Case study provided by Dr David Sweetnam, FRCS (Ortho) Dip Sports Med, London, UK. The patient's name has been changed to maintain confidentiality.  Some sporting knee injuries need urgent medical attention, as the case below illustrates. Presentation James is a 26-year-old semi-professional basketball player who unfortunately experienced a sudden sharp pain within his left knee when he landed awkwardly after taking a shot at the basket during a training session. Immediately upon landing, James was aware of a very sharp pain within the outer aspect of his left knee, which he was then not able to straighten. He limped off the court and was seen by the coach. Ice packs were applied, but James still had difficulty walking once the training session had finished, and was still unable to straighten his knee. The coach was suspicious of a serious injury to the knee and recommended that the James should see the club’s orthopedic consultant. Diagnosis The orthopedic consultant suspected that James’ knee was “locked” as a result of a cartilage tear that was mechanically blocking the full extension of his knee joint. A magnetic resonance imaging (MRI) scan was therefore arranged to confirm this diagnosis. The MRI scan confirmed the surgeon’s suspicions, and showed a “bucket handle” tear of the outer (lateral) meniscus. This type of injury occurs when the meniscus flips over similar to a bucket handle being moved from side to side. Unfortunately bucket handle meniscal tears are considered to be a surgical emergency, as the knee cannot be straightened while this mechanical block is in place. The surgeon therefore decided to admit James to the local hospital a day later as an emergency case to have arthroscopic surgery on his locked knee. 
Arthroscopic view showing a bucket handle tear of the lateral meniscus.
Surgical intervention At the hospital the next day, James was taken to the operating theatre and given a general anesthetic. Once the anesthetic had taken effect, a 4 mm incision was made in the front of James’ knee, and an arthroscope introduced through the opening (portal). The diagnosis of a tear of the outer cartilage was confirmed quite quickly, and as the surgeon had suspected, the cartilage had been torn right along its length and had flipped inside the joint in the fashion of a bucket handle being turned over. Fortunately the tear was quite near the edge of where the cartilage attaches to the capsule of the knee joint where the blood supply is good, making it possible for the surgeon to repair the cartilage rather than remove it. In order to repair the tear, the cartilage was returned to its normal position and the tear was held back in place with a series of stitches (sutures), which were applied by a separate portal in the front of the knee. Good repair of the meniscus was achieved by this technique and the previously unstable fragment of cartilage was once again felt to be stable. Examination of the rest of the knee at the time of arthroscopy revealed that all of the ligaments were intact and that the inside (medial) meniscus was undamaged. Outcome In order to protect the repair immediately after this operation, James was given crutches and advised not to bear weight on his knee for six weeks. He was also restricted in his ability to use the knee using a brace, which prevented full extension and significant flexion. Two weeks after the operation, James was progressing well and his wounds were well healed. To allow the repair to have the best chance or healing, however, James’ physiotherapist encouraged him to keep the weight off his leg for a further four weeks. After this period he was once again allowed to put weight on this leg and continue physiotherapy to regain a full range of motion. James returned to sport approximately three months after this operation and was able to play basketball for his club approximately four months later. |
