Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury

Abstract

Purpose of review: The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies.

Recent findings: Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.

Keywords: Anterior cruciate ligament injury; Anterior cruciate ligament reconstruction; Lateral meniscal oblique radial tear of the posterior horn; Meniscal ramp lesion; Meniscal repair; Meniscus tear.

Fig. 1

Acute ACL tear with concomitant LMORT in a 21-year-old female collegiate soccer player. A) Coronal T2-weighted MRI demonstrating complete ACL tear. B) Coronal, C) sagittal, and D) axial T2-weighted MRI demonstrating lateral meniscus tear (white arrows). E) Arthroscopic image identifying the tear as a LMORT. F) Arthroscopic image demonstrating suture repair of the LMORT. ACL, anterior cruciate ligament. LMORT, lateral meniscal oblique radial tear of the posterior horn. MRI, magnetic resonance imaging

Fig. 2

A) Coronal T2-weighted MRI and B) arthroscopic image demonstrating complete ACL deficiency (white arrow). C) Coronal T2-weighted MRI and D) arthroscopic image demonstrating complete medial meniscus posterior horn root tear (white arrow). E) Arthroscopic image demonstrating a transtibial root repair. ACL, anterior cruciate ligament. MRI, magnetic resonance imaging

Fig. 3

Acute ACL tear with concomitant meniscal ramp lesion in a 19-year-old male sustained from a contact injury. A) Sagittal T2-weighted MRI demonstrating bony contusions at the sulcus terminalis and posterior lateral tibial plateau, and B) sagittal T2-weighted MRI demonstrating complete ACL rupture. C-D) Sagittal T2-weighted MRI and E) arthroscopic image demonstrating a meniscal ramp lesion (white arrows). F) Arthroscopic image demonstrating suture repair of the ramp lesion. ACL, anterior cruciate ligament. MRI, magnetic resonance imaging