meniscal injuries
TRANSCRIPT
Dr . SAYF ALDEEN HUSSAMDr . SAYF ALDEEN HUSSAMALAL-WASITY TEACHING HOSPITAL-WASITY TEACHING HOSPITAL
●Menisci is a crescentric
shaped fibrocartilagenous
structures between the
condyles of femur & tibia
●Peripheral edges are thick,
convex& fixed to inner
surface of capsule.
●Triangular in cross section
●Covers peripheral 2/3 rd of
articular surface.
●Each menisci has
2 ends---- anterior and posterior
horns
2 borders----outer and inner border
2 Surfaces ---upper and lower
C shaped, larger in radius than lateral
meniscus Anterior horn: Attached anterior
to intercondylar eminence and to the ACL
Posterior horn: Attached in front of
attachment of PCL, posterior to the
intercondylar eminence
Entire peripheral border firmly
attached to the medial capsule and through
coronary ligament to the upper border of
tibia
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
Attached posteriorly to the
medial femoral condyle by
either the ligament of Humphry
or the ligament of wrisberg
●outer one-third: supply from the peripheral meniscal plexus, in turn formed from the medial, lateral and middle genicular arteries
●inner two-thirds: no vascular supply; diffusion dependent
VASCULAR ZONES
●Red-red zone: fully vascular
●Red-white :minimal blood
supply
●White-white: fully avascular
●outer one-third innervated by posterior articular branch of the tibial nerve and terminal obturator and femoral nerve branches
●posterior horns have highest concentration of mechanoreceptors
●The inner two-thirds has no nerve fibers.
1-Joint lubrication2-Joint stability- ( rotary)
3-Shock absorbers-reduce the stress on articular cartilage
4-Load bearing function5-Deepening the cavity
6 -Prevents impingement during joint motion.7-Medial meniscus – provides stability to Anterior
Cruciate Ligament deficient knees.(ACL)
●occur with rotational force ,on a partially flexed knee
like Foot ball players
●Most common site- posterior horn
●Most common type- longitudinal tear
●Length ,depth, position of tear depend on the position
of the meniscus in relation to condyles at the time of
injury.
1-Trauma
2-Meniscal cyst
3-Decreased mobility of the meniscus
4-Discoid meniscus
5-Aging- degeneration
6-Abnormal mechanical axis- ligamentous laxity.
7-Congenitally relaxed joints
8-Inadequate tone and musculature.
1-Longitudinal tears
2-Horizontal tears
3-Oblique tears
4-Radial tears
5-complex tears
●Most common type
●affect young pt.
●Post trauma
●2 types:
- Vertical incomplete tear
- Vertical complete: Displaced
tear (bucket handle)
●Extend from inner margin to
capsule horizontally
●Common in posterior horn
of medial meniscus & lateral
meniscus
●Full thickness tear extending obliquely
from the inner margin into the body
●Types:
-Anterior oblique
-posterior oblique
●Commonly seen at the junction of
middle & posterior 1/3 of medial
meniscus
●Extend radially from inner margin into
the body
●Common in middle 1/3 of lateral
Meniscus
: ●types-complete
-incomplete
-parrot beak tear-(Radial tear
with longitudinal or oblique extension)
●Combination of all the above
●Common in chronic meniscal lesions & degenerative
menisci
●Predisposing conditions:
* Discoid lateral meniscus
* Meniscal cyst
* Calcium pyrophosphate deposition
●History :
*May be asymptomatic
*Pain
*Sports injuries
*Trauma
*Giving way
*Locking
●Physical signs:
*Effusion
*Quadriceps wasting
*Joint line tenderness
*Limitation of movements.
●Mc Murray test .
●Apley’s grinding test
●For medial meniscus tear
Fully flex the knee
Externally rotate the leg
Keep the fingers on the medial joint line.
Then Slowly abduct and external rotate the
knee.
Click and pain is indicative
●For lateral meniscus tear:
Fully flex knee ,internally rotate and extend the leg.
If a click or pain is indicative
●confirms this after examining the other normal knee for clicks of other
origins like tendon and soft tissues snapping etc.
*Prone position
*Bend examiner knee and press the
patients thigh.
*Hold the ankle and the foot by both
hands
*Compress the leg downwards and
rotate internaly and externally.
*If patient elicit pain it indicated
meniscal tear
*X-Ray-Antero posterior ,lateral view of knee &
intercondylar notch view
*MRI
*Arthroscopy
*Arthrography
Grade I –increase in signal,not extending to articular surfaceGrade II- linear increased density, not extending to articular surface
GradeIII- signal extending to articular surface
*Gold standard for diagnosis and treatment
*Thorough inspection of menisci, ligaments &cartilage
is possible
*Anteromedial or anterolateral portals
*Full extent ,type, site of tears & degenerative changes
can be seen
NON- SURGICAL
SURGICAL
Indications:
1-Incomplete meniscal tear
2-A small stable peripheral tear (5mm) without any
other injuries.
*Grion-ankle cylindrical cast 4 - 6 weeks
*Toe-touch partial weight bearing
*Rehabilitative exercise program for 6 weeks to
strengthen quadriceps, hamstrings, gastro-soleus
&hip.
Meniscal repair
Meniscectomy
Meniscal transplant
*Depend on the location of the tear, its morphology and patients factors
*indications:1-Peripheral tear(Red on Red region Also on red on
white region)2-Size <1-2 cm
3-Vertical longitudinal tears are ideal*young patient shows better outcome
*Can be done Open or Arthroscopicaly
1-Tear>3 cm
2-Transverse tear even in periphery
3-Flap tear, radial tear, vertical tear with secondary
lesions.
4-Ligament instability
1-inside out technique -considered gold standard
-medial approach to capsule-lateral approach to capsule
2-all inside technique (suture devices with plastic or bioabsorbable anchors)
-most common-many complications (device breakage, iatrogenic chondral
injury) 3-outside in repair
–useful for anterior horn tears-open repair
*Limit knee flexion to 90 degree
*Low impact activity for 3months
*Full activity after 6months
3 types:
1-Partial
2-Subtotal
3-Total
Methods:
Open
Arthroscopic
*Excision of only torn portion of meniscus. :*Indications
1-Tears >5mm from menisco-synovial junction .2-Flap tears
3-Complex and horizontal tears.*Treatment of choice in young adults who require
vigorous activities.:Advantage
Short operating time.
*requires excision of portion of peripheral rim of meniscus
- Most of the anterior horn and a portion of middle 3 rd of
the meniscus are not resected
*used in complex tears of posterior horn
Indications:
1-if Meniscus is detached from its periphery.
2-extensive meniscal tears and degenerative
Early:1-Haemarthrosis
2-Chronic Synovitis3-Synovial fistulae4-Painful neuromas5-Thrombophlebitis
6-Infection 7-Reflex sympathetic dystrophy
Retained meniscal fragment 8-
Late changes :Degenerative changes within the joint. Fairbank described three changes :
1-Narrowing of joint space
2-Flattening and squaring of femoral
condyle
3-Antero-posterior ridge formation
By using either meniscal allografts
or autograft fascial material or synthetic menisci scaffolds
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 :1 -Age more than 60 yrs.
2 -Bony architectural changes.3 -Prior infection .
4 -Significant malalignment .5 -Instability.