Preoperative MRI predictors of repairability in bucket handle meniscal tears: a tertiary centre evaluation of 101 cases.

OBJECTIVES: To identify MRI findings that independently predict surgical repairability in bucket-handle meniscal tears and quantify their association with specific surgical decisions. METHODS: This IRB-approved retrospective study included 101 consecutive patients with arthroscopically confirmed bucket-handle meniscal tears treated between January 2021 and December 2023. Two fellowship-trained musculoskeletal radiologists, blinded to outcomes, independently evaluated MRI for central flipped fragment signal (binary, 4-grade degeneration), peripheral signal, tear width, posterior root extension, and contralateral meniscal involvement. Repairability was defined by the surgical procedure performed (repair versus partial meniscectomy or debridement) and therefore reflects the intra-operative surgical decision. Statistical analysis included univariate and multivariable logistic regression; interobserver agreement was assessed with Cohen's kappa and intraclass correlation coefficient. RESULTS: Repair was performed in 67/101 (66.3%), partial meniscectomy in 23/101 (22.8%), and debridement in 11/101 (10.9%). In multivariable analysis, altered signal of the central component (OR = 4.96, 95% CI 1.74-14.18; p = 0.003) and extension to the posterior root (OR = 6.79, 95% CI 2.10-21.98; p = 0.001) were independent predictors of non-repairability. Each 1-grade increase in central degeneration raised meniscectomy odds (OR = 4.35, 95% CI 1.50-12.60; p = 0.001) and debridement odds (OR = 16.7, 95% CI 3.90-71.30; p < 0.001). Interobserver agreement was good (κ = 0.73; ICC = 0.72). CONCLUSIONS: Altered signal of the central component and posterior root extension were independently associated with the surgeon's decision not to repair in bucket-handle meniscal tears. Higher central component degeneration grades correlate with increasing surgical invasiveness (debridement). CLINICAL RELEVANCE: Radiologists can now use a simple, reproducible 4-grade MRI scoring system to predict meniscal repairability preoperatively, enabling better surgical planning and meniscal preservation strategies.