Indications (Who Needs Surgery, When, Why, and Goals)
- Surgery for meniscus tears is reserved for people who have symptoms such as localized knee pain, and other symptoms including locking, recurrent swelling, and giving way of the knee, and for those in whom conservative treatment for the tear has failed. It is also recommended for those with displaced tears that prevent full knee range of motion (“locked knee”), which is a sign of a “bucket handle” tear. A bucket handle tear is when the meniscus tears and flips to the center of the knee, like moving a bucket handle from one side of the bucket to the other.
- Surgery is performed electively, but locked knees should be operated on at the earliest convenient time. The success of meniscus repair has not been shown to be any better immediately after injury as compared with a couple of months later.
- Only the outer 10% to 30% of the meniscus cartilage has blood supplying it. Blood is needed to help a meniscus heal. Because of this, fewer than 20% of all meniscus tears are repairable by suturing (sewing) it together. The rest of the tears are treated by meniscectomy (removal of part of the meniscus).
- A torn meniscus usually does not heal itself, unless the tear is in the outer portion of the meniscus where the blood supply is. Thus most tears do not heal on their own. Further, meniscus cartilage that is removed does not regenerate. Once removed, it is gone.
- The success of meniscus repair (healing of the tear) is about 80% in knees with an intact anterior cruciate ligament (ACL). However, meniscus repair when the ACL is torn and not reconstructed is successful only 40% of the time. Thus if the meniscus tear is repairable and you also have an ACL tear, most surgeons also recommend reconstructing the ACL. The age of the patient has no effect on healing of a repair.
- Because one function of the meniscus is to distribute joint forces, a torn meniscus may be associated with the early development of arthritis of the knee joint. Thus the goal of meniscal surgery is to eliminate the symptoms in your knee while trying to save as much of the meniscus as possible. This would be by repairing the meniscus, if possible, or removing as little of the meniscus as possible.
- Removing all or part of a torn meniscus allows for contouring of the cartilage and removal of torn edges that prevents
- progression of the tear (making a smaller tear larger) and
- Displacement of the tear, causing recurrence of symptoms of locking, giving way, and swelling.
- Infection of the knee
- Inability or unwillingness to complete the postoperative program (for meniscus repair) or to perform the rehabilitation necessary
- Pain or symptoms not related to the meniscus
- Infection
- Bleeding
- Injury to nerves (numbness, weakness, paralysis)
- Blood clot in the calf or thigh
- Recurrence of symptoms (giving way, locking, or swelling), including tearing the remaining meniscus if menisectomy is performed, and retear or nonhealing of the meniscal repair
- Knee stiffness (loss of knee motion)
- Continued pain
- Weakness of the quadriceps muscles
- Possible knee arthritis later in life
Arthroscopy has become the standard way of operating on meniscal tears. This is done on an outpatient basis (you go home the same day) and may be done under general anesthesia, spinal anesthesia, and sometimes local anesthesia. Small shavers and cutting instruments are used to remove and contour torn cartilage that is not repairable. For tears that are repairable, the edges of the tear are freshened; then sutures (to sew), anchors, or tacks are used to hold the torn edges together while the meniscus heals.
From Shankman GA: Fundamental Orthopaedic Management for the Physical Therapy Assistant. St. Louis, Mosby Year Book, 1997, p. 167.
Postoperative Course
- Keep the wound clean and dry in the initial postoperative period.
- Keep the foot and ankle elevated above heart level as much as possible for the first 1 to 2 weeks after surgery.
- I will prescribe pain medications and an anti-inflammatory medication
- Icing the knee will help reduce swelling.
- For partial meniscus removal, you may put as much weight on the operated leg as possible, although you will be given crutches after surgery until you can walk without a limp.
- For meniscus repair, you will be in a knee brace, and you will be on crutches for 4 to 6 weeks with only partial weight on the operated leg.
- Postoperative rehabilitation and exercises are very important to regain motion and then strength. You may be referred to a physical therapist, although this is usually not needed.
- Return to sports depends on the type of sport and the position played.
- It may take 6 weeks before sports can be resumed after meniscectomy (although may be as early as 1 to 2 weeks) or 6 to 9 months after a meniscus repair.
- Full knee motion and strength are necessary before sports can be resumed.
- You experience pain, numbness, or coldness in the foot
- Any of the following signs of infection occur after surgery: fever, increased pain, swelling, redness, drainage, or bleeding in the surgical area
- New, unexplained symptoms develop (drugs used in treatment may produce side effects)
From Nicholas JA, Hershman EB: The Lower Extremity and Spine in Sports Medicine. St. Louis, Mosby Year Book, 1995, p. 765.
In the figure above, the torn meniscus is partially removed and normal meniscus is left behind. Most meniscus surgery is performed this way.
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