Meniscal Injuries: Evaluation and Management – Current Review

Page 1 of 6

Critical review

Meniscal injuries: evaluation and management – current review

1 2 Trauma & Orthopaedics SM Sedeek *, THC Andrew

Abstract daily living is common. Whether inju- implications for meniscal repair sur- Introduction ries occur in isolation or are associat- gery because healing is enhanced The menisci play important roles ed with ligamentous injury, meniscal greatly in the vascular regions. in the function of the knee. Menis- tears can result in marked physical The menisci are C-shaped or semi- cal injuries are common; the tradi- impairment2. The history and physi- tional treatment had been excision cal examination, along with the use of with bony attachments at the anteri- of the torn meniscus. Nonetheless, magnetic resonance imaging (MRI), orcircular and posterior fibrocartilaginous aspects of structures the tibial recently, there has been an increase remain the primary methods of diag- plateau. The medial meniscus is C- in the awareness of the biomechani- nosing meniscal pathology. Deciding shaped, with the posterior horn larg- cal and functional importance of the on the treatment of meniscal injury er than the anterior horn in the an- meniscus. This has resulted in the teroposterior dimension. The lateral evolvement of the treatment modali- well as the nature of the meniscal pa- meniscus is also anchored anteriorly ties. The purpose of this article is to thologyis influenced2. The aim by patientof this review factors was as and posteriorly through bony attach- review the literature on meniscal to evaluate and discuss the manage- ments and has an almost semicircu- injuries providing background infor- ment of meniscal injuries. mation on this topic including patho- portion of the tibial articular surface genesis, diagnosis and the most re- Discussion thanlar configuration. the medial meniscus It covers7,8. a larger cent management modalities. Anatomy The lateral meniscus translates as Conclusion much as 9–11 mm in the anteropos- When feasible, it is preferable that structures3, which consist of approxi- terior (AP) plane, whereas the me- meniscal repair can be done in an matelyThe menisci 75% Type are fibrocartilaginous I collagen. The dial meniscus is less mobile translat- attempt to maintain the meniscal in- ing only 2–5 mm. This relative lack of tegrity. If meniscal repair cannot be longitudinal axis, with oblique and motion may be clinically important done, partial meniscectomy could be collagen fibres lie mostly along the as a contributing factor to the in- considered aiming to retain as much integrity. The viscoelastic properties creased incidence of meniscal tears viable meniscal tissue as possible. If ofradial the fibres menisci that allowenhance compressive structural on the medial side7,8. total meniscectomy is required, me- loads to be dissipated along circum- niscal transplantation can be con- Function of the meniscus templated if it is not contraindicated. impact forces on the articular carti- The primary function of the me- lageferential3,4. fibres, thereby reducing the nisci is load sharing, which is ac- Introduction Arnoczky and Warren5,6 - complished through improving knee The importance of the menisci for scribed the blood supply of each congruency and increasing the joint the normal function the human knee meniscus: the peripheral 20%–30% first de contact area. Forces across the knee is well understood, especially in of the medial meniscus and the pe- could be as high as two- to four times younger patients who are athletically ripheral 10%–25% of the lateral body weight during walking and active or involved in strenuous occu- meniscus are vascular. Branches as high as six- to eight times body pations1. Injury to the meniscus from from the superior, inferior and lat- weight during running. When the both athletic events and activities of eral geniculate arteries supply this meniscus is loaded in weight bear- vascular zone. The avascular zone of the menisci, which includes at least as they are pushed to the periph- * Corresponding Author ing,4 the meniscus fibres elongate E-mail: [email protected]; sedeeko the inner one-third of each meniscus, ery . The medial and lateral menisci [email protected] - transmit 50% and 70% of their com- 1 Sports Medicine Service, Department of Or- sion. The middle one-third zone may partmental loads, respectively; this thopaedic Surgery, Al Ahly Hospital, Alexan- haveis nourished some blood by synovial supply, yet fluid most diffu of suggests that patients who have lat- dria, Egypt its nourishment is likely to be from eral meniscectomy may be at high- 2 Sports Medicine Service, Department of Orthopaedic Surgery, Singapore General - er risk for early subsequent joint Hospital, Singapore tribution has important clinical degeneration2,9. the synovial fluid. The vascular dis Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

Sedeek SM, Andrew THC Competing interests: none declared. Conflict of interests: none declared. interests: none declared. Conflict of interests: Competing the final manuscript. preparation, read and approved and design, manuscript conception to All authors contributed rules of disclosure. ethical Ethics (AME) for Medical the Association All authors abide by For citation purposes: . Meniscal injuries: evaluation and management - current review. Hard Tissue 2013 Aug 01;2(4):36. Page 2 of 6

Critical review

The menisci also play a role in knee with ACL injury. Accuracy in this bearing view of both the knees, a stability. Isolated medial or lateral study was 54.9% for medial menis- true lateral radiograph and a Mer- meniscectomy does not result in sig- cus tears and 53.2% for lateral me- chant or skyline view. These radio- 10. niscus tears. This could be explained However, the menisci act as second- by the confounding variables that oc- diagnosis of meniscal tear; none- arynificant stabilisers increases in the in AP knee translation that is an- cur with anterior cruciate ligament theless,graphic they views are cannot extremely confirm impor the- (ACL) injury, such as bone bruising posterior horn of the medial menis- and collateral ligament injury. evaluating the knee for joint space custerior is cruciateparticularly ligament important deficient. for Thethis In the McMurray test, the patient narrowingtant in defining2. bony pathology and function because it acts as a wedge to resist anterior translation11,12. to 90°. Then, the examiner applies Magnetic resonance imaging Lastly, the menisci have a role in alies varus supine or valgus and thestress knee to the is flexed knee MRI has many advantages in evalu- shock absorption; meniscectomy has while internally or externally rotat- ating patients with suspected me- been reported to decrease the shock ing the leg. The test is considered niscal tears, such as its non-invasive absorption capabilities of the knee positive when a pop or click is pal- nature, the ability to assess the knee by as much as 20%13. pated at the joint line while the knee in multiple planes, the absence of is slowly extended17. ionising radiation and the capacity to Examination Evans et al.18 studied the accuracy evaluate other structures within the History and interexaminer reliability of the joint. MRI has become the imaging The mechanism of injury and the on- McMurray test for the diagnosis of procedure of choice. However, there set of symptoms and are often clues has been some controversy about its to the diagnosis. The patient often McMurray sign found to correlate added value in the diagnosis4,17. describes a twisting injury of the withmeniscal meniscal tears. injury The only was significant a “thud” In a study conducted by a Miller20, elicited on the medial joint line with the overall accuracy for the clinical kneeling)2. diagnosis of meniscal tear was 80.7% kneePain or localisedfull flexion to of the kneejoint (as line in - and the corresponding accuracy for swelling may be present, and pa- tivitya medial of only meniscal 15%. tear. This finding MRI was 73.7%. He concluded that tients often complain of this. Dis- hadFor a specificitythe Apley ofgrind 98% test, but athe sensi pa- relying on MRI alone without us- placed fragments of meniscus can ing clinical judgement might lead to act as a mechanical block causing the to 90°. The examiner assesses for the inappropriate treatment in a high knee to catch, give way or lock2,14. paintient bylies performing prone with anthe internal knee flexed and percentage of cases. In a study com- external rotation of the leg while ap- paring clinical evaluation with MRI Physical examination plying axial load. The sensitivity of of athletes with suspected meniscal A complete examination of the lower this test is 41% for both medial and pathology, Muellner et al.21 demon- extremity is required for any patient. strated similar effectiveness. They An inspection could assess joint effu- 93% and 86% for medial and lateral showed essentially equivalent accu- sion or quadriceps muscle atrophy. meniscallateral tears, tears, and respectively the specificity17. is racy (94.5% vs 95.5%), sensitivities To determine the presence of a me- The Thessaly test was described chanical block to extension or loss by Karachalios et al.19. The patient (87.0% vs 85.5%). In this study, MRI stands on the affected knee and added(96.6% little vs 98.0%)to the clinical and specificities examina- assessed14. While palpation for joint tion in making the diagnosis of me- lineof flexion, tenderness range ofis motion recommended, should be externally rotates the knee and body. niscal tear. clinical studies have documented Aflexes positive it to test 20° produces then internally either pain and mixed results with regard to the use- at the joint line or a locking or catch- Arthroscopy fulness of the joint line tenderness in ing sensation. The Thessaly test was Arthroscopy is the most direct meth- obtaining a diagnosis. Weinstabl et found to have sensitivity of 89% and od of establishing a diagnosis of me- al.15 found that joint line tenderness niscus injury. The diagnosis must was the best clinical sign of a menis- for the medial and lateral menisci, re- include adequate and careful prob- cal tear, with 74% sensitivity and spectively.92% and specificity of 97% and 96% ing of the meniscus. Sometimes it 50% positive predictive value. Nev- ertheless, Shelbourne et al.16 demon- Diagnostic studies posterior horn, and especially of the strated that joint line tenderness was Radiography medialcan be difficultmeniscus. to Indetect these tears cases, of the A standard series include a 30° or use of an accessory portal may be preoperatively, which is associated required22. not useful in defining meniscal injury Licensee OA Publishing London45° posteroanterior 2013. Creative flexion Commons weight- Attribution License (CC-BY)

Critical review

Classification of meniscal tears shown that rim remodelling and Meniscal tears are described by loca- this type of tear. They can give rise to smoothing happen at 6–9 months. tion and shape. Based on the location information on the significance of- The probe should be used repeat- of vascularity, tears could be located ically stable25. edly to get more information about in the peripheral vascular zone (red– flap tears but are otherwise mechan • the mobility and texture of the re- red), middle zone (red–white) and Decision making in the treatment maining rim. central zone (white–white). Cooper of meniscus tear All efforts should be made to pro- et al.23 categorised 12 zones with Numerous factors are involved in tect the meniscocapsular junction, each meniscus divided into thirds deciding upon the correct line of • as this maintains meniscal stabil- both longitudinally and radially. treatment for a meniscus tear. How- ity. ever, due to the importance of the in- Both manual and motorised resec- as acute or degenerative tears. The tact functional meniscus tissue, the tion instruments should be used latterTears could of meniscus occur in can elderly, be classified patients • simultaneously. This will optimise with chronic knee instability or mala- the viable tissue as possible, and the lignment2. first goal is to preserve as much of allow a more controlled resection Different types of meniscal tears that9. whileefficiency, motorised as manual instruments instruments re- are revealed in various patterns, in- treatment decision should reflect move loose debris. cluding vertical longitudinal, oblique, Non-surgical treatment Short-term results of a partial me- complex, transverse (radial) and Non-surgical treatment for a menis- niscectomy are excellent. Jaureguito horizontal. Metcalf et al.24 found that cus tear may be suitable for asymp- et al.27 reported 90% good or excel- 81% of tears were oblique or vertical tomatic tears, for older patients who lent outcomes at 2-year follow-up, longitudinal. are willing to change their life styles, with 85% of patients returning to Vertical longitudinal tears can be and for those who are at the high risk their desired activity level. However, complete, such as the bucket-handle of surgery. some long-term results have led to tear, or incomplete tear, and usually Patients initially should be man- it occurs in younger patients. Bucket- aged with rest, ice compression and meniscectomy. Fauno and Nielsen28 handle tears usually begin in the pos- elevation of the knee. Rehabilitation questionsfound that onosteoarthritic the efficacy radiograph of partial- terior horn. They are often unstable with painless full range of motion 14 ic changes occurred in 53% of knees and can cause mechanical symptoms and strengthening is performed . that have undergone meniscectomy or locking24. Surgical management at 8 years follow-up. Oblique tears usually occur at the Total meniscectomy was previously a junction of the posterior and middle common procedure. However, as the Meniscal repair thirds of the meniscus. Symptoms long-term results have become avail- Although meniscal preservation is may result from the torn free edge of able, the procedure has fallen out of important, only certain types of tear 2. Com- favour. In 7 years follow-up in stable are amenable to repair. The indica- plex tears occur in multiple planes knees, Yocum et al.26 only found sat- tions of meniscal repair include: andthe flapare more catching common in the in joint older age isfactory results in 54% of the cases. groups. They are often associated Tears more than 1 cm and less Additionally, 20 patients had lost with degenerative changes of the ar- than 4 cm in length: tears measur- motion. ticular cartilage of the knee2. • ing less than 1 cm are considered Partial resection of the meniscus Transverse or radial tears could stable and repair is usually un- is advocated when repair is not fea- occur in conjunction with other necessary, while tears measuring sible. General guidelines have been tears. They are typically at the junc- more than 4 cm are unstable to the provided by Metcalf et al.24 for ar- tion of posterior and medial thirds degree that attempted repairs usu- throscopic resection. of the medial meniscus or near the ally fail17. posterior attachment of the lateral All mobile fragments that can be Red–red zone tear: the vascular meniscus. A complete radial tear pulled past the inner margin of supply of a meniscal tear is the will result in the loss of load-bearing • the meniscus into the centre of the • most important intrinsic fac- function2. joint should be removed. tor in healing. Scott et al.29 have Horizontal cleavage tears are fre- The remaining meniscus rim found that tears within 2 mm of quent and may exist without clinical should be smoothed to avoid any the meniscal vascular rim have symptoms. They are generally con- • further tear. Nonetheless, a per- higher rates of healing after re- sidered to begin near the inner mar- fectly smooth rim is not manda- pair compared with other types gin of the meniscus. There is little tory, as repeated arthroscopy has of tears.

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

Critical review

Vertical tears: these are commonly Van der Reis and Cannon31 followed repaired because they are amena- up 172 patients with inside-out me- • 17. niscal repairs. Healing was evaluated sutureaccomplished technique. fixations that were as Patients aged less than 40 years: it by either second-look arthroscopy strong as the fixations in outside-in hasble tobeen suture presumed fixation that the menis- (131 repairs) or by arthrograms (41 Enhancement of the healing process • ci of younger patients have more repairs). Satisfactory anatomic heal- Biological factors could be of greater healing responses. Moreover, some ing was evident in 70% of the cases. importance than previously thought studies have shown better success Nevertheless, on clinical assessment, to the success of meniscal repair. Ex- in younger patients17,23. However, 88% of the repairs had no symptoms other studies have shown no dif- and were deemed clinically healed. healing in humans. It is postulated ference based on age29. thatogenous the fibrinclots clotsact as seem a chemotactic to improve Acute tear: Tengrootenhuysen et Outside-in technique mitogenous stimulus25,34. It has been al.30 The sutures are passed through the shown that trephination or rasping • success rate in tears repaired less meniscus from the outside. This pro- alone without suturing the menis- than found6 weeks a significantlyfrom the injury. higher In cedure was developed to decrease cus could be a viable option in stable contrast, Scott et al.29 indicated no the risks associated with the inside- tears. difference in the healing rate no out technique. However, outside-in Fox et al. 35reported good to excel- matter when the injury occurred. repairs are mainly limited to the an- lent results in 90% of cases that were Concurrent ACL reconstruction: terior portions of the medial and lat- treated by rasping or trephination. outcome studies have demonstrat- eral menisci. Studies have indicated • ed that repairs of the meniscus success with this technique17. In a Allograft transplantation performed concurrently with ACL study conducted by Morgan and Cas- The indications for allograft meniscal reconstruction are more success- scells32, 70 patients who had outside- transplantation continue to change ful than repairs done in ACL-intact in meniscal repair were followed as the clinical experience increases. knees. Therefore, it is generally rec- from 12 to 28 months. There were Currently, the ideal patient is one ommended that ACL reconstruc- excellent results in 98.6% of patients. who has previously had total or near tion and meniscal repair should be total meniscectomy with joint line done concurrently29,30. All-inside technique pain, early chondral changes, nor- All-inside repair techniques have mal anatomic alignment and a sta- Repair techniques become popular because they avoid ble knee. Any ligamentous injuries Generally, meniscal repair begins many of the potential complications or malalignment must be addressed with a complete arthroscopic assess- of other repair techniques and de- at the same time. Allograft meniscal ment of the knee and full evaluation crease the operative time. Tears that transplantation success rates are dif- of the tear. The margins are debrided are anterior to the posterior one- - with or without rasping17. third of the meniscus are usually ied criteria of success that has been not amenable to this technique9. The used.ficult toMoreover, quantify in because the literature, of the var the Inside-out technique results of meniscus transplants have Sutures are inserted into the menis- involved the insertion of rigid ar- ranged from promising to disap- cus using a needle cannula under ar- rowfirst or generation screw implant all-inside devices technique made pointing36. throscopic visualisation. A medial or of absorbable polymers; however, Van Arkel and de Boer37 evaluated lateral incision is required to retrieve the devices were prone to breaking. the clinical results of 23 patients with suture needles as they exit the joint The second generation of the head- a cryopreserved non-tissue-antigen- capsule. Proper positioning of the less screws and arrows showed less matched meniscal transplant at a 2- incision and appropriate dissection 17. to 5-year follow-up. Twenty patients down to the capsule are required to The third generation all-inside su- had satisfactory results while only minimise the risk of neurovascular turingprotrusion system and remainsbetter rigid a viable fixation op- three transplantations failed and the bundle. This technique can treat all tion for meniscal repair. It involves allografts were removed after 12, 20 types of tears and provides excellent insertion of the sutures and suture and 24 months. - - However, Hommen et al.38 report- es are that there are potential risks vices allow the placement of sutures ed that 25% of medial allografts and tofixation. neurovascular However, somestructures; disadvantag it is a infixators. the meniscus Fourth generation without repairusing dean 50% of lateral allografts had failed at technically demanding procedure; 17. Gunes a mean of 141 months of follow-up. and there is a need for accessory et al.33, in their mechanical study, The investigators reported that when incisions17. concludedincision or thata fixator these system repair devices they added second-look surgery, MRI

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

Critical review

and improvement survey results to 8. Maitra RS, Miller MD, Johnson DL. Me- resonance imaging and its effect on their analysis, the overall failure rate niscal reconstruction: part I: indications, clinical outcome. Arthroscopy. 1996 was 55%. Moreover, 85% of the pa- techniques, and graft considerations. Am Aug;12(4):406–13. tients had undergone subsequent J Orthop. 1999 Apr;28(4):213–8. 21. Muellner T, Weinstabl R, Schabus R, procedures on the transplanted knee. 9. McCarty EC, Marx RG, DeHaven KE. Vécsei V, Kainberger F. The diagnosis of Meniscus repair: considerations in treat- meniscal tears in athletes. A comparison ment and update of clinical results. Clin of clinical and magnetic resonance imag- Conclusion Orthop Relat Res. 2002 Sep;(402):122– ing investigations. Am J Sports Med. 1997 The menisci have an essential func- 34. Jan;25(1):7–12. tion in force transmission across the 10. Markolf KL, Mensch JS, Amstutz HC. 22. Andrish JT. Meniscal injuries in chil- knee. Injury to the meniscus is com- Stiffness and laxity of the knee: The con- dren and adolescents: diagnosis and mon; the tears are most frequently tributions of the supporting structures: management. J Am Acad Orthop Surg. located in the midportion and pos- a quantitative in vitro study. J Bone Joint 1996 Oct;4(5):231–7. terior horn. In making a decision on Surg Am. 1976 Jul; 58(5):583–94. 23. Cooper DE, Arnoczky SP, Warren RF. whether surgery is viable, the overall 11. Bargar WL, Moreland JR, Markolf KL, Meniscal repair. Clin Sports Med. 1991 Shoemaker SC, Amstutz HC, Grant TT. In Jul;10(3):529–48. clinical situation must be evaluated. vivo stability testing of post-meniscec- 24. Metcalf RW, Burks RT, Metcalf MS, Generally, when feasible, it is pref- tomy knees. Clin Orthop Relat Res. 1980 McGinty JB: Arthroscopic meniscectomy. erable that meniscal repair be done Jul–Aug;(150):247–52. In: McGinty JB, Caspari RB, Jackson RW, in an attempt to maintain the menis- 12. Levy IM, Torzilli PA, Gould JD, Warren Poehling GG, editors. Operative arthros- cal integrity. If meniscal repair cannot RF. The effect of lateral meniscectomy on copy 2nd ed. Philadelphia, PA: Lippin- be done, partial meniscectomy could motion of the knee. J Bone Joint Surg Am. cott-Raven; 1996.p263–97. be considered aiming to retain as 1989 Mar;71(3):401–6. 25. Stärke C, Kopf S, Petersen W, Becker much viable meniscal tissue as possi- 13. Voloshin AS, Wosk J: Shock absorp- R. Meniscal repair. Arthroscopy. 2009 ble. If total meniscectomy is required, tion of meniscectomized and painful Sep;25(9):1033–44. meniscal transplantation can be con- knees: a comparative in-vivo study. J Bi- 26. Yocum LA, Kerlan RK, Jobe FW, Carter templated if it is not contraindicated. omed Eng. 1983 Apr; 5(2):157–61. VS, Shields CL Jr, Lombardo SJ, Collins 14. McCarty EC, Marx RG, Wickiewicz HR. Isolated lateral meniscectomy. A TL. Meniscal tears in the athlete. Op- study of twenty-six patients with iso- References erative and nonoperative management. lated tears. J Bone Joint Surg Am. 1979 1. Noyes FR, Barber-Westin SD. Treat- Phys Med Rehabil Clin N Am. 2000 Apr;61(3):338–42. ment of meniscus tear during anterior Nov;11(4):867–80. 27. Jaureguito JW, Elliot JS, Lietner T, cruciate ligament reconstruction. Ar- 15. Weinstabl R, Muellner T, Vécsei V, Dixon LB, Reider B. The effects of arthro- throscopy. 2012 Jan;28(1):123–30. Kainberger F, Kramer M. Economic con- scopic partial lateral meniscectomy in 2. Greis PE, Bardana DD, Holmstrom MC, siderations for the diagnosis and therapy an otherwise normal knee: a retrospec- Burks RT. Meniscal injury: basic science of meniscal lesions: can magnetic reso- tive review of functional, clinical, and and evaluation. J Am Acad Orthop Surg. nance imaging help reduce the expense? radiographic results. Arthroscopy. 1995 2002 May;10(3):168–76. World J Surg. 1997 May;21(4):363–8. Feb;11(1):29–36. 3. Beaupre A, Choukroun R, Guidouin R, 16. Shelbourne KD, Martini DJ, McCarroll 28. Faunø P, Nielsen AB. Arthroscopic Garneau R, Gerardin H, Cardou A. Knee JR, VanMeter CD. Correlation of joint partial meniscectomy: a long-term fol- menisci: correlation between micro- line tenderness and meniscal lesions low-up. Arthroscopy. 1992 Mar;8(3): structure and biomechanics. Clin Orthop in patients with acute anterior cruciate 345–9. Relat Res. 1986 Jul;(208):72–5. ligament tears. Am J Sports Med. 1995 29. Scott GA, Jolly BL, Henning CE. Com- 4. Arnoczky SP, Dodds JA, Wickiewicz TL. Mar;23(2):166–9. bined posterior incision and arthroscopic Basic science of the knee. In: McGinty JB, 17. Laible C, Stein DA, Kiridly DN. Menis- intra-articular repair of the meniscus. an Caspari RB, Johnson RW, editors. Opera- cal repair. J Am Acad Orthop Surg. 2013 examination of factors affecting healing. tive arthroscopy. Philadelphia, PA: Lip- Apr;21(4):204–13. J Bone Joint Surg Am. 1986 Jul;68(6): pincott-Raven; 1996.p211–39. 18. Evans PJ, Bell GD, Frank C. Prospec- 847–61. 5. Arnoczky SP, Warren RF. Microvascula- tive evaluation of the McMurray test. Am 30. Tengrootenhuysen M, Meermans G, ture of the human meniscus. Am J Sports J Sports Med 1993 July; 21(4):604–8. Pittoors K, van Riet R, Victor J. Long-term Med. 1982 Mar–Apr;10(2):90–5. 19. Karachalios T, Hantes M, Zibis AH, Za- outcome after meniscal repair. Knee 6. Arnoczky SP, Warren RF. The microvas- chos V, Karantanas AH, Malizos KN. Diag- Surg Sports Traumatol Arthrosc. 2011 culature of the meniscus and its response nostic accuracy of a new clinical test (the Feb;19(2):236–41. to injury: an experimental study in the Thessaly test) for early detection of me- 31. Van der Reis W, Cannon WD Jr. Arthro- dog. Am J Sports Med. 1983 May–Jun; niscal tears. J Bone Joint Surg Am. 2005 scopic meniscal repair using the inside- 11(3):131–41. May;87(5):955–62. out technique. Sports Med Arthrosc Rev 7. Sekiya JK, Ellingson CI. Meniscal allo- 20. Miller GK. A prospective study com- 1999 Apr;7(8):19. graft transplantation. J Am Acad Orthop paring the accuracy of the clinical diag- 32. Morgan C, Casscells S. Arthroscopic Surg. 2006 Mar; 14(3):164–74. nosis of meniscus tear with magnetic meniscus repair: a safe approach to

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

Critical review

the posterior horns. Arthroscopy. 1986 Arthroscopic meniscal repair using an 37. Van Arkel ER, de Boer HH. Human Jul;2(5):3–12. meniscal transplantation: prelimi- 33. Gunes T, Bostan B, Erdem M, Asci Res. 1990 Mar; (252):64–72. nary results at 2- to 5-year follow-up. M, Sen C, Kelestemur MH. Biomechani- 35.exogenous Fox JM, fibrinRintz clot.KG, Ferkel Clin Orthop RD. Trephi Relat- J Bone Joint Surg Br. 1995 Jul;77(4): cal evaluation of arthroscopic all-inside nation of incomplete meniscal tears. Ar- 589–95. meniscus repairs. Knee Surg Sports throscopy. 1993 Nov;9(4):451–5. 38. Hommen JP, Applegate GR, Del Pizzo Traumatol Arthrosc. 2009 Nov;17(11): 36. Greis PE, Holmstrom MC, Bardana W. Meniscal allograft transplantation: 1347–53. DD, Burks RT. Meniscal injury: II. Man- Ten-year results of cryopreserved al- 34. Henning CE, Lynch MA, Yearout KM, agement. J Am Acad Orthop Surg. 2002 lografts. Arthroscopy. 2007 Apr;23(4): Vequist SW, Stallbaumer RJ, Decker KA. May–Jun;10(3):177–87. 388–93.

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)