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10

Meniscal Injury

Topic updated on 02/07/16 1:51pm
Introduction
  • Epidemiology
    • most common indication for knee surgery
    • higher risk in ACL deficient knees
  • Location
    • medial tears
      • more common than lateral tears
        • the exception is in the setting of an acute ACL tear where lateral tears are more common
      • degenerative tears in older patients usually occur in the posterior horn medial meniscus
    • lateral tears
      • more common in acute ACL tears
Anatomy
  • Anatomy of meniscus
Classification
  • Descriptive classification
    • location
      • red zone (outer third, vascularized)
      • red-white zone (middle third)
      • white zone (inner third, avascular)
    • size
    • pattern
      • vertical/longitudinal
        • common, especially with ACL tears
        • repair when peripheral
      • bucket handle
        • vertical tear which may displace into the notch
      • oblique/flap/parrot beak
        • may cause mechanical locking symptoms
      • radial
      • horizontal
        • more common in older population
        • may be associated with meniscal cysts
      • complex
Presentation
  • Symptoms
    • pain localizing to medial or lateral side
    • mechanical symptoms (locking and clicking)
    • delayed or intermittent swelling
  • Exam
    • joint line tenderness is the most sensitive physical examination finding 
    • effusion
    • provocative tests
      • Apley compression
      • Thessaly test
        • standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking.
      • McMurray's test
        • flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension.
        • a palpable pop or click is a positive test and can correlate with a medial meniscus tear.
Imaging
  • Radiographs
    • Should be normal in young patients with an acute meniscal injury
    • Meniscal calcifications may be seen in crystalline arthropathy (ex. CPPD)
  • MRI
    • indications
      • MRI is most sensitive diagnostic test, but also has a high false positive rate 
    • findings
      • MRI grade III signal is indicative of a tear- linear high signal that extends to either superior or inferior surface of the meniscus  
      • parameniscal cyst indicates the presence of a meniscal tear
      • may see "double PCL" sign that indicates a bucket-handle meniscal tear
Treatment
  • Non-operative
    • rest, NSAIDS, rehabilitation
      • indications
        • indicated as first line of treatment for degenerative tears
  • Operative
    • partial meniscectomy
      • indications
        • tears not amenable to repair (complex, degenerative, radial tear patterns)
      • outcomes
        • >80% satisfactory function at minimum follow-up
        • 50% have Fairbanks radiographic changes (osteophytes, flattening, joint space narrowing)
        • predictors of success
          • age <40yo
          • normal alignment
          • minimal or no arthritis
          • single tear
    • meniscal repair
      • indications
        • best candidate for repair is a tear with the following characteristics
          • peripheral in the red zone (vascularized region)
          • rim width is the distance from the tear to the peripheral meniscocapsular junction (blood supply).
          • rim width correlates with the ability of a meniscal repair to heal (lower rim width has better blood supply)
          • vertical and longitudinal tear
          • 1-4 cm in length
          • acute repair combined with ACL reconstruction
      • technique (see below)
      • outcomes
        • 70-95% successful
        • highest success when done with concomitant ACL reconstruction
        • poor results with untreated ACL-deficiency (30%)
    • meniscal transplantation
      • indications  
        • young patients with near total meniscectomy, especially lateral
      • contraindications
        • inflammatory arthritis
        • instability
        • marked obesity
        • grade IV chondrosis (if not concurrently addressed)
        • malalignment (if not concurrently addressed)
        • diffuse arthritis
      • technique (see below)
      • outcomes
        • requires 8-12 months for graft to fully heal
        • return to sports by 6-9 months 
        • 10 year follow-up showed:
          • persistent improvement in subjective pain and function scores
          • most had radiographic progression of degenerative changes
        • re-tears or extrusion are common 
    • total meniscectomy
      • of historical interest only
      • outcomes
        • 20% have significant arthritic lesions and 70% have radiographic changes three years after surgery
        • 100% have arthrosis at 20 years
        • severity of degenerative changes is proportional to % of the meniscus that was removed
Techniques
  • Partial Meniscectomy
    • approach
      • standard arthroscopic approach
    • technique
      • minimize resection (DJD proportional to amount removed)
      • do not use thermal (heat probes)
    • postoperative
      • early active range of motion
      • prolonged immobilization (10 weeks) is detrimental to healing in a dog model
  • Meniscal repair
    • approach
      • inside-out technique
        • considered gold standard
        • medial approach to capsule
          • expose capsule by incising the sartorius fascia, retracting the pes tendons and semimembranosus posteriorly, and developing the plane between the medial gastrocnemius and capsule.
        • lateral approach to capsule
          • expose capsule by developing plane between the iliotibial band and biceps tendon interval, then retract lateral head of gastrocnemius posteriorly.
      • all-inside technique (suture devices with plastic or bioabsorbable anchors)
        • most common
        • many complications (device breakage, iatrogenic chondral injury)
      • outside-in repair
        • useful for anterior horn tears
      • open repair
        • uncommon except in trauma, knee dislocations
    • technique
      • vertical mattress sutures are strongest because they capture circumferential fibers
      • healing is enhanced by rasping
    • risks
      • saphenous nerve and vein (medial approach)
      • peroneal nerve (lateral approach)
      • popliteal vessels
  • Meniscal Transplantation
    • technique
      • bone to bone healing with plugs at each horn or a bridge between horns
      • peripheral vertical mattress sutures
      • correct sizing of the allograft is essential  (commonly based on radiographs, within 5-10% error tolerated) 

 

Complications
  • Saphenous neuropathy (7%)
  • Arthrofibrosis (6%)
  • Sterile effusion (2%)
  • Peroneal neuropathy (1%)
  • Superficial infection (1%)
  • Deep infection (1%)

 

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Qbank (15 Questions)

TAG
(SBQ07.7) An 18-year-old competitive tennis player sustains a twisting injury to his knee. He develops pain and swelling and is unable to straighten his knee. The MRI is shown in the Figure A. What is the most approriate treatment? Topic Review Topic
FIGURES: A          

1. Arthroscopic medial meniscectomy or repair
2. Arthroscopic lateral meniscectomy or repair
3. Meniscus transplantation
4. Physical therapy with gradual stretching exercises
5. Corticosteroid injection for acute inflammation

PREFERRED RESPONSE ▶
TAG
(SBQ07.8) Splitting between the iliotibial band and biceps tendon, then retracting the gastrocnemius posteriorly provides exposure for which of the following procedures? Topic Review Topic

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

PREFERRED RESPONSE ▶
TAG
(SBQ07.22) Following meniscal repair, saphenous nerve injury is more common with which of the following techniques? Topic Review Topic

1. Inside-out lateral repair
2. All-inside lateral repair
3. Inside-out medial repair
4. All-inside medial repair
5. Equal rates for both lateral and medial

PREFERRED RESPONSE ▶
TAG
(SBQ07.44) All of the following variables have a negative impact on the outcomes of isolated meniscal allograft transplantation EXCEPT? Topic Review Topic

1. Axial malalignment
2. Anterior cruciate ligament insufficiency
3. The use of a fresh frozen graft
4. Femoral condyle flattening
5. Graft size mismatch of 15%

PREFERRED RESPONSE ▶
TAG
(SBQ04.31) A young athlete sustains an isolated meniscal tear and undergoes arthroscopy. The surgeon performs a meniscal repair. Which of the following factors is most important in determining healing rates? Topic Review Topic

1. Days from injury to repair
2. Medial versus lateral meniscus
3. Width of the meniscal rim
4. Use of growth hormone
5. Dominant versus non-dominant leg

PREFERRED RESPONSE ▶
TAG
(OBQ11.93) The meniscal injury pattern of the left knee seen in the arthroscopic video shown in Figure A is best described as which of the following? Topic Review Topic
FIGURES: V          

1. Medial horizontal cleavage tear
2. Lateral radial tear
3. Medial parrot beak-type tear
4. Medial displaced bucket-handle tear
5. Lateral cyclops tear

PREFERRED RESPONSE ▶
TAG
(OBQ10.90) An 18-year-old football player sustained a twisting injury to his knee approximately 1 month ago. He complains of continued knee pain with occasional locking and catching. Figure A demonstrates the injury on a T1 sagittal MRI. What physical exam finding is classically seen with this injury? Topic Review Topic
FIGURES: A          

1. No endpoint with valgus stressing of the knee
2. Positive apprehension sign with passive lateral patellar translation
3. Painful click is elicited as the knee is brought from flexion to extension with internal or external rotation
4. No endpoint with varus stressing of the knee
5. A positive posterior drawer and quadriceps active test

PREFERRED RESPONSE ▶
TAG
(OBQ07.192) Which of the following is NOT a contra-indication to isolated medial meniscal transplantation? Topic Review Topic

1. ACL deficiency
2. Patient age over thirty
3. Inflammatory arthritis
4. Varus alignment
5. Grade IV chondromalacia

PREFERRED RESPONSE ▶
TAG
(OBQ06.9) A "double PCL sign" seen on a sagittal MRI image of a knee is indicative of which of the following conditions? Topic Review Topic

1. Skeletal immaturity
2. ACL tear
3. PCL injury
4. Combined ACL and PCL tear
5. Bucket-handle meniscal tear

PREFERRED RESPONSE ▶
TAG
(OBQ06.88) 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? Topic Review Topic

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 ▶
TAG
(OBQ05.260) 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? Topic Review Topic

1. Increased blood supply
2. Increased elesticity
3. Increased type II collagen
4. Increased type I collagen
5. Increased glycosaminoglycan content

PREFERRED RESPONSE ▶
TAG
(OBQ04.270) A 19-year-old male is playing football and hears a pop in his left knee during a tackle 12 days ago. He was unable to return to the game and reports a large amount of swelling in the knee. On examination today he lacks full extension. A coronal and sagittal MRI is shown in Figures A and B, respectively. Which of the following is the best next step in management. Topic Review Topic
FIGURES: A   B        

1. Rest and icing followed by physical therapy for definitive management
2. Arthroscopic removal of osteochondral loose body
3. Arthroscopic meniscus repair followed by immediate joint mobilization
4. Physical therapy for immediate joint mobilization followed by delayed arthroscopic PCL reconstruction once ROM is near normal
5. Immediate ACL reconstruction

PREFERRED RESPONSE ▶
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