The effect of kinematic and kinetic changes on meniscal strains during gait

The menisci play an important role in load distribution, load bearing, joint stability, lubrication, and proprioception. Partial meniscectomy has been shown to result in changes in the kinematics and kinetics at the knee during gait that can lead to progressive meniscal degeneration. This study examined changes in the strains within the menisci associated with kinematic and kinetic changes during the gait cycle. The gait changes considered were a 5 deg shift toward external rotation of the tibia with respect to the femur and an increased medial-lateral load ratio representing an increased adduction moment. A finite element model of the knee was developed and tested using a cadaveric specimen. The cadaver was placed in positions representing heel-strike and midstance of the normal gait, and magnetic resonance images were taken. Comparisons of the model predictions to boundaries digitized from images acquired in the loaded states were within the errors produced by a 1 pixel shift of either meniscus. The finite element model predicted that an increased adduction moment caused increased strains of both the anterior and posterior horns of the medial meniscus. The lateral meniscus exhibited much lower strains and had minimal changes under the various loading conditions. The external tibial rotational change resulted in a 20% decrease in the strains in the posterior medial horn and increased strains in the anterior medial horn. The results of this study suggest that the shift toward external tibial rotation seen clinically after partial medial meniscectomy is not likely to cause subsequent degenerative medial meniscal damage, but the consequence of this kinematic shift on the pathogenesis of osteoarthritis following meniscectomy requires further consideration.     

Meniscus maturation in the swine model: changes occurring along with anterior to posterior and medial to lateral aspect during growth

The meniscus plays important roles in knee function and mechanics and is characterized by a heterogeneous matrix composition. The changes in meniscus vascularization observed during growth suggest that the tissue‐specific composition may be the result of a maturation process. This study has the aim to characterize the structural and biochemical variations that occur in the swine meniscus with age. To this purpose, menisci were collected from young and adult pigs and divided into different zones. In study 1, both lateral and medial menisci were divided into the anterior horn, the body and the posterior horn for the evaluation of glycosaminoglycans (GAGs), collagen 1 and 2 content. In study 2, the menisci were sectioned into the inner, the intermediate and the outer zones to determine the variations in the cell phenotype along with the inner–outer direction, through gene expression analysis. According to the results, the swine meniscus is characterized by an increasing enrichment in the cartilaginous component with age, with an increasing deposition in the anterior horn (GAGs and collagen 2; P < 0.01 both); moreover, this cartilaginous matrix strongly increases in the inner avascular and intermediate zone, as a consequence of a specific differentiation of meniscal cells towards a cartilaginous phenotype (collagen 2, P < 0.01). The obtained data add new information on the changes that accompany meniscus maturation, suggesting a specific response of meniscal cells to the regional mechanical stimuli in the knee joint.     

Effect of meniscus replacement fixation technique on restoration of knee contact mechanics and stability

The menisci are important biomechanical components of the knee. We developed and validated a finite element model of meniscal replacement to assess the effect of surgical fixation technique on contact behavior and knee stability. The geometry of femoral and tibial articular cartilage and menisci was segmented from magnetic resonance images of a normal cadaver knee using MIMICS (Materialise, Leuven, Belgium). A finite element mesh was generated using HyperWorks (Altair Inc, Santa Ana, CA). A finite element solver (Abaqus v6.9, Simulia, Providence, RI) was used to compute contact area and stresses under axial loading and to assess stability (reaction force generated during anteroposterior translation of the femur). The natural and surgical attachments of the meniscal horns and peripheral rim were simulated using springs. After total meniscectomy, femoral contact area decreased by 26% with a concomitant increase in average contact stresses (36%) and peak contact stresses (33%). Replacing the meniscus without suturing the horns did little to restore femoral contact area. Suturing the horns increased contact area and reduced peak contact stresses. Increasing suture stiffness correlated with increased meniscal contact stresses as a greater proportion of tibiofemoral load was transferred to the meniscus. A small incremental benefit was seen of simulated bone plug fixation over the suture construct with the highest stiffness (50 N/mm). Suturing the rim did little to change contact conditions. The nominal anteroposterior stiffness reduced by 3.1 N/mm after meniscectomy. In contrast to contact area and stress, stiffness of the horn fixation sutures had a smaller effect on anteroposterior stability. On the other hand suturing the rim of the meniscus affected anteroposterior stability to a much larger degree. This model emphasizes the importance of the meniscus in knee biomechanics. Appropriate meniscal replacement fixation techniques are likely to be critical to the clinical success of meniscal replacement. While contact conditions are mainly sensitive to meniscus horn fixation, the stability of the knee under anteroposterior shear loads appeared to be more sensitive to meniscal rim fixation. This model may also be useful in predicting the effect of biomaterial mechanical properties and meniscal replacement shape on knee contact conditions.     

The effect of meniscal tears and resultant partial meniscectomies on the knee contact stresses: a finite element analysis

Knee osteoarthritis (OA) is believed to result from high levels of contact stresses on the articular cartilage and meniscus after meniscal damage. This study investigated the effect of meniscal tears and partial meniscectomies on the peak compressive and shear stresses in the human knee joint. An elaborate three-dimensional finite element model of knee joint including bones, articular cartilages, menisci and main ligaments was developed from computed tomography and magnetic resonance imaging images. This model was used to model four types of meniscal tears and their resultant partial meniscectomies and analysed under an axial 1150 N load at 0° flexion. Three different conditions were compared: a healthy knee joint, a knee joint with medial meniscal tears and a knee joint following partial meniscectomies. The numerical results showed that each meniscal tear and its resultant partial meniscectomy led to an increase in the peak compressive and shear stresses on the articular cartilages and meniscus in the medial knee compartment, especially for partial meniscectomy. Among the four types of meniscal tears, the oblique tear resulted in the highest values of the peak compressive and shear stresses. For the four partial meniscectomies, longitudinal meniscectomy led to the largest increase in these two stresses. The lateral compartment was minimally affected by all the simulations. The results of this study demonstrate meniscal tear and its resultant partial meniscectomy has a positive impact on the maintenance of high levels of contact stresses, which may improve the progression of knee OA, especially for partial meniscectomy. Surgeons should adopt a prudent strategy to preserve the greatest amount of meniscus possible.     

Scanning electron microscopy study of the meniscus of the knee in patients with anterior cruciate ligament lesions]

In the aim of bringing a contribution to role of the knee menisci and the functional connection between meniscal lesions and knee joint instability, four patients have been studied, who underwent arthroscopy for sub-acute tear of anterior cruciate ligament without clinical or morphological evidence of meniscal pathology. In these patients biopsies have been taken from one of the menisci and processed for the examination by the SEM. As control, meniscal fragments from two healthy knees have been studied from patients who underwent amputation at thigh for accidental trauma with irreparable lesion of femoral artery. In patients affected by ligamentous tear, on the meniscal surface a lot of deposited material appears, as well as many microlesions as clefts or cracking and distortion of superficial collagenous fibers. All described alteration are more evident in the central portion of menisci than in the anterior or posterior horns. The above mentioned patterns suggest a strong correlation of the knee instability due to ligamentous lesions and meniscal degenerative process which would onset before its clinical or macroscopical evidence.     

Sensitivities of medial meniscal motion and deformation to material properties of articular cartilage, meniscus and meniscal attachments using design of experiments methods

This study investigated the role of the material properties assumed for articular cartilage, meniscus and meniscal attachments on the fit of a finite element model (FEM) to experimental data for meniscal motion and deformation due to an anterior tibial loading of 45 N in the anterior cruciate ligament-deficient knee. Taguchi style L18 orthogonal arrays were used to identify the most significant factors for further examination. A central composite design was then employed to develop a mathematical model for predicting the fit of the FEM to the experimental data as a function of the material properties and to identify the material property selections that optimize the fit. The cartilage was modeled as isotropic elastic material, the meniscus was modeled as transversely isotropic elastic material, and meniscal horn and the peripheral attachments were modeled as noncompressive and nonlinear in tension spring elements. The ability of the FEM to reproduce the experimentally measured meniscal motion and deformation was most strongly dependent on the initial strain of the meniscal horn attachments (epsilon(1H)), the linear modulus of the meniscal peripheral attachments (E(P)) and the ratio of meniscal moduli in the circumferential and transverse directions (E(theta)E(R)). Our study also successfully identified values for these critical material properties (epsilon(1H) = -5%, E(P) = 5.6 MPa, E(theta)E(R) = 20) to minimize the error in the FEM analysis of experimental results. This study illustrates the most important material properties for future experimental studies, and suggests that modeling work of meniscus, while retaining transverse isotropy, should also focus on the potential influence of nonlinear properties and inhomogeneity.     

The histological structure of dog knee menisci with comments on its possible significance.

Knee-joint menisci are poorly understood terminologically, structurally and functionally in spite of their almost universal occurrence in mammals and their considerable clinical significance in man. A study was therefore undertaken of dog knee menisci utilizing several histological techniques. Terminologically, it is proposed that the part of the meniscus extending between the anterior and posterior horns and exclusive of them be called the meniscal "body." Structurally, the horns and body differ in anumber of ways. The horns are oval in cross section, the body triangular. Hyalinized areas are much more frequent in the body than in the horns. The collagen of the horns is organized into discrete bundles that are separated from one another by loose connective tissue septa, while that of the body is arranged in a "herringbone" pattern; no septa are present in the body. Finally, the meniscal horns are richly supplied with blood vessels are nerves (including large myelinated fibers which apparently terminate in the horns) while the body is almost completely devoid of blood vessels and nerves. Functionally, it is hypothesized that knee-joint menisci may serve important sensory functions.     

Anatomical variant of the meniscus related to posterior junction: a case report

Background

There are several reports on anatomical differences of the meniscus. However, there are only a few reports on abnormalities in both menisci and anatomical differences in anterior cruciate ligament insertions.

Case presentation

This is a case report of a 36-year-old Hispanic man presenting symptoms, including knee pain, locking, and effusion, with an anatomical abnormality of the menisci corresponding to the fusion of the posterior horns of the menisci in tandem with the insertion of the posterior meniscus fibers in the anterior cruciate ligament.

Conclusions

This is the first study describing a meniscus anatomical variant with isolated posterior junction of the posterior horn with an anomalous insertion to the anterior cruciate ligament. The recognition of meniscus variants is important as they can be misinterpreted for more significant pathology on magnetic resonance images.

     

Postnatal deletion of Alk5 gene in meniscal cartilage accelerates age-dependent meniscal degeneration in mice

Activation of transforming growth factor-β (TGF-β) signaling has been used to enhance healing of meniscal degeneration in several models. However, the exact role and molecular mechanism of TGF-β signaling in meniscus maintenance and degeneration are still not understood due to the absence of in vivo evidence. In this study, we found that the expression of activin receptor-like kinases 5 (ALK5) in the meniscus was decreased with the progression of age and/or osteoarthritis induced meniscal degeneration. Col2α1 positive cells were found to be specifically distributed in the superficial and inner zones of the anterior horn, as well as the inner zone of the posterior horn in mice, indicating that Col2α1-CreER^T2 mice can be a used for studying gene function in menisci. Furthermore, we deleted Alk5 in Col2α1 positive cells in meniscus by administering tamoxifen. Alterations in the menisci structure were evaluated histologically. The expression levels of genes and proteins associated with meniscus homeostasis and TGF-β signaling were analyzed by quantitative real-time PCR analysis (qRT-PCR) and immunohistochemistry (IHC). Our results revealed severe and progressive meniscal degeneration phenotype in 3- and 6-month-old Alk5 cKO mice compared with Cre-negative control, including aberrantly increased hypertrophic meniscal cells, severe fibrillation, and structure disruption of meniscus. qRT-PCR and IHC results showed that disruption of anabolic and catabolic homeostasis of chondrocytes may contribute to the meniscal degeneration phenotype observed in Alk5 cKO mice. Thus, TGF-β/ALK5 signaling plays a chondro-protective role in menisci homeostasis, in part, by inhibiting matrix degradation and maintaining extracellular matrix proteins levels in meniscal tissues.     

Regional biochemical and morphological characteristics of rat knee meniscus

The biochemical and morphological characteristics of the anterior and posterior regions of the rat knee meniscus were studied. The anterior meniscal horn was thicker and contained a lower concentration of DNA, hydroxyproline, and uronic acid as compared to the posterior region. The calcium concentration in the anterior region, however, was significantly greater than the calcium concentration in the posterior horn. Presence of a significant concentration of calcium in the normal rat knee meniscus is unique to rats and uncommon in other mammalian species.     

Nanoindentation of human meniscal surfaces

Menisci are crescent shaped fibrocartilaginous structures which support load distribution of the knee. The menisci are specifically designed to fit the contour of the femoral condyles, aiding to disperse the stresses on the tibial plateau and in turn safeguarding the underlying articular cartilage. The importance of the meniscal superficial layer has not been fully revealed and it is suspected that this layer plays a pivotal role for meniscal function. In this study, both femoral (proximal) and tibial (distal) contacting meniscal surfaces were mechanically examined on the nano-level among three distinct regions (anterior, central and posterior) of the lateral and medial menisci. Nanoindentation testing showed no significant differences among regions, surfaces or anatomical locations, possibly elucidating on the homogeneity of the meniscal superficial zone structure (E(instantaneous): 3.17-4.12MPa, E(steady-state): 1.47-1.69MPa). Nanomechanical moduli values were approximately an order of magnitude greater than micro-scale testing derived moduli values. These findings validate the structural homogeneity of the meniscal superficial zone, showing that material properties are statistically similar regardless of meniscal surface and region. Understanding the mechanical behavior of meniscal surfaces is imperative to properly design an effective meniscal replacement.     

An overview of the different approaches used in the development of meniscal tissue engineering

The menisci are important fibrocartilaginous structures which give lubrication, shock absorption, nutrition and stabilisation to the knee joint, and also help transfer load. The meniscus' extracellular matrix possesses a complex architecture which is not uniform throughout the tissue. The inner third of the meniscus is composed of hyaline cartilage and the outer meniscus is composed of fibrocartilage. In a mature meniscus only the outer 10-25% is vascularised. There are various types of pathology associated with the meniscus. Previously, surgical techniques used to be considered as conventional treatment for meniscal lesions. However lesions in the avascular regions of the meniscus would rarely heal appropriately. It has been found that total menisectomies in patients may increase their chance of suffering from osteoarthritis in the future. Meniscal tissue engineering has been developed in an attempt to help improve the healing potential of avascular meniscal regions. Many different concepts and approaches have been tried and tested, such as the application of natural and synthetic scaffolds, mesenchymal stem cells, growth factors, fibrin glue and more. The objective of this review is to summarise the different approaches that have been used in the development of meniscal tissue engineering. The focus of this review is to evaluate the strengths and weaknesses of the studies that have been carried out, and from there determine what we have learnt from them in order to further the development in meniscal tissue engineering.     

Failure properties and strain distribution analysis of meniscal attachments

The menisci are frequently injured due to both degeneration and traumatic tearing. It has been suggested that the success of a meniscal replacement is dependent on several factors, one of which is the secure fixation and firm attachment of the replacement to the tibial plateau. Therefore, the objectives of the current study were to (1) determine the failure properties of the meniscal horn attachments, and (2) determine the strain distribution over their surfaces. Eight bovine knee joints were used to study the mechanical response of the meniscal attachments. Three meniscal attachments from one knee of each animal were tested in uniaxial tension at 2%/s to determine the load deformation response. During the tests, the samples were marked and local strain distributions were determined with a video extensometer. The linear modulus of the medial anterior attachment (154+/-134 MPa) was significantly less than both the medial posterior (248+/-179 MPa, p=0.0111) and the lateral anterior attachment (281+/-214 MPa, p=0.0007). Likewise, the ultimate strain for the medial anterior attachments (13.5+/-8.8%) was significantly less than the medial posterior (23+/-13%, p<0.0001) and the lateral anterior attachment (20.3+/-11.1%, p=0.0033). There were no significant differences in the structural properties or ultimate stress between the meniscal attachments (p>0.05). No significant differences in ultimate strain or moduli across the surface of the attachments were noted. Based on the data obtained, a meniscal replacement would need different moduli for each of the different attachments. However, the attachments appear to be homogeneous.     

A new in vivo technique for 3-dimensional analysis of the translation of femoral condyles and the menisci responding to antagonistic muscle forces]

The aim of our study was to develop a 3-D MR-based technique for the analysis of meniscal and femoral translations during flexion of the knee, and under the influence of antagonistic muscle forces in healthy subjects. In an open MR system, 5 knees were examined at 30 degrees and 90 degrees flexion using a T1-weighted 3-D gradient echo sequence. A force of 30 Newtons, first in the extending and then in the flexing direction, was applied to the distal lower leg. After three-dimensional reconstruction, the minimal distances between the centre of the tibial plateau and the posterior edge of the menisci and femoral condyles were determined. At 30 degrees flexion, the minimum distance for the meniscus was larger medially than laterally (23.2 +/- 1.8 mm vs. 16.2 +/- 3.3 mm), and this also applied to the condyles (25.1 +/- 1.5 vs. 19.0 +/- 3.0 mm). During flexion to 90 degrees, a posterior translation of 0.5 +/- 0.2 mm was observed for the lateral, and of 3.4 +/- 1.2 mm for the medial, meniscus. The condyles demonstrated a different posterior translation (lateral 2.2 +/- 0.56 mm; medial 1.8 +/- 1.9 mm). No obvious differences were found between extension and flexion muscle activity for the different positions of the knee. In the present study, a new 3-D technique is presented for the analysis of the femoral and meniscal translation at various positions of the knee, and under muscle activity. The results suggest different translation for the menisci and condyles.     

Geometry,time-dependent and failure properties of human meniscal attachments

Meniscectomies have been shown to lead to osteoarthritis and the success of meniscal replacements remains questionable. It has been suggested that the success of a meniscal replacement is dependent on several factors, one of which is the secure fixation and firm attachment of the replacement to the tibial plateau at the horn locations. To aid in the development of meniscal replacements, the objectives of the current study were to determine the time-dependent and failure properties of human meniscal attachments. In contrast to the time-dependent tests, during uniaxial failure testing a charge-coupled video camera was used to document the local strain and linear modulus distribution across the surface of the attachments. The lateral attachments were statistically smaller in cross-sectional area and longer than the medial attachments. The anterior attachments were statistically longer and had a smaller cross-sectional area than the posterior attachments. From the stress relaxation tests, the load and stress relaxation rates of the medial anterior attachment were statistically greater than the medial posterior attachment. There were no significant differences in the creep, structural properties or the ultimate stress between the different attachments. Ultimate strain varied between attachments, as well as along the length of the attachment. Ultimate strain in the meniscus region (10.4±6.9%) and mid-substance region (12.7±16.4%) was smaller than the bony insertion region (32.2±21.5%). The lateral and anterior attachments were also found to have statistically greater strain than the medial and posterior attachments, respectively. The linear modulus was statistically weaker in the bony insertion region (69.7±33.7 MPa) compared to the meniscus region (153±123 MPa) and mid-substance region (195±121 MPa). Overall the anterior attachments (169±130 MPa) were also found to be statistically stronger than the posterior attachments (90.8±64.9 MPa). These results can be used to help design tissue-engineered replacement menisci and their insertions and show the differences in material properties between attachments, as well as within an attachment.     

Is the meniscus of the knee joint a fibrocartilage?

A histological analysis of the structure of intact knee joint menisci was carried out in adult dogs. By means of specific histochemical methods for the connective tissue and cartilage, it was found that the meniscus as a whole does not have a unique structure. The anterior and posterior horns are populated by round chondroid cells encircled by abundant interstitial substance and branched wavy connective fibers; blood vessels are present. The outer third of the meniscus is constituted of cross bundles of connective fibers, fibrocytes and spindle-like areas of loose connective tissue with blood vessels. The inner avascular two thirds of the meniscus are filled with parallel circumferentially oriented fascicles of connective fibers, ovally elongated chondroid cells, and a small quantity of chondroid interstitial substance. In some menisci, in the inner two thirds of the body, there are isles of typical cartilage, which show metachromasia of the beta type and rarely of the gamma type. The occurrence and way of the manifestation of cartilage are of an individual character. The structural duality of the knee meniscus is accounted for by its functional duality manifested in offering resistance to the forces of traction and pressure, the latter ones favoring the process of evolution of tissue from connective, through chondroid, to cartilaginous.     

Radial fibre proportions in human knee joint menisci. Measurement by scanning optical microscopy

The proportions of medial and lateral knee joint menisci represented by radially orientated collagen (COL) were measured in 42 specimens from 24 hospital patients examined post-mortem. Images of the fibre bundles were obtained by the 488-nm laser confocal scanning of hydrated, fixed radial blocks taken from the anterior, middle and posterior regions of the menisci after staining with picro-Sirius red. Measurements of the percentage of each image occupied by fluorescent, doubly refractile COL were made by means of a Kontron IBAS image analyser, after interactive segmentation. In areas adjoining the outer, lateral parts of both the medial and lateral menisci, the proportion of all samples identified as radial COL was 7.56 +/- 0.28%. The corresponding figure for areas near the inner, medial edges of the menisci was 17.80 +/- 0.80%. However, no relationship was demonstrable between age and sex and meniscal radial fibre optical density, and there was no difference between the proportion of radial fibres in the anterior, middle or posterior regions.     

Comparison of shear forces and ligament loading in the healthy and ACL-deficient knee during gait

The purpose of this study was to predict and explain the pattern of shear force and ligament loading in the ACL-deficient knee during walking, and to compare these results to similar calculations for the healthy knee. Musculoskeletal modeling and computer simulation were combined to calculate ligament forces in the ACL-deficient knee during walking. Joint angles, ground-reaction forces, and the corresponding lower-extremity muscle forces obtained from a whole-body dynamic optimization simulation of walking were input into a second three-dimensional model of the lower extremity that represented the knee as a six degree-of-freedom spatial joint. Anterior tibial translation (ATT) increased throughout the stance phase of gait when the model ACL was removed. The medial collateral ligament (MCL) was the primary restraint to ATT in the ACL-deficient knee. Peak force in the MCL was three times greater in the ACL-deficient knee than in the ACL-intact knee; however, peak force sustained by the MCL in the ACL-deficient knee was limited by the magnitude of the total anterior shear force applied to the tibia. A decrease in anterior tibial shear force was brought about by a decrease in the patellar tendon angle resulting from the increase in ATT. These results suggest that while the MCL acts as the primary restraint to ATT in the ACL-deficient knee, changes in patellar tendon angle reduce total anterior shear force at the knee.     

3D finite element model of meniscectomy: changes in joint contact behavior

The goal of this study is to quantify changes in knee joint contact behavior following varying degrees of the medial partial meniscectomy. A previously validated 3D finite element model was used to simulate 11 different meniscectomies. The accompanying changes in the contact pressure on the superior surface of the menisci and tibial plateau were quantified as was the axial strain in the menisci and articular cartilage. The percentage of medial meniscus removed was linearly correlated with maximum contact pressure, mean contact pressure, and contact area. The lateral hemi-joint was minimally affected by the simulated medial meniscectomies. The location of maximum strain and location of maximum contact pressure did not change with varying degrees of partial medial meniscectomy. When 60% of the medial meniscus was removed, contact pressures increased 65% on the remaining medial meniscus and 55% on the medial tibial plateau. These data will be helpful for assessing potential complications with the surgical treatment of meniscal tears. Additionally, these data provide insight into the role of mechanical loading in the etiology of post-meniscectomy osteoarthritis.     

Hyperelastic properties of human meniscal attachments

Meniscal attachments are ligamentous tissues anchoring the menisci to the underlying subchondral bone. Currently little is known about the behavior of meniscal attachments, with only a few studies quantitatively documenting their properties. The objective of this study was to quantify and compare the tensile mechanical properties of human meniscal attachments in the transverse direction, curve fit experimental Cauchy stress-stretch data to evaluate the hyperelastic behavior, and couple these results with previously obtained longitudinal data to generate a more complete constitutive model. Meniscal attachment specimens were tested using a uniaxial tension test with the collagen fibers oriented perpendicular to the loading axis. Tests were run until failure and load-optical displacement data was recorded for each test. The medial posterior attachment was shown to have a significantly greater elastic modulus (6.42±0.78 MPa) and ultimate stress (1.73±0.32 MPa) when compared to the other three attachments. The Mooney-Rivlin material model was selected as the best fit for the transverse data and used in conjunction with the longitudinal data. A novel computational approach to determining the transition point between the toe and linear regions is presented for the hyperelastic stress-stretch curves. Results from piece-wise non-linear longitudinal curve fitting correlate well with previous linear elastic and SEM findings. These data can be used to advance the design of meniscal replacements and improve knee joint finite element models.