Meniscus Tear in the Knee - David Menche, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I’m back talking remotely with Dr. David Menche. Dr. Menche is an orthopaedic surgeon who practices in New York City. Dr. Menche did his medical school training at New York University. From there he completed an orthopaedic residency at the Hospital for Joint Diseases and after that completed a fellowship in Gothenburg, Sweden, with Dr. Lars Peterson. Thanks for joining us again, Dr. Menche.

Dr. Menche: Thank you, Dr. Sechrest, it’s good to be here.

Dr. Sechrest: Dr. Menche, thanks for joining us again today. What I thought we would discuss is a condition that’s fairly common in the knee and that is meniscal tear. I think that, in a previous discussion, you and I have talked a bit about the difference between articular cartilage injuries and what is commonly called a cartilage tear or a cartilage injury which, to and I, really means that we interpret that the patient has torn a meniscus – the small little cartilages or gaskets that are in the knee, one on each side. But people hear about this in sports medicine all the time. They are very familiar with this concept but I’m not certain that patients are very familiar about what a cartilage tear or a meniscal tear is and really how we as orthopaedic surgeons approach that and try to repair or fix that injury. So if you could, start out by talking a little bit about what’s the distinction between what we commonly call a meniscal tear versus a cartilage injury and some of the other injuries that can occur in the knee that people may mistake for a meniscal tear.

Dr. Menche: So the meniscus is the shock absorber in the knee. There’s an inside meniscus or the medial meniscus, and the outside or the lateral meniscus, and injuries to the meniscus are one of the common injuries as we see as sports medicine physicians. Commonly they’re called cartilage injuries. The problem with that is that there’s another cartilage in the knee and that is the articular cartilage. The articular cartilage is the white surface that covers the bone. The bone is typically very rough and this articular cartilage or white surface let the knee move with very little friction. So a patient needs to really distinguish when they say that they have a cartilage injury did they have a meniscus injury or shock absorber injury or was there an injury to the joint surface. Injuries to the meniscus very commonly will happen during sporting events or traumatic events but also we see this in the aging population as the degenerative or wear and tear situations happen with damage to the meniscus as well.

Dr. Sechrest: Dr. Menche, when patients present with a torn meniscus in your office what do they commonly present complaining of, and what type of injuries do you see that they’ve had immediately before they may have started having these symptoms?

Dr. Menche: Well, there are many different types of meniscus injuries. Very commonly in a younger athletic population its going to be an acute traumatic event where there’s either a twisting injury or somebody fell down and they’re going to come in and know that they had an event and there still hurting after a period of time. In an older population, there may not be any trauma at all, but one common factor between both groups usually is a relatively sharp pain, many times relatively pin-point around the knee that just doesn’t get better over a period of time.

Dr. Sechrest: So the main thing is pain. I think that some of these patients may have some swelling, may have a knee that tends to swell off and on especially if they’re having a lot of problems with it. Can you describe this concept that you and I, as orthopaedic surgeons, sometimes talk about in terms of locking-when the knee is locked. I think patients may have heard of a locked knee, but what does that really signify to you and I as orthopaedic surgeons?

Dr. Menche: So certainly with meniscus tears many times patients will have problems with their activities of daily living and besides pain they can get swelling. Locking typically is due to either a meniscus tear that is displaced or moved from its anatomical position, or from a loose body or loose piece that’s floating around the knee. In this discussion where we’re talking about meniscus injuries, it’s where a meniscus which is normally in its location has usually moved from the periphery or the outside of the joint more into the center of the joint. Locking, in my definition, is a situation where the patient cannot fully extend their knee not because it hurts, but it just won’t go; and that’s because something is jamming the knee from straightening out which, as I’ve stated, could be either the meniscus or sometimes there could be a free loose piece floating around and one has to define what the situation is in order to alleviate that locking. It’s a mechanical problem that is not going away and is one of the strict surgical indications that we have as orthopaedic surgeons that one must go in a situation where the knee is being blocked due to a mechanical problem.

Dr. Sechrest: When you say go in, you’re really talking about it’s time to consider doing something surgically, like an arthroscopy, fairly quickly and not let that continue to be the case where the knee is locked and you can’t straighten it out. I’m assuming that’s what you’re mentioning.

Dr. Menche: Right. So there are many meniscal tears that may not need surgical intervention. But if the meniscus is displaced, if the knee is locked, that’s usually a large tear that’s not going to get better with nonsurgical means. It’s not going to get better with physical therapy. It’s not going to go back into its anatomical position and heal, so one has to go in there surgically and hopefully in order to anatomically put it back into place and to do a repair if indicated.

Dr. Sechrest: Well, let’s talk a little bit about when the patient shows up in your office, how you’re going to assess that patient and how you’re going to evaluate the knee and determine whether they have a torn meniscus or not. What sort of process do you use to make that diagnosis?

Dr. Menche: Well, the first thing, for all of us as orthopaedic surgeons, is really to listen to the patient, to get the history from the patient of what’s been going on? How did it happen? How long has this been going on? How is this affecting the patient’s lifestyle? What is the type of pain, is it sharp or dull? Where’s the location of the pain? Physical examination after that history many times isolate the area – many patients will have this pinpoint tenderness along the joint line where the meniscus lies – which is a very good indicator, although not a 100% indicator, that the patient may have a meniscus or shock absorber tear issue. Then if that was the case, where on history and physical examination, that the signs pointed to a meniscus tear and that this was affecting the patient’s lifestyle, then consideration to performing an MRI would be done where, again, MRIs are not 100%, but if the MRI shows a tear, the history suggests a tear, that physical examination is pointing to a tear, then certainly the surgeon has a very high degree of probability that that’s what’s going on, and then depending upon the situation at hand, would start to define different treatments that may be necessary in that specific patient.

Dr. Sechrest: Now let’s talk a little bit about the options that the patient has. I think that a lot of patients have this notion that if they have a torn meniscus that they’re going to need, there are no options, that surgery is the only option for this. Do you counsel patients that there are conservative options that perhaps could be tried before they resort to surgery? Or do you tell patients that pretty much we ought to take a look, a look inside with the arthroscope, and we ought to try and go ahead and do something surgically to either repair the situation or take out the loose fragment if that’s the only choice?

Dr. Menche: I have many, many patients who’ve we’ve treated in a nonsurgical way. So not all tears are unstable. Not all tears have symptoms for the patients. So really unless the knee is having a mechanical problem like the locking that we discussed, I do believe that there are certainly many instances that a nonsurgical approach can be performed. If we can get patients to where they were before they had the problem, if they are relatively asymptomatic and can do what they want to do, then surgical intervention may not be indicated. There is no data that I know that shows that if you have a cartilage tear and you’re asymptomatic that there’s a long-term difference in that patient whether you operate on them or not. But if a patient is having a mechanical problem, if the patient is fighting through the pain, if the patient is changing their lifestyle and one can attribute that to that meniscus tear, then surgical intervention will be indicated.

Dr. Sechrest: When you advise a patient to go ahead and consider surgery and you’re talking to them about the options of surgery, how are you having that conversation with the patient before you actually do the arthroscopy and go in and look? What are you telling the patient to expect?

Dr. Menche: Well, it depends upon the situation. So if we have a young patient, let’s say, who may have torn their anterior cruciate ligament and has torn their meniscus we’re going to do whatever we can to preserve that meniscus in that patient and to try to do a meniscus repair. A meniscus repair meaning actually putting that meniscus back into its anatomical place using various stitches or devices that we have. On the other hand, if we have a 55 year old patient where the MRI shows a complex tear of the meniscus where it’s torn in multiple directions, it’s not going to fit back anatomically. It doesn’t have a good blood supply, then meniscus repair terminology should not be used, but a partial meniscectomy is going to be performed or taking out some parts of that meniscus will need to be performed in order to alleviate the patients symptoms, trying to leave as much functional tissue that we can. Occasionally I’ll even leave torn tissue, meaning sometimes the meniscus can have a horizontal tear where the meniscus is sort of sliced in the middle. So if you can imagine a bagel cut in half where there’s a top part and a bottom part, that top part may be stable, that bottom part may be stable, that meniscus could be functional. If we did an MRI that day, it would show a tear, but still in my hand, I’m going to leave that alone because I think that’s going to have some preservation of the joint and hopefully will not cause any symptoms in that patient.

Dr. Sechrest: I think that’s a very important point that you’ve just brought up and that is, in the old days, especially when meniscal resections or any type of meniscal surgery was done as an open procedure, before the day of the arthroscope, essentially the surgeon went in and took the whole meniscus out regardless of what was torn or anything less. That was just the only thing that you could do. With the arthroscope I think that we’ve clearly seen that we can do much more, I would say, surgical approaches where you just go in and take out what’s causing the problem; and I think we’ve learned over time that the meniscus is not something that you can simply throw away and expect the knee to function appropriately. It will function for a while and it will do very well for a while, but if you take out that shock absorption, take out that stabilizer in the knee, you’re going to pay a price down the road and I think a lot of high school athletes, probably my age, had their meniscus removed in the days when it was just considered if it’s bothering you, you go in and take it out. Now we’re seeing the results of that years later, when these folks develop fairly significant osteoarthritis and probably are going to need an artificial knee replacement a little earlier than if someone had been able to do an arthroscopy at that time. I think the take home message of this long diatribe that I’ve just gone through is really – our understanding of the meniscus has improved and having that discussion with patients and say we’re going to go in and try to give you a functional anatomically, maybe not normal meniscus, but something that can prevent so much down the road arthritis and if you continue to have symptoms that may be a reasonable price to pay for maintaining of that meniscus. At least that’s the way I envision it and maybe I didn’t explain it quite as nicely as you could, so I would be interested in your opinion on that.

Dr. Menche: Actually the art of what we do to really look at that meniscus which, when we do the arthroscopy, everything is exquisitely magnified on a TV monitor so we can see exactly the damaged tissue, the extent of the damaged tissue; simply put what part of that meniscus is stable. What part is unstable, unstable meaning it’s sort of flip-flopping in the joint which can cause more joint surface problems and create pain; and the goal basically in my mind, to simplify this is to make an unstable meniscus into a stable meniscus if we’re doing a partial meniscectomy or removing parts of the meniscus, trying to leave as much tissue as we can that’s functional, that’s not going to cause symptoms. Yes, in the old days we used to just go in there and take out the whole meniscus and I think that was because of frankly a lack of understanding at that point and also lack of technology to be able to really visualize the meniscus in such detail that we can really pinpoint exactly what we need to do. Let’s talk a little bit about the rehabilitation after these procedures for either meniscectomy or meniscal repair. Clearly, meniscectomy, I think, that it’s done as an outpatient and we get patients back at their activities fairly quickly. Meniscal repair probably requires the patient to do a little bit more in terms of protecting that meniscal repair and probably a little bit more in terms of rehabilitation. So define for me your approach as you’re advising patients on what they should expect after these two surgeries.

Dr. Menche: So with a partial meniscectomy or removing some of the meniscus tissue, we’re not really waiting for any biological process to happen. So I usually tell patients that there’s nothing that they can really do to damage what I’ve done so really we try to progress them as they can, and we move them as quickly as they can to try to achieve full range-of-motion, no effusion or no swelling, and increased strength and get them back to what they want to do as quickly as we can. With a meniscal repair where we’re actually putting the meniscus back, we are waiting for biological healing. A good proportion of these patients may have had an anterior cruciate ligament reconstruction at the same time, and if they have, number one, the results are a lot better than in patients who have not had an anterior cruciate ligament reconstruction, but in general, we don’t really modify the program, the postoperative program or the rehabilitation program, too much in a patient who’s had an anterior cruciate ligament reconstruction. If it’s a very large tear we may go a little bit slower on the motion but basically it’s going to be a 6 month process to return to sports. In an isolated meniscal repair, in that one I will go a little bit slower, having the patient using a knee immobilizer until they get some good quad strength, have them on crutches for a couple weeks, which typically we don’t do with a meniscectomy, and again, it would be a six month total program until they got their range-of-motion, swelling, and strength up and adequate biological healing in order to get them back to sports.

Dr. Sechrest: Well, let’s talk a little bit about you what you feel like patients should know about what goes wrong in during these procedures. These are relatively common procedures that we do on a day-to-day basis and complications are actually fairly unusual in these types of procedures, but talk a little bit about what you are concerned with as an orthopaedic surgeon both during the procedure and then in the rehabilitation phase in terms of complications in terms of what can go wrong. Well, whether it’s a complication, potential infection with any surgical procedure is there, so we take every precaution as every surgeon takes every precaution not to have an infection and I guess that’s the main concern in the peri-operative period. In a meniscal repair, which is a little bit more extensive, there are case reports of some damage to nerves and blood vessels but again that’s going to be relatively rare thankfully with the techniques that have been developed over a period of time. I think the main potential complication, again not really a complication, is failure of the repair that can happen after a meniscus repair. With an anterior cruciate ligament reconstruction, if the meniscus repair is done, the results are in the 90% range of healing. Without an anterior cruciate ligament repair, then the meniscus repair results are less good and failure rates have been reported between 20 and 30%. So the conversation comes up as to why you do a meniscus repair where maybe 20% of the time the surgeon may need to go back because a repair didn’t take place. I think that’s a very important conversation that the surgeon needs to have with the patient considering also that the patient’s going to have to go through a prolonged postoperative course as we just discussed where they may be on crutches and a knee immobilizer and not being able to get back to sports for 6 months. If you have a 20-30% failure rate where it may not heal, why would one go through that. The general feeling is 1) that should be presented to the patients and discussed because you are going to have a 70 or 80% success rate and ideally, if that meniscus does heal, if that shock absorber does heal and there is no other problem in that knee, one could theoretically have a relatively normal knee for the rest of their life, and these procedures of meniscal repair are usually done in a younger population. So if you’re in that 70 or 80% pool where it’s going to heal and not have any further problem, then that risk for benefit ratio really needs to be discussed. Certainly there are some patients who are going to say to the surgeon, “Well, if there’s a 20-30% chance of this not working, I’m not going through that whole process just take out as little as you have to, do what you need to do, but I don’t want to ever have another surgical intervention because that meniscus repair didn’t work.” So again it goes into expectations and discussions of what should be done at the time of the surgical intervention of the meniscus.

Dr. Sechrest: I think that’s an excellent point. I think that it brings up two things that I think should be take home messages from our discussion today: 1) is that over the last 30 years we’ve become increasingly concerned about the role of the meniscus and how important it is to maintain the role of the meniscus in the knee for long-term prevention or at least reducing the risk of developing osteoarthritis. So probably you and I as orthopaedic surgeons if there’s a 70% chance that we could go through an operation and get a functional meniscus, we would take that chance even though we understand that there’s a 20-30% chance that you’re going to come back in 6 months and just take it out. I think that’s a risk I’m willing to take. I think that the other piece is this notion about expectations and really understanding what the patients expectations are and making sure that they reflect the reality that we, as orthopaedic surgeons, understand it and communication is the key there. Sitting down and having that discussion, as you talked about, making sure that we’re clear as orthopaedic surgeons and that the patients are clear of what our expectations are. I think that’s time well spent for anybody whether you’re an orthopaedic surgeon or a patient – having that discussion with your surgeon or as an orthopaedic surgeon having that discussion with the patient.

Dr. Menche: Yes, absolutely so. I think that treatment needs to be individualized, not all meniscal tears need surgical intervention. Some patients with meniscal tears will get better with rest, controlled exercise, physical therapy, but if a patient is having symptomatic problems from the meniscus, depending upon whether that meniscus is amenable to repair or not, that needs to be discussed and all the variables and potential issues need to be explained and the surgeon and the patient need to be on the same page with that prior to any surgical intervention.

Dr. Sechrest: Well, I think this has been a very useful discussion for patients. I think we’ve clearly identified a couple of things: 1) is the difference between what an articular cartilage injury is and what a meniscal injury is, what is commonly referred to as a torn cartilage; 2 ) and I think we’ve really covered fairly thoroughly, all of the options in terms of treatment that a patient should consider when they have suffered a meniscal tear and sit down with their surgeon to discuss what next. Is there anything that you would like patients to know that we have not discussed during this conversation? Let’s go through that now.

Dr. Menche: I think that’s really the scenario. Some patients come in and they’ve had an MRI and they’ve been told that they have a meniscus tear that they immediately think that they’re going to need surgery and that’s the only treatment, and in my mind that’s not necessarily true. On the other hand, the surgeon and the patient should be prepared to do what needs to be done in order to give that patient the best result. If a patient is having persistent pain, certainly if they’re having locking of the knee as we discussed, that surgical intervention may be their best option and sometimes surgical repair of the meniscus may be their best option, and they should be prepared to do that if necessary.

Dr. Sechrest: Well, thanks for joining us again today. I look forward to further discussions about knee surgery and hope to have you back on the show. Thanks a lot.

Dr. Menche: Thank you so much. It was really a pleasure. Thank you.