MENISCUS TEARS AS WE AGE: DIAGNOSIS AND ...forms.acsm.org/tpc2017/PDFs/21 Hame.pdfMENISCUS TEARS AS...

MENISCUS TEARS AS WEAGE: DIAGNOSIS ANDTREATMENTSharon L. Hame, MDProfessor of Clinical Orthopaedic SurgeryAssociate Team Physician, UCLADavid Geffen School of Medicine at UCLALos Angeles, CA

DISCLOSURES

• Board Member FORUM, awomen’s orthopaedic sportsmedicine society

• Institutional Support for Fellowship• Smith & Nephew• Storz

OBJECTIVES

1. Diagnose an athlete with ameniscus tear

2. Learn the treatment optionsfor a meniscus tear

INTRODUCTION• The most common reason for knee

surgery.• Medial meniscus tears more common

than lateral tears• Older patient degenerative tears

occur most commonly in the posteriorhorn

• In setting of ACL tear, lateral meniscustear more common

FUNCTION OF THE MENISCUS

Force TransmissionIncreases congruency

Contact area = LoadingShock absorption

Transmits 50% weight-bearing load in extension and 85% inflexion

StabilityThe posterior horn medial meniscus is a secondary stabilizerto anterior translation of the tibia.

Lubrication

COMPOSITION• Fibroelastic cartilage• Interlacing network of collagen,

glycoproteins, proteoglycan, and cellularelements

• 65-75% water• Collagen-90% Type 1 collagen• Fibers-allows meniscus to expand under

pressure• Radial• Longitudinal (circumferential)

• Dissipates hoop stresses

ANATOMY OF THEKNEE

• Medial Meniscus• C-shaped with triangular cross section• 9-10 mm wide & 3-5 mm thick

• Lateral Meniscus• More circular

• Can be discoid• Covers more of the articular surface• More mobile• 10-12 mm wide & 4-5 mm thick

MedialLateral

ANATOMY OF THE KNEE

• Attachments• Transverse (intermeniscal) ligament

• Anterior• Connects medial and lateral meniscus

• Coronary ligaments• Peripheral• Lateral meniscus less rigid fixation

• Meniscofemoral ligament• Posterior horn of lateral meniscus to substance of PCL• Humphrey Ligament (anteriorly)• Ligament of Wrisberg (posteriorly)

ACL

Medial Lateral

CLASSIFICATION

• Location• Red-Red Zone

• Outer 1/3,vascularized

• Red-White Zone• Middle third

• White Zone• Inner 1/3,

avascularRed red

CLASSIFICATION

• Pattern• Vertical/longitudinal

• Oblique/flap/parrot beak

• Radial

• Horizontal

• Complex

• Bucket Handle

Complex

Oblique Radial

DIAGNOSIS

• History• Mechanism

• Twisting injury• Degenerative tears may have minimal

trauma

• Pain localized to the medial or lateraljoint line

• Clicking or popping• Locking• Knee swelling• Decreased range of motion

• Locked knee

PHYSICAL EXAMINATION• Knee effusion• Tenderness medial or lateral joint line

• Most sensitive test• Decreased range of motion• McMurray’s Test

• Flex knee• With hand on medial joint line, externally rotate and extend• Positive test: palpable click/pop

• Apley’s Compression Test• Prone, flexed knee, internal/external rotation

• Thessaly Test• Stand with knees at 20 degrees flexion• Twist internal and external• Pain/clicking: positive test

RADIOGRAPHIC STUDIESRadiographs

AP, Lateral, notch, sunrise viewStanding views if possibleUsually normal

MRIHigh Sensitivity-70-98%High Specificity-74-98%Other pathology

Discoid MeniscusBaker’s Cyst

TREATMENT

Conservative Treatment

NSAIDs

Physical therapy

Bracing

Surgical Treatment

Arthroscopy

Meniscal Debridement

Meniscal Repair

• 20F, varsity tennis player• Suffered non-contact L knee injury• C/O knee pain and difficulty with

tennis• Failed conservative management

including medication.• PE

• + effusion• ROM: 0-120• + McMurray’s sign• + lateral joint line tenderness• No instability

Meniscus Tear in a Tennis Player

MRI TENNIS PLAYER

Lateral MeniscusLateral Meniscus

ARTHROSCOPY OF THE KNEE

Lateral Meniscus Posterior Horn

Lateral Meniscus Mid Portion

ARTHROSCOPY OF THE KNEE

Arthroscopy of the Knee

Lateral Meniscus Posterior Horn Debridement

Lateral Meniscus Mid Portion Debridement

MENISCAL REPAIR

• Criteria• Younger age• Red red zone• Red white zone• Size > 1cm

• Types• All Inside• Inside Out• Outside In

Repair

Tear

MENISCAL REPAIR

FAILED MENISCAL REPAIR• 25F w/ right knee pain

medial joint line• Hx of gymnastics injury• Arthroscopy x 2, meniscal

repair• Subjective instability and

buckling sensation withactivity

• Physical exam• 0-140 degrees• TTP over MJL• Positive McMurray’s

test• Bilateral genu varum

FAILED MENISCAL REPAIR

Debridement

DISCOID MENISCUS

Discoid Meniscus

Bow Tie

Wide Lateral Joint Space,Squaring off

Normal

Discoid Meniscus

DISPLACED BUCKET HANDLE TEAR

Displaced Bucket Handle Tear

Double Bundle PCL

Locked knee-Emergent surgery needed

DISPLACED BUCKET HANDLE TEAR

Reduced and Repaired Meniscus

Displaced Bucket Handle Tear

MENISCUS AS WE AGEBaker’s Cyst

Arthritis

ArthritisArthritis

Degenerative Meniscus Tear

• Increased stiffness• Decreased elasticity• Loss of cellular elements• Increase in fibrous tissue• Color Changes-yellow

15 yr. old

CONCLUSIONS

• Meniscus tears are common inathletes.

• Meniscus tears can be treatedconservatively, or with surgeryincluding debridement and repair

• The meniscus changes as we age

BIBLIOGRAPHY1. Arnoczky SP. Gross and vascular anatomy of the meniscus and its role in

meniscal healing, regeneration and remodeling In: Mow VC, Arnoczky SP,Jackson DW, eds. Knee Meniscus Basic and Clinical Foundations, New York, NY:Raven Press; 1992:1-14.

2. Arnoczky SP and Warren RF: Microvasculature of the human meniscus. Am JSports Med 1982; 10: 90-95.

3. Brelim AM, Rue JH. Return to play following meniscus surgery. Clinics Sports Med,2016; 35(4):669-678.

4. De Smet AA, Norris MA, Yandow DR, et al. MR diagnosis of meniscal tears of theknee: Importance of high signal in the meniscus that extends to the surface. AmJ Roentgenol 1993; 161:101-107.

5. Fox AS, Bedi A, Rodeo S: The basic science of human menisci: Structure,composition and function. Sports Health, 2012 4(4): 340-351.

6. Greis PE, Bardana DD, Holstrom MC, Burks RT. Meniscal Injury: 1. Basic scienceand evaluation. J Am Acad Orthop Surg 2002; 10:168-176.

7. McCarty EC, Marx RG, Wickiewicz TL. Meniscal tears in the athlete: Operative andnon-operative management. Physical Med Rehab Clin N Am, 2000;11(4):867-880.

8. Merkel KHM. The surface of human menisci and its aging alterations during age:A combined scanning and transmission electron microscope examination. ArchOrthop Trauma Surg 1980; 97:185-191.

9. Miller GK. A prospective study comparing the accuracy of the clinical diagnosisof meniscal tear with magnetic resonance imaging and its effect on clinicaloutcome. Arthroscopy 1996; 12:406-413.

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