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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