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Peripheral Meniscal Tears: How to Diagnose and Repair 7

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Peripheral Meniscal Tears: How to Diagnose and Repair 7 Peripheral Meniscal Tears: How to Diagnose and Repair 7 Jorge Chahla, Bradley M. Kruckeberg, Gilbert Moatshe, and Robert F. LaPrade Contents 7.1 Introduction 7.1 Introduction 77 Peripheral meniscal tears are located in the most 7.2 Diagnosis 79 7.2.1 Physical Examination 79 vascular portion of the menisci and comprise 39–72 % [2, 3, 56, 69, 82] of all meniscal tears. 7.3 Imaging 81 The younger population, particularly males with 7.3.1 Standard Radiographs 81 7.3.2 Ultrasound 82 knee instability, is most commonly affected by 7.3.3 Magnetic Resonance Imaging 82 this type of tear [56]. The vascularity of the 7.3.4 CT Arthrography 82 peripheral menisci is primarily derived from the 7.4 Surgical Techniques 83 superior and inferior medial and lateral genicu- 7.4.1 Inside-Out Repair 83 late arteries [7]. A synovial fringe that extends 7.4.2 Outside-In Repair 85 approximately 3 mm over the surface of each 7.4.3 All-Inside Technique 85 meniscus adds further to the peripheral vascular- 7.5 Outcomes 86 ity. This intricate blood supply results in the outer 7.6 Rehabilitation 87 rim of the meniscus being vascularized up to Conclusion 87 30 % of its width on the medial side and 25 % on the lateral side [7]. There is discrepancy in the References 88 vascularity of the menisci, with the peripheral parts being more vascular than the central zones. The vascularity of the menisci has also been shown to decrease and become more peripheral with age [59]. Thus, the healing potential of the J. Chahla, MD (*) meniscus depends on the location of the lesion Steadman Philippon Research Institute, The and the age of the patient [7, 41, 44]. Because of Steadman Clinic, Vail, CO, USA e-mail: [email protected] the high vascularity, peripheral meniscal tears (red-red and part of the red-white zone) have the B.M. Kruckeberg • G. Moatshe Steadman Philippon Research Institute, greatest potential for healing [44] (Fig. 7.1). Vail, CO, USA Due to their anatomic position and attach- R.F. LaPrade ments, the menisci are vulnerable to injury when The Steadman Clinic, particular forces are placed on the knee joint, 181 West Meadow Drive, Suite 400, with specific maneuvers placing certain meniscal Vail, CO 81657, USA areas at highest risk for injury. In this regard, e-mail: [email protected] © ISAKOS 2017 77 R.F. LaPrade et al. (eds.), The Menisci, DOI 10.1007/978-3-662-53792-3_7 78 J. Chahla et al. Fig. 7.1 Schematic diagram of a left knee (disarticulated Fig. 7.2 Schematic diagram of a left knee (disarticulated from the femur) demonstrating the location of the periph- from the femur) demonstrating the location of a ramp eral zones of both menisci (demarcated in red) lesion in the posteromedial meniscocapsular junction of the medial meniscus. As per definition, ramp lesions are located in the meniscocapsular region and are less than when the knee is in flexion and the tibia in inter- 2.5 cm in length nal rotation, the posterior horn of the medial meniscus is stretched and pulled anteriorly [70]. This action may lead to a peripheral tear near its the disruption of the large circumferential fiber posterior attachment via the coronary ligaments bundles [31, 55]. However, it has been reported [21], which is one of the most common locations that peripheral tears with meniscal rim involve- for meniscal tears [47, 69, 79]. These tears, ment have a significant association with the known as ramp lesions (Fig. 7.2), often occur in development of radiographic osteoarthritis (OA) conjunction with ACL tears [13, 44, 79] and are [63], likely resulting from altered biomechanics. commonly under-recognized when using stan- The role of the meniscus as a secondary stabi- dard anterolateral and anteromedial arthroscopic lizer of the knee joint should not be overlooked. portals due to their location within the postero- The posterior horn has demonstrated importance medial “blind spot” [75]. Ramp lesions have been in anterior tibial translation [9, 67]. In the setting reported to be present in 9–17 % of all ACL tears of ACL deficiency, peripheral meniscal tears [10, 53]. Conversely, the anterior horn of the have been reported to drastically alter knee bio- medial meniscus is less commonly injured and, mechanics, similar to that of a total meniscec- therefore, not well described in the literature. tomy [1]. Allen et al. [5] reported that a resultant Chen et al. [15] demonstrated in porcine knees force in the medial meniscus of an ACL-deficient that the anterior horn of the medial meniscus knee increased by over 50 % in full extension restrains external rotational torque of the tibia. and nearly 200 % at 60° of flexion. In contrast, in Thus, providing a possible mechanism of injury a knee with otherwise intact ligamentous struc- for humans in which the knee is in full extension tures, Goyal et al. [37] reported that there was no and external rotational torque is placed on the alteration in tibiofemoral kinematics or joint tibia [15]. contact pressures when simulating a peripheral Peripheral tears, in general, are believed to lateral meniscal tear. Additionally, a recent partially preserve the load distribution function cadaveric study demonstrated that anterior tibial of the meniscus, whereas other tears, such as translation and external rotation laxities were radial tears or more central, complex tears, do significantly increased after inducing a ramp not preserve the load distribution function due to lesion in an ACL- deficient knee [74]. Therefore, 7 Peripheral Meniscal Tears: How to Diagnose and Repair 79 the menisci play an important role of the biome- in-depth descriptions of surgical techniques, chanics of the knee joint, particularly in the set- patient outcomes, and postoperative ting of ACL-deficient knees when additional rehabilitation. force and stress is placed on the menisci. This increase in mechanical force likely leads to meniscal tears following ACL injury with 7.2 Diagnosis delayed or inadequate repair. When taking into account the various biomechanical properties Meniscal tears can be challenging to diagnose at and roles of the menisci, it is clear that injury to times, even for an experienced surgeon, but an the menisci can have detrimental effects on the effective history and physical examination can knee joint. By reaching an appropriate, timely direct the working diagnosis toward a meniscus diagnosis with subsequent repair, surgeons can problem. In this chapter, we will not cover his- minimize future complications such as increased tory taking in the setting of suspected meniscal graft forces or OA [20, 56]. pathology but focus on physical examination The diagnosis of peripheral meniscal tears maneuvers and diagnostic imaging involved in often includes a detailed history, physical exami- the diagnosis of peripheral meniscal tears. After a nation, and diagnostic imaging. Despite these pertinent patient history is obtained, physical diagnostic techniques, a peripheral meniscal examination follows and is one of the major con- injury can be misdiagnosed. Once identified, a tributors to reach a diagnosis of a meniscal tear. surgeon must consider the characteristics of the When interpreting the findings from the various tear, such as the location, size, appearance, chro- tests and examinations, it is important to under- nicity, and presence of secondary tears, prior to stand the sensitivity, specificity, and limitations intervention [44]. Furthermore, patient factors of each examination. As previously stated, a such as age, activity level, compliance, and con- timely diagnosis of peripheral meniscal tears is comitant ACL injury must be taken into account important in limiting degenerative changes in the as well [44] due to their influence on patient cartilage and the menisci that results from the outcomes. changed joint loading and biomechanics. Better comprehension of the function (shock absorption, stability, force transmission) and vascularity of the menisci, as well as the knowl- 7.2.1 Physical Examination edge of degenerative articular changes after meniscectomy, has led to the development of Many clinical tests have been described to assist numerous surgical meniscal repair procedures in diagnosing meniscal tears, including joint line used to preserve the meniscus. Described surgi- palpation, McMurray and Apley tests, as well as cal techniques include open, outside-in, inside- the figure-4 test [6, 25, 26, 33, 44, 48–50, 56, 60, out, and all-inside, in addition to nonoperative 70, 85]. Tibiofemoral joint line palpation is treatment in certain circumstances [4, 11, 14, among the most basic diagnostic physical exam 28]. Outcomes with these techniques have been test for meniscal pathology. During this exam, favorable overall [3, 4, 20, 24, 28, 38, 40, 43, manipulation of the knee joint allows for the pal- 46, 58, 69], with arthroscopic techniques pation of specific meniscal regions. For example, becoming the mainstay for surgical interven- flexion of the knee allows for the palpation of the tion. Improved outcomes are often associated anterior half of each meniscus, valgus force on with the type of tear, location, knee stability, knee joint exposes the medial edge of the medial surgery less than 8 weeks from injury, and age meniscus, and varus force on the knee enhances [2, 4, 24]. palpation of the lateral meniscus (Fig. 7.3) [54]. The following chapter includes diagnostic The literature reports the sensitivity and specific- techniques and imaging studies used in the diag- ity of joint line tenderness to be 55–85 % and nosis of peripheral meniscal tears, followed by 29.4–67 %, respectively [6, 33, 49, 85]. 80 J. Chahla et al. ab Fig. 7.3 Image demonstrating joint line tenderness test on a (a) lateral meniscus of a left knee while extruding the meniscus with a varus force and (b) medial meniscus of a right knee while extruding the meniscus with a valgus force Additionally, joint line tenderness has potential position, which may be difficult in patients with discrepancies with laterality, showing increased limited mobility.
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