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Management of Meniscal Tears w/ ACL Deficiency

- See:
     - meniscal injury
     - anterior cruciate ligament:
            - evaluation of ACL injuries:
            - bone patellar bone reconstruction:
            - hamstring reconstruction:
            - allograft reconstruction:

- Discussion:
    - note that the combination of ACL tear and meniscal tear is especially likely to contribute to instability, and early osteo-arthritis;
    - lateral meniscal tear:
            - in the acute setting, lateral meniscal tears can be up to 4 times more common than medial tears (ie lateral meniscus tears as a part of index injury);
            - ref: Meniscal injuries associated with acute anterior cruciate ligament tears in alpine skiers
    - medial meniscus
            - ACL tears combined w/ medial meniscal tears result in more anterior translation than lateral meniscal tears;
            - explains why medial meniscus tears occur as a long term consequence of ACL deficiency;
    - menisectomy in the ACL deficient knee:
          - menisectomy in the ACL deficient knee may lead to a significant increase in laxity;
          - partial menisectomy may increase peak loads upto 65% whereas total meniscectomy may increase peak loads upto 235%;
          - the radiographic consequences of total menisectomy have been characterized by Fairbank and include: joint space narrowing, squaring
                 of the condyle, and ridge formation;
          - references:
                 - Meniscectomy and repair in the anterior cruciate ligament-deficient patient.
                 - Arthroscopic meniscectomy in the anterior cruciate ligament-deficient knee.  
                 - Arthroscopic partial meniscectomy in the anterior cruciate deficient knee
                 - Results of meniscectomy in the knee with anterior cruciate ligament deficiency.
                 - Results of partial meniscectomy related to the state of the anterior cruciate ligament. Review at 20 to 35 years.
    - meniscal repair in the ACL deficient knee:
          - see techniques for meniscal repair;
                  - the best results in meniscal repair occur w/ concomitant ACL reconstruction;
          - indications:
                  - if tear is w/in 3 mm of the periphery, it is considered vascular; (see vascular anatomy)
                  - area 3-5 mm from periphery is grey zone, & > 5 mm from periphery is considered avascular;
                  - unstable tears or tears within vascular zone that are > 7 mm are repairable;
          - controversies: how to handle the locked bucket handle meniscal tear w/ concomitant ACL tear?
                 - Shelbourne KD and Johnson GE (1993), advocate staged treatment of concomitant bucket handle and ACL injuries;
                 - theoretical advantages of staged repair and reconstruction:
                        - more aggressive use of repair rather than removal of a displaced torn meniscus;
                        - prevention of problems in regaining range of motion;
                        - allows a second look to judge the success of meniscal repair;
                        - allows time for the patient to prepare for ACL reconstruction;
                 - references:
                        - Locked bucket-handled meniscal tears in knees with chronic anterior cruciate ligament deficiency.
                        - Arthroscopic evaluation of meniscal repairs after anterior cruciate ligament reconstruction and immediate motion.

Outcomes After Anterior Cruciate Ligament Reconstruction Using the Norwegian Knee Ligament Registry of 4691 Patients.
       How Does Meniscal Repair or Resection Affect Short-term Outcomes?

The Fate of Meniscus Tears Left In Situ at the Time of Anterior Cruciate Ligament Reconstruction

"Aggressive" nontreatment of lateral meniscal tears seen during anterior cruciate ligament reconstruction.

Treatment of the anterior cruciate ligament-absent knee with associated meniscal tears. Instrumented testing and clinical evaluation of two patient groups.

Double-blind assessment of the value of magnetic resonance imaging in the diagnosis of anterior cruciate and meniscal lesions.

Reconstruction of the anterior cruciate ligament using a torn meniscus.

The role of the meniscus in the anterior-posterior stability of the loaded anterior cruciate-deficient knee. Effects of partial versus total excision.

Meniscal lesions and chronic anterior cruciate ligament deficiency. Meniscal tears occuring before and after reconstruction.  
The natural history of the meniscus in anterior cruciate ligament insufficiency. Arthroscopic analysis.  

Meniscal injury in the anterior cruciate-deficient knee. A rationale for clinical decision-making.

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