Semimembranosus tendon–sparing arthroscopic inside-out repair of medial meniscus bucket-handle tears with routine posteromedial inspection: a retrospective controlled study

To investigate whether posteromedial safety-incision inspection and release of intraoperatively confirmed semimembranosus tendon-related sutures is associated with improved postoperative pain, functional recovery, and reduced posteromedial knee pain after arthroscopic inside-out repair of medial meniscal bucket-handle tears. We retrospectively reviewed 65 patients with medial meniscal bucket-handle tears treated at Fujian Medical University Union Hospital and the First Affiliated Hospital of Chongqing Medical University between January 2023 and November 2024. Patients were divided into a release group and a control group according to whether posteromedial safety-incision inspection and release of semimembranosus tendon-related sutures was performed (release group, n = 29; control group, n = 36). In the release group, semimembranosus tendon-related suture entrapment or tethering was confirmed intraoperatively through the posteromedial safety incision and then released. In the control group, no posteromedial exploration was performed; therefore, the presence or absence of semimembranosus tendon-related suture involvement was unknown. All patients underwent arthroscopic inside-out repair and were followed for 12 months. Lysholm, visual analog scale (VAS), and Tegner scores were compared preoperatively and at 3, 6, and 12 months postoperatively. The incidence of posteromedial knee pain was also recorded. There were no significant between-group differences in preoperative Lysholm, VAS, or Tegner scores ( P > 0.05). In the release group, semimembranosus tendon-related suture entrapment or tethering was identified in all included patients during safety-incision inspection, and 1 to 3 sutures per patient required release. During follow-up, the release group demonstrated significantly better Lysholm and VAS scores than the control group at 3, 6, and 12 months postoperatively ( P < 0.05). Tegner scores did not differ significantly between groups at any time point ( P > 0.05). At 12 months, no patients in the release group reported posteromedial knee pain, whereas 8 patients in the control group experienced posteromedial pain. In both groups, all postoperative scores improved significantly compared with preoperative values ( P < 0.05). Posteromedial safety-incision inspection and release of intraoperatively confirmed semimembranosus tendon-related sutures during arthroscopic inside-out repair of medial meniscal bucket-handle tears was associated with better pain relief, improved early knee function, and a lower incidence of posteromedial knee pain. Intraoperative safety-incision inspection can directly identify semimembranosus tendon-related suture entrapment or tethering in selected cases. However, because the control group was not explored and postoperative MRI or second-look arthroscopy was not routinely performed, the role of semimembranosus tendon-related suture involvement in control-group symptoms should still be interpreted cautiously.