IME,Inc.
211 Beaumont
Traverse City,
Michigan MI 49684
Tel: (800)
968-4637
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Independent Medical Evaluations, Inc.
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Tear,
Meniscus of the I.
Background Tears
of the menisci of the knee are common and occur in three
categories of patients: 1) the athletic teenager or young adult
who sustains trauma to the knee with immediate symptoms; 2) the
middle-aged patient whose injury to the knee usually involves weightbearing
and twisting motion, and 3) the patient who has no
recognized injury to the knee or who injures a degenerative knee
meniscus after minimal trauma. The presenting complaints are
usually pain over the joint line and a "catching"
sensation. The patient may also describe a "giving
way" sensation or locking or blocking of knee motion. The
physician may note mild to moderate knee joint swelling. II.
Diagnostic Criteria A. Pertinent historical and physical findings The patient usually gives a history of knee injury, often
associated with a rotational
component. The patient may note an inability to extend
the knee fully or a blocking sensation to knee motion. Physical
findings include joint effusion, joint line tenderness,
and pain on rotational stress to the knee frequently referred to the joint line area. Mild thigh muscle atrophy may be
present. McMurray's or varus loading test may be positive. B. Appropriate diagnostic tests and examinations (one or more of the
following may be indicated to establish the diagnosis) 1.
AP
and lateral radiographs, preferably with the patient standing.
Additional views may be indicated (e.g. 30-degree flexed knee
views; lateral, tunnel and patellar axial radiographs) 2.
Arthrocentesis
with synovial fluid analysis if indicated 3.
Arthrogram 4.
MRI 5.
Arthroscopy
(diagnostic) 6.
Bone
scan if osteonecrosis is suspected 7.
Blood
serum analysis if indicated C. Supporting evidence Diagnostic arthroscopy is effective in identifying most meniscus
tears. In older patients in
whom degenerative tears are common, bone
scan and other diagnostic tests may be necessary to verify
that the symptoms are not caused by other problems such as osteonecrosis,
crystalline-induced synovitis or tumor.
A.
Outpatient treatment 1.
Nonoperative treatment a.
Indications 1)
Patients
with mild knee symptoms and no functional disability 2)
Patients
in whom medical contraindications to surgical treatment exist b.
Treatment options 1)
Nonsteroidal
anti-inflammatory drugs 2)
Arthrocentesis 3)
Short-term
immobilization and/or limited weightbearing c.
Home health care may be self-administered d.
Rehabilitation 1)
Range
of motion and strengthening exercises 2)
Protected
weightbearing e.
Supporting evidence Tears
of the meniscus may be associated with only mild and nondisabling
symptoms. Degenerative tears in older patients are often not
disabling. 2.
Ambulatory surgery a.
Indications Symptomatic
tear of the meniscus in a healthy patient b.
Treatment options 1)
Arthroscopic
meniscectomy 2)
Arthroscopic
meniscus repair, open, closed, or combined 3)
Arthrotomy,
when arthroscopic techniques not feasible c.
Home health care d.
Rehabilitation 1)
Strengthening
and range of motion exercises 2)
Progressive
weightbearing e.
Supporting evidence Arthroscopic meniscectomy in the ambulatory setting is an acceptable
procedure in the healthy patient
and has been shown not to be associated with an increased
morbidity. B. Inpatient treatment 1.
Nonoperative
treatment: not indicated 2.
Operative
treatment a.
Indications for admission 1)
Patients
whose associated medical conditions contraindicate knee surgery in
an ambulatory setting 2)
Associated
injury (e.g. ligament injury, tibial plateau fracture) b.
Treatment options 1)
Arthroscopic
meniscectomy 2)
Arthroscopic
meniscus repair, open, closed, or combined 3)
Arthrotomy c.
Indications for discharge 1)
Uncomplicated
cases may be discharged as soon as the patient is ambulatory, in
some cases with protected weightberring. 2)
Complicated a)
If
knee joint drain required postoperatively b)
If
severe postoperative pain requires medication, intramuscularly c)
If
wound complications occur d)
If
medical complications arise e)
If
more extensive surgery is necessary d.
Home health care may be needed for 1)
Medically
ill patients with wound problems 2)
Older
patients whose recovery is compromised e.
Rehabilitation 1)
Strengthening
and range of motion knee exercises 2)
Progressive
weightbearing f.
Supporting evidence Surgery
in an ambulatory setting poses some risk to medically unstable
patients, so inpatient management is indicated for them. Admission
is also indicated if there is an increased chance for wound
complications, as in a patient with associated diabetes mellitus,
or for a patient who needs considerable assistance in
rehabilitation. C. Estimated duration of care 1.
Depends
on age of patient, amount of pathologic change
found in the knee, and treatment of the torn meniscus
(repair or removal) 2.
Generally
extends for about six months D. Anticipated outcomes a.
Improved
knee joint function with few or no residual symptoms b.
Possible
predisposition to the development of degenerative joint disease. c.
Outcome
may be influenced by the type of tear, the severity
of tear, the type of procedure and the general integrity of
the joint. E. Evolving therapeutic procedures 1.
Meniscal transplantation F. Modifiers (age, sex, and co-morbidity) Meniscal
tears occur in a broad range of patients, who exhibit a variety of
pathologic changes. The mechanisms of injury include acute
trauma, or minimal trauma in patients with degenerative changes.
These changes may themselves cause the tear without attendant
injury. A single identifiable course of patient management is
difficult to determine because of the variability of symptoms
presented by this differing population. There
are no conclusive scientific studies available to confirm
these clinical impressions.
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