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Meniscus Tears

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What are the meniscus tears associated with ACL injury?

LM tear more common in acute ACL

Lateral Meniscal Oblique Radial Tears Are Common With ACL Injury: A Classification System Based on Arthroscopic Tear Patterns in 600 Consecutive Patients

Aaron J. Krych, MD,* † Matthew D. LaPrade, BS, † Corey S. Cook, MA, ‡ Devin Leland, BS, † Lucas K. Keyt, BS, † Michael J. Stuart, MD, † and Patrick A. Smith, MD ‡ § Meniscal root tears and ramp lesions have been rigorously characterized in recent literature.

www.ncbi.nlm.nih.gov

MM tear more common in chronic ACL

Anterior cruciate ligament reconstruction performed within 12 months of the index injury is associated with a lower rate of medial meniscus tears - Knee Surgery, Sports Traumatology, Arthroscopy

Purpose To verify the correlation of time to surgery with the prevalence of concomitant intra-articular injuries detected on arthroscopy during anterior cruciate ligament (ACL) reconstruction. Methods The medical records of 653 patients who underwent ACL reconstruction surgery were retrospectively analyzed.

link.springer.com

Anterior cruciate ligament reconstruction performed within 12 months of the index injury is associated with a lower rate of medial meniscus tears - Knee Surgery, Sports Traumatology, Arthroscopy

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Medial Meniscus (MM) or Lateral Meniscus (LM) tear has worse prognosis?

LM tear Because LM occupies more of the lateral tibial plateau (70% vs 50%)
Lateral tibial plateau more convex while medial is concave! ➔ natural tendency to point loading and increased contact stresses

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Classic signs on MRI?

Bucket handle tear = double PCL

The Double Posterior Cruciate Ligament Sign

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pubs.rsna.org

The Double Posterior Cruciate Ligament Sign

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How can you classify tears?

Mechanism - traumatic or degenerative
Morphology

Bucket handle tear (locking, a/w with high grade laxity)
Vertical, radial tear
Horizontal Cleavage tears – usually degenerative, a/w cyst

Chronicity

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How about TRAUMATIC tears?

PATIENT and INJURY factors
Patient factors: age, activity level, and alignment
Tear characteristics: bucket handle with mechanical block, tear location, and associated ligament injury

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What surgical techniques do you know? Which part of meniscus uses what?

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Inside-out (gold standard) = Needles go from inside out

Creation of windows of safety on both sides — both are anterior to the gastrocnemius and hamstring muscles

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Medial window is anterior to both the pes anserinus and medial gastrocnemius muscles

Longitudinal incision medially, dissect anterior to the pes. With knee in flexion, retract the pes posterior (protecting saphenous nerve), go deep to the medial head of the gastroc and insert protector

Posterior wall = gastrocnemius
Anterior wall = posteromedial capsule
Inferior wall = pes anserinus

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Lateral window is anterior to the biceps femoris and lateral head of gastrocnemius

Incision at posterior border of ITB, incise ITB, blunt dissection anterior to lateral gastrocnemius head and posterolateral capsule

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Outside-in = Needles go from outside to in

Economical
Good for anterior horn repairs

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All-inside

Advantage: easy to perform
Vs Inside-out?

No difference in outcomes (Elmallah et al. Meta-analysis)

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How can you optimize meniscus repair healing?

Rasping and shavers to freshen both sides ("synovial abrasion")
Trephination of meniscus with spinal needle
Autologous blood clot
Fibrin clot augmentation (draw blood, stir to get clot, shape clot, implant clot)

main (8).pdf1300.8KB

Stem cell, PRP

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What are your post-op instructions for meniscus tear?

Non-weight bearing for 6 weeks
Note: No consensus on weight-bearing status (Robert Sprang et al. Systematic review)

Rehabilitation following meniscal repair: a systematic review - PubMed

There is a lack of consensus regarding the optimal postoperative protocol following meniscal repair. Small clinical studies support rehabilitation protocols that allow early motion. Additional studies are needed to better clarify the interplay between tear type, repair method and optimal rehabilitat ...

pubmed.ncbi.nlm.nih.gov

Rehabilitation following meniscal repair: a systematic review - PubMed

Perkins et al. 2017 for vertical tear repairs — no difference in reoperation rates between immediate weight-bearing vs non-weight-bearing with flexion >90°

Weightbearing Versus Nonweightbearing After Meniscus Repair - PubMed

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pubmed.ncbi.nlm.nih.gov

Weightbearing Versus Nonweightbearing After Meniscus Repair - PubMed

Radial tears — 6 weeks non-weight-bearing to prevent retear

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What are the outcomes of repair? Association with ACL reconstruction?

Better outcomes with concurrent ACL reconstruction
90% success rate in conjunction with ACL reconstruction (drilling releases healing factors)
60% success without ACL reconstruction
30% success if ACL deficient and not reconstructed

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What are perimeniscal cysts? How to manage?

A/w Horizontal flap tears due to one way valve
Technique: Haybale stitches to repair horizontal tear

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