Upload
dr-thouseef-abdul-majeed
View
87
Download
0
Embed Size (px)
Citation preview
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