Updated: 12/30/2018

Meniscal Injury

Topic
Review Topic
0
0
Questions
24
0
0
Evidence
27
0
0
Videos
24
Cases
5
Techniques
5
https://upload.orthobullets.com/topic/3005/images/3_moved.jpg
https://upload.orthobullets.com/topic/3005/images/meniscus.jpg
https://upload.orthobullets.com/topic/3005/images/scope-mmtear-pcm.jpg
https://upload.orthobullets.com/topic/3005/images/photo-mmtransplant-pcm.jpg
Introduction
  • Epidemiology
    • most common indication for knee surgery
    • higher risk in ACL deficient knees
  • Location
    • medial tears
      • more common than lateral tears
        • the exception is in the setting of an acute ACL tear where lateral tears are more common
      • degenerative tears in older patients usually occur in the posterior horn medial meniscus
    • lateral tears
      • more common in acute ACL tears
Anatomy
  • Anatomy of meniscus
Classification
  • Descriptive classification
    • location
      • red zone (outer third, vascularized)
      • red-white zone (middle third)
      • white zone (inner third, avascular)
    • size
    • pattern
      • vertical/longitudinal
        • common, especially with ACL tears
        • repair when peripheral
      • bucket handle
        • vertical tear which may displace into the notch
      • oblique/flap/parrot beak
        • may cause mechanical locking symptoms
      • radial
      • horizontal
        • more common in older population
        • may be associated with meniscal cysts
      • complex
Presentation
  • Symptoms
    • pain localizing to medial or lateral side
    • mechanical symptoms (locking and clicking)
    • delayed or intermittent swelling
  • Exam
    • joint line tenderness is the most sensitive physical examination finding 
    • effusion
    • provocative tests
      • Apley compression
        • prone
      • Thessaly test
        • standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking.
      • McMurray's test
        • flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension.
        • a palpable pop / click + pain is a positive test and can correlate with a medial meniscus tear.
Imaging
  • Radiographs
    • Should be normal in young patients with an acute meniscal injury
    • Meniscal calcifications may be seen in crystalline arthropathy (ex. CPPD)
  • MRI
    • indications
      • MRI is most sensitive diagnostic test, but also has a high false positive rate 
    • findings
      • MRI grade III signal is indicative of a tear 
        • linear high signal that extends to either superior or inferior surface of the meniscus  
      • parameniscal cyst indicates the presence of a meniscal tear
      • bucket handle menscal tears indicated by
        •  "double PCL"  sign   
        • "double anterior horn" sign    
Treatment
  • Non-operative
    • rest, NSAIDS, rehabilitation
      • indications
        • indicated as first line of treatment for degenerative tears
  • Operative
    • partial meniscectomy
      • indications
        • tears not amenable to repair (complex, degenerative, radial tear patterns)
        • repair failure >2 times
      • outcomes
        • >80% satisfactory function at minimum follow-up
        • 50% have Fairbanks radiographic changes (osteophytes, flattening, joint space narrowing)
        • predictors of success
          • age <40yo
          • normal alignment
          • minimal or no arthritis
          • single tear
    • meniscal repair
      • indications
        • best candidate for repair is a tear with the following characteristics
          • peripheral in the red-red zone (vascularized region)
          • rim width is the distance from the tear to the peripheral meniscocapsular junction (blood supply).
          • rim width correlates with the ability of a meniscal repair to heal (lower rim width has better blood supply)
          • vertical and longitudinal tear
            • rather than radial, horizontal or degenerative tear
            • bucket handle meniscus tear 
          • 1-4 mm in length
          • acute repair combined with ACL reconstruction
            • traditional literature report higher healing rates with concurrent ACL reconstruction
            • current literature shows no difference in healing for 2nd generation all-inside repairs with/without concomittant ACL reconstruction
      • technique (see below)
      • outcomes
        • 70-95% successful
        • highest success when done with concomitant ACL reconstruction
        • poor results with untreated ACL-deficiency (30%)
    • meniscal transplantation
      • indications  
        • young patients with near-total meniscectomy, especially lateral
      • contraindications
        • inflammatory arthritis
        • instability
        • marked obesity
        • grade IV chondrosis (if not concurrently addressed)
        • malalignment (if not concurrently addressed)
        • diffuse arthritis
      • technique (see below)
      • outcomes
        • requires 8-12 months for graft to fully heal
        • return to sports by 6-9 months 
        • 10 year follow-up showed:
          • persistent improvement in subjective pain and function scores
          • most had radiographic progression of degenerative changes
        • re-tears or extrusion are common 
    • total meniscectomy
      • of historical interest only
      • outcomes
        • 20% have significant arthritic lesions and 70% have radiographic changes three years after surgery
        • 100% have arthrosis at 20 years
        • severity of degenerative changes is proportional to % of the meniscus that was removed
Techniques
  • Partial Meniscectomy
    • approach
      • standard arthroscopic approach
    • technique
      • minimize resection (DJD proportional to amount removed)
      • do not use thermal (heat probes)
    • postoperative
      • early active range of motion
      • prolonged immobilization (10 weeks) is detrimental to healing in a dog model
  • Meniscal repair
    • approach
      • inside-out technique
        • considered gold standard
        • medial approach to capsule
          • expose capsule by incising the sartorius fascia
          • retract pes tendons / semimembranosus posteriorly 
          • developing plane between the medial gastrocnemius and capsule
        • lateral approach to capsule
          • develop plane between IT band and biceps tendon
          • then retract lateral head of gastrocnemius posteriorly 
      • all-inside technique (suture devices with plastic or bioabsorbable anchors)
        • most common
        • many complications (device breakage, iatrogenic chondral injury)
      • outside-in repair
        • useful for anterior horn tears
      • open repair
        • uncommon except in trauma, knee dislocations
    • technique
      • vertical mattress sutures are strongest because they capture circumferential fibers 
      • healing is enhanced by rasping
    • risks
      • saphenous nerve and vein (medial approach)
      • peroneal nerve (lateral approach)
      • popliteal vessels
  • Meniscal Transplantation
    • technique
      • bone to bone healing with plugs at each horn or a bridge between horns
      • peripheral vertical mattress sutures
      • correct sizing of the allograft is essential  (commonly based on radiographs, within 5-10% error tolerated) 

 

Complications
  • Saphenous neuropathy (7%)
  • Arthrofibrosis (6%)
  • Sterile effusion (2%)
  • Peroneal neuropathy (1%)
  • Superficial infection (1%)
  • Deep infection (1%)
 

Please rate topic.

Average 3.9 of 75 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Technique Guides (5)
Questions (24)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ13.265) A 26-year-old elite female swimmer underwent a left medial meniscal allograft transplantation. She returns to clinic 3 years later with knee pain. What is the most likely cause for late presenting knee pain in this patient population? Review Topic

QID: 4900
1

Late immune rejection of the meniscal graft

4%

(202/5141)

2

Loss of graft fixation

14%

(703/5141)

3

Osteoarthritis

12%

(627/5141)

4

Graft tear due to acellularity

69%

(3544/5141)

5

Late-onset graft infection

1%

(34/5141)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ13.257) A 38-year-old man is being considered for medial meniscus transplantation following an arthroscopic subtotal meniscectomy performed at the time of ACL reconstruction. His body mass index (BMI) is 28kg/m2. Laboratory tests are shown in Figure A. Standing long-leg radiographs reveal a 4 degree valgus deformity compared with the contralateral side, with the weightbearing line running through the lateral tibial spine. His arthroscopic photos also revealed a 1.7cm wide Outerbridge II chondral lesion over the lateral femoral condyle and synovitis. What factor in this patient is an absolute contraindication to meniscal transplantation? Review Topic

QID: 4892
FIGURES:
1

Rheumatoid arthritis

77%

(3126/4081)

2

Previous anterior cruciate ligament reconstruction with allograft tissue

1%

(41/4081)

3

Malalignment

14%

(565/4081)

4

Chondral defect

7%

(281/4081)

5

Body mass index

1%

(32/4081)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(SAE07SM.22) Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear? Review Topic

QID: 8684
1

Failure

4%

(5/136)

2

Intra-articular synovitis

0%

(0/136)

3

Peroneal nerve injury

4%

(6/136)

4

Saphenous nerve injury

89%

(121/136)

5

Arthrofibrosis

2%

(3/136)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(SAE07SM.8) When performing an inside-out lateral meniscal repair, capsule exposure is provided by developing the Review Topic

QID: 8670
1

iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius anteriorly.

3%

(4/118)

2

iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius posteriorly.

88%

(104/118)

3

iliotibial band and biceps tendon interval, then retracting the lateral collateral ligament posteriorly.

3%

(4/118)

4

iliotibial band and biceps tendon interval, then splitting the lateral head of the gastrocnemius.

1%

(1/118)

5

lateral head of the gastrocnemius and biceps tendon interval, then retracting the biceps tendon anteriorly.

3%

(4/118)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ05.260) Tears in the peripheral one-third of the meniscus have higher healing rates following meniscal repair than those in a more central location. This clinical observation is explained by which of the following anatomic factors? Review Topic

QID: 1146
1

Increased blood supply

98%

(649/664)

2

Increased elesticity

0%

(1/664)

3

Increased type II collagen

0%

(2/664)

4

Increased type I collagen

0%

(3/664)

5

Increased glycosaminoglycan content

0%

(3/664)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(SBQ07SM.8) Splitting between the iliotibial band and biceps tendon, then retracting the gastrocnemius posteriorly provides exposure for which of the following procedures? Review Topic

QID: 1393
1

Two-incision ACL reconstruction

2%

(31/1487)

2

Tibial-inlay PCL reconstruction

13%

(190/1487)

3

Peroneal nerve exploration

9%

(129/1487)

4

Inside-out medial meniscus repair

1%

(22/1487)

5

Inside-out lateral meniscus repair

75%

(1111/1487)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ07.192) Which of the following is NOT a contra-indication to isolated medial meniscal transplantation? Review Topic

QID: 853
1

ACL deficiency

4%

(20/556)

2

Patient age over thirty

78%

(434/556)

3

Inflammatory arthritis

4%

(23/556)

4

Varus alignment

8%

(42/556)

5

Grade IV chondromalacia

6%

(35/556)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ10.90) An 18-year-old football player sustained a twisting injury to his knee approximately 1 month ago. He complains of continued knee pain with occasional locking and catching. Figure A demonstrates the injury on a T1 sagittal MRI. What physical exam finding is classically seen with this injury? Review Topic

QID: 3178
FIGURES:
1

No endpoint with valgus stressing of the knee

3%

(59/2140)

2

Positive apprehension sign with passive lateral patellar translation

12%

(256/2140)

3

Painful click is elicited as the knee is brought from flexion to extension with internal or external rotation

82%

(1762/2140)

4

No endpoint with varus stressing of the knee

1%

(28/2140)

5

A positive posterior drawer and quadriceps active test

1%

(21/2140)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(SBQ07SM.44) All of the following variables have a negative impact on the outcomes of isolated meniscal allograft transplantation EXCEPT? Review Topic

QID: 1429
1

Axial malalignment

2%

(8/507)

2

Anterior cruciate ligament insufficiency

4%

(19/507)

3

The use of a fresh frozen graft

82%

(414/507)

4

Femoral condyle flattening

6%

(28/507)

5

Graft size mismatch of 15%

7%

(35/507)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(SBQ07SM.7) An 18-year-old competitive tennis player sustains a twisting injury to his knee. He develops pain and swelling and is unable to straighten his knee. The MRI is shown in the Figure A. What is the most approriate treatment? Review Topic

QID: 1392
FIGURES:
1

Arthroscopic medial meniscectomy or repair

6%

(60/1077)

2

Arthroscopic lateral meniscectomy or repair

91%

(982/1077)

3

Meniscus transplantation

1%

(12/1077)

4

Physical therapy with gradual stretching exercises

2%

(21/1077)

5

Corticosteroid injection for acute inflammation

0%

(1/1077)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ06.88) A 16-year-old female field hockey player sustains a twisting injury to her knee. On exam, she cannot extend the knee past 30 degrees. Arthroscopy confirms a displaced bucket-handle tear of the lateral meniscus with a 3-mm peripheral rim. What is the most appropriate treatment? Review Topic

QID: 199
1

Partial meniscectomy

5%

(65/1281)

2

Sub-total meniscectomy

1%

(9/1281)

3

Meniscal repair using all-inside bioabsorbable arrows/darts

6%

(73/1281)

4

Meniscal repair using inside-out horizontal mattress sutures

13%

(170/1281)

5

Meniscal repair using inside-out vertical mattress sutures

75%

(958/1281)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(SBQ04SM.31) A young athlete sustains an isolated meniscal tear and undergoes arthroscopy. The surgeon performs a meniscal repair. Which of the following factors is most important in determining healing rates? Review Topic

QID: 2116
1

Days from injury to repair

6%

(60/1054)

2

Medial versus lateral meniscus

3%

(27/1054)

3

Width of the meniscal rim

91%

(957/1054)

4

Use of growth hormone

0%

(1/1054)

5

Dominant versus non-dominant leg

0%

(4/1054)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(SBQ07SM.22) Following meniscal repair, saphenous nerve injury is more common with which of the following techniques? Review Topic

QID: 1407
1

Inside-out lateral repair

3%

(37/1190)

2

All-inside lateral repair

1%

(8/1190)

3

Inside-out medial repair

91%

(1084/1190)

4

All-inside medial repair

4%

(53/1190)

5

Equal rates for both lateral and medial

0%

(5/1190)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ11.93) The meniscal injury pattern of the left knee seen in the arthroscopic video shown in Figure A is best described as which of the following? Review Topic

QID: 3516
FIGURES:
1

Medial horizontal cleavage tear

5%

(144/3185)

2

Lateral radial tear

4%

(142/3185)

3

Medial parrot beak-type tear

86%

(2743/3185)

4

Medial displaced bucket-handle tear

4%

(125/3185)

5

Lateral cyclops tear

0%

(10/3185)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ04.270) A 19-year-old male is playing football and hears a pop in his left knee during a tackle 12 days ago. He was unable to return to the game and reports a large amount of swelling in the knee. On examination today he lacks full extension. A coronal and sagittal MRI is shown in Figures A and B, respectively. Which of the following is the best next step in management. Review Topic

QID: 1375
FIGURES:
1

Rest and icing followed by physical therapy for definitive management

7%

(39/555)

2

Arthroscopic removal of osteochondral loose body

5%

(28/555)

3

Arthroscopic meniscus repair followed by immediate joint mobilization

72%

(399/555)

4

Physical therapy for immediate joint mobilization followed by delayed arthroscopic PCL reconstruction once ROM is near normal

7%

(37/555)

5

Immediate ACL reconstruction

9%

(50/555)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ06.9) A "double PCL sign" seen on a sagittal MRI image of a knee is indicative of which of the following conditions? Review Topic

QID: 20
1

Skeletal immaturity

1%

(8/1133)

2

ACL tear

2%

(27/1133)

3

PCL injury

2%

(20/1133)

4

Combined ACL and PCL tear

3%

(31/1133)

5

Bucket-handle meniscal tear

92%

(1042/1133)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
ARTICLES (58)
VIDEOS (24)
CASES (5)
Topic COMMENTS (50)
Private Note