Musculoskelet Surg

DOI 10.1007/s12306-017-0454-3

REVIEW

MR imaging evaluation of the postoperative meniscus

A. Russo1 • R. Capasso2 • C. Varelli3 • A. Laporta4 • M. Carbone5 •

G. D’Agosto6 • S. Giovine1 • M. Zappia2 • A. Reginelli7

Received: 11 October 2016 / Accepted: 15 January 2017

Ó Istituto Ortopedico Rizzoli 2017

Abstract MR imaging has been widely evaluated in the Introduction

assessment of patients with recurrent or residual symptoms
following meniscal surgery. Importantly, the causes of such The surgical management of internal derangements of the
symptoms may relate to failure or complication of the knee joint has increased in recent years, paralleling
surgical procedure, a possible recurrent or residual improvements in surgical biologic reconstruction tech-
meniscal tear, or may be related to other causes of joint niques and recognition of the impact of untreated liga-
symptoms, including tears of the contralateral meniscus, or mentous, meniscal, and traumatic articular cartilage
local hyaline cartilage, or marrow abnormalities subjacent injuries on progressive joint disease and degeneration
to or distant to the meniscal surgical site. The complex [1–13]. Among other imaging modalities, postoperative
diagnostic issues involved in the MR imaging evaluation of magnetic resonance (MR) imaging of the knee plays an
the postoperative meniscus were identified in early MR important role in the noninvasive documentation of tem-
imaging studies. The knowledge of the normal MR imag- poral changes at the surgical site reflective of procedural
ing appearance of the knee after the more common repair success or potential failure. MR imaging additionally plays
procedures will allow radiologists to recognize complica- a critical role in the evaluation of patients with recurrent or
tions associated with such procedures. In this article, we residual symptoms after the operation, documenting find-
discuss the MR imaging evaluation of the knee after ings of surgical complication, reinjury, or other sources of
meniscal surgery. symptoms unrelated or indirectly related to the prior sur-
gery [14–18]. Accurate MR imaging assessment of the
Keywords Meniscal surgery
Meniscal tear
MRI postoperative knee requires an understanding of the com-
mon surgical procedures performed, their normal postop-
erative imaging appearance as well as the MR features of
& A. Russo the potential procedural complications [19–27]. The
[email protected] knowledge of the normal MR imaging appearance of the
1
knee after the more common repair procedures will allow
Department of Radiology, S. G. Moscati Hospital, Via
Gramsci, 81031 Aversa, Italy
radiologists to recognize complications associated with
2
such procedures. In this article, we discuss the MR imaging
Department of Medicine and Health Sciences, University of
Molise, Campobasso, Italy
evaluation of the knee after meniscal surgery [20]. Mag-
3
netic resonance (MR) imaging of the postoperative knee
Varelli Diagnostic Institute of Naples, Naples, Italy
has become more common because more arthroscopic
4
Department of Radiology, Solofra Hospital, Avellino, Italy repair procedures are performed [28]. Specific findings of
5
Department of Radiology, A.O.U. San Giovanni di Dio e retorn meniscus following meniscal repair or partial
Ruggi d’Aragona, Salerno, Italy meniscectomy are increased signal intensity extending
6
Diagnostic DAM Institute, Nocera Inferiore (Salerno), Italy through the site of repair on T2-weighted images, displaced
7
Department of Internal Clinical and Experimental Medicine meniscal fragments, and abnormal signal intensity at a site
and Surgery, Second University of Naples, Caserta, Italy distant from the repair (Fig. 1) [3, 19–22, 28, 29].

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Fig. 1 MRI coronal (a) and sagittal (b) images show the presence of external meniscal tear with hyperintense signal after surgery

Menisci vascular supply [20, 38–41]. The goals of successful

meniscectomy are the removal of any unstable or poten-
The menisci play critical roles in load transmission across tially unstable meniscal tissue, with the preservation of as
the knee joint as well as contributing to knee stability much stable smoothly contoured residual meniscal tissue as
[30–32]. Meniscal tearing is among the commonest possible [39]. Meniscus-sparing surgery has replaced total
pathology of the knee joint. Clinically, meniscal tearing meniscectomy as the standard of care in meniscal surgery
whether degenerative or traumatic in origin may manifest to preserve as much meniscal function as possible and to
with joint pain, joint locking, and can significantly alter prevent the acceleration of degenerative changes of the
joint function and predispose articular cartilage to degen- knee [42, 43]. Following partial meniscectomy or meniscal
erative changes and osteoarthritis. As a result, a large repair, it can often be difficult clinically to distinguish knee
amount of interest has been directed toward the surgical pain caused by retearing of the meniscus from other causes
treatment of meniscal tears. of knee pain, and a reliable imaging method is needed.
When it is performed on non repaired knees, MR imaging
has been shown to be extremely valuable in the evaluation
Meniscal Surgery and postoperative MRI of primary meniscal injuries, with a sensitivity, specificity,
and accuracy of approximately 85–90% [44–48]. Standard
Meniscal tears amenable to meniscal repair are generally MR imaging criteria for the diagnosis of primary meniscal
tears which are unstable to surgical probing and which are tears include regions of increased intrameniscal signal
located peripherally within the meniscus along or subjacent intensity (on short echo time images) that reach an articular
to the peripheral perimeniscal vascular plexus [33–35]. surface and abnormal meniscal morphology [39]. After
Communication with the perimeniscal vascular plexus is meniscectomy, meniscal morphology may differ from that
necessary for vascular supply to the repair and to restore of a nonoperative meniscus with its postoperative appear-
meniscal morphology, and stabilization of an unsta- ance dependent on the amount and anatomical location of
ble meniscal tear segment through the use of meniscal meniscal tissue resected, and the morphology of the pre-
suture, and/or fixation appliances including staples, arrows, vious meniscal tear [49] (Figs. 2, 3). On MR imaging, such
and darts, to promote fibrovascular repair and healing postsurgical variations in meniscal shape typically include
across the tear and normal biomechanical function of the diminution in the overall size of the meniscus or meniscal
meniscus [22, 36, 37]. In contrast to meniscal repair, horns, blunting of the meniscal apical margin, or variable
meniscectomy or partial meniscal resection is usually degree of meniscal truncation. Increased short TE intra-
reserved for the treatment of nonrepairable complex or meniscal signal extending to the meniscal articular surface
degenerative meniscal tears and tears remote from a viable after the operation may also be seen as a normal finding on

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Fig. 2 MRI coronal (a), axial (b), and sagittal (c) images showing normal findings after external meniscal surgery

may persist as areas of increased short TE signal change on

MR imaging for 6 months to up to 12 years following
successful meniscal repair [50–52] (Fig. 4). In the evalu-
ation of postoperative menisci, however, these criteria have
proved more problematic, particularly when more than
25% of the meniscus has been resected. If greater than 25%
of the meniscus has previously been resected, the meniscus
will appear truncated with a portion of the meniscus being
absent. The margins of the meniscal remnant can be highly
irregular, and abnormal signal intensity that extends to the
new articular surface can be seen in stable meniscal rem-
nants [32]. The MR imaging findings of contour abnor-
malities and signal intensity abnormalities reaching an
articular surface (as seen on short echo time images) are
less accurate for the diagnosis of retorn menisci, with an
accuracy of 66–80%, which is substantially below that for
primary meniscal tears [3, 32, 35]. This decrease in accu-
racy is caused primarily by a decrease in specificity of
Fig. 3 MRI images show normal finding after internal meniscal
these findings in postoperative menisci. The findings of
surgery
high-signal intensity joint fluid extending into a cleft within
MR imaging [39]. Such surfacing meniscal signal in the the meniscal fragment on T2-weighted images or of a
setting of an intact meniscus after the operation may be displaced meniscal fragment are specific but not sensitive
seen secondary to a preexistent intrameniscal degenerative signs of a retorn meniscus [53–55]. In an attempt to
signal change or an intrasubstance healed component of a improve the accuracy of MR imaging for diagnosing retorn
tear cleft, which extends to the resection surface margin of menisci, the use of direct MR arthrography, which involves
the meniscus following removal of adjacent unsta- the injection of intra-articular contrast material, has been
ble meniscal tissue at the time of meniscectomy [20]. proposed. Advantages of MR arthrography over conven-
Surfacing-increased short TE intrameniscal signal may also tional MR imaging include the ability to obtain adequate
be seen following successful meniscal repair. Surfacing joint distension, the greater penetration of contrast material
intrameniscal signal changes in this setting may be reflec- altered joint fluid into the meniscal tear because of its
tive of immature fibrovascular granulation tissue and lower viscosity, and the ability to use T1-weighted images,
mature fibrocartilaginous scar tissue at the repair site which which have higher signal-to-noise ratio and frequently

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Fig. 4 MRI sagittal (a, b) images reveal the presence of high-signal areas due to incomplete healing after internal meniscal repairs

greater spatial resolution than T2- weighted images Patient consent Informed consent was obtained from all patients
[44–46]. On MR arthrograms, meniscal tears are diagnosed before diagnostic examination.
as areas of increased signal intensity (equal to that of the
intra-articular gadolinium contrast material) within the
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