Jewett Orthopaedic Clinic There are two types of cartilage in the
Jewett Orthopaedic Clinic There are two types of cartilage in the
Meniscus Tears and Arthroscopy of the Knee Richard M. Konsens, M.D. Jewett Orthopaedic Clinic There are two types of cartilage in the knee. Hyaline cartilage is the glistening white surface seen when one opens a chicken joint. When this hyaline cartilage is worn or damaged, it is called arthritis. The other type of cartilage in the knee is a fibrous washer known as the meniscus. The medial meniscus is on the inside of the knee and the lateral meniscus is on the outside. They are thick, fibrous washers that act as shock absorbers, protecting the glistening joint cartilage from wear, helping joint motion and providing stability. Tears of the meniscus are one of the most common knee conditions. Acute tears more commonly occur in young, athletic patients with hyperextension or twisting trauma. Chronic meniscus tears can occur gradually without an injury or with minor trauma and are more common in the middle and older age groups. These chronic tears may cause symptoms for months or even years before the patient consults a physician. Symptoms of meniscus tears can vary but frequently include swelling, stiffness, popping and clicking noises, varying degrees of pain and locking of the knee joint. The meniscus tear may be diagnosed clinically from the patient's history and physical examination. Sometimes an MRI scan is helpfulto confirm the diagnosis. ln general, we employ conservative management in the treatment of cartilage tears. The first line of treatment may include icing the knee three or four times a day for 10 minutes, antiinflammatory medication to reduce swelling and inflammation, simple exercises to maintain range of motion and strength and restrictions to avoid the activities that aggravate the knee. lf the symptoms are not responsive to these simple treatments, an intraarticular steroid injection may be helpful to relieve the symptoms. ln cases where mechanical symptoms persist, we consider arthroscopic surgery. The history of endoscopy, or scoping within the body, began in Europe in the 1850s. lt was not until the early 1970s that its application to knee surgery became apparent. Over the past 40 years improvements in instrumentation, technique and experience have made arthroscopic surgery one of the most common techniques in modern orthopaedics. Whereas most knee surgeries previously required an open incision, now many treatments can be performed through the arthroscope. lf the meniscus is torn we can evaluate the tear in terms of its exact location, size and geometry. About 5% of meniscus tears can be sewn back together. These tend to be acute tears in younger patients. ln most cases, this is not done because the healing potential and type of tear prevent sewing the meniscus back together. Usually the part of the meniscus that is torn is simply removed or resected, leaving the intact rim as a shock absorber. Research shows that retaining as much healthy meniscal tissue as possible helps reduce the risk of future arthritis and disability of the -2- knee. Additionally, removing torn meniscus fragments and contouring the remaining meniscal rim can help the swelling, pain, clicking and locking that may be associated with the tear. The advantages of arthroscopy are numerous. The procedure generally takes less than 30 minutes to perform. This means less anesthetic, less risk of infection, medical risks, phlebitis and pneumonia compared to longer surgical procedures. We start with an examination of the knee under anesthesia before the arthroscope is inserted. We do the procedure through two small portals, each about onethird of an inch in length which are repaired with a single suture in each. Once the arthroscope is inserted, a routine "tour" of the entire joint is performed assessing the main ligaments, articular surfaces, synovial capsule and meniscus. We can remove loose fragments of bone or cartilage, do biopsies, remove inflammatory tissue and smooth and treat roughened arthritic cartilage. Before embarking on any procedure the risks should be understood. With arthroscopy the risks have certainly been reduced from prior techniques. First is the risk of infection. This occurs in approximately one out of 1000 patients who undergo the procedure. The symptoms of an infected knee could include high fever, inability to move the knee, drainage, redness, extreme pain and swelling. ln the unlikely event of an infection we would immediately return you back to surgery and re-arthroscope the knee to clean it out. You would generally be on antibiotics for a period of time after that. The next potential risk is phlebitis. Phlebitis or a blood clot is very uncommon after arthroscopic surgery. Risk factors for phlebitis include obesity, steroid use, birth control pills, smoking and a prior history of phlebitis. Perhaps the most common risk of arthroscopy is an incomplete relief of symptoms. Those patients who have significant arthritis in addition to the meniscus tears still generally do improve, but the improvement can take three or more months to occur. Most of the arthroscopic procedures are performed under general anesthesia. The expertise of the anethesiologist as well as the newer anesthetic agents make general anesthesia very safe for most patients. Once you decide to undergo the arthroscopy, you can call my scheduling secretary. She will check with your insurance company and schedule the surgery and office visits. Most patients under 40 years of age may not require any labs but most over the age of 50 require a simple blood test, urine analysis and an EKG. Most will be seen a day or two prior to the surgery in the office to check the labs, sign consents and answer any last minute questions. Antiinflammatory medication and all herba! supplements should be discontinued for at least two weeks prior to the operation if possible. lf you are taking a blood thinner such as Plavix or Coumadin, check with your medical doctor and stop -3- it at least five days prior to the surgery. !t can generally be restarted on the evening after the operation. The surgery generally takes about 30 minutes and you will be in the operating room for approximately 40 minutes. After surgery most people spend about a half an hour in the recovery room and then are allowed to return home. Most patients do not require crutches and can walk full weightbearing as tolerated. After the surgery you will be given specific postoperative instructions. !n most cases it is important to apply ice to the knee as much as possible for at least 20 minutes every hour while awake for the first day or two and then two or three times a day until seen in the office. ! encourage elevation of the knee to decrease swelling when sitting or lying. On the second or third postoperative day you may remove the Ace bandage and dressings and apply Band-Aids to the two small wounds. You should expect mild discomfort at times and swelling as well. Warning signs include severe swelling, elevated fever, chills, night sweats, increasing pain and calf pain. lf you have any of the warning signs, please do not hesitate to ca!! the office. Besides full weightbearing we encourage motion of the knee in almost all cases. Unless otherwise instructed using a stationary bicycle or doing stretching exercises can be quite helpful. You will be prescribed pain medication and if no other antiinflammatories are prescribed a course of Aleve after the surgery may help relieve some of the swelling. Generally we recommend a followup appointment at the Jewett Clinic seven days after surgery to remove the sutures and go over the diagnosis and treatment plan. Usually four weeks after the surgery a final followup is arranged. This concludes the arthroscopy of the knee information handout. Of course it is impossible to answer every question in a summary such as this. lf there are additional questions, please write them down and do not hesitate to ask.
Meniscus Disorders, Knee The Medical Disability Advisor: Workplace Guidelines for Disability Duration