The menisci of the knee joint. Anatomical and functional characteristics, and a rationale for clinical treatment

Nutrition pathways to the symphysis pubis

The blood supply of the symphysis pubis is still the subject of some debate. Classic anatomy books state that this joint is avascular, whereas some published works have shown blood vessels in young specimens. As several articular discs such as the knee menisci are known to have blood vessels in their peripheries, we decided to investigate the possible nutrition pathways to the interpubic disc and ligaments. We used 60 Wistar rats, male and female, aged between 28 and 32 days, or between 90 and 100 days. Samples were processed using a variety of techniques: regular histology, immunohistochemestry, India ink injection and corrosion casting. The interpubic disc consisted of an inner bearing portion and an outer fibrous rim. The interpubic ligaments and the fibrous rim were well vascularized in all groups. Marrow contacts between the interpubic disc and the subchondral bone were also observed. Blood vessels formed an authentic arterial circle embracing the joint, from which blood vessels branched into capillary loops facing the avascular inner bearing portion of the disc. These results confirm the need for future studies on the human symphysis pubis, to provide more details on its structure, which would enable clinicians such as physiotherapists to improve prognosis and treatment design. Future studies may also explain the pathways down which the hormone relaxin reaches its targets within this joint.

Gapping phenomenon of longitudinal meniscal tears

OBJECTIVE

To investigate the gapping behaviour of longitudinal meniscal tears.

DESIGN

The gap size of longitudinal meniscal tears was measured in porcine knee joints under various joint loading conditions.

BACKGROUND

Many meniscal fixation implants have low pull out forces. However, it is unknown if these forces are less than the forces the implants must resist in vivo. It is also unknown if gapping occurs in longitudinally torn menisci and what joint loads induce gapping.

METHODS

Longitudinal tears were set in the medial menisci of eight porcine knee joints. To observe the tears an opaque placeholder of the same shape as the original articular surface replaced the medial tibial plateau. The knees were exposed to flexion-extension cycles in a loading and motion simulator under 30 and 200 N axial joint load without external moments, under tibial rotation moments, varus or valgus moments, and combined moments. For each load condition the maximum gap of the tear was registered.

RESULTS

Maximum gapping (1.59 mm, SD 0.47) occurred in the 3 cm tear at 200 N axial joint load under the combination of a valgus and external rotation moment. An internal tibial rotation moment produced the smallest gaps in tears of any length and at any axial joint load.

CONCLUSIONS

The maximum gap size found in this study and the previously published pull out stiffnesses of meniscal fixation implants reveal maximum forces on the implant in vivo of only 8.4 N. This explains why meniscal tears fixed with implants of low pull out strength can heal.

RELEVANCE

The current study shows that moderate joint loads only lead to small gaps of meniscal tears. Clinically, this means that fixation implants of low pull out strength are not in danger of failure in a normal rehabilitation regimen.

Histology of the bone-tendon interfaces of limb muscles in lizards

Lizards exhibit continual bone growth at the epiphysis, and their limb muscles are distributed differently from those of mammals because of differences in weight bearing. We therefore characterized the bone-tendon (B-T) interface (also termed the enthesis) in lizards. Using the forelimbs of five monitor lizards and three iguanas, we performed histological investigations on 57 B-T interfaces. Most reptilian tendons were very short and were often composed of wavy fiber bundles. Fibrocartilage (FC)-mediated direct insertion was observed at all epiphyses, whereas periosteum-mediated indirect insertions, including fleshy attachments, were often located on the flat surfaces of the pectoral girdles and at the diaphyses of the limb bones. The reptilian B-T interface was characterized by variability in the morphology of the FC-mediated insertions, especially by morphologies intermediate between those of FC- and periosteum-mediated interfaces; i.e., 1) various degrees of absence of the clear FC zonation seen in mammals, including the tidemark; 2) involvement of the periosteum in the FC; 3) the presence of various types of FC cells in the tendon near the interface, to reinforce the tendon against compression or shear stress; and 4) both FC and hyaline cartilage (lateral articular cartilage) receiving the tendon at the epiphysis. Overall, variations in the connective tissue, especially the FC tissue, were very evident in the reptilian B-T interface. The specific structures of the interfaces probably represent adaptations to the continuous growth and loose joint structures of lizards.

Biomechanical properties under cyclic loading of seven meniscus repair techniques

The purpose of the current study was to obtain additional information about the biomechanical behavior of different fixation techniques for meniscus repair using recently developed biodegradable implants and suture repair techniques. The posterior horns of human menisci were used to investigate the meniscus repair construct of the Arrow, Screw, Stinger, Fastener, T-fix, and horizontal and vertical mattress suture. A 20 mm-longitudinal incision was made in the meniscus, similar to a bucket handle lesion, 3 mm from the meniscosynovial rim and was repaired. One hundred cycles between 5 N and 15 N were done using a tension load machine with a loading rate of 10 N/second. The stiffness, displacement, and pullout strength were examined. The significantly highest stiffness was found for the vertical mattress suture (17.1 N/mm) and Stinger (15 N/mm) followed by the Arrow (13.7 N/mm), T-fix (10.5 N/mm), and horizontal mattress suture (10 N/mm). Superior load to failure was obtained for the suture repair in comparison with the biodegradable implants. Despite the lower pullout strength of biodegradable implants, similar stiffnesses were found for the Stinger and Arrow in comparison with the mattress suture technique. These techniques provide the most rigid fixation that is essential for tissue healing.

The clinical significance of anterior horn meniscal tears diagnosed on magnetic resonance images

We assessed the accuracy of magnetic resonance imaging in detecting clinically significant lesions of the anterior horn of the meniscus by reviewing 947 consecutive knee magnetic resonance imaging reports. Of these, 76 (8%) indicated a tear of the anterior horn of the medial or lateral meniscus. Thirty-one of these 76 patients underwent a subsequent arthroscopic examination, and their operative reports were reviewed. The 45 patients who were not examined arthroscopically were contacted and interviewed for clinical follow-up. Among the 31 patients who underwent arthroscopic examination, 8 anterior horn tears were noted in the predicted area (26% true-positive results), 23 patients had intact anterior horns (74% false-positive results), and 18 had normal intact menisci in all zones. Of the 45 patients who did not undergo arthroscopic surgery, 6 had isolated anterior horn tears reported on magnetic resonance imaging, and 5 of the 6 were asymptomatic at follow-up. The other 39 patients had multiple pathologic conditions noted on the magnetic resonance imaging report and continued to report knee pain at the follow-up interview. Increased signal intensity at the anterior horn of the meniscus seen on magnetic resonance imaging commonly does not represent a clinically significant lesion. We recommend correlation with the physical examination when interpreting this "positive" finding on knee magnetic resonance imaging examinations.

Formation of vascularized meniscal tissue by combining gene therapy with tissue engineering

Ingrowth of host blood vessels into engineered tissues has potential benefits for successful transplantation of engineered tissues as well as healing of surrounding host tissues. In particular, the use of a vascularized bioengineered tissue could be beneficial for treating injuries to the meniscus, a structure in the knee where the lack of a vascular supply is associated with an inadequate healing response. In this study, gene transfer using an adenovirus vector encoding the hepatocyte growth factor gene (AdHGF) was used to induce blood vessel formation in tissue-engineered meniscus. Bovine meniscal cells were treated with AdHGF, a vector encoding a marker gene E. coli beta-galactosidase (Adbetagal), or no virus. Cells were seeded onto poly-glycolic acid felt scaffolds and then transplanted into the subcutaneous pouch of athymic nude mice for 8 weeks. Expression of the marker gene and HGF was detectable for several weeks after gene transfer. Ink injection studies showed that AdHGF-treated meniscal cells formed tissue which contained fourfold more blood vessels at 2 weeks (p < 0.02) and 2.5-fold more blood vessels at 8 weeks (p < 0.001) posttransplantation than controls. This study demonstrates the feasibility of using adenovirus-mediated gene transfer to engineer a blood supply in the bioengineered meniscal tissue.

Interleukin-1, tumor necrosis factor alpha, and interleukin-17 synergistically up-regulate nitric oxide and prostaglandin E2 production in explants of human osteoarthritic knee menisci

OBJECTIVE

In osteoarthritis (OA), a combination of biochemical and biomechanical factors may damage both menisci and articular cartilage. Nitric oxide (NO) and prostaglandin E2 (PGE2) have been implicated as mediators of inflammation in OA. The goals of this study were to determine if menisci from patients with OA produce NO and PGE2, and if the proinflammatory cytokines interleukin-1beta (IL-1beta), tumor necrosis factor a (TNFalpha), and IL-17 augment NO and PGE2 production by these tissues.

METHODS

Menisci were obtained from 17 patients (age 47-75 years) undergoing total knee replacement for OA. Tissue explants were cultured alone or with IL-1beta, IL-17, or TNFalpha, and the release of NO and PGE2 from the tissue as well as the presence of type 2 nitric oxide synthase (NOS2) and cyclooxygenase 2 (COX-2) antigens were measured.

RESULTS

All menisci constitutively produced NO, and significant increases in NO production were observed in the presence of IL-1beta, TNFalpha, or IL-17 (P < 0.05). The combination of IL-17 and TNFalpha significantly increased NO production compared with either cytokine alone. Basal and cytokine-stimulated NO synthesis was inhibited by the NOS inhibitors NG-monomethyl-L-arginine or N-3-aminoethylbenzylacetamidine (1400W). IL-1beta significantly increased PGE2 production. The combination of IL-1beta and TNFalpha had an additive effect on PGE2 production, while addition of IL-17 to TNFalpha or IL-1beta synergistically enhanced PGE2 production. Inhibition of NO production by 1400W significantly increased IL-1beta-stimulated PGE2 production, and inhibition of PGE2 production by the COX-2 inhibitor N-[2-(cyclohexyloxy)-4-nitrophenyl]-methanesulfonamide significantly increased IL-17-stimulated NO production.

CONCLUSION

Menisci from humans with OA spontaneously produced NO and PGE2 in a manner that was synergistically or additively augmented by cytokines. NO and PGE2 exhibited reciprocal regulatory effects on one another, suggesting that pharmaceutical agents designed to inhibit NOS2 or COX-2 production may in fact be influencing both pathways.

Interleukin-1 induces pro-mineralizing activity of cartilage tissue transglutaminase and factor XIIIa

Two transglutaminases (TGases), Factor XIIIa and tissue TGase (tTGase), are expressed in temporal-spatial association with matrix calcification in growth plates. Meniscal and articular cartilage matrix calcification are prevalent in osteoarthritis (OA) and aging. Here, we demonstrated up-regulation of tTGase and Factor XIIIa in superficial and deep zones of knee OA articular cartilage and the central (chondrocytic) zone of OA menisci. Transforming growth factor-beta and interleukin (IL)-1beta induced Factor XIIIa and tTGase expression in cartilage and meniscal organ cultures. Thus, we studied TGase activity. Donor age-dependent, OA severity-related, and IL-1-induced increases in TGase activity were demonstrated in both knee menisci and cultured meniscal cells. Meniscal cell TGase activity was stimulated by nitric oxide donors and tumor necrosis factor-alpha, but transforming growth factor-beta did not stimulate TGase activity. The iNOS inhibitor N-monomethylarginine (NMMA) and an inhibitor of tumor necrosis factor receptor-associated factor (TRAF)2 and TRAF6 signaling (the zinc finger protein A20) suppressed IL-1 induction of TGase activity. Increased Factor XIIIa and tTGase activities, achieved via direct transfection of chondrocytic TC28 and meniscal cells, both induced matrix apatite deposition. Thus, Factor XIIIa and tTGase activities were increased in aging, degenerative cartilages and induced by IL-1. Because TGase activity promoted apatite deposition, our findings potentially implicate inflammation in the pathogenesis of cartilage matrix calcification.

Up-regulated expression of the phosphodiesterase nucleotide pyrophosphatase family member PC-1 is a marker and pathogenic factor for knee meniscal cartilage matrix calcification

OBJECTIVE

Elevated cartilage inorganic pyrophosphate (PPi) production and PPi-generating nucleoside triphosphate pyrophosphohydrolase (NTPPPH) activity are strongly linked with aging-related cartilage calcification in meniscal and articular cartilages. We hypothesized that there were divergent relationships of 3 NTPPPH isozymes with cartilage matrix calcification and sought to identify them.

METHODS

We studied knee medial meniscal expression in situ of 3 NTPPPH isozymes of the phosphodiesterase nucleotide pyrophosphatase (PDNP) family: plasma cell membrane glycoprotein 1 (PC-1, or PDNP1), autotaxin (ATX, or PDNP2), and B10/PDNP3. We also used complementary DNA transfection to assess differential functions in matrix calcification of each NTPPPH isozyme in vitro in meniscal cells.

RESULTS

We observed diffuse cell-associated ATX and B10/PDNP3 expression in central (chondrocytic) and, to a lesser degree, peripheral (fibroblastic) regions of normal, degenerative uncalcified, and degenerative calcified menisci. In contrast, PC-1 expression was only robust at sites of apoptotic cells and calcification in central regions of degenerative menisci. Only PC-1 was abundant at the perimeter of meniscal cells and in association with meniscal cell-derived matrix vesicles (MVs). Because each PDNP-family isozyme was expressed by cells near calcifications, we transfected the isozymes in nonadherent knee meniscal cells cultured with ascorbic acid, beta-glycerophosphate, and dexamethasone supplementation to stimulate them to calcify the matrix. PC-1, but not ATX or B10/PDNP3, consistently promoted increased MV NTPPPH, MV-associated PPi, and extracellular PPi. PC-1 also increased matrix calcification (with hydroxyapatite crystals) by meniscal cells. ATX uniquely induced alkaline phosphatase activity, but promoted only moderately increased matrix calcification.

CONCLUSION

We identified divergent effects of 3 PDNP-family NTPPPH isozymes on meniscal cell matrix calcification. Increased expression of PC-1 is both a marker and a potential pathogenic factor for knee meniscal cartilage matrix calcification.

Biomechanical investigations of different meniscal repair implants in comparison with horizontal sutures on human meniscus

PURPOSE

The use of biodegradable implants for arthroscopic repair of meniscal lesions is becoming increasingly popular. The aim of this study was to test the biomechanical stability and the mode of failure of these implants.

TYPE OF STUDY

Biomechanical testing study.

METHODS

Biomechanical investigations were performed on human menisci using 6 commonly used biodegradable implants for meniscal repair to compare them with horizontal mattress suture using 2/0 Ethibond (Ethicon, Norderstedt, Germany). Included in this study were the Meniscus Arrow (Bionx, Tampere, Finland), Dart (Arthrex, Naples, FL), Stinger (Linvatec, Largo, FL), Meniscal Screw (Innovasive, Marlborough, MA), T-Fix (Acufex, Mansfield, MA), and the Fastener (Mitek, Westwood, MA). The tests were carried out using a material testing machine at a loading rate of 10 N/second. The ultimate tension load (UTL), elongation, and stiffness were evaluated for each implant technique.

RESULTS

The highest UTL was shown by Ethibond (62 +/- 7.91 N) and the T-Fix (51.35 +/- 16.31 N), followed by the Fastener (32.67 +/- 2.97 N). All other implants had a significantly lower UTL (P =.001). Less elongation under a load of 5 N was noted for Ethibond (0.64 +/- 0.25 mm) and for T-Fix (0.43 +/- 0.32 mm) compared with the other implants. The greatest elongation was found for the Fastener (2.239 +/- 0.581 mm). The stiffness of the fixation was similar in all implants, except for the Dart and Fastener, which were significantly inferior (P <.05).

CONCLUSIONS

All of the biodegradable implants had lower UTL than the suture techniques. Therefore, when using the implants, they should be inserted close together to provide sufficient stability. In cases of an extended lesion, there might even be an option to combine the implant and suturing techniques.

The cells of the rabbit meniscus: their arrangement, interrelationship, morphological variations and cytoarchitecture

Four major morphologically distinct classes of cells were identified within the adult rabbit meniscus using antibodies to cytoskeletal proteins. Two classes of cell were present in the fibrocartilage region of the meniscus. These meniscal cells exhibited long cellular processes that extended from the cell body. A third cell type found in the inner hyaline-like region of the meniscus had a rounded form and lacked projections. A fourth cell type with a fusiform shape and no cytoplasmic projections was found along the superficial regions of the meniscus. Using a monoclonal antibody to connexin 43, numerous gap junctions were observed in the fibrocartilage region, whereas none were seen in cells either from the hyaline-like or the superficial zones of the meniscus. The majority of the cells within the meniscus exhibited other specific features such as primary cilia and 2 centrosomes. The placement of the meniscal cell subtypes as well as their morphology and architecture support the supposition that their specific characteristics underlie the ability of the meniscus to respond to different types of environmental mechanical loads.

Toward tissue engineering of the knee meniscus

This review details current efforts to tissue engineer the knee meniscus successfully. The meniscus is a fibrocartilaginous tissue found within the knee joint that is responsible for shock absorption, load transmission, and stability within the knee joint. If this tissue is damaged, either through tears or degenerative processes, then deterioration of the articular cartilage can occur. Unfortunately, there is a dearth in the amount of work done to tissue engineer the meniscus when compared to other musculoskeletal tissues, such as bone. This review gives a brief overview of meniscal anatomy, biochemical properties, biomechanical properties, and wound repair techniques. The discussion centers primarily on the different components of attempting to tissue engineer the meniscus, such as scaffold materials, growth factors, animal models, and culturing conditions. Our approach for tissue engineering the meniscus is also discussed.

The hip joint: the fibrillar collagens associated with development and ageing in the rabbit

The fibrillar collagens associated with the articular cartilages, joint capsule and ligamentum teres of the rabbit hip joint were characterised from the 17 d fetus to the 2-y-old adult by immunohistochemical methods. Initially the putative articular cartilage contains types I, III and V collagens, but when cavitation is complete in the 25 d fetus, type II collagen appears. In the 17 d fetus, the cells of the chondrogenous layers express type I collagen mRNA, but not that of type II collagen. Types III and V collagens are present throughout life, particularly pericellularly. Type I collagen is lost. In all respects, the articular cartilage of the hip joint is similar to that of the knee. The joint capsule contains types I, III and V collagens. In the fetus the ligamentum teres contains types I and V collagens and the cells express type I collagen mRNA; type III collagen is confined mainly to its surface and insertions. After birth, the same distribution remains, but there is more type III collagen in the ligament, proper. The attachment to the cartilage of the head of the femur is marked only by fibres of type I collagen traversing the cartilage; the attachment cannot be distinguished in preparations localising types III and V collagens. The attachment to the bone at the lip of the acetabulum is via fibres of types I and V collagens and little type III is present. The ligament is covered by a sheath of types III and V collagens. Type II collagen was not located in any part of the ligamentum teres. The distribution of collagens in the ligamentum teres is similar to that in the collateral ligaments of the knee. Its insertions are unusual because no fibrocartilage was detected.

Characterization of the "red zone" of knee meniscus: MR imaging and histologic correlation

PURPOSE

To determine the extent and vascularity of knee menisci with conventional and gadolinium-enhanced magnetic resonance (MR) imaging in cadaveric specimens, with histologic findings as the reference standard, and to investigate signal intensity changes in menisci and perimeniscal soft tissues in symptomatic patients.

MATERIALS AND METHODS

Radial dimensions and enhancement patterns of menisci were recorded and compared in (a) 12 cadaveric menisci examined with conventional and gadolinium-enhanced intermediate-weighted and fat-suppressed T1-weighted spin-echo MR imaging, high-spatial-resolution T1-weighted and fast low-angle shot MR imaging, and gross anatomic and histologic specimens and (b) 18 patients examined with conventional and gadolinium-enhanced fat-suppressed T1-weighted spin-echo MR imaging.

RESULTS

No differences in radial measurements of the meniscus were found for different MR techniques (P =.551). Despite the presence of vessels in the peripheral 10%-15% of the menisci, no enhancement of menisci was detected in specimens or patients. Perimeniscal soft-tissue enhancement adjacent to the posterior horn was greater than that adjacent to the anterior horn (P <.05), and enhancement of the lateral meniscal body was greater than that of the medial meniscal body (P <.05).

CONCLUSION

The wedge-shaped low-signal-intensity structure seen on MR images represents the entire meniscus. Intravenous injection of contrast material does not appear to be useful for differentiation of the vascularized from the nonvascularized zone of the meniscus.

Effects of intraoral splint wear on proteoglycans in the temporomandibular joint disc

Intraoral splints are a common dental treatment for dysfunctions of the temporomandibular joint (TMJ), but their effects on the structures of the joint, specifically the disc, have not been well investigated. This study examined proteoglycans (PGs) of the TMJ disc of the miniature pig and tested for alterations resulting from intraoral splint wear. Sixteen female pigs were divided into three groups: control (C), control splint (CS), and protrusive splint (PS). Splinted groups received chrome-cobalt ramp splints which were worn continuously for 2 months. PG content within various disc locations was determined by colorimeteric assay. PG synthesis and type were examined by labeling with (35)S-sulfate and SDS-PAGE analysis. Average water content of the disc was 77.1%, which places it at the high end of the normal range for collagenous biomaterials (60-80%). PGs migrating to the positions typical of aggrecan, biglycan, and decorin on SDS-PAGE were present in all locations of all groups. The highest content and synthesis of PGs were always found in the intermediate band of the disc regardless of group (P < 0.05), supporting the notion that this band encounters heavy compressive loading during function. The joints of animals from both splinted groups showed a high frequency of gross pathology. Biglycan synthesis was increased in both splinted groups (P < 0.05). Newly synthesized biglycan had a shorter migration distance in the intermediate bands of the CS group, suggesting increased hydrodynamic size. These findings suggest that intraoral splint wear may cause disc damage or remodeling.

Meniscal tears of the knee: diagnosis and individualized treatment

Meniscal tears are very common sports injuries. Typical symptoms include pain, catching, and buckling. Signs on physical exam include joint-line tenderness, effusion, and, possibly, a click when the knee is taken through full range of motion. MRI is often needed to confirm tears and differentiate pain from that caused by other injuries such as articular cartilage damage. Treatment comprises physical therapy and rest, partial meniscectomy, or, in special instances, surgical repair. Therapeutic goals, which are often achieved, are to restore a high level of pain-free function and to prevent premature joint degeneration.

Meniscal regeneration or meniscal transplantation?

Owing to the initial necrosis to which any freely transplanted biological graft is subjected, meniscus transplantation is based on similar principles to meniscal regeneration. Both methods rely on repopulation of extrinsic cells of the graft. In the former procedure a biological matrix (meniscus, tendon, fatpad) is used as graft (scaffold), whereas in meniscal regeneration commercially available resorbable or non-resorbable scaffolds are implanted. However, the cellular (re)population and (re)vitalization process is deleterious rather than beneficial for the function of the graft as the remodelling of the tissue leads to shrinkage and narrowing of the implant. In addition, improper fixation and subsequent elongation of the anterior and posterior bony attachments leads to peripheral graft dislocation, loss of the load distribution function, and subsequently to cartilage degeneration. Hence, meniscus transplantation or regeneration faces two major problems: 1) remodelling of graft to inferior tissue properties after allograft transplantation, or lacking establishment of normal tissue properties after use of biological matrixes other than the meniscus (fatpad, tendon), or commercially available matrixes; 2) improper fixation with elongation of the anterior and posterior attachments. Furthermore, use of allografts incorporates the risk for disease transmission. Today we are unable to control these problems, and therefore the concept of meniscal replacement does not work yet. Further research is necessary to control remodelling and improve fixation to make this procedure a successful one in the future.