Knee Surgery, Sports Traumatology, Arthroscopy

https://doi.org/10.1007/s00167-018-5009-0

KNEE

Meniscal root tears occur frequently in multi-ligament knee injury

and can be predicted by associated MRI injury patterns
Jonathan D. Kosy1 · Luigi Matteliano1 · Anshul Rastogi2 · Dawn Pearce1 · Daniel B. Whelan1

Received: 12 December 2017 / Accepted: 1 June 2018

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Abstract
Purpose  The frequency of meniscal root tears in association with multi-ligament knee injury has not been established but
adds to the complexity of surgical reconstruction and may have long-term consequences. Therefore, identifying root tears,
on preoperative imaging, is important. The aim of this study was to identify the frequency of meniscal root tears, on pre-
operative magnetic resonance imaging, following multi-ligament injury and distinguish associated injury patterns that may
aid detection.
Methods  Cases were identified from a prospectively collected institutional database. The magnetic resonance imaging of
188 multi-ligament injuries [median age 31 years (range 16–64)] was retrospectively reviewed by three musculoskeletal
radiologists with the presence of meniscal injuries recorded alongside the ligament injury pattern and intra-articular fractures.
Assessment of injury pattern was solely made on this imaging.
Results  38 meniscal root injuries were identified in 37 knees (overall frequency = 20.2%; medial = 10.6%; lateral = 9.6%).
The frequency of meniscal root tears was not increased in higher grade injuries (21.5% vs. 17.0%, n.s.). Valgus injury pat-
terns were associated with lateral root tears (p < 0.05) and varus patterns were associated with medial root tears (p < 0.05).
Further, fractures in the same compartment were associated with both medial and lateral root tears (p < 0.05).
Conclusions  Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated
anterior cruciate rupture. Root tears can be predicted by ligament injury patterns and fractures sustained (suggestive of a
compressive force). In multi-ligament cases, the preoperative magnetic resonance imaging can be used to detect these tears
and associated patterns of injury.
Level of evidence IV.

Keywords  Multi-ligament injury · Knee dislocation · Meniscal root tear · Magnetic resonance imaging · Radiologic

Introduction
Multi-ligament knee injuries are rare (less than 2% of ortho-
paedic injuries) but are associated with considerable short-
and long-term consequences [16]. The surgical management
of these cases is particularly challenging, with multiple inju-
ries requiring operative consideration. Reconstruction can be
successfully performed as either a single operation or staged
procedure [12, 22]. Magnetic resonance imaging (MRI) is
* Jonathan D. Kosy
jonkosy@yahoo.co.uk
1
St Michael’s Hospital, 30 Bond Street, Toronto,
ON M5B 1W8, Canada
2
New Victoria Hospital, 184 Coombe Lane West,
Kingston Upon Thames, Surrey KT2 7EG, UK
used to both identify the pattern of injuries and inform surgi-
cal planning. The Schenck classification is most commonly
used to describe these injuries—with increasing grade relat-
ing to a more significant injury pattern [31].
Meniscal root tears have been shown to lead to signifi-
cant changes in the biomechanics of the knee resultant from
extrusion of the meniscus (during loading) [1, 14, 21, 28]
and rapid deterioration of the articular cartilage [1, 14, 17,
20]. These injuries have also been implicated in the patho-
genesis of spontaneous osteonecrosis of the knee (SONK)
[10, 32] Untreated, these injuries correspond with poor func-
tion and a high likelihood of further surgery [8, 18, 20].
Conversely, timely treatment of meniscal root tears effec-
tively restores contact pressures and stability with improved
function (although long-term outcomes may not be as pre-
dictable) [6, 7, 13, 25]. Both radiological and arthroscopic

13
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classifications have been proposed with that of LaPrade et al.
being the most consistently used in the literature [2, 20].
Degenerative root tears can occur without significant
trauma but the frequency of traumatic tears has been shown
to increase in association with rupture of the anterior cruci-
ate ligament (ACL) [22]. Overall, the frequency of meniscal
root tears, in cases with isolated ACL rupture, is reported
to be between 5 and 10% [5, 8, 24, 27]. The frequency of
meniscal root tears, in the context of multi-ligament injury,
is not well established with only small numbers and incom-
plete descriptions within the literature [14, 15, 30]. When
associated with multi-ligament injury, meniscal root tears
have the potential to further worsen laxity and instability
given the role of the menisci as secondary restraints to trans-
lation [30].
Degenerative medial root tears are associated with high
body mass index (BMI), varus alignment, female gender
and low-exercise level while traumatic tears are associated
with contact injuries, male gender and the interval between
injury and reconstruction (particularly in lateral root tears)
[8, 11]. It is suggested that varus alignment increases the
risk to the degenerative medial root tears as the meniscus is
loaded in compression—resulting in injury and extrusion as
hoop stresses exceed tolerated values [11]. Further, injuries
involving direct contact, male patients, and a high BMI may
be associated with higher forces accounting for the occur-
rence of a meniscal root tear [5].
The aim of this study was to establish the frequency
of meniscal root tears, on preoperative MRI imaging, fol-
lowing multi-ligament knee injury and identify associated
injury patterns that may aid detection. Due to the increased
forces involved, an increased frequency of meniscal root
tears (compared to previous reports in ACL rupture) was
the primary hypothesis. Associations between high-grade
injury and specific injury patterns with a higher frequency
of meniscal root tears were the secondary hypotheses. In
particular, we predicted that valgus patterns would be associ-
ated with a lateral root tear and varus injuries with a medial
root tear.
Materials and methods
The setting for the study was a major trauma centre in North
America. A prospectively collected institutional database
was used to identify cases of multi-ligament knee injury
between 2004 and 2016. Cases were clinically identified
and radiologically classified with all cases undergoing MRI
assessment. Inclusion criteria were injury to one or both
cruciate ligaments with a total of at least two ligaments (cru-
ciate or collateral) injured; age 16–65 years (to limit the
population to adult patients and exclude patients with likely
degenerative meniscal lesions); a clear history of recent
13
Knee Surgery, Sports Traumatology, Arthroscopy
trauma (within 2 weeks of MRI); availability of a complete
preoperative MRI examination (as defined below). Those
cases not fulfilling these criteria were thus excluded. 188
cases were identified that fulfilled these criteria. The demo-
graphics are summarised in Table 1. Demographics were
calculated and reported to one decimal place. High-energy
injuries included motor vehicle collisions, falls from height
and pedestrians or cyclists hit by vehicles. Low-energy inju-
ries included those sustained during sports and low-level
falls. The proportions of cases in each subgroup are reported
to one decimal place.
The imaging was retrospectively reviewed by three fel-
lowship-trained musculoskeletal radiologists. All cases were
reviewed by at least two of the radiologists. Where disa-
greement occurred, cases were then reviewed by the third
radiologist and disagreement resolved. Injuries to the ACL,
posterior cruciate ligament (PCL), medial collateral liga-
ment (MCL), lateral collateral ligament (LCL) and postero-
lateral ligament complex (PLC) were individually recorded.
All of the scans were performed using 1.5T magnets
(MAGNETOM Avanto, Siemens Healthcare, Erlangen,
Germany) with a dedicated knee coil. Each was performed
using our standard knee protocol: knee imaged in a fully
extended position (or as near as possible) in an extremity
coil; T1-weighted scans in the sagittal plane (time to repeti-
tion (TR) = 578 ms; time to echo (TE) = 11 ms) and proton
density scans in the sagittal (TR = 3460 ms, TE = 13 ms),
coronal (TR = 3180, TE = 13 ms) and axial (TR = 2240 ms,
TE = 13 ms) planes. Slice thickness was 3 mm, in the sagittal
and coronal planes, and 4 mm in the axial plane.
Information was recorded about ligament injury pat-
tern, meniscal tears (including root tears) and the pres-
ence of intra-articular fractures based on the MRI findings.
Table 1  Patient demographics and injury details
Variable Number/median (%/range)
Total cases 188
Age 31 years (16–64)
Gender
 Male 134 (71.3%)
 Female 54 (28.7%)
BMI 31.3 kg/m2 (18.5–46.3)
Mechanism of injury
 High energy (MVC, fall from height, 68 (36.2%)
pedestrian/cyclist hit by vehicle)
 Low energy (sports, low-level fall) 120 (63.8%)
Laterality
 Right knee 102 (54.3%)
 Left knee 86 (45.7%)
BMI body mass index, MVC motor vehicle collision
Knee Surgery, Sports Traumatology, Arthroscopy
Additional data—gender and injury mechanism—were
gained from the patients’ hospital notes.
Injury patterns were recorded using a modification of the
knee dislocation (KD) classification system described by
Schenck et al.: KD-I = single cruciate with collateral liga-
ment injury; KD-II = ACL and PCL injuries (with intact
collateral ligaments); KD-IIIM = ACL, PCL and MCL
injuries (LCL and PLC intact); KD-IIIL = ACL, PCL and
LCL + PLC injuries (MCL intact); KD-IV = ACL, PCL,
MCL and LCL + PLC injuries; KD-V; multi-ligament injury
with associated fractures [31]. The original description of
this classification combines both clinical examination and
MRI [31]. Our use of this classification, based solely on
MRI, therefore, may differ from clinical findings. Minor
ligament injuries were excluded with only significant partial-
thickness (Grade 2) and full-thickness (Grade 3) injuries
recorded. The accuracy of MRI, in detecting injury pat-
terns in multi-ligament injury, has been shown to be greater
than 90% in previous studies with greater accuracy for
these higher grade injuries (comparison using the original
Schenck classification) [9, 23].
Meniscal injuries were recorded in terms of their ana-
tomical location. Particular attention was paid to root tears.
As described by previous work, meniscal root tears were
defined as the presence of either avulsion of the root or a
complete radial tear within 9 mm of the root [20]. MRI evi-
dence of an meniscal root tear included: a “ghost sign” on
the sagittal image (area of increased signal within meniscus
or complete absence), vertical linear defect on a coronal
slice, or a radial linear defect on an axial slice (Fig. 1). This
is consistent with the methodology used in previous stud-
ies [14, 20]. Those tears that were likely degenerative in
nature with complex changes throughout the adjacent menis-
cal tissue were excluded. This is consistent with previous
studies showing degenerative root tears, in the absence of
trauma, and reduced success of repair in these cases [3, 8].
Fig. 1  a “Ghost sign”—absence of posterior root of lateral meniscus
seen on T2-weighted sagittal MRI slice of right knee; b linear defect
in posterior root of lateral meniscus seen on T1-weighted coronal
No comparison was performed with intra-operative data as
this was found to be incomplete and meniscal root tear treat-
ment was not always explicit.
Fractures were defined as a complete cortical breach seen
on MRI with displacement. Microtrabecular fractures (seen
in association with bone oedema) were not considered suf-
ficient but were frequently seen in these cases. Only intra-
articular fractures were included with distribution recorded
by compartment and bone affected.
Institutional review board approval was given prior to
commencing the project—ref number: 14–124 (St Michael’s
Hospital Research Ethics Board, Toronto). Informed consent
was obtained, from the patients, for use of the imaging in
research.
Statistical analysis
Statistical analysis was performed using the SPSS pro-
gramme (Version 16.0; SPSS Inc., Chicago, IL., USA).
The frequency of meniscal root tears was calculated within
the entire study population. Frequencies were calculated
and reported to one decimal place. A Chi-squared test (or
Fisher’s exact test for small sample size) was used to com-
pare low-grade (KD-I to KD-III) with high-grade (KD-
IV to KD-V) injuries. Cases with varus injury patterns
(KD-I to KD-V with LCL/PLC injury and without MCL
injury, isolated fractures within the medial compartment,
or fibula head avulsion fracture) or valgus injury patterns
(KD-I to KD-V with MCL injury and no LCL/PLC injury
or isolated fractures within the lateral compartment) were
identified. In addition, KD-V cases were divided in cases
involving medial compartment fractures versus lateral
compartment fractures. These cases underwent subgroup
analysis (with Chi-squared or Fisher’s exact tests) with
regard to the presence of either a medial or lateral menis-
cal root tear. A multivariate logistical regression analysis
MRI slice of left knee; c radial defect, on transverse T2-weighted
MRI slice, seen at posterior root of lateral meniscus of right knee
(black arrows point to pathology described)
13
 Knee Surgery, Sports Traumatology, Arthroscopy

(ANOVA) was performed including previously identified Results

risk factors for meniscal root tears: BMI, gender, injury
mechanism, and age. Incomplete information was avail-
able about pre-injury alignment and this variable was not
included.
Statistical significance for each of the test was set at
p < 0.05. Results are reported to two decimal places where
significant and as “n.s.” where non-significant. A post hoc
calculation based on our recorded frequency (20.2%), the
reported frequency in isolated ACL rupture (10%), an
alpha-value of 0.05 and a beta-value of 0.80 showed a
sample size of 150 was required. This is based on the high-
est published frequency published (for isolated ACL rup-
ture) and would be lower if a lower frequency was used.
The results are summarised in Table 2. In total, 38 menis-
cal root tears were identified in 37 knees. Of these, 20 were
medial and 18 were lateral tears. Therefore, the overall fre-
quency of meniscal root tears was 20.2% (10.6% medial;
9.6% lateral).
Table 3 also shows the distribution of meniscal root tears
compared with injury grade (ligament injury pattern—high
versus low grade), varus and valgus injury patterns, and the
occurrence of fractures with each root tear. The frequency
of meniscal root tears did not increase significantly with
higher modified Schenck grade (KD-I to KD-III = 17.0%;
KD-IV and KD-V = 21.5%; n.s.). No association was found

Table 2  Distribution of Injury Total meniscal root Medial meniscal Lateral meniscal No meniscal root tear
meniscal root tears by ligament tears root tears root tears
injury pattern (modified
Schenck classification) All cases 38 (20.2%) 20 (10.6%) 18 (9.6%) 150 (79.8%)
KD-I 4 (17.4%) 1 (4.4%) 3 (13%) 19 (82.6%)
KD-II 1 (50%) 1 (50%) 0 (0%) 1 (50%)
KD-IIIM 2 (10%) 1 (5%) 1 (5%) 18 (90%)
KD-IIIL 2 (25%) 2 (25%) 0 (0%) 6 (75%)
KD-IV 11 (20%) 7 (12.7%) 4 (7.3%) 44 (80%)
KD-V 18 (22.5%) 8 (10%) 10 (12.5%) 62 (77.5%)

Table 3  Association of Injury group Meniscal root tear Number (frequency) p value

meniscal root tears with injury
pattern and fractures High grade Total 29 (21.5%)
(KD-I to KD-III) Medial 15 (11.1%)
Lateral 14 (10.4%)
Low grade Total 9 (17%) n.s.a
(KD-IV and KD-V) Medial 5 (9.4%) n.s.a
Lateral 4 (7.6%) n.s.a
Varus injury pattern Total 14 (19.7%)
Medial 13 (18.3%) 0.01b
Lateral 1 (1.4%) < 0.01b
Valgus injury pattern Total 18 (30.5%)
Medial 4 (6.8%) n.s.c
Lateral 14 (23.7%) < 0.01c
Fracture in medial compartment Total 11 (20.4%)
Medial 10 (18.9%) 0.02d
Lateral 1 (1.9%) 0.03d
Fracture in lateral compartment Total 13 (33.3%)
Medial 4 (10.3%) n.s.e
Lateral 9 (23.1%) 0.01e

p values quoted in comparison to: alow-grade injuries, ball cases without varus injury pattern, call cases
without valgus injury pattern, dall cases without a medial compartment fracture, and eall cases without a
lateral compartment fracture; all fractures documented were displaced and intra-articular
n.s. not significant

13
Knee Surgery, Sports Traumatology, Arthroscopy
when medial root tears or lateral root tears were considered
individually.
Varus-pattern injures were associated with medial menis-
cal root tear and valgus-pattern injuries were found to be
associated with the occurrence of a lateral root tear. The
associations were both statistically significant (p < 0.01).
In comparing the occurrence of fractures within the same
compartment, fractures within the medial compartment were
associated with medial meniscal root tear (p = 0.02). Simi-
larly, fractures within the lateral compartment were associ-
ated with a lateral meniscal root tear (p = 0.01).
Multivariate linear regression analysis showed that none
of the previously described risk factors for meniscal root tear
showed significance (Table 4). Therefore, the investigated
factors—varus/valgus pattern and fractures within the same
compartment—can be considered independent.
Discussion
The most important findings were that meniscal root tears
occurred in 20% of preoperative MRIs of multi-ligament
knee injuries and were associated with specific injury pat-
terns. The frequency of meniscal root tears was higher than
previously reported levels in cases of isolated ACL rupture
proving our primary hypothesis. A compression force—
manifest by ipsilateral intra-articular fractures or contralat-
eral collateral ligament injury—was associated with the
presence of a meniscal root tear but not high-grade injury.
Our secondary hypothesis was, therefore, only partially
proven.
Untreated meniscal root tears have consequences, due
to both changes in load distribution and stabilisation, that
may be even more relevant in the multi-ligament-injured
knee. Transosseous repair techniques may be superior, due
to the release of growth factors and mesenchymal stem
cells [4, 26], but increase the potential for tunnel collision
in multi-ligament cases Therefore, a detailed preoperative
plan is essential including the necessity for meniscal root
tear repairs.
Table 4  Results of multivariate analysis for known risk factors
Risk factor Meniscal root No meniscal
tear root tear
Median age (years) 31 31
Gender (% male) 62.9 73.2
Median BMI (kg/m2) 26.9 27.5
Mechanism of injury (% 28.6 37.9
high force)
BMI body mass index, n.s. not significant
This plan may include the use of preoperative MRI. Some
authors, including Ozkoc et al., have suggested difficulty
in detecting meniscal root tears, using MRI, in association
with isolated ACL rupture [27]. In their study, one-third of
medial root tears were missed [27]. However, in the multi-
ligament-injured knee, this may not be such an issue with
the large haemarthrosis making detection easier [24, 26].
In a study of 9 patients, Kim et al. identified 100% of intra-
operative medial root tears on preoperative MRI [14]. The
relative ease of detection warrants further investigation. It
has been further shown that the accuracy of MRI increases
dramatically when meniscal root tears are specifically looked
for suggesting that identifying associated injury patterns, to
prompt this, is important [25].
We compared our frequency of meniscal root tears to pre-
vious studies in association with isolated ACL rupture. In a
study of 673 arthroscopies (243 ACL tears), Matheny et al.
found eight medial root tears (3.29% of ACL tear cases) and
21 lateral root tears (8.64%) [24]. Similarly, Feucht et al.
found that 27 (10%) of 268 patients with an ACL rupture
had a lateral meniscal root tear [5]. In the multi-ligament-
injured knee, the recorded frequency of meniscal root tears
has varied. Ra et al. found seven medial root tears (13.7%)
in a study of 51 patients [30], whereas Kim et al. found
only 10 medial root tears (2.74%) in 365 surgeries [14]. Our
study investigated both medial and lateral meniscal root tears
in the multi-ligament-injured knee. The overall frequency
found (20.2%) is double than that seen in isolated ACL rup-
ture. Whilst the frequency of lateral meniscal root tears is
similar (9.6% compared to 8–10%) [29], it is the frequency
of medial root tears (10.6% compared to 3.29%) [24, 29]
that markedly increases. The exact forces involved in multi-
ligament injury are difficult to define (and likely very vari-
able between cases). However, it may be that the specific
pivoting (seen in isolated ACL rupture) is protective to the
medial compartment with further disruption making both
compartments equally vulnerable. Further work is necessary
to define these forces and disruption patterns. In our data,
no difference in BMI or age was found between medial and
lateral root tears suggesting this is due to the forces involved
rather than degeneration.
The association of meniscal root tears with specific
injury patterns, in the multi-ligament-injured knee, has
been a subject of limited investigation [19, 30]. In terms
of increasing injury grade, Krych et al., in a study of 122
p value
knees, found no association [19]. The current study con-
firmed this finding. The association with injury mecha-
n.s. nisms is also variably reported. The study by Krych et al.
n.s. showed no association between the side of injury and
n.s. meniscal or chondral pathology (although the majority of
n.s. cases were PCL-based injuries and no KD-V cases were
included in their series) [19]. In contrast, Ra et al showed
seven medial meniscal root tears in 14 cases (50%) of
13

multi-ligament injury with severe medial instability [30].
The authors suggested the opposite mechanism to our
study—avulsion of the medial root in combination with
valgus disruption [30]. The higher frequency, in their
study, is notable but interpretation is limited by lower
numbers and no analysis of other injury patterns or the
lateral meniscus. Our study showed two associations sug-
gestive of a compressive force leading to a meniscal root
tear—both intra-articular fractures in the same compart-
ment and valgus (lateral root tear) or varus (medial root
tear) ligamentous disruption. The consistency of these
findings is important. Further study using video-analysis
of injury mechanisms (in place of the surrogate MRI find-
ings of this study) may be indicated to validate these find-
ings. It should be noted that this study included relatively
more KD-V patients than other studies. This may be due
to the MRI classification used or the major trauma centre
setting but could have an influence on the association we
found with fracture presence.
Limitations of our study include the absence of correla-
tion with intra-operative findings and the lack of outcome
data to define the clinical significance of these injuries.
Further, a control group of isolated ACL injuries was not
included meaning the frequency of injuries was compared
to published results (in which the MRI protocol may have
been different). The retrospective design also confers some
inherent limitations. MRI was chosen to identify menis-
cal root tears as this is performed, preoperatively, in the
majority of multi-ligament cases. The aim of this study
was, therefore, to identify injury patterns suggestive of
a meniscal root tear to facilitate preoperative planning.
The accuracy of MRI, in the detection of meniscal root
tears, has been shown to increase when this pathology is
specifically looked for and is very high in previous multi-
ligament injury studies [24, 26]. However, it is acknowl-
edged that it was not possible to derive these results due
to the lack of intra-operative data. As follow-up functional
data were not included, additionally, commenting on the
relative success of repair is difficult (where performed).
Our use of the modified Schenck grading (based solely on
MRI findings) may also represent some discrepancy from
clinical findings. Further, the grouping of cases into high
or low grade (based on this modified classification) is not
validated and, thus, grouping them in an alternative way
may have produced different results.
The increased frequency of meniscal root tears, found in
this study, demonstrates the importance of specifically look-
ing for these injuries (in these cases) and considering repair
in preoperative planning. The consequence of untreated inju-
ries, in this group, is yet undefined but likely carries an infe-
rior prognosis. Therefore, the use of preoperative imaging
to identify injuries and associated patterns has high clinical
significance.
13
Knee Surgery, Sports Traumatology, Arthroscopy
Conclusion
This study shows that meniscal root tears occur in 20% of
multi-ligament knee injuries—double the frequency seen
in isolated ACL rupture. Signs of compression injuries are
associated with meniscal root tears and may help in local-
ising injury. Therefore, these injuries should be suspected
and specifically looked for on preoperative MRI. This can
help with preoperative planning and should prompt spe-
cific intra-operative evaluation.
Funding  No external funding was used.
Compliance with ethical standards 
Conflict of interest  We declare that we have no conflicts of interest in
the authorship or publication of this contribution.
Ethical approval  This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent  For this type of study formal consent is not required.
References
1. Allaire R, Muriuki M, Gilbertson L, Harner CD (2008) Bio-
mechanical consequences of a tear of the posterior root of the
medial meniscus: similar to total meniscectomy. J Bone Joint
Surg Am 90:1922–1931
2. Bin SI, Jeong TW, Kim SJ, Lee DH (2016) A new arthroscopic
classification of degenerative medial meniscus root tear that
correlates with meniscus extrusion on magnetic resonance
imaging. Knee 23:246–250
3. Bonasia DE, Pellegrino P, D’Amelio A, Cottino U, Rossi R
(2015) Meniscal root tear repair: why, when and how? Orthop
Rev (Pavia) 7:5792
4. Chahla J, Moulton SG, LaPrade CM, Dean CS, LaPrade RF
(2016) Posterior meniscal root repair: the transtibial double tun-
nel pullout technique. Arthrosc Tech 5:e291–e296
5. Feucht MJ, Bigdon S, Bode G, Salzmann GM, Dovi-Akue D,
Sudkamp NP, Niemeyer P (2015) Associated tears of the lateral
meniscus in anterior cruciate ligament injuries: risk factors for
different tear patterns. J Orthop Surg Res 10:34
6. Forkel P, von Deimling C, Lacheta L, Imhoff FB, Foehr P, Will-
inger L, Dyrna F, Petersen W, Imhoff AB, Burgkart R (2018)
Repair of the lateral posterior meniscal root improves stabil-
ity in the ACL-deficient knee. Knee Surg Sports Traumatol
Arthrosc. https​://doi.org/10.1007/s0016​7-018-4949-8
7. Frank JM, Moatshe G, Brady AW, Dornan GJ, Coggins A,
Muckenhirn KJ, Slette EL, Mikula JD, LaPrade RF (2017) Lat-
eral meniscus posterior root and meniscofemoral ligaments as
stabilizing structures in the ACL-deficient knee: a biomechani-
cal study. Orthop J Sports Med 5:2325967117695756
8. Guermazi A, Hayashi D, Jarraya M, Roemer FW, Zhang Y, Niu
J, Crema MD, Englund M, Lynch JA, Nevitt MC, Torner JC,
Lewis CE, Felson CT (2013) Medial posterior meniscal root
tears are associated with development or worsening of medial
Knee Surgery, Sports Traumatology, Arthroscopy
tibiofemoral cartilage damage: the multicenter osteoarthritis
study. Radiology 268:814–821
9. Halinen J, Koivikko M, Lindahl J, Hirvensalo E (2009) The effi-
cacy of magnetic resonance imaging in acute multi-ligament inju-
ries. Int Orthop 33:1733–1738
10. Hussain ZB, Chahla J, Mandelbaum BR, Gomoll AH, LaPrade RF
(2018) The role of meniscal tears in spontaneous osteonecrosis of
the knee. Am J Sports Med. https​://doi.org/10.1177/03635​46517​
74373​4
11. Hwang BY, Kim SJ, Lee SW, Lee HE, Lee CK, Hunter DJ, Jung
KA (2012) Risk factors for medial meniscus posterior root tear.
Am J Sports Med 40:1606–1610
12. Jiang W, Yao J, He Y, Sun W, Huang Y, Kong D (2015) The tim-
ing of surgical treatment of knee dislocations: a systematic review.
Knee Sports Surg Traumatol Arthrosc 23:3108–3113
13. Kaplan DJ, Alaia EF, Dold AP, Meislin RJ, Strauss EJ, Jazrawi
LM, Alaia MJ (2017) Increased extrusion and ICRS grades at
2-years follow-up following transtibial medial meniscal root repair
evaluated by MRI. Knee Surg Sports Traumatol Arthrosc. https​://
doi.org/10.1007/s0016​7-017-4755-8
14. Kim YJ, Kim JG, Chang SH, Shim JC, Kim SB, Lee MY (2010)
Posterior root tears of the medial meniscus in multiple knee liga-
ment injuries. Knee 17:324–328
15. King AH, Krych AJ, Prince MR, Sousa PL, Stuart MJ, Levy BA
(2015) Are meniscal tears and articular cartilage injury predic-
tive of inferior patient outcome after surgical reconstruction
for the dislocated knee? Knee Surg Sports Traumatol Arthrosc
23:3008–3011
16. Klimkiewicz JJ, Petrie RS, Harner CD (2000) Surgical treatment
of combined injury to anterior cruciate ligament, posterior cruci-
ate ligament, and medial structures. Clin Sports Med 19:479–492
17. Koenig JH, Ranawat AS, Umans HR, Difelice GS (2009) Meniscal
root tears: diagnosis and treatment. Arthroscopy 25:1025–1032
18. Krych AJ, Reardon P, Johnson NR, Mohan R, Peter L, Levy BA,
Stuart MJ (2017) Non-operative management of medial meniscus
posterior horn root tears is associated with worsening arthritis
and poor clinical outcome at 5-year follow-up. Knee Surg Sports
Traumatol Arthrosc 25:383–389
19. Krych AJ, Sousa PL, King AH, Engasser WM, Stuart MJ,
Levy BA (2015) Meniscal tears and articular cartilage damage
in the dislocated knee. Knee Surg Sports Traumatol Arthrosc
23:3019–3025
20. LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L,
LaPrade RF (2015) Meniscal root tears: a classification system
based on tear morphology. Am J Sports Med 43:363–369
21. LaPrade CM, Jansson KS, Dornan G, Smith SD, Wijdicks CA,
LaPrade RF (2014) Altered tibiofemoral contact mechanics due
to lateral meniscus posterior horn root avulsions and radial tears
can be restored with in situ pull-out suture repairs. J Bone Joint
Surg Am 96:471–479
22. Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart
MJ, Boyd JL, MacDonald PA, Marx RG (2009) Decision making
in the multiligament injured knee: an evidence based systematic
review. Arthroscopy 25:430–438
23. Lonner JH, Dupuy DE, Siliski JM (2000) Comparison of magnetic
resonance imaging with operative findings in acute traumatic dis-
locations of the adult knee. J Orthop Trauma 14:183–186
24. Matheny LM, Ockuly AC, Steadman JR, LaPrade RF (2015) Pos-
terior meniscus root tears: associated pathologies to assist as diag-
nostic tools. Knee Surg Sports Traumatol Arthrosc 23:3127–3131
25. Marzo JM, Gurske-DePerio J (2009) Effects of medial meniscus
posterior horn avulsion and repair on tibiofemoral contact area
and peak contact pressure with clinical implications. Am J Sports
Med 37:124–129
26. Moatshe G, Chahla J, Slette E, Engebretsen L, LaPrade RF (2016)
Posterior meniscal root injuries. Acta Orthop 87:452–458
27. Ozkoc G, Circi E, Gonc U, Irgit K, Pourbagher A, Tandogan RN
(2008) Radial tears of the root of the posterior horn of the medial
meniscus. Knee Surg Sports Traumatol Arthrosc 16:849–854
28. Padalecki JR, Jansson KS, Smith SD, Dornan GJ, Pierce CM,
Wijdicks CA, LaPrade RF (2014) Biomechanical consequences
of a complete radial tear adjacent to the medial meniscus posterior
root attachment site: in situ pull-out repair restores derangement
of joint mechanics. Am J Sports Med 42:699–707
29. Petersen W, Forkel P, Feucht MJ, Zantop T, Imhoff AB, Brucker
PU (2014) Posterior root tear of the medial and lateral meniscus.
Arch Orthop Trauma Surg 134:237–255
30. Ra HJ, Ha JK, Jang HS, Kim JG (2015) Traumatic posterior
root tear of the medial meniscus in patients with severe medial
instability of the knee. Knee Surg Sports Traumatol Arthrosc
23:3121–3126
31. Schenck R (2003) Classification of knee dislocation. Oper Tech
Sports Med 11:193–198
32. Yamagami R, Taketomi S, Inui H, Tahra K, Tanaka S (2017) The
role of the medial meniscus posterior root tear and the proximal
tibial morphology in the development of spontaneous osteonecro-
sis and osteoarthritis of the knee. Knee 24:390–395
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