The tear was treated by partial meniscectomy at second surgery. This emphasizes the importance of baseline MRI comparison for evaluation of the postoperative meniscus.3. When bilateral, they are usually symmetric. The meniscal repair is intact. Discoid lateral meniscus in children. The incidence was calculated based on arthroscopic findings, and the potential secondary signs of meniscal ramp tears were evaluated on MRI. The Postoperative Meniscus - Radsource Disadvantages include patient discomfort, increased cost, physician time needed for the procedure and radiation exposure during fluoroscopy. Arthroscopy revealed a horizontal tear of PHMM, and a partial medial meniscectomy was performed. Become a Gold Supporter and see no third-party ads. Thirty-one of these patients underwent subsequent arthroscopic evaluation to allow clinical correlation. Clin Orthop Relat Res 2012; 470: pp. Radiology. The most important clinical concern at the time of MRI imaging is often high-grade articular cartilage loss. Similarly, the postoperative meniscus is at increased risk for a recurrent tear either at the same or different location due redistribution of forces and increased stress on the articular surface. 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. 9 The lateral meniscus is more loosely attached than the medial and can translate approximately 11mm with normal knee motion. The meniscus may also become hypertrophic. Radiographs are usually not diagnostic, but they may show a of the menisci can be summarized as providing: Clark and Ogden studied the natural development of the menisci in the does not normally occur.13. trials, alternative billing arrangements or group and site discounts please call 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. Knee Surg Sports Traumatol Arthrosc. Thompson WO, Thaete FL, Fu FH, Dye SF. both enjoyable and insightful. frequently. that this rare condition is also clinically asymptomatic. problem in practice. A new longitudinal tear has occurred more centrally in the meniscus (arrowhead) with linear high signal extending to the tibial and femoral surfaces as well as fluid signal and gadolinium contrast in the defect. The anomalous insertion hypoplastic meniscus was not the cause of the patients pain, suggesting 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. They were first described by M J Pagnaniet al. 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. An alternative way of fastening the allograft to the donor knee involves harvesting the meniscus with a small bone plug attached to each root and then securing the plugs within osseous tunnels drilled in the recipient tibia. 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. 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 anterior and posterior sutures are shuttled down the tibial tunnel (arrowhead). Advantages include a less invasive method of introducing intraarticular contrast, the ability to identify areas of hyperemic synovitis or periarticular inflammation based on enhancement and administration can be performed by the technologist. an adult), and approximately twice the size of the anterior horn on There is a medial and a lateral meniscus. MRI features are consistent with torn lateral meniscus with flipped anterior horn superomedial and posterior, resting superior to the posterior horn. horns to the meniscal diameter on a sagittal slice that shows a maximum A tear of the ACL should also, in practice, not be a as at no time in development does the meniscus have a discoid 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. The Journal of bone and joint surgery American volume. The articular cartilage is well seen on the pre-operative sagittal proton density-weighted image (19B). Congenital absence of the meniscus is extremely rare and has been documented in TAR syndrome and in isolated case reports.2,3 At second look arthroscopy, the posterior horn tear was healed and the anterior horn tear was found to be unstable and treated by partial meniscectomy. Methods Eighteen patients who had arthroscopically confirmed partial MMPRTs were included. ADVERTISEMENT: Supporters see fewer/no ads. Reporting knee meniscal tears: technical aspects, typical pitfalls and 4). collapse and widening of the medial joint space (Figure 7). The MFL was not observed in five (19%) of 26 studies of an LMRT. As DLM is a congenital anomaly, the ultrastructural features and morphology differ from those of the normal meniscus, potentially leading to meniscal tears. the posterior horn is usually much larger than the anterior horn (the Normal Of the 54 participants, 5 had PHLM tears and 49 were normal. Midterm results in active patients. 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. Illustration of the medial and lateral menisci. medial meniscus are extremely uncommon and should not be a diagnostic Bilateral complete discoid medial menisci combined with anomalous insertion and cyst formation. intra-articular structures at 8 weeks gestation. Figure 8: Medial oblique menisco-meniscal . The MRI sign of a radial tear is a linear, vertical cleft of abnormal high signal at the free edge (Fig. 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 Incidence and Detection of Meniscal Ramp Lesions on Magnetic Resonance MR arthrogram fat-suppressed sagittal T1-weighted image (11C) shows no gadolinium in the repair. 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). At the time the case was submitted for publication Mostafa El-Feky had no recorded disclosures. Diagnosis - clinical presentation with exclusion of advanced knee osteoarthritis. Meniscus repair is superior to partial meniscectomy in preventing osteoarthritis and facilitating return to athletic activity.11 However, the period of postoperative immobilization and activity restriction associated with meniscus repair is longer than that associated with partial meniscectomy and requires a compliant, motivated patient to be successful. 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. Pinar H, Akseki D, Karaoglan O, et al. Type (Tr. If the tear does not show, it is considered a Grade 1 or 2 and is not as serious. 5 In the first instance, tears of the lateral aspect of the anterior horn of the medial meniscus are extremely uncommon and should not be a diagnostic snapping knee due to hypermobility. Discoid lateral meniscus. History of a longitudinal medial meniscus tear managed by repair and concurrent ACL reconstruction. of these meniscal variants is the discoid lateral meniscus, and the No paralabral cyst. What is a Grade 3 meniscus tear? Mechanical rasping or trephination of the torn meniscus ends and parameniscal synovium is used to promote bleeding and vascular healing. Association of Parameniscal Cysts With Underlying Meniscal Tears as Discoid lateral meniscus APPLIED RADIOLOGY Examination of the knee showed a mild effusion, 1+ Lachman, positive Pivot shift, and mild tenderness to both medial and lateral joint lines. A Klingele KE, Kocher MS, Hresko MT, et al. At surgery, the torn part of the meniscus was in the intercondylar notch and chewed up and not amenable to repair. Weight-bearing knee X-rays showed a 50 % narrowing in the medial compartment. Source: Shepard MF, et al. Sagittal proton density-weighted image (6A) through the medial meniscus following partial meniscectomy and debridement of the inferior articular surface shows increased PD signal contacting the inferior articular surface (arrow) but no T2 fluid signal at the surgical site (6B) and no gadolinium signal in the meniscus (6C). menisci develop from this mesenchymal tissue in a site where this tissue of the meniscus. found that the absence of a line of increased signal through the meniscus extending to the articular surface on proton density and T2-weighted images was a reliable MRI finding for an untorn post-operative meniscus with 100% sensitivity. Connolly B, Babyn PS, Wright JG, Thorner PS. Volunteerism and Sports Medicine: Where do We Stand? How I Diagnose Meniscal Tears on Knee MRI. to the base of the ACL or the intercondylar notch. It is located in the lateral portion of the knee interior of the knee joint. Fellowship-trained musculoskeletal radiologists read 99% of the MRIs. separate the cavity. Examination showed lateral joint line tenderness and a positive McMurray sign. The posterior cruciate ligament is intact. 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). Lateral Meniscus Tear | Tyler Welch, MD [emailprotected]. runs from the anterior horn of the medial meniscus to either the ACL or is in fact reducing the volume of the meniscus and restoring a normal . Most horizontal tears extend to the inferior articular surface. Posterior Horn Lateral Meniscus Tear | Knee Specialist | Minnesota Generally, A meta-analysis of 44 trials. MRI features are consistent with torn lateral meniscus with flipped anterior horn superomedial and posterior, resting superior to the posterior horn. PDF Coronal extrusion of the lateral meniscus does not increase after Meniscal root tear. The meniscus can separate from the joint capsule or tear through the allograft. Radial or oblique tear congurations close to or within the meniscus . anterior horn of the medial meniscus into the anterior cruciate ligament 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. 4. The patient underwent meniscal repair but had recurrent pain prompting repeat MRI 8 months post-operative. Bucket-handle tear of the lateral meniscus: Flipped meniscus sign The avulsed anterior horn of the lateral meniscus is flipped over and situated above the posterior horn. Indications for meniscal repair typically include posttraumatic peripheral (red zone) longitudinal tears located near the joint capsule, ideally in younger patients (less than 40). Sagittal proton density-weighted image (8A) through the medial meniscus demonstrates signal extending to the tibial surface (arrow). Continuous meniscal tissue bridged the anterior and posterior horns of the lateral meniscus on 3 consecutive sagittal slices (Figure 1B). 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. reported.4. The symptoms The medial meniscus is more tightly anchored than the lateral meniscus, allowing for approximately 5mm of anterior-posterior translation. You have reached your article limit for the month. of the Wrisberg ligament in patients with a complete lateral discoid 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. Figure 7: Meniscofemoral ligament. Meniscus tears are either degenerative or acute. 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. Posteroinferior displacement of the meniscal tissue (arrowheads) is also diagnostic of recurrent tear. 2002; 222:421429, Ciliz D, Ciliz A, Elverici E, Sakman B, Yuksel E, Akbulut O. Anterior horn lateral meniscus tear A female asked: Mri: "macerated anterior horn lateral meniscus with inferiorly surfacing tear. 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. Otherwise, the increased vascularity in children has sometimes led to false-positive reading of a meniscus tear. Additionally, the postoperative complication of new extensive synovitis is apparent on the axial view (18D). MRI has high sensitivity and specificity for detecting meniscus tears in patients without prior knee surgery. patella or Hoffas fat pad, and should be fairly easily differentiated 2020;49(1):42-49. Horizontal (degenerative) tears run relatively parallel the tibial plateau. Medial meniscus posterior horn peripheral longitudinal tear (arrow) seen on the sagittal proton density-weighted image (15A) and managed by repair. Each meniscus attaches to the tibia bone in the back and front via the "meniscal roots." The primary role of the meniscus is to serve as a shock-absorber and protect the underlying articular cartilage and bone. 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. Magnetic resonance imaging (MRI), was performed in another facility and, showed normal medial and lateral menisci except for the absence of a medial posterior root insertion both on coronal and on sagittal images. Check for errors and try again. Monllau J, Gonzalez G, Puig L, Caceres E. Bilateral hypoplasia of the medial meniscus. This article focuses on asymptomatic, although there is a greater propensity for discoid menisci Rao PS, Rao SK, Paul R. Clinical, radiologic, and arthroscopic assessment of discoid lateral meniscus. Pathology - a tear that has developed gradually in the meniscus. Repair techniques include side-to-side repair, stabilization with suture anchors, and the transtibial pull-out technique (figure 4).12. The MRI showed complete ACL tear with displaced bucket handle medial meniscus tear. . trauma; however, other symptoms include clicking, snapping, and locking 2013;106(1):91-115. Tachibana Y, Yamazaki Y, Ninomiya S. Discoid medial meniscus. Anterior Horn Meniscal Tears — Fact or Fiction - Relias Media There are MR imaging and MR arthrography for diagnosis of recurrent tears in the postoperative meniscus. | Semantic Scholar Significant increase in signal intensity at the anterior horn of the lateral meniscus near its central attachment site on sagittal magnetic resonance (MR) images of the knee is a normal finding. Bilateral Hypoplasia of the Medial and Lateral Menisci - PMC Arthrofibrosis and synovitis are also relatively common. Description. Pre-operative fat supressed coronal proton density-weighted image (19A) demonstates a posterior root radial tear (arrow). AJR Am J Roentgenol 211(3):519527, De Smet AA. Shepard and colleagues at UCLA specifically analyzed this by reviewing 947 consecutive MRIs. Most studies have shown increased accuracy for direct and indirect MR arthrography compared to conventional MRI for partial meniscectomies of 25% or more.16. measurements of the posterior horn of the medial meniscus may vary, but 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. 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. 22 year-old male with a history of ACL and MCL reconstruction and medial meniscus posterior root repair. Materials and methods . The meniscus root plays an essential role in maintaining the circumferential hoop tension and preventing meniscal displacement. 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. Skeletal radiology. continued knee pain after meniscus surgery In contrast to the medial meniscus, the posterior horn of the lateral meniscus is additionally secured by the meniscofemoral ligaments (MFL). The anterior root of the lateral meniscus attaches to the tibia, just lateral to the midline and posterior to fibers of the anterior cruciate ligament (ACL). Sagittal T2-weighted image (18A) demonstrates high T2 fluid signal in the medial meniscus posterior horn consistent with a recurrent tear (arrow). The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. in this case were attributed to an anterior cruciate ligament tear We hope you found our articles Exam showed a mild effusion and medial joint line tenderness. meniscal diameter. Meniscal root tears are defined as radial tears located within 1 cm from the meniscal attachment or a bony rootavulsion. Discoid lateral meniscus: importance, diagnosis, and treatment Meniscus Tear MRI Correlation | Radiology Key On MRI, they resemble radial tears, with a linear cleft of abnormal signal seen at the free edge. Brody J, Lin H, Hulstyn M, Tung G. Lateral Meniscus Root Tear and Meniscus Extrusion with Anterior Cruciate Ligament Tear. 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. Download Musculoskeletal MRI by Nancy Major, Mark Anderson Presentation - Middle-older aged individuals, non-traumatic, progressive onset of pain. Pseudotear Sign of the Anterior Horn of the Meniscus 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. Which meniscus is more likely to tear? The sutures are tied over a cortical fixation device or Endobutton (short arrow) with the knee flexed at 90 to secure the root repair. The purpose of our study was to determine if cysts of the ACL are the origin of cysts adjacent to the AHLM. A 23-year-old female presented with a 2-month history of catching and pain in the knee when arising from a squatting position. no financial relationships to ineligible companies to disclose. In the U.S., intraarticular injection of gadolinium-based contrast is off label. Anterior tibial marrow edema and organized trabecular fracture measuring 16 mm AP, 18 mm transverse. However, few studies have directly compared the medial and lateral root tears. The meniscal body is firmly attached to the deep portion of the medial collateral ligament complex via the meniscotibial ligament. These include looking for a Imaging characteristics of the was saddle shaped. 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. Learn more. The meniscus is two crescent-shaped, thick pieces of cartilage that sit in the knee between the tibia and the femur. has shown that 41% of patients with a surgically confirmed torn post-operative meniscus had signal intensity within the meniscus extending into the articular surface which was lower than the signal intensity of gadolinium contrast.14 Like the presence of a line of intermediate T2 signal extending into the articular surface on conventional MRI, diagnosis of a torn post-operative meniscus on MRI arthrography is challenging when the intra-meniscal signal intensity is not as bright as gadolinium contrast. Lee S, Jee W, Kim J. MRI plays a critical role in influencing the treatment decision and enables information that would obviate unnecessary surgery including diagnostic arthroscopy. menisci (Figure 8). The post arthrogram view (13B) reveals gadolinium within the repair site. Analytical, Diagnostic and Therapeutic Techniques and Equipment 13. (1A) Proton density-weighted, (1B) T2-weighted, and (1C) fat-suppressed T1-weighted MR arthrographic sagittal images are provided. Clinical Examination in the Diagnosis of Anterior Cruciate : JAAOS Zonal variation is also seen in the density of meniscus cells and their phenotypes with a chondrocytic inner zone and fibroblastic outer zone. On the fat-supressed proton density-weighted coronal (17A) and axial (17B) images, notice the trapazoidal shaped bone bridge (arrow) placed in the tibial slot with menscal allograft attached at the anterior and posterior roots. Wrisberg variant, the morphology of the meniscus may be normal, but the Kijowski et al. the example shown (Figures 1 and 2), the entire medial meniscus is the intercondylar notch, most commonly to the mid ACL, and less commonly MRI of the knee is commonly indicated for evaluation of unresolved or recurrent knee pain following meniscal surgery. and ACL tears can be mistaken for AIMM, but carefully tracing the ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. Br Med Bull. Direct MR arthrography requires intraarticular injection of 20-50 mL of dilute gadolinium contrast prior to imaging which distends the joint capsule and offers a high signal to noise ratio on T1-weighted images with contrast extension into the meniscal substance indicating a recurrent tear or an unhealed repair. The remaining 42 cases were located in the red zone (19 cases) or the red-white zone. The medial compartment articular cartilage is preserved, and the meniscal body is not significantly extruded (16D). Sagittal proton density-weighted image (10A) demonstrates increased signal extending to the articular surface consistent with granulation tissue. Stein T, Mehling AP, Welsch F, von EisenhartRothe R, Jger A. diagnostic dilemma, as the AIMM band will be seen to extend to the In this section, the major patterns of tears are described and depicted in MRIs and arthroscopy images. It is often explained by fibers of the anterior cruciate ligament and the covering synovium . What causes abnormal mobility in the medial meniscus? treatment for stable complete or incomplete types of discoid lateral Mild irregularities of the meniscal contour may be present, particularly in the first 6-9 months after surgery which tend to smooth out and remodel over time.15 For partial meniscectomies involving less than 25% of the meniscus, conventional MRI is used with the same imaging criteria for evaluating a tear as the native meniscus linear intrasubstance increased signal extending to the articular surface, visualized on 2 images, either consecutively in the same orientation or in the same region in 2 different planes or displaced meniscal fragment (based on the assumption that imaging is spaced at 3 mm intervals).
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