堀部秀二，田中美成，米谷泰一，塩崎嘉樹：半月板損傷をどう治療するか．整形外科 2007;52：1239-1246.
J H Mink, T Levy, J V Crues
Tears of the anterior cruciate ligament and menisci of the knee: MR imaging evaluation.
Radiology. 1988 Jun;167(3):769-74. doi: 10.1148/radiology.167.3.3363138.
Abstract/Text
In 242 of 3,000 patients who underwent magnetic resonance (MR) imaging of the knee between September 1986 and August 1987, original MR imaging reports were compared with subsequent arthroscopic reports to determine the value of MR imaging in the evaluation of suspected meniscal and complete tears of the anterior cruciate ligament. The overall accuracy for the menisci was 93% (sensitivity, 95%; specificity, 91%) with a false-negative rate of 4.8%. For the anterior cruciate ligament the overall accuracy was 95%. T2-weighted sequences were associated with greater sensitivity, specificity, and accuracy than were T1 sequences; the false-negative rate was 0% in the T2-weighted group. MR imaging of the knee is an extremely accurate means for noninvasive assessment of the integrity of the menisci and anterior cruciate ligament, and the accuracy exceeds that usually reported for arthrography.
M J Matava, K Eck, W Totty, R W Wright, R A Shively
Magnetic resonance imaging as a tool to predict meniscal reparability.
Am J Sports Med. 1999 Jul-Aug;27(4):436-43.
Abstract/Text
One hundred six patients who underwent high field strength magnetic resonance imaging and subsequent arthroscopy of the knee were evaluated to determine the accuracy of magnetic resonance imaging in predicting meniscal tear reparability. Each scan was independently read by three examiners with varying degrees of expertise: a musculoskeletal radiologist, a senior orthopaedic surgeon, and a general radiologist. Each suspected tear was characterized by its morphologic type, maximum length, and minimum distance from the meniscosynovial junction. A prediction was then made of whether the tear was reparable. There were 115 meniscal tears noted in the 106 patients studied. The examiners' ability to correctly estimate tear type was only fair, with correct estimates made only 14% to 67% of the time. The overall correlation of the three examiners to correctly predict the method of treatment was fair. The average accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of magnetic resonance imaging in predicting meniscal reparability were 74%, 29%, 89%, 50%, and 80%, respectively; for predicting meniscectomy, these values were 69%, 68%, 75%, 90%, and 43%, respectively. There were no significant differences between the three examiners in the accuracy of their treatment predictions. The results of this study suggest that magnetic resonance imaging is only moderately reliable for the prediction of meniscus reparability. In addition, the training of the reader does not appear to significantly influence the results.
Yoshiki Shiozaki, Shuji Horibe, Tomoki Mitsuoka, Norimasa Nakamura, Yukiyoshi Toritsuka, Konsei Shino
Prediction of reparability of isolated semilunar lateral meniscus tears by magnetic resonance imaging.
Knee Surg Sports Traumatol Arthrosc. 2002 Jul;10(4):213-7. doi: 10.1007/s00167-002-0280-4. Epub 2002 Feb 20.
Abstract/Text
Sixty-one menisci in 60 patients who underwent preoperative MRI and subsequent arthroscopic operation for symptomatic isolated semilunar lateral meniscus tears were evaluated. The MRI criterion of reparability was the presence of a longitudinal or oblique high signal intensity line within 3 mm meniscosynovial junction without a high signal intensity area in the meniscal body, and the criterion of irreparability was high signal intensity line greater than 5 mm from the meniscosynovial junction and/or abnormal high intensity area in the meniscal body. Perioperatively the menisci were repaired for longitudinal unstable tears located at the outer one-half and were excised for other type of tears. Consequently 30 menisci were repaired, and 31 menisci underwent menisectomy. Overall, MRI was useful for detecting the meniscus tears in 42 (69%). The accuracy and sensitivity of MRI in predicting reparability were 91% and 33%; for predicting irreparability the respective values were 90% and 90%. The findings of this retrospective study suggest that MRI is not always useful in predicting reparability of the symptomatic isolated lateral semilunar meniscus tears, and that the most symptomatic cases with normal MRI are reparable.
Patricia Thoreux, Frédérique Réty, Geoffroy Nourissat, Xavier Rivière, Patrick Safa, Sébastien Durand, Alain-Charles Masquelet
Bucket-handle meniscal lesions: magnetic resonance imaging criteria for reparability.
Arthroscopy. 2006 Sep;22(9):954-61. doi: 10.1016/j.arthro.2006.04.111.
Abstract/Text
PURPOSE: The purpose of this study was to determine the accuracy of magnetic resonance imaging (MRI) in predicting knee bucket-handle meniscal tear (BHMT) reparability.
METHODS: Twenty-eight patients who underwent knee arthroscopy by a single surgeon for BHMT with prior MRI examination were included. BHMTs were diagnosed by MRI based on the association of a displaced meniscal fragment on coronal images and one of the following three signs on sagittal slices: flipped meniscus sign, double posterior cruciate ligament, and meniscal fragment within the intercondylar notch. BHMT patients' MRIs were retrospectively reviewed independently to search for criteria of reparability by 2 observers with different degrees of experience in musculoskeletal radiology, and disagreements were arbitrated to consensus. The criteria for BHMT reparability were as follows: (1) rim width of less than 4 mm; (2) tear length of 1 cm or greater, regardless of total lesion length; and (3) generation of isosignals by the inner meniscal fragment and peripheral rim compared with the normal contralateral meniscus of the same knee. The first 2 criteria indicate an adequate meniscal lesion length in the vascularized zone (only the peripheral third), enabling meniscal healing after repair; the third criterion guarantees that the meniscus is nondegenerative.
RESULTS: Of the BHMTs, 5 (17.9%) were arthroscopically reparable and 23 (82.1%) were not. Interpretation of magnetic resonance images correctly predicted reparability in 4 of 5 reparable BHMTs and irreparability in 22 of 23 irreparable BHMTs (26/28 lesions). Interobserver agreement was good for the prediction of reparability (kappa = 0.7).
CONCLUSIONS: These results suggest that knee BHMTs that are predicted to be reparable by MRI would have a high likelihood of actually being reparable.
LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on basis of consecutive patients and gold standard.
S Horibe, K Shino, K Nakata, A Maeda, N Nakamura, N Matsumoto
Second-look arthroscopy after meniscal repair. Review of 132 menisci repaired by an arthroscopic inside-out technique.
J Bone Joint Surg Br. 1995 Mar;77(2):245-9.
Abstract/Text
From 1986 to 1993, we repaired 278 torn menisci in 264 patients using an arthroscopically assisted inside-out technique. A total of 132 meniscal repairs in 122 patients were evaluated by second-look arthroscopy. At review, only nine patients had meniscal symptoms, such as locking, swelling or pain. Ninety-seven menisci (73%) had healed completely at the repair site, but there were new tears in different areas of 21 menisci, some of which had complete healing at the repair site. Incomplete healing, seen in 23 menisci (17%), was frequently near the popliteus tendon, most commonly where there had been an associated anterior-cruciate-ligament injury. Arthroscopically-assisted meniscal repair seems to be a reliable procedure, but some clinically successful cases had incomplete healing at the repair site or a newly-formed tear in the meniscal body or both. These lesions may cause meniscal symptoms to appear at a later date.
S Horibe, K Shino, A Maeda, N Nakamura, N Matsumoto, T Ochi
Results of isolated meniscal repair evaluated by second-look arthroscopy.
Arthroscopy. 1996 Apr;12(2):150-5.
Abstract/Text
Thirty-six isolated torn menisci in 35 patients (average age, 24 years) which had been repaired arthroscopically using an inside-out technique were evaluated by second-look arthroscopy. The time from meniscal repair to second-look arthroscopy ranged from 2 to 10 months with a mean of 5 months. The indications for meniscal repair were a longitudinal or oblique tear located at the outer half of the meniscus. Twenty (56%) were graded as excellent, 10 (28%) as good, and 6 (16%) were graded as poor. Neither age nor length of time between injury and repair affected meniscal healing. The medial meniscal repairs showed better results than the lateral repairs (rate of excellent results: medial, 82%; lateral, 44%; P < .01, chi-squared test). The rate of excellent results for those with normal meniscal bodies at the time of repair was 79%, which was significantly higher than that seen in the cases with deformed and/or superficial damage to the meniscal body (36%; P < .05, chi-squared test).
Christian Stärke, Sebastian Kopf, Wolf Petersen, Roland Becker
Meniscal repair.
Arthroscopy. 2009 Sep;25(9):1033-44. doi: 10.1016/j.arthro.2008.12.010. Epub 2009 Feb 26.
Abstract/Text
The meniscus plays an important role in preventing osteoarthritis of the knee. Repair of a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with concurrent anterior cruciate ligament reconstruction, and in younger patients. The probability of healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Age or extension of the tear into the avascular area are not exclusion criteria. Numerous repair techniques are available, and suture repair seems to provide superior biomechanical stability. However, the clinical success rate does not correlate well with the mechanical strength of the repair technique. Biologic factors might be of greater importance to the success of meniscal repair than the surgical technique. Therefore, the decision on the most appropriate repair technique should not rely on biomechanical parameters alone. Contemporary all-inside repair systems have decreased the operating time and the level of surgical skill required. Despite the ease of use, there is a potential for complications because of the close proximity of vessels, nerves, and tendons, of which the surgeon should be aware. There is no clear consensus on postoperative rehabilitation. Weight bearing in extension would most likely not be crucial in typical longitudinal lesions. However, higher degrees of flexion, particularly with weight bearing, give rise to large excursions of the menisci and to shear motions, and should therefore be advised carefully. Long-term studies show a decline in success rates with time. Further studies are needed to clarify the factors relevant to the healing of the menisci. Tissue engineering techniques to enhance the healing in situ are promising but have not yet evolved to a practicable level.
Yuji Uchio, Mitsuo Ochi, Nobuo Adachi, Kenzo Kawasaki, Junji Iwasa
Results of rasping of meniscal tears with and without anterior cruciate ligament injury as evaluated by second-look arthroscopy.
Arthroscopy. 2003 May-Jun;19(5):463-9. doi: 10.1053/jars.2003.50109.
Abstract/Text
PURPOSE: Meniscal rasping without suturing has been experimentally shown to stimulate vascular induction in tears in the avascular zone of menisci, resulting in meniscal healing. The goals of this study were to arthroscopically assess the results of meniscal rasping and analyze the factors affecting meniscal healing.
TYPE OF STUDY: Retrospective cohort study.
METHODS: Forty-eight torn menisci in 47 patients (age range, 14-47 years; average, 24 years) treated arthroscopically with the meniscal rasping technique were evaluated by second-look arthroscopy. The interval between the injury and the time of surgery ranged from 3 weeks to 13 years. There were 35 lateral and 13 medial meniscal tears associated with 44 anterior cruciate ligament injuries; 28 of the menisci had a full-thickness longitudinal tear and the other 20 had a partial-thickness tear. The length of the tears ranged from 10 to 33 mm (mean, 14.4 mm). The distance from the capsule to the tear ranged from 1 to 9 mm (mean, 5.0 mm).
RESULTS: Thirty-four menisci (71%) healed completely (without a marked visible unhealed area), 10 (21%) healed incompletely, and 4 (8%) showed no evidence of healing. There were no relationships between outcome and age, gender, injured side, or time from injury and rasping. Both the distance from the capsule to the tear and the length of the tear were longer in the unhealed menisci. Stable tears had a high healing rate after meniscal rasping.
CONCLUSIONS: Meniscal rasping without suturing is an easy procedure to perform and seems to be a reliable way to repair longitudinal tears in the avascular region of the meniscus, although the healing potential of the procedure is affected by the distance from the capsule to the tear site and the length and the stability of the tear.
Kazuyoshi Yagishita, Takeshi Muneta, Takashi Ogiuchi, Ichiro Sekiya, Kenichi Shinomiya
Healing potential of meniscal tears without repair in knees with anterior cruciate ligament reconstruction.
Am J Sports Med. 2004 Dec;32(8):1953-61.
Abstract/Text
BACKGROUND: Few previous studies have documented the healing potential of meniscal tears that are left to heal without repair.
PURPOSE: To determine the healing rates of meniscal tears left without repair in knees with anterior cruciate ligament reconstruction.
STUDY DESIGN: Prospective cohort study.
METHODS: One hundred and ninety-two knees were evaluated at the time of anterior cruciate ligament reconstruction and repeat arthroscopy. The healing rates of 41 medial and 42 lateral torn menisci without repair were evaluated by the same 2 surgeons in an identical fashion.
RESULTS: Of 41 medial torn menisci left without repair, 22 (56%) were considered completely healed, 3 (7%) were incompletely healed, 11 (24%) were unhealed, and 5 (10%) had expanded unhealed lesions. Of 42 lateral torn menisci, 31 (74%) were considered completely healed, 2 (5%) were incompletely healed, 6 (14%) were unhealed, and 3 (7%) had expanded unhealed lesions. The healing rate of a medial meniscal tear was length dependent and not related to reconstructed ligament stability.
CONCLUSIONS: Stable meniscal tears at the time of anterior cruciate ligament reconstruction possibly could be left in situ. However, longer medial meniscal tears are thought to require additional stabilizing procedures.
T J FAIRBANK
Knee joint changes after meniscectomy.
J Bone Joint Surg Br. 1948 Nov;30B(4):664-70.
Abstract/Text
Yasukazu Kobayashi, Masashi Kimura, Hiroshi Higuchi, Masanori Terauchi, Kenji Shirakura, Kenji Takagishi
Juxta-articular bone marrow signal changes on magnetic resonance imaging following arthroscopic meniscectomy.
Arthroscopy. 2002 Mar;18(3):238-45.
Abstract/Text
PURPOSE: Postmeniscectomy osteonecrosis of the knee has been reported in the past decade but the etiology remains unclear. Some investigators have indicated that bone marrow signal changes evident on magnetic resonance imaging (MRI) could be early warning signs of osteonecrosis. The purpose of this study was to determine the incidence rate, location, and magnitude of such changes in bone marrow of the knee after arthroscopic meniscectomy, using MRI.
TYPE OF STUDY: Cohort analytic study.
METHODS: Ninety-three patients with no bone marrow signal abnormalities on preoperative MRI were examined after isolated arthroscopic meniscectomy. There were 51 men and 42 women with an age range of 11 to 62 years (mean, 36.6 years). Of the total, 57 patients underwent partial meniscectomy (34 medial and 23 lateral) and the others total meniscectomy (10 medial and 26 lateral). MRI examinations were performed independently of postoperative knee symptoms, 1 to 24 months after surgery. Bone marrow changes of the treated knees were evaluated by T1- and T2*-weighted MRI.
RESULTS: Thirty-two of 93 patients (34%) had bone marrow signal changes in femoral or tibial condyles shown on postoperative MRI. No patients had these changes in the femoral or tibial condyles opposite from the meniscectomy side and, in the majority of cases, the size was less than half that of the condyle. Fifteen of the 44 patients who underwent medial meniscectomy and 17 of the 49 patients who underwent lateral meniscectomy had such changes. The meniscectomy side did not affect the incidence rate, and frequently both femoral and tibial condyles were involved. Age, gender and articular cartilage condition at the surgery were not risk factors. In contrast, the extent of meniscectomy affected the incidence rate.
CONCLUSIONS: This study suggests a positive correlation between arthroscopic meniscectomy and postoperative bone marrow signal changes of the knee.
J Winslow Alford, Paul Lewis, Richard W Kang, Brian J Cole
Rapid progression of chondral disease in the lateral compartment of the knee following meniscectomy.
Arthroscopy. 2005 Dec;21(12):1505-9. doi: 10.1016/j.arthro.2005.03.036.
Abstract/Text
We present 2 cases of severe, rapidly progressive chondral disease in the lateral compartment within 12 months after meniscectomy. In both cases, the lateral compartment was salvaged with simultaneously performed cartilage repair techniques and meniscal transplantation. The first case is of a 16-year-old boy who suffered a complex irreparable posterior horn lateral meniscus tear that was treated with an aggressive partial meniscectomy, and developed a rapid onset of severe lateral compartment symptoms associated with a focal grade IV chondral defect of the lateral femoral condyle within 10 months of his index meniscectomy. The second case is that of an athletic 43-year-old orthopaedic surgeon who suffered a complex lateral meniscus tear that required a near total lateral meniscectomy. Within 5 months of the lateral meniscectomy, he developed severe lateral symptoms with a focal grade IV chondral defect of the lateral femoral condyle. In both cases, the articular cartilage defects were treated with osteochondral grafting at the time of lateral meniscus transplantation with excellent results at 2-year follow-up. These cases highlight the significant need for a heightened the awareness of the relatively increased risk of rapid lateral compartment degeneration following lateral meniscectomy. This, in combination with the appropriate use of cartilage restoration techniques, provides the potential to salvage or prevent rapid onset, unicompartmental degenerative disease, and the ability to reduce symptoms and improve function in these challenging patients.
Kazunari Ishida, Ryosuke Kuroda, Hiroshige Sakai, Minoru Doita, Masahiro Kurosaka, Shinichi Yoshiya
Rapid chondrolysis after arthroscopic partial lateral meniscectomy in athletes: a case report.
Knee Surg Sports Traumatol Arthrosc. 2006 Dec;14(12):1266-9. doi: 10.1007/s00167-006-0091-0. Epub 2006 May 19.
Abstract/Text
We present a patient with a severe chondrolysis after arthroscopic partial lateral meniscectomy in a 17-year-old high school basketball player. This is a rare but severe complication after arthroscopic partial lateral meniscectomy. At 7 months after the first operation, a second-look arthroscopy showed numerous cartilaginous debris floating in the knee and a high-grade cartilage damage on the lateral compartment of the tibia. This unexpected complication and a consideration of its etiology are shown.
Pier Paolo Mariani, Raffaele Garofalo, Fabrizio Margheritini
Chondrolysis after partial lateral meniscectomy in athletes.
Knee Surg Sports Traumatol Arthrosc. 2008 Jun;16(6):574-80. doi: 10.1007/s00167-008-0508-z. Epub 2008 Mar 12.
Abstract/Text
Rapid chondrolysis after partial arthroscopic lateral meniscectomy has been seldom reported in literature. Considering the relatively high number of partial lateral meniscectomy performed, we cannot understand why this complication is so rare. The purpose of this paper is to report a series of athletes developing a chondrolysis associated with posterolateral corner laxity after a partial lateral meniscectomy and attempt to hypothesize the pathogenesis of this devastating complication. Five male professional soccer players of Italian championship with a mean age of 26.8 years underwent a partial lateral meniscectomy because of a traumatic lateral meniscus tear. Patients showed a slight varus knee and there were clinical signs compatible with a meniscal tear. No other pathological sign were found. An MRI scan confirmed these findings. After surgery patients were unable to resume sport activities because of swelling and knee pain during training sessions. At a mean time of 8 months (range 6-12 months) from surgery patients were re-examined and a new MRI scan was performed. Clinical examination revealed a slight swelling of the knee and signs of posterolateral corner laxity. MRI scan revealed intra-articular fluid and pathological findings of knee posterolateral corner associated with a thinning of the articular cartilage. Arthroscopy showed free cartilagineous debris floating into the knee and a high grade of cartilage damage on the lateral compartment. The evaluation of lateral compartment, ruled-out a new tear of the meniscal remnant and showed a positive drive-trough sign with knee in the Fig. 4 positioning. All patients had an open re-tensioning of the posterior meniscofemoral capsule, and in one case, an augmentation of the popliteal tendon using a free semi-tendinous graft was also done. This surgery gave a complete resolution of symptoms and patients resumed sports activities without any restriction after a period between 4 and 5 months. Based on this experience we hypothesize that partial lateral meniscectomy may have a role in causing a subtle rotatory instability that combined with high stress of sports activity can dramatically increase the susceptibility of joint to chondrolysis, Varus knee seems to be a possible predisposing factor. Open surgery addressing the insufficiency of lateral or posterolateral corner has been found to be effective in improving knee function and resolve patients symptoms at a short-term follow-up.
Young-Mo Kim, Kwang-Jin Rhee, June-Kyu Lee, Deuk-Soo Hwang, Jun-Young Yang, Sung-Jae Kim
Arthroscopic pullout repair of a complete radial tear of the tibial attachment site of the medial meniscus posterior horn.
Arthroscopy. 2006 Jul;22(7):795.e1-4.
Abstract/Text
We developed an effective arthroscopic pullout technique for repairing complete radial tears of the tibial attachment site of the medial meniscus posterior horn (MMPH). In our technique, the torn meniscus is reattached to the tibial plateau immediately medial or anteromedial to the posterior cruciate ligament (PCL) using two No. 2 Ethibond sutures (Ethicon, Somerville, NJ). After a complete radial tear of the tibial attachment site of the MMPH and its reparability were confirmed, using a Caspari suture loaded with a suture shuttle, one No. 2 Ethibond suture is placed through the meniscus, through the red-red zone, 3 to 5 mm medial to the torn edge of the MMPH, and the other is passed through the meniscocapsular junction 3 to 5 mm medial to the torn edge of the meniscus. Then, a tibial tunnel, 5-mm in diameter, is made from the anteromedial aspect of the proximal tibia to the previously prepared tibial plateau, immediately medial or anteromedial to the PCL, and the two No. 2 Ethibond sutures are pulled out through the tibial tunnel and then fixed to the proximal tibia using a 3.5-mm cortical screw and washer. Firm reattachment of the torn meniscus was confirmed arthroscopically.
Nam-Hong Choi, Tae-Hyung Kim, Kyung-Mo Son, Brian N Victoroff
Meniscal repair for radial tears of the midbody of the lateral meniscus.
Am J Sports Med. 2010 Dec;38(12):2472-6. doi: 10.1177/0363546510376736. Epub 2010 Sep 8.
Abstract/Text
BACKGROUND: Radial meniscal tears historically have been treated by partial meniscectomy, although they are more biomechanically detrimental than longitudinal tears. Clinical results after meniscal repair for radial tears of the midbody of the lateral meniscus have been reported rarely.
STUDY DESIGN:
CASE SERIES: Level of evidence, 4.
METHODS: Fourteen consecutive patients who had radial tears of the midbody of the lateral meniscus underwent arthroscopic repair. Inclusion criteria were radial tears involving the red-red or red-white zone. All patients underwent all-inside meniscal repair using absorbable sutures. Postoperative evaluation was performed using joint-line tenderness, McMurray test, range of motion, and follow-up magnetic resonance imaging (MRI) scan at 6 months postoperatively. Lysholm knee score and Tegner activity level were evaluated at last follow-up. In 4 patients, second-look arthroscopies were performed.
RESULTS: The average follow-up was 36.3 months. No patient had joint-line tenderness. Three patients complained of pain or a click on McMurray test. The mean follow-up range of motion was 138.6°. Follow-up MRI scans demonstrated that 5 (35.7%) menisci were healed, 8 (57.1%) were partially healed, and 1 (7.1%) was not healed. The follow-up Lysholm score was 94.7 (range, 81-100; standard deviation [SD] = 6.4) and Tegner score was 5.7 (range, 3-7; SD = 1.4). Second-look arthroscopies in 4 patients showed partial healing of meniscal tears.
CONCLUSION: Meniscal repair for radial tears of the midbody of the lateral meniscus may be an effective, alternative treatment to partial meniscectomy.
Tamiko Kamimura, Masashi Kimura
Repair of horizontal meniscal cleavage tears with exogenous fibrin clots.
Knee Surg Sports Traumatol Arthrosc. 2011 Jul;19(7):1154-7. doi: 10.1007/s00167-011-1404-5. Epub 2011 Feb 3.
Abstract/Text
PURPOSE: A novel indication and technique using exogenous fibrin clots to repair horizontal cleavage tears of the meniscus is presented.
METHODS: Vertical sutures were placed on the meniscus using FasT-Fix (Smith & Nephew Endoscopy, Andover, MA, USA), and exogenous fibrin clots were inserted within the cleft to promote healing and to preserve function.
RESULTS: Repeat arthroscopy showed healing and closure of the cleft of the meniscus without affecting the articular cartilage. Three medial and six lateral menisci were treated, and all of the patients showed improvements in their functional scores and their quality of life.
CONCLUSIONS: It appears that the exogenous fibrin clots act as a scaffold to promote the healing process and that growth factors in the fibrin clots had a beneficial effect on meniscal healing. This procedure should be considered to treat degenerative menisci for which repair options have been limited until now.
LEVEL OF EVIDENCE: IV.
