The knee meniscus: management of traumatic tears and degenerative lesions

Abstract

Meniscectomy is one of the most popular orthopaedic procedures, but long-term results are not entirely satisfactory and the concept of meniscal preservation has therefore progressed over the years. However, the meniscectomy rate remains too high even though robust scientific publications indicate the value of meniscal repair or non-removal in traumatic tears and non-operative treatment rather than meniscectomy in degenerative meniscal lesionsIn traumatic tears, the first-line choice is repair or non-removal. Longitudinal vertical tears are a proper indication for repair, especially in the red-white or red-red zones. Success rate is high and cartilage preservation has been proven. Non-removal can be discussed for stable asymptomatic lateral meniscal tears in conjunction with anterior cruciate ligament (ACL) reconstruction. Extended indications are now recommended for some specific conditions: horizontal cleavage tears in young athletes, hidden posterior capsulo-meniscal tears in ACL injuries, radial tears and root tears.Degenerative meniscal lesions are very common findings which can be considered as an early stage of osteoarthritis in middle-aged patients. Recent randomised studies found that arthroscopic partial meniscectomy (APM) has no superiority over non-operative treatment. Thus, non-operative treatment should be the first-line choice and APM should be considered in case of failure: three months has been accepted as a threshold in the ESSKA Meniscus Consensus Project presented in 2016. Earlier indications may be proposed in cases with considerable mechanical symptoms.The main message remains: save the meniscus! Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160056. Originally published online at www.efortopenreviews.org.

Keywords: consensus; degenerative meniscal lesions; guidelines; knee; meniscectomy; meniscus; meniscus repair.

Fig. 1

Diagram showing the location of meniscus tears.

Fig. 2

Osteoarthritis 24 years after arthroscopic bimeniscectomy in a stable knee.

Fig. 3

Vertical longitudinal tear. Repair using all-inside device (FasT-Fix, Smith & Nephew): a) intra-operative view; b) final stage.

Fig. 4

Small lateral meniscus tear in conjunction with an anterior cruciate ligament injury.

Fig. 5

Horizontal cleavage tear in a young athlete (medial meniscus): a,b) CT scan and MRI of the same knee. The CT scan shows a normal pattern of the meniscus while the MRI shows a grade 2 lesion; c) posteromedial open repair with release of the menisco-synovial junction showing the cleavage which is debrided with curettes; d) the cleavage is closed using vertical sutures (PDS 0, Ethicon); e) final aspect after closure of the menisco-synovial junction.

Fig. 6

a) Acute traumatic posterior medial root tear; b) sutures are passed through the meniscus using a hook; c) trans-tibial fixation.

Fig. 7

Degenerative medial meniscal lesion: a) typical grade 3 MRI pattern; b) arthroscopic findings.

Fig. 8

Degenerative meniscus lesion: flap dislocated in the tibial gutter causing mechanical symptoms.

Fig. 9

Degenerative meniscus lesion. Algorithm proposed by the ESSKA Meniscus Consensus Project. AP, anteroposterior; LAT, lateral; OA, osteoarthritis.