the presentation about meniscal pathologies, meniscal cysts, etc...

1. Dr.V.Sivani
MODERATOR: Dr. K.Vamsi Krishna
MS(ortho)

2. Anatomy of Menisci

4. MEDIAL MENISCUS
 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 anterior cruciate
ligament.
 The posterior horn is anchored immediately in front
of the attachment of posterior cruciate ligament
posterior to the intercondylar eminence.

5.  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.

6. LATERAL MENICUS
 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.

7.  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.

8.  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,
 During rotation they follow the femur and move
on the tibia.

9. MICROSCOPY
 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.

10. Structure of menisci

11. Anatomy

12. Anatomy

13. Function
 Force transmission
1. increasing
congruency
2. shock-absorption
3. transmits 50%
weight-bearing load
in extension, 85% in
flexion

14. BLOOD SUPPLY
 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;
 early adulthood: eventual peripheralization of the
vascularity to the outer third of meniscus.

15.  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
10% to 30% of the width of the medial meniscus
0% to 25% of width of lateral meniscus.

16. Repair and healing of meniscus

17. MENISCAL INJURIES

18. Mechanism of injury
•Injury with rotational force
,on a partially flexed knee
.Eg:Foot ball players,Kabadi
players

19. Predisposing Factors
 Trauma
 Meniscal cyst
 Decreased mobility of the meniscus
 Discoid meniscus
 Aging- degeneration
 Abnormal mechanical axis- ligamentous laxity.
 Congenitaly relaxed joints
 Inadequate tone and musculature

20. O’CONNOR CLASSIFICATION OF TEARS
1. Longitudinal tears
2. Horizontal tears
3. Oblique tears
4. Radial tears
5. Variations-flap tears
complex tears
( degenerative )

22. • Most common site- posterior horn
• Most common type- longitudinal tear
• Tears within the meniscus can be complete or incomplete
• Most tears involve the inferior surface .
• Transverse, radial or oblique tears most common in lateral
meniscus.

24. LONGITUDINAL TEARS
 Most common
 young
 Post trauma
 Associated with ACL injuries.
 More common in medial meniscus
 2 types-
Vertical incomplete tear
Vertical complete
Displaced tear (bucket handle)
Peripheral tear

25. LONGITUDINAL TEAR OF
MEDIAL MENISCUS
Both longitudinal and radial
tears may appear vertical on MR
images , but longitudinal tears
extend parallel to the c-shaped
circumference of the meniscus,

26. HORIZONTAL TEARS
 Extend from inner margin to
capsule in a horizontal cleavage
plane
 Common in posterior horn of
medial meniscus & mid segment of
lateral meniscus
 Common in older people.
 Flap tears and complex tears begin
with horizontal component.

27. HORIZONTAL TEAR
OF MEDIAL MENISCUS

28. OBLIQUE TEARS
 Full thickness extending obliquely
from the inner margin into the body
Types
 Anterior oblique or posterior oblique
 Commonly seen at the junction of
middle & posterior 1/3 of medial
meniscus

29. The curvilinear course of oblique tears
often results in abnormal vertical signal
(arrows) that progresses towards or away
from the free edge of the meniscus on
consecutive image

30. RADIAL TEARS
 Extend radially from inner margin into
the body
 Common in middle 1/3 of lateral
meniscus
 3 types - complete
-incomplete
-parrot beak tear-(Radial tear
with longitudinal or oblique extension)

31. RADIAL TEAR OF LATERAL
MENISCUS

32. FLAP TEARS
 Oblique tears with a
horizontal cleavage
 Degenerative

33. Fat suppressed proton density-
weighted (15a) coronal and reveal a
tibial sided flap tear of the body
of the medial meniscus, with
displacement of the undersurface
component (arrows) into the
inferior gutter. Reactive synovitis
and edema (arrowheads) are
readily apparent deep to the tibial
collateral ligament on the coronal
view.

34. COMPLEX TEARS
 Combination of all the above
 Common in chronic meniscal lesions & degenerative
menisci
 Predisposing conditions:
* Discoid lateral meniscus
*Meniscal cyst
*Calcium pyrophosphate deposition

35. A GRE T2*-weighted sagittal image reveals a
complex tear of the posterior horn of the
medial meniscus, having horizontal
(arrows) and longitudinal (arrowhead)
components. Complex tears like this are
likely to be unstable.

36. Lateral meniscus Tears
 Less common
- Lateral meniscus is more mobile
- not attached to the ligaments
-Forcible external rotation of femur on fixed tibia with
knee in flexion.---anterior horn tear
-Medial rotation of femur on fixed tibia followed by
violent flexion- posterior horn tear

37.  Less chance of bucket handle tear
 More chance for transverse tear
 Common location –posterior horn
 Length, depth and position of tear depend on the position
of the meniscus in relation to femur and tibia

38. Clinical diagnosis
History :
Most commonly noted in a middle aged person who
sustains a weight bearing twist on knee or who has
pain after squatting.
Recall of symptoms like mild catching, snapping,
clicking or occasional swelling in tears of degenerated
menisci.

39. Locking
 The syndromes of tears in menisci can be divided into
two types:
1. With locking
2. Without locking.
 Locking seen commonly in longitudinal especially
bucket handle tears of medial meniscus
 Should be differentiated from false locking.

40. Physical signs Effusion
 Quadriceps wasting
 Joint line tenderness
 Limitation of movements.

41. Different clinical tests
 Mc Murray test
 Apleys grinding test
 Thessaly test
 Squat test

42. Radiography
 AP view, lateral view and intercondylar notch view are
taken.
 Just to rule out other conditions like loose bodies,
osteochondritis dissecans.

43. MRI
 Most commonly used investigative modality for
meniscal tears.
 Areas of increased signal in the menisci depict
meniscal pathologies.
 The current accuracy in detecting meniscal tears using
MRI is approximately 95%.

44. MRI grading of meniscal tears:
Grade 0: Normal meniscus
Grade 1: punctate or amorphous signal abnormality
without extension to the articular surface.
Grade 2: linear signal abnormality without extension
into articular surface
Grade 3: signal abnormality extending to atleast one
articular surface.

45. Normal meniscus on MRI (left) and during arthroscopy (right)

46. Torn meniscus on MRI (left) and during arthroscopy (right)

48. Treatment
Non operative treatment
 Incomplete meniscal tears or a small 5mm stable
peripheral tear with no other pathology conditions.
 Stable vertical longitudinal tear in peripheral vascular
area
 Tears associated with ligamentous instability if the
patient defers ligament reconstruction

49.  Non-operative treatment:
1. A groin to ankle cylinder cast for 4 to 6 weeks
2. Progressive isometric exercises for quadriceps
strengthening during period of cast.
3. Crutch walking with touch down weight bearing when
patient gains control of extremity in cast.
4. After 4 to 6 weeks, intensification of exercises of muscles
of hip and knee

50. Contra indications for non
operative treatment
 Chronic tears with superimposed acute injury
 Patient with locked knee because of bucket handle
tears
Non operative or delayed operative treatment of
ligamentous injuries increases risk of medial meniscus
tear.

51. Operative treatment
 Partial meniscectomy
 Subtotal meniscectomy
 Total meniscectomy
 Arthroscopic meniscal repair
 Open meniscal repair
 Meniscal autografts and allografts

52. Meniscectomy

53.  Partial meniscectomy:
Stable and balanced peripheral rim of meniscus is
preserved.
Only loose, unstable meniscal fragments are removed
 Subtotal Meniscectomy:
Done in case of complex or degenerative tears of
posterior horn.
Resection also involves peripheral rim of meniscus.
 Total Meniscectomy:
Total meniscectomy is required when it is detached from
its peripheral menisco synovial attachment

54.  Tears within 2 to 3mm from peripheral margin.
 Knee in 60 degrees flexion if medial meniscus is torn.
 Posteromedial arthrotomy incision
 Debridement of edges
 Interrupted non absorbable sutures vertically
oriented.

55. Open meniscal repair

56. ARTHROSCOPIC PORTALS FOR
MENISCAL REPAIRS
Posteromedial portal:
The posteromedial portal is located in a small triangular
soft spot formed by
 the posteromedial edge of the femoral condyle and
 the posteromedial edge of the tibia.
This portal is useful for repair or removal of displaced
posterior horn meniscal tears and for removal of
posterior loose bodies that cannot be displaced into
the medial compartment and removed through an
anterior portal.

57. Posterolateral portal
 The knee should be flexed to 90 degrees, and the joint
should be maximally distended.
 The landmark for the posterolateral portal is at the
point where a line drawn along the posterior margin of
the femoral shaft intersects a line drawn along the
posterior aspect of the fibula.
 This is about 2 cm above the posterolateral joint line at
the posterior edge of the iliotibial band and the
anterior edge of the biceps femoris tendon.
 This portal is useful for assisting with repair of lateral
meniscal tears

58. Resection of bucket handle tear

60. Longitudinal incomplete tears

61. Steps in arthroscopic meniscal
repair
 Selection of the patient
 Tear debridement and local synovial, meniscal and
capsular abrasion to stimulate proliferative fibroblastic
healing response
 Suture placement to reduce and stabilize the meniscus

62. The common criteria for meniscal
repair include:
 A vertical longitudinal tear of more than 1 cm in the
peripheral area of meniscus
 A tear that is unstable and displaceable into the joint
 An informed and co operative patient who is active and
younger than 40 years.
 A knee that is either stable or would be stabilized with a
ligamentous reconstruction simultaneously.
 Bucket handle portion and remaining meniscal rim are in
good condition

64. Arthroscopic meniscal repair
 Repair techniques and indications:

65. Inside to outside technique
 Double-limbed sutures are passed using
arthroscopic assistance through the meniscus and
capsule and are then retrieved through a small,
extracapsular counter incision.
 Anterolateral portal is used to pass the canula of the
suturing instrumentation

66. Inside to outside technique

67. Postero lateral incision

68. Posteromedial incision

69. Steps of the surgery
 Position: supine position and the operative knee
flexed to 90 degrees for access to the lateral
compartment and just slight flexion for the medial
compartment
 the arthroscope should be placed in the ipsilateral
anterior portal.
 The arthroscopic needle guide is then placed in the
contralateral portal to ensure that the needles are not
angled directly posterior.
 Vertical mattress sutures are used whenever possible.

70.  Careful placement of the posteromedial or
posterolateral counter incision and exposure of the
joint capsule are crucial for easy, safe suture passage
and knot placement
 Double-limbed 2-0 absorbable or nonabsorbable
sutures attached to flexible long needles are used for
repair.
 Ideally, sutures shouldbe placed on the superior and
inferior aspects of the meniscusto improve rigid
meniscal fixation.
 After all sutures have been placed, the knee should be
flexed to 15 to 20 degrees and the sutures can be
directly tied to the extraarticular side of the capsule
under direct visualization.

71. OUTSIDE IN TECHNIQUE
 Sutures passed percutaneously across the tear through 18 G
spinal needle
 Knot is tied inside the joint
 Repeated every 4-5mm
 Advantage: simple,
safe and cheap
 Disadvantage: cannot be used for posterior.1/3rd tears

73. Post operative period
 Immobilized for 7 to 10 days.
 ROM ( 20 to 80 degrees) are started immediately,
20min, 4 times a day
 Touch down weight bearing for 2 weeks
 Partial weight bearing for 2 to 4 weeks
 Full weight bearing after 4 to 6 weeks.
 Jogging at 3 months and sports after 6 months

74. ALL INSIDE TECHNIQUE
 For repair of posterior horn peripheral tear
 Needle is inserted into the meniscus & exits within the joint
 Specialised instrumentation needed.
 Allows placement of vertical sutures

75. Meniscal repair by biological
stimulation
 Trephination
 Synovial abrasion
 Fibrin clot

76. Meniscal replacement
 Candidate for meniscal transplantation should be:
1. Skeletally mature
2. Too young for total knee arthroplasty
3. Has significant knee pain and limited function
4. The cause of meniscal damage should be mechanical and not
degenerative.
5. Should not have any synovial disease.
 Stages in meniscal replacement:
1. Graft preparation
2. Tunnel placement
3. Graft insertion
4. Graft fixation

78. Contraindication to meniscal transplantation
1. Age > 50 years, skeletal immaturity
2. Diffuse advance chondral degeneration ( type iv)
3. Flattening of involved condyles or significant
osteophytes
4. Knee extension loss > 5 degrees compared to
contralateral limb and flexion < 125 degrees.
5. Inflammatory arthritis or synovial disease
6. Unaddressed cruciate insufficiency
7. Unaddressed skeletal mal alignment
8. Obesity ( BMI >35)

79. Preservation of meniscal allografts
1. Fresh
2. Fresh frozen ( deep freezing)
3. Freeze dried ( lyophilization)
4. Cryopreserved

80. Complications
 chondral injury
 implant failure
 postoperative joint-line irritation
 nerve injury,
 arthrofibrosis
 effusion, infection
 deep venous thrombosis
 and pulmonary embolus.

81. Cysts of menisci
 Etiology:
1. Trauma
2. Degeneration with age
3. Developmental inclusion of synovial cells into the
meniscus
4. Displacement of synovial cells into meniscus
through micro tears in fibro cartilage

82. Clinical features
 They are firm swellings being palpable anterior and proximal to
fibular collateral ligament when placed on lateral side
 Contain gelatinous substance in them
 Usually multilocular.
 They become prominent on extension and decrease in size on
flexion.
 Pisani sign: they completely disappear when knee is flexed
 Pain is an important clinical feature
 Large cysts can even erode the tibial condyles.

83. MRI IMAGE OF
MENISCAL CYST

84. Treatment is
 Arthroscopic partial meniscectomy
 Arthroscopic meniscectomy in case of multiple
meniscal cysts
 Decompression of the cyst

86. Discoid meniscus
 Types of discoid meniscus:
1. Complete type
2. Incomplete type
3. Wrisberg type
This is based on
1. The coverage of the lateral tibial plateau
2. Presence of posterior menisco tibial attachment

87. Wrisberg type
 No posterior menisco tibial attachment
 Occur at younger age group
 Not associated with trauma
 Abnormal motion of this meniscus causes poppping sound
during knee flexion and extension ( snapping knee
syndrome).
 Total meniscectomy is done generally.

89. Treatment
 Tears of complete or incomplete discoid meniscus that
cause pain, popping and snapping within the knee
 Hypermobile medial segment with intact peripheral
attachments are treated by
Saucerization of mobile fragment or subtotal
meniscectomy

91. Calcification and ossification of
menisci
 Most commonly the posterior horn of a meniscus is
involved.
Types:
1. Primary type: occurs with advanced age and afflicted
with degenerative arthritis.
2. Secondary type: younger person with symptoms of a
torn meniscus.

92. ARTICULAR CARTILAGE INJURIES

93.  Articular cartilage is a complex tissue that is able to
withstand tremendous forces over many cycles but
does not have ability to heal even after a minor injury.
 Patients with articular cartilage injuries usually
complain of pain, effusion, and mechanical symptoms.
 Femoral lesions: pain at medial or lateral
tibiofemoral compartment
worse with weight bearing or high-impact activity.
 Patellar lesions: pain with kneeling, stair climbing, and
prolonged sitting.

94. Plain radiographs
 Evaluation of a patient suspected of having a chondral
or osteochondral lesion of the knee should include
1. Weightbearing anteroposterior,
2. 45-degree posteroanterior,
3. lateral
4. patellar (Merchant or sunrise) views of the involved
extremity
5. bilateral standing hip-knee-ankle anteroposterior

96.  cartilage-sensitive MRI to determine lesion location,
size, and grade

97. Treatment

99. MINI ARTHROTOMY MOSAICPLASTY

101. Autologous chondrocyte implantation

102. Autologous chondrocyte implantation
 Sandwich technique:

103. Osteochondritis Dissecans
 Osteochondritis dissecans is the most common source
of loose bodies in the knee joint.
Other sources are
(1) Synovial chondromatosis
(2) osteophytes,
(3) fractured articular surfaces
(4) damaged menisci
PATHOLOGY:

104. COMMON SITES OF OCD
LATERAL ASPECT OF MEDIAL FEMORAL CONDYLE
NEAR ATTACHMENT OF PCL : M/C SITE

105. Pathology:
An area of subchondral bone becomes necrotic and
degenerative changes usually occur in the cartilage
overlying it
They gradually separate from adjacent bone and
cartilage and together become a loose body
Unless interrupted by surgery or natural healing
process.
The lesion usually is located on the lateral aspect of the
medial femoral condyle near the attachment of the
posterior cruciate ligament

106.  More common in males and during adolescence.
 It occurs in two groups of patients:
(1) young patients, before physeal closure,
(2) Adults
It is bilateral in 20 to 30 % cases

107. Etiology
 ischemia,
 repetitive microtrauma,
 familial predisposition,
 endocrine imbalance,
 Epiphyseal
abnormalities
 accessory centers of
ossification,
 Growth disorders,
 osteochondral fracture,
 repetitive microtrauma
with subsequent
interruption of
interosseous blood
supply to the
subchondral area of the
epiphysis,
 anatomical variations in
the knee, and
 congenitally abnormal
subchondral bone.

108. Clinical features:
 The most common symptom is vague, aching
discomfort in the knee, of several months.
 effusion
 joint line tenderness or tenderness over the lesion
 limitation of motion
 McMurray sign

109.  quadriceps atrophy.
 Wilson sign: The patient may walk with an externally
rotated gait to avoid contact of the medial femoral
condyle with the medial tibial spine
 Catching and popping seen after partial or complete
separation.
 palpable loose body within the joint.

110. Classification of loose bodies
 Osteo cartilagenous: osteochondritis dissecans
osteochondral fractures, osteophytes, and synovial
osteochondromatosis.
 Cartilagenous: radiolucent
Originate from articular cartilage
 Fibrous : radiolucent and originate from synovium
 Others: intra articular tumours, lipomas, arthroscopic
instruments

111. Investigations
 Intercondylar or tunnel
view along with AP and
lateral views
 Bilateral radiographs in
adolescents
 Technetium-99m bone
scans: to assess healing
and result of the
treatment

112. Lateral radiograph of the knee reveals a
calcified loose body (white arrowhead) in
the infrapatellar fat pad and lucency in the
articular surface of the patella (black
arrowhead).
Sagittal T2-weighted image of the knee
demonstrates a calcified loose body (white
arrowhead) in the infrapatellar fat pad.

114. Common MRI characteristics
 MRI is the test of choice, with high sensitivity (92%)
and specificity (90%) in the detection of separation of
the osteochondral fragment. This is essential in
determining management.
 T1 : variable signal overall with intermediate to low
signal adjacent to fragment and variable fragment
signal
 T2: high signal line demarcating fragment from bone
usually indicates an unstable lesion

115. ARTHROSCOPIC AND MRI
CLASSIFICATION OF OCD

116. LOCATION OF
LESIONS OF
OCD

117. Treatment
 Conservative treatment: young patients with open physis
 surgical treatment :
1. drilling or excision of the fragment
2. debridement or microfracture of the crater
3. Different forms of fixation and grafting
Indications for operative treatment:
 Symptomatic knee in a patient skeletally older than 12 years
 a lesion larger than 1 cm in diameter
 involvement of the weight-bearing surface.

118. Osteochondritis dissecans can be classified at surgery
into 4 stages:
stage I
stable
lesion in continuity with the host bone
covered by intact cartilage
stage II
stable on probing
partial discontinuity of the lesion from the host bone
stage III
unstable on probing
fragment not dislocated
complete discontinuity of the "dead in situ" lesion
stage IV
dislocated fragment

119. Excision of loose bodies
Indications include :
 Small fragments (<2 cm),
 multiple fragments,
 fragments with inadequate bone stock (usually purely
cartilaginous), and
 fragments that cannot be secured with internal fixation

120. REMOVAL OF LOOSE BODIES
 Large loose bodies by
triangulation
 Small loose bodies by
suction and lavage
 Suprapatellar pouch:
suction tip
 Spinal needle and grasping
 Midpatellar portal for loose
bodies in the anterior
compartment

121. TECHNIQUE FOR DRILLING INTACT
LESION IN OCD
1. 30 degree arthroscope in
anterolateral portal.
2. Probing of defect through
anteromedial portal
3. 0.045 k wires are used for
drilling
4. Inferocentral lesions
through antero medial
portal
5. Latero central lesion via
anterolateral portal

122.  Good results have been reported with the fixation of
loose fragments with headless screws, cannulated
screws, and biodegradable pins and screws.
 Biodegradable implants are currently the preferred
method of fixation

123. Complications :
 infection and hemarthrosis
 iatrogenic cartilage damage
 hardware loosening
 Aggressive drilling of an intact lesion can cause
fragmentation of the lesion.
 Metallic screws can damage adjacent articular
cartilage; removal usually is recommended.

124.  Absorbable fixation devices have been reported to
cause foreign body reactions on occasion.
 Unabsorbed screw heads have been found as
intraarticular loose bodies.
 Fibrocartilage hypertrophy has been reported at
osteochondral autograft donor sites,

125. References …
1. Campbell’s operative orthopaedics vol 3
2. Turek’s othopaedics Principles and Application 7th
edition, vol 2
3. DELEE & DREZ’Sorthopaedic Sports Medicine
PRINCIPLES AND PRACTICE 4th edition