lateral versus medial meniscus: what is the difference ... · lateral versus medial meniscus: what...
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Lateral versus Medial meniscus:
What is the difference ?
Tim Spalding
Lior Laver
University Hospital Coventry and Warwickshire NHS Trust, UK
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McDermott and Amis JBJS B 2006
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Articular contact Kinematics Tethering
Load sharing
Effect of loss Effect of replacement Effect of repair
Injury Risk
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Variable level of evidence in this presentation
Warning!
7 Areas of focus
Functional anatomy
Injury patterns
Traumatic tears
Total loss
Partial meniscectomy
Meniscal repair
Meniscal transplantation
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1. Anatomy and functional differences
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Medial Lateral
Posterior
Courtesy of Andrew Amis
Covers 80% surface Covers 60% surface
Posterior horn takes most load Lateral moves in flexion
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Anterior Horn
Anterior to the apex of
medial tibial eminence
Anterolateral to the
edge of the medial
articular cartilage
Smigielski 2015
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Posterior Horn
Posterior and lateral
from the medial apex of
medial tibial spine
Smigielski 2015
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Posterior part of medial
meniscus:
The superior edge does
not attach to the joint
capsule
The inferior part attaches
to the tibia through the
menisco-tibial ligament.
Smigielski 2015
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Mid part of medial
meniscus:
The entire part of the
meniscus is attached
to the joint capsule.
Smigielski 2015
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Reminder of load transmission
Medial: 50% of compartment load
Lateral: 70% of compartment load
Transmit
50% of load in extension,
85% of load in flexion
Contact area decreases 30-70%
following menisectomy
Seedhom BB, Dowson D, Wright V. Proceedings: functions of the
menisci. A preliminary study. Ann Rheumatic Dis. 1974;33:111.
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Medial v Lateral
Medial meniscectomy:
Decreases contact area by 50% to 70% and
Increases contact stress by 100%
Lateral meniscectomy
Decreases contact area by 40% to 50%
Increases contact stress by 200% to 300%
Greis PE, Holmstrom MC, Bardana DD, Burks RT. Meniscal injury. II:
management. J Am Acad Orthop Surg. 2002;10(3):177-187.
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Meniscal motion by dynamic MRI
Both move peripherally
Lateral moves more posteriorly
Anterior horns move more than posterior
Weight bearing knee flexion 0-90
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Meniscal motion
Courtesy Andy Williams
Medial Lateral
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Meniscal motion in deep flexion
Johal, Williams et al 2005
Load on fixed medial meniscus in flexion
Lateral slides away
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Result: Biomechanical Differences
Congruity medial v lateral
Lateral Smaller articular contact area
Kinimatics: Lateral larger excursion
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2. Patterns of Tears and symptoms
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Radial tears: Feature of lateral meniscus
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Hidden tears: Ramp lesion MEDIAL
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Root tears
Lateral/Medial different implications
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Varus knee with extrusion
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Horizontal tears
KSSTA 2013
Medial : Lateral 2 : 1
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3. Traumatic meniscal tears
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Meniscal tears in knee injury
Overall Figure
Acute meniscal tears: Medial 55-60%
Lateral 40-45%
Bilateral 5%
Fan R, Ryu R; Meniscal lesions: diagnosis and treatment. Medscape Orthopaedics
& Sports Medicine 4(2), 2000
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Meniscal tears in knee injury
In ACL deficient knees:
Acute injuries: Lateral more common: Short tears in
vascular zone Medial 25-45%
Lateral 31-65%
Chronic injuries: Medial more common: Longer tears, more
unstable, or complex. Increase rate over time
Cipolla M, Scala A, Gianni E, Puddu G (1995) Different patterns of meniscal tears in acute anterior cruciate ligament (ACL)
ruptures and in chronic ACL-deficient knees. Classification, staging and timing of treatment. Knee Surg Sports Traumatol
Arthrosc 3(3):130–134,
Smith JP 3rd, Barrett GR (2001) Medial and lateral meniscal tear patterns in anterior cruciate ligament deficient knees. A
prospective analysis of 575 tears. Am J Sports Med 29(4):415–419.
Indelicato PA, Bittar ES (1985) A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases.
Clin Orthop Relat Res (198):77–80
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Meniscal tears in knee injury
In Children
Stable knees: Medial 70% Lateral 30% Medial tears mainly vertical 78% and peripheral on PM wall 75%
ACL tears: up to 70% associated with meniscal lesion Mainly Lateral, vertical tear posterior segment
Chronic tears: more medial tears
Terzidis IP, Christodoulou A, Ploumis A, Givissis P, Natsis K, Kointzis M (2006) Meniscal tear characteristics in young athletes
with a stable knee; Arthroscopic evaluation (378 Meniscal tears) AJSM 34 (7): 1170-1175.
Graf BK, Lange RH, Fujisaki CK, Landry GL, Saluja RK (1992) Anterior cruciate ligament tears in skeletally immature patients:
meniscal pathology at presentation and after attempted conservative treatment. Arthroscopy 8(2):229–233
Samora WP 3rd, Palmer R, Klingele KE (2011) Meniscal pathology associated with acute anterior cruciate ligament tears in
patients with open physes. J Pediatr Orthop 31(3):272–276.
Millett PJ, Willis AA, Warren RF (2002) Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a
delay in treatment increase the risk of meniscal tear? Arthroscopy 18(9):955–959
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4. Results of ‘TOTAL’ menisectomy
Clear Data on Natural history after
total meniscectomy lacking
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Meniscectomy leads to symptomatic OA knee
16% TKR
132-fold increase in the rate of total knee
replacement in comparison to their geographical
and age-matched peers
Medial / Lateral (in survivors):
No difference in Grade of OA
Medial Trend LOWER IKDC score 59 v 69 (P=0.16 ns)
JBJS (B) 2012
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Older studies
Lateral meniscectomy significantly more knee function deterioration,
Lower Lysholm scores (P=0.03),
higher rate of instability (P=0.02)
Hede A, Larsen E, Sandberg H. The long term outcome of open total and partial meniscectomy related to the
quantity and site of the meniscus removed. Int Orthop. 1992;16:122-125.
Hede A, Larsen E, Sandberg H. Partial versus total meniscectomy: a prospective, randomized study with long-term
follow-up. J Bone Joint Surg Br. 1992;74:118-121.
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5. Results of ‘partial’ menisectomy
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90 soccer players, mean age 23
42 lateral:
RTP 7 weeks
AE’s 69% Pain and swelling
Re-operation 7%
48 medial:
RTP 5 weeks
AE’s 8%
Re-operation 0%
AJSM 2014
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Lateral:
Most Mid zone, middle third
Complex pattern
Radial 29%
Medial:
Most J Posterior/Mid zone, outer third
Vertical orientation
Radial 6%
More volume removed
Conclusion: Lateral slower and more trouble
AJSM 2014
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4 RCTs, 2 prospective cohorts, and 23
retrospective cohorts
Radiographic OA: Lateral v Medial 7 studies
4 Lateral higher
2 no difference
1 Medial higher (60% v 33%)
Higuchi H, Kimura M, Shirakura K, Terauchi M, Takagishi K. Factors affecting long-term
results after arthroscopic partial meniscectomy. Clin Orthop Relat Res. 2000;377:161-168
AJSM 2010
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Retrospective comparative study: 10 yr min F/U
362 Medial and 109 Lateral
Satisfaction: Medial 95% Lateral 95.5%
Free of symptoms: Medial 86% Lateral 80%
X-Ray changes: Medial 22% Lateral 39% (other
compartment normal)
Lateral reduced activity level (P<0.001)
The rate of repeat surgeries for osteoarthritis was
less than 0.2%
Arthroscopy 2003
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RCT 164 pat BTB or ST graft 1995-1997
134 pat after 14 y 57% medial OA (KL ≥ 2)
Strongest risk factor for OA was meniscus resection
Medial Odds Ratio 4.2,
Lateral Odds Ratio 5.1
Odds Ratio for OA
Same in repair group as intact menisci
4.3 in Resection vs Repair (CI 1.1-16) p=0.03
Hugh Jackson
Award 2015
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6. Results of meniscal repair
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Conclusion:
Meniscal repairs: higher reoperation rate but better long-term
outcomes.
Result PM v Repair
Short term (0-4 years) 1.4% v 16.5%
Long term (>10 years) 3.9% v 20.7%
Result by side
Lateral Repair: Lower reoperation rate (23v29%)
Lateral partial meniscectomy: Higher reoperation rate (1.4 v 0.5%)
Arthroscopy 2011
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Lateral vs. Medial Meniscus
Surgery
Lateral Meniscus Surgery Medial Meniscus Surgery
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9609 meniscal repairs between 2003 and 2010 (2223 Lat, 2261 Both)
Median F/U 3 yrs
Result
8.9% overall frequency of subsequent meniscectomy:
Lower if: Concomitant ACL repairs (HR 0.67)
Isolated Lateral
Older age (>30)
High volume surgeon (>24 a year) (HR 0.71)
Conclusion:
Repairing a meniscus is a safe and effective procedure in the long term.
AJSM 2013
Lateral better than medial
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13 studies
Medial failure 24.2% (17-36%)
Higher in 4 studies
Lateral failure 20.2% (7-43%)
Higher in 3 studies
JBJS 2012
Trend to lower failure in lateral
P=0.17 on random-effects model
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SÖS & Capio Artro Clinic 1999-2011
Median 23 y (12-60)
58% male
62% Medial menisci
62% Associated ACL inj
918 meniscus repair
Submitted to AAOS 2017
Courtesy of Karl Eriksson
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Failure = resection within 3 years 29%
Significant difference
• Medial > Lateral
• Arrows > Sutures
• Isolated > combined ACL
No Significant difference
• Patient age
• Age of injury
• Vascularised zone
Courtesy of Karl Eriksson
Lateral better than Medial
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Medial vs Lateral
35% failure medial
p = 0.000
HR 3.006
Cox regression
17% failure lateral
Time to failure (days)
Survival functions
Yellow = both (4% of study)
Courtesy of Karl Eriksson
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7. Meniscal transplantation
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35 Eligible studies (update on El-Attar 2011)
1,332 patients (1,374 knees)
587 medial / 657 lateral allografts
Outcome tool: PROMS at final follow up
Mean follow-up 5.1 years
Failure rate: 10.6 % at 4.8 years (KR or removal)
Complication rate: 13.9 % at 4.7 years.
KSSTA Jan 2015
Insufficient data on Medial v Lateral
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Personal series Coventry UK
200 Meniscal transplants
Mean age 30 (8-55)
Lateral: 75% Medial 25% (ns male female)
Male: 65%
Right knee: 58%
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Analysis 125 >1yr follow up
Lateral 75%
Failure (Revision or removal or Uni/TKR)
Lateral 7/92 (7.6%)
Medial 6/19 (31%)
Survival Curve
Lateral 89%
Medial 62%
OJSM 2016
Significant on regression analysis
Grade of wear most important
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Clinical Results
0
10
20
30
40
50
60
70
80
90
100
Preop 2y
IKDC Pre-Op to 2 year
Lateral Medial
NSD
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Other reports
Lateral failure less than Medial
Stone 2013
Van Arkel 2002
Cole 2006
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No significant difference out to 16yrs
Medial 11/39 (28%) at 6 yrs
Lateral 10/61 (16%) at 4.8 yrs
JBJS 2005
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Lateral vs Medial: Courtesy of Peter Verdonk 2015 Results
Lateral
Medial
No difference
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Messages: Data to inform patients
Anatomical differences:
Medial: tethered and sees more load when ACL damaged.
Lateral: larger takes more load
Loss is worse for Lateral (xray changes)
Partial meniscectomy: lateral reduced activity
Back to sport easier and quicker for medial
Repair is better for lateral
Transplantation seems better for lateral
Lacking good data on natural history of total loss and
prediction of OA
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Better if you lose meniscus Better if you repair or replace meniscus
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Thank you for your attention
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