MENISCAL TEAR

The rupture of the meniscus of the knee is one of the most common injuries among athletes, but not limited to them. The meniscus is strong, resistant structures that play an important role in the biomechanics of the knee joint. They function as mechanical link allows a better distribution of loads on articular surfaces of the femur and tibia, absorbs vibrations exerted on them, thus contributing to the stability of the knee. About 60% of the joint loads pass through the meniscus.


Posterior root rupture of the medial meniscus (red circle)


Anterior root meniscal rupture (black circle)

Knee MRI:  The 'bucket handle medial meniscal tear'.  Green arrow shows the rupture of the meniscus.  Red arrow shows the intact posterior cruciate ligament.

CAUSE

The meniscus is prone to injury and degenerative processes. The causes can cause rupture of the meniscus is:
• extreme moves such as the knee bends stabilized tread
• too much bending of joints can cause harm by creating large or small lacerations.
• direct trauma (hitting)

SYMPTOMS

The patient may experience:

• mild to severe pain that can readily be resolved by the end of the day in small cases of rupture,
• swelling of the knee which usually occurs after 12-24 hours
• involvement of joints in flexion for an extended break.
• feeling of joint instability
• loss of full range of motion

The injured meniscus is essentially intrarticular foreign body if not treated will cause damage to articular cartilage that is premature osteoarthritis.

Arthroscopic view: normal meniscus

Arthroscopic view:  meniscal tear

Arthroscopic view: severe damage of the meniscus

  
Radial meniscal tear


Parrot beak tear of meniscus
(Operative techniques 'Sport Knee Surgrey" Miller M.)

  

Ventral Longitudinal tear


Displaced flap of the meniscus


'Bucket handle' meniscal tear that block the knee movement

After the injury must stop any activity to be placed ice around the affected joint.
The visit to the specialist Orthopaedic Surgeon should be done as soon as possible to the clinical examination and the paraclinical testing (radiography, magnetic resonance imaging) to determine the type of injury and design a treatment plan.

CONSERVATIVE TREATMENT
THERAPY: 

CONSERVATIVE TREATMENT

How the specialist surgeon Orthropaidikos will face the trauma of the meniscus depends on the type of rupture, the size and the region.
The outer third of the meniscus has a rich blood supply which means a large potential for healing (arthroscopic suture of the meniscus). The elongated tear exemplifies.
Contrary both proximal triarchs the meniscus does not have any blood supply and therefore do not have and healing ability. These sections may not be taped and usually removed.
If the meniscus tear is very small and no clear resolution of symptoms (pain, swelling) then treated with conservative treatment that includes:

• Rest
• Ice therapy lasting 10 minutes several times a day
• Physiotherapy, which aims to strengthen muscle groups of the knee and restoring full range of motion.
• anti-inflammatory medication if there is a specific reason

OPERATIVE TREATMENT
THERAPY: 

KNEE ARTHROSCOPY

In previous years as today in tears of the meniscus partial or subtotal meniscectomy was the only solution. The deduction, however, part of the meniscus is essentially removing a significant factor in protecting the articular cartilage causing premature wear this for two reasons:

• create the development of large focal power between the femur and tibia cartilage in point deficit and meniscus
• grow bigger and paradoxical movement of the bone between them.

The evolution of biotechnology synthetic grafts and the refinement of arthroscopic techniques and tools, provided an opportunity today to specialized orthopedic surgeons to perform transplants meniscus (synthetic or allograft) restoring thereby the deficit left by the excision of the meniscus avoiding premature damage and the development of osteoarthritis.

The tears of the meniscus treated:

• stapled and maintain the posted section (if the department is maintained in good condition), where possible, is the ideal solution and treatment,
• partial or subtotal meniscectomy ie remove the broken section and normalizing the remaining edges.
• meniscus transplantation from cadaveric donor (allograft)
• synthetic meniscus transplantation. The synthetic meniscus is the latest development of biotechnology and Orthopedic Surgery Sports Injuries of the world and constitutes the scaffold on which to develop the new crescent of the patient.

ARTHROSCOPIC MENISCECTOMY

Arthroscopic meniscectomy is an indication in patients with rupture of the meniscus and knee pain and mechanical symptoms such as entanglement and instability of the joint. Initially an assessment of whether it is possible to suture the meniscus. Many times because of the nature of the tear stitching can be done. The broken part is removed carefully and the remaining part normalized by creating a physiological substrate motion of the joint.

Arthroscopic tools

Design of anatomical - drivers points (portals) of arthroscopy of the knee.

Knee artrhoscopy video

Artrhoscopic meniscectomy

  

Arthroscopic view:  degenerative tears of meniscus

Subtotal meniscectomy

Bucket handle type of tear

Subtotal meniscectomy

MENISCAL SUTURING

In many cases the suture of the meniscus is the ideal solution for the patient, allowing healing and virtually definitive treatment.
The evolution of arthroscopic techniques and materials now allow the skilled Orthopaedic Surgeon to staple the meniscus in different ways depending on the type of rupture and anatomical region.

 

 

 

Suture of the meniscus with special device.
(Operative techniques 'Sports Knee Surgery' M. Miller, Saunders Elsevier Publications)

Meniscal suturing device

The meniscus is sutured

 

 

Meniscal suturing with 'outside in' method.
(Operative techniques 'Sports Knee Surgery' M. Miller, Saunders Elsevier Publications)

Arthroscopical view of meniscal suturing with Outside in method

MENISCAL TRANSPLANTATION (ALLOGRAFT)

The meniscus transplant is a specialized surgery that is universally applied in special centers. Taking the graft made ​​from cadaver donor and having received the appropriate treatment and special controls can be transplanted to a person with a prior subtotal removal of the meniscus of his own.

The criteria to become a meniscus transplant include:

• persistent pain on movement of the knee
• loss of more than half of the meniscus from previous arthroscopic meniscectomy
• failure suturing of the meniscus due to heavy destruction
• the articular cartilage of the joint is not greatly affected
(established osteoarthritis is a contraindication for transplantation)
• active patient aged under 55 years
• patient is normal body weight

The existence of proper alignment of the limb and the integrity of the ligaments of the knee joint are prerequisites for successful surgery. If concomitant injuries such as ruptured anterior cruciate it must be reconstructed at the same operative time.
The clinical examination of a patient who will conduct the Orthopaedic Surgeon, a radiological monitoring and control joints with magnetic resonance imaging will determine the treatment plan.
The goal of transplantation of the meniscus is to relieve the patient from pain and protection from the biomechanical consequences of the absence of the meniscus (early osteoarthritis).

Cadaveric part of the knee included meniscus.  The meniscus removed with special techniques.

Manufacture and preparation of the allograft meniscus which is ready to be placed on the knee of the patient

Implementation of the meniscus in the knee joint and containing at certain points.
(Master techniques in Orthopaedic Surgery 'Knee Reconstruction' Third Edition, Douglas Jackson editor, Wolters Kluwer
Lippicnott Williams & Wilkins).

Meniscal allograft suturing with multiple sutures.
(Master techniques in Orthopaedic Surgery 'Knee Reconstruction' Third Edition, Douglas Jackson editor, Wolters Kluwer
Lippicnott Williams & Wilkins).

Meniscal allograft is already sutured

SYNTHETIC MENISCAL TRANSPLANTATION

After a lengthy investigation, in cooperation with leading experts, created a synthetic scaffold of the meniscus, which is the next step in surgery of the knee. The synthetic meniscus consists of a synthetic biodegradable polymer with specific cellular device, allows the flow of blood inside providing locations for new cell growth by creating conditions healing process and create a new meniscus tissue.

After removing the damaged part of the meniscus is placed with absolute precision the synthetic scaffold and stapled with special techniques. By the end of the year new tissue grows via the scaffolding is gradually replacing. The scaffold is absorbed by the body and in its place now is a new meniscus.

The advantages we offer this procedure are:

• normal range of motion of joints
• joint move without pain
• preventing the development of early osteoarthritis

Clinical studies in humans have shown improved quality of life and also restore them to pre-injury health status of their knees.

Synthetic meniscal scaffold

 

Schematic synthetic arthroscopic meniscal transplantation process.
a). remove the broken portion of the meniscus
b). the space left be assessed and measured with a specific meter

 

c). installation of the synthetic scaffold meniscus covering the gap with an accuracy
d). compilation of the synthetic scaffold of the meniscus with special stitches

REHABILITATION: 

MENISCECTOMY

After surgery, your doctor may put your knee in a cast or brace to keep it from moving.

Once the initial healing is complete, your doctor will prescribe rehabilitation exercises. Regular exercise to restore your knee mobility and strength is necessary. You will start with exercises to improve your range of motion. Strengthening exercises will gradually be added to your rehabilitation plan.

For the most part, rehabilitation can be carried out at home, although your doctor may recommend physical therapy.

MENISCAL REPAIR

Immobilization. You will need to wear a knee brace and use crutches for the first 4 to 6 weeks after surgery. This gives the transplanted tissue time to become firmly attached to the bone.

Physical therapy. Once the initial pain and swelling has settled down, physical therapy can begin. Specific exercises can restore range of motion and strength.

A therapy program focuses first on flexibility. Gentle stretches will improve your range of motion. As healing progresses, strengthening exercises will gradually be added to your program.

Return to daily activities. Most patients are not able to return to work for at least 2 weeks. Many patients with active jobs require 2 to 3 months of rehabilitation before they resume their jobs. Your doctor will discuss with you when it is safe to return to work, as well as any sports activity. Full release is typically given 6  months after surgery.

MENISCAL ALLOGRAFT TRANSPLANT

 The initial goal of the postoperative rehabilitation program is to prevent excessive weight-bearing and joint compressive forces that could disrupt the healing meniscus allograft (Table 11-1). Patients are placed in a long-leg postoperative brace immediately after surgery, and the brace is worn for approximately 6 weeks. Knee range-of-motion exercises from 0 to 90 degrees are begun the first day. Knee flexion is increased 10 degrees each week to allow 135 degrees after 4 weeks. Patients are allowed only toe-touch (5 lb) weight bearing during the first 2 weeks, and then are slowly progressed to bear 50% of body weight at 4 weeks and full weight bearing at 6 weeks.
Flexibility and quadriceps strengthening exercises are begun immediately postoperatively. Stationary bicycling with low resistance is begun at 8 weeks, and swimming and walking programs are initiated between 9 and 12 weeks. Return to light recreational sports is delayed for at least 12 months. Patients are advised not to return to high-impact, strenuous athletics due to the joint damage present and questionable ability of the meniscus transplant to restore normal load-bearing function.

SYNTHETIC MENISCAL TRANSPLANT

Rehabilitation after surgery naturally has to be slow as the body has to grow tissue into the scaffold and this is a slow process. Full weight on the leg is allowed at 8 – 10 weeks and the specific rehabilitation program is tailored to each patient depending on the state of the knee surfaces and the amount of new meniscus inserted.