Meniscal injury

ppt on meniscal injury

1. Meniscal Injury Dr Manoj Das Department of orthopaedics Institute Of Medicine,TUTH , Nepal

2. Introduction Meniscal tears are the most common soft tissue injury of the knee joint and are responsible for 750,000 arthroscopies per year in the US.   Traumatic meniscal tears most commonly occur in young, active people during twisting sports such as football and basketball. Degenerative tears commonly occur in patients with osteoarthritis, although the exact incidence and prevalence are not known.

3. Anatomy Menisci are two fibrocartilagenous crescents Each menisci has:- - Two ends - Two borders - Two surfaces

4. MEDIAL MENISCUS C shaped structure forming 3/5 of the ring anterior horn attached to the tibia anterior to the intercondylar eminence to the anterior cruciate ligament posterior horn anchored immediately in front of the attachment of posterior cruciate ligament posterior to the intercondylar eminence.

5. MEDIAL MENISCUS... peripheral border attached to the medial capsule and through the coronary ligament to the upper border of tibia Most of the weight borne on the posterior portion of the meniscus

6. LATERAL MENISCUS circular forming 4/5 the of the ring with symmetrical anterior and posterior horn anterior horn attached to the tibia in front of the intercondylar eminence posterior horn attached to posterior aspect of the intercondylar eminence in front of posterior attachment of the medial meniscus

7. Lateral Meniscus… The posterior horn receives anchorage to the femur via the ligament of Wrisberg and ligament of Humphrey and from fascia covering the popliteus muscle The tendon of the popliteus separates the posteriolateral periphery of the lateral meniscus from the joint capsule and fibular collateral ligament

8. Microscopy composed of dense, tightly woven Type-I collagen with some Type-III) and elastin to create a compressible structure major orientation of collagen fibres in the menisci is circumferential; radial and perforating are also present. circumferential fibres function in hoops to accept stress without gross deformation or extrusion of the joint. Radial fibres stabilizes the meniscus, preventing circumferential splits as wells resists excessive compressive loads.

9. Blood Supply The menisci of the knee develop at eight weeks of gestation as a collection of fibroblasts. At birth, the menisci are vascularised through their substance; with ageing through early adulthood, there is eventual peripheralization of the vascularity to the outer third of meniscus

10. Blood supply… Vascular supply is from the lateral and medial geniculate vessels ( inferior and superior ). The branches from the vessels give rise to perimeniscal capillary plexus within the Synovial and capsular tissue and supply the peripheral border of meniscus . The depth of the vascular penetration is 10% to 30% of the width of the medial meniscus and 0% to 25% of width of lateral meniscus

11. Miller, Warner and Harner classification a. Red-Red -fully within vascular area b. Red-White -at the border of vascular area c. White-White within the avascular area

12. Functions 1.Load distribution - Increase contact surface area and reduce contact stresses Medial menisectomy decreases contact area by 50-70% and increase contact stress by 100% Lateral menisectomy decrease contact by 40-50% and increase contact stress by 200- 300%

13. Functions 2. Acts as joint filler compensating for the gross incongruity between tibial and femoral articulating surfaces 3. Prevent capsular and Synovial impingement during flexion-extension movements 4. Joint lubrication help to distribute Synovial fluid through the joint and aiding the nutrition of articular cartilage.

14. Functions… 5. Contribute to stability in all planes but are important rotatory stabilizers. 6. Shock absorption; the larger area provided by the meniscus reduces the average contact stress between the bones.

15. Mechanism of injury T urning or twisting of the loaded joint may trap the menisci between the joint and tear the meniscus MEDIAL MENISCUS Internal rotation of femur over tibia with knee in flexion forces the posterior segment of medial meniscus towards the centre of the joint. The posterior horn may be trapped in this position by sudden extension of knee

16. Mechanism of injury… LATERAL MENISCUS Vigorous external rotation of femur while the knee is flexed displace the posterior half of the lateral meniscus toward the centre of the joint During sudden extension of the knee, an anterioposterior distracting force tends to straighten the cartilage and imposes a strain on the medial concave rim, which tears transversely and obliquely .

17. Mechanism of injury… Which meniscus is commonly injured??? the lateral meniscus, because it is firmly attached to the popliteus muscle and to the ligament of Wrisberg or of Humphry , follows the lateral femoral condyle during rotation In addition, when the tibia is rotated internally and the knee flexed, the popliteus muscle, by way of the arcuate ligament, draws the posterior segment of the lateral meniscus backward, thereby preventing the meniscus from being caught between the condyle of the femur and the plateau of the tibia.

18. Classification O’Connor classification Based on the type of tear found at surgery a. Longitudinal tear b. Horizontal c. Oblique d. Radial tears e. Variations which include flap tears, complex tears and degenerative tears .

19. Clinical Features History H/O twisting injury Pain LOCKING -common in longitudnal tear( bucket-handle tear) Sensation of giving away : - feeling of subluxtion or “the joint jumping out of place” usually on rotary movement

20. Clinical Features… Effusion : - Indicates irritation of synovium - limited specific diagnostic value - Sudden onset after an injury denotes a hemarthrosis - Repeated displacement of torn portion of a meniscus produce chronic synovitis with an effusion of a nonbloody nature.

21. Clinical Features… Physical Examination Tenderness most important physical finding - along medial or lateral joint line or over periphery of meniscus - most commonly located posteromedially or posterolaterally

22. Clinical Features… Atrophy - recurring disability of the knee Clicks, snaps, or catches:- If the noises localized to the joint line, the meniscus most likely contains a tear

23. McMurray test McMurray first described his test in 1942 and published in paper entitled “ Semilunar Cartilage ”

24. APLEY’S GRINDING TEST

25. SQUAT TEST Consists of several repetitions of full squat with the feet and leg alternately rotated as the squat is performed Pain in the internally rotated position suggests injury to the lateral meniscus Pain in the external rotation suggests injury to the medial meniscus

26. Thessaly test clinician holds the patient's outstretched hands for support, while the patient stands flat-footed Knee flexed to 20 degrees and rotates their body and knee three times, internally and externally The test is positive if symptoms are reproduced on rotation

27. STEIMANN’S TEST Position: Sitting Patient sits with the leg bent over the table about 90 degree To assess the M.M. tear, the foot is externally rotated which produces some discomfort.

28. Modified Helfet Test Position-sitting on the edge of a table with knee flexed to 90°, then patient extends their knee Normal- tibial tuberosity in line with the midline of the patella in full flexion During extension, the tibia rotates and the tibial tubercle moves into line with the lateral border of the patella ( Qangle ) Failure of the tibia to rotate during extension indicates a meniscal lesion or cruciate ligament pathology.

29. Investigations Radiological Examination: - AP, Lateral and intercondylar notch view with a tangential view of inferior surface of patella -It is essential to exclude loose bodies, osteochondritis and other derangements of the knee

30. ARTHROGRAPHY Accuracy in diagnosis Medial menisci-95% Lateral menisci-85% With the improvement in CT scan and MRI arthrography is rarely used.

31. MRI - great value in the diagnostic evaluation of meniscal tears. -The accuracy of meniscal tears – 98% for medial meniscus and 90% for lateral meniscus ( Campbell’s operative Orthopaedics 12 th Edi)

32. ARTHROSCOPY Is the diagnostic procedure to detect the meniscal injuries. accuracy of diagnostic arthroscopy is 97% ( campbell’s operative orthopaedics 12 th Edi )

33. Non Operative Treatment Indications - Incomplete meniscal tear or small ( < 3mm) stable peripheral tear with no other pathological conditions. - Tears associated with ligamentous instabilities can be treated non-surgically if patient defers ligament reconstruction or if reconstruction is contraindicated.

34. Non Operative Treatment… Contraindications 1. Chronic tears with superimposed acute injury 2. In a locked knee with bucket handle tear of meniscus.

35. Non Operative Treatment… Management An acute episode without locking but with an acute synovitis with effusion requires immediate abstinence from weight bearing rest with knee flexion application of ice packs compression dressing

36. Non Operative Treatment… Management… - cylindrical cast or knee immobilizer for 4-6 wks -Crutch walking with touch-down weight bearing permitted when the patient gains active control of the extremity in the cast -progressive isometric exercise in cast - At 4 to 6 weeks, the immobilization discontinued, and the rehabilitative exercise program for the muscles around the hip and knee intensified.

37. Non Operative Treatment … Most important aspect of nonoperative treatment:- - Restoration of the power of the muscles around the injured knee to a level comparable with that of the opposite knee

38. SURGICAL TREATMENT Meniscectomy By arthrotomy By arthroscopy Meniscal repair By arthrotomy By arthroscopy Meniscal transplantation With autografts , allograft, prosthetic scaffolds.

39. Repair Vs Resection

40. EXCISION OF MENISCI Partial meniscectomy : - Only the loose, unstable fragments excised -stable and balanced peripheral rim preserved

41. EXCISION OF MENISCI... ii )) Subtotal meniscectomy : - requires excision of portion of peripheral rim of meniscus Most of the anterior horn and a portion of middle 3 rd of the meniscus are not resected . iii) Total meniscectomy : Done when meniscus is detached from its peripheral menisco -synovial attachment and intrameniscal damage and tears are extensive.

42. Open menisectomy EXCISION OF MEDIAL MENISCUS Using single anteromedial incision :

43. Open menisectomy … EXCISION OF MEDIAL MENISCUS... Using two incision: HENDERSON -An additional posteromedial incision -Permits easier and complete detachment of posterior horn - Posterior incision is made 5 cm parallel and slightly posterior to the tibial collateral ligament.

44. Open menisectomy … EXCISION OF THE LATERAL MENISCUS

45. Open menisectomy … AFTER TREATMENT compression bandage Knee immobilized in extension with posterior plaster splint or with a knee immobilizer for 5-7 days Quadriceps exercises When the good muscular control is achieved, patient allowed to walk with crutches and with partial weight bearing

46. ARTHROSCOPIC SURGERY OF MENISCUS Arthroscopic Meniscectomy General principles Partial meniscectomy is always prefarable to subtotal or total meniscectomy To determine accurately the type of meniscectomy required, the meniscal lesion must be carefully probed and classified objective is to remove the torn, mobile meniscal fragment and contour the peripheral rim, leaving a balanced, stable rim of meniscal tissue

47. 4. Excision of the pathological tissue can be done either with en bloc resection of the mobile fragment or by morcellization of the fragments and subsequent removal

48. Arthroscopic Resection of Bucket handle tear

49. Arthroscopic Removal of longitudinal incomplete intrameniscal tears

50. Arthroscopic Removal of horizontal, Oblique, Radial, and complex tear In evaluating horizontal, oblique, radial, and complex tears, it is imperative to evaluate and remove only damaged tissue, while maintaining functional, healthy meniscal tissue

51. COMPLICATIONS AFTER MENISCECTOMY Post operative haemarthrosis . Chronic synovitis . Synovial fistulae. Painful neuromas of the branches of the infrapatellar portion of saphanous nerve. Thrombophlebitis Postoperative infection Reflex sympathetic dystrophy. Retained meniscal fragment.

52. Late changes: Degenerative changes within the joint. Fairbank described three changes i ) Narrowing of joint space ii) Flattening of the peripheral half of the articular surface of condyle iii) Development of anteroposterior ridge that projected distally from the margin of femoral condyle .

53. Arthroscopic Repair of torn Menisci CRITERIA Location : within 3 mm of periphery Stability : partial thickness Full thickness- oblique and vertical tears less than 10 mm with inability to displace the central portion with a probe greater than 3mm

54. Arthroscopic Repair of torn Menisci… CRITERIA… Tear pattern : peripheral , vertical and longitudinal tears repaired. Bucket handle, flap, degenerative, complex, radial tears are excised Patient age : less than 50 yrs Chronicity : Acute tears less than 8 weeks old have better healing potential Ligament stability : ACL deficiency must also be corrected simultaneously to prevent instability.

55. Arthroscopic Repair of torn Menisci…

56. Arthroscopic Repair of torn Menisci…

57. Recent Advances Enhancement of meniscal healing Arthroscopic repair of torn meniscus using fibrin clot Meniscal replacement with - allograft meniscus - autograft fascial material - synthetic meniscus Biologic tissue scaffolds

58. Enhancement of meniscal healing Vascular access channels: creating access of peripheral vessels to avascular region, by a channel (trephination) allows avascular portion of the meniscus to heal throught the proliferation of the fibrous scar. Synovial abrasion : encourages vascular extension to avascular regions via., formation of vascular synovial pannus.

59. ARTHROSCOPIC REPAIR USING FIBRIN CLOT Acts as a chemotactic and mitogenic stimulus for reparative cells and provide scaffolding for reparative process Arnocky and Warren reported the injection of exogenous fibrin clot obtained from the patients coagulated blood to improve meniscal healing. Exogenous fibrin clot is injected with a blunt needle in the stem of the tear.

60. MENISCAL REPLACEMENT AIM -To prevent degenerative changes, in the post meniscectomy patient. Indication Age < 40 yr who had previous meniscectony Symptoms localized to tibiofemoral compartment No advanced arthrosis Contraindications Malalignment and instability in the patient who does not want to wish to have corrected Chondromalacia > grade III Previous joint infection

61. MENISCAL REPLACEMENT

62. Conclusion…. Meniscal tear management tree

63. THANK YOU