MENISCUS TEARS AS WE AGE: DIAGNOSIS AND ...forms.acsm.org/tpc2017/PDFs/21 Hame.pdfMENISCUS TEARS AS...
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MENISCUS TEARS AS WEAGE: DIAGNOSIS ANDTREATMENTSharon L. Hame, MDProfessor of Clinical Orthopaedic SurgeryAssociate Team Physician, UCLADavid Geffen School of Medicine at UCLALos Angeles, CA
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DISCLOSURES
• Board Member FORUM, awomen’s orthopaedic sportsmedicine society
• Institutional Support for Fellowship• Smith & Nephew• Storz
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OBJECTIVES
1. Diagnose an athlete with ameniscus tear
2. Learn the treatment optionsfor a meniscus tear
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INTRODUCTION• The most common reason for knee
surgery.• Medial meniscus tears more common
than lateral tears• Older patient degenerative tears
occur most commonly in the posteriorhorn
• In setting of ACL tear, lateral meniscustear more common
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FUNCTION OF THE MENISCUS
Force TransmissionIncreases congruency
Contact area = LoadingShock absorption
Transmits 50% weight-bearing load in extension and 85% inflexion
StabilityThe posterior horn medial meniscus is a secondary stabilizerto anterior translation of the tibia.
Lubrication
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COMPOSITION• Fibroelastic cartilage• Interlacing network of collagen,
glycoproteins, proteoglycan, and cellularelements
• 65-75% water• Collagen-90% Type 1 collagen• Fibers-allows meniscus to expand under
pressure• Radial• Longitudinal (circumferential)
• Dissipates hoop stresses
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ANATOMY OF THEKNEE
• Medial Meniscus• C-shaped with triangular cross section• 9-10 mm wide & 3-5 mm thick
• Lateral Meniscus• More circular
• Can be discoid• Covers more of the articular surface• More mobile• 10-12 mm wide & 4-5 mm thick
MedialLateral
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ANATOMY OF THE KNEE
• Attachments• Transverse (intermeniscal) ligament
• Anterior• Connects medial and lateral meniscus
• Coronary ligaments• Peripheral• Lateral meniscus less rigid fixation
• Meniscofemoral ligament• Posterior horn of lateral meniscus to substance of PCL• Humphrey Ligament (anteriorly)• Ligament of Wrisberg (posteriorly)
ACL
Medial Lateral
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CLASSIFICATION
• Location• Red-Red Zone
• Outer 1/3,vascularized
• Red-White Zone• Middle third
• White Zone• Inner 1/3,
avascularRed red
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CLASSIFICATION
• Pattern• Vertical/longitudinal
• Oblique/flap/parrot beak
• Radial
• Horizontal
• Complex
• Bucket Handle
Complex
Oblique Radial
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DIAGNOSIS
• History• Mechanism
• Twisting injury• Degenerative tears may have minimal
trauma
• Pain localized to the medial or lateraljoint line
• Clicking or popping• Locking• Knee swelling• Decreased range of motion
• Locked knee
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PHYSICAL EXAMINATION• Knee effusion• Tenderness medial or lateral joint line
• Most sensitive test• Decreased range of motion• McMurray’s Test
• Flex knee• With hand on medial joint line, externally rotate and extend• Positive test: palpable click/pop
• Apley’s Compression Test• Prone, flexed knee, internal/external rotation
• Thessaly Test• Stand with knees at 20 degrees flexion• Twist internal and external• Pain/clicking: positive test
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RADIOGRAPHIC STUDIESRadiographs
AP, Lateral, notch, sunrise viewStanding views if possibleUsually normal
MRIHigh Sensitivity-70-98%High Specificity-74-98%Other pathology
Discoid MeniscusBaker’s Cyst
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TREATMENT
Conservative Treatment
NSAIDs
Physical therapy
Bracing
Surgical Treatment
Arthroscopy
Meniscal Debridement
Meniscal Repair
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• 20F, varsity tennis player• Suffered non-contact L knee injury• C/O knee pain and difficulty with
tennis• Failed conservative management
including medication.• PE
• + effusion• ROM: 0-120• + McMurray’s sign• + lateral joint line tenderness• No instability
Meniscus Tear in a Tennis Player
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MRI TENNIS PLAYER
Lateral MeniscusLateral Meniscus
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ARTHROSCOPY OF THE KNEE
Lateral Meniscus Posterior Horn
Lateral Meniscus Mid Portion
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ARTHROSCOPY OF THE KNEE
Arthroscopy of the Knee
Lateral Meniscus Posterior Horn Debridement
Lateral Meniscus Mid Portion Debridement
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MENISCAL REPAIR
• Criteria• Younger age• Red red zone• Red white zone• Size > 1cm
• Types• All Inside• Inside Out• Outside In
Repair
Tear
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MENISCAL REPAIR
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FAILED MENISCAL REPAIR• 25F w/ right knee pain
medial joint line• Hx of gymnastics injury• Arthroscopy x 2, meniscal
repair• Subjective instability and
buckling sensation withactivity
• Physical exam• 0-140 degrees• TTP over MJL• Positive McMurray’s
test• Bilateral genu varum
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FAILED MENISCAL REPAIR
Debridement
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DISCOID MENISCUS
Discoid Meniscus
Bow Tie
Wide Lateral Joint Space,Squaring off
Normal
Discoid Meniscus
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DISPLACED BUCKET HANDLE TEAR
Displaced Bucket Handle Tear
Double Bundle PCL
Locked knee-Emergent surgery needed
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DISPLACED BUCKET HANDLE TEAR
Reduced and Repaired Meniscus
Displaced Bucket Handle Tear
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MENISCUS AS WE AGEBaker’s Cyst
Arthritis
ArthritisArthritis
Degenerative Meniscus Tear
• Increased stiffness• Decreased elasticity• Loss of cellular elements• Increase in fibrous tissue• Color Changes-yellow
15 yr. old
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CONCLUSIONS
• Meniscus tears are common inathletes.
• Meniscus tears can be treatedconservatively, or with surgeryincluding debridement and repair
• The meniscus changes as we age
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BIBLIOGRAPHY1. Arnoczky SP. Gross and vascular anatomy of the meniscus and its role in
meniscal healing, regeneration and remodeling In: Mow VC, Arnoczky SP,Jackson DW, eds. Knee Meniscus Basic and Clinical Foundations, New York, NY:Raven Press; 1992:1-14.
2. Arnoczky SP and Warren RF: Microvasculature of the human meniscus. Am JSports Med 1982; 10: 90-95.
3. Brelim AM, Rue JH. Return to play following meniscus surgery. Clinics Sports Med,2016; 35(4):669-678.
4. De Smet AA, Norris MA, Yandow DR, et al. MR diagnosis of meniscal tears of theknee: Importance of high signal in the meniscus that extends to the surface. AmJ Roentgenol 1993; 161:101-107.
5. Fox AS, Bedi A, Rodeo S: The basic science of human menisci: Structure,composition and function. Sports Health, 2012 4(4): 340-351.
6. Greis PE, Bardana DD, Holstrom MC, Burks RT. Meniscal Injury: 1. Basic scienceand evaluation. J Am Acad Orthop Surg 2002; 10:168-176.
7. McCarty EC, Marx RG, Wickiewicz TL. Meniscal tears in the athlete: Operative andnon-operative management. Physical Med Rehab Clin N Am, 2000;11(4):867-880.
8. Merkel KHM. The surface of human menisci and its aging alterations during age:A combined scanning and transmission electron microscope examination. ArchOrthop Trauma Surg 1980; 97:185-191.
9. Miller GK. A prospective study comparing the accuracy of the clinical diagnosisof meniscal tear with magnetic resonance imaging and its effect on clinicaloutcome. Arthroscopy 1996; 12:406-413.
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THANK YOU!