Correlation Between Synovial Coverage of the Reconstructed Anterior Cruciate Ligament and Healing of Bucket-Handle Medial Meniscal Tears After Combined ACL Reconstruction and Meniscal Repair.

BACKGROUND: Meniscal healing after repair of bucket-handle medial meniscal tear (BHMMT) concomitant with anterior cruciate ligament (ACL) reconstruction (ACLR) remains variable despite advances in surgical technique. The biological environment within the knee joint, particularly the degree of synovialization of the reconstructed ACL graft, may influence meniscal healing outcomes, but this relationship has not been systematically investigated. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the arthroscopic relationship between synovial coverage of the reconstructed ACL and the healing of repaired BHMMTs following combined ACLR and meniscal repair. It was hypothesized that greater synovialization of the reconstructed ACL would be associated with higher rates of meniscal healing. STUDY DESIGN: Cross-sectional study. METHODS: A retrospective analysis was performed on patients who underwent ACLR combined with BHMMT repair between January 2020 and January 2025 and subsequently underwent tibial hardware removal with second-look arthroscopy (SLA). A total of 59 patients met the inclusion criteria. Functional outcomes were assessed preoperatively and before SLA using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, International Knee Documentation Committee (IKDC) score, and Tegner activity scale. Arthroscopic videos obtained during SLA were reviewed to evaluate graft synovialization, categorized as good (>80%), fair (50%-80%), or poor (<50%) and to assess the healing status of the repaired meniscus. Meniscal healing was defined as the absence of retear or the need for additional repair or meniscectomy. RESULTS: All functional outcome scores (KOOS, Lysholm, IKDC, and Tegner) improved significantly postoperatively compared with preoperative values (P < .05). A significant positive correlation was observed between the degree of synovial coverage of the reconstructed ACL and meniscal healing (r = 0.724; P < .001). Overall, meniscal healing was observed in 36 of 59 patients (61%). According to synovial coverage grade, healing rates were 100.0% in the good group, 44.4% in the fair group, and 0.0% in the poor group. A small 1- to 2-mm free-edge lesion, described in this study as a minor superficial fissure, was observed arthroscopically in 44 of 59 patients (75%). CONCLUSION: In patients undergoing ACLR combined with BHMMT repair, the degree of synovial coverage of the reconstructed ACL was significantly and positively associated with meniscal healing. Greater synovialization of the ACL graft was associated with a higher likelihood of meniscal healing. The extent of synovial coverage may serve as a useful arthroscopic indicator of intra-articular biological healing potential and may help inform postoperative evaluation and clinical decision-making.