The following is designed to present an overview of Meniscal (Cartilage) Tears so that you might better understand what it means and the treatment options available.
There are two types of cartilage in the knee joint. The first type is located between the two bones of the joint, and these are called the medial and lateral menisci (meniscus, singular). The two of these cartilage structures sit on top of the tibial plateau; one on the inner side or medial side of your knee, and other on the outer side or lateral side of your knee. These are fairly thick, fibrous, C-shaped structures that cushion, protect and stabilize the knee, yet are often torn in injuries. In cross section, or when cut across, they are triangular in shape. They are important and have multiple functions, the most important of which are weight bearing and/or load transmission, joint stability, cushioning, and joint lubrication.
The other kind of cartilage lines the joint surfaces and acts like a cap to cover the ends of each bone. This cartilage is called articular cartilage. It is a smooth, slick, shiny white substance which, in its normal, healthy state, covers, protects and cushions the joint itself, as well as allowing the surfaces to glide against each other. You have probably seen this on the ends of animal bones, such as chicken joints, etc. This is the type of cartilage which is affected by the wearing-down process of arthritis
The meniscus can be torn in many different ways. The most common mechanisms are twisting, bending or squatting. This is often a painful episode accompanied by a click, a pop, or a catching sensation. Some patients, however, can tear a cartilage and have no specific recollection of when or how they did it. In general, the meniscus is tougher and harder to tear in young people, and a history of significant trauma is often the case in this age group. Most patients with a torn cartilage will have one or more of the following symptoms: pain, clicking, popping, catching, locking, and/or swelling. Locking occurs when the torn part of the cartilage gets caught between the two bones and cannot get out of this position.
The diagnosis of a meniscal tear is usually made by the patient telling the physician about the type of injury, the symptoms, and the physician’s examination. The x-ray is helpful After ACL Injury in determining other factors which may be related to other diagnoses. X-rays show only the bone, and menisci, being cartilage, have no bone in them. Plain x-rays will not make a diagnosis of a torn cartilage. There is an old x-ray test called an arthrogram in which dye is injected into the knee by a radiologist and the x-rays are made with the dye in the knee. The dye highlights the tear and then can be seen on plain x-rays.
A newer and much more sensitive test is called MRI, or magnetic resonance imaging. As the name implies, a magnet is used to form images of the structures inside the knee. These images are various “shadows” of the structures based on the different amount of water in each different type of tissue. Studies have shown that MRIs are 90 to 95% accurate in being able to determine if there is a tear in a meniscus. In some very specific cases, I may recommend an MRI arthrogram. In those cases, a special dye is injected into the knee and then the MRI is performed. Like the old arthrograms, the dye highlights the tears and injured regions within the knee, making them more easily seen on MRI.
What else could be wrong besides a torn cartilage? There are several conditions which can mimic a torn cartilage very closely. The first and most common condition is arthritic changes in the knee. It is also possible to have both. The arthritis can be on the same side of the knee with the torn cartilage or the other side, or behind the kneecap. X-ray is helpful in making the diagnosis of arthritis, but it does not show the earlier stages. The second is an abnormally tight or thick band of joint lining which might be developmental, congenital, or secondary to trauma, can mimic the signs and symptoms of a torn cartilage. The medical term for this is plica or shelf.
What are your treatment options? These will vary depending on how much trouble you are having, your age, health, activity level, desires, and so forth. In general, cartilage tears will not heal by themselves. They may become less symptomatic with rest, crutches, and medication, but the symptoms usually recur with resumption of normal activity. One option, therefore, is to rest, (usually with crutches) do some exercises and try to maintain good muscle tone, and take an anti-inflammatory medication.
For most, the symptoms either are or have been severe enough to warrant having something further done. In my opinion, the best way to establish a diagnosis with 100% certainty, and to do something about it, is to arthroscope the knee. An arthroscope is a small telescope which allows me to see inside the knee after inserting it through a small, approximately 5 mm puncture wound. This is done as an outpatient at the hospital or surgery center. Anesthetic is required and the anesthesiologist will discuss the kind of anesthetic with you after you are admitted to the hospital. Most patients have a general anesthetic (go to sleep), but it can be done with a spinal epidural or a local anesthetic. The type of anesthetic used will be determined by your desires, other medical conditions, your anxiety level, and other factors.
Once the arthroscope is in the knee, the entire internal portion or intra-articular portions of the knee can be examined and the cartilage tear can be found. Some cartilage tears are not repairable. In that case, one or more small instruments are inserted through other small puncture wounds, and the torn part of the cartilage is removed. The unaffected portion of the cartilage is left intact. The damaged part is usually about a sixth or a third of the total volume of cartilage. It can be substantially more or less.
Some other cartilage tears may be considered to be repairable. In these, stitches or sutures can be placed cross the torn part of the cartilage with arthroscopic control. If this is done, sometimes a small incision may be necessary on the back or the side of the knee to tie the stitches. Most often today, the repairs can be made totally within the knee without the need of making external incisions. Even though repair seems like more surgery, patients can still go home on the same day.
The main difference between taking out the torn meniscus and repairing the tear is that, if the torn part is removed, your time on crutches will be about a week or so and you will be able to put all your weight on your knee fairly quickly. However, if the tear is repaired with sutures, as described above, sometimes (rarely) hinged-brace is needed to restrict some of the knee motion for a total of six weeks. Crutches are also needed for six weeks as you can only put some weight on that side (partial weight bearing). After that, the recovery is pretty much standard, with full resumption of sports and activities without restrictions occurring three months from the time of repair. There is a chance (approximately 20% to 30%) that the cartilage will re-tear. The decision to attempt repair depends on the type of the tear, the age of the patient, and other factors. In general, the younger the patient and larger the tear, the stronger I feel about trying to repair it. The specifics of your case will be discussed with you.
Patients that work for themselves or have a sedentary or office type job, can go back to work within the next few days following surgery, if they feel like it. Labor and most athletic activities require about three to six weeks, depending on several variable factors, such as type of surgery, age, desire, motivation, and so forth.
Complications from arthroscopic surgery are rare. The most common is swelling. If this occurs, it will prolong your recovery, but ultimately will resolve and not be a long term problem. Do not take anything with aspirin in it for at least ten days prior to the surgery. Aspirin, or medicines containing aspirin, diminish the ability of blood to clot and can result in excessive bleeding and swelling in the knee after an arthroscopic procedure. Infection, which means pus in the knee, can occur. This is serious and will require re-admission to the hospital, prolonged intravenous antibiotic treatment, and one or more arthroscopies to clean out the knee. Residual stiffness and loss of motion can occur secondary to this complication. Blood clots in the leg, or thrombo-phlebitis, can occur and will often require admission to the hospital and specific treatment with blood thinners. If the blood clot goes to the lung, it can be life threatening. Anesthesia complications will be discussed by the anesthesia physician, or anesthesiologist. Complications can occur if the cartilage is repaired; these are also rare. Since needles are being pushed through the cartilage and out the sides and back of the knee, punctured nerves and blood vessel can occur. In the case of a damaged nerve, numbness and/ or hypersensitivity of the skin and partial paralysis of some of the muscles below the knee can occur. Blood vessel damage, in the worst scenario, could result in loss of limb. I have not had any of these complications except occasional numbness and hypersensitivity of the skin, which is usually not a serious problem.
Reflex sympathetic dystrophy is the medical term for an extremely rare complication following injury and/or surgery on the extremities. It is an abnormal response to injury and/or surgery which involves the small nerves (sympathetic nerves) which supply the blood vessels and sweat glands. It is painful, and the symptoms can involve the whole limb. They include hypersensitivity, increased sweating, color change, and others. Once diagnosed, it can usually be successfully treated, but this can be long, difficult and frustrating for both the patient and the physician.
The consequences of partial removal of a torn cartilage are not completely known. The most common long term problem is the development of arthritis on the side from which the cartilage was removed. This typically may occur many years later. I think it is less common when only a portion of the cartilage has to be removed as opposed to having to remove all the cartilage. Leaving the torn cartilage however, is not usually a viable option. In addition to continuing and usually disabling pain, joint surface damage or arthritis will often develop. This is the reason that I do think if it is feasible, a repair should be carried out when conditions are favorable. What you can expect from having a partial removal should be a knee that functions better and to get rid of most of your symptoms. A repair that is successful and without complication and does not re-tear should be nearly normal. The presence of arthritis or the development of it later will cause developing or continued pain with swelling in the knee. Sometimes, the arthritic situation can be improved a bit by arthroscopy, but never cured.
After surgery, the hope is that your knee will be improved, and significantly so. Even under the best of circumstances, you should expect at least some residual symptoms such as occasional clicks, hopefully non-painful pops, slight swelling, weather change pain, and the like. Arthroscopic surgery cannot restore a knee or other joint to complete normality.
The information contained here is intended to help you and your families/caretakers better understand a particular diagnosis and/or the treatment options available. If you have any questions after reading this, please don’t hesitate to contact Dr. Longobardi’s office at 201.343.1717 for a further explanation.
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