Two-Stage Procedure Gives Patients a Functional Knee

Following simultaneous anterior cruciate ligament (ACL) reconstruction and repair or removal of a locked bucket-handle meniscus tear, patients were having difficulty regaining full range of motion (ROM). “After surgery, the patient had a stable knee, but it was stiff and not functional,” says K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center.

To solve this problem, Dr. Shelbourne developed a two-stage meniscus repair and ACL reconstruction procedure in which the meniscus is repaired immediately and the ACL is reconstructed after the patient regains ROM. Patients complete physical therapy focused on regaining full ROM equal to the non-involved knee after meniscus repair for 2–3 months before undergoing ACL reconstruction. Post-ACL reconstruction, they participate in Shelbourne Knee Center’s accelerated ACL post-op rehab program.

This innovative approach gives patients a functional knee and has enabled Dr. Shelbourne to evaluate meniscus healing and determine the optimal treatment for meniscus tears.

Research Supports the Two-Staged Procedure

The first study Dr. Shelbourne did compared 16 athletes treated with the two-staged procedure (Group 1) and 16 matched athletes treated with simultaneous repair or removal of a locked bucket-handle meniscus tear and ACL reconstruction. (Group 2). No patients in Group 1, and four patients in Group 2, required a second procedure or a cast to regain full ROM equal to the non-involved knee.1

Another study evaluated 52 patients with 55 meniscus repairs who underwent meniscus repair by trephination, followed by ACL reconstruction after the patient had obtained full range of motion. In trephination, the needle going through the meniscus into the capsule creates blood channels for healing. Trephination avoids the risks of meniscus repair with sutures.

At the time of ACL reconstruction:

  • 30 menisci (55%) appeared healed
  • 19 menisci (34%) were partially healed
  • 6 menisci (11%) showed no healing (4 of which were removed).2

At an average follow-up of 4.3 +/- 3.1 years, 36 of the 43 (83.7%) meniscus tears with no bleeding in the peripheral rim or the inner edge of the tear (the white-on-white zone) remained asymptomatic. All other repaired meniscus tears remained asymptomatic.

The researchers concluded that locked bucket-handle meniscus tears heal at a high rate when repaired as an isolated procedure, even when full weightbearing and activity before reconstruction is allowed and when the tear is in a white-on-white zone.

Therapy Improves Outcomes

Pre-op rehab for ACL reconstruction, focused on improving range of motion before strengthening, has been standard care at Shelbourne Knee Center since the center’s research showed the importance of returning the knee to a normal state (except for the ACL tear) prior to surgery. Doing so reduces recovery time and allows patients to more easily achieve their goals.3 After surgery, patients participate in the accelerated ACL post-op rehab program, which also focuses on improving range of motion before strengthening.

“The two-staged procedure with pre- and post-op rehab gives patients with an ACL tear and a locked bucket-handle meniscus tear the best chance of a normal knee in the long term,” says Dr. Shelbourne.

Treatment of Other Types of Meniscus Tears

Most meniscus tears that occur with ACL tears are asymptomatic4 and don’t require repair. This includes bucket-handle tears that are not locked. “Even most symptomatic meniscus tears will get better on their own with proper physical therapy,” says Dr. Shelbourne.

Unnecessary meniscus repair is common, and can jeopardize ACL rehab by restricting weight-bearing and ROM. It also can lead to possible complications:

  • Damage to articular surfaces
  • Repair device left in meniscus causing symptoms.

“The decision of whether to treat a meniscus tear depends on many factors, including the type of meniscus tear, how symptomatic it is, and its capacity for healing,” says Dr. Shelbourne. Most lateral meniscus tears, for example, can be left in situ, says Dr. Shelbourne, based on data from patients at Shelbourne Knee Center.5,6

For more information about 2-staged meniscus repair with ACL reconstruction at Shelbourne Knee Center, call 888-FIX-KNEE or email


  1. Shelbourne KD, Johnson GE. Locked bucket-handle meniscal tears in knew with chronic anterior cruciate ligament deficiency. Am J Sports Medicine. 1993; 21(6); 779-782.
  2. John J O'Shea JJ, Shelbourne KD. Repair of locked bucket-handle meniscal tears in knees with chronic anterior cruciate ligament deficiency. Am J Sports Med. Mar-Apr 2003;31(2):216-20.  doi: 10.1177/03635465030310021001.
  3. Biggs A, et al. Rehabilitation for patients following ACL reconstruction: A knee symmetry model. North Am J Sports Phys Ther. 2009;4:2-12.
  4. Shelbourne KD, Benner RW. Correlation of joint line tenderness and meniscus pathology in patients with subacute and chronic anterior cruciate ligament injuries. J Knee Surg. 2009 Jul;22(3):187-90.
  5. Fitzgibbons RE, Shelbourne KD. “Aggressive” nontreatment of lateral meniscal tears seen during anterior cruciate ligament reconstruction. Am J Sports Med. 1995 Mar-Apr;23(2):156-9.
  6. Shelbourne KD, Heinrich J. The long-term evaluation of lateral meniscus tears left in situ at the time of anterior cruciate ligament reconstruction. Arthroscopy.2004 Apr;20(4):346-51.