Overview of Meniscectomy

Meniscectomy is a common surgery often done to relieve knee pain in an older group of patients who have a condition called meniscal pathology. This type of knee problem typically affects older individuals due to the wear and tear over the years, leading to meniscal tears. A meniscal tear is a tear in the shock-absorbing cartilage of the knee, called the meniscus.

In the general public, about 16% of women between the ages of 50 and 59 have these types of degenerative changes in their knee cartilage, known as meniscal lesions. For men aged between 70 and 90, this percentage goes up, with over half experiencing these changes. Despite these high numbers, not everyone with a meniscal tear will feel pain or show symptoms.

However, if these tears start to cause knee pain, a surgery called a partial meniscectomy can be carried out to help reduce these symptoms in the short term. This procedure involves removing the damaged part of the meniscus.

Who benefits from a partial meniscectomy depends on various factors, including a person’s anatomy and their individual experience with pain and mobility. Medical professionals consider these factors when deciding on the best course of action.

Anatomy and Physiology of Meniscectomy

The meniscus is a part of your knee that helps distribute weight and keep your knee stable. Picture it like two cushiony, crescent-shaped pads. The one on the inside, the medial meniscus, is more like a “C” shape, while the one on the outside, the lateral meniscus, is more “U” shaped.

These menisci work to spread the pressure from your body weight across your knee when you stand or move. They can do this because of their unique shape, their makeup (mostly types 1 and 2 collagen), and how they’re attached to your shin bone.

To get a bit more detailed, both the medial and lateral meniscus have three layers of fibers. The deepest layer contains fibers that go around in circles and keep the knee stable when you put weight on it. The middle layer has fibers that are oriented in a radial manner, providing even more resistance to hoop stresses and preventing a split. The top layer is made of fibers parallel to the meniscal surface, allowing for smoother movements of the knee when you walk or run.

Now, every body part needs a blood supply to stay healthy, and the menisci are no exception. Three areas receive blood: the inner third lacks blood vessels but gets its nutrition from the fluid in your knee. The middle third gets a bit of both. And the outer third receives direct blood supply, which matters if you have a knee injury and need surgery.

The medial meniscus is better anchored, as it’s attached to the deep medial collateral ligament and the knee capsule as well as the anterior and posterior parts of your shin bone. On the other hand, the lateral meniscus isn’t as attached because of a tendon called the popliteus tendon. However, there are two ligaments, called the ligaments of Humphrey and Wrisberg, that connect the back of the lateral meniscus to the thigh bone. Though not everybody has both ligaments, nearly all people have at least one.

Why do People Need Meniscectomy

If a person has a torn meniscus, one of the cushions in their knee, they will often experience mechanical issues like clicking, popping, or a locking feeling while walking. They may also experience swelling in their knee occasionally, with or without pain. If you were to check their knee, the most common symptom would be pain along the inside or outside of the knee joint. Generally, their range of motion remains normal or is minimally affected.

For most people with a suspected or known meniscus tear, the first line of treatment involves non-surgical methods primarily aimed at relieving symptoms. They may be advised to take anti-inflammatory medications, apply ice, modify their activities, or undergo physical therapy. Injections of corticosteroids, a type of medication, are often used to help manage pain from the tear. These non-surgical treatments do not mend the actual tear, but they can help manage the symptoms.

Surgery, specifically partial removal of the meniscus or ‘partial meniscectomy’, is generally held in reserve for people who continue to experience pain or mechanical symptoms despite trying non-surgical treatments. Any other possible causes for their knee pain and symptoms should also be ruled out using a physical exam, a review of medical history and through imaging tests. Magnetic Resonance Imaging (MRI), which uses magnetic fields and radio waves to create detailed images of the body’s structures, is considered the standard method for identifying meniscus problems.

If a patient’s non-surgical treatments fail to provide relief after at least 6 months, and a meniscus tear is confirmed on an MRI scan along with physical exam findings, the decision to proceed with the surgical option of arthroscopic partial meniscectomy can be made. Arthroscopy is a minimally invasive surgical procedure in which a tiny camera is inserted into the body through a small incision to allow the surgeon to visualize, diagnose, and treat problems.

When a Person Should Avoid Meniscectomy

If a person has a certain type of tear in the meniscus (a piece of cartilage in the knee that acts like a cushion), where there’s good blood supply, doctors generally try to fix the tear instead of removing part of the meniscus. Though there’s some disagreement, most experts believe that older individuals with tears due to wear and tear over time might not benefit from surgery that only removes part of the meniscus. This type of surgery seems to work better for people with more sudden, injury-related tears.

Also, if patients show a lot of arthritis in their knee when doctors take images, these individuals often don’t do well with surgery that only removes part of the meniscus. For such patients, knee replacement surgery, or arthroplasty, is usually the preferred surgical treatment.

Equipment used for Meniscectomy

Here’s what doctors need to successfully perform a meniscectomy, a surgical procedure to remove a damaged part of a meniscus in the knee:

Firstly, they will need a standard operating room table where the surgery will take place. A lateral post, or a support that provides balance, is also necessary. It is used to provide opposing force or “counter-traction”. Another option is a circumferential leg holder, a device that can securely hold the patient’s leg during the procedure.

They’ll also need a 30-degree arthroscopic camera – a small, special camera that’s inserted into your knee through a small cut in the skin, so the doctor can see the inside of your knee on a video screen.

As part of the standard arthroscopic tower equipment, the doctors will need to have a system to display the camera’s video (the “arthroscopic camera system”), a device to trim unwanted tissue (the “arthroscopic shaver console”), a source of illumination inside your knee (the “arthroscopic light source”), and a system to manage fluid flow inside the knee (the “fluid pump management”). Also, a radiofrequency ablation console – a device that uses radio waves to generate heat and helps to treat small areas of damage in the knee – is required. This equipment is rounded out with a photo printer for making copies of the images taken by the arthroscopic camera.

Lastly, the doctors will be using ‘basic arthroscopic instruments’. These will include tools such as a ‘grasper’, a tool that helps to hold or secure tissue, and a ‘meniscal biter’, used to cut or bite off damaged pieces of the meniscus.

Who is needed to perform Meniscectomy?

A meniscectomy is a type of surgery where a part of your knee is fixed. To do this procedure, we need a team of people who work in the operating room. This includes a surgeon, who is a doctor specially trained to perform surgeries, and a surgical assistant who could be another surgeon, a physician assistant, or a resident physician (a doctor who is still in training). We also have an anesthesiologist, who is responsible for putting you to sleep so you don’t feel anything during the surgery, a scrub technician who helps the surgeon with the medical tools, and a circulating nurse who moves around the room making sure everything goes smoothly. This whole team works together to make sure the surgery is successful and safe.

Preparing for Meniscectomy

When having a meniscectomy, which is a surgery to remove part or all of a damaged meniscus in your knee, you will be laying down flat (or supine) on the operating table. After you have received general anesthesia, which puts you to sleep so that you will not feel pain during surgery, your leg will be properly positioned. This could be by putting it into a special leg holder that goes around your entire leg, or by attaching a post to the side of the operating table near your kneecap. If the leg holder is used, your other leg will also be put in a holder and will dangle freely over the side of the table. Your arms will be placed on special, padded arm holders at a 90-degree angle.

Your surgeon might decide to give you a shot of lidocaine or another local anesthetic at the place where they will make the incisions for the surgery. This can help reduce any discomfort you might have after the surgery. They may also inject a solution made of salt water and a small amount of epinephrine directly into your joint. This can help control bleeding during the arthroscopy, which is a type of minimally invasive surgery where the doctor uses a tiny camera to see inside your knee.

How is Meniscectomy performed

First, the patient is positioned so the doctor can check their knee to see how well it can move and if there’s any looseness. The doctor will then feel the bottom part of the kneecap and make a mark on the skin. They’ll also mark the sides of the band of tissue that connects the kneecap and the bump on the shinbone. The two most common points for the doctor to make small cuts for knee inspections are below and to the inside and outside of this tissue. A thin, long needle is used to help determine where the first cut should be made.

The doctor then makes a small cut with a very sharp knife on the outside part of the tissue at the joint line while the knee is bent. A blunt instrument is used to access the knee joint while straightening the leg at the same time. A tiny camera is inserted through a tube to give the doctor a view inside the knee. Tubes are connected to allow fluid to flow into and out of the knee, which increases the space inside the joint and removes any loose bits of tissue or blood.

The doctor first checks a space above the knee. They then move the camera downwards to check the joint of the kneecap and thigh bone, the space on the outside of the joint, and the space behind the knee. They also check the space on the inside of the joint before moving the camera to the inner part of the joint, while moving the leg outward to open up the joint. The doctor notes anything unusual. The inner knee cushion (or meniscus) can be partially seen at this point. The doctor then checks the ligaments at the front and back of the joint by moving the camera to the gap between the thighbones. To see the outside of the knee, the leg is moved inward. Once the initial inspection is complete, the camera is moved back to the inner part of the kneecap. A long, thin needle is used to make a second small cut under the direct view of the camera.

As for meniscus surgery, a stick-like tool is inserted through the second cut to check for damage. The doctor identifies the type of tear. Then, a tool that works like a mini, surgical clipper is inserted to trim the damaged part of the knee cushion. It’s important to make a smooth edge that blends with the healthy part of the knee cushion in order to allow the knee to work properly. When the damaged part is removed, the surgical clipper is replaced with a tiny surgical vacuum-cleaner-like device that smooths the knee cushion while simultaneously sucking up small bits of tissue from the joint. The doctor ensures to avoid damaging the outside layers of the thighbone and shinbone. The position of the leg helps in making enough space to avoid accidental injury. Once the doctor is satisfied, the surgical tools are removed. The tube is left inside while a vacuum is used to remove any remaining saline and loose bodies. The cuts are closed with stitches and then properly bandaged.

Possible Complications of Meniscectomy

Some people may face complications from having a part of their knee cartilage, called a meniscus, surgically removed (partial meniscectomy). These can include accidental damage to the cartilage by a surgeon, leaving too much knee cartilage behind, and infections. But not to worry, these complications are quite rare, typically happening to between 0.5% and 1.7% of these surgeries. In one large-scale study of over 700,000 surgeries, the overall complication rate was just 0.61%. The chance of getting an infection within the first three months after surgery was also quite low, with about 0.135% of cases.

Another possible complication that might happen after partial meniscectomy is having a bloody knee joint (hemarthrosis). This could be caused if there’s excess saltwater solution or blood left in the knee after surgery or if bleeding isn’t fully controlled during the procedure. This could result in a bruise (hematoma). Some patients might also get a blood clot in the deep veins of their legs (deep vein thrombosis) after surgery, with up to 18% of cases reported. But it’s very rare for these clots to cause serious problems like blocking lung arteries (pulmonary embolism), which happens in less than 0.1% of cases.

As for long-term complications, some people might need another surgery because they develop a type of joint disease called osteoarthritis. Some studies have reported that, on average, it takes about 9 months for patients with degenerative meniscal tears to need a total knee replacement after a partial meniscectomy. This underlines the importance of the meniscus in maintaining knee health and protecting the knee’s surface. Taking out too much meniscus could lead to osteoarthritis, which might require more surgery sooner.

What Else Should I Know About Meniscectomy?

Meniscectomy is a regular and effective surgery performed when the meniscus, a piece of cartilage in your knee that cushions and stabilizes the joint, is damaged or torn. It’s important for the doctor to identify a tear pattern that cannot be repaired before carrying out this surgery.

A study by Herrlin and others looked at patients with non-traumatic, wear-and-tear type meniscus tears. They compared patients who didn’t have surgery with those who underwent a less invasive type of surgery called arthroscopic partial meniscectomy. Both groups saw improved health up to 5 years later. However, a third of patients who initially didn’t have surgery ended up needing it later due to the ineffective non-surgical treatments, and they reported improved outcomes after the surgery.

For those with sudden, traumatic meniscal tears, they also benefited from the arthroscopic partial meniscectomy. A recent study examined 154 patients undergoing this surgery for sudden, traumatic meniscus tears and found an improvement in health outcomes 4 years later.

However, outcomes can be worse for patients with higher body weight (BMI) and severe knee cartilage damage (grade 3 or 4 Outerbridge chondral lesion) beforehand. But with the right patient selection and understanding of the tear, this less invasive surgery can offer significant benefits.

Frequently asked questions

1. What are the potential risks and complications associated with a meniscectomy? 2. How long is the recovery period after a meniscectomy? 3. Will I need physical therapy after the surgery? If so, how long will it last? 4. Are there any alternative treatments or procedures that I should consider before opting for a meniscectomy? 5. How likely is it that I will need additional surgeries or treatments in the future due to the removal of part of my meniscus?

Meniscectomy is a surgical procedure to remove part or all of a damaged meniscus in the knee. The meniscus helps distribute weight and keep the knee stable, so removing it can affect the stability and function of the knee. After a meniscectomy, you may experience pain, swelling, and limited range of motion in the knee, and there is a risk of developing arthritis in the future. Physical therapy and rehabilitation are often recommended to help regain strength and mobility in the knee.

You may need a meniscectomy if you have a tear in the meniscus that cannot be repaired and is causing significant pain or limited mobility. This type of surgery is typically recommended for individuals with sudden, injury-related tears in the meniscus. However, if you are an older individual with a tear due to wear and tear over time, surgery that only removes part of the meniscus may not be beneficial. Additionally, if you have a lot of arthritis in your knee, meniscectomy may not be the preferred surgical treatment, and knee replacement surgery may be recommended instead. It is important to consult with a healthcare professional to determine the best course of treatment for your specific condition.

A person should not get a Meniscectomy if they have a certain type of tear in the meniscus with good blood supply, as doctors generally try to fix the tear instead of removing part of the meniscus. Additionally, if a patient shows a lot of arthritis in their knee, knee replacement surgery is usually the preferred treatment over surgery that only removes part of the meniscus.

The recovery time for meniscectomy can vary, but generally, patients can expect to be on crutches for a few days to a week after surgery. Physical therapy is usually recommended to help regain strength and range of motion in the knee, and full recovery can take several weeks to a few months depending on the individual and the extent of the surgery. It's important to follow the post-operative instructions provided by the surgeon to ensure proper healing and minimize the risk of complications.

To prepare for a Meniscectomy, the patient should follow non-surgical treatments such as taking anti-inflammatory medications, applying ice, modifying activities, and undergoing physical therapy. If these treatments fail to provide relief after at least 6 months, and a meniscus tear is confirmed on an MRI scan along with physical exam findings, the decision to proceed with the surgical option of arthroscopic partial meniscectomy can be made. The patient should also be aware of the possible complications and long-term effects of the surgery, such as the development of osteoarthritis.

The complications of Meniscectomy include accidental damage to the cartilage, leaving too much knee cartilage behind, infections, bloody knee joint (hemarthrosis), bruising (hematoma), blood clots in the deep veins of the legs (deep vein thrombosis), and the development of osteoarthritis requiring another surgery.

Symptoms that require Meniscectomy include mechanical issues like clicking, popping, or a locking feeling while walking, occasional swelling in the knee with or without pain, and pain along the inside or outside of the knee joint.

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