The document discusses meniscal injuries and pathology. It provides information on the anatomy and function of the menisci, as well as types of meniscal tears. The diagnosis of meniscal tears involves taking a history of the injury and examining for symptoms like joint line tenderness, effusion, and a locking sensation. Investigations may include x-rays, MRI, arthrography and arthroscopy. Treatment options discussed include non-surgical management for minor tears and surgical repair or resection for larger tears.

1. D R . A N U B H A V V E R M A
M O D E R A T O R : D R . R A V I K I R A N H G
1 S T M A R C H 2 0 1 6
D E P A R T M E N T O F O R T H O P E D I C S
J S S H O S P I T A L
M Y S O R E
MENISCAL INJURIES AND
PATHOLOGY
1

2. OUTLINE
 FUNCTION AND ANATOMY
 MENISCAL HEALING AND REPAIR
 TEARS OF MENISCI
 DIAGNOSIS
 INVESTIGATIONS
 TREATMENT
2

3. FUNCTION OF MENISCI
 JOINT FILLER: compensating for gross incongruity
between femoral and tibial articulating surfaces.
Prevent capsular and synovial impingement
 JOINT LUBRICATION: distribute synovial fluid
throughout the joint
 STABILITY: flexion to extension, pure hinge to a
gliding/rotary motion
 SHOCK ABSORBER: 40 – 60 % of body weight in
standing position
3

4. JOINT FILLER
 Following meniscectomy: Flattening of femoral condyl
and formation of osteophytes
 Contact area inversely proportional to contact stress
 Decreased contact area (Approx 40%), increased contact
stress (100% medial meniscus. 200% lateral meniscus
because of relative convex surface of lateral tibial
plateau)
4

5. STABILITY
 Increased joint laxity following meniscectomy.
 Insignificant if ligamentous structures intact
 ACL deficient knee: increased tibial translation by 58%
after medial meniscectomy (c.f. lateral meniscectomy –
not affixed firmly and does not act as efficient posterior
wedge to prevent translation)
 May account for different patterns of meniscal injuries in
ACL deficient knee
5

6. ANATOMY
6

7. MEDIAL MENISCUS
 C shaped, larger in radius than lateral meniscus
 Anterior horn: Attached anterior to intercondylar
eminence and to the ACL
 Posterior horn: Attached in front of attachment of PCL,
posterior to the intercondylar eminence
 Entire peripheral border firmly attached to the medial
capsule and through coronary ligament to the upper
border of tibia
7

8. LATERAL MENISCUS
 Smaller, More circular, thicker in periphery, wider in
body and more mobile than medial meniscus
 ANTERIOR HORN: attached medially in front of the
intercondylar eminence
 POSTERIOR HORN: inserts into the posterior
aspect of the intercondylar eminence and in front of
posterior attachment of medial meniscus.
 Attached to both cruciate ligaments and posteriorly
to the medial femoral condyle by either the ligament
of Humphry or the ligament of wrisberg
8

9. 9

10. LATERAL MENISCUS
Smaller in diameter
Circular
Thicker in periphery
Wider Body
More Mobile
Attached to both ACL/PCL
MEDIAL MENISCUS
Larger in diameter
C shaped
Thinner in periphery
Thinner body
Less mobile
Not attached to ACL/PCL
10

11. STRUCTURE
11

12. 12

13. ROLE OF HOOP TENSION
13

14. VASCULAR SUPPLY
14

15. 15

16. MENISCAL HEALING AND REPAIR
 Meniscal tears have been classified on the basis of
their location in three zones of vascularity—
 red (fully within the vascular area),
 red-white (at the border of the vascular area),
 white (within the avascular area)
 Peripheral lesions have been shown to heal better
than the partial vascular and avascular areas of the
meniscus
16

17.  for a meniscus to regenerate, the entire structure
must be resected to expose the vascular synovial
tissue
 In subtotal meniscectomy, the excision must
extend to the peripheral vasculature of the meniscus.
 Subtotal excisions of the meniscus within the
avascular central half of the meniscus do not show
any regeneration potential.
17

18. MENISCAL TEARS
 Mechanism: The menisci follow the tibial condyles
during flexion and extension, but during rotation
they follow the femur and move on the tibia;
consequently, the medial meniscus becomes
distorted.
 Its anterior and posterior attachments follow the
tibia, but its intervening part follows the femur; thus
it is likely to be injured during rotation.
18

19. WHY L.M. IS SPARED?
 However, the lateral meniscus, because it is firmly
attached to the popliteus muscle and to the ligament
of Wrisberg or of Humphry, follows the lateral
femoral condyle during rotation and therefore is less
likely to be injured.
19

20.  During vigorous internal rotation of the femur on the
tibia with the knee in flexion, the femur tends to
force the medial meniscus posteriorly and toward the
center of the joint
 The posterior part of the meniscus is forced toward
the center of the joint, is caught between the femur
and the tibia, and is torn longitudinally when the
joint is suddenly extended.
 Most common location: posterior horn of
meniscus
 Most common type: longitudinal
20

21. BUCKET HANDLE TEAR
21

22. CLASSIFICATION OF TEARS
 (1) longitudinal tears,
 (2) transverse and oblique tears,
 (3) a combination of longitudinal and transverse
tears,
 (4) tears associated with cystic menisci,
 (5) tears associated with discoid menisci.
22

23. 23

24. 24

25. 25

26. DIAGNOSIS
 HISTORY: middle aged person who sustains a
weight-bearing twist on the knee or who has pain
after squatting.
 The syndromes caused by tears of the menisci can be
 divided into two groups:
 1. With Locking
 2. Without Locking
26

27. THE LOCKING KNEE
 Inability to completely extend the knee joint
 occurs only with longitudinal tears and is much more
common with bucket-handle tears
 Intra articular tumor, an osteocartilaginous loose body,
and other conditions can also cause locking.
 False locking :hemorrhage around the posterior part of
the capsule or a collateral ligament with associated
hamstring spasm prevents complete extension of the
knee.
 locking may not be recognized unless the injured knee is
compared with the opposite knee, which should exhibit
the 5 to 10 degrees of recurvatum that normally is
present.
27

28. NON LOCKING KNEE
 typically gives a history of several episodes of trouble
referable to the knee, often resulting in effusion and
a brief period of disability but no definite locking.
 A sensation of “giving way” or snaps, clicks, catches,
or jerks in the knee may be described
 IMPORTANT CLUES IN AN INJURED NON
LOCKING KNEE: a sensation of giving way,
effusion, atrophy of the quadriceps, tenderness over
the joint line (or the meniscus), and reproduction of
a click by manipulative maneuvers during the
physical examination.
28

29. GIVING AWAY
 a tear in the posterior part of a meniscus, the patient
usually notices this on rotary movements of the knee
and often associates it with a feeling of subluxation
or “the joint jumpin out of place.”
 When giving way is a result of other causes, such as
quadriceps weakness, it usually is noticeable
during simple flexion of the knee against resistance,
such as in walking down stairs.
29

30. OTHER FEATURES
 EFFUSION: occcurs when vascularised peripheral area
of a meniscus is torn. Mostly it is a hemarthrosis.
 MUSCLE ATROPHY: especially of the vastus medialis
 JOINT LINE TENDERNESS: most important
physical finding. Localised over the medial or lateral
joint line or over the periphery of the meniscus. The
meniscus itself is without nerve fibers except at its
periphery; therefore, the tenderness or pain is related to
synovitis in the adjacent capsular and synovial tissues.
30

31. THE MC MURRAY TEST
 Medial Meniscus: Keeping the knee completely
flexed, the leg is externally rotated as far as possible
and then the knee is slowly extended. As the femur
passes over a tear in the meniscus, a click may be
heard or felt.
 Lateral Mensicus: palpating the posterolateral
margin of the joint, internally rotating the leg as far
as possible, and slowly extending the knee while
listening and feeling for a click.
31

32. 32

33.  CLICK: caused by a posterior peripheral tear of the
meniscus and occurs between complete flexion of the
knee and 90 degrees
 POPPING: occurs with greater degrees of extension
when it is definitely localized to the joint suggests a
tear of the middle and anterior portions of the
meniscus
 The position of the knee when the click occurs thus
may help locate the lesion.
33

34. APLEY’S GRINDING TEST
 With the patient prone, the knee is flexed to 90
degrees and the anterior thigh is fixed against the
examining table. The foot and leg are then pulled
upward to distract the joint.
 with the knee in the same position, the foot and leg
are pressed downward and rotated as the joint is
slowly flexed and extended
 when a meniscus has been torn, popping and pain
localized to the joint line may be noted.
34

35. 35

36. OTHER TESTS
 Seinmann’s test.
 Squat test.
 Duck waddle test.
 Helfet’s sign.
 Bounce home test.
 0’donoghue’s test.
 Payr’s test
 Bragard’s sign.
 Anderson medial – lateral grind test.
 Passlar rotational grind test.
 Cabot’s popilteal sign.
36

37. Mod. Helfet Test Payr’s Sign
37

38. Bragard’s Sign
38

39. Anderson Medial- Lateral
Grind Test39

40. Cabot’s Popliteal Sign
40

41. Investigations
 X Ray:
 A.P
 Lateral
 Intercondylar notch
view
 Tangential view of
inferior surface of patella.
 It is essential to exclude
loose bodies
ostechondritis and other
derangements of the knee.
41

42. Arthrography
It is an invasive procedure. Air and an opaque contrast material
such as iothalamic magleramine or diatrizote sodium and
renografin 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
mensci into profile.
 Accuracy in diagnosis – Medial menisci – 95%; lateral
menisci – 85%
 It is contraindicated in pyoarthosis, bleeding disorder and
allergy to contrast material.
 With the improvement in CT and MRI scanning, arthography
is rarely used.
42

43. Arthroscopy
• It has an accuracy of 98% for
medial meniscus & 90% for
lateral meniscus.
43

44. MRI
Grading:
 Grade I Tear of the menisus 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 menisus.
 Grade III Signal that traverses through
the meniscal surface.
 Grade IV There is extension of tear
through both tibial and femoral surfaces of
the menisus.
Grade I and II changes appear
normal on arthoscopic evaluation.
44

45. 45

46. Non-Surgical Management
Indications:
 Partial thickness splits.
 full thickness oblique or vertical tears less than
5mm, if stable
 Short radial tears.
 Degenerative tears in OA, without mechanical
symptoms.
 Stable tears with inability to displace the central
portion, by greater than 3mm.
Contra indications:
 Chronic tears with superimposed acute injury.
 In a locked knee caused by bucket handle tear of
meniscus.
46

47. Non-Surgical Management
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,
 compression dressing,
 Buck’s traction with 5-7
pounds of weight.
47

48.  Groin to ankle
cylinderical cast in worn
for 4 to 6 weeks.
 Isometric exercise
program during the time
the leg is in the cast
48

49.  At 4-6 weeks cast is
removed and rehabilitative
exercise program is
intensified.
 If symptoms recur after a
period of NST,
surgical repair or removal
of the damaged menisus
may be necessary.
49

50. Surgical Management
1. Meniscectomy
 By arthrotomy or
 By arthroscopy
2. Meniscal repair
 By arthrotomy or
 By arthoscopy
3. Meniscal transplantation
 With autografts, allografts or prosthetic scaffolds.
.
50

51. General Principles
 Partial meniscectomy is always preferable to subtotal or total
meniscectomy.
 The objective is to remove the torn, mobile meniscal fragment and
contour the peripheral rim, leaving a balanced, stable rim of meniscal
tissue.
 Pneumatic tourniquet to be used to avoid constant sponging which
prolongs and damages the joint surfaces. Before wound closure
tourniquet to be released and bleeding vessels are ligated or
electrocauterized.
 The knee should be examined carefully for stability after the patient is
anesthetized.
 The anterior compartment of knee should be explored first, then the
posteomedial and lastly the lateral compartment should be explored.
 The condition of the synovial membrane, articular surfaces, medial and
lateral menisci and ligaments should be noted.
51

52. Objective of the Treatment
 to remove the torn
mobile meniscal
fragment
 contour the peripheral
rim leaving a balance
stable rim of meniscal
tissue.
 No standard technique
can be used in every
case.
52

53. Meniscectomy
O Connor
classification
1. Partial meniscectomy:
Only the loose unstable
fragments are excised;
e.g: displaced inner
fragments in bucket handle
tear, flap in oblique tears.
In this a stable and balanced
peripheral rim is preserved.
53

54. 2. Subtotal meniscectomy:
This requires excision of
portion of peripheral rim of
meniscus. Most of the anterior
horn and a portion of middle
3rd of the meniscus are not
resected.
3. Total meniscectomy:
meniscus is detached from its
peripheral menisco-synovial
attachment
-intrameniscal damage
-tears are extensive.
54

55. Partial Total Meniscectomy ?
Deciding factors
 Location of tear
 Length
 Pattern
 Stability
 Condition of whole meniscus
55

56. Advantages of Partial Over Total
 Shorter operating time
 Faster recovery
 Better post operative function
 Better self assessment of outcome
56

57. POST MENISCECTOMY REHAB
PROTOCOL
 A compression bandage is
applied to the knee.
 Knee is immobilized for 5-7
days. Then it is discontinued.
 Ice is applied over the knee
and limb is elevated for 24-
48 hours postoperatively.
57

58.  Quadriceps exercises are started
on 2nd day onwards, SLR
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 at 2
weeks and gentle resistive
exercises are begun.
58

59. Open Excision of Medial Meniscus
 Using anteromedial incision
 Begin the incision just medial to patella, 5 cm distally
parallel with patella and patellar tendon. Incise the
fascia and capsule 0.5 cm medial to the edge of patellar
tendon .
 Grasp the synovium, make a small opening through it
into the joint. Mobilize the anterior third segment of
meniscus.
 Grasp the anterior segment with martin clamp.
 Free the middle third of the meniscus at its
periphery.
 Mobilize the posterior third of meniscus.
 Displace the meniscus into the intercondylar notch,
leave a stable balanced menisceal rim.
 Close the incision, evert the cut edge of synovium.
 Close fascia, extensor aponeurosis and capsule in one
layer.
59

60. Open Excision of Lateral
Meniscus
 Anterolateral incision : begin the incision
at the level at the middle portion of the
patella extend it distally to the upper tibial
surface incise the anterolateral capsule
and synovium.
 Free the anterior third of lateral meniscus,
and grasp it with martin grasper
 Maintain traction on free anterior
segment.
 Flex the knee, place the foot on opposite
knee and apply varus strain.
 By continued gentle traction, posterior
third of meniscus is separated, and
complete lateral meniscus is excised. Close
the capsule with intermediate sutures.
60

61. Arthroscopic Meniscectomy
Longitudinal tears:
30 degree oblique viewing arthroscope is inserted through an AL
portal.
Probe is placed through the AM portal.
Horizontal tear:
30 degree oblique viewing arthroscope is used through AL portal.
Superior and inferior leaves of the tear is removed with basket
forceps. Peripheral rim is trimmed and contoured.
Oblique tears:
Three portal procedures is adopted. Small posteriorly based
oblique tears are usually removed by morcellation of the flaps
with basket forceps or motorized cutter, trimmer instruments.
Large posterior or oblique tears are removed intact enbloc.
Anterior oblique tears are removed by triangulation technique.
61

62. Three Portal Technique
 It is used excision of large
complete intrameniscal
tears of posterior horn.
 Arthoscope, grasping
instrument and cutting
instruments are used
through the three portals.
 Arthroscope placed in AL
portal. Probe the posterior
limits of displaced bucket
handle through AM portal.
.
62

63.  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.
 Basket forceps or motorized
shaver are introduced
through AM portal to
smoothen the remaining rim.
63

64. Complications after Meniscectomy
1. Post operative haemarthrosis.
2. Chronic synovitis.
3. Svnovial fistulae.
4. Painful neuromas of the branches of the
infrapatellar portion of saphenous 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
indicates the onset of pyarthrosis.
64

65. 7. Reflex sympathetic dystrophy.
8. Retained meniscal fragment.
9. Capsular and ligamentous laxity.
10. Late changes degenerative changes with
in the joint. Fairbank described three
changes.
a. Narrowing of joint space.
b. Flattening of peripheral half of the articular
surface of condyle.
c. Development of anteroposterior ridge that
projected distally from the margin of
femoral condyle.
65

66. OPEN MENISCAL REPAIR
66

67. Arthroscopic Meniscal Tear Repair
Consists of 3 important steps:
1. Appropriate patient selection – should have
documented tear that is able to heal.
2. Tear debridement and local synovial, meniscal and
capsular ablation to stimulate a proliferative
fibroblastic healing response.
3. Suture placement to reduce and stabilize the
meniscus.
67

68. CRITERIA
 Location : within 3 mm of periphery are presumed vascular.
More than 5mm are avascular.
 Stability : partial thickness.
Full thickness- oblique and vertical tears less than 10 mm with
inability to displace the central portion with a probe greater than 3mm.
 Length : Stable tear <10mm in length left alone.
Radial tear <5mm in length left alone.
 Tear pattern : peripheral , vertical and longitudinal tears repaired.
Bucket handle, flap, degenerative, complex, radial tears are
excised.
 Patient age : should be less than 50 yrs.
 Chronicity : Acute tears less than 8 weeks old have better healing
potential.
 Ligament stability : ACL deficiency must also be corrected simultaneously
to prevent instability.
68

69. TECHNIQUES
 Inside to outside.
Single cannula
Double cannula
 Outside to inside.
 All – inside technique.
69

70. Inside – to – Outside Technique
Single cannula :
 Carry out the diagnostic arthroscopy.
 For repair of medial meniscus, place 30 degree angle of arthroscope through the AL
portal.
 Freshen and debride the surfaces.
 If straight cannula technique is used, approach an anterior and middle third tears of
medial meniscus, from lateral portal, under the arthroscope.
 Approach posterior third tear, by inserting the cannula throught AM portal.
 2-0 PDS sutures are used.
 Keep the knee in 10 to 20 degree in flexion as the sutures are passed.
 Pass the cannula of the suturing instrument in AM portal.
 All sutures are tied over the bridge of the capsule, close the skin incision.
Double cannula system:
 Instruments consists of Straight and curved double lumen cannulas, through which
needles may be passed.
70

71. Outside – to – Inside Technique
 In this method suture is introduced through the spinal
needle i.e. Inserted from outside to inside.
 This technique is safe approach to posterior horn.
 Technique is same for both menisci.
 For large peripheral lesions of medial meniscus, such as
bucket handle tears, combination of inside to outside
and outside to inside methods can be used.
71

72. All Inside Technique
 Morgan described, this technique for repair of posterior horn.
Advantages:
 It allows placement of vertical sutures.
 Smaller incision can be used.
Disadvantages:
 Need for special instrumentation.
 Difficulty with intraarticular knot tieing.
 All inside technique, can be performed by using commercial
available T – fix sutures.
72

73. Advantages of Open Technique
1. Vertically oriented sutures are easy to do by open arthrotomy.
It is more secure than more horizontally oriented suturing by
arthoscope techniques.
2. In repair of posterior horn peripheral tears by open arthotomy
technique, posteromedial or posterolateral capsular
reconstruction can be done concurrently.
3. Immobilization required is the same for both open and
arthroscopic technique.
73

74. 1. Small incisions .
2. Short stay.
3. Early mobilization.
4. All corners of the joint can be visualised.
5. Cosmeticaly very minimal scar.
6. Cost effective.
7. Patient is comfortable.
8. Less infection.
9. Less joint stiffness.
10. Morbidity is less.
Advantages of arthroscopic
technique
74

75. Arthroscopic Disadvantages
 Prolonged learning curve
 Specific instrumentation
75

76. After Treatment
 Knee is placed in a hinged brace and immediate
range of motion from 0-90 degrees is permitted.
 Touchdown weight bearing is permitted
immediately, and
 Full weight bearing is permitted at 6 weeks when
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.
76

77. Exercises after Injury to the Meniscus
Are designed to build up the quadriceps and
hamstring muscles and increase flexibility and
strength:
 Warming up the joint by riding a stationary bicycle,
then straightening and raising the leg (but avoiding
straightening the leg too much).
 Extending the leg while sitting (a weight may be
worn on the ankle for this exercise).
 Raising the leg while lying on the stomach.
 Exercising in a pool.
77

78. 78

79. 79

80. 80

81. 81

82. 82

83. Recent Advances
 Enhancement of meniscal healing.
 Arthroscopic repair of torn meniscus using fibrin
clot.
 Meniscal replacement with
- allograft meniscus
- autograft fascial material
- synthetic meniscus
Biologic tissue scaffolds
83

84. Enhancement of Meniscal Healing
 Vascular access channels:
creating access of peripheral vessels to avascular region, by a
channel (trephination) allows avascular portion of the
meniscus to heal throught the proliferation of the fibrous
scar.
 Synovial abrasion :
encourages vascular extension to avascular regions via.,
formation of vascular synovial pannus.
 Exogenous fibrin clot :
a clot precipitated on a sterile glass surface, and placed
within the defect within the vascular zone can promote
healing.
84

85. Arthroscopic Repair of Torn Meniscus
using Fibrin Clot
 The fibrin clot appears to act as a chemotoctic and mitogenic stimulus
for reparative cells and provide scaffolding for reparative process.
 Arnocky and Warren reported the injection of exogenous fibrin clot
obtained form the patients coagulated blood as promoting improving
meniscal healing. Exogenous fibrin clot is injected with a blunt needle in
the stem of the tear. 1 to 2ml of clot was sufficient to fill an average defect.
When gaps are big, a facial sheath was used to cover these defects and
the exogenous fibrin clot was injected under the cover of sheath i.e., for
complex tears.
 Repairs of tears less than 2 months from the time of injury to surgery
result higher healing rates than those of more chronic tears.
 Isolated repairs heal significantly better with exogenous fibrin clot
injection.
85

86. Meniscal Replacement
 Attempts at meniscal replacement with allograft
menisci, autograft fascial material and synthetic
menisci scaffold are in various stage of study.
 Investigation studies of biological tissue scaffolds are
in progress. These grafts may provide a more
acceptable meniscal replacement in the future.
 As technology and the biomechanics and physiology
of menisci tissue are better understood. These
techniques may become more popular.
86

87. Allograft Meniscal Transplantation
Aim:
 To prevent degenerative changes, in the post meniscectomy
patient.
Indications:
 Patient less than 45 yrs age, with pain and discomfort associated
with early OA, without ACL deficiency or significant
malalignment.
Contraindications:
 Age more than 60 yrs.
 Bony architectural changes.
 Prior infection.
 Significant malalignment.
 Instability.
87

88. Graft Preservation Technique:
 Fresh freezing.
 Cryo preservation.
 Freeze dried.
 Secondary sterilization with radiation less than 2.5 M Rad.
Steps:
 Graft preparation.
 Tunnel placement.
 Graft insertion.
 Graft fixation.
After Treatment:
 Limb placed in long leg hinged knee brace.
 Range of movement from 0 to 90 degree begin immediatiely.
 Partial weight bearing with brace for first 6 weeks.
 Brace removed at 6 weeks.
 Full weight bearing started.
 Deep flexion avoided for 6 months.
88

89. Bio- absorbable Implants
 Poly glycolic acid
 Poly levo lactic acid
 Raecemic poly lactic acid
 Poly dexanone.
 All these materials degrade into co2 and
water.
 Devices include Anchors,Arrows,
 screws,staplers.
89

90. Experimental Studies
 Angiogenin, a potent blood vessel inducing
protein- a 123 AA protein
 Implantation into the experimentally injured
menisci in rats induces neo vascularisation of
meniscus
90

91. References
 Campbell’s operative orthopaedics. Vol. 3, 11th
Edition.
 Orthopaedics principles and their applications.
6th Edition Turek.
 Mercer’s Orthopaedic Surgery, 10th Edition.
 Rockwood and Green’s Fractures in Adults. Vol 2.
7th Edition.
 Techniques in Therapeutic Arthroscopy by J.
Serge Parisien.
 Athletic Injuries and Rehabilitation by James.
David and William .
 JBJS.
 Current Orthopedic Diagnosis and Treatment.
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