1. Generally, Choi S, Bae S, Ji S, Chang M. The MRI Findings of Meniscal Root Tear of the Medial Meniscus: Emphasis on Coronal, Sagittal and Axial Images. The Wrisberg variant may present with a In this section, the major patterns of tears are described and depicted in MRIs and arthroscopy images. measurements of the posterior horn of the medial meniscus may vary, but Arthrofibrosis and synovitis are also relatively common. 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. Davidson D, Letts M, Glasgow R. Discoid meniscus in children: Treatment and outcome. posterior horn of the medial meniscus include a triangular hypointense The anterior meniscofemoral ligament (Humphrey ligament) attaches proximally on the medial femoral condyle, inferior to the PCL insertion. These features constitute O'Donoghue unhappy triad. Following a meniscal repair procedure, the meniscus can be categorized as healed if there is no fluid signal in the repair, partially healed if fluid signal extends into less than 50% of the repair site, or not healed if fluid signal extends into greater than 50% of the repair site. What are the findings? Most horizontal tears extend to the inferior articular surface. Again, this emphasizes the importance of accurate history, prior imaging and operative reports. On the sagittal fat-suppressed T2-weighted image (7B), fluid extends into the tear. Thirty-one of these patients underwent subsequent arthroscopic evaluation to allow clinical correlation. The meniscal repair is intact. There When evaluating a portion of the meniscus that is in a different location than the repair, criteria for evaluating a virgin meniscus may be used for that area. Neuschwander DC, Drez D Jr, Finney TP. A meta-analysis of 44 trials. Sometimes T2 signal in a healed tear may look similar to fluid. Of the 45 patients who were interviewed and evaluated clinically without surgery at a minimum of 1 year, 32 reported continued pain but no mechanical symptoms suggestive of a meniscal tear. The most widely used diagnostic modalities to assess the ligament injuries are arthroscopy and Magnetic Resonance Imaging (MRI). According to these authors, increased signal to the surface on only one slice should be interpreted as a possible tear. Cases of only one abnormal slice correlated to tears at arthroscopy 55 % of the time for the medial meniscus and 30 % for the lateral [, Accuracy of diagnosing meniscus tear with these criteria has been good. On examination, there was marked medial joint line tenderness and a large effusion. The meniscus can separate from the joint capsule or tear through the allograft. structure on sagittal images on T1, proton density, and fat-saturated Indications for a partial meniscectomy include meniscal tears not amenable to repair which includes non-peripheral tears with a horizontal, oblique or complex tear pattern and nontraumatic tears in older patients. There is no universally accepted system for classifying meniscal tear patterns. Papalia R, Vasta S, Franceschi F, D'Adamio S, Maffulli N, Denaro V. Meniscal Root Tears: From Basic Science to Ultimate Surgery. 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. 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. Radial Tear of the Medial Meniscal Root: Reliability and Accuracy of MRI for Diagnosis. The trusted source for healthcare information and CONTINUING EDUCATION. Discoid lateral meniscus: Prevalence of peripheral rim instability. Intensity of signal contacting meniscal surface in recurrent tears on MR arthrography compared with that of contrast material. 2006; 187:W565568. of the meniscus. immediatly lateral to the anterior horn of lateral meniscus and posterior to the tubercle of anteriro horn of medial meniscus . Objectives: Low-field MRI at 0.55 Tesla (T) with deep learning image reconstruction has recently become commercially available. 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). Disadvantages include increased cost, increased patient time, potential for adverse reactions to contrast agent compared to conventional MRI and lack of joint distention. 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 [. Intact meniscal roots. mesenchymal mass that differentiates into the tibia, femur, and 2006; 88:660667, Boutin RD, Fritz RC, Marder RA. Arthroscopy revealed a horizontal tear of PHMM, and a partial medial meniscectomy was performed. show cupping of the medial tibial plateau, proximal medial tibial physis 9 The lateral meniscus is more loosely attached than the medial and can translate approximately 11mm with normal knee motion. The lateral meniscus is one of two fibrocartilaginous menisci of the knee. 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 . Relevant clinical history, prior imaging and use of operative reports will significantly improve accuracy of post-operative interpretations. This case features the following signs of meniscal tear: absent bow tie appearance of the lateral meniscus ghost meniscus: empty location of the anterior horn of the lateral meniscus Monllau et al in 1998 proposed adding a fourth type, The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. treatment for stable complete or incomplete types of discoid lateral They are usually due to an acute injury [. seen on standard 4- to 5-mm slices.21 The Wrisberg ligament may also be thick and high in patients with a complete discoid lateral meniscus.22 Other criteria used to diagnose lateral discoid meniscus include the following: In the 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 problem in practice. Type Sagittal T2-weighted (18B) and fat-suppressed sagittal proton density-weighted sagittal (18C) images demonstrate fluid-like signal in the posterior horn suggestive of a recurrent tear. Tears morphology but lacks its posterior attachments; ie, the meniscotibial Analytical, Diagnostic and Therapeutic Techniques and Equipment 13. 2008; 32:212219, Magee T. Accuracy of 3-Tesla MR and MR arthrography in diagnosis of meniscal retear in the post-operative knee. Surgery is useful if they are unstable and flipping in and out of the joint causing pain. What is your diagnosis? ligament and meniscal fascicles. The anterior horn inserts on the tibia and continues laterally to the anterior horn of the lateral meniscus via the transverse intermeniscal ligament. Following meniscal allograft transplantation (Figure 17), complications occur in up to 21% of procedures, including allograft failure and progressive cartilage loss.19 Repeat operations occur in up to 35% of patients, 12% requiring conversion to total knee arthroplasty. ligaments and menisci causing severe knee dysplasia in TAR syndrome. Sagittal proton density-weighted image (8A) through the medial meniscus demonstrates signal extending to the tibial surface (arrow). A recurrent tear was proved at second look arthroscopy. Exam showed a mild effusion and medial joint line tenderness. (as previously described), meniscal cyst,26 discoid lateral meniscus in the same knee (Figure 9),25 and pathologic medial patella plica.27. Normal One important reason for such discrepancies is a failure to understand the transverse geniculate ligament of the knee (TGL). 2013;106(1):91-115. The reported prevalence is 0.06% to 0.3%.25 It is located in the lateral portion of the knee interior of the knee joint. Grade II hyperintense horizontal signal of posterior horn of medial meniscus is noted. The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. 4). Medial meniscus posterior horn peripheral longitudinal tear (arrow) seen on the sagittal proton density-weighted image (15A) and managed by repair. Normal shape and signal of the horns of the medial meniscus, with no evidence of tears or degenerations seen. Shepard et al conclude that with a 74% false-positive rate, anterior horn tears should be treated surgically only if clinical correlation exists. However, this conjecture and others pre- highest.13,27,34,42 Tear locations, such as the posterior sented in literature are mostly speculative. It is often explained by fibers of the anterior cruciate ligament and the covering synovium . In these cases, MR arthrography may provide additional diagnostic utility. Radiographs are usually not diagnostic, but they may show a At least one meniscofemoral ligament is present in 7093 % Of knees 2008;191(1):81-5. The same imaging criteria (as for the case of greater than 25% partial meniscectomy), the presence of fluid signal on T2-weighted or contrast extending into the meniscal substance is used to diagnose a recurrent tear. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Of these patients treated nonoperatively, 6 had a diagnosis of an isolated anterior horn tear on MRI. hypoplastic meniscus was not the cause of the patients pain, suggesting This mesenchymal Grades 1 and 2 are not considered serious. In cases like this, MR arthrography is quite helpful. On the proton density-weighted image (12A) persistent high signal extends to the tibial and femoral surfaces (arrow). asymptomatic, although there is a greater propensity for discoid menisci What causes abnormal mobility in the medial meniscus? The self-reported complication rate for partial meniscectomy is 2.8% and meniscus repair is 7.6%. Discoid lateral meniscus of the knee joint: Nature, mechanism, and operative treatment. Most patients are asymptomatic, but injury to the meniscus can 2014; 43:10571064, McCauley TR. snapping knee due to hypermobility. 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). 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. no specific MR criteria for classifying discoid medial menisci, and the meniscus are not uncommon; they include an anomalous insertion of the 800-688-2421. Proper preoperative sizing of the allograft is critical for surgical success and usually performed with radiographs. (PubMed: 17114506), BakerJC, FriedmanMV, RubinDA (2018) Imaging the postoperative knee meniscus: an evidence-based review. bilaterally absent menisci reported by Tolo et al,3 the Source: Shepard MF, et al. 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. We will review the common meniscal variants, which 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. Samoto N, Kozuma M, Tokuhisa T, Kobayashi K. Diagnosis of discoid lateral meniscus of the knee on MR imaging. Type 1 is most common, and type 10 from AIMM. Lateral meniscus bucket handle tears can produce the double anterior horn sign or double ACL sign. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. 2012;199(3):481-99. Sagittal proton density (PD) images through normal medial (, The medial meniscus is larger, more oblong, and normally has a larger posterior horn than anterior horn in cross section. ligaments are absent, most commonly the anterior cruciate ligament (ACL) Meniscal transplants can fail at the implantation site by avulsion, failure of bone plug incorporation or bone bridge fracture. 2012;20(10):2098-103. of the Wrisberg ligament in patients with a complete lateral discoid 1). In these cases, surfacing meniscal signal on low TE series may represent recurrent tear, granulation tissue or residual grade 2 degenerative signal that contacts the meniscal surface after debridement. collapse and widening of the medial joint space (Figure 7). 2059-2066, Kinsella S.D., and Carey J.L. In this case, we can determine that there is a new tear in a different location. Partial meniscectomy is by far the most common procedure. The Journal of bone and joint surgery American volume. Torn lateral meniscus with superomedial and posterior flipped anterior horn. 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. 6 months post-operative she had increased pain prompting follow-up MRI. partly divides a joint cavity, unlike articular discs, which completely Clin Orthop Relat Res 2013; 471: pp. Extrusion is commonly seen following root repair. rim circumferentially, anteriorly, and posteriorly,19 which Posterior meniscal root repairs: outcomes of an anatomic transtibial pull-out technique. For root tears in general, sagittal imaging may demonstrate a meniscal ghost sign. There are 3 main types, according to the Watanabe classification:18. If a meniscus tear shows up on a MRI, it is considered a Grade 3. Root tears are often large radial tears that extend through the entire AP width of the meniscus. Midterm results in active patients. diminutive (1 mm) with no increased signal to suggest root attachment These are like large radial tears and can destabilize a large portion of the meniscus. A meniscus is a crescent-shaped fibrocartilaginous structure that trauma; however, other symptoms include clicking, snapping, and locking Clinical imaging. Conventional MRI is useful for evaluation of posterior root morphology at the tibial tunnel fixation site, meniscal extrusion and articular cartilage. 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. Biologic augmentation with application of exogenous fibrin clot or growth factors may be combined with the repair to promote healing. A tear was found and the repair was revised at second look arthroscopy. Diagnosis - clinical presentation with exclusion of advanced knee osteoarthritis. 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. 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. Sagittal T2-weighted (8B) and fat-suppressed coronal T2-weighted (8C) images reveal fluid signal (arrows) extending into the meniscal substance indicating a recurrent tear which was confirmed at second look arthroscopy. Learn more. The clinical significance of anterior horn meniscal tears diagnosed on magnetic resonance images. However, the tear changes plane of orientation over its course. Tears in the red zone have the potential to heal and are more amenable to repair. the posterior horn is usually much larger than the anterior horn (the Weight-bearing knee X-rays showed a 50 % narrowing in the medial compartment. 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 ]. discoid meniscus, although discoid medial menisci can occur much less Both the healed peripheral tear and the new central tear were proved at second look arthroscopy. MRI: When you tear your meniscus, a magnetic resonance imaging (MRI) scan will show the injury as white lines on black. Development of the menisci of the human knee Type 2: An incomplete slab of meniscal tissue with 80% coverage of the lateral tibial plateau. Grade 3 is a true meniscus tear and an arthroscope is close to 100 percent accurate in diagnosing this tear. The patient subsequently underwent successful partial medial meniscectomy. This is a critical differentiation because the latter represents meniscal tears that can be The patient underwent an all-inside lateral meniscus repair. The meniscus root plays an essential role in maintaining the circumferential hoop tension and preventing meniscal displacement. of the distal femur and proximal tibia, and in the case report of appearance.12 It is now believed that the knee develops from a The ends of the anterior and posterior horns are firmly attached to the tibia at their roots. no financial relationships to ineligible companies to disclose. to tear. Discoid meniscus in children: Magnetic resonance imaging characteristics. 2006;239(3):805-10. The medial meniscus is asymmetrical with a larger posterior horn. The meniscus may also become hypertrophic. 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 Each meniscus has three main parts, the back (posterior horn), middle (body), and front (anterior horn). An athletic 52-year-old male, who was an avid runner all his adult life, presented with medial pain and a popping sensation in knee. Examination of the knee showed a mild effusion, 1+ Lachman, positive Pivot shift, and mild tenderness to both medial and lateral joint lines. It is believed that discoid anterior horn of the medial meniscus into the anterior cruciate ligament [emailprotected]. The MRI revealed a longitudinal tear in the posterior horn of the lateral meniscus. The discoid lateral-meniscus syndrome. These findings are also frequently associated with genu However, clinically significant tears that can mechanically impinge were unlikely to have been missed. proximal medial tibia was convex and the distal medial femoral condyle This emphasizes the importance of baseline MRI comparison for evaluation of the postoperative meniscus.3. 7 Therefore, it is important for the radiologist to be familiar with the appearance of a recurrent tear versus an untorn postoperative meniscus. may simulate a peripheral tear (Figure 6).23 The only Findings indicate an intact meniscus following partial meniscectomy with normal intrameniscal signal. The posterior root lies anterior to the posterior cruciate ligament. RESULTS. Congenital absence of the meniscus is extremely rare and has been documented in TAR syndrome and in isolated case reports.2,3 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 . Tear between 1-4 cm vertical tear red-red meniscal root <40 yo Maybe concominant ACL surgery . A tear of the ACL should also, in practice, not be a Meniscus tears, indicated by MRI, are classified in three grades. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Report CT arthrography is a recommended alternative for patients who are not MR eligible. MRI appearance of Wrisberg variant of discoid lateral meniscus. Methods Eighteen patients who had arthroscopically confirmed partial MMPRTs were included. By continuing to use our site, you consent to the use of cookies outlined in our Privacy Policy. for the ratio of the sum of the width of the anterior and posterior Note the symmetrical shape of the lateral meniscus (left) with similar size of the anterior and posterior horns. 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. Become a Gold Supporter and see no third-party ads. Repair devices including arrows, darts and sutures are used to approximate the torn edges of the meniscus. pretzels dipped in sour cream. intra-articular structures at 8 weeks gestation. Lee S, Jee W, Kim J. They divide the meniscus into superior and inferior halves (Fig. 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. 2020;49(1):42-49. The examiner can test the entire posterior horn up to the middle segment of the meniscus using the IR of the tibia followed by an extension. A These include looking for a After failing conservative management with NSAIDs, PT, and activity modification, he underwent an MRI. > 20% ratio of meniscus to tibia on the coronal image; Minimum diameter 14-15 mm on a midcoronal image; 75% Pain is typically medial and activity-related (e.g. Magnetic Resonance Imaging Arthroscopy Orthodontic Extrusion Anterior Cruciate Ligament Reconstruction Arthroscopes Suture Anchors Tissue Culture Techniques Tissue Engineering Injections, Intra-Articular Range of Motion, Articular Arthrography Hardness Tests Orthopedic Procedures To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. 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. Longitudinal lateral meniscus tear status post repair (arrow). Radiology. Description. The medial compartment articular cartilage is preserved, and the meniscal body is not significantly extruded (16D). This high rate of success, however, may not apply to anterior horn tears, which occur much less commonly than posterior horn and meniscal body tears. variant, and discoid medial meniscus. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. runs from the anterior horn of the medial meniscus to either the ACL or The anterior horn of the menisci, especially the lateral meniscus, is an area commonly confused on MRI. You have reached your article limit for the month. On imaging alone, the radiologist may not be able to distinguish a residual tear (failed repair) from a recurrent tear in the same location. An abnormal shape may indicate a meniscal tear or a partial meniscectomy. Objective Parameniscal cysts have a very high association with meniscal tears in all locations except the anterior horn lateral meniscus (AHLM). of the anterior horn of the medial meniscus, an inferior patella plica, 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. 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). 3: The Wrisberg variant, where the meniscus may have a normal 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. MR criteria for discoid lateral menisci are used for discoid medial
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