Guardian of the Meniscus

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MedicineThe American Journal of Sports

http://ajs.sagepub.com/content/37/8/1475The online version of this article can be found at:

DOI: 10.1177/0363546509342559

2009 37: 1475Am J Sports MedBruce Reider

Guardian of the Meniscus

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American Orthopaedic Society for Sports Medicine

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1475

The American Journal of Sports Medicine, Vol. 37, No. 8

DOI: 10.1177/0363546509342559

2009 American Orthopaedic Society for Sports Medicine

Guardian of the Meniscus

secondary injury. Eventually he would prove it in a scientific

manner, but John wanted to communicate this concept to

the orthopaedic sports medicine community immediatelyhence the urgency to get these 2 case reports into print.

They say that when the only tool you have is a hammer,

everything looks like a nail. In an era when arthroscopy

was in its infancy and MRI was unknown, meniscectomy

was a very popular hammer. The atavistic meniscus was

often assumed to be the cause of otherwise unexplained

knee symptoms13

; when a meniscus tear was actually pres-

ent, there was little impetus to look beyond it for any asso-

ciated lesions. The main point of the paper was that an

acutely locked knee might conceal a chronically torn ACL

that had precipitated the more obvious meniscus tear. Two

similar cases were presented to illustrate this lesson. In an

attempt to go slightly beyond pure anecdote, histologic sec-tions were included to show that the meniscus tears had

indeed been the result of degenerative attrition.

Although the orthopaedic community was barely aware

of the concept of a hierarchy of evidence in the 1970s, John

Marshall knew that the Guardian of the Meniscus was not

high science. Using the canine model, he had previously

demonstrated that loss of the ACL triggered a progressive

deterioration of the knee that usually included destruction

of the medial meniscus.10

If John had lived past 1980, he

undoubtedly would have contributed more to the accumu-

lation of evidence documenting the relationship between

the ACL and the medial meniscus. Two years after his

death, colleagues showed that excising the medial menis-

cus further increased pathologic anterior laxity in an ACL-

deficient knee.9Later laboratory research would measure

the increased force on the medial meniscus resulting from

ACL deficiency and document the ability of ligament

reconstruction to restore that force to normal.16

Over the years, clinical evidence has also suggested that

ACL deficiency leads to a steadily increasing risk of medial

meniscus injury. Numerous case series of ACL reconstruc-

tion have shown that the prevalence of medial meniscus

tears increases as the time from injury to reconstruction

lengthens.1,2,12,14,17,21

Most recently, the relationship

between ACL injuries and meniscus tears has been dra-

matically demonstrated from the rapidly accumulating

mountain of data in the Norwegian National KneeLigament Registry.

7 Analyzing the first 3475 patients

enrolled in the registry, Granan et al7calculated that the

odds of a meniscus tear being present in the knee of a

young adult increased by a factor of 1.004 for each month

that elapsed following an ACL tear.

Although compelling, this evidence is nevertheless indi-

rect, as it is derived by comparing different patients at

varying times after their ACL injuries. In a new study

appearing in this issue ofAJSM,Yoo et al24

were able to

document progressive deterioration in the condition of the

medial meniscus in a series of 31 patients who had MRI

studies at 2 or more different time points while awaiting

Editorial

The menisci were invariably severely damaged, the

medial meniscus usually more than the lateral.

Marshall JL, Olsson S-E. Instability of the knee: a

long-term experimental study in dogs.

J Bone Joint Surg Am. 1971;53:1561-1470.

The commanding voice on the phone could only belong to The

Dragon. That was not her real name, of course, but the affec-

tionate soubriquet she had earned for the fire-breathing

ferocity with which she protected the privacy of her bosss

inner sanctum. Even when The Dragons mission was to

summon a resident or fellow to the office, as it was now, her

inflection seemed to betray a tinge of resentment that even

John Leahy Marshall had the power to override her other-

wise complete authority.

A summons to Johns office usually meant that he hadunexpectedly encountered a few minutes of downtime and

wanted to discuss the status of ongoing research or a recent

inspiration for a new undertaking. The distinction between

these 2 categories wasnt always clear; Johns creative mind

could get so far ahead of itself that he would ask about your

progress on a project that he had never previously men-

tioned. In my more cynical moments, I wondered if this

wasnt his way of obviating the possibility that you might

decline to add yet another assignment to your workload if

invited in the usual manner.

The focus of our conversation that day was to be, The

Anterior Cruciate: Guardian of Meniscus.19

The inspira-

tion for this undertaking had arisen earlier in the weekwhen we were operating on the locked knee of a 30-year-

old attorney. While a displaced medial meniscus had pre-

cipitated the patients surgery, the underlying cause of his

problem was a previously undiagnosed chronic anterior

cruciate ligament (ACL) tear. Although John approached

orthopaedics scientifically, his investigations were inspired

by a mixture of careful observation and an intuitive under-

standing of the way the body works. In this case, the

picturesque title captured his vision of the intimate rela-

tionship between the ACL and the medial meniscus. Johns

experience as a veterinarian probably explained the vehe-

mence of his vendetta against ACL tears. Anterior cruciate

ligament injuries are common in certain breeds of dogs,and their depredations in the canine knee are particularly

swift and merciless.10

In the 1970s, John Marshall belonged to a small coterie

of American orthopaedic surgeons who believed that the

ACL was clinically important.3,4

To John, the landmark

work of Ivar Palmer15

carried the authority of holy writ. He

believed fervently that an ACL tear was the beginning

of the end of the knee. Rupture of the ACL increased the

load on the medial meniscus, he held, often leading to a

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1476 Editorial The American Journal of Sports Medicine

ACL reconstruction. During the period of the study, the

authors routinely advised patients who delayed their ACL

reconstruction by 6 months or more to have a repeat MRI

scan performed. In these 31 patients, the first MRI scan

was carried out a mean of 8.5 months after injury and the

second after an additional 36.8 months had passed. All

MRI studies were conducted with the same technicalparameters and evaluated by the same pair of blinded

musculoskeletal radiologists. In the interval between the 2

MRIs, the prevalence of medial meniscus tears increased

from 55% to 84%; 9 patients developed a new meniscus

tear and 4 progressed from a longitudinal to a bucket-

handle tear.

In each case, the patient was responsible for postpon-

ing the surgery. Although the exact reasons for the

delays were not documented, the activity level of the

patients and the interim occurrence of reinjury were

recorded: The Tegner activity level averaged 5.9 (range,

2-9) and reinjury episodes were reported in 13 patients.

Given the available number of patients, the authors

could not find a relationship between the risk of menis-

cus deterioration and a patients age, activity level, the

occurrence of reinjuries, or the amount of time that

elapsed between the MRI studies. The interval between

the 2 MRI scans was at least 12 months for all patients

in the study; it is possible that a shorter interval would

have been able to detect a relationship between the

length of delay and the increase in the risk of medial

meniscus deterioration.

Yoo et al conclude that it is important to perform an ACL

reconstruction at an early stage after injury to avoid sec-

ondary meniscus tears. This recommendation assumes, of

course, that ACL reconstruction will reduce the likelihood

of secondary medial meniscus tears. Although agreementon this assumption is not universal, there is some evidence

to support it. Several clinical studies that have compared

surgical with nonsurgical treatment of ACL injuries have

reported an increased prevalence of meniscus injury in

knees treated without surgery.5,8,11

Unfortunately, as I dis-

cussed last month,18

although ACL reconstruction may

help preserve the medial meniscus, it has not been proven

to lower the risk of osteoarthritis after ACL tear.

When John Marshall died in an aviation accident at the

age of 43, less than 9 years had passed since the comple-

tion of his own orthopaedic training.25

A modest black-and-

white portrait in the AOSSM Hall of Fame attests to the

remarkable legacy that he compiled during his brief career.He worshipped anatomy like a zealot; his anatomic inves-

tigations are still widely referenced.6,20,22,23

If the ACL is

the Guardian of the Meniscus, John Marshall was the self-

appointed Guardian of the ACL. He would be delighted to

know that evidence to support his insights is still appear-

ing nearly 30 years after his departure. John belonged to

the breed of orthopaedic surgeons who believe that clinical

practice should have a firm basis in scientific investiga-

tion. His career shows us that this research can proceed

with amazing swiftness when a keen intuition is guiding it

in the right direction.

Bruce Reider, MD

Chicago, Illinois

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experimental study in dogs. J Bone Joint Surg Am. 1971;53(8):

1561-1570.

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repair or non-surgical treatment of anterior cruciate ligament rupture:

a randomized study with a 15-year follow-up. Scand J Med Sci

Sports.2007;17:230-237.

12. Millett PJ, Willis AA, Warren RF. Associated injuries in pediatric and

adolescent anterior cruciate ligament tears: does a delay in treat-

ment increase the risk of meniscal tear? Arthroscopy. 2002;18:

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25. Zelko RR. In memoriam: John L. Marshall, DVM, MD, 1936-1980.Am

J Sports Med.1980;8:216-217.


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