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Much has been written about treatment advances for knee injuries. Yet, the knee is a relatively simple anatomic structure and most of the surgical techniques applied to the knee are simple as compared to the hand. From the advances made in fiberoptics for knee arthroscopy came advances in hand surgery when the same principles were put into play. In fact Dr. Ikutsu's first endoscopic carpal tunnel releases were performed with knee arthroscopy equipment!
Menisci are wedge shaped cushions responsible for transfer of weight across the true cartilage surface of the knee. There are two of them; a medial or inner side meniscus and the lateral or outer side meniscus. A meniscus is torn by shearing stress while the knee is in the bent (flexed) position. Isolated meniscal lesions are most common in active people over thirty-five years old. There are a few different tear configurations. Most tears are degenerative and involve the inner edge of the mid to posterior meniscus. They result in joint line soreness and typically result in a limp. The doctor will note localized joint line tenderness and pain with guarding against full motion. An x-ray is used to make certain there is no broken bone. It is necessary to be certain the person's pain and tenderness are not just due to a ligament strain or sprain or early degenerative arthritis. Non steroidal anti inflammatory medication (NSAID) such as meloxicam is very useful. Little is lost from a period of conservative care. A torn meniscus will usually continue to hurt and require arthroscopy while ligament injury and arthritis will feel better. Meniscal lesions are more significant when they occur at the time of anterior cruciate ligament (ACL) rupture from sports injury.
Meniscal Tear Variations
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To offer the best care possible and predict the outcome of the care, variations in the shape and location of a meniscal tear are tracked. The majority of torn menisci have complex tears which are treated best by trimming the damaged tissue away to a normal rim. These occur relatively spontaneously from day-to-day activities in individuals over the age of 35. Complex tears tend to look a little bit like shredded wheat and they are not repairable. Trimming down the torn tissue in these eliminates pain.
Meniscal tears that have the best potential for repair are described as bucket handle; these are the ones that are typically repaired and account for a minority. A torn portion of the meniscus flips out of its position towards the front of the knee like a bucket handle flipping from side to side of the top of a bucket. When this occurs the patient may feel a painful pop and the knee may become locked in that position because of pain with the torn meniscus acting as a weight. With the meniscus pushed back into place it then may be sewn up and allowed to heal.
In a very old person particularly with other health problems even a bucket handle tear may be best treated by removal.
Transverse tears are probably the most difficult and unreliable to repair of those that are classically considered repairable because it is hard to put sutures in this to hold it in place and the torn meniscus includes both the avascular (no bloody supply) portion towards the center of the knee which is least likely to heal along with the peripheral part of the meniscus in the vascular zone that is most likely to heal.
A horizontal cleavage tear may be a variation of a parrot-beaked tear, both of which involve undermining of the meniscus with a cleft in both the underside of the meniscus as well as towards the center of the knee. Generally these are best treated by trimming it down to a stable rim. There are occasions when a loose portion can be trimmed away and the bulk can be sewn back together.
Surgery and Recuperation
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There are numerous methods of repair that have been developed over the years that have allowed a greater percentage of menisci to be repaired faster, i.e. less time in the operating room under anesthesia, with less technical difficulty for the surgeon. These include both outside-in technique and inside-out technique, but overall the decision for what technique is utilized should be left to the surgeon as he will do the best job for the situation with the skills that he has developed. The outside-in technique was utilized on this 12-year-old girl who was jumping on a bed and the inside-out technique was used for a very long tear in a young maintenance worker.
With meniscal repair there is usually a lot greater discomfort for a few days after the surgery and, depending upon the tear and how secure the repair is, the surgeon may want the person to wear a knee immobilizer and be either partial or non-weight-bearing for a few weeks while initial healing is occurring. Avoidance of running, jumping, and sports is advisable for at least 6 weeks with full recovery taking at least 3 to 6 months.
If a meniscal repair with sutures is possible, based on the shape of the torn meniscus and location, it should be done. Only a small percentage are repairable though and these are usually the tears occurring at the time of ACL disruption. The rest of the meniscal tears require trimming.
Arthroscopic meniscectomy refers to removal of a damaged knee "cartilage". An arthroscopic meniscectomy is the preferred treatment since it has been available beginning about 1980. It causes minimal discomfort along the joint line where the injury occurred in the first place which usually lasts no more than 3 months.
You can request one of my brochures on anterior cruciate ligament injury or meniscal injury by contacting us.