#Meniscus injury#Dr Atanu Kayal#Burdwan medical college

1. Injuries of the Semilunar
Cartilages (MENISCI)
By Atanu Kayal, PGT( Orthopaedics), BMCH

2. Anatomy
• Two surfaces
• Two borders
• Two horns

3. Composition
 The meniscus is a
dense extracellular
matrix.
 water (72%)
 collagen
(22%), Proteoglycans
 type –I
Collagen(90%)
 Radial and
longitudinal fibers

4. Vascular anatomy
• Medial and lateral
geniculate arteries
• Peri meniscal capillary
plexus
• Three zones
1. Red-Red
2. Red-White
3. White-White

5. Medial vs Lateral
meniscus
Posterior horn of lateral meniscus receives anchorage
from Ligament of Wrisberg
Ligament of Humphrey

6. Functions
Load distribution- Increase contact surface and reduce contact stress
Joint lubrication-Help synovial fluid distribution
Shock absorption- Reduce contact stress between bones
Prevent capsular and synovial impingement during knee flexion and
extension
Act as joint filler
Stability to all plane but important rotatory stabilizers

7. Mechanism of injury
Medial meniscus
• Internal rotation of femur over
tibia in knee flexion
• Posterior segment of medial
meniscus towards the center of
joint
• Sudden extension of knee
• The posterior horn trap
this position
• Lateral meniscus
• Vigorous external rotation of femur
when knee flexion
• Displace posterior half of lateral
meniscus towards center of joint
• Sudden extension of knee causes
transverse and oblique tears

8. Classification
Classified according
to........................
Location in relation to vascular
supply
Position ( Anterior, middle or
posterior third)
Appearance and orientation
Traumatic vs Degenerative

9. Classification

10. Clinical features
H/0 twisting injury
Pain
Locking - Common in longitudinal bucket -handle tear
Sensation of giving away – usually on rotatory movement
Knee effusion
 Hemarthrosis
 Indicates irritation of synovium

11. Clinical presentation
• Trauma ( Younger)
• Twisting injury
• Next day swelling
• Ongoing instability
• Point specific pain
• Atraumatic
• Older patients
• Degenerative

12. Physical examination
Tenderness
Along medial and lateral joint line
Most commonly located posteromedial and posterolateral side
Inability to squat
Clicks, Snap or Catches – noise localized to joint line

13. Clinical tests
McMurray test
Apley's grinding test
Squat test
Dial test
Thessaly test

14. Investigations
X-ray
AP/ LATERAL View
Intercondylar notch view
To exclude loose
bodies, fractures....
Arthrography
Accuracy in diagnosis....
Medial meniscus- 95%
Lateral meniscus- 85%

15. MRI
Accuracy of medial
meniscus tear-98%
Accuracy of
lateral meniscus tear-90%
More sensitive and specific

16. MRI - double PCL" sign vs double anterior horn" sign
In bucket handle meniscal tears

17. Arthroscopy
• Gold standard technique for
diagnosis and treatment

18. Treatment
• Non-operative
Indications
Degenerative meniscal tear without mechanical symptoms
Incomplete , small ( <2mm),stable peripheral tear with no
pathological condition
Contraindications
Chronic tear with superimposed acute injury ( traumatic)
Locked knee with bucket handle tear

19. Non-operative
Stop weight bearing
rest
 NSAIDS
 Rehabilitation
• Cylindrical cast or knee
immobilizer for 6 weeks
• Crutch walking with toe
touch weight bearing
• >6weeks discontinue
immobilization and rehabilitation

20. Operative
Meniscectomy
Meniscal repair Arthrotomy vs Arthroscopy
Meniscal transplantation
 With Autografts, Allografts, Prosthetic scaffolds

21. Meniscectomy
Partial meniscectomy
indications
tears not amenable to repair (complex,
degenerative, radial tear patterns) and
Loose unstable fragments
outcomes
• >80% satisfactory function at
minimum follow-up
predictors of success
age <40yo
normal alignment
minimal or no arthritis
single tear
Sub-total meniscectomy
Excision of portion of peripheral rim
Most of anterior horn and middle third
of posterior horn not resected
Total meniscectomy
No longer followed today

22. Open meniscectomy
Single anteromedial incision
Vs
Two incision : Handerson
Additional posteromedial
incision
5cm posterior and parallel to
tibial collateral ligament

23. Open meniscectomy

24. Arthroscopic surgery
• General principles
Partial meniscectomy is always preferable to sub-total and total
meniscectomy
To determine accurate type of meniscectomy , meniscal lesion must
be carefully probed and classified
Main objectives to remove the torn , mobile meniscal fragment and
maintain contour the peripheral rim
 Leaving a Balanced and stable meniscal tissue

25. Arthroscopic repair criteria
Location: Within 3 mm of periphery
• Stability: Partial thickness
Full thickness – Oblique and vertical tears <10 mm
• With inability to displace the central portion with a probe more than 3 mm
• Tear pattern – peripheral, vertical and longitudinal tear
• Bucket handle, flap, degenerative, complex, radial tear excised
• Patients age <50 years
• Chronicity – Acute tear <8 weeks better healing
• Ligament instability- ACL deficiency must corrected simultaneously to
prevent instability

27. Complications after meniscectomy
• Postoperative hemarthrosis
• Synovitis
• Synovial fistulae
• Painful neuroma of infrapatellar
branch of saphenous nerve
• Iatrogenic chondral cartilage injury
• Postoperative infection
• Reflex sympathetic dystrophy
• Late changes: Degenerative change
within the joint
Fairbank described three changes
Narrow joint space
Flattening of peripheral articular
surface of condyle
Development of anteroposterior
ridge of femoral condyle

28. Meniscal replacement
Controversial: to prevent
degenerative changes
 Allografts meniscus
 Autograft fascial material
 Synthetic
• Biologic tissue scaffold
 Indications:
 <40 years with meniscectomy
 No advanced arthritis
 Contraindications:
 Malalignment and instability
 Chondromalacia grade>3
 Previous joint infection

29. Summary.........................................