72: Meniscal Injuries

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CHAPTER 72

Meniscal Injuries

Paul Lento, MD; Venu Akuthota, MD

Synonyms

Cartilage tears

Locked knee

ICD-9 Codes

717.3   Other and unspecified derangement of medial meniscus

717.4   Derangement of lateral meniscus

717.40  Derangement of lateral meniscus, unspecified

717.41  Bucket-handle tear of lateral meniscus

717.42  Derangement of anterior horn of lateral meniscus

717.43  Derangement of posterior horn of lateral meniscus

717.49  Derangement of lateral meniscus, other

717.5   Derangement of lateral meniscus, not elsewhere classified

717.9   Unspecified internal derangement of the knee

836.0   Acute tear of medial meniscus of knee

836.1   Acute tear of lateral meniscus of knee

ICD-10 Codes

M23.300  Other meniscus derangements, unspecified lateral meniscus, right knee

M23.301  Other meniscus derangements, unspecified lateral meniscus, left knee

M23.302  Other meniscus derangements, unspecified lateral meniscus, unspecified knee

M23.303  Other meniscus derangements, unspecified medial meniscus, right knee

M23.304  Other meniscus derangements, unspecified medial meniscus, left knee

M23.305  Other meniscus derangements, unspecified medial meniscus, unspecified knee

M23.306  Other meniscus derangements, unspecified meniscus, right knee

M23.307  Other meniscus derangements, unspecified meniscus, left knee

M23.309  Other meniscus derangements, unspecified meniscus, unspecified knee

S83.251   Bucket-handle tear of lateral meniscus, current injury, right knee

S83.252   Bucket-handle tear of lateral meniscus, current injury, left knee

S83.259   Bucket-handle tear of lateral meniscus, current injury, unspecified knee

Add seventh character to S83 for episode of care

M23.341  Meniscus derangements, anterior horn of lateral meniscus, right knee

M23.342  Meniscus derangements, anterior horn of lateral meniscus, left knee

M23.349  Meniscus derangements, anterior horn of lateral meniscus, unspecified knee

M23.351  Meniscus derangements, posterior horn of lateral meniscus, right knee

M23.352  Meniscus derangements, posterior horn of lateral meniscus, left knee

M23.359  Meniscus derangements, posterior horn of lateral meniscus, unspecified knee

M23.361  Other meniscus derangements, other lateral meniscus, right knee

M23.362  Other meniscus derangements, other lateral meniscus, left knee

M23.369  Other meniscus derangements, other lateral meniscus, unspecified knee

S83.241  Other tear of medial meniscus, current injury, right knee

S83.242  Other tear of medial meniscus, current injury, left knee

S83.249  Other tear of medial meniscus, current injury, unspecified knee

S83.281  Other tear of lateral meniscus, current injury, right knee

S83.282  Other tear of lateral meniscus, current injury, left knee

S83.289  Other tear of lateral meniscus, current injury, unspecified knee

Definition

The menisci serve important roles in maintaining proper joint health, stability, and function [1]. The anatomy of the medial and lateral menisci helps explain functional biomechanics. Viewed from above, the medial meniscus appears C shaped and the lateral meniscus appears O shaped (Fig. 72.1)[1]. Each meniscus is thick and convex at its periphery (the horns) but becomes thin and concave at its center. This contouring serves to provide a larger area for the rounded femoral condyles and the relatively flat tibia. Menisci do not move in isolation. They are connected by ligaments to each other anteriorly and to the anterior cruciate ligament, the patella, the femur, and the tibia [2,3].

f72-01-9781455775774
FIGURE 72.1 Superior view of medial and lateral menisci.

The medial meniscus is less mobile than the lateral meniscus. This is due to its firm connections to the knee joint capsule and the medial collateral ligament. This decreased mobility, in conjunction with the fact that the medial meniscus is wider posteriorly, is cited as the usual reason for the higher incidence of tears within the medial meniscus than within the lateral meniscus [1]. The semimembranosus muscle (through attachments from the joint capsule) helps retract the medial meniscus posteriorly, serving to avoid entrapment and injury to the medial meniscus as the knee is flexed [3]. The lateral meniscus is not as adherent to the joint capsule. Unlike the medial meniscus, the lateral meniscus does not attach to its respective collateral ligament. The posterolateral aspect of the lateral meniscus is separated from the capsule by the popliteus tendon. Therefore the lateral meniscus is more mobile than the medial meniscus [1,3]. The attachment of the popliteus tendon to the posterolateral meniscus ensures dynamic retraction of the lateral meniscus when the knee internally rotates to return out of the screw-home mechanism [2]. Therefore both the medial and the lateral menisci, by having attachments to muscle structures, share a common mechanism that helps avoid injury.

The architecture of the vascular supply to the meniscus has important implications for healing [1,4]. Capillaries penetrate the menisci from the periphery to provide nourishment. After 18 months of age, as weight bearing increases, the blood supply to the central part of the menisci recedes. In fact, research has shown that eventually only the peripheral 10% to 30% of the menisci, or the red zone, receives this capillary network (Fig. 72.2) [5]. Therefore the central and internal portion or white zone of these fibrocartilaginous structures becomes avascular with age, relying on nutrition received through diffusion from the synovial fluid. Because of this vascular arrangement, the peripheral meniscus is more likely to heal than are the central and posterolateral aspects [4].

f72-02-9781455775774
FIGURE 72.2 Vascular zones of the meniscus. Tears within the red zone have a higher healing potential.

The primary but not sole function of the menisci is to distribute forces across the knee joint and to enhance stability [1,68]. Multiple studies have shown that the ability of the joint to transmit loads is significantly reduced if the meniscus is partially or wholly removed [1,6,7,9]. Fairbank [10] published a seminal article in 1948 suggesting that the menisci are vital in protecting the articular surfaces. He reported that individuals who had undergone total meniscectomies demonstrated premature osteoarthritis.

Meniscal tears are classified by their complexity, plane of rupture, direction, location, and overall shape. Tears are commonly defined as vertical, horizontal, longitudinal, or oblique in relation to the tibial surface (Fig. 72.3)[11]. Most meniscal tears in young patients will be vertical-longitudinal, whereas horizontal cleavage tears are more commonly found in older patients [12]. The bucket-handle tear is the most common type of vertical (or longitudinal) tear [13] (Fig. 72.4). Tears are also described as complete, full-thickness or partial tears. Complete, full-thickness tears are so named as they extend from the tibial to femoral surfaces. In addition, medial meniscus tears outnumber lateral meniscus tears from 2:1 to 5:1 [14,15].

f72-03-9781455775774
FIGURE 72.3 Types of meniscal tears.
f72-04-9781455775774
FIGURE 72.4 Bucket-handle type of meniscal tear.

Meniscal injuries may result from an acute injury or from gradual degeneration with aging [16]. Vertical tears (e.g., bucket-handle tears) tend to occur acutely in individuals 20 to 30 years of age and are usually located in the posterior two thirds of the meniscus [13,17]. Sports commonly associated with meniscal injuries are soccer, football, basketball, baseball, wrestling, skiing, rugby, and lacrosse. Injury commonly occurs when an axial load is transmitted through a flexed or extended knee that is simultaneously rotating [16]. Degenerative tears, in contrast, are usually horizontal and are seen in older individuals with concomitant degenerative joint changes [13,18].

On the basis of arthroscopic examination, the majority of acute peripheral meniscal injuries are associated with some degree of occult anterior cruciate ligament laxity [19]. In addition, true anterior cruciate ligament tears are associated with lesions of the posterior horns of the menisci [19]. Lateral meniscal tears appear to occur with more frequency with acute anterior cruciate ligament injuries, whereas medial meniscal tears have a higher incidence with chronic anterior cruciate ligament injuries. With chronic anterior cruciate ligament injuries, the medial meniscus may be more frequently damaged because its posterior horn serves as an important secondary stabilizer of anterior-posterior instability [20].

Symptoms

The history will help diagnose a meniscal injury 75% of the time [12,21]. Young patients who experience meniscal tears will recall the mechanism of injury 80% to 90% of the time and may report a “pop” or a “snap” at the time of injury. Deep knee bending activities are often painful, and mechanical locking may be present in 30% of patients [22

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