The meniscus is the distal cartilage tissue that is found between the weightbearing bones of the knee joint. It acts as a shock absorber. It is usually very tough and rubbery. It does grow weaker with age and meniscal tears can occur with fairly minor injuries in older patients. In younger populations a tear is usually the result of a fairly forceful injury. When the meniscus tears a piece of cartilage can move abnormally in the joint causing catching, buckling and swelling. Swelling usually occurs initially and can sometimes continue occurring with a meniscal tear. TREATMENT
OPTIONS If a tear is very small and symptoms resolve quickly and there is just occasional discomfort but no instability, a patient can be treated with an exercise and range of motion program. If the symptoms continue then a meniscus can be repaired or partially removed arthroscopically. A large part of a meniscus has no direct blood supply and therefore spontaneous healing on its own is unusual. To repair a meniscus sutures can be used or new absorbable tact can be used. Using the newer absorbable tacks all the work can be done without additional incisions in the knee. In cases where a meniscus cannot be repaired just the offending torn tissue is removed in order to preserve as much cartilage function as possible. Arthroscopy
is done on an outpatient basis. Usually
three small incisions in the knee are used.
The patient is begun on immediate weightbearing and to move the knee as
tolerated. NEW
TECHNIQUES In certain cases where most of the medial or lateral meniscus has been removed meniscus transplantation is now being performed. This is where a meniscus is transplanted from a cadaver after being appropriately sized by new measurements and studies.
The patella is your kneecap. It is a small bone that sits in front of your knee joint. It actually is embedded in the quadriceps tendon. It slides in a groove called the trochlea on the femur as the knee moves. The patella has a thick cartilage lining but is also subject to high stresses. CHONDROMALACIA
PATELLA This is a Latin term meaning “bad cartilage” or breakdown or softening of cartilage. It is one of the most common problems of the knee. Running and jumping can aggravate this condition. Symptoms include pain in the front of the knee and a crunching or grinding sound with motion. Swelling can occur at times. Symptoms seem to be worse with climbing up or down stairs or a hill. Also, getting up from prolonged sitting can cause pain. The cartilage surface on the underside of the patella becomes soft. Part of the cartilage can become stringy and flake off at times. Part of the surface may become roughened. The synovium in the knee which is a normal substance that helps lubricate the knee joint can sometimes be aggravated in this condition and contribute to the grinding feeling. Treatment Initial treatment for chondromalacia patella emphasize strengthening activities. Often a therapist is used to teach a patient quadriceps exercises to help the patella become rebalanced in a sense. Anti-inflammatory medication can be used temporarily as well as ice. Occasionally, a therapist may teach an athlete taping techniques that are helpful. In cases not responsive to conservative treatment, arthroscopy may be helpful. PATELLA
MALTRACKING The normal patella should track in the groove of the femur in a relatively straight manner. There are varying degrees of malalignment and tracking. In some cases the patella may tend to track more to the side of the knee or actually be tilted as it goes back and forth in its groove. On occasion it may actually come partially out of the groove, which is called subluxation. Some patients have a positive “J-sign” in which, in full extension, the patella tilts and is pulled strongly to the side of the leg. The tracking of the patella can be influenced by different things. Most of it is influenced by the anatomical shape of the knee. The following can all contribute to the maltracking of the patella: shallowness of the femoral groove, the angle of the knees (knock-knees), rotation of the hips, foot positioning on the floor (pronation or flat feet), weakness of the quadriceps, and the shape of the patella. Treatment Treatment for this emphasizes quadriceps strengthening. The middle muscle of the quadriceps, called the vastus medialis obliquus, or VMO, is the muscle that is focused on to try to balance the patella in its motion. Occasionally, taping can also help with this. If conservative measures are not helpful, surgical treatment is reasonable. Rebalancing the kneecap by opening some tissue on the outside of the knee can be done arthroscopically. Occasionally tightening the medial structures can also help. In most patients, this type of surgery would be all that they would need. In some patients with a significant problem and with patella subluxation or dislocation, a more extensive realignment procedure is sometimes used. PATELLA
DISLOCATION When the patella is completely out of its groove it is called dislocated. Features listed above contributing to maltracking kneecaps can also attribute to a kneecap that is easier to dislocate. A common scenario is standing full weightbearing on a leg with a foot planted and twisting the opposite way from the leg and feeling a sudden tear or pop in the knee with the kneecap dislocating. Sometimes the kneecap will pop back into place by itself and sometimes a trip to a medical facility is needed. Once a kneecap has dislocated, typically the medial structures become loose and it is easier to re-dislocate. The danger of patella dislocation or recurrent dislocation is continued abnormal tracking with cartilage damage under the kneecap or cartilage being chipped off as the patella dislocates over the edge of the femur. Treatment Treatment for this again emphasizes strengthening but surgery is more common for this type of patella problem. Again, arthroscopic release of the tissues on the outside of the knee will sometimes help prevent further dislocating problems. On occasion, a more extensive procedure is needed. Either way, strengthening exercises are critical for treatment.
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