Knee - Meniscal pathology

Radiology department of the Washington University School of Medicine, St. Louis, USA and the Rijnland hospital in Leiderdorp, the Netherlands

by David Rubin and Robin Smithuis

Normal Meniscal Anatomy

Medial meniscus Both horns are triangular in shape and have very sharp points. The posterior horn is always larger than the anterior horn (figure). If this is not the case than the shape is abnormal, which can be a sign of a meniscal tear or a partial meniscectomy. Medial meniscus: The posterior horn is always larger than the anterior horn. The posterior root is immediately anterior to the posterior cruciate ligament. If it is missing on the sagittal images, then there is a meniscal root tear (figure). The anterior horn has an insertion on the tibia and a second portion that travels from medial to lateral to connect to the anterior horn of the lateral meniscus ( intermeniscal or transverse ligament).

LEFT: normal medial meniscal root immediately anterior to the posterior cruciate ligament. RIGHT: missing posterior root due to meniscal root tear.

Lateral meniscus On sagittal images the posterior horn is higher in position than the anterior horn. Both horns are about the same size.

Lateral meniscus. Both horns are about the same size. The lateral meniscus posteriorly comes up higher over the tibial spine to insert near the posterior cruciate ligament. This upward position of the posterior horn may be the reason for the higher signal intensity of the posterior horn in all planes due to magic angle effect.

Lateral meniscus: posterior horn and posterior meniscal root.

Meniscal tears

Criteria for tears The two most important criteria for meniscal tears are an abnormal shape of the meniscus and high signal intensityon PD-images unequivocally contacting the surface .

High signal intensity not unequivocally contacting surface. Small black line on inferior margin of the meniscus. At arthroscopy the meniscus was normal.

It is a misunderstanding that menisci should be homogeneously low in signal intensity on proton-density images. The meniscus does not have to be black. Only when the high signal unequivocally reaches the surface of the meniscus you can make the diagnosis of a tear. If there is doubt whether the high signal touches the surface, look at all the adjacent images and if there still is doubt than do not diagnose a tear. If you have a questionmark in your head, say meniscus is normal. (figure) Nomenclature of Meniscal Tears Shapes. There are 3 basic shapes of meniscal tears: longitudinal, horizontal and radial . Complex tears are a combination of these basic shapes.

Basic shapes: Longitudinal, Horizontal and Radial. Displaced Tears Bucket-handle tear = displaced longitudinal tear. Flap tear = displaced horizontal tear. Parrot beak = displaced radial tear.

Bucket handle, Horizontal Flap tear and Parrot beak. Longitudinal, horizontal and radial tears Longitudinal tears Longitudinal tears parallel the long axis of the meniscus dividing the meniscus in an inner and outer part. So the distance between the tear and the outer margin of the meniscus is always the same (figure). The tear never touches the inner margin.

Longitudinal tears follow the collagen bundles that parallel the contour of the meniscus. If a longitudinal tear has other components (horizontal or radial) than it is a complex tear violating the collagen bundles. This requires a higher energy trauma.

Three sagittal images of a longitudinal tear Longitudinal tear (2) Bucket handle tear is a displaced longitudinal

LEFT: abnormal shape of posterior horn. a piece is missing. RIGHT: displaced fragment in the intercondylar fossa. On coronal images bucket handle tears are easier to recognize. Normally there are only two structures in the intercondylar fossa: the anterior and posterior cruciate ligament. Any other structure in the intercondylar fossa is abnormal and a displaced meniscal fragment is the most likely possibility.

LEFT: meniscus is abnormal in shape and there is a displaced fragment. RIGHT: Three structures in intercondylar fossa: post cruciate lig (1), ant cruciate lig (2) and displaced fragment (3). Longitudinal tear (3) Flipped meniscus is a form of bucket handle tear. There is a capsular detachment or peripheral tear of the meniscus, usually the posterior horn. The posterior horn flippes over onto the anterior horn.

Flipped meniscus: posterior horn is missing because it is flipped over and located on top of the anterior horn.

Horizontal tear with a meniscal cyst

Horizontal tears Horizontal tears divide the meniscus in a top and bottom part (pitta bread). If horizontal tears go all the way from the apex to the outer margin of the meniscus they may result in the formation of a meniscal cyst. The synovial fluid runs through the horizontal tear and accumulates periferally to the meniscus. The connection with the joint space is often lost, so they will not fill with contrast on MR-arthrography. The synovial fluid is absorbed and is replaced by a gelatinous substance. There are 3 criteria for the diagnosis of a meniscal cyst: 1. Horizontal tear. 2. Fluid accumulation bright on T2. 3. Flat lining against the outside margin of the meniscus. The diagnosis of a meniscal cyst is important to the surgeon because it takes one operation on the outside of the knee to remove the cyst and another operation on the inside for the meniscus. Radial tears Radial tears are perpendicular to the long axis of the meniscus. They violate the collagen bundles that parallel the long axis of the meniscus. These are high energy tears. They start at the inner margin and go either partial or all the way through the meniscus dividing the meniscus into a front and a back piece. Radial tears are difficult to recognize. You have to combine the findings on sagittal and coronal images to make the diagnosis. The following combination of findings is diagnostic: In one plane: triangle missing the tip and in the other plane: a disrupted bow tie.

LEFT: triangle missing the tip. RIGHT: disrupted bow tie. Small radial tears are difficult to diagnose. Sometimes the only sign is a disrupted bow tie.

Disrupted bow tie indicating a small radial tear.

If you image a complete radial tear directly along the length of the tear you will see an absent or empty meniscus. These complete radial tears open up and give the impression that there is a part missing. However you will not find a displaced meniscal fragment. It is simply separation of the meniscal parts.

LEFT: Absent or empty meniscus on sagittal image. RIGHT: Axial image shows complete radial tear leading to a defect in the meniscus. Meniscal root tear A meniscal root tear is a radial tear located at the meniscal root. Normally when you image the posterior cruciate ligament on sagittal images you should see a considerable posterior horn of the meniscus on that image or the image adjacent to it. If this is not the case it is an absent or empty meniscus-sign indicating a radial tear.

Meniscal root tear: on sagittal images there is an absent or empty meniscus-sign adjacent to the posteior cruciate ligament where the meniscal root should be. On coronal images a meniscal root tear is confirmed.

Post-operative Menisci
Post-operative Menisci are harder to evaluate because the two most important criteria, i.e. abnormal signal and abnormal shape, do not work any more. Abnormal signal is not anymore a reliable sign of a tear, because if there has been a suture repair, this will heal with scar tissue, which also has high signal on PD-images (figure). However if there is also high signal on T2-weighted images than you can make the diagnosis of a tear as as this is the result of synovial fluid leaking into a tear. This however is an uncommon finding. Abnormal shape can be the result of partial meniscectomy. So you need to know what procedure was performed during arthroscopy. Only when you can compare with prior postoperative images, you can say if an abnormal shape is a new finding indicative of a new tear. Sometimes differation between normal post-op findings and a re-tear is not possible on conventional MR-images. In these cases MR-arthrography with 40cc diluted Gadolineum helps to make the distinction because even small amounts of Gadolineum that leak into a tear are readily visible on fat saturated T1 images.

PD and T2W images. Prior partial meniscectomy and suture repair. At arthroscopy no tear.

Post-operative Meniscus 1 The case on the left shows a meniscus with an abnormal shape aswell as abnormal signal touching the surface on PD but not on T2W-images. This patient had a prior partial meniscectomy and a suture repair. On the basis of these imaging findings it's impossible to tell if this is a tear or normal postoperative finding. This patient had another operation for ACL reconstruction. They also looked at the meniscus and the meniscus was found to be normal i.e. no tear. Post-operative Meniscus 2 This patient had a suture repair for meniscal tear. There was a new injury. On the new MR impossible to determine if the old tear had healed. However a new tear is seen, so this case ia easy.

LEFT: Old MR exam with tear. Patient had a suture repair. RIGHT: On new exam there is a new tear (yellow arrow). Not possible to tell if old tear has healed. On a MR-arthrogram there was very high signal intensity in the new tear comparable with the synovial fluid, but only moderate signal intensity at the healed old tear. So comparison with the old films was diagnostic for the new tear, while the arthrogram showed that the old tear has healed.

MR-arthrogram: In the new tear the signal is as bright as in the synovial fluid (yellow arrows). In the healed tear the signal is not as bright. Post-operative Meniscus 3 This patient also had a suture repair for meniscal tear. After a new injury the PD-images show high signal unequivocally reaching the surface of the meniscus (seen on the original films, but not clearly seen on the compressed image on the left. On this image it is not possible to tell if the tear has healed. So a MR-arthrogram was performed which showed that the tear has healed.

PD and MR-arthrogram after suture repair for meniscal tear: healed tear.