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The American Journal of Sports


Guardian of the Meniscus

Bruce Reider
Am J Sports Med 2009 37: 1475
DOI: 10.1177/0363546509342559
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American Orthopaedic Society for Sports Medicine

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Guardian of the Meniscus

The menisci were invariably severely damaged, the
medial meniscus usually more than the lateral.

secondary injury. Eventually he would prove it in a scientific

manner, but John wanted to communicate this concept to
the orthopaedic sports medicine community immediately
hence 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 present, there was little impetus to look beyond it for any associated 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 sections 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 accumulation of evidence documenting the relationship between
the ACL and the medial meniscus. Two years after his
death, colleagues showed that excising the medial meniscus further increased pathologic anterior laxity in an ACLdeficient knee.9 Later 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 reconstruction 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 dramatically demonstrated from the rapidly accumulating
mountain of data in the Norwegian National Knee
Ligament Registry.7 Analyzing the first 3475 patients
enrolled in the registry, Granan et al7 calculated 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 indirect, as it is derived by comparing different patients at
varying times after their ACL injuries. In a new study
appearing in this issue of AJSM, 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

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 affectionate 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 otherwise complete authority.
A summons to Johns office usually meant that he had
unexpectedly 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 mentioned. 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 inspiration for this undertaking had arisen earlier in the week
when we were operating on the locked knee of a 30-yearold attorney. While a displaced medial meniscus had precipitated 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 understanding of the way the body works. In this case, the
picturesque title captured his vision of the intimate relationship between the ACL and the medial meniscus. Johns
experience as a veterinarian probably explained the vehemence 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
The American Journal of Sports Medicine, Vol. 37, No. 8
DOI: 10.1177/0363546509342559
2009 American Orthopaedic Society for Sports Medicine


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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 technical
parameters 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 buckethandle tear.
In each case, the patient was responsible for postponing 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 meniscus 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 secondary meniscus tears. This recommendation assumes, of
course, that ACL reconstruction will reduce the likelihood
of secondary medial meniscus tears. Although agreement
on 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 discussed 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 completion of his own orthopaedic training.25 A modest black-andwhite 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 investigations are still widely referenced.6,20,22,23 If the ACL is
the Guardian of the Meniscus, John Marshall was the selfappointed Guardian of the ACL. He would be delighted to
know that evidence to support his insights is still appearing 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 investigation. 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

1. Church S, Keating JF. Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and
regenerative change. J Bone Joint Surg Br. 2005;87:1639-1642.
2. Cipolla M, Scala A, Gianni E, Puddu G. Different patterns of meniscal
tears in acute anterior cruciate ligament (ACL) ruptures and in chronic
ACL-deficient knees: classification, staging and timing of treatment.
Knee Surg Sports Traumatol Arthrosc. 1995;3:130-134.
3. Feagin JA Jr. The syndrome of the torn anterior cruciate ligament.
Orthop Clin North Am. 1979;10(1):81-90.
4. Fetto JF, Marshall JL. The natural history and diagnosis of anterior
cruciate ligament insufficiency. Clin Orthop Relat Res. 1980;147:
5. Fithian DC, Paxton EW, Stone ML, et al. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligamentinjured knee. Am J Sports Med. 2005;33:335-346.
6. Furman W, Marshall JL, Girgis FG. The anterior cruciate ligament: a
functional analysis based on postmortem studies. J Bone Joint Surg
Am. 1976;58:179-185.
7. Granan LP, Bahr R, Lie SA, Engebretsen L. Timing of anterior
cruciate ligament reconstructive surgery and risk of cartilage
lesions and meniscal tears: a cohort study based on the Norwegian
National Knee Ligament Registry. Am J Sports Med. 2009;37:
8. Kessler MA, Behrend H, Henz S, Stutz G, Rukavina A, Kuster MS.
Function, osteoarthritis and activity after ACL-rupture: 11 years follow-up results of conservative versus reconstructive treatment. Knee
Surg Sports Traumatol Arthrosc. 2008;16:442-448.
9. Levy IM, Torzilli PA, Warren RF. The effect of medial meniscectomy on
anterior-posterior motion of the knee. J Bone Joint Surg Am. 1982;
10. Marshall JL, Olsson S-E. Instability of the knee: a long-term
experimental study in dogs. J Bone Joint Surg Am. 1971;53(8):
11. Meunier A, Odensten M, Good L. Long-term results after primary
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 treatment increase the risk of meniscal tear? Arthroscopy. 2002;18:
13. Murdoch G. Meniscus removed in error. Clin Orthop. 1960;18:

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Vol. 37, No. 8, 2009

14. Murrell GAC, Maddali S, Horovitz L, Oakley SP, Warren RF. The effects
of time course after anterior cruciate ligament injury in correlation with
meniscal and cartilage loss. Am J Sports Med. 2001;29:9-14.
15. Palmer I. On the injuries to the ligaments of the knee joint: a clinical
study. Acta Chir Scand. 1938;81(suppl 53):1-282.
16. Papageorgiou CD, Gil JE, Kanamori A, Fenwick JA, Woo SLY, Fu FH.
The biomechanical interdependence between the anterior cruciate
ligament replacement graft and the medial meniscus. Am J Sports
Med. 2001;29:226-231.
17. Papastergiou SG, Koukoulias NE, Mikalef P, Ziogas E, Voulgaropoulos
H. Meniscal tears in the ACL-deficient knee: correlation between
meniscal tears and the timing of ACL reconstruction. Knee Surg
Sports Traumatol Arthrosc. 2007;15:1438-1444.
18. Reider B. ACL and OA. Am J Sports Med. 2009;37:1279-1281.
19. Reider B, Marshall JL. The anterior cruciate guardian of meniscus.
Orthop Rev. 1979;8(5):83-87.
20. Seebacher JR, Inglis AE, Marshall JL, Warren RF. The structure of the
posterolateral aspect of the knee. J Bone Joint Surg Am. 1982;64:

21. Tandogan RN, Taser O, Kayaalp A, et al. Analysis of meniscal and

chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport. Knee Surg
Sports Traumatol Arthrosc. 2004;12:262-270.
22. Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing mechanisms
preventing anterior dislocation of the glenohumeral joint. J Bone Joint
Surg Am. 1981;63:1208-1217.
23. Warren LF, Marshall JL. The supporting structures and layers on the
medial side of the knee: an anatomical analysis. J Bone Joint Surg
Am. 1979;61:56-62.
24. Yoo JC, Ahn JH, Lee SH, Yoon YC. Increasing incidence of medial
meniscal tears in nonoperatively treated anterior cruciate ligament
insufficiency patients documented by serial magnetic resonance
imaging studies. Am J Sports Med. 2009;37:1478-1483.
25. Zelko RR. In memoriam: John L. Marshall, DVM, MD, 1936-1980. Am
J Sports Med. 1980;8:216-217.

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