On the proton density-weighted image (12A) persistent high signal extends to the tibial and femoral surfaces (arrow). The self-reported complication rate for partial meniscectomy is 2.8% and meniscus repair is 7.6%. The patient had a recent new injury with increased pain. Biologic augmentation with application of exogenous fibrin clot or growth factors may be combined with the repair to promote healing. According to one source, they are thought to account for ~10% of all arthroscopic meniscectomies 5. The MRI also demonstrated moderate degenerative spurring at the lateral joint compartment, a large knee joint effusion with . A previous study by De Smet et al. MRI: When you tear your meniscus, a magnetic resonance imaging (MRI) scan will show the injury as white lines on black. The anterior horn of the menisci, especially the lateral meniscus, is an area commonly confused on MRI. does not normally occur.13. sagittal magnetic resonance (MR) images. They often tend to be radial tears extending into the meniscal root. What is a Lateral Meniscus Tear? Recent evidence suggests that decreased extrusion may correlate to better clinical outcomes.18. Heron, D, Bonnard C, Moraine C,Toutain A. Agenesis of cruciate The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. 2059-2066, Kinsella S.D., and Carey J.L. Most studies have shown increased accuracy for direct and indirect MR arthrography compared to conventional MRI for partial meniscectomies of 25% or more.16. These findings are also frequently associated with genu 3 years later the sagittal proton density-weighted image (15B) shows a healed posterior horn (arrow) with a new flap tear in the medial meniscus anterior horn (arrowhead). 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. to tear. MRI Findings: Medial meniscus: Tear of the posterior horn seen to the inferior articular surface continuing into the posterior body and becoming more vertical. to the base of the ACL or the intercondylar notch. There was no evidence of meniscal extrusion or a meniscal ghost sign (Fig. Synopsis: In a consecutive series of nearly 1000 knee MRIs, there was a 74% false-positive rate for the diagnosis of anterior horn meniscal tears. Longitudinal medial meniscus tear managed by repair (arrow). However, clinically significant tears that can mechanically impinge were unlikely to have been missed. Materials and methods . It is believed that discoid this may extend to to the mid body." is this a bucket tear? Criteria for a recurrent tear after greater than 25% meniscectomy Definite surfacing T2 fluid signal (or high T1 signal isointense to intra-articular gadolinium on MR arthrography) on 2 or more images or displaced meniscal fragment.17 Definite surfacing fluid signal on only one image represents a possible tear. It has been calculated that the lateral meniscus absorbs about 70% of the forces across the lateral compartment of the knee. Meniscus tears, indicated by MRI, are classified in three grades. least common is complete congenital absence of the menisci. 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. . Absence of the meniscus results in a 200 to 300% increase in contact stresses on the articular surfaces.8The meniscus has a heterogeneous cellular composition with regional and zonal variation, with high proteoglycan content at the thin free edge where compressive forces predominate and low proteoglycan content at the thicker peripheral region where circumferential tensile loads predominate. Regardless of the imaging protocol chosen for evaluation of the postoperative meniscus, optimal imaging interpretation includes: The normal MRI appearance after partial meniscectomy is volume loss and morphologic change, commonly truncation or blunting of the meniscal free edge. What is your diagnosis? These include looking for a A 510, 210-pound 16-year-old male injured his left knee while kicking a football. Meniscal root tears are a form of radial tear that involves the central attachment of the meniscus (12a). occur with minor trauma. Controlling Blood Pressure During Pregnancy Could Lower Dementia Risk, Researchers Address HIV Treatment Gap Among Underserved Population, HHS Announces Reorganization of Office for Civil Rights, FDA Adopts Flu-Like Plan for an Annual COVID Vaccine. 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. 3: The Wrisberg variant, where the meniscus may have a normal Sometimes T2 signal in a healed tear may look similar to fluid. Sagittal T2-weighted image (10B) reveals no fluid at the repair site. The ends of the anterior and posterior horns are firmly attached to the tibia at their roots. On examination, there was marked medial joint line tenderness and a large effusion. proximal medial tibia was convex and the distal medial femoral condyle Am J Sports Med 2010; 38:15421548, LaPrade RF, Matheny LM, Moulton SG, James EW, Dean CS. Case 9: posterior root of medial meniscus, View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, Ahlback classification system in assessing osteoarthritis of the knee joint, Kellgren and Lawrence system for classification of osteoarthritis, anterior cruciate ligament mucoid degeneration, MRI grading system for meniscal signal intensity, shortening or absence of the root on sagittal images, vertical fluid cleft on coronal fluid-sensitive (T2) images. Tear between 1-4 cm vertical tear red-red meniscal root <40 yo Maybe concominant ACL surgery . Learn more. Meniscal root tears are a type of meniscal tear in the knee where the tear extends to either the anterior or posterior meniscal root attachment to the central tibial plateau. Because there is less pressure on the meniscus there, it is difficult to evaluate the anterior region of the meniscus. Intact meniscal roots. On medial posterior root tears there is often 2: On posterior root radial tears of the lateral meniscus, the appearance may be similar to radial tears in other locations. Fukuta S, Masaki K, Korai F. Prevalence of abnormal findings in magnetic resonance images of asymptomatic knees. MRI of the knee is commonly indicated for evaluation of unresolved or recurrent knee pain following meniscal surgery. CT arthrography is a recommended alternative for patients who are not MR eligible. Am J Sports Med 2017; 45:884891, Zaffagnini S, Grassi A, Marcheggiani Muccioli GM, et al. 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 [. Grade 3 is a true meniscus tear and an arthroscope is close to 100 percent accurate in diagnosing this tear. 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. By comparison, the complication rate for ACL reconstruction is 9% and PCL reconstruction is 20%.20 Potential complications associated with arthroscopic meniscal surgery include synovitis, arthrofibrosis, chondral damage, meniscal damage, MCL injury, nerve injury (saphenous, tibial, peroneal), vascular injury, deep venous thrombosis and infection.21 Progression of osteoarthritis and stress related bone changes are seen with increased frequency in the postoperative knee, particularly with larger partial meniscectomies. The incidence was calculated based on arthroscopic findings, and the potential secondary signs of meniscal ramp tears were evaluated on MRI. The common insertion of the anterior cruciate ligament (ACL) and the AHLM root may provide a pathway for disease. The lateral meniscus attaches to the popliteus tendon and capsule via the popliteomeniscal fascicles at the posterior horn and to the medial femoral condyle by the meniscofemoral ligaments. that this rare condition is also clinically asymptomatic. On sagittal proton-density and T2-weighted images, this lesion was demonstrated by sensitive but nonspecific signs, such as the flipped meniscus . 2012;20(10):2098-103. Resnick D, Goergen TG, Kaye JJ, et al. In this case the roots remained intact at the bone bridge, but the meniscal allograft detached from the joint capsule at the posterior and middle third with displacement into the central weightbearing surface (arrowheads) on sagittal T2-weighted (17C) and fat-suppressed axial proton density-weighted (17D) images. The most commonly practiced Collagen fibers are arranged for transferring compressive loads into circumferential hoop stresses, secured by radially oriented tie fibers. Menisci are present in the knees and the was saddle shaped. The MRI showed complete ACL tear with displaced bucket handle medial meniscus tear. 2006; 88:660667, Boutin RD, Fritz RC, Marder RA. However, this conjecture and others pre- highest.13,27,34,42 Tear locations, such as the posterior sented in literature are mostly speculative. Of these 45 patients, there was an average of 3.74 additional pathological conditions noted on the MRI scan, mainly including degenerative arthrosis or patellar chondromalacia to explain the patients continued pain. The intrameniscal ligament where it diverges from the back of the anterior horn of the lateral meniscus is also a common area misinterpreted as a tear. . Thus, the loss of the lateral meniscus can often lead to rather rapid onset of osteoarthritis. 1427-143. Pain is typically medial and activity-related (e.g. Menisci ensure normal function of the MRI showed posterior horn of the medial meniscus (PHMM) horizontal tear with early degenerative changes. This is because most tears occur in the posterior horns [, Whether a torn meniscus is reparable depends on the type or pattern of tear, its location, and the quality of the meniscal tissue. The lateral meniscus is produced by the varus tension and tibial IR. Shepard and colleagues at UCLA specifically analyzed this by reviewing 947 consecutive MRIs. Kim EY, Choi SH, Ahn JH, Kwon JW. No meniscal tear is seen, but the root attachment was also noted to be History of longitudinal medial meniscus tear managed by meniscal repair (arrows). Also, the inferior patella plica inserts on the 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. ; Lee, S.H. Following partial meniscectomy, the knee is at increased risk for osteoarthritis. Associated anomalies in a discoid medial Sagittal proton density-weighted image (5A) through the medial meniscus at age 12 shows the initial horizontal tear in the posterior horn (arrow) subsequently treated with partial meniscectomy. Discoid lateral meniscus in children. A displaced longitudinal tear is a "bucket handle" tear. The MRI revealed a vertical flap (oblique) tear of the medial meniscus. Radial tears comprise approximately 15 % of tears in some surgical series [. Disadvantages include risks associated with joint injection, radiation exposure and lower contrast resolution compared to MRI, particularly in the extraarticular soft tissues. Kim SJ, Moon SH, Shin SJ. There is a medial and a lateral meniscus. On MRI, they exhibit abnormal horizontal linear signal contacting the inferior articular surface near the free edge or less commonly the superior surface. Intensity of signal contacting meniscal surface in recurrent tears on MR arthrography compared with that of contrast material. MRI plays a critical role in influencing the treatment decision and enables information that would obviate unnecessary surgery including diagnostic arthroscopy. An intact meniscal repair was confirmed at second look arthroscopy. 2019: Factors associated with bilateral discoid lateral meniscus tear in patients with symptomatic discoid lateral meniscus tear using MRi and X-ray Orthopaedics and Traumatology Surgery and Research: Otsr 105(7): 1389-1394 MRI c spine / head jxn - they can have stenosis of foramen magnum . There is no telling how much this error rate will change for radiologists less experienced with MRI. described in thrombocytopenia absent radius syndrome (TAR syndrome).2,3 Bilateral hypoplasia of the medial meniscus has also been reported.4. Healed peripheral medial meniscus posterior horn repair and new longitudinal tear in a different location. The medial meniscus covers 60% of the medial compartment. Again, this emphasizes the importance of accurate history, prior imaging and operative reports. Become a Gold Supporter and see no third-party ads. Examination showed lateral joint line tenderness and a positive McMurray sign. A 64-year-old female with no specific injury presented with knee pain, swelling, and locking that she first noticed after working out at the gym. Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-40036, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":40036,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/meniscal-root-tear/questions/1112?lang=us"}. Radial Meniscal Tear: Pearls May be degenerative or traumatic, vertical, millimeters in size, on the inner edge of the lateral meniscus more commonly than the medial meniscus At the time the article was last revised Yahya Baba had 2a, 2b, 2c). AJR Am J Roentgenol 211(3):519527, De Smet AA. hypermobility. A slightly overweight 44-year-old male sought evaluation for medial knee pain that persisted for months after running on the beach. Indications for meniscal repair typically include posttraumatic peripheral (red zone) longitudinal tears located near the joint capsule, ideally in younger patients (less than 40). Problems encountered in a discoid medial meniscus are the same as a ligament will help to exclude these conditions.5 In the first Repair techniques include side-to-side repair, stabilization with suture anchors, and the transtibial pull-out technique (figure 4).12. Illustration of the transtibial pullout repair for a tear of the posterior horn medial meniscal root (arrow). the menisci of the knees. The menisci are C-shaped fibrocartilaginous structures composed of radial and circumferential collagen fibers that have several roles, including joint stabilization, load distribution, articular cartilage protection and joint lubrication. morphology. Sagittal proton density-weighted image (7A) through the medial meniscus demonstrates increased signal extending to the tibial surface (arrow). The meniscus is two crescent-shaped, thick pieces of cartilage that sit in the knee between the tibia and the femur. The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. The post arthrogram view (13B) reveals gadolinium within the repair site. Kelly BT, Green DW. At 1 year, 5 of 6 were completely asymptomatic with the remaining patient minimally painful with no suggestion of meniscal symptoms. This patient had relief after the initial repair surgery, then had a second injury with recurrent symptoms, which is why the surgeon felt this was a recurrent tear. 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 ]. high fibula head and a widened lateral joint space.20 Several 2012;199(3):481-99. The MFL was not observed in five (19%) of 26 studies of an LMRT. Posterior root repair (Figure 16) is being performed with increasing frequency and has been shown to have better outcomes and decreased risk of osteoarthritis compared to posterior root tears treated non-operatively. Br Med Bull. The medial meniscus is asymmetrical with a larger posterior horn. Forty-five of the remaining patients did not undergo surgery but did undergo clinical follow-up and interview at a minimum of 1 year after the MRI to determine if they had any residual symptoms or if they received further medical treatment. Magnetic resonance imaging (MRI) revealed an elongated free edge of the diffusely enlarged lateral meniscus extending toward the intercondylar region on coronal T1-weighted images (Figure 1A). Financial Disclosure: None of the authors or planners for this educational activity have relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients. It can be divided into five segments: anterior horn, anterior, middle and posterior segments, and posterior horn. 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? The reported prevalence is 0.06% to 0.3%.25 Fat supressed coronal proton density-weighted (19C, D) and sagittal proton density-weighted (19E) images demonstrate postoperative changes from interval posterior horn partial meniscectomy with a thin rim of posterior horn remaining (arrow) and subchondral fractures in the medial femoral condyle and medial tibial plateau (arrowheads) with marked progression of full-thickness chondral loss in the medial compartment and extruded meniscal tissue. These are like large radial tears and can destabilize a large portion of the meniscus. MRI Knee - Sagittal PDFS - Displaced meniscus Part of a torn meniscus can be displaced into another part of the knee joint In this image the anterior part of the meniscus (the anterior horn) is correctly located The posterior horn is displaced such that it is located next to the anterior horn The correct position of the posterior horn is shown rim circumferentially, anteriorly, and posteriorly,19 which insertion of the medial meniscus (AIMM) has been described, and it is meniscal diameter. Cho JM, Suh JS, Na JB, et al. in this case were attributed to an anterior cruciate ligament tear The sagittal proton density-weighted image (2A) demonstrates increased signal intensity at the periphery of the medial meniscus posterior horn (arrow) but no fluid signal on the sagittal T2-weighted image (2B) and no gadolinium extension into this area on the MR arthrogram sagittal fat-suppressed T1-weighted arthrographic image (2C) consistent with a healed repair. 7 Therefore, it is important for the radiologist to be familiar with the appearance of a recurrent tear versus an untorn postoperative meniscus. Grades 1 and 2 are not considered serious. separate the cavity. 4). mimicking an anterior horn tear. Seventy-four cases of bucket-handle tears (mean age, 27.2 11.3 years; 38 medial meniscus and 36 lateral meniscus; 39 concomitant anterior cruciate ligament (ACL) reconstruction) were treated with arthroscopic repair from June 2011 to August 2021. The torn edges are aligned, and stable fixation applied with sutures or bioabsorbable implants at approximately 5 mm intervals. attachment of the posterior horn is the Wrisberg meniscofemoral small meniscus is also seen in the wrist joint. Type 1 is most common, and type The patient subsequently underwent successful partial medial meniscectomy. Clin Orthop Relat Res 2012; 470: pp. the intercondylar notch, most commonly to the mid ACL, and less commonly Pagnani M, Cooper D, Warren R. Extrusion of the Medial Meniscus. The MRI sign of a radial tear is a linear, vertical cleft of abnormal high signal at the free edge (Fig. Both ligaments attach distally to the posterior horn of the lateral meniscus and contribute to posterior drawer stability . Repair techniques include inside-out, outside-in or all-inside approaches. Medial meniscus posterior horn peripheral longitudinal tear (arrow) seen on the sagittal proton density-weighted image (15A) and managed by repair. 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. Radial or oblique tear congurations close to or within the meniscus . In the above case there is no gross chondral defect although the articular cartilage is noticeably thinner compared to the baseline study despite the patients young age. Interested in Group Sales? include hypoplastic menisci, absent menisci, anomalous insertion of the Complete radial tears, root tears and large partial meniscectomies result in markedly increased contact forces at the articular surface; and in this case, full-thickness chondral loss and subchondral fractures on both sides of the joint. patella or Hoffas fat pad, and should be fairly easily differentiated the posterior horn is usually much larger than the anterior horn (the These tears are usually degenerative in nature and usually not associated with a discrete injury [. We look forward to having you as a long-term member of the Relias Examination of the knee showed a mild effusion, 1+ Lachman, positive Pivot shift, and mild tenderness to both medial and lateral joint lines. This has also been described as grade 2 signal [, Sagittal fat-suppressed T2 image of a 14-year-old patient showing a grade 2 signal in the posterior horn of the medial meniscus (PHMM). pivoting). Nakajima T, Nabeshima Y, Fujii H, et al. Conventional MRI is useful for evaluation of posterior root morphology at the tibial tunnel fixation site, meniscal extrusion and articular cartilage. posterior horn of the medial meniscus include a triangular hypointense Increased signal intensity at the anterior horn of the lateral meniscus was seen on the images of seven of the 11 MR studies of the volunteers. AJR Am J Roentgenol. treatment for stable complete or incomplete types of discoid lateral Presentation - Middle-older aged individuals, non-traumatic, progressive onset of pain. 1. The example above demonstrates the importance of baseline MRI comparison when evaluating the postoperative meniscus. mesenchymal mass that differentiates into the tibia, femur, and There was no history of a specific knee injury. Dr. Diduch, Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, is Editor of Sports Medicine Reports. A tear of the meniscal root means the tear is near where it attaches to the bone, usually far in the back. These features constitute O'Donoghue unhappy triad. The anterior meniscofemoral ligament (Humphrey ligament) attaches proximally on the medial femoral condyle, inferior to the PCL insertion. They were first described by M J Pagnaniet al. Lateral meniscus tears of the posterior root are a common concomitant injury to anterior cruciate ligament (ACL) tears [6, 16, 20]. 2013;106(1):91-115. The location of meniscal tears or signal alterations (anterior/posterior horn or body of the medial/lateral meniscus) and the grade (normal/intra-substance signal abnormality = 0 and tear = 1) were determined on 2D .
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