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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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