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MENISCAL TEAR
orthopedic consultant
cairo university

BUC

Meniscal Tears
Meniscal tears are common sports-related injuries in young athletes and can also
present as a degenerative condition in older patients
...

pathoantomy
 non-contact pivoting injury
 tibia translates anteriorly while knee is in slight flexion and
valgus
 blow to the lateral aspect of the knee
 common activities are soccer, basketball, skiing, and football
Associated conditions
 meniscal tears
o lateral meniscal tears in 54% of acute ACL tears, medial in chronic cases



PCL, LCL/PLC injuries
chronic ACL deficient knees associated with
o chondral injuries

Anatomy
o two bundles measuring combined 32mm length x 7-12mm width
o bundles named for tibial attachment




anteromedial bundle
 tightest in flexion
 primarily responsible for restraining anterior tibial translation
(anterior drawer test)
posterolateral bundle





tightest in extension
primarily responsible for rotational stability (pivot shift test)

femoral attachment









lateral intercondylar ridge demarcates the anterior edge of the
ACL
 bifurcate ridge separates the anteromedial and posterolateral
bundle attachment
tibial attachment
 anterior tibia, between intercondylar eminences

Composition
o 90% Type I collagen
o 10% Type III collagen
Blood supply
o middle geniculate artery
Innervation

o



posterior articular nerve (branch of tibial nerve)
Biomechanics and Function
o

provides 85% of the stability to prevent anterior translation of the tibia relative
to the femur
o acts as a secondary restraint to tibial rotation and varus/valgus rotation

PRESENTATION

History
o felt a "pop"
o pain deep in the knee
o immediate swelling (70%) / hemarthrosis




Symptoms
o generalized knee pain
o feelings of instability preventing return to sport
o difficulty weightbearing
Physical exam
o inspection
 effusion
 quadricep avoidance gait (does not actively extend knee)
 coronal or sagittal plane deformity
 varus deformity increases risk for ACL re-rupture
o

motion







lack of full extension secondary to meniscal injury or arthrofibrosis
evaluate for meniscal or concomitant ligamentous injuries (McMurray,
Dial test, varus/valgus stress)

Neurovascular
o evaluate peroneal function following high energy mechanisms and suspicion for
multi-ligamentous injury pattern
Provocative tests
o Lachman's test
 most sensitive exam test
 PCL tear may give "false" Lachman due to posterior subluxation
o Pivot shift
o Anterior drawer test

IMAGING
 Radiographs
o recommended views
 AP, lateral, /skyline view
o findings
 often normal
Segond fracture (avulsion fracture of the proximal lateral tibia)



MRI
indications
to confirm clinical diagnosis of ACL rupture and evaluate for concomitant
pathology

TREATMENT
 Treatment individualized to patient based on activity level, age, demands, and
concomitant pathology
Nonoperative
o physical therapy, lifestyle modifications
 indications
 low demand patients with decreased laxity
Operative
 ACL reconstruction
indications
 must have full motion of knee restored following injury (unless meniscal
tear causing mechanical block)
 lack of pre-operative motion risk factor for post-operative
arthrofibrosis






younger, more active patients
prior ACL reconstruction failure

ACL repair
indications
 previously abandoned but increased interest recently in pediatric
populations and avulsion rupture patterns
outcomes
 high failure rates
revision reconstruction
indications
 failure of prior ACL reconstruction with instability during
desired activities

Concurrent pathology
o MCL injury
 indications
 if low grade MCL injury amenable to non-operative treatment,
allow MCL to heal prior to ACL reconstruction
 if high grade MCL injury necessitating repair/reconstruction,
may be done concurrently with ACL

o meniscal tears
indications
 perform meniscal repair or meniscectomy at time of ACL reconstruction
outcomes
 increased meniscal healing rate when repaired at the same time as ACL
o chondral injuries
indications
 partial- or full-thickness chondral injury may be treated at time of ACL
reconstruction in staged fashion if injury necessitates
outcomes
 presence of chondral defects consistently lowers long-term patientreported outcomes following ACL reconstruction
o posterior cruciate ligament and posterolateral corner injuries
indications
 may reconstruct concurrently with ACL reconstruction or as staged
procedure
outcomes
 failure to recognize and address PCL/PLC injuries will lead to varus
instability and ACL graft overload
o high tibial osteotomy or distal femoral osteotomy
indications
 limb malalignment in both the coronal and sagittal plane must be
addressed before or at the same time as ligament reconstruction

outcomes
 high ACL failure rates in unaddressed limb malalignment
PEDIATRIC CONSIDERATIONS
 Physis
o < 14 yrs with open physis
o the onset of menarche is the best determinant of skeletal maturity in females


Treatment
o Nonoperative
 indications
 compliant, low demand patient with no additional intra-articular
pathologies
 partial ACL tear (60% of adolescents have partial tears) with
near normal Lachman and pivot shift
o Surgery
 indications
 complete ACL tear

Techniques
 intra-articular
o physis-sparing (all intra-epiphyseal)
o trans-physeal
o

partial trans-physeal

REHABILITATION
 Early post-operative
o immediate
 aggressive cryotherapy (ice)
 immediate weight bearing shown to reduce patellofemoral pain
 emphasize early full passive extension
o early rehab
 focus rehab on exercises that do not place excess stress on graft






emphasize closed chain exercises

avoid
open chain quadriceps strengthening

Return to play
o no widely accepted criteria supporting clearance or timing to return to sport
 previously held consensus is no sooner than 9 months following surgery
 clearance for return to play should be made between surgeon and patient
 psychological factors play large role in timing of return and should not
be overlooked

COMPLICATION
Intra-operative complications






graft-tunnel mismatch
posterior wall blowout
Graft failure due to tunnel malposition
Graft failure due to other causes eg: inadequate graft fixation or hardware failure,
missed diagnosis of concomitant ligamentous injuries or bony malalignment
Infection and septic arthritis
Loss of motion & arthrofibrosis




Late osteoarthritis
RSD (complex regional pain syndrome)






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