Meniscal Knee Injuries: Difference between revisions
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==Non-Operative Management== | ==Treatment== | ||
===Non-Operative Management=== | |||
*The meniscus can repair = “masterly neglect” | *The meniscus can repair = “masterly neglect” | ||
*Greatest healing potential are those that are short (<1cm), longitudinal, stable, and asymptomatic. | *Greatest healing potential are those that are short (<1cm), longitudinal, stable, and asymptomatic. | ||
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*In high level athletes - high risk of tear progression, become symptomatic and eventually require a partial meniscectomy | *In high level athletes - high risk of tear progression, become symptomatic and eventually require a partial meniscectomy | ||
==Operative Mx== | ===Operative Mx=== | ||
Three broad types of surgery | Three broad types of surgery | ||
#Preservation: Long recovery but reduce risk of OA | #Preservation: Long recovery but reduce risk of OA | ||
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#Replacement of damaged tissue | #Replacement of damaged tissue | ||
===Meniscus Zones=== | ====Meniscus Zones==== | ||
Three zones in the meniscus, with reducing blood supply the more centrally located the tissue | Three zones in the meniscus, with reducing blood supply the more centrally located the tissue | ||
#Red-red zone | #Red-red zone | ||
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#White-white zone | #White-white zone | ||
===Meniscal Repair=== | ====Meniscal Repair==== | ||
*Tear selection for repair | *Tear selection for repair | ||
**Ideal = Unstable, vertical-longitudinal tear in periphery | **Ideal = Unstable, vertical-longitudinal tear in periphery | ||
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**Return to competition in 6-8 months | **Return to competition in 6-8 months | ||
===Partial Meniscectomy Classic Criteria=== | ====Partial Meniscectomy Classic Criteria==== | ||
Indication = where masterly neglect or repair have a low chance of success | Indication = where masterly neglect or repair have a low chance of success | ||
| Line 44: | Line 45: | ||
Good at resolving acute symptoms, recovery in several weeks, but more long term OA | Good at resolving acute symptoms, recovery in several weeks, but more long term OA | ||
===Meniscus Replacement=== | ====Meniscus Replacement==== | ||
Allografts | Allografts | ||
Synthetic scaffolds | Synthetic scaffolds | ||
Does not allow return to competitive sport | Does not allow return to competitive sport | ||
==Degenerative Tears== | ===Degenerative Tears=== | ||
Evaluated in an RCT by Sihvonen et al<ref>Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … Järvinen, T. L. N. (2013). Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. New England Journal of Medicine, 369(26), 2515–2524. doi:10.1056/nejmoa1305189 </ref> | Evaluated in an RCT by Sihvonen et al<ref>Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … Järvinen, T. L. N. (2013). Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. New England Journal of Medicine, 369(26), 2515–2524. doi:10.1056/nejmoa1305189 </ref> | ||
*146 patients with degenerative meniscal tears without OA. Included those with locking symptoms. | *146 patients with degenerative meniscal tears without OA. Included those with locking symptoms. | ||
Revision as of 20:34, 17 June 2020
Treatment
Non-Operative Management
- The meniscus can repair = “masterly neglect”
- Greatest healing potential are those that are short (<1cm), longitudinal, stable, and asymptomatic.
- Stability – evaluated arthroscopically with probing
- In high level athletes - high risk of tear progression, become symptomatic and eventually require a partial meniscectomy
Operative Mx
Three broad types of surgery
- Preservation: Long recovery but reduce risk of OA
- Removal of damaged tissue: Speedy recovery but risk future OA
- Replacement of damaged tissue
Meniscus Zones
Three zones in the meniscus, with reducing blood supply the more centrally located the tissue
- Red-red zone
- Red-white zone
- White-white zone
Meniscal Repair
- Tear selection for repair
- Ideal = Unstable, vertical-longitudinal tear in periphery
- Meniscus zones: Only peripheral 10-25% of the meniscus is vascularised
- However acceptable healing rates can occur in the other zones
- Also beneficial: tear <12 weeks, younger patients, combined ACL repair
- Bucket handle = vertical longitudinal peripheral tear. Locked knees should be repaired urgently to prevent long term motion loss
- Techniques
- Inside-out (gold standard) or outside-in
- Newer fixation devices (all inside)
- All forms of repair require many months of prolonged rehabilitation
- Postoperative rehab
- typically includes restrictions in knee flexion RO and weight bearing for 6 weeks.
- Low impact exercise but no running for 2-3 months
- Return to competition in 6-8 months
Partial Meniscectomy Classic Criteria
Indication = where masterly neglect or repair have a low chance of success
- complex tear patterns
- chronic displaced tears with plastic deformation
- tears in white-white region (rim width > 8mm)
- Failed repair
- Degenerative tears (despite being a disproven treatment)
Good at resolving acute symptoms, recovery in several weeks, but more long term OA
Meniscus Replacement
Allografts Synthetic scaffolds Does not allow return to competitive sport
Degenerative Tears
Evaluated in an RCT by Sihvonen et al[1]
- 146 patients with degenerative meniscal tears without OA. Included those with locking symptoms.
- Partial meniscectomy vs sham surgery
- No difference at 12 months
- Considered one of the highest quality RCTs that exist in all of the surgical literature, and one of the only placebo controlled trials in the entire orthopaedic surgery literature.
Even experienced orthopaedic surgeons cannot predict who will benefit from surgery for degenerative meniscal tears.[2] I think there is a logical fallacy going on in some surgeons minds. If conservative management fails, the default isn’t to do something (surgery) that has been disproven to work (and can even make it worse with OA)
References
- ↑ Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … Järvinen, T. L. N. (2013). Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. New England Journal of Medicine, 369(26), 2515–2524. doi:10.1056/nejmoa1305189
- ↑ van de Graaf VA, Bloembergen CH MD, Willigenburg NW PhD, et al. Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions. Br J Sports Med. 2020;54(6):354-359. doi:10.1136/bjsports-2019-100567
