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DR.ANUBHAV VERMA

MODERATOR: DR. RAVI KIRAN HG

1 S T MARCH 2016DEPARTMENT OF ORTHOPEDICS

JSS HOSPITALMYSORE

MENISCAL INJURIES AND PATHOLOGY

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OUTLINE

FUNCTION AND ANATOMYMENISCAL HEALING AND REPAIRTEARS OF MENISCIDIAGNOSISINVESTIGATIONSTREATMENT

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FUNCTION OF MENISCI

JOINT FILLER: compensating for gross incongruity between femoral and tibial articulating surfaces. Prevent capsular and synovial impingement

JOINT LUBRICATION: distribute synovial fluid throughout the joint

STABILITY: flexion to extension, pure hinge to a gliding/rotary motion

SHOCK ABSORBER: 40 – 60 % of body weight in standing position

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JOINT FILLER

Following meniscectomy: Flattening of femoral condyl and formation of osteophytes

Contact area inversely proportional to contact stress

Decreased contact area (Approx 40%), increased contact stress (100% medial meniscus. 200% lateral meniscus because of relative convex surface of lateral tibial plateau)

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STABILITY

Increased joint laxity following meniscectomy.

Insignificant if ligamentous structures intact

ACL deficient knee: increased tibial translation by 58% after medial meniscectomy (c.f. lateral meniscectomy – not affixed firmly and does not act as efficient posterior wedge to prevent translation)

May account for different patterns of meniscal injuries in ACL deficient knee

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ANATOMY

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MEDIAL MENISCUS

C shaped, larger in radius than lateral meniscusAnterior horn: Attached anterior to

intercondylar eminence and to the ACLPosterior horn: Attached in front of attachment

of PCL, posterior to the intercondylar eminenceEntire peripheral border firmly attached to the

medial capsule and through coronary ligament to the upper border of tibia

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LATERAL MENISCUS

Smaller, More circular, thicker in periphery, wider in body and more mobile than medial meniscus

ANTERIOR HORN: attached medially in front of the intercondylar eminence

POSTERIOR HORN: inserts into the posterior aspect of the intercondylar eminence and in front of posterior attachment of medial meniscus.

Attached to both cruciate ligaments and posteriorly to the medial femoral condyle by either the ligament of Humphry or the ligament of wrisberg

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LATERAL MENISCUS

Smaller in diameter

Circular

Thicker in periphery

Wider Body

More Mobile

Attached to both ACL/PCL

MEDIAL MENISCUS

Larger in diameter

C shaped

Thinner in periphery

Thinner body

Less mobile

Not attached to ACL/PCL

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STRUCTURE

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ROLE OF HOOP TENSION

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VASCULAR SUPPLY

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MENISCAL HEALING AND REPAIR

Meniscal tears have been classified on the basis of their location in three zones of vascularity—

red (fully within the vascular area), red-white (at the border of the vascular area),white (within the avascular area)Peripheral lesions have been shown to heal

better than the partial vascular and avascular areas of the meniscus

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for a meniscus to regenerate, the entire structure must be resected to expose the vascular synovial tissue

In subtotal meniscectomy, the excision must extend to the peripheral vasculature of the meniscus.

Subtotal excisions of the meniscus within the avascular central half of the meniscus do not show any regeneration potential.

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MENISCAL TEARS

Mechanism: The menisci follow the tibial condyles during flexion and extension, but during rotation they follow the femur and move on the tibia; consequently, the medial meniscus becomes distorted.

Its anterior and posterior attachments follow the tibia, but its intervening part follows the femur; thus it is likely to be injured during rotation.

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WHY L.M. IS SPARED?

However, the lateral meniscus, because it is firmly attached to the popliteus muscle and to the ligament of Wrisberg or of Humphry, follows the lateral femoral condyle during rotation and therefore is less likely to be injured.

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During vigorous internal rotation of the femur on the tibia with the knee in flexion, the femur tends to force the medial meniscus posteriorly and toward the center of the joint

The posterior part of the meniscus is forced toward the center of the joint, is caught between the femur and the tibia, and is torn longitudinally when the joint is suddenly extended.

Most common location: posterior horn of meniscus

Most common type: longitudinal

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BUCKET HANDLE TEAR

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CLASSIFICATION OF TEARS

(1) longitudinal tears, (2) transverse and oblique tears, (3) a combination of longitudinal and

transverse tears, (4) tears associated with cystic menisci, (5) tears associated with discoid menisci.

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DIAGNOSIS

HISTORY: middle aged person who sustains a weight-bearing twist on the knee or who has pain after squatting.

The syndromes caused by tears of the menisci can be

divided into two groups: 1. With Locking

2. Without Locking

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THE LOCKING KNEE

Inability to completely extend the knee jointoccurs only with longitudinal tears and is much morecommon with bucket-handle tearsIntra articular tumor, an osteocartilaginous loose body, and

other conditions can also cause locking.False locking :hemorrhage around the posterior part of

the capsule or a collateral ligament with associated hamstring spasm prevents complete extension of the knee.

locking may not be recognized unless the injured knee is compared with the opposite knee, which should exhibit the 5 to 10 degrees of recurvatum that normally is present.

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NON LOCKING KNEE

typically gives a history of several episodes of trouble referable to the knee, often resulting in effusion and a brief period of disability but no definite locking.

A sensation of “giving way” or snaps, clicks, catches, or jerks in the knee may be described

IMPORTANT CLUES IN AN INJURED NON LOCKING KNEE: a sensation of giving way, effusion, atrophy of the quadriceps, tenderness over the joint line (or the meniscus), and reproduction of a click by manipulative maneuvers during the physical examination.

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GIVING AWAY

a tear in the posterior part of a meniscus, the patient usually notices this on rotary movements of the knee and often associates it with a feeling of subluxation or “the joint jumpin out of place.”

When giving way is a result of other causes, such as quadriceps weakness, it usually is noticeable during simple flexion of the knee against resistance, such as in walking down stairs.

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OTHER FEATURES

EFFUSION: occcurs when vascularised peripheral area of a meniscus is torn. Mostly it is a hemarthrosis.

MUSCLE ATROPHY: especially of the vastus medialis

JOINT LINE TENDERNESS: most important physical finding. Localised over the medial or lateral joint line or over the periphery of the meniscus. The meniscus itself is without nerve fibers except at its periphery; therefore, the tenderness or pain is related to synovitis in the adjacent capsular and synovial tissues.

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THE MC MURRAY TEST

Medial Meniscus: Keeping the knee completely flexed, the leg is externally rotated as far as possible and then the knee is slowly extended. As the femur passes over a tear in the meniscus, a click may be heard or felt.

Lateral Mensicus: palpating the posterolateral margin of the joint, internally rotating the leg as far as possible, and slowly extending the knee while listening and feeling for a click.

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CLICK: caused by a posterior peripheral tear of the meniscus and occurs between complete flexion of the knee and 90 degrees

POPPING: occurs with greater degrees of extension when it is definitely localized to the joint suggests a tear of the middle and anterior portions of the meniscus

The position of the knee when the click occurs thus may help locate the lesion.

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APLEY’S GRINDING TEST

With the patient prone, the knee is flexed to 90 degrees and the anterior thigh is fixed against the examining table. The foot and leg are then pulled upward to distract the joint.

with the knee in the same position, the foot and leg are pressed downward and rotated as the joint is slowly flexed and extended

when a meniscus has been torn, popping and pain localized to the joint line may be noted.

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OTHER TESTS

Seinmann’s test. Squat test. Duck waddle test. Helfet’s sign. Bounce home test. 0’donoghue’s test. Payr’s test Bragard’s sign. Anderson medial – lateral grind test. Passlar rotational grind test. Cabot’s popilteal sign.

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Mod. Helfet Test Payr’s Sign

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Bragard’s Sign

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Anderson Medial- Lateral Grind Test

40Cabot’s Popliteal Sign

InvestigationsX Ray:

A.P Lateral Intercondylar notch

view Tangential view of

inferior surface of patella.

It is essential to exclude loose bodies ostechondritis and other derangements of the knee.

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Arthrography It is an invasive procedure. Air and an opaque contrast

material such as iothalamic magleramine or diatrizote sodium and renografin are injected into the joint under sterile condition. Multiple roentgenographic views are then made by rotating the joint and bringing all portions of medial and lateral mensci into profile.

Accuracy in diagnosis – Medial menisci – 95%; lateral

menisci – 85%

It is contraindicated in pyoarthosis, bleeding disorder and allergy to contrast material.

With the improvement in CT and MRI scanning,

arthography is rarely used. 42

Arthroscopy

• It has an accuracy of 98% for medial meniscus & 90% for lateral meniscus.

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MRI Grading:

Grade I Tear of the menisus has increased signal in the meniscal substance.

Grade II Involves a more pronounced and frequently linear signal that does not break the surface of the menisus.

Grade III Signal that traverses through the meniscal surface.

Grade IV There is extension of tear through both tibial and femoral surfaces of the menisus.

Grade I and II changes appear normal on arthoscopic evaluation.

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Non-Surgical ManagementIndications:Partial thickness splits.full thickness oblique or vertical tears less

than 5mm, if stableShort radial tears.Degenerative tears in OA, without

mechanical symptoms.Stable tears with inability to displace the

central portion, by greater than 3mm.

Contra indications:Chronic tears with superimposed acute

injury. In a locked knee caused by bucket handle

tear of meniscus.

Non-Surgical Management

An acute episode without locking but with an acute synovitis with effusion requires

immediate abstinence from weight bearing,

rest with knee flexion, application of ice packs,compression dressing, Buck’s traction with 5-7

pounds of weight.

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Groin to ankle cylinderical cast in worn for 4 to 6 weeks.

Isometric exercise program during the time the leg is in the cast

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At 4-6 weeks cast is removed and rehabilitative exercise program is intensified.

If symptoms recur after a period of NST,

surgical repair or removal of the damaged menisus may be necessary.

Surgical Management

1. Meniscectomy

By arthrotomy or By arthroscopy

2. Meniscal repair

By arthrotomy or By arthoscopy

3. Meniscal transplantation

With autografts, allografts or prosthetic scaffolds.

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General Principles Partial meniscectomy is always preferable to subtotal or total

meniscectomy.

The objective is to remove the torn, mobile meniscal fragment and contour the peripheral rim, leaving a balanced, stable rim of meniscal tissue.

Pneumatic tourniquet to be used to avoid constant sponging

which prolongs and damages the joint surfaces. Before wound closure tourniquet to be released and bleeding vessels are ligated or electrocauterized.

The knee should be examined carefully for stability after the patient is anesthetized.

The anterior compartment of knee should be explored first, then the posteomedial and lastly the lateral compartment should be explored.

The condition of the synovial membrane, articular surfaces, medial and lateral menisci and ligaments should be noted.

Objective of the Treatment

to remove the torn mobile meniscal fragment

contour the peripheral rim leaving a balance stable rim of meniscal tissue.

No standard technique can be used in every case.

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Meniscectomy O Connor

classification

1. Partial meniscectomy: Only the loose unstable

fragments are excised; e.g: displaced inner

fragments in bucket handle tear, flap in oblique tears.

In this a stable and balanced peripheral rim is preserved.

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2. Subtotal meniscectomy:

This requires excision of portion of peripheral rim of meniscus. Most of the anterior horn and a portion of middle 3rd of the meniscus are not resected.

3. Total meniscectomy:

meniscus is detached from its peripheral menisco-synovial attachment

-intrameniscal damage -tears are extensive.

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Partial \ Total Meniscectomy ?

Deciding factors Location of tear Length Pattern Stability Condition of whole meniscus

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Advantages of Partial Over Total

Shorter operating timeFaster recoveryBetter post operative functionBetter self assessment of outcome

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POST MENISCECTOMY REHAB PROTOCOL

A compression bandage is applied to the knee.

Knee is immobilized for 5-7 days. Then it is discontinued.

Ice is applied over the knee and limb is elevated for 24-48 hours postoperatively.

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Quadriceps exercises are started on 2nd day onwards, SLR isometric quadriceps exercises are carried out on every hour when the patient is awake.

When the good muscular control is achieved patient is allowed to walk with crutches and with partial weight bearing.

The sutures are removed at 2 weeks and gentle resistive exercises are begun.

Open Excision of Medial Meniscus

Using anteromedial incision Begin the incision just medial to patella, 5 cm

distally parallel with patella and patellar tendon. Incise the fascia and capsule 0.5 cm medial to the edge of patellar tendon .

Grasp the synovium, make a small opening through it into the joint. Mobilize the anterior third segment of meniscus.

Grasp the anterior segment with martin clamp.

Free the middle third of the meniscus at its periphery.

Mobilize the posterior third of meniscus.

Displace the meniscus into the intercondylar notch, leave a stable balanced menisceal rim.

Close the incision, evert the cut edge of synovium.

Close fascia, extensor aponeurosis and capsule in one layer. 59

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Open Excision of Lateral Meniscus

Anterolateral incision : begin the incision at the level at the middle portion of the patella extend it distally to the upper tibial surface incise the anterolateral capsule and synovium.

Free the anterior third of lateral meniscus, and grasp it with martin grasper

Maintain traction on free anterior segment.

Flex the knee, place the foot on opposite knee and apply varus strain.

By continued gentle traction, posterior third of meniscus is separated, and complete lateral meniscus is excised. Close the capsule with intermediate sutures.

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Arthroscopic MeniscectomyLongitudinal tears: 30 degree oblique viewing arthroscope is inserted through an

AL portal. Probe is placed through the AM portal.

Horizontal tear: 30 degree oblique viewing arthroscope is used through AL

portal. Superior and inferior leaves of the tear is removed with basket forceps. Peripheral rim is trimmed and contoured.

Oblique tears: Three portal procedures is adopted. Small posteriorly based

oblique tears are usually removed by morcellation of the flaps with basket forceps or motorized cutter, trimmer instruments. Large posterior or oblique tears are removed intact enbloc.

Anterior oblique tears are removed by triangulation technique.

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Three Portal TechniqueIt is used excision of

large complete intrameniscal tears of posterior horn.

Arthoscope, grasping instrument and cutting instruments are used through the three portals.

Arthroscope placed in AL portal. Probe the posterior limits of displaced bucket handle through AM portal.

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Through AM portal anterior horn attachment of the meniscus is released.

Grasping clamp is placed through the AM portal to grasp the anterior horn and it is removed.

Now probe is used through AM portal to check the stability of the remaining rim and look for any tears.

Basket forceps or motorized shaver are introduced through AM portal to smoothen the remaining rim.

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Complications after Meniscectomy

1. Post operative haemarthrosis. 2. Chronic synovitis. 3. Svnovial fistulae. 4. Painful neuromas of the branches of the

infrapatellar portion of saphenous nerve. 5. Thrombophlebitis – suggested by

postoperative pain and swelling in the calf and distal extremity with low-grade fever.

6. Postoperative infection – increasing effusion, pain and fever beginning 2 to 3 days after surgery indicates the onset of pyarthrosis.

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7. Reflex sympathetic dystrophy. 8. Retained meniscal fragment. 9. Capsular and ligamentous laxity. 10. Late changes degenerative changes

with in the joint. Fairbank described three changes.

a. Narrowing of joint space.b. Flattening of peripheral half of the

articular surface of condyle. c. Development of anteroposterior

ridge that projected distally from the margin of femoral condyle.

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OPEN MENISCAL REPAIR

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Arthroscopic Meniscal Tear Repair

Consists of 3 important steps:

1. Appropriate patient selection – should have documented tear that is able to heal.

2. Tear debridement and local synovial, meniscal and capsular ablation to stimulate a proliferative fibroblastic healing response.

3. Suture placement to reduce and stabilize the meniscus.

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CRITERIA

Location : within 3 mm of periphery are presumed vascular. More than 5mm are avascular. Stability : partial thickness. Full thickness- oblique and vertical tears less than 10 mm

with inability to displace the central portion with a probe greater than 3mm.

Length : Stable tear <10mm in length left alone. Radial tear <5mm in length left alone. Tear pattern : peripheral , vertical and longitudinal tears repaired. Bucket handle, flap, degenerative, complex, radial

tears are excised. Patient age : should be less than 50 yrs. Chronicity : Acute tears less than 8 weeks old have better healing

potential. Ligament stability : ACL deficiency must also be corrected

simultaneously to prevent instability.

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TECHNIQUES

Inside to outside. Single cannula Double cannula Outside to inside.

All – inside technique.

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Inside – to – Outside Technique Single cannula : Carry out the diagnostic arthroscopy. For repair of medial meniscus, place 30 degree angle of arthroscope

through the AL portal. Freshen and debride the surfaces. If straight cannula technique is used, approach an anterior and middle third

tears of medial meniscus, from lateral portal, under the arthroscope. Approach posterior third tear, by inserting the cannula throught AM portal. 2-0 PDS sutures are used. Keep the knee in 10 to 20 degree in flexion as the sutures are passed. Pass the cannula of the suturing instrument in AM portal. All sutures are tied over the bridge of the capsule, close the skin incision.

Double cannula system: Instruments consists of Straight and curved double lumen cannulas,

through which needles may be passed.

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Outside – to – Inside TechniqueIn this method suture is introduced through the

spinal needle i.e. Inserted from outside to inside.This technique is safe approach to posterior

horn.Technique is same for both menisci. For large peripheral lesions of medial meniscus,

such as bucket handle tears, combination of inside to outside and outside to inside methods can be used.

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All Inside Technique

Morgan described, this technique for repair of posterior horn.

Advantages:

It allows placement of vertical sutures. Smaller incision can be used. Disadvantages:

Need for special instrumentation. Difficulty with intraarticular knot tieing.

All inside technique, can be performed by using commercial available T – fix sutures.

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Advantages of Open Technique

1. Vertically oriented sutures are easy to do by open arthrotomy. It is more secure than more horizontally oriented suturing by arthoscope techniques.

2. In repair of posterior horn peripheral tears by open arthotomy technique, posteromedial or posterolateral capsular reconstruction can be done concurrently.

3. Immobilization required is the same for both open and arthroscopic technique.

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1. Small incisions .

2. Short stay.

3. Early mobilization.

4. All corners of the joint can be visualised.

5. Cosmeticaly very minimal scar.

6. Cost effective.

7. Patient is comfortable.

8. Less infection.

9. Less joint stiffness.

10. Morbidity is less.

Advantages of arthroscopic technique

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Arthroscopic Disadvantages

Prolonged learning curve Specific instrumentation

76After Treatment

Knee is placed in a hinged brace and immediate range of motion from 0-90 degrees is permitted.

Touchdown weight bearing is permitted immediately, and

Full weight bearing is permitted at 6 weeks when the brace and crutches are discarded.

No sports are allowed for 3 months. If tear is large crutches are discarded at 8

weeks. No sports are allowed for 6 months.

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Exercises after Injury to the Meniscus

Are designed to build up the quadriceps and hamstring muscles and increase flexibility and strength:

Warming up the joint by riding a stationary bicycle, then straightening and raising the leg (but avoiding straightening the leg too much).

Extending the leg while sitting (a weight may be worn on the ankle for this exercise).

Raising the leg while lying on the stomach. Exercising in a pool.

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83Recent Advances

Enhancement of meniscal healing. Arthroscopic repair of torn meniscus using

fibrin clot.Meniscal replacement with - allograft meniscus - autograft fascial material - synthetic meniscus

Biologic tissue scaffolds

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Enhancement of Meniscal Healing

Vascular access channels: creating access of peripheral vessels to avascular

region, by a channel (trephination) allows avascular portion of the meniscus to heal throught the proliferation of the fibrous scar.

Synovial abrasion : encourages vascular extension to avascular regions

via., formation of vascular synovial pannus.

Exogenous fibrin clot : a clot precipitated on a sterile glass surface, and

placed within the defect within the vascular zone can promote healing.

85Arthroscopic Repair of Torn Meniscus using Fibrin Clot

The fibrin clot appears to act as a chemotoctic and mitogenic stimulus for reparative cells and provide scaffolding for reparative process.

Arnocky and Warren reported the injection of exogenous fibrin clot obtained form the patients coagulated blood as promoting improving meniscal healing. Exogenous fibrin clot is injected with a blunt needle in the stem of the tear. 1 to 2ml of clot was sufficient to fill an average defect. When gaps are big, a facial sheath was used to cover these defects and the exogenous fibrin clot was injected under the cover of sheath i.e., for complex tears.

Repairs of tears less than 2 months from the time of injury to surgery result higher healing rates than those of more chronic tears.

Isolated repairs heal significantly better with exogenous fibrin clot injection.

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Meniscal Replacement

Attempts at meniscal replacement with allograft menisci, autograft fascial material and synthetic menisci scaffold are in various stage of study.

Investigation studies of biological tissue scaffolds are in progress. These grafts may provide a more acceptable meniscal replacement in the future.

As technology and the biomechanics and physiology of menisci tissue are better understood. These techniques may become more popular.

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Allograft Meniscal Transplantation

Aim: To prevent degenerative changes, in the post

meniscectomy patient.

Indications: Patient less than 45 yrs age, with pain and discomfort

associated with early OA, without ACL deficiency or significant malalignment.

Contraindications: Age more than 60 yrs. Bony architectural changes. Prior infection. Significant malalignment. Instability.

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Graft Preservation Technique: Fresh freezing. Cryo preservation. Freeze dried. Secondary sterilization with radiation less than 2.5 M Rad.

Steps: Graft preparation. Tunnel placement. Graft insertion. Graft fixation.

After Treatment: Limb placed in long leg hinged knee brace. Range of movement from 0 to 90 degree begin immediatiely. Partial weight bearing with brace for first 6 weeks. Brace removed at 6 weeks. Full weight bearing started. Deep flexion avoided for 6 months.

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Bio- absorbable Implants

Poly glycolic acid Poly levo lactic acid Raecemic poly lactic acid Poly dexanone. All these materials degrade into co2

and water. Devices include Anchors,Arrows, screws,staplers.

90Experimental Studies

Angiogenin, a potent blood vessel inducing protein- a 123 AA protein

Implantation into the experimentally injured menisci in rats induces neo vascularisation of meniscus

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References Campbell’s operative orthopaedics. Vol. 3,

11th Edition. Orthopaedics principles and their

applications. 6th Edition Turek. Mercer’s Orthopaedic Surgery, 10th

Edition. Rockwood and Green’s Fractures in

Adults. Vol 2. 7th Edition. Techniques in Therapeutic Arthroscopy by

J. Serge Parisien. Athletic Injuries and Rehabilitation by

James. David and William . JBJS. Current Orthopedic Diagnosis and

Treatment.