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Meniscal surgery

Overview

The menisci or shock absorbing cartilages are very important for cushioning and protecting the joint surfaces of the knee.

If the meniscus is damaged or torn there are a number of different surgical treatment options available. Every effort should be made to repair the torn portion but this may not be possible in which case the tear is "debrided" or tidied up. A number of factors influence the choice of treatment for meniscal tears. These include the patient’s age, activity levels, time since injury and most importantly the type of tear. The aim of surgical treatment is to repair and preserve as much of the meniscus as possible in order to minimise the detrimental long-term effects following loss of this important structure.

Not all meniscal tears require surgery and some may settle down with a combination of physiotherapy and anti-inflammatory medications.

 

Watch: What is a knee meniscus?

meniscal surgery



Meniscal Resection

Certain types of meniscal tears are not repairable. In this situation the torn area needs to be removed. We only take away damaged or crushed tissue at the time of surgery and any normal or functioning tissue is preserved. This is called a meniscal debridement or partial meniscectomy and is the most commonly performed key-hole meniscal procedure. This is an extremely straightforward and safe procedure. The surgery involves a short general anaesthetic and is routinely done as a day-case. Following surgery patients are encouraged to do very little for 48 hours and then return to normal activities including driving. Crutches are not required. Patients are encouraged to take 1-2 weeks off work and sport can be resumed 4-6 weeks following the procedure. If the rest of the knee is normal then an excellent outcone is usual.

 



Meniscal repair

Certain types of meniscal tears are repairable. Typically the knee is injured by a twisting mechanism and most commonly during sport. There may be other associated injuries to the knee such as a torn ligament or joint surface damage. Usually the operation can be carried out by key-hole surgery alone, without the need for any external incisions. This is called an "all inside repair". Sometimes, particularly where there has been a large tear it may be necessary to make a small external incision on the side of the the knee, so sutures can be placed arthroscopically through the tear and then retrieved through the incision where the sutures are tied externally. This is called an inside-out repair. Wherever possible the torn meniscal tissue should be repaired. This is technically challenging surgery and should be carried out by a knee specialist for the best results. In the best hands the chance of success with meniscal repair is 60-70%. The menisci frequently tear at the same time as a ligament is ruptured and meniscal repair is most commonly carried out at the time as an ACL reconstruction. The success rate for meniscal repair improves to 80% where the patient undergoes a ligament reconstruction at the same time. See Video of Surgical Procedure of Meniscus Repair (Inside – Out)

 

Meniscal Surgery - Meniscal Tear after a Meniscal Repair

Key-hole appearance of  the meniscal tear following a meniscal repair.

Meniscal Surgery Instrument - A Rasp

This surgical instrument, a rasp, is used to prepare the meniscal tear for a repair

 

 

 

 

 

 

 

 

 

 

 

 

Watch: Meniscal surgery (meniscal repair) - All inside technique

Note: The following video shows graphic surgical scenes, produced for technical training.

meniscal surgery

 

Meniscal transplantation

The role that the meniscus/shock absorber cartilage plays in knee function is very important, especially in the case of the outer/lateral meniscus. If too much tissue is lost as a result of tears and subsequent surgery, the lining of the knee joint can be damaged leading to arthritis. In certain patients, meniscal transplantation may be indicated. This is done with donor or "allograft" meniscal tissue. Patients need to be carefully selected as this procedure only works in patients who have normal or limited damage to the lining of the joint (articular cartilage).

 

Meniscal before surgery

Preparation for Meniscal Transplantation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

preparing_allograft

Preparation for Allograft



The Actifit® meniscal scaffold

If you have a degenerative meniscal tear and only a portion of the meniscus is badly damaged, it may be possible to restore the shock absorbing function to your knee using a meniscal scaffold.

 

Mr Adrian Wilson is one of the UK’s leading surgeons with knowledge and expertise in this area and performs20-30 procedures each year.



What is a meniscal scaffold?

The principle behind the treatment is to replace the damaged part of the medial meniscus (the pad of tissue on the inside of the knee) with a material that has an open honeycomb-like structure.

 

The tiny cavities within the scaffold allow cells and blood vessels to enter during the healing progress. Over a few weeks and months, the scaffold become filled with healthy living tissue and this then takes over the shock absorbing function of the original meniscus.

 

The implanted scaffold becomes fully integrated with the rest of the meniscus and results are very good. Patients implanted with a scaffold are much less likely to develop osteoarthritis in their knee as a result of the meniscal tear.



What is the Actifit® system?

Meniscal scaffolds have been in use in orthopaedic surgery since about 2000. The early ones were made from collagen that was harvested from cows. The Actifit® system has been in use in Europe during the last seven years and many European surgeons have reported that it gives excellent results. Mr Wilson started using this specially developed system provided by Orteq three years ago.

 

The Actifit® scaffold is made from non-toxic polycaprolactones and urethanes. It is soft yet strong and is completely biodegradable. The components of Actifit® are similar to those used to make biodegradable sutures.

 

The Actifit® scaffold stays in place for while the body’s own tissue is growing within it then it is slowly absorbed over the next four to six years.

 

After that time, healing is complete, and the meniscus has been replaced by tissue that is entirely from the body of the patient.



Surgical implantation of Actifit®

The keyhole surgery to implant the scaffold takes about an hour and is combined with a simple meniscal resection. This means that the damaged meniscus is first trimmed back so that only the healthy part remains.

 

Meniscal Surgery - Meniscal scaffold
Meniscal Surgery - Meniscal scaffold


The strip of scaffold is then cut exactly to fit in each patient.

 

It is easy to cut and already shaped like natural meniscal tissue. Trimming can be done using a scalpel blade. Everything is done in theatre and completely aseptically to reduce the risk of infection.

 

Mr Wilson has now done over 60 implantations of Actifit and has a 0% infection rate with no failures to date.

 

The scaffold is then introduced through one of the small incisions and guided into place using a camera within an arthroscope.

 

It is stitched securely within the knee in exactly the right position.

 

Note: The following video shows graphic surgical scenes, produced for technical training.

meniscal surgery



Recovering from implantation of a meniscal scaffold

The meniscal scaffold is delicate and needs time to heal. Mr Wilson uses special braces for patients during the first six weeks, which restrict the movement in the joint. You will be given crutches to help you start moving about gently.

 

After six weeks this is replaced by a more flexible brace that allows you to start to move about a little more.

 

By 12 weeks you should be walking unaided and gentle exercise is recommended at first.

 

 

Orthopaedic consultation

Orthopaedic consultation

Key-hole  knee surgery

Key-hole knee surgery

Mr Wilson carrying out knee arthroscopy surgery

Mr Wilson carrying out knee arthroscopy surgery

Scrub team before ACL surgery

Scrub team before ACL surgery

Setting up for knee surgery

Setting up for knee surgery

Arthroscopic knee surgery

Arthroscopic knee surgery

Knee osteotomy surgery in progress

Knee osteotomy surgery in progress

Anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction