Meniscus injury is one of the most frequent injuries to the knee, especially in sportsmen and women

The meniscus is a fibro-cartilaginous structure found inside the knee and also in the acromio-clavicular joint.

Its main function is to absorb shocks and intervene in the rolling and sliding movements of the joint, facilitating the movement between the condyle-femoral and tibial plateau.

In the knee there are two: the medial meniscus and the lateral meniscus.

Why does a meniscus injury occur?

Acting as a shock absorber, the meniscus tries to reduce longitudinal and transverse loads on the joints by protecting the cartilage.

When the meniscus is injured, it is usually because it is affected by a traumatic event.

The main traumas are rotations and hyperflexion or hyperextension of the knee.

In this regard, the medial meniscus is much more easily injured than the lateral meniscus, and this is because the medial meniscus is less mobile than the lateral meniscus and therefore ‘escapes’ the traumatic event less, and is more easily injured.

In addition to the traumatic event, there are also other meniscal injury situations that depend on a degenerative framework: with time, in fact, our meniscus can undergo wear and tear, losing part of its malleability and pliability, becoming a rigid structure that confers painful symptoms.

Meniscus injury, symptoms

The symptomatology of meniscal injuries is usually characterised by elective pain occurring during walking (i.e. during loading) and aggravated by extreme degrees of articulation, i.e. in hyperextension and hyperflexion.

The patient always reports a pain in a precise point that usually corresponds to the site of the meniscal lesion although, in some cases, it may be more extensive.

There are some extremely dangerous meniscal injuries (e.g. flap lesions and bucket-handle lesions) that can give rise to what is known as acute joint locking, which occurs when a fragment of meniscus moves into the knee and breaks the normal joint between the femoral condyles and the tibial plateau.

This is an extremely serious and dangerous situation that requires an immediate surgical approach, precisely because patients find themselves unable to articulate and move their knee correctly.

In the case of a meniscal injury due to cartilage degeneration, the symptoms can be very similar to those of an injury due to trauma, which is why it is necessary to try to assess the cause of the pain through a thorough medical history.

Therefore, meniscal symptoms are not only caused by the meniscal injury but also by a possible meniscosis, i.e. an inflammatory or degenerative process of the meniscus.

There are some people who are more prone to meniscal injury and these are those who have significant axial deviations of the limbs.

Imagine, for example, a varus or valgus knee, i.e. a knee that distributes body loads more on one side of the knee: the force loads will be greater on the medial and lateral sides, leading to greater stress, a possible cause of degeneration and subsequent meniscal injury.

How a meniscus injury is diagnosed

Diagnosis of a meniscal injury is both clinical, through specific tests that allow us to understand whether or not the meniscus is actually involved, and instrumental, preferably using MRI.

It is important that the MRI is high field, at least 1.5 tesla.

If it is low field, MRI may not show certain types of meniscal injury, especially if they affect the portions closest to the joint capsule.

Treatment

Is it possible to live with a ruptured meniscus? The answer is yes.

Today, it is safe to say that the surgical approach to a meniscal injury is much more considered.

It used to be that if you had knee pain, you would immediately operate on the meniscus.

The removal of the meniscus, whether partial or total, could be the cause of the onset of an arthritic degenerative framework or of a chondropathy, or in any case of significant chondral suffering that over the years can also lead to arthrosis proper and therefore to the need for a more demanding operation such as a mono-compartmental or total prosthesis.

Nowadays, therefore, the approach to the meniscus is dictated by 2 very important factors:

• the type of lesion;
• the anatomical location of the lesion.

The particularity of the meniscus is the fact that it is a partly vascularised structure, i.e. it is reached by blood.

Important scientific studies have shown that the part that is adherent to the joint capsule receives a large quantity of blood, while the free part in the joint receives nothing.

This underlines the fact that some injuries, depending on whether they are located in the vascularised or non-vascularised part, must be treated differently.

If the lesion is located in the vascularised part it is possible to hope for spontaneous healing, whereas if it is located in an avascularised area it will be necessary to consider a surgical approach of partial removal.

Meniscectomy

If surgical treatment is chosen, arthroscopy is the most suitable technique and consists of making two small holes in the dermis which allow the surgeon to enter the joint with an optical probe, assess the severity of the lesion and decide whether or not to proceed with a meniscectomy.

A meniscectomy should be as selective as possible, i.e. one should try to remove only the part of the meniscus affected by the lesion while preserving the remaining part of the meniscus.

Total meniscectomies are extremely rare and are performed in special cases, unlike before the advent of arthroscopy.

Meniscal suturing

Meniscal suturing can be used for some types of injury, especially if they are located in the vascularised area of the meniscus.

With this technique, the meniscus is not removed, but rather repaired.

In this regard, there are many devices on the market that allow selective suturing using special techniques such as, for example, spinal needles, which allow the thread to be passed outside-in, inside-out, and then to wrap around the meniscal lesion and bring it back into closure, facilitating healing.

Also in this case, the choice of meniscal suture is strictly related to the type of lesion and anatomical location.

In the case of suturing, it is advisable to:

• to observe rest by avoiding flexing the knee beyond 90 degrees, i.e. reaching the extreme degrees of articulation, because these are the ones that pull and push on the meniscus, preventing it from healing properly;
• for 60-70 days, therefore, avoid significant stress on the knee, both in flexion and extension;
• strictly avoid torsional and rotational movements;
• avoid all sports with a sudden change of direction, such as basketball, football, volleyball or tennis.

It is recommended to do a lot of stretching, a lot of stretching and a lot of postures in extension, trying to recruit the quadriceps muscle with isometric and eccentric contraction.

Meniscus injury, rehabilitation treatment

From a rehabilitation point of view, if surgery is performed, the treatment is simple and involves the recovery of normal articulation and muscle tone-trophism.

Usually, within 1 month, you can return to your daily activities without pain.

Recovery after a meniscal suture

The rehabilitation programme is different when a meniscal suture is performed, where it is necessary to respect the biological healing time of the suture, following some simple indications:

• Use crutches;
• do not subject the knee to excessive loads;
• not subjecting the knee to excessive stress.

When a meniscal suture is performed, recovery times are considerably longer, up to 3-4 months after surgery; in the case of a conservative approach, it is necessary to be very patient, and to strictly respect the orthopaedist’s indications, especially when performing physiotherapy.

Recurrences are possible and are linked to the fact that nowadays, as mentioned, there is a tendency to perform selective meniscectomies, so the remaining part of the meniscus, which at that moment is healthy, could become pathological, in relation to a new traumatic event.

If a meniscal suture is performed, the chances of recurrence are quite high and can be as high as 30-40%.

The meniscal suture is linked to joint stability, i.e. the integrity of the ligaments.

It is therefore contraindicated in an unstable knee, i.e. in the presence of injuries to the anterior, posterior or collateral cruciate ligaments.

In this context, the chances of a meniscus being subjected to longitudinal and transverse tensile forces are greatly increased by a poor distribution of forces over the joint.

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Source:

GSD