Meniscus Disease and Treatment A Guide for Patients

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1 Meniscus Disease and Treatment A Guide for Patients Anil K. Gupta, MD, MBA Sports Medicine and Shoulder Surgery Toledo Orthopaedic Surgeons 1

2 Background Meniscal tears are among the most common knee injuries. In addition, meniscus related surgeries are among the most common surgeries in Orthopaedics. Athletes, particularly those who play contact sports, are at risk for meniscal tears. However, anyone at any age can tear a meniscus. Anatomy Three bones make up the knee joint the femur, tibia, and patella Two C-shaped pieces of cartilage act as "shock absorbers" during joint loading. These are called menisci. Meniscus Tear Menisci tear in different ways. Sports-related acute meniscal tears often occur along with other knee injuries, such as anterior cruciate ligament tears. Degenerative meniscus tears can occur over time and can be seen with or without osteoarthritis. Common tears include horizontal cleavage, longitudinal, parrot-beak, flap, bucket handle, and mixed/ complex Common types of tears 2

3 Mechanism of Injury Sudden meniscal tears often happen during sports via a twisting mechanism while the foot is planted. Older adults are more likely to develop degenerative meniscal tears over time. This is in part due to decreased hydration status of the meniscus, leaving it more susceptible to injury. Symptoms Occasionally patients can feel a pop when they sustain an acute meniscus tear. Most people can still walk on their injured knee. Rarely, the knee can become locked where you cannot straighten the knee. In this circumstance you will find it very difficult to bear weight and will need crutches. In the degenerative setting, patients typically feel a gradual progression of pain with intermittent swelling. They may also experience an occasional catching sensation. The most common symptoms of meniscal tear are: Pain Loss of motion Stiffness and swelling Catching or locking of the knee The sensation of the knee "giving way" Pain with getting in and out of a car, rolling over in bed, or other twisting maneuvers Physical Examination After obtaining your history, Dr. Gupta will examine your knee. He will perform a thorough examination of the knee evaluating all of the ligaments, tendons and bony landmarks to ensure that you do not have additional sources of your pain. Mild swelling with pain along the joint line are the most common examination findings in the setting of a meniscus tear. Rotational maneuvers may also worsen the pain. Radiology Tests X-rays Although X-rays do not show meniscal tears, they may show other causes of knee pain, such as osteoarthritis, loose pieces of bone, and abnormal alignment. Magnetic resonance imaging (MRI) MRI is the most accurate diagnostic test to evaluate for a meniscus tear. It also allows for evaluation of the articular cartilage, ligaments, and tendons. Treatment How Dr. Gupta manages your tear will depend on the type of tear you have, its size, and location. It also depends on your functional goals. He will discuss this in detail with you. 3

4 The outside one-third of the meniscus has a rich blood supply. A tear in this "red" zone may heal on its own (if stable), or can often be repaired with surgery (if unstable, or loose ). A longitudinal tear is an example of this kind of tear. Peripheral 1/3 Longitudinal Tear in the red zone Complex tears with very poor tissue quality (even if in the peripheral red zone) usually do not do well with primary repair. Dr. Gupta will do everything he can to repair your meniscus and preserve the tissue. But if the pattern, location, and quality of the tissue are not amenable to repair, however, you may do better with a trimming of the torn meniscus portion so that the remaining meniscus is smooth and stable. Dr. Gupta focuses on meniscal conservation and therefore will remove only the diseased tissue if necessary. The inner two-thirds of the meniscus typically lacks a blood supply. Without nutrients from blood, tears in this "white" zone have a very poor healing rate, and therefore patients can often do worse if repair is attempted at this site. Therefore a trimming is commonly performed. Dr. Gupta specializes in meniscus surgery and preservation. Please keep in mind that if a meniscus tear is repairable (ie. appropriate pattern, tissue quality, and in the appropriate zone to allow for healing), he will repair it. Nonsurgical Treatment Non-surgical management is typically reserved for small, stable tears that do not lead to persistent swelling or mechanical symptoms. Options include, but are not limited to: Activity Modification - Take a rest period from the activity that caused the injury. Avoiding activities that exacerbate the pain. Icing - Can be applied before and after acitivities to help with pain and swelling. Core Strengthening and Weight loss Strengthening your core (ie. abdominal muscles, pelvis muscles, hip muscles, and low back muscles) and weight loss can significantly reduce your pain level. Non-steroidal anti-inflammatory medicines Drugs such as Naproxen and Ibuprofen reduce pain and swelling. 4

5 Physical Therapy Physical Therapy has a limited role in the treatment of meniscal tears. It has not been proven to aid in the healing of meniscal tears, but it may help with its associated symptoms. Surgical Treatment Persistent pain and functional loss secondary to a meniscal tear that does not respond well to conservative treatment are the main indications for surgical management. Meniscus repair and/or partial meniscus trimming is performed using an arthroscope. Knee arthroscopy is one of the most commonly performed surgical procedures. Dr. Gupta is fellowship trained in this technique. A small camera is introduced into the knee via a 1 cm incision. Instruments are then introduced into the knee through a separate 1 cm incision to complete the procedure. The procedure is performed under anesthetic sedation in the outpatient (ie. same day) setting. Knee Arthroscopy Large meniscus tear in red zone Repair with sutures Risks of Surgery Meniscus surgery is considered a low-risk procedure. It is therefore typically performed in the outpatient setting. Despite the low risk, there are risks that you should be aware of. The most common risks/complication include, but are not limited to, bleeding, infection, damage to surrounding nerves and blood vessels, blood clot, stiffness, and repair failure. Dr. Gupta will discuss these risks in detail with you prior to surgery. Postoperative Expectations If a partial meniscus trimming in performed, the recovery is relatively quick. Patients will use crutches for 1-3 days and then gradually wean themselves off of them. Full weight-bearing is allowed. 5

6 If a meniscus repair is performed, patients are placed on crutches for a longer period of time. It is also not uncommon to be placed on weight-bearing precautions for at least 6 weeks to allow the meniscus to heal. The duration may vary depending on the severity of the tear and complexity of the repair. However, recovery and predictability of outcome is best determined after arthroscopy has been performed, as it is dependent on the type of tear, quality of tissue and quality of the repair. Sources of Above Information: Additional Resources Regarding Dr. Gupta

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