Surgical and Post-Op Management of Meniscal Tears

What to expect if I need surgery for meniscal tears?

In recent years, knee meniscal injuries have taken to the forefront of exercise rehab and injury prevention. They are becoming increasingly common within younger populations – Ridley et al. discovered in 2017 that isolated lateral meniscus tears were occurring more in their cohort under the age of 20, when compared to the age group between 20-30 years. Acute meniscal tears have also been found to affect male athletes more than their female counterparts – by a significant 20% (Jones et al., 2012).

However, female athletes do not have all the luck in the world regarding knee injuries either. Especially as on the flip side, female basketball players have an incidence of ACL rupture 3.5 times higher than male athletes within the same sport (Journal of Orthopaedics, 2016).

We recently uploaded a blog depicting the mechanism and anatomy behind acute meniscal tears (see here), which focused on the conservative management of these injuries. But what happens when conservative measures aren’t enough to reduce your pain and get you back to your baseline function? This blog will delve deeper into the surgical management, and post-operative care of meniscal tears.

Most athletes, and even social exercisers will have a friend or a relative that has suffered a meniscal injury in the past. But what makes Tom’s meniscal injury different from Harry’s? Why did your cousin need surgery but your colleague got back to exercising with just the help of their physio? The answer lies within the anatomy of the meniscus. Sometimes the location of the tear will tell us more than the extent of the tear size.

Here’s a quick recap. The meniscus is a C-shaped ring of cartilage, found within the knee joint. Each knee has 2 menisci, so therefore we can name them by their position – medial (inner) and lateral (outer) meniscus. They are shock absorbers that help with stabilisation of the joint, and that provide a lubrication for the knee joint to glide easily during movement.

Now meniscal blood flow differs depending on the location. Zones around the outskirts of the menisci benefit from better blood supply compared to inner aspects of the cartilage. Tears deeper within the cartilage rings will have more difficulty succeeding in self-healing. Persistent pain will be a challenge during knee examination and treatment with these types of tears and may indicate the need for an orthopaedic review.

Other factors that will determine the course of action will be the type and complexity of the tear.

 Tears that involve poorly vascularised tissue such as oblique or complex tears have poorer rehab potential with conservative management. Complex tears such as complete vertical tear may give rise to a flap of loose cartilage flipping over and back in a way known as “the bucket-handle mechanism”.  Loose bodies of cartilage can float within the knee joint after larger meniscal injuries and must be removed. Using symptoms such as constant high pain levels, persistent flare ups despite proper management, or mechanical symptoms such as clicking, locking, or sometimes giving way of the knee joint can indicate one of these complex injuries, and should prompt a surgical review. It is important to remember that we would ideally trial a period of rehab prior to jumping to a surgical conclusion, but some tears lack the capacity to heal by themselves, and it may be in the patient’s best interest to have a surgical consult within the first 6-8 weeks of injury.

Orthopaedic surgeons can identify the magnitude and the location of the tear by MR imaging. If the consensus of a review is leaning towards surgical management, then ideally the patient will be able to prepare with a short period of pre-op management – nowadays commonly known as Prehab. Ensuring a patient has optimal range of motion at the knee, and as much relative quads, hamstring and glute strength as possible has been found to improve their outcomes post-surgery.

Surgeons are changing their practice as more evidence comes out regarding meniscal repairs. It used to be common practice to remove as much of the problematic cartilage as they saw fit. This was because of the belief that cartilage was pretty much redundant within the knee, and that the joint would manage perfectly without portions of meniscus. However, an alarming amount of athletes in later life were suffering from a continued decrease in range and control at the knee, and many had persistent pain. Damaged menisci and large scale meniscal removal has been found to create osteoarthritic changes within otherwise healthy knees, and this created a change in the surgical procedures.

When you undergo a meniscal surgery now, commonly known as a meniscectomy, only loose fragments, or pieces that cannot re-heal are removed. A big attempt is commonly made to repair torn cartilage, and there is a larger emphasis nowadays on salvaging as much of the meniscus as possible.

After a meniscectomy, you can expect some pain and swelling. Scars are relatively small as routine repairs are now done through “keyhole” surgery or arthroscopically. It is commonplace now for physiotherapy to begin as soon as the day of surgery. Early stage rehab includes gentle range of motion, which includes bending as much as comfortable and regaining full extension, and activating the quads and hamstring muscles via strength exercises. In run-of-the-mill surgeries, weight bearing is encouraged straight away, and crutches can be used for stability for up to 10 days. Knee braces have been introduced to post-op rehab in the last 15 years, but administering them usually depends on the surgeon involved. There is no major evidence to show that the use of a Don Joy brace will improve ones outcomes post meniscectomy, but can be beneficial on a case by case basis. For example, large-scale meniscal removal, intra-capsular stitching, or weak muscles leading to an unstable knee.

Once the early stage rehab in complete, its up to you and your physio to work on goals similar to any patient post surgery. Improve function, reduce pain, and return to your desired sport or activity. The usual timeline for return to sport in ordinary meniscectomies can be anything from 12 to 24 weeks. 

References:

Jones JC, Burks R, Owens BD, Sturdivant RX, Svoboda SJ, Cameron KL. Incidence and risk factors associated with meniscal injuries among active-duty US military service members. J Athl Train. 2012;47(1):67-73. doi:10.4085/1062-6050-47.1.67

Ridley TJ, McCarthy MA, Bollier MJ, Wolf BR, Amendola A. Age Differences in the Prevalence of Isolated Medial and Lateral Meniscal Tears in Surgically Treated Patients. Iowa Orthop J. 2017;37:91-94. 

The female ACL: Why is it more prone to injury?. J Orthop. 2016;13(2):A1-A4. Published 2016 Mar 24. doi:10.1016/S0972-978X(16)00023-4