MENISCAL INJURIES

1. MENISCAL TEARS
PROF.DR.K.PRAKASAM
M.S.Ortho,D.Ortho,DSc(HON)
MODERATOR:PROF.DR.A.E.MANOHARAN
PRESENTOR:DR.THOUSEEF A MAJEED

2. 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.

3.  Triangular in cross section
 Covers peripheral 2/3 rd of
articular surface.

4. Each menisci has
 2 ends---- anterior and posterior horns
 2 borders----outer and inner border
 2 Surfaces ---upper and lower

5. Attachments to Tibia
 Margins – Coronary ligaments
 Inter condylar area – by Horns
 To Medial Collateral Ligament

6. 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.

7. BLOOD SUPPLY
 Superior & Inferior
branches of medial &
lateral geniculate arteries
 Perimeniscal capillary
plexus within the synovium
& capsule

8. VASCULAR ZONES
 Red-red zone-fully vascular
 Red-white :minimal blood
supply
 White-white: fully avascular

9. FUNCTIONS OF MENISCI
 Joint lubrication
 Joint stability- ( rotary)
 Joint nutrition
 Shock absorbers-reduce the stress on articular cartilage
 Load bearing function
 Deepening the cavity

10.  Prevents impingement during joint motion.
 Medial meniscus – provides stability to Anterior
Cruciate Ligament deficient knees.(ACL)

11. 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

12.  1928- McMurray- sign of torn meniscus
 1962 – Arthroscopic surgery begins

13. 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.

14. Pedisposing Factors
 Trauma
 Meniscal cyst
 Decreased mobility of the meniscus
 Discoid meniscus
 Aging- degeneration
 Abnormal mechanical axis- ligamentous laxity.

15.  Congenitaly relaxed joints
 Inadequate tone and musculature.

16. O’CONNOR CLASSIFICATION OF TEARS
1. Longitudinal tears
2. Horizontal tears
3. Oblique tears
4. Radial tears
5. Variations-flap tears
complex tears
( degenerative )

18. LONGITUDINAL TEARS
 Most common
 young
 Post trauma
 2 types-
Vertical incomplete tear
Vertical complete
Displaced tear
(bucket handle)

19. HORIZONTAL TEARS
 Extend from inner margin to
capsule horizontally
 Common in posterior horn of
medial meniscus & lateral
meniscus

20. 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

21. 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)

22. FLAP TEARS
 Oblique tears with a
horizontal cleavage
 Superior or inferior
 Degenerative

23. COMPLEX TEARS
 Combination of all the above
 Common in chronic meniscal lesions & degenerative
menisci
 Predisposing conditions:
* Discoid lateral meniscus
*Meniscal cyst
*Calcium pyrophosphate deposition

24. 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

25.  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

26. Tears associated with Cystic degeneration
 Trauma ---- degeneration or secondary mucinous
changes in the periphery.
Tears associated with congenital anomalies
Discoid meniscus hyper mobility

27. Clinical diagnosis
History
 May be asymptomatic
 Pain
 Sports injuries
 Trauma
 Giving way
 Locking

28. Physical signs
 Effusion
 Quadriceps wasting
 Joint line tenderness
 Limitation of movements.

29. Special tests.
 Mc Murray test.
 Apley’s grinding test

30. 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

31.  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.

32. 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

33. DIFFERENTIAL DIAGNOSIS
 Loose bodies
 Osteochondritis dissecans

34. INVESTIGATIONS
 X-Ray-Antero posterior ,lateral view of knee &
intercondylar notch view
 Magnetic Resonance Imaging (MRI)-sensitivity
 Arthroscopy
 Arthrography

35. 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

36. 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

37. 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

38. HEALING RESPONSE
 Radial tears healed with fibrocartilaginous scar- 10
weeks
 Maturation of scar takes longer.

39. MANAGEMENT
 NON- SURGICAL
 SURGICAL

40. NON SURGICAL MANAGEMENT
Indications
 Incomplete meniscal tear
 A small stable peripheral tear (5mm) without any other
injuries.

41. 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.

42. OPERTIVE MANAGEMENT
 Meniscal repair
 Meniscectomy
 Enhancement of meniscal repair
 Meniscal allograft

43. 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

44. Meniscal Repair
 young patient shows better outome
 Can be done Open or Arthroscopicaly

45. Meniscal repair-Contarindication
 Tear>3 cm
 Transverse tear even in periphery
 Flap tear, radial tear, vertical tear with secondary
lesions.
 Ligament instability

46. 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

47. ARTHROSCOPIC MENISCAL REPAIR
 Patient selection
 Tear debridement of local synovial , meniscal and
capsular abrasions
 Suture placement

48. SUTURE TECHNIQUES
 Inside-out : Gold standard
 Outside-in
 All inside

49. 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

51. 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

53. 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

54. Arthroscopic Repair- Disadvantages
Difficulty in intraarticular knot tying
No long term clinical studies
Time away from sports.

55. After care
 Limit knee flexion to 90 degree
 Low impact activity for 3months
 Full activity after 6months

56. Bio-absorbable implants
 Poly glycolic acid.
 Poly levolactic acid.
 Raecemic poly lactic acid.
 Poly dexanone.

57.  All these materials degrade into CO2 and water
 Devices includes Anchors, Arrows, screws and
staplers.

58. Meniscal repair associated with Anterior
cruciate ligament (ACL)
 There is 30-40% failure rate .
 Repair Anterior cruciate ligament first followed by
meniscal repair

59. MENISCECTOMY
3 types
 Partial
 Subtotal
 Total
Methods
 Open
 Arthroscopic

60. PARTIAL MENISCECTOMY
 Less articular cartilage degeneration
 Excision of only torn portion of meniscus .
Indications
 Tears >5mm from menisco-synovial junction.
 Flap tears

61.  Complex and horizontal.
 Treatment of choice in young adults who require
vigorous activities.
Advantage
 Short operating time.

62. 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

63. OPEN –OR- ARTHROSCOPIC ?
 Long term results of arthroscopic meniscectomy are
comparable to skilful open partial meniscectomy.

64. APPROACHES
Medial meniscectomy
 Single anterio medial
 Second incision:Henderson posteromedial incision
Lateral meniscectomy
 Antero-lateral
 Anterolateral+posterolateral

65. 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.

66. Complications
 Haemarthrosis
 Chronic Synovitis
 Synovial fistulae
 Painful neuromas
 Thrombophlebitis

67.  Infection
 Late degenerative arthritis
 Reflex sympathetic dystrophy

68. FAIRBANK’S CHANGES
 Post meniscectomy change
 Narrowing of joint space
 Flattening and squaring of femoral condyle
 Antero posterior osteophyte formation

69. 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.

70. 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.

71. 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.

72. Meniscal transplantation

73. RECENT ADVANCES
 Bioabsorbable meniscal fixators (meniscal dart,arrow)
 Collagen meniscus implant-from bovine achilles tendon
 Synthetic scaffolds
 Future- gene therapy & Stem cells