Type Of Meniscal Tear Research Articles

Meniscal Repair and Transplantation: Indications, Techniques, Rehabilitation, and Clinical Outcome

The purpose of this paper is to provide current knowledge regarding the indications, operative techniques, rehabilitation programs, and clinical outcomes of meniscus repair and transplantation procedures. Meniscus tears that occur in the periphery may be repaired using a variety of operative procedures with high success rates. Complex multiplanar tears that extend into the central one-third avascular zone can also be successfully repaired using a meticulous vertically divergent suture technique. The outcome of these repairs justifies preservation of meniscal tissue, especially in younger athletic individuals. Meniscal transplantation is a valid treatment option for patients who have undergone meniscectomy and have related tibiofemoral joint pain, or in whom articular cartilage deterioration in the meniscectomized compartment is present. Rehabilitation after these operations includes knee motion and quadriceps-strengthening exercises initiated the first day postoperatively. The initial goal is to prevent excessive weight bearing and joint compressive forces that could disrupt the healing meniscus repair or transplant. The protocol contains modifications according to the type of meniscal tear, if a concomitant procedure is done (such as a ligament reconstruction) or if noteworthy articular cartilage deterioration is present. Patients who have repairs of peripheral meniscus tears are generally progressed more rapidly than those who have repairs of tears extending in the central one-third region or those who undergo meniscal transplantation. The safety and effectiveness of the rehabilitation program has been demonstrated in several clinical studies. We recommend preservation of meniscal tissue, regardless of age, in active patients whenever possible.

Is There an Association Between Articular Cartilage Changes and Degenerative Meniscus Tears?

The objective of the present study was to evaluate whether horizontal cleavage and complex meniscus tears, which are degenerative tears, are associated with an increased incidence of cartilage damage, in comparison with patients having other patterns of meniscal injury. Case series study. Data were collected prospectively from 497 consecutive knee arthroscopies carried out from 1997 to 2001. Patient data (age, sex, duration of symptoms, injuries, and possible mechanism of injury), operative details (types and number of portals, equipment used), intra-articular findings (articular, meniscal and synovial lesions, and stability characteristics), and procedures performed were recorded. Articular lesions were noted on anatomic articular maps of the different functional zones using a system that presaged the current Internal Cartilage Repair Society system. A comparison of patients with horizontal cleavage and complex meniscal tears to patients with other types of meniscal tear showed for the former (1) increased incidence of chondral lesions (88.4% v 69.6%, respectively, P < .001), (2) increased severity--type III and IV Outerbridge classification--of chondral lesions (52.8% v 29.4%, respectively, P < .001), and (3) increased incidence of patients having more than 1 chondral lesion (65.3% v 33%, respectively, P < .001). Complex and horizontal cleavage meniscal tears are highly associated with an increased incidence and severity of cartilage degeneration compared with other types of meniscal tears. Degenerative meniscus tears are not as benign as was previously thought. New age-related categories of chondral damage are emerging. Level IV, case series prognostic study.

The use of axial reconstructed images from three-dimensional MRI datasets for morphological diagnosis of meniscal tears of the knee

In recent years, three-dimensional (3D) MRI has been utilized to detect meniscal tears and has displayed several advantages over 2D MRI. The diagnostic performance to discriminate the type of meniscal tears by 2D MRI (sagittal and coronal images) and axial images from 3D MRI datasets has not been reported yet. The aim of the present study is to evaluate the efficacy of the axial reconstructed images from 3D MRI datasets for the morphological diagnosis of meniscal tears of the knee. Seventy-four menisci in 37 patients who underwent arthroscopic surgery of the knee were studied. All patients were examined by 2D sagittal and coronal MRI and by axial images from 3D MRI datasets prior to surgery. First, we compared the diagnostic performance for meniscal tears by 2D sagittal and coronal MRI to that by axial images from 3D MRI datasets as judged by arthroscopic findings. Second, we compared the correlation of tear types presumed from 2D sagittal and coronal MRI to arthroscopy with those presumed from axial images from 3D MRI datasets to arthroscopy. For the diagnostic performance of meniscal tears on 2D MRI, the sensitivity, specificity and accuracy were 93.5%, 88.4% and 90.5%, respectively. On axial images from 3D MRI, the sensitivity, specificity and accuracy were 96.8%, 79.1% and 86.5%, respectively. Nine cases were false-positive on axial images, while 5 cases were false-positive on 2D images. Correlations to arthroscopy were 100% by both scans for longitudinal tears and discoid meniscus tears. Only 29% were correctly diagnosed by 2D sagittal and coronal images for radial tears, however, all radial tears could be correctly diagnosed by axial images. All horizontal tears were correctly diagnosed on 2D sagittal and coronal images, while none of the horizontal tears could be correctly diagnosed from axial images. Axial images from 3D MRI datasets were useful in the diagnosis of radial tears, but two limitations are noted concerning the use of axial images. First, medial menisci should be carefully read on axial slices because of the relatively high rate of false-positives on medial menisci. Second, axial images cannot discriminate horizontal tears from other types of meniscus tears.

The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion.

The purpose of our study was twofold: to better understand the relationship between medial meniscal extrusion (MME) and degenerative joint disease (DJD), and to determine whether a relationship exists between MME and medial meniscal root (MMR) pathology, radial tear and joint effusion. Two hundred and five consecutive MR imaging examinations of the knee were prospectively evaluated, regardless of indication, for the presence and degree of MME, medial compartment marginal osteophytes, medial compartment articular cartilage loss, joint effusion, medial meniscal tear and MMR pathology. MME >or=3 mm was considered abnormal. All studies were performed using a 1.5 T GE Signa MR unit with a quadrature knee coil. The standard protocol included oblique sagittal, coronal and axial imaging. We found a strong association ( P<0.0001) between >or=3 mm MME and medial joint line osteophytosis (77%), medial compartment articular cartilage loss (69%), MMR pathology (64%) and radial tear (58%) when compared with knees without these findings. Fifty-one percent of cases with a moderate/large joint effusion had <3 mm MME. We found that 20% (31/155) of patients with minimal or no evidence of DJD had >or=3 mm MME. Of this group, 62% (19/31) had either MMR pathology and/or radial tear, 13% (4/31) had joint effusion as their only abnormality and 6% (2/31) had a normal examination (other than the presence of MME). The remaining 19% consisted of three cases of different types of meniscal tear and three cases of small joint effusions but no other detectable pathology. MME >or=3 mm is strongly associated with DJD, MMR pathology and radial tear. A significant number of cases with no or minimal evidence of DJD (20%) had >or=3 mm MME, suggesting that MME precedes, rather than follows, the development of DJD. We also found that joint effusion was not strongly associated with >or=3 mm MME.

Complex and horizontal cleavage meniscal tears: association with significant cartilage damage (SS-25)

Complex and horizontal cleavage meniscal tears: association with significant cartilage damage (SS-25)

Meniscal tear—a feature of osteoarthritis

Meniscectomy is recognized as an important risk factor for the development of knee osteoarthritis (OA), a disease that traditionally has been considered as a simple "wear and tear" phenomenon. However, despite numerous reports, little evidence has been presented that a limited meniscal resection, compared with a more extensive resection, reduces the risk of OA by preserving meniscal function. Why? This thesis provides one possible answer to that question. Patients, who had undergone isolated meniscal resection in 1973, 1978, or between 1983 and 1985 at Lund University Hospital, Sweden, were reviewed clinically and radiographically 15-22 years after the surgical procedure. Of the subjects (n = 317) almost 50% had developed radiographic OA in their operated knee, but just over half of these patients were symptomatic. An additional 20% of the patients had knee symptoms, but did not have radiographic knee OA. These results confirm a limited correlation between radiographic features of the disorder and symptoms. A degenerative type of meniscal tear and obesity were the factors most strongly associated with both radiographic knee OA and symptomatic radiographic knee OA. Partial meniscal resection induced less radiographic changes related to knee OA compared with total meniscectomy, but the patient-relevant outcomes remained essentially the same. If radiographic hand OA was present there was an increased likelihood of the patient also having knee OA following meniscectomy. This finding was independent of age, and therefore an inherited susceptibility to the disease contributes to the risk of knee OA after meniscal tear. Genetic and environmental risk factors interact in OA development. A degenerative meniscal lesion is often associated with early-stage knee OA, a disorder also involving the meniscal tissue. The tear may thus represent the first "signal" feature of OA. The challenge for the health professional is to discriminate between symptoms caused by a meniscal tear and those caused by OA. Meniscal resection may not benefit the patient with early-stage knee OA. The intervention merely removes evidence of the disorder, while the OA joint degradation proceeds.

Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls.

To investigate long-term radiographic and patient-relevant outcome of isolated limited meniscectomy with regard to type of meniscal tear and extent of surgical resection. We studied 155 patients with intact cruciate ligaments (mean +/- SD age 54 +/- 12 years) who had undergone meniscectomy an average of 16 +/- 1 years earlier. The patients were examined using standardized radiography and validated self-administered questionnaires. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to quantify knee-related symptoms, and the definition of a symptomatic knee was determined. We used 68 control subjects matched for age, sex, and body mass index to calculate the relative risks (RRs). Radiographic tibiofemoral osteoarthritis (OA) (Kellgren/Lawrence grade > or =2) was present in 66 index knees (43%), of which 39 (59%) were considered to be symptomatic according to the KOOS. In total, 77 patients (50%) had a symptomatic index knee. In a multivariate model, degenerative meniscal tears were associated with both radiographic OA (P = 0.030) and combined radiographic and symptomatic OA (P < or = 0.015). The RRs for combined radiographic and symptomatic OA after degenerative and traumatic types of meniscal tear were 7.0 (95% confidence interval [95% CI] 2.1-23.5) and 2.7 (95% CI 0.9-7.7), respectively, compared with matched controls. An isolated meniscal tear treated by limited meniscectomy is associated with a high risk of radiographic and symptomatic tibiofemoral OA at 16-year followup. Factors associated with worse outcome were degenerative meniscal lesions and extensive resections. We suggest that degenerative meniscal tears may be associated with incipient OA, and that the meniscal tear signals the first symptom of the disease.

Natural History of the Post-Meniscectomy Knee

Understanding the natural history of the post-meniscectomy knee and having an appreciation for factors that influence surgical outcome enable the surgeon to individualize patient treatment and optimize results. This article reviews the various biomechanical changes in the knee after meniscectomy. There is a resultant increase in tibiofemoral contact forces proportional to the amount of tissue removed, and an alteration in knee kinematics. Clinical studies that characterized the results after meniscectomy in terms of patient functional outcome and radiographic changes are also reviewed. Several studies have demonstrated that results after meniscectomy are negatively influenced by pre-existing osteoarthritis, chondral damage, anterior cruciate ligament deficiency or other significant ligament injury, extent and location of meniscectomy (lateral vs. medial), type of meniscal tear (degenerative vs. traumatic), and knee malalignment. However, there is no definitive correlation between gender and age and surgical outcome after partial meniscectomy, provided that the knee has no other concomitant pathology.

Patient-relevant outcomes fourteen years after meniscectomy: influence of type of meniscal tear and size of resection.

To study long-term patient-relevant outcomes after meniscectomy, a surgical procedure associated with a high risk of knee osteoarthritis (OA). Principal objectives were to compare traumatic with degenerative meniscal tear and partial with subtotal meniscectomy. We studied a well-defined cohort of 205 patients who had undergone isolated unilateral meniscectomy between 1983 and 1985. There was no previous knee surgery and all knees were stable. The type of meniscal tear and surgical resection was ascertained by review of medical records. Patients were followed up after 14 yr (range 12-15 yr) by self-administered questionnaires, one generic [Short Form 36 (SF-36)] and one disease-specific [Knee Injury and Osteoarthritis Outcome Score (KOOS)]. In a multivariate analysis, using the Sports and Recreation Function and knee-related Quality of Life subscales of the KOOS questionnaire as dependent variables, patients with a degenerative tear scored significantly worse than individuals with a traumatic tear (P < or = 0.001). When we analysed unmatched subgroups and age- and sex-matched patients with degenerative or traumatic lesions, the same result was found for the knee-specific outcome (P < or = 0.02) and SF-36 except for Social Functioning (P < or = 0.04). There was no difference in outcome for the total cohort according to the type of resection. However, subgroup analyses showed that patients who underwent subtotal meniscectomy for a degenerative tear scored significantly worse on the knee-specific outcome than individuals who had had a partial meniscectomy for the same type of tear (P < or = 0.02). The long-term outcome of meniscal injury and surgery appears to be determined largely by the type of meniscal tear. Furthermore, our findings support the use of minimal meniscal resection in the treatment of degenerative tears. We suggest that the disease processes associated with the development of OA of the joint cartilage may also be active in the meniscus, and that a tear in a meniscus with degenerative changes might be regarded as the first sign of OA of the joint.

Effects of the type of meniscal lesion on knee function

The relationship between the type of meniscal lesion (bucket-handle, flap or degenerative tears) and preoperative knee function (5.1±6.2 days before arthroscopic meniscectomy) was studied in 35 patients. Patients with bucket-handle tears (group B, n=12) had large knee extension work deficits during maximal voluntary contractions at 30° and 180°/s (Kin-Com dynamometer). These work deficits were accompanied by proportional decreases in the prime mover or agonist-EMG levels (VM: vastus medialis and/or VL: vastus lateralis). These patients had smaller deficits during flexion movements at 30°/s. Moreover, a larger number of negative clinical signs and symptoms (pain at rest and during tests, locking, thigh atrophy, extension and flexion movement deficits larger than 10°) were found with an equal or a higher prevalence in group B than in the other groups. Patients with flap tears (group F, n=15) had deficits in work and agonist-EMG activity (VM and VL) only during the extension tests. In contrast, patients with degenerative tears (group D, n=8) had a work deficit and a concomitant decrease in the EMG level of the medial gastrocnemius (MG), only during the flexion test at 30°/s. Comparable mean knee function scores, as measured by the Lysholm and Gillquist questionnaire [35], were obtained for the three groups of patients, suggesting that this measure was not sensitive enough to discern functional differences related to types of meniscal tears. The results of this study have demonstrated a link between the type of meniscal lesion and the consequent preoperative knee joint disability profile as defined by comparison with the sound leg. These results emphasize the need to consider meniscal lesion type and an individual's preoperative strength deficit when group comparisons of patients are made or the effects of therapy (arthroscopic surgery and rehabilitation) are evaluated.

Chondrocalcin as a marker of articular cartilage degeneration in anterior cruciate ligament-deficient knees.

This study assessed articular cartilage deterioration and the effect of meniscal tears to evaluate the usefulness of chondrocalcin as a joint fluid marker in 43 patients with anterior cruciate ligament (ACL) deficiency. A significant correlation was found between the cartilage damage and time after injury. The high incidence of long longitudinal tears of the medial meniscus with increased cartilage damage, especially in chronic cases, suggests that this type of meniscal tear contributed to the deterioration of ACL-deficient knees. Chondrocalcin concentrations were found to have a significant correlation with cartilage damage.

Classijications of meniscal tears and principles of arthroscopic meniscal resection

The aim is tO examine meniscal tear types in details and to j/nd out the most suitable methods of surgical treatment. A Classijication system which shows localization of meniscal tears has been built up in order to talk about the various types ofmeniscal tears and to make clinical documentation easy. The principles of resection which is very orthopedie surgeon. The correct approach to the treatment ofmeniscal tears is possible with the understanding of the jimetion, biology and the strueture of the meniscus, its repair and the resection prineiples.

Paradoxical phenomena of the McMurray test. An arthroscopic investigation.

We evaluated 200 patients who had a positive McMurray test and found atypical McMurray test results in 24 patients (12%). These patients revealed pain or clicking or both either in the medial compartment of the knee when the leg was internally rotated or in the lateral compartment of the knee when the leg was externally rotated. The authors analyzed these paradoxical findings at arthroscopic examination to identify the relationship between the type of meniscal tear and the direction of leg rotation that elicited the catching and displacement of the torn meniscal portion during the McMurray test. Contrary to conventional McMurray test findings, three different types of meniscal tears were found on the side of the knee where pain or a clicking sound occurred. The three types were 1) anteriorly based posterior oblique tears with anterior displacement of the meniscus, 2) bucket-handle tears in the posterior half of the menisci, and 3) peripheral detachment of discoid menisci in the posterior half of the torn portions.

MRI appearance of meniscal cysts

The purpose of this study was to review the MRI criteria for the distinction of meniscal cysts from other cystic lesions in the knee so that appropriate treatment may be planned. A retrospective review of 62 knee MRI scans possibly showing meniscal cysts was performed. The type of meniscal tear, the appearance of the connection between the cyst and the meniscal tear, and the location, size, morphology, and signal characteristics of the meniscal cysts were recorded. Other types of fluid collections that had been mistaken for meniscal cysts were described. Sixty-two patients were studied, ages 16-79 years, 61% male, 39% female. Most of the meniscal cysts (91%) occurred immediately adjacent to the meniscal tear (98% horizontal cleavage tears, 49% anterolateral), with the tear leading directly into the cysts. In two cases, the cyst had dissected into the soft tissues distant from the meniscus and a connecting stalk was visualized. Fluid collections in normal bursae and recesses that had been mistaken for meniscal cysts had no direct connection to a meniscal tear. MRI can be used to distinguish meniscal cysts from other fluid collections that may mimic meniscal cysts. Pitfalls can be avoided by familiarity with the normal bursal and capsular anatomy, and by the application of specific diagnostic criteria.

Partial lateral meniscectomy in athletes

Arthroscopic partial lateral meniscectomies performed for isolated meniscal tears, without associated ligamentous injury, in 41 athletes between August 1, 1988 and June 1, 1991 were reviewed for clinical and functional outcome. The study population was composed of 27 males and 14 females, with an average age of 26 years (range 17-40). Thirty-seven patients (90%) reported previous trauma to the knee. At an average follow-up of 3 years (range 2-5), 85% of the patients had excellent/good results, and 98% of the athletes returned to full sports activities after an average of 55 days. Patients' prognoses depended on (a) type of meniscal tear and (b) presence/absence of an articular cartilaginous lesion. Athletes who had isolated, longitudinal type tears of the lateral meniscus had the best outcome: 100% achieved excellent/good results and averaged 41 days to return to full sports activities. Athletes with complex meniscal tears and tears associated with articular cartilaginous lesions had the poorest results, achieving 79% and 64% excellent/good results, respectively, and averaging 64 and 78 days, respectively, for return to full sports activities.

The arthroscopic meniscal repair. Techniques and clinical experience.

Conservative meniscal repair should limit resection to only pathologic portions of the meniscus. The periphery of the meniscus is well vascularized, enabling healing of longitudinal tears. Sutures that perforate the meniscus vertically usually lead to stable healing. In arthroscopic meniscal surgery, isolated tears are sutured from within the joint, usually using techniques related to specially developed instrumentation. Our system uses three curved cannulas of various radii and a specific needle of 1.2 mm thickness, and can be operated by one hand while the joint is distracted with an AO/ASIF femoral distractor. In our series of 54 arthroscopic meniscal repairs, 42 (78%) healed without reinjury. Retears occurred in 12 patients, and were refixed again using the same techniques. Our experience has led us to conclude that the type of meniscal tear most suitable for arthroscopic repair is a vertical longitudinal lesion that involves the vascularized zone; abrading the synovial surfaces is helpful, as is positioning the sutures tightly together; the repair should be checked at 4 months by arthroscopy or by arthrogram; and a combination of nonabsorbable and resorbable sutures is most satisfactory. We believe that with experience arthroscopic meniscal repair becomes a less involved procedure than open repair, and that in the future such repair will be successfully extended to the more centrally located lesions.

Meniscectomy in children: a long-term follow-up study.

In order to more accurately document the effects of meniscus removal, 20 children and adolescents with isolated meniscal tears were examined an average of 5.5 years after surgery. All patients with concomitant ligamentous injuries and a history of prior surgery on either knee, and those with bilateral knee pathology or knee pathology outside the meniscus, were excluded. At followup, 60% of the 20 study patients had unsatisfactory results. The clinical results did not correlate with the site of meniscectomy, the type of meniscal tear, the severity of radiographic changes, or whether the patient had total or partial meniscectomy. Evaluation of lower extremity muscle function revealed a statistically significant (P less than 0.05) decrease in hip abductor strength in patients with unsatisfactory results. This study indicates that meniscectomy in the child or adolescent is not a benign procedure, and that failure to rehabilitate hip abductor strength to normal levels significantly comprises the clinical end results.

Injuries of the knee joint.

Five thousand meniscectomies, well studied and documented by the author, constitute an experience that allows for broad statistical comparisons of each and every type of meniscal tear and its probable mechanism of production. Associated injuries of ligaments and likely sequelae are clearly categorized as to expectations from normal repair, while abundant diagnostic hints indicate the circumstances when these expectations can be improved by surgical repair. Perhaps the greatest value of the book is the author's instructive chapter on Surgical Anatomy and Physiology of the Menisci, which creates an image that makes the remainder of the book easy reading. The tables of incidence, the predictability of outcome, and the likelihood or accuracy of diagnosis would, in themselves, serve as yardsticks of expectations against which to judge the individual case. Any doctor or medical team who encounters knee injuries, whether sustained from sports or industry, must have this book available. The volume