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Journal of ISAKOS : Joint Disorders &... Jan 2021The discoid meniscus is a congenital morphological abnormality encountered far more commonly on the lateral than the medial side. The discoid lateral meniscus (DLM) is... (Review)
Review
The discoid meniscus is a congenital morphological abnormality encountered far more commonly on the lateral than the medial side. The discoid lateral meniscus (DLM) is more prevalent in Asia with an incidence of 10%-13%, than in the Western world with an incidence of 3%-5%. DLM can be bilateral in more than 80% cases. Due to its abnormal shape and size, the discoid meniscus is prone to tearing and has an impact on gait mechanics. The discoid meniscus has deranged collagen arrangement and vascularity which can have implications for healing after a repair. Patients with a DLM may or may not be symptomatic with mechanical complaints of locking, clicking, snapping or pain. Symptoms often arise due to a tear in the body of the meniscus or a peripheral detachment. Asymptomatic patients usually do not require any treatment, while symptomatic patients who do not have locking are managed conservatively. When a peripheral detachment is present, it must be stabilised while preserving the meniscus rim to allow transmission of hoop stresses. Rehabilitation after surgery is highly individualised and return to sports is possible after more than 4 months in those undergoing a repair. The functional outcomes and onset of radiographic arthritis after saucerisation and repairing a discoid meniscus are better in the long term, compared with a subtotal meniscectomy. However, there is no compelling evidence currently favouring a repair as results deteriorate with increasing follow-up. Poor prognosis is reported in patients undergoing a total meniscectomy, a higher age at presentation and valgus malalignment.
Topics: Arthroscopy; Cartilage Diseases; Female; Humans; Joint Diseases; Knee Joint; Male; Meniscectomy; Menisci, Tibial; Pain; Return to Sport; Rupture; Tibial Meniscus Injuries
PubMed: 33833041
DOI: 10.1136/jisakos-2017-000162 -
Orthopaedics & Traumatology, Surgery &... Dec 2017Meniscectomy remains one of the most frequent orthopedic procedures, despite meniscal sparing having been advocated for several decades now. Incidence is excessive in... (Review)
Review
Meniscectomy remains one of the most frequent orthopedic procedures, despite meniscal sparing having been advocated for several decades now. Incidence is excessive in the light of scientifically robust studies demonstrating the interest of meniscal repair or of nonoperative treatment for traumatic tear and of nonoperative treatment for degenerative meniscal lesions. It is high time that the paradigm shifted, in favor of meniscal preservation. In traumatic tear, and most particularly longitudinal vertical tear in vascularized zones, repair shows a high success rates in terms of recovery time, functional outcome and cartilage protection. Leaving the meniscus alone may be an option in asymptomatic lesions of the lateral meniscus during anterior cruciate ligament (ACL) reconstruction. Posterior ramp lesions (in associated ACL tear), traumatic root tears and radial lesions are also excellent indications for repair, although it has to be borne in mind that the natural history of these lesions is not completely understood and nonoperative treatment also may be considered. Degenerative meniscal lesions are frequently revealed by MRI in middle-aged or elderly subjects. They are closely related to tissue aging and thus probably to osteoarthritic processes. Meniscectomy was long considered the treatment of choice. All but 1 of the 8 recent randomized studies reported non-superiority of arthroscopy over nonoperative treatment, which should thus be the first-line choice, with arthroscopic meniscectomy reserved for cases of failure, or earlier in case of "considerable" mechanical symptoms. Horizontal cleavage in young athletes is a particular case, requiring meniscal repair, to avoid a meniscectomy, which would inevitably be extensive in a young active patient. More than ever, the take-home message is: save the meniscus!
Topics: Anterior Cruciate Ligament Injuries; Arthroscopy; Conservative Treatment; Humans; Magnetic Resonance Imaging; Meniscectomy; Menisci, Tibial; Organ Sparing Treatments; Radiography; Tibial Meniscus Injuries
PubMed: 28873348
DOI: 10.1016/j.otsr.2017.08.003 -
Knee Surgery, Sports Traumatology,... Apr 2020The importance of meniscus integrity in the prevention of early osteoarthritis is well known, and preservation is accepted as the primary goal. The purpose of the ESSKA... (Review)
Review
PURPOSE
The importance of meniscus integrity in the prevention of early osteoarthritis is well known, and preservation is accepted as the primary goal. The purpose of the ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) European consensus on traumatic meniscus tears was to provide recommendations for the treatment of meniscus tears based on both scientific evidence and the clinical experience of knee experts.
METHODS
Three groups of surgeons and scientists elaborated and ratified the so-called formal consensus process to define the recommendations for the management of traumatic meniscus tears. A traumatic meniscus tear was defined as a tear with an acute onset of symptoms caused by a sufficient trauma. The expert groups included a steering group of eight European surgeons and scientists, a rating group of another nineteen European surgeons, and a peer review group. The steering group prepared twenty-seven question and answer sets based on the scientific literature. The quality of the answers received grades of A (a high level of scientific support), B (scientific presumption), C (a low level of scientific support) or D (expert opinion). These question and answer sets were then submitted to and evaluated by the rating group. All answers were scored from 1 (= totally inappropriate) to 9 (= totally appropriate) points. Thereafter, the comments of the members of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the finalized question and answer sets were submitted for final review by the peer review group composed of representatives of the ESSKA-affiliated national societies. Eighteen representatives replied.
RESULTS
The review of the literature revealed a rather low scientific quality of studies examining the treatment of traumatic meniscus tears. Of the 27 questions, only one question received a grade of A (a high level of scientific support), and another received a grade of B (scientific presumption). The remaining questions received grades of C and D. The mean rating of all questions by the rating group was 8.2 (95% confidence interval 8.1-8.4). A general agreement that MRI should be performed on a systematic basis was not achieved. However, MRI was recommended when arthroscopy would be considered to identify concomitant pathologies. In this case, the indication for MRI should be determined by a musculoskeletal specialist. Based on our data, stable left in situ lateral meniscus tears appear to show a better prognosis than medial tears. When repair is required, surgery should be performed as early as possible. Evidence that biological enhancement such as needling or the application of platelet-rich plasma would improve healing was not identified. Preservation of the meniscus should be considered as the first line of treatment because of an inferior clinical and radiological long-term outcome after partial meniscectomy compared to meniscus repair.
DISCUSSION
The consensus was generated to present the best possible recommendations for the treatment of traumatic meniscus tears and provides some groundwork for a clinical decision-making process regarding the treatment of meniscus tears. Preservation of the meniscus should be the first line of treatment when possible, because the clinical and radiological long-term outcomes are worse after partial meniscectomy than after meniscus preservation. The consensus clearly states that numerous meniscus tears that were considered irreparable should be repaired, e.g., older tears, tears in obese patients, long tears, etc. LEVEL OF EVIDENCE: II.
Topics: Arthroscopy; Consensus; Humans; Magnetic Resonance Imaging; Meniscectomy; Menisci, Tibial; Rupture; Tibial Meniscus Injuries
PubMed: 32052121
DOI: 10.1007/s00167-020-05847-3 -
Biomaterials Oct 2011Extensive scientific investigations in recent decades have established the anatomical, biomechanical, and functional importance that the meniscus holds within the knee... (Review)
Review
Extensive scientific investigations in recent decades have established the anatomical, biomechanical, and functional importance that the meniscus holds within the knee joint. As a vital part of the joint, it acts to prevent the deterioration and degeneration of articular cartilage, and the onset and development of osteoarthritis. For this reason, research into meniscus repair has been the recipient of particular interest from the orthopedic and bioengineering communities. Current repair techniques are only effective in treating lesions located in the peripheral vascularized region of the meniscus. Healing lesions found in the inner avascular region, which functions under a highly demanding mechanical environment, is considered to be a significant challenge. An adequate treatment approach has yet to be established, though many attempts have been undertaken. The current primary method for treatment is partial meniscectomy, which commonly results in the progressive development of osteoarthritis. This drawback has shifted research interest toward the fields of biomaterials and bioengineering, where it is hoped that meniscal deterioration can be tackled with the help of tissue engineering. So far, different approaches and strategies have contributed to the in vitro generation of meniscus constructs, which are capable of restoring meniscal lesions to some extent, both functionally as well as anatomically. The selection of the appropriate cell source (autologous, allogeneic, or xenogeneic cells, or stem cells) is undoubtedly regarded as key to successful meniscal tissue engineering. Furthermore, a large variation of scaffolds for tissue engineering have been proposed and produced in experimental and clinical studies, although a few problems with these (e.g., byproducts of degradation, stress shielding) have shifted research interest toward new strategies (e.g., scaffoldless approaches, self-assembly). A large number of different chemical (e.g., TGF-β1, C-ABC) and mechanical stimuli (e.g., direct compression, hydrostatic pressure) have also been investigated, both in terms of encouraging functional tissue formation, as well as in differentiating stem cells. Even though the problems accompanying meniscus tissue engineering research are considerable, we are undoubtedly in the dawn of a new era, whereby recent advances in biology, engineering, and medicine are leading to the successful treatment of meniscal lesions.
Topics: Animals; Biomechanical Phenomena; Humans; Menisci, Tibial; Regeneration; Tissue Engineering; Tissue Scaffolds
PubMed: 21764438
DOI: 10.1016/j.biomaterials.2011.06.037 -
Journal of Anatomy Oct 2013In 1879, the French surgeon Segond described the existence of a 'pearly, resistant, fibrous band' at the anterolateral aspect of the human knee, attached to the...
In 1879, the French surgeon Segond described the existence of a 'pearly, resistant, fibrous band' at the anterolateral aspect of the human knee, attached to the eponymous Segond fracture. To date, the enigma surrounding this anatomical structure is reflected in confusing names such as '(mid-third) lateral capsular ligament', 'capsulo-osseous layer of the iliotibial band' or 'anterolateral ligament', and no clear anatomical description has yet been provided. In this study, the presence and characteristics of Segond's 'pearly band', hereafter termed anterolateral ligament (ALL), was investigated in 41 unpaired, human cadaveric knees. The femoral and tibial attachment of the ALL, its course and its relationship with nearby anatomical structures were studied both qualitatively and quantitatively. In all but one of 41 cadaveric knees (97%), the ALL was found as a well-defined ligamentous structure, clearly distinguishable from the anterolateral joint capsule. The origin of the ALL was situated at the prominence of the lateral femoral epicondyle, slightly anterior to the origin of the lateral collateral ligament, although connecting fibers between the two structures were observed. The ALL showed an oblique course to the anterolateral aspect of the proximal tibia, with firm attachments to the lateral meniscus, thus enveloping the inferior lateral geniculate artery and vein. Its insertion on the anterolateral tibia was grossly located midway between Gerdy's tubercle and the tip of the fibular head, definitely separate from the iliotibial band (ITB). The ALL was found to be a distinct ligamentous structure at the anterolateral aspect of the human knee with consistent origin and insertion site features. By providing a detailed anatomical characterization of the ALL, this study clarifies the long-standing enigma surrounding the existence of a ligamentous structure connecting the femur with the anterolateral tibia. Given its structure and anatomic location, the ALL is hypothesized to control internal tibial rotation and thus to affect the pivot shift phenomenon, although further studies are needed to investigate its biomechanical function.
Topics: Aged; Aged, 80 and over; Cadaver; Dissection; Female; Femur; Humans; Knee Joint; Ligaments, Articular; Male; Menisci, Tibial; Middle Aged; Tibia
PubMed: 23906341
DOI: 10.1111/joa.12087 -
Osteoarthritis and Cartilage Oct 2022We conducted a systematic review in order to understand the relationship between imaging-visualised meniscus pathologies, hyaline cartilage, joint replacement and pain... (Review)
Review
OBJECTIVE
We conducted a systematic review in order to understand the relationship between imaging-visualised meniscus pathologies, hyaline cartilage, joint replacement and pain in knee osteoarthritis (OA).
DESIGN
A search of the Medline, Excerpta Medica database (EMBASE) and Cochrane library databases was performed for original publications reporting association between imaging-detected meniscal pathology (extrusion or tear/damage) and longitudinal and cross-sectional assessments of hyaline articular cartilage loss [assessed on magnetic resonance imaging (MRI)], incident joint replacement and pain (longitudinal and cross-sectional) in knee OA. Each association was qualitatively characterised by a synthesis of data from each analysis, based upon study design and quality scoring (including risk of bias assessment and adequacy of covariate adjustment using Cochrane recommended methodology).
RESULTS
In total 4,878 abstracts were screened and 82 publications were included (comprising 72 longitudinal analyses and 49 cross-sectional). Using high quality, well-adjusted data, meniscal extrusion and meniscal tear/damage were associated with longitudinal progression of cartilage loss, cross-sectional cartilage loss severity and joint replacement, independently of age, sex and body mass index (BMI). Medial and lateral meniscal tears were associated with cartilage loss when they occurred in the body and posterior horns, but not the anterior horns. There was a lack of high quality, well-adjusted meniscal pathology and pain publications and no clear independent association between meniscal extrusion or tear/damage with pain severity, progression in pain or incident frequent knee symptoms.
CONCLUSION
Meniscal features have strong associations with cartilage loss and joint replacement in knee OA, but weak associations with knee pain. Systematic review PROSPERO registration number: CRD 42020210910.
Topics: Arthroplasty, Replacement; Cartilage, Articular; Cross-Sectional Studies; Humans; Knee Joint; Magnetic Resonance Imaging; Menisci, Tibial; Osteoarthritis, Knee; Pain
PubMed: 35963512
DOI: 10.1016/j.joca.2022.08.002 -
Knee Surgery, Sports Traumatology,... Jun 2023This study aimed to evaluate and compare the time required to return to sports (RTS) after surgery, the rate of revision surgery and the time required for RTS after... (Review)
Review
PURPOSE
This study aimed to evaluate and compare the time required to return to sports (RTS) after surgery, the rate of revision surgery and the time required for RTS after revision surgery in elite athletes undergoing meniscal repair or partial meniscectomy, particularly analysing the difference between medial and lateral menisci. It was hypothesised that both procedures would entail similar, high rates of RTS, with the lateral meniscus exhibiting higher potential healing postprocedure compared to the medial meniscus.
METHODS
A systematic review was conducted based on the PRISMA guidelines. Quality assessment of the systematic review was performed using the AMSTAR-2 checklist. The following search terms were browsed in the title, abstract and keyword fields: 'meniscus' or 'meniscal' AND 'tear,' 'injury' or 'lesion' AND 'professional,' 'elite' or 'high-level' AND 'athletes,' 'sports,' 'sportsman,' 'soccer,' 'basketball,' 'football' or 'handball'. The resulting measures extracted from the studies were the rate of RTS, level of RTS, complications, revision surgery and subsequent RTS, Tegner, International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS).
RESULTS
In this study, the cohort consisted of 421 patients [415 (98.6%) men and 6 (1.4%) women] with a mean age of 23.0 ± 3.0 years. All patients were elite athletes in wrestling, baseball, soccer, rugby or handball. While 327 (77.7%) patients received partial meniscectomy at a mean age of 23.3 ± 2.6 years, 94 (22.3%) patients received meniscal repair at a mean age of 22.1 ± 4.0 years. After partial meniscectomy, 277 patients (84.7%) returned to their competitive sports activity and 256 (78.3%) returned to their pre-injury activity levels. A total of 12 (3.7%) patients required revision surgery because of persistent pain [5 (1.5%) patients], chondrolysis [2 (0.7%) patients] or both chondrolysis and lateral instability [5 (1.5%) patients]. Ten (83.3%) of the twelve patients had involvement of the lateral meniscus, whereas the location of injury was not specified in the remaining two patients. After revision surgery, all patients (100%) resumed sports activity. However, after meniscal repair, 80 (85.1%) athletes returned to their competitive sports activity and 71 (75.5%) returned to their pre-injury activity levels. A total of 16 (17.0%) patients required partial meniscectomy in cases of persistent pain or suture failure. Of these, 4 (25%) patients involved lateral and medial menisci each and 8 (50%) patients were not specified. After revision surgery, more than 80.0% of the patients (13) resumed sports activity.
CONCLUSIONS
In elite athletes with isolated meniscal injury, partial meniscectomy and meniscal suture exhibited similar rates of RTS and return to pre-injury levels. Nonetheless, athletes required more time for RTS after meniscal repair and exhibited an increased rate of revision surgery associated with a reduced rate of RTS after the subsequent surgery. For lateral meniscus tears, meniscectomy was associated with a high rate of revision surgery and risk of chondrolysis, whereas partial medial meniscectomy allowed for rapid RTS but with the potential risk of developing knee osteoarthritis over the years. The findings of this systematic review suggested a suture on the lateral meniscus in elite athletes because of the high healing potential after the procedure, the reduced risk of developing chondrolysis and the high risk of revision surgery after partial meniscectomy. Furthermore, it is important to evaluate several factors while dealing with the medial meniscus. If rapid RTS activity is needed, a hyperselective meniscectomy is recommended; otherwise, a meniscal suture is recommended to avoid accelerated osteoarthritis.
LEVEL OF EVIDENCE
Level IV.
STUDY REGISTRATION
PROSPERO-CRD42022351979 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=351979 ).
Topics: Male; Humans; Female; Young Adult; Adult; Adolescent; Menisci, Tibial; Meniscectomy; Knee Joint; Soccer; Cartilage Diseases; Athletes; Retrospective Studies; Arthroscopy
PubMed: 36319751
DOI: 10.1007/s00167-022-07208-8 -
Orthopaedic Surgery Apr 2023Discoid lateral meniscus (DLM) is the most common congenital variant of the lateral meniscus, which is prone to degeneration and lesions, and often leads to knee...
Discoid lateral meniscus (DLM) is the most common congenital variant of the lateral meniscus, which is prone to degeneration and lesions, and often leads to knee osteoarthritis. At present, there is no consensus on the clinical practice of DLM, and this expert consensus and practice guidelines on DLM was developed and approved by Chinese Society of Sports Medicine according to the Delphi method. Among 32 statements drafted, 14 statements were excluded for redundant information, and 18 statements achieved consensus. This expert consensus focused on the definition, epidemiology, etiology, classification, clinical manifestations, diagnosis, treatment, prognosis, and rehabilitation of DLM. Restoring the normal shape, retaining appropriate width and thickness, and ensuring the stability of the remnant meniscus is critical to sustaining the physiological function of the meniscus and preserving the knee. The partial meniscectomy with or without repair should be the first-line treatment when possible, given that the clinical and radiological long-term outcomes of total or subtotal meniscectomy are worse.
Topics: Humans; Menisci, Tibial; Arthroscopy; Meniscectomy; Knee Joint; Meniscus
PubMed: 36878896
DOI: 10.1111/os.13687 -
Journal of ISAKOS : Joint Disorders &... Dec 2022The purpose of the current study was to measure extrusion of the intact lateral meniscus as a function of knee flexion angle and loading condition and to compare the...
PURPOSE
The purpose of the current study was to measure extrusion of the intact lateral meniscus as a function of knee flexion angle and loading condition and to compare the changes in extrusion with a posterior root tear using a robotic testing system and ultrasound.
STUDY DESIGN
Controlled laboratory study.
METHODS
Eight fresh-frozen cadaveric knees were subjected to external loading conditions (passive path position (no external load), 200 axial compression, 5-N-m internal tibial torque, 5-N-m valgus torque) at full extension, 30°, 60° and 90° of flexion using a robotic testing system. A linear array transducer was placed in the longitudinal orientation. Extrusion and kinematics data were recorded for two meniscus states: intact and posterior lateral root deficiency. Therefore, a complete radial root tear in the lateral meniscus at 10 mm from the tibial insertion was made in all 8 cadaveric knees using arthroscopy. The resultant forces in the lateral meniscus were also quantified by reproducing recorded paths after the removal of the lateral meniscus.
RESULTS
A lateral meniscus root tear resulted in a statistically significant increase (up to 250%) of extrusion for the lateral meniscus (p < 0.05) in comparison to the intact lateral meniscus for all externally applied loads. Without external load (passive path position), significant differences were also found between the intact and posterior lateral root deficient meniscus except at full extension (1.0 ± 0.7 mm vs. 1.9 ± 0.4 mm) and 30° of flexion (1.4 ± 0.5 mm vs. 1.8 ± 0.5 mm). Overall, with increasing flexion angle, lateral meniscus extrusion decreased for the intact as well as for the posterior lateral root deficient meniscus, with the lowest measurements in response to internal tibial torque at 90° of flexion (-3.3 ± 1.1 mm). Knee kinematics were similar whether intact or posterior lateral root tear (n.s.). Ultrasound measurement of lateral meniscus extrusion showed good inter-rater (0.65 [0.30-0.97]-0.71 [0.34-0.94]) and excellent intra-rater reliability (0.81 [0.43-0.99]).
CONCLUSION
Dynamic Ultrasound is a reliable diagnostic modality to measure the lateral meniscus extrusion which can be helpful in the diagnosis and quantification of lateral meniscal root tears.
LEVEL OF EVIDENCE
III.
Topics: Humans; Menisci, Tibial; Tibial Meniscus Injuries; Knee Injuries; Reproducibility of Results; Rupture; Lacerations; Cadaver
PubMed: 36182072
DOI: 10.1016/j.jisako.2022.08.001 -
Journal of ISAKOS : Joint Disorders &... Jun 2023Meniscus tears are prevalent in isolation and in combination with anterior cruciate ligament (ACL) injury. Meniscus lesions can be difficult to access and often display...
Meniscus tears are prevalent in isolation and in combination with anterior cruciate ligament (ACL) injury. Meniscus lesions can be difficult to access and often display complex tear patterns, which result in technical challenges for the operating surgeon during surgical treatment. The aim of this video article is to demonstrate technical tips and tricks for performing all-inside repair of challenging meniscus tears. The presented techniques are indicated in young, physically active patients with symptomatic tears of the lateral and medial menisci, with or without concomitant ACL injury. The procedure is performed using standard anterolateral and anteromedial arthroscopic portals for direct visualization of complex meniscus tear patterns and all-inside instrument access. A suture passing device is used for the placement of suture loops for meniscus root repair. All-inside repair devices are used to repair the radial meniscal tears along the native circumferential fibers using a horizontal mattress suture configuration, with curved devices to achieve optimal access to challenging tears affecting the anterior and posterior aspects at the mid-body of the meniscus. Repair of radial tears at the avascular zone of the meniscus may be augmented with an autologous fibrin clot delivered using an arthroscopic cannula.
Topics: Humans; Arthroscopy; Tibial Meniscus Injuries; Anterior Cruciate Ligament Injuries; Knee Injuries; Menisci, Tibial
PubMed: 36924826
DOI: 10.1016/j.jisako.2023.02.007