Operate, do not operate, totally remove or suture? These are the most frequent questions that the doctor and the patient ask themselves following a meniscal injury
BACKGROUND: The meniscus has no blood vessels except for its two ends. In young adults this vascular system penetrates inside the medial meniscus for about 10-30% of its length, while in the lateral one the penetration is slightly lower (10-25%). It follows that, with the exception of small peripheral lesions, in the case of a strong trauma its repair capabilities are extremely low.
Conservative treatment
The initial treatment of meniscal lesions follows the classic RICE protocol (rest, ice, compression and elevation). Under these rules the injured limb must first be immobilized and put to rest. Ice will then be applied to the injured area (four or five daily applications for 10-15 minutes in the 24-48 hours following the trauma). The cryotherapy associated with rest will thus help reduce local swelling and pain. Eventually, only on medical advice, non-steroidal anti-inflammatory drugs can be used to control pain.
If the subject is young, particularly lucky and if the knee is stable and there are no signs of joint blockage, conservative treatment may be sufficient for a complete healing of the injured meniscus.
If instead there is a fragment of a mobile meniscus inside the joint, surgical removal is absolutely necessary.
Degenerative lesions, which occur without a significant traumatic event, require instead a waiting period. Thanks to the movements it can happen that these meniscal fringes become limpid making the pain disappear.
It is therefore important for the patient to be patient with good patience, enduring the local pain and discomfort for a few months.
SPECIAL CASE: if the meniscus breaks, but the fragment does not interpose between the articular heads, when the hydrartre is reabsorbed or sucked with a syringe (ARTROCENTESIS), the knee acts as a healthy joint (pseudo-healing).
From pseudo-healing we return to clinical disease if, due to a movement, even a trivial one, the broken meniscus flap comes again to interpose between the femoral condyle and the tibial plateau (taking the stairs, walking on uneven ground, etc.). The classic symptoms of the meniscal lesion will recur and the patient returns to the doctor complaining of pain, head and functional limitation.
PHYSICAL THERAPIES: meniscal lesions, with rare exceptions, can only be cured by surgery. As a result, physical therapy cannot have any effect on meniscus repair. However, it can work by reducing pain and relieving symptoms. After the acute phase of the trauma heat can for example be useful to combat local stiffness.
Infiltrations with high molecular weight hyaluronic acid can help cartilage better withstand joint stress after total meniscectomy. These infiltrations also favor the function of the joint by lubricating the two bone ends and nourishing the cartilage.
Surgical treatment
INTRODUCTION: Once the menisci were considered important but not indispensable and were therefore removed in the event of injury. Although in the short term these interventions quickly restored the lost joint function, some subsequent studies showed a profound incidence of arthrosis and degenerative pathologies in patients who had undergone this operation (meniscectomy).
Today the old techniques have been almost completely replaced by arthroscopic surgery which, if the injury makes it possible, does not remove but sutures the damaged part of the meniscus. A succession of numerous studies has clearly shown that the preservation of the meniscus protects the articular cartilage from degenerative processes and that these are directly proportional to the portion of the meniscus removed.
Surgical treatment has the possibility of:
suture the meniscal lesion, promoting healing and spontaneous regeneration
only remove the damaged part of the meniscus (selective meniscectomy)
completely remove the injured meniscus (meniscectomy)
As seen in the introductory part, in some particular situations both of traumatic and degenerative origin, the meniscus has a certain capacity to repair itself. This characteristic is directly related to the local vascularization: the greater the blood supply and the greater the chances of recovery.
The suturing procedure exploits these principles by stitching up the lesion and favoring spontaneous regeneration. The most suitable area for this treatment is the peripheral one. The suturing procedure is performed in arthroscopy and has a much lower risk of complications in the medium and long term compared to meniscectomy interventions. The operation, however, involves rather long recovery times and obliges the subject to four weeks on crutches and a few months of rehabilitation before resuming physical activity. In any case it is a long-term investment, given that meniscal suturing, if indicated and performed well, considerably reduces the risk of long-term cartilage degeneration.
Importance of menisci
The removal even of only parts of the meniscus alters the normal articular relations of the knees causing, in the long run, degenerative phenomena that lead to a self-consumption of the cartilage (arthrosis).
It is clearly demonstrated that preserving, as far as possible, a stable and balanced meniscus protects the cartilage from further overloads and degenerative processes
In particular, some studies have shown that each year after the total meniscus removal operation leads to the loss of 6.5% of the total cartilage volume. For this reason, if the removal is really necessary, it must still be as selective as possible, saving the part of the meniscus that has remained intact.
Once the need for surgery has been established, thanks to arthroscopy the surgeon will be able to see the state of health of the meniscuses, removing the piece of damaged meniscus through small instruments.
MENISCAL TRANSPLANTATION from deceased donors (allograft): it is indicated in patients who have had a total removal of the meniscus and begin to suffer pain while still having intact articular surfaces. In the United States this type of intervention is quite widespread and good results have been reported clinically.
It must however be considered that the transplanted meniscus will be slightly different from that of mother nature. This jeopardizes the functionality of the joint while guaranteeing good mobility and significantly reducing the risk of osteoarthritis.
Today it is also possible to replace the part of the meniscus removed with a special collagen implant that will promote healing by stimulating the regenerative capacity of the meniscus.
PREPARATION FOR SURGICAL INTERVENTION : to ensure a faster recovery after the operation it is essential that patients awaiting surgery daily exercise the anterior thigh musculature.
Isometric contractions of the quadriceps: sitting on the ground, with the injured leg extended and adherent to the ground, the other bent. Push the injured knee towards the ground by contracting the quadriceps (anterior thigh muscle). Hold for 10 seconds, relax and repeat 3 times
Extensions of the lower limb: seated on the ground, with the injured leg extended and adherent to the ground, the other bent. Contract the quadriceps muscles to lift the injured limb by 20 cm keeping the knee fully extended. Hold for 10 seconds, relax and repeat 3 times
Obviously these exercises will be performed only after consulting the doctor as in particular situations they could be contraindicated.
CONTINUE: rehabilitation after meniscal injury »
