Arthroscopic Meniscus Repair
Overview
The menisci are pieces of cartilage in the knee that help to absorb pressure on the knee joint by preventing the shinbone and thighbone from rubbing together. They can be torn apart by sudden twisting motions. This type of injury can occur at any age. Tears are more common in athletes and people over the age of 30, because the menisci weaken over time. The severity and location of the tear determine the course of treatment.
For a long time, menisci were thought to be functionless structures. Despite the fact that meniscal excision is well known to cause early degenerative arthritis, meniscectomy remains one of the most commonly performed procedures in orthopedic surgery.
The menisci play an important role in joint stability, joint kinematics, and load transfer. Recent advancements in meniscal repair techniques and biological augmentation have ushered in a new era of meniscal conservative surgery, resulting in more physiological knee function following surgery.
Meniscal repair has become the preferred approach for many meniscal tears since the advent of arthroscopy and advanced arthroscopic techniques.
Meniscus Tears
The meniscus is a tough, rubbery cartilage that absorbs shock and distributes weight across the knee joint between the shin and thigh bones. When this cartilage tears, it can cause knee pain and instability. Meniscus tears can occur as a result of a twisting injury in sports such as football or soccer, or as a result of something as simple as turning to put the dishes away.
The medial meniscus is shaped like a C and is slightly smaller than the lateral meniscus. The lateral meniscus is typically longer and wider, with a variable shape, size, and mobility that ranges from a C-shape to an almost discoid shape.
They are designed for the lateral and medial compartments of the knee, facilitating femoral and tibial surface engagement. The medial meniscus encompasses 50–60% of the medial plateau, while the lateral meniscus encompasses 70–80% of the lateral plateau. However, the shape and total surface of the meniscus can vary from person to person, particularly in the lateral meniscus.
Symptoms of Meniscus Tears
Meniscus injuries can affect people of all ages, but each age group has different types of tears and treatment options. Almost all tears exhibit the same symptoms, which include:
- Pain
- Swelling
- Tenderness
- Giving way
- Mechanical symptoms, such as locking, popping, and catching
Diagnosing a Meniscus Tear
When you have these symptoms, you should see an orthopaedic surgeon so that your knee can be examined and an accurate diagnosis can be made.
Occasionally, a description of the injury and an examination of the patient reveal the diagnosis. However, X-rays and magnetic resonance imaging (MRI) are frequently used to assist in the identification of any other associated injuries.
Tenderness over the joint line where the meniscus is torn, swelling, and sometimes loss of motion are the most common exam findings.
Reasons to repair a meniscal tear
Meniscal rupture causes the release of a complex chain of degradative enzymes into the otherwise healthy knee (e.g., interleukin-6, tumor necrosis factor alpha, etc.). It has been shown that these harmful biochemical changes can last for months, creating a "chronic inflammation environment" that can eventually lead to cartilage degeneration.
Furthermore, restoring meniscal biomechanical properties can improve joint stability. Anterior cruciate ligament (ACL) tears associated with medial meniscus tears resulted in increased anterior tibial translation at 24-month follow-up when compared to cases with isolated ACL tears.
When a meniscectomy is performed, higher contact pressures between articular surfaces are observed when compared to an intact meniscus. Meniscectomy has also been linked to the progression of articular cartilage damage in the ACL-reconstructed knee. Meniscal repair appears to be a process that should always be performed, both biomechanically and biologically.
This is supported by improved long-term outcomes. However, meniscal repair has a higher reoperation rate than meniscectomy, so the indication for meniscal repair should be carefully evaluated.
Arthroscopic meniscus repair
The damaged tissue must be removed if the tear is on the inner edge of your meniscus, where there is no blood flow. This is known as an arthroscopic meniscectomy. To examine the condition of the knee, the surgeon makes several small incisions around the joint and inserts a narrow fiber optic scope (called an arthroscope). To remove all or part of the torn meniscus, tiny instruments are used.
Once a meniscus tear has been diagnosed, you should consult with your orthopaedic surgeon about your treatment options. Most people with a symptomatic meniscus tear undergo arthroscopic surgery to remove or repair the torn tissue. If you have arthritis, however, you may benefit from injections and physical therapy instead of surgery.
Arthroscopy has transformed the way knee surgery is performed. Previously, a torn meniscus necessitated a three- to four-inch incision and an overnight (or two) hospital stay.
The arthroscope can now repair the meniscus tear through two tiny (less than a half-inch) incisions. The surgery can be done as an outpatient procedure in less than an hour.
The surgery is usually performed under regional anesthesia with sedation, so there is little anesthesia risk. Small stitches are occasionally used to sew the torn cartilage back together; this technique can successfully treat large tears in younger people. If the tear is minor, it may be surgically repaired.
Surgical Options for Torn Meniscus
Meniscus tears can be treated by removing the meniscus (meniscectomy), repairing the meniscus, or, in rare cases, replacing the meniscus. Meniscus repair is attempted when the tear is repairable, as the goal of surgery is to preserve healthy meniscus.
Meniscectomy, or the removal of damaged meniscus tissue, has good short-term results but leads to arthritis ten to twenty years later. Meniscus repair has good results as well, but it takes longer to recover than meniscectomy and is limited to tears that can be repaired.
Meniscus replacement is considered for young, active patients who have previously had the majority of their meniscus removed and are experiencing pain in the area without advanced degenerative changes to the articular (gliding surface) cartilage.
Goal of Arthroscopic Meniscus Repair
Meniscus surgery aims to preserve healthy meniscus tissue. A blood supply is required for a meniscus tear to heal. Only the outer third of the meniscus has enough blood supply to heal a tear. Repairs are typically limited to the meniscus's periphery.
Many types of meniscus tears occur in the meniscus region where there is insufficient blood supply for healing. Meniscus removal is generally recommended when tears occur in areas of the meniscus that do not have a blood supply.
Who should consider arthroscopic meniscus repair?
Even though the recovery time for a meniscus repair is longer than for a meniscectomy, any repairable meniscus should be repaired in most cases. Meniscus repair is considered when the following conditions exist:
- The patient is in good health and wants to stay active;
- The patient understands the rehabilitation process and is willing to accept the risks of surgery;
- The meniscus tear is on the meniscus's periphery,
- The meniscus tissue is of good quality, and
- The surgeon is skilled in meniscus repair.
Preparation
Because arthroscopic meniscus repair is a surgical procedure, the patient's situation can be optimized for success. Because mobility will be impaired, someone should be present at home for the first few days. There should be no active infections at this time. There should be no sores or scratches on the knee. On the day of surgery or the day before surgery, the knee should not be shaved.
Smoking cessation or cessation reduces the risk of infection and blood clots and improves healing. Plane flights should be avoided for the first five days after surgery to reduce the risk of blood clots. Dental work frequently introduces bacteria into the bloodstream, so it should be avoided for the first six weeks after surgery. If it is unavoidable, antibiotics taken near the time of the dental work may reduce the risk of infection.
In general, you should:
- Certain medications should be avoided. Your doctor may advise you to refrain from taking medications or dietary supplements that may increase your risk of bleeding.
- Fast ahead of time. Depending on the type of anesthesia you'll be receiving, your doctor may advise you to refrain from eating or drinking six to twelve hours before the procedure.
- Make arrangements for a ride. You will not be permitted to drive yourself home after the procedure, so make arrangements for someone to pick you up. If you live alone, arrange for someone to check on you that evening or, ideally, to stay with you for the rest of the day.
- Wear loose clothing. If you're having knee arthroscopy, wear loose, comfortable clothing, such as baggy gym shorts and slip-on shoes, so you can easily dress after the procedure.
Timing
Meniscus repair is best performed within the first two months after a meniscus tear to maximize meniscus healing. Walking on a 'locked' knee (one that does not fully straighten) may cause further damage to the meniscus and render a tear irreparable. Squatting should be avoided prior to surgery because it may displace a piece of meniscus into the joint and cause 'locking.'
Arthroscopic meniscus repair takes about an hour to an hour and a half. The time may vary depending on how much additional surgery is required to address other issues in the knee.
Pain and pain management
Arthroscopic meniscus repair is a mildly painful procedure. It is more painful than a standard arthroscopy but less painful than a ligament reconstruction or another procedure that requires drilling holes through the bone because more soft tissue surgery is performed. Although local anesthetic is used to reduce pain during surgery, patients usually have a swollen, painful knee for the first three days after surgery, which is manageable with oral narcotic and anti-inflammatory pain medication.
Quick Recovery Time
The recovery time from arthroscopic meniscus tear surgery is relatively short, with most people able to resume normal activities within a few weeks, depending on the size of the tear and the repair required. The pain relief is dramatic, and the pain from the surgical incision is minimal.
The three early postoperative rehabilitation goals are to straighten the knee, reduce swelling, and regain quadriceps muscle control. Patients are encouraged to perform straight leg raises while wearing the brace immediately following surgery. For six weeks, the brace is worn while walking with the knee extended. Generally, range of motion is started soon after surgery from 0 to 90 degrees, with no weight-bearing during motion.
At six weeks, the brace is unlocked and weaned off when good quadriceps control is demonstrated. At six weeks, motion is increased as tolerated, but deep squats are avoided until 12 weeks. Swimming and exercise machines are encouraged at 12 weeks, with progress to cutting and pivoting sports generally occurring at 16 weeks. A physical therapist's assistance is extremely beneficial in achieving a full recovery as quickly as possible.
Physical therapy is frequently required during the recovery process. There are risks, as with any surgery, such as infection or blood clots. There are also risks associated with the anesthesia used during the surgical procedure. While meniscus tears are common, painful, and activity-limiting, they can be identified and treated quickly, easily, and successfully.
Following arthroscopic meniscus repair, the patient is usually fitted with a cryocuff and a knee brace. The cryocuff is a cold compression device made up of a bladder wrapped around the knee and a cooler filled with ice water. The knee can be kept cool by using gravity to empty and fill the bladder, allowing swelling and pain to be reduced. The brace maintains the leg's straightness.
Full weight-bearing in the brace may be permitted immediately after surgery, depending on the pattern of the tear. Taking it easy for the first two days after surgery, with the limb propped up when sitting, helps keep swelling at bay and speeds recovery. Pumping the ankle up and down is recommended during this time to improve blood flow in the leg. Prior to discharge, specific post-operative instructions will be reviewed.
Duration of rehabilitation
Returning to sports necessitates the ability to execute sport-specific drills at competition speed. Return to a chosen sport typically takes four to five months, depending on the rigors of the sport, the preoperative condition, associated injuries, and other individual factors. Rehabilitation should be continued until the patient's athletic objectives are met.
Returning to ordinary daily activities
Three to four days after arthroscopic meniscus repair, patients are usually able to resume normal daily activities. These activities will be carried out initially while wearing a brace. It is beneficial to have assistance at home for the first few days following surgery.
Long-term patient limitations
Patients have no limitations after complete rehabilitation and recovery. However, if significant articular (gliding) cartilage injury or degeneration is discovered during a diagnostic arthroscopy, high impact sports are discouraged in order to slow the progression of arthritis.
Risks Of arthroscopic meniscus repair
Meniscus repair is a risk-free procedure with a 1.3 percent complication rate. The most common complications are skin nerve injuries, the vast majority of which resolve without the need for additional procedures three months after surgery. Larger nerves and blood vessels are rarely injured, and blood clots are uncommon. Knee stiffness, infections, and other complications are uncommon, but they do occur. Special techniques are used by an experienced surgical team to reduce these risks, but they cannot be completely eliminated.
Nothing you can think of that could go wrong hasn't gone wrong at some point. Meniscus repair, on the other hand, is a safe procedure with a complication rate of 1.3 percent. The most common complications are skin nerve injuries, the vast majority of which resolve without the need for additional procedures three months after surgery.
Larger nerves and blood vessels are rarely injured, and blood clots are uncommon. Knee stiffness, infections, and other complications are uncommon, but they do occur. Special techniques are used by an experienced surgical team to reduce these risks, but they cannot be completely eliminated.
Drowsiness, slowness of breathing, difficulty emptying the bladder and bowel, nausea, vomiting, and allergic reactions are all possible side effects of narcotic pain medications. Patients who have recently used narcotics or alcohol may find that standard doses of pain medication are less effective. Balancing the benefits and side effects of pain medication can be difficult for some patients. Patients should inform their surgeon if they have previously experienced problems with pain medication or pain control.
Managing risk
The most effective way to treat complications is to avoid them in the first place. For example, giving antibiotics prior to surgery reduces the risk of infection, and using anti-embolism stockings reduces the risk of blood clots. If infection occurs, repeat arthroscopy to remove infected tissue and debris, along with antibiotics for six weeks, is usually effective.
If blood clots form, blood thinners are administered for three months to reduce the likelihood of the clots growing or breaking off and traveling to the lungs. Physical therapy and braces are frequently used to treat knee stiffness, but arthroscopic releases may be required to restore motion. Because most complications can be effectively managed if they are identified early, if patients have questions or concerns about the post-operative course, they should contact the surgeon as soon as possible.
Arthroscopic Meniscus Repair Cost
Arthroscopic surgery, the standard outpatient treatment for more troublesome tears, typically costs $7,400-$9,000 or more, depending on the patient's age, the severity and exact location of the injury, the presence of other injuries, and the hospital where the procedure is performed. Outpatient arthroscopic surgery typically costs $8,970, according to the Healthcare Cost and Utilization Project, a collection of medical databases sponsored by the Agency for Healthcare Research and Quality.
What should Cost include:
Patients seeking treatment for a torn meniscus must first be evaluated by a doctor to determine the extent of the damage, according to the American Academy of Orthopedic Surgeons. The doctor may examine the knee for tenderness around the meniscus as well as bend, straighten, and rotate it. These motions will produce a clicking sound if there is a tear. Imaging tests may also be ordered by the doctor.
If the tear is small and on the outer portion of the meniscus, rest, ice, bandaging, and elevating the knee may suffice. Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce swelling and pain. Otherwise, a doctor may recommend arthroscopic surgery, which involves inserting instruments through a small incision in the knee.
Non-Surgical Treatments
Medications
Anti-inflammatory medications, taken by mouth or injected directly into the knee, can be useful to reduce the pain and swelling symptoms associated with meniscus tears, but do not improve healing. No medications or nutritional supplements have been scientifically documented as beneficial for meniscus healing.
Exercises
Quadriceps strengthening exercises can help reduce swelling and regain muscle control in an injured knee. They are beneficial in reducing symptoms and hastening rehabilitation.
Conclusion
The meniscus is an important structure in the knee for load transmission and shock absorption. During activity, the knee is subjected to up to 5 times its body weight, with half of this force transmitted through the meniscus when the knee is straight and 85 percent of the force transmitted through the meniscus when the knee is bent 90 degrees. The loss of the meniscus puts more pressure on the articular (gliding) cartilage, leading to degenerative changes. A successful meniscus repair preserves meniscus tissue and slows the progression of these changes.
Arthroscopic meniscus repair is a minimally invasive surgical procedure used to repair torn knee cartilage. To allow healing, the torn meniscus is repaired using a variety of minimally invasive techniques. Physical therapy can help you regain full knee function, which usually takes 4-5 months after surgery.
Meniscus repair is highly successful when performed by an experienced surgeon, with good results in approximately 90% of patients. Any knee that has been injured is more likely to develop arthritis. A successful repair retards the progression of arthritic changes. Repair within 2 months, more peripheral tear location, and concomitant ACL reconstruction are all associated with higher rates of meniscus healing.
Patients are generally pleased with their progress during rehabilitation and frequently feel ready to do more than is permitted during each phase. Following this protocol resulted in a successful outcome. If the exercises appear to be especially difficult or painful, the patient should consult with a therapist or surgeon.