1 s2.0 S0749806321003960

Degenerative Medial Meniscus Tear With a Displaced
Flap Into the Meniscotibial Recess and Tibial

Peripheral Reactive Bone Edema Presents Good
Results With Arthroscopic Surgical Treatment
Camilo Partezani Helito, M.D., Ph.D., Paulo Victor Partezani Helito,
Marcel Faraco Sobrado, M.D., Pedro Nogueira Giglio, M.D., Tales Mollica Guimaraes, M.D.,
José Ricardo Pécora, M.D., Ph.D., Riccardo Gomes Gobbi, M.D., Ph.D.,
Marcelo Bordalo Rodrigues, M.D., Ph.D., and Bruno Vande Berg, M.D., Ph.D.
Purpose: To report the arthroscopic treatment results of a degenerative medial meniscus tear with a displaced flap into
the meniscotibial recess, tibial peripheral reactive bone edema, and focal knee medial pain. As a secondary objective, we
propose to identify possible factors associated with a good or poor prognosis of the surgical treatment of this lesion.
Methods: From 2012 to 2018, patients who had this specific meniscus pathology and underwent arthroscopic surgical
treatment were retrospectively evaluated. Patients with Kellgren-Lawrence (KL) classification greater than 2 were
excluded. KL classification, the presence of an Outerbridge grade III/V chondral lesion of the medial compartment, limb
alignment, body mass index, and smoking were evaluated. The subjective outcomes included the International Knee
Documentation Committee score, improvement in the pain reported by patients, and the Global Perceived Effect (GPE)
scale score. Results: A total of 69 patients were evaluated. The mean age was 58.6 7.1 years. The follow-up time was
48.7 20.8 months. Fifty-five (79.7%) patients reported pain improvement. The postoperative International Knee
Documentation Committee was 62.6 15.4, and the mean GPE was 2.3 2.6. Fourteen patients (20.3%) showed no
improvement in pain, and 7 patients (10.2%) presented complications. Groups that improved (GPE > 0) and did not
improve (GPE < 0) did not present differences regarding age, sex, follow-up time, chondral lesions, or body mass index.
Patients without improvement had a greater incidence of smoking (P ¼ .001), varus alignment (P ¼ .008), and more
advanced KL classification (P < .001). In the multivariate analysis based on the GPE score, KL classification (P ¼ .038) and
smoking (P ¼ .003) were significant. Conclusions: Arthroscopic surgical treatment of degenerative medial meniscal tears
with a meniscal flap displaced into the meniscotibial recess and adjacent focal bone edema in the tibia shows good results
in approximately 80% of cases. Smoking and KL grade 2 were factors associated with poor prognosis of surgical treatment.
Level of Evidence: Level IV (case series).
From the Grupo de Joelho (C.P.H., M.F.S., P.N.G., T.M.G., J.R.P., R.G.G.)
and Grupo de radiologia musculoesqueléticas (P.V.P.H., M.B.R.), Instituto de
Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de
T he treatment of degenerative meniscus lesions is
still controversial in the literature. A recent sys-
tematic review comparing conservative treatment with
Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Sírio
Libanês São Paulo, Brazil (C.P.H., P.V.P.H., M.F.S., M.B.R.); and Université partial arthroscopic meniscectomy found no difference
Catholique de Louvain - UCLouvain | UCLouvain $ Department of Radiology between the 2 methods.1 In addition, no difference was
and Medical Imaging e RAIM, Ottignies-Louvain-la-Neuve, Belgium found in a prospective randomized study conducted by
(B.V.B.). Sihvonen et al.,2 who compared partial meniscectomy
The authors report that they have no conflicts of interest in the authorship
and publication of this article. Full ICMJE author disclosure forms are
and placebo surgery for patients with degenerative
available for this article online, as supplementary material. meniscal tears. In contrast, Lizaur-Utrilla et al.3
Received September 25, 2020; accepted April 15, 2021. concluded that in middle-aged patients without severe
Address correspondence to Marcel F. Sobrado, Rua Dr. Ovídio Pires de osteoarthritis, partial meniscectomy can be successfully
Campos, 333 Cerqueira Cesar e São Paulo- SP e CEP: 05403-010, Brazil. performed when conservative treatment fails. Karpin-
E-mail: marcelfs@gmail.com
Ó 2021 by the Arthroscopy Association of North America
ski et al.4 also advocated arthroscopy for specific groups
0749-8063/201552/$36.00 of patients, and a consensus on degenerative meniscus
https://doi.org/10.1016/j.arthro.2021.04.033 lesions published by Hohmann et al.5 considered
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 37, No 11 (November), 2021: pp 3307-3315 3307
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January 24, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
3308 C. P. HELITO ET AL.
arthroscopy a viable alternative after failure of conser- focal knee medial pain. As a secondary objective, we
vative treatment. propose to identify possible factors associated with a
This controversy in the treatment of degenerative good or poor prognosis of the surgical treatment of this
meniscal lesions may lead surgeons to perform fewer lesion. We hypothesized that most patients would
knee arthroscopies and tend to initially indicate con- benefit from surgical treatment of this specific type of
servative treatment.6 Nevertheless, the configurations degenerative meniscal pathology and that greater
of degenerative meniscal tears and the clinical contexts cartilage degeneration would be a risk factor for worse
in which they occur are very diverse, and the clinical outcomes.
outcomes are variable.3,4 Degenerative medial
meniscus posterior root tears, for example, present Methods
worse outcomes with conservative treatment and par- From 2012 to 2018, patients who presented with
tial meniscectomy than with root repair at its native focally located knee pain and had degenerative medial
bed.7-9 Thus, individualizing degenerative meniscal tear meniscus tears with a meniscal flap displaced into the
treatment is essential, and therefore, it is of great in- meniscotibial recess with bone edema of the peripheral
terest to identify subgroups of patients who would medial tibial plateau, limited to the bone marrow
benefit from each treatment. around the meniscal fragment, who underwent surgical
A specific type of degenerative meniscal tear previ- treatment were retrospectively evaluated via prospec-
ously described in the literature is the trapped or tive data collection. Patients were identified through
incarcerated meniscus in the meniscotibial recess.10,11 clinical and surgical notes and MRI reports. Patients
Lecouvet et al.,10 Jung et al.,12 and Bassett et al.13 were operated only if they did not improve with con-
classified this lesion as difficult to diagnose with mag- servative treatment for at least 12 weeks. Conservative
netic resonance imaging (MRI) because the displaced treatment mainly consisted of knee analgesia and in-
flap sometimes cannot be properly characterized or flammatory control and quadriceps and glute
because it can be mistakenly characterized as meniscus strengthening exercises. Patients with diffuse pain on
extrusion. In addition to the displacement of the physical examination, previous surgeries on the knee or
meniscal fragment into the recess, these lesions are ipsilateral limb, previous surgeries on the contralateral
accompanied by bone changes in the periphery of the knee, inflammatory diseases or other associated knee
medial plateau,14,15 which include remodeling and, pathologies that required concomitant surgical treat-
particularly, bone marrow edema. So far, it is unclear ment, such as osteotomy or ligamentous or chondral
whether the tibial edema is caused by the dislocated procedures, or surgical procedures in the lateral
meniscus flap or if it is caused by the resultant arthritic meniscus were excluded. Patients with a
reaction due to the meniscus deficiency. Also, the pain KellgrenLawrence (KL) classification of osteoarthritis
related to this syndrome happens in an acute onset and greater than 2 also were excluded. The imaging ex-
is focally located in the topography of the flap/bone aminations were evaluated by an orthopaedist and a
edema. The terms “osteomeniscal impingement,” radiologist who specialized in musculoskeletal diseases
“osteomeniscal impact,” “osteomeniscal impact to confirm the presence of a displaced meniscal frag-
edema,” “comma sign,” and “apostrophe sign” (when ment and bone marrow edema at the peripheral medial
the flap is displaced superiorly) have previously been tibial plateau (Figs 1 and 2).
used to characterize this pathology, as well as the term All patients underwent surgical treatment by
“conflit ostéoméniscal” from the French litera- arthroscopy for flap resection followed by regulariza-
ture.13,16,17 Some studies suggest that this type of injury tion of the meniscal remnant to eliminate unstable
may have good results with surgical treatment, but meniscal fragments (Figs 3-5). Patients were encour-
there is a lack of literature regarding the surgical aged to bear weight on the operated limb as tolerated
treatment outcomes for this type of injury with a starting on the first postoperative day, and no range of
minimum follow-up of 2 years.11,14,18 One of the few motion restriction was imposed.
studies that we are aware of with a minimum 2 years’ Patient demographic data, the radiographic KL clas-
follow-up was performed by Jung et al.12 These authors sification at the time of surgery, the presence of an
evaluated a small series of 16 cases with an inferiorly Outerbridge grade III or IV chondral lesion of the
displaced medial meniscus flap and concluded patients medial compartment at the time of surgery, the limb
presented better International Knee Documentation alignment measured with long leg standing radio-
Committee (IKDC) and Lysholm scores after surgical graphs, body mass index (BMI), and smoking were
treatment. evaluated by 2 orthopaedic surgeons. The subjective
Thus, the main purpose of this study is to report the outcomes were also evaluated by 2 orthopaedic sur-
arthroscopic treatment results of a degenerative medial geons and included the IKDC score, improvement in
meniscus tear with a displaced flap into the meniscoti- the pain reported by patients, and the Global Perceived
bial recess, tibial peripheral reactive bone edema, and Effect (GPE) scale score,15 in which patients evaluated
ARTHROSCOPY FOR DEGENERATIVE MENISCUS FLAP 3309
Fig 1. T2-weighted magnetic

resonance images of the right
knee of a 52-year-old patient.
(A) Coronal image showing
lesion of the medial meniscus
with a fragment displaced into
the meniscotibial recess (white
arrow) and edema in the
adjacent tibial margin (arrow-
head). (B). Axial image
showing that bone edema (ar-
rowheads) is related to the
meniscal fragment location.
their overall status before and after treatment on a as grade 0, 44 (63.8%) patients were classified as grade
numerical scale ranging from 5 (worse than ever) 1, and 17 (24.6%) patients were classified as grade 2.
to þ5 (fully recovered). Six (8.7%) patients were smokers, and 23 (33.3%)
patients had a BMI greater than 30.
Data Analysis Regarding the clinical outcome, 55 (79.7%) patients
Multivariate logistic regression was used to evaluate reported pain improvement with the surgical proced-
independent determinants of therapeutic success ure. The postoperative IKDC score was 62.6 15.4, and
assessed by the GPE scale with the following preoper- the mean GPE score was 2.3 2.6. Among the patients
ative variables: age, KL classification, obesity, smoking, who showed improvement, the GPE was 3.4 1.1.
sex, and varus alignment.19 The numerical variables are Fourteen patients (20.3%) showed no improvement in
described by the mean and standard deviation. A P pain, and of these, 7 (10.2%) had objective complica-
value < .05 was considered statistically significant. The tions throughout the follow-up period: 5 developed a
sample size was not calculated because all available subchondral fracture in the medial femoral condyle
patients were included in the study. The statistical during follow-up (one of whom underwent total knee
software SPSS 22 (IBM Corp., Armonk, NY) was used arthroplasty 27 months after the arthroscopy surgery),
for the analyses. one developed an acute postsurgical infection treated
To evaluate the risk factors for postoperative pro- with arthroscopic surgical cleaning, and one required a
gression, patients were separated into 2 groups: those new surgical procedure to treat a new meniscal tear 18
with subjective improvement in pain and those without months after the initial arthroscopy surgery.
subjective improvement in pain. Numerical variables The comparison of patients who showed improve-
were compared between groups using the ment in subjective pain with patients who did not
MannWhitney U test. For categorical variables, the report improvement is shown in Table 1. We did not
Fisher exact test was used in the respective contingency find differences between the groups regarding age, sex,
tables. follow-up time, chondral lesion in the medial
compartment, or BMI. Patients without improvement
Results had a greater incidence of smoking, greater incidence of
A total of 86 patients were initially included in this varus alignment, and more advanced KL classification.
study. Seventeen (19.7%) patients improved with In the multivariate analysis based on the GPE score, the
nonoperative treatment; thus, the final sample evalu- preoperative factors KL classification and smoking were
ated consisted of 69 patients. The mean age of patients significant variables.
in this series was 58.6 7.1 years. Thirty-six patients
were female and 33 were male. The mean follow-up Discussion
time was 48.7 20.8 months, with a minimum of 24 The main finding of this study is that the vast majority
months. Most patients had a neutral or varus align- of patients with focal medial knee pain and degenera-
ment, and one half of the patients had grade III or IV tive medial meniscus tears associated with a meniscal
chondral lesions in the medial compartment. Regarding flap rotated into the meniscotibial recess and peripheral
the KL classification, 8 (11.6%) patients were classified tibial bone edema improve with arthroscopic surgical

(A) Coronal image showing
lesion of the medial meniscus
with a fragment displaced into
the meniscotibial recess and a
very pronounced edema in the
adjacent tibial margin (white
arrow) (B). Axial image
showing that bone edema
(white arrow) is related to the
meniscal fragment location
and is located more anteriorly
than Figure 1.
treatment. Patients who are smokers and those with a which we did not study. All of these authors referred in
high KL classification have worse results with surgical their studies to the same pathology that we prefer to
treatment. Thus, our initial hypothesis was confirmed, call osteomeniscus impingement or by the French ter-
and we suggest that treatment of this type of lesion minology of “conflit ostéoméniscal.” Although none of
should be evaluated separately from other degenerative these previous studies focused specifically on the results
meniscal lesions. of the surgical treatment of this lesion, all authors
Degenerative meniscal tears with an inferiorly dis- suggest that surgical treatment of this pathology leads to
placed flap and reactive bone edema in the tibia are not good results. In our series, we corroborate this sugges-
a new entity in the literature.18 Several studies have tion as only around 20% improved with nonoperative
previously described this lesion, but different names treatment and were not referred to surgery and the
have been used to describe this specific pathology, ones subjected to surgical treatment presented
which may cause some confusion in the literature. improvement in 80% of the cases.
Marcillaud et al.16 referred to this lesion as “conflit Jung et al.12 also evaluated 79 patients with meniscus
osteomeniscale” or menisco-osseous impingement, flaps but only 16 were inferiorly displaced. Similar to
Krych et al.14 called it osteomeniscal impact edema, our study, Jung et al.12 found improvement after
Herschmiller et al.11 named it trapped meniscus, and arthroscopic partial meniscectomy, but the reported
Salem et al.17 referred it as “comma sign.” Basset et al.13 mean postoperative IKDC values were greater than the
also named a displaced flap as “apostrophe sign,” but values reported in this study (91.7 vs 62.6). The dif-
these authors referred to a superiorly displaced flap, ferences could be explained because patients in the

(A) Coronal image showing a
degenerative lesion of the
medial meniscus with a frag-
ment displaced into the
meniscotibial recess (white ar-
row) and edema in the adja-
cent tibial margin
(arrowhead). (B) Axial image
showing that bone edema (ar-
rowheads) is focal and is
limited to the bone marrow
near the meniscal fragment.
Fig 4. Arthroscopic images of

the same 64-year-old patient’s
right knee presented in
Figure 2. (A) Anterolateral
portal view showing the
degenerative meniscal tear
with a displaced flap (black
circle) to the meniscotibial
recess. A probe introduced
from the anteromedial portal is
used to remove the flap from
the recess (B) and bring it to
the medial compartment (C).
(D) After the flap is removed,
no more meniscal fragments
are interposed in the recess
and a probe is used to lift the
meniscal remnant and check it
properly. (MFC, medial
femoral condyle; MM, medial
meniscus; MTP, medial tibial
plateau.)
study performed by Jung et al.12 were younger (45.6 vs when dealing with this pathology. Even when bone
58.6 years) and the follow-up was shorter (27.2 vs edema is present, it is important to differentiate where
48.7) considering degenerative pathologies. However, it is located and its main cause.25 Krych et al.14 showed
apart from the differences presented, both studies re- that the characteristics of bone edema in the tibia
ported improvements with surgical treatment of these caused by a displaced meniscal flap are different from
degenerative meniscus tears. overload edema caused by a meniscal root tear. The
Arthroscopy for degenerative meniscal tears has edema associated with meniscal impingement is focal,
recently been viewed as discredited because some peripheral, and adjacent to the displaced meniscal
studies comparing surgery with conservative treatment fragment.10,14,15,18,26 In these situations, the edema
did not show outcome differences between pa- should not be considered equivalent to joint degener-
tients.1,2,20 Although some methodologic flaws are ation or subchondral bone overload.27 Studies focused
open to discussion, studies conducted by Sihvonen on MRI scans describe these lesions as shiny corners,
et al.2,20 showed that arthroscopy treatment of a and in our clinical practice, meniscal impingement is a
degenerative meniscal tear was not superior to placebo prevalent cause of this condition.15 Preoperative eval-
surgery and should not be encouraged. Perhaps for this uation with careful MRI observation is essential in this
reason, the number of arthroscopies performed for the type of lesion, as the meniscal flap is not easily observed
treatment of meniscal tears decreased from 2013 to by arthroscopic exploration. Even in MRI evaluation it
2015 according to Essilfie et al.6 Coincidentally, the first can be difficult to properly identify the displaced flap.
study published by Sihvonen et al. on this topic in a Jung et al.12 reported that the sensitivity of MRI for
high-impact journal was in 2013, which may have had preoperative detection of flap tears with displaced
some influence on these results. Nevertheless, several fragments in the meniscotibial recess was only 69%
important researchers consider that although conser- compared with 91% sensitivity for detection of flap
vative treatment is the first line of treatment for tears without displaced fragments. Bassett et al.13 also
degenerative meniscal tears, arthroscopy may be indi- highlighted that flap tears with large fragments dis-
cated after its failure.5,21-24 placed into the meniscal recess can be mistakenly
It is important to mention that there are several types characterized as meniscus extrusion. In the case of
of degenerative meniscal lesions and that they may suspicion of this lesion, it is essential to palpate the
behave differently and this fact can lead to confusion inferior surface of the meniscus with a probe both
Fig 5. Arthroscopic images of a 62-year-old patient’s right knee. (A) Anterolateral portal view showing the degenerative medial
meniscal tear. (B) Under the meniscus is possible to visualize a flap (black circle) entering to the meniscotibial recess. A probe
introduced from the anteromedial portal is used to remove the flap from the recess (C) and bring it to the medial compartment
(D). (E) It is possible to visualize the entire flap after removing the probe. (F) After the flap is removed, no more meniscal
fragments are interposed in the recess. (MFC, medial femoral condyle; MM, medial meniscus; MTP, medial tibial plateau.)
through the anterolateral portal and through the In our case series, the patient satisfaction was nearly
anteromedial portal and, in the case of difficulty in 80% with a mean follow-up of 48 months. In the case
visualizing the flap, a pie-crust technique should be of a degenerative tear, we believe that the improve-
performed to slightly release the medial collateral ligament rate is significant. In addition, in cases in which
ment and open the compartment.28 Normally, the flap improvement was noted, the mean GPE score was 3.4,
is anteriorly rotated and a tibial plateau bone depression which can be considered a substantial improvement.
can be found in its topography. Despite knowing that these patients may eventually
Table 1. Patient Data and Comparison Between Groups With and Without Improvement According to the Global Perceived
Effect (GPE) Scale
Patients With Subjective Patients Without Subjective

All Patients Pain Improvement (GPE > 0) Pain Improvement (GPE < 0) P Value
Number of patients 69 55 (79.7%) 14 (20.3%)
Age, y 58.6 7.1 58.5 7.5 (56.4-60.5) 59.1 5.2 (56.1-62.1) .525
Female sex 36 (52.2%) 26 (47.3%) 10 (71.4%) .106
BMI > 30 (obesity) 23 (33.3%) 16 (29.1%) 7 (50%) .204
Smoking 6 (8.7%) 1 (1.8%) 5 (35.7%) .001
Follow-up time, mo 48.7 20.8 49.5 21.8 (44.0-55.8) 44.0 15.9 (34.7-56.2) .497
KL classification grade 0: 8 (11.6%) 0: 6 (10.9%) 0: 2 (14.3%) <.001
1: 44 (63.8%) 1: 41 (74.5%) 1: 3 (21.4%)
2: 17 (24.6%) 2: 8 (14.5%) 2: 9 (64.3%)
Grade III or IV chondral lesion 34 (49.3%) 25 (45.5%) 9 (64.3%) .208
in the medial compartment
Limb alignment Varus 33 (47.8%) Varus 21 (38.2%) Varus 12 (85.7%) .008
Valgus 7 (10.1%) Valgus 7 (12.7%) Valgus 0 (0%)
Neutral 29 (42.0%) Neutral 27 (49.1%) Neutral 2 (14.3%)
IKDC score 62.5 15.4 69.5 6.2 (67.8-71.2) 35.2 8.2 (30.4-39.9) <.001
GPE score 2.3 2.6 3.4 1.1 (3.1-3.7) e2.5 1.2 (e3.1 to e1.7) <.001
NOTE. The confidence interval is shown in parentheses for the numeric variables.
IKDC, International Knee Documentation Committee.
experience worsening of pain and progression to oste- association likely exists between varus and worsening
oarthritis in the future, an improvement over a period degeneration in the medial compartment. However,
of 48 months for patients with a mean age at surgery of surgical treatment should also be indicated with caution
58.6 years should be considered relevant. Based on in patients with asymmetric varus, unlike patients with
these results, we consider the treatment of such lesions neutral or valgus alignment, in whom the results were
should be considered separately from the spectrum of mostly satisfactory. Furthermore, in the case of non-
other degenerative medial meniscus tears. reduction of the medial space in the radiographs, even
Even though the postoperative results presented were if patients had medial chondral lesions, surgical treat-
satisfactory, this series also presented a significant ment was satisfactory.
number of complications. It is important to mention
that the complications reported were not always Limitations
directly related to the surgical treatment and occurred The limitations of the present study include the
throughout the follow-up time. Apart from one acute retrospective nature of the sample, although data were
postoperative knee infection, most of the other patients collected prospectively. Time from diagnosis to the date
presented complications related to the progression of of surgery also could have affected the results, having
the degenerative alteration in the knee joint. possible relationship with poorer outcomes; however,
The risk factors for poor outcome of surgical treat- we think these data can vary a lot, as patients do not get
ment were similar to other knee pathologies of the an MRI immediately when the pain starts and these
medial compartment and included worsening of joint data could lead to some confusion in a retrospective
degeneration, varus alignment, and smoking. In our scenario. In addition, as no sample size calculation was
setting, the percentage of smokers was low, but we performed, it is possible that there was not sufficient
believe that this is a factor that should be considered power in the univariate analysis for significant differ-
whenever some type of surgical treatment is indicated. ences to be detected for some variables, since the group
Previous studies of various types of arthroscopic treat- with GPE scores less than 0 had greater absolute
ment have shown that smoking is associated with numbers of female patients, patients with a BMI greater
worse functional outcomes,29-31 greater complication than 30, and patients with chondral lesions in the
rates, and a greater rate of hospital readmission. medial compartment. We attempted to minimize this
Regarding the degree of joint degeneration, we suggest limitation by performing a multivariate analysis. The
that a worse situation of the affected compartment will lack of postoperative control MRI examinations for all
lead to a greater likelihood of poor outcome with sur- patients is also a limitation because we could not
gical treatment. We do not indicate arthroscopic treat- measure the progression or disappearance of peripheral
ment for patients with KL grade 3 or 4, and indication bone edema in the medial plateau and determine how
for grade 2 should also be made with caution. A weight- this affects the clinical outcomes (Fig 6). Also, the fact
bearing radiograph is mandatory in the preoperative that only patients that had bone edema were included
study of these patients. The varus alignment alone was is itself a possible limitation. By saying that, it is still not
not significant in the multivariate analysis because an clear if the edema is caused by the meniscus fragment
Fig 6. Preoperative coronal

and T2-weighted magnetic
resonance (MRI) images of the
left knee of a 54-year old pa-
tient. A degenerative lesion of
the medial meniscus with a
small fragment displaced into
the meniscotibial recess (white
arrow) and bone changes in
the adjacent tibial margin
characterized by remodeling
and edema (arrowheads) is
observed in (A). Postoperative
MRI showing resection of the
meniscal fragment (white ar-
row shows the operated
meniscus) and regression of
bone marrow edema (arrow-
head) is observed in (B).
or by the arthritic reaction due to meniscus deficiency. 10. Lecouvet F, Van Haver T. Acid S, et al. Magnetic reso-
It is clear further study is needed to elucidate that point. nance imaging (MRI) of the knee: Identification of
Also, even though we used the GPE score to search for difficult-to-diagnose meniscal lesions. Diagn Interv Imaging
subjective improvement after surgery, we have no data 2018;99:55-64.
11. Herschmiller TA, Anderson JA, Garrett WE, Taylor DC.
of preoperative IKDC to compare, and this can be
The trapped medial meniscus tear: An examination ma-
considered a major limitation as well.
neuver helps predict arthroscopic findings. Orthop J Sports
Med 2015;3:2325967115583954.
12. Jung M, Lee DH, Kim S-J, et al. Preoperative diagnosis
Conclusions and treatment outcomes of incarcerated inferiorly dis-
Arthroscopic surgical treatment of degenerative placed flap tear of the medial meniscus: Comparison be-
medial meniscal tears with a meniscal flap displaced tween flap tears with and without incarcerated fragment.
into the meniscotibial recess and adjacent focal bone Biomed Res Int 2018;2018:5941057.
edema in the tibia shows good results in approximately 13. Bassett AJ, Hadley CJ, Tjoumakaris F, Freedman KB. The
80% of cases. Smoking and KL grade 2 were factors meniscal grammar signs: Comma and apostrophe signs for
associated with poor prognosis of surgical treatment. characterization of a displaced fragment in the meniscal
recess. Arthrosc Tech 2019;8:e727-e732.
14. Krych AJ, Wu IT, Desai VS, et al. Osteomeniscal impact
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Degenerative Medial Meniscus Tear With a Displaced

Flap Into the Meniscotibial Recess and Tibial

Fig 1. T2-weighted magnetic

Fig 2. T2-weighted magnetic

Fig 3. T2-weighted magnetic

Fig 4. Arthroscopic images of

Patients With Subjective Patients Without Subjective

Fig 6. Preoperative coronal

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