MENISCAL TEARS

PROF.DR.K.PRAKASAM

M.S.Ortho,D.Ortho,DSc(HON)

MODERATOR:PROF.DR.A.E.MANOHARANPRESENTOR:DR.THOUSEEF A MAJEED

ANATOMY

Menisci is a crescentric shaped

fibro cartilagenous structures

between the condyles of femur &

tibia

Peripheral edges are thick,

convex& fixed to inner surface of

capsule.

Triangular in cross section

Covers peripheral 2/3 rd of

articular surface.

Each menisci has

2 ends---- anterior and posterior horns

2 borders----outer and inner border

2 Surfaces ---upper and lower

Attachments to Tibia

• Margins – Coronary ligaments

• Inter condylar area – by Horns

• To Medial Collateral Ligament

Attachments to FEMUR

1)Menisco femoral ligaments.

Ligament of Humphrey(anterior

menisco femoral)

Ligament of Wrisberg(posterior

menisco femoral)

2) To Popliteus tendon

To each other- transverse ligament.

BLOOD SUPPLY

Superior & Inferior

branches of medial &

lateral geniculate arteries

Perimeniscal capillary

plexus within the synovium

& capsule

VASCULAR ZONES

Red-red zone-fully vascular

Red-white :minimal blood

supply

White-white: fully avascular

FUNCTIONS OF MENISCI

Joint lubrication

Joint stability- ( rotary)

Joint nutrition

Shock absorbers-reduce the stress on articular cartilage

Load bearing function

Deepening the cavity

Prevents impingement during joint motion.

Medial meniscus – provides stability to Anterior

Cruciate Ligament deficient knees.(ACL)

History

• 1773- William Bromfeild- meniscal locking

• 1803- William Hay – Internal Derangement of Knee.

• 1834-John Reid- Pathology of Meniscal tear.

• 1885- Thomas Annan Dale-Operation for displaced

meniscal tear.

• 1918-Kenji Takagi-Cystoscope into a cadaveric knee

• 1928- McMurray- sign of torn meniscus

• 1962 – Arthroscopic surgery begins

MENISCAL INJURIES

Injury with rotational force ,on a partially flexed knee

.Eg:Foot ball players,Kabadi players

Most common site- posterior horn

Most common type- longitudinal tear

Length ,depth, position of tear– position of the

meniscus in relation to condyles at the time of injury.

Pedisposing Factors

Trauma

Meniscal cyst

Decreased mobility of the meniscus

Discoid meniscus

Aging- degeneration

Abnormal mechanical axis- ligamentous laxity.

Congenitaly relaxed joints

Inadequate tone and musculature.

O’CONNOR CLASSIFICATION OF TEARS

1. Longitudinal tears

2. Horizontal tears

3. Oblique tears

4. Radial tears

5. Variations-flap tears

complex tears

( degenerative )

LONGITUDINAL TEARS

Most common

young

Post trauma

2 types-

Vertical incomplete tear

Vertical complete

Displaced tear

(bucket handle)

HORIZONTAL TEARS

Extend from inner margin to

capsule horizontally

Common in posterior horn of

medial meniscus & lateral

meniscus

OBLIQUE TEARS

Full thickness extending obliquely

from the inner margin into the body

Types

Anterior oblique or posterior oblique

Commonly seen at the junction of

middle & posterior 1/3 of medial

meniscus

RADIAL TEARS

Extend radially from inner margin

into the body

Common in middle 1/3 of lateral

meniscus

3 types - complete

-incomplete

-parrot beak tear-(Radial

tear with longitudinal or oblique

extension)

FLAP TEARS

Oblique tears with a

horizontal cleavage

Superior or inferior

Degenerative

COMPLEX TEARS

Combination of all the above

Common in chronic meniscal lesions & degenerative

menisci

Predisposing conditions:

* Discoid lateral meniscus

*Meniscal cyst

*Calcium pyrophosphate deposition

Lateral meniscus Tears

• Less common

- Lateral meniscus is more mobile

- not attached to the ligaments

-Forcible external rotation of femur on fixed tibia with

knee in flexion.---anterior horn tear

-Medial rotation of femur on fixed tibia followed by

violent flexion- posterior horn tear

• Less chance of bucket handle tear

• More chance for transverse tear

• Common location –posterior horn

• Common type---longitudinal horn

• Length, depth and position of tear depend on the position

of the meniscus in relation to femur and tibia

Tears associated with Cystic degeneration

• Trauma ---- degeneration or secondary mucinous

changes in the periphery.

Tears associated with congenital anomalies• Discoid meniscus hyper mobility

Clinical diagnosis

History

• May be asymptomatic

• Pain

• Sports injuries

• Trauma

• Giving way

• Locking

Physical signs

• Effusion

• Quadriceps wasting

• Joint line tenderness

• Limitation of movements.

Special tests.

• Mc Murray test.

• Apley’s grinding test

McMurray test

• Fully flex the knee

• Externally rotate the leg

• Keep the fingers on the medial joint

line.

• Slowly abduct and external rotate

the knee.

• Click and pain is indicative

Fully flex ,internally rotate and extend the leg.

If a click or pain elicit confirms this after examining

the other normal knee for clicks of other origins like

tendon and soft tissues snapping etc.

Apleys grinding test• Prone position

• Bend examiner knee and press the

patients thigh .

• Hold the ankle and the foot by both

hands

• Compress the leg down wards and

rotate internaly and externally.

• If patient elicit pain it indicated

meniscal tear

DIFFERENTIAL DIAGNOSIS

• Loose bodies

• Osteochondritis dissecans

INVESTIGATIONS

• X-Ray-Antero posterior ,lateral view of knee &

intercondylar notch view

• Magnetic Resonance Imaging (MRI)-sensitivity

• Arthroscopy

• Arthrography

Magnetic Resonance Imaging (MRI)

Grade I –increase in signal,not extending to articular

surface

Grade II- linear increased density,not extending to

articular surface

GradeIII-signal extending to articular surface

ARTHROSCOPY

• Gold standard for diagnosis and treatment

• Thorough inspection of menisci, ligaments &cartilage

is possible

• Anteromedial or anterolateral portals

• Full extent ,type, site of tears & degenerative changes

can be seen

HEALING OF MENISCUS

Determined by blood supply

Fibrin clot formation

Proliferation of vessels into fibrin scaffold

Proliferation of differentiated mesenchymal cells

Cellular fibro-vascular scar formation

HEALING RESPONSE

Radial tears healed with fibrocartilaginous scar- 10

weeks

Maturation of scar takes longer.

MANAGEMENT

• NON- SURGICAL

• SURGICAL

NON SURGICAL MANAGEMENT

Indications

Incomplete meniscal tear

A small stable peripheral tear (5mm) without any other

injuries.

Conservative treatment

Grion-ankle cylindrical cast -4 x 6 weeks

Toe-touch partial weight bearing

Rehabilitative exercise program for 6 weeks to

strengthen quadriceps, hamstrings, gastro-soleus

&hip.

OPERTIVE MANAGEMENT

Meniscal repair

Meniscectomy

Enhancement of meniscal repair

Meniscal allograft

Meniscal repair

Depend on the location of the tear, its morphology and

patients factors

Peripheral tear--- Red on Red region

Also on red on white region

Size <1-2 cm

Vertical longitudinal tears are ideal

Meniscal Repair

young patient shows better outome

Can be done Open or Arthroscopicaly

Meniscal repair-Contarindication

Tear>3 cm

Transverse tear even in periphery

Flap tear, radial tear, vertical tear with secondary

lesions.

Ligament instability

OPEN MENISCAL REPAIR

• For posterior 1/3rd tear not more than 2mm from the

menisco synovial junction

Advantage

• More precise suture placement

• Sutures placed vertically through meniscus

• Better preparation of site

ARTHROSCOPIC MENISCAL REPAIR

• Patient selection

• Tear debridement of local synovial , meniscal and

capsular abrasions

• Suture placement

SUTURE TECHNIQUES

• Inside-out : Gold standard

• Outside-in

• All inside

INSIDE- OUT TECHNIQUE ( Gold Standard)

• Use zone specific canulas to pass sutures

• Sutures are attached to flexible needle

• Brought out through a posterior skin incision

• Advantage

:can be used in post.1/3 tear

• Disadvantage

: neurovascular injury

costly

OUTSIDE IN TECHNIQUE

• Sutures passed percutaneously across the tear through

18 G spinal needle

• Knot is tied inside the joint

• Repeated every 4-5mm

• Advantage: simple,

safe and cheap

• Disadvantage: cannot be used for posterior.1/3rd tears

ALL INSIDE TECHNIQUE

• For repair of posterior horn peripheral tear

• Needle is inserted into the meniscus & exits within the joint

• Specialised instrumentation needed.

• Allows placement of vertical sutures

Arthroscopic Repair- Disadvantages

Difficulty in intraarticular knot tying

No long term clinical studies

Time away from sports.

After care

Limit knee flexion to 90 degree

Low impact activity for 3months

Full activity after 6months

Bio-absorbable implants

Poly glycolic acid.

Poly levolactic acid.

Raecemic poly lactic acid.

Poly dexanone.

All these materials degrade into CO2 and water

Devices includes Anchors, Arrows, screws and

staplers.

Meniscal repair associated with Anterior cruciate ligament (ACL)

There is 30-40% failure rate .

Repair Anterior cruciate ligament first followed by

meniscal repair

MENISCECTOMY

3 types

• Partial

• Subtotal

• Total

Methods

• Open

• Arthroscopic

PARTIAL MENISCECTOMY

• Less articular cartilage degeneration

• Excision of only torn portion of meniscus .

Indications

• Tears >5mm from menisco-synovial junction.

• Flap tears

Complex and horizontal.

Treatment of choice in young adults who require

vigorous activities.

Advantage

Short operating time.

TOTAL MENISCECTOMY

Indication:

• Meniscus is detached from its periphery.

• Indicated in extensive meniscal tears and degenerative

SUBTOTAL MENISCECTOMY

• Complex tears of posterior horn

• Anterior horn & portion of mid 1/3 of meniscus is

preserved

OPEN –OR- ARTHROSCOPIC ?

Long term results of arthroscopic meniscectomy are

comparable to skilful open partial meniscectomy.

APPROACHES

Medial meniscectomy

Single anterio medial

Second incision:Henderson posteromedial incision

Lateral meniscectomy

Antero-lateral

Anterolateral+posterolateral

Postoperative

Compressive bandage

Knee immobilized in extension for 1 week

Quadriceps exercises on next day.

Crutch walking with partial weight bearing on next day

Isometric exercises continued till 90 degree of flexion.

Complications

Haemarthrosis

Chronic Synovitis

Synovial fistulae

Painful neuromas

Thrombophlebitis

Infection

Late degenerative arthritis

Reflex sympathetic dystrophy

FAIRBANK’S CHANGES

• Post meniscectomy change

• Narrowing of joint space

• Flattening and squaring of femoral condyle

• Antero posterior osteophyte formation

Regeneration of menisci after excision

• After complete meniscectomy – fibrous regeneration

with in 6 weeks to 3 months

• Thinner and narrower than normal meniscus

• Decrease surface area and mobility.

Meniscal transplantation

• No long term study at present

• Meniscal allografts available.

• Survival rates better in patients with no degenerative

changes.

• Correctly sized implants with attached bone blocks

recommended.

Meniscal transplantation

• Allograft and auto graft replacement

• Quadriceps, patellar tendon & infrapatellar pad of fat

are used as allogenic substitutes for meniscus

• No uniformly satisfactory results.

Meniscal transplantation

RECENT ADVANCES

Bioabsorbable meniscal fixators (meniscal dart,arrow)

Collagen meniscus implant-from bovine achilles tendon

Synthetic scaffolds

Future- gene therapy & Stem cells