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Arthroscopic surgery for meniscus tears

Who out there has had arthroscopic surgery to trim a torn meniscus?  I've recently had significant knee swelling and the MRI results showed a second tear in the medial meniscus of my left knee.  The first tear was deemed to be a "good" tear back in 2010, so I was not too surprised to learn that there was additional wear and tear.   The only thing that surprised me was that there was no traumatic preceding the knee swelling.  I increased my running volume and three weeks later, I had a sore knee.  My doctor told me that it could have been torn for quite a while but that the increased run volume brought it to my attention.  Unfortunately, the meniscus can degenerate and tear pretty easily when we reach a certain age.  

The topics I am hoping to cover would be: 
- Pre-hab: I am not sure if this even a word, but it seems that I should show up for surgery in optimal form: reduced swelling, max strength and improved flexibility
- Rehabilitation: What are the best strategies to getting back on track to train?  Clearly, I want to strengthen my quads, improve my stabilizing muscles and improve flexibility.  Not sure the best way to achieve all these.  
- Change in range of capabilities, post-op: My doctor says that I should be "back to normal" after six weeks.  However, I wonder how much I will have to modify my running and other activities.  
- Long-term implications: There are clear benefits to removing debris that interferes with movement and that can irritate the cartalidge on your femur and tibia.  But does anyone have a view on long-term risks for arthritis in the knee caused by reduced volume of cushioning from the meniscus? 

Thanks for any thoughts you might have.  
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  • This is an article I read just this week comparing outcomes from operative and nonoperative therapies.  May or may not apply to our specific situation, but could spark a good discussion with your ortho 

    Am Fam Physician. 2017 Jul 1;96(1):55.

    Clinical Question

    Is arthroscopy better than nonsurgical treatment for patients with meniscal tears?

    Bottom Line

    The existing research base, with biases that typically make interventions look better, is unable to demonstrate that arthroscopy for meniscal injuries is any better than nonoperative approaches. Because this is a costly intervention and is being used more often, perhaps insurance companies should reevaluate whether to continue paying for it. (Level of Evidence = 1a–)

    Synopsis

    These authors searched multiple databases, including registries of clinical trials and the reference lists of retrieved studies, to identify randomized trials of systematic reviews published in English. Two authors independently decided which studies to include and determined the risk of bias in the included studies. They resolved disagreements through conversation and, when necessary, through third-party adjudication. Ultimately, they included nine randomized trials and eight systematic reviews. The clinical trials included 68 to 351 patients and the systematic reviews included 98 to 1,374 patients. All of the systematic reviews were published after 2012, so the variation in sample size is rather striking and reflects the inclusion criteria. For example, the largest systematic review evaluated case series, only slightly less biased than expert opinion in determining the effectiveness of an intervention. The main recurring problems with the randomized trials were the lack of adequate masking and the selective outcome reporting. Only two of the trials compared arthroscopy with sham surgery. The others used active comparisons (e.g., resection, exercise, physical therapy, steroid injections, bioabsorbable arrows). The follow-up duration for the studies ranged from six months to five years. The studies also used several different outcome assessments: repeat tear, radiographic findings, pain on a visual analog scale, Western Ontario and McMaster Universities Osteoarthritis Index score, Knee Injury and Osteoarthritis Outcome Score, and so forth.

    The authors, appropriately, decided not to pool the data and just summarized the findings. Most of the systematic reviews failed to identify clinically meaningful improvements, and only one of the randomized trials found “marginal benefit” in patients treated arthroscopically. Because the systematic reviews included cohort and case-control study designs, and the randomized trial flaws all tend to be biased in favor of intervention, the existing data strongly suggest that arthroscopy for meniscal injuries is ineffective. I find it remarkable that so many systematic reviews exist with only nine clinical trials. This seems like overanalyzing the existing data. The authors seem disappointed, and no matter how many times the data demonstrate no advantage to arthroscopy, they will likely call for more clinical trials. No, we do not have an urgent need for evidence—the existing evidence is plenty.

    Study design: Systematic review

    Funding source: Government

    Setting: Various (meta-analysis)

    Reference: Monk P, Garfjeld Roberts P, Palmer AJ, et al. The urgent need for evidence in arthroscopic meniscal surgery. Am J Sports Med. 2017;45(4):965-973.

    HENRY C. BARRY, MD, MS

    Professor

    Michigan State University

    East Lansing, Mich.

    POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.


  • Am Fam Physician. 2016 Aug 15;94(4):317a-318.

    Clinical Question

    Does partial meniscectomy fix mechanical symptoms—knee catching or locking—better than sham surgery?

    Bottom Line

    Removing the torn bits of meniscus in middle-aged patients who have intermittent knee catches or locking does not decrease their likelihood of experiencing symptoms in the following year compared with diagnostic arthroscopy (i.e., looking but not touching). In general, meniscectomy does not improve knee pain, regardless of the symptoms (N Engl J Med. 2013;369(26):2515–2524). (Level of Evidence = 1b−)

    Synopsis

    This report is a substudy of a larger study investigating the effect of arthroscopic surgery on (relatively) young patients with meniscal tear but without signs of osteoarthritis. These Finnish investigators enrolled 146 patients, 35 to 65 years of age, who had knee pain for at least three months and evidence of a degenerative meniscal tear but did not respond to conservative treatment. They excluded patients with a verified locked knee (unable to straighten), although they included patients (n = 69) who had symptoms of catching or occasional or frequent locking. All patients underwent arthroscopic surgery, although slightly more than one-half were randomly assigned, using concealed allocation, to a group that did not have the tear addressed (sham surgery). In the surgery group, damaged and loose parts were removed; in the sham surgery group, diagnostic arthroscopy was performed, and the surgeon simulated actual surgery (because patients were awake) without removing anything. In the subsequent 12 months, 23 (72%) in the surgery group and 22 (59%) in the sham surgery group with preoperative mechanical symptoms reported symptoms at least once. Only nine of 32 patients (28%) in the surgery subgroup and 15 of 37 (41%) in the sham surgery subgroup reported complete resolution of their symptoms.

    Study design: Randomized controlled trial (double-blinded)

    Funding source: Foundation

    Allocation: Concealed

    Setting: Outpatient (specialty)

    Reference: Sihvonen R, Englund M, Turkiewicz A, Järvinen TL; Finnish Degenerative Meniscal Lesion Study Group. Mechanical symptoms and arthroscopic partial meniscectomy in patients with degenerative meniscus tear: a secondary analysis of a randomized trial.  Ann Intern Med. 2016;164(7):449–455.

    ALLEN F. SHAUGHNESSY, PharmD, MMedEd

    Professor of Family Medicine

    Tufts University

    Boston, Mass.

    POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

    Here’s another one on locking and catching 


  • Comparing PT alone to surgery plus PT when there is arthritis 

    Am Fam Physician. 2013 Oct 15;88(8):542.

    Clinical Question

    Is surgery or physical therapy (PT) more effective for patients with osteoarthritis and a meniscal tear?

    Bottom Line

    For middle-aged or older adults with osteoarthritis and a meniscal tear, there seem to be no significant differences between arthroscopic surgery plus PT and PT alone. A subset of patients who do not respond well to PT alone will eventually have surgery, but if they cross over to surgery within six months of beginning PT, their 12-month outcomes are not worse for the delay. (Level of Evidence = 1b)

    Synopsis

    For patients with osteoarthritis and a meniscal tear, surgery is the standard of care in the United States. This study randomized 351 persons 45 years or older with a meniscal tear and osteoarthritis on magnetic resonance imaging to receive surgical therapy plus PT or PT alone. Surgery consisted of arthroscopic partial meniscectomy and removal of loose bodies. PT consisted of land-based progressive home exercise that addressed inflammation, range of motion, strengthening, and aerobic conditioning. The mean age of patients was 58 years, 43% were men, and 85% were white. Analysis was by intention to treat, and groups were balanced at the start of the study. Interestingly, the left knee was more likely to be involved (58%), perhaps because that is the plant or pivot leg for right-handed persons. For example, right-handed high jumpers or long jumpers usually jump from the left leg. The primary outcome was improvement in the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score. There was no difference between the amount of improvement in the WOMAC score for patients in the surgery group compared with those in the PT group (20.9 points for surgery vs. 18.5 points for PT; difference = 2.4 points; 95% confidence interval, –2.4 to 6.5). There were no differences in pain or quality-of-life scores, either. Of the patients who were assigned to PT, approximately 30% crossed over to surgery within six months. These patients had less early improvement with PT than those who stuck with the PT program.

    Study Information

    Study design: Randomized controlled trial (nonblinded)

    Funding source: Government 

    Allocation: Concealed

    Setting: Inpatient (any location) with outpatient follow-up

    Reference: Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis [published correction appears in N Engl J Med. 2013;369(7):683]. N Engl J Med. 2013; 368( 18): 1675– 1684.

    MARK H. EBELL, MD, MS

    Associate Professor

    University of Georgia

    Athens, Ga

  • @Leslie Knight - Thanks!  Those three articles are terrific.  I had heard of similar outcomes, and had discussed this topic with the orthopedic surgeon who looked at my first meniscus tear in 2010.  At that time, my doctor said that I had a horizontal cut, so the prognosis was good with only PT.  He was reluctant to operate.  However, he said that after a few years, I ran a high risk of having a degenerative tear.  I am assuming (but cannot know) that is what happened recently because there was no traumatic event that triggered my knee swelling.   This conversation has since been in the back of my mind, so I was not surprised to see a second tear in the same spot.    

    I will certainly raise these articles to my doctor at my next consultation.  It will be interesting to hear how my doctor responds.  In addition, I will ask another orthopedist in his practice to take a look at the MRI results. 

    Given that this was my second tear in the same spot, I went into this series of consultations and the MRI fully expecting that I would need surgery.  I have read that if the meniscus tear has a flap, then it will trigger swelling and possibly increase the risk of arthritis.  There is now a flap from my second tear.   I don't know if this is true, but I have read it on several medical websites.  

    I prefer not to have surgery.  Even an arthroscopic surgery, which is billed as minimally invasive, still introduces a lot of trauma to the knee.  

  • @Leslie Knight - I got a few opinions, and will proceed with the surgery on October 31st.  

    The tear is perpendicular to my old tear, so now I have a big flap in back of my knee, with the point of the rip pointing towards the middle of the knee.  

    I haven't the faintest idea when this happened.  I didn't have any traumatic falls or trips.  During my marathon build, I woke up one day with some pain in my knee, and then it swelled up.  After trying a few cycles of icing and resting my knee, I got the good advice to see an orthopedist.  

    The doctor won't let me run, cycle or kick while swimming until after my surgery.  I am going stir-crazy and eager to get to other side of this.  I can start cycling and do full swimming in mid-November and will be able to start running in mid-December.  

    It's unclear how much of my meniscus will get removed given that it isn't easy to tell how big the tear is from the MRI.  The only good thing is that the swelling in my knee and the pain are almost completely gone.  Unfortunately, I will have swelling and pain agin in two weeks.  

    I am doing my best to go into this surgery as healthy as possible.  I am doing yoga or core workouts six times a week, plus swimming 3-4 times a week.  I am already researching exercises to do for rehab.  

    Will post after my surgery.  
  • @Patrick Marsh-  Good luck and best wishes for a strong and fast recovery. Sounds like you’re doing everything possible to set yourself up for success. 
  • I had ACL replacement 5 years ago. I did the whole rehab thing including PT for several months. I began running six months after the surgery and my knee began to swell. After a set of MRI pictures they determined it was the meniscus and it needed to be “shaved”. The pre-op picture of the meniscus looked like hair coming out of my knee and the post-op looked like if all of that hair was shaved.

    The meniscus surgery was successful and the rehab began again. I was able to ride and swim within 2 months but it took a whole year before running again. I focused that year on cycling events only.

    After several years, running still doesn’t feel like before. I hope you have a speedy recovery. The only advice I can give you is not to rush it. Take the recovery step by step. Lots of PT and strength training at the gym before running again.
  • @Jorge Duque Thanks for the post.  I am definitely not going to rush my return to running.  

    This past Tuesday, I had my surgery.  Fortunately, it was very efficient.  I showed up at 6:15 am in a fasted state.  Within 30 minutes, I had completed my paperwork and was dressed for surgery.  At 6:45, I was wheeled into a very bright, very white and very cold room filled with pleasant masked doctors and nurses.  The next thing I knew, I was back in the staging room and 90 minutes had passed.  It took me about 15 minutes or so to get my bearings, but I was pretty lucid for the rest of the day.  I was sent home around 10:30 am, and my girlfriend Karen kindly watched after me the rest of the day.

    The doctor removed about 30% of my meniscus.  I had a horizontal cleavage from a 2010 injury.  At some point, I tore the same spot perpendicular to the first rip.  Therefore, I had a triangular flap that the doctor removed.  

    Day 1 was Halloween.  I sat on my girfriend's couch and read.  I took alternating double doses of Tylenol and ibuprofen for the first 24 hours.  I was given Oxycodene, but fortunately I didn't need these and tossed them on Day 2.  On the first day, I had a huge wrap consisting of multiple layers of bandages that was bound together by an enormous ace bandage.  This immobilized my leg.  There was not too much pain from the surgery, and I could tell immediately that the tenderness from the torn meniscus on the inside of my knee was gone.  Surprisingly, I was able to walk almost immediately after the surgery.  However, I only walked a few steps the whole day, and spent the day on the couch with my foot elevated.  Day two was more of the same - sitting with my foot up.  

    On day 3, I removed my bandages.  It was a bit of a bloody mess inside there.  I took a shower and sponged off the mess.  Then I put band aids on, and wrapped the knee again in ace bandages.  There was some evident swelling from the surgery, and it felt like I had three bruises from where the probes were inserted.  However, overall I felt good.  I went back to work on the afternoon of day 3, and attended a client dinner.  This was the only time like I felt like I had pushed it, so that night I went home and iced the knee twice.  On day 4, I had to take the Acela train to a meeting in Delaware, and I iced my knee on the train and only had to walk a few times.  On Friday night, I iced the knee three more times.  Then I slept nine hours as I had not been comfortable the previous three nights.

    Yesterday was Saturday - day 5, and I started my rehab - quadricep contractions and heel raises.  I iced my knee pretty much all day and again, sat for most of the day with my foot up.  I did three rounds of rehab, and also did a lot of stretching of my shoulders and torso.  (I have been doing yoga five days a week since I injured the meniscus).  Last night, I went out to dinner and my knee felt great.  The swelling is localized around the holes where the probes entered, however the knee did not "blow up".

    Today, I am continuing to keep my foot up.  I will ice the knee several times.  Also, I have found some yoga routines to do for post-knee surgery.  They consist of rehab exercises and stretches you can do lying on your back.

    Overall, I feel great.  I going a bit stir crazy after five days of being seated with an ice pack, but I am getting in some quality reading time.  Also, I am glad that the knee is not significantly swollen.  I am going to continue to do seated/supine stretching and rehab exercises until my one-week checkup.  Also, I continue to ice my knee several times a day.  

    As soon as I get the stitches removed, I will be allowed to get in the pool for aqua running.  By the end of week-two, I will be permitted to swim and lightly spin in addition to the rehab, stretching and aqua running.  

    Overall, I am surprised by how good my knee feels.  I can extend my knee almost completely without pain, and as of this morning I can flex the knee well beyond 90 degrees.  I only have localized pain where the stitches are.  More importantly, the pain on the inside of my knee is gone.  

    Despite these encouraging signs, I am being very careful not to overdo it because I have read about a lot of people's long recoveries that were lengthened by going out too fast after surgery.  

    I will post again next week.  
  • Hey Patrick,

    I'm very happy for you. It seems that you are having a super speedy recovery.

    Don't push it. Take nice and easy.
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