Your activity level, age, the type and location of the tear, the severity, your symptoms, and any other associated knee injuries will be considered todetermine whether conservative or surgical treatment options are more appropriate. Once your medical professional has diagnosed your meniscus tear, he/she can better recommend the most effective treatment for your knee pain.
Meniscal tears are graded on 3 levels; 1 being the least severe and 3 being the most. Grade 1 and 2 tears may not even be apparent during an arthroscopic exam and can usually be repaired without surgery. Grade 3 tears generally require surgery.
Conservative treatments, such as Blood Flow Stimulation Therapy™, are generally recommended for partial, stable and degenerative meniscus tears. Surgical options are used more often for larger, complex or displaced tears.
At one time, surgeons removed injured menisci believing they served no purpose, however doctors now know the importance of the meniscus to the knee joint mechanics and function. Removing part of the meniscus should be avoided if possible, especially if it will weaken the periphery since it will compromise the load absorption capabilities and can increase the risk of degeneration. However, if the meniscus is at risk of further damage or the knee cannot flex or extend properly, surgery many be required to minimize damage (i.e. remove the flap to prevent more tearing) and restore joint function. It is beneficial to try to heal a meniscus tear prior to surgery to avoid it if possible or to minimize the amount of meniscus that needs to be repaired or trimmed.
If an anterior cruciate ligament (ACL) injury occurs when the medial meniscus is torn, surgery may be required to repair the ACL.
If conservative treatments are unable to treat your tear completely, your physician may recommend a surgical option. A comprehensive arthroscopic exam is usually performed prior to surgery to determine the location and nature of the tear and whether or not it can be repaired.
You are generally a candidate for surgery if you have injured your meniscus and you:
- Experience symptoms that interfere with your daily living after 2 – 3 months (knee catching or locking, very stiff and painful, major instability).
- Have a larger, complex or displaced tear.
- Have major instability in your knee (often due to a combined meniscus/ACL injury)
- Are a high-level athlete
Types of Meniscus Surgery
Treating a torn meniscus is one of the most common of all knee surgeries. The type of surgery you require will depend on the size, shape and location of your meniscus injury. There are generally 3 types of meniscus surgery: a meniscectomy, a meniscal repair, or a meniscal replacement. All of these will beperformed arthroscopically while under some type of anesthesia; they usually don’t require an overnight hospital stay. Your orthopedic surgeon will determine which surgery is most suited to your condition.
Arthroscopic surgery involves making tiny incisions around your knee jointand inserting a pencil-thin, fiber optic camera with a small lens and lighting system in one hole, and small surgical instruments in the other holes. The surgeon will take a look inside your joint to investigate all the soft tissues and bones. These images will then be transmitted to a TV monitor, which allow the doctor to make a diagnosis and/or perform the meniscus surgery under video control.
Most surgeries will require rehabilitation utilizing conservative treatments such as cold compression therapy and Blood Flow Stimulation Therapy™. Cold compression should be used immediately following surgery to reduce pain and swelling. Blood Flow Stimulation Therapy™ can begin once your incisions have healed, with permission from your doctor. Physical therapy and strengthening normally begin a few weeks after surgery (depending on the type of surgery). Your surgeon should provide a treatment plan to help you regain normal use as soon as possible.
A meniscal repair is generally preferred over a meniscectomy, as it fixes the damage and helps prevent deterioration of your meniscus. However, this involves a more complex surgery, the recovery is longer and it is not always possible (depending on the location). Early diagnosis definitely can affect the outcome of this surgery. Younger people tend to be the best candidates as their tears are often stable and located near the periphery of the meniscus. These tears have a better chance of healing than those farther in the joint because of the blood supply. After surgery and with permission from your surgeon and Blood Flow Stimulation Therapy™ can help promote blood circulation to the injured areas to help you heal faster.
Trepanation (Abrasion Technique) involves making small holes or shaving torn edges in your meniscus to promote bleeding and enhance healing. Longitudinal tears or bucket handle tears often won’t heal unless they are abraded.
Suturing involves using stitches to reconnect the tear, repair the damage, and save your meniscus. The sutures are spaced 3-4 mm apart to prevent gapping and sewn while your knee is fully extended (or at 10 degrees maximum) to allow for full extension after surgery.
The most common meniscus surgery is a Partial Meniscectomy or Resection, which involves removal of the torn or damaged part of your meniscus. It is generally used for degenerative and horizontal tears located in the inner 2/3 of your meniscus (the white-on-white zone). This area has a poor healing rate because it receives little or no blood supply, therefore it is better to remove the damaged part rather than try to fix it. The goal of this surgery is stabilization, which will prevent catching, buckling and locking in your knee joint. The surgeon will trim and smooth out frayed edges on the inner rim (which can be difficult to reach), and remove the damaged part or flap of your meniscus.
In the case of a discoid meniscus that did not heal through conservative treatments, part of your meniscus may be removed to relieve symptoms, prevent further tearing and preserve some of your meniscus cushioningfunction.
A Complete Meniscectomy or Resection may be required if there is extensive damage to the meniscus and it is determined unsalvageable. This involves surgical removal of your entire meniscus. If you have your meniscus removed, the rest of your joint gets overloaded (resulting in a 200%-350% increase in contact pressure). This surgery is only performed if necessary, as removal of the meniscus can lead to joint narrowing, ridging, flattening, and becoming bow-legged or knock-kneed. Complete meniscectomy patients often express dissatisfaction with the corrected knee as time goes on.
Although meniscectomies have faster recovery than other meniscus surgeries they can often lead to arthritis as the size of your meniscus (shock absorber) is reduced and/or removed. Normal knees have 20% better shock-absorbing capacity than meniscectomized knees.
A Meniscal Replacement involves implanting a new meniscus into your knee. There are two different replacements that can be used:
An allograft is a transplant from a donor. Agood candidate for this type of replacement issomeone who is young, has minimal ACL damage, is a previous menisectomy patient, and has developed pain in the knee capsule. If the patient is obese, suffers from gout or arthritis, has an infection or any metabolic disease (being unable to convert food to energy) they are not likely candidates for this procedure. The success of this surgery is dependent on proper knee alignment, ligament stability, and amount of articular cartilage that is present.
A collagen implant is also an option to replace the meniscus. The implant is stitched into place with the hope that your body’s own cells will begin to regenerate new meniscal tissue by attaching itself to the porous surface of the implant. In this way, the implant works as a scaffold to assist the body with its own repair process.
Rehabilitation Following Surgery
Initially following a meniscal repair, the knee is immobilized in full extension with a postoperative immobilizer which is eventually replaced with a long leg brace. This brace is worn continuously (expect during rehabilitation exercises) for at least 2 weeks, with the range allowance of the brace increasing as the weeks progress. This continues until the knee can be fully flexed. Note, in some cases such as a central zone repair or a mensical transplant the brace may be necessary for 6 weeks or longer. Following apartial meniscectomy, immobilization is not required and full extension with 90 degree flexion is possible approximately 10 days after surgery.
With a meniscus repair you may be allowed to bear some weight on your repaired knee with the assistance of crutches and a brace immediately following surgery. The amount of weight and progression of weight allowed will depend on your specific case. However, you will be able to bear full weight within 4-8 weeks if your quadriceps control is good. In the case of a partial meniscectomy, you should be able to bear full weight within 4-7 days.
The goal of professionally led exercises during the first month of rehabilitation is to regain range of motion in the joint, regain muscle control in the leg, ensure the patella does not lose mobility, maintain flexibility and strength in the hip and ankle, and restore stability. You doctor, surgeon or physical therapist will assist you with these exercises to achieve these goals without causing re-injury.
Following a meniscal repair, you should avoid pivoting, squatting, twisting and deep lunging exercises for at least 4-6 months following surgery. Jogging or running should be avoided for 5-6 months of rehabilitation. Generally you will be able to return to normal activities and sports approximately 6 weeks after a partial meniscectomy and 3-4 months after a meniscal repair or replacement. However, it is always recommended that you get your surgeon’s approval before beginning any exercises or activities following meniscus surgery.
Research indicates pain relief after a partial meniscectomy or abrasion is about 50 – 75%. Healing and recovery time is generally dependent on the degree of damage done, your age, pre-injury level of function, and your rehabilitation. Tenderness, pain, stiffness and weakness are very common after surgery. That is why a strong commitment to rehabilitation utilizing the conservative treatments such as Blood Flow Stimulation Therapy™ and ColdCure Technology® is essential!