Our preferred repair method utilizes a two-tunnel transtibial pull-out technique. Common tears include bucket handle, flap, and radial. Reactive synovitis and edema (arrowheads) are readily apparent deep to the tibial collateral ligament on the coronal view. Identification of a meniscal root tear on MRI may be challenging due to the relatively small size of the root. (16a) Sagittal and (16b) axial proton density weighted images reveal a very large radial tear (arrows) that extends broadly across the entire width of the anterior body of the lateral meniscus. This technique allows for anatomic reduction and fixation of the meniscal root by restoring the joint contact pressure and area similar to the intact state. Henning C, Lynch M, Clark J. Vascularity for healing of meniscus repairs. Age of injury peaks at 2029 years.7 Partial meniscectomy (removal of the torn section) is one of the most commonly performed orthopaedic surgical procedures.8. The one towards the back of leg is the posterior horn. X-rays and MRIsallow the doctor to evaluate the bone and soft tissue at the knee. Radiology 2000; 217:193-200. More often, the patient will complain of joint line pain with a minor traumatic event, such as squatting. Vertical flap (oblique, flap, parrot's beak) tears are unstable tears and occur in younger patients. However, anyone at any age can tear the meniscus. Rosemont, Ill. American Academy of Orthopaedic Surgeons. Damaged avascular meniscus must be removed.27 However, meniscectomy causes long term osteoarthritis,28 so is only performed when the patient suffers joint locking or mensical pain that is refractory to conservative management. An MRI scan assesses the soft tissues in your knee joint, including the menisci, cartilage, tendons, and ligaments. Reciprocally, an increased force is also placed on an ACL graft with a deficient medial meniscus. Currently, routine MR images do not reveal signal intensity differences between the red and white zones of the menisci. It is important to describe your symptoms accurately. They will also consider the type, size, and location of the injury. In fact, the tear will most likely get bigger leading to additional damage if not taken care of soon. 1993;9(1):33-51. 1 article features images from this case The medial meniscus is more frequently torn, partly because of this different shape but also because of its attachment to the medial collateral ligament, whereas the lateral is pulled out of the way of compression between femur and tibia by politeus. Conservative management of the patient with a meniscal tear. The best known displaced tear that is amenable to repair is the bucket-handle tear. Seldom are they the sign of a problem. The tear can be seen as a white line through the dark body of the meniscus. 1890 LPGA Blvd., Suite 240 Daytona Beach, FL 32117, Port Orange North & South https://orthop.washington.edu/patient-care/articles/sports/torn-meniscus.html, Phone Medial and lateral menisci are crescent-shaped fibrocartilage structures that provide joint congruity, stabilization and lubrication and act as shock absorbers for joint preservation. 1) [50], [51], [52].Its reported prevalence in middle-aged (45-55 years) individuals . Choose a doctor and schedule an appointment. In other words, when the majority of the meniscus forms the handle, that requires tear formation near the meniscal periphery, resulting in a vascular site for operative repair. Every care is taken to reproduce articles accurately, but the publisher accepts no responsibility for errors, omissions or inaccuracies contained therein or for the consequences of any action taken by any person as a result of anything contained in this publication. 7 Yao L, Stanczak J, Boutin RD. You might feel a pop when you tear the meniscus. The surgery requires a few small incisions and takes about an hour. At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. This information is not intended as a substitute for professional medical care. In younger patients, this is typically a twisting force on a weightloaded flexed knee. In addition to the root tear, the MRI often shows chondral loss or fissuring, other areas of meniscal tearing, bone marrow edema or osteophyte formation (Figure 5). How is Oblique Fracture Treated? If you continue to use this site we will assume that you are happy with it. Arthroscopy. Lufkin R. The MRI manual. 11 Noyes FR, Barber-Westin SD. Pain and/or clicking on compression suggest a meniscal lesion 1,32, Figure 3. Knee arthroscopy is one of the most commonly performed surgical procedures. Research is currently investigating the possibility of implantation of collagen, allogenic and xenogenic cells, embryonic and adult stem cells, or scaffolds derived from polymers, hydrogels, tissues and extracellular matrix,7 and action of biological stimuli (eg. Sekiya JK, West RV, Groff YJ, Irrgang JJ, Fu FH, Harner CD. If the knee is still painful, or if it locks, your doctor may recommend surgery. 14 Marzo JM, Kumar BA. This most often happens when the tear develops over a period of time. Oblique tears commonly cause flaps and flaps are generally not good. Psterior horn of medial meniscus Poterior oblique ligament . The second patient reviewed in this video is an 11-year-old girl who fell while playing tag and hit the front of her left lower leg. Both longitudinal and radial tears may appear vertical on MR images (5a,6a), but longitudinal tears extend parallel to the c-shaped circumference of the meniscus, whereas radial tears lie perpendicular to the meniscal circumference. These are the horns. (6a) A radial tear of the body of the lateral meniscus also appears vertical on sagittal MR images (arrow), though in the case of radial tears, the lesion is oriented perpendicular to the c-shaped fibers of the meniscus. Knowing where and how a meniscus was torn helps the doctor determine the best treatment.. Complex or degenerative tears are where two or more tear patterns exist. For these, please consult a doctor (virtually or in person). It is caused by direct impact in contact sports or twisting. Making a medial meniscal root tear diagnosis is difficult because the typical history of locking, catching or giving way is less likely to be present. Jul 2000;35(3):217-30. 6 It absorbs shock in your knee and keeps it stable. If you have a meniscus tear, this movement may cause pain, clicking, or a clunking sensation within the joint. Arthroscopic repair of isolated meniscal tears in patients 18 years and younger. Call us today at (410) 644-1880 or (855) 4MD-BONE (463-2663) to schedule an appointment. New advances in musculoskeletal pain. The arthroscope is inserted near the knee via a tiny incision. The Royal Australian College of General Practitioners, 100 Wellington Parade, East Melbourne, Victoria 3002, Australia. Complex tears like this are likely to be unstable. Unhappy Triad: Stress is put on medial side of the knee which potentially tears three related structures ICD 9 Codes: 717.4 derangement of the lateral meniscus 717.3 derangement of the medial meniscus 836.0 lateral meniscus tear 836.1 medial meniscus tear Case Type / Diagnosis: Functional Anatomy: The menisci are semi lunar shaped cartilages on the medial and lateral sides of the knee joint. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. The treatment of these type of tears can be either arthroscopy (surgery through a tiny hole in knee) or conservative. MR is also able to assess the stability of meniscal tears,6 an important factor, as unstable tears require operative treatment for symptom relief. McMurray (Figure 1) and Apley tests (Figure 2) are often positive, although these are specific but not sensitive specificity being 5798% and 8099%, and sensitivity being 1066% and 1658% respectively.2,9 The most useful clinical test for meniscal injury is the Thessaly test, which is demonstrated in Figure 3. Although a successful outcome of a meniscal root repair is predicated upon appropriate indications for the repair, not all medial meniscal root tears should be repaired. Also know what the side effects are. A loose piece of cartilage can get stuck in the joint, causing the knee to temporarily lock, preventing full extension of the leg. RICE stands for Rest, Ice, Compression, and Elevation. What is Meniscus Radial Tear. A longitudinal tear is an example of this kind of tear. A meniscal cyst may present with signs and symptoms consistent with typical meniscal pathology. This leads to decreased contact area and increased contact pressure and ultimately results in joint overloading and degenerative changes in the knee similar to a total meniscectomy state. The loss of the central attachment of the posterior horn may allow extrusion of the body of the meniscus relative to the joint (13a). All rights reserved. If the fracture is stable or closed where the bones do not move out of alignment then simple immobilization with the use of a sling, splint or cast for a few weeks allowing the fracture to heal may be enough. Meniscal tear incidence may be as high as six per 1000 population6 with a 2.5 to 4 times male predominance. No meniscal tears were observed. These tendons have poor blood supply and will not heal themselves. Thessaly test: The clinician holds the patient's outstretched hands for support, while the patient stands flat-footed with their knee flexed to 20 degrees and rotates their body and knee three times, internally and externally. Meniscus tears are extremely common knee injuries. I have an oblique tear of the posterior horn of the medial meniscus, what is the treatment for that? The meniscus is a piece of rubber-like cartilage in the knee situated within the femur and tibia, or thigh bone and shin bone. Question options: . Meniscal tears may be categorized into five common configurations, including horizontal, longitudinal, radial, oblique (parrot-beak), and complex. This is termed the 'red-red zone' (denoting area of vascularity).2,4 repair of the 'red-white zone' (watershed area between vascular and avascular meniscus) is controversial25 with many different surgical techniques.26 tears in the 'white-white zone' (avascular zone) are rarely repaired rather the damaged segment is resected (meniscectomy). As recognition of the critical function of the menisci in normal biomechanical function of the knee has grown, attempts at preserving meniscal tissue via repair as opposed to partial meniscectomy have also gained favor. Scuderi G, Tria A. Detailed review of funding for diagnostic imaging services. The posterior horn is located on the back half of the meniscus. Know why a test or procedure is recommended and what the results could mean. See your ortho for an evaluation. Trauma to medial collateral ligament usually also involves medial meniscus. Non-anatomic placement of a PCL reconstruction tibial tunnel is a reported cause of iatrogenic medial meniscal posterior root tears. Nonsurgical treatment is an option for elderly patients, those with significant comorbidities and those with advanced OA (Outerbridge grade 3 or 4 chondromalacia of the ipsilateral compartment). A horizontal meniscus tear runs along the circumference of the fibers of the meniscus. (9a) This irregular tibial surface tear (arrow) clearly lies within the peripheral, red zone, of the meniscus. Immediate conservative measures include the RICE regimen: Longer term measures include activity modification, nonsteroidal antiinflammatory drugs (NSAIDs) and physiotherapy.4,1921 Nonsteroidal anti-inflammatory drugs are often recommended for 812 weeks,20 although paracetamol can be considered if NSAIDs are contraindicated or poorly tolerated.22 Where available, intensive physiotherapy is very useful and should include range of motion, proprioceptive work and muscle strengthening exercises. Posterior medial meniscal root tears are often times degenerative, but these can also occur with multi-ligament knee injuries in the acute setting. London;1897. Severe pain and swelling may occur up to 24 hours afterward. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Magnetic resonance imaging (MRI) scans. Operative Arthroscopy, 3rd Edition, 2002, Lippincott Williams and Wilkins. Meniscal ramp lesions can be defined as longitudinal vertical and/or oblique peripheral tears affecting posterior horn of medial meniscus, in a mediolateral direction of less than 2.0 cm, that may lead to meniscocapsular or meniscotibial disruption [ 1 ]. It has been reported that the force experienced by the medial meniscus in the ACL-deficient knee increased by 52% in full extension and by 197% at 60 of flexion under a 134-N load. Another exam finding is palpating the anteromedial joint line, while placing a varus stress on a fully extended knee and feeling for meniscal extrusion. Matthew H. Blake, MD, can be reached at the Kentucky Clinic, 740 Limestone, Suite K415, Lexington, KY 40536; email: Darren L. Johnson, MD, can be reached at the Kentucky Clinic, 740 S Limestone, Suite K415, Lexington, KY 40536; email: Jorge Chahla, MD; Andrew G. Geeslin, MD; and Robert F. LaPrade, MD, PhD, can be reached at Steadman Philippon Research Institute, The Steadman Clinic, 181 West Meadow Dr., Suite 400, Vail, CO 81657; Chahlas email. The preferred nomenclature for this tear pattern is: A gradient-echo T2*-weighted sagittal image, A. Arthroscopy 2010;26:13689. For information:Questions and Answers for Patients Regarding Elective Surgery and COVID-19. These tears occur within the avascular zone of the meniscus where there is no blood supply. Your doctor will generally ask you how the injury occurred, how your knee has been feeling since the injury and whether you have had other knee injuries. Medial meniscal root tears: Fix it or leave it alone Orthopedics Today | Medial and lateral menisci are crescent-shaped fibrocartilage structures that provide joint congruity, stabilization and. Surgical treatment is usually reserved for younger patients with a vertical longitudinal tear within the vascularised outer third of the meniscus. Arthroscopy. Typically, complex tears are not treated with meniscus repair due to their complex nature. They include: Referral is also indicated if the diagnosis is uncertain for review and to access MRI. With the foot as close to the hip as possible, the clinician holds the knee joint (with fingers along the joint line) with one hand, and the other hand rotates the tibia internally and externally while extending and flexing the knee. Skeletal Radiol 2007;36:14551. Explains two kinds of surgery. For patients whose procedures have not yet been rescheduled:What to Do If Your Orthopaedic Surgery Is Postponed. Peripheral meniscal tears are located in the most vascular portion of the menisci and comprise 39-72 % [2, 3, 56, 69, 82] of all meniscal tears. Grades 1 and 2 are not considered serious. Disclosures: LaPrade reports he is a consultant for and receives royalties from Arthrex, Ossur and Smith & Nephew. Knee Surg Sports Traumatol Arthrosc 2008;16:4826. We use cookies to ensure that we give you the best experience on our website. This type of tear is particularly devastating to meniscal function. Oblique tear of the posterior horn and body of the medial meniscus involving inferior articular surface and peripheral meniscal margin. They will manipulate your leg into various positions, observe you while you walk, and bend at the knee. or ? Grade 3 is a true meniscus tear and an arthroscope is close to 100 percent accurate in diagnosing this tear. The meniscus can tear from acute trauma or as the result of degenerative changes that happen over time. When a meniscus tear occurs, you may hear a popping sound around your knee joint. The primary objective is to control the disease process to avoid the complications . As people age, they are more likely to have degenerative meniscus tears. Diagnosis can be suspected clinically with joint line tenderness and a positive Mcmurray's test, and can be confirmed with MRI studies. Meniscal intra-substance signal abnormalities are defined as an increased signal that does not fulfill the criteria for a meniscal tear according the "two-slice-touch" rule (i.e., it does not reach the meniscal surface on two consecutive views) and is a common finding on routine MRI of the knee (Fig. Whats the best way to treat an oblique fracture? Treatment varies on a case-by-case basis. Horizontal cleavage, oblique, and complex meniscal tear patterns have traditionally been poor candidates for meniscal repair. Pain, especially when twisting or rotating your knee. These tears can be challenging to recognize on MRI,9 but are important to diagnose since they are often highly symptomatic due to a reactive synovitis. Orthop Clin North Am. The majority of these types of tears do not need surgery. As orthopaedic surgeons increasingly consider meniscal repair, accurate pre-operative assessment with MR becomes more important, allowing proper planning on the part of both the surgeon and the patient. a feeling that your knee is catching or locking, usually when it's bent - you may notice it clicking. Several variations in meniscal tear patterns have been granted specific names that recognize the unique characteristics of the tear. Aged, worn tissue is more prone to tears. Includes interactive tool to help you decide. Meniscus surgery is a common operation to remove or repair a torn meniscus, a piece of cartilage in the knee. The medial meniscus has a firmer capsular attachment than the lateral meniscus. However, whether they will respond well to surgery depends on the type of tear, the location, and blood flow in the area where the tear occurred. OKeefe R, et al. In many areas, nonessential orthopaedic procedures that were postponed due to COVID-19 have resumed. If your tear is on the outer one-third of the meniscus, it may heal on its own or be repaired surgically. Meniscus Surgery. This website also contains material copyrighted by third parties. The outer one-third of the meniscus has a rich blood supply. The Thessaly test is the most sensitive and specific clinical test to diagnose meniscal injury. Meniscus tears simply do not heal on their own, regardless of conservative treatment. Feb 1995;11(1):29-36. Larger, unstable tears of this type often cause mechanical symptoms, however, and therefore warrant operative treatment, usually via partial meniscectomy. 1175 Dunlawton Ave., Suite 101, Port Orange, FL 32127, Palm Coast A recent study demonstrated 46% of patients with degenerative meniscal tears elected not to have surgery after 4 weeks of nonoperative treatment, and their functional improvement matched patients in the operative group.21 Another study of degenerative tears demonstrated that supervised exercise caused the same reduction in knee pain and the same increase in function and satisfaction as partial meniscectomy plus exercise.23 As degenerative tears are more common in elderly patients, this group is more likely to respond to conservative treatment. Bernstein J. (Lateral one = ACL, medial one= chondral injury) Normal knee anatomy. Also write down any new instructions your provider gives you. Locking presents in two ways. I read on a medical site that it is difficult to get to the posterior horn of the meniscus and sometimes there is a need to make an incision or the knee becomes dislocated. Still, many people with a torn meniscus can walk, stand, sit, and sleep without pain. Symptoms of a meniscus tear. Educational text answers on HealthTap are not intended for individual diagnosis, treatment or prescription. The medial meniscus is the cushion that is located on the inside part of the knee. If you have unusual pain and discomfort in your knee, let us help you get back to doing the things you love. Skeletal Radiology 2004; 33:260-264. 13 Newman AP, Daniels AU, Burks RT. Singapore: World scientific, 2010. Meniscal injury and repair: clinical status. Surgery is most likely needed to resolve your problem. This type of tear has an unusual pattern. Regular exercise to restore your knee mobility and strength is necessary. J Bone Joint Surg Am 1988;70:120917. Meniscal repair is a more difficult surgical technique and requires a motivated, diligent patient in order to be successful. There is no resting pain. I have a oblique grade 3 tear posterior horn of the medial meniscus. Conservative management is important in all patients with acute rest, intensive rehabilitation with physiotherapy and modification of activity. Flaps cause mechanical instability - meaning they interrupt the smooth function of the knee joint and will make your knee joint feel unstable. 2nd edn. Get prescriptions or refills through a video chat, if the doctor feels the prescriptions are medically appropriate. Meniscus tears can happen during physical activities, but they can also occur from: Sometimes, a torn meniscus can occur due to degenerative changes in the knee, even if there is little to no trauma. Rehabilitation time for a meniscus repair is about 3 to 6 months. If you undergo surgery it will likely be followed by physical therapy to optimize knee strength and stability. The most common symptom of a torn meniscus is localized pain in the knee that worsens when rotating the leg. There may be some pain. Strengthening exercises will gradually be added to your rehabilitation plan. Br Med Bull 2007;84:523. If your meniscus tear is not severe, your doctor will likely recommend the following treatment: If you have a meniscus tear, physical therapy can help to strengthen the muscles around the knee as well the muscles in your legs which in turn will stabilize and support the knee. Conservati For a young person arthroscopic meniscal repair is the best solution. what is the treatment? controlling the movements of the knee joint. Br Med Bull 2011;2011:89106. Get the latest news and education delivered to your inbox, Receive an email when new articles are posted on, Please provide your email address to receive an email when new articles are posted on. Pathology - a tear that has developed gradually in the meniscus. AJR Am J Roentgenol 1998;170:5761. Clin Sports Med 2010;29:81106. 15 Koski JA, Ibarra C, Rodeo SA. The skilled interpreter of MR of the knee must do more than simply identify the presence of a meniscal tear. In older patients, referral is appropriate if conservative management fails to improve symptoms. The posterior horn it the back portion of the menisci at the end of the curve, where it tapers . Be unable to extend your leg comfortably and may feel better when your knee is bent (flexed). Inferiorly displaced flap tears of the medial meniscus: MR appearance and clinical significance. Acta Orthop Scand 1982;53:9759. In some cases, your doctor may suggest an arthroscopyto examine and possibly treat your knee. Meniscus Repair. Brain Res Rev 2009;60:187201. This often signals a tear. It is generally divided into 3 separate portions, the anterior horn, the mid-body and the posterior horn. For patients requiring meniscectomy, meniscal autograft has been utilised with good outcomes,2931 but is only performed in specialist centres. 2023 Cedars-Sinai. As the risk of osteoarthritis is increased if meniscal structures are not optimally functional,7 it may also be appropriate to refer all young patients for opinion if symptoms do not rapidly improve. If the test is positive (suggesting a meniscal tear), the patient will feel pain and the clinician will feel and/or hear meniscal movement when the meniscus is compressed between the tibia and femur 32, Figure 2. In some cases, a meniscal repair may also be possible, though this is dependent on the size and location of the tear. Because other knee injuries can cause similar symptoms, your doctor may order imaging tests to help confirm the diagnosis. The procedure begins with a complete diagnostic arthroscopy using a 30-degree arthroscope. The menisci act as cushions between your shin bone (tibia) and your thigh bone (femur). Treatment of meniscal tears includes simple observation, meniscectomy, and meniscal repair. Metcalf MH, Barrett GR. The lateral meniscus has a symmetrical C-shape, whereas the medial meniscus is more crescentic (3a), as the posterior horn of the medial meniscus is always larger than the anterior horn. The meniscus is a thick cartilage structure that sits between the bones of the knee. Once the initial healing is complete, your doctor will prescribe rehabilitation exercises. The meniscus root attachment aids meniscal function by securing the meniscus in place and allowing for optimal shock-absorbi These are paraphrased. Meniscal root tears are a form of radial tear that involves the central attachment of the meniscus (12a). Over 2 to 3 days, however, the knee will gradually become more stiff and swollen. Meniscal pain occurs during torsional, weight bearing knee movements (classically pivoting on the knee while walking) as a sharp stab lasting several seconds, often followed by a dull ache for several hours. Sagittal peripheral meniscal images demonstrate the normal anatomical 'bow-tie configuration' (the central meniscal body with the anterior and posterior horns as well circumscribed triangles. summary. Recent kinematic/biomechanical studies have also shown the importance of the medial meniscus to anterior translation of the knee. The medial meniscus is C-shaped, while the lateral meniscus is more . Although some reports have described successful repair of the avascular portion of the meniscus,11 it is generally accepted that meniscal repair is more likely to be successful if it involves or at least communicates with the meniscal red zone, lying within three to four millimeters of the capsular rim.12 A basic principle of meniscal repair is to rasp the tear edges and the parameniscal synovium above and below the meniscus, which is thought to enhance the vascular healing process. However, coronal sections may reveal the presence of meniscal extrusion or vertical defects, and sagittal sections may reveal the ghost sign (absence of an identifiable meniscus or increased signal replacing the normal hypointense signal of meniscal tissue). Patients describe meniscal tears in a variety of ways. The medial meniscus is on the innermost side of your knee (the C-shaped curve faces in toward your body, the opposite knee). Indications for meniscal root repair are acute, traumatic root tears in patients with nearly normal or normal cartilage (Outerbridge grade 0 to 2) and chronic symptomatic root tears in active patients without significant pre-existing osteoarthritis (OA). These tears often occur in association with ACL tears, but even if found in isolation, are highly likely to be clinically relevant, as the displaced meniscal fragment frequently results in knee locking. Verdonk PC, Demurie A, Almqvist KF, Veys EM, Verbruggen G, Verdonk R. Transplantation of viable meniscal allograft. Survivorship analysis and clinical outcome of one hundred cases. In the present case, a full-thickness radial tear of the medial meniscus is visualized (Fig 1).An arthroscopic torpedo shaver (Arthrex, Naples, FL, U.S.A.) is used to debride the meniscus tear edges back to a healthy, stable rim (Fig 2).For improved access to the medial meniscus, an 18-gauge spinal . Grade 3 meniscus tears usually require surgery, which may include: Tips to help you get the most from a visit to your healthcare provider: Cedars-Sinai has a range of comprehensive treatment options. Of course, if a displaced meniscal fragment is identified, the tear is by definition unstable. As such, it is critical to repair medial meniscal root tears during ACL reconstruction to help stabilize the knee, as well as to decrease stresses that the graft experiences. Magnetic resonance imaging as a tool to predict reparability of longitudinal full-thickness meniscus lesions. The meniscus is broken down into the outer, middle, and inner thirds. Meniscal tear configurations: categorization with MR imaging. The anterior horn of the medial meniscus demonstrates half of the normal anatomic 'bow-tie configuration'. Proton weighted sagittal image demonstrates an example of a posterior horn medial meniscal horizontal tear (white arrow). Superior and inferior branches of the medial and lateral geniculate arteries supply the peripheral third of the menisci via the perimeniscal capillary plexus.3,4, Meniscal tears occur due to a shear force between the femur and tibia. The healing time in children is a little less as the healing process is faster in children than in adults.
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