Meniscal Surgery

Introduction

A meniscus tear is the commonest knee injury in young athletes, especially those involved in contact sport such as soccer, rugby and netball. A forceful twisting or hyper-flexing of the knee can cause a traumatic meniscal tear. In the elderly, the cartilage wears and weakens with age and so they are more predisposed to degenerative tears. The knee has two crescent shaped meniscus (lateral and medial) which are positioned between the thigh (femur) and lower leg (tibia) bones. They act to protect and cushion the joint and act like "shock absorbers".

The patient with torn meniscus usually presents with:

  • Pain.
  • Stiffness and swelling.
  • Catching or locking of knee.
  • The sensation of the knee “giving way”.
  • Loss of knee normal range of movements of knee.

Dr Lane will take clinical history and examine your knee. An MRI knee scan is helpful to confirm clinical suspicions of meniscal tear.

If the tear is small on the periphery of the meniscus, non-surgical treatment (rest, elevation, compression, NSAIDs and physiotherapy), may be recommended.

Knee arthroscopy is the recommended surgical procedure for meniscal tear. The surgical treatment options include meniscus removal or meniscal surgery.

Indications for meniscal surgery

  • Failure of conservative treatment.
  • Symptoms of instability, locking, swelling and pain interfering with daily activities.

Pre-operative Instructions

Once surgery is recommended, Dr Lane will discuss the proposed procedure with you. Information leaflets covering the procedure, surgical risks and knee arthroscopy- after care will be supplied for your information. 

Anti-inflammatory drugs such as Feldene, Naprosyn, Brufen, Ibuprofen, Indocid, Voltaren, Mobic and Celebrex should be stopped 5 days before surgery. These drugs increase the risk of bleeding. Aspirin or other blood thinning drug usage prior to theatre should be discussed with Dr Lane as this would depend on the patients underlying medical condition. The knee to be operated on should be free of cuts, scratches and sores as this can increase the risk of infection. If there is damaged skin in the area that has to be operated on, then it is highly likely that the operation will be postponed. The patient is also encouraged not to smoke prior to the operation to reduce the risk of deep venous thrombosis.

Almost all knee arthroscopy surgery is done as an outpatient. You will be given clear instructions when to attend the hospital depending on your surgery time. You are advised to take your knee X rays or scans, Medicare, DVA or private health care cards and not to eat or drink anything 6 hours prior to your procedure.

  • You will be admitted by the duty nurse and baseline observations taken.
  • Theatre gown and clean disposable underwear given to wear.
  • The knee will be inspected by the nursing staff and anti-septic applied to the leg and then covered with a sterile drape.
  • The other leg will have a TED stocking applied to reduce the risk of thrombosis after surgery.

You will be taken from the Day Hospital to the theatre complex by the nursing staff and then to the anaesthetic bay. There you will meet your anaesthetist who will discuss the anaesthetic options depending on your fitness. Knee arthroscopy is usually performed with the patient asleep under a general anaesthetic. It is possible to do the procedure using a spinal or epidural anaesthetic technique.

Procedure

When the patient is asleep in theatre, a tourniquet is applied to the thigh. This gives a blood less field for surgery. The skin is then washed with an anti-septic solution and sterile drapes covers the patient leaving a window for the operative site.

Dr Lane inserts the arthroscope through a small incision in the knee. Using this portal, fluids are introduced to expand the joint giving access and enabling repair. A further one or two small incisions are made to introduce the small instruments into the knee. During meniscectomy, these small instruments shave and excise the torn meniscus.  The aim of the surgery is to reduce the mechanical problem which the torn meniscus is creating, and to prevent further damage to the meniscus. In young patients, meniscal repair can be performed with pinning or suturing depending on the extent of the tear.

When the arthroscopic surgery is finished, the incisions are closed with steri-stripes or occasionally sutured (if large incision made), and then covered with Primapore band aids. Local anaesthetic combined with morphine (unless the patient is allergic) and occasionally a steroid like solution (if evidence of inflammation in the joint) is injected into the joint to aid post-operative pain relief. The leg is then covered with a bulky outer dressing – velband (padding) with outer crepe bandage.

The procedure normally takes around 30 to 60 minutes depending on the complexity of the surgery.

Post-operative Instructions

After the procedure, the patient is taken to the recovery room for a brief period and when fully awake and observations stable, taken back to the day Ward. Most patients are able to go home within one or two hours after their knee arthroscopy. Patients must be taken home by a family member or a friend when they are discharged from hospital.

Recovery from surgery is usually rapid. Rest and elevation are particularly important for the first day or two to reduce pain and swelling. 

  • Pain relief – Simple analgesia, such as paracetamol or paracetamol combined with codeine, is usually adequate to manage pain.
  • Walking – For most procedures (but not following microfracturing or actual meniscal repair – where  there is protected weight bearing for 6 weeks) walking may be done as soon as possible. Crutches are usually not required
  • Wound care – The incision and dressing over the knee need to be kept clean and dry. The outer bulky dressing may be removed after the third day. The Primapore band aids over the wound should not be removed for 10 days.
  • Exercise programme –Gentle exercise can begin once the pain and swelling has decreased- usually after the first day or two. An exercise programme is given to each patient with clear instructions to follow.
  • Driving – this may be done as soon as able unless otherwise directed. You will not be able to drive yourself home from hospital. Most people will avoid driving for 3 to 4 days.
  • Work – Clerical work - it is usually OK to resume work in approximately one week. Manual work - moderate duties, 2 weeks off work. Heavy duties - 3 to 4 weeks off work.
  • Sport – No sport for 3 weeks. No leg weights or resisted exercises for 3 weeks.

Patient will attend for follow-up at Lake Kawana Specialist Centre in Birtinya two to three weeks after the procedure. The operative findings will be discussed with patients and photographs given of operative findings.

The outcome of the knee arthroscopy depends on what the surgeon has found within the knee joint and the degree of damage present in the knee. Recovery time varies markedly from patient to patient, and not all arthroscopies are the same. If there is significant degenerative changes in the knee joint (osteoarthritis) full recovery may not occur. Most patients who have meniscal tears or simple removal of loose bodies make a full recovery.

Risks

General (rare) associated with Anaesthetic

  • Death.
  • Heart attack.
  • Stroke.
  • Pneumonia

Local (uncommon):

  • Infection.
  • Nerve palsy.
  • Bleeding.
  • Reflex sympathetic Dystrophy.
  • Deep Venous thrombosis 

Patients who are smokers, diabetic or have multiple pre-existing medical conditions are at a higher risk of complication.

The patient should contact Dr Lane immediately if any of the following symptoms occur:

  • Warmth and redness around the knee.
  • Fever, sweats or shakes.
  • Significant pain not responding to rest, elevation and simple painkillers.
  • Pain behind the calf muscle at the back of the knee.