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Meniscal Surgery

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The meniscus is very important to the long-term health of the knee. In the past, surgeons would simply take out part or all of an injured meniscus. But today's surgeons know that removing the meniscus can lead to early knee arthritis. Whenever possible, they try to repair the tear. If the damaged area must be removed, care is taken during surgery to protect the surrounding healthy tissue.

This Guide Will Help You Understand:

  • What parts of the knee are treated during meniscal surgery
  • What operations are used to treat a damaged meniscus
  • What to expect before and after meniscal surgery
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Anatomy

What parts of the knee are involved?

There is one meniscus on each side of the knee joint. The C-shaped medial meniscus is on the inside part of the knee, closest to your other knee. (Medial means closer to the middle of the body.) The U-shaped lateral meniscus is on the outer half of the knee joint. (Lateral means further out from the center of the body.)

The menisci (plural for meniscus) protect the articular cartilage on the surfaces of the thighbone (femur) and the shinbone (tibia). Articular cartilage is the smooth, slippery material that covers the ends of the bones that make up the knee joint. The articular cartilage allows the joint surfaces to slide against one another without damage to either surface.

Most of the meniscus is avascular, meaning no blood vessels go to it. Only its outer rim gets a small supply of blood. We call this area the red zone. The ends of a few vessels in the red zone may actually travel inward to the middle section, the red-white zone. The inner portion of the meniscus, closest to the center of the knee, is called the white zone. It has no blood vessels at all. Although a tear in the outer rim has a good chance of healing, damage further in toward the center of the meniscus will not heal on its own.

Rationale

The meniscus is a pad of cartilage that acts as a shock absorber to protect the knee. The meniscus is also vital for knee stability.

When the meniscus is damaged or is surgically removed, the knee joint can become loose, or unstable. Without the protection and stability of a healthy meniscus, the surfaces of the knee can suffer wear and tear, leading to a condition called osteoarthritis.

Most tears of the meniscus do not heal on their own. A small tear in the outer rim (the red zone) has a good chance of healing. However, tears in the inner part of the meniscus often require surgery. When tears in this area are causing symptoms, they tend to get bigger. This puts the articular cartilage on the surfaces of the knee joint at risk of injury.

The doctor's primary goal is to save the meniscus. If an injured part is required to be removed, only the smallest amount of the meniscus is taken out. Preserving the nearby areas of the meniscus is vital for keeping the knee healthy. If a tear can possibly be repaired, the doctor will recommend a meniscal repair.

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A torn meniscus may cause symptoms of pain and swelling and sometimes catching and locking. The goal of surgery is to take these symptoms away.

When the knee locks and you have to tug on it to get it moving, a small flap from a meniscal tear may have developed. The flap may be getting caught in the knee joint as you bend it. Or a small piece of the meniscus could actually be stuck between the bones of the knee joint. This fragment, called bucket handle tear, gets lodged between the moving parts of the knee, causing the knee to lock. In these cases, surgery may be needed, sometimes right away, to repair the torn fragment or trim it to cure the locking.

Only when the majority of the meniscus is damaged beyond repair is the entire meniscus removed. This will significantly increase your risk of developing arthritis.

Preparations

You may also need to spend time with the physical therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this preoperative visit is to record a baseline of information. The therapist will check your current pain levels, ability to do your activities, and the movement and strength of each knee.

The second purpose of the preoperative visit is to prepare you for surgery. The therapist will teach you how to walk safely both with and without support. And you'll begin learning some of the exercises you'll use during your recovery.

Surgical Procedure

What happens during meniscal surgery?

Meniscal surgery is done using an arthroscope, a small fiber-optic TV camera that is used to see and operate inside the joint. Only small incisions are needed during arthroscopy. The surgeon does not need to open the knee joint.

Partial Meniscectomy

The procedure to carefully remove a damaged portion of the meniscus is called a partial meniscectomy. The surgeon starts by inserting the arthroscope into one of the portals. A probe is placed into another portal. The surgeon (+the patient) watches on a screen while probing the meniscus. All parts of the inside of the knee joint are examined. When a meniscal tear is found, the surgeon determines the type and location of the tear. Surgical instruments are placed into another portal and are used to remove the torn portion of the meniscus.

When the problem part of the meniscus has been removed, the surgeon checks the knee again with the probe to be sure no other tears are present. A small motorized cutter is used to trim and shape the cut edge of the meniscus. The joint is flushed with sterile saline to wash away debris from the injury or from the surgery. The portals are closed with sutures.

Meniscal Repair

There are 3 techniques for meniscus repair
  • All inside repair
  • Outside on repair
  • Inside out repair
Suture Repair (inside out repair)

Using the arthroscope and a probe, the surgeon locates the tear. The probe is used to push the torn edges of the meniscus together. A small rasp or shaver is used to roughen the edges of the tear. Then a hollow tube called a cannula is inserted through one of the portals. The surgeon threads a suture through the cannula and into the knee joint. The suture is sewn into the two edges of the tear. The surgeon tugs on the thread to bring the torn edges close together. The suture is secured by tying two to three knots. Additional sutures are placed side by side until the entire tear is fixed.

OUTSIDE IN REPAIR

An alternate method is to pierce the knee joint with one or two curved needles. The needle goes from the outer edge of the meniscus completely through the tear. The surgeon may feed a suture from another portal into the end of the needle. Or the suture can be threaded into the needle from the outside of the knee. Both ways get the suture through the tear and allow us to sew the torn edges of the meniscus together.

Special fasteners, called suture anchors, are sometimes used to anchor the torn edges of the meniscus together. Suture anchors usually have a small piece of suture or synthetic tack (PEEK material) that deploys behind the meniscus and suture is attached that brings the two edges together.

Usually, only two or three anchors are needed. The anchors bring the two torn edges together while the tear heals.

Meniscal Transplantation

If the meniscus cannot be repaired or has been previously removed, a new form of treatment may offer a way to slow the onset of knee arthritis. Meniscal transplantation uses borrowed tissue to take the place of the original meniscus.

Experiments have been tried using various replacement materials. One material that is showing promise is an allograft. An allograft is a tissue that is from a donor, usually preserved human meniscus tissue. Because it is relatively new, this surgery is currently only available for select patients in a limited number of locations.

Complications

What can go wrong?

As with all major surgical procedures, complications can occur. This document doesn't provide a complete list of the possible complications, but it does highlight some of the most common problems which you need to understand as a patient. Some of the most common

complications following meniscal surgery are

  • Infection
  • Retear
  • Slow Recovery & Walking with support
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Infection

Following surgery, it is possible that skin portals can become infected. This may require antibiotics and possibly another surgical procedure to drain

Slow Recovery

Not everyone after meniscal surgery gets quickly back to routine activities. Some people feel better and have less swelling and eecover in 1-2 weeks.

But patient with concomitant injuries to other ligaments or cartilage injuries have a longer recoverytime of 6-12 weeks.

Also, patients undergoing MENISCUS REPAIR take about 4-8 weeks to recover.

RETEAR

In cases of meniscus repairs, we are stockholders back the torn tissue and hoping for the body to heal them. We need to understand that if the body fails to heal the torn part, ultimately the Fibre repair threads are going to break leading to research of the meniscus. The reported retear rates have been reported from 14 to 16% in literature. Rates are lesser in India as we avoid repair in case with poor quality tissue. Still, it is worth giving a thought to repair in cases of major tear to preserve the life and functionality of the knee.

Ongoing Pain

Pain relief does not always occur with meniscal surgery. It may be related to associated ailments and the pre-existing Osteoarthritis changes in the knee.

After Surgery

What happens after meniscal surgery?

Patients go home the same or next day as the surgery. The portals are covered with surgical dressing, and the knee may be wrapped in an elastic bandage.

Crutches may be used after meniscal repairs. They may only be needed for one to two days after a simple meniscectomy. The surgeon will specify how much weight can be borne after meniscal repair. Patients having meniscal repair are usually told not to place any weight on the foot for four to six weeks after surgery. After a transplant procedure, most patients are instructed to touch only the toes of the operated leg on the ground for four to six weeks.

Patients who have had a meniscal repair or transplant usually wear a knee brace for at least six weeks. The brace keeps the knee straight. It is removed often during the day to do easy range-of-motion exercises for the knee.

Rehabilitation

What will my recovery be like?

Your rehabilitation will depend on the type of surgery you had. You probably won't need formal physical therapy after partial meniscectomy. Most patients can do their exercises as part of a home program. If you require outpatient physical therapy, you will probably need to attend therapy sessions for two to four weeks. You should expect full recovery to take in a maximum of 6 to 12 weeks.

MENISCUS REPAIR.

For the first 3 weeks after a meniscal repair, you may be instructed avoid bending the knee more than 90 degrees. Then it is safe to gradually bend the knee fully. However, you should avoid squatting for at least three months while the repair fully heals. It is not advisable to run, jump, or twist the knee for at least four to six months. Patients mostly resume sport activities within four to six months.

The physical therapist's goal is to help you keep your pain under control and improve your knee's range of motion and strength.

MILESTONES IN RECOVERY

PARTIAL Meniscectomy

  • Day 2 : Normal walking without support
  • Day 10 : stich removal, start of light exercises like cycling
  • 1 month: gradual return to sports

MENISCUS REPAIR

  • 0 to 3 weeks waking with support / brace, bending 90 degrees
  • 3 - 6 weeks: waking with partial weight bearing, bending till 120 degree
  • 6 to 12 weeks : Full weight bearing walking without support, full movements allowed
  • 4 to 5 months: Gradual resumption of running, jumping, jogging and light trading
  • 5 to 6 months : RETURN TO SPORTS