Meniscal tear

from Wikipedia, the free encyclopedia
Classification according to ICD-10
M23.2 Meniscus damage from old tear or injury
S83.2 Meniscal tear, acute
ICD-10 online (WHO version 2019)
Basket handle tear, front view. Large parts of the outer meniscus (red) are shifted inwards into the joint. The inner meniscus (green) is still intact.

A meniscus tear or meniscus rupture is a tear in one or both menisci of the knee joint . Internal meniscus injuries ( i.e. the meniscus medialis ) are much more common than those of the external meniscus ( meniscus lateralis ). The cracks are divided into longitudinal cracks, radial cracks and oblique cracks (flap cracks) according to their direction. With regard to the spatial level, a distinction is made between vertical cracks and horizontal cracks. Special forms are complex cracks, the basket handle crack and a "flipped meniscus". The diagnosis is made through clinical examination, magnetic resonance imaging and arthroscopy (joint endoscopy). Meniscal tears are quite common and often there is no pain or restriction. Not every meniscal tear needs treatment.

frequency

There is a prospective study on 991 randomly selected people from Framingham , Massachusetts . Composition of the study participants:

  • 57% women
  • 93% white
  • 11% smokers

Meniscus tears or severe degenerative meniscus damage were found in 35% of the participants. The inner meniscus was affected in 28% and the outer meniscus in 12% of the cases. Of the 308 participants (31%) with a meniscus tear, 66% had a tear in the inner meniscus, 24% in the outer meniscus and 10% in both meniscus. The posterior horn was affected by the external or internal meniscus in 66%, the intermediate region in 62% and the anterior horn in only 11%. The tear was horizontal in 40% of cases, complex in 37%, oblique in 12%, radial in 15% and longitudinal in 7%. With this classification, a meniscus could also have several cracks.

In the 50 to 59 age group, the incidence was only 19% in women, while it increased in men and with age. In men between 70 and 79 years of age, it reached 56%.

If there was osteoarthritis confirmed by x-ray (Kellgren-Lawrence grade 2 or higher) with knee pain or stiffness, meniscus damage was found in 63%. In asymptomatic participants in 60%. Without radiological signs of osteoarthritis, participants who had pain in the knee at least once in the year prior to the examination had meniscus tears in 32% of participants. Without symptoms, meniscus tears were found in 23% of the participants. There was no correlation with knee joint complaints in any group .

Classification

Damage pattern:
a) normal condition
b) longitudinal crack
c) oblique crack
d) radial crack
e) degeneration

The degenerative meniscus damage always begins centrally in the meniscus. They are divided into four grades, with a meniscus tear only from grade 3:

Degree morphology
1 central, punctiform
2 Horizontal but not reaching the meniscus surface
3 Ribbon-shaped and reaching the meniscus surface
4th Multiple

Basket handle tear

A basket handle tear is the name given to a meniscus tear that runs parallel to the main direction of the fibers. The meniscus is split lengthways along its course, the anterior and posterior ends of the fragment remain connected to the rest of the meniscus. The free edge dislocates into the joint space and causes acute pain.

Such a tear in the basket handle can cause diagnostic problems during the clinical examination, because sometimes the fragment rests on its origin again, then the “typical meniscus symptoms” cannot be found.

Degenerative changes

Just as the cartilage surface of a joint changes degeneratively over time, the menisci also wear out. The meniscus tissue is rolled out under load and becomes thinner and thinner until it finally tears. These changes are collectively referred to as meniscopathy and are part of what happens in the development of osteoarthritis . In the case of accidental injuries that are to be classified as occupational accidents, the histological examination of the meniscus tissue is of decisive importance for the recognition of a causal accident connection. Further degenerative changes can also be caused by an eversion angle other than zero degrees.

therapy

How to treat a meniscal tear depends on a few factors. Age, athleticism and pain of the patient play a major role, but physiotherapy is usually recommended first. Ointments, pain relievers or a non-steroidal anti-inflammatory drug are also often prescribed.

Since most meniscus tears do not cause any symptoms, then no therapy is necessary, and in the case of complaints, a distinction must be made as to the extent to which these are actually from the meniscus tear or possibly from other problems, such as B. cartilage damage.

Separated meniscus parts can occasionally move freely in the joint ( free joint body , "joint mouse") and cause, for example, a joint lock. Meniscus tissue has the same surface hardness as the joint cartilage, so that permanent cartilage damage can result.

Symptoms of a torn meniscus are mostly flexion and extension deficits. In addition, there is severe pain in the hollow of the knee and on the sides above the meniscus in question, which can extend into the shin.

Before an operation, the diagnosis usually has to be confirmed by an MRI . A partial resection of the torn parts of the meniscus is then usually carried out by means of knee joint arthroscopy ( arthroscopy ).

When treating meniscus damage, it is of crucial importance to consider the current stability situation of the affected knee joint. A meniscus suturing or transplantation should not be carried out without (simultaneous) stabilization surgery in z. B. Cruciate ligament rupture can be performed, since the instability is primarily responsible for the meniscus pathology.

Meniscal refixation (meniscus suture)

Schematic blood supply in the meniscus: division into three zones (white-white, white-red, red-red)

With a meniscus suture, the tear is reattached with special suture material, suture systems or meniscus arrows made of absorbable materials. However, this is only possible with certain types of cracks and in areas with blood circulation (red-red or red-white zone). In younger patients, refixation is attempted even in the case of tears that are less close to the base, in order to avoid possible consequences of a meniscus resection on the joint. The earlier meniscal tears are treated surgically, the greater the prospect of healing. To improve the healing process, the sutures are freshened up (so-called needling ), as a result of which the blood circulation is locally improved. The sewn meniscus then has to heal and a long follow-up treatment is necessary. The movement of the knee joint is restricted in the first phase after the operation. A stretching splint is worn for this purpose. The load can be built up quickly because the meniscus is not stressed. After about three weeks, the movement of the knee joint can increasingly be released, a full resumption of sporting activity only after six months, or earlier if the healing process is good. "Gentle" sporting activities such as strength training, cycling or swimming can be started after about two months. Preserving the meniscus with sutures is the most successful treatment with the best perspective for the knee joint.

Meniscus resection

The other surgical variant is the arthroscopic partial meniscus resection: Here the torn piece of the meniscus is removed. After a partial removal of the meniscus, a pain-oriented transition to full load can take place on the day of the operation. Forearm canes can be used for a few days as a support. In addition, physiotherapy is recommended in the first few weeks after the operation. The ability to work is usually restored after one to two weeks. In the case of physically active patients who put strain on the knees, however, it can take a few weeks before the patient can return to his professional and sporting activities. The partial resection is performed especially in the case of degenerative meniscus tears far from the base.

Before the age of arthroscopic partial resection, a complete meniscus resection was usually performed using an arthrotomy, which was originally introduced in the 1970s by I. Smillie (who falsely assumed that the meniscus would form again). The more meniscus was resected, the earlier knee osteoarthritis developed . In a Scottish follow-up examination in the middle forty years after a complete resection of the medial or lateral meniscus in adolescence (mean 15.6 years) already seven of 53 patients had a knee prosthesis (13.2%) and all other patients examined had clear to severe signs of one Arthrosis. Compared to the data from the Scottish prosthesis register, there is a 132-fold risk of early prosthesis implantation after complete meniscus resection with no difference between the medial and the lateral meniscus. Surgical treatment of a meniscus tear in the presence of osteoarthritis does not have any advantages compared to physiotherapy.

Meniscus replacement

A so-called "meniscus replacement ", an implant made of polyurethane (Actifit), collagen (CMI) or a human donor ( allograft ), is used in place of the removed meniscus, so that, at best, the body's own meniscus tissue can develop anew. However, the insertion of the implant entails a longer follow-up treatment, athletes have to expect a break of several months. Meniscus replacement is only used in very special cases and is therefore not a standard procedure. Long-term investigations and controlled clinical studies that compare replacement with pure partial resection have been published on this.

Transplantation of a donor meniscus

Patients who lose a meniscus as a result of an accident at a young age are at risk of developing early osteoarthritis in the medium to long term. Often the beginning of painful cartilage damage of the thigh roll and the tibial head joins early . Pain and effusion in the knee joint are the first signs of the development of osteoarthritis and an important indication of an early overload of the joint section. An important surgical procedure in this situation is the transplantation of a donor meniscus. Both the inner and outer meniscus can be replaced. The procedure requires a precise diagnosis, accordingly the size and side of the meniscus must be determined individually. The donor meniscus is usually ordered from internationally active tissue banks and was donated by deceased accident victims. A rejection reaction as with internal organs with a lifelong drug intake, as z. B. is required after heart transplants, does not occur here. The donor meniscus is removed under sterile operative conditions and then examined for pathogens according to internationally accepted criteria. The risk of the transmission of infectious diseases is negligible, but just as important as the unregulated legal situation for surgeons in Germany. According to the current legal situation, the latter is solely responsible for the quality of the donor meniscus. After the foreign tissue has been properly stored and laboriously transported, the meniscus transplant is carried out. The donor meniscus is used in a minimally invasive manner as part of a jointoscopy. After the donor meniscus has been precisely prepared, it is introduced into the knee joint through an approximately 1 cm small access and sutured in place. The disadvantage of a donor meniscus is the often months-long waiting time for a suitable transplant. The follow-up treatment essentially corresponds to that after a meniscus suture. The primary purpose of transplanting a donor meniscus is to prevent early osteoarthritis and relieve pain. Intensive sporting activity after the transplant must be clarified in consultation with the surgeon. Clinical studies show a significant reduction in pain and very good ingrowth behavior of the donor menisci. In addition, long-term studies show the slow progression of osteoarthritis, although no controlled clinical studies are yet available. The majority of patients get on well with the donor meniscus, and under certain circumstances, accompanying operations to correct the leg axis are necessary in order to achieve optimal relief of the damaged joint section with the donor meniscus.

Implantation of an artificial meniscus

In recent years, the importance of artificial meniscus implants has increased. If large parts of the meniscus have to be removed, filling the defect with a meniscus implant can be considered. Symptomatic patients in particular can benefit from the restoration of the circular structure. Decisive factors for or against the use of the implants are: intact meniscus marginal ridge, cartilage status, leg axis deformity, compliance .

Sewn-in, artificial meniscus implant

Both the inner and the outer meniscus can be substituted. The materials used in common implants consist of collagen ( biological ) or polyurethane ( synthetic ). The size of the implant is adjusted during the operation and then it is fixed in the defect using arthroscopic suturing systems. The knee joint concerned must then be spared so that the tissue can regenerate. There are currently two approved meniscal implants:

  • Synthetic meniscus implant : The meniscus implant made of the plastic polyurethane (Actifit) has had a European CE mark since 2008 . Only follow-up observations are available for this meniscus implant, but no comparative randomized study. In contrast to the collagen meniscus, the synthetic polyurethane meniscus grows together with its surroundings and is not broken down.
  • Biological meniscus implant: The collagen meniscus implant (CMI) consists of cattle - collagen type 1, was developed by Richard Steadman developed and has been used for the 2000th It has both a European CE mark and an American FDA approval. The porous collagen framework of the implant is broken down by the body over time and replaced by the body's own regenerated meniscus.

By using both meniscus implants, patients benefit primarily from pain reduction and from maintaining the cartilage status. Around 60 percent have returned to their normal level of sport. After the meniscus transplant, the partial load phase is extended to five to six weeks, otherwise there are no significant differences to the meniscus suturing. Even when using an artificial meniscus, about six weeks of partial weight bearing and wearing an orthosis are necessary.

literature

  • Becker R., Schaller C. (2015): Image atlas meniscus surgery: Fundamentals, technology. Application . KVM Verlag, ISBN 3-940698-99-7
  • P. Fehrmann and J. Mockenhaupt (1991): Theoretical and experimental analyzes on the importance of the intact and the damaged meniscus for the static stress on the knee joint . In: Trauma Surgery 17 (4): 187-93. PMID 1949353
  • TJ Fairbank (1948): Knee joint changes after meniscectomy . In: J Bone Joint Surg Am 30 (4): 664-70. PMID 18894618
  • M. Englund et al. (2008): Incidental meniscal findings on knee MRI in middle-aged and elderly persons. In: N Engl J Med 359 (11): 1108-1115. PMID 18784100
  • P. Bulgheroni et al. (2010): Follow-up of collagen meniscus implant patients: Clinical, radiological, and magnetic resonance imaging results at 5years. In: Knee 17 (3): 224-9. PMID 19800801
  • WG Rodkey et al. (2008): Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial. In: J Bone Joint Surg Am 90 (7): 1413-26. PMID 18594088
  • P. Buma, T. van Tienen, R. Veth (2007): The collagen meniscus implant. In: Expert Rev Med Devices 4 (4): 507-16. PMID 17605686
  • S. Zaffagnini et al. (2007): Arthroscopic collagen meniscus implant results at 6 to 8 years follow up . In: Knee Surgery, Sports Traumatology, Arthroscopy 15 (2): 175-83. PMID 16845545
  • E. Genovese et al. (2007): Follow-up of collagen meniscus implants by MRI . In: Radiol Med 112 (7): 1036-48. PMID 17952676
  • RD Linke, M. Ulmer, AB Imhoff (2006): Replacement of the meniscus with a collagen implant (CMI) . In: Oper Orthop Traumatol 18 (5-6): 453-62. PMID 17171330
  • M. Ronga, FA Grassi, A. Manelli, P. Bulgheroni (2006): Tissue engineering techniques for the treatment of a complex knee injury . In: Arthroscopy 22 (5): 576.e1-3. PMID 16651180
  • V. Martinek et al. (2006): Second generation of meniscus transplantation: in-vivo study with tissue engineered meniscus replacement. In: Arch Orthop Trauma Surg 126 (4): 228-34 PMID 16215722
  • JR Steadmen and WG Rodkey (2005): Tissue-engineered collagen meniscus implants: 5- to 6-year feasibility study results . In: Arthroscopy 21 (5): 515-25. PMID 158917154
  • M. Reguzzoni et al. (2005): Histology and infrastructure of a tissue-engineered collagen meniscus before and after implantation . In: J Biomed Mater Res B Appl Biomater 74 (2): 808-16. PMID 15981176
  • WG Rodkey et al. (1999): A clinical study of collagen meniscus implants to restore the injured meniscus . In: Clin Orthop Relat Res 367 (Suppl): S281-92. PMID 10546653
  • KR Stone et al. (1997): Regeneration of meniscal cartilage with use of a collagen scaffold. Analysis of preliminary data . In: J Bone Joint Surg Am 79 (12): 1770-7. PMID 9409790

Web links

Commons : Meniscus tear images with scrollable MRI series  - collection of images, videos and audio files
Wiktionary: meniscus tear  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ^ Meniscus update. S. Waldt in Radiologie up2date 4/2013 p. 285
  2. ↑ Martin Englund, Ali Guermazi, Daniel Gale, David J. Hunter, Piran Aliabadi, Margaret Clancy, David T. Felson: Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons , in: The New England Journal of Medicine , 2008 ; Volume 359, Issue 11, September 11, 2008, pages 1108-1115; doi: 10.1056 / NEJMoa0800777 .
  3. ↑ The MR trainer: lower extremity. Martin Breitenseher. Thieme. 2003
  4. ↑ Kurzweil PR, Lynch NM et al .: Repair of horizontal meniscus tears: a systematic review. Arthroscopy. 2014 Nov; 30 (11): 1513-9. PMID 25108905 doi: 10.1016 / j.arthro.2014.05.038
  5. ^ Moulton SG, Bhatia S. et al .: Surgical Techniques and Outcomes of Repairing Meniscal Radial Tears: A Systematic Review. Arthroscopy. 2016 Sep; 32 (9): 1919-25. PMID 27234653 doi: 10.1016 / j.arthro.2016.03.029
  6. ↑ IP Pengas, A. Assiotis, W. Nash, J. Hatcher, J. Banks, MJ McNicholas: Total meniscectomy in adolescents . A 40-year follow-up, in: Journal of Bone and Joint Surgery , 2012, Volume 94-Br, Issue 12 of December 2012, pages 1649-1654
  7. ↑ Jeffrey N. Katz, Robert H. Brophy, Christine E. Chaisson, Leigh de Chaves, Brian J. Cole, Diane L. Dahm, Laurel A. Donnell-Fink, Ali Guermazi, Amanda K. Haas, Morgan H. Jones, Bruce A. Levy, Lisa A. Mandl, Scott D. Martin, Robert G. Marx, Anthony Miniaci, Matthew J. Matava, Joseph Palmisano, Emily K. Reinke, Brian E. Richardson, Benjamin N. Rome, Clare E. Safran -Norton, Debra J. Skoniecki, Daniel H. Solomon, Matthew V. Smith, Kurt P. Spindler, Michael J. Stuart, John Wright, Rick W. Wright, Elena Losina: Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. In: The New England Journal of Medicine. 368, 2013, pp. 1675–1684, doi: 10.1056 / NEJMoa1301408
  8. ^ Leroy A., Beaufils P. et al .: Actifit polyurethane meniscal scaffold: MRI and functional outcomes after a minimum follow-up of 5 years. Orthop Traumatol Surg Res. 2017 Jun; 103 (4): 609-614 PMID 28373139 doi: 10.1016 / j.otsr.2017.02.012
  9. ↑ Grassi A., Zaffagnini S. et al .: Clinical outcomes and complications of a collagen meniscus implant: a systematic review. Int Orthop. 2014 Sep; 38 (9): 1945-53, PMID 24947329 doi: 10.1007 / s00264-014-2408-9
  10. ↑ Rodkey WG, DeHaven KE et al .: Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial. J Bone Joint Surg Am. 2008 Jul; 90 (7): 1413-26. PMID 18594088 doi: 10.2106 / JBJS.G.00656
  11. ↑ Vaquero J., Forriol F .: meniscus tear surgery and meniscus replacement. Muscles Ligaments Tendons J. 2016 May 19; 6 (1): 71-89. PMID 27331034 doi: 10.11138 / mltj / 2016.6.1.071
  12. ^ Mutsaerts EL, van Eck CF et al .: Surgical interventions for meniscal tears: a closer look at the evidence. Arch Orthop Trauma Surg. 2016 Mar; 136 (3): 361-70, PMID 26497982 doi: 10.1007 / s00402-015-2351-2
  13. ^ Moran CJ, Withers DP: Clinical Application of Scaffolds for Partial Meniscus Replacement. Sports Med Arthrosc. 2015 Sep; 23 (3): 156-61. PMID 26225576 doi: 10.1097 / JSA.0000000000000072
  14. ↑ Dhollander A., Verdonk P .: Treatment of Painful, Irreparable Partial Meniscal Defects With a Polyurethane Scaffold: Midterm Clinical Outcomes and Survival Analysis . Am J Sports Med. 2016 Oct; 44 (10): 2615-2621. PMID 27432054 doi: 10.1177 / 0363546516652601
  15. ^ Leroy A., Beaufils P. et al .: Actifit polyurethane meniscal scaffold: MRI and functional outcomes after a minimum follow-up of 5 years. Orthop Traumatol Surg Res. 2017 Jun; 103 (4): 609-614. PMID 28373139 doi: 10.1016 / j.otsr.2017.02.012
  16. ↑ Grassi A., Zaffagnini S .: Clinical outcomes and complications of a collagen meniscus implant: a systematic review. Int Orthop. 2014 Sep; 38 (9): 1945-53. PMID 24947329 doi: 10.1007 / s00264-014-2408-9
  17. ↑ Monllau JC, Gelber PE et al .: Outcome after partial medial meniscus substitution with the collagen meniscal implant at a minimum of 10 years' follow-up. Arthroscopy. 2011 Jul; 27 (7): 933-43. PMID 21621373 doi: 10.1016 / j.arthro.2011.02.018
  18. ↑ Bulgheroni E., Grassi A. et al .: Comparative Study of Collagen versus Synthetic-Based Meniscal Scaffolds in Treating Meniscal Deficiency in Young Active Population. Cartilage. 2016 Jan; 7 (1): 29-38. PMID 26958315 doi: 10.1177 / 1947603515600219
  19. ↑ Zaffagnini S. Grassi A .: MRI evaluation of a collagen meniscus implant: A systematic review. Knee Surg Sports Traumatol Arthrosc. 2015 Nov; 23 (11): 3228-37 PMID 24993568 doi: 10.1007 / s00167-014-3155-6
  20. ^ Papalia R., Franceschi F .: Scaffolds for partial meniscal replacement: an updated systematic review. Br Med Bull. 2013; 107: 19-40. PMID 23457205 doi: 10.1093 / bmb / ldt007
  21. ↑ Filardo G., Andriolo L. et al .: Meniscal scaffolds: results and indications. A systematic literature review. Int Orthop. 2015 Jan; 39 (1): 35-46. PMID 24973973 doi: 10.1007 / s00264-014-2415-x