Introduction Overview meniscal tears are common in young patients with sports-related injuries and older patients as a degenerative condition Epidemiology most common indication for knee surgery higher risk in ACL deficient knees Pathophysiology 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) position (anterior, middle, posterior third, root) 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 root functionally equivalent to a total meniscectomy lateral root tears associated with ACL tears medial root tears associated with chondral injuries Presentation Symptoms pain localizing to medial or lateral side mechanical symptoms (locking and clicking), especially with squatting delayed or intermittent swelling Physical exam joint line tenderness is the most sensitive physical examination finding effusion provocative tests Apley compression prone-flexion compression 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 meniscal tears indicated by "double PCL" sign "double anterior horn" sign Tested Differential MCL sprain pain with valgus stress at 30° knee flexion, which isolates the superficial MCL gapping of medial joint line Plica syndrome pain is typically in the medial parapatellar region may have palpable medial parapatellar cord Osteochondral lesions may present very similarly differentiated with imaging (MRI) Treatment Nonoperative rest, NSAIDS, rehabilitation indications indicated as first line treatment for degenerative tears outcomes improvement in knee function following physical therapy "noninferior" when compared to arthroscopic partial meniscectomy 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 cm in length root tear 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 concomitant ACL reconstruction outcomes 70-95% successful highest success when done with concomitant ACL reconstruction (90%) modest result when done with an intact ACL (60%) poor results with untreated ACL-deficiency (30%) meniscal transplantation indications controversial young patients with near-total meniscectomy, especially lateral contraindications inflammatory arthritis instability marked obesity grade III and IV chondral changes malalignment (if not concurrently addressed) diffuse arthritis 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 Rest, NSAIDS, rehabilitation technique PWB, ROM as tolerated 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 allows tensioning of the construct 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 knee flexion beyond 90 degrees should be avoided postoperatively 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) oversizing leads to meniscal extrusion undersizing results in poor congruity and increased load transmission Complications Saphenous neuropathy (7%) Arthrofibrosis (6%) Sterile effusion (2%) Peroneal neuropathy (1%) Superficial infection (1%) Deep infection (1%)
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Lateral Meniscus Transplant Neil Duplantier Patrick McCulloch Knee & Sports - Meniscal Injury Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Medial Meniscus Transplant Neil Duplantier Knee & Sports - Meniscal Injury Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Meniscal Repair - Inside Out Neil Duplantier Knee & Sports - Meniscal Injury Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Meniscectomy Neil Duplantier Knee & Sports - Meniscal Injury Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Meniscus Repair All Inside Orthobullets Team Knee & Sports - Meniscal Injury
QUESTIONS 1 of 27 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ17.195) A 22-year-old professional volleyball player presents with acute knee pain following an awkward landing. She feels that her knee is locked and ROM is limited to 20-90 degrees. Figure A shows an arthroscopic image from her surgery. Which of the following MRI's most closely correlates with the intraoperative findings? Tested Concept QID: 210282 FIGURES: A B C D E F Type & Select Correct Answer 1 B 2% (53/2238) 2 C 2% (43/2238) 3 D 5% (116/2238) 4 E 13% (299/2238) 5 F 74% (1662/2238) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK 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? Tested Concept QID: 4900 Type & Select Correct Answer 1 Late immune rejection of the meniscal graft 4% (230/6182) 2 Loss of graft fixation 13% (828/6182) 3 Osteoarthritis 13% (813/6182) 4 Graft tear due to acellularity 68% (4234/6182) 5 Late-onset graft infection 1% (39/6182) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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? Tested Concept QID: 4892 FIGURES: A Type & Select Correct Answer 1 Rheumatoid arthritis 77% (3925/5107) 2 Previous anterior cruciate ligament reconstruction with allograft tissue 1% (54/5107) 3 Malalignment 13% (686/5107) 4 Chondral defect 7% (355/5107) 5 Body mass index 1% (39/5107) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 3516 FIGURES: V Type & Select Correct Answer 1 Medial horizontal cleavage tear 5% (179/3863) 2 Lateral radial tear 5% (181/3863) 3 Medial parrot beak-type tear 86% (3310/3863) 4 Medial displaced bucket-handle tear 4% (152/3863) 5 Lateral cyclops tear 0% (13/3863) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 3178 FIGURES: A Type & Select Correct Answer 1 No endpoint with valgus stressing of the knee 2% (63/2661) 2 Positive apprehension sign with passive lateral patellar translation 10% (259/2661) 3 Painful click is elicited as the knee is brought from flexion to extension with internal or external rotation 85% (2261/2661) 4 No endpoint with varus stressing of the knee 1% (29/2661) 5 A positive posterior drawer and quadriceps active test 1% (29/2661) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (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? Tested Concept QID: 8684 Type & Select Correct Answer 1 Failure 4% (15/425) 2 Intra-articular synovitis 1% (6/425) 3 Peroneal nerve injury 4% (19/425) 4 Saphenous nerve injury 86% (365/425) 5 Arthrofibrosis 4% (15/425) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07SM.8) When performing an inside-out lateral meniscal repair, capsule exposure is provided by developing the Tested Concept QID: 8670 Type & Select Correct Answer 1 iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius anteriorly. 4% (23/600) 2 iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius posteriorly. 84% (501/600) 3 iliotibial band and biceps tendon interval, then retracting the lateral collateral ligament posteriorly. 7% (41/600) 4 iliotibial band and biceps tendon interval, then splitting the lateral head of the gastrocnemius. 2% (10/600) 5 lateral head of the gastrocnemius and biceps tendon interval, then retracting the biceps tendon anteriorly. 3% (20/600) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (SBQ07SM.8) Splitting between the iliotibial band and biceps tendon, then retracting the gastrocnemius posteriorly provides exposure for which of the following procedures? Tested Concept QID: 1393 Type & Select Correct Answer 1 Two-incision ACL reconstruction 2% (36/1997) 2 Tibial-inlay PCL reconstruction 12% (247/1997) 3 Peroneal nerve exploration 9% (180/1997) 4 Inside-out medial meniscus repair 2% (33/1997) 5 Inside-out lateral meniscus repair 74% (1484/1997) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ07.192) Which of the following is NOT a contra-indication to isolated medial meniscal transplantation? Tested Concept QID: 853 Type & Select Correct Answer 1 ACL deficiency 4% (30/834) 2 Patient age over thirty 78% (654/834) 3 Inflammatory arthritis 3% (29/834) 4 Varus alignment 9% (73/834) 5 Grade IV chondromalacia 5% (43/834) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (SBQ07SM.44) All of the following variables have a negative impact on the outcomes of isolated meniscal allograft transplantation EXCEPT? Tested Concept QID: 1429 Type & Select Correct Answer 1 Axial malalignment 1% (11/750) 2 Anterior cruciate ligament insufficiency 3% (21/750) 3 The use of a fresh frozen graft 84% (629/750) 4 Femoral condyle flattening 5% (35/750) 5 Graft size mismatch of 15% 6% (45/750) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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? Tested Concept QID: 1392 FIGURES: A Type & Select Correct Answer 1 Arthroscopic medial meniscectomy or repair 6% (86/1482) 2 Arthroscopic lateral meniscectomy or repair 90% (1337/1482) 3 Meniscus transplantation 1% (20/1482) 4 Physical therapy with gradual stretching exercises 2% (28/1482) 5 Corticosteroid injection for acute inflammation 0% (1/1482) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (SBQ07SM.22) Following meniscal repair, saphenous nerve injury is more common with which of the following techniques? Tested Concept QID: 1407 Type & Select Correct Answer 1 Inside-out lateral repair 3% (56/1622) 2 All-inside lateral repair 1% (13/1622) 3 Inside-out medial repair 90% (1462/1622) 4 All-inside medial repair 5% (76/1622) 5 Equal rates for both lateral and medial 1% (10/1622) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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? Tested Concept QID: 199 Type & Select Correct Answer 1 Partial meniscectomy 5% (88/1819) 2 Sub-total meniscectomy 1% (12/1819) 3 Meniscal repair using all-inside bioabsorbable arrows/darts 7% (122/1819) 4 Meniscal repair using inside-out horizontal mattress sutures 15% (269/1819) 5 Meniscal repair using inside-out vertical mattress sutures 72% (1317/1819) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ06.9) A "double PCL sign" seen on a sagittal MRI image of a knee is indicative of which of the following conditions? Tested Concept QID: 20 Type & Select Correct Answer 1 Skeletal immaturity 1% (9/1602) 2 ACL tear 2% (36/1602) 3 PCL injury 2% (29/1602) 4 Combined ACL and PCL tear 2% (35/1602) 5 Bucket-handle meniscal tear 93% (1488/1602) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (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? Tested Concept QID: 1146 Type & Select Correct Answer 1 Increased blood supply 98% (919/937) 2 Increased elesticity 0% (2/937) 3 Increased type II collagen 0% (2/937) 4 Increased type I collagen 0% (3/937) 5 Increased glycosaminoglycan content 0% (3/937) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (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? Tested Concept QID: 2116 Type & Select Correct Answer 1 Days from injury to repair 6% (77/1328) 2 Medial versus lateral meniscus 3% (36/1328) 3 Width of the meniscal rim 90% (1196/1328) 4 Use of growth hormone 0% (2/1328) 5 Dominant versus non-dominant leg 0% (6/1328) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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. Tested Concept QID: 1375 FIGURES: A B Type & Select Correct Answer 1 Rest and icing followed by physical therapy for definitive management 6% (58/939) 2 Arthroscopic removal of osteochondral loose body 5% (43/939) 3 Arthroscopic meniscus repair followed by immediate joint mobilization 70% (660/939) 4 Physical therapy for immediate joint mobilization followed by delayed arthroscopic PCL reconstruction once ROM is near normal 7% (70/939) 5 Immediate ACL reconstruction 11% (104/939) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept
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