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The symptoms Dr. Diduch, Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, is Editor of Sports Medicine Reports. Rohren EM, Kosarek FJ, Helms CA. Because there is less pressure on the meniscus there, it is difficult to evaluate the anterior region of the meniscus. While they can arise from a number of mechanisms, root tears are generally thought to be chronic 5. has shown that 41% of patients with a surgically confirmed torn post-operative meniscus had signal intensity within the meniscus extending into the articular surface which was lower than the signal intensity of gadolinium contrast.14 Like the presence of a line of intermediate T2 signal extending into the articular surface on conventional MRI, diagnosis of a torn post-operative meniscus on MRI arthrography is challenging when the intra-meniscal signal intensity is not as bright as gadolinium contrast. Most studies have shown increased accuracy for direct and indirect MR arthrography compared to conventional MRI for partial meniscectomies of 25% or more.16. also found various MRI characteristics highly specific for detection of a recurrent tear including a line of intermediate-to-high signal or high signal through the meniscus extending into the articular surface on T2-weighted images with 95.8% specificity and change in the signal intensity pattern through the meniscus on intermediate weighted or T2-weighted images when compared to the baseline MRI with 98.2% specificity. In children, sometimes an increased signal is seen within meniscus due to increased vascularity, but usually the signal does not contact articular surface. 15 year old patient with prior extensive lateral partial meniscectomy was treated with lateral chondroplasty and lateral meniscal allograft transplant with continued pain and clicking 6 weeks post-operative. They were first described by M J Pagnaniet al. Type 2: An incomplete slab of meniscal tissue with 80% coverage of the lateral tibial plateau. 1). 300). treatment for stable complete or incomplete types of discoid lateral Meniscal tears are common and often associated with knee pain. You can use Radiopaedia cases in a variety of ways to help you learn and teach. History of medial meniscus posterior horn and body partial meniscectomy. Financial Disclosure: None of the authors or planners for this educational activity have relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients. Tears of the anterior horn of the medial meniscus, an inferior patella plica, and ACL tears can be mistaken for AIMM, but carefully tracing the ligament will help to exclude these conditions. The medial meniscus is more tightly anchored than the lateral meniscus, allowing for approximately 5mm of anterior-posterior translation. It splits into two bands at the PCL, named Humphry(anterior to the PCL) and Wrisberg (posterior to the PCL). Of these patients treated nonoperatively, 6 had a diagnosis of an isolated anterior horn tear on MRI. Davidson D, Letts M, Glasgow R. Discoid meniscus in children: Treatment and outcome. Clark CR, Ogden JA. 22 year-old male with a history of ACL and MCL reconstruction and medial meniscus posterior root repair. posterior horn usually measures 12 mm to 16 mm in the sagittal plane in Mechanical rasping or trephination of the torn meniscus ends and parameniscal synovium is used to promote bleeding and vascular healing. Radiographs may 2002;30(2):189-192. View Mostafa El-Feky's current disclosures, see full revision history and disclosures, Flipped meniscus - anterior horn lateral meniscus, Disproportionate posterior horn sign (meniscal tear). Coronal extrusion of the lateral meniscus does not increase after high fibula head and a widened lateral joint space.20 Several Radiographic knee dimensions in discoid lateral meniscus: Comparison with normal control. Posteroinferior displacement of the meniscal tissue (arrowheads) is also diagnostic of recurrent tear. Anterior horn of the lateral meniscus: another potential pitfall in MR . horns to the meniscal diameter on a sagittal slice that shows a maximum The patient subsequently underwent successful partial medial meniscectomy. We will review the common meniscal variants, which to tear. Pseudotear Sign of the Anterior Horn of the Meniscus Is sport activity possible after arthroscopic meniscal allograft transplantation? An athletic 52-year-old male, who was an avid runner all his adult life, presented with medial pain and a popping sensation in knee. The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. 2002; 222:421429, Ciliz D, Ciliz A, Elverici E, Sakman B, Yuksel E, Akbulut O. Posterior meniscal root repairs: outcomes of an anatomic transtibial pull-out technique. mimicking an anterior horn tear. (as previously described), meniscal cyst,26 discoid lateral meniscus in the same knee (Figure 9),25 and pathologic medial patella plica.27. MRI Gallery - MRI Knee - Meniscal tears - Radiology Masterclass Nakajima T, Nabeshima Y, Fujii H, et al. Increased signal intensity at the anterior horn of the lateral meniscus was seen on the images of seven of the 11 MR studies of the volunteers. The purpose of our study was to determine if cysts of the ACL are the origin of cysts adjacent to the AHLM. The intrameniscal ligament where it diverges from the back of the anterior horn of the lateral meniscus is also a common area misinterpreted as a tear. collapse and widening of the medial joint space (Figure 7). The reported prevalence is 0.06% to 0.3%.25 The MFL was not observed in five (19%) of 26 studies of an LMRT. MR criteria are used to make the diagnosis. Fellowship-trained musculoskeletal radiologists read 99% of the MRIs. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. As a result, the accuracy rate of diagnosis by MRI is 83.3%. 36 year old male with history of meniscus surgery 7 years ago. Of the anterior horn tears read on MRI, 85% involved the lateral meniscus anterior horn and about one half were judged to extend into the middle or body of the same meniscus. Samoto N, Kozuma M, Tokuhisa T, Kobayashi K. Diagnosis of discoid lateral meniscus of the knee on MR imaging. Description. Their conclusion that one should not perform surgery unless clinical correlation exists with effusions, mechanical catching or locking, or the failure to respond to nonoperative measures I believe is a good recommendation that we can all follow. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. The congenitally absent meniscus appears to influence the development Advantages include a less invasive method of introducing intraarticular contrast, the ability to identify areas of hyperemic synovitis or periarticular inflammation based on enhancement and administration can be performed by the technologist. On the fat-supressed proton density-weighted coronal (17A) and axial (17B) images, notice the trapazoidal shaped bone bridge (arrow) placed in the tibial slot with menscal allograft attached at the anterior and posterior roots. Brody J, Lin H, Hulstyn M, Tung G. Lateral Meniscus Root Tear and Meniscus Extrusion with Anterior Cruciate Ligament Tear. meniscus is partial meniscal excision, leaving a 6- to 7-mm peripheral A preliminary report, Principles and decision making in meniscal surgery, The Anterior Meniscofemoral Ligament of the Medial Meniscus, Accurate patient history including site and duration of symptoms, Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. However, the use of MRI arthrography should be considered for post-operative menisci with equivocal findings on conventional MRI as the presence of high gadolinium-like signal within the meniscus would allow for a definitive diagnosis of re-tear. Neuschwander DC, Drez D Jr, Finney TP. Which meniscus is more likely to tear? Diagnostic performance is decreased following partial meniscectomy since the standard criteria used to diagnose a meniscus tear cannot be applied to the post-operative meniscus.3,4,5,6 Partial meniscectomy may distort the normal morphology of the meniscus and increased meniscal signal intensity may extend to the articular surface when a portion of the meniscus has been resected, simulating a tear. An abnormal shape may indicate a meniscal tear or a partial meniscectomy. 2. incomplete breakdown of the central meniscus, but this is now disputed, What is your diagnosis? The lateral meniscus attaches to the popliteus tendon and capsule via the popliteomeniscal fascicles at the posterior horn and to the medial femoral condyle by the meniscofemoral ligaments. Pullout fixation of posterior medial meniscus root tears: correlation between meniscus extrusion and midterm clinical results. Check for errors and try again. Shepard et al conclude that with a 74% false-positive rate, anterior horn tears should be treated surgically only if clinical correlation exists. On this page: Article: Epidemiology Pathology Radiographic features History and etymology A 23-year-old female presented with a 2-month history of catching and pain in the knee when arising from a squatting position. Mucinous degeneration of meniscus can also produce abnormal signal within a meniscus which does not contact an articular surface and should not be mistaken for a tear. At least one meniscofemoral ligament is present in 7093 % Of knees Their 74% false-positive rate I believe is accurate and one that we can incorporate mentally into our practice as we evaluate patients and the MRI scan results. There are Anterior Horn Meniscal Repair Using an Outside-In Suture Technique A detached posterior root is functionally equivalent to a total meniscectomy with loss of its ability to withstand hoop stress. If missing on MR images, a posterior root tear is present. Radial tears comprise approximately 15 % of tears in some surgical series [. Meniscal transplant is usually reserved for patients younger than 50 years who have normal axial alignment. Intact meniscal roots. variants of the meniscus are relatively uncommon and are frequently Meniscus Tear MRI Correlation | Radiology Key MR imaging is useful for evaluation of many possible complications following meniscal surgery. Comparison of Postoperative Antibiotic Regimens for Complex Appendicitis: Is Two Days as Good as Five Days? morphology. the example shown (Figures 1 and 2), the entire medial meniscus is The medial meniscus is more firmly attached to the tibia and capsule than the lateral meniscus, presumably leading to the increased incidence of tears of the medial meniscus [ 8, 11, 12 ]. 2020;49(1):42-49. Anatomic variability and increased signal change in this area are commonly mistaken for tears. 6 months post-operative she had increased pain prompting follow-up MRI. found that the absence of a line of increased signal through the meniscus extending to the articular surface on proton density and T2-weighted images was a reliable MRI finding for an untorn post-operative meniscus with 100% sensitivity. The example above illustrates marked degenerative changes caused by loss of meniscal function. is affected. The medial meniscus covers 60% of the medial compartment. Anterior lateral cysts extended . Papalia R, Vasta S, Franceschi F, D'Adamio S, Maffulli N, Denaro V. Meniscal Root Tears: From Basic Science to Ultimate Surgery. MR imaging and MR arthrography for diagnosis of recurrent tears in the postoperative meniscus. However, recognizing these variants is important, as they can PDF ssslideshare.com Kim EY, Choi SH, Ahn JH, Kwon JW. ligament will help to exclude these conditions.5 In the first Stay up to date with the latest in Practical Medical Imaging and Management with Applied Radiology. For DSR inquiries or complaints, please reach out to Wes Vaux, Data Privacy Officer, Acute partial interstitial to near complete anterior cruciate ligament tear is noted at its posterior end with femoral deep lateral sulcus sign. . It is possible that there could have been some tears missed at arthroscopy that were on the undersurface of the anterior horn, an area which is extremely difficultif not impossibleto visualize. The anterior horn of the menisci, especially the lateral meniscus, is an area commonly confused on MRI. Skeletal radiology. (PDF) Sensitivity and Specificity of MRI in Diagnosing Concomitant Youderian A, Chmell S, Stull MA. Monllau et al in 1998 proposed adding a fourth type, reported.4. 2019: Factors associated with bilateral discoid lateral meniscus tear in patients with symptomatic discoid lateral meniscus tear using MRi and X-ray Orthopaedics and Traumatology Surgery and Research: Otsr 105(7): 1389-1394 Lateral meniscus tears of the posterior root are a common concomitant injury to anterior cruciate ligament (ACL) tears [6, 16, 20]. They are most frequently seen at the posterior horn of the medial meniscus. The MRI showed complete ACL tear with displaced bucket handle medial meniscus tear. Normal shape and signal of the horns of the medial meniscus, with no evidence of tears or degenerations seen. The incidence was calculated based on arthroscopic findings, and the potential secondary signs of meniscal ramp tears were evaluated on MRI. menisci develop from this mesenchymal tissue in a site where this tissue Knee Surg Sports Traumatol Arthrosc 2011; 19:147157, Gwathmey F.W., Golish S.R., Diduch D.R., et al: Complications in brief: meniscus repair. However, this conjecture and others pre- highest.13,27,34,42 Tear locations, such as the posterior sented in literature are mostly speculative. Bucket-handle tear of the lateral meniscus: Flipped meniscus sign The condition is typically asymptomatic and, therefore, is infrequently diagnosed.14 70 year-old female with history of medial meniscus posterior horn radial tear. Objectives: Low-field MRI at 0.55 Tesla (T) with deep learning image reconstruction has recently become commercially available. anterior horn of the medial meniscus into the anterior cruciate ligament pretzels dipped in sour cream. What are the findings? Of the 45 patients who were interviewed and evaluated clinically without surgery at a minimum of 1 year, 32 reported continued pain but no mechanical symptoms suggestive of a meniscal tear. By continuing to use our site, you consent to the use of cookies outlined in our Privacy Policy. meniscus | Search | Radiopaedia.org 800-688-2421. The meniscal body is firmly attached to the deep portion of the medial collateral ligament complex via the meniscotibial ligament. . of the menisci can be summarized as providing: Clark and Ogden studied the natural development of the menisci in the The example above demonstrates the importance of baseline MRI comparison when evaluating the postoperative meniscus. Am J Sports Med 2017; 45:4249, ElAttar M, Dhollander A, Verdonk R, Almqvist KF, Verdonk P. Twenty six years of meniscal allograft transplantation: is it still experimental? In the U.S., intraarticular injection of gadolinium-based contrast is off label. Pathology - a tear that has developed gradually in the meniscus. The camera can visualize the meniscus and other structures within the knee. This emphasizes the importance of meniscal repair over meniscectomy when possible and the need for meniscal preservation when a partial meniscectomy is necessary. Most horizontal tears extend to the inferior articular surface. Shepard and colleagues at UCLA specifically analyzed this by reviewing 947 consecutive MRIs. Lateral Meniscus Tear | Tyler Welch, MD Tibial meniscal dynamics using three-dimensional reconstruction of magnetic resonance images. Arthroscopy: The Journal of Arthroscopic & Related Surgery. The meniscus root plays an essential role in maintaining the circumferential hoop tension and preventing meniscal displacement. MR imaging evaluation of the postoperative knee. In these cases, thin-section or well-placed axial images confirm that the tear is not a simple radial tear but rather a vertical flap tear (Fig. Discoid lateral meniscus of the knee joint: Nature, mechanism, and operative treatment. discoid lateral meniscus is a relatively uncommon developmental variant The anterior horn of the menisci, especially the lateral meniscus, is an area commonly confused on MRI. Posterior Horn Lateral Meniscus Tear | Knee Specialist | Minnesota Increased intrameniscal signal is commonly seen in the transplanted allograft but does not correlate with clinical outcome. It has been calculated that the lateral meniscus absorbs about 70% of the forces across the lateral compartment of the knee. The ideal technique for imaging the postoperative meniscus is a matter of active controversy and depends on the operation performed, surgeon preference and clinical question (concern for recurrent meniscal tear versus articular cartilage). The speckled appearance of the anterior horn of lateral meniscus is a feature that can be seen as a normal variant on MRI knee scans. as at no time in development does the meniscus have a discoid The anterior root of the lateral meniscus attaches to the tibia, just lateral to the midline and posterior to fibers of the anterior cruciate ligament (ACL). Total meniscectomy is rarely performed unless the meniscus is so severely damaged that no salvageable meniscal tissue remains. Discoid lateral meniscus: importance, diagnosis, and treatment Meniscal Roots: Current Concepts Review This case is almost identical to the previous case with a different clinical history. At the time the article was created Yuranga Weerakkody had no recorded disclosures. The incidence of lateral meniscus posterior root tears was approximately 4 times higher than of medial meniscus posterior root tears in both primary (12.2% vs 3.2%) and revision (20.5% vs 5.6%) ACLRs. Pinar H, Akseki D, Karaoglan O, et al. Medial meniscus bucket handle tears can result in a double PCL sign. Case study, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-75066. These tears are usually degenerative in nature and usually not associated with a discrete injury [. Sometimes T2 signal in a healed tear may look similar to fluid. As visualized on sagittal MR images, the anterior horn of the medial meniscus is shorter than the posterior horn, whereas the anterior and posterior horns of the lateral meniscus are of equal length. On examination, the patient had medial joint line tenderness with positive McMurray test. The same imaging criteria (as for the case of greater than 25% partial meniscectomy), the presence of fluid signal on T2-weighted or contrast extending into the meniscal substance is used to diagnose a recurrent tear. The most commonly practiced Lee, J.W. congenital anomalies affect the lateral meniscus, most commonly a noted to be diminutive, with the posterior horn measuring 7 mm to 8 mm. Monllau J, Gonzalez G, Puig L, Caceres E. Bilateral hypoplasia of the medial meniscus. They are usually due to an acute injury [. Twenty-one had ACL tears; all those with an PHLM tear had an ACL tear. Normal 2006;239(3):805-10. Unable to process the form. An intact meniscal repair was confirmed at second look arthroscopy. MRI features are consistent with torn lateral meniscus with flipped anterior horn superomedial and posterior, resting superior to the posterior horn. Methods Eighteen patients who had arthroscopically confirmed partial MMPRTs were included. Learn more. There Anatomic variability and increased signal change in this area are commonly mistaken for tears. The MRI revealed a vertical flap (oblique) tear of the medial meniscus. horn of the lateral meniscus, and oblique tear orientation In the present study, the patients analyzed came from the have been the most difficult for imaging planes to visualize same geographical area . Fat suppressed sagittal T1-weighted MR arthrogram (5C) demonstrates gadolinium within the tear (arrow). For partial meniscectomies involving 25% or more, conventional MRI has lower accuracy. is much greater than in a discoid lateral meniscus, and the prevalence 17. Bucket Handle Tear of Lateral Meniscus on MRI - A Case Report Stein T, Mehling AP, Welsch F, von EisenhartRothe R, Jger A. O'Donoghue unhappy triad | Radiology Case | Radiopaedia.org Repair techniques include side-to-side repair, stabilization with suture anchors, and the transtibial pull-out technique (figure 4).12. The medial meniscus is more firmly attached to the tibia and capsule than the lateral meniscus, presumably leading to the increased incidence of tears of the medial meniscus [ 8, 11, 12 ]. Sagittal proton density-weighted image (5B) through the medial meniscus at age 17 reveals an incomplete tibial surface longitudinal tear (arrow) in a new location and orientation. The medial meniscus is more firmly attached to the tibia and capsule than the lateral meniscus, presumably leading to the increased incidence of tears of the medial meniscus [. As such, I can count on my hands the number of isolated anterior horn meniscal tears that I have seen at surgery that I felt were symptomatic over the past 5 years. Examination showed lateral joint line tenderness and a positive McMurray sign. Dickhaut SC, DeLee JC. Flipped meniscus - anterior horn lateral meniscus | Radiology Case The articular cartilage is well seen on the pre-operative sagittal proton density-weighted image (19B). problem in practice. discoid meniscus, although discoid medial menisci can occur much less The anterior and posterior meniscofemoral ligaments (Humphrey and Wrisberg respectively) are commonly present with one or both found in 93-100% of patients. It can be divided into five segments: anterior horn, anterior, middle and posterior segments, and posterior horn. AJR American journal of roentgenology. No paralabral cyst. Meniscal root tear | Radiology Reference Article - Radiopaedia of the Wrisberg ligament in patients with a complete lateral discoid Shepard et al have done a nice job of telling us just how frequently this mistake can be made by fellowship trained musculoskeletal radiologists. Meniscus | Radiology Key Anterior horn of the lateral meniscus: another potential - PubMed It is believed that discoid Biologic augmentation with application of exogenous fibrin clot or growth factors may be combined with the repair to promote healing. MRI: When you tear your meniscus, a magnetic resonance imaging (MRI) scan will show the injury as white lines on black. 2012;20(10):2098-103. Bucket Handle Meniscal Tear - Diagnosis - MRI Online ; Lee, S.H. meniscal injury. Healed peripheral medial meniscus posterior horn repair and new longitudinal tear in a different location. asymptomatic, although there is a greater propensity for discoid menisci Repair techniques include inside-out, outside-in or all-inside approaches. However, few studies have directly compared the medial and lateral root tears. The patient failed conservative management of aspiration and cortisone injection. A meniscus is a crescent-shaped fibrocartilaginous structure that Imaging characteristics of the AJR Am J Roentgenol 2009;193:515-523. Root tears are often large radial tears that extend through the entire AP width of the meniscus. MRIs of BHT may have several characteristic appearances including (1) fragment in the notch sign; (2) double anterior horn sign, in which there is an additional meniscal fragment in the anterior joint on top of the native anterior horn; (3) the absent bow tie sign; (4) the double PCL sign, in which the centrally displaced fragment lies just anterior and parallel to the PCL giving the appearance of two PCLs; and (5) the coronal truncation sign, in which the free edge of the meniscal body appears clipped off on coronal images (Fig. [emailprotected]. Lateral meniscus bucket handle tears can produce the double anterior horn sign or double ACL sign. the medial meniscus. At the time the case was submitted for publication Mostafa El-Feky had no recorded disclosures. Thirty-one of these patients underwent subsequent arthroscopic evaluation to allow clinical correlation. Congenital discoid cartilage. The most important clinical concern at the time of MRI imaging is often high-grade articular cartilage loss. History of medial meniscus posterior horn partial meniscectomy. frequently. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. This is because most tears occur in the posterior horns [, Whether a torn meniscus is reparable depends on the type or pattern of tear, its location, and the quality of the meniscal tissue. typically into the anterior cruciate ligament. Indications for meniscal repair typically include posttraumatic peripheral (red zone) longitudinal tears located near the joint capsule, ideally in younger patients (less than 40). In this case, we can determine that there is a new tear in a different location. Criteria for a recurrent tear after greater than 25% meniscectomy Definite surfacing T2 fluid signal (or high T1 signal isointense to intra-articular gadolinium on MR arthrography) on 2 or more images or displaced meniscal fragment.17 Definite surfacing fluid signal on only one image represents a possible tear. In contrast to the medial meniscus, the posterior horn of the lateral meniscus is additionally secured by the meniscofemoral ligaments (MFL). Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Posterior Instability and Labral Pathology, Imaging Evaluation of the Painful or Failed Shoulder Arthroplasty, Other Entities: PLRI, HO, Triceps, and Plica, MRI-Arthroscopy Correlations in the Overhead Athlete, Acetabular Fossa, Femoral Fovea, and the Ligamentum Teres. The shape of the meniscus is formed at the eighth week of He presented after a few months with symptoms of instability. Br Med Bull. Meniscal root tears are defined as radial tears located within 1 cm from the meniscal attachment or a bony rootavulsion. The remaining 42 cases were located in the red zone (19 cases) or the red-white zone. Interested in Group Sales? Radial or oblique tear congurations close to or within the meniscus . Sagittal proton density-weighted image (9A) demonstrates no high signal abnormality. immediatly lateral to the anterior horn of lateral meniscus and posterior to the tubercle of anteriro horn of medial meniscus . Meniscus Tears: Understand your MRI results | Scott Hacker MD