Meniscal tears

 Meniscal function is essential to normal
function of the knee joint
 When the menisci is removed the joint
contact area is reduced by 40% the
contact area is 2.5 times greater when the
menisci are present.
 In 1948 Fairbank first reported the
roentenographic changes after
meniscectomy

 In 1970 DeHaven began to perform the open
meniscal repair through posterior arthrotomy,
usually in conjunction with ligament
reconstruction.
 Ikeuchi performed the first meniscectomy in
Tokyo n 1979.
 In 1980 Hening performed the first
meniscectomy in the United States.
 O’Connor is the Pioneer of arthroscopic repair.

 Menisci are two fibrocartilagenous
crescents
 They try to deepen the articular surfaces of
the condyles of the tibia, partially divide
the joint cavity into upper and lower
compartments.

 Each menisci has
Two ends- attached to the tibia.
Two borders- the outer border is thick,
convex and fixed
to the fibrous band; the inner
border is thin concave and
free

 Two surfaces- the
upper surface is
concave for femur;
the lower surface is
flat for peripheral two
thirds of the tibial
condyles.

 It is a C shaped structure forming 3/5 of the
ring asymmetrically larger posteriorly than
anteriorly.
 The anterior horn is attached to the tibia
anterior to the intercondylar eminence and to
the anterior cruciate ligament.
 The posterior horn is anchored immediately in
front of the attachment of posterior cruciate
ligament posterior to the intercondylar
eminence.

 Its entire peripheral border is attached to
the medial capsule and through the
coronary ligament to the upper border of
tibia.
 Most of the weight is borne on the
posterior portion of the meniscus.

 It is circular forming 4/5 the of the ring
with symmetrical anterior and posterior
horn.
 The anterior horn is attached to the tibia
in front of the intercondylar eminence.
 The posterior horn is attached to
posterior aspect of the intercondylar
eminence in front of posterior attachment
of the medial meniscus.

 The posterior horn receives anchorage to
the femur via the ligament of Wrisberg
and ligament of Humphrey and from
fascia covering the popliteus muscle.
 The tendon of the popliteus separates the
posteriolateral periphery of the lateral
meniscus from the joint capsule and
fibular collateral ligament.

 The lateral meniscus is smaller in diameter,
thick in periphery, wide in body and more
mobile.
 In contrast the medial meniscus is
much larger in diameter is thinner in the
periphery, narrower in body and less mobile.
 The menisci follow the tibial condyles during
flexion and extension, but during rotation they
follow the femur and move on the tibia.

 Menisci are composed of dense, tightly woven
Type-I collagen with some Type-III)
and elastin to create a compressible structure.
 The major orientation of collagen fibres in the
menisci is circumferential; radial and
perforating are also present.
 The circumferential fibres function in hoops to
accept stress without gross deformation or
extrusion of the joint.

 Radial fibres stabilizes the meniscus,
preventing circumferential splits as wells
resisting excessive compressive loads.

 The medial meniscus is semicircular and
attached to the medial collateral ligament
(medial collateral ligament) of the knee
joint.
 It only moves 2-5 mm within the joint and
is hence more prone to tears than the
lateral meniscus which is more circular in
shape and moves 9-11mm.

 The menisci of the knee are present
developmentally at eight weeks as a
collection of fibroblasts.
 At birth, the menisci are vascularised
through their substance; with ageing
through early adulthood, there is
eventual peripheralization of the
vascularity to the outer third of meniscus.

 Vascular supply is from the lateral and medial
geniculate vessels ( inferior and superior).
 The branches from the vessels give rise to
perimeniscal capillary plexus within the
Synovial and capsular tissue and supply the
peripheral border of meniscus.
 The depth of the vascular penetration is 10% to
30% of the width of the medial meniscus and
0% to 25% of width of lateral meniscus.

 Acts as joint filler compensating for the
gross incongruity between tibial and
femoral articulating surfaces.
 Prevent capsular and Synovial
impingement during flexion-extension
movements.
 Joint lubrication help to distribute
Synovial fluid through the joint and
aiding the nutrition of articular cartilage.

 Contribute to stability in all planes but
are important rotatory stabilizers.
 Shock absorption; the larger area
provided by the meniscus reduces the
average contact stress between the
bones.

 Traumatic lesions of the menisci are most
commonly produced as the flexed knee
moves toward an extended position.
 The most common location of injury is
the posterior horn of the meniscus, and
longitudinal tears are the most common
type of injury.

 Menisci with peripheral cyst formation.
 Menisci that have been rendered less
mobile from previous injury or disease.
 Congenital anomalies-discoid lateral
meniscus.
 Areas of degeneration that develop as a
result of aging.
 Abnormal mechanics in the joint
incongruities or ligamentus disruptions.

 Congenitally relaxed joints.
 Inadequate musculature especially quadriceps.
 Certain sports are commonly associated with
meniscal injuries. Soccer players are
particularly liable, especially when pivoting
with the weight on one leg with the knee
flexed. Other sports such as hockey, tennis,
badminton, squash, and skiing are liable to
meniscal injury.

 Turning or twisting of the loaded joint
may trap the menisci between the joint
and tear the meniscus.
MEDIAL MENISCUS
 Internal rotation of femur over tibia with
knee in flexion forces the posterior
segment of medial meniscus towards the
centre of the joint.

 The posterior horn may be trapped in
this position by sudden extension of
knee.This excessive force results in tear
of the meniscus from its peripheral
attachment and causes a longitudinal
splitting of its substance.

 Vigorous external rotation of femur while
the knee is flexed will displace the
posterior half of the lateral meniscus
toward the centre of the joint.
 During sudden extension of the knee, an
anterioposterior distracting force tends
to straighten the cartilage and imposes a
strain on the medial concave rim, which
tears transversely and obliquely.

 Smillie’s classification
Peripheral detachments(10%)
Complete(23%)
Segmental-either anterior or
posterior(2%)
Horizontal tears-Posterior, middle or
anterior(48%)
Cystic degeneration(12%)

 Congenital anomalies
 Degenerative lesions

 Based on the location
of the tear in the three
zones of vascularity.
a. Red-Red-fully within
vascular area
b. Red-White-at the
border of vascular
area
c.White-White within
the avascular area

 Based on the type of tear found at
surgery
a. Longitudinal tear.
b. Horizontal
c. Oblique
d. Radial tears
e.Variations which include flap tears,
complex tears and degenerative tears.

 Most commonly occur as a result of trauma to a
reasonably normal meniscus.
 The tear is vertically oriented and may extend
completely through the thickness of the
meniscus or may extend only partially or
incompletely through it.

 Medial side is 3 times
more commonly
involved than lateral.
 If the tear is near the
meniscocapsular
attachment of the
meniscus, it is
referred to as
peripheral tear.

 Complete tear is
associated with ACL
injury.
 Long tears that extend at
least two third of the
circumference of the
meniscus produce an
unstable fragment that
displaces into the
intercondylar notch,
referred to as bucket
handle tear.

 Most common in older
patients in the posterior
horn of the medial
meniscus or in the mid
portion of lateral
meniscus.
 The horizontal cleavage
divides the meniscus
into superior and
inferior leaves
resembling a fish
mouth.

 Full thickness tears running obliquely
from the inner edge of the meniscus out
into the body.
 If the base of the tear is posterior, it is
referred to as posterior oblique tear; the
base of an anterior oblique tear is in the
anterior horn of the meniscus.

 Common in lateral
meniscus and middle
third is commonly
involved.
 Three varieties are
encountered,
1.Incomplete
2.Complete
3.Parrot beak
 In incomplete type, tear
extends all the way from
the inner edge of
meniscus out towards
periphery.

 In the complete type,
tear extends all the
way from the inner
edge to
meniscosynovial
rim.
 In parrot beak variety,
longitudinal or oblique
tears are added to
incomplete or
complete radial tears.

 It begins as horizontal
cleavage tears in the
degenerative tissue of
an older patient.
 It is superior or
inferior flap
depending on the
location of the base of
the flap.

 It may contain elements of all the above
types of tears.
 More common in chronic meniscal
lesions or in older degenerative menisci.

 Most often seen in older patients.
 Present with marked irregularity and
complex tearing within the meniscus.

 An accurate detailed history is essential
and its importance is frequently greater
than that of the clinical examination.
Patient gives history of a twisting injury
to the knee while the joint was flexed.

 Locking: Locking means inability to extend the
knee fully.This results as displaced segment
interpose between the tibial and femoral
condyle preventing full extension.
 Sensation of giving away:The patient notices
this on turning around suddenly, walking on
uneven ground or on stepping on a mall stone
and often associates it with a feeling of
subluxtion or “the joint jumping out of place”.

 Effusion: Indicates that something is
irritating the synovium and has limited
specific diagnostic value. Sudden onset
after an injury denotes a hemarthrosis.
Repeated displacement of torn portion of
a meniscus can produce chronic synovitis
with an effusion of a nonbloody nature.

 Tenderness: Most important physical
finding in localized tenderness along the
medial or lateral joint line or over the
periphery of meniscus.This is most often
located posteromedially or
posterolaterally

 Atrophy of the quadriceps suggest
recurring disability of the knee.
 Clicks, snaps, or catches, either audible
or detected by palpation can be valuable
diagnostically. If the noises are localized
to the joint line, the meniscus most likely
contains a tear.

 Often it is difficult to diagnose the cause
of knee symptoms on history and clinical
examination.
 Such non specific symptom complex is
termed as internal derangement of the
knee.

 Position: Supine
 Examiner stands on
the affected side;
grasps the foot firmly
with one hand and
the knee with other
hand
 The joint is slowly
extended slowly
keeping the foot in
externally rotated
and abducted.

 As the femur passes over the tear in the
meniscus, patient complains of pain.
 At the same time click will be felt by the hand
at the knee.
 On the similar exercise with the foot in internal
rotation and knee adducted if elicits click and
pain indicates tear in lateral meniscus.

 Position: prone
 With the knee flexed
to 90 degree and the
thigh fixed to the
examination table
clinician applies
compression and
lateral rotation to the
leg from foot.

 If the patient experiences pain it
indicates M.M. tear.
 If patient experiences pain on internal
rotation of leg, a tear in lateral meniscus
is suspected.

 Consists of several repetitions of full
squat with the feet and leg alternately
rotated as the squat is performed.
 Pain in the internally rotated position
suggests injury to the lateral meniscus.
 Pain in the external rotation suggests
injury to the medial meniscus.

 Position: Sitting
 Patient sits with the
leg bent over the
table about 90
degree.
 To assess the M.M.
tear, the foot is
externally rotated
which produces some
discomfort.

 Position: Supine
 The examiner grasps the leg near the
ankle with one hand while flexing the
knee to 30 degree with the other hand.
 The patient is asked to relax and the
knee is forcible and quickly extended in
one moment or jerk.

 As the patient passes from flexion to
recurvatum the patient experiences a
sharp pain on the side with the damaged
meniscus which may radiate up and
down the limb.

 Radiological Examination:
AP, Lateral and intercondylar notch view
with a tangential view of inferior surface
of patella.
It is essential to exclude loose bodies,
osteochondritis and other derangements
of the knee.

 Arthrography of the knee has proved to be a
valuable supplement to analysis of knee
disorders.
 It is an invasive procedure.
 Air and an opaque contrast material such as
Iothalamate meglumine or diatrizoates sodium
and megleomine are injected into the joint
under sterile condition.

 Multiple roentgenographic views are
then made by rotating the joint and
bringing all portions of medial and
lateral menisci into profile.

 Accuracy in diagnosis
Medial menisci-95%
Lateral menisci-
85%
 It is contraindicated in pyoarthrosis,
bleeding disorder and allergic to
contrast material.
 With the improvement in CT scan and
MRI arthrography is rarely used.

 Is the diagnostic procedure to detect the
meniscal injuries.
 It has an accuracy of 98% for medial
meniscus injury.
 It has an accuracy of 90% for lateral
meniscus injury.

 Ultrasound
 Scintigraphy
 CT
 MRI:
Is currently of great value in the
diagnostic evaluation of meniscal tears.
The accuracy of meniscal tears exceeds
90%.They are graded as

 Grade I Tear of the meniscus has increased
signal in the meniscal substance.
 Grade II Involves a more pronounced and
frequently linear signal that does not break the
surface of the meniscus.
 Grade III Signal that traverses through the
meniscal surface
 Grade IV There is extension of tear through
both tibial and femoral surfaces of the
meniscus.

 Grade I and Grade II changes appear
normal on arthroscopic evaluation.

 Injury to the alar pad of fat.
 Rupture of the medial ligament.
 Rupture of the cruciate ligament.
 Fracture of the tibial spine.
 Loose bodies.
 Osteo arthritis.
 Recurrent dislocation.
 Chondromalacia patella.

 The damage to the menisci is often but
one component of a complex injury to
knee.The plan of treatment should be
modified to accommodate for associated
lesions.
 Non Surgical management
 Surgical Management

 Indication:
1. Incomplete meniscal tear or small
(5mm) stable peripheral tear with no
pathological condition.
2.Tears associated with ligamentous
instabilities can be treated non-
surgically if patient defers ligament
reconstruction or if
reconstruction is contraindicated.

1. Chronic tears with superimposed acute
injury.
2. In a locked knee with bucket handle
tear of meniscus.

 Initial treatment of a meniscal tear follows
the basic RICE formula: rest, ice,
compression and elevation, combined
with nonsteroidal anti-inflammatory
medications for pain.

1. An acute episode without locking but
with an acute synovitis with effusion
requires immediate abstinence from
weight bearing, rest with knee flexion,
application of ice packs and
compression dressing.
2. Traction with 5 to 7 pounds of weight.
3. Fluid should be aspirated.

5. A single intra-articular steroid injection
should be permissible.
6. Squatting, flexion, external rotation and
valgus stress to the knee to be avoided
in the first week.
7. Groin to ankle cylindrical cast to be
worn for 4 to 6 weeks.
8. Isometric exercise program during the
time the leg is in cast.

9. At 4 to 6 weeks cast is removed and
rehabilitative program is intensified.
10.If symptoms recur after a period of NST,
surgical repair or removal of damaged
meniscus may be necessary.

1. Meniscectomy
 By arthrotomy
 By arthroscopy
2. Meniscal repair
 By arthrotomy
 By arthroscopy
3. Meniscal transplantation
 With autografts, allograft, prosthetic
scaffolds.

 Treatment of proven meniscal tear is
usually either through arthrotomy or
arthroscopy.
 Arthroscopic techniques are preferred to
arthrotomy unless associated injuries,
such as ligament disruption or
osteochondral fracture, require open
techniques.

 Types of meniscal excisions:
Depending upon the amount of meniscal
tissue to be removed O Connor classified:
i) Partial meniscectomy: Only the loose,
unstable fragments are excised; e.g.
Displaceable inner fragment in bucket
handle tear , the flap in flap tears or flap in
oblique tears.
ii) In this stable and balanced peripheral rim is
preserved.

ii) Subtotal meniscectomy:This requires
excision of portion of peripheral rim of
meniscus.
 Most of the anterior horn and a
portion of middle 3 rd of the meniscus
are not resected.

iii) Total meniscectomy: Done when
meniscus is detached from its peripheral
menisco-synovial attachment and
intrameniscal damage and tears are
extensive.

1. Using single anteromedial incision:
Begin the incision just medial to the
patella, continue it approximately 5 cm
distally, parallel to the patella and the
patellar tendon and end it at the level of
upper tibia. Incise the fascia and capsule
0.5 cm medial to the edge of patella and
patella tendon.

 Using two incision: HENDERSON
An additional posteromedial incision is
used.
Permits easier and complete
detachment of posterior horn.
Posterior incision is made 5 cm parallel
and slightly posterior to the tibial
collateral ligament.

 An anterolateral incision is made.
 Begin the incision at the level of mid
portion of the patella and extend it
distally parallel to the patella and
patellar tendon to the upper tibial
surface.
 If the posterior horn is not visible a
second incision (HENDERSON) can be
used.

 A compression bandage is applied to the
knee.
 Knee is immobilized in extension with
posterior plaster splint or with a knee
immobilizer for 5-7 days.
 Ice is applied over the knee and limb is
elevated for 24-48 hours postoperatively.

 Quadriceps exercises are started 2 nd
day onwards, isometric quadriceps
exercises are carried out on every hour
when the patient is awake.
 When the good muscular control is
achieved, patient is allowed to walk with
crutches and with partial weight bearing.

 The sutures are removed 2 weeks and
gentle resistive exercises are begun.

 It is carried out as an diagnostic and an
therapeutic procedure.
 The objective of the treatment is to
remove the torn mobile meniscal
fragment and contour the peripheral rim
leaving a balance , stable rim of meniscal
tissue.

 Longitudinal displaced complete intra
meniscal tears (Bucket handle tear)
 Technique: AM and AL portal’s is used to
do partial meniscectomy.

 It is used in the excision of large
complete, intrameniscal tears of
posterior horn.
 Arthroscope, grasping instruments,
cutting instruments are used through the
three portals.
 Arthroscope placed through the AL
portal. Probe the posterior limits of
displaced bucket handle through AM
portal.

 Through AM portal anterior horn
attachment of the meniscus is released.
 Grasping clamp is placed through the
AM portal to grasp the anterior horn and
it is removed.
 Now probe is used through AM portal to
check the stability of the remaining rim
and look for any tears.

 Motorized shaver are introduced through
AM portal to smoothen the remaining
rim.

 30 degree viewing Arthroscope is
inserted through an AL portal.
 Probe is placed through the AM portal.
 Objective is to perform partial
meniscectomy.
 Complete the contouring and balancing
of the meniscal rim with the motorized
shaver.

 30 degree oblique
viewing Arthroscope
is used through AL
portal.
 Superior and inferior
leaves of the tear is
removed with the
basket forceps.
 Peripheral rim is
trimmed and
contoured.

 Three portal technique is adopted, small
posteriorly based oblique tears are
usually removed by morcellation of flaps
with basket forceps or motorized cutter,
trimmer instruments.
 Large posterior or oblique tears are
removed enbloc.
 Anterior oblique tears are removed by
triangulation.

1. Post operative haemarthrosis.
2. Chronic synovitis.
3. Synovial fistulae.
4. Painful neuromas of the branches of the
infrapatellar portion of saphanous nerve.
5. Thrombophlebitis- suggested by
postoperative pain and swelling in the calf
and distal extremity with low-grade fever.

6. Postoperative infection-Increasing
effusion, pain and fever beginning 2 to
3 days after surgery indicate the onset
of pyarthrosis.
7. Reflex sympathetic dystrophy.
8. Retained meniscal fragment.
9.Late changes: Degenerative changes
within the joint.

 Fairbank described three changes
i) Narrowing of joint space.
ii) Flattening of the peripheral half of the
articular surface of condyle.
iii) Development of anteroposterior ridge
that projected distally from the margin of
femoral condyle.

 Vertically oriented sutures are easy to do
by open arthrotomy. It is more secure
than more horizontally oriented suturing
by arthroscopic techniques.
 In repair of posterior horn peripheral
tears by open arthrotomy technique,
posteromedial or posterolateral capsular
reconstruction can be done concurrently.

 Since open incision is required to expose
the capsule with arthroscopic techniques
have no advantage over open technique.
 Immobilization required is the same for
both open and arthroscopic technique.

 Certain tears are easier to suture by
arthroscopic technique- posterolateral
tears and tears central to menicosynovial
junction.

 Knee is placed in a hinged brace and
immediate range of motion from 0 to 90
degree is permitted.
 Touch down weight bearing is permitted
immediately, and full weight bearing in 6
weeks after the brace and crutches are
discarded.
 No sports are allowed for 3 months.

 If tear is large crutches are discarded at 8
weeks.
 No sports are allowed for 6 months.

 Tears that are definitely reparable
include ,single vertical tear in the
peripheral vascular portion of menisci,
red-red zone, red-white zone within 3 mm
of the junction.

 Inside to outside
 Outside to inside
 All inside technique

 Diagnostic arthroscopy
 Repair of M.M. tear place 30 degree of
Arthroscope through AL or central portal
 Anterior limit of tear is seen with strong
valgus strain with the knee flexed to 10-
20 degree.

 To approach anterior and middle third of
medial meniscus tear straight cannula
technique is used from lateral portal
crossing under the arthroscope which is
central or AM portal.
 To approach posterior third of M.M. tear
through AM portal with arthroscope
located central or AL.

 If the peripheral tear extends beyond PM
corner of the knee an incision of 5-7 cm
is made to preserve the popliteal vessels.
 Long needles with swaged 2-0 ethaband
are used.

 Posterior tear of the lateral meniscus.
 30 degree arthroscope view with an AM
portal and the probe in anterolateral
portal.
 Place the leg in figure of four position
and advance 30 viewing arthroscope
from AM portal to AL compartment.
 Tear is sutured in 90 degree flexion.

 The suture is introduced through a spinal
needle that is inserted from outside to
inside.
 Safe technique for posterior horns.
 Large peripheral tears (bucket handle
tear) a combination of inside to outside
and outside to inside methods are used.

 Morgan described all inside technique.
 Posterior horn peripheral meniscal tears
within 3 mm of the menisco-synovial
junction.
 Advantages It allows the placement of
vertical sutures thus securing the
circumferentially oriented meniscal
collagen fibres.

 Smaller incision can be used.
 Disadvantages Need for special
instrumentation.
 Difficulty in tying the knot in a confined
space.

 It acts as a chemo tactic and mitogenic
stimulus for reparative cells and provide
scaffolding for reparative process.
 Arnocky and Warren reported the
injection of exogenous fibrin clot
obtained from the patients coagulated
blood to improve meniscal healing.

 Exogenous fibrin clot is injected with a
blunt needle in the stem of the tear.
 1-2 ml of clot was sufficient to fill an
average defect.
 When gaps are large facial sheath was
used and fibrin clot is injected under the
cover of the sheath.
 Repairs of tears less than 2 months show
higher healing rates.

 Attempts at meniscal
replacement with
allograft menisci, auto
graft fascial material
and synthetic menisci
scaffold are in various
stages of study.

Meniscal tears

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