Arthroscopic Knee Surgery Meniscus Tear
Dr. Richard Cunningham, M.D. of Vail Summit Orthopaedics in Vail, Colorado, explains how he repairs a torn meniscus.
The meniscus is a cartilage cushion, which rests between the bones of the knee and acts as a shock absorber. Meniscus tears are often repaired arthroscopically.
Patients can either tear their medial (inside of the knee) or lateral (outside of the knee) meniscus. Medial meniscus tears are much more common than lateral meniscus tears.
Symptoms of a Meniscus Tear
Patients typically experience well-localized pain, popping or catching. Squatting usually increases the pain. There is often minimal swelling present.
Unlike bone or muscle, meniscus tissue has very poor blood supply. As such it has a very low healing potential. Most patients tear along the thin, inner rim of the meniscus where there is no blood supply. These tears cannot be repaired. Instead, Dr. Cunningham removes just the torn portion of the meniscus and preserves as much of the healthy, functioning portion of the meniscus as possible.
In a typical meniscus tear requiring arthroscopy, 10–15% of the meniscus has to be removed. If a patient has minimal arthritis (wearing of the coating cartilage on the end of the femur and/or tibia), then the patient can expect a great outcome. If there is a meniscus tear and arthritis, then the outcome is typically inversely related to how severe the arthritis (ie. the worse the arthritis, the less optimal the outcome). There is no need for crutches or a brace after arthroscopic menisectomy.
Arthroscopic Meniscal Repair
If the meniscus tissue is torn in the peripheral 3mm (where there is blood supply), the meniscus can be repaired and preserved. Repairing the meniscus is always Dr. Cunningham’s preference.
So called “bucket handle tears” where the meniscus tears longitudinally along the outer rim and then flips into the center of the knee like a bucket handle, are tears that Dr. Cunningham commonly repairs.
The alternative to repairing these bucket handle tears is to remove 50% or more of the meniscus. Removing this amount of the meniscus, which is the “shock absorber” cartilage, is known to predispose the knee to early arthritis.
The gold standard for repairing the meniscus is to pass sutures “inside-out.” While viewing through the arthroscope, sutures are precisely passed through the meniscus and tied over the capsule of the knee joint. There are newer “all inside” meniscal repair devices where sutures don’t have to be passed through a small incision outside the knee. Dr. Cunningham uses these all inside devices for smaller tears or for hard to reach tears.
Recovery and Rehabilitation
The rehabilitation after a meniscal repair is more entailed than after an arthroscopic menisectomy. For a repair, the patient is kept in a knee brace with their knee locked straight whenever up walking for 6-8 weeks, depending on the size of the tear.
However, immediately after surgery, we encourage you to unlock the brace or remove it when sitting down and start gentle knee range of motion exercises. After 6-8 weeks, the brace is discontinued, but no squatting is allowed for up to 12 weeks as this places high shear stresses on the repaired meniscus, and we want to be sure it has been given every opportunity to heal.
Unfortunately, not all meniscus repairs heal despite our best efforts. This is again due to the poor blood supply and compromised healing potential of the meniscus. We do not do follow up MRI scans to confirm healing as these are unreliable. Instead, we look out for symptoms of a meniscus that did not heal, which are very similar to the symptoms patients had before surgery (catching, locking, well localized pain over the meniscus).
To learn more about post-surgery rehabilitation, consult with Dr. Cunningham for more information.
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