Ten Pearls for Bucket Handle Medial Meniscus Repair

Bucket-handle medial meniscus tears are complex injuries that represent approximately 10% of all meniscal lesions. Because of their vascular location, mainly being in the red-red zone, these injuries often have a favorable prognosis when properly treated. Surgical repair is the gold standard to preserve meniscal function and prevent osteoarthritis. This Technical Note outlines a 10-step technique for the effective evaluation and repair of medial bucket-handle medial meniscus tears using both inside-out and all-inside suturing techniques. Key surgical pearls include proper patient positioning, portal placement, and medial collateral ligament pie-crusting and knee-stressing technique to optimize access to the medial compartment. Meniscal wall reduction and preparation are followed by anatomic fixation using a mixed suture approach: inside-out for the meniscal body, all-inside sutures for the posterior horn and outside-in repair if the anterior horn is involved. Vertical suture configurations are preferred for their superior biomechanical strength, with undersurface stitches added to obtain anatomic reduction. This technique is safe, reproducible, and minimizes neurovascular risk while ensuring a stable, anatomic repair.