Review Question - QID 220128

Meniscal Tears Classification Descriptive classification QID: 220128 (SBQ24SM.99)

QID 220128 (Type "220128" in App Search)

A 43-year-old male presents to the orthopedic clinic after a knee injury while performing a squat. He endorses a prior history of medial-sided left knee pain. As part of a new workout program, he did a deep squat and felt a pop in his left knee with immediate pain. On physical exam, he has medial joint line tenderness and pain with deep flexion. Video A shows coronal slices of his MRI. The patient recently increased his activity and wants to stay active. He also reports his father had a bad experience with knee arthroplasty and the patient desires to avoid knee arthroplasty in the future. What is the most appropriate next step in management?

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Trial of conservative management with physical therapy

15%

115/763

Corticosteroid injection and repeated clinical exam in 3-6 months

5/763

Arthroscopic partial meniscectomy

34/763

Arthroscopic meniscal root repair

79%

605/763

Arthroscopic meniscal transplant

4/763

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This patient presents with a medial meniscus root tear, which is biomechanically similar to a total meniscectomy. The most appropriate treatment for long-term chondral health is a meniscus root repair (Answer 4).

A meniscal root tear is defined as a complete radial tear within 1 cm of the meniscal attachment or an avulsion. Lateral root tears are typically associated with ligamentous injuries in younger active patients. Medial root tears are more common in older patients and result from chronic, often low-energy attritional mechanisms. The meniscus roots convert axial load as hoop stress across the meniscus. When the root is disrupted, the meniscus loses function and hoop stress. This increases the peak contact pressures in that compartment by 25%. The natural history of root tears is trying, with up to 28% of patients undergoing total knee arthroplasty at a mean of 3.2 years from diagnosis. Meniscal root repairs restore the knee biomechanics to pre-injury contact pressures.

Krych et al published a review article regarding the biomechanics, diagnosis, and treatment of meniscal root tears. The authors note the menisci absorb 50-70% of the axial load of the knee, with a root tear being equivalent to a total meniscectomy. The authors recommend root repair and complete effort to reduce meniscal extrusion.

Allaire et al published a cadaveric study of 9 fresh-frozen cadavers who had 1000N of force applied in four flexion angles in the following states: intact meniscus, medial meniscus posterior root tear, posterior root repair, or full medial meniscectomy. No difference in peak contract pressure was found between the total medial meniscectomy and posterior root tear groups. Repair of the medial root tear returned peak contact pressures to normal.

Video 1 shows a coronal MRI with a medial meniscus posterior root tear.

Incorrect Answers:
Incorrect Answers 1 & 2: Nonoperative management will not restore the biomechanics of the medial compartment.
Incorrect Answer 3: Arthroscopic meniscectomy will not address the extrusion or loss of hoop stress.
Incorrect Answer 5: While a meniscal transplant can restore meniscus function, the first line of treatment should aim to preserve the patient’s native anatomy with a meniscal root repair.