Meniscal injury

Meniscal Injury
team VI ZP – LA – MC - ZK
Supervisor Dr. dr. M. Andry Usman, PhD, Sp.OT(K)
Tuesday, 25th sept 2018

We start of with a case report

HISTORY TAKING
 Patient male 39-year-old with chief complaint pain at his right
knee.
 Suffered since 3 month before admitted to Wahidin general
hospital due to trauma
 Patient was running when his knee hit the door. Pain was
intermittent and aggravated by activity, particularly while walking
and squatting.
 No history of locking sensation
 No history of previous treatment

PHYSICAL EXAMINATION
Left Knee Region
Look :
Deformity (-), swelling (-), hematom (-), scar (-)
Feel : Tenderness (-), Patellar tapping (-), patellar grinding (-)
Move Active and passive movement of knee joint is limited, ROM 0o-
130o
NVD :
Sensibility normal, pulsation artery dorsalis pedis and tibialis
anterior palpable, CRT <2”
Special
tests
:
Lachmann test (-), anterior drawer test (-), posterior drawer test
(-), Mcmurray test (-)

Right Knee Region
Look :
Deformity (-), swelling (-), hematom (-), scar (-)
Feel : Tenderness (-), Patellar tapping (-), patellar grinding (-)
Move Active and passive movement of knee joint is limited, ROM 0o-
130o
NVD :
Sensibility normal, pulsation artery dorsalis pedis and tibialis
anterior palpable, CRT <2”
Special
tests
:
Lachmann test (-), anterior drawer test (-), posterior drawer test
(-), Mcmurray test (+)

 Patient was diagnosed with a suspected meniscus tear and ACL rupture and was
performed a diagnostic arthroscopic procedure  medial condyle osteochondral
defect, degenerative tear lateral meniscus.
 A synovectomy and debridement was performed
 Final diagnosis was :
 degenerative tear lateral meniscus
 Osteochondral defect medial condyle
 Fibrotic synovial right knee
 Patient was reffered to rehabilitation after surgery for muscle strengthening exercise

Meniscus anatomy
“If it is torn, take it out! Take it all out! Even if you just think it’s torn, take it out.”
Those were the slogan words by Smillie in 1967 referring to meniscal injuries
 Meniscus is a latin word, from greek meniskos meaning crescent
 Meniscal tears are the most common pathology of the knee with a mean annual
incidence of 66 per 100000 with knee arthroscopy as the most common methods of
treatment.
 Traditionally, meniscal tears were managed with meniscectomy.
 However, since the long-term morbidities of meniscus removal became apparent (eg,
early development of knee osteoarthritis), management has been increasingly focused
on meniscal preservation.

 Medial meniscus : U shaped, covering 60% of medial compartment
 Lateral meniscus : C shaped, covering 80% of lateral compartment
 The horns anchor to the subchondral bone of tibial plateau

 Meniscus is composed of :
 Water (72%)
 Collagen (22%), responsible for tensile strength of
meniscus. Predominant type 1 (80%) in red zone, and
type 2 : type 1, 60:40 in white zone
 The medial and lateral menisci are each
approximately 3 cm wide.
 The medial meniscus is approximately 4 to 5 cm in
length, and the lateral meniscus is approximately 3
to 4 cm in length.
 2 types of fibres :
 Radial
 Prevent longitudinal splitting of circumferential fibres
 Longitudinal (circumferential)
 predominance in outer third
 From anterior horn insertianl ligament to posterior horn
insertional ligament
 Absorb energy by dissipating hoop stresses

 Blood supply is from the periphery, via medial and lateral geniculate arteries
 Cadaveric studies demonstrated that 10-25% peripheral area of meniscus receive blood supply
 2 distict zones : red-red, white-white, separated by red-white region
 Red-red zone is a vascular zone, thick and convex
 white-white zone is an avascular zone with very low (very unlikely) healing capability, concave,
thin and unattached
 Posterior horns have the highest concentration of mechanoreceptors

Meniscus enables effective articulation between the
concave femoral condyle and the flat tibial plateau
Acts as a shock absorber
to transmit sheer and tensile load from soft tissue to
bone
Function to decrease contact area
Joint lubrication
Proprioception

Meniscus injury
 Common source of pain and disability of knee
 60-70/100.000 case
 Male : female = 2.5-4:1
 Peak incidence in males 21-30 years
 Medial meniscal tear are more common than lateral tears
 Lateral tears occur in acute ACL tear
 Traumatic tears occur in younger more active groups
 Degenerative tears occur due to cumulative stress
 Combination of :1axial loading, 2rotational force

HISTORY
 Tears of normal menisci usually are associated with more significant trauma or
injury but are produced by a similar mechanism:
the meniscus is entrapped between the femoral and tibial condyles in flexion,
tearing as the knee is extended.
 Patients with tears in degenerative menisci may recall symptoms of mild catching,
snapping, or clicking as well as occasional pain and mild swelling in the joint.
Robert H. Knee injuries. Campbell’s operative orthopaedic

SYMPTOMS
 Pain localizing to medial or lateral side
 Mechanical symptoms (locking and clicking)
 Delayed or intermittent swelling
 The syndromes caused by tears of the menisci can be divided into two groups:
- those in which there is locking and the diagnosis is clear,
- and those in which locking is absent and the diagnosis is more difficult
Patrick. Meniscal injury. Orthoblullet

Locking
 Locking usually occurs only with longitudinal tears and is much more common with
bucket-handle tears, usually of the medial meniscus.
 Locking of the knee must not be considered pathognomonic of a bucket-handle
tear of a meniscus;
an intraarticular tumor, an osteocartilaginous loose body, and other conditions can cause
locking.
 False locking occurs most often soon after an injury in which hemorrhage around
the posterior part of the capsule or a collateral ligament with associated hamstring
spasm prevents complete extension of the knee

No locking
 If a patient does not have locking, the diagnosis of a torn meniscus is more
difficult even for the most astute surgeon.
 A patient 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, or the history may be even more indefinite, with recurrent episodes of
pain and mild effusion in the knee and tenderness in the anterior joint space after
excessive activity.

 Joint line tenderness (most sensitive physical examination finding )
 Effusion
 Provocative tests
 McMurray
 Apley grind test
 Squat test
 Thessaly test
One analysis determined that joint line tenderness is the best “common” test, while the other found
sensitivities and specificities similar among the three tests: McMurray, 70% and 71%; Apley, 60% and
70%; and joint line tenderness, 63% and 77%.
Patrick. Meniscal injury. Orthoblullet

Mc Murray test
 With the patient supine and the knee
acutely and forcibly flexed, the examiner
can check the medial meniscus by
palpating the posteromedial margin of
the joint with one hand while grasping the
foot with the other hand.
 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.

 A click produced by the McMurray test usually is caused by a posterior peripheral
tear of the meniscus and occurs between complete flexion of the knee and 90
degrees.
 Popping, which occurs with greater degrees of extension when it is definitely
localized to the joint line, suggests a tear of the middle and anterior portions of the
meniscus.

Apley Grind 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 and rotated to place rotational
strain on the ligaments when ligaments have
been torn, this part of the test usually is painful.
 Next, 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

Squat test
 consists of several repetitions of a full squat
with the feet and legs alternately fully internally
and externally rotated as the squat is
performed.
 Pain usually is produced on either the medial or
lateral side of the knee, corresponding to the
side of the torn meniscus.
 Pain in the internally rotated position  the
lateral meniscus,
 pain in the external rotation  medial
meniscus.

Thessaly test
 Accuracy rates of 94% in detecting tears of the
medial meniscus and 96% in the detection of
tears of the lateral meniscus
 The examiner supports the patient by holding
his or her outstretched hands while the patient
stands flatfooted on the floor.
 The patient then rotates his or her knee and
body, internally and externally, three times with
the knee in slight flexion (5 and 20 degrees)
 Patients with suspected meniscal tears
experience medial or lateral joint-line
discomfort and may have a sense of locking or
catching

Mechanism of injury
Generally categorized as during sport activity or non
sport activity
Sport :
Contact : excessive application of force to meniscus, twisting /
shearing motion with varus/valgus force on flexed knee
non contact (most common) : due to cutting, decelerating or
landing from a jump
Non sport : due to degenerative changes

Meniscus tear
 Cooper classification
of meniscal tear
 3 radial zones
 4 circumferential zones
 Main categories of meniscal
Tears include :
 Vertical longitudinal
 Transverse / radial
 Horizontal
 Complez
 Bucket handle

Radial / transverse tears
 Usually occur at junction of posterior and middle third, may extend
toward periphery
 Due to trauma
 Majority in posterior horn of meniscus
 This tear disrupt ability to distribute hoop stresses

Horizontal tears
 Usually parallel to tibial plateau  superior and inferior segments
 Tears can extend into articular surface of meniscus
 Most common in posterior aspect of
medial meniscus
 Mechanism of injury : 2ndary to shear force
Between superior and inferior surface of meniscus
 Repeated load to meniscal tear result in
Tear propagation, fragment displacement,
Edge instability  lead to mechanical symptoms
 Excision of unstable portions usually performed
As tears not repairable

complex tears
 Have 2 or more tear configuration
 Most common of all lesion (up to 30%)
 Peak incidence 41-50 yr of age
 Minimal to no healing potential
 Not amenable to repair

Bucket handle tears
 Vertical or oblique tear with longitudinal extension toward anterior
horn. Inner fragment frequently displaced toward intercondylar notch
 The displaced fragment resembles a handle, the nondisplaced
portions resembles a bucket
 Common in ACL deficient knee
 Most common type of displaced flap tear

Meniscus imaging
Standard radiography :
exclude bony pathologies
Assess concomitant presence of degenerative changes
Standing weight bearing x ray to view :
Joint space narrowing
Loose bodies
Chondrocalcinosis
Osteophytes
Subchondral bone cysts
sclerosis

Magnetic Resonance Imaging
Accuracy rate 80-95%
For medial meniscus : sensitivity 93%, specificity 88%
For lateral meniscus : sensitivity 79%, specificity 95%
Most commonly used sequence is Spin-echo, fast spin-
echo proton density, with or without fat saturation, T1
and gradient echo
Meniscus MRI made easy

Diagnostic arthroscopy is becoming the gold standard for assessing :
meniscal injuries
feasibility of successful repair
Determine :
size of tear
degree of instability
quality of tissue
zone of tear
evaluation of width and integrity of meniscal rim

Meniscus treatment
 Goal of treatment is :
 Relieve pain
 Return to daily ADL prior to injury
 Prevent early degeneration of knee joint
 Non operative treatment for meniscal tear includes the use of NSAID, rest and
rehabilitation.
 It is indicated for first line treatment for degenerative tears
 Muscle strengthening procedure will be explained further down the slides
“If it is torn, take it out! Take it all out! Even if you just think it’s torn, take it out.”
Those were the slogan words by Smillie in 1967 referring to meniscal injuries

Meniscus treatment
 Before.. Meniscus was considered useless / functionless remnant vestige
 Total menisectomy WAS a gold standard
 However, after the advance of technology in arthroscopy, improvement in
surgical techniques, understanding of biomechanical function of meniscus  lead
to preservation of meniscus
 Partial meniscectomy was still indicated if repair was not possible, with up to 80%
satisfactory function

Meniscal repair
 Any loose or frayed fragments is removed
 Opposing edges are rasped to promote healing response
 70-95 % successful rate
 Highest success when done with concomitant ACL reconstruction
 Tears such as flaps, radial tears, degenerative tears  not
repaired
 Best done on :
Narrow peripheral meniscal rim (0-2mm)
Longitudinal tears less than 3 cm in length
Within peripheral zone of meniscus

Inside out technique
 Gold standard
Outside in repair
 For anterior horn tears
Both inside out and outside in technique involve passing a suture via arthroscopy and tied
beyond joint capsule
 It is used for anterior and middle third tear
All inside technique
 Suture devices with plastic or bioabsorbable anchors
 Most common
Open repair is rarely performed
Postoperative recovery after meniscal repair is slow (4months approximately) due to the
need to protect healing tissue

Inside out tech
 A
Outside in tech

Meniscal transplantation
 Candidates are patient who develop pain and swelling due to early degenerative
changes following meniscectomy
 Indication is : pain localized to involved compartment
 expected outcome is painless knee during activities of daily living
 Contraindication is : advanced arthrosis, obesity, synovial disease, inflammatory
arthritis, significant OA, joint infection
Video

Meniscus rehabilitation
 Rehabilitation has been used as a non operative methods and also for rehabilitation of
post meniscus procedure.

Meniscus questions
 Tears in the peripheral one-third of the meniscus have higher healing rates following
meniscal repair than those in a more central location. This clinical observation is
explained by which of the following anatomic factors?
1. Increased blood supply
2. Increased elesticity
3. Increased type II collagen
4. Increased type I collagen
5. Increased glycosaminoglycan content

 PREFERRED RESPONSE 1
 The meniscus recieves its blood supply from the geniculate vessels at its capsular
attachment. The peripheral third of the meniscus is the most vascular part, and is
known as the red-red zone. This has the best potential for healing following repair. The
middle third (red-white zone) and the inner third (white-white zone) have lower healing
rates. The distribution of collagen and GAGs is similar and has not been shown to affect
healing. The paper by Henning describes improved healing rates of meniscal tears with
up to 5mm of rim width by rasping the synovium. The Turman paper is a review which
covers the fact that there is both a decreased vascularity and healing rate for repairs of
tears with larger rim widths.


 A 17-year-old presents with persistent left knee pain after a twisting injury
during a soccer match 24 hours ago. On physical exam he has a mild
effusion. He has tenderness to palpation on the medial joint line. Lachman
test, anterior drawer test and posterior drawer test are attempted but
limited secondary to pain. Dial test reveals a side-to-side external rotation
difference of roughly 5 degrees. His MRI images are seen in Figures A-D.
These findings would be most consistent with

1. ACL tear and medial meniscal tear
2. Medial mensical tear only
3. PCL tear and medial meniscal tear
4. PLC tear and meniscal tear
5. PCL tear only

 The patient has sustained a complex tear involving the posterior horn of the medial
meniscus. Localizing joint line tenderness is the most sensitive physical examination
finding for this injury.

 Splitting between the iliotibial band and biceps tendon, then retracting the
gastrocnemius posteriorly provides exposure for which of the following procedures?
1. Two-incision ACL reconstruction
2. Tibial-inlay PCL reconstruction
3. Peroneal nerve exploration
4. Inside-out medial meniscus repair
5. Inside-out lateral meniscus repair


 The posterior-lateral capsular exposure needed to protect the neurovascular structures and
allow suturing for an inside-out lateral meniscal repair is performed by developing the
interval between the iliotibial band and biceps tendon. The lateral gastrocnemius is then
retracted posteriorly and medially where it helps protect the neurovascular structures.
Splitting below the biceps tendon puts the peroneal nerve at risk.
According to Turman & Diduch, the gold standard remains inside-out vertical mattress
suture repairs. They stated that all-inside repairs are best reserved for special circumstances,
such as in the setting of concurrent ACL reconstruction.
Illustration A shows a diagram of the postero-lateral approach.
Incorrect Responses:
1. The capsular exposure is not needed for 2-incision ACL.
2. Open inlay PCL is usually performed from a direct posterior approach, or postero-
medially.
3. The peroneal nerve can be explored by dissecting below the biceps.
4. Medial meniscus is approached from the medial side.


 Which of the following is NOT a contra-indication to isolated medial meniscal
transplantation?
1. ACL deficiency
2. Patient age over thirty
3. Inflammatory arthritis
4. Varus alignment
5. Grade IV chondromalacia

 All of the answers are absolute contra-indications except patient age over 30.
The Rijk paper is a review which discusses that early reports of transplantation in knees
with Outerbridge grade IV chondromalacia yielded up to 50% graft failure within 2
years. Contraindications include uncorrected malalignment prior to surgery, ligament
insufficiency, chondral injury, a flattened femoral condyle or tibial plateau. Good results
can be obtained if these are addressed prior to or at the time of meniscal
transplantation (ie. concomitant ACL reconstruction or corrective osteotomy).
The Cole paper reported on 44 meniscal transplants with 77% of patients mostly or
completely satisfied with their result at a minimum follow-up of 2 years.


 An 18-year-old man sustains a twisting injury to
the left knee while playing football. An MRI scan is
shown in Figure 48. What is the most likely
diagnosis?
1. Anterior cruciate ligament rupture
2. Posterior cruciate ligament rupture
3. Medial meniscus tear
4. Lateral meniscus tear
5. Osteochondral lesion

 The MRI scan shows a displaced, bucket-handle lateral meniscus tear. The sagittal
view shows the typical "large anterior horn" sign, or "double meniscus" sign in
which the displaced bucket-handle fragment appears just anterior to the native
anterior horn of the lateral meniscus. The presence of the fibula on the sagittal view
confirms this as the lateral compartment. The image is lateral and the cruciate
ligaments are not visualized. The articular cartilage shown does not demonstrate an
osteochondral lesion.

 A 38-year-old man is being considered for medial meniscus
transplantation following an arthroscopic subtotal meniscectomy
performed at the time of ACL reconstruction. His body mass index (BMI) is
28kg/m2. Laboratory tests are shown in Figure A. Standing long-leg
radiographs reveal a 4 degree valgus deformity compared with the
contralateral side, with the weightbearing line running through the lateral
tibial spine. His arthroscopic photos also revealed a 1.7cm wide
Outerbridge II chondral lesion over the lateral femoral condyle and
synovitis. What factor in this patient is an absolute contraindication to
meniscal transplantation?

1. Rheumatoid arthritis
2. Previous anterior cruciate ligament reconstruction with allograft tissue
3. Malalignment
4. Chondral defect
5. Body mass index

 This patient has rheumatoid arthritis. Inflammatory arthritis is an absolute
contraindication to meniscal transplantation.
Besides inflammatory arthritis, other absolute contraindications include diffuse
arthritis, Outerbridge grade IV changes, untreated tibiofemoral subluxation,
synovial disease, previous joint infection, skeletal immaturity, or marked obesity.

 A 16-year-old female field hockey player sustains a twisting injury to her knee. On
exam, she cannot extend the knee past 30 degrees. Arthroscopy confirms a
displaced bucket-handle tear of the lateral meniscus with a 3-mm peripheral rim.
What is the most appropriate treatment?
 1. Partial meniscectomy
 2. Sub-total meniscectomy
 3. Meniscal repair using all-inside bioabsorbable arrows/darts
 4. Meniscal repair using inside-out horizontal mattress sutures
 5. Meniscal repair using inside-out vertical mattress sutures

 PREFERRED RESPONSE ▶ 5
 A young patient with a peripheral bucket-handle meniscal tear should be treated
with meniscal repair. While there is a trend towards using more all-inside devices
for smaller tears, the standard for bucket-handle tears is an inside-out repair.
Vertical mattress sutures have been found to be the strongest suture configuration.

Meniscuses references
 Treatment of meniscal tears : an evidence based approach. World J orthop. 2014 jul
18;5(3):233-241
 The knee meniscus: management of traumatic tears and degenerative lesions, EFORT
Open Rev 2017;2.
 The Human Meniscus: A Review of Anatomy, Function, Injury, and Advances in
Treatment, Clinical Anatomy 00:00–00 (2014) 2014 Wiley Periodicals, Inc.
 The Meniscus: Recent Advances in MR Imaging of the Knee. American Journal of
Roentgenology. 2002;179: 1115-1122. 10.2214/ajr.179.5.1791115

Sagittal
Posterior Horn
Anterior Horn
Mid Body

Sagittal
Superior
Surface
Inferior
Surface

Sagittal
Free
Edge
Arthoscopic View

Tears
Bucket
Handle
Tear
Coronal

Tears
Bucket
Handle
Tear
Sagittal

Tears
Bucket
Handle
Tear
SagittalDouble
PCL
Sign Displaced
Meniscus
Normal
PCL

Double
PCL
Sign
Tears
Bucket
Handle
Tear
SagittalTriple
PCL
Sign Displaced
Meniscus
Normal
PCLTorn
ACL

Meniscal injury

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