ProviderPulse
The Meniscal Tear: To Fix or Not to Fix, That is the Question
Featured Story
January 2012
Contributed by James T. Johnson, M.D.
What is the meniscus? It is a C-shaped cartilage pillow situated between the tibia and femur. This cartilage is similar to the rubbery cartilage found in your nose or the firm part of the ear. Two menisci are found on the inside (medial) and the outside (lateral) aspects of the knee, and they have many functions: lubrication, passive stabilization, shock absorption and distribution of loads transmitted across the knee joint. They distribute 50 percent of the load with the knee in extension and 85 percent of the load in flexion. The forces across the joint can reach up to two to four times your body weight while walking and up to six to eight times your body weight during running. When the menisci are completely removed, there is a greater than 200 percent increase in contact pressure, which will increase the probability and severity of degenerative joint disease.
How do menisci tear?
In the younger population, tears frequently occur secondary to acute trauma. They are associated with a twisting injury, forceful squat or a quick change in direction. This is often associated with effusions (swelling) of the knee the following day. Degenerative tears commonly occur in individuals older than 40. A significant specific traumatic event is not always recalled. These can present with recurrent effusions. Meniscal tears are among the most common injuries to the knee. The incidence of acute meniscal tears in the general population is six per 10,000 people. In patients over 65 years of age, the incidence of degenerative tears is 60 percent; however, many of these are asymptomatic.
Which type of tear needs to be repaired?
Treatment of meniscal tears varies between conservative non-operative treatment and surgical intervention, which includes partial menisectomy or meniscal repair. Many factors must be considered when deciding on treatment: patient’s age, activity level, duration of symptoms, type of meniscal tear and associated ligamentous pathology, (e.g., an ACL tear). Once again, not all meniscal tears are symptomatic and not all meniscal tears require surgery. Some small stable partial tears may heal over time. Therefore, individuals can be observed for one to two months with controlled activity (e.g., no squatting beyond 90 degrees, jumping or twisting). If they become asymptomatic after this period, they will not require surgical intervention. If the symptoms do not improve, surgery is recommended. However, in patients who cannot afford to wait or choose not to wait — such as laborers or professional, competitive or recreational athletes — sooner surgical intervention is recommended. If a symptomatic tear is not addressed, a small tear can easily propagate into a larger tear.
What surgical options exist?
Surgery is performed arthroscopically through three small incisions. In the event of a large unstable tear, surgery is recommended. The meniscal tear can either be removed or repaired. The load sharing property of the meniscus is so crucial that we must compromise between removing the unstable torn cartilage and preserving as much of the meniscus as possible. Sometimes meniscal tears will heal, which depends on the blood supply to the torn area. When we visualize the meniscus, it can be divided into thirds: the outer third, the middle third and inner third. The blood supply is located in the outer third with regularity and in the middle third with variability. The inner third is avascular (no supply). The blood supply to the outer rim decreases with increasing age and, in turn, the body’s ability to heal the tear decreases with age. The far majority of meniscal tears undergo arthroscopic debridement. The unstable portion of the meniscus is removed leaving healthy stable meniscus. This meniscal cartilage does not grow back. If the tear occurs through the vascular portion of the meniscus, the surgeon may attempt to fix it. This is often determined at the time of the surgery by the surgeon. If repairable, the meniscus will be fixed with sutures arthroscopically or through a small incision. The patient may have restrictions on range of motion and weight bearing for several weeks.
Why are not all menscial tears repaired?
You can attempt to repair the tear, but it may not heal. Again, this depends on the blood supply and chronicity of the tear. The meniscal tear can be thought of as a piece of steak that is cut, lengthwise, into two pieces. If it is addressed in a timely fashion, two healthy portions remain that can be repaired with a suture through both sides. With good blood supply, this should heal. However, if the meniscal tear is not addressed in a timely fashion and the patient continues with aggressive activities, the outer rim of the meniscus may remain healthy but the inner portion will be significantly more traumatized and damaged. When this happens, the tissue will not hold a suture placed through it. As the patient increases activities, the sutures will pull out and the symptoms will return. Two to four months later, the patient would then need to undergo another surgery to remove the failed symptomatic meniscal repair. The patient would have spent a considerable amount of time, money and resources only to have the surgery repeated.
As you can see, there are many variables involved when deciding whether or not to repair or remove a meniscal tear, and each individual case is different. Sometimes conservative treatment will be enough, while other times surgical repair or removal is indicated.
In the younger population, tears frequently occur secondary to acute trauma. They are associated with a twisting injury, forceful squat or a quick change in direction. This is often associated with effusions (swelling) of the knee the following day. Degenerative tears commonly occur in individuals older than 40. A significant specific traumatic event is not always recalled. These can present with recurrent effusions. Meniscal tears are among the most common injuries to the knee. The incidence of acute meniscal tears in the general population is six per 10,000 people. In patients over 65 years of age, the incidence of degenerative tears is 60 percent; however, many of these are asymptomatic.
Which type of tear needs to be repaired?
Treatment of meniscal tears varies between conservative non-operative treatment and surgical intervention, which includes partial menisectomy or meniscal repair. Many factors must be considered when deciding on treatment: patient’s age, activity level, duration of symptoms, type of meniscal tear and associated ligamentous pathology, (e.g., an ACL tear). Once again, not all meniscal tears are symptomatic and not all meniscal tears require surgery. Some small stable partial tears may heal over time. Therefore, individuals can be observed for one to two months with controlled activity (e.g., no squatting beyond 90 degrees, jumping or twisting). If they become asymptomatic after this period, they will not require surgical intervention. If the symptoms do not improve, surgery is recommended. However, in patients who cannot afford to wait or choose not to wait — such as laborers or professional, competitive or recreational athletes — sooner surgical intervention is recommended. If a symptomatic tear is not addressed, a small tear can easily propagate into a larger tear.
What surgical options exist?
Surgery is performed arthroscopically through three small incisions. In the event of a large unstable tear, surgery is recommended. The meniscal tear can either be removed or repaired. The load sharing property of the meniscus is so crucial that we must compromise between removing the unstable torn cartilage and preserving as much of the meniscus as possible. Sometimes meniscal tears will heal, which depends on the blood supply to the torn area. When we visualize the meniscus, it can be divided into thirds: the outer third, the middle third and inner third. The blood supply is located in the outer third with regularity and in the middle third with variability. The inner third is avascular (no supply). The blood supply to the outer rim decreases with increasing age and, in turn, the body’s ability to heal the tear decreases with age. The far majority of meniscal tears undergo arthroscopic debridement. The unstable portion of the meniscus is removed leaving healthy stable meniscus. This meniscal cartilage does not grow back. If the tear occurs through the vascular portion of the meniscus, the surgeon may attempt to fix it. This is often determined at the time of the surgery by the surgeon. If repairable, the meniscus will be fixed with sutures arthroscopically or through a small incision. The patient may have restrictions on range of motion and weight bearing for several weeks.
Why are not all menscial tears repaired?
You can attempt to repair the tear, but it may not heal. Again, this depends on the blood supply and chronicity of the tear. The meniscal tear can be thought of as a piece of steak that is cut, lengthwise, into two pieces. If it is addressed in a timely fashion, two healthy portions remain that can be repaired with a suture through both sides. With good blood supply, this should heal. However, if the meniscal tear is not addressed in a timely fashion and the patient continues with aggressive activities, the outer rim of the meniscus may remain healthy but the inner portion will be significantly more traumatized and damaged. When this happens, the tissue will not hold a suture placed through it. As the patient increases activities, the sutures will pull out and the symptoms will return. Two to four months later, the patient would then need to undergo another surgery to remove the failed symptomatic meniscal repair. The patient would have spent a considerable amount of time, money and resources only to have the surgery repeated.
As you can see, there are many variables involved when deciding whether or not to repair or remove a meniscal tear, and each individual case is different. Sometimes conservative treatment will be enough, while other times surgical repair or removal is indicated.
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