TREATMENTS
Menisectomy
Definition
Meniscectomy (or partial meniscectomy) refers to removal of all or part of a damaged cartilage within the knee called the meniscus. This is probably one of the most common procedures now performed by knee surgeons in the UK and is performed using a technique referred to as arthroscopy. The arthroscopy involves inserting a small telescope attached to a camera into a small incision at the front of the knee (portal). This allows the whole of the knee to be inspected with water being used to inflate the knee. This procedure takes place with the patient under either a general or regional anaesthetic. This allows the knee to be fully examined and the suspected damage to the cartilage (meniscus) to be confirmed and treated at the same time.
The procedure of meniscectomy was traditionally performed using an open cut to the knee but due to advances in telescope technology, it is almost universally performed using this minimally invasive technique. The advantages of reducing the size of the incision to look inside the knee and indeed to do the operation relate to the minimal amount of damage that is done to the capsule of the knee in gaining access to the damaged cartilage.
What is a meniscus?
The menisci (plural of meniscus) are horizontal horse shoe shaped wedges of tissue that exist both on the inside and outside aspects of the knee acting as shock absorbers between the long bones making up the knee. They are made of smooth white glistening fibrous material, and have a vital function in reducing dissipating shock forces acting on the knee during day to day activity. Each knee has 2 menisci, one to support each of the rounded ends of the femur (thigh bone). They are wedge shaped and curved, with the wider part of the wedge forming the outer rim and the inner rim being the sharp surface. The majority of the meniscus does not have a blood supply and it is for this reason that healing of these tissues once damaged is virtually impossible.
Consequently, people who have damaged their cartilages often ultimately require surgery to excise the torn fragments.
The symptoms of a damaged meniscus?
Damage to the menisci or cartilage can occur at any age. Whilst one classically associates this injury with a young footballer sustaining a dramatic injury, in my experience it is seen just as commonly in a slightly older population who can be doing no more than simply going for an unusually long walk at a weekend. In short, the damage to the meniscus is an extremely common condition that can occur during practically any form of activity.
It is not unusual for patients to present with symptoms or signs of a torn meniscus without being aware of any specific episode to which they can attribute the damage to the cartilage. With the meniscus is associated with the classical symptom of pain felt along the inside or outside aspect of the knee depending on which cartilage has been torn. Often this pain is slightly intermittent in nature and may appear to get “better” only to come back and trouble the patient at a later stage. The pain is often associated with a swelling which comes on gradually after the tear but in some cases does not occur at all. This twinging discomfort that patients often feel is often exacerbated by any twisting activity of the knee and may occasionally be associated with more classical symptoms of a sense of giving way within the knee and very occasionally of locking (inability to fully straighten the leg).
All these symptoms are obviously troublesome to patients and often prevent them from returning to any sporting activity. As a result of this, often a specialist opinion is sought and further investigations can be undertaken to confirm the diagnosis.
Diagnosis
Whilst plain x-rays (radiographs) of the knee are not particularly helpful in showing evidence of damage to soft tissue such as the cartilage within the knee, they can be useful in excluding the presence of a significant degenerative disease such as osteoarthritis.
Once you have seen the specialist it is likely that the knee will be examined particularly looking for signs of inflammation such as an effusion (swelling within the knee) or tenderness around the joint line surface. Whilst signs on examination point towards the possibility of a torn cartilage, the best way of confirming this if surgery is to be considered is to undertake a magnetic resonance scan. This investigation involves placing the knee in a magnetic loop coil which produces very high resolution pictures detailing the condition of the soft tissues associated with the knee. This includes not only the cushion on the end of the bones but also the menisci and ligaments. These scans are accurate enough to show whether a meniscus is torn and thus a decision can be taken about the need for surgery.
There is never an absolute need for surgery just because the cartilage is torn, however if the symptoms are annoying enough the patients often elect to press on with surgery which in over 90% of cases is curative of the pain.
Arthroscopy
A small incision is made into the knee, and a fibre optic telescope instrument is used to view the internal cavity of the knee. The surgeon makes another incision through the other side of the front of the knee to insert small instruments to cut away the loose or torn fragment of the damaged meniscus. Whenever possible the surgeon will remove only the damaged portion of the cartilage leaving as much of the cushion function of the cartilage intact.
The tear in the cartilage is often found at the back portion of the knee and access to this area can be difficult which is why the experience of the surgeon is critical. At the end of the procedure, which often lasts approximately half an hour, the 2 small puncture mark incisions are closed either with a small stitch or a paper strip. The patient remains in hospital until later that evening (if a day case) or if operated on later in the day, until the following morning. The surgeon will see the patient before they are discharged, hopefully having explained what was found at the time of surgery.
 1. Diagram : Bucket Handle Tear |
 1. Bucket Handle Tear |
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 2. Diagram : Meniscal Flap Tear |
 2. Meniscal Flap Tear |
Post-operative Instructions
It is advisable in the immediate post-operative period to decrease the amount of inflammation after the operation by providing the patient with a cooling cuff (icing the knee) and a supply of anti-inflammatory medication. On discharge general advice is given that walking should be kept to a minimum, although the patients are not encouraged to use crutches or to remain in bed.
Whilst we encourage patients to get up and about after surgery, they are discouraged from going back to work for approximately a one week period. Sometimes due to work commitment patients have to return earlier than this and these cases they are urged to be driven to the door of their work place or ideally work from home.
In the 2 weeks following the operation, patients are encouraged to keep a compression bandage on the knee to reduce the swelling and also to visit their physiotherapist on a couple of occasions to work on strengthening the muscles around the knee. Patients will be given an outpatient follow up 2 weeks post surgery in order to inspect the wounds and check that the movement of the knee and the pain is satisfactory.
Despite the fact that the cartilages do not possess nerve function, pain can be felt post-operatively as it was pre-operatively. It is not unusual to have experienced continued “twinges” of discomfort at the area of the meniscectomy as the cut surface of the cartilage can remain slightly sensitive for at least a 2-6 week period.
Each individual patient’s recovery time varies enormously but in general between 2 and 6 weeks post surgery the patient should be returning to near normal activity with resuming sporting activity approximately one month. The guideline about returning to sport will be given by the treating consultant at the time of initial review.