Scar tissue after meniscus surgery

Contents

Knee Arthroscopy/Meniscectomy: The Process

Basic information about this procedure:

You are scheduled for an arthroscopic surgery to remove torn meniscus and/or cartilage tissues from your knee. For this surgery, most people “go to sleep completely” during surgery with a general anesthetic. Surgery with a spinal anesthetic is also an option. Three small incisions are made to allow special instruments, including a fiber-optic camera, to be placed into your knee. Sterile saline (saltwater) is brought into the knee joint continuously with tubing to provide a clear view for the surgeon. Torn parts of the meniscus and/or damaged cartilage on the bone surfaces are carefully removed with special arthroscopic instruments. The end result is a knee lined with smooth and stable tissues rather than rough, torn, and unstable edges. The actual surgery time is usually about 30 minutes, but if extensive work is needed, the procedure may last slightly longer. At the end of the surgery, local anesthesia medication is injected into the knee and reduces pain for about 10 to 12 hours after surgery. This explains why patients often note that their pain is not severe at first, then worse the day after surgery.

In most cases, the small incisions are closed with Steri-strips only and no skin stitches are used. Steri-strips are somewhat waterproof, lasting seven to ten days, and then they begin to peel back at the edges. If nylon stitches are used at the skin level, they will need to be removed at roughly 7 to 14 days after surgery. This will be done at your first post-operative visit.

The initial bandage often gets soaked with fluid and blood, and may need to be changed several times during the first 48 to 72 hours . Drainage after surgery should gradually decrease within 48 hours. If desired, dry sterile gauze pads and an Ace wrap can be continued beyond 48 hours to protect the incisions from irritation from clothing, pets, young children, etc. Other patients elect to use large Band-Aids only after 48 hours if there is no major drainage from the incisions. Once the incisions are completely dry, the use of Band-Aids or a bandage is optional.

Expectations / Risks / Recovery:

This surgery has a very high success rate. In almost all cases, your recovery will be smooth and relatively quick, allowing you to resume all activities that you want to participate in within 4 to 6 weeks. However, everyone heals from knee surgery at a different pace; a small number of people still experience pain and swelling several months after surgery.

Arthroscopic knee surgery has a very low complication rate (less than 1%). The standard risks of surgery include post-operative infection, blood clots in the leg (DVT), nerve or blood vessel injury, or anesthesia complications.

Immediately after surgery, if your pain is minimal when walking, then the use of crutches or a walker is not required. If necessary due to pain, patients may opt to use crutches or a walker for a few days after surgery. Once more comfortable, most people are able to walk with a minimal limp within one or two weeks after surgery. Most patients realize a benefit from arthroscopic knee surgery within 4 to 6 weeks. Reduction of pain and swelling, and improvement in knee strength, motion, and coordination may continue for three to four months after surgery.

Meniscal Tears

Meniscal Tear Fundamentals

A meniscal tear is a tear in the cartilages, or menisci, that are located between the femur and tibia bones in the lower leg. The menisci provide stability and help distribute body weight by keeping the bones from rubbing together. In addition, the menisci help distribute nutrients into the tissues and cartilage that cover the femur and tibia bones. Ensuring that these tissues are healthy helps prevent degenerative arthritis. As shock absorbers, the menisci help absorb the pressure exerted on the knee joint.

What causes a meniscal tear?

A meniscal tear is caused by sudden twisting or other movements that may occur from sports or related injuries. These types of injuries are more common for people over 30. Those that are younger have fewer injuries since the meniscus is fairly tough and rubbery and more resilient. As we get older, the meniscus weakens and injuries can occur more easily, even from simple movements such as squatting or stepping on an uneven surface. Meniscal tears can also occur from degenerative conditions such as osteoarthritis, rather than a specific injury.

What are the benefits of treatment for meniscal tears?

Treatment for meniscal tears focuses on keeping pain and inflammation under control. RICE, which stands for rest, ice, compression, and elevation, is the standard treatment. For the first few days after injury, ice should be applied every three or four hours for 30 minutes. Applying ice will help minimize the pain and discomfort. Wrapping the knee in an elastic bandage and taking non-steroidal anti-inflammatory medication such as ibuprofen or one that you can tolerate will also help keep the swelling down. With this treatment, you can gradually return to normal activity.

Arthroscopic surgery can help diagnose the pain associated with meniscal tears and is one of the most predominant forms of treatment when the pain is severe and occurs frequently. If the menisci are damaged, the knee can become very unstable and arthritis may result. Surgery may provide the best alternative to preserving the knee from further damage and later problems.

Some key benefits of this type of surgery are relief from pain and improvement in mobility. Repairs for meniscal tears with arthroscopic surgery are a safe procedure, allowing patients to maintain a normal and active lifestyle with greater comfort.

What are the risks of treatment for meniscal tears?

There may be some complications associated with surgery for meniscal tears, including unforeseen complications with anesthesia, such as respiratory or cardiac malfunction. Infections may result from surgery, in addition to injury to nerves and blood vessels, fracture, weakness, stiffness or instability of the joint, pain, inability to repair the meniscus, repeated rupture of the meniscus, or the need for additional surgeries.

Patients should be made aware that not all meniscal tears are repairable. The cartilage in the knee may have simply worn away over time, preventing the surgeon from repairing the remaining cartilage with sutures. In these cases, the surgeon will remove all the torn cartilage and repair any other problems in the knee.

Surgical procedures and risks associated with meniscal surgery will depend on the patient’s condition and his or her individual needs. Patients should keep in mind that their age does play an important role in the success of the procedure. Repairs tend to be most effective for people under the age of 30 who have the procedure done within the first two months after injury. For people over 30, the likelihood of success of surgery diminishes because the meniscal tissue begins to naturally deteriorate and weaken with age.

How do I prepare for surgery?

Do not eat or drink anything after midnight the night before surgery.

There are many things that you can do to prepare for meniscal surgery. Prior to your surgery, you will have a physical examination and will also be given a written prescription for pain medication. You should have your prescription filled at your local pharmacy several days before the date of surgery to make sure that you have the medication available to you immediately after surgery. You will also have an appointment with Cleveland Clinic Sports Medicine Physical Therapy to be fitted with crutches and instructed how to use them. It is important that you complete all of your testing and appointments prior to surgery, which may include bloodwork, X-rays, MRI, EKG, and medical and anesthesia clearance. Surgery may be postponed if clearance for these tests is not obtained. If you develop any health changes prior to surgery, such as a cold, fever, infection, rash or wound, you should contact your surgeon’s office prior to surgery.

What do I do the day of surgery?

On the day of surgery, patients are admitted at Desk P-20 (in the lobby of the P building). The physician’s assistant will advise you as to what time you will be admitted on the day of surgery. Parking is available in the E.90th Street Parking Street Garage adjacent to the P-20 Surgical Center.

You should bring your crutches with you to surgery, as you will need them to walk following your surgery, in addition to loose-fitting shorts or non-constricting pants (warm-up style) that will fit over your dressing after surgery. Also, arrange for a responsible adult to drive you home after surgery and stay with you the first night after surgery.

What happens during surgery?

Arthroscopic surgery to diagnose and repair meniscal tears lasts for approximately one hour. If the surgeon can see the tear with the arthroscope, he or she can determine if the tear is repairable or if the meniscus should be removed. If the meniscus can be repaired, the procedure is completed during arthroscopic surgery; another incision is made, and the surgeon uses surgical instruments to repair the meniscus. A meniscus repair involves suturing the torn edges back into place and allowing the meniscus to heal on its own. Only 10 percent of menisci are repairable using this method. In the majority of cases, a partial meniscectomy is required where part of the meniscus is removed and the healthy tissue is left intact. Recovery from a partial meniscectomy is easier, but there are also future risks, such as the development of arthritis.

In most cases, if the meniscus is in good condition, despite the tear, repair is preferable to removing the meniscus. Tears on the outer edges of the meniscus, called a peripheral menisco-capsular tear, can be repaired using arthroscopic surgery leaving the meniscus to heal. In addition, tears that run vertically through the meniscus can frequently be repaired with arthroscopic surgery leaving the entire meniscus intact. Bucket handle tears may require partial removal, depending on the severity of the injury. Repairs are treated with a combination of sutures that are inserted to treat the torn cartilage.

What happens after surgery?

Knee arthroscopic surgery for meniscal tears lasts for approximately one hour. Following surgery, once patients are comfortable, able to walk on crutches, able to take fluids orally, and able to urinate, they will be discharged to go home in the care of a responsible adult. In the majority of cases, patients are discharged from the hospital to go home on the same day of surgery.

After surgery, a dressing will be applied to the knee, wrapped with an Ace bandage, which will help protect the knee and minimize swelling and pain. An ice pack will be applied to the knee, which will also help prevent swelling and pain. Patients should leave the bandage in place until they receive physical therapy. Patients will also be given pain medication after surgery to reduce the pain.

Many times there will be small amounts of bloody drainage on the dressing after surgery. Make sure to notify your surgeon’s office if you have any of the following: steadily increasing drainage on the dressing, elevated temperature above 101 degrees Fahrenheit, pus-like or foul smelling drainage from any of the incisions, breathing difficulties, pain in your calf when you flex your foot up and down that is unrelieved by rest or elevation, or swelling in your calf, foot or ankle.

When resting, elevate your knee higher than your heart level on two or three pillows with your back flat on the bed. This will also aid in preventing swelling of the joint after surgery. Also, make sure to use crutches to walk. The crutches will protect your knee from undue stress until it is fully rehabilitated.

Call your surgeon’s office if you have any questions or concerns following surgery. After hours you may call 216.444.2200 and ask to speak with the Cleveland Clinic orthopaedic doctor on call.

How long is the recovery period after surgery?

Following surgery, there is a recovery time of up to two weeks to allow time for frequent physical therapy and appropriate treating of the knee to ensure a quick return to normal activity. As part of physical therapy, patients will be taught exercises, in addition to having guided therapy. Patients will continue to receive physical therapy three times per week after they are discharged from the hospital. The length of the rehabilitation period depends on the patient’s condition and recovery progress. If a meniscal repair is done, the recovery time and rehabilitation period may be extended – up to six weeks in a knee brace or with crutches.

What is the rehab after surgery?

The physical therapy process is dependent on the patient’s general physical health and condition following surgery. Typically, a patient’s physical therapy program after knee arthroscopic surgery can be divided into three phases: regaining control of the leg muscles and weaning from crutches, regaining full knee motion and strength and returning to normal activity. Sometimes a physical therapy program is recommended as an alternative to surgery. Or, conservative treatment and physical therapy are recommended as alternatives to surgery to control inflammation, pain and swelling. This treatment includes the NICE method, which stands for non-steroidal anti-inflammatories, ice, compression and elevation.

The following exercises (in three phases) are designed to optimize patients’ recovery following surgery. The timeline for these phases depends on the specific patient and his or her physical condition and progress following surgery.

Phase 1

Exercises during this early phase help patients regain balance and coordination and should be started immediately following discharge from the hospital. Crutch walking is not considered an exercise, but it is an important part of the physical therapy program after surgery. Patients should use crutches provided by their physical therapist until they have good muscular control over their leg and can bear weight on the knee without much discomfort.

The isometric quadriceps exercise (also known as “quad sets”) may be started in the sitting or lying position. For patients with low back trouble, this exercise is best done in the sitting position. During the exercise, press your knee down against a table or floor, holding the position for 6 seconds. The exercise can be repeated 10 to 15 times for each set. Two to three sets should be completed in each exercise period.

The straight leg raising exercise is done sitting or lying. The ankle of the leg to be exercised should be bent at a 90-degree angle, and the knee is straightened as much as possible. Then, the entire leg and thigh are lifted off the floor to a height of approximately 1 to 1-1/2 feet and held in the air for 6 seconds. The exercise should be repeated 10 to 15 times for each set; two to three sets should be completed in each exercise period. Patients may add weights for this exercise, beginning with 2 lb weights and adding increments of 1-2 lbs.

Phase 2

These exercises help patients regain full knee motion and strength once they discontinue using crutches.

The range of motion exercise is done by sitting on the table and letting the leg hang over the edge. Patients may use their good leg to help straighten (extension) and bend (flex) the knee.

Patients can begin doing bicycle exercises on a stationary bicycle as soon as the knee has a fairly good range of motion.

Short arc quadriceps extensions are used for the development of the quadriceps muscle. To perform this exercise, patients should be lying down with the unaffected knee bent placing a flat foot on a resting surface. The affected knee is supported off the table by a firm, padded object. The knee is then extended fully to zero degrees from its bent position of approximately 30 to 40 degrees. The leg is then held straight for 6 seconds and then gently lowered.

Initially, no ankle weights are used for this exercise, but as patients gain strength, they may choose to add weight to the ankle. Patients can start with 2 lbs and add increments of 1-2 lbs.

The knee flexion exercise is done while lying face down. The foot is rested on a rolled towel to prevent the toes from striking the table. The foot is slowly raised and lowered to the table. Initially, no weights are used, but as the patient’s knee gains strength weights may be added.

Phase 3

When patients have reached Phase 3 of the physical therapy program, they are ready to return to normal physical activity. The length of time leading up to this phase depends on the individual patient and their recovery progress following surgery.

How can I manage at home during recovery from the procedure?

Once patients are comfortable, able to walk on crutches, able to take fluids orally, and able to urinate, they will be discharged to go home. In the majority of cases, patients are discharged from the hospital to go home on the same day of surgery. To reduce pain and swelling, make sure to elevate your leg while at home, and for the first several days (48 hours), ice the knee 20 to 30 minutes a few times per day to minimize pain and swelling. On discharge, patients will receive a prescription for pain medication. Patients should not drive or operate dangerous equipment while taking prescription pain medication.

Patients are able to shower when they receive the confirmation that it is okay to do so from their doctor. Patients may be asked to cover their leg with plastic to avoid wetting the bandage and incisions, which increases the chance of infection. Patients may drive a car as soon as they have good control and mobility of the knee. When patients can comfortably put full weight on their leg, and have good muscular control, they may discard their crutches.

If patients develop a fever of 101 degrees or higher, redness or increasing amounts of pain not relieved by rest, ice or pain medication, they should contact their doctor’s office.

How frequently should I schedule follow up appointments with my doctor following surgery?

Patients will schedule a follow up appointment with their surgeon nine days to two weeks following their surgery. Additional appointments may be scheduled based on the patient’s individual condition and recovery.

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Arthroscopic Knee Surgery/Meniscectomy Recovery

What is Arthroscopic Knee Surgery?

Arthroscopic knee surgery involves making a small incision through the skin so doctors can diagnose and treat knee problems. A small camera is inserted through the incision, which then displays images of the knee.

From here, surgeons can insert small medical instruments to perform a surgical debridement, which is the removal of dead, damaged or infected tissue. This process helps the healthy tissue in the area heal.

Surgical debridement of the knee can include:

  • Removing torn areas of meniscus tissue
  • Removing loose bodies
  • Removing and cleaning up areas of cartilage damage
  • Other minimally invasive procedures that do not include any repairs

What is a Knee Meniscectomy?

The surgical removal of a torn meniscus is called a meniscectomy, which is a type of arthroscopic knee surgery. The meniscus is a cushion for your knee and helps keep your knee steady by balancing your weight.

Meniscus tears are most common in the knee joints and are usually caused by twisting or turning the knee quickly.

Arthroscopic Knee Surgery Recovery

After a meniscectomy, your surgeon will likely advise physical therapy to put you on the best path toward recovery. The day after your surgery, you will need to see your physical therapist to:

  • Change your dressings
  • Take initial measurements
  • Learn an initial home exercise program

Your physical therapist will also review information about what to expect, how to take care of your incisions and how to manage your pain. Handouts outlining everything you will learn will be provided.

Physical therapy appointments will be scheduled twice a week for approximately 6 to 8 weeks.

Walking with Crutches

Some patients are released from the surgical center with crutches, but most can walk immediately. If you were given crutches, we will likely encourage you to stop using them as soon as possible.

Returning to Work & Daily Activities

Most people can get back to desk work, school or sedentary activity 3 to 5 days after surgery.

If your right knee was operated on, it may be up to 2 weeks before the knee is strong enough to hit the brakes to drive safely. For heavy work, it may take 4 to 6 weeks before the leg is strong enough to allow for working. You should never drive or operate heavy machinery if you are still taking prescription pain relievers.

Returning to Sports

Approximately 4 weeks after surgery, patients typically begin to perform higher level activities during physical therapy visits.

With your physical therapist’s guidance at 4 to 6 weeks, you will begin the gradual transition back to your sport. However, your surgeon will make the final decision about your full return to activity.

Week-by-Week Rehabilitation

Weeks 0 to 2

During the first few weeks of your arthroscopic knee surgery recovery, you should be bearing weight as tolerated with crutches. You should be progressing to full weight bearing without the use of crutches.

Range of Motion (ROM)

  • 0 to 125 degrees is expected

Rehab Exercises

    • Quad sets, glute sets
    • Ankle pumps
    • Hamstring and calf stretches
    • Multi-angle isometrics for quads (90 to 60 degrees)
    • Straight leg raises (multi-plane)
    • Knee extension, open chain 90 to 40 degrees
    • Patellar mobs
    • Heel slides to tolerance
    • Bicycle for ROM
    • Passive range of motion (PROM) focused on improving full extension ROM
    • Standing weight shifts
    • Standing mini squats 0 to 30 degrees
    • Low-level balance and proprioceptive exercises in standing
      • Proprioceptive exercises focus on the ability to sense movement within joints.

Weeks 2 to 4

Range of Motion (ROM)

  • Full ROM is expected

Rehab Exercises

  • Continue exercises from weeks 0 to 2 and all passive and active ROM
  • Standing hamstring curls
  • Bilateral protected ROM leg press
  • Bicycle for ROM and light cardiovascular endurance with no resistance
  • Stationary mini-lunge forward
  • Step-ups
  • Calf raises (standing bilateral –> unilateral)
  • Wall slides
  • Progress standing balance and proprioceptive exercises
  • Pool walking program once incisions are fully closed

Weeks 4 to 6

Rehab Exercises

  • Continue exercises from previous weeks and all passive and active ROM as needed
  • Step-downs
  • Lateral step-ups
  • Squats (increased ROM)
  • Stair stepper machine <20 minutes
  • Continue with exercises to achieve terminal knee extension
  • Bicycle for cardiovascular endurance with light to moderate resistance

Weeks 6 to 8

During these weeks and the following weeks, there are no restrictions to activities of daily living (ADLs).

Rehab Exercises

  • Continue exercises from previous weeks
  • Advance closed kinetic chain (CKCs) and functional exercises
  • Begin walking program for cardiovascular endurance
  • Gradually increase time on stair stepper for cardio endurance
  • Functional movement screen (FMS) at 8 weeks

Weeks 8 to 12

Rehab Exercises

  • Light plyometrics (jump training) if good hip and knee mechanics, gradually advancing
  • Linear forward jogging in short bouts, gradually progressing jog intervals
  • Perturbation training (also known as improving reaction times)
  • May initiate gentle yoga
  • Initiate elliptical for cardiovascular endurance
  • Initiate forward agility drills (progressing to lateral as appropriate)
  • Begin a strength and conditioning program, like Access Acceleration

Week 12+

During this time period, your surgeon must clear you before you’re able to return to your sport.

Rehab Exercises

  • Progress jogging program, intervals and/or sprint training
  • Sport-specific training as needed: cutting, jumping, deep squats, etc.

Meniscus Surgery: What Can I Expect?

Meniscal surgery is the “bread and butter” procedure performed by most orthopedic surgeons in the country. In my physical therapy practice, it is one of the most common post-surgical diagnoses that we see.

A short anatomy lesson: there are two (2) menisci that are found in each of your knee joints. They are horseshoe-shaped pieces of cartilage that are somewhat loosely anchored down onto the top of the tibia (shin) bone, and they serve to lessen some of the forces that we place on the knee with weight bearing activities. Think of the menisci as our own “shock absorption” system.

Like everything else in the body, the menisci have the tendency to degenerate over time. Tears in the menisci can develop as a result of a trauma, or as a result of long-term usage. Acute tears of the menisci can be quite painful: Deep pain in the knee joint line is noted, and depending on the severity of the tear, the knee can also at times lock during range of motion.

Recovering From Meniscus Surgery

Surgeons have become very adept at clearing out the torn portion of the meniscus that is pain producing. The surgeon’s goal is to maintain as much healthy meniscus as possible. In terms of directing post-surgical rehabilitation, here are some guidelines and suggestions.

1. During the first month following surgery, walk only when you absolutely have to! Your knee joint has been traumatized by surgical instruments; allow your knee the opportunity to heal. Some surgeons tell their patients that they are free to walk as much as they can tolerate almost immediately after surgery. I disagree with this advice. Too many times I have seen post-surgical patients who have encountered extreme pain and unnecessary inflammation because of excessive walking. Losing a form of cardio exercise for one month will not kill you, and your knee will thank you for it.

2. Work on strengthening your VMO, the vastus medialis oblique portion of the quadriceps. Please check out video #1 (quad sets) from the following link http://www.physiodc.com/exercise-videos/knee-exercises/ for a quick demonstration of how to find your VMO and ideas on how to train it.

The VMO tends to lose its function even if a small amount of swelling is present in the knee. Postoperative knee patients need to pay particular attention to this muscle as it functions to control the motion of the knee cap with day to day activities.

3. The knee will be stiff and difficult to move after surgery. Work with your physical therapist on maintaining full extension, or “straightening” of the knee. Knees that cannot fully straighten because of scar tissue and inflammation can lead to problems related to pelvic alignment.

Knee flexion, or bending, generally speaking will easily improve on its own. I think that some physical therapists spend too much time forcing the post-surgical knee into flexion. This tends to only inflame the joint. Gently using a recumbent bicycle to get the knees flexing is a far less painful way of assuring better ranges of motion.

4. Do not forget to perform strengthening exercises for the muscles in the hip and the muscles in the foot. The hip and the foot play vital roles in stabilizing your knee and assuring normal joint mechanics with walking. A weak gluteus maximus or weak foot muscles place undue stress on the knee. Talk to your physical therapist about strengthening these areas.

Swelling and stiffness after meniscus surgery

This week’s Ask Dr. Geier Column addresses one of the most common concerns I hear from readers and listeners – continued knee problems after surgery for a meniscus tear. Are swelling and stiffness after meniscus surgery common, and what can you do to treat or prevent them?

Ivan in Fremantle, Australia writes:
I tore a meniscal in my right knee about 4 years ago. About 12 months later I went for keyhole surgery to sew it up. Years later I still seem to be having problems with swelling and stiffness after sports or physical activities. I am a very active sportsman. My physio has said its loose cartilage in the knee. I was just wondering if you have any recommendation or advice on how to clear this problem. For the past 18 months, I have been taking a glucosamine sulfate supplement as advised by my physician.
Your feedback would be greatly appreciated.

This is a tricky question, as not all surgeries for a meniscus tear are alike. Some meniscus tears are located near the periphery of the meniscus and occur in a certain orientation, so they can be repaired. Rehab and recovery from a meniscus repair surgery is very different from the more common procedure – a partial meniscectomy to trim out the torn portion of the meniscus.

Also read:
Partial meniscectomy: Frequently asked question
Ask Dr. Geier: Return to activity after meniscus surgery
Ask Dr. Geier – Recovery from meniscus repair

Another factor that affects recovery is the presence of any coexisting arthritis within the knee. Often an older patient with a degenerative meniscus tear has damage to the articular cartilage. Arthritis complicates the decision to undergo partial meniscectomy surgery, as it can be difficult to know if the meniscus tear or the osteoarthritis causes a patient’s pain.

The presence of degenerative changes in the knee can be one of the main causes of persistent symptoms, like swelling and stiffness after meniscus surgery. Pain, stiffness and swelling with activity can remain, or develop, in the months and years after surgery.

The challenge in a patient with wear and tear of the articular cartilage is finding a remedy. Orthopedic surgeons have no real way to make cartilage new again. “Cleaning up” the damaged cartilage at the time of the meniscus surgery might make it smoother, but it doesn’t provide much long-term benefit.

Also read:
Ask Dr. Geier – Is surgery necessary for a meniscus tear?
Ask Dr. Geier – Arthritis after a meniscus tear
Ask Dr. Geier – Meniscus Tears

Other treatment options really aim to treat symptoms rather than the underlying problem. Physical therapy, anti-inflammatory medications, glucosamine and chondroitin, cortisone injections, viscosupplementation injections, braces and activity modification are all options to decrease pain and other symptoms. Talk to your doctor before surgery to discuss ways to prevent swelling and stiffness after meniscus surgery.

Discover The Solution To Your Biggest Meniscus Injury Challenge Even If You Have No Medical Knowledge and You’ve Looked Everywhere and Haven’t Been Able To Find an Answer!

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If only surgical treatment worked so perfectly that the patient would hop of the operating table, cured, with no painful recovery required. For knee surgery, that is not the case.

Today, most surgical procedures on the crescent-shaped, fibrous knee joint cartilage called the meniscus are performed with tiny incisions, cameras and instruments. Thus, the recovery timeframe is much shorter than for the once more common open-knee surgeries.

The meniscus, the knee’s shock absorber, is composed of rings of spongy cartilage located between the thigh bone (femur) and shin bone (tibia). When the meniscus is torn by injury and surgery is recommended, postsurgical measures frequently include the use of crutches. How long you use them will depend on several factors, including whether the meniscus tear was actually repaired or if, more simply, a piece of it was just removed (partial meniscectomy).

With a partial meniscectomy, crutches may be needed until you can walk without limping (usually five to seven days). With a proper rehabilitation program, you can usually expect to resume sports within four to six weeks after the surgery.

Following a repair, you will typically use crutches for at least three weeks to allow the repaired tissue to become attached and to avoid retearing the meniscus. Maximal weight training is not allowed for two to three months, and a return to running and agility sports is permitted after three to four months if strength and motion have returned and there is no pain in the joint. Of course, your pre- and postoperative condition and the progress of your overall recovery will influence that timeframe.

In addition to using crutches, you may also engage in physical therapy to

  • strengthen your leg muscles
  • strengthen and regain full motion in your knee
  • return to a normal activity level

We will be happy to work with you and your surgeon to customize a physical therapy plan that will meet your goal of returning to work, home responsibilities and sports as quickly, comfortably and safely as possible.

Arthroscopic Meniscus Repair

Arthroscopic Meniscus Repair: Minimally invasive surgery to repair torn knee cartilage

Overview

Arthroscopic meniscus repair is an outpatient surgical procedure to repair torn knee cartilage. The torn meniscus is repaired by a variety of minimally invasive techniques and requires postoperative protection to allow healing. Physical therapy is useful to regain full function of the knee, which occurs on average 4-5 months after surgery.

Symptoms of Torn Meniscus

Torn knee cartilage generally produces pain in the region of the tear and swelling in the knee joint. These symptoms are made worse with pivoting motions, squatting, and vigorous activities. Torn meniscus fragments can get caught in the knee joint and cause catching sensations. If a large enough fragment becomes lodged between the bearing surfaces, the knee may ‘lock’ and become unable to be fully bent or extended.

For more detailed information on symptoms and diagnosis, please see our article on torn meniscus.

Goal of Arthroscopic Meniscus Repair

The goal of meniscus surgery is to preserve healthy meniscus tissue. A meniscus tear requires a blood supply to heal. Only the outer third portion of the meniscus has blood supply to enable healing of a tear. Repairs are generally limited to this peripheral region of the meniscus.

Many types of meniscus tears occur in the region of the meniscus without adequate blood supply for healing. Meniscus removal is generally recommended for tears to regions of the meniscus without blood supply. Please see arthroscopic meniscectomy for more information.

Figure 1Figure 2

Surgical Options for Torn Meniscus

Meniscus tears can be treated by meniscus removal (meniscectomy), meniscus repair, or in unusual circumstances, meniscus replacement. Since the goal of surgery is to preserve healthy meniscus, meniscus repair is attempted when the tear is repairable.

Meniscectomy, removal of the damaged meniscus tissue, has good short term results but leads to the development of arthritis ten to twenty years later.

Meniscus repair also has good results, but has a longer recovery time than meniscectomy and is limited to tears which are amenable to repair.

Meniscus replacement is considered for young, active patients who have previously had most of their meniscus removed, and develop pain in the area without having advanced degenerative changes to the articular (gliding surface) cartilage. Please see meniscus replacement for additional information.

Effectiveness

When performed by an experienced surgeon, meniscus repair is highly successful , with good results in approximately 90% of patients. Any knee that is injured has a higher likelihood of developing arthritis. A successful repair slows the development of arthritic changes. Factors associated with higher rates of meniscus healing include repair within 2 months, more peripheral tear location, and concomitant ACL reconstruction.

Possible benefits of arthroscopic meniscus repair

The meniscus is an important structure for load transmission and shock absorption in the knee. The knee is subjected to up to 5 times body weight during activity, and half this force is transmitted through the meniscus with the knee straight, and 85% of the force goes through the meniscus with the knee bent ninety degrees. Loss of the meniscus increases the pressure on the articular (gliding) cartilage, which leads to degenerative changes. A successful meniscus repair preserves meniscus tissue and mitigates these changes.

Who should consider arthroscopic meniscus repair?

Even though the recovery is longer for a meniscus repair than for a meniscectomy, any repairable meniscus should generally be repaired. Meniscus repair is considered when:

  • the patient is healthy and wishes to remain active,
  • the patient understands the rehabilitation, and accepts the risks of surgery,
  • the meniscus tear is located in the periphery of the meniscus,
  • the meniscus tissue is of good quality, and
  • the surgeon is experienced in meniscus repair

Surgical Animation

The surgical animation below is an example of the arthroscopic meniscus repair procedure. Not all surgical cases are the same. The animation below is only an example to be used for patient education.

Not all surgical cases are the same, this is only an example to be used for patient education.

Non-Surgical Treatments

Medications

Anti-inflammatory medications, taken by mouth or injected directly into the knee, can be useful to reduce the pain and swelling symptoms associated with meniscus tears, but do not improve healing. No medications or nutritional supplements have been scientifically documented as beneficial for meniscus healing.

Exercises

Quadriceps strengthening exercises are useful to reduce swelling and restore normal muscular control to an injured knee. They useful to reduce symptoms and speed rehabilitation.

What happens without surgery?

In the best case scenario, the tear would heal back in the appropriate place, achieving the same result as a meniscus repair. This is very unlikely. In the worst case scenario, a repairable meniscus would tear further and become unrepairable, and fragments of torn meniscus would injure the articular (gliding) cartilage leading to accelerated arthritis.

About Arthroscopic Meniscus Repair

Urgency

Surgery for a meniscus tear is not an emergency. Arthroscopic meniscus repair is an elective procedure that can be scheduled to minimize disruption of patients’ lives. Results are maximized by repairing meniscus tears within the first two months of injury.

Risks

All surgery has risks. There is likely nothing you could imagine could go wrong that has not gone wrong at some time. That being said, meniscus repair is a safe procedure with a complication rate of 1.3%. The most common complications are injuries to skin nerves, the vast majority of which resolve without additional procedures by three months post surgery. Injury to larger nerves or blood vessels is rare, as are blood clots. Knee stiffness, infections, and other problems are uncommon, but can occur. An experienced surgical team uses special techniques to minimize these risks, but unfortunately they cannot be completely eliminated.

Managing risk

The most effective treatment of complications is prevention. For example, the risk of infection is decreased by giving antibiotics prior to surgery, and the risk of blood clots is decreased by using anti-embolism stockings. If infection does occur, repeat arthroscopy to remove infected tissue and debris, in conjunction with antibiotics for six weeks is generally effective. If blood clots occur, blood thinners are used for three months to decrease the chance of clots growing or breaking off and traveling to the lungs. Knee stiffness can often be managed with physical therapy and braces, but may require arthroscopic releases to restore motion. Since most complications can be effectively managed when identified promptly, if patients have questions or concerns about the post-operative course, the surgeon should be informed as soon as possible.

Preparation

Since arthroscopic meniscus repair is an elective procedure, the patient’s situation can be optimized for successful surgery. There should be someone to help at home for the first several days since mobility will be impaired. There should be no current infections. The knee should have no sores or scratches. The knee should not be shaved on the day of surgery or the day preceding surgery. Cutting down or stopping smoking will decrease risk of infection and blood clots, and improve healing. Airplane flights should not be scheduled within the first five days following surgery to decrease chances of blood clots. Dental work often releases bacteria into the blood, so should not be scheduled in the first six weeks after surgery. If unavoidable, antibiotics around the time of the dental work may decrease infection risk.

Timing

Meniscus repair is optimally performed within the first two months after meniscus tear to maximize meniscus healing. Walking on a knee that is ‘locked’ (does not fully straighten) may damage the meniscus further and make a tear unrepairable. Squatting should be avoided prior to surgery, as that may displace a piece of meniscus into the joint and cause ‘locking’.

Costs

The surgeon’s office should provide a reasonable estimate of the surgeon’s fees, the hospital fee, the anesthesia fee, and the degree to which these should be covered by the patients insurance.

Surgical team

Arthroscopic meniscus repair is an advanced surgical skill that should be performed by an orthopedic surgeon trained in arthroscopic techniques. The surgery should be performed in a hospital or outpatient surgical center that handles a large volume of arthroscopic knee surgeries.

Finding an experienced surgeon

Surgeons who have had fellowship training in sports medicine have received additional advanced training in arthroscopic techniques such as meniscus repair. The operation is best performed by a surgeon with an interest and experience in arthroscopic meniscus repair. Surgeons with these qualifications can be located through university schools of medicine, and are often members of specialty societies such as the American Orthopedic Society for Sports Medicine and Arthroscopy Association of North America.

Facilities

Arthroscopic meniscus repair is an outpatient surgery that is performed in a hospital or outpatient surgical center. A center that handles a large volume of arthroscopic knee surgeries has experienced nurses and therapists to assist patients recover.

Technical details

After the anesthetic is administered and knee examined, a tourniquet is placed on the upper thigh and the thigh is secured to the table in a padded limb holder. The knee and lower leg are cleansed and draped and a diagnostic arthroscopy is performed. A diagnostic arthroscopy is a thorough examination of the inside of the joint with a camera hooked up to viewing screens. The instruments are approximately 5mm in diameter and are inserted through three or four 1cm incisions around the knee. One incision is for sterile saline inflow, used to improve visualization within the joint. A systematic inspection of the knee documents any problems, which can also be addressed. The meniscus tear is identified and probed with a small metal hook. The size, pattern, location, stability, and tissue quality of the meniscus tear are assessed, and decision made about repair versus removal of the damaged tissue. The opposing edges of the meniscus tear prepared to enhance healing using a small rasp or motorized shaver. If the blood supply to the tear is questionable, several techniques can be used to improve healing including; placing a blood clot in between the two parts of the tear, creating small vascular access channels in the peripheral rim of meniscus, or making the joint lining bleed. The meniscus is then secured back in place with one or more of a variety of devices including; suture, an absorbable tack, or a meniscus repair device. Sutures require additional small incisions to tie down.

Anesthetic

Arthroscopic meniscus repair can be safely performed under general or spinal anesthetic. In addition, local anesthetic is injected into the knee and incision sites. The patient is encouraged to discuss preferences with the anesthesiologist prior to surgery.

Length of arthroscopic meniscus repair

Arthroscopic meniscus repair generally takes between an hour and an hour and a half. Depending on how much other surgery is necessary to take care of other problems in the knee, the time may be a bit more or less.

Pain and pain management

Arthroscopic meniscus repair is moderately painful. Because more soft tissue surgery is performed, it is more painful than a standard arthroscopy, but less painful than a ligament reconstruction or another procedure that requires drilling holes through the bone. Local anesthetic is used during surgery to minimize pain, but patients generally have a swollen, painful knee for the first three days after surgery, which is manageable with oral narcotic and anti-inflammatory pain medication.

Use of medications

Oral anti-inflammatory medication is taken by mouth on a schedule, and narcotic pain medicine is taken by mouth as needed. Patients require narcotic pain medications an average of 2-5 days after surgery.

Effectiveness of medications

The combination of narcotic and anti-inflammatory pain medication produces highly effective pain relief with minimal side effects. Good pain control is a balance between effectiveness and side effects. Since all narcotic pain medicine can cause nausea and be constipating, drinking plenty of fluid and taking a stool softener after surgery can decrease these problems.

Important side effects

Narcotic pain medications can cause drowsiness, slowness of breathing, difficulty emptying the bladder and bowel, nausea, vomiting and allergic reactions. Patients who have substantial narcotic medications or alcohol in the recent past may find that 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 meniscus repair is an outpatient procedure. After surgery, the patient spends one to two hours in the recovery room, and is discharged to home with a friend or family member.

Hospital discharge

After arthroscopic meniscus repair, the patient generally has a cryocuff and a knee brace. The cryocuff is cold, compression device, that consists of a bladder around the knee and a cooler for ice a water. Using gravity to empty and fill the bladder, the knee can be kept cool to minimize swelling and decrease pain. The brace keeps the leg straight. Depending on the pattern of the tear, full weight-bearing in the brace may be permitted immediately after surgery. Taking it easy the first two days after surgery, with the limb propped up when sitting helps keep swelling to a minimum, and will actually speed recovery. During this time, pumping the ankle up and down is recommended to improve blood flow in the leg. Specific post operative instructions will be reviewed prior to discharge.

Convalescent assistance

Even though patients go home after arthroscopic meniscus repair, they will appreciate some assistance for the first several days after surgery. Driving is not recommended until a patient is comfortable off all narcotic pain medications.

Physical therapy

The three early postoperative rehabilitation goals are; get the knee out fully straight, decrease swelling, and regain quadriceps muscle control. Patients are encouraged to do straight leg raises in the brace immediately after surgery. The brace is used to walk with the knee in extension for six weeks. Range of motion is generally started soon after surgery from 0-90 degrees, without any weight-bearing during motion. The brace is unlocked at six weeks and weaned off when good quadriceps control is demonstrated. Motion is increased as tolerated at six weeks, but deep squats are avoided until 12 weeks. Low impact type activities such as swimming and exercise machines are encouraged at 12 weeks, with advancement to cutting and pivoting sports generally at 16 weeks. The assistance of a physical therapist is very helpful in achieving a rapid full recovery.

Rehabilitation options

The Sports Medicine Center has experienced physical therapists, who regularly guide patients through meniscus repair rehabilitation. Since much of the work of rehabilitation is done at home, the surgeon, patient and therapist are partners in a successful outcome. Since many patients come a distance for our expertise, we have developed working relationships with many therapy clinics in the surrounding area to make therapy more convenient.

Usual response

Patients are generally satisfied with the progress made during rehabilitation, and often feel ready to do more than allowed during each phase. Adherence to this protocol has led to successful outcome. If the exercises seem particularly difficult or painful, the patient should contact the therapist or surgeon.

Risks

This is a safe rehabilitation program with minimal risk.

Duration of rehabilitation

Return to sports requires the ability to perform sports specific drills at competition speed. Depending on the rigors of the sport, the preoperative condition, associated injuries, and other individual factors, return to a chosen sport generally takes four to five months. Rehabilitation should continue until the patient’s athletic goals are achieved.

Returning to ordinary daily activities

Patients are generally able to get back to activities of daily living three to four days after arthroscopic meniscus repair. These activities will initially be performed while wearing a brace. Help at home for the first several days after surgery is beneficial.

Long-term patient limitations

After full rehabilitation and recovery, patients have no limitations. However, if significant articular (gliding) cartilage injury or degeneration is noted at the time of diagnostic arthroscopy, high impact type sports are discouraged to slow the progression of arthritis.

Costs

Since much of the rehabilitation is done at home, rehabilitation is cost-effective. The surgeon and therapist should be able to provide the usual cost of the rehabilitation program.

Summary of arthroscopic meniscus repair for meniscus tear

  • In the hands of an experienced surgeon, arthroscopic meniscus repair is effective outpatient surgical procedure to repair torn knee cartilage.
  • The torn meniscus is repaired by a variety of minimally invasive techniques and requires postoperative protection to allow healing.
  • Physical therapy is useful to regain full function of the knee, which occurs on average 4-5 months after surgery.

Edited By John R. Trey Green III, M.D., Associate Professor, Sports Medicine, UW Orthopaedics & Sports Medicine

Last updated: January 24, 2013

Recovery


Arthroscopy

Recovery advice

You’ll probably feel tired and light-headed after having a general anaesthetic, so you’ll need to ask someone to take you home and stay with you for the first 24 hours after surgery. Most people will recover from the effects of the anaesthetic within 48 hours.

Make sure you elevate the joint and apply ice packs to help reduce the swelling when you get home, if advised to do so. You should also do any joint exercises that have been recommended for you.

Keep dressings as dry as possible by covering them with a plastic bag when having a bath or shower. If your dressings get wet or fall off, they’ll need to be replaced. Dressings can usually be removed after 5 to 10 days.

Your wounds should start to heal within a few days. If non-dissolvable stitches were used, they’ll need to be removed after a week or two. This can usually be done by a practice nurse at your local GP surgery.

You’ll have a follow-up appointment a few weeks after the operation to discuss the results of the surgery, your recovery, and any additional treatment you may need.

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