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Medial Meniscus Anatomy—From Basic Science to Treatment

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Medial Meniscus Anatomy—From Basic Science to Treatment See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/270004929 Medial meniscus anatomy—from basic science to treatment Article in Knee Surgery Sports Traumatology Arthroscopy · December 2014 DOI: 10.1007/s00167-014-3476-5 · Source: PubMed CITATIONS READS 40 1,012 4 authors, including: Robert Smigielski Roland Becker Medical University of Warsaw Hospital Brandenburg, Teaching Hospital of the Charite University of Berlin 55 PUBLICATIONS 408 CITATIONS 206 PUBLICATIONS 2,659 CITATIONS SEE PROFILE SEE PROFILE Urszula Zdanowicz Carolina Medical Center 31 PUBLICATIONS 196 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Surgical Anatomy of the Knee Joint View project vitamys VEPE View project All content following this page was uploaded by Urszula Zdanowicz on 28 August 2016. The user has requested enhancement of the downloaded file. Medial meniscus anatomy—from basic science to treatment Robert Śmigielski, Roland Becker, Urszula Zdanowicz & Bogdan Ciszek Knee Surgery, Sports Traumatology, Arthroscopy ISSN 0942-2056 Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3476-5 1 23 Your article is protected by copyright and all rights are held exclusively by European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA). This e-offprint is for personal use only and shall not be self- archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3476-5 KNEE Medial meniscus anatomy—from basic science to treatment Robert S´migielski · Roland Becker · Urszula Zdanowicz · Bogdan Ciszek Received: 5 December 2014 / Accepted: 6 December 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014 Abstract This paper focuses on the anatomical attach- understand its importance and also improve the anatomi- ment of the medial meniscus. Detailed anatomical dissec- cal approach to its repair. There are many anatomical tions have been performed and illustrated. Five zones can studies about menisci. The current paper focuses on the be distinguished in regard to the meniscus attachments anatomy of the medial meniscus. This anatomical study anatomy: zone 1 (of the anterior root), zone 2 (anterome- was performed with the specific intention of identifying dial zone), zone 3 (the medial zone), zone 4 (the posterior the meniscus insertions, which is of relevance to meniscus zone) and the zone 5 (of the posterior root). The under- surgery. standing of the meniscal anatomy is especially crucial for meniscus repair but also for correct fixation of the anterior and posterior horn of the medial meniscus. Gross anatomy Keywords Anatomy · Medial meniscus · Attachment The medial meniscus forms almost a semicircular shape and covers up to 50–60 % of the articular surface of medial tibial plateau [4] (Fig. 1a, b). The width of the Introduction medial meniscus is about 11 mm significantly bigger at the posterior region and becomes gradually smaller The menisci have received increased attention during the towards the anterior horn. During knee flexion, the main last two decades. Numerous clinical studies have proven loading occurs at the posterior region of the meniscus [2]. the importance of the menisci for joint protection and The posterior horn of the meniscus slides slightly over the prevention of early osteoarthritis [5, 15]. A better under- posterior rim of the tibial plateau during deep knee flex- standing of meniscus anatomy may help surgeons to ion. This is the moment where significant stress occurs on the posterior horn and should be avoided early on after meniscus repair. Five anatomical zones of the medial meniscus are distin- guishable in regard to the meniscus anatomy: the anterior R. S´migielski (*) · U. Zdanowicz Orthopaedic and Sports Traumatology Department, root (zone 1); the anteromedial zone (zone 2a and 2b); the Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland medial zone (zone 3); the posterior zone (zone 4); and the e-mail: [email protected]; [email protected] posterior root (zone 5) (Fig. 2). This zonal division is based URL: http://www.carolina.pl on different anatomical characteristics and is in contrast to R. Becker the previous descriptions. Department of Orthopaedic and Traumatology, Weiss et al. [17] divided the medial meniscus into five City Hospital Brandenburg, Brandenburg, Germany equal parts, each one representing exactly one-fifth of the length [17]. This was modified by Yagishita et al. [19] by B. Ciszek Department of Descriptive and Clinical Anatomy, combining the anterior and anterior junctional zone into Medical University of Warsaw, Warsaw, Poland one, resulting in four zones. 1 3 Author's personal copy Knee Surg Sports Traumatol Arthrosc Fig. 1 a Anatomical dissection of proximal tibial articular surface rior cruciate ligament, PCL posterior cruciate ligament, MTC medial (plan view, femur removed). 1 medial meniscus; 2 lateral meniscus; 3 tibial condyle, LTC lateral tibial condyle, aMM anterior root of tibial attachment of anterior cruciate ligament; and 4 tibial attachment medial meniscus, pMM posterior root of medial meniscus, aML ante- of posterior cruciate ligament. b The medial meniscus covers up to rior root of lateral meniscus, pML posterior root of lateral meniscus 50–60 % of the articular surface of medial tibial condyle. ACL ante- Fig. 3 Zone 1 of medial meniscus. Anatomical dissection showing type 1 of anterior tibial attachment of medial meniscus (marked with black arrows). ACL anterior cruciate ligament, aMM anterior root of medial meniscus, aML anterior root of lateral meniscus Fig. 2 Anatomical dissection showing five anatomical zones within tibial tuberosity and proximal and medial to the centre of medial meniscus. ACL anterior cruciate ligament, tl transverse liga- the superior edge of the tibial tuberosity [9]. ment (anterior intermeniscal ligament), PT patellar tendon, PCL pos- According to Berlet et al. [1], there are four insertion terior cruciate ligament, ML lateral meniscus, PoT Popliteus tendon, hl Humphry ligament (anterior menisco-femoral ligament) patterns of the anterior root of the medial meniscus. Type I, the most frequent (Fig. 3), has the insertion located in the flat intercondylar region of the tibial plateau (also called by Zone 1—anterior root Jacobsen the cristae area intercondylaris anterior). Type II has a more medial insertion, closer to articular tibial sur- As Homo sapiens changed from occasional to habit- face. Type III has a more anterior insertion, which is on the ual bipedalism, the anatomy of the human menisci also downslope of tibia. Type IV shows no solid fixation, and changed. In contrast to tetrapods, there are two tibial inser- only coronal fibres control meniscus stability. tions indicating the full extension phase during gate [16]. The insertion site of the anterior root includes supple- The anterior root of the medial meniscus is located proxi- mentary, lower density fibres. The mean total tibial attach- mal to the superior aspect of the medial edge of the medial ment area is about 110.4 mm2, but only 50 % belong to the 1 3 Author's personal copy Knee Surg Sports Traumatol Arthrosc central, prominent root fibres (mean 56.3 mm2), which are the most dense [9]. Radiographic landmarks were identified in order to describe the attachment of the anterior horn [7]. The follow- ing measurements are used on antero-posterior radiographs: • 2.8 mm distal to proximal joint line • 3.1 mm medial to medial tibial eminence line • 17 mm medial to lateral tibial eminence line On the lateral radiographic view, the following measure- ments were identified: • 12.2 mm anterior to tibial long axis • 19.3 mm proximal to champagne glass drop (CGD) line • 4.8 mm posterior to anterior tibial plateau line [8] Rainio et al. [12] describe atypical insertion sites of Fig. 4 Anatomical dissection of anterior aspect of the left knee joint. anterior root to anterior cruciate ligament in 1 % of cases. Within zone 2a superior edge of medial meniscus remains free and has no connections to surrounding tissues (marked with arrows). MM The absence or the hypermobility of the anterior root of the medial meniscus, ML lateral meniscus, MFC medial femoral condyle, medial meniscus is one of the major anomalies. However in LFC lateral femoral condyle, ACL anterior cruciate ligament, PCL all cases, the oblique ligament was present connecting the posterior cruciate ligament, HP Hoffa pad anterior horn of medial meniscus to the proximal area of anterior cruciate ligament. Zone 2—anteromedial zone The anteromedial zone includes the anterior horn of medial meniscus and finishes with the anterior border of the medial collateral ligament. The zone can be further divided into two sub-zones: anterior 2a (from anterior root to the transverse ligament) and 2b (from transverse ligament to anterior border of the medial collateral ligament (Fig. 2). The meniscus of zone 2a, 2b, 3, 4 attaches to the tibia by inferior periphery only, with menisco-tibial ligament (also called coronary ligament) [9, 10]. Although described in previous studies [13, the outer border of the medial meniscus in zone 2 is not attached to the joint capsule. The superior periphery of medial meniscus at zone 2a shows no attachment to the surrounding tissues (Fig. 4). In zone 2b, however, the most superior periphery of the meniscus is attached to the synovial tissue (Fig. 5). Fig. 5 Anatomical dissection of antero-medial aspect of the knee joint.
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