This document discusses meniscal injuries of the knee. It provides information on meniscal anatomy, vascular supply, types of tears including longitudinal, horizontal, and bucket handle tears. It outlines signs and symptoms of meniscal tears including joint line tenderness. Physical exam tests like McMurray's test and MRI are discussed for diagnosis. Treatment options including non-surgical management for small peripheral tears versus surgical options like partial meniscectomy, meniscal repair, and allograft transplantation are summarized. Post-operative rehab and potential complications are also briefly mentioned.

1. Meniscal injuries

2. MENISCUS
• Wedge shaped
• Fibro cartilaginous
• Triangular on CS
• Cover ½- 2/3 of surface
• Lateral – Shorter
• Small O shaped
• Medial- longer C shaped

3. MENISCUS
• Meniscus is a fibrocartilage that carries
type 1 collagen.
• Meniscus is triangular shaped in cross
section

4. MENISCUS
• Composed of densely
woven collagen fibers
• Blood supply : Largely
avascular except
periphery
• From Medial and
Lateral Geniculate
Arteries

5. MENISCUS
Vascular Zones
• White on White
• White on Red
• Red on Red

6. MENISCUS
– LATERAL MENISCUS: circular, covers
70% of lateral tibial plateau. More mobile than
the medial meniscus. Not attatched to
ligament
–

7. MENISCAL INJURIES
• LATERAL
MENISCUS
– LESS COMMON
– NOT ATTACHED TO
LIGAMENTS
– FORCIBLE EXTERNAL
ROTATION OF FEMUR
ON FIXED TIBIA WITH
KNEE IN FLEXION- ANT.
HORN TEAR

8. MENISCUS
– MEDIAL MENISCUS: C.shaped, covers
50% of medial tibial plateau. Medial meniscal
tears occurs about three times more often
than that of lateral as its attached to collateral
ligamentsniscus.
–

9. MENISCAL INJURIES
• MEDIAL MENISCUS-
COMMONLY INJURED
– ATTACHED TO
COLLATERAL LIGANENTS
– DUE TO ROTATIONAL
STRAIN ON A FLEXED
KNEE AND FORCIBLE
ABDUCTION

10. MENISCUS
• Common location –post horn
• Length, depth and position of tear
depend on the position of the
meniscus in relation to femur and
tibia

11. MENISCAL INJURIES
• LATERAL MENISCUS
– MORE CHANCE OF TRANSVERSE TEAR
• MEDIAL MENISCUS
– MORE CHANCE OF BUCKET HANDLE TEAR

12. MENISCUS
FUNCTION
– SHOCK ABSORPTION
– LUBRICATION AND NUTRITION
– LOAD SHARING
– DEEPENING THE CAVITY
– JOINT STABILITY

13. MENISCAL INJURIES
INCREASED CHANCE OF TEAR SEEN IN
• Menisci with peripheral cyst
• Less mobile meniscus
• Discoid meniscus
• Increased age—degenerative
• Abnormal joint mechanical axis
• Relaxed joints—inadequate Quadriceps
contraction power

14. MENISCAL INJURIES
• Types of Tears
– Longitudinal
– Horizontal

15. MENISCAL INJURIES
Longitudinal Tears
- Peripheral detachment
• Complete
• Segmental – anterior / posterior horn

16. MENISCAL INJURIES

17. MENISCAL INJURIES

18. LARGE FLAP TEAR RADIAL TEAR

19. MENISCAL INJURIES
Horizontal Tears
• Transverse/radial/ oblique
• Affects both medial and lateral meniscus
• More common in lateral meniscus
• Ant/ middle/ post segments
• More in junction of ant. &middle 3rd

20. MENISCAL INJURIES

21. TEARS ASSOCIATED WITH
CYSTIC DEGENERATION
• Trauma  degeneration and secondary
mucinous and cystic changes in the periphery
of the meniscus that leads to less mobile
meniscus and more susceptible to tearing

22. MENISCAL INJURIES
• TEARS ASSOCIATED WITH CONGENITAL
ANOMALIES
– DISCOID MENISCUS
• THICKER THAN NORMAL
• OVAL OR DISC SHAPED
• MORE PRONE TO INJURY
• PAIN , SWELLING, STIFFNESS(+)
• INABILTY TO EXTEND KNEE
• IF ASYMPTOMATIC , NO TREATMENT NEEDED

23. MENISCAL INJURIES
• CLINICAL DIAGNOSIS
• HISTORY
– MAY BE SYMPTOMATIC
– H/O TRAUMA
– IMMEDIATE AND SEVERE PAIN
– SWELLING
• ISOLATED TEAR
• HEAMARTHROSIS WITH LIGANMENT INJURY

24. MENISCAL INJURIES
• CLINICAL DIAGNOSIS
• GIVING AWAY
• LOCKING

25. MENISCAL INJURIES
• PHYSICAL SIGNS
• EFFUSION
• QUADRICEPS WASTING
• JOINT LINE TENDERNESS
• LIMITATION OF MOVEMENTS

26. MENISCAL INJURIES
• PHYSICAL SIGNS
• BOHLER’S SIGN
• VALGUS STRESS TEST
– MEDIAL COLLATERAL LIG.
• VARUS STRESS TEST
– LATERAL COLLATEAL LIG.

27. MENISCAL INJURIES
• PHYSICAL SIGNS
• THESSALY’S TEST
– KNEE 20 DEGREE FLEXED
– FOOT FLAT ON GROUND
– FULL WEIGHT ON THE SAME LEG WITH
SUPPORT
– TWIST BODY TO EITHER SIDE 3 TIMES
– +VE IF PAIN/ LOCKING.

28. MENISCAL INJURIES
• PHYSICAL SIGNS
PAYR ‘S SIGN
• Medial knee pain indicates a
posterior horn lesion of the
medial meniscus.

29. MENISCUS
• SPECIAL TEST
• MC MURRAY TEST
• APLEY’S GRINDING TEST
• STIENMANN TEST
• CHILDRESS TEST

30. MCMURRAYS TEST
• The knee is then external rotated
and extended in order to test the
medial meniscus.
• Lateral meniscus tear diagnosed
with McMurray’s test with internal
rotation of the knee.
• Painful pop / click of knee from flexion
to extension.

31. APLEY’S DISTRACTION-COMPRESSION TEST
• Make the patient in prone ,stabilize thigh with your knee ,
pull leg up in 90 degree flexion
• Then, rotate foot internally and externally: if painful ,
abandon test.
• If no pain , perform in compression, if pain is elicited on
medial side, MCL injury, If lateral ,LCL injury.
• This test is used
to evaluate the
collateral
integrity of knee

32. MENISCUS
• SPECIAL TEST
STIENMANN TEST

33. MENISCUS
• SPECIAL TEST
CHILDRESS TEST
• IN SQUATING POSITION
• ASK PATIENT TO MOVE
FORWARD , BACKWARDS
AND BOTH SIDES
• LOOK FOR PAIN

34. MENISCAL TEAR
INVESTIGATIONS
• XRAYS- Usually Normal
• ARTHROGRAPHY
• ARTHNROSCOPY
• MRI- Reliable and Confirmatory than
arthroscopy

37. MRI or Arthroscopy?
• False positive with MRI
• Increased signal intensity with in the
post 3rd of med. Meniscus due to central
myxoid degeneration.
• Appropriate use of MRI can reduce the no.
of diagnostic arthroscopies.

38. TREATMENT
• NON SURGICAL
• SURGICAL
– TOTAL MENISCECTOMY
– PARTIAL MENISCECTOMY
– MENISCAL REPAIR
• ARTHTOSCOPIC
• OPEN

39. TREATMENT DEPENDS ON
• Type of tear
• Stability
• Site of tear
• Associated injuries
• Age
• Compliance

40. NON SURGICAL TREATEMENT
• Indications
1. Incomplete meniscal tear
2. A small stable peripheral tear (5mm) without any
other injuries
• Healing in 3-6 weeks
• Limb to be protected – cylinder cast or knee
immobilizer

41. MENISCAL TEAR
• SURGICAL TREATMENT

42. SURGICAL TREATMENT
Total meniscectomy
1.It is justified only when meniscus
is irreparably torn
2.To be avoided as much as possible
3.Late degenerative changes after Total
Meniscectomy  Fairbank’s triad
1. Development of an AP ridge that
project distally from margin of femoral
condyle
2. Flattening of the peripheral half of
the articular surface of the condyle
3. Narrowing of the joint space
More in lat meniscus and More in
older people

43. SURGICAL TREATMENT
Partial Meniscectomy /
Balancing
• Less articular cartilage
degeneration
• Excision of only the torn portion of
meniscus( balancing)
• Treatment of choice in young
adult/ who require vigorous
activities
• Short operative time.

44. POST OPERATIVE
• Comp. Bandage
• Knee immobilised in ext . for 1 week
• Quadriceps exercises on next day.
• Crutch walking with partial weight bearing
on next day
• Isometric exercises continued till 90* of
flexion
• Then, progressive resistance exercises

45. COMPLICATIONS
• Haemarthrosis
• Chronic synovitis
• Synovial fistulae
• Painful neuroma
• Infections
• Late Degenerative Arthritis

46. REGENERATION OF MENISCI
AFTER EXCISION
• After complete meniscectomy – fibrous
regeneration with in 6 weeks to 3 months
• Thinner and narrower than normal
meniscus
• Decreased surface area and mobility
• Tears are rare

47. MENISCAL REPAIR
• Depends on
- location of the tear,
- its morphology
- patient factors
• Age – young patient, better outcome
• can be open or Arthroscopic.

48. LOCATION OF REPAIR
• Peripheral tear- red on red region
• Also on red on white region
• Size <1-2 cms
• Appearance- vertical longitudinal tear is
ideal.

49. Meniscal repair- contraindications:
• > 3 cm Tear
• Transverse tear even in periphery
• Flap tear, radial tear, vertical tear with
secondary lesions
• Ligament instability.

50. Open repair
• For post 1/3 tear, no more than 2 mm
from the menisco – Synovial junction
• Advantage:
- More precise suture placement
-Sutures placed vertically through
meniscus
- Better preparation of site

51. Arthroscopic repair
• Techniques
* Inside To Outside
* Outside To Inside
* All Inside

52. Arthroscopic Examination of Knee

53. Techniques
• Inside out
• Use zone specific canulas to pass sutures
through joint and across the tear.
• Sutures attached to flexible needle.
• Small post incision.
• Gold standard repairable techniques for
medial and lateral menisci

54. Techniques
• Outside in
• Sutures passed
percutaneously
across the tear
through spinal needle
and retrieved intra
articularly.
• Used for repair in
anterior horn and
mid-third tears

55. Techniques
• All inside
• For repair of post. Horn peripheral
tear.
• Allows placement of vertical sutures.
• Smaller incision

56. Arthroscopy Disadvantages:
• Need for second incision
• Potential for needle stick injuries
• Neurovascular complications
• Prolonged learning curve
• Specific instrumentation
• Difficulty in intraarticular Knot tying
• No long term clinical studies
• Prolonged immobilization

57. Suture Materials
• Poly glycolic acid
• Poly levo lactic acid
• Raecemic poly lactic acid
• Poly dexanone.

58. Meniscal transplant
• Allograft implantation: Transplant issues
 Poor fixation technique
 Difficulties with finding a donor of correct
size
• Recent Options: SIS and CMI

59. • Indications
 Patients that have had meniscectomy
 Patients with pain and discomfort associated with
osteoarthritis
 Patients undergoing ACL reconstruction for increased
stability
 Athletes for determent of osteoarthritis development
• Preservation techniques
 Fresh
 Freeze-Dried
 Cryo-preserved
Meniscal Allograft Transplants (MAT)

60. • Bone Bridge in Slot
• Loose bridge in slot allows
condyle capture to aid in
optimal anteroposterior
placement
• Guide prepares slot parallel
to tibial slope
• Fixation independent of
bridge placement
J Farr et al 2004
MAT-Bone Bridge

62. Failure to
capture femur
Proper
capture of
femoral
condyle
Proper size and position allows:
“capture” of femoral condyle
MAT-Size and Position

63. • Availability
• Reproducibility/Accuracy of Sizing
• Lack of control over final cellular and extracellular matrix
composition/ mechanical properties
• Potential for disease transmission
• Variation of Surgical Technique/ Placement
MAT problems

64. • Transplant is immunopriveliged -No immunosuppressants
• Avascular meniscus has been frozen-Decreased viability
• Inflammatory response
• Disease transmission risk (eg. HIV risk 1/Million)
• Meniscus may or may not be fully repopulated by patient
MAT-problems

65. • Manipulated Meniscal Allograft
• Collagen Meniscal Implant (CMI)
• Small Intestine Submucosal (SIS) Implant
• Adult Mesenchymal Stem Cell Implants
• Tissue Engineered Meniscus: Scaffolds + Cells0
• Tissue Engineered Meniscus: Cell-based Therapies
• Tissue Engineered Meniscus: Gene Therapies
Meniscal Substitutes

67. THE END