0:00

Now, we said earlier that this vertical longitudinal

0:05

tear is one type of up and down tear.

0:08

There's another kind of up and down

0:09

tear that we should talk about,

0:12

and that is one that starts in the inner third,

0:16

and instead of going

0:19

up and down,

0:21

that's parallel to the capsule.

0:24

In other words, that's parallel to the capsule,

0:27

which we'll imagine is here in red.

0:30

That has some blood in it.

0:31

It is perpendicular to the capsule,

0:35

kind of like the spokes on a wheel,

0:39

right.

0:41

The spokes on the wheel are perpendicular

0:43

to the outer part of this circle,

0:48

kind of like the wheels on the bus

0:49

go round and round. Right.

0:51

So what does that look like?

0:53

Well, here's the spoke on the wheel right here.

0:55

It's coming right at you.

0:56

It's coming at you.

0:58

Sometimes it makes a little v.

1:01

That's a radial tear,

1:03

and that goes into the screen.

1:04

That also goes up and down.

1:06

It's just in a different axis.

1:08

Now,

1:09

we're interested in this tear because this

1:13

tear can get a little bit nasty.

1:16

Well, how come?

1:19

Because it's in an area that doesn't heal.

1:21

Remember, we have outer third, red red zone,

1:24

middle third, red white zone, inner third,

1:27

white white zone.

1:29

The white white zone has no vascularity,

1:31

doesn't heal.

1:32

Okay, so we have a little tear there.

1:35

When do we mess with it?

1:36

When it's symptomatic. But what kind of symptoms?

1:39

Pain, maybe not because pain alone,

1:43

maybe it breaks off. Maybe it's scars.

1:45

Maybe the pain goes away.

1:46

But if it's pain and clicking or pain and locking

1:49

or pain and progressive arthritis,

1:52

then it has to be addressed.

1:53

Now, in the orthopedic literature,

1:55

they say that if the tear has a depth of greater

2:01

than six to 8, are more likely to become unstable,

2:07

to propagate,

2:09

and even to lead to consequences like

2:12

fragmentation, locking, and chondromylation.

2:14

But I think we've gotten a little more liberal as

2:17

time has gone on and less aggressive in trying to

2:20

resect these tears because there's no sewing them.

2:23

You just go in with a claw,

2:24

and you just claw them out of there,

2:25

which is kind of ugly.

2:28

So what do we mean by depth?

2:31

Depth is the measurement from here,

2:34

the inner edge, to the outer edge.

2:37

So depth goes this way.

2:39

Remember,

2:40

length is completely different for

2:41

the longitudinal vertical tear.

2:44

For the radial vertical tear,

2:47

we're more interested in this character.

2:50

Now,

2:50

we also have gapping the side to side dimensions

2:54

so the tears can get a little wide.

2:56

And the more gap they are,

2:58

the more troublesome they are.

2:59

So depth is important.

3:01

The measurement from here to here,

3:03

greater than six to 8 mm,

3:05

but also the side to side dimension,

3:09

because gapping can lead to instability.

3:13

Instability of what? Instability of the meniscus.

3:18

So where might we see a problematic area of

3:22

gapping back here, near the meniscus root.

3:27

Remember, we have a posterior horn posture, third,

3:30

a body middle third,

3:32

an anterior horn anterior third.

3:35

To keep it simple,

3:36

we also have,

3:38

in the deepest attachment of the meniscus,

3:41

the meniscus root, in the back and in the front.

3:44

And although we haven't drawn them in,

3:46

there are ligaments.

3:47

Don't confuse the meniscus root,

3:49

which is meniscus,

3:50

with the meniscus root ligament.

3:53

You can tear the meniscus from its root,

3:56

you can tear the ligament from the bone.

3:59

Now, they both have the same consequence,

4:01

but what happens if you have one of these

4:03

radial tears and it keeps going back,

4:07

to quote Chris Berman,

4:09

and it keeps going back and boom,

4:12

it goes to the outer surface.

4:14

Now we got a problem, right?

4:16

The meniscus isn't anchored to itself anymore.

4:20

Doesn't matter where the ligament is still there.

4:23

This is not attached to that.

4:25

And so they spread apart,

4:29

and the meniscus starts to float this way

4:33

out of the edge of the femur and the tibia.

4:37

And now you essentially have a meniscus

4:39

that extrudes itself.

4:40

So these very large radial root

4:44

tears are problematic.

4:46

The little ones, we leave all of those alone.

4:49

We hardly ever touch the root.

4:52

Radial tears that don't go all the way through,

4:55

even the ones that almost go all the way through,

4:58

we don't touch.

4:59

But the ones that clearly go all the way from

5:01

the inner third to the outer third,

5:03

the meniscus is starting to gap and

5:04

separate those we got to go after.

5:08

So we've learned about two very important

5:12

vertically oriented tears today.

5:14

The one that's longitudinal and parallel to the

5:17

outer portion of the meniscus and the one that's

5:20

perpendicular to the outer arc of the meniscus,

5:25

the one that's parallel,

5:27

is less problematic because it's in the red,

5:29

red zone.

5:31

The one that is perpendicular is problematic.

5:34

Now, if this radial tear were to arc,

5:36

if it were to do something like, say this,

5:40

we would call it a flap tear.

5:43

See,

5:43

radial tears are straighter

5:46

if it were to arc and it were to get a little

5:48

bit wider and a little bit longer.

5:51

Now we're into a parrot beak tear,

5:55

which happens to, like, the body horn junctions.

6:00

Let's draw another meniscus for a moment,

6:04

just so we can demonstrate one

6:05

other thing for completeness.

6:07

I realize my meniscus is a little bit thin here,

6:11

but I think you can see it.

6:13

Actually,

6:13

I'm going to make it thicker because I know

6:16

I'm going to get reprimanded if I don't.

6:18

Let's make a thicker meniscus.

6:21

Erase this one.

6:23

Give you

6:25

a little more visual

6:29

stimulation here. Oh, wow,

6:31

that's a really thick one.

6:33

Yeah.

6:33

This is for all of us out there

6:35

that are over age 60.

6:37

So here's a big, fat meniscus.

6:41

Okay, now let's make it thinner.

6:44

Let's make our line thinner,

6:46

and let's change the color.

6:49

And now let's assume we have a longitudinal

6:52

tear and it's in the middle third.

6:57

It would be a vertical longitudinal

6:59

tear in the middle third.

7:01

But if that vertical longitudinal tear starts to

7:04

gap and get wider and wider and wider and wider,

7:07

and all of a sudden this portion of

7:09

the meniscus starts to go inwards.

7:12

Now we have ourselves a bucket handle tear.

7:17

So a bucket handle tear really starts

7:19

out as a vertical tear,

7:20

usually in the center of the meniscus,

7:22

and that will be a story for another day.