Arthroscopic Meniscectomy-Minimally Invasive Arthroscopic Surgery for Torn Meniscus Cartilage in the Knee.
Edited By: Carol C. Teitz, M.D.
Last updated Wednesday, January 12, 2005
Arthroscopic Meniscectomy - MRI showing a torn meniscus Arthroscopic Meniscectomy - Types of Meniscal Tears Arthroscopic Meniscectomy - MRI showing a torn meniscus Arthroscopic Meniscectomy - Set-up for Arthroscopic Meniscectomy SummaryOverview Arthroscopic meniscectomy is an outpatient minimally invasive surgical
procedure used to treat a torn meniscus cartilage in the knee. The
meniscus is often torn as a result of sport-related injury in athletic
individuals. Only the torn segment of the meniscus is removed. Some
patients require assistance from physical therapists postoperatively.
The average time of return to all activities is 4-6 weeks after the
surgery.Characteristics of torn meniscus cartilage in the knee A torn meniscus usually produces swelling and well-localized pain in
the knee. The pain is made worse by twisting or squatting motions.
Sometimes a fragment of torn meniscus can displace inside the knee in
such a way as to "lock" the knee, allowing only a toggle of motion.Types A tear can occur in one or more directions in the meniscus. Traumatic
tears are usually vertical whereas degenerative tears are usually
horizontal. The shape that the meniscus and its torn portion assume has
led to names like "bucket handle tear," "parrot beak tear," and others.
Sometimes the meniscus deteriorates to the point where the tear is no
longer a "clean" tear, but rather the meniscus is shredded and
resembles crab meat.Similar conditions ometimes the symptoms from a torn meniscus can be confused with those from significant knee arthritis
with loose articular (gliding) cartilage. Occasionally a chronically
inflammed knee will produce similar findings.
Usually these conditions can be distinguished from a torn meniscus by
history and a good physical exam. Sometimes, though, they can only be
distinguished by MRI or diagnostic arthroscopy.
Incidence and risk factors Meniscal tears are common especially in people participating in sports.
Traumatic tears usually occur as a result of a twisting or hyperflexion
injury. Degenerative tears are more common in people over 40 and may
occur without a specific injury. Smokers are at higher risk for
degenerative tears.Diagnosis A torn meniscus is diagnosed on the basis of the patient's history and
a thorough physical exam. An MRI is often used to confirm the diagnosis.Medications Medications can relieve pain and swelling temporarily, but will not actually produce healing of the torn meniscus.
Exercises Quadriceps strengthening exercises can help prevent the muscle atrophy that is associated with a painful, swollen knee.Possible benefits of arthroscopic meniscectomy-minimally invasive arthroscopic surgery When the torn part of the meniscus is removed, any catching or locking
should be gone immediately. Pain is usually minimal by 1 week after
surgery. Full motion of the knee returns as the swelling disappears,
usually within 4-6 weeks after the surgery.Types of surgery recommended The surgical treatment for a torn meniscus is either to remove or
repair the torn segment of the meniscus using an arthroscope and
specially designed instruments. Because only the outer 1/4 of the
meniscus has blood supply, repairs are successful when the tear occurs
in this vascular region of the meniscus. Tears in the non-vascular
region are unlikely to heal and therefore are removed. (For information
on meniscal repair, see article on that topic).Who should consider arthroscopic meniscectomy-minimally invasive arthroscopic surgery? Occasionally the symptoms from a degenerative tear will quiet down
without surgery. Surgery for a torn meniscus should be considered when
the knee is "locked",
the knee is persistently swollen,
the patient can not participate in normal activities,
the patient understands and accepts the risks, and the surgeon is
fellowship trained and experienced in arthroscopic meniscectomy.
What happens without surgery? In the best case scenario, the symptoms of swelling and pain will
resolve and the patient will be able to resume activities.
In the worst case scenario, the torn fragment of meniscus will "lock"
the knee, preventing all but a small amount of motion. This makes
activities of daily living difficult.
Effectiveness In the hands of an experienced fellowship trained orthopaedic surgeon,
removal of the torn part of a meniscus is very effective in restoring
comfort and function to the knee. The knee will usually function
normally for decades. If an entire meniscus needs to be removed, that
section of the knee is likely to become arthritic 10-15 years later.Urgency Removal of a torn segment of meniscus is urgent only when the knee is
locked. Even then the urgency is about the patient's comfort and
ability to get around more than it is about the long term effects on
the rest of the knee joint. A torn segment of meniscus that catches,
locks, or produces swelling on a frequent basis should be removed
relatively quickly (within a few months) so that it does not damage the
articular (gliding) cartilage in the rest of the knee. Waiting to
remove the mobile torn fragment can also lead to muscle atrophy and
joint contracture which make it more difficult for the patient to
ultimately regain normal function after surgery.Risks The risks of arthroscopic meniscectomy include but are not limited
to infection and deep vein thrombosis ( blood clot) in the operated
leg. If a clot forms and travels to the lung, the situation can be life
threatening. Fortunately this is uncommon. Sometimes there will be
numbness around the small scars where the instruments have entered the
knee. There are also risks to anesthesia. An experienced team will take
care to minimize these risks, but cannot totally eliminate them.
Managing risk The risk of infection can be decreased by using intravenous
antibiotics during surgery. If infection occurs, the patient is taken
back to the operating room where the knee is washed out using
arthroscopic equipment. The patient is then put on intravenous
antibiotics, usually for 6 weeks depending on the organism causing the
infection.
If a blood clot forms in the leg, the patient is usually put on blood
thinners to prevent the clot from expanding or moving. If the patient
has concerns about the post operative course of events, the surgeon
should be informed as soon as possible.
Preparation Prior to surgery, the patient should have no ongoing infections, and
the knee should have no sores or scratches. The patient should NOT
shave the knee the day before surgery. The patient should have someone
to help at home for 24-36 hours after the surgery.
Because airplane flight is also associated with blood clots in the leg,
we recommend that patients not travel by plane in the first 5 days
after surgery. Similarly, because dental work releases bacteria into
the blood stream, we recommend that dental work be put off until after
the knee has fully recovered from surgery, typically 4-6 weeks. When
this is not possible, we recommend antibiotic coverage around the time
of the dental work.
Costs The surgeon's office should provide a reasonable estimate of the
surgeon's fee, the hospital fee, the anesthesia fee, and the degree to
which these should be covered by the patient's insurance.Surgical team Arthroscopic meniscectomy should be performed by an orthopaedic surgeon
fellowship trained in arthroscopic surgery of the knee. The procedure
should be done in a medical center or outpatient surgical facility that
is accustomed to doing arthroscopic meniscectomies frequently.Finding an experienced surgeon Surgeons specializing in arthroscopic meniscectomy can be located
through university schools of medicine, county medical societies or
state orthopaedic associations. Other resources include the American Orthopaedic Society for Sports Medicine and the American Academy of Orthopaedic Surgeons.Technical details Once the patient is asleep or the knee is anesthetized, three small
holes (portals) are made in the knee. The arthroscope is inserted into
one of the portals. Another portal is used for a cannula to keep a
saline solution flowing through the knee to improve visibility and
maneuverability of the instruments. The third portal is for the working
tools. The arthroscope and the tools are typically 4.5 mm in diameter.
The entire inside of the knee is inspected, including the kneecap, the
ends of the thigh and leg bones that form the knee, the menisci, and
the cruciate ligaments. The tear is identified and probed with a small
hook to determine where it starts and ends and how mobile it is.
The torn fragment is then cut free and removed. The edge of the
remaining meniscus is then shaved smooth. Any shaggy articular
(gliding) cartilage is also shaved. The knee is then reinspected to
make sure there are no other abnormal findings.
Finally additional saline is flushed through the knee to wash out any
tiny particles that may be floating around.
The portals are each closed with one stitch and a long acting pain
reliever is injected into the joint.Anesthetic Arthroscopic meniscectomy can be performed with the patient under a
general anesthetic or with a spinal block. Before surgery, patients can
discuss their preferences and the risks and benefits of various types
of anesthesia with the anesthesiologist.
Because arthroscopic surgery is done with a camera on the arthroscope,
a patient who has chosen to stay awake may watch and talk to the
surgeon during the procedure.
Length of arthroscopic meniscectomy-minimally invasive arthroscopic surgery The procedure usually takes about one hour. However, the
preoperative preparation and the postoperative recovery may add several
hours to this time.
Pain and pain management In the first 24-48 hours after arthroscopic meniscectomy, the operated
knee is swollen and moderately painful. However most patients are able
to return to sedentary jobs by the third postoperative day. Medications
used to manage pain in the first 48 hours include oral narcotics such
as hydrocodone or oxycodone. Some patients obtain good pain relief in
the immediate postoperative period with Vioxx. Subsequently,
acetaminophen or ibuprofen are sufficient.
The application of ice or other cold therapeutic devices to the knee
are also very helpful in controlling pain and swelling.Use of medications Most patients do not use any pain relievers after the first postoperative week.Important side effects Narcotic pain medications can cause drowsiness, slowness of breathing,
difficulties emptying bowel and bladder, nausea, vomiting, and allergic
reactions. Anti-inflammatory medications can cause stomach irritation,
nausea and headaches. Patients who have had substantial exposure to
narcotic medications or alcohol in the recent past may find that the
usual doses of pain medication are less effective. For some patients,
balancing the benefit and the side effects of pain medication is
challenging. Patients should notify their surgeon if they have had
previous difficulties with pain medication or pain control.Hospital stay Arthroscopic meniscectomy is an outpatient procedure. After surgery the
patient remains in the recovery room until the effects of anesthesia
have worn off, usually for 1-2 hours.Hospital discharge By the time the patient leaves the recovery room, he or she may put
as much weight as tolerated on the operated limb. Many patients choose
to use crutches for a few days. Staying relatively quiet, keeping the
limb elevated and the knee iced for 48 hours is the best way to keep
swelling to a minimum thus speeding return to full activities. During
the first 48 hours, before the patient is fully up and around, it is
also important to flex one's feet up and down regularly to help prevent
blood clots from forming in the calf veins.
Convalescent assistance Patients do not require a convalescent facility after arthroscopic
meniscectomy. They may require some assistance with self-care for the
first day or two. Driving may be difficult in the first postoperative
week until the swelling has resolved enough to allow sufficient knee
motion.Physical therapy The keys to full functional recovery are regaining knee range of motion
and Quadriceps muscle strength. Both are limited as long as the knee is
swollen. Many patients are able to regain their motion and strength
with exercises at home. Some patients require the assistance of a
physical therapist. Usually at the first post operative visit, the
surgeon can determine whether or not PT is necessary.Usual response Most patients respond well to rehabilitation after arthroscopic
meniscectomy. Usually as the swelling resolves, motion increases and it
is easier to work on muscle strengthening exercises. If the exercises
are difficult or painful, the patient should contact the therapist or
surgeon.Risks Rehabilitation after arthroscopic meniscectomy carries little or no risk.Duration of rehabilitation Rehabilitation is continued until the knee has regained full range of motion and strength .Returning to ordinary daily activities Usually patients return to activities of daily living in 48 hours
postoperatively. Depending on the amount of swelling, driving may be
difficult for an additional 2-3 days. Returning to sports is usually
discouraged until the patient has recovered full range of motion and
strength. On average this takes 4-6 weeks.Long-term patient limitations Usually there are no limitations on the patients after full recovery
and rehabilitation. However, if at the time of surgery the surgeon
noted significant arthritic changes in the knee, running sports may be
discouraged to slow down the progression of the arthritis.Costs Most of the rehabilitation after arthroscopic meniscectomy is done
at home. Nevertheless, when physical therapy is required, the surgeon
or therapist can provide information on the usual cost for physical
therapy visits. Each insurance company has its own plan for coverage of
physical therapy.
Summary of arthroscopic meniscectomy-minimally invasive arthroscopic surgery for torn meniscus cartilage in the knee In the hands of an experienced fellowship trained orthopaedic
surgeon, Arthroscopic Meniscectomy ( removal of the torn part of the
meniscus) can be a most effective method for restoring comfort and
function to a knee with a torn meniscus.
The surgery is done on an outpatient basis.
Full recovery requires elimination of swelling, and regaining full
range of motion and strength. Physical therapy is sometimes needed.
Complete recovery and return to sporting activities takes an average of 4-6 weeks.
Surgery for Torn Meniscus Cartilage in the Knee at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-543-1552 or 425-646-7777 to make an appointment.
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