Table Of ContentRobert F. LaPrade
Elizabeth A. Arendt
Alan Getgood
Scott C. Faucett
Editors
The Menisci
A Comprehensive Review of their
Anatomy, Biomechanical Function and
Surgical Treatment
The Menisci
Robert F. LaPrade • Elizabeth A. Arendt
Alan Getgood • Scott C. Faucett
Editors
The Menisci
A Comprehensive Review of their
Anatomy, Biomechanical Function
and Surgical Treatment
Editors
Robert F. LaPrade Alan Getgood
Steadman Philippon Research Institute University of Western Ontario
Vail Fowler Kennedy Sport Medicine Clinic
Colorado London
USA Ontario
Canada
Elizabeth A. Arendt
University of Minnesota Scott C. Faucett
Department of Orthopaedic Surgery The Orthopaedic Center, P.A.
Minneapolis Washington
Minnesota District of Columbia
USA USA
ISBN 978-3-662-53791-6 ISBN 978-3-662-53792-3 (eBook)
DOI 10.1007/978-3-662-53792-3
Library of Congress Control Number: 2017932554
© ISAKOS 2017
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Preface
We extend our appreciation to ISAKOS for providing sponsorship and to
Springer for the editorial leadership for this book on the menisci. This text-
book was a collaborative project between the Sports Medicine and Knee
Committee members and their research staff. The authors of this textbook
certainly have a passion in trying to promote preservation of the menisci. As
surgeons, it appears that the one factor that we can effect to prevent osteoar-
thritis more than any other is to perform a meniscus repair when it is possible.
Thus, this textbook aims to review the different types of meniscus tears, those
types of meniscus tears that are repairable, and the benefits that can be seen
from repairing them.
We anticipate that this work will prove beneficial to surgeons worldwide.
In the future, we believe that further biologic augmentation of meniscus
repairs should stretch the indications for meniscal repairs even further com-
pared to the types of tears that we repair commonly. We certainly hope that
this textbook proves to be beneficial both for the arthroscopist in training and
for those at advanced levels of sports medicine practice.
Vail, CO, USA Robert F. LaPrade, MD, PhD
Minneapolis, MN, USA Elizabeth A. Arendt, MD
London, ON, Canada Alan Getgood, MD
Washington, DC, USA Scott Faucett, MD, MS
v
Contents
1 Meniscus Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Urszula Zdanowicz and Robert Śmigielski
2 The Biomechanical Function of the Menisci . . . . . . . . . . . . . . . . . 9
Scott Caterine, Maddison Hourigan, and Alan Getgood
3 Classification of Meniscal Tears . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Sergio Rocha Piedade
4 Meniscectomy: Updates on Techniques and Outcomes . . . . . . . . 31
Gianluca Camillieri
5 Meniscal Root Tears: A Missed Epidemic?
How Should They Be Treated? . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Alexandra Phocas, Jorge Chahla, and Robert F. LaPrade
6 Meniscal Ramp Lesions: Diagnosis
and Treatment Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Rebecca Young, Brian M. Devitt, and Timothy Whitehead
7 Peripheral Meniscal Tears: How to Diagnose
and Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Jorge Chahla, Bradley M. Kruckeberg, Gilbert Moatshe,
and Robert F. LaPrade
8 Radial Meniscal Tears: Updates on Repair Techniques
and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Taylor J. Ridley, Elizabeth A. Arendt,
and Jeffrey A. Macalena
9 All-Inside Meniscal Repair: Updates on Technique . . . . . . . . . 103
Sergio Rocha Piedade, Rodrigo Pereira da Silva Nunes,
Camila Cohen Kaleka, and Tulio Pereira Cardoso
10 Step-By-Step Surgical Approaches for Inside-Out
Meniscus Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Ryan D. Scully and Scott C. Faucett
11 The Role of Alignment in Meniscal Tears and the Role
of Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Aad Dhollander and Alan Getgood
vii
viii Contents
12 O utside-in Meniscal Repair: Technique and Outcomes . . . . . . 129
Jorge Chahla, James Gannon, Gilbert Moatshe,
and Robert F. LaPrade
13 B iological Augmentation of Meniscal Repairs . . . . . . . . . . . . . . 137
Adam William Anz
14 M eniscal Repair Outcomes: Isolated Versus
Combined with Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . 147
Mark R. Hutchinson, Mitchell Meghpara, Danil Rybalko,
and Garrett Schwarzman
15 T reatment of Meniscus Degeneration
and Meniscus Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Hakan Boya, Hasan Tatari, and Halit Pinar
16 D iscoid Menisci and Their Treatment . . . . . . . . . . . . . . . . . . . . . 165
Chih-Hwa Chen and Chian-Her Lee
17 M eniscal Allograft Transplantation:
Updates and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Sverre Løken, Gilbert Moatshe, Håvard Moksnes,
and Lars Engebretsen
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
1
Meniscus Anatomy
Urszula Zdanowicz and Robert Śmigielski
Contents 1.1 Introduction
1.1 I ntroduction ................................................ 1
Originally described by Bland Sutton in 1897
1.2 M edial Meniscus ........................................ 1
[14] as “functionless remnants of intraarticular
1.2.1 Zone 1: Anterior Root .................................. 1
1.2.2 Zone 2: Anteromedial Zone ......................... 2 leg muscles,” menisci are currently recognized as
1.2.3 Zone 3: At the Level of Medial one of the most important structures determining
Collateral Ligament ..................................... 3 the future of the knee joint [1, 5]. Therefore,
1.2.4 Zone 4: Posterior Horn ................................ 3
awareness of meniscal anatomy and attempts to
1.2.5 Zone 5: Posterior Root ................................. 3
save the menisci is a key in preventing early knee
1.3 L ateral Meniscus ........................................ 3
osteoarthritis.
1.3.1 Anterior Root ............................................... 3
1.3.2 Anterior Horn............................................... 4
1.3.3 Area at the Level of Hiatus Popliteus .......... 4
1.3.4 Meniscofemoral Ligaments ......................... 6 1.2 Medial Meniscus
1.3.5 Posterior Root .............................................. 6
Bibliography ........................................................... 7 The medial meniscus has a semilunar shape of
fibrocartilage localized between the medial fem-
oral and medial tibial condyle [8]. The medial
meniscus covers up to 60 % of the articular sur-
face of medial tibial condyle [4] and helps with
the loading distribution in medial compartment.
In 2015, Śmigielski et al. [17] proposed a new,
anatomical division of medial meniscus into five,
uneven anatomical zones (Fig. 1.1). Within each
zone, there is similar anatomy and identical liga-
ments attaching the meniscus to surrounding struc-
tures. Therefore, not only anatomy but also technique
U. Zdanowicz
of suturing may need to differ between zones.
Carolina Medical Center,
Pory 78, 02-757 Warsaw, Poland
e-mail: [email protected]
R. Śmigielski (*) 1.2.1 Zone 1: Anterior Root
Orthopaedic and Sport Traumatology Department,
Carolina Medical Center,
The anterior root of the medial meniscus inserts
Pory 78, 02-757 Warsaw, Poland
along the anterior intercondylar crest of the anterior
e-mail: [email protected]
© ISAKOS 2017 1
R.F. LaPrade et al. (eds.), The Menisci, DOI 10.1007/978-3-662-53792-3_1
2 U. Zdanowicz and R. Śmigielski
Fig. 1.1 Cadaveric
specimen of left knee joint.
Femur removed. Division
into five anatomical zones
of medial meniscus is
shown. PT patellar tendon,
ACL anterior cruciate
ligament, PCL posterior
cruciate ligament, MTC
medial tibial condyle, LTC
lateral tibial condyle, MCL
medial collateral ligament,
aMFL anterior
meniscofemoral ligament,
SMt semimembranosus
tendon
Fig. 1.2 Arthroscopic
view of anteromedial
compartment of the left
knee joint. MM medial
meniscus, MFC medial
femoral condyle, taACL
tibial attachment of
anterior cruciate ligament.
The absence of solid
fixation of anterior root of
medial meniscus is marked
with red arrow
slope of the tibia [11]. In the anatomical study of 48 that the area of the anterior root attachment of
cadaveric knees, Berlet et al. [2] reported on four medial meniscus was about 110.4mm2 [12].
types of bony attachment of the anterior root of the According to Rainio, in 1 % of cases, there
medial meniscus: might be an atypical insertion of the anterior root
Type I (59 % of all cases) is located in the flat of the medial meniscus, which the most frequent is
intercondylar region of the tibial plateau. the absence or hypermobility of the anterior root
Type II (24 %) occurs on the downward slope attachment of the medial meniscus [16] (Fig. 1.2).
from the medial articular plateau to the intercon-
dylar region.
Type III (15 %) occurs on the anterior slope of 1.2.2 Zone 2: Anteromedial Zone
the tibial plateau.
Type IV (3 %) demonstrates no solid fixation. Zone 2 may be further divided by the meniscal
In his anatomical study of 12 nonpaired attachment of the transverse ligament into two
human cadaveric knees, LaPrade et al. reported subzones: 2a and 2b. Zone 2a starts at anterior
1 Meniscus Anatomy 3
Fig. 1.3 Cadaveric
specimen of the left knee
joint. Cross section of
medial meniscus at the
level of zone 3.
Meniscofemoral and
meniscotibial (coronary
ligament) is marked with
yellow arrows. Medial
collateral ligament is
marked with red arrows.
MM medial meniscus,
MTC medial tibial condyle.
Notice at this level, outer
part of medial meniscus
fully attaches to deep part
of medial collateral
ligament (also called
thickening of joint capsule)
root of medial meniscus and ends by the attach- this zone, the medial meniscus has only its attach-
ment of the transverse ligament, where zone 2b ment to the tibia, via the meniscotibial (coronary)
begins to end at the anterior border of medial col- ligament, which attaches to the tibia about
lateral ligament. The meniscus in this zone 7–10 mm below its articular surface. The menis-
attaches to the tibia by the meniscotibial ligament, cal superior edge and outer part do not attach to
also called the coronary ligament. The superior anything (Figs. 1.4 and 1.9a). Behind the outer
edge of the medial meniscus within zone 2a shows part of the medial meniscus in this zone, there is
no attachment to the surrounding tissues. In zone a large posterior femoral recess [6]. Closing this
2b, the most superior periphery of the medial recess by nonabsorbable sutures fixing the medial
meniscus is attached to the synovial tissue [17]. meniscus to joint capsule clearly might impair
meniscal biomechanics and therefore might be
responsible for failure of the meniscal repair.
1.2.3 Zone 3: At the Level of the
Medial Collateral Ligament
1.2.5 Zone 5: Posterior Root
This is the only zone where the entire outer part
of the medial meniscus fully attaches to the joint The posterior root attachment of the medial
capsule. The deep part of the medial collateral meniscus is localized posterior from the medial
ligament, also considered as a thickening of the tibial eminence apex, lateral from the articular
medial joint capsule, has distinct meniscofemoral cartilage inflection point of the medial tibial pla-
and meniscotibial components [13] (Fig. 1.3). teau, and anteromedial from the tibial attachment
of posterior cruciate ligament [10, 17] (Fig. 1.5).
1.2.4 Zone 4: Posterior Horn
1.3 Lateral Meniscus
Zone 4 of the medial meniscus attachment
extends from the superficial medial collateral 1.3.1 Anterior Root
ligament to the meniscal posterior root attach-
ment. It is a very important zone, because it is the The anterior root of the lateral meniscus inserts to
most frequently injured and sutured area. Within the tibia deeply beneath the tibial attachment of
