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Meniscus tears
What are the menisci?
The menisci are pieces of cartilage in the knee playing a vital role in athletes. These are two C-shaped structures that are located between the femur and tibia on the inside ("medial") and outside (lateral) aspects of the knee. They mostly consist of water and collagen fibers. Historically, the role of the meniscus was not clear, and some even considered vestiges remnants of embryonic tissues such as the appendix. For this reason, complete removal of the meniscus (total meniscectomy) was not uncommon in the area out a symptomatic meniscal tear.
• Load tranmission – the meniscus are responsible for transmission from 50% to 70% of the loads through the knee joint. In his absence, these loads are transmitted directly articular cartilage at the ends of bones.
• Joint stability – the meniscus are secondary stabilizers of the knee at many levels, and become primary stabilizer front to back (anterior-posterior) movement of the knee when the anterior cruciate ligament (ACL) is broken.
• shock absorption
• Joint lubrication and Nutrition
What is the anatomy of the meniscus?
The menisci are "wedge-shaped" pieces of cartilage that rest between the thigh bone (femur) and bone of the lower leg (tibia) in the knee joint. There are two menisci, medial one on the inside "of the knee and a lateral on the" outside "of the knee. The medial meniscus is C-shaped, while the lateral meniscus is semicircular in shape. Both are based on the tibial surface and anchored to the bone in the front and back of the plateau ('the meniscus root ").
Each meniscus can be divided into parties on the basis of (i) location within the knee, or (ii) blood supply. By location, the meniscus can be divided into a (i) dorsal horn, (ii) the body, and (iii) anterior horn. These terms are useful to describe the location of meniscal tear. Tears in the posterior horn are the most common.
The blood supply of the meniscus is at the periphery where it joins the wall of the knee joint (capsule). For this reason, the peripheral one third of the menisci are generally well perfused, whereas the interior areas have a blood supply is more limited and therefore limited potential for healing. These places different from peripheral plants have been called the "red-red", "red-white and "white-white" areas. This classification is important when evaluating meniscus tear and taking into account their ability to heal after a surgical repair.
Unfortunately, the total meniscectomy in young patients has been shown to dramatically accelerate the degeneration of wear knee. In addition, several critical functions of the menisci of the knee health maintenance have been well established. These include:
What are torn meniscus in athletes?
A meniscus tear is one of the most common orthopedic injuries and has been colloquially referred to as "cartilage torn in the knee. They have affected virtually every sport athletes. Though more frequent in the posterior horn, which can occur anywhere and affect the medial, lateral, or both.
In athletes, a meniscus tear is usually a traumatic origin. They are the result or the forces abnormally high that the substance of the meniscus. While these are often the result of strong twisting or pivotal movements can also occur with a seemingly innocuous activity such as squatting or jogging. Baseball receptors professional defensive lineman, almost every sport and player position has been affected by this injury. Some names that are recognized include Umeniyora Osi, Johan Santana, Sedrick Ellis, and Shawne Merriman – have all struggled meniscus tear in his career.
In patients elderly, a meniscus tear may not be traumatic, but rather part of degenerative changes in the knee. These tears are often accompanied of some arthritic changes in the knee and are known as "degenerative" tears.
How is a meniscus tear classified?
A meniscus tear can be classified in several ways – by the anatomical location and the proximity to blood supply, etc. Several tear and configurations have been described. These include:
• Radial tears
• Flap or Parrot beak tear
• Peripherals, tears longitudinal
• bucket handle tears
• Horizontal split tears
• Complex tears, degenerative
These tears may be further classified then by its proximity to the blood supply of the meniscus, ie if they are in the "red-red", "red-white" or "white-white" areas.
The functional significance of these classifications, however, ultimately determine if you can repair a meniscus. Given the critical functions of the meniscus in athletes, who must be preserved and repaired whenever possible. The repairability of a meniscus depends on a number of factors. These include:
• Age
• Activity Level
• Cut Pattern
• The chronicity of the tear
• Associated injuries (ACL injury)
• Potential cure
What injuries can accompany to a meniscus in athletes?
While a torn meniscus can certainly occur in isolation, often accompanied by other injuries to the knee too. In the establishment of a high-energy trauma, associated fractures of the proximal tibia (tibial plateau) can occur. Meniscus tears are reported to be as common as 50% of these fractures.
A torn meniscus often accompany the tears of the anterior and / or collateral ligaments too. The posterior horn of medial meniscus is the stabilizer secondary to anteroposterior translation of the joint, so it is particularly vulnerable to injury deficient ACL (anterior-posterior primary stabilizer of the joint).
How does a meniscus present in athletes?
A meniscal tear can occur in several ways. Sometimes an explosion, "" feeling experienced by the athlete during an event traumatic. In general, significant pain along the joint line on the side of the tear (medial or lateral). Sometimes, athletes can continue to walk on the knee, while other large tears may cause too much pain to allow weight bearing. Sometimes the tear pattern may cause a portion of the meniscus to be trapped between the articular surfaces or within the notch of the knee. In these cases, the knee is often blocked and the athlete can not bend or straighten the knee. The classic signs to look for a torn meniscus include:
• Pain, often along the line of the knee joint
• Swelling ("Stroke" in the joint) often develops due to inflammation and / or bleeding from the lesion
• Inability to fully extend or bend the knee without discomfort
• Locking or catching of the knee
• Weakness of the leg, especially in the quadriceps muscle. This can be evident when it comes to performing a straight leg or climbing stairs.
In addition to examining the above signs and symptoms, the doctor may check the capacity athlete squatting on the knee without discomfort. They doctor may also do a test 'McMurray in which the knee is bent, straightened, and rotated in an attempt to trap the meniscus tear within the joint. If you have a meniscus tear, the motion may play click and pain.
What imaging studies help confirm the presence of a meniscus tear?
Plain X-rays (radiographs) of the knee may be useful for evaluating the presence of associated injuries such as tibial plateau fractures or ligament avulsions. They will not, however, confirm or rule out a tear meniscus.
Magnetic resonance imaging (MRI) of the knee has become the gold standard of imaging studies of a meniscal tear. These images High-resolution from multiple perspectives allow a greater% sensitivity in detecting a meniscal tear 95. They also provide valuable information relation to the breaking of patterns and configuration to help the surgical planning and evaluation of the repairability of the tear.
MRI of the knee not only helps define the tear, but allows the evaluation of other important anatomical structures of the knee. The state of the security and cruciate ligaments as well as areas of joint cartilage can be evaluated in order to help design the best treatment plan.
How is a meniscus in athletes treated?
With this greater appreciation of the role of the meniscus, surgical techniques have focused on conservation and where possible repair in athletes. Arthroscopy has various strategies for minimally invasive repair and excellent visibility. However, Model tear shall be repaired and the tissue has the ability to heal from a repair to be successful. In addition, the athlete's age, expectations and injuries partner must also be considered. For this reason, no definitive set of guidelines can be provided for determining that the tears should not be treaties, which must be repaired or must be partially removed (partial meniscectomy). However, some good general principles include:
• Rim width is the most important prognostic criterion for healing after meniscus repair. Therefore, peripheral tears, longitudinal within 3-mm ("red-red" vascular zone) meniscocapsular union must be repaired. Longitudinal tears less than 3-6 mm wide (red-white zone) have success less predictable, but still should be considered for repair in younger patients.
• The tears over the 6-mm peripheral blood supply are generally avascular and are not suitable for repair.
• acute traumatic tears have a better prognosis healing compared with chronic, degenerative diseases.
• longitudinal tears are more willing to make the flap, horizontal slit, degenerative or complex patterns.
• The management of radial fracture is controversial. Large radial tears extending to the periphery are technically easier repair and should be considered for repair in young patients to restore hoop stresses and load transfer function of the meniscus.
• The age should not be used as an absolute criterion to determine the feasibility of repair. While younger patients have a more favorable prognosis, to heal the wounds has been reported in elderly patients.
• The highest failure rates were observed in the context of unstable knees secondary to efforts prevent excessive cutting healing. Therefore, a failure of anterior cruciate ligament (ACL) must be reconstructed at the time of meniscus repair. Reconstruction ACL at the time of meniscus repair has been associated with a more favorable rate of healing of the meniscus.
• partial tear thickness that are shallow and stable (<3 mm in height and <1 cm in length) usually heal spontaneously. Unstable partial-thickness tears, however, must be repaired.
What does surgery meniscus in athletes?
If a meniscus tear is symptomatic and limiting ability of an athlete to play again, it is usually treated with surgery. The vast majority of meniscus surgery with arthroscopy can be performed through small incisions in the skin. The camera is used to visualize and define carefully the tear pattern.
By irreparable tears, the broken fragments are remove the residual meniscus and gently contoured. We must be careful to preserve as much tissue as stable as possible to preserve the important functions of the load is transmitted meniscus. To repair the tears, the instruments are introduced to refresh the torn edges, align ("reduce" the tear), and suture the tear. Several techniques to suture the meniscus tear edges are described. These are divided into general categories of repair of ruptured entirely within the joint ("all Within "), from inside to outside the joint (" inside out "of the repair), or from outside the joint (" from outside-in "). Each technique has associated advantages and limitations. Whether they are used, however, the ultimate goal is a rather small and meniscus safely through the repair of torn edges.
If the blood supply to the tear olocation is dim, the increase of substances to stimulate healing can be considered. fibrin clot has been used with some effectiveness in this regard. Increased platelet-rich plasma in place of the tear can be beneficial and studies are currently underway to evaluate its effects on the healing of meniscus.
What is the recovery of athletes after meniscus surgery, and when I can play again?
The program of recovery from his knee after surgery depends greatly specific procedure performed as well as the specific nature of its use. Their expectations and sport must be so considered.
In general, meniscectomy irreparable partial tears allow faster recovery than the meniscus repair surgery. This is because the time interval to allow healing of tissues is not necessary. After partial meniscectomy, the body weight is gradually allowed to tolerance and exercises are initiated quickly to achieve the full range of motion of the knee. Strengthening exercises were started subsequently. Although the time to return to sports is variable, a goal of 3 to 4 months is always viable.
For meniscus repair surgery, a period of range does not support the weight and restricted movement is usually performed after operation to optimize the environment for tissue healing. A range of motion and strengthening program is subsequently implemented. In general, a target 6 months to play again is typical, but may be much higher depending on the severity and tear functional goals.
Some useful principles of rehabilitation meniscus repair include:
• The effect of tear configuration and knee range of motion in the rehabilitation of the meniscus guide healing.
• compression loads in the peripheral longitudinal tears in the knee in extension often reduce the tear edge.
• The compressive loads in the peripheral longitudinal tears in flexion move to the back horn and tear edges.
• The meniscus is then translated with knee flexion, but minimally 0-60 degrees. The side shown that translation of the medial meniscus.
• Some typical protocols meniscus repair are:
or peripheral longitudinal tears: hinged knee brace after surgery locked in extension for 3-4 weeks. part-load for 4 weeks with the brace locked in extension. Advance Range of motion and body weight for 3-6 weeks. training Sport-specific and strengthening at 6-8 weeks. No running for four months.
or radial tears / Complex tears knee hinged brace after the operation is locked in extension for 3-4 weeks. Toe touch the body weight for 4 weeks with the locked brace extension. Range of motion and body weight gradually progress in strengthening at 4-6 weeks.
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References:
1. Rangger C, T Klestil, Gloetzer W, Kemmler G, Benedetto KP. Osteoarthritis after arthroscopic partial meniscectomy. I J Sports Med 1995, 23:240-244.
2. Hede A, Larsen E, H. The long-term Sandberg result of the opening of the total and partial meniscectomy, in relation to the quantity and location of the meniscus removed. Int Orthop 1992, 16:122-125.
3. Diduch DR, KA Poelstra. The evolution of the whole within-repair meniscus. Operative Techniques in Sports Medicine 2003, 11:83-90.
4. King DJ, and MJ Matav. Devices-all inside meniscal repair. Operative Techniques in Sports Medicine 2004, 12:161-169.
5. Medvecky MJ, and FR Noyes. Surgical approaches to the posteromedial and posterolateral aspects of the knee. J Am Acad Orthop Surg 2005, 13:121-128.
6. DB Cohen, and TL Wickiewicz. The outside-in technique for arthroscopic repair of the meniscus. Operative Techniques in Medicine Sports 2003, 11:91-103.
About the Author
Dr. Asheesh Bedi is an Assistant Professor of Sports Medicine and Shoulder Surgery at the University of Michigan and MedSport Program. He is a team physician for the University of Michigan Athletic Department and specializes in both arthroscopic and open surgery for athletic injuries of the shoulder, elbow, hip, and knee.
Dr. Bedi completed his undergraduate training at Northwestern University where he graduated Summa Cum Laude. He graduated from the University of Michigan Medical School with AOA recognition, and remained in Ann Arbor to pursue residency training in Orthopaedic Surgery at the University of Michigan. After completing his training, Dr. Bedi completed a two-year fellowship in sports medicine and shoulder surgery at the Hospital for Special Surgery and Weill Cornell Medical College in New York. He has also pursued additional dedicated training with Dr. Bryan Kelly in arthroscopic hip surgery for young athletes. While in New York, he was an assistant team physician for the New Jersey Nets professional basketball and New York Mets professional baseball organizations with Dr. Riley Williams, Struan Coleman, and David Altchek. He was also an orthopaedic consultant for the U.S. Open Tennis Tournament in 2007 and 2008 with Dr. David Dines and an assistant team physician for Iona College Athletic Programs.