MRI of the Knee: Part 2 - menisci. Mark Anderson, M.D. University of Virginia Health System

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1 MRI of the Knee: Part 2 - menisci Mark Anderson, M.D. University of Virginia Health System

2 Learning Objectives At the end of the presentation, each participant should be able to: describe the normal anatomy of the menisci and the MR imaging appearance of each discuss the most common types of meniscal tears and list which are most important to the surgeon. recognize at least five imaging pitfalls that may mimic a meniscal tear on MR images.

3 Lecture Outline Normal anatomy / variants Meniscal tears radial / longitudinal / parrot beak / horizontal displaced Diagnostic pitfalls

4 Menisci Fibrocartilage Medial/Lateral Functions: Joint congruity Shock absorption Load transmission MED LAT

5 Menisci Segments anterior horn body A posterior horn B MED LAT A B P P

6 White Zone Red Zone

7 Medial Meniscus Larger C Post horn > ant horn Attached more tightly to the capsule Covers ½ contact surface of tibial plateau

8

9 Lateral Meniscus Tighter C Post horn = ant horn Attached more loosely to the capsule Popliteus tendon (fascicles) Covers ¾ contact surface of tibial plateau

10

11

12 Meniscus: anatomy and function Bullough, JBJS, 1970 Collagen bundles longitudinal radial ( tie fibers ) MED LAT

13 Meniscus: anatomy and function Cartilage protection shock absorption load distribution Hoop stresses Roots anterior/posterior anchors

14 Menisci: Attachments Tibia Capsule Ligaments

15 Meniscal Attachments: medial Tibia: roots Anterior largest footprint anterior tibial rim Posterior Medial and slightly ant to distal PCL PCL

16

17 Meniscal Attachments: medial Capsule firmly attached

18 Meniscal Attachments: medial Capsule firmly attached Deep fibers of MCL femoral limb to bone or superficial MCL tibial limb aka coronary ligament

19 Meniscal Attachments: lateral Roots Anterior adjacent to ACL fibers intermingle Posterior post to post-lat bundle of ACL

20

21

22 Meniscal Attachments: lateral Lateral attachments capsule popliteus hiatus fascicles anterior inferior posterior superior (posterior inferior) LM

23 Meniscal Attachments Meniscofemoral ligs PHLM MFC Wrisberg (post) Humphrey (ant) PCL LM

24 Meniscal Attachments Meniscofemoral ligs PHLM MFC Wrisberg (post) Humphrey (ant) Anteromedial M-F lig Soejima, Arthroscopy 2003 Coulier, JBR-BTR 2008 ant horn medial meniscus anterior notch

25

26 Menisci: attachments Transverse ligament ant horn ant horn

27 Menisci: variants Discoid enlarged meniscus embryologic, congenital? lateral > medial prone to tear types complete incomplete Wrisberg variant

28 Prone to tear - Sagittal: too many bow ties

29 Meniscus: meniscal ossicle Posterior horn MM cancellous bone Uncertain etiology vestigial? post-traumatic? root avulsion - PHMM May be symptomatic Imaging loose body

30 Gradient Echo

31 Meniscal Tear: MRI Abnormal Signal intensity Morphology

32 Meniscal Tear: MRI Signal Intensity Globular Linear Contact with articular surface (not capsular surface alone) TEAR

33 Meniscal Tear: MRI Morphology shape size blunted, truncated

34 Mensical Tears: types VERTICAL HORIZONTAL Radial Longitudinal

35 Meniscal Tear: radial Vertical Perpendicular to long axis across longitudinal bundles Unrepairable? always involve the white zone

36 Meniscal Tear: radial

37 Meniscal Tear: radial

38

39

40

41 Medial Meniscus: posterior root Attaches next to PCL tear releases posterior anchor Avulsion / tear quartet of findings root tear meniscal extrusion (> 3mm) cartilage loss insufficiency fracture (aka SONK)

42

43 Medial Meniscus: posterior root Repair? Depends on: patient s age acute vs. chronic articular cartilage College football player with hyperextension injury PCL Pull out repair Allaire R, JBJS(Am) 2008;90:

44 Meniscal Tear: longitudinal Longitudinal Vertical Along axis of meniscus Bucket handle displaced fragment medial meniscus locking

45 Longitudinal Tear: peripheral Vertical longitudinal Confined to outer 1/3 peripheral vascularized potential for healing / repair < 1 cm in length = conservative Rx > 1 cm = repair Often seen with ACL tears

46 Longitudinal Tear: peripheral In outer 1/3 in all planes Axial images may help 32 yr old male tore ACL while playing soccer Stable, no tear at time of arthroscopy May heal prior to surgery Peripheral Tear vs. Meniscocapsular Separation

47 Periph Tear vs. MC Separation

48 Meniscal Tear: parrot beak Combination radial + longitudinal oblique to long axis Meniscal Flap *

49 Meniscal Tear: horizontal Often degenerative Older patients May be asymptomatic

50 Meniscal Tear: horizontal Often degenerative Older patients May be asymptomatic Parameniscal cysts - often w/ horizontal tears - fluid extrudes through tear trapped at M-C junction cyst may recur if tear is not addressed

51 33M marathon runner

52 Bucket Handle Tear Small meniscus? Find the fragment

53 Displaced Tears Bucket handle Longitudinal tear displaced flap notch medial >>> lateral Coronal central fragment

54

55 Sagittal: Double PCL P

56 Bucket Handle Tear: variant Double bucket-handle tear second tear may be missed

57

58

59

60 Bucket Handle Tear: variant Hemi-bucket-handle tear fragment displaced into notch not vertical peripheral horizontal undersurface less amenable to repair Engstom, Skeletal Radiol, 2012

61 Horizontal tear: displaced fragment

62 Displaced Meniscal Tears Flipped posterior horn fragment 1 2 double anterior horn sign

63 Displaced Meniscal Tears: importance Bucket handle tear Flipped ant/post horn detected early - repair detected late plastic deformity Horizontal flap tear fragment may be missed at arthroscopy T

64 Meniscal Tear: Pitfalls Artifacts Patient motion Phase artifact (artery) Magic Angle Gas/hemosiderin Chondrocalcinosis PD

65 Meniscal Tear: Pitfalls Anatomy Transverse ligament Meniscofemoral liagments Oblique meniscomeniscal lig Lateral inf geniculate artery Popliteus tendon Edge artifact

66 Meniscal Tear: mimic Transverse ligament

67 Meniscal Tear: mimic Meniscofemoral ligament

68 If signal extends > 4 slices lateral to the PCL think tear Park LS, Skeletal Radiol 2007?

69 Meniscal Tear: mimic Oblique meniscomeniscal ligament ant horn one meniscus post horn of the other courses between cruciates may simulate BHT Displaced fragment? Sanders TG, Radiology 1999

70 Meniscal Tear: mimic Posterior root pseudotear? PCL

71 Meniscal Tear: mimic Lat inf geniculate vessels parallel lateral meniscus along its outer margin volume avg artifact may mimic obl meniscal tear

72 Meniscal Tear: mimic Semimembranosus tendon 5 arms anterior direct capsular inferior obl popliteal ligament Anterior arm may mimic displaced meniscal fragment

73 Summary: menisci Know the normal anatomy Signal intensity and morphology Small meniscus? Find the displaced fragment Become familiar with common pitfalls

74 What the Surgeon Wants to Know Peripheral Longitudinal Tear Radial tear Avulsion post root med meniscus Parameniscal cyst Flap tear / Bucket handle tear Good prognosis vs. M-C separation Poor prognosis Articular cartilage Look for horiz. tear Displaced tissue gutters / notch

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