1. Osteoarthritis
2. Meniscal tear
3. Chondromalacia patella..

Osteoarthritis of the right knee; Waterfall Hospital

Osteoarthritis

Osteoarthritis is a degenerative condition of the knee. In layman’s terms it can be thought of as “wear and tear” in the knee joint.The knee consists of three areas or compartments, the medial or inner compartment, the lateral or outer compartment, and the patellofemoral joint (the area under the patella or knee cap). Arthritis in the knee affects one or more of these areas in the knee. The most encountered situation is the development of arthritis in the medial or inner compartment. As the condition progresses there is a gradual narrowing of the joint space on the inner aspect of the knee due to cartilage thinning and a deformity can result which can give the legs a bow-legged appearance. Swelling is often present with arthritis. If the arthritis progresses and becomes unresponsive to non-operative interventions, a total knee replacement may eventually be required.

Arthroscopic picture of a vertical meniscus tear; Waterfall Hospital

Meniscal Tear

The meniscus is a C-shaped cartilage structure in the knee which acts as a “shock absorber”. There are two such structures in the knee, a medial meniscus on the inner side and a lateral meniscus on the outer side. The meniscus can be torn through injury to the knee, but not uncommonly it can also be injured after even minor trauma if the meniscal tissue is weak. Patients complain of pain along the inner side of the knee and there may be associated symptoms such as swelling, clicking and locking. Arthroscopy is often required to treat a meniscus tear.

Chondromalacia patella is usually treated by a muscle strengthening program

Chondromalacia Patella

Chondromalacia patella is an extremely common cause of knee pain. It typically affects younger women but can occur in men and in other age groups as well. The pain is typically located in the front of the knee and is worse when using the stairs or sitting for long periods of time. Patients usually develop a crunching sensation in the knee. Chondromalacia patella literally means softening of the cartilage of the patella and the crunching or crepitus is because of progressive roughness and fissuring of this cartilage. Due to the nerves supplying the knee, the pain from chondromalacia patella can often refer to the inner side of the knee and occasionally causes difficulties in diagnosing the condition. Fortunately surgery is uncommonly needed to treat this condition and strengthening treatment with a physiotherapist or biokineticist is usually all that is needed.

What should do if I have pain on the inner side of the knee?

The above conditions may all present in a similar way, but the treatment for each is usually very different, and ranges from conservative measures such as starting a rehabilitation or strengthening programme, to having major surgery like a total knee replacement. In some instances obtaining an accurate diagnosis may be difficult initially and I would recommend that you see an experienced knee surgeon for a thorough assessment. I see and treat many patients with each of these conditions at Waterfall Hospital in Waterfall/Midrand and at Morningside Clinic in Sandton.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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Please use the form below to get in touch with Dr Matthee’s rooms. A representative will respond to you shortly.

The post Three causes of pain on the inner side of the knee appeared first on Dr Warren Matthee.

I need a meniscal repair..but what is the meniscus?

The meniscus is c-shaped cartilage structure in the knee. There are two such structures in each knee. The medial meniscus is found on the inner part of the knee. The lateral meniscus is found on the outer part. They are located between the femur above, and the tibia below. They are made out of fibrocartilage.

The meniscus functions as a supporting structure in the knee. It provides a small amount of stability and position-sense. It also helps with lubrication. A meniscal tear can occur at any age group. It is uncommon in children, however. It is more common after trauma in younger people. In older people the cartilage may have become weaker. A tear may arise from minor injury or even just with repetitive activity or overuse.

Symptoms of a meniscal tear

An example of a beak-type meniscal tear causing symptoms of locking

These may include pain on the sides of the knee, swelling and clicking (read: Three signs that you may have a meniscus tear).  Occasionally there may be locking. When this happens the knee does not want to straighten fully. Sometimes it feels as if there is something caught inside the joint preventing movement.

The diagnosis can sometimes be made clinically. If there is any doubt an MRI scan will be needed.

Can a meniscus tear heal on its own?

Unfortunately, the meniscus has a poor of supply. Once it is torn it usually does not heal without treatment. If a meniscal tear is small, stable and located in an area with good blood supply in a young and healthy patient, it may heal. The chances of this are slim. Sometimes tears which have not been treated may become pain-free. This may lead one to think the tear has healed when in fact it has not.

What happens if you leave a torn meniscus untreated?

This may be associated with the development of a painful arthritis in later years. This may require further surgery such as a total knee replacement. A meniscal tear can also cause continued pain and swelling in the knee. This may limit activities of daily living and sporting activities.

Sometimes a torn fragment of meniscal tissue may get stuck in the knee and caused it to become “locked”. This means that you cannot straighten the knee fully. You will have difficulty in standing and walking. This situation usually requires urgent surgery.

If the knee already has arthritis then specific treatment of a meniscus tear may not make any difference to the outcome. Surgery is mostly indicated in a patient with otherwise healthy knees.

Meniscal repair or removal (meniscectomy)?

A vertical tear in the posterior horn of the meniscus in an area with good blood supply – suitable for repair. The tear is debrided (cleaned) with a meniscal rasp before the repair

There are a few factors to consider when deciding between a meniscal repair and a simple removal of the torn fragment (meniscectomy). This is the topic of some debate. The decision will be made after discussion with your surgeon. It is usually made on factors such as your age and general health, your activity levels, and the tear age, type and location.

Meniscal repair technique

There are three techniques which are used. These techniques may overlap or be used together (hybrid technique). The choice of technique depends on surgeon preference and experience, and the location and type of tear. The three techniques are:

1. The “all-inside” technique
2. The “inside-out” technique
3. The “outside-in” technique

Meniscal repairs are usually performed arthroscopically through small “stab” incisions. Depending on the technique, however, some of the procedure may involve open surgery. This will then involve a separate, bigger cut on the skin. Arthroscopic surgery is associated with faster recovery times and minimal scarring.

“All-inside” meniscal repair

If the “all-inside” technique is used, the entire repair is done arthroscopically. This is used when the tear is located at the back or main portion of the cartilage (posterior horn and body tears). A special device is used through one of the small arthroscopy portals to insert a stitch into the meniscus. Usually more than one stitch is needed. If more than three or four are required then a different technique may be preferred, e.g. inside-out meniscal repair.

“Inside-out” meniscal repair

With this method stitches are placed into the meniscus from inside the knee. The stitch enters through one of the small arthroscopy portals at the front of the knee. This is done under direct vision using the arthroscopy camera. The needle used to place the stitch is long and flexible. The needle is passed right through the meniscus and out the skin behind the cartilage. Several stitches are usually in this repair. An incision must be made on the skin on the side of the knee to allow the needles to pass through. Once the stitches have been passed they are tied and the knot will be outside the knee joint (but under the skin).

The advantage of this repair is that it is a strong repair as many stitches are usually used. The stitches themselves are inexpensive. This technique is used when there is a very large tear requiring multiple stitches. This is often the case with a large “bucket-handle” meniscus tear. These tears can involve almost the entire length of the meniscus.

“Outside-in” meniscal repair

This is the least commonly used method. The needle and stitch is inserted from the outside of the knee through the skin. The needle therefore passes through the meniscus from the peripheral end of the cartilage. The stitch is retrieved inside the knee under direct vision with the arthroscopy camera. It is then passed back through the meniscus and out the skin again.

Once the stitches are in place they are tied with the knot on the outside of the knee in a similar way to the “inside-out” technique. This technique is useful for “hard-to-reach” tears in the front of the meniscus (anterior horn).

Can you walk immediately after a meniscus repair?

After a meniscal repair, the repair must be protected. This means a period of not taking weight on the knee. I usually recommend non-weight-bearing or touch weight-bearing for six weeks. You will need two crutches to get around. You will also require a brace. This is to prevent the knee from bending more than 90°. If the knee bends more than this it creates excessive pressure on the repair site. This can cause the repair to fail.

How long does it take to recover from meniscus repair surgery?

At six weeks the brace is discarded and you will be allowed to start taking weight on the leg again. You will then be allowed to progress to full weight-bearing status. This is best done in conjunction with physiotherapy and rehabilitation. Return to running and sport is possible at around four months or later.

In summary…

A meniscal repair is the first-choice procedure if you have a meniscal tear, but within reason. A successful result is essential to prevent arthritis developing in the knee in later years. This success of a meniscal repair depends on many factors. The tear should be repairable. An attempted repair on a meniscus with poor healing potential will likely fail. This will result in further surgery. Success is also dependent on patient factors. This may include general medical health and compliance with post-operative instructions.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

Get in Touch

Please use the form below to get in touch with Dr Matthee’s rooms.

The post How is a meniscal repair performed? appeared first on Dr Warren Matthee.

Three signs that you may have a torn cartilage (meniscus tear) are:

1. Pain along the sides of the joint, or pain in the back of the knee which moves towards the back of the calf. The pain is usually worse when you put weight on the knee. It may be aggravated with twisting movements. Squatting may also cause pain. See also: Knee Pain from a meniscal tear.
2. Swelling. This may come and go, and is often associated with activity. If the knee becomes very swollen it will begin to feel stiff. When this happens it is uncomfortable to bend the knee.
3. Clicking. Many people have a harmless click in their knee, but if a new click has appeared, this may be significant, especially if it is painful or prevents the knee from straightening (this is called locking). The click is different from a “crunching” type of noise. This is usually associated with another condition in the knee.

What should I do if I have these symptoms?

Having these symptoms does not necessarily mean that you have a torn meniscus (see: Three causes of pain on the inner side of the knee), but a proper examination is recommended. If surgery is needed for a meniscal tear, this can be performed as a day case at Waterfall Hospital in Waterfall/Midrand or at Morningside Mediclinic in Sandton. The operation is done arthroscopically (“keyhole surgery”).

A beak-type meniscal tear, requiring removal of the torn fragment

As an orthopaedic surgeon with a special interest in knee surgery, I see and treat many patients who have a meniscus tear. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. I also treat patients from many other areas as well, including Rosebank, Sunninghill and Fourways.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

The post Three signs that you may have a meniscus tear appeared first on Dr Warren Matthee.

There are two such structures in each knee. One is on the inner aspect of the joint and one on the outer aspect. The meniscus has a poor blood supply for the most part, and this makes healing of injuries to the cartilage difficult.  Injuries in the periphery of the tissue have better healing potential as the blood supply here is better.

Arthroscopic view of a normal meniscus

Mechanism of Injury and Clinical Examination

Although trauma can result in an injury, occasionally there is no history of trauma. The cartilage may be torn by movements such as a sudden twist or repeated squatting. Sometimes you may not be able to recall the exact event. The usual complaint is that of pain which is mainly felt along the joint margins on the side of the knee.

Pain may be felt at the front or back of the knee depending on the nature and location of the tear. Often there is clicking, catching, locking, pinching or a sensation of “giving way”. The pain may be accompanied by intermittent swelling.

For further reading on possible signs of a meniscal tear please see this useful article: Three signs that you may have a torn cartilage in your knee (meniscal tear)

A thorough history and complete physical examination is needed to evaluate a patient who may have a meniscal tear. It is important to exclude other possible causes of the pain. The exact location of the tenderness, the presence or absence of fluid in the knee, and the range of motion are determined. The McMurray test may be positive. This involves putting the knee through a range of rotatory movements in flexion and extension to try and elicit the pain and/or click from a torn meniscus.

Investigations

Cartilage cannot be seen directly on X-rays of the knee. X-rays are usually obtained, however, to exclude other possible causes for the pain such as a fracture or osteoarthritis. An MRI scan is a highly detailed scan which can image all the internal structures of the knee. This includes the meniscal cartilage and ligaments and may be used to help diagnose a tear.

An example of a meniscal tear

A vertical tear of the meniscus

Treatment

In some instances it is possible for a person with a small tear in an area with good blood supply to heal without surgery. Such conservative management may include rest or activity modification, the use of anti-inflammatories, and physiotherapy.

Most tears, however, do not heal without intervention. The tear may progress and become more painful. It may even become dislodged from its normal position and cause a “locked” knee, where you are unable to fully straighten the leg. Unattended tears can be the cause of cartilage damage elsewhere in the knee. Eventually this may result in painful osteoarthritis of the joint.

The goal of surgery

The basic goal of surgery is to “save the meniscus”. A meniscal repair with stitches is performed if this is feasible. A number of factors are taken into account. These include age, activity level, type of tear and associated ligamentous injury. For non-repairable, complex tears and those in an area of poor blood supply, the torn part of the meniscus is removed (partial meniscectomy). The aim is to leave as much stable meniscal tissue as possible behind.

In the past, the operation would involve open surgery and make use of larger incisions to repair the injury. Today the procedure is safely and successfully carried out arthroscopically (using “keyhole surgery”). A high definition camera is used to inspect the joint, and repair or remove the torn meniscus.

The benefits of arthroscopy include smaller scars, improved vision, faster recovery and rehabilitation and better outcomes. Surgery is generally successful and gives a high level of patient satisfaction. However, in a person with an arthritic knee, arthroscopy may have more limited benefit.

The complication rate is quite low. Possible complications include infection, damage to blood vessels and nerves, and blood clots in the legs (DVT). Occasionally there may be bleeding into the joint, joint stiffness and persistent pain. Some attempted repairs may fail if the blood supply is poor. In the long term, the aim of a meniscal repair is to reduce the risk of developing osteoarthritis. The risk of this is higher if part of the meniscus had to be removed.

A beak-type meniscal tear

A horizontal or cleavage tear of the meniscus

Recovery

The recovery after surgery for a torn meniscus depends on the procedure that was performed. If a partial removal was performed, the recovery is usually faster. The patient can begin full weight bearing without any limitations on knee movement as soon as this is comfortable.

If a repair was performed, it is usually necessary to use crutches to avoid putting any weight on the leg. A brace is used to prevent excessive bending of the knee for about six weeks to allow the repair to heal. During this period and afterwards, physiotherapy is valuable. This is aimed at maintaining or improving muscle strength and range of motion.

Return to work is possible soon after surgery unless the occupation involves physical labour. Return to sport can be as soon as two to three weeks for a meniscectomy. It may take longer (six to eight weeks) for a repair.

Braking function returns to normal approximately four weeks after knee arthroscopy. Therefore, I do not recommend driving during this period if the right knee was operated on. Driving may be allowed earlier with the left knee. Patients should also not drive with a brace or if they need analgesics to operate the vehicle.

Summary

A meniscal tear is a common cause of pain in the knee. Therefore, those who have developed persistent pain, especially after an injury should visit their doctor for an assessment. An appropriate examination and investigations should be performed. The risk of delaying treatment could result in the development of an arthritic knee.

As an orthopaedic surgeon with a special interest in knee surgery, I see and treat many patients who have a meniscal tear. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. I also treat patients from many other areas as well, including Rosebank, Sunninghill and Fourways.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

The post Knee pain from a meniscal tear appeared first on Dr Warren Matthee.