Copyright

1989

Non-Operative
BY

CARL

KENNETH

B.

WEISS,

E.

DEHAVEN,
From

M.D.t,

MAGNUS

ROCHESTER,

the Department
and

of Bone and Join:

Treatment

ROCHESTER,

M.D.t,

by The Journal

YORK,

M.D.t,

AND

University

of Orthopaedic

Incorporated

of Meniscal

LUNDBERG,

NEW

of Orthopaedics,

the Department

Surgery.

JAN

PER

HAMBERG,

GILLQUIST,

of Rochester

Surgery,

Tears*

Medical

University

M.D.,

M.D.1,
Center,

Hospital.

LINKOPING,

LINKOPING,

SWEDEN

Rochester.

Linkoping

ABSTRACT:
In a retrospective
review of the results
of 3,612 arthroscopic
procedures
that were performed
for the treatment
of an acute or a chronic
meniscal
lesion, with or without
an associated
ligamentous
lesion,
we identified
eighty meniscal
tears (in seventy-five
patients)
that had been assumed
to be stable. Seventy were
vertical
longitudinal
tears and ten were vertical
radial
tears. The seventy
longitudinal
tears included
fifty-two
lateral and eighteen
medial meniscal
lesions.
All of the
radial tears were in the lateral meniscus.
Of the seventyfive patients,
fifty-two
had been followed
for two to ten
years. At the time of follow-up,
only six of these fiftytwo patients
had needed additional
intervention
because
of symptoms
that were related to the meniscal
tear. Four
of them had the intervention
after a sports-related
traumatic extension
of a stable tear, and two, because
per-

have great potential

for healing.
The tear should be left
alone unless it is the only abnormality
that is found and

sistent

meniscectomy
than they do in the contralateral,
knees7.
Finally,
degenerative
changes
develop
frequently in knees that have had a meniscectomy

symptoms

were caused

by the original

meniscal

lesion.
A repeat

arthroscopy

was performed

on thirty-two
tear and

patients (twenty-six
of whom had a longitudinal
six of whom had a radial tear), at an average

of twenty-

six months
after the original
arthroscopy.
Seventeen
of
the twenty-six
longitudinal
tears had completely
healed.
Five of the six radial tears had no evidence
of healing
and one had extended.
Neither ligamentous
laxity nor a
meniscal
tear that was chronic
at the time when it was
discovered
appeared
to preclude
healing
of the stable
longitudinal
tears. No localized
degenerative
changes
in
the adjacent
articular
cartilage
were found in association
with any of the stable
vertical
longitudinal
or radial
meniscal
lesions.
Excluding
the six patients
who had had additional
surgical
treatment,
none of the fifty-two
patients
who
filled out a questionnaire
reported
that they had symptoms of a meniscal
lesion,
and none of the forty-two
patients
who were re-examined
two years or more after
the operation
had signs of a meniscal
lesion.
Stable vertical longitudinal
tears, which tend to occur in the peripheral
vascular
portions
of the menisci,

it

is causing

Recent

No benefits

in any

form

have

been

received

or will

be received

from

a commercial
party related
directly
or indirectly
to the subjectofthis
article.
No funds were received
in support
of this study.
t Department
of Orthopaedics,
University
of Rochester
Medical
Center, 601 Elmwood
Avenue,
P.O.
Box 665, Rochester,
New York 14642.
Department
of Orthopaedic
Surgery,
University
Hospital,
S-58 186
Linkoping,
Sweden.

VOL.

71-A,

NO. 6. JULY

1989

long-term

that degenerative
that

that

warrant

have

follow-up

changes

had

contralateral

treatment.

a total

knees

times

more

often

investigations

develop

Stable

more

meniscectomy

have

shown

frequently
than

in knees

they

do

in the

in which the menisci are found to be

Radiographic
and clinical studies have

intactu
1.16.18.19,30
also shown
that degenerative
in knees

changes
that

develop

have

associated
ligamentous
instability92
Biomechanical
studies
have
have
important
load-transmitting

been

four

treated

to seven
by partial

unaffected
even more
and have

#{176}.

shown
and

that the menisci

energy-absorbing

functions2192025272933.
They carry 30 to 70 per cent of the
total load that is transmitted
across
the knee joint.
They do
so even when they are torn, provided
that the peripheral
circumferential
provide
passive
sue restraints

fibers are intact21272833.

The menisci
also
stability,
functioning
as secondary
soft-tisthat

prevent

anterior

displacement

of the tibia

on the femur3.
The

blood

supply

of the menisci

has

The

potential

for healing

of tears

tensively.

been

studied

ex-

in the vascular

outer 15 to 25 per cent of the width of the meniscus was

demonstrated
by Scapinelli26 and by Arnoczky et al.2. The
validity

of

excellent

these

clinical

authors
results

findings
after

was

repair

supported

of acute

and

by

the

chronic

peripheral
meniscal
tears46804526.
This understanding
of the function
and importance
of
the menisci
has prompted
a selective
approach
in the treatment of meniscal
tears.
It has been the general
practice
to
preserve

symptoms

radial tears, which tend to occur in the avascular

inner
one-third
of the meniscus,
have little potential
for healing. Whether
it is best to leave these lesions alone or to
fashion
an intact
rim by contouring
the meniscus
was
not established
by this study.

as much

that the long-term

than

those

after

meniscal

tissue

as possible,

results after such treatment

total

stable
stable

hope

meniscectomy924.

The goal of this study was to identify

ically
lyzed

in the

will be better

meniscal
tears that
tears that had been

a subset of

can be left alone.

We
identified
arthroscopically,

din-

ana-

811

812

C.

FIG.
Fig.
Fig.

1 : A stable
2: A stable

on the basis of arbitrary

the clinical
experience
We categorized
stable
type,

and

portance,
tification

location,

B.

WEISS

we

attempted

FIG.

to establish

if any, of each of these parameters

of lesions
for which
no surgical

the

in the
intervention

imidenis

needed.

Materials
dures

Between
1972
were performed

AL.

partial-thickness
vertical
longitudinal
tear of the lateral
radial
tear of the inner one-third
of the lateral
meniscus.

criteria
that were developed
through
of two of us (K. E. DeH. and J. G.).
tears on the basis of length,
depth,
and

ET

3,612
who

using
a probe.

a probe.

A vertical
meniscus
was

longitudinal
tear involving
the body
classified
as stable
when the portion

meniscus

was

that

central

to the tear

more
(Fig.

than three millimeters

from
1). The amount
ofdisplacement

each

tear

was

being

could

the

thoroughly

not be displaced

intact peripheral
was determined

probed,

on both

arthroscopic
procehad signs and symp-

ruler,
and the surface
or surfaces
on which
the
occurred
were also documented.
All partial-thickness
were classified
as stable.

of us (K. E. DeH.)
performed
all of the procedures
in
Rochester,
and one of us (J. G.),
in Linkoping.
At both
medical
centers,
the patients
were healthy
and athletic.
The

of the

average
sixteen

number
of such tears were treated
by arthroscopic
ment, with removal
of the torn portion
of the inner

age of all of the patients

was 25.4 years (range,
to forty-seven
years).
All of the patients
were seen
had acute
different

used, for each

was performed
expertise
patients

symptoms
portals

in the knee.
may have been

patient
a thorough
arthroscopic
examination
by two orthopaedists
who had comparable

in arthroscopic
were

or chronic
arthroscopic

assumed

and were treated

not all meniscal
articular
changes

surgery.

The

to be a roughly

two

populations

homogeneous

rim
while

the

toms of an acute or chronic

meniscal
tear, with or without
an associated
ligamentous
tear; 1 , 177 of the procedures
were
done at the University
of Rochester
Medical
Center
and
2,435,
at the University
Hospital,
Linkoping,
Sweden.
One

because
they
Although

of the
of the

tibial

and the femoral

surfaces,
using a five-millimeter
nerve-hook
that had a three-millimeter-long
tip below
the curve of the
hook.
Each tear was probed
carefully
to determine
whether
it was full thickness
or partial
thickness.
The length of each
tear was determined
using the tip of the nerve-hook
as a

and Methods

and 1985,
on patients

meniscus,
demonstrated
demonstrated
using

Radial

tears

width

in Linkoping
ten such tears

contouring

group

by two surgeons
who both believed
that
tears are symptomatic
or cause secondary
and that some meniscal
tears can be left

involved

less

meniscus

than

were

of the

meniscus

so

the inner

considered

but not in Rochester

(Fig.
were left alone. In Rochester,

that

its

had
tears

one-third

to be stable

2). In LinkOping,
an undetermined

inner

d#{233}briderim and

margin

was

smooth
and not indented.
Although
only a few radial tears
were left alone in this study,
and the findings
are therefore
of uncertain

of

that

of the

tear

significance,

are interesting
Slightly

and
more

meniscal

tears

described

criteria.

were

the follow-up

are included
than 6 per
stable,

as defined

If the ten radial

tears

on these

tears

of the

1,316

by

the

that

were

previously
followed

alone.

in Linkoping
longitudinal

As a result
of the arthroscopic
examinations,
1,287
patients
who had 1,316
meniscal
tears were identified.
In
the remainder
of the patients,
either
isolated
ligamentous
chondral
lesions
or symptomatic
plicas were identified.
Of

(seventy
of 1 ,306).
The seventy
vertical
longitudinal
meniscal tears in sixty-five
patients
were in the lateral meniscus
in forty-six,
in the medial
meniscus
in fourteen,
in both the
medial
and the lateral
meniscus
in four, and in both lateral

these
ified

menisci
in one.
To determine

1 ,316 tears, eighty

in seventy-five
patients
as stable in accordance
with the following

were classcriteria.

are excluded,
meniscal
tears

data

in this report.
cent (eighty)

the frequency
of stable
vertical
is slightly
more than S per cent

the locations
THE JOURNAL

of the tears
OF BONE

AND

within
JOINT

the meSURGERY

NON-OPERATIVE

MEDIAL
(1 8 Vertical

Tibial

Tibial

10

Surface

tears)

(44

& Femoral

Surface

tified

the torn surface

or surfaces
of the menisci
(Fig.
3) and the body of each meniscus

of the stable

were idenwas divided

tudinal

tear.

For

meniscal
lesion
knee
was not

the

nine

patients

who

71-A,

NO.

6.

JULY

1989

ligamentous
The
patients

had

an

manlongiisolated

injuries),
the
walked
using
crutches,
progressively
increasing
weight-bearing
until they
discontinued
the crutches,
usually
within
a week.
The remaining
fifty-six
patients
had an associated
acute
VOL.

(no associated
immobilized.

The postoperative
who had a vertical

tears)

longitudinal

Femoral

Surface

31 (70%)

Femoral

&

Surface

Full Thickness

into three equal areas and five equal zones,

which were used
to locate the tears more exactly
(Fig. 4).
The seventy
vertical
longitudinal
tears all were left
alone.
No attempt
was made to debride
or freshen
the torn
meniscal
surfaces.
The tears were manipulated
only during
examination
with the nerve-hook.
agement
varied
for the patients

MENISCUS

LATERAL
Vertical

3 (7%)

Tibial

FIG.

locations

813

TEARS

Surlace

6 (33%)
The

MENISCAL

Tibial

(56%)

2 (11%)

Full Thickness

isci,

OF

MENISCUS
longitudinal

Surface

Femoral

TREATMENT

2 (5%)

8 (18%)

3
longitudinal

meniscal

tears.

or chronic
ligamentous
lesion,
and they were treated
with
varying
amounts
of immobilization.
Of the thirty
patients
who had an acute injury,
in twenty-four
the knee was immobilized
after repair or reconstruction
of an acute rupture
of the

anterior

cruciate

cruciate

ligament

of other
ligaments,
knee was immobilized
for rehabilitation,
and preferential
tuted.

Active

ligament.

was

with

either

an

which included
range-of-motion
strengthening
of the hamstrings,
quadriceps

For the remaining

injury,

anterior

or without

repair

or a torn meniscus
was repaired,
the
for six weeks.
After this, a protocol

exercises,

flexed
45 degrees
and then
until the twelfth
postoperative
amentous

When

reconstructed,

the knee

in which

fully extended,
week.

six patients
was

exercises
was instithe

knee

was

were

not

done

who had an acute hg-

immobilized

for two

to three

814

C.

B.

WEISS

ET

AL.

AREAS

ZONES
Posterior

-Outer

1/3

Central

1/3

1/3

sOQter

1/3

1/3

Fi.
Each

weeks.

This

zone

was

represents

followed

one-fifth

of the

length

by a rehabilitation

of the meniscus

program

and

patients
who
lesion,
reconstruction

ligamentous

ciate ligament
was done in seventeen.
therefore
managed
with a protocol
was similar
to that for the patients
acute

anterior-cruciate

lesion.

had

a chronic
meniscal
of the anterior
cru-

Those seventeen
for rehabilitation
who had a repair

For the nine

patients

4
each

sim-

ilar to the one for the other twenty-four

patients,
except
for
the inclusion
of quadriceps
exercises
against
resistance,
involving
moving
the knee through
a full range of motion.

Of the twenty-six

and

were
that
of an

who

had

area

reviewed

made

during

Eight
lateral

ligament.
Of the six patients
who had an acute radial tear,
four were immobilized,
while
two had no immobilization
postoperatively.

The average
eighty
radial)

age of the seventy-five

stable
meniscal
was 25.4 years

tears
(range,

Fifty-six
patients
were male
five patients
had a sports-related

(seventy
sixteen
and

patients

who had

longitudinal
to forty-seven

and ten
years).

nineteen,
female.
Sixtyinjury,
and in ten the injury

was caused
by another
type of trauma.
Of the eighty
meniscal lesions,
forty-five
were diagnosed
during
an arthroscopic examination
for an acute injury and thirty-five,
during
arthroscopic
evaluation
for chronic
symptoms.
Eighty-four
per cent of the forty-five
acute
meniscal
tears were associated

with

an acute

seven per cent

with a chronic

tear

of the anterior

of the thirty-five
chronic
rupture
of the anterior

cruciate.

Seventy-

tears were
cruciate.

associated

width

patients,

the operation.

of the

the arthroscopic
ofthe

Written

and postoperative
reviewed.
From

meniscus.

findings

videotapes

that were

descriptions

of the op-

drawings
ofeach
these
sources,

meniscal
data were

collected
on the type, location,
length,
and depth
of each
tear.
All data were reviewed
by two of us (C. B. W. at the
University
of Rochester
and P. H . at the University
Hospital,
Linkoping)
who were not directly
involved
in the surgical

associated
with a rupture
or with an isolated
sprain

ligament
collateral

of the

by re-examination

erative
findings
tear were also

treatment

cruciate
or lateral

one-third

For all seventy-five

were

chronic
anterior-cruciate
insufficiency
but did not have reconstruction,
immobilization
was not used,
as if the meniscal
lesion
were
isolated.
No stable
meniscal
tear was
of the posterior
of the medial

represents

or postoperative

management

the follow-up
examinations.
who were originally
identified,
patients
meniscus

but who

did perform

Of the seventy-five
patients
four were lost to follow-up.

who had a vertical

longitudinal
tear
were excluded
because
the information

of the
con-

cerning
the location,
length,
and depth of the tear was incomplete.
Five other patients
were excluded
because
they
had not been followed
for at least two years.
At the time
of the most recent
follow-up,
none of those
seventeen
patients had had any persistent
or recurrent
symptoms
related
to the meniscal

tear.

patients
had had
tear that originally

However,

further
had

by this

time,

six additional

surgical
treatment
of a meniscal
been thought
to be stable
(as will

be described).

Of the fifty-two
minimum
4.3 years)
four were
twenty-eight,

patients
who had been followed
for a
of two years (range,
two to ten years;
average,
and had had no further
surgical
treatment,
twentyre-examined
at the University
of Rochester
and
at the University
Hospital,
Linkoping.
A ques-

tionnaire
was used to determine
and the patients
level of activity.
THE

JOURNAL

the function
The answers
OF BONE

AND

of the knee
to the quesJOINT

SURGERY

NON-OPERATIVE
TABLE
THE

LYSH0LM-II

TREATMENT

OF

MENISCAL

copy.
Twenty-four
meniscus
(eighteen

SCORE2332

eight,

Points
Limp
None
Slight
or periodic
Severe
and constant
Support
None
Stick or crutch
needed

Weight-bearing

.,

athletic

20

20

or a positive

McMurray

examination
Including

tears,

.,

surgical
treatment
the knee,
a total
VOL.

71-A,

NO.

for persistent
of thirty-two

6. JULY

1989

both

the

femoral

and

the

Of the

forty-four

vertical

longi-

zone.

The

ten radial
zone

tears

area of the posterior

area of the anterior
were

all located

of the lateral

meniscus

in the
(Figs.

eight

tears,
thirty-eight
six, five millimeters
longitudinal
tears

lateral
meniscus
arthroscopy.

of the ten vertical

were five to
long or less.
and six of the

were evaluated
for
Of these twenty-four

longitudinal

tears

in the outer

area of the posterior

zone, the one tear in the outer area of
the posterior
junctional
zone,
and the one tear in the outer

of this study,
a satisfactory

TABLE
LOCATIONS

a score
result.

test.

or recurrent
patients
had

lotears
forty-

(70 per cent) involved

the
three (7 per cent),
the tibial

one,

menisci.

rating system
knee is given
a

ofthe knee, and twenty-six

the six patients
who had

type,

meniscus
that is, the patient
tears in the same meniscus.
The
were full thickness
and involved
both

ten radial
tears of the
healing
by second-look

Finally,
the twenty-eight
patients
at the University
pital,
Linkoping,
were offered
a so-called
second-look
throscopic
the offer.

of eight

and

5
4

knee was carefully

assessed
for physical
signs
derangement,
such as effusion,
tenderness
at

line,

to the

to

same

In addition
to filling
out the questionnaire,
forty-two
patients
(twenty-eight
in LinkOping
and fourteen
in Rochester) were re-examined.
The examination
included
detailed
questioning
concerning
the level of activity
and the function
ofthe knee, with particular
emphasis
on any meniscal
symp-

the joint

only;

surface

the forty-four
longitudinal
ten millimeters
long and
Eighteen
of the forty-four

score of 100 points.

For the purposes
of more than 80 points
was considered

three

Thirty-six
of the forty-four
vertical
longitudinal
tears
of the lateral
meniscus
were partial
thickness,
and eight
were full thickness.
All of the ten radial
tears were full
thickness,
dividing
the inner
margin
of the meniscus.
Of

using the Lysholm-II

an asymptomatic

meniscal

knee

tears, thirty-one
surface
only;

inner area of the middle

3 and 4 and Table
II).

of the

relative

all information

junctional

10
6

of fiexion

and the

(range,

length
of fifty-four
lateral
meniscal
longitudinal
and ten radial).
Ofthe

10
6

Impossible

meniscus.

months

the posterior
zone; three,
in the central
junctional
zone; and two, in the central

10

problem

medial

arthroscopy

tudinal
tears, thirty-three
were located
in the outer one-third
of the posterior
or posterior
junctional
zone;
two,
in the
outer area of the middle
zone; four, in the central
area of

25

No problem

analyzed

four longitudinal
femoral
meniscal

surfaces

5
0

Slight
problem
One step at a time
Impossible
Squatting

of the

the initial

twenty-six

tibial surfaces
of the
had two partial-thickness
remaining
eight tears

25

Stairs
No problem

toms.
Each
of meniscal

Tears

Meniscal

We

10

tions were then scored

(Table
1)2332,
in which

Lateral

cation,
depth,
and
(forty-four
vertical

15
10
6

15

900

was

Occasionally
during
daily activities
Often
during
daily activities
Every step
Pain
None
Inconstant
and slight during
strenuous
activities
Marked
during
or after
walking
>2 km
Marked
during
or after
walking
<2 km
Constant
Swelling
None
After
strenuous
activities
After ordinary
activities
Constant

Not beyond

procedure
100 months).

a tear of the lateral

and six radial)
and

Results

activities

Slight

tear

impossible

during

longitudinal

time between

repeat

5
3

Locking
None
Catching
sensation,
but no locking
Locking
occasionally
Locking
frequently
Locked
joint at examination
Instability
Never
Rarely
during
athletic
activities
Frequently

of them
had had
vertical
longitudinal

a vertical

The average

815

TEARS

Hosar-

accepted
additional

symptoms
in
repeat
arthros-

OF

OF THE SEVENTY-TWO

THE
FOR

MEDIAL
WHICH

L ateral
Outert

Zone*
Posterior
Posterior
junctional
Middle
Anterior
junctional
Anterior
Total
*

Each

of

II

AND
DATA

STABLE

LATERAL
WERE

AVAILABLE

M edial

Meniscus

Centralt

TEARS

MENISCI

Innert

Outert

Meniscus

Centralt

Innert

3
0

0
0

25
8

4
3

0
0

6
8

2
0

0
2

101
0

0
0

0
1

0
0

0
35

0
9

0
10

0
14

0
4

0
0

the

five

zones

See text and Fig. 4.

t Each
of the three
areas
meniscus.
See text and Fig. 4.
1: All radial tears.

represents

one-fifth

represents

one-third

of

the

length

of

the

meniscus.

of

the

width

of the

816

C.

B.

WEISS

ET

TABLE
RESULTS

AT THE

TIME

Type of
Case

Age
(Yrs.)

Meniscus

Tear

III

OF REPEAT

Length
of Tear

Areat

Zone*

AL.

ARTHROSCOPY

Thickness
of Tear

Stability
of the
Knees

Immobilization

(itt,::)

30

Lat.

Acute

veIl.

Length
of
Follow-up
(Mos.)

Result

Post.

Outer

5-10

Full

Stable

No

52

Healed

Post.

Central

5-10

Full

Unstable

No

16

Healed

Post.
junci.
Post.

Outer

5-10

Full

Unstable

Yes

Healed

Outer

5-10

Full

Unstable

Yes

Healed

vert.

Post.

Outer

5-10

Full

Stable

No

10

Healed

yen.

Post.
junct.
Post.

Outer

10

Full

Unstable

Yes

25

Healed

Outer

5-10

Full

Unstable

Yes

25

Healed

Post.

Outer

5-10

Full

Unstable

Yes

12

Healed

Post.
junct.
Post.

Outer

5-10

Partial

Stable

Yes

50

Healed

Central

5-10

Partial

Stable

Yes

Healed

Post.

Outer

5-10

Partial

Unstable

Yes

26

Healed

Post.

Outer

<5

Partial

Stable

No

27

Healed

vert.

Post.

Outer

5-10

Partial

Stable

Yes

27

Healed

Chronic
vert.
longit.
Chronic
veIl.
longit.
Acute
vert.
longit.
Acute
vert.
longit.
Acute
veil.

Post.

Outer

5-10

Partial

Unstable

Yes

16

Healed

Mid.

Outer

>

Partial

Unstable

Yes

35

Healed

Post.

Outer

5-10

Partial

Stable

Yes

27

Healed

Post.
junct.
Ant.
junct.
Ant.
junct.
Post.

Outer

5-10

Full

Unstable

Yes

30

Unchanged

Central

5-10

Full

Unstable

Yes

100

Unchanged

Central

>

Partial

Stable

No

37

Unchanged

Outer

5-10

Partial

Unstable

Yes

79

Unchanged

Post.
junct.
Mid.
Mid.
Mid.
Mid.
Mid.
Post.

Outer

5-10

Partial

Stable

No

21

Unchanged

Inner
Inner
Inner
Inner
Inner
Outer

<5
<5
<5
<5

Full
Full
Full
Full
Full

Partial

Unstable
Stable
Stable
Unstable
Unstable
Stable

Yes
No
No
Yes
Yes
No

7
42
77
19
II
3

Unchanged
Unchanged
Unchanged
Unchanged
Unchanged
Unchanged#

Post.

Outer

5-10

Partial

Stable

No

Unchanged#

Post.

Central

5-10

Full

Unstable

Yes

16

Post.

Central

5-10

Partial

Unstable

Yes

Mid.
Post.

Inner
Outer

<5
5-10

Full
Partial

Unstable
Unstable

Yes
No

longit.
2

25

Lat.

21

Lat.

24

Lat.

Acute
vert.
longit.
Acute
veIl.
longit.
Acute
vert.

longit.
5

34

Lat.

17

Med.

Chronic
longit.
Chronic

longit.
7

19

Lat.

29

Lat.

22

Med.

10

18

Lat.

Chronic
vert.
longit.
Chronic
vert.
longit.
Acute
vert.
longit.
Acute
vert.

longit.
11

26

Lat.

12

26

Med.

Acute
vert.
longit.
Chronic
veIl.

longit.
13

29

Lat.

Chronic

longit.
14

31

Lat.

15

22

Lat.

16

25

Med.

17

30

Med.

18

22

Lat.

longit.
19

22

Lat.

Acute

yen.

longit.
20

16

Lat.

21

30

Med.

22
23
24
25
26
27

21
24
28
35
21
23

Lat.
Lat.
Lat.
Lat.
Lat.
Med.

28

18

Med.

29

33

Lat.

30

21

Lat.

31
32

24
27

Lat.
Lat.

Acute
vert.
longit.
Chronic
yen.
longit.
Acute
radial
Acute
radial
Acute
radial
Acute
radial
Acute
radial
Acute
veIl.
longit.
Chronic
veIl.
longit.
Acute
veIl.
longit.
Acute
vert.
longit.
Acute
radial
Chronic
vert.

10

10

<5
<5

Retorn#**

24

Retorn#**

6
II

Retorn#**
Retorn#**

longit.
Each

of the

five

t Each

of the

three

zones
areas

represents
represents

one-fifth
one-third

of the
of the

length
width

of the

meniscus.

of the meniscus.

See
See

text

and

text

and

Fig.
Fig.

4.
4.

1: As determined
Treated by

by the Lachman
and pivot-shift
tests.
open repair
of the meniscus.
#{182}
Twenty
per cent of this tear had filled
in (healed)
at three
# Had additional
treatment.
**
Treated
by arthroscopic
partial
meniscectomy.

months,

when

the

meniscus

was

repaired.

TIlE

JOURNAL

OF BONE

AND

JOINT

SURGERY

NON-OPERATIVE
TABLE
CORRELATION
HEALING

Zone*

OF THE
TIME

Lateral

Meniscus

Posterior
Healed
Unhealed
Retear
or progression
Total

area
OF THE

OF REPEAT

(N

Centralt

TEARS

AND

24)

Innert

Medial

Meniscus

(N

Centralt

Outert

8)

Innert

2
0
2
4

0
0
0
0

2
2t
0
4

0
0
0
0

0
0
0
0

I
0

0
0

0
0

2
2

0
0

0
0

Middle
Healed
Unhealed
Retear
or progression
Total

li
0
0
1

0
0
0
0

0
1
6

0
0
0
0

0
0
0
0

0
0
0
0

Anterior
junctional
Healed
Unhealed

0
0
0
0

0
2
0
2

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

represents

one-fifth

of the length

represents

one-third

of the width

Retear

or progression

Total

Retear
or progression
Total

Each

text
text
one

of the

five

Fig. 4.
t Each of the three

zones

of the

and

Fig.

three

months

after

OF

THE

Lateral
Outert
Zone*

Partial

Posterior
Healed

THE

(Table

and one (Case

a sports-related
might

Meniscus

(N

Partial

have

the two

as stable

acute
sixteen,

or more.

3 1) had
injury.

of the lateral
five

had

became

each of
In each

The

could

knee

meniscus
evidence

that

because

of the

by d#{233}bridement.
arthroscopy,
five of the

and seven
of the nine full-thickness
tears had healed
(Table
IV-B).
Also

the lengths

of the vertical

longitudinal

with healing
(Table
IV-C),
in each category
to permit

HEALING

AT

THE

TIME

OF

REPEAT

Medial

24)

Partial

Outert
Full

tears

Partial

ARTHROSCOPY

Meniscus

(N

8)

Centralt
Full

Partial

Innert
Full

Partial

Full

Retear
or progression
Total

1
5

0
5

Posterior
junctional
Healed
Unhealed
Retear
or progression
Total

0
0
0
0

1
0
0
1

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

1
1
0
2

1
1
0
2

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

Middle
Healed
Unhealed
Retear
or progression
Total

l
0
0
1

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
51
1
6

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

Anterior
junctional
Healed
Unhealed
Retear
or progression
Total

0
0
0
0

0
0
0
0

0
l
0
1

0
11
0
1

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

Anterior
Healed
Unhealed
Retear
or progression
Total

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

length

of the

of the

five

of the

three

1: A
All

vertical

radial

zones
areas

longitudinal
tears.

represents
represents
tear.

one-fifth
one-third

of the
of the

width

of the

meniscus.
meniscus.

See
See

text
text

and
and

Fig.
Fig.

4.
4.

at

were

but there
were too
definite
conclusions.

Each

were

rim after
tear that

IV-B

AND

had

of healing

not be evaluated

partial-thickness
longitudinal
time,

no

third

and reconstruction
arthroscopy.

Unhealed

t Each

tears

sports-related
inand twenty-four

extended
to the peripheral
Any healing
of this radial

nine

this

tears
III),

occurred

Innert
Full

injury.
This tear was treated
At the time of the second-look

Centralt
Full

designated

second

vertical

time

TEARS

was

Of the six radial

See

OF

previously

rating

re-examined

of the meniscus.

THICKNESS

been

after
a subsequent
arthroscopy,
eleven,

Lachman-test

TABLE

had

correlated
few tears

CORRELATION

However,

chronic
anterior-cruciate
insufficiency,
was performed
at the time of the repeat

See

at which

had healed.

of these knees,
the torn portion
of the meniscus
was debrided.
In two of them,
the anterior
cruciate
ligament
was
reconstructed
initially,
and at the time of follow-up
the

meniscus.

the diagnosis.

zone

months
after the initial
arthroscopy,
showed
that
the three tears had extended
and become
unstable.

4.

t These two tears were repaired

of them was partially
healed.
A vertical
longitudinal
tear.
qT All radial
tears.

that

symptomatic
jury. Repeat

and

areas

817

TEARS

of the middle

area)

Anterior

Healed
Unhealed
Retear
or progression
Total

MENISCAL

in the central
area of the anterior
junctional
zone showed
no signs of healing
at the time of the repeat
arthroscopy
(Tables
III and IV-A).
Three
longitudinal
tears in the posterior
zone of the
lateral
meniscus
(two in the central
and one in the outer

ARTHROSCOPY

8
1
1
10

Posterior
junctional
Healed
Unhealed

OF

IV-A

LOCATION

AT THE

Outer1

TREATMENT

818

c.

B.

WEISS

TABLE
CORRELATION

OF

THE

LENGT

H OF

THE

TEARS

Lateral

5-10

>10

<5

5-10

>10

0
0
0
0

1
1
0
2

1
1
0
2

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

1
2
0
3

1
0
0
1

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
5
1
6

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
1
0
1

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
1
0
1

0
0
0
0

0
0
0
0

8
1
1
10

0
0
0
0

0
0
0
0

2
0
2
4

0
0
0
0

Posterior
junctional
Healed
Unhealed
Retear
or progression
Total

0
0
0
0

1
0
0
1

0
0
0
0

0
0
0
0

0
0
0
0

Middle
Healed
Unhealed
Retear
or progression
Total

0
0
0
0

0
0
0
0

1
0
0
1

0
0
0
0

Anterior
junctional
Healed
Unhealed
Retear
or progression
Total

0
0
0
0

0
0
0
0

0
0
0
0

Anterior
Healed
Unhealed
Retear
or progression
Total

0
0
0
0

0
0
0
0

0
0
0
0
one-fifth

represents

of the

one-third

length

of the

Still, the location

of a tear within
the meniscus
be the most important
determinant
of healing
longitudinal
tears of the lateral
meniscus.
Medial

Meniscal

were
partial

partial
cent),

on type,

for all eighteen

vertical

<5

of the meniscus.
of the

longitudinal

thickness

on

location,
medial
tears.

the

tibial

depth,

seemed
to
of vertical

and

meniscal

tears.

Ten

(56

tears

surface;

two

length

was

All eighteen
per cent)
(1 1 per

See

meniscus.

Tears

Information
available

width

Innert

<5

0
0
0
0

represents

8)

>10

Posterior
Healed
Unhealed
Retear
or progression
Total

areas

5-10

>10

zones

(N

Centralt

<5

>10

5-10

five

ARTHROSCOPY

Meniscus

Outert

5-10

<5

of the

Medial
Innert

>10

Each

IV-C

= 24)

(N

5-10

AL.

RS) AND HEAL ING AT THE T IME OF REPEAT

Centralt

<5

t Each of the three

1: All radial tears.

IMETE

MILL

Meniscus

Outert

Zone*

(IN

ET

cent),

and

text

Fig.

and

Fig.

4.
4.

All of the tears of the medial

meniscus
that were evaluated by second-look
arthroscopy
were ten millimeters
long
or less. The length ofthe
tear did not appear
to affect healing
(Table
IV-C).
Of the four tears that were in the outer area
of the posterior
junctional
zone,
two healed
(Cases
6 and
9) and two showed
no evidence
of healing
(Cases
17 and
21)

were

text

See

at the

obvious

time

of the

differences

the two

that

repeat

between

did not.

arthroscopy.
the

Similarly,

two

There

tears

that

of the four

were
healed

no
and

partial-thickness

thickness
on the femoral
surface;
and
full thickness
(Fig. 4). Eight of the tears

six (33 per

were in the

tears in the outer

area of the posterior
zone,
two healed
(Cases
12 and 16) and two did not (Cases
27 and 28).

outer area of the posterior

junctional
zone; six,
area of the posterior
zone; three,
in the central

in the outer
area of the

The
the outer

two partial-thickness
area of the posterior

tears
zone

of the undersurface
that did not heal

of
were

posterior
zone;
and one,
in the central
area of the anterior
junctional
zone (Table
II). Fifteen
of the eighteen
tears were
five to ten millimeters
long; two, ten millimeters
long or
longer;
and one was less than five millimeters
long. There

isolated
lesions.
Initially,
they were left alone and the knees
were not immobilized
since there was no associated
ligamentous
or meniscal
lesion.
However,
three months
after
the diagnostic
arthroscopy,
both patients
still had pain over

were

the posteromedialjoint
line. Because
these isolated
meniscal
tears were thought
to be the cause
of the symptoms,
open
meniscal
repair
was performed.
When
the repeat
arthroscopy was done,
just before
the open
repair,
one of the

assess

tears

no radial tears of the medial

meniscus
in this series.
During
the second-look
arthroscopy,
it was possible
to
the location,
depth,
and length ofeight
ofthe eighteen
of the medial
meniscus
(Tables
III through
IV-C).

However,
because
there were so few tears in each category,
no conclusions
could be drawn
relative
to each of the var-

patients
per cent

iables.

The

Four

of

the

eight

tears

in the

outer

areas

of

the

other

(Case 27) had

of the previous
patient

posterior
and posterior
junctional
zones
of the medial
meniscus healed
(Table IV-A).
Three of these four healed tears
had been partial
thickness
and one, full thickness
(Table

LysholmIl

IV-B).

the questionnaire

The

(Case

some evidence
partial-thickness
28)

had

of healing;
tear had

no evidence

about
filled

20
in.

of healing.

Scores

responses

of all fifty-two
were

rated

patients

using

THE JOURNAL

the
OF

BONE

who

Lysholm-II
AND

JOINT

answered
scoring
SURGERY

NON-OPERATIVE

TREATMENT

OF

TABLE
CORRELATION

OF

STABILITY

Stable
Immobilized

(N

Longit.
Lat.

Knees
4)

HEALING

OF

THE

(N

KNEE

AT

Lat.

Med.

AND

TIME

LATERAL

OF

MENISCI

REPEAT

AND

ARTHROSCOPY

Unstable

Immobilized

(N

Longit.

Med.

MEDIAL
THE

819

TEARS

12)

Not

Radial

OF

MENISCAL

Lat.

8)

Immobilized

Radial

(N

Longit.

Knees

16)

(N

Radial

Med.

Lat.

Med.

Lat.

Med.

Lat.

20)

Not Immobilized

(N = 4)

Longit.

Radial

Med.

Lat.

Med.

Lat.

Med.

Healed

Unchanged

Retear

or

progression

Total

system22.
Forty-two
patients
(80 per cent) had a score of 80
points
or more (mean,
93 points),
and the other ten (20 per
cent) had a mean score of7l
points (range,
53 to 79 points).
All six patients
who had had subsequent
surgical
treatment
of the meniscal
lesion
eventually
had
(average,
86 points).
In the ten patients
isfactory
score,
there was no evidence
was due
functional

to the meniscal
lesion.
Six of the ten had to use a
brace and limit activity
because
of anterior
cru-

instability.

ciate

stairs

a satisfactory
score
who had an unsatthat the poor result

and

Three

performing

had

difficulty

other

activities

going

up and

because

femoral
symptoms,
and the remaining
some limitation
of motion
of the knee

down

of patello-

patient
had troublesecondary
to arthro-

13

these

tears.
None of the

cluding
healing.

the

five

one

radial

that

had

tears

that

extended)

of diagnosis

(Table
knee

III).

was

At

were

the

determined

with

the

knee

flexed

acute
of the

of laxity,

using

Lachman
test, as
drawer
test that is

20 to 30 degrees.

al. classified
the result as positive
lation on the side of the injured

of

tears, at the

and eight,
stability

assessment

pivot-shift
tests.
The
et al.32, is an anterior

(ex-

evidence

longitudinal

had been chronic

most
recent
follow-up,
by clinical

evaluated
any

eight

the Lachman
and
described
by Torg
performed

had

Of the sixteen healed vertical

time

Torg

if the anterior
tibial
knee was increased

et

transcom-

fibrosis
that had developed
after reconstruction
of the antenor
cruciate
ligament.
This patient
had a repeat
arthroscopy
and arthroscopic
lysis
of adhesions
twenty-seven

pared
with that on the side of the uninjured
knee.
In the
present
study,
we graded
the Lachman
test as 1 + if there
was a one to five-millimeter
increase
of anterior
tibial trans-

months
after reconstruction
ofthe
anterior
cruciate
At that time,
the tear of the lateral
meniscus,

lation
on the side of the injured
knee compared
with that
on the side of the normal
knee, as 2 + if there was a six to
ten-millimeter
increase,
and as 3 + if there was an eleven

been

previously
At the

had

left
time

alone,

had

healed.

of follow-up,

a satisfactory

the

Lysholm-II

forty-two

score

had

derness
at the joint line. The McMurray
and none of the mechanical
symptoms
or giving-way)
were noted.

that are characteristic

We searched
diligently

Factors

As
were

already

performed

months)
of the

that

Could

Have

noted,

the

three

to 100

meniscal

months

who
or ten-

negative,
locking,

of a meniscal
for tenderness

lesion
at the
tear

in all

Healing

arthroscopic

procedures

(average,

after the initial diagnostic

arthroscopy
original
seventy-five
patients
(Table

twenty-six
in thirty-two
III). Of these

thirty-two
procedures,
two were performed
because
of persistent
symptoms
and four, because
another
sports-related
injury had occurred.
The other twenty-six
procedures
were
elective,
and they were done to determine
previously
torn meniscus.
Of these twenty-six
tears, twenty-one
were vertical
longitudinal

the status of the

asymptomatic
and five, radial.

Sixteen
of the vertical
longitudinal
tears had healed
and five
had not. As already
noted,
there were too few vertical
longitudinal
tears in each subset
to permit
statistically
significant
(Table
VOL.

correlations
between
location
(Table
IV-B),
or length
(Table
IV-C)
and
71-A,

NO.

6. JULY

1989

to fifteen-millimeter
increase.
of laxity were not performed.
on the examiners

clinical

The findings
Galway
instability
is

This

insufficient.

IV-A),
depth
the healing
of

to a flexed
or severe,

However,
instrumented
Instead,
the grading
was
feel

test

tests
based

of the knee.

of the pivot-shift

test, as described

and MacIntosh3,
correlate
better
with
in a knee in which the anterior
cruciate

of the anterolaterally
gus force is applied

influenced

repeat

patients

no effusion
test was
(clicking,

joint line in the region

of the previous
knees,
but none was noted.
Other

ligament.
which
had

demonstrates

the shift

by

functional
ligament
or reduction

displaced
tibia that takes place as valand the knee moves
from full extension

position.
We rated this shift as mild,
based on the clinical
feel of the knee.

moderate,

We designated

a knee as stable if the patient had essentially

normal
laxity
that is, if the Lachman test was
less than 1 + and the pivot shift was negative.
Knees for
which
the Lachman
test was more than 1 + or for which
-

the pivot
the same

shift
time,

was positive,
we assessed

were considered
unstable.
At
the functional
instability
on the

basis of the history

and the Lysholm-II
score,
but these
subjective
data were not considered
in the determination
of
stability.
Of the sixteen
healed
vertical
longitudinal
tears,
seven
were in knees
that were considered
stable
and nine
were in unstable
knees.

We also tried to determine

whether

the knee after the tear was first diagnosed

on healing
(Table V). Ofthe
sixteen
knees

immobilization
had any influence
that had a vertical

of

820

C.

B.

WEISS

tear that healed,

twelve
(75 per cent) had been
for six weeks
in a plaster
cast or in a lockedin 30 to 40 degrees
of flexion
after the initial

longitudinal
immobilized
hinge brace

ET

AL.

extended

as a result
of
longitudinal
tears

vertical

the one radial

tear

a sports-related
injury;
the three
became
bucket-handle
lesions
and

extended

to involve

nearly

the full

width

This was done because

other associated
meniscal tears had been repaired
or ligaments
had been reconstructed
at the time of the initial arthroscopy.
The other four

of the meniscus.
Three of these four knees were treated
with
arthroscopic
excision
of the bucket-handle
fragment
and
one, with sufficient
tapering
of the two sides of the radial

(of the

tear

arthroscopy.

had

sixteen)

knees

not

been

immobilized,

but

they

to produce

The

Of the seven
that
and

had

healed.

knees

that had a vertical

longitudinal

tear

longitudinal

did not heal, three (43 per cent) had been immobilized
four had not. Two of the three knees
that had been

immobilized
thought

had a subsequent

to be

severe

sports-related

enough

to cause

injury
a tear

tear

the tibial
persistent

that was

stable

who

rim.

had a partial-thickness

in the outer

area

of the

diagnostic
was found.

arthroscopy.
At the time

vertical

posterior

surface
of the medial
meniscus
symptoms
along the posteromedial

the original
symptoms

in a normal

a smooth,

two patients

zone

continued
joint

No other
of repair,

on

to have
line after

cause for the

no articular

meniscus.
These two knees had a repeat tear, or an extension
of a tear that had been previously
classified
as stable , sixteen

damage
was seen that could account
for the posteromedial
symptoms.
In fact, no localized
degenerative
changes
were

and twenty-four
months
after the initial arthroscopy.
The
two patients had no meniscal
symptoms
before the reinjury

observed

and,

therefore,

one

can

only

speculate

as to whether

tears had healed

before
the reinjury.
which a vertical
longitudinal
tear caused
after

a sports-related

months

after

the

anterior-cruciate
after the initial

injury,
initial

insufficiency
arthroscopic

these

In the third knee in

recurrent
symptoms

injury

occurred

This

knee

eleven

had

chronic

and had not been immobilized

procedure.
The anterior
cruciate

ligament
was reconstructed
tomy was performed
after
toms

the

arthroscopy.

and a partial
lateral
the reinjury.
Eventually

ness. Four
millimeters
the outer

were
long

meniscecthe symp-

area

meniscus;

zone

two,

of the posterior

junctional

in the central

of the lateral

area

meniscus;

cartilage

recent

the

of

adjacent

follow-up,

contralateral
only six patients
score

eral explanations
may not accurately
to instability

to any

meniscal

nineteen

knee)
had

of the

to be unsatisfactory.

knee

There

may

(only

25 points

are

knee.
laxity

of the knee,
while
non-athletic
patients
who
laxity of the knee may be unable
to do so.

and one was in the outer

meniscus
and
that extended),

At the most

tears

that

area

The

that

the location,
length,
notably
from those
did

had a radial

heal.

tear

repeat
arthroscopy
(including
four had been immobilized

recent

follow-up,

asymptomatic

and one

had extended.

This

had

of the lateral

shortcomings

extension

symptomatic
occurred

selected
us

(K.

criteria
E.

the criteria,

were

because

a retrospective

of this
review

to define

DeH.

and

study

it

six months

patients

are quite

from

parameters
had any value
would
heal, the resulting

margin.

that

who

had additional

surgical

treat-

ment because
of symptoms
related
to the meniscal
tear, four
(three vertical
longitudinal
tears and the one radial tear) had
an unstable
knee
In these four knees , the stable tear had
.

was

evident.

a stable

based

meniscal

initiated

the

on
lesion.

study

This

arbitrarily
Two

of

because

of

tears cause
is left alone.
were based

as described
in the Materials
and
few stable meniscal
lesions
fulfilled
both

Sweden

and New

York

were

selected,
even though
we realized
that the two populations
could not be combined
into a strictly
homogeneous
group.
Finally,
when we attempted
to determine
if several
different

after the initial arthroscopy,

and it was treated
by contouring
the flaps on each side of the tear back to form an intact

Of the six patients

that

J. G.)

on clinical
judgment,
Methods
section.
Since

the radial
tear
and two had not.

five of the six tears

become

traumatic

similar

Discussion

junctional

the belief that an undefined

subset
of meniscal
no additional
symptoms
in the knee if the tear
The criteria
that were used to define
stability

longitudinal

to
their
of the

have

junctional
and depth

vertical

assigned

Third,
some patients
may be able to compensate
for
of the knee by setting
the quadriceps
and hamstrings
at just
the right time to avoid episodes
of instability

was

Of the six knees

be sev-

First, the Lysholm-II

score
or give sufficient
emphasis

of the posterior
zone of the lateral meniscus.
The reason
or
reasons
why these tears did not heal are not clear, because,
excluding
the two tears in the central
area of the anterior

of the

thirty-

had a 1 + Lachtibial excursion

with that on the

of the medial

of the anterior

zone of the lateral

meniscus,
of these tears did not differ

that

or a positive
pivot
shift.
sufficient
instability
for the

for this finding.

reflect laxity

of the

of the

tears

instability).
Second,
these patients
may have altered
level of activity
enough
to compensate
for the laxity

muscles

and one, ten

tears were in

zone

most

Lysholm-1122

with chronic
symptoms.
the other two, full thick-

five to ten millimeters

long
or longer.
Two of these five

At the

However,

resolved.

one,
and

articular

two patients
who had a repeat
arthroscopy
man test (five millimeters
or more of anterior
on the side of the involved
knee compared
side

Excluding
the two isolated
longitudinal
tears that were
treated
by open meniscal
repair
three months
after the diagnosis,
five longitudinal
tears did not heal. When
these
five tears were first diagnosed
arthroscopically,
four were
associated
with acute
and
Three
were partial
thickness

in the

thirty-two
vertical
longitudinal
or radial
were examined
with repeat
arthroscopy.

for the prediction

of which lesions
subsets
of knees
were so small

only limited
conclusions
Despite
these drawbacks,
repeat
arthroscopy
documented
stable
clinical

could be drawn.
this study is valuable
healing
of some

because
of these

meniscal
lesions.
Since
we found
no symptoms
signs in the knees
that had a stable
meniscal
THE

JOURNAL

OF BONE

AND

JOINT

or
tear

SURGERY

NON-OPERATIVE

that did not heal,

follow-up

one wonders

provides

ofsuch

tears.

nerve

supply,

meniscal

the
are

often

to estimate
the
not recognized
arthroscopic
during

and historical

meniscus
has no sensory
that are associated
with

to interpret.

It should

evaluation,

It is impossible

thus

lesions
that are
or even during
be emphasized

it is essential

to probe

hished

vertical
by

sixteen)

longitudinal

meniscal

this

study.

However,

of the

healed

vertical

examined

by repeat

immobilized

for

to

V),

four

were

were

six

scopic
examination
(Table
had a vertical
longitudinal
(Table

longitudinal

arthroscopy
four

stable

tears

was

three-quarters

weeks

in knees
after

the

of
were

arthro-

III). Of the seventeen

knees that
tear and had been immobilized
and thirteen

were

unstable.

All

four

vertical
longitudinal
tears in the stable
knees
healed,
as did eight
of the thirteen
in the unstable
knees.
Of nine
knees that had a vertical
longitudinal
tear and had not been
immobilized,
six were stable and three,
unstable.
Three of
the six vertical
the three
The
healing
our
were

longitudinal

in unstable
belief that
of a torn

study,
small

tears

but stable

that were classified

or greater
or a positive

were

in knees

that were

one had not. The

may have provided

immobilization
protection

twenty-one

thirty-two

copy,
ament

and one

of

for the

not supported

by

in the different
groups
healed tears, nine were

as stable

follow-up.
Of the nine unstable
healed,
eight had been immobilized

of the

was

as unstable
pivot shift,

classified

knees

is a prerequisite

meniscus

but the numbers

of knees
(Table
V). Ofthe
sixteen

in knees

in stable

knees healed.
a stable
knee

(a Lachman
test of
or both) and seven
at the most

recent

knees
in which
the
after arthroscopy

tear
and

of these unstable
knees
that encouraged
healing.
In
knees

that

had

a reconstruction
or repair of the anterior
had been attempted,
but stability
was

repeat

arthros-

cruciate
restored

hg(that

the Lachman
test was less than 1 + and the pivot shift
was negative)
in only seventeen
of the twenty-one
at the
most recent follow-up.
Whether
the repair or reconstruction
is,

of the ligament
had
the healing
meniscus
associated
the seven

with
stable

initially
from

been tight enough

to protect
the abnormal
forces
that are

instability
of the knee is unknown.
knees in which the tear did heal,

Among
there was

four

immobilization
had

Of the sixteen

the

been

any

effect.
and

longitudinal

tears

conceivably
Since

tears

could

the peripheral

outer

area

in this

area

in the posterior

heal

zone

the

medial
meniscus
probably
seems
especially
true of tears

are associated
with
tears have a great
fact

that,

IV-A).

in this

involving
not heal

by

The

stimulated

the

such

Arnoczky

formation

of

and

histological

tears

in the

of both

cruciate
healing,

thirteen

noted,

the avascular
in dogs unless

is created2.

not

of the meniscus

are avulsion
of the lateral

a torn anterior
potential
for
series,

As already

had

that healed,

have
part

fibrocartilage,
with the result that the gross
appearance
of the meniscus
is normal2626.
We believe
that vertical
longitudinal
cular

Of those

three

and eight were acute at the time of the

No attempt
was made
to debride
or
of the chronic
tears,
but the probing

nerve-hook
response.

is vascularized,

had

immobilized

vertical

eight were chronic

initial
arthroscopy.
freshen
the margins
healing

that had been

initial

V).

with

not estabthat

(Table

821

TEARS

that

knees,

that,

(twelve
tears

MENISCAL

seven

thor-

and visualize
both surfaces
of each
meniscus
to
any partial-thickness
tears.
The effect of immobilization
of the knee on the healing

of stable

OF

no suggestion

as to the outcome

of stable
meniscal
clinical
evaluation

examination.

arthroscopic

oughly
identify

difficult

number
during

clinical

information

the body ofthe

clinical
findings

Since

tears

whether

reliable

TREATMENT

and

injuries.
meniscus

This
that

ligament.
as shown
tears

vas-

the lateral

Those
by the

healed

(Table

et al. showed

that

tears

inner two-thirds
of the meniscus
do
a vascular
channel
to the periphery

findings

in our

study

supported

this

obser-

vation
since none of the five asymptomatic
radial tears that
were re-examined
during
second-look
arthroscopy
showed
any signs of healing.
The best way to manage
a stable
radial
tear that is
confined
remains

to the avascuhar
be established.
in this study,
leaving

inner one-third
of the meniscus
In the few knees
that had that
the tear alone appeared
to have

to

lesion

no detrimental
follow-up

effect.
might

concentration

show
that

prospective

studies

findings

structure

a larger

that these

tears

lead

In conclusion,
dental

However,
to extension

are needed

stable

in the knee.

who

Stable

and

a longer

as areas

of stress

of the tears.

to determine

meniscal

in patients

series

serve

lesions

Controlled

if this

is true.

are often

have

had an injury

vertical

longitudinal

mci-

to another
tears,

es-

pecially
be left

in the vascular
outer area of the meniscus,
should
alone unless
no other lesions
are present
and there
is sufficient
disability
to warrant
treatment.
A chronic
tear
or a tear
dication

in an unstable

knee

is not

necessarily

a contrain-

meniscal
tear alone.
No conclusions
as to the management
of stable radial
tears are warranted
on the basis of this study.
However,
the
second-look
arthroscopic
examinations
showed
no evidence
of healing
are needed

to leaving

a stable

in any radial
to establish

tear. Prospective
longitudinal
studies
the optimum
treatment
for such tears.

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