medial meniscus, and not be confined to the ACL as seen in an ACL tear. Semin Musculoskelet Radiol 2005;9(2):11624, Chung KS, Ha JK, Ra HJ, Nam GW, Kim JG. of the anterior horn of the medial meniscus, an inferior patella plica, 2006; 88:660667, Boutin RD, Fritz RC, Marder RA. Conventional MRI imaging correlates well with arthroscopic evaluation of the transplants for tears of the posterior and middle thirds of the meniscus allograft with a high sensitivity, specificity and accuracy, but results were poor for evaluation of the anterior third with a low specificity and accuracy.16 Allograft shrinkage and meniscus extrusion are common findings on postoperative MRI but do not always correlate with patient pain and function. Conventional MRI is useful for evaluation of posterior root morphology at the tibial tunnel fixation site, meniscal extrusion and articular cartilage. This injury is biomechanically comparable to a total meniscectomy, leading to compromised hoop stressesresulting in decreased tibiofemoral contact area and increased contact pressures in the involved compartment.These changes are detrimental to the articular cartilage and . no specific MR criteria for classifying discoid medial menisci, and the FSE T2-weighted images, with a slab-like appearance on coronal images. The most common ADVERTISEMENT: Supporters see fewer/no ads. Advantages include a less invasive method of introducing intraarticular contrast, the ability to identify areas of hyperemic synovitis or periarticular inflammation based on enhancement and administration can be performed by the technologist. When evaluating a portion of the meniscus that is in a different location than the repair, criteria for evaluating a virgin meniscus may be used for that area. Sagittal proton density-weighted (14A) and coronal T1-weighted (14B) images reveal a recurrent bucket-handle tear through the original repair site with typical findings of a displaced meniscal flap (arrow) into the intercondylar notch. One important reason for such discrepancies is a failure to understand the transverse geniculate ligament of the knee (TGL). Suprapatellar plica noticed, with no related cartilaginous erosions. this may extend to to the mid body." is this a bucket tear? The medial meniscus is more firmly attached to the tibia and capsule than the lateral meniscus, presumably leading to the increased incidence of tears of the medial meniscus [. These findings are also frequently associated with genu You have reached your article limit for the month. Radiology. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Close clinical correlation is advised before recommending surgery based on this finding alone. Brody J, Lin H, Hulstyn M, Tung G. Lateral Meniscus Root Tear and Meniscus Extrusion with Anterior Cruciate Ligament Tear. Meniscal root tears are a type of meniscal tear in the knee where the tear extends to either the anterior or posterior meniscal root attachment to the central tibial plateau. A 2003 systematic review of the literature, in which 29 publications met strict inclusion criteria, demonstrated pooled weighted sensitivity and specificity of 93.3 % and 88.4 % for the medial meniscus and 79.3 % and 95.7 % for the lateral meniscus, respectively [, Most meniscal tears are visible and best seen on sagittal images. In the above case there is no gross chondral defect although the articular cartilage is noticeably thinner compared to the baseline study despite the patients young age. 2006;239(3):805-10. Special thanks to David Rubin, MD for providing several cases used in this web clinic. acromioclavicular, sternoclavicular, and temporomandibular joints. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. The examiner can test the entire posterior horn up to the middle segment of the meniscus using the IR of the tibia followed by an extension. reported.4. Intact meniscal roots. Get unlimited access to our full publication and article library. The patient failed conservative management of aspiration and cortisone injection. Tolo VT. Congenital absence of the menisci and cruciate ligaments of the knee: A case report. Anterior horn tear of the lateral meniscus in footballers with a stable knee is characterized by pain at the anterolateral aspect of the knee during knee extension, especially when kicking. They may not even be apparent with an arthroscopic examination. Sagittal T2-weighted (18B) and fat-suppressed sagittal proton density-weighted sagittal (18C) images demonstrate fluid-like signal in the posterior horn suggestive of a recurrent tear. Generally, MRI: When you tear your meniscus, a magnetic resonance imaging (MRI) scan will show the injury as white lines on black. The patient underwent a successful partial medial meniscectomy and was encouraged to seek low-impact exercise. proximal medial tibia was convex and the distal medial femoral condyle CT arthrography is a recommended alternative for patients who are not MR eligible. A tear of the meniscal root means the tear is near where it attaches to the bone, usually far in the back. 15 year old patient with prior extensive lateral partial meniscectomy was treated with lateral chondroplasty and lateral meniscal allograft transplant with continued pain and clicking 6 weeks post-operative. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The meniscus is two crescent-shaped, thick pieces of cartilage that sit in the knee between the tibia and the femur. Arthroscopy evaluation found a lateral meniscus peripheral (red-white zone) longitudinal tear. The incidence of lateral meniscus posterior root tears was approximately 4 times higher than of medial meniscus posterior root tears in both primary (12.2% vs 3.2%) and revision (20.5% vs 5.6%) ACLRs. 3 is least common. immediatly lateral to the anterior horn of lateral meniscus and posterior to the tubercle of anteriro horn of medial meniscus . MR imaging and MR arthrography for diagnosis of recurrent tears in the postoperative meniscus. Symptomatic anomalous insertion of the medial meniscus. They are most frequently seen at the posterior horn of the medial meniscus. However, few studies have directly compared the medial and lateral root tears. That reported case was also associated with Diagnosis - clinical presentation with exclusion of advanced knee osteoarthritis. Among these 26 studies of an LMRT . does not normally occur.13. At the time the article was last revised Yahya Baba had trials, alternative billing arrangements or group and site discounts please call Report RESULTS. Fat suppressed sagittal T1-weighted MR arthrogram (5C) demonstrates gadolinium within the tear (arrow). hypoplastic meniscus was not the cause of the patients pain, suggesting Magnetic resonance imaging (MRI) is the most accurate imaging technique in the diagnosis of meniscal lesions and represents a standard tool in knee evaluation. mesenchymal mass that differentiates into the tibia, femur, and menisci occurs. Because most meniscal tears are not isolated to the red zone, it is understandable that most meniscal surgeries are partial meniscectomies which aim to restore meniscus stability while preserving as much native meniscal tissue as possible, to decrease the risk of osteoarthritis. The most commonly practiced What are the findings? also found various MRI characteristics highly specific for detection of a recurrent tear including a line of intermediate-to-high signal or high signal through the meniscus extending into the articular surface on T2-weighted images with 95.8% specificity and change in the signal intensity pattern through the meniscus on intermediate weighted or T2-weighted images when compared to the baseline MRI with 98.2% specificity. the intercondylar notch, most commonly to the mid ACL, and less commonly Total meniscectomy is rarely performed unless the meniscus is so severely damaged that no salvageable meniscal tissue remains. the menisci of the knees. Stein T, Mehling AP, Welsch F, von EisenhartRothe R, Jger A. Magnetic resonance imaging (MRI) and computed tomography (CT) arthrography are both well suited for evaluation of these lesions though somewhat limited by cost and access for MRI and by invasiveness for CT arthrography . On examination, there was marked medial joint line tenderness and a large effusion. of the transverse ligament is comparable to the general population.5. It is usually seen near the lateral meniscus central attachment site. The MRI showed complete ACL tear with displaced bucket handle medial meniscus tear. This scan showed a radial MMT. Neuschwander DC, Drez D Jr, Finney TP. A classification system developed by the International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine [, Longitudinal-vertical tear. in this case were attributed to an anterior cruciate ligament tear Discoid lateral meniscus (DLM) is a common anatomic variant in the knee typically presented in young populations, with a greater incidence in the Asian population than in other populations. When the cruciate On this page: Article: Epidemiology Pathology Radiographic features History and etymology Bilateral complete discoid medial menisci combined with anomalous insertion and cyst formation. medial meniscus are extremely uncommon and should not be a diagnostic attachment of the posterior horn is the Wrisberg meniscofemoral Discoid lateral meniscus of the knee joint: Nature, mechanism, and operative treatment. 2005; 234:5361. The anterior and posterior meniscofemoral ligaments (Humphrey and Wrisberg respectively) are commonly present with one or both found in 93-100% of patients.9 The lateral meniscus is more loosely attached than the medial and can translate approximately 11mm with normal knee motion.10. Am J Sports Med 2016; 44:625632, De Smet AA, Horak DM, Davis KW, Choi JJ. : Complications in brief: arthroscopic partial meniscectomy. the example shown (Figures 1 and 2), the entire medial meniscus is The medial meniscus is asymmetrical with a larger posterior horn. There Magn Reson Imaging Clin N Am 2014;22(4): 517555, White LM, Schweitzer ME, Weishaupt D, Kramer J, Davis A, Marks PH. Source: Shepard MF, et al. The sutures are tied over a cortical fixation device or Endobutton (short arrow) with the knee flexed at 90 to secure the root repair. 7 Therefore, it is important for the radiologist to be familiar with the appearance of a recurrent tear versus an untorn postoperative meniscus. Following partial meniscectomy, the knee is at increased risk for osteoarthritis. found that the absence of a line of increased signal through the meniscus extending to the articular surface on proton density and T2-weighted images was a reliable MRI finding for an untorn post-operative meniscus with 100% sensitivity. Symptoms of anterior horn tears were very similar to those of meniscal tears of the midbody or posterior horn, including catching, pain with knee flexion, and swelling. The Journal of bone and joint surgery American volume. joint: Morphologic changes and their potential role in childhood Criteria for a recurrent tear after greater than 25% meniscectomy Definite surfacing T2 fluid signal (or high T1 signal isointense to intra-articular gadolinium on MR arthrography) on 2 or more images or displaced meniscal fragment.17 Definite surfacing fluid signal on only one image represents a possible tear. For partial meniscectomies involving 25% or more, conventional MRI has lower accuracy. AJR Am J Roentgenol 211(3):519527, De Smet AA. The anterior horn inserts on the tibia and continues laterally to the anterior horn of the lateral meniscus via the transverse intermeniscal ligament. These are like large radial tears and can destabilize a large portion of the meniscus. A 510, 210-pound 16-year-old male injured his left knee while kicking a football. 7.2 Medial and Lateral Menisci Medial meniscus is larger than the lateral meniscus and is more "open" (=less C-like) and less wide. Additionally, the postoperative complication of new extensive synovitis is apparent on the axial view (18D). Their 74% false-positive rate I believe is accurate and one that we can incorporate mentally into our practice as we evaluate patients and the MRI scan results. Midterm results in active patients. No meniscal tear is seen, but the root attachment was also noted to be The tear was treated by partial meniscectomy at second surgery. Twenty-one had ACL tears; all those with an PHLM tear had an ACL tear. A previous study by De Smet et al. MRI failed to detect anterior horn injury of lateral meniscus in six (16.7%) cases, all of which were longitudinal fissure in the red zone. Posteroinferior displacement of the meniscal tissue (arrowheads) is also diagnostic of recurrent tear. 2002;30(2):189-192. 10 Arthrofibrosis and synovitis are also relatively common. Vertical flap (oblique, flap, parrots beak) tears are unstable tears and occur in younger patients. Kelly BT, Green DW. Meniscus tears, indicated by MRI, are classified in three grades. The aim of this study was to evaluate diagnostic values involved in conventional magnetic resonance imaging (MRI) features of MM posterior root tears (MMPRTs) and find other MRI-based findings in patients with partial MMPRTs. The posterior horn is always larger than the anterior horn. bilaterally absent menisci reported by Tolo et al,3 the Disadvantages include patient discomfort, increased cost, physician time needed for the procedure and radiation exposure during fluoroscopy. The fat-suppressed sagittal T1-weighted post arthrogram view (7C) demonstrates gadolinium extending into the meniscal substance. Thirty-one of these patients underwent subsequent arthroscopic evaluation to allow clinical correlation. the medial meniscus. The sagittal proton density-weighted image (2A) demonstrates increased signal intensity at the periphery of the medial meniscus posterior horn (arrow) but no fluid signal on the sagittal T2-weighted image (2B) and no gadolinium extension into this area on the MR arthrogram sagittal fat-suppressed T1-weighted arthrographic image (2C) consistent with a healed repair. The meniscal body is firmly attached to the deep portion of the medial collateral ligament complex via the meniscotibial ligament. Radiographic knee dimensions in discoid lateral meniscus: Comparison with normal control. Extrusion is commonly seen following root repair. Nakajima T, Nabeshima Y, Fujii H, et al. A 23-year-old female presented with a 2-month history of catching and pain in the knee when arising from a squatting position. Indirect MR arthrography is less commonly used and relies on excretion of intravascular gadolinium into the joint through synovial cells after intravenous administration of gadolinium contrast 20-90 minutes prior to the MRI exam. (as previously described), meniscal cyst,26 discoid lateral meniscus in the same knee (Figure 9),25 and pathologic medial patella plica.27. Controlling Blood Pressure During Pregnancy Could Lower Dementia Risk, Researchers Address HIV Treatment Gap Among Underserved Population, HHS Announces Reorganization of Office for Civil Rights, FDA Adopts Flu-Like Plan for an Annual COVID Vaccine. The purpose of our study was to determine if cysts of the ACL are the origin of cysts adjacent to the AHLM. An intact meniscal repair was confirmed at second look arthroscopy. mimicking an anterior horn tear. ligaments and menisci causing severe knee dysplasia in TAR syndrome. 2020;49(1):42-49. Meniscal disorders: Normal, discoid, and cysts. Meniscal root tearsare a type of meniscal tearin the knee where the tear extends to either the anterior or posterior meniscal root attachment to the central tibial plateau. 300). Type 1 is most common, and type Evaluation of postoperative menisci with MR arthrography and routine conventional MRI. In this case, having the prior MRI exam is useful for showing the location of the initial tear and the new tear in a different location. A Wrisberg type variant has not been documented in meniscal diameter. We use cookies to create a better experience. In contrast to the medial meniscus, the posterior horn of the lateral meniscus is additionally secured by the meniscofemoral ligaments (MFL). A There is no universally accepted system for classifying meniscal tear patterns. A 22-years old male presented with injury to right knee in a road traffic accident MRI images shows double posterior horn of lateral meniscus and absent anterior horn in coronal (A: PD; B: STIR; C . Check for errors and try again. Imaging characteristics of the The insertion site Monllau et al in 1998 proposed adding a fourth type, Anterior horn lateral meniscus tear A female asked: Mri: "macerated anterior horn lateral meniscus with inferiorly surfacing tear. 17. They often tend to be radial tears extending into the meniscal root. Knee Surg Sports Traumatol Arthrosc. View Mostafa El-Feky's current disclosures, see full revision history and disclosures, Flipped meniscus - anterior horn lateral meniscus, Disproportionate posterior horn sign (meniscal tear). Again, this emphasizes the importance of accurate history, prior imaging and operative reports. . Similarly, the postoperative meniscus is at increased risk for a recurrent tear either at the same or different location due redistribution of forces and increased stress on the articular surface. Longitudinal medial meniscus tear managed by repair (arrow). Anterior horn of the lateral meniscus: another potential pitfall in MR imaging of the knee. An athletic 52-year-old male, who was an avid runner all his adult life, presented with medial pain and a popping sensation in knee. Direct MR arthrography requires intraarticular injection of 20-50 mL of dilute gadolinium contrast prior to imaging which distends the joint capsule and offers a high signal to noise ratio on T1-weighted images with contrast extension into the meniscal substance indicating a recurrent tear or an unhealed repair. Pagnani M, Cooper D, Warren R. Extrusion of the Medial Meniscus. My own experience has been similar and I make it a policy not to recommend surgery based on this diagnosis alone without good clinical correlation. This case is almost identical to the previous case with a different clinical history. 6 months post-operative she had increased pain prompting follow-up MRI. The Wrisberg variant may present with a They divide the meniscus into superior and inferior halves (Fig. is much greater than in a discoid lateral meniscus, and the prevalence AJR Am J Roentgenol 2009;193:515-523. Anatomic variability and increased signal change in this area are commonly mistaken for tears. Stay up to date with the latest in Practical Medical Imaging and Management with Applied Radiology. An alternative way of fastening the allograft to the donor knee involves harvesting the meniscus with a small bone plug attached to each root and then securing the plugs within osseous tunnels drilled in the recipient tibia. In this case the roots remained intact at the bone bridge, but the meniscal allograft detached from the joint capsule at the posterior and middle third with displacement into the central weightbearing surface (arrowheads) on sagittal T2-weighted (17C) and fat-suppressed axial proton density-weighted (17D) images. There was no evidence of meniscal extrusion or a meniscal ghost sign (Fig. We hope you found our articles Anomalous The medial compartment articular cartilage is preserved, and the meniscal body is not significantly extruded (16D). Radial Tear of the Medial Meniscal Root: Reliability and Accuracy of MRI for Diagnosis. Exam showed a mild effusion and medial joint line tenderness. Associated anomalies in a discoid medial asymptomatic, although there is a greater propensity for discoid menisci A 64-year-old female with no specific injury presented with knee pain, swelling, and locking that she first noticed after working out at the gym. There is no telling how much this error rate will change for radiologists less experienced with MRI. of the AIMM into the ACL is classified as Type 1 (inferior third), Type 2 least common is complete congenital absence of the menisci. Discoid meniscus in children: Magnetic resonance imaging characteristics. This has also been described as grade 2 signal [, Sagittal fat-suppressed T2 image of a 14-year-old patient showing a grade 2 signal in the posterior horn of the medial meniscus (PHMM). MRI features are consistent with torn lateral meniscus with flipped anterior horn superomedial and posterior, resting superior to the posterior horn. Extension to the anterior cortex of . Increased intrameniscal signal is commonly seen in the transplanted allograft but does not correlate with clinical outcome. Increased signal intensity at the anterior horn of the lateral meniscus was seen on the images of seven of the 11 MR studies of the volunteers. 5. By continuing to use our site, you consent to the use of cookies outlined in our Privacy Policy. Variations in meniscofemoral ligaments at anatomical study and MR imaging. On MR images of the knee it is sometimes impossible to determine with confidence if a focus of high signal in the meniscus is confined to the substance of the meniscus or if it extends to involve the surface. Tears in the red zone have the potential to heal and are more amenable to repair. slab-like configuration on sagittal MR images, with > 3 bowties Sagittal proton density-weighted image (10A) demonstrates increased signal extending to the articular surface consistent with granulation tissue. Following a meniscal repair procedure, the meniscus can be categorized as healed if there is no fluid signal in the repair, partially healed if fluid signal extends into less than 50% of the repair site, or not healed if fluid signal extends into greater than 50% of the repair site. They often tend to be radial tears extending into the meniscal root. Repair techniques include side-to-side repair, stabilization with suture anchors, and the transtibial pull-out technique (figure 4).12. ; Lee, S.H. sagittal magnetic resonance (MR) images. Most lateral meniscal tears are due to twisting or turning activities or falls. The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. The superior, middle and inferior geniculate arteries are the main vascular supply to the menisci. AJR Am J Roentgenol. Pullout fixation of posterior medial meniscus root tears: correlation between meniscus extrusion and midterm clinical results. Tears of the anterior horn of the medial meniscus, an inferior patella plica, and ACL tears can be mistaken for AIMM, but carefully tracing the ligament will help to exclude these conditions. The ideal technique for imaging the postoperative meniscus is a matter of active controversy and depends on the operation performed, surgeon preference and clinical question (concern for recurrent meniscal tear versus articular cartilage). Samoto N, Kozuma M, Tokuhisa T, Kobayashi K. Diagnosis of discoid lateral meniscus of the knee on MR imaging. AJR Am J Roentgenol. Acute partial interstitial to near complete anterior cruciate ligament tear is noted at its posterior end with femoral deep lateral sulcus sign. On imaging alone, the radiologist may not be able to distinguish a residual tear (failed repair) from a recurrent tear in the same location. Examination showed lateral joint line tenderness and a positive McMurray sign. It has been calculated that the lateral meniscus absorbs about 70% of the forces across the lateral compartment of the knee. Radial or oblique tear congurations close to or within the meniscus . Weight-bearing knee X-rays showed a 50 % narrowing in the medial compartment. The most frequent symptom is pain that usually begins with a minor Thus, the loss of the lateral meniscus can often lead to rather rapid onset of osteoarthritis. Objectives: Low-field MRI at 0.55 Tesla (T) with deep learning image reconstruction has recently become commercially available. The example above demonstrates the importance of baseline MRI comparison when evaluating the postoperative meniscus. Of these 45 patients, there was an average of 3.74 additional pathological conditions noted on the MRI scan, mainly including degenerative arthrosis or patellar chondromalacia to explain the patients continued pain. If missing on MR images, a posterior root tear is present. Klingele KE, Kocher MS, Hresko MT, et al. Discoid lateral meniscus in children. the rare ring-shaped meniscus, to the classification. ligament will help to exclude these conditions.5 In the first The meniscus can separate from the joint capsule or tear through the allograft. The camera can visualize the meniscus and other structures within the knee. Kim SJ, Choi CH. It can be divided into five segments: anterior horn, anterior, middle and posterior segments, and posterior horn. A preliminary report, Principles and decision making in meniscal surgery, The Anterior Meniscofemoral Ligament of the Medial Meniscus, Accurate patient history including site and duration of symptoms, Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. According to one source, they are thought to account for ~10% of all arthroscopic meniscectomies 5. Analytical, Diagnostic and Therapeutic Techniques and Equipment 13. At the time the article was created Yuranga Weerakkody had no recorded disclosures. The most widely used diagnostic modalities to assess the ligament injuries are arthroscopy and Magnetic Resonance Imaging (MRI). Papalia R, Vasta S, Franceschi F, D'Adamio S, Maffulli N, Denaro V. Meniscal Root Tears: From Basic Science to Ultimate Surgery. Meniscal surgery is common and requires accurate post-operative imaging interpretation to guide the treatment approach. Their conclusion that one should not perform surgery unless clinical correlation exists with effusions, mechanical catching or locking, or the failure to respond to nonoperative measures I believe is a good recommendation that we can all follow. During an arthroscopy, we have the choice of either repairing the meniscus tear or removing the torn piece. Fellowship-trained musculoskeletal radiologists read 99% of the MRIs. Am J Sports Med 2017; 45:884891, Zaffagnini S, Grassi A, Marcheggiani Muccioli GM, et al. The intrameniscal ligament where it diverges from the back of the anterior horn of the lateral meniscus is also a common area misinterpreted as a tear. No gadolinium extension into the meniscus on fat-suppressed sagittal T1-weighted (9B) post arthrogram view. Of the anterior horn tears read on MRI, 85% involved the lateral meniscus anterior horn and about one half were judged to extend into the middle or body of the same meniscus. How I Diagnose Meniscal Tears on Knee MRI. At the time the case was submitted for publication Mostafa El-Feky had no recorded disclosures. 2. meniscus. intra-articular structures at 8 weeks gestation. Posterior meniscal root repairs: outcomes of an anatomic transtibial pull-out technique. appearance.12 It is now believed that the knee develops from a Laundre BJ, Collins MS, Bond JR, Dahm DL, Stuart MJ, Mandrekar JN: MRI accuracy for tears of the posterior horn of the lateral meniscus in patients with acute anterior cruciate ligament injury and the clinical relevance of missed tears. Normal menisci. We look forward to having you as a long-term member of the Relias Mild irregularities of the meniscal contour may be present, particularly in the first 6-9 months after surgery which tend to smooth out and remodel over time.15 For partial meniscectomies involving less than 25% of the meniscus, conventional MRI is used with the same imaging criteria for evaluating a tear as the native meniscus linear intrasubstance increased signal extending to the articular surface, visualized on 2 images, either consecutively in the same orientation or in the same region in 2 different planes or displaced meniscal fragment (based on the assumption that imaging is spaced at 3 mm intervals). An intact meniscal repair was confirmed at second look arthroscopy. Menisci are present in the knees and the Relevant clinical history, prior imaging and use of operative reports will significantly improve accuracy of post-operative interpretations. Disadvantages include risks associated with joint injection, radiation exposure and lower contrast resolution compared to MRI, particularly in the extraarticular soft tissues. Fukuta S, Masaki K, Korai F. Prevalence of abnormal findings in magnetic resonance images of asymptomatic knees. varus deformity (Figure 3). insertion of the medial meniscus (AIMM) has been described, and it is The speckled appearance of the anterior horn of lateral meniscus is a feature that can be seen as a normal variant on MRI knee scans. Youderian A, Chmell S, Stull MA. Biologic augmentation with application of exogenous fibrin clot or growth factors may be combined with the repair to promote healing.
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