What is the meniscus?
The meniscus is a hard but at the same time elastic structure composed mainly of water and collagen fibers. Each knee has two menisci, the medial and the external. The menisci have an extremely important role in the function of the knee by increasing the contact surface between the two bones, while at the same time stabilizing the knee and at the same time absorbing shocks during loading, making the movement of the joint smoother. A meniscus tear is one of the most common knee conditions.
How does a meniscus tear happen?
Meniscal tears are classified into acute and degenerative. Acute lesions usually occur in young patients, mainly athletes. Usually these patients experience acute pain with swelling of the knee and possibly “locking” of the joint. Degenerative tears concern older patients, due to the “aging” of the tissue with loss of elasticity. Usually patients report a mild mechanism of injury (simply standing or deep sitting), while it is not uncommon for patients to have recurrent episodes of knee edema (swelling) with relatively mild pain without any significant prior injury.
Treatment of meniscal tears
A meniscal tear can be treated conservatively or surgically, depending on whether it is of acute or degenerative etiology. As a rule, small tears of degenerative etiology can be treated conservatively for a period of about 2-3 months. Conservative treatment includes rest, short-term use of nonsteroidal anti-inflammatory drugs, modification of patient activities, cryotherapy, and rehabilitation with physical therapy and muscle strengthening. After this period and appropriate recovery, a large number of patients become asymptomatic. However, a percentage of patients continue to have symptoms despite conservative treatment. If the pain or swelling persists and makes the patient’s daily life difficult, then surgical treatment of the problem is indicated.
Acute tears in young patients require, with very few exceptions, surgical treatment with the arthroscopy method. Arthroscopy is a modern surgery, with which the orthopedist, through a small incision of about 5 millimeters, inserts a camera connected to a fiber optic lens (arthroscope) and sees in magnification each intra-articular damage with excellent accuracy. Then, from one or more additional incisions of the same length, with the help of special surgical instruments depending on the occasion and with extreme precision of movements, he intervenes to correct it. During surgery, either an attempt is made to save the meniscus (Save the meniscus!) by suturing the damage, or the injured part of the meniscus is removed (partial meniscectomy). The choice of treatment depends on the location and consequently the blood supply of the torn part of the meniscus, as well as the morphology and age of the lesion.
What is arthritis?
Knee arthritis is an inflammatory disease characterized by the destruction of the structural elements of the joint. It usually affects middle-aged and older people. Its main symptoms are pain, swelling, and stiffness of the joint, while it can significantly affect the patient’s quality of life by making his daily life difficult. The most common form of knee arthritis is osteoarthritis. Osteoarthritis is due to the progressive degeneration of the elements of the knee, mainly the articular cartilage. Other common forms of arthritis are rheumatoid and post-traumatic.
What are the symptoms of the disease?
In the initial stages of the disease, the pain is usually more intense in the morning and subsides during the day. Progressively the pain becomes more and more intense and worsens with activities such as walking while in the later stages it becomes constant. Many patients complain of severe worsening of pain with the change of weather and especially with humidity.
The diagnosis of osteoarthritis is made by taking a detailed history and clinical examination while it is confirmed by radiological control. Rarely, an MRI is necessary to accurately visualize the joint.
Conservative treatment or surgery?
Unfortunately, there is no treatment that can restore the knee to its previous state. In the early stages of the disease, symptoms can subside with conservative measures. These include avoiding activities that exacerbate pain (such as long hours of walking or using stairs) while encouraging activities that strengthen the muscles that stabilize the knee.
Pharmaceutically, the intra-articular injection of hyaluronic acid, either alone or in combination with cortisone or platelet-rich plasma (PRP), can limit symptoms and perhaps slow the progression of disease.
In cases of more advanced disease or when conservative treatment fails, surgical treatment is recommended, with the aim of improving the patient’s quality of life. Arthroplasty is the operation in which an orthopedist replaces the worn surface of the knee with a special prosthesis. With the new minimally invasive techniques as well as the fast track surgery protocols, the patient’s hospitalization is minimized, blood loss and post-operative pain are reduced while ensuring a faster return to daily activities.
In recent years there has been a revolution in the field of knee arthroplasty with the introduction of robotics. During robotically assisted knee arthroplasty a three-dimensional model of the patient’s knee is created with the help of a CT scan. The surgeon using this model preoperatively personalizes the operation to the anatomy and needs of the specific patient. Then the orthopedist, with the help of the robotic arm, proceeds with extreme precision in the preparation of the bone and the placement of the materials.
A chondral defect is a localized area of articular cartilage damage on a joint surface. In most cases, chondral defects develop in the knee joints, so the knee will be the focus of this blog article. Articular cartilage is the tough, smooth and durable substance that covers joint surfaces and ensures that the bones of the knee glide over each other without friction during movement. Damage to this cartilage leads to a lot of painful friction and inflammation within the knee joint.
Chondral defects are characterized by grade based on severity.
- Grade I: Cartilage becomes soft and indented
- Grade II-III: Cartilage becomes progressively more shredded, ragged, and fragmented
- Grade IV: Cartilage wears away completely, exposing the underlying bone
People of all ages can develop chondral defects. Keep reading to learn more about symptoms and treatment options.
What Causes Chondral Defects?
Chondral defects may be caused by acute trauma to the knee from a direct blow, a sudden pivot or twist, or a fall. In some cases, cartilage injuries accompany other knee injuries like ligament tears. And in other cases, chondral defects develop as articular cartilage naturally wears down over time.
Signs and Symptoms
The primary function of articular cartilage is to enable smooth, frictionless movement between bones of a joint during movement. When articular cartilage is damaged, the bones rub painfully during movements like walking, running and climbing stairs. The following symptoms may develop:
- Joint pain
- Loss of range of motion
- Instability, buckling, or “giving way” of the knee
- Locking or catching during bending motions
- A grating sound during movement
If left untreated, chondral defects can lead to degenerative osteoarthritis, chronic joint pain, and loss of movement in the knee joint. If you have any of the symptoms listed above, see your doctor as soon as possible for an evaluation and treatment.
Your doctor will probably use several of the following tests to accurately diagnose a chondral defect.
- Medical history and physical exam. Your doctor will take down your medical history and ask you about recent injuries or traumatic incidents. He or she will perform a physical exam to assess your pain, swelling, range of motion, and other physical symptoms. A physical exam alone is not enough to diagnose a chondral defect.
- X-ray exam. Your doctor may request an X-ray to rule out conditions like arthritis or bone spurs. While an X-ray won’t reveal a cartilage defect, your doctor may look for decreased space between bone surfaces. Joint space narrowing is an early indicator of cartilage loss.
- MRI scan. An MRI exam will reveal cartilage damage and defects.
- Arthroscopy. Arthroscopy provides your doctor with the best look at cartilage damage inside the knee joint. During an arthroscopic procedure, your doctor will insert a small fiber optic camera in the joint, and use guided images to assess the location, size and severity of a chondral defect.
Your treatment options will depend on the size and severity of the defect. Initially, your doctor will likely recommend conservative treatments that can help relieve your symptoms: anti-inflammatory medications, cortisone injections, hyaluronic acid injections, physical therapy, and weight loss.
Non-operative treatments can help reduce pain and improve functional mobility, but can’t facilitate cartilage regrowth. Further treatment requires a surgical procedure.
Currently, there are several surgical options available to treat chondral defects, with varying levels of success.
- Microfracture. During a microfracture, your surgeon will create a controlled area of bleeding in the bone. The blood clots and forms scar tissue, called fibrocartilage. Fibrocartilage isn’t as strong or long-lasting as articular cartilage, but it is durable enough to function as cartilage does for many years.
- Osteochondral autograft transfer. During an osteochondral autograft transfer, plugs of healthy cartilage are removed from elsewhere in the knee and transplanted in the defect.
- Autologous chondrocytes implantation. During autologous chondrocytes implantation, articular cartilage cells are removed from your knee and cultured in a lab. Afterward, the cells are implanted to create a new cartilage surface over the defect. This procedure is typically used for large defects.
Some of these procedures are relatively new and don’t have enough research to decisively prove long-term efficacy. After undergoing any of these procedures, you may experience short-term relief but begin having symptoms again down the road. Surgical procedures like cartilage transfers and implantations require more research in the field.