Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: 2. Clinical investigation.

Treatment of abnormal mobility of the popliteal tendon area of the lateral meniscus is described. Twenty-seven patients who exhibited an abnormally mobile posterior segment with no obvious ruptures in the lateral meniscus were directly examined by us after an average of 4 years and 3 months from the time of the arthroscopic procedure. The main complaints associated with this condition before the surgery were pain and locking during deep knee flexions. The patients were divided into three groups according to surgical method: partial meniscectomy, subtotal meniscectomy, or meniscal repair. The subtotal meniscectomy and repair groups showed significantly higher scores than the partial meniscectomy group. A locking phenomenon recurred in one case of the meniscal repair group. In this case, the menisco-femoral coronary ligament posterior to the popliteal tunnel could not be sutured.     

Stage-based treatment by partial meniscectomy, meniscal refixation and transplantation

Clinical and experimental studies have demonstrated that the meniscus is important for normal knee function. Loss of meniscus results in abnormal load transmission across the knee and may lead to degenerative joint disease. Preservation of meniscal tissue is therefore important. About 10 % of all meniscal tears are repairable. The most successful repairs occur in younger patients who have an acute, vertical tear in the vascular portion of the meniscus. Currently, arthroscopic meniscal repair procedures include the inside-out, the outside-in and the all-inside technique. Vertical suture techniques are superior to horizontally placed sutures. From a biomechanical point of view, 2-0 to 1 sutures are recommended for suture repair. Various meniscus implants are also available for meniscal repair. The initial fixation strength of the implants is lower compared to vertical sutures. A combination of suture techniques and implants might be a treatment option in posterior meniscal lesions. The collagen meniscus implant has been designed to support tissue ingrowth after segmental medial meniscectomy. Although fibrocartilage matrix formation has been shown, long-term clinical follow-ups are still required. Meniscal allograft transplantation may be indicated in limited situations. Younger patients with meniscal deficiency due to previous meniscectomy who have only early arthrosis, normal axial alignment, and a stable knee may currently considered appropriate candidates for meniscal transplantation.     

1310例侧膝关节半月板损伤关节镜下诊治效果分析

目的　分析关节镜下半月板损伤不同修复方法的效果 ,提出半月板损伤修复较适用方法。方法　随访 1310例侧膝关节半月板损伤镜下修复的患者 ,从发病年龄、损伤类型、镜下修复方法及效果进行分析 ,其中男性 880例 (90 9例侧 ) ,女性 374例 (4 0 1例侧 ) ,平均 2 5 5岁 ,平均患病时间半年。半月板缝合 6 8例侧 ,部分切除成形术 75 6例侧 ,半月板全切除 4 80例侧 ,6例儿童半月板损伤镜检确定后未行镜下处理 ,于镜检后石膏固定。结果　术后平均随访 4年 3个月 ,Lysholm评分 :半月板缝合术前 4 7 5分 ,术后 86 3分 ;半月板部分切除成形术前 4 5 1分 ,术后 84 0分 ;半月板全切除术前4 5 4分 ,术后 76 1分。 6例少年儿童半月板损伤 ,Lysholm评分术前 4 5 0分 ,术后 98 7分。三种治疗方法效果有显著性差异 (t=2 876 ,P <0 0 1)。结论　半月板损伤应在关节镜下行缝合或部分切除成形治疗 ,避免半月板切除 ;<14岁盘状半月板损伤需部分切除成形 ,半月板损伤非手术治疗可获得较好疗效     

Degenerative meniscus: Pathogenesis,diagnosis, and treatment options

The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than one-third of the adult meniscus, healing potential in the setting of chronic degeneration remains low. Continued hoop and shear stresses upon the degenerative meniscus results in gross failure, often in the form of complex tears in the posterior horn and midbody. Patient history and physical examination are critical to determine the true source of pain, particularly with the significant incidence of simultaneous articular pathology. Joint line tenderness, a positive McMurray test, and mechanical catching or locking can be highly suggestive of a meniscal source of knee pain and dysfunction. Radiographs and magnetic resonance imaging are frequently utilized to examine for osteoarthritis and to verify the presence of meniscal tears, in addition to ruling out other sources of pain. Non-operative therapy focused on non-steroidal anti-inflammatory drugs and physical therapy may be able to provide pain relief as well as improve mechanical function of the knee joint. For patients refractory to conservative therapy, arthroscopic partial meniscectomy can provide short-term gains regarding pain relief, especially when combined with an effective, regular physiotherapy program. Patients with clear mechanical symptoms and meniscal pathology may benefit from arthroscopic partial meniscectomy, but surgery is not a guaranteed success, especially with concomitant articular pathology. Ultimately, the long-term outcomes of either treatment arm provide similar results for most patients. Further study is needed regarding the short and long-term outcomes regarding conservative and surgical therapy, with a particular focus on the economic impact of treatment as well.     

Arthroscopic partial meniscectomy of a posteriorly flipped superior leaflet in a horizontal medial meniscus tear using a posterior transseptal portal

This article describes a case of an arthroscopic partial meniscectomy of a posteriorly flipped superior leaflet in a horizontal medial meniscus tear using the posterior transseptal portal. An arthroscopic partial meniscectomy for bucket handle or flap tears in medial or lateral compartments using ordinary portals is a relatively common procedure in irreparable cases. However, the posterior compartment of the knee is not readily accessible through ordinary arthroscopic portals. Therefore, it has been considered a blind spot. Through the posterior transseptal portal, surgeons can achieve excellent arthroscopic visualization of the posterior compartment and easily perform arthroscopic procedures of the posterior compartment of the knee. A 48-year-old woman presented with a 1-year history of pain in the medial aspect of the right knee joint. Preoperative magnetic resonance imaging revealed a thinning of the medial meniscus posterior horn in coronal images and a sharp-edged triangle arising from the medial meniscus posterior horn between the medial femoral condyle and medial meniscus posterior horn on sagittal images (flipped-over sign). During the arthroscopic procedure, we found that the flipped leaflet was displaced posteriorly and was not mobile between the medial femoral condyle and medial meniscus posterior horn. Partial meniscectomy for a posteriorly displaced fragment can be performed successfully using the posterior transseptal portal. The posterior transseptal portal is useful for an arthroscopic partial meniscectomy of a posteriorly flipped leaflet in the posterior compartment of the knee.     

Analysis of the discoid meniscus in Koreans.

Discoid meniscus is a relatively common disorder of the knee in Koreans. Its arthroscopic treatment is one of the most technically demanding procedures of this field. The purposes of this study were to define the clinical features of the discoid meniscus in Koreans and to suggest an adequate arthroscopic technique. We performed arthroscopic meniscectomy on 37 knees with a lateral discoid meniscus. The average length of follow up was 21 months. The presence of synovial hypertrophy in the knee with discoid was significantly higher than that with a non-discoid meniscal lesion. A medial midpatellar portal for the arthroscope is advisable for clean arthroscopic surgery in this situation. We obtained satisfactory results through the partial resection of the discoid meniscus, leaving the normal semilunar-shaped meniscus intact as much as possible.     

老年膝关节半月板损伤关节镜手术方式选择及疗效评估

目的:探讨关节镜治疗老年半月板损伤的方法和疗效。方法 :自2014年1月至2018年6月,86例符合纳入标准的老年半月板损伤患者,其中男35例,女51例;年龄60～76岁,平均63.7岁;有明确外伤史32例,无明确外伤史54例。关节镜下半月板部分切除75例,部分切除及前角修补2例,部分切除及体部修补2例,后角水平分层破裂部分切除及修补7例;28例合并关节轻度退变,同时行髁间窝钻孔减压。术前及末次随访采用Lysholm评分和IKDC评分评定膝关节功能,视觉模拟评分法(VAS)评估疼痛情况。结果:所有病例成功完成关节镜下手术,随访6～36个月,平均15个月。膝关节Lysholm评分由术前(51.26±12.00)分,提高至末次随访的(81.20±4.89)分(t=22.07,P0.001);IKDC评分由术前(48.05±10.68)分,提高至末次随访的(76.97±6.26)分(t=23.04,P0.001);VAS由术前(3.37±0.84)分,改善至末次随访的(0.57±0.62)分(t=36.27,P0.001)。2例非外伤性退变性内侧半月板损伤伴内侧骨关节炎患者,术后1年症状无明显改善,行人工全膝关节置换术。结论:老年膝关节半月板损伤行关节镜下半月板部分切除,或部分切除及修补术治疗,可获得较满意的临床效果;如果合并关节轻度退变性变,同时行髁间窝钻孔减压。     

Is it important to secure the horns during lateral meniscal transplantation? A cadaveric study

The purpose of this investigation was to determine if secure attachment of the horns of the lateral meniscus during transplantation affects the load-bearing function of the meniscus. Six knee joints were loaded in compression (310 N) and the interarticular contact pressure in the joint measured using pressure-sensitive film inserted into the joint. Each knee was tested first with the original intact meniscus and then after each of the following surgical procedures involving the original lateral meniscus: (1) total meniscectomy; (2) meniscal transplantation with a tibial bone bridge; (3) meniscal transplantation with neither horn secured; (4) meniscal transplantation with the anterior horn secured; (5) meniscal transplantation with the posterior horn secured; and (6) meniscal transplantation with both horns secured. The results are as follows, (1) The intact joint gave the largest contact area and the smallest peak contact pressure. The joint with the total meniscectomy gave the smallest contact area and the largest peak contact pressure. (2) A meniscal transplantation with either a tibial bony bridge or with both horns secured gave results similar to those for the intact joint. (3) A meniscal transplantation with only one horn secured gave results somewhere in between those for the intact joint and those for the joint without a meniscus. A meniscal transplantation with neither horn secured gave results similar to those for a joint without a meniscus.     

Arthroscopic partial meniscectomy

Meniscal tears are among the most common problems surgically addressed in the practice of knee surgery. Arthroscopic partial meniscectomy has become the standard in managing meniscal damage not suitable for repair or allograft replacement. Current techniques involve low morbidity, rapid rehabilitation, and early return to functional activities. However, recent studies suggest that the optimistic early results of arthroscopic partial meniscectomy may deteriorate over time.     

Meniscal allograft transplant in a 16-year-old male soccer player: A case report

Meniscal allograft transplantation (MAT) is a relatively new procedure that has gained popularity in the last couple of decades as a possible alternative to a meniscectomy to provide significant pain relief, improve function, and prevent the early onset of degenerative joint disease (DJD). As of present, evidence is limited and conflicting on the success of such procedures. In this case, a 16-year old male athlete underwent numerous surgical procedures to correct a left anterior cruciate ligament (ACL) rupture with associated medial and lateral meniscal damage that occurred as a result of a non-contact mechanism of injury. Following multiple procedures, including repair of both menisci and follow-up partial meniscectomy of the lateral meniscus, the patient continued to experience symptoms on the left lateral knee, making him a candidate for MAT. This case is used to highlight what a MAT is, what makes someone a candidate for this type of procedure, the current evidence surrounding the success of this intervention, and some rehabilitation considerations following surgery. The role of chiropractors and primary clinicians is to ensure that young athletes undergo early intervention to offset any degenerative changes that would be associated with sustained meniscal lesions.     

Is repeated repair of the meniscus worthwhile?

Meniscal injuries are one of the most commonly encountered problems by orthopaedic surgeons. It is well established that meniscectomy will result in increased joint surface contact forces and the predictable progression of arthritis. The management of meniscal tears has evolved and current evidence would suggest that every attempt should be made to repair meniscal tears when appropriate. The reported success rate of meniscal repair is encouraging, but relatively little is known about the outcome of repeated repair of a re-torn meniscus. This review presents an illustrative case of a recurrent lateral meniscal tear in a young female, that has required surgical repair on three occasions over a fourteen year period. Despite recurrent tears of her lateral meniscus, the patient was symptom-free in the intervening periods and at her latest operation, her articular cartilage showed minimal evidence of chondral damage. Longer-term follow-up is required to determine whether repair of a re-torn meniscus prevents the progression of degenerative changes within the knee joint that is associated with meniscectomy.     

Arthroscopic meniscectomy for discoid lateral meniscus in children and adolescents: 10-year follow-up.

Seventeen adolescents underwent arthroscopic lateral meniscectomy for discoid lateral meniscus. The average age at surgery was 13.6 years (range: 5-18 years). The main preoperative symptom was pain in 16 knees and extension loss in 1 knee. At arthroscopy, 10 menisci were complete, 4 were incomplete, and 3 were Wrisberg type. Arthroscopic total meniscectomy was performed in the 3 Wrisberg types, 2 complete types, and 1 incomplete type. The remaining menisci underwent partial meniscectomy. The average follow-up was 10 years (range: 5-15 years). According to the Ikeuchi rating system, 12 knees were rated as excellent (no symptoms and full range of motion), 4 were rated as good (occasional pain), and 1 was rated as fair (patellofemoral pain in an obese patient). Radiographic evaluation showed development of minor osteophytes in the lateral compartment of 8 knees and <50% narrowing of the lateral joint space in 11 knees. No correlation was found between meniscal type, type of meniscectomy (partial or total), and clinical and radiographic results. Arthroscopic lateral meniscectomy for discoid lateral meniscus in adolescents was effective in relieving symptoms during a 10-year follow-up period. Longer follow-up is needed to ascertain the significance of the radiographic changes seen in this study.     

Advances in arthroscopic surgery

Removal of the whole meniscus from the knee has been shown to be associated with a high incidence of degenerative change. The degeneration is proportional to the amount of meniscus removed. After meniscal injury, retention of the meniscus in part (partial meniscectomy) or in whole (meniscal suture) is preferable. Replacement of a previously removed meniscus (meniscal transplantation) may be feasible in the future. Fifty patients had arthroscopic partial meniscectomies performed alternately by standard mechanical techniques or by electrosurgical techniques. The latter group was found to have less pain and swelling. Another 46 patients had meniscal sutures performed on one or more menisci. Twenty-one of these patients had a follow-up arthroscopy for recurrence of symptoms and only one meniscus had not healed. Another single patient had a meniscal transplant, and a follow-up arthroscopy six months after surgery revealed the meniscus to be largely intact.     

Meniscal Root Tears

Meniscus root tears are a specific type of meniscal injury that have gained attention over the past 5 years and have been reported to account for 10% to 21% of all meniscal tears, affecting nearly 100,000 patients annually. Meniscal root tears either are defined as an avulsion of the insertion of the meniscus attachment or complete radial tears that are located within 1 cm of the meniscus insertion. Biomechanical studies have demonstrated that meniscal root injuries interrupt the continuity of the circumferential fibers, and hence lead to failure of the normal meniscal function to convert axial loads into transverse hoop stresses. The most common presenting symptoms in meniscal root tears are posterior knee pain and joint line tenderness, especially with deep squatting.Another common symptom is a popping sound heard while participating in light activities such as ascending stairs or squatting. Magnetic resonance imaging signs of medial meniscus root tears include: (1) medial meniscal extrusion of ≥3 mm in a coronal section; (2) high signal indicating a disruption of the posterior meniscal root region in an axial view; and (3) a “ghost sign,” which is the absence of an identifiable meniscus in the sagittal plane, or increased signal replacing the normally dark meniscal tissue signal at the posterior root attachment. Active patients, regardless of age, should be referred early and considered for a meniscal root repair. Indications for a meniscal root repair include acute, traumatic root tears in patients with nearly normal or normal cartilage and chronic symptomatic root tears in young or middle-aged patients without significant preexisting osteoarthritis.Meniscal root repair has been demonstrated to have high satisfaction rates and superior outcomes to arthroscopic meniscectomy for root tears. To restore the function of the meniscus after medial meniscus root tears, a transosseous meniscal root repair technique is most commonly used. The advantage of this technique is the ability to reduce and fix the meniscal root to the broad anatomic footprint to maximize its healing potential. In addition, the transtibial tunnels may contribute to the release of biological factors that can enhance the healing of the meniscal root repair.     

Entrapment of the meniscus in a fracture of the intercondylar eminence of the tibia

Summary: Entrapment of the meniscus in a fracture of the tibial intercondylar eminence is very rare. We have experienced 2 cases of it and report on them to emphasize the importance of diagnostic arthroscopy especially for meniscal injuries in tibial intercondylar eminence fracture. Our case series was composed of 2 patients (a 30-year-old man and a 54-year-old woman). Both had been in a car accident and showed a type III fracture of the tibial intercondylar eminence on the initial radiographs. During arthroscopic examination, we found a bucket-handle tear of the lateral meniscus, and, in 1 case, the entire torn portion was displaced medially and entrapped in the fracture site, and in the other case, a longitudinally torn medial meniscus (the mid to anterior horn), of which the torn portion of the medial meniscus was rotated internally and entrapped in the fracture site. They were treated with arthroscopic meniscal repair or partial meniscectomy with pullout suture for the fracture of the tibial eminence. The results were excellent. At 6-month follow-up, the woman denied any pain and limitation of motion. At 1-year follow-up in the other case, the man did not have any complaint except slight limitation of knee flexion due to arthrofibrosis. After arthroscopic fibrolysis in the second-look operation, he showed normal range of motion of the knee. In conclusion, entrapped meniscus can cause pain, lack of full knee extension, and minimal anterior instability. Also, it tends to hinder the reduction of a fracture of the tibial eminence. Thus, arthroscopy should be diagnostic, and release of the trapped meniscus, if present, with partial meniscectomy or meniscal repair would be expected to relieve the symptoms.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 4 (May-June), 2000: pp 7–7     

Meniscus pathology, osteoarthritis and the treatment controversy

The menisci are internal structures that are of central importance for a healthy knee joint; they have a key role in the structural progression of knee osteoarthritis (OA), and the risk of the disease dramatically increases if they are damaged by injury or degenerative processes. Meniscus damage might be considered a signifying feature of incipient OA in middle-aged and elderly people. As approximately every third knee of people in these groups has a damaged meniscus, tears are common incidental findings of knee MRI. However, as most tears do not cause symptoms, careful clinical evaluation is required to determine if a damaged meniscus is likely to directly impact a patient's symptoms. Conservative management of patients with knee pain and a degenerative meniscal tear should be considered as a first-line therapy before surgical treatment is contemplated. Patients with mechanical interference of joint movements, such as painful catching or locking, might need surgical treatment with meniscal repair if possible. In a subset of patients, meniscal resection might relieve pain and other symptoms that potentially originate directly from the torn meniscus. However, the possibility of an increased risk of OA if functional meniscal tissue is removed cannot be overlooked.     

Factors affecting long-term results after arthroscopic partial meniscectomy

The purpose of this study was to determine functional and radiographic changes on long-term followup of knees with isolated meniscal tears. Sixty-seven patients were evaluated retrospectively with an average of 12.2 years' followup using the scale of Tapper and Hoover. The criteria for the radiographic results were the Fairbank's changes as the standard comparing the preoperative and the postoperative conditions of the affected knee with the contralateral knee. Seventy-nine percent of the patients had a satisfactory outcome in terms of function. The amount of meniscus removed and the Outerbridge classification of the articular cartilage at the time of the meniscectomy were determining factors for long-term functional results. Osteoarthritic deterioration was seen in 48% of patients after the surgery, but radiographic deterioration after arthroscopic partial meniscectomy was mild on long-term followup. Medial meniscectomy and the amount of meniscus removed were risk factors for postoperative radiographic change. Age, gender, and the degree of cartilage degeneration at the time of operation, in contrast, showed no significant association. Arthroscopic partial meniscectomy for isolated meniscal injury yields favorable functional results but leads to significantly increased osteoarthritic change in the long-term.     

Arthroscopic meniscectomy for discoid lateral meniscus in children

We reviewed the cases of forty-six children who were less than fifteen years old and in whom total, subtotal, or partial arthroscopic meniscectomy was performed for symptomatic discoid lateral meniscus in fifty-three knees. The average length of follow-up was 31.2 months. A meniscal tear was evident in each knee. The extent of the meniscectomy depended on the site and shape of the tear, as did the symptoms and signs. We tried to establish the width of partial meniscectomy of a discoid meniscus that would prevent new tears.     

Editorial Commentary: Degenerative Meniscal Tear: Sojourn to the Oracle

Degenerative meniscal tears are prevalent and give rise to more than 400,000 arthroscopic partial meniscectomies annually in the United States. These lesions often occur in the setting of knee osteoarthritis and are generally regarded as a component of the tissue damage (to cartilage, meniscus, bone, synovium among others) that comprises osteoarthritis. A wide array of clinicians, ranging from orthopaedic surgeons to general practitioners, regularly encounter symptomatic degenerative meniscal tears, especially among patients with knee osteoarthritis. Clinical evidence suggests that initial treatment for these injuries should be nonoperative, with arthroscopic partial meniscectomy reserved for those whose pain persists despite physical therapy.     

Torn discoid lateral meniscus treated using partial central meniscectomy and suture of the peripheral tear

We present the cases of 5 patients with a torn discoid lateral meniscus treated using partial central meniscectomy in conjunction with the suture repair of the tear. The patients were 4 boys and 1 girl with a mean age of 15.4 years (range, 11 to 17). Preoperatively, all patients complained of knee pain during daily or sports activities. At the final follow-up evaluation, more than 2 years later, 4 patients’ conditions were graded as excellent and 1 patient’s condition was graded as fair according to Ikeuchi’s grading scale. The average Lysholm score improved from 83.4 points (range, 70–90) to 95.8 points (range, 89–100) postoperatively. In the 3 patients who underwent second-look arthroscopy, complete healing was seen in 2 patients. One patient had severe degenerative changes in the meniscus; the repaired site was not united and required an additional partial meniscectomy along the tear. We believe that with the current advancement in arthroscopic meniscal repair techniques, a partial central meniscectomy in conjunction with the suture repair of the peripheral tear can be effective treatment for patients with a torn complete or incomplete discoid meniscus.