The Role of Meniscal Tears in Spontaneous Osteonecrosis of the Knee: A Systematic Review of Suspected Etiology and a Call to Revisit Nomenclature

Abstract

Background: The cause of spontaneous osteonecrosis of the knee (SONK) and postarthroscopic osteonecrosis of the knee is unknown, and the mechanisms involved have been poorly characterized. Hypothesis/Purpose: The purpose of this study was to perform a detailed systematic review of the literature to examine proposed etiological mechanisms for SONK in order to establish an improved understanding of the processes involved. We hypothesized that the etiology of SONK would be multifactorial. Study Design: Systematic review. Methods: A systematic review of the literature was performed by searching PubMed, Medline, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. Inclusion criteria were all original research articles presented in the English language that reported on the suspected etiology of SONK. Reviews, case reports with fewer than 3 patients, cost-effectiveness studies, technical reports, editorial articles, surveys, special topics, letters to the editor, personal correspondence, and studies that only proposed factors for the progression of SONK were excluded. Results: After a comprehensive review of 255 articles, 26 articles were included for final analysis. Twenty-one (80.7%) of 26 articles implicated the role of the meniscus in the development of SONK, in an association with either meniscal tears or its development after meniscectomy. The medial meniscus and posterior meniscal root tears were implicated more frequently. All 4 studies incorporating histological findings supported the insufficiency fracture hypothesis as a pathological basis of SONK. Conclusion: Physicians should be cognizant of the high prevalence of medial meniscus root tears in patients with SONK. Meniscectomy and meniscal tears, particularly of the medial meniscus posterior root, increase contact pressures and create an environment from which insufficiency fractures can emanate. We believe the term SONK is a misrepresentation of the etiology and pathogenesis of the condition and should be replaced with subchondral insufficiency fractures of the knee. Further elucidation of the etiology is required.