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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. Bucket Handle Tear of Lateral Meniscus on MRI - A Case Report This mesenchymal A tear was found and the repair was revised at second look arthroscopy. The anterior horn inserts on the tibia and continues laterally to the anterior horn of the lateral meniscus via the transverse intermeniscal ligament. The location of meniscal tears or signal alterations (anterior/posterior horn or body of the medial/lateral meniscus) and the grade (normal/intra-substance signal abnormality = 0 and tear = 1) were determined on 2D . You can use Radiopaedia cases in a variety of ways to help you learn and teach. Illustration of the medial and lateral menisci. On MRI, they resemble radial tears, with a linear cleft of abnormal signal seen at the free edge. The patient underwent partial medial meniscectomy and ACL reconstruction. Lee, J.W. Magn Reson Imaging Clin N Am 2014;22(4): 517555, White LM, Schweitzer ME, Weishaupt D, Kramer J, Davis A, Marks PH. discoid lateral meniscus is a relatively uncommon developmental variant Discoid lateral meniscus APPLIED RADIOLOGY Comparison of Medial and Lateral Meniscus Root Tears - PLOS in this case were attributed to an anterior cruciate ligament tear Diagnosis of recurrent meniscal tears: prospective evaluation of conventional MR imaging, indirect MR arthrography, and direct MR arthrography. typically into the anterior cruciate ligament. rim circumferentially, anteriorly, and posteriorly,19 which Indirect MR arthrography is less commonly used and relies on excretion of intravascular gadolinium into the joint through synovial cells after intravenous administration of gadolinium contrast 20-90 minutes prior to the MRI exam. Absence of the meniscus results in a 200 to 300% increase in contact stresses on the articular surfaces.8The meniscus has a heterogeneous cellular composition with regional and zonal variation, with high proteoglycan content at the thin free edge where compressive forces predominate and low proteoglycan content at the thicker peripheral region where circumferential tensile loads predominate. . is much greater than in a discoid lateral meniscus, and the prevalence Anterior lateral cysts extended . no specific MR criteria for classifying discoid medial menisci, and the slab-like configuration on sagittal MR images, with > 3 bowties Similarly, the postoperative meniscus is at increased risk for a recurrent tear either at the same or different location due redistribution of forces and increased stress on the articular surface. attachment of the posterior horn is the Wrisberg meniscofemoral A tear of the lateral meniscus can occur from a sudden injury, or from chronic wear and overload. Thompson WO, Thaete FL, Fu FH, Dye SF. Sagittal proton density-weighted image (9A) demonstrates no high signal abnormality. CT arthrography is recommended for patients with MRI contraindications or when extensive susceptibility artifact from hardware obscures the meniscus. Meniscal Roots: Current Concepts Review measurements of the posterior horn of the medial meniscus may vary, but This is a critical differentiation because the latter represents meniscal tears that can be OITE 7 Flashcards | Chegg.com To assess the prevalence of meniscal extrusion and its . Interested in Group Sales? Definite surfacing signal or distortion on only one image represents a possible tear. Of these 45 patients, there was an average of 3.74 additional pathological conditions noted on the MRI scan, mainly including degenerative arthrosis or patellar chondromalacia to explain the patients continued pain. Note that signal does not contact articular surface, The most common criterion for diagnosing meniscus tear on MRI is an increased signal extending in a line or band to the articular surface. In children, sometimes an increased signal is seen within meniscus due to increased vascularity, but usually the signal does not contact articular surface. The examiner can test the entire posterior horn up to the middle segment of the meniscus using the IR of the tibia followed by an extension. anterior horn of the medial meniscus into the anterior cruciate ligament Connolly B, Babyn PS, Wright JG, Thorner PS. Meniscal root tears are a type of meniscal tear in the knee where the tear extends to either the anterior or posterior meniscal root attachment to the central tibial plateau. Studies on meniscus root tears have investigated the relationship of osteoarthritis and an anterior cruciate ligament tear. Results: Arthroscopic examination of the anterior horn of the lateral meniscus in all 22 patients was normal. The anterior and posterior meniscofemoral ligaments (Humphrey and Wrisberg respectively) are commonly present with one or both found in 93-100% of patients.9 The lateral meniscus is more loosely attached than the medial and can translate approximately 11mm with normal knee motion.10. Davidson D, Letts M, Glasgow R. Discoid meniscus in children: Treatment and outcome. Footballer's Lateral Meniscus: Anterior Horn Tears of the Lateral Check for errors and try again. The example above demonstrates the importance of baseline MRI comparison when evaluating the postoperative meniscus. 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. 1. Type 1: A complete slab of meniscal tissue with complete tibial coverage. Bilateral discoid medial menisci: Case report. These tears are usually degenerative in nature and usually not associated with a discrete injury [. runs from the anterior horn of the medial meniscus to either the ACL or Also, the inferior patella plica inserts on the (Figure 1). tissue only persists at the edges, where differentiation into the Sagittal proton density-weighted image (5A) through the medial meniscus at age 12 shows the initial horizontal tear in the posterior horn (arrow) subsequently treated with partial meniscectomy. Dr. Michael Gabor answered Diagnostic Radiology 35 years experience No,: It doesn't sound like a bucket handle tear The condition is typically asymptomatic and, therefore, is infrequently diagnosed.14 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. Intensity of signal contacting meniscal surface in recurrent tears on MR arthrography compared with that of contrast material. Congenital discoid cartilage. 7 Therefore, it is important for the radiologist to be familiar with the appearance of a recurrent tear versus an untorn postoperative meniscus. There He presented after a few months with symptoms of instability. On MRI, they exhibit abnormal horizontal linear signal contacting the inferior articular surface near the free edge or less commonly the superior surface. posterior fascicles and meniscotibial ligament are absent and a high 2006; 88:660667, Boutin RD, Fritz RC, Marder RA. The meniscus is two crescent-shaped, thick pieces of cartilage that sit in the knee between the tibia and the femur. No meniscal tear is seen, but the root attachment was also noted to be Radial tears comprise approximately 15 % of tears in some surgical series [. Neuschwander DC, Drez D Jr, Finney TP. Copy. The anterior horn of the menisci, especially the lateral meniscus, is an area commonly confused on MRI. Discoid medial meniscus. On examination, there was marked medial joint line tenderness and a large effusion. 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. Objective Parameniscal cysts have a very high association with meniscal tears in all locations except the anterior horn lateral meniscus (AHLM). Extrusion is commonly seen following root repair. Close clinical correlation is advised before recommending surgery based on this finding alone. Grade II hyperintense horizontal signal of posterior horn of medial meniscus is noted. patella or Hoffas fat pad, and should be fairly easily differentiated MR imaging evaluation of the postoperative knee. Associated anomalies in a discoid medial After failing conservative management with NSAIDs, PT, and activity modification, he underwent an MRI. Medial meniscus posterior horn peripheral longitudinal tear treated with repair. In Medial meniscus posterior horn peripheral longitudinal tear (arrow) seen on the sagittal proton density-weighted image (15A) and managed by repair. A meniscus is a crescent-shaped fibrocartilaginous structure that Lateral Meniscus Root Tear and Meniscus Extrusion with Anterior MRI c spine / head jxn - they can have stenosis of foramen magnum . (as previously described), meniscal cyst,26 discoid lateral meniscus in the same knee (Figure 9),25 and pathologic medial patella plica.27. The meniscus is diffusely vascularized in early life but in adults, only 10-30% of the peripheral meniscus is vascularized, often referred to as the red zone. the medial meniscus. Incidence and Detection of Meniscal Ramp Lesions on Magnetic Resonance Monllau et al in 1998 proposed adding a fourth type, 10 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. occur with minor trauma. congenital anomalies affect the lateral meniscus, most commonly a was saddle shaped. Recent evidence suggests that decreased extrusion may correlate to better clinical outcomes.18. It is important to know the age of the patient when interpreting the MRI. Healed peripheral medial meniscus posterior horn repair and new longitudinal tear in a different location. Figure 8: Medial oblique menisco-meniscal . signal fluid cleft interposed between the posterior horn and the capsule However, this conjecture and others pre- highest.13,27,34,42 Tear locations, such as the posterior sented in literature are mostly speculative. Note the symmetrical shape of the lateral meniscus (left) with similar size of the anterior and posterior horns. insertion of the medial meniscus (AIMM) has been described, and it is [emailprotected]. Mechanical rasping or trephination of the torn meniscus ends and parameniscal synovium is used to promote bleeding and vascular healing. 1427-143. Magnetic resonance imaging (MRI) of both knee joints showed an almost complete absence of the anterior and posterior horns of the medial meniscus, except for the peripheral portion, hypoplastic anterior horns and tears in the posterior horns of the lateral meniscus in both knees (Fig. Clark CR, Ogden JA. seen on standard 4- to 5-mm slices.21 The Wrisberg ligament may also be thick and high in patients with a complete discoid lateral meniscus.22 Other criteria used to diagnose lateral discoid meniscus include the following: In the A Am J Sports Med 2010; 38:15421548, LaPrade RF, Matheny LM, Moulton SG, James EW, Dean CS. They often tend to be radial tears extending into the meniscal root. At the time the article was created Yuranga Weerakkody had no recorded disclosures. are reported cases of complete absence of the medial meniscus as On this page: Article: Epidemiology Pathology Radiographic features History and etymology Clinical Examination in the Diagnosis of Anterior Cruciate : JAAOS However, few studies have directly compared the medial and lateral root tears. Lateral meniscus posterior horn peripheral longitudinal tear managed by repair. 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. Media community. PRIME PubMed | Posterior horn lateral meniscal tears simulating AJR Am J Roentgenol. Singh K, Helms CA, Jacobs MT, Higgins LD. the intercondylar notch, most commonly to the mid ACL, and less commonly Sagittal T2-weighted (18B) and fat-suppressed sagittal proton density-weighted sagittal (18C) images demonstrate fluid-like signal in the posterior horn suggestive of a recurrent tear. Stay up to date with the latest in Practical Medical Imaging and Management with Applied Radiology. Surgical Outcomes Lysholm Score MRI of the knee is commonly indicated for evaluation of unresolved or recurrent knee pain following meniscal surgery. Lateral Meniscus - ProScan Education - MRI Online Br Med Bull. Conventional MRI is useful for evaluation of posterior root morphology at the tibial tunnel fixation site, meniscal extrusion and articular cartilage. Both the healed peripheral tear and the new central tear were proved at second look arthroscopy. 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. The Wrisberg variant may present with a Become a Gold Supporter and see no third-party ads. Discoid lateral meniscus: Prevalence of peripheral rim instability. At the time the case was submitted for publication Mostafa El-Feky had no recorded disclosures. noted to be diminutive, with the posterior horn measuring 7 mm to 8 mm. MRI appearance of Wrisberg variant of discoid lateral meniscus. (PubMed: 17114506), BakerJC, FriedmanMV, RubinDA (2018) Imaging the postoperative knee meniscus: an evidence-based review. Bucket-handle tear of the lateral meniscus: Flipped meniscus sign hypoplastic meniscus was not the cause of the patients pain, suggesting What is a Grade 3 meniscus tear? On the sagittal fat-suppressed T2-weighted image (7B), fluid extends into the tear. Lateral Meniscus: Anatomy The lateral meniscus is seen as a symmetric bow tie in the sagittal plane on at least one or two sections before it divides into two asymmetric triangles near the midline. The torn edges are aligned, and stable fixation applied with sutures or bioabsorbable implants at approximately 5 mm intervals. Klingele KE, Kocher MS, Hresko MT, et al. 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. Pathology - a tear that has developed gradually in the meniscus. {"url":"/signup-modal-props.json?lang=us"}, El-Feky M, Flipped meniscus - anterior horn lateral meniscus. At 1 year, 5 of 6 were completely asymptomatic with the remaining patient minimally painful with no suggestion of meniscal symptoms. of these meniscal variants is the discoid lateral meniscus, and the The anterior root of the medial meniscus attaches to the anterior midline of the tibial plateau or sometimes the anterior surface of the tibia just below the plateau. Variations in meniscofemoral ligaments at anatomical study and MR imaging. On MR arthrography, (12B), gadolinium extends through the repair site indicating a tear. 1 ). Most patients are asymptomatic, but injury to the meniscus can Indications for meniscal repair typically include posttraumatic peripheral (red zone) longitudinal tears located near the joint capsule, ideally in younger patients (less than 40). History of a longitudinal medial meniscus tear managed by repair and concurrent ACL reconstruction. Download Musculoskeletal MRI by Nancy Major, Mark Anderson Illustration of the transtibial pullout repair for a tear of the posterior horn medial meniscal root (arrow). These findings are also frequently associated with genu The articular cartilage is well seen on the pre-operative sagittal proton density-weighted image (19B). The meniscal repair is intact. ligament and meniscal fascicles. 7.2 Medial and Lateral Menisci Medial meniscus is larger than the lateral meniscus and is more "open" (=less C-like) and less wide. Thus, the loss of the lateral meniscus can often lead to rather rapid onset of osteoarthritis. does not normally occur.13. 2002; 222:421429, Ciliz D, Ciliz A, Elverici E, Sakman B, Yuksel E, Akbulut O. Root tears are associated with a high risk for osteoarthritis. from AIMM. Examination of the knee showed a mild effusion, 1+ Lachman, positive Pivot shift, and mild tenderness to both medial and lateral joint lines. ; Lee, S.H. When interpreting MR images of the knee, it is important to assess for any change from the expected shape of the menisci. posterior horn usually measures 12 mm to 16 mm in the sagittal plane in St. Louis County's newspaper of politics and culture least common is complete congenital absence of the menisci. While this test will show a tear up to 90% of the time, it does not always. Clinical History: An 18 year-old male with a history of a posterior horn medial meniscus peripheral longitudinal tear treated with meniscal repair at age 16 presents for MR imaging. An abnormal shape may indicate a meniscal tear or a partial meniscectomy. By comparison, the complication rate for ACL reconstruction is 9% and PCL reconstruction is 20%.20 Potential complications associated with arthroscopic meniscal surgery include synovitis, arthrofibrosis, chondral damage, meniscal damage, MCL injury, nerve injury (saphenous, tibial, peroneal), vascular injury, deep venous thrombosis and infection.21 Progression of osteoarthritis and stress related bone changes are seen with increased frequency in the postoperative knee, particularly with larger partial meniscectomies. Meniscus Tears: Understand your MRI results | Scott Hacker MD When it involves the posterior root, medial root tears are easier to diagnose than lateral root tears. Relevant clinical history, prior imaging and use of operative reports will significantly improve accuracy of post-operative interpretations. This case features the following signs of meniscal tear: Case courtesy, Prof. Dr. Khaled Matrawy, Professor of radiology, Alexandria university, Egypt. Clin Orthop Relat Res 2013; 471: pp. Total meniscectomy is rarely performed unless the meniscus is so severely damaged that no salvageable meniscal tissue remains. Meniscal transplants can fail at the implantation site by avulsion, failure of bone plug incorporation or bone bridge fracture. morphology but lacks its posterior attachments; ie, the meniscotibial (1A) Proton density-weighted, (1B) T2-weighted, and (1C) fat-suppressed T1-weighted MR arthrographic sagittal images are provided. Sagittal T2-weighted (8B) and fat-suppressed coronal T2-weighted (8C) images reveal fluid signal (arrows) extending into the meniscal substance indicating a recurrent tear which was confirmed at second look arthroscopy. Association of Parameniscal Cysts With Underlying Meniscal Tears as Anterior horn lateral meniscus tear A female asked: Mri: "macerated anterior horn lateral meniscus with inferiorly surfacing tear. Semin Musculoskelet Radiol 2005;9(2):11624, Chung KS, Ha JK, Ra HJ, Nam GW, Kim JG. Pseudotear Sign of the Anterior Horn of the Meniscus mesenchymal mass that differentiates into the tibia, femur, and Imaging characteristics of the 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. The trusted source for healthcare information and CONTINUING EDUCATION. Efficacy of Arthroscopic Treatment for Concurrent Medial Meniscus Shepard and colleagues at UCLA specifically analyzed this by reviewing 947 consecutive MRIs. Kim SJ, Choi CH. This is a well-done study with clinical correlation and adequate follow-up. Skeletal radiology. meniscus are not uncommon; they include an anomalous insertion of the A detached posterior root is functionally equivalent to a total meniscectomy with loss of its ability to withstand hoop stress. At the time the article was last revised Yahya Baba had The insertion site 70 year-old female with history of medial meniscus posterior horn radial tear. Partial meniscectomy is by far the most common procedure. 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 lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. treatment for stable complete or incomplete types of discoid lateral 4. They often tend to be radial tears extending into the meniscal root. The clinical significance of anterior horn meniscal tears diagnosed on magnetic resonance images. These features constitute O'Donoghue unhappy triad. 2013;106(1):91-115. Another MRI was later performed due to worsening symptoms, and demonstrated a bucket-handle tear with complete anterior luxation of the posterior horn of the left lateral meniscus (Figs. posterior horn of the medial meniscus include a triangular hypointense Congenital absence of the meniscus is extremely rare and has been documented in TAR syndrome and in isolated case reports.2,3 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. Direct and indirect MR arthrography have been shown to be superior to conventional MRI for detection of recurrent meniscal tears in greater than 25% partial meniscectomies and meniscal repairs; however, conventional MRI is commonly used for initial evaluation of the postoperative meniscus with MR arthrography reserved for equivocal cases. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. Meniscal root tear | Radiology Reference Article - Radiopaedia proximal medial tibia was convex and the distal medial femoral condyle 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. Renew or update your current subscription to Applied Radiology. The post arthrogram view (13B) reveals gadolinium within the repair site. Torn lateral meniscus with superomedial and posterior flipped anterior horn. Complete radial tears, root tears and large partial meniscectomies result in markedly increased contact forces at the articular surface; and in this case, full-thickness chondral loss and subchondral fractures on both sides of the joint. Horizontal (degenerative) tears run relatively parallel the tibial plateau. An algorithm for computing tear meniscus profile MR criteria for discoid lateral menisci are used for discoid medial Flipped meniscus - anterior horn lateral meniscus | Radiology Case Meniscus tears are either degenerative or acute. in 19916. This arises from the posterior horn of the lateral meniscus and attaches to the lateral aspect of the medial femoral condyle. MRI plays a critical role in influencing the treatment decision and enables information that would obviate unnecessary surgery including diagnostic arthroscopy. This case is almost identical to the previous case with a different clinical history. Knee Surg Sports Traumatol Arthrosc. Conventional MRI imaging correlates well with arthroscopic evaluation of the transplants for tears of the posterior and middle thirds of the meniscus allograft with a high sensitivity, specificity and accuracy, but results were poor for evaluation of the anterior third with a low specificity and accuracy.16 Allograft shrinkage and meniscus extrusion are common findings on postoperative MRI but do not always correlate with patient pain and function. Methods Eighteen patients who had arthroscopically confirmed partial MMPRTs were included. Biologic augmentation with application of exogenous fibrin clot or growth factors may be combined with the repair to promote healing. Symptomatic anomalous insertion of the medial meniscus. There is a medial and a lateral meniscus. mimicking an anterior horn tear. is affected. When bilateral, they are usually symmetric. joint: Morphologic changes and their potential role in childhood On the sagittal proton density-weighted image (11A), signal contacts the tibial surface. as at no time in development does the meniscus have a discoid Repair techniques include side-to-side repair, stabilization with suture anchors, and the transtibial pull-out technique (figure 4).12. 1991;7(3):297-300. Posterior meniscal root repairs: outcomes of an anatomic transtibial pull-out technique. MRI showed posterior horn of the medial meniscus (PHMM) horizontal tear with early degenerative changes. MRI features are consistent with torn lateral meniscus with flipped anterior horn superomedial and posterior, resting superior to the posterior horn. for the ratio of the sum of the width of the anterior and posterior Regardless of the imaging protocol chosen for evaluation of the postoperative meniscus, optimal imaging interpretation includes: The normal MRI appearance after partial meniscectomy is volume loss and morphologic change, commonly truncation or blunting of the meniscal free edge. Tears can be characterized by length, depth, shape, gap, displacement, stability, dysplasia (discoid) show cupping of the medial tibial plateau, proximal medial tibial physis 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. It can be divided into five segments: anterior horn, anterior, middle and posterior segments, and posterior horn. The lateral meniscus is more circular with a shorter radius, covering 70% of the articular surface with the anterior and posterior horns approximately the same size. Case study, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-75066.