MENISCUS, MENISCUS REPAIR AND MENISCECTOMY

Introduction and Anatomy of Meniscus

The knee contains two cartilaginous tissues or pads squeezed between the rounded ends of the femur bone and the flattened ends of the tibia bone and providing structural integrity to the knee when it undergoes tension and torsion. These tissues are called menisci (singular: meniscus) and they are the shock-absorbers of the knee. The two menisci are named lateral meniscus and medial meniscus. The medial meniscus is on the inner aspect of the knee and the lateral meniscus on the outer aspect of the knee.

Anatomy of Meniscus

The menisci work by dispersing friction in the knee joint between the lower leg (tibia) and the thigh (femur). They are shaped like orange wedges (concave on the top and flat on the bottom) lying on their side, articulating the tibia. They are attached to the small depressions (fossae) between the condyles of the tibia (intercondyloid fossa), and towards the center they are unattached and their shape narrows to a thin shelf.

The menisci act to disperse the weight of the body and reduce friction during movement. Since the condyles of the femur and tibia meet at one point (which changes during flexion and extension), the menisci spread the load of the body's weight.

MENISCUS TEAR / MENISCUS INJURY

The two most common causes of a meniscus tear are traumatic injury (often seen in athletes) and degenerative processes (seen in older patients who have more brittle cartilage). The most common mechanism of a traumatic meniscus tear occurs when the knee joint is bent and the knee is then twisted.

Unhappy Triad: When a meniscus tear occurs along with injuries to the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) - this situation of these three problems occurring together is known as "unhappy triad". It is seen in sports such as football when the player is hit on the outside of the knee.

The most common symptoms of a meniscus tear are:
•  Knee pain
•  Swelling of the knee
•  Tenderness when pressing on the meniscus
•  Popping or clicking within the knee
•  Limited motion of the knee joint
•  Persistent pain in the joint pain

DIAGNOSIS OF MENISCUS TEAR (TORN CARTILAGE)

Patients with meniscus tear can be differentiate from patients with knee pain from other conditions through a careful history of how the injury occurred and physical examination. Your doctor may ask you to recall any events / accidents involving twisting injury, followed by swelling of the knee and joint line pain, etc. He may also perform specific clinical tests like McMurray's test or Apley's test to assess a possible meniscal tear.

If a meniscus tear is found, X-rays may be taken to determine evidence of degenerative or arthritic changes to the knee joint. MRI test may also be done to visualize the meniscus.

TORN MENISCUS TREATMENT

Not all meniscus tears require surgery. In the case that the doctor decides that surgery is not necessary, the patient will probably have to take a small break from his or her normal activities, allowing the knee to heal. You should try strengthening exercises for the knee muscle (stronger and bigger muscles will protect the meniscus cartilage by absorbing a part of the weight). You may be given some anti-inflammatory medications.

If surgery is necessary then there are three surgical options to treat the meniscus tear:
•  Meniscus Repair
•  Meniscectomy
•  Meniscus Replacement

Meniscus Repair

The procedure to repair the torn meniscus is called meniscus repair. Your surgeon will generally try to repair your meniscus where practical as this procedure can restore the normal anatomy of the knee, and has a better long-term prognosis when successful. There are a number of repair materials available, which include meniscal sutures, meniscal arrows, T-fix, etc. However, the meniscus repair is a more significant surgery, the recovery is longer, and, because of limited blood supply to the meniscus, it is not always possible.

Meniscectomy

If the tear is far away from the meniscus' blood supply or if the tears are so frayed that they cannot be sutured together, then repair is unlikely. In such cases, meniscectomy is performed, which removed the torh tissue and allows the knee to function with some meniscus missin. Meniscectomy is far more commonly performed than repair. Menisectomy is usually employed in younger patients who are more resilient and react well to this treatment.

Meniscectomy is of two types: complete meniscectomy (or total meniscectomy) and partial meniscectomy. As is obvious from the name, in a complete meniscectomy (total medial meniscectomy or total lateral meniscectomy) the complete meniscus is removed right up to and including the meniscal rim. A partial meniscectomy (partial medial meniscectomy or partial lateral meniscectomy), on the other hand, removed a piece of the damaged meniscus. However, the actual amount removed can vary from minor trimming of a frayed edge to a major portion of the meniscus being removed.

Meniscectomy can be done using arthroscopic surgery. In an arthroscopic surgery, the surgeon makes a small incision in the joint (arthrotomy) to insert a small camera to look inside the joint. Your surgeon makes one or more small incisions to place other instruments inside the knee to remove the torn cartilage.

An issue involving complete arthritis is that it can lead to arthritis. Therefore, your orthopedist will generally try to preserve the external meniscal rim at all costs.

Meniscus Replacement

Meniscus replacement is a relatively new field in knee surgery. It replaces the absent or very damaged meniscus with another one. There are two ways of doing meniscus replacement:
•  Meniscal allograft (meniscus transplant): The patient's meniscus is replaced by the meniscus from dead donor's knee.
•  Meniscal prosthesis or scaffold: A synthetic meniscus is fixed in place of a torn meniscus.

REHABILITATION AFTER MENISCUS SURGERY

After a successful surgery for treating the destroyed part of the meniscus, patients must follow a rehabilitation program (recovery program) to have the best result. The rehabilitation following a meniscus surgery depends on whether the entire meniscus was removed or repaired.

If the damaged part of the meniscus was removed, patients can usually start walking a day or two after surgery and return to normal activities after a few weeks (2 or 3). However, each case is different and patients must consult the surgeon.

If the meniscus was repaired the rehabilitation program that follows is a lot more intensive. After the surgery a hinged knee brace is placed on the patient. This brace allows controlled movement of the knee. The patient is encouraged to walk using crutches from the first day, and most of the times can put weight on the knee. After four weeks the patient can start walking using the hinged knee brace only. Starting from the second month the patient can walk freely and can also do various "light" exercises (static bicycle, swimming, etc.). If the rehabilitation is done properly the patient can gradually return back to "heavier" activities (like running). However, each case is different and the patient must consult the doctor and physiotherapist (physical therapist) regarding a proper rehabilitation program.

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