term risk of osteoarthritis by preserving meniscal function and integrity (Kopf et al., 2020) (Chung et al., 2016).

This method is particularly advantageous for younger patients and athletes, for whom maintaining robust meniscal integrity is critical for long-term joint health and continued participation in high-impact activities, thereby potentially delaying or obviating the need for more invasive interventions like total knee arthroplasty (Chauhan et al., 2009).

Furthermore, advancements in imaging modalities and biomechanical modeling could offer deeper insights into the healing cascade and stress distribution within the repaired meniscus, optimizing rehabilitation protocols and surgical refinements.

TABLES

Table 1: Functional Outcome Scores Over Time

Table 2: Implant Cost Comparison Between Techniques

Appendix

Full Patient Data Table (n = 150)

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