MENISCUSES JOINT

From Big Medical Encyclopedia

MENISCUSES JOINT (menisci articulares; grech, meniskos a lunar sickle) — the intra joint cartilaginous flat educations in a knee joint increasing the contact area and congruence of joint surfaces and partly bearing buffer function.

Anatomy

Meniscuses of a knee joint are stuffed up on 18 — 20th week of pre-natal development in the form of sites of the condensed mesenchyma, to 26 weeks they are already created and consist of collagenic and fibrous cartilaginous tissue.

Fig. 1. Habit view of meniscuses of a knee joint and joint surface of the right tibial bone (from above): 1 — a lateral meniscus; 2 — a back meniskobedrenny sheaf; 3,4 — back and front crucial ligaments; 5 — a medial meniscus; 6 — a front meniskobedrenny sheaf: 7 — a cross ligament of a knee.

At newborns meniscuses in the form of disks cover all joint surface of a tibial bone. When the child starts walking, the central part of meniscuses atrophies and gradually they become a crescent form (fig. 1).

M of page of the adult have the wedge-shaped form on cross section, their peripheral edge is thickened and attached to the capsule of a joint, and the edge turned in a joint, is thinned and free. The upper surface of meniscuses is dugoobrazno bent, lower, turned to a tibial bone, flattened. The peripheral edge of meniscuses almost repeats a configuration of the upper edge of condyles of a tibial bone. In both meniscuses the body (middle part), front and back horns distinguish. On M.'s structure of page happen three types: a) the back horn is wider than front; b) both horns of meniscuses are equal in size; c) the front horn is wider back (seldom). The first option, for lateral — the second is typical for a medial meniscus.

Except a typical crescent form, the lateral meniscus can have semi-discal (6,5%) or discal (1,6%) a form.

The sizes M. of page of the adult are presented in the table.

Table. The SIZES of JOINT MENISCUSES of the ADULT (according to Yu. V. Labunsky, 1968)



Front and back horns of a lateral meniscus are strengthened by sheaves, however in a middle part and kzad from it it is not spliced with the capsule of a knee joint, and strengthened by fibrous stretching of a subnodal muscle, the upper edge a cut terminates at a back semi-circle of a meniscus. It provides big mobility of a lateral meniscus, as prevents it from damage. To an ectocondyle of a femur the constant lobbies and back meniskobedrenny sheaves which are consisting of bunches of collagenic fibers, slowing down the movement of a meniscus of a kzada and increasing its congruence with a joint surface of a condyle of a femur depart from a lateral meniscus. Between a lateral meniscus and the joint capsule there is a synovial pocket up to 1 — 2 cm in depth providing freedom of the movement for back department of a lateral meniscus in relation to the joint capsule.

Narrower front horn of a medial meniscus is fixed by a front sheaf to a first line of a tibial bone; the back horn can be fixed to tibial and to a femur. The union with the joint capsule strengthens durability of fixing of a medial meniscus, i.e. reduces degree of its mobility therefore it is injured by nearby bones by 8 — 9 times more often than much more mobile lateral meniscus.

In front meniscuses are connected by the cross ligament of a knee stabilizing front horns of meniscuses at full extension in a knee joint.

Fig. 2. Scheme of blood supply of meniscuses of the right knee joint: 1 — a medial meniscus; 2 — a front crucial ligament; 3 — a lateral meniscus; 4 — a back crucial ligament; numerous branches from an average knee artery and joint arterial network are visible.

To a medial meniscus there are branches of an average knee artery. In a lateral meniscus the most dense vascular networks are developed in points of its fixing to a tibial bone. From adjacent departments of a synovial membrane where dense melkopetlisty networks of blood vessels are located, the branches getting between bunches of collagenic fibers into thickness of meniscuses in the direction from lateral edge to medial (fig. 2) depart, forming capillary loops in a meniscus. Cartilaginous zones of an inner edge of meniscuses — avascular also eat for the account synovial fluid (see). Arteries of meniscuses widely anastomose among themselves and with vessels of a synovial membrane of the joint capsule. Outflow of blood is carried out on veins, quantity to-rykh more, than arteries, and outflow of a lymph — on limf, to the vessels making by 8 years uniform network.

The innervation of meniscuses is carried out by constant branches of tibial and sciatic nerves, and also the non-constant branches from a locking nerve getting from a back surface of the joint capsule and branches from the perivascular textures forming intra meniscal networks. Trailer structures are presented by the long low-branched free nervous stipitates and not numerous sacculated receptors which are located preferential in outside departments of meniscuses.

The microstructure of meniscuses of newborns, children and teenagers of 12 — 14 years is characterized by dominance of a fibrous cartilage, availability of collagenic fibers in average departments and the friable connecting fabric containing vessels, nerves and fatty tissue on the periphery of meniscuses. Tissue of a meniscus contains many cellular elements.

Fig. 3. Microdrugs of tissue of meniscuses of the newborn and man of 27 years: the quantity of cellular elements (black points) decreases with age, and the amount of intercellular substance increases.

After 14 years the hyaline cartilage begins to develop. By 16 — 18 years in meniscuses chondrocytes form small isogenic groups with increase in intercellular substance (fig. 3), and tissue of a meniscus gets all signs of a hyaline cartilage. After 60 years the razvolokneniye and a softening of a cartilage of meniscuses, an obliteration of vessels develops, there are microcracks and uzura.

Physiological value of meniscuses

At the movements in a knee joint meniscuses move within 1 cm on upper joint surfaces of condyles of a tibial bone. At extension they move kpered, during the bending — kzad. This shift is more at a lateral meniscus. The rotational movements of a shin at the bent knee also shift meniscuses and change their form that is more expressed at a lateral meniscus. Thus, both meniscuses represent as if the moving joint surface, filling the congruence of joint surfaces lacking at the extreme movements.

Meniscuses are the peculiar cartilaginous buffers protecting joint cartilages from damage at pushes and the forefront of the capsule of a knee joint from infringement at full extension.

Pathology

the Most frequent type of pathology of M. of page is their damage — a rupture of meniscuses, there are diseases owing to hron, their microtraumatizations less often.

Injuries of meniscuses among myagkotkanny damages of a knee joint win first place and average 45 — 60%. The medial meniscus is injured 8 — 9 times more often than lateral. In 3 — 4% of cases both meniscuses are injured. Ruptures of meniscuses at athletes and persons of physical work aged from 18 up to 40 years are most frequent; more young than 14 years they occur at children seldom. At men this injury happens more often than at women, in a proportion 3: 2: the right and left knee joints are surprised equally.

Most often a rupture of a meniscus — a consequence of the forced rotation of a shin of a knaruzha (for a medial meniscus) or knutr (for a lateral meniscus) at the bent knee joint (the typical mechanism of damage). The gap can also occur at sharp or excessive extension of a knee joint, assignment or reduction of a shin, is more rare at a direct injury. Quite often, except meniscuses, the capsule, the copular device, an adipose body, a cartilage and other internal formations of a knee joint are damaged.

Fig. 4. Diagrammatic representation of some types of injury of meniscuses. Parakapsulyarny gaps: 1 — a front horn, 2, 3 — a front horn and a body, 4 — bodies of a meniscus, 5 — a back horn and a body of a meniscus; transkhondralny gaps: 6 — in the form of the handle of a watering can, 7 — a rupture of a back horn.

Distinguish the following types of injuries of meniscuses (fig. 4): 1) a separation of a meniscus in a parakapsulyarny zone in the field of front, back horns, a body of a meniscus; 2) a rupture of a front, back horn and a body of a meniscus in a transkhondralny zone; 3) various combinations of these damages. The rupture of meniscuses can be full and incomplete, longitudinal and cross, loskutoobrazny, shattered.

There is a rupture of a body of a meniscus with transition to back and front horns («the handle of a watering can») more often, the isolated damage of a back horn (25 — 30%) is more rare, the front horn (9%) is even less often injured. Gaps can be without shift and with the shift of the torn-off part.

In a wedge, a picture of injury of meniscuses of a knee joint distinguish acute and hron, the periods. In the acute period the localized pain in the area of a joint crack according to a zone of damage (a body, a front and back horn), sharp restriction of movements, especially extensions is characteristic; existence hemarthrosis (see) or exudate. At the first injury there are bruises, anguishes, infringements and even crush of a meniscus without separation and its separation from the capsule more often. At repeated injuries the characteristic symptom complex develops: pain and infiltration of the capsule at the level of joint cracks, pain at the rotational movements, repeated blockade of a joint, a synovitis, pain on a projection of joint cracks at passive extreme extension of a shin (symptoms of extension of Baykov), an atrophy of a medial wide muscle of a hip and tension of a sartorial muscle at active lifting of the unbent leg («a sartorial symptom» of Chaklin), etc.

the So-called blockade of a joint caused by infringement of the torn-off part or all meniscus between the joint surfaces of a femoral and tibial bone is most characteristic of injury of a medial meniscus (a gap as «the handle of a watering can»). At the same time the knee joint of the patient is in the forced fixed situation at an angle 140 — 160 °. Blockade needs to be differentiated from reflex muscular contracture (see), often arising at bruises and stretchings of the capsular and copular device of a knee joint. At injuries of a lateral meniscus blockade of a joint arises seldom, the symptom of a rift or click described by I. M. Volkovich is more often noted to-ry appears at bystry extension of a knee joint from sharply bent situation, the elastic swelling is expressed as the roller in the area of an outside joint crack.

Injury of both meniscuses seldom happens simultaneous. The contributing factor is the rupture of a cross ligament of knee that leads to excessive mobility of meniscuses. In symptomatology of a rupture of both meniscuses the clinic of injury of a medial meniscus usually prevails.

Many of the listed symptoms meet also at other damages and diseases of a knee joint (pain on a projection of joint cracks and at rotation of a shin, Chaklin's symptoms, Baykova, etc.) - Therefore early identification of ruptures of meniscuses in some cases presents considerable difficulties. They arise at recognition of a rupture of the copular device of meniscuses (a mobile meniscus), at hron, traumatizations of meniscuses (meniskopatiya), at diagnosis of atypical shapes of a meniscus (a discal or continuous meniscus), at injuries of both meniscuses and other injuries of myagkotkanny formations of a knee joint.

Ruptures of meniscuses need to be differentiated with a disease of Goffy (see. Goffy disease ), joint mouse (see), a disease of Keniga (see. Keniga disease ), injuries of a joint cartilage and the capsular and copular device (see. Knee joint ), with arthritises (see).

From polyfocal damages the rupture of a medial meniscus and a tibial side sheaf most often meets. At the massive injury which is followed by the shift of joint surfaces also the front crucial ligament is quite often torn. There is a so-called «unfortunate triad of a joint». Ruptures of meniscuses are often combined with damages of the capsule, adipose bodies, a cover cartilage, a synovial membrane and degenerative and dystrophic processes (the deforming arthrosis). Crucial importance for diagnosis in these cases has the anamnesis, the mechanism of an injury, a wedge, a current.

Fig. 5. A direct artropnevmogramma of a knee joint at injury of a medial meniscus: deformation and shortening of a shadow of a medial meniscus (1); under a meniscus a layer of gas (2).

Specify the diagnosis usual and contrast artrografiya (see) and an arthroscopy (see. Joints ). Normal on an artropnevmogramma a shadow of a medial meniscus triangular, is uniform, without breaks, there is no gas under a meniscus; the lateral meniscus is a little raised, under it there is a layer of gas, and also the strip of gas crossing a shadow of a meniscus near the capsule. At injuries of meniscuses roughness of their contours, deformation of a shadow of a meniscus, a strip of an enlightenment on it, a short shadow of a meniscus or absence it in a joint crack, an additional shadow in intercondyloid space, a strip of an enlightenment under a shadow of a medial meniscus, etc. appear (fig. 5). Artropnevmografiya allows to reduce significantly number of discrepancies of clinical and operational diagnoses.

In doubtful cases big differentsialno - diagnostic value has an arthroscopy. It allows to reveal both parakapsulyarny, and transkhondralny injuries of meniscuses. The last usually are defined easily since disturbance of a smooth surface of meniscuses is well visible. Rather easily also dystrophic regeneration of meniscuses on discoloration and softer comes to light than it is normal of a consistence (during the pressing by a needle). Recognition of parakapsulyarny ruptures of meniscuses without shift is at a loss flows of a synovial membrane, edges are often blocked by the field of damage. The gap usually is defined at the movements in a joint. An arthroscopy allows to diagnose also accompanying damages and a disease of a knee joint (a condition of joint cartilages, a synovial membrane, intra joint and adipose bodies).

Treatment of injuries of meniscuses in the acute period, as a rule, conservative. Its basic element — elimination of blockade, i.e. conservative reposition of the restrained fragment of a pla of all meniscus. For this purpose make a puncture of a knee joint and after removal of blood enter 15 — 20 ml of 1% of solution of novocaine into his cavity. The patient is seated so that the shin overhung, without concerning a floor. In 15 — 20 min. the assistant fixes a hip, and the surgeon two hands makes traction of a shin from top to bottom, reduction or its assignment with simultaneous rotation. Reposition is demonstrated by recovery of full extension of a shin. After elimination of blockade on a hip and a shin impose a back plaster splint on 2 weeks, hold sessions of UVCh, LFK for muscles of a hip in the isometric mode (their static stress). Parakapsulyarny ruptures of meniscuses at primary injury can grow together with a strong hem in view of good blood supply of this area while gaps in a cartilaginous zone, as a rule, do not grow together.

If blockade (after the first injury) does not manage to be eliminated, and also at repeated blockade of a joint operational treatment — a meniscectomy is shown. Timely removal of the injured meniscus is prevention of development of the deforming arthrosis of a knee joint therefore it is not necessary to postpone an operative measure more than 2 — 3 months in the presence of indications. Operation is made preferential under local or intra bone anesthesia. From surgical accesses to a thicket apply internal and outside parapatellyarny, to-rye if necessary it is possible to expand easily. At a rupture of a back horn the best review is reached at a slanting section along the line of a joint crack. Sometimes for removal of a back horn do an additional section of a kzada and parallel to a tibial side sheaf. At an arthrotomy of a knee joint layer-by-layer cuts kozhn, capsules, a synovial membrane it is reasonable to do at the different levels for prevention of emergence of the rough soldered hem. It is necessary to avoid traumatizing a zone of an attachment of a front horn to the capsule where the developed network of vessels and nerves is located. Besides, at cutting off of a front horn it is necessary to spare a cross ligament of meniscuses since at its damage the lateral meniscus can suffer in the subsequent. At any kind of injury of meniscuses their removal with leaving of a parakapsulyarny zone for regeneration is shown. After removal of a meniscus the joint is washed out solution of novocaine, delete possible intra joint free bodies, examine a cartilage, ligaments, adipose bodies and surely the second meniscus. The wound is layer-by-layer sewn up tightly, antibiotics, as a rule, do not enter, apply a compressing bandage, stack an extremity on Beler's tire or a pillow. The immobilization is required by the plaster tire for 5 — 7 days at flexion contractures in connection with blockade of a joint (for its elimination), and also during removal of two meniscuses.

At an extirpation of a meniscus, i.e. removal it with a parakapsulyarny part, complete regeneration is not observed.

Fig. 6. A leg on the special tire — recovery treatment by situation after a meniscectomy.
Fig. 7. The diagrammatic representation of exercises of remedial gymnastics after a meniscectomy: 1 — in a ventral decubitus passive bending of the operated leg by means of a rubber tape; 2 — in a sitting position active extension of the operated leg in a knee joint.

In the postoperative period carry out treatment of a possible synovitis, take measures for bystry recovery of function of a knee joint. After a meniscectomy as the indication to use of physical exercises in a complex with other means of recovery treatment serve restriction of movements in a knee joint, decrease in a tone and force of muscles of a hip, their muscular atrophy. The complex of means of recovery treatment includes to lay down. gymnastics, physical exercises in water, massage manual and underwater, treatment by situation, a thermotherapy and electrostimulation of muscles. With 2 — the 3rd day after operation carry out treatment by situation — periodic change of situation in a knee joint by means of the special tire (fig. 6) in combination with isometric tension by the four-head of a muscle of a hip. Change of position of a leg is made every 1,5 — 2 hour (the knee joint is kept by the tire or the roller for 20 — 30 min. in the bent situation). The four-head of a muscle and sgibatel of a knee joint patients make isometric tension in 2 hours (from 10 to 20 slow muscular tension lasting 4 — 6 sec.). With 3 — the 5th day (depending on features of the postoperative period) lying make the facilitated movements of bending and extension in a knee joint with a support of a leg on a bed (fig. 7).


After a removal of sutures intensity to lay down. gymnastics increase: carry out the active movements lying on spin, the movements in a bathtub. At achievement of satisfactory volume of movements start the exercises strengthening muscles of a leg: a load (the cuff filled with sand weighing 0,5 — 1 kg), with a resistance of a rubber tape or a healthy leg of the patient, and also to exercises costing exercises with burdening of the lower extremity, with partial, and then full load. At the expressed atrophy of muscles of a hip manual massage is supplemented with underwater massage (water temperature 36 — 37 °, pressure of 0,5 — 1,5 atm, duration from 5 to 10 min.).

Recovery of the general working capacity occurs in 4 — 6 weeks after operation, sports — through 2U2 — 4 month depending on the nature of damage, a profession or sport. Terms of disability increase at persons with the deforming arthrosis of a knee joint.

The long-term results of meniscectomies are in most cases favorable. The excised meniscus as show experimental and a wedge, data, is usually replaced with a full-fledged regenerate.

Timely diagnosis and operational treatment of the injured meniscuses gives the chance to prevent development of the deforming arthrosis of a knee joint. After the operational treatment which is carried out in the period of development of the deforming arthrosis, the forecast is less favorable since there can be joint pains. Prevention of injuries of meniscuses is most developed in sport. For this purpose various means protecting a joint are used; the rational organization of sports occupations, medical control are important.

Diseases of meniscuses: meniskopatiya and cystous regeneration of a meniscus.

Meniskopatiya (a synonym a chronic traumatic meniscitis) develops at hron, traumatizations of a knee joint, after its overloads and therefore is more often observed at athletes. Development of a meniskopatiya is promoted a so-called mobile meniscus (the raised degree of mobility of a meniscus as a result of a rupture of a cross sheaf), by static deformations, such as a valgus, varus knee, flat-footedness. Symptoms of a meniskopatiya are erased; typical blockade are very rare, periodically there is only joint pain in the area of a joint crack, a synovitis. At survey find Baykov and Chaklin's positive symptoms. On operation at a meniskopatiya find out that it is deprived of gloss, it is a little elastic, yellowish color, with cracks and a razvolokneniye of fabric; a meniscus it is excessive it is mobile, it is easily torn. At gistol, a research find dystrophic changes of various degree.

Cystous regeneration of a meniscus (cyst of a meniscus) arises probably after its repeated bruises that is promoted by existence of a discal meniscus. Distinguish three degrees of a disease: The I degree — cystous cavities come to light only histologically, moderate morbidity and hypostasis or consolidation of the capsule clinically is determined by a projection of a joint crack; The II degree — cystous changes take tissue of meniscuses and a prikapsulyarny zone, in the area of a joint crack at extension in a knee joint painful formation of an elastic consistence comes to light small, a cut at extension of a joint decreases in sizes or disappears absolutely (owing to the shift of a meniscus in depth of a joint); The III degree — the cyst takes okolomeniskovy fabric; in this stage there is a mucous regeneration of a meniscus to formation of cysts in the capsule and sheaves; tumorous education reaches the considerable sizes and does not disappear during the bending of a joint. Diagnosis of II and III degrees of a cyst of a lateral meniscus of difficulties usually does not cause.

At diseases of meniscuses and absence explicit kliniko-rentgenol, symptoms of their gap treatment is begun with conservative actions. Apply UVCh-therapy, fonoforez with a hydrocortisone, a temporary immobilization, massage of a hip. In the absence of success the meniscectomy with postoperative treatment, as is shown at a rupture of a meniscus. The forecast is favorable. At conservative treatment of a meniskopatiya a recurrence is possible.



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P. I. Merkulova; A. F. Kaptelin (to lay down. physical.), L. K. Semenova (An.).

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