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Arthroscopic Repair of Bucket Handle Medial Meniscal Tear

Sachin Tapasvi

Volume 4 | Issue 1 | Jan – April 2019 | Page 38


Author: Sachin Tapasvi[1]

[1] Orthopaedic Speciality Clinic, Pune Mahatrahtra.

Address of Correspondence
Dr Sachin Tapasvi
Orthopaedic Speciality Clinic, Pune Mahatrahtra.
Email: stapasvi@gmail.com


Abstract

19-year-old female dancer presented with pain and locking with no instability. She walked with antalgic gait with rom of 10 degrees to 130 degrees. The anterior drawers were grade 1 with the firm endpoint and Mcmurray’s test was positive. A previous surgery in the form of transportal ACL reconstruction was done. MRI revealed a bucket handle tear of the medial meniscus. This video demonstrates the Outside In technique of meniscal repair of the bucket handle tear


How to Cite this article: Tapasvi S. Arthroscopic Repair of Bucket Handle Medial Meniscal Tear. Asian Journal of Arthroscopy Jan – April 2019;4(1):38


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Endoscopic Plantar Fasciotomy with Gastrocnemius Recession for Chronic Plantar Fasciitis

Meniscus Ramp Lesion

Bertrand Sonnery Cottet, Sanesh Tuteja, Nuno Camelo Barbosa, Mathieu Thaunat

Volume 1 | Issue 2 | Aug – Nov 2016 | Page 28-34.


Author: Bertrand Sonnery Cottet[1], Sanesh Tuteja[1], Nuno Camelo Barbosa[1], Mathieu Thaunat[1].

[1] Investigation performed at the Centre Orthopédique Santy, FIFA medical center of Excellence, Groupe Ramsay-Générale de Santé, Lyon, France

Address of Correspondence

Dr Bertrand Sonnery-Cottet
Centre Orthopédique Santy, 24 Avenue Paul Santy, Lyon, 69008, France
Email: sonnerycottet@aol.com.


Abstract

Ramp Lesions of the Medial Meniscus (MM) are associated with 9 to 17% of ACL Tears and are seldom recognized on preoperative magnetic resonance imaging (MRI) scans. They also often remain undiagnosed when viewing from the standard anterior compartment arthroscopic portals. Improved visualization is the key to achieving good meniscal repair results as it improves diagnosis of longitudinal tears in posterior horn MM, safeguards better debridement prior to repair and ensures good approximation of the torn ends under vision. A systematic posteromedial exploration allows discovery of and debridement of the hidden MM lesion and repair with a suture hook device is associated with low morbidity and must be undertaken whenever possible.
Keywords: Medial meniscus, Ramp lesion, Repair, Healing, Anterior cruciate ligament, Knee.


Introduction

Meniscal lesions of the posterior horn of medial meniscus (MM) are very often associated with an ACL rupture (16,32,49). Certain specific lesions of the Medial Meniscus (MM) such as meniscosynovial or meniscocapsular tears and meniscotibial ligament lesions are associated with 9 to 17% of ACL Tears (8,21) and are seldom recognized on preoperative magnetic resonance imaging (MRI) scans (8,38). They also often remain undiagnosed when viewing from the standard anterior compartment arthroscopic portals including a probing. They were named in the 1980s by Strobel et al (42) as ‘‘Ramp’’ lesions of the meniscus and have drawn a lot of attention over the past few years (3,8,21,38,42). The aim of this article will be to write a narrative review of this Ramp meniscal lesion.

History
Hamberg et al (15) first described “a peripheral vertical rupture in the posterior horn of the medial or lateral meniscus with an intact body” in 1983. They repaired these lesions through a postero-medial vertical arthrotomy; with the belief that the capillary blood supply from the capsule aids healing of the meniscus. They reported promising results (84% healing) in old and new lesions alike, thus providing some valuable insight into the philosophy of meniscal conservation. Morgan et al (25) in 1991 described the first arthroscopic vertical suture of the PHMM using Polydioxanone (PDS) sutures with an outside-to-inside technique. They reported a 16% failure rate occurring in patients with a concurrent ACL injury. They proposed that the rotation axis of the knee joint was altered in an ACL deficit knee thus placing excessive loads on the posterior horn of the medial meniscus. The kinematics of the posterior horn of the medial meniscus in the ACL deficient knee was therefore not conducive to meniscal healing after repair despite a peripheral blood supply. They also noted that, when combined with an ACL reconstruction, peripheral meniscal repair healing rates improved and approached those obtained in an ACL intact knee (25). Ahn et al (5) in 2004 described the first clinical series of an arthroscopic all-inside suture technique for tears in posterior horn of medial meniscus. Using a suture hook thorough 2-posteromedial portals, PHMM tears were repaired with concurrent reconstruction of the ACL. They concluded that the arthroscopic all-inside vertical suture using a hook resulted in a high healing rate even in large and complex vertical tears. Seil et al (38) in 2009 highlighted the indications for meniscal repairs based on the presence of associated ligamentous injuries and morphology of the lesion.
They advocated that Meniscal repairs be ‘‘ideally’’ carried out in:
1. Young patients (< 40 years)
2. No associated joint degeneration.
3. Vertical lesions in the peripheral third of the meniscus (3mm of the meniscosynovial junction) (4) and in conjunction with an ACL reconstruction.
4. Significantly displaced bucket-handle tear or an MMPH tear with vertical step off (5).

Epidemiology
The prevalence for a meniscal lesion with an ACl tear has been reported between 47% to 61% (13,14). In 2010, S. Bollen et al (8) reported menisco-capsular lesions in 9.3% of their prospective series of 183 ACL reconstructions whereas Liu et al (21) described a prevalence of 16.6% in a series of 868 consecutive ACL reconstructions. In our series (40) on ACL deficient knees, a meniscal tears was identified in 125 out of the 302 patients. Following a systematic algorithm for exploration of the knee joint (Figure. 1), we found that; 75 (60%) medial meniscal body lesions were diagnosed through a standard anterior portal exploration, 29 (23.2%) ramp lesions were diagnosed during exploration of the posteromedial compartment, and 21 (16.8%) were discovered by probing the tear through a posteromedial portal and after minimal debridement of a superficial soft tissue layer with a motorized shaver. All-in-all, 42% (21/50) of the lesions diagnosed via inspecting the posterior compartment appeared only after superficial soft tissue debridement and were classified as ‘‘hidden lesions.’’ An ACL injury with an age at presentation above 30 years, male sex and a delay between injury and surgery are considered risk factors for concomitant meniscal lesions (8).

Biomechanical Implication on ACL
The importance of the meniscus in stabilizing the knee joint in chronically ACL-deficient knees has been validated by multiple studies (9, 39). A Peripheral posterior horn tear is caused by the recurrent trauma sustained by the Medial Meniscus, which acts as a ‘‘bumper’’ in ACL-deficient knees (2). In addition, contraction of the semimembranosus at its insertion along the posteromedial capsule may stress the peripheral meniscus, resulting in meniscocapsular tearing (17). This could occur at the time of injury or during subsequent instability episodes in the subacute or chronic situation (43). A capsular injury might also occur during the so-called medial contrecoup injury (18) after subluxation of the lateral tibial plateau and during subsequent reduction of the tibia (41).  A longitudinal tear of the PHMM in ACL-deficient knees increases the anterior translation of the tibia and a repair of this lesion reduces Anteroposterior tibial translation significantly at most flexion angles (17) and most prominently at 30 degrees of flexion (12, 30).  Peltier et al (30) observed that the PHMM was stabilised by the meniscotibial ligament posteriorly, which in turn inserted onto the posterior aspect of the proximal tibia. The capsule of the knee joint inserts more distally on this posterior surface. The posterior capsule hence lacks insertion onto the posterior aspect of the PHMM. Detachment of the ligament therefore results in an abnormal mobility of the entire PHMM, producing rotational instability. The authors observed that the division of the menisco-tibial ligament resulted in a statistically significant increase in internal tibial rotation. Such lesions occur either in the mid-substance (repairable) or as a bony avulsion (irreparable). Stephen et al (41) reported that the anterior tibial translation and external rotation were both significantly increased compared with the ACL-deficient knee after posterior meniscocapsular sectioning and these parameters were not restored after ACL reconstruction alone but were restored with ACL reconstruction combined with posterior meniscocapsular repair.
Classification [46] (Figure. 2)
We have proposed a classification for ramp lesions which is as follows:
Type 1: Ramp lesions. Very peripherally located in the synovial sheath. Mobility at probing is very low. (B)
Type 2: Partial superior lesions. It is stable and can be diagnosed only by trans-notch approach. Mobility at probing is low. ©
Type 3: Partial inferior or hidden lesions. It is not visible with the trans-notch approach, but it may be suspected in case of mobility at probing, which is high. (D)
Type 4: Complete tear in the red-red zone. Mobility at probing is very high. (E)
Type 5: Double tear.

figure-1-and-2

Surgical Technique (46)
With the patient supine on the operating table, a tourniquet is placed high on the thigh, and the knee placed at 90º of flexion with a foot support to allow full range of knee motion.  Using standard arthroscopy portals, high lateral as viewing and medial portal for instrumentation, articular inspection is performed and we engage a probe in the posterior segment of the meniscus and force an anterior excursion of the meniscus. If the meniscus subluxates under the condyle, it is an indicator for instability and an indirect sign of a ramp lesion. Direct visualization of the posteromedial compartment is mandated to diagnose and repair these lesions. Even if the meniscus appears stable on probing, a systematic exploration of the posterior segment must be performed using the protocol in (Figure.1) Through a Guillquist maneuver, the arthroscope in the anterolateral portal is advanced in the triangle formed by the medial femoral condyle, the posterior cruciate ligament, and the tibial spines. With valgus force applied initially in flexion followed by knee extension, the arthroscope is pass through the space at the condyle border of the medial femoral condyle. Internal rotation applied to the tibia further enhances visualization; this causes subluxation of the posterior tibial plateau causing a posterior translation of the middle third segment. Almost two-thirds of peripheral lesions can be diagnosed with this maneuver. Tears of the posterior segment must be approached posteromedially. The posteromedial portal is placed superior to the hamstring tendons and posterior to the medial joint line, also trans illumination allows observation of the great saphenous vein, that is in close relation to the infra-patellar branch of the internal saphenous nerve, that must be avoided.  The needle is introduced from outside to inside, in the direction of the lesion. The portal is prepared with a number 11blade scalpel under arthroscopic control. The all-inside suture is accomplished with or without a working cannula, depending on the surgeons choice. Using a shaver the lesion is debrided and the intervening fibrous tissue is excised. Suturing is carried out using a 25º curved hook (Suture Lasso, Arthrex): a left curved hook is used for a right knee and vice versa. The curved hook is loaded with a no. 2 non-absorbable braided composite suture (Fiberwire, Arthrex) or a absorbable no.1 PDS introduced through the posteromedial portal. The curved hook must penetrate the peripheral wall of the MM, and then the inner wall of the MM. The free end of the suture in the posteromedial space is grasped and brought out through the posteromedial portal. A sliding knot (fishing knot type) is applied to the most posterior part of the meniscus with the help of a knot pusher and then cut. The sutures are repeated as required depending on the length of the tear (usually we place a knot every 5 mm of the tear). During suturing, care must be taken to not splinter the meniscus that can occur with multiple failed attempts to pass the curved hook. Additionally, entangling of the sutures must be avoided. In some patients, the tear may extend to the mid-portion of the meniscus requiring further repair through the standard anterior portal with meniscal suture anchor and/or an outside-in suture. The stability of the suture is then tested with the probe.

figure-3

Post-operative
Post operatively, active and passive range of motion is limited to 0-90º in the first six weeks. Full weight bearing is allowed by six weeks post-operatively. Jogging is permitted after 4 months, pivoting activity at 6 months, and unrestricted activities by 9 months.

Results
Ahn et al (4) in 140 patients showed complete healing in 118, incomplete healing in 17 and failure 5 repairs. The clinical success rate was 96.4% (135 of 140). Healing was associated with the type of tear and location. Incomplete healing and failures had complex tears or tears involving the red-white zone. Seventeen patients had incomplete healing at second-look arthroscopy but had no clinical sign of a meniscal tear. The mean Lysholm score and HSS scores improved post surgery (Table. 1) and 134 (95.7 %) patients had a normal (104 patients, 74.3%) or nearly normal (30 patients, 21.4%) the objective IKDC scores. In our prospective evaluation (46) of 132 patients undergoing a MM repair through a posteromedial portal in conjunction with ACL reconstruction, fifteen patients were found to be symptomatic according to Barret’s criteria on follow-up (6). The clinical failure rate was 9%, 4.9% in the subgroup “limited tear” and 15.7% in the subgroup “extended tear.” A limited tear was defined as one restricted to the posterior segment whereas those with a tear that extended to the mid-portion of the meniscus were classified as an extended tear. The extended tears required an additional repair through the standard anterior portal with meniscal suture anchor and/or an outside-in suture. The extended lesions had an increased risk of clinical failure. Out of the fifteen, 9 patients underwent revision surgery. Nine patients (6.8%) had failure of the meniscal repair; 3.7% (3/81) occurred in the subgroup of limited tears and 11.7% (6/51) in the subgroup extended tears. In the subgroup of extended tears, the cumulative survival rate did not decrease significantly and were not associated with a significant increased risk of revision of the MM. The average subjective IKDC improved at last follow-up and The Tegner activity scale at the last follow-up was slightly lower than before surgery (Table. 1).

table-1

Complications
The main complications may be related to the posteromedial portal placement. Damage to the infra-patellar branch of the saphenous nerve due to a posteromedial portal has been reported owing to the proximity of the nerve to the portal site causing hypoesthesia or paresthesia below the patella (27). Having said that, hypoesthesia resulting from harvesting the Semi-tendinous and Gracilis tendons in a concomitant ACL reconstruction may be responsible for 74% of the times (35). Transient hypoesthesia of the Sartorial branch of the saphenous nerve has also been reported probably due to an access portal situated too anteriorly (24). McGinnis et al (23) studied the neurovascular safety zone for the posteromedial access and recommended a portal through the posterior soft spot located formed by the medial head of the gastrocnemius, the tendon of the semimembranosus and the medial collateral ligament at the posterior aspect of the joint line for creation of the posteromedial portal. Hemarthrosis due to the long saphenous vein injury may occur in the postero medial approach (27). Among other complications, an iatrogenic medial meniscus tear may occur from repeated attempts at suturing the meniscus with a curved hook, rending suture impossible. Also, to our knowledge no popliteal artery, common peroneal and tibial nerve lesions has been reported, however they are at risk of damage during creation of the posterior portals. These complications may be avoided by placing the posterior portals with knee in 90 degrees of flexion. This moves the neurovascular structures posteriorly, away from the posteromedial portal site. Also, the Guillquist maneuver that provides trans-illumination may help visualize the course of the superficial veins and the accompanying nerves thus preventing inadvertent damage (35). Our series (46) also has a low complications rate with only two cases of hemarthrosis post operatively. Also, no patient developed a neuroma around the location of the posteromedial approach, although it was difficult to be accurately determining the incidence of saphenous nerve lesions due to the posteromedial approach as the hamstring tendon harvesting can cause hypoesthesia in the different territories of the saphenous nerve.

table-2

Discussion
The forces acting on the MM increase by as much as 200% after an ACL injury. Furthermore, forces acting on the ACL replacement graft increase by 33% to 50% after a medial meniscectomy (12,28). Deficiency of the medial meniscus has therefore been proposed as a secondary cause of ACL failure. It has thus been recommended that an ACL-deficient knee be reconstructed to protect the menisci (39,50). Conversely, identification and repair of a ramp lesion during an ACL reconstruction is imperative to reduce the risk of secondary graft failures, as these lesions may increase the anterior tibial translation (2,12, 30) and subsequently the strain on the graft.  The success rates for meniscal repairs have been reported to be from 70% to 90% in vascular regions (11,13,16,36). Anh et al (12) reported a clinical successful healing rate of 96.4% in PHMM repairs with concomitant ACL reconstruction. Tenuta and Arciero (45) reported higher healing rates in concomitant ACL reconstruction than for isolated repairs (90% vs 57%). Meniscal repair in conjunction with ACL reconstruction has been reported to create a favorable environment for meniscal healing because of fibrin clot formation associated with intra-articular bleeding generated during ACL reconstruction (44).  Multiple techniques for suturing the meniscus are available. The indications, advantages and disadvantages of each are mentioned in (Table.2). The all-inside suture repair technique using a hook is especially useful in a ramp lesion, as the use of newer devices makes the repair procedure blind and placing a suture in the vertical configuration is technically challenging. In addition Choi et al reported that the use of meniscal devices failed to provide sufficient strength of fixation. They recommended that during suturing, the posteromedial capsule should be elevated and approximated to the PHMM to ensure precise approximation of tear site (10). In spite of the development of the newer all-inside suture devices, the failure rate of the repair of PHMM tears continues to remains high, (19) which may be attributed to various factors that include inadequate visualization and debridement of the lesions of the PHMM; failure to confirm the reduction of the lesion with the all inside technique (48) and tissue failure due suture pullout through the meniscal tissue (45).
The mechanical strength of the vertical suture is greater than that of the horizontal suture (45). Having said that, most meniscal fixators cannot facilitate meniscal repair in a vertical mattress fashion (7,34) especially in the posteromedial corner of the medial meniscus, small or tight knee joints. Sutures spaced at every 3 to 5 mm have been recommended however; the optimal number is unknown (44). Pujol et al (33) using meniscal devices reported an overall healing rate of 73.1%. van Trommel et al (47) reported similar results (76%) with the outside-in technique. (Table. 3) Both studies observed a strong trend toward a relatively lower healing rate of the posterior horn (Zone A), as compared with the body (Zone B). (Table. 4) They also observed that, partial healing in all tears extending from the posterior to the middle third of the medial meniscus. We observed similar results in our study with a higher failure rate in the extended tear subgroup (6/51) (46). Pujol et al (33) attributed this to the difficulty in performing an adequate abrasion of the posterior segment using standard anterior arthroscopic portals whereas van Trommel et al (47) attributed that same to the relatively anterior placement of the needles with the outside-in technique, making a perpendicular repair extremely difficult. This resulted in a decrease in the coaptation force of the sutures. In addition, they observed that an oblique suture placement in the posterior zone with the outside-in technique made the sutures enter more anterior than they exit. Ahn et al (5) postulated that a torn posterior menisco-capsular structure moved inferiorly against the remaining meniscus, displacing the tear during knee flexion. They suggested that this motion of the torn medial meniscus can partially explain the slow healing observed in MMPH peripheral rim tears despite a rich vascular supply to the red-red zone. Pujol et al (31) in 2011 reported a secondary meniscectomy rate of 12.5%. The authors observed that the volume of meniscus removed decreased in 35% of cases, with respect to the initial tear and noted that a secondary meniscectomy following repair can partially save the meniscus and the failure called a ‘‘partial’’ failure. They recommended that suturing a tear therefore preserved the meniscal volume in a subsequent meniscectomy performed for a failure of repair or repeat tears. Tachibana et al (44) reported newly formed meniscal tears occurring in an area different from the initial repair site, on the surface of 34.5% of the healed and incompletely healed menisci. These new injuries were 1 to 3 mm in length partial- or full-thickness lesions and located central to the peripheral repair. In our series (46), the high rate of recurrent tear was as a result of newly formed tears that were confirmed on the surface of 5 menisci. It is conceivable that these injuries were attributable to a residual cleft left by the path of the Suture Lasso and maintained by the use of a strong no. 2 non-absorbable suture.

table-3

These clefts on the avascular meniscal substance may remain in situ without healing and would favor the recurrence of a more centrally located lesion in the white-white zone. Using a small suture hook device may therefore be desirable as it may reduce the size of the clefts created during suturing. In addition, the ‘cheese wiring effect’ due to the higher co-efficient of friction of a non-absorbable suture may contribute to a failure. We therefore decided to change our suture from a strong non-absorbable suture to a number 0 or 1 PDS suture, which are recommended to reduce the risk of these newly formed injury (37).
Nepple et al (26) observed that the time between injury and repair was the most important factor influencing healing. The zone of tear in reference to blood supply is another major factor affecting the results of a meniscal repair and ramp lesions in the red-red zone are expected to heal more readily than are those in the red-white zone (20). The criteria for healing based on follow-up arthro-CT corresponding to thickness of healing was suggested by Henning et al (36) can supplement clinical evaluation to improve diagnostic accuracy (Figure 3). The clinical failure rate in a systematic review ranged from 0% to 43.5%, with a mean failure rate of 15% (22). Failures after two years represented nearly 30% (26). Although numerous studies have reported short-term outcomes of various techniques of meniscal repair, relatively few have reported medium to long-term outcomes. The rate of meniscal repair failure appears to increase from short-term follow-up to medium to long-term follow-up regardless of the technique (26). There are limited numbers of studies assessing the outcomes of meniscal repair using the PM approach (4,5,10,46). Further prospective analysis with long – term follow-up is required to validate the promising early results of meniscal repairs performed with this approach.  Finally, improved visualization is the key to achieving good meniscal repair results as it improves diagnosis of longitudinal tears in posterior horn MM (30), safeguards better debridement prior to repair and ensures good approximation of the torn ends under vision (1). It is thus important to perform a systematic exploration of the knee during an ACL reconstruction (Figure 1). A transnotch visualization combined with palpation of the meniscus with a needle or probe through the postero-medial portal aids in diagnosis of ramp lesions, which may otherwise be missed. Hidden lesions furthermore may be either very peripheral, covered by a layer of synovial or scar tissue or may not be reachable with a probe. It is therefore essential to identify these lesions during an ACL reconstruction and repair them whenever they are found to be unstable (40).

table-4

Conclusions
A systematic posteromedial exploration allows discovery of and debridement of the hidden MM lesion and repair with a suture hook device is associated with low morbidity. Failure Rates following a ramp lesion repair are low and occurs during the first 20 months. Even if a failure occurs the subsequent meniscectomy is limited and the volume of meniscal tissue debrided is reduced. An arthroscopic repair of meniscal ramp lesions should therefore be undertaken whenever possible.


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How to Cite this article:. Sonnery-Cottet B, Tuteja S, Barbosa NC, Thaunat M. Meniscus Ramp Lesion. Asian Journal of Arthroscopy  Aug – Nov 2016;1(2):28-34.

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Menisci: Structure and Function

Ankit Chawla, Amite Pankaj Aggarwal

Volume 1 | Issue 2 | Aug – Nov 2016 | Page 3-7


Author: Ankit Chawla[1], Amite Pankaj Aggarwal[1]

[1] Unit of Joint Replacement, Arthroscopy and Orthopaedics, Fortis Hospital, Shalimar Bagh, New Delhi, India.

Address of Correspondence

Dr. Amite Pankaj Aggarwal
Fortis Hospital Shalimar Bagh
New Delhi, India.
Email: amitepankaj@gmail.com.


Abstract

Meniscal injuries are recognized as a cause of significant musculoskeletal morbidity. The menisci are vital for the normal function and long-term health of the knee joint. And loss of a meniscus increases the risk of subsequent development of degenerative changes in the knee. A review of anatomy and ultrastructure of the meniscus, and its relationship to normal function in terms of load transmission, shock absorption, joint stability, lubrication and nutrition is a necessary prerequisite to understanding pathologies associated with the knee.
Keywords: Meniscus, Medial meniscus, lateral meniscus, Anatomy, Function.


Introduction

The word meniscus comes from the Greek word me-niskos, meaning “crescent,” diminutive of me-ne-, meaning “moon.” The menisci are semilunar discs of fibrocartilaginous tissue which are vital for the normal biomechanics and long-term health of the knee joint [1]. The characteristic shape of the lateral and medial menisci is attained between the 8th and 10th week of gestation. They arise from a condensation of the intermediate layer of mesenchymal tissue to form attachments to the surrounding joint capsule[2,3].

Gross Anatomy
These crescent-shaped wedges of fibrocartilage are located on the medial and lateral aspects of the knee joint (Fig. 1A,1B). The peripheral, vascular border of each meniscus is thick, convex, and attached to the joint capsule. The innermost border tapers to a thin free edge. The superior surfaces of menisci are concave, enabling effective articulation with their respective convex femoral condyles. The inferior surfaces are flat to accommodate the tibial plateau [4,5].

Medial Meniscus
The medial meniscus is a C-shaped structure larger in radius than the lateral meniscus, with the posterior horn being wider than the anterior. The anterior horn is attached firmly to the tibia anterior to the intercondylar eminence and to the anterior cruciate ligament. The posterior horn is anchored immediately in front of the attachments of the posterior cruciate ligament posterior to the intercondylar eminence. Its entire peripheral border is firmly attached to the medial capsule and through the coronary ligament to the upper border of the tibia. At its midpoint, the medial meniscus is more firmly attached to the femur through a condensation in the joint capsule known as the deep medial collateral ligament [5]. The transverse, or “intermeniscal,” ligament is a fibrous band of tissue that connects the anterior horn of the medial meniscus to the anterior horn of the lateral meniscus [5,6].

Lateral Meniscus
The lateral meniscus is more circular in form, covering up to two thirds of the articular surface of the underlying tibial plateau [7]. The anterior horn is attached to the tibia medially in front of the intercondylar eminence, whereas the posterior horn inserts into the posterior aspect of the intercondylar eminence and in front of the posterior attachment of the medial meniscus. The lateral meniscus is loosely attached to the capsular ligament; however, these fibers do not attach to the lateral collateral ligament. The posterior horn of the lateral meniscus attaches to the inner aspect of the medial femoral condyle via the anterior and posterior meniscofemoral ligaments of Humphrey and Wrisberg, respectively, which originate near the origin of the PCL (Fig. 1A) [8]. Their estimated prevalence is 74 % for Humphrey ligament, 69 % for Wrisberg ligament, and both ligaments found together in around 50 % of knees [9]. The lateral meniscus is smaller in diameter, thicker in periphery, wider in body, and more mobile than the medial meniscus.

figure-1-and-2

Extracellular matrix and cellularity
Considering composition by wet weight, the meniscus has high water content (72 %). The remaining 28 % consists of an organic component, mostly ECM and cells.10 Collagens comprise the majority (75 %) of the organic matter, followed by GAGs (17 %), DNA (2 %), adhesion glycoproteins (<1 %), and elastin (<1 %) [10,11]. These proportions vary according to age, injury, or pathological conditions [12]. Collagen is the main fibrillar component of the meniscus. Different collagen types exist in various quantities in each region of meniscus. In the red–red zone, type I collagen is predominant (80 % composition in dry weight). In the white–white zone, 60 % is type II collagen and 40 % is type I collagen [13]. The major orientation of collagen fibers in the meniscus is circumferential; radial fibers and perforating fibers also are present.(Fig. 3) [13]. Proteoglycans are heavily glycosylated molecules that constitute a major component of the meniscus ECM [14]. These molecules are comprised of a core protein which is decorated with glycosaminoglycans (GAGs). The main types of GAGs found in normal human meniscal tissue are chondroitin 6 sulfate (60%), dermatan sulfate(20-30%), chondroitin 4 sulfate (10-20%), and keratin sulfate(15%) [15]. Their main function is to enable the meniscus to absorb water, whose confinement supports the tissue under compression [10]. Adhesion glycoproteins are also important components of the meniscus matrix, as they serve as a link between ECM components and cells [16]. The main adhesion glycoproteins present in the human meniscus are fibronectin, thrombospondin, and collagen VI [16,17]. Outer zone cells have an oval, fusiform shape and are similar in appearance and behaviour to fibroblasts, described as fibroblast-like cells [18]. The matrix surrounding the cells is mainly comprised of type I collagen, with small percentages of glycoproteins and collagen types III and V present. In contrast, cells in the inner portion have rounded appearance and are embedded in an ECM comprising largely type II collagen intermingled with a smaller but significant amount of type I collagen and higher concentration of GAGs [18]. This relative abundance of collagen type II and aggrecan in the inner region is more reminiscent of hyaline articular cartilage. Therefore, cells in this region are classified as fibrochondrocytes or chondrocyte like cells. In summary, cell phenotype and ECM composition render the outer portion of the meniscus akin to fibrocartilage, while the inner portion possesses similar, but not identical, traits to articular cartilage [19,20].

figure-3

Vascularity and Innervation
The vascular supply to the medial and lateral menisci originates predominantly from the lateral and medial geniculate vessels (both inferior and superior). Branches from these vessels give rise to a perimeniscal capillary plexus within the synovial and capsular tissue. (Fig. 2) Radial branches from the plexus enter the meniscus at intervals, with a richer supply to the anterior and posterior horns. Vessels supplying the body are limited to the meniscus periphery with a variable penetration of 10–30 % for medial meniscus and 10–25 % for lateral one. This has important implication for meniscal healing [21]. The remaining portion of each meniscus (65% to 75%) receives nourishment from synovial fluid via diffusion or mechanical pumping (ie, joint motion) [22, 23]. The knee joint is innervated by the posterior articular branch of the posterior tibial nerve and the terminal branches of the obturator and femoral nerves. The lateral portion of the capsule is innervated by the recurrent peroneal branch of the common peroneal nerve. These nerve fibers penetrate the capsule and follow the vascular supply to the peripheral portion of the menisci and the anterior and posterior horns, where most of the nerve fibers are concentrated. The inner menisci core has no nerve fibers [21].

Biomechanical Function
­­­The biomechanical function of the meniscus is a reflection of the gross and ultrastructural anatomy and of its relationship to the surrounding intra-articular and extra-articular structures. The meniscus withstands many different forces such as shear, tension, and compression. It also plays a crucial role in load-bearing, load transmission, shock absorption, stability, propioception as well as lubrication and nutrition of articular cartilage [24-27]. They also serve to decrease contact stresses and increase contact area and congruity of the knee [28,29].

Meniscal Biomechanics
The biomechanical properties of the knee meniscus are appropriately tuned to withstand the forces exerted on the tissue. Many studies have helped to quantify the properties of the tissue both in humans and in animal models. According to these studies, the meniscus resists axial compression with an aggregate modulus of 100-150 kPa [30]. The tensile modulus of the tissue varies between the circumferential and radial directions; it is approximately 100-300 MPa circumferentially and 10 fold lower than this radially [31]. Finally, the shear modulus of the meniscus is approximately 120 kPa [31]. The contact forces on the meniscus within the human knee joint have been mapped. It has been calculated that the intact menisci occupy approximately 60% of the contact area between the articular cartilage of the femoral condyles and the tibial plateau, while they transmit >50% of the total axial load applied in the joint [32,33]. However, these percentages are highly dependent on degree of knee flexion and tissue health. For every 30o of knee flexion, the contact surface between the two knee bones decreases by 4% [34]. When the knee is in 90o of flexion the applied axial load in the joint is 85% greater than when it is in 0o of flexion [33]. In full knee flexion, the lateral meniscus transmits 100% of the load in the lateral knee compartment, whereas the medial meniscus takes on approximately 50% of the medial load [29]. Studies confirm that there is a significant difference in segmental motion during flexion between the medial and lateral menisci. The anterior and posterior horn lateral meniscus ratio is smaller and indicates that the meniscus moves more as a single unit [35]. Alternatively, the medial meniscus (as a whole) moves less than the lateral meniscus, displaying a greater anterior to posterior horn differential excursion. Thompson et al found that the area of least meniscal motion is the posterior medial corner, where the meniscus is constrained by its attachment to the tibial plateau by the meniscotibial portion of the posterior oblique ligament, which has been reported to be more prone to injury [35,36]. A reduction in the motion of the posterior horn of the medial meniscus is a potential mechanism for meniscal tears, with a resultant “trapping” of the fibrocartilage between the femoral condyle and the tibial plateau during full flexion. The greater differential between anterior and posterior horn excursion may place the medial meniscus at a greater risk of injury [35]. The differential of anterior horn to posterior horn motion allows the menisci to assume a decreasing radius with flexion, which correlates to the decreased radius of curvature of the posterior femoral condyles [35]. This change of radius allows the meniscus to maintain contact with the articulating surface of both the femur and the tibia throughout flexion.

Load Transmission
Fairbank described the increased incidence and predictable degenerative changes of the articular surfaces in completely meniscectomized knees [37]. Weightbearing produces axial forces across the knee, which compress the menisci, resulting in “hoop” (circumferential) stresses [38]. Hoop stresses are generated as axial forces and converted to tensile stresses along the circumferential collagen fibers of the meniscus. Firm attachments by the anterior and posterior insertional ligaments prevent the meniscus from extruding peripherally during load bearing [39]. Medial meniscectomy decreases contact area by 50% to 70% and increases contact stress by 100%. Lateral meniscectomy decreases contact area by 40% to 50% but dramatically increases contact stress by 200% to 300% because of the relative convex surface of the lateral tibial plateau [40,41]. This significantly increases the load per unit area and may contribute to accelerated articular cartilage damage and degeneration [42].

Shock absorption
The menisci play a vital role in attenuating the intermittent shock waves generated by impulse loading of the knee with normal gait [43,44]. Voloshin and Wosk showed that the normal knee has a shock-absorbing capacity about 20% higher than knees that have undergone meniscectomy [38]. As the inability of a joint system to absorb shock has been implicated in the development of osteoarthritis, the meniscus would appear to play an important role in maintaining the health of the knee joint [45]

Joint stability
The geometric structure of the menisci provides an important role in maintaining joint congruity and stability. The superior surface of each meniscus is concave, enabling effective articulation between the convex femoral condyles and flat tibial plateau. When the meniscus is intact, axial loading of the knee has a multidirectional stabilizing function, limiting excess motion in all directions [46]. The studies for effects of meniscectomy on joint laxity for anteroposterior and varus-valgus motions and rotation have indicated indicated that the effect on joint laxity depends on whether the ligaments of the knee are intact and whether the joint is bearing weight. In the presence of intact ligamentous structures, excision of the menisci produces small increases in joint laxity. In an anterior cruciate ligament–deficient knee, medial meniscectomy has been shown to increase tibial translation by 58% at 90o, whereas primary anterior and posterior translations were not affected by lateral meniscectomy [47]. Shoemaker and Markolf demonstrated that the posterior horn of the medial meniscus is the most important structure resisting an anterior tibial force in the ACL-deficient knee. [48] Recently, Musahl et al reported that the lateral meniscus plays a role in anterior tibial translation during the pivot-shift maneuver [49].

Joint Nutrition and Lubrication
The menisci may also play a role in the nutrition and lubrication of the knee joint. The mechanics of this lubrication remains unknown; the menisci may compress synovial fluid into the articular cartilage, which reduces frictional forces during weightbearing [50]. There is a system of microcanals within the meniscus located close to the blood vessels, which communicates with the synovial cavity; these may provide fluid transport for nutrition and joint lubrication [51,52].

Conclusions
Mechanoreceptors have been identified in the anterior and posterior horns of the menisci, middle and outer third of the meniscus. The identification of these neural elements indicates that the menisci are capable of detecting proprioceptive information (joint motion and position) in the knee joint, thus playing an important afferent role in the sensory feedback mechanism of the knee [53,54].


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How to Cite this article:. Chawla A, Aggarwal AP. Menisci: Structure and Function. Asian Journal of Arthroscopy  Aug – Nov 2016;1(2):3-7 .

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