The most commonly practiced Indications for meniscal repair typically include posttraumatic peripheral (red zone) longitudinal tears located near the joint capsule, ideally in younger patients (less than 40). Lateral Meniscus: Anatomy The lateral meniscus is seen as a symmetric bow tie in the sagittal plane on at least one or two sections before it divides into two asymmetric triangles near the midline. The shape of the meniscus is formed at the eighth week of 2014; 43:10571064, McCauley TR. On the sagittal fat-suppressed T2-weighted image (7B), fluid extends into the tear. Conventional MRI imaging of the postop meniscus offers a noninvasive evaluation of the knee, but postoperative changes can mimic a recurrent or residual meniscus tear. Sagittal proton density-weighted image (5B) through the medial meniscus at age 17 reveals an incomplete tibial surface longitudinal tear (arrow) in a new location and orientation. Because most meniscal tears are not isolated to the red zone, it is understandable that most meniscal surgeries are partial meniscectomies which aim to restore meniscus stability while preserving as much native meniscal tissue as possible, to decrease the risk of osteoarthritis. In this case, the patient never obtained relief from the initial surgery, and the surgeon felt this was a residual tear (failed repair) rather than a recurrent tear. this may extend to to the mid body." is this a bucket tear? The patient underwent partial medial meniscectomy and ACL reconstruction. In the U.S., intraarticular injection of gadolinium-based contrast is off label. from AIMM. Meniscal surgery is common and requires accurate post-operative imaging interpretation to guide the treatment approach. 2006; 187:W565568. This case features the following signs of meniscal tear: Case courtesy, Prof. Dr. Khaled Matrawy, Professor of radiology, Alexandria university, Egypt. Meniscal tears were found on MRI or arthroscopy in all 28 patients with a lateral cyst overlying the body or posterior horn of the lateral meniscus, whereas a tear was found on MRI or arthroscopy in only 14 (64%) of 22 patients with cysts adjacent to or extending to the lateral meniscus anterior horn (p = 0.006). The medial meniscus is more firmly attached to the tibia and capsule than the lateral meniscus, presumably leading to the increased incidence of tears of the medial meniscus [ 8, 11, 12 ]. Pullout fixation of posterior medial meniscus root tears: correlation between meniscus extrusion and midterm clinical results. 2059-2066, Kinsella S.D., and Carey J.L. Stein T, Mehling AP, Welsch F, von EisenhartRothe R, Jger A. (middle third), or Type 3 (superior third; intercondylar notch) (Figure Their conclusion that one should not perform surgery unless clinical correlation exists with effusions, mechanical catching or locking, or the failure to respond to nonoperative measures I believe is a good recommendation that we can all follow. Pinar H, Akseki D, Karaoglan O, et al. The patient underwent meniscal repair but had recurrent pain prompting repeat MRI 8 months post-operative. In Normal menisci. These findings are also frequently associated with genu MR imaging is useful for evaluation of many possible complications following meniscal surgery. Longitudinal lateral meniscus tear status post repair (arrow). 3. discoid lateral meniscus, including a propensity for tears to occur and A 22-years old male presented with injury to right knee in a road traffic accident MRI images shows double posterior horn of lateral meniscus and absent anterior horn in coronal (A: PD; B: STIR; C . On the sagittal proton density-weighted image (11A), signal contacts the tibial surface. Results: In a consecutive series of 301 ACL reconstructions, 50 patients (33 male, 17 female) with a mean age of 29.6 years (range, 14-61 years) were diagnosed with a medial meniscal ramp lesion at . Figure 7: Meniscofemoral ligament. Diagnostic performance is decreased following partial meniscectomy since the standard criteria used to diagnose a meniscus tear cannot be applied to the post-operative meniscus.3,4,5,6 Partial meniscectomy may distort the normal morphology of the meniscus and increased meniscal signal intensity may extend to the articular surface when a portion of the meniscus has been resected, simulating a tear. Exam showed a mild effusion and medial joint line tenderness. Tears Suprapatellar plica noticed, with no related cartilaginous erosions. Clark CR, Ogden JA. Resnick D, Goergen TG, Kaye JJ, et al. Both the healed peripheral tear and the new central tear were proved at second look arthroscopy. Another MRI was later performed due to worsening symptoms, and demonstrated a bucket-handle tear with complete anterior luxation of the posterior horn of the left lateral meniscus (Figs. At surgery, the torn part of the meniscus was in the intercondylar notch and chewed up and not amenable to repair. Note that signal does not contact articular surface, The most common criterion for diagnosing meniscus tear on MRI is an increased signal extending in a line or band to the articular surface. Direct and indirect MR arthrography have been shown to be superior to conventional MRI for detection of recurrent meniscal tears in greater than 25% partial meniscectomies and meniscal repairs; however, conventional MRI is commonly used for initial evaluation of the postoperative meniscus with MR arthrography reserved for equivocal cases. Most horizontal tears extend to the inferior articular surface. MRI: When you tear your meniscus, a magnetic resonance imaging (MRI) scan will show the injury as white lines on black. snapping knee due to hypermobility. Another finding is the abnormal size or shape of the meniscus, which would indicate damaged surfaces [, To provide a greater degree of accuracy, De Smet advocated the two-slice-touch rule. To call a definite tear, one should see increased signal contacting the articular surface of the menisci on at least two images (sagittal or coronal). Arthroscopy is considered gold standard in the diagnosis of knee ligament injuries, with diagnostic accuracy up to 94% [1], [2]; and can be used therapeutically as well. Lateral meniscus tears of the posterior root are a common concomitant injury to anterior cruciate ligament (ACL) tears [6, 16, 20]. both enjoyable and insightful. menisci develop from this mesenchymal tissue in a site where this tissue They divide the meniscus into superior and inferior halves (Fig. A meniscal allograft transplant frequently leads to significant improvements in pain and activity level and hastens the return to sport for most amateur and professional athletes.13 A common method of meniscal allograft transplant includes a cadaveric meniscus (fresh or frozen) attached by its anterior and posterior roots to a bone bridge with a trapezoidal shape harvested from a donor tibia. Brody J, Lin H, Hulstyn M, Tung G. Lateral Meniscus Root Tear and Meniscus Extrusion with Anterior Cruciate Ligament Tear. At 1 year, 5 of 6 were completely asymptomatic with the remaining patient minimally painful with no suggestion of meniscal symptoms. Check for errors and try again. With age, increased connective tissue stiffness of the meniscus develops secondary to elastin degradation and collagen rigidification.2. A tear of the anterior horn of the lateral meniscus is damage to the front part of one of the two structures that act as shock absorbers between the thigh bone and the lower leg, explains The Steadman Clinic. Volunteerism and Sports Medicine: Where do We Stand? Arthrofibrosis and synovitis are also relatively common. in this case were attributed to an anterior cruciate ligament tear Associated anomalies in a discoid medial Discoid lateral meniscus. Bilateral hypoplasia of the medial meniscus has also been MRI failed to detect anterior horn injury of lateral meniscus in six (16.7%) cases, all of which were longitudinal fissure in the red zone. While they can arise from a number of mechanisms, root tears are generally thought to be chronic 5. The anterior horn inserts on the tibia and continues laterally to the anterior horn of the lateral meniscus via the transverse intermeniscal ligament. De Smet A. As such, I can count on my hands the number of isolated anterior horn meniscal tears that I have seen at surgery that I felt were symptomatic over the past 5 years. Close clinical correlation is advised before recommending surgery based on this finding alone. Repair techniques include side-to-side repair, stabilization with suture anchors, and the transtibial pull-out technique (figure 4).12. Arthroscopy evaluation found a lateral meniscus peripheral (red-white zone) longitudinal tear. The camera can visualize the meniscus and other structures within the knee. CT arthrography is recommended for patients with MRI contraindications or when extensive susceptibility artifact from hardware obscures the meniscus. meniscus are not uncommon; they include an anomalous insertion of the This is a well-done study with clinical correlation and adequate follow-up. They are usually due to an acute injury [. According to one source, they are thought to account for ~10% of all arthroscopic meniscectomies 5. The MRI showed complete ACL tear with displaced bucket handle medial meniscus tear. 7.2 Medial and Lateral Menisci Medial meniscus is larger than the lateral meniscus and is more "open" (=less C-like) and less wide. Knee Surg Sports Traumatol Arthrosc. Materials and methods . The meniscus can separate from the joint capsule or tear through the allograft. Most patients are asymptomatic, but injury to the meniscus can However, many clinicians opt to use conventional MRI as the initial postoperative imaging study and reserve MR arthrography for equivocal cases. In these cases, MR arthrography may provide additional diagnostic utility. On MRI, they exhibit abnormal horizontal linear signal contacting the inferior articular surface near the free edge or less commonly the superior surface. the rare ring-shaped meniscus, to the classification. asymptomatic, although there is a greater propensity for discoid menisci published a case series of anterior horn tears of the lateral meniscus in 14 soccer players (mean age 20.2 years). Posterior meniscal root repairs: outcomes of an anatomic transtibial pull-out technique. Menisci ensure normal function of the A Study of Retrieved Allografts Used for ACL Surgery, Long-Term Results of Meniscus Allograft Transplantation with Concurrent ACL Reconstruction, Anterior Horn Meniscal Tears — Fact or Fiction, How Triathletes Can Use Cycling Cadence to Maximize Running Performance, Pharmacology Watch: HRT - Position Paper Places Benefits in Question, Clinical Briefs in Primary Care Supplement. In this case, having the prior MRI exam is useful for showing the location of the initial tear and the new tear in a different location. Am J Sports Med 2017; 45:4249, ElAttar M, Dhollander A, Verdonk R, Almqvist KF, Verdonk P. Twenty six years of meniscal allograft transplantation: is it still experimental? Magnetic resonance imaging (MRI) is the most accurate imaging technique in the diagnosis of meniscal lesions and represents a standard tool in knee evaluation. Pathology - a tear that has developed gradually in the meniscus. Kocher MS, Klingele K, Rassman SO. Youderian A, Chmell S, Stull MA. High signal close to fluid intensity contacts the tibial surface on the sagittal T2-weighted image (11B) and is equivocal. History of a longitudinal medial meniscus tear managed by repair and concurrent ACL reconstruction. Atypically thick and high location Shepard and colleagues at UCLA specifically analyzed this by reviewing 947 consecutive MRIs. It splits into two bands at the PCL, named Humphry(anterior to the PCL) and Wrisberg (posterior to the PCL). as at no time in development does the meniscus have a discoid In this section, the major patterns of tears are described and depicted in MRIs and arthroscopy images. There was no evidence of meniscal extrusion or a meniscal ghost sign (Fig. trauma; however, other symptoms include clicking, snapping, and locking also found various MRI characteristics highly specific for detection of a recurrent tear including a line of intermediate-to-high signal or high signal through the meniscus extending into the articular surface on T2-weighted images with 95.8% specificity and change in the signal intensity pattern through the meniscus on intermediate weighted or T2-weighted images when compared to the baseline MRI with 98.2% specificity. Conventional MRI is the least invasive modality for evaluation of a meniscal repair but has lower sensitivity, specificity and accuracy than direct or indirect arthrographic MRI. . Copy. The MRI also demonstrated moderate degenerative spurring at the lateral joint compartment, a large knee joint effusion with . The torn edges are aligned, and stable fixation applied with sutures or bioabsorbable implants at approximately 5 mm intervals. 1991;7(3):297-300. Total meniscectomy is rarely performed unless the meniscus is so severely damaged that no salvageable meniscal tissue remains. We look forward to having you as a long-term member of the Relias There is a medial and a lateral meniscus. AJR American journal of roentgenology. The example above demonstrates the importance of baseline MRI comparison when evaluating the postoperative meniscus. Studies on meniscus root tears have investigated the relationship of osteoarthritis and an anterior cruciate ligament tear. When it involves the posterior root, medial root tears are easier to diagnose than lateral root tears. Additionally, the postoperative complication of new extensive synovitis is apparent on the axial view (18D). We hope you found our articles Root tears are often large radial tears that extend through the entire AP width of the meniscus. We use cookies to create a better experience. The Wrisberg variant may present with a The anterior and posterior sutures are shuttled down the tibial tunnel (arrowhead). The articular cartilage is well seen on the pre-operative sagittal proton density-weighted image (19B). Diagnosis - clinical presentation with exclusion of advanced knee osteoarthritis. A tear was found and the repair was revised at second look arthroscopy. 17. 1 ). The meniscal repair is intact. Results: Arthroscopic examination of the anterior horn of the lateral meniscus in all 22 patients was normal. Type AJR Am J Roentgenol 211(3):519527, De Smet AA. History of longitudinal medial meniscus tear managed by meniscal repair (arrows). Vertical flap (oblique, flap, parrots beak) tears are unstable tears and occur in younger patients. horn of the lateral meniscus, and oblique tear orientation In the present study, the patients analyzed came from the have been the most difficult for imaging planes to visualize same geographical area . Considered a feature of knee osteoarthritis. Their 74% false-positive rate I believe is accurate and one that we can incorporate mentally into our practice as we evaluate patients and the MRI scan results. Indirect MR arthrography is less commonly used and relies on excretion of intravascular gadolinium into the joint through synovial cells after intravenous administration of gadolinium contrast 20-90 minutes prior to the MRI exam. 2. Lateral meniscus tears of the posterior root are a common concomitant injury to anterior cruciate ligament (ACL) tears [6, 16, 20]. is in fact reducing the volume of the meniscus and restoring a normal MRI plays a critical role in influencing the treatment decision and enables information that would obviate unnecessary surgery including diagnostic arthroscopy. Create a new print or digital subscription to Applied Radiology. partly divides a joint cavity, unlike articular discs, which completely However, few studies have directly compared the medial and lateral root tears. If a horizontal tear involves a long segment of the meniscus, the central fragment may displace centrally from the peripheral portion of the meniscus [, Bucket handle tears (BHT) often cause pain and mechanical symptoms, such as locking, catching, and giving way [. Mucinous degeneration of meniscus can also produce abnormal signal within a meniscus which does not contact an articular surface and should not be mistaken for a tear. The superior, middle and inferior geniculate arteries are the main vascular supply to the menisci. 1. A preliminary report, Principles and decision making in meniscal surgery, The Anterior Meniscofemoral Ligament of the Medial Meniscus, Accurate patient history including site and duration of symptoms, Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. The Journal of bone and joint surgery American volume. MRIs of BHT may have several characteristic appearances including (1) fragment in the notch sign; (2) double anterior horn sign, in which there is an additional meniscal fragment in the anterior joint on top of the native anterior horn; (3) the absent bow tie sign; (4) the double PCL sign, in which the centrally displaced fragment lies just anterior and parallel to the PCL giving the appearance of two PCLs; and (5) the coronal truncation sign, in which the free edge of the meniscal body appears clipped off on coronal images (Fig. hypoplastic meniscus was not the cause of the patients pain, suggesting Direct intraarticular injection of 20-50 mL of dilute iodinated contrast is performed with rapid image acquisition using multidetector CT with high spatial resolution and multiplanar reformatted images. Sometimes T2 signal in a healed tear may look similar to fluid. While this test will show a tear up to 90% of the time, it does not always. At the time the article was created Yuranga Weerakkody had no recorded disclosures. At the time the article was last revised Yahya Baba had 2a, 2b, 2c). On examination, there was marked medial joint line tenderness and a large effusion. MRI features are consistent with torn lateral meniscus with flipped anterior horn superomedial and posterior, resting superior to the posterior horn. Findings indicate an intact meniscus following partial meniscectomy with normal intrameniscal signal. congenital absence of the cruciate ligaments. Meniscal root tearsare a type of meniscal tearin the knee where the tear extends to either the anterior or posterior meniscal root attachment to the central tibial plateau. After preparing the recipient knee by creating a matching keyhole trough in the tibia, the surgeon slides the allograft bone plug into its matching tibial slot and sutures the periphery of the allograft meniscus to the capsule. Zonal variation is also seen in the density of meniscus cells and their phenotypes with a chondrocytic inner zone and fibroblastic outer zone. Sagittal proton density-weighted image (9A) demonstrates no high signal abnormality. 15 year old patient with prior extensive lateral partial meniscectomy was treated with lateral chondroplasty and lateral meniscal allograft transplant with continued pain and clicking 6 weeks post-operative. The MRI revealed a vertical flap (oblique) tear of the medial meniscus. 2006; 88:660667, Boutin RD, Fritz RC, Marder RA. Medial meniscus bucket handle tears can result in a double PCL sign. This emphasizes the importance of meniscal repair over meniscectomy when possible and the need for meniscal preservation when a partial meniscectomy is necessary. 2008; 32:212219, Magee T. Accuracy of 3-Tesla MR and MR arthrography in diagnosis of meniscal retear in the post-operative knee. variants of the meniscus are relatively uncommon and are frequently However, the tear changes plane of orientation over its course. Of the anterior horn tears read on MRI, 85% involved the lateral meniscus anterior horn and about one half were judged to extend into the middle or body of the same meniscus. There are Check for errors and try again. Klingele KE, Kocher MS, Hresko MT, et al. Each meniscus has three main parts, the back (posterior horn), middle (body), and front (anterior horn). Unable to process the form. The anterior root of the medial meniscus attaches to the anterior midline of the tibial plateau or sometimes the anterior surface of the tibia just below the plateau. ; Lee, S.H. Arthroscopy revealed a horizontal tear of PHMM, and a partial medial meniscectomy was performed. Sagittal T2-weighted image (18A) demonstrates high T2 fluid signal in the medial meniscus posterior horn consistent with a recurrent tear (arrow). frequently. medial meniscus are extremely uncommon and should not be a diagnostic He presented after a few months with symptoms of instability. The most important clinical concern at the time of MRI imaging is often high-grade articular cartilage loss. A tear of the lateral meniscus can occur from a sudden injury, or from chronic wear and overload. The medial meniscus is more firmly attached to the tibia and capsule than the lateral meniscus, presumably leading to the increased incidence of tears of the medial meniscus [ 8, 11, 12 ]. Tears can be characterized by length, depth, shape, gap, displacement, stability, dysplasia (discoid)
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