Meniscal Repair

Original Editor - Rachael Lowe, Jennifer Uytterhaegen

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Definition/Description

An arthroscopic meniscectomy is a surgical procedure to remove a part or the complete medial or lateral meniscus of the knee joint using arthroscopic or keyhole surgery. In a complete meniscectomy the meniscus including the meniscal rim is removed. Partial meniscectomy is a procedure where the meniscus is partially removed. This may vary from minor trimming of a frayed edge to anything short of removing the rim. This is a minimally invasive procedure often undergone as an outpatient in a one-day clinic

Clinically Relevant Anatomy

Anatomical description shows a difference between the medial and the lateral meniscus :

• The medial meniscus is larger than the lateral meniscus and has a C shape. It will combine with the Lig. Collaterale Mediale
• The lateral meniscus is smaller than the medial meniscus and has an O-shape. This is more mobile than the medial meniscus and will combine with the M. Popliteus.  
• When the patient performs flexion of the knee, the menisci move posteriorly to the tibial plateau. By extension, the original position taken
• When the patient performs internal rotation, the medial meniscus but slightly forward while the lateral is moved slightly to the dorsal. In external rotation is the inverse
• Both menisci are composed of cartilage and collagen type I.

Indication for Procedure

Meniscal tears that are not suitable for meniscal repair.

Clinical Presentation

• joint line tenderness and effusion
• symptoms are frequently worsened by flexing and loading the knee, activities such as squatting and kneeling are poorly tolerated.
• complaints of 'clicking', 'locking' and 'giving way' are common
• functionally unstable knee
• symptoms are frequently worsened by flexing and loading the knee, activities such as squatting and kneeling are poorly tolerated because of stiffness and pain
  

Diagnostic Tests

1. Joint line tenderness has been reported to be the best common test for meniscal injury  
   
2. McMurray's test positive if a pop or a snap at the joint line occurs while flexing and rotating the patient's knee.
   
3. Apley's test performed with the patient prone, and with the examiner hyperflexing the knee and rotating the tibial plateau on the condyles.
   
4. Steinman's test performed on a supine patient by bringing the knee into flexion and rotating.
   
5. Ege's Test is performed with the patient squatting, an audible and palpable click is heard/felt over the area of the meniscus tear. The patient's feet are turned outwards to detect a medial meniscus tear, and turned inwards to detect a lateral meniscus tear.
   
6. MRI: The demonstration of meniscal lesions by MRI has a crucial role in patients with combined injuries as the menisci. The main challenge for MRI is the assessment of the meniscal surfaces. MRI signs of abnormal findings :

• grade I: discreet central degeneration: an intrameniscal lesion of increased signal without connection to articular surface
• Grade II: Extensive central degeneration: larger intrameniscal area of increased signal intensity, may be horizontal in orientation or lineair, again without connection to articular surface
• Grade III: menisci tear: increased intrameniscal signal intensity with contour disruption of articular surface, may be associated with displacement of meniscal fragments or superficial step formation
• Grade IV: complex meniscal tear: multiple disruption of meniscal surfaces
  The difference of tears in the red and in the white zone of the meniscus is important since reattachment of meniscal fragments is promising only in the vascularized zone.

Medical Management

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Physical Therapy Management

The first concern after a arthroscopic meniscectomy is to control the pain and to restore function. The program depends on the surgical procedure and of the protocol of the treating physician.

Early, after the operative period, it is common to begin the therapy with heat treatment. This could be used to relax the tissues around the knee. After that, the therapy could be concluded with a cold treatment in order to control the pain and swelling thay may follow after the exercise.

The next goal is to restore motion and strength to the involved knee
Exercise may be progressed based on the recommendations of the physician. If a meniscal repair has been performed, extreme flexion and rotation should be limited until the wound in the meniscus has had time to heal (8 to 12 weeks). It may be necessary to strengthen the adjacent joints if limited weight bearing was necessary pre- or post-operatively. Knee range of motion exercises can help to restore full mobility to the joint.
Therapy should include flexibility exercises throughout the period of strengthening. While strong muscles around the joint are critical, flexibility of the same muscle groups must be considered. It is important to emphasize closed chain exercises, in which the foot is stabilized, as well as open chain exercises, in which the foot is free to move, when appropriate. Therapy may continue to include the use modalities as needed to control pain and swelling.  

When full, pain-free motion is regained and the individual has sufficient strength for all activities of daily living, the individual may be progressed to balance and proprioceptive exercises. The physician, individual, and physical therapist will determine the extent of these exercises.

• Control the pain and inflammation by using: cryotherapy, analgaesics, NSAIDs.  
• Restore ROM by doing exercises within any limits in range that the consultant has requested

1. improvement of the ROM of the knee joint

• Restore muscle function by doing specific strengthening exercises including quadriceps, hamstrings, hip. Examples:

1. for quadriceps: squads
2. for hamstrings: leg curl with resistance (eg thera band)
3. for hip: bridging

• Optimize neuromuscular coordination - propriocetive re-education.
• Progress weight bearing: weight bearing and joint stress are necessary to enhance the functionality of the meniscal repair so should be progressed as indicated by the consultant.
  

Pre-Op

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Post-Op

The goal of rehabilitation is to restore patient function based on individual needs. It is important to consider:

• the type of surgical procedure
• which meniscus was repaired
• the presence of coexisting knee pathology (particularly ligamentous laxity or articular cartilage degeneration)
• the type of meniscal tear
• the patient's age
• preoperative knee status (including time between injury and surgery)
• decreased range of motion or strength
• the patient's athletic expectations and motivations
  
  Some indications:
• Full weight bearing or bearing weight as tolerated immediately after the meniscectomy.
• Passive and active range-of-motion exercises begin immediately postoperatively and quadriceps strengthening exercises.
• Crutches are usually required for 2-5 days until the patient is able to fully put his/her body weight on the knee without discomfort.
• Return to full daily activity usually at 4-6 weeks, only if there is full range of motion and what about strength
• Sporters are allowed to return to full athletic activities when their quadriceps muscle tone is returned (how do you evaluate this?) and they have painless range of motion.
  --> EMG-B (electromyography-biofeedback) is an effective treatment in improving quadriceps muscle strength after arthroscopic meniscectomy surgery

Type of exercises :

• Stability exercises, then coordination and finally strength exercises. Training of the Quadriceps is really important, and of course training of the hamstrings.
• In the beginning of the therapy the therapist can use some overload exercises since this doesn’t harm.
• At first closed chain exercises are advised and compressive joint load for less drive strength in the joint. Example of exercises are cycling, leg press. For coordination squat and lunches can be given as exercises.

Key Research

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Resources

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Timothy Brindle,John Nyland and Darren L. Johnson (2001) The Meniscus: Review of Basic Principles With Application to Surgery and Rehabilitation. Journal of Athletic Training, 36(2), 160–169.

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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