There are two menisci in your knee; each rests between the thigh bone (femur) and shin bone (tibia). The menisci are made of tough cartilage and conform to the surfaces of the bones upon which they rest. One meniscus is on the inside of your knee; this is the medial meniscus. The other meniscus rests on the outside of your knee, the lateral meniscus.
Why perform a meniscus repair?
In some situations, your surgeon may offer a meniscus repair as a possible surgery for damaged or torn cartilage. Years ago, if a patient had torn cartilage, and surgery was necessary, the entire meniscus was removed. These patients actually did quite well after the surgery. The problem was that over time, the cartilage on the ends of the bone was worn away more quickly. This is thought to be due to the loss of the cushioning effect and the diminished stability of the joint that is seen after a meniscus is removed.
When arthroscopic surgery became more popular, more surgeons performed partial menisectomies. A partial meniscectomy is performed to remove only the torn segment of the meniscus. This works very well over the short and long term if the meniscus tear is relatively small. But for some large meniscus tears, a sufficient portion of the meniscus is removed such that problems can again creep up down the road.
Who needs meniscus repair surgery?
Tears of the meniscus that cause so-called "mechanical symptoms" tend to respond best to surgical treatment. A mechanical symptom is caused by the meniscus physically impeding the normal movement of the knee.
Common "mechanical symptoms" include:
- Locking of the knee (unable to bend)
- Inability to fully straighten the knee
- A popping or clicking sound or sensation
In the operating room, the surgeon has two primary options, either remove the torn meniscus (a partial meniscectomy) or perform a meniscus repair to place the edges together with sutures or tacks.
Is A Meniscus Repair Better?
The meniscus is a circular piece of cartilage with its blood supply coming from the outer rim. In order for the meniscus repair to heal, the tear must be near this outer edge in an area of good blood supply (nutrients from the blood vessels are necessary for healing)--this is the so-called red (vascular)-white (non-vascular) region of the meniscus.
Tears in the central portion of the meniscus will not heal even if a meniscus repair is performed. These central tears will be removed by your surgeon. However, studies seem to show that if a meniscus repair is possible, the long-term outcome is better for the patient because of a decreased the risk of arthritis later in life.
What treatment options do I have?
Some people with meniscus tears will respond to non surgical treatment, including rest, medications, and physical therapy. Most meniscus tears do not heal, but the symptoms from the tear can quiet down or resolve. In some cases, a cortisone injection can also be helpful to resolve the pain and swelling. Whether or not you are a good candidate for conservative treatment will depend on the type of tear, age of the tear, and your activity level. If your symptoms do not resolve, then you may require surgical treatment.
How is the surgery for the meniscus performed?
Meniscal surgery is performed by arthroscopy. The arthroscope is a small fiber optic instrument that is placed into the knee joint through a small incision. The camera is then viewed on a TV monitor, and pictures can be taken. The arthroscope allows a complete evaluation of knee joint, including the kneecap (patella), the cartilage surfaces, the meniscus, the ligaments (ACL & PCL), and the joint lining. Small instruments ranging from 3-5 millimeters in size are inserted through an additional incision and injury can be diagnosed, and damaged tissue can be repaired or removed. Before the development of arthroscopy, large incisions had to be made over the knee joint to treat or diagnose injuries. Today’s arthroscopic techniques allow more complete evaluations of the knee joint while accelerating the rehabilitation process.
What is the difference between partial meniscectomy and meniscal repair?
Depending on the type of tear, the piece of meniscus that is torn may be removed from the knee (partial meniscectomy) or repaired (sewn back in place). Whether or not a tear is repaired depends on the likelihood of the tear healing. If a tear occurs in the outer one-third of the meniscus (peripheral tear), there is usually adequate blood supply for the tear to heal and it is fixed. However, tears in the inner two-thirds of the meniscus (where most tears occur) have no blood supply, and will not heal with repair. Therefore, the torn piece needs to be removed. Every effort is made to try and repair a tear that may heal.
If the tear is repaired, it may require a small incision on the inside or outside of the knee to tie down the stitches and protect the nerves and arteries for the repair. Many times the meniscus can be repaired all arthroscopically without any additional incisions.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital. You will be admitted and taken to a preoperative holding are where you are prepared for surgery. You will be asked several times which knee is being operated on, and the surgical site will be initialed. Please note that you are asked this question many times on purpose. After the operation, you will be taken to the recovery room to be monitored. Once the effects of anesthesia have worn off and your pain is under good control, you will be taken to another area where you can see your family and finish recovering. You will be given all of your post-operative instructions and pain medication before leaving.
Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from anesthesia takes the majority of the day. I would recommend that you and your family members bring along some reading material to make the process easier for all.
How should I care for my knee after surgery?
Prior to your discharge, you will be given specific instructions on how to care for your knee.
In general, you can expect the following:
- Diet: Resume your regular diet as soon as tolerated. It is best to start with clear liquids before advancing to solid food.
- Medication: You will be given a prescription for pain medication.
- Bandage: You will have a thick dressing on the knee. You will be instructed on when it can be removed, usually in 3 days. After your dressing is removed, you should cover your sutures with a Band-Aid to protect the area from irritation.
- Showering: You may shower after your dressing is removed, after 2 –3 days. You cannot take a bath until the wounds are completely sealed, usually 2 –3 weeks after surgery.
- Crutches: You will have crutches after surgery, and will be instructed on how to use them. How long you use crutches will depend on the type of surgery performed. Crutches are commonly only required for a few days to one week.
- Brace: If a meniscus repair is performed, you may receive a brace to restrict the motion of your knee up to 90 degrees. This is to protect the repair for the first six weeks, to allow the area to heal.
- Ice: You may receive an ice machine that continually surrounds your knee with cold water. If not, you may apply ice over the dressings for 30 minutes every hour for several days. Do not use heat.
- Suture removal: Your stitches will be removed at your office visit 7-10 days after surgery. Occasionally, sutures are used which resorb and do not need to be removed.
- Follow-up office visit: You will be instructed on when to follow-up in the office. This is usually 7-10 days after surgery.
- Exercise: You will be instructed on exercises you can do immediately after surgery. You will start physical therapy within 1 to 2 weeks after surgery.
- Return to work or school: You can return to school or work within 3 –5 days using the crutches. If your job involves more extended walking or heavy activity, you may be out of work or school for a longer period of time.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissue to heal; 2) regaining motion; 3) regaining strength; and 4) return to sports. After partial meniscectomy, the rehabilitation generally occurs very rapidly. Most patients can return to strenuous work in two to six weeks. Following meniscus repair, you will be restricted from bending beyond 90 degrees or squatting for the first 4 - 6 weeks. The specific rehabilitation protocol will be reviewed after surgery.
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