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BLOG: A teenage patient with a concurrent meniscal injury with ACL tear
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Meniscal tears frequently occur concomitantly with acute and chronic ACL tears. The reported incidence of concurrent ACL and meniscal tears have ranged from 16% to 82% in acute ACL tears and up to 96% in chronic ACL tears. In acute ACL tears, the lateral meniscus is more often injured while the medial meniscus is more commonly injured in chronic tears.
A variety of meniscal tear patterns have been described in association with ACL tears. Meniscocapsular separation, radial tears and meniscal root tears have been shown to cause increased joint laxity, increased cartilage contact pressure, decreased tibiofemoral contact area and contribute to abnormal knee kinematics that lead to early arthritis. Cadaveric biomechanical evaluation of meniscal repairs with ACL reconstruction have been shown to restore these abnormalities and, as such, repair of the meniscus should be performed in patients undergoing ACL reconstruction.
Case
A 14-year-old male patient who is a running back sustained a right knee buckling event while performing a cutting maneuver. He was initially diagnosed by an outside provider with a hamstring strain. A week later, he returned to play and sustained another non-contact buckling event and removed himself from the game. The patient presented to our clinic 3 weeks after the index event after having obtained radiographs and MRI. On exam, the knee was in normal alignment, had an effusion, a positive Lachman, a pivot shift and anterior drawer. The knee had a negative posterior drawer, and was stable to varus and valgus stress at full extension and at 30° of flexion. He had tenderness to palpation along the lateral joint line with a negative bounce home and McMurray test.
Radiographs (Figure 1) revealed a deep lateral femoral notch sign. MRI revealed an ACL tear and a lateral meniscal tear (Figures 2 and 3).
Figure 2. Coronal T2 MRI with lateral meniscal tear is shown.
Figure 3. Lateral T2 MRI with lateral meniscal tear is shown.
Surgery
An epiphyseal ACL reconstruction using hamstring autograft with allograft and lateral meniscal repair was planned. Diagnostic arthroscopy was performed, and the ACL was visualized to be ruptured from the femur (Figure 4). The medial compartment of the knee was unremarkable. The lateral compartment revealed a grade 2 chondral lesion of the lateral femoral condyle, a grade 2 chondral lesion of the lateral tibial plateau, as well as a 1-cm defect of the lateral meniscus at the popliteal hiatus (Figure 5). In addition, a lateral meniscocapsular separation had occurred near the posterior meniscal root. The meniscal edges were unable to be reapproximated due to the meniscal defect. The meniscocapsular separation was repaired using an all-inside technique. The ACL was reconstructed according to the surgical plan (Figure 6).
Figure 4. An ACL tear is shown.
Figure 5. Lateral meniscal tear with grade 2/3 bipolar lesion of the articular cartilage is shown.
Figure 6. The ACL reconstruction is shown.
Discussion
Loss of meniscal tissue can result in pain, decreased joint stability, abnormal kinematics and irreversible joint damage. Therefore, meniscal tissue should be preserved whenever possible. Meniscal replacement should be considered when more than 25% of the meniscal tissue has been lost to prevent or minimize the development of osteoarthritis. Two applicable methods for meniscus substitution are allograft transplantation and repair with a collagen meniscus scaffold. However, use of these techniques in the acute setting have not yet been described.
Questions posed
What would you do for the chondral lesions? How would you address the missing meniscal tissue in this 14-year-old active male patient? Would you perform a lateral meniscal allograft or a collagen meniscus implant? Would you do this during the ACL reconstruction or wait until the patient becomes symptomatic? What other options do you have to offer this patient? What would you tell him about returning to sporting activities?
Matthew H. Blake, MD, is an orthopedic sports medicine fellow at the University of Kentucky Sports Medicine Program. Darren L. Johnson, MD, is professor and chairman of the Department of Orthopaedic Surgery and director of Sports Medicine at the University of Kentucky School of Medicine in Lexington, Ky.
Disclosures: Blake and Johnson report no financial disclosures.
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