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TREATMENT of MENISCAL LESIONS



Meniscal lesion is a frequent lesion in young or adult patient. The main etiologies are sport's traumatology by direct or repeated traumatisms, and work pathology as tile-layer or masons who kneel.
This pathology is the most frequent indication for knee arthroscopy.


ANATOMY


There are two menisci : medial and lateral. They lie on the rim of the tibial articular surfaces.

The anterior (AH) and posterior (PH) horns are fixed on the tibia near the cruciate ligaments insertions, and are attached to the capsule on their periphery.

The cross section is triangular allowing a contact with the femoral and tibial cartilage. They are nor visible on standard Rx.

Their structure is visco-elastic, and their role is to better distribute load and to absorb the shocks. They increase the contact area and allow a better morphological adaptation and better stability of the of articular surfaces.

Medial and lateral

Meniscus

MENISCAL LESIONS

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DIAGNOSTIC


Clinical examination allow to well rientate the diagnostic that is confirmed with MRI or CT scan with intra-articular injection.


CATEGORISATION


Meniscus horizontal lesion
horizontal lesion
Meniscus horizontal lesion
horizontal lesion
Meniscus vertical lesion
vertical lesion
Meniscal dislocation
meniscal dislocation

TREAMENT

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When the meniscus is torn, spontaneous healing is rare and surgery is required either to repare or to resect the torn portion.


RESECTION


Resection with punch
resection with punch
Removal of the torn meniscus
removal of the torn meniscus

This resection is performed with a basket-punch, and/or a motorized shaver (Laser beam has also been used).
The surgeon remove the lesser portion as possible of the torn lesion to prevent coming of future arthrosis (even if there is no statistic reality of effective prevention in long term follow-up).


Normal life is possible round one month after the operation.


MENISCAL SUTURE


It is generaly performed when the meniscal lesion is situated at the peripheric capsular attachment to get the best pourcentage of success.
The surgeon is the only one able to determine if it is possible or not according with the meniscal status and the type of lesion seen during arthroscopy.


Many techniques have been describe :

1/ Inside-out technique :



Suture threads are knotted outside the capsule through a small approach.

Suture apparatus
suture apparatus
intra-articular threads intra-articular threads Threads before knotting threads before knotting

2/ Outside-in technique :

Many special material may be used to suture the meniscal lesion without any complementary approach : harpon, stapple... or any thread knotted inside.

After arthroscopy, you will allow to move and walk with full weightbaring regarding with the surgeons prescriptions. 1 day hospitalisation is necessary. Cryotherapy and post-operative rehabilitation are required, the same as anticoagulation treatment.


CHECK-UP BEFORE SURGERY

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In order to detect vital risk for anesthesiology, and to assess a potential risk of post-operative complication in a short or long term follow-up, a medical questionnaire checking list is needed before the operation , to be planed by the surgeon and his team.


Risk factors influencing complications are :


- Obesity is associated with a higher risk of infection and operative difficulties with the risk of brakage of instruments.
- Diabetis is associated with a higher risk of infection
- Previous infection of the joint is associated with a higher risk of infection


Factors increasing risks for medical complications


- American Society of Anesthesiology (ASA) scores > 3 is at risk.
- Previous algo neuro dystrophy may be a recurrent risk.
- Previous deep veinous thrombosis is a predisposing factor to recurrent episode.


COMPLICATIONS

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Even with a carefull act performed by perfectly trained team, any complications may happen the same as in all surgical acts.
These are exceptionnal. The list below is not exhaustive

Infection : is one of the most dreaded complications, but is extremely rare as arthroscopy is performed under a continuous liquid flow through only small incisions (1/2500). In case of infection the joint is burning, red, swelling and very painfull; you must comme back immediateley to be examined by the surgeon. Reoperation is necessary.

Synovial kyst : along the incision. Sometimes it is necessary to remove it surgicaly.

Post-operative swelling : This is not a complication as it desappeares spontaneously in one to three weeks. You may use coldpacks, anti-inflammatory medications, and reduce active physiotherapy.

Vascular lesion : Hematoma may be seen in case of small veinous lesion at skin incision; this has no consequence.
Some extremely rare popliteal vascular lesions have been published; Treatment must be performed by vascular surgeon.

nerve lesion : local superficial dysesthesy may be seen in case of lesion round skin incision ; this has no consequence and desappear s but could be awkward complete lesion of sciatic nerve may occur postoperatively as a result of nerve compression secondary to edema, hematoma, infection, or the application of long duration of tourniquet.

Phlebitis : preventive mesure (early mobilisation, anti-thrombotic socks, low Weight Molecular Heparin anti-embolic prophylaxis for one to four weeks according to the surgery.

Complex regional pain syndrome : is a disorder characterized by the presence of symptoms as temperature alterations, abnormal skin color, abnormal sudomotor activity, and/or edema.
The estimated prevalences have ranged from 2.3% to 4% following arthroscopic knee surgery.


Last updated : 9/12/2007

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