Cysts of the lateral meniscus: arthroscopy versus arthroscopy plus open cystectomy

A retrospective analysis was performed on 32 knees in 31 patients with the diagnosis of cyst of the lateral meniscus. Average follow-up was 41 months, with a range of 16-72 months. Surgical and histological examination demonstrated pathology varying from large meniscal tears with minimal cyst formation to large cysts with no demonstrable meniscal tear. Two theories of etiology emerged: (a) The tear begins in the meniscus and spreads through the periphery. (b) The lesion begins as a compression injury to the vascular periphery and spreads centrally, producing a meniscus tear, or peripherally, producing a cyst, or both. In our series, 20 patients managed by arthroscopic partial meniscectomy and open cystectomy had 80% excellent-good results versus 50% excellent-good results in 12 patients treated with arthroscopy and partial meniscectomy without extraarticular cystectomy. We recommend the following treatment: arthroscopy with a diligent search for a lateral meniscal tear, especially peripherally. If none is found, proceed to extraarticular cystectomy. If a tear is found, remove all unstable meniscal fragments, leaving a rim, if possible, especially adjacent to the popliteus recess, and then proceed to open cystectomy.     

Arthroscopic treatment of cysts of the menisci. A preliminary report

A retrospective clinical study evaluated the results of arthroscopic management of cysts of the menisci. From 1979 to 1984, 24 patients with a diagnosis of meniscal cysts associated with tears of the semilunar cartilage were treated with partial meniscectomy and cyst decompression. The mean age was 29.9 years (range, 14-52 years). Each patient had tenderness over the joint line with a palpable mass. There were 25 cases of meniscal cysts, with one patient having a bilateral cyst. Twenty-two cysts involved the lateral meniscus, and three cysts were on the medial side of the knee. The follow-up period ranged from 16 to 48 months (mean, 33.5 months). All patients had a meniscal tear; most tears were either horizontal or transverse, with or without flap formation. The pathology was in the middle or anterior one-third of the meniscus. The arthroscopic surgery consisted of partial excision of the meniscal tear, leaving a peripheral rim at times, coupled with aspiration of the cyst material or manipulation of its contents into the joint cavity. No cyst recurred, and in every patient except one, preoperative symptoms disappeared. All patients but one were satisfied with the results. Two patients had a second arthroscopy, and no evidence of instability of the peripheral rim was found.     

The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears

Purpose: The purpose of this study was to document the accuracy of joint line tenderness in the diagnosis of meniscal tears. Type of Study: Prospective cohort study. Methods: There were 104 male recruits (age range, 18 to 20 years; mean, 19.2 years) with suspected meniscal lesions who underwent arthroscopy. A thorough history and physical examination was performed on each patient by a physician with 4 years’ experience on arthroscopic knee surgery. Twenty-six (25%) patients sustained injuries while in the Turkish Army, and 78 patients (75%) sustained injuries before they came to the army. On physical examination, assessment of joint line tenderness at the lateral and medial joint lines was performed with the patient’s knee flexed 90°. The accuracy, sensitivity, specificity, and positive and negative predictive values of joint line tenderness for medial and lateral sides were calculated based on arthroscopic findings. Results: In 104 knees, the diagnosis was correct in 71 (68%) and incorrect in 33 (32%) knees. A total of 37 medial meniscal tears and 27 lateral meniscal tears were identified at arthroscopy. Other pathology included 11 anterior cruciate ligament (ACL) tears, 5 medial femoral chondral lesions, 4 chondromalacia patellae, and 1 medial plica. No discernable abnormalities were seen in 21 knees. A preoperative diagnosis of a medial meniscal tear was made in 54 knees and 32 were confirmed at arthroscopy. A lateral meniscus tear was suspected in 27 knees and confirmed in 25. Five medial meniscus and 2 lateral meniscus tears were seen at arthroscopy. These had not been suspected with tenderness over the joint line. The accuracy of the test was lower with the presence of ACL lesions and condromalacia patella. Conclusions: I concluded that joint line tenderness as a test for lateral meniscal tears is accurate (96%), sensitive (89%), and specific (97%). However, for medial meniscal tears, rates are lower.     

Partial meniscus arthroscopic resection

Arthroscopic meniscectomy was performed in 393 patients in the "three portal technique" in the years 1981 through 1983. The medial meniscus showed a bucket handle tear in 40.3% and a flap tear in 37.3% whereas the lateral meniscus showed a bucket handle tear in 12.2% and a flap tear in 46.1%. More than one third of the meniscus lesions were associated by chondromalacia of patella or femoral condyle. Arthroscopic meniscectomy was combined with shaving of the cartilage or shaving and arthroscopic subchondral drilling in 71 cases. Second-look arthroscopy was performed in 10 patients because of rupture of the remnant rim after the first partial meniscectomy.     

关节镜下半月板部分切除术治疗中老年人内侧半月板损伤

目的：探讨关节镜下半月板部分切除术治疗中老年人内侧半月板损伤的临床疗效及其临床价值.方法：自2010年10月至2012年10月,对49例符合纳入标准的膝关节内侧半月板损伤患者,通过关节镜下半月板部分切除术进行治疗.其中男31例,女18例;年龄50～60岁,平均（55.3±2.8）岁;左膝22例,右膝27例.49例平均屈曲角度（116.01±12.03）°.术前膝关节HSS功能评分平均48.73±8.43,Lysholm评分平均63.95±5.45.均采用标准半月板部分切除术,切除损伤部分半月板,遗留前方正常半月板组织.结果：所有手术成功,无严重并发症.术后随访12～36个月,无失访病例.所有患者保持5级肌力,膝关节活动度正常,能完全伸直及完全屈曲.49例平均屈曲角度（136.77±18.56）°,较术前提高（t=17.56,P=0.001）;终末随访膝关节HSS功能评分86～95分,平均90.17±4.10,较术前提高（t=12.65,P=0.001）;Lysholm评分82～91分,平均87.84±5.16,较术前提高（t=13.45,P=0.001）.结论：关节镜下半月板部分切除治疗中老年人单纯内侧半月板损伤疗效优良.严格掌握适应证是保证疗效的前提,精确的手术技术是保证疗效的关键.术后短期内部分患者存在膝关节活动受限,但经过治疗及康复均能完全恢复.     

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     

Lateral Meniscal Injury After a Successful Medial Unicompartmental Knee Arthroplasty

A case of an active 52-year-old woman who, after a medial unicompartmental knee arthroplasty, began complaining of lateral joint line pain and a persistent knee effusion. A lateral meniscal tear was diagnosed clinically, and she underwent an arthroscopic partial meniscectomy that resolved her problems. This case demonstrates the importance of considering a meniscal problem as the cause of any unexplained joint line pain in the unoperated compartment after a successful unicompartmental knee arthroplasty and not simply attributing it to progression of degenerative change within the lateral compartment.     

Partial meniscectomy in the presence of severe osteoarthritis does not hasten the symptomatic progression of osteoarthritis

Purpose:This study had 2 aims: to determine whether arthroscopic partial meniscectomy improved symptoms in patients with a torn meniscus and severe degenerative change and to determine whether meniscectomy hastened the symptomatic progression of osteoarthritis in these patients.Type of Study:An outcome study.Methods:The study group consisted of 126 patients with Outerbridge grade IV degeneration (exposed bone) in the same compartment as a meniscal tear. These patients underwent arthroscopic partial meniscectomy. The control group consisted of 13 patients with exposed bone in the tibiofemoral compartment but intact menisci. They underwent washout. Data were obtained from a database of over 3,000 consecutive arthroscopies, patient medical records, and patients directly. Outcome was assessed a minimum of 12 months after surgery.Results:Meniscectomy improved symptoms initially in 82 cases (65%). At a median of 52 months after meniscectomy, 41 patients (32%) had undergone further surgery (39 total knee arthroplasty, 1 unicompartmental knee arthroplasty, and 1 tibial osteotomy). Fifty patients (40%) reported subjective improvement. The subjective outcome assessment by patients was consistent with patient activity, use of nonsteroidal anti-inflammatory drugs, and the Lysholm score. Meniscectomy did not hasten the progression of osteoarthritis because more patients required joint replacement after washout (P = .04), and the mean time to further surgery was greater for meniscectomy than for washout (74 months [standard error, 4.11] and 50 months [standard error, 12.3], respectively, P = .067).Conclusions:Arthroscopic partial meniscectomy in the presence of Outerbridge grade IV degenerative change is likely to improve symptoms initially in patients with symptomatic meniscal tears and may provide lasting benefit. It does not appear to hasten the progression of the osteoarthritis in these patients.     

Arthroscopic decompression of meniscal cysts: report of 14 cases

Meniscal cysts are a painful disorder of the knee affecting young to middle-aged adults. The recommended treatment has been total meniscectomy. With the widespread use of arthroscopic surgery there has been a trend to a more conservative management of meniscal pathology in general. We treated 14 patients with meniscal cysts (13 lateral, one medial) by partial arthroscopic meniscectomy and decompression. At a mean follow-up of 19 months, results were satisfactory in 12 patients; there was one recurrence and one patient had reinjured his knee. We concluded that arthroscopic decompression of meniscal cysts is a promising form of treatment.     

Juxta-articular bone marrow signal changes on magnetic resonance imaging following arthroscopic meniscectomy

Purpose: Postmeniscectomy osteonecrosis of the knee has been reported in the past decade but the etiology remains unclear. Some investigators have indicated that bone marrow signal changes evident on magnetic resonance imaging (MRI) could be early warning signs of osteonecrosis. The purpose of this study was to determine the incidence rate, location, and magnitude of such changes in bone marrow of the knee after arthroscopic meniscectomy, using MRI. Type of Study: Cohort analytic study. Methods: Ninety-three patients with no bone marrow signal abnormalities on preoperative MRI were examined after isolated arthroscopic meniscectomy. There were 51 men and 42 women with an age range of 11 to 62 years (mean, 36.6 years). Of the total, 57 patients underwent partial meniscectomy (34 medial and 23 lateral) and the others total meniscectomy (10 medial and 26 lateral). MRI examinations were performed independently of postoperative knee symptoms, 1 to 24 months after surgery. Bone marrow changes of the treated knees were evaluated by T1- and T2*-weighted MRI. Results: Thirty-two of 93 patients (34%) had bone marrow signal changes in femoral or tibial condyles shown on postoperative MRI. No patients had these changes in the femoral or tibial condyles opposite from the meniscectomy side and, in the majority of cases, the size was less than half that of the condyle. Fifteen of the 44 patients who underwent medial meniscectomy and 17 of the 49 patients who underwent lateral meniscectomy had such changes. The meniscectomy side did not affect the incidence rate, and frequently both femoral and tibial condyles were involved. Age, gender and articular cartilage condition at the surgery were not risk factors. In contrast, the extent of meniscectomy affected the incidence rate. Conclusions: This study suggests a positive correlation between arthroscopic meniscectomy and postoperative bone marrow signal changes of the knee.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 238–245     

Risk of total/subtotal meniscectomy for respective medial and lateral meniscus injury: correlation with tear type,duration of complaint,age, gender and ACL rupture in 6034 Asian patients

Background

To evaluate the risk factor associated with total or subtotal meniscectomy for respective medial and lateral meniscus injury.

Methods

The data of all the meniscus injured patients undergoing arthroscopy in our institute between January 15th, 2000 and December 31st, 2008 was collected and 6034 patients with 7241 injured menisci met the inclusion criteria. The mean patient age was 33.6?±?14.9 years and there were 4785 males and 2456 females with 3568 medial and 3673 lateral menisci. The decision tree approach was applied to investigate the correlation of the tear type, the duration of complaint, age, gender, ACL rupture and total/subtotal meniscectomy for respective medial and lateral meniscus.

Results

The tear type was associated with both medial (χ2?=?70.901, P?<?0.001) and lateral (χ2?=?268.019, P?<?0.001) total/subtotal meniscectomy. The strongest risk of total/subtotal meniscectomy of both medial and lateral meniscus tear was shown for the complex tear followed by the longitudinal, oblique, horizontal and radial tear of the medial meniscus and followed by horizontal, longitudinal, radial and oblique tear of the lateral meniscus. The risk of total/subtotal medial meniscectomy was significantly elevated for the patients with complex tear and the age of ≤40 years old (χ2?=?21.028, P?<?0.001) and those with the oblique, horizontal or radial tear accompanied by ACL rupture (χ2?=?6.631, P?=?0.01). Besides, the duration of complaint was also associated with total/subtotal meniscectomy of the medial longitudinal tear with ACL rupture (χ2?=?17.155, P?<?0.001). On the other side, the risk of total/subtotal lateral meniscectomy was significantly elevated for the complex tear of the female patients (χ2?=?5.877, P?=?0.015) with no ACL rupture (χ2?=?50.501, P?<?0.001). The ACL rupture was associated with a decreased risk of total/subtotal meniscectomy for all the types of the lateral meniscus (complex: χ2?=?50.501, P?<?0.001; horizontal: χ2?=?20.897, P?<?0.001; oblique: χ2?=?27.413, P?<?0.001; longitudinal and radial: χ2?=?110.85, P?<?0.001).

Conclusion

Analyzing data from a big sample available in an Asian patient database, we found different risk factors associated with total/subtotal meniscectomy for respective medial and lateral meniscus. Identifying patients at high risk for total/subtotal meniscectomy may allow for interventions after meniscus injury.

     

Electrosurgical methods for arthroscopic meniscectomy: A review of the literature

Purpose: To outline the development of electrosurgical (radiofrequency) devices, explain the basic principles, and review the current orthopaedic literature regarding the application of electrosurgery to arthroscopic partial meniscectomy. Materials and Methods: The history and principles of electrosurgery were obtained from various pertinent texts and journal articles. A literature search was performed using MEDLINE; reviewed articles consisted of articles in the English language cataloged between 1966 and January 1999. Results: The history and principles of electrosurgery are reviewed. The articles pertaining to arthroscopic electrosurgical meniscectomy are discussed with a separate discussion on the potential complications of using radiofrequency energy for meniscal ablation, including articular cartilage damage, osteonecrosis, and damage caused by irrigant. Conclusion: Electrosurgery has been shown to be an effective tool in arthroscopic meniscectomy. Further research and refinement is warranted because it may show superiority to other methods in certain situations.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 8 (November-December), 2000: pp 813–821     

Arthroscopic partial lateral meniscectomy in an otherwise normal knee: Clinical, functional, and radiographic results of a long-term follow-up study

Purpose: To determine the clinical, functional, and radiographic long-term results of patients who underwent arthroscopic partial lateral meniscectomy in an otherwise normal knee. Type of Study: This was a retrospective case-control study. Methods: Between 1982 and 1991, 107 arthroscopic partial lateral meniscectomies were performed; 75 of these patients had an isolated lateral meniscal tear and their data were evaluated using the Lysholm score and a questionnaire recording patients’ subjective satisfaction. Radiographic analysis was performed according to the Jäger-Wirth classification and Fairbank changes. Results: All 75 patients were examined by questionnaire, 55 underwent physical examination, and 58 had radiographic analysis. The follow-up period ranged from 5 to 15 years. Excellent and good Lysholm score results decreased from 77% at maximal improvement to 66% at follow-up; 43% of patients maintained their level of maximal improvement, 78% showed one or more Fairbank changes at follow-up, and using the Jäger-Wirth score, 84% showed radiographic deterioration. Conclusions: Although deterioration of functional and especially radiographic results occurred after arthroscopic partial lateral meniscectomy, the number of good results, even with mean follow-up of 12.3 years, is remarkable. There was a high percentage of radiographic changes in our study, but there is no significant correlation between them and subjective symptoms or between them and functional outcome. We believe that careful meniscectomy provides good results for a long period of time but, the longer the follow-up, the more radiographic changes have to be expected; when meniscal refixation is possible, it should be performed.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 946–952     

Editorial Commentary: Arthroscopic Partial Meniscectomy Is Not a First-Line Treatment for Degenerative Meniscus Tear: To Meniscectomize or Not to Meniscectomize?

A painful knee with a degenerative meniscal tear is a quite common problem in the middle-aged patient. Arthroscopic partial meniscectomy is too often used to alleviate pain and seems to work in the short-term. However, arthroscopic partial meniscectomy does not guarantee success, particularly in the long run, particularly in patients with greater grades of osteoarthritis, patients who are older than 60 years, female patients, patients with malalignment, and patients having lateral meniscectomy. There is a need for better science to recommend arthroscopic meniscectomy in those cases.     

Does Arthroscopic Knee Surgery Work?

A recent randomized trial from the Finnish Degenerative Meniscal Lesion Study Group was published in the New England Journal of Medicine and attempted to determine the efficacy of partial meniscectomy without osteoarthritis. Patients were randomized to either arthroscopic partial meniscectomy or sham surgery. The authors concluded that the clinical outcomes after arthroscopic partial meniscectomy were no better than those after the sham surgical procedure. However, there are several important limitations of this trial that make it difficult to generalize to the 700,000 arthroscopic partial meniscectomies performed in the United States each year. In this small sample of 146 patients, patients with traumatic meniscal tears and locking symptoms—those most likely to benefit from a partial meniscectomy—were excluded. In addition, although patients with radiographic arthritis were excluded, most of the patients in the study had degenerative changes at the time of arthroscopy. Therefore it is difficult to determine whether the patients were symptomatic from their chondral degeneration or their degenerative meniscal tear. In our opinion this study does not change the role of surgery in current clinical practice. The primary indication for arthroscopic partial meniscectomy remains symptoms of well-localized joint line pain with acute onset and mechanical symptoms such as catching or locking that have failed comprehensive nonoperative management.     

Arthroscopic medial meniscectomy on stable knees

We reviewed 74 partial medial meniscectomies in 57 patients with stable knees, to assess the long-term functional and radiological outcome. The International Knee Documentation Committee score and the residual laxity were assessed in both knees. At the time of surgery the mean age of the patients was 36 +/- 11 years and the mean follow-up was 12 +/- 1 years. All had a limited medial meniscectomy. The anterior cruciate ligament was intact in all cases. The meniscal tear was vertical in 95% and complex in 5%. The posterior part of the meniscus was removed in 99%. A peripheral rim was preserved in all cases. After 12 years 95% of the patients were satisfied or very satisfied with their knee(s). Objectively, 57% had grade A function and 43% were grade B. The outcome correlated only with the presence of anterior knee pain at final follow-up. In the 49 cases of arthroscopic meniscectomy for which there was a contralateral normal knee there was narrowing of the 'joint-space' in 16% of the operated knees. There was no correlation between this and other parameters such as age or different meniscal pathologies.     

Associated injuries in pediatric and adolescent anterior cruciate ligament tears: Does a delay in treatment increase the risk of meniscal tear?

Purpose: To evaluate the incidence of associated injuries and meniscal tears in children and adolescents with anterior cruciate ligament (ACL) tears, we performed a retrospective review of patients, age 14 and younger, who were treated surgically at our institution. Type of Study: Retrospective review. Methods: We reviewed 39 patients (30 girls, 9 boys) with an average age of 13.6 years (range, 10 to 14 years) who underwent surgical treatment of the ACL; 24 right knees and 15 left knees were treated. Of the injuries treated, 24 occurred by a twisting mechanism, 10 were the result of contact, and 5 occurred from hyperextension. Thirty-five injuries occurred during sports activities, and 2 were sustained in motor vehicle accidents. The mean duration from injury to operative treatment was 101 days (range, 7 to 696 days). Injuries were classified as acute (n = 17) if surgery was performed within 6 weeks of injury and chronic (n = 22) if surgery was performed after 6 weeks from injury. Relationships between medial and lateral meniscal injuries and the time from injury to surgery were analyzed, and the 2 groups, acute and chronic, were compared. Finally, the patterns of meniscal injury were compared. Results: Twenty-six patients had associated injuries (10 medial meniscal tears, 15 lateral meniscal tears, 3 medial collateral ligament tears, and 1 fractured femur). The association between medial meniscal tears and time from injury to surgery was highly statistically significant (P = .0223). There was no statistical significance between the incidence of lateral meniscal tears and time. Medial meniscal tears were more common in the chronic group (36%) than in the acute group (11%), whereas lateral meniscal tears were found with equal frequency. Medial meniscal tears that required surgical treatment (either partial excision or repair) were more common in the chronic group, and lateral meniscal tear patterns were equally distributed. Conclusions: Evidence from this study supports the contention that associated injuries are common in young individuals with ACL tears. Furthermore, the data also show that a delay in surgical treatment was associated with a higher incidence of medial meniscal tears.     

Die arthroskopische Meniskusrefixierung mit bioresorbierbaren Schrauben

Objective Repair of meniscal tears to restore meniscal shape and function as well as to preserve meniscal chondroprotective and knee-stabilizing properties. Indications Peripheral incomplete or complete longitudinal tears of the medial or lateral meniscus.“Bucket-handle tears”. Contraindications Unstable joint not treated successfully.Complex meniscal tears or radial tears.Degenerative meniscal tissue.Meniscal lesions in the avascular central zone.Osteoarthritis.Infections.Local cutaneous affections. Surgical Technique Knee arthroscopy and inspection of the meniscal lesion. Freshening of the meniscal edges using a rasp or shaver. Intraarticular placement of the meniscal screws using a cannulated device. Perforation of the meniscus and refixation of the tear. Results 60 patients of a toal of 65 were followed up by clinical examination after an average of 18 (8–34) months. Two patients had already undergone a partial meniscectomy at the time of follow-up, three had a recurrence of typical clinical signs of a meniscal tear. The other 55 patients rated the overall clinical results as “excellent” (n = 21), “good” (n = 31), or “satisfactory” (n = 3). The average Lysholm score at the time of examination was 93 (49–100) points.     

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.