Meniscus Tear, ABOS Oral Boards Preparation

This is a 30-year-old male firefighter who injured his right knee three weeks ago. He was carrying equipment on a wet floor, his foot planted, and his body twisted over it. He felt something catch in his knee. Since then, he has had intermittent true locking, his knee gets stuck in flexion and he has to manually wiggle it to regain full extension. That has happened twice in the past week. No prior knee injuries.

On exam, he had a small effusion. He was tender along the medial joint line. McMurray test produced a palpable click and pain with the knee in external rotation and valgus stress, classic for a medial meniscus tear. Thessaly test was positive. Importantly, Lachman and anterior drawer were negative, his ACL was intact. When unlocked, he had full range of motion.

MRI showed a bucket-handle tear of the medial meniscus with the displaced fragment flipped into the intercondylar notch, that is the cause of his true locking. The tear extended from the posterior horn through the body of the meniscus, involving the red-red and red-white vascular zones. ACL and PCL intact. No articular cartilage damage. Lateral meniscus normal.

A bucket-handle tear with true mechanical locking in a 30-year-old firefighter is a clear indication for urgent surgical intervention. The displaced fragment is blocking extension and, if left unreduced, will cause cartilage damage. The key decision is repair versus excision. Given his age, the tear pattern involving vascular tissue, an intact ACL, which improves healing rates, and his high functional demands, repair is the right choice. Meniscectomy in a 30-year-old leads to accelerated arthritis. We discussed this and he agreed.

I performed an arthroscopic meniscal repair. I reduced the displaced bucket-handle fragment and repaired it with vertical mattress sutures using an inside-out technique. The repair was stable to probing.

Post-operatively, he was placed in a hinged knee brace locked in extension for weight-bearing to protect the repair. I allowed immediate range of motion from 0 to 90 degrees during non-weight-bearing exercises to prevent stiffness. At six weeks, the repair had healed sufficiently to allow full weight-bearing without the brace. At three months, he had regained near-full strength and range of motion. At four months, he returned to full firefighting duty. At one year, he had no mechanical symptoms, no effusions, and was functioning without limitations.

He was happy to be back on duty with no restrictions. If I saw this case again, I might consider an all-inside repair technique for the posterior horn component of the tear. The inside-out technique gave me excellent suture placement, but it required a separate posteromedial safety incision to protect the saphenous nerve and vein. An all-inside technique for the posterior portion could have reduced that exposure without compromising the repair quality. I monitored for signs of repair failure, recurrent locking or effusion, and he remained symptom-free throughout.