Updated: 4/7/2020

Meniscal Injury

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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
  • 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%)
 

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Technique Guides (5)
Questions (27)
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(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:
1

B

2%

(53/2244)

2

C

2%

(43/2244)

3

D

5%

(116/2244)

4

E

13%

(302/2244)

5

F

74%

(1665/2244)

L 2 A

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(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
1

Late immune rejection of the meniscal graft

4%

(230/6184)

2

Loss of graft fixation

13%

(829/6184)

3

Osteoarthritis

13%

(813/6184)

4

Graft tear due to acellularity

68%

(4235/6184)

5

Late-onset graft infection

1%

(39/6184)

L 3 B

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(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:
1

Rheumatoid arthritis

77%

(3929/5111)

2

Previous anterior cruciate ligament reconstruction with allograft tissue

1%

(54/5111)

3

Malalignment

13%

(686/5111)

4

Chondral defect

7%

(355/5111)

5

Body mass index

1%

(39/5111)

L 3 B

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(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:
1

Medial horizontal cleavage tear

5%

(179/3880)

2

Lateral radial tear

5%

(182/3880)

3

Medial parrot beak-type tear

86%

(3326/3880)

4

Medial displaced bucket-handle tear

4%

(152/3880)

5

Lateral cyclops tear

0%

(13/3880)

L 2 C

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(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:
1

No endpoint with valgus stressing of the knee

2%

(63/2672)

2

Positive apprehension sign with passive lateral patellar translation

10%

(260/2672)

3

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

85%

(2272/2672)

4

No endpoint with varus stressing of the knee

1%

(29/2672)

5

A positive posterior drawer and quadriceps active test

1%

(29/2672)

L 2 C

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(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
1

Failure

4%

(15/426)

2

Intra-articular synovitis

1%

(6/426)

3

Peroneal nerve injury

4%

(19/426)

4

Saphenous nerve injury

86%

(366/426)

5

Arthrofibrosis

4%

(15/426)

L 1 E

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

QID: 8670
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 E

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(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
1

Two-incision ACL reconstruction

2%

(37/2003)

2

Tibial-inlay PCL reconstruction

12%

(249/2003)

3

Peroneal nerve exploration

9%

(181/2003)

4

Inside-out medial meniscus repair

2%

(33/2003)

5

Inside-out lateral meniscus repair

74%

(1487/2003)

L 3 B

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

QID: 853
1

ACL deficiency

4%

(30/840)

2

Patient age over thirty

79%

(660/840)

3

Inflammatory arthritis

3%

(29/840)

4

Varus alignment

9%

(73/840)

5

Grade IV chondromalacia

5%

(43/840)

L 1 D

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

QID: 1429
1

Axial malalignment

1%

(11/753)

2

Anterior cruciate ligament insufficiency

3%

(21/753)

3

The use of a fresh frozen graft

84%

(631/753)

4

Femoral condyle flattening

5%

(35/753)

5

Graft size mismatch of 15%

6%

(46/753)

L 2 C

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(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:
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 B

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

QID: 1407
1

Inside-out lateral repair

3%

(56/1630)

2

All-inside lateral repair

1%

(13/1630)

3

Inside-out medial repair

90%

(1470/1630)

4

All-inside medial repair

5%

(76/1630)

5

Equal rates for both lateral and medial

1%

(10/1630)

L 1 B

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(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
1

Partial meniscectomy

5%

(88/1820)

2

Sub-total meniscectomy

1%

(12/1820)

3

Meniscal repair using all-inside bioabsorbable arrows/darts

7%

(122/1820)

4

Meniscal repair using inside-out horizontal mattress sutures

15%

(269/1820)

5

Meniscal repair using inside-out vertical mattress sutures

72%

(1318/1820)

L 3 C

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(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
1

Skeletal immaturity

1%

(9/1603)

2

ACL tear

2%

(36/1603)

3

PCL injury

2%

(29/1603)

4

Combined ACL and PCL tear

2%

(35/1603)

5

Bucket-handle meniscal tear

93%

(1489/1603)

L 1 C

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(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
1

Increased blood supply

98%

(925/943)

2

Increased elesticity

0%

(2/943)

3

Increased type II collagen

0%

(2/943)

4

Increased type I collagen

0%

(3/943)

5

Increased glycosaminoglycan content

0%

(3/943)

L 1 C

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(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
1

Days from injury to repair

6%

(78/1337)

2

Medial versus lateral meniscus

3%

(37/1337)

3

Width of the meniscal rim

90%

(1203/1337)

4

Use of growth hormone

0%

(2/1337)

5

Dominant versus non-dominant leg

0%

(6/1337)

L 1 D

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(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:
1

Rest and icing followed by physical therapy for definitive management

6%

(58/946)

2

Arthroscopic removal of osteochondral loose body

5%

(44/946)

3

Arthroscopic meniscus repair followed by immediate joint mobilization

70%

(666/946)

4

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

7%

(70/946)

5

Immediate ACL reconstruction

11%

(104/946)

L 2 D

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