[Medical Insight 65th] Treatment of rupture of the posterior attachment of the medial meniscus cartilage disc informed by orthopedic surgeons

□ Broadcast date and time: January 3, 2025 (Fri) 10:20 p.m.
□ Producer in charge: Lee Siwoo
□ Author in charge: Kim Bae-jeong and Kim Hyun-jung
□ Cast: Kim Young-mo (Chungnam University Hospital Orthopedic Surgeon General)
□ Broadcast channel
IPTV - GENIE TV No. 159 / BTV No. 243 / LG Uplus No. 145
SkyLife Number 90
Cable - Delive No. 138 / Hyundai HCN No. 341 / LG HelloVision No. 137 / BTV Cable No. 152

* The text below may differ from the actual broadcast content, so please check the broadcast for more accurate information.


◆ Kim Young-mo: Hello, I'm Kim Young-mo, an orthopedic surgeon. What I prepared today is about knee health. This is the latest treatment for meniscus fracture.

◇ Voice actor Park Sang-hoon: A disease that should be suspected if severe knee pain occurs suddenly with a stiff pain or "fang" in the knee joint after middle age. If you live a sedentary lifestyle like Korea, the inner meniscus cartilage is likely to rupture, and among them, the root ligament is likely to rupture. There are two treatments for rupture of the posterior attachment of the medial meniscus cartilage. There are conservative treatments such as drugs and injections, and surgical treatments that connect the torn cartilage plate by checking the rupture area with an endoscope, and surgical treatment is said to be the key to how hard and strong the cartilage plate is sewn. Latest treatment for rupture of posterior attachment of medial meniscus cartilage. Let's take a closer look at Kim Young-mo, a specialist who is recognized as a name in the field of meniscus suture surgery at domestic and foreign knee joint societies.

<Understanding Diseases>
◆ Kim Young-mo: The meniscus cartilage in the knee has various forms of rupture. Today, I would like to talk about the symptoms and treatments of rupture of the posterior attachment of the medial meniscus cartilage, which occurs frequently enough to account for about 10-20% of all meniscus cartilage fractures.

<Structure of Knees>
◆ Kim Young-mo: The knee joint consists of three parts. They are the knee femoral joint located in front of it, the inner tibia joint located in the inside, and the outer tibia joint located in the outside. The bones in the joint area are surrounded by white-looking articular cartilage, along with a plate-like meniscus between the inner and outer joints.

<Structure and Function of the meniscus cartilage>
◆Kim Young-mo: The histological structure of the meniscus cartilage is a structure that densely contains C-shaped annular circumferential fibers with the front and rear ends firmly attached to the sciatic bones. When a normal cartilage plate is subjected to a weight load, the C-shaped annular columnar fibers are stretched by the force and the meniscus is drawn out as a result, absorbing the loaded weight through this series of processes. This is called a support stress. Through this support stress, normal meniscus cartilage plays a very important role in shock absorption, stress and load transfer, and knee joint protection. It also functions as a secondary structure that provides joint consistency and joint stability by filling the empty space between the two articular cartilage created by the placement of a round femur on a flat scapula, and acts as a joint lubrication and proprioceptive organ. The end of the cartilage plate is a bit of an unusual structure. The cartilage plate is a fibrocartilage structure, but it doesn't stick to the bone as it is. It changes to a ligament-like structure and sticks to the bone. That's why this ligament structure is called the root ligament, meaning the ligament that the cartilage plate roots in the bones. It's also called the rear attachment.

<Symptoms of Disease>
◆ Kim Young-mo: I want to talk today about the most common rupture, which is the rupture of the posterior attachment of the medial meniscus cartilage. If the rear attachment of the medial meniscus cartilage is ruptured, the olfactory part of the ruptured meniscus will move inward as shown in the picture, and cartilage plate function will be lost along with the loss of support stress of the meniscus. In conclusion, the posterior root ligament of the medial cartilage plate, which was normal, is torn, and if it continues as it is, the articular cartilage cannot overcome the constant stress and gradually breaks down and is destroyed faster than normal. That's why degenerative osteoarthritis comes faster. The clinical findings of rupture of the posterior appendage of the medial meniscus are generally similar to those of the medial meniscus in clinical symptoms. However, there are two notable differences. What most patients get off the bus. Or crossing the crosswalk. In this life process, there are many patients who suddenly hear a "pop" in their knees, feel severe pain, and even collapse without getting up. Of course, it may occur slowly without these events. Second, very severe tenderness is occurring in the inner joint line, especially the posterior joint line. Since there is a significant relationship with age, it is being investigated as a degenerative cartilage plate rupture that occurs independently of trauma in people in their 40s or older. This is an example
. A 69-year-old female patient visited the hospital with internal pain in her right knee and brought an MRI. The overall content you are talking about was very similar to the rupture of the inner meniscus cartilage. If you look at the MRI at the first visit, only a significant degree of degenerative changes are observed in the posterior attachment of the medial meniscus cartilage, but no rupture is seen.
I told you that if you suddenly have a severe pain in your knee that makes you unable to walk, you should take an MRI immediately and come to the outpatient clinic. Such an event occurred in just one month, and the rear attachment of the medial meniscus was completely ruptured on the re-imaging MRI, and the rupture condition was a sign of chronic rupture.

<Form of rupture>
◆Kim Young-mo: The shape of this rupture is slightly different. In some patients, the cartilage plate ruptures at the site of transition to the root ligament, in others, in the parenchyma of the root ligament, and in other patients, in very rare form, in the form of a scapular fracture at the scapula to which the root ligament is attached. The natural course after the rupture tends to improve in the case of symptoms. However, it can also worsen. It is known that osteoarthritis continues to progress compared to the case where no rupture has occurred.

<Cure Guidelines for Disease>
◆ Kim Young-mo: You'll see two patients who have been treated conservatively. The results are quite different. The first patient is a 68-year-old woman. MRI confirms rupture of the posterior attachment of the medial cartilage disc when visiting the hospital for the first time. The overall lower extremity alignment was good on the radiographs, and it was in good condition with no definite arthritis findings in the medial joint. It was a very happy case with no symptoms of cartilage plate rupture after 10 years of follow-up with conservative treatment for symptoms. But sometimes it's quite the opposite. She's a 67-year-old woman. Radiograms taken early in symptoms show mild medial joint osteoarthritis, as well as rupture of the posterior attachment of the medial cartilage disc. Conservative treatment was performed, and the patient's pain continued to worsen, and radiographs taken six months later showed rapid progression of osteoarthritis. What treatment method would be most appropriate for the patient in front of me at the moment? When we treat patients, we move forward from the current state to the future. However, looking at the outcome of a patient's treatment is looking back on the past from a future position. Therefore, the treatment outcome for all patients cannot be predicted and appropriate treatment guidelines are required accordingly. In the case of rupture in the posterior attachment of the medial meniscus cartilage, the general treatment guidelines should first consider whether surgical suture is possible for this patient. If surgical treatment is inappropriate for the patient or the patient does not want surgery, the follow-up can be performed while leaving it as it is. Nevertheless, if the patient complains of pain continuously, and if osteoarthritis is too severe, you should think about how to remove the cartilage plate, and if the joint is very clean and the cartilage plate is clean overall, you can consider surgical suture. This is a 54-year-old male patient. Arthroscopy pictures show osteoarthritis that has already progressed badly. In the joint state, most of the bones are lost. The meniscus cartilage is also showing a chronic rupture in a fairly advanced and poor condition. In this case, it is a principle to provide conservative treatment because surgical treatment is meaningless. This image was taken during proximal tibia osteotomy, not for surgery. This is a 54-year-old female patient. I was a patient who visited the hospital with severe knee pain. If you look at the joint endoscopy, the condition of the cartilage plate is very poor and shows advanced chronic degenerative rupture, along with the findings of damage to the articular cartilage that has progressed severely beyond stage 3. In the case of this patient, an operation was performed to remove the cartilage plate to improve symptoms. This is a 49-year-old male patient who visited the hospital a week ago due to severe pain with a "stopping" sound from his knee. An MRI was taken, and it was confirmed that the root ligament was ruptured in the posterior attachment of the medial cartilage plate. The joint cartilage was in good condition, so we performed sutures. And six months later, a second arthroscopic examination was performed, and it was confirmed that the ruptured cartilage plate was again very well attached to the sciatic bone. The patient had no symptoms and was not uncomfortable at all. Surgical treatment would be a better option if it was a relatively healthy cartilage plate, not so severe joint cartilage damage, and the alignment of the joints was clean. Since I published surgical sutures for this rupture in the Journal of the North American Arthroscopic Society in 2006, various surgical methods have been introduced. I'm still trying to find a way to operate more effectively and presenting the results.

<Type of suture>
◆Kim Young-mo: Then I will tell you about the surgical treatment method. The area where the rupture exists itself is very small, so it is very difficult to surgically insert a machine. Also, because the area that sticks to the bone has ruptured, both ends cannot be attached. Therefore, different suture methods are used depending on the condition of the knee joint being operated. There is a simple suture method that simply passes two or three threads up and down and sew them. There is also a modified Mason-Allen suture that sews in the form of a cross. Although this method is safer and more robust than a simple suture, it has the disadvantage of being more difficult to operate. There are several types of threads that are used as absorbent and non-absorbent. Fixing the thread in front of the scapula is also not an easy task. This is because the position where the cartilage plate is sewn and the position where the thread is fixed is far away, so it is difficult to fix it tightly. So, various fixing methods are being supplemented and used. These surgical methods can be combined in various ways, and the conditions of the knee and the experience of the doctor doing the surgery are important. The suturing method I use is called Mason-Allen suturing, which I designed to re-transform the cross suturing method so that the end and end of the ruptured area stick together after the suturing. [Voiceover] What you're seeing here is a simple vertical suture. First, tunnel through the shinbone and pass a strand of thread through the bone tunnel. After that, you need to check exactly where the holes in the tunnel are located within the joint. For this patient, the final hole position is suitable for simple vertical suture. Now it's time to vertically seal the cartilage plate. A hook-shaped special instrument through which thread passes from the inside, piercing the cartilage plate from top to bottom and advancing the thread into the instrument to insert the thread vertically into the cartilage plate. The first thread I passed through is an absorbent thread. It's turning it into a firmer, non-absorbent yarn. After the two threads are inserted, pass them through the tibia tunnel and secure them in front of the shinbone. After the operation, check for a relatively strong fixed cartilage plate rupture and complete the operation. As you can see in this patient, the rear part of the meniscus is very narrow, so it is not easy to operate. The video you're looking at shows me performing surgery with the modified Mason-Allen suture method that I developed. Similarly, first, tunnel through the shinbone and pass a strand of thread through the bone tunnel. After that, we check exactly where the hole in the tunnel is located within the joint. For this patient, the hole position is suitable for the modified Mason-Allen suture. Now we're sealing the cartilage plate. Using the same special hook-shaped instrument, penetrate the cartilage plate from top to bottom and advance the thread into the instrument. Then, unlike the vertical suture, the cartilage plate is once again pierced from top to bottom in the optimal position around it and the thread is advanced into the instrument to make one thread grip tightly. We're turning the first absorbent thread through into a firmer, non-absorbent thread. This makes the cartilage plate more powerful to withstand sutured threads than simple vertical sutures. Perform a second suture to cross the first suture. The two threads inserted into the cartilage plate are then passed through the tibia tunnel and secured in front of the shinbone. This allows you to check for a relatively robustly fixed cartilage plate rupture. Arthroscopic surgery photo immediately after surgery with tibia pulling suture. It's an example of eight people. I used the modified Mason-Allen method I made, and I used a non-absorbent suture. A second arthroscopic examination performed one year later confirmed a well-healed cartilage plate rupture in seven patients. However, in one example, it was confirmed that the rupture occurred again.

<Re-sealing>
◆ Kim Young-mo: It is difficult to guarantee that even suturing surgery will necessarily heal as in other forms of cartilage plate rupture. This is especially true because this rupture is a degenerative cartilage plate rupture, so various conditions are unfavorable to healing. The reality is that the failure of suture surgery for root ligament rupture at the posterior attachment of the medial cartilage plate varies from doctor to doctor, but it is reported with considerable frequency. In this case, I usually don't think any more suture surgery is possible. I don't think that's necessarily the case. This is a 62-year-old female patient. If you look at the video, the second arthroscopic examination after suture surgery confirms the failure of suture. However, the patient was relatively young and in good joint condition. So it's difficult, but I did the suture once again. Fortunately, the cartilage plate was well healed in the second arthroscopic examination. In addition, it was confirmed that the joint cartilage of the damaged femur was also slightly better than in the past. This patient is a 53-year-old woman. MRI and arthroscopic examination confirm the rupture of the root ligament of the posterior attachment. Based on various research results related to suturing, I developed the re-modified Mason-Allen suturing surgery I made to adapt to the surgery. Simple sutures and re-modified Mason-Allen sutures were performed simultaneously with four-stranded absorbent sutures, and the second arthroscopic examination performed six months later confirmed that they were firmly sutured. I'm a 57-year-old female patient. The same lesion was identified in this patient, and as before, the simple suture and the suture method I developed were performed simultaneously using four-stranded absorbent sutures, and the second arthroscopic examination performed six months later confirmed that they were firmly sutured.

<Advantage of suture>
◆Kim Young-mo: In many papers, sutures for rupture of the posterior attachment of the medial meniscus cartilage have been reported to have a better effect than conservative treatment or partial resection. Suture showed higher functional scores for patients compared to conservative treatment or partial resection, could lower the progression of osteoarthritis, and was found to lower the progression to artificial joint replacement. In this paper published in 2020, 15 patients were left without surgical treatment, and partial resection or sutures were performed. When followed up for an average of 74 months, there was no case in patients who underwent sutures at the frequency of transition to artificial joint replacement. Therefore, it is reported that suturing can significantly reduce the progression of arthritis and lower the conversion to artificial joint replacement. In this video, you can see that when you bend the knee joint, the olfactory part of the medial meniscus is pushed back considerably. This means that the act of bending the knee itself can act with significant tension on the area of the meniscus where the sutures were performed, leading to re-cracking of the sutures area. Therefore, although there may be some differences between the operators, most operators restrict joint movement for about two to six weeks after suture.

<Disease Risk Factors>
◆Kim Young-mo: According to my research results, horizontal rupture tends to occur in the olfactory part of the medial meniscus cartilage in the knee showing normal alignment. On the other hand, in those with slightly O-shaped legs, such as variceal deformation, rupture is more likely to occur in the posterior attachment. The reason is that the stress is applied more severely to the inside of the knee as shown in the O-shaped leg shape, and it is also thought that the force called shear force works. Therefore, rupture of the posterior attachment of the medial meniscus cartilage, which is common in middle-aged and older, is very commonly associated with the internal varnish, what we call the O-shaped leg. This patient was a 60-year-old male patient with approximately 7.7 degrees of varus deformation in the knee and rupture of the posterior attachment of the medial cartilage disc. Therefore, proximal tibial osteotomy was performed at the same time to reduce the load on the inner joint along with the suture of the cartilage plate. The second arthroscopic examination conducted a year later confirmed the strong healing of the ruptured cartilage plate. That's the conclusion. There are many studies that show that sutures for rupture of the posterior appendage of the medial meniscus are superior to cartilage plate resection or conservative treatment. Also, this rupture is a very strong risk factor for osteoarthritis. Therefore, if a rupture is suspected, it is most important to accurately diagnose early through MRI and provide appropriate treatment according to the patient's condition. If surgical sutures are an indication, arthroscopic sutures are the best treatment for now.

<Medical AI Q&A>
◆ Kim Young-mo: Viewers sent me questions about the rupture of the posterior attachment of the medial meniscus cartilage. Shall we check it out together?

◇ Y-ON (AI Anchor): My daughter, who is in her second year of middle school, ruptured her olfactory part of her meniscus while dancing. The doctor in charge wants to do endoscopic surgery, but isn't there a case of natural healing for growing children?

◆ Kim Young-mo: In this case, it seems to be a slightly different type of file than what I was talking about today. It is expected that a vertical rupture occurred in the olfactory part of the traumatic inner meniscus cartilage that occurred at a young age. In this case, if the cartilage rupture ruptures in a well-blooded area, and if the size is quite small, or if it is partially and incompletely ruptured without being completely broken, natural healing can be expected. However, depending on the location, shape, and size of the rupture, it is often difficult to expect natural healing. Also, cartilage plate surgery has nothing to do with growth, so if you say you need surgery, it's never helpful to postpone it. In the case of cartilage plate surgery, the space where the surgery is performed is very narrow. Because surgery is required in such a small space, there is a high possibility that the articular cartilage surrounding the bones of the joint described earlier will be damaged during the operation. Therefore, if possible, I recommend you to get surgery from an experienced orthopedic knee specialist.

◇ Y-GO (AI Anchor): A woman in her 60s. I was diagnosed with a meniscus fracture and underwent surgery, but I fixed my knee after surgery. What's the reason?

◆ Kim Young-mo: This patient seems to have undergone a cartilage plate suture. Depending on the pattern of the first torn cartilage plate rupture, the location of the tear, the suture method, and how tightly and firmly the ruptured cartilage plate is fixed, there are cases where the patient is fixed. In the case of rupture of the posterior attachment of the meniscal cartilage, it is common to fix the joint for about two to six weeks, although it varies from person to person to person in order to reduce the possibility of re-destruction after surgery and to help heal the ruptured area, as described earlier.

◇ Y-ON (AI Anchor): A woman in her 50s. I was diagnosed with a rupture of the meniscus cartilage, but I'm putting off the surgery because I'm in pain, but I'm okay with it. Do I really need to have surgery?

◆ Kim Young-mo: I think it's probably a horizontal rupture of the meniscus because the patient is about 50 years old, middle-aged and has no trauma. A patient's meniscus horizontal rupture is a very common degenerative cartilage rupture that occurs with age. In general, surgical treatment is often not required. However, there are cases where other types of rupture such as cartilage plate flap rupture, which is not easily visible on MRI, exist. After taking an MRI, another new rupture may occur between intervals in the process, so it is important to take MRI scans periodically and treat them according to symptoms.

<Remember this>
◆ Kim Young-mo: Some patients with rupture of the posterior attachment of the meniscus cartilage think that 'it will be okay over time'. However, as time elapses after the rupture, arthritis progresses with the degeneration of the cartilage plate, which can lead to missing the timing of surgical treatment. Knee pain, don't hold back now, and I hope you get back to your health through treatment. I hope my story today has helped our viewers live a happy and healthy life. Thank you.