MENISCUS TEARSMeniscus tears are some of the most commonly treated disorders in orthopedics, and it is a commonly treated item here at our practice. The most commonly involved comparted is the medial compartment, although the lateral compartment can also have meniscus tears as well. There are tears that resemble a hangnail tear where it is a very simple procedure, and you go in and you basically trim the hangnail. Then there are tears that may require an actual repair. Those are bigger repairs and more often times involved in association of an anterior cruciate ligament tear or a multiligament tear as well, but can exist in absence of a ligament tear. Treatment for meniscus tears is usually operative. It is very important to make sure that there is no concomitant arthritis in the knee joint, so appropriate x-rays are very necessary to obtain as a compliment to the MRI. Typically what the patient experiences is locking, catching or swelling. There are many causes to meniscus tears, any type of twisting of the knee in conjunction with an axial load. So this can occur with getting up from a seated position, such as a chair or in a car, which is a common mechanism. Other mechanisms are in sports, pivoting sports like basketball, soccer or football, can cause that was well. Or everyday activities can cause meniscus tears. Physical examination typically involves inspecting the joints. They may be present with swelling in the knee. Swelling is a secondary finding that usually indicates that there is some sort of pathology or derangement going on within the knee and can be associated with meniscus tears. The exam also will look at the range of motion of the knee and determine whether there is tenderness specifically with palpation along the joint lines. There are two joint lines. There is the inside or medial joint line, and the outside lateral joint line. With palpation of those structures if there is pain, then that is considered a positive finding for a meniscus tear. There are other maneuvers that are performed by the physician or clinician: The Steinman maneuver, and that is typically the knee in 90 degrees and twisting with concomitant palpation. The McMurray sign which basically takes the knee from range of motion and then eliciting either tenderness, clicking or a pop or pain. That can be performed on either joint line. Then pain with hyperextension of the knee is usually indicative of a medial meniscus tear. It is a physical finding that we see with a medial meniscus tear. Treatment, if conservative management has failed within a time period of six weeks, then what is recommended is an arthroscopy. We are the only ones that offer the single portal arthroscopy with the Stryker system. Most meniscus pathologies can be addressed with that system, and there are some advantages to that. Or there is a conventional dual portal system. The procedure for a partial medial meniscectomy takes about 10 to 15 minutes, and then the patient can go home that same day. Then after 4 to 6 weeks of physical therapy they are basically recovered from that injury as long as there are no injuries. For a meniscus repair where a suture would be used to repair the structure, the timeframe is longer. It is about three months of therapy. Those patients again would go home as an outpatient. They would then be in therapy as an outpatient for about three months and would be able to go home after therapy. That is it for meniscus tears.
CHONDRAL DAMAGEChondral damage or articular cartilage damage can be seen at the time of arthroscopy and can cause swelling. It is basically that glistening that you see at the end of a chicken bone, and that is damaged. Unfortunately, once it is damaged it is like a crack in a windowpane. The cartilage cells are basically unable to heal themselves, and so as a result the damage can get bigger with time. When it becomes the full thickness of the actual articular surface, or cartilage surface, then that is the definition of arthritis because exposed bone would then be present. In those situations patients have pain with weightbearing. They may have swelling. Their physical findings are nonspecific, but an MRI can show bone marrow edema and damage to the cartilage depending on the quality of the MRI. X-rays may or may not show anything but are very important to rule out advanced disease and should always be obtained in the evaluation. The treatment for chondral damage would be arthroscopy, and it can vary with stem cell techniques. The one that I use is a nanofracture device which is 1 mm in diameter and 9 mm deep, which allows full penetration into the marrow-rich elements to attract stem cells and allow stem cells to basically migrate in that area. I would do that in conjunction with an arthroscopic chondroplasty using radiofrequency energy. If that procedure is recommended as necessary and to be performed, it usually is done in lesions that are 10 x 10 mm and no greater than that. Again, that would be done as an outpatient. They would go home the same day. It would be about a 20 minute procedure. They would have about three months of physical therapy. They would be nonweightbearing for six months and have a postop MRI at three months. The results are usually fairly good with this type of repair of cartilage using marrow stem cells. The other option in lesions that are larger, in patients under the age of 40, would be an osteoarticular allograft transplant, or cartilage transplant. That would basically be a procedure that would be arthroscopic and then arthroscopic assisted with a small open incision where we can actually put in a *dowel of osteoarticular cartilage that matches the donor site where the damage is. We would prepare the area and then implant the cartilage to match the surface anatomically of that area that is involved. That can be done anywhere. That can be done on the medial femoral condyle. It can be done along the lateral femoral condyle. It can be done in the patellofemoral joint. Those procedures are outpatient. Patients are nonweightbearing for six weeks. MRIs are performed at six weeks and at three months, and then they need about three months of therapy and have good results.
PATELLOFEMORAL JOINTThe patellofemoral joint is very common joint that is involved in pain and most often requires conservative management or treatment. There are some indications for operative treatment in the event of patellofemoral instability or chronic patellofemoral dislocations. An arthroscopy can be performed, a lateral retinacular release and then an MPFL reconstruction using allograft, and a small incision can be performed. Again, those are outpatient procedures. The MPFL, or medial patellofemoral ligament, is a check rein to prevent recurrent dislocations. Usually the therapy for that is six weeks in a brace and then postop PT from six to three months. Then after three months they are discharged.
ACL OR ANTERIOR CRUCIATE LIGAMENTThe anterior cruciate ligament is the most common ligament torn in the human body. Oftentimes it is seen in patients that play pivoting sports like basketball, soccer or football. They oftentimes experience a pop and can experience the acute onset of swelling and then have instability as well. On physical examination typically there is swelling, but there may not be swelling, but most often in acute ACLs there is. The patients have difficulty moving the knee in some instances, and if the knee is locked that can be because of the torn stump of the ACL or a bucket handle tear of the meniscus, which can be associated with an ACL tear as well. So it is very important to look for secondary structure damage. Physical exam also would show that there would be a positive Lachman test which is noted, or a positive anterior drawer test, or a positive pivot shift test on exam. The typical treatment is once full range of motion is restored with physical therapy, then the ACL is reconstructed anatomically. For this reason I freehand my femur to make sure that I am at an anatomic point reconstructing the ACL, and I use allograft tendon because that is a fast recovery and does not sacrifice other anatomic structures that in my opinion is very necessary, like the hamstrings or the patellar tendon. Those are necessary structures that should not be sacrificed. From a technical standpoint, it is an outpatient procedure. It takes about 40 minutes to do an ACL reconstruction. The patients go home the same day. They are in therapy for about three months as an outpatient, and then they go to a home exercise program. They are discharged at six months. The PCL is less commonly involved. A lot of times isolated PCL injuries are rare, but can be seen. Their typical presentation is a hyperextension injury with a little bit of swelling and pain. Physical exam would be positive for a posterior drawer test. Again, it is important to get x-rays and MRI. Physical therapy is the initial hallmark treatment, but if patients fail physical therapy and continue to have issues mainly of patellofemoral pain, then a posterior cruciate ligament reconstruction would be performed. It is done as an outpatient with allograft, and they would be in therapy for about three to four months.
ARTHRITISEarly arthritis of the knee in patients over the age of 40 is a very difficult area to treat. It is very important to know whether there is no joint space collapse, but exposed bone. A lot of times the workup that is needed in these situations would be x-rays, MRI and most likely a failed arthroscopy with associated lesions greater than 10 mm in circumference. Those lesions can be treated in the office with injections such as Supartz or any type of viscosupplementation. Cortisone is only a temporary treatment. There are stem cell treatments, both autologous stem cell treatments that can be done in the office or allograft stem stems, and the Regenokine program is also a very good treatment for early arthritis that is nonoperative. They all have their benefits in terms of their mechanism of action. Early arthritis can be treated surgically with an inlay resurfacing technique. Over the age of 40, biologic treatment of early arthritis does not work very well. The Arthrosurface inlay implant is a very good option in these situations, and I have published reports of this. Not only a second look report that was published in the Journal of Surgical Orthopedic Advances, looking at how the body reacts to the implants over time showing an overgrowth of cartilage on those implants and preservation of that actual joint space, but we also show a high level of return to function. That was presented at the ISAKOS Conference in Leon, France, where we looked at 33 consecutive knees for Worker’s Compensation claims that had failed knee arthroscopies because of the early arthritis that was present in the knee. All those patients had inlay resurfacing implants performed, and 91% returned to work, 65% returned without restrictions. So it is a very good alternative for early arthritis. If patients that have unicompartmental arthritis, then partial knee replacements would be the way to go. In both these instances they are outpatient procedures. In the case of the inlay procedure, they are nonweightbearing versus the partial knee replacement where they are weightbearing. The partial knee replacement gives you a more kinematic knee than a total knee replacement. Less is taken out. There is less bone loss. The literature is now showing that the return to function is good and complications are low.