Current concepts review

Discoid lateral meniscus: current concepts

1
Orthopaedics, Sahyadri Super
Speciality Hospital Deccan
Gymkhana, Pune, Maharashtra,
India
2
Orthopedic Surgery, Stockholm
South Hospital, Karolinska
Institutet, Stockholm, Sweden
Correspondence to
Dr Sachin Tapasvi, Orthopaedics,
Sahyadri Super Speciality
Hospital Deccan Gymkhana,
Pune 411004, Maharashtra,
India; ​stapasvi@​gmail.​com
Received 29 March 2020
Revised 24 July 2020
Accepted 27 July 2020
Published Online First
16 September 2020
Sachin Tapasvi  ‍ ‍,1 Anshu Shekhar  ‍ ‍,1 Karl Eriksson2
ABSTRACT
Current concepts
The discoid meniscus is a congenital morphological
abnormality encountered far more commonly on the
►► The discoid lateral meniscus (DLM) is not just
lateral than the medial side. The discoid lateral meniscus
a morphological variant but has abnormal
(DLM) is more prevalent in Asia with an incidence of
vascularity and microarchitecture (collagen
10%–13%, than in the Western world with an incidence
orientation) as well.
of 3%–5%. DLM can be bilateral in more than 80%
►► The presence of peripheral rim detachments
cases. Due to its abnormal shape and size, the discoid
is now understood and classifiable on
meniscus is prone to tearing and has an impact on gait
preoperative MRI scans. These must be carefully
mechanics. The discoid meniscus has deranged collagen
studied to prepare a surgical plan.
arrangement and vascularity which can have implications
►► Asymptomatic DLMs should not be treated with
for healing after a repair. Patients with a DLM may or
surgery. The best treatment is observation and if
may not be symptomatic with mechanical complaints of
symptoms arise arthroscopic inspection/repair/
locking, clicking, snapping or pain. Symptoms often arise
partial resection is indicated.
due to a tear in the body of the meniscus or a peripheral
►► When a DLM tears or has a peripheral
detachment. Asymptomatic patients usually do not
detachment, as much of the tissue as possible
require any treatment, while symptomatic patients who
must be preserved. It is now known that
do not have locking are managed conservatively. When
performing a greater amount of meniscectomy
a peripheral detachment is present, it must be stabilised
leads to poorer outcomes.
while preserving the meniscus rim to allow transmission
►► The meniscus is repaired preserving 6-8 mm
of hoop stresses. Rehabilitation after surgery is highly
periphery with the belief of maintaining
individualised and return to sports is possible after
biomechanical function without increasing the
more than 4 months in those undergoing a repair. The
risk of retear. However, MRI studies have shown
functional outcomes and onset of radiographic arthritis
that the residual meniscus continues to extrude
after saucerisation and repairing a discoid meniscus
and reduce in width and thickness.
are better in the long term, compared with a subtotal
►► The known factors associated with poor
meniscectomy. However, there is no compelling evidence
outcome after surgery include higher age and
currently favouring a repair as results deteriorate with
performance of subtotal or total meniscectomy.
increasing follow-­up. Poor prognosis is reported in
patients undergoing a total meniscectomy, a higher age
at presentation and valgus malalignment.

Future perspectives

INTRODUCTION ►► The widely used Watanabe’s classification of

© International Society of
Arthroscopy, Knee Surgery and
Orthopaedic Sports Medicine
2021. No commercial re-­use.
See rights and permissions.
Published by BMJ.
To cite: Tapasvi S, Shekhar A,
Eriksson K. J ISAKOS
2021;6:14–21.
14
The discoid meniscus is a congenital abnormal
variant of the lateral meniscus. The spectrum of
this condition encompasses vagaries in shape and
stability of meniscal tissue. It has been an enigma
to deal with, ever since it was first described in a
cadaveric specimen by Young.1 The true incidence
of this entity is unknown because a discoid lateral
meniscus (DLM) may exist without any symptoms.
The reported incidence is greater in the Oriental
world (10.6% in Korea, 13% in Japan) than in the
West (USA 3%–5%).2–4 The prevalence of bilateral
DLM is also higher in Asia and has been reported
to be between 79% and 97% on MRI and arthros-
copy in patients having symptomatic DLM in one
knee.5 6 It is therefore recommended to investigate
the asymptomatic contralateral knee in patients
with unilateral symptomatic DLM. This associa-
tion was found to be 89.5% in the asymptomatic
knee on arthroscopy, with 84.2% being of identical
shape.7
A DLM is not just a morphological variant or
anomaly, but also has a distinct biological behaviour
as well. Kim et al arthroscopically studied the
Tapasvi S, et al. J ISAKOS 2021;6:14–21. doi:10.1136/jisakos-2017-000162. Copyright © 2021 ISAKOS
DLM does not help in making any therapeutic
decisions. It would be worthwhile to classify
this condition in a manner which provides
guidelines on managing each type.
►► Long-­term data after reshaping (saucerisation)
and meniscus repair of torn DLMs, especially
their healing rates, are not yet available.
This will provide more objective evidence for
repairing an abnormal tissue, which is currently
disputed.
►► Standardised techniques to stabilise a
peripheral rim detachment (anterior or
posterior) must be developed and validated to
improve standard of care.
►► The role of meniscus repair in improving clinical
outcome and reducing radiographic arthritis
needs to be defined.
►► It would be worthwhile to investigate the
biomechanical effects/outcomes of isolated rim
stabilisation without saucerisation for isolated
peripheral detachments.

peripheral rim instability of normal and discoid lateral menisci in
a patient population who had the surgery for a medial meniscus
pathology. They found that DLMs have greater instability of the
anterior and posterior horns, but not the mid-­body, compared
with normal lateral meniscus.8 This could be the reason why
a DLM is more prone to tearing. However, DLMs have been
known to exist without ever causing symptoms and detected
incidentally.
This review analyses the current concepts in the understanding
of DLM, present evidence in the management of tears and its
outcomes.
Morphology and histology
There are several hypotheses regarding the origin of the DLM,
whether it is a congenital anomaly or a morphological variant.
Fetal cadaveric studies have shown that the discoid shape may
exist in earlier gestational ages and undergoes morphological
development from the second to the third trimester.9 10 Discoid
morphology may persist after birth but the reason for this
is unclear. Discoid menisci have poor vascularity of the inner
areas, a finding described by Bisicchia et al in meniscal speci-
mens of children and adolescents who had undergone partial
meniscectomy.11 Furumatsu et al reported that central area of
a complete DLM has significantly lesser blood vessels than the
intercondylar regions.12 On comparing complete and incom-
plete discoid menisci, Inoue et al noted poorer vascularity in the
innermost areas of incomplete DLM than the intercondylar areas
of complete DLM.13 These findings could have implications for
healing after saucerisation and repair of either a complete or
incomplete DLM. The tissue margin that is preserved in either
case would have compromised vascularity.
The orientation of collagen fibres in discoid menisci has been
studied by Cui and Min using direct polarising filter microscope
with Sirius red staining and scanning electron microscope.14
They classified the DLM into seven symmetrical layers, each
with its own fibrillar orientation (figure 1). This is different
from the normal meniscus, where collagen fibrils are arranged in
only two orientations primarily. The bulk of fibres are arranged
circumferentially while fibres on the surface are arranged
Figure 1  The seven-­layered collagen fibril texture of discoid lateral
meniscus having (A) surface layer (femoral side), (B) surface layer (tibial
side), (C) outer layer, (D) inner layer, (E) lateral side of the central layer,
and (F) medial side of the central layer. Reprinted with permission from
Cui JH, Min B-­H, Collagenous fibril texture of the discoid lateral meniscus,
Arthroscopy 2007;23(6):635–41. Copyright (2007), with permission from
Elsevier.14
Tapasvi S, et al. J ISAKOS 2021;6:14–21. doi:10.1136/jisakos-2017-000162
Current concepts review
radially.15 The DLM has a central layer in the axial plane, which
is further categorised into four zones based on collagen fibre
arrangement. In the anterior and posterior zones, collagen is
arranged radially and is suited for anchoring of the two ends
of the meniscus to the tibial roots. The medial middle zone has
an irregular arrangement of collagen while the lateral middle
zone has circularly arranged collagen, parallel to the long axis
of the meniscus. This bundle orientation of collagen is ideally
suited to resist hoop stresses and hence peripheral tissue must
be retained in any surgery on the DLM.14 However, the collagen
fibre system is disorganised and this has been noted in children,
adolescents and adults.11 16
Biomechanics and kinematics
There are no biomechanical studies which have measured the
peak contact pressure or contact area in a knee with a DLM. The
abnormal size and shape of the DLM predisposes to abnormal
biomechanics of the knee, especially in the gait cycle. Lin et al
used a motion capture system to compare and characterise the
motion of knees with a torn DLM, a torn lateral meniscus and
a normal lateral meniscus during treadmill walking. They found
that knees with a torn DLM had significantly different kinematics
compared with the other two groups. The maximum lateral tibial
translation was 2 mm lesser and maximum internal tibial rota-
tion was reduced by 2º in the torn DLM group compared with
those with normal lateral meniscus injury.17 A three-­dimensional
gait analysis was performed in patients with bilateral DLM, one
side being symptomatic and the other asymptomatic. Patients
with normal lateral menisci were used as controls. While the
frontal plane movements were not found to differ, sagittal and
axial plane knee excursion was reduced on the symptomatic side.
This difference was especially pronounced during heel strike and
mid-­stance phases of the gait cycle.18
CLASSIFICATION
The most commonly used and understood classification for
DLM is the arthroscopic classification proposed by Watanabe
and Ikeuchi in 1969.19 They classified DLMs into three types.
Type I refers to a ‘stable, complete discoid meniscus’ covering
the entire lateral tibial plateau. Type II is a ‘stable, partial discoid
meniscus’, which covers up to 80% of the tibia. Type III is the
‘unstable’ discoid meniscus because it is devoid of the menisco-
tibial attachments and is displaceable on probing. This variant is
also called the Wrisberg type since the posterior meniscofemoral
ligament of Wrisberg is the only posterior anchor. This classifica-
tion system is flawed as it does not provide any guide to manage-
ment or prognosis.
Hypermobility due to peripheral rim instability was found
to be almost 28% by Klingele et al in a series of symptomatic
DLMs.20 They established that this was present in both complete
and incomplete discoid menisci and could be anterior or poste-
rior. Based on this, a formal classification system was proposed
by Good et al.21 They recommended that DLMs be classified as
either complete or incomplete. Further, these could be subclas-
sified as stable or unstable and this instability could either be
anterior or posterior, based on location. Also, the presence of
tears in the meniscus body must be noted. This classification is
more useful in making surgical decisions and formulating treat-
ment strategies.
Ahn et al proposed an MRI-­ based classification to help
surgeons choose treatment methods in symptomatic DLMs,
based on the type of ‘shift’ of the meniscus due to periph-
eral capsular detachments.22 The types described are no shift
15
 Current concepts review
Figure 2  Ahn’s classification of peripheral capsular detachments. (A)
Posterocentral shift caused by detachment of the anterior horn causing the
discoid meniscus to displace posteriorly and centrally. (B) Anterocentral
shift following detachment of the posterior horn, displacing the meniscus
anteriorly and centrally. (C) Central shift due to detachment in the mid-­
body area adjacent to the popliteal hiatus.
(no capsular detachment), anterocentral shift (posterior horn
detachment), posterocentral shift (anterior horn detachment)
and central shift (posterolateral detachment with displace-
ment of entire meniscus) (figure 2). This classification is thus
an MRI translation of the Good classification, and is based on
arthroscopic probing. A thickened Wrisberg ligament and high
femoral attachment on MRI are positively correlated with
posterocentral shift type of peripheral detachment.23
CLINICAL PRESENTATION
In the vast majority of patients, a DLM can exist without ever
being symptomatic.24 Symptoms typically occur in an unstable
or torn DLM, but tears may exist without causing symptoms
as well. The classic symptoms of a discoid meniscus include
pain, effusion, clicking or snapping, sensation of give way,
extension or flexion loss, quadriceps wasting and locking.25 26
Patient presentation is influenced by the age, type of discoid
meniscus, presence of instability or tear in the DLM. A stable
discoid meniscus can remain innocuous and present only when
a tear occurs with complaints of pain, swelling or mechanical
features like locking.27 Younger children may present with a
snapping knee, in which a clunk is heard at terminal flexion.
This may be intermittent and occurring spontaneously, and is
due to peripheral rim instability.28 Older children may present
more acutely with tearing of the DLM.29 The sensitivity of clin-
ical examination for diagnosing a DLM is about 88.9%.27 It is
imperative, however, to perform a careful examination of the
contralateral knee in the presence of a symptomatic DLM in
one knee because of high prevalence of bilateral occurrence.30
In DLM, higher body mass index, female gender, presence
of symptoms for >6 months and high activity are predictive
of cartilage injury.31–33 Interestingly, age at presentation is not
predictive of cartilage involvement in DLM. When comparing
the sensitivity and specificity of history, clinical examination and
MRI for diagnosing articular cartilage injury, Lau et al found
that a symptomatic duration of >6 months and complaint of
extension block had the highest sensitivity (71.4%) and speci-
ficity (75%).33
Diagnostic imaging
Plain radiographic features of a DLM have been described
although the radiographs maybe normal. The radiographic
signs include widening of the lateral joint space up to 11
mm, squared-­off appearance of the lateral femoral condyle,
cupping of lateral tibial plateau and hypoplasia of lateral tibial
eminence.34 35 Radiography maybe rather inappropriate for
diagnostic purposes, since the discoid meniscus is not directly
visible.
16
Figure 3  MRI diagnostic features. (A) The presence of continuity
between anterior and posterior horns in three consecutive 5 mm thick
sagittal sections in proton density fat-­saturated sequence. (B) On T2-­
weighted coronal section, the width of lateral meniscus is >20% (yellow
arrow) of the total width of the tibia. (C) An axial section through the
menisci shows the distinct discoid morphology (yellow arrows) of the
lateral meniscus, covering >80% of the lateral tibial plateau.
An MRI scan is the only useful imaging tool for diagnosing a
DLM in symptomatic knees (figure 3). The presence of conti-
nuity between anterior and posterior horns of the meniscus in
three consecutive 5 mm thick sagittal sections is indicative of a
DLM.36 On the coronal MRI section, two parameters have been
described for detection of a DLM. A maximal meniscus width of
>15 mm between the periphery and free margin,37 or the ratio
of minimum meniscus width to maximum tibia width of >20%38
is considered diagnostic for a DLM. However, an incomplete
DLM may pose a diagnostic dilemma with a near normal MRI
appearance. The Wrisberg variant may show anterior sublux-
ation of the posterior horn of the lateral meniscus or a hyperin-
tense signal between the meniscus and capsule on T2-­weighted
section.39 Nonetheless, MRI is very useful is detecting tears in
the DLM and the presence of shift of the torn segment, which
can aid in planning the surgical approach.22 Moreover, the pres-
ence of intrasubstance pathologies causing symptoms can be seen
only on MRI and not on arthroscopy, as shown by Hamada et
al.40
TREATMENT OF DLM
Asymptomatic DLMs
In general, the presence of an asymptomatic DLM (which
usually is identified incidentally during MRI examination)
requires no particular treatment. It is however recommended
that these patients are followed regularly and if any symptoms
commence, a conservative approach is adopted first. Surgical
inspection/treatment should be considered when the patient
presents with locking. It is important to preserve meniscus
function and easy resection of the meniscus must be avoided
unless absolutely necessary. However, it has been reported by
Ahn et al that prolonged symptom duration prior to partial
Tapasvi S, et al. J ISAKOS 2021;6:14–21. doi:10.1136/jisakos-2017-000162
 Current concepts review

Figure 4  Arthroscopic saucerisation of a complete DLM. Right knee arthroscopy with knee in figure-­of-4 position, viewing from anterolateral portal
with a 30° arthroscope and working from the anteromedial portal. (A) The discoid meniscus is seen to cover the entire lateral tibia and is probed carefully
with a hook probe to look for any instability. (B) Resection of the meniscus is usually begun by removing the central portion with a basket forceps. (C) An
arthroscopic knife is a useful tool, especially to cut the extra portion in the anterior horn. (D) A curved punch (right curved in this case) can be used to resect
the meniscus by improving the trajectory. (E) An arthroscopic shaver can be used to smoothen out the irregular free margins obtained after resection. (F)
A completed saucerisation surgery, leaving about 6–8 mm of the meniscus all around, with stable, regular margin. ACL, anterior cruciate ligament; DLM,
discoid lateral meniscus; LFC, lateral femoral condyle; LM, lateral meniscus; LTC, lateral tibial condyle.

Figure 5  Arthroscopic management of peripheral capsular detachment of discoid lateral meniscus (DLM). Right knee arthroscopy with knee in figure-­
of-4 position, viewing from anteromedial portal with a 30° arthroscope and working from the anterolateral portal. (A) The anterior horn of the discoid
meniscus is detached from the capsule and meniscus is displaced in the notch (posterocentral shift), leaving a bare area of the lateral tibia. (B) Saucerisation
is performed to reshape the meniscus to its ‘normal shape’. (C) Complete reducibility of the shift is confirmed with a hook probe. (D) Repair of the anterior
horn to the capsule is begun by the outside-­in technique. (E) A No 0 FiberWire is passed through the anterior horn from outside the joint and one free end is
to be retrieved using the snare. (F) Both strands of FiberWire passing through the meniscus are seen. (G) The meniscus is seen approximated to the capsule
when the two ends of FiberWire are tied outside on the capsule. (H) A completed repair demonstrating a fully reduced, stable meniscus with a retained
6–8 mm margin all around. ACL, anterior cruciate ligament; LFC, lateral femoral condyle; LM, lateral meniscus; LTC, lateral tibial condyle.
Tapasvi S, et al. J ISAKOS 2021;6:14–21. doi:10.1136/jisakos-2017-000162 17
 Current concepts review
Figure 6  MRI scan of a horizontal tear. (A) A proton density fat-­
saturated sequence sagittal section scan showing hyperintense signal
(yellow arrow) in the anterior horn of a discoid lateral meniscus, splitting
the meniscus into a superior and an inferior leaflet. (B) T2-­weighted coronal
image of the same patient showing a peripheral parameniscal cyst (yellow
arrow) at the site of the tear.
meniscectomy is an independent risk factor for progression to
high-­grade osteoarthritis later.41 There are no specific studies
that present evidence of preventive exercises for asymptomatic
DLM to remain asymptomatic. It seems reasonable, however,
to recommend general physiotherapy programme to prevent
excessive joint overload.
Figure 7  Arthroscopic management of a horizontal tear. Right knee
arthroscopy of the same patient as in figure 5. The knee is in figure-­
of-4 position, viewing from anterolateral portal with a 30° arthroscope
and working from the anteromedial portal. (A) An incomplete discoid
meniscus is seen, covering almost half of the tibial articular surface. (B) The
peripheral margin is excised using a basket forceps. (C) The horizontal tear
is revealed with a superior and an inferior leaflet (red arrows). (D) The two
leaflets are repaired to each other using an all-­inside technique, to obtain
a stable and normally shaped lateral meniscus. ACL, anterior cruciate
ligament; DLM, discoid lateral meniscus; LFC, lateral femoral condyle; LTC,
lateral tibial condyle.
18
Symptomatic DLM without tear
The presence of symptoms in a DLM is more likely where there
is a tear. However, a DLM can present with the symptoms of
snapping, locking or pain even when no tear is apparent on an
MRI scan or arthroscopy. In a population-­based study over 18
years, Sabbag et al reported that only 27.8% of patients with a
DLM did not have a tear on MRI scan or diagnostic arthroscopy
in spite of being symptomatic.42 Morphologically, this DLM may
or may not be of the Wrisberg variant as per Watanabe’s classifi-
cation or may have peripheral rim instability. Such patients who
have occasional symptoms should be treated symptomatically
and followed up. Nonetheless, persistence of symptoms, severe
symptoms or loss of knee extension merits surgical intervention.
The traditional treatment of DLM was partial or total menis-
cectomy to relieve the symptoms by removing the offending
tissue. However, removal of meniscus is problematic because
of the onset on osteoarthritic changes in the lateral compart-
ment, consistently seen in long-­ term follow-­ up studies.43–45
Arthroscopic saucerisation is a type of partial meniscectomy
to reshape the discoid meniscus46 and is more commonly
performed now. Nothing more needs to be done if there is no
rim instability or a tear. The goals of saucerisation are to create
a functional meniscus for shock absorption, and yet leave only
enough stable tissue which does not tend to retear again.34 A
6–8 mm peripheral portion is preserved (figure 4) to maintain
hoop stresses while reducing chances of tear in the residual
meniscus. Larger remnants are associated with increased retear,
while a small residual meniscus width increases the risk of degen-
erative changes.47–49
Symptomatic DLM with tear
A discoid meniscus is more prone to tearing because of the
abnormal microarchitecture and gross morphology, compro-
mised vascularity and, in some cases, lack of peripheral
anchorage.21 There are two possible scenarios where the DLM is
structurally compromised:
A. Peripheral rim detachment—The absence of meniscotibial
capsular attachment causes peripheral rim instability, which
maybe anterior, middle or posterior depending on location.
This can cause various symptoms. Kang et al have described
various clinicoradiological features which could be predic-
tive of this instability. The predictive factors of anterior in-
stability were female sex, symptom of clicking and central
displacement of the anterior meniscus. Middle instability
was predicted by presence of flexion deformity of >10° and
peripheral tear of the middle body. Posterior instability was
likely to be present when there was central displacement of
the posterior meniscal margin and tears of the anterior and
mid-­body periphery.50 Traditional methods like an inside-­
out, outside-­in or all-­inside repair may be used to reduce and
stabilise such detachments to the capsule (figure 5). A novel
technique to preserve the meniscus while relieving symptoms
in patients with an unstable peripheral rim is meniscopexy,
first described by Gilbert et al.51 The technique involves an
anterolateral arthrotomy, securing the anterior horn with su-
tures and retrieving it from the subluxed position and fixing
it to the tibia rim with suture anchors. A small series of 10
knees treated with this technique was reported by Johnson et
al with median 4.5 years of follow-­up. The median Lysholm
score was 91 (8–100) and the meniscus morphology nor-
malised with time as seen on MRI studies.52 An arthroscopic
technique to stabilise the unstable peripheral rim and ‘cen-
tralize’ the extruded lateral meniscus using all-­suture anchor
Tapasvi S, et al. J ISAKOS 2021;6:14–21. doi:10.1136/jisakos-2017-000162

Figure 8  A flow chart describing the treatment strategies for a discoid lateral meniscus.
was described by Koga et al.53 A similar technique has been
described by Ohnishi et al in their series of 52 patients. They
performed saucerisation of the discoid portion, preserving a
10 mm peripheral rim. When an unstable rim was present,
it was secured using an all-­suture anchor, shuttling sutures
through the meniscus and tying the meniscus in situ to pre-
vent lateral subluxation.54 Kinugasa et al described a series
of four patients in whom the peripheral meniscus was reat-
tached without any reshaping or saucerisation to preserve all
the tissue. They performed inside-­out repair using vertical
mattress stacked suture configuration and augmented the re-
pair with fibrin clot.55
B. Peripheral body or intrasubstance tear—The most common
type of tear in a DLM is a horizontal cleavage tear with asso-
ciated mucoid degeneration of the central portion of the me-
niscus.56 A longitudinal tear of the peripheral portion or a ra-
dial tear is encountered less frequently. In their series of 329
cases of symptomatic torn DLM in patients older than 20
years, Ahn et al classified the tear patterns into five types: (A)
horizontal tear, (B) peripheral tear, (C) peripheral and hori-
zontal tear, (D) posterolateral corner loss type, and (E) others
which are difficult to define (transverse tear or marginal de-
generative tear).57 When a horizontal tear is present, initial
reshaping to obtain symmetrical superior and inferior leaf-
lets is first performed. This can be followed by repair of the
two leaflets by an all-­inside technique58 or inside-­out sutures
(figures 6 and 7). A small redundant or unstable leaflet may
Tapasvi S, et al. J ISAKOS 2021;6:14–21. doi:10.1136/jisakos-2017-000162
Current concepts review
sometimes have to be excised. In the inside-­out technique, it
is helpful to use zone-­specific cannulae and a posterolateral
safety incision to retrieve suture needles. Biological augmen-
tation methods such as rasping, trephination, microfracture
or fibrin clot increase chances of healing when any isolat-
ed meniscus repair is performed.59 60 Peripheral tears can be
present at the meniscocapsular junction in the anterior horn,
posterior horn or entire posterior horn and mid-­body, called
the posterolateral loss type. The posterolateral loss-­type tear
is difficult to salvage and invariably results in a subtotal me-
niscectomy.22 A technique to repair this posterolateral loss
type and augment with the thickened central portion of the
discoid meniscus has been described by Kim et al.61
Rehabilitation after surgery
There are no universal guidelines for rehabilitation following
surgery for a DLM. The patients may be allowed immediate
weight bearing and knee range of motion (ROM) if only a sauce-
risation or total meniscectomy is performed. Initial physical
therapy is directed towards oedema reduction by icing. Later
therapy is begun to regain quadriceps strength at about 2 weeks
postoperatively. Progression to return to sport or recreational
activity begins after full knee ROM and strength are achieved,
which typically occurs approximately 8 weeks postoperatively.62
For those who have had saucerisation with meniscal repair,
protected weight bearing and restriction of knee ROM in a
19
 Current concepts review
brace is advised initially. Gradual progressive weight bearing
and ROM are allowed with the intention of full motion and full
weight bearing after 6–8 weeks postoperatively. There can be
no timeline for return to sports in these children and subjective
criteria are applied for making this decision. Usually, 3–4 months
elapse before full ROM and full strength are achieved.62
DISCUSSION
The treatment of DLMs is still largely conservative and this
method must be exhausted even when a patient presents with
symptoms and a visible tear on MRI (figure 8). Even arthroscopic
surgery must be conservative to reshape the meniscus where
necessary. Performing repairs for peripheral detachments or
intrasubstance tears is perhaps better than performing a complete
meniscectomy. However, whether such repairs preserve the
meniscal function and are durable in the presence of compro-
mised biology is unknown. There are no level 1 or 2 studies
in literature comparing different surgical treatments for DLM.
A large number of therapeutic case series in limited number of
patients are available from all geographic locations employing
varying treatment modalities. The outcomes following surgery
for DLM include both patient-­reported outcome measures and
radiological, as discussed below.
Patient-reported outcome measures
The systematic review by Lee et al demonstrated that Ikeuchi
score was excellent or good in 72.3%–94% of patients and
International Knee Documentation Committee (IKDC) score
was normal or nearly normal in 76.5%–94.3% of patients, irre-
spective of the type of surgery.63 Similarly, a recent meta-­analysis
found no difference in clinical outcomes between partial or total
meniscectomy.64 Smuin et al performed a level IV systematic
review to compare saucerisation versus complete resection for
symptomatic DLM and found superior results in the saucerisa-
tion group. Interestingly, those who had suture repair of tears
did not demonstrate improved outcomes over partial meniscec-
tomy without repair.65 Ohnishi et al reported better outcomes
after saucerisation with or without repair/centralisation in chil-
dren lesser than 13 years of age treated for symptomatic DLM
in their series.54 Haskel et al found that there is increasing inci-
dence of pain and mechanical or functional limitations on long-­
term follow-­up after saucerisation alone.66 Similar, unfavourable
clinical outcomes were reported in more than 30% of patients,
10 years after a partial lateral meniscectomy in the series by Lee
et al. The clinical outcomes assessed by Lysholm scores were
related to the symptom duration before surgery and alignment
at last follow-­up.67
Radiological
In Lee et al’s systematic review, majority of the knees had
mild joint space narrowing but none demonstrated advanced
degeneration. They believed that higher age at surgery, perfor-
mance of subtotal or total meniscectomy and longer follow-­up
could be risk factors for arthritis.63 The meta-­analysis by Lee
et al reported significantly greater chondral changes in those
who has undergone a total meniscectomy for DLM.64 In Ahn
et al’s series of 48 knees, the overall incidence of osteoarthritic
changes at mean 10.1 years was 40% but 88% of those with
subtotal meniscectomy had degeneration on radiographs.68 A
small residual meniscal width and greater extrusion has been
shown to co-­relate with greater degeneration.49 An MRI analysis
by Lee et al revealed that the width and thickness of residual
meniscus continued to decrease over time following a partial
20
meniscectomy, while lateral compartment arthritis progressed.69
In another MRI study, the residual meniscus demonstrated
deformation and extrusion even after a partial meniscectomy
and repair.70
To summarise, the clinical outcome scores tend to deteriorate
with time in patients following DLM surgery and it is unclear
if this related to the amount of meniscus resection. However,
greater tissue resection does lead to more radiographic arthritis.
Meniscus repair of the abnormal tissue has not been proven to
improve clinical or radiological results. It would be worthwhile
examining if preserving the entire discoid tissue and performing
a peripheral stabilisation only as described by Kinugasa et al
might improve the outcome.55 Finally, one peculiar complication
associated to DLM surgery is the occurrence of osteochondritis
dissecans of the lateral femoral condyle. It is hypothesised that
impact on the immature cartilage after partial or total meniscec-
tomy and change in alignment to valgus, causing concentrated
stress on the cartilage, could predispose to this condition.71 72
Twitter Sachin Tapasvi @sachintapasvi
Contributors  ST designed the layout of the text and was involved in writing the
manuscript and review of the completed paper. AS performed the literature search
and wrote the manuscript. KE contributed to writing the manuscript and review of
the completed paper.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Commissioned; externally peer reviewed.
Data availability statement  There are no data in this work.
ORCID iDs
Sachin Tapasvi http://​orcid.​org/​0000-​0002-​9778-​3042
Anshu Shekhar http://​orcid.​org/​0000-​0002-​3529-​9060
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