Meniscus Surgery: Understanding Meniscectomy and Meniscal Repair

What are the two types of meniscus surgery?

The two primary types of meniscus surgery are meniscectomy, which involves the partial or total removal of damaged meniscal tissue, and meniscal repair, which aims to sew or fix the torn meniscus back together.

Understanding the Meniscus

The menisci (plural for meniscus) are two C-shaped pieces of cartilage in each knee joint, located between the thigh bone (femur) and the shin bone (tibia). The medial meniscus is on the inner side of the knee, and the lateral meniscus is on the outer side.

Key Functions of the Meniscus:

• Shock Absorption: They act as cushions, distributing load across the knee joint.
• Joint Stability: They contribute to the overall stability of the knee.
• Lubrication and Nutrition: They help distribute synovial fluid, aiding in joint lubrication and cartilage nutrition.
• Load Transmission: They increase the contact area between the femur and tibia, reducing stress on the articular cartilage.

Meniscus tears can occur due to sudden twisting motions, direct impact, or degenerative changes over time. Symptoms often include pain, swelling, stiffness, a popping sensation, and difficulty extending or bending the knee.

When is Surgery Considered?

Not all meniscal tears require surgery. Many tears, especially smaller, stable ones in the less vascularized "white-white" zone, or degenerative tears in older individuals, may be managed non-surgically with rest, ice, compression, elevation (R.I.C.E.), physical therapy, and pain management.

Surgical intervention is typically considered when:

• Symptoms persist despite conservative management.
• There is a mechanical block (e.g., "locking" or "catching" of the knee).
• The tear is in a vascularized area (the "red-red" or "red-white" zones) with good potential for healing.
• The tear type (e.g., bucket-handle tear) significantly impairs knee function.
• The patient is young and active, and preserving meniscal tissue is crucial for long-term knee health.

Type 1: Meniscectomy (Partial or Total)

A meniscectomy involves the surgical removal of the torn or damaged portion of the meniscus. This is the more common type of meniscus surgery.

Procedure:

• Most meniscectomies are performed arthroscopically, using a small camera and instruments inserted through tiny incisions.
• The surgeon identifies the torn segment and carefully shaves away or removes only the damaged tissue, leaving as much healthy meniscus as possible. This is known as partial meniscectomy.
• In rare, severe cases where the entire meniscus is irreparably damaged, a total meniscectomy may be performed, though this is generally avoided due to its long-term implications.

Indications:

• Degenerative tears (common in older adults).
• Complex tears that are not amenable to repair.
• Tears in the avascular (white-white) zone of the meniscus, which has poor healing potential.
• When the torn flap causes mechanical symptoms (locking, catching).

Pros:

• Generally a quicker recovery time compared to repair.
• Patients can often bear weight and return to light activities sooner.
• Effective at alleviating immediate symptoms like pain and locking.

Cons:

• Removing meniscal tissue reduces the knee's natural shock absorption.
• Increases the risk of developing osteoarthritis in the knee joint over time due to increased stress on the articular cartilage. The more tissue removed, the higher the long-term risk.

Recovery:

• Weight-bearing is often allowed immediately or shortly after surgery.
• Rehabilitation focuses on restoring range of motion, reducing swelling, and strengthening the quadriceps and hamstrings.
• Return to sport or full activity can typically occur within 4-8 weeks, depending on the individual and activity demands.

Type 2: Meniscal Repair

Meniscal repair is a surgical procedure aimed at stitching or fixing the torn meniscus back together, preserving the meniscal tissue.

Procedure:

• Like meniscectomy, meniscal repair is typically performed arthroscopically.
• The surgeon uses specialized sutures or fixation devices (e.g., arrows, darts) to reattach the torn edges of the meniscus to the stable, healthy meniscal rim.
• The goal is to create a stable environment for the tear to heal, relying on the body's natural healing processes.

Indications:

• Tears located in the "red-red" or "red-white" zones, which have a good blood supply and thus better healing potential.
• Longitudinal tears, bucket-handle tears (if reducible), or radial tears that are stable.
• Younger, active patients where preserving the meniscus is highly desirable for long-term joint health.
• Acute tears, as they tend to have better healing potential than chronic tears.

Pros:

• Preserves the natural shock-absorbing and stabilizing functions of the meniscus.
• Significantly reduces the long-term risk of developing osteoarthritis compared to meniscectomy.

Cons:

• Longer and more restrictive recovery period to allow for healing.
• Weight-bearing may be restricted for several weeks.
• Higher risk of re-tear compared to meniscectomy, especially if rehabilitation protocols are not strictly followed.
• Not all tears are repairable.

Recovery:

• A period of non-weight-bearing or restricted weight-bearing (e.g., using crutches) for 4-6 weeks is common.
• Bracing may be used to limit knee flexion and protect the repair.
• Rehabilitation is slower and more progressive, focusing on protecting the repair while gradually restoring motion and strength.
• Return to sport or full activity can take 4-6 months, or even longer, depending on the sport and individual.

Deciding Between Meniscectomy and Meniscal Repair

The decision between a meniscectomy and a meniscal repair is complex and depends on several factors, including:

• Patient age and activity level: Younger, active individuals are often candidates for repair.
• Tear type and configuration: Longitudinal, radial, or bucket-handle tears may be repairable, while complex or degenerative tears often are not.
• Tear location: Tears in the vascularized zones (red-red, red-white) are more likely to heal.
• Tear chronicity: Acute tears generally have a better chance of successful repair.
• Overall knee health: Presence of other knee injuries (e.g., ACL tear) can influence the decision.
• Surgeon's expertise and preference.

Post-Surgical Rehabilitation

Regardless of the type of surgery, post-operative rehabilitation is critical for a successful outcome. A structured physical therapy program will guide patients through:

• Pain and swelling management: R.I.C.E., medication.
• Restoring range of motion: Gentle exercises to regain full knee movement.
• Strengthening: Progressive exercises for quadriceps, hamstrings, glutes, and calves.
• Proprioception and balance training: Improving the knee's awareness and stability.
• Gradual return to activity: Sport-specific drills and progressive loading as appropriate.

Adherence to the physical therapy protocol is paramount to optimize recovery and minimize the risk of complications or re-injury.

Potential Risks and Complications

While both procedures are generally safe, potential risks include:

• Infection
• Bleeding
• Blood clots (DVT, PE)
• Nerve or blood vessel damage
• Persistent pain or stiffness
• Failure of the repair (for meniscal repair)
• Development or progression of osteoarthritis (especially after meniscectomy)

Conclusion

Understanding the two primary types of meniscus surgery—meniscectomy and meniscal repair—is crucial for anyone facing a meniscal tear. Meniscectomy offers a quicker recovery by removing damaged tissue but increases long-term osteoarthritis risk. Meniscal repair aims to preserve the meniscus, offering better long-term joint health, but requires a longer and more restrictive rehabilitation. The choice between these procedures is highly individualized, based on the tear characteristics, patient profile, and a thorough discussion with an orthopedic surgeon. Comprehensive post-surgical rehabilitation is essential for optimizing recovery and achieving the best possible functional outcome for both surgical approaches.