Meniscus Tears

Episode 16 - Meniscus Tears

Dr. Eric Chehab:Welcome to IBJI’s OrthoInform where we talk all things ortho to help you move better. I’m your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day.

Today, it’s my pleasure to welcome Dr. Greg Portland, who will be speaking about the meniscus. As a brief introduction, Dr. Portland graduated from Dartmouth College, magna cum laude, and Phi Beta Kappa with a degree in Chinese Language and Culture in 1991. He earned his medical degree at the University of Virginia School of Medicine in 1995 and came to the Chicago area to begin his residency at Northwestern University Memorial Hospital. Following his surgical residency, he pursued specialty training in sports medicine in Australia at the University of Adelaide, considered one of the world’s premier sports medicine training programs. Following the completion of his fellowship training, Dr. Portland returned to the Chicago area and joined Illinois Bone and Joint Institute, where he has practiced ever since.

Dr. Portland served as a team physician for Northwestern University from 2001 until 2010. He served on the faculty of Northwestern and currently is on the faculty at the University of Chicago. He has been the head team physician for Glenbrook North High School for nearly 20 years. He has earned a certificate of added qualification as a specialist in sports medicine surgery.

And he has served as a consultant for Major League Baseball and the National Football League. Dr. Portland has helped thousands of athletes of all ages recover from knee, shoulder, and sports-related injuries. He’s an outstanding surgeon and even better person and a great friend and colleague to me, Greg, welcome to OrthoInform and thanks for being here today.

Dr. Greg Portland:
Thanks for having me here today, Eric.

Dr. Eric Chehab:
So I just wanted to start with the basics about the meniscus. First of all, what is it?

Dr. Greg Portland:
So the meniscus is a disc that sits inside the knee. So, we have one on the inner or medial aspect and another on the outer or lateral aspect. And the job of the meniscus basically is to function as a shock absorber.

So, as we do activity or load the knee, the meniscus takes some of the load away from the joint part of our knee called the cartilage and the cartilage when we don’t have any at all, is arthritis. So, the job of the meniscus is really to keep our knee from developing arthritis over time.

Dr. Eric Chehab:
So this tissue–it’s not big in volume.

It’s a small piece of tissue, but it performs this incredibly important function within the knee. What other types of cartilage do patients need to know about that are in the knee?

Dr. Greg Portland:
Well, the most critical one is what I just mentioned, which is articular cartilage. So, the articular cartilage is essentially the ball-bearings of our joints.

It coats the ends of our bone. And the reason why we get pain with arthritis is as our joints lose their cartilage, our bone sees stress. And when the bone sees stress, it swells– our bone is a living thing. So, the articular cartilage is the most critical part. And then the meniscus is what’s called fibrocartilage.

So, it’s almost like a little spongy disc that we have, and it’s incredibly durable, but unfortunately it can get damaged like anything else.

Dr. Eric Chehab:
So you mentioned arthritis. There are two types of cartilage in the knee that you had discussed, both articular cartilage and the meniscus cartilage. Tell us a little bit more about the articular cartilage and its function.

So, the job of the articular cartilage is to coat the end of the bone. And by doing that, it provides a very smooth gliding surface for our joints to move.

That way, we’re not really conscious of feeling our joints as we do any of our activity. The other thing that it does is it provides a durable coding to the ends of our bones so that we don’t get any stress breaks or we don’t get any swelling of the bone. So, it really provides two functions

Dr. Eric Chehab:
And the meniscus protects that cartilage–

Dr. Greg Portland:
Yeah. So basically, it literally is a shock absorber. So just like our car, it really keeps the articular cartilage from wearing at a premature rate.

Dr. Eric Chehab:
Now everybody will develop a meniscus tear if they’ve lived long enough, that’s something that I’ll tell patients. Do you agree with that?

Dr. Greg Portland:
Oh, I completely agree. I pretty much tell everyone who comes in with a meniscus tear expecting surgery, that as we age, the likelihood of having a meniscus tear rises in a direct fashion.

Someone who’s the age of 50– there’s probably 40 to 50% of people aged 50 walking around with a torn meniscus that don’t even know it. It becomes a little bit more of the rule than the exception as we age to develop a tear.

Dr. Eric Chehab:
How does it come to people’s attention that they even have a meniscus tear?

Dr. Greg Portland:
Well, whenever people develop pain, oftentimes they’ll seek medical treatment and a lot of times–and this is I’m sure your experience as well–we’ll see someone who has the rapid onset of pain and the knee jerk reaction, a lot of times, is ‘I want to get an MRI.’ So a lot of times I’ll see patients coming in my door who haven’t really had a significant injury, but come in with an MRI. And then they have a tear.

And even though they may have the development of arthritis going along with a tear, they always assume that, ‘hey, it’s my meniscus causing my pain.’ And you know, one of the big limitations of MRIs is it doesn’t give us chronicity, meaning it doesn’t say this is what hurts, and this is when it started to hurt–because if we had that, sometimes it very well may be the meniscus that’s causing their pain.

But a lot of times it may be the loss of cartilage or something else going on in or around the knee that’s causing the pain.

Dr. Eric Chehab:
So when patients have pain in the knee and they have an MRI, it’s almost harder sometimes for us to explain that the pain could be coming from a multiple of factors. And most commonly that pain is self-limiting.

When do we distinguish it’s a meniscus versus something else within the knee? What are some of the clues that it is the meniscus that’s causing some of the pain?

Dr. Greg Portland:
Yeah, my opinion, this is where the value of seeing a physician is incredibly invaluable. Because a lot of times we can look at a report and, and we’ll get a sense that this is why you hurt.

But alternatively, if you do what’s called a history. If we have a conversation with a patient, there are a lot of clues that they can tell us, like, what is the origin of their pain. And then we use the exam to kind of confirm our theories from their story. And it really is incredibly valuable to providers to have that interaction with our patients, because it enables us to have a far more accurate diagnosis than the MRI.

Personally, you know, as I get older and older in my life and my career, I believe much more in the patient’s story and my exam in giving me an accurate diagnosis much more than the MRI.

Dr. Eric Chehab:
So you’ll use the MRI to confirm the suspicion that has been arisen from their history and their physical.

Dr. Greg Portland:
Absolutely.

Dr. Eric Chehab:
So what is the story that a patient will tell? What’s a typical story of a patient who’s injured their meniscus that’s causing them the pain in their knee?

Dr. Greg Portland:
Well, I think there are two different stories.

Okay. The first is what we call traumatic and the other is degenerative. So from a traumatic meniscus tear, an individual will come and see you and I in the office. And then they’ll say, ‘I twisted and I felt a pop and pain.’

So a lot of the buzzwords from a meniscus tear from the origin will stem from, I felt a sudden jolt of pain, or I felt a pop, or my knee felt locked up where I couldn’t extend it.

All of these are classic stories for the origin of a meniscus tear. Some accompanying things that we hear is, ‘do I have any swelling? Did I develop any swelling?’ And then the pain is either on the inside or outside part of the knee, not the front of the knee inside or outside part of the knee when I squat or twist.

Now from a degenerative tear. It’s much harder to make a diagnosis where the meniscus is the sole cause of the pain, because it can mimic a lot of other things. A lot of times people will say, yeah, I just develop pain with working out or with playing golf. And it’s more of a non-specific thing.

And the biggest thing it can mimic is the development of some arthritis. They kind of mimic each other. Where the pain is, what different things cause it. And some response to anti-inflammatories, but it’s not a perfect response. So, they mimic each other quite a bit.

Dr. Eric Chehab:
And you alluded to this a little bit–what’s the mechanism that you commonly see for how patients injure their meniscus?

Dr. Greg Portland:
In my opinion, there’s two things. The first is for an isolated meniscus tear. So the most common thing from an isolated meniscus tear is a plant and a twist or a squat. And the other big thing that you and I see a lot of meniscus tears from, as if athletes injure a structure called the ACL and the ACL is just a rope that connects our thigh bone to the shinbone.

And if that tears, our knee can buckle. And a lot of times, the force of that buckle will cause the meniscus to tear as well.

Dr. Eric Chehab:
So let’s take a patient who has a meniscus tear that is symptomatic. That seems to be at the root of their problem that they’re coming to see you for. What are some of the treatment options that they have in front of them?

Dr. Greg Portland:
Well, to me, the first thing that I want to know from the patient is, is it pain that bothers them? Or is it a sensation of a catching or locking?

If it’s pain most of the time, you and I will try non-surgical things to try and help their pain. And the things that have been shown to help their pain are anti-inflammatory, physical therapy, occasionally a shot of steroid, and occasionally a brace may help their symptoms. Now intuitively it’s, it’s sometimes confusing for patients when we recommend this because their feeling is, ‘Hey, I still have a tear, even though I don’t have pain.’ And part of our job is to convince them that the number one goal of everything is to feel normal and not necessarily to correct what you feel.

So, a win, non-surgically, is where you accept that there is a tear and you get them back to whatever they want to do without pain.

Dr. Eric Chehab:
Right. Sometimes I’ll explain to patients that a meniscus tear can almost be like a hangnail. Where a small piece of tissue is getting caught in the knee. And the non-operative treatment is like having a small rock in your shoe that will kind of wear down to, from a rock to gravel, to sand, to dust, and kind of go away.

It’s not healing itself, but the problem sort of rights itself, for lack of a better term. And then the surgical treatment with that rock in your shoe analogy is like dumping out the rock. And so I, totally agree. The hardest part is when patients have a meniscus tear in their mind, they feel that the problem to be solved is to repair the tear, to do something about it.

And how does physical therapy or an injection do anything about it? Yet, most frequently, that’s the way we treat people. There are far many more meniscus treated without surgery than with surgery.

Dr. Greg Portland:
Yeah. And, and going back to my original statement, then the second category, if their complaint is other than pain, is where if they feel like they get a catch or a lock, or where their knee gets stuck. And that, that tends to be a surgical thing. Once again, this is going back to the original point I made, where if you sit down and have an honest discussion with people and people are really honest about what brings them in there, a lot of times that will help dictate what your ultimate treatment is going to be.

Dr. Eric Chehab:
There’s a big movement towards meniscal preservation. And explain why that is. I mean, it’s intuitive to me and you, but for patients, why is it that we want to preserve their meniscus so desperately?

Dr. Greg Portland:
Yeah, I mean, there was a study done in Sweden a couple of years ago and they looked at the incidence of people needing knee replacement.

And remember how going back to the point, like the job of the meniscus is to protect the articular cartilage. So, if we have a normal meniscus, let’s say the risk of our knees needing a replacement when we hit 60, is one in 10. Okay. And then if we develop a tear, that risk jumps almost tenfold, you know, so it’s quite a large jump where this is the likelihood of us needing it.

And then they did a study where if they looked at people and filed them five years out of fixing their meniscus, their risk basically got cut in half. So you know, part of us as orthopedic surgeons is looking at people, not just short-term, but long-term, and for those individuals who are willing to go through a repair recovery, which is much harder than a trim recovery, that our hope is if we can get that meniscus to heal, they’re still at higher risk of getting a knee replacement, but we’ve cut that down significantly from where that risk was, if we’re able to preserve or stitch their meniscus.

Dr. Eric Chehab:
Just to summarize, I mean, you mentioned it, there are two types of meniscus surgery in general: trimming the meniscus and repairing the meniscus. In any instance, we would love to be able to repair the meniscus if it’s amenable to that, because it reduces the risk of patients developing arthritis down the road.

In the absence of their meniscus or with an injury to the meniscus, that’s not something that can be repaired and sewn back together, the risk of arthritis goes up significantly.

So, what are some of the features of a meniscus tear that allows it to be repaired, versus the features that force our hands to trim the meniscus?

Dr. Greg Portland:
Yeah. I think the first thing is to say, are there associated injuries? And like I talked about, is if someone tears their ACL, when we injure the ACL and we do surgery to reconstruct the ACL, the likelihood of the meniscus healing and then in that scenario is as good as it gets. So for what you and I do, we’re very aggressive stitching the meniscus for that, because not only does it heal the best, but oftentimes, that athlete is a young person. And in looking at them, extrapolating them 20, 30, 40, 50, 60 years, we want to be very aggressive trying to get that meniscus to heal, to serve that person the best possible.

The second thing that we look at is geographic location. The meniscus is basically triangular in shape, and the closer you get to the base of that triangle, the better blood, the blood supply there is. So there is a difference in blood supply, depending on our meniscus type, or the geographic location of the tear.

The third thing is just technique. When you and I first started, for the first 10 years, we had limitations technically of what tears we were able to fix, just because we didn’t have the right equipment to pass stitches in, in the correct way that we would love to pass them. We have much better technology now.

So, this has led some people to really push the envelope of fixing all tears. And we’ve gotten better data to have an idea as far as how certain tears do as far as fixing and a lot of tears, we previously thought weren’t fixable can heal. Now, it may only be a 50% healing rate, but they can heal.

And the final thing that I look at, and I’m sure you do as well is, what’s the cartilage look like? And what is the size of that person look like if we have an individual, who’s no offense to me, but I’m 51. Um, and they’re extremely heavy, being a realist, the likelihood of that repair taking is going to be marginal at best, just because of the repetitive load on the repair.

And the other thing is, is just what’s the status of the cartilage. If someone has arthritis, well then, we don’t really gain much by stitching the meniscus, because they’ve already had arthritis. So to me, I look at those four things. And to me, that’s really kind of where I start to formulate my own opinion.

Like who am I going to have a discussion regarding either trimming or repairing the meniscus?

Dr. Eric Chehab:
Age plays a role also in the idea of being able to repair it. A lot of these degenerative tears that happen as we age become increasingly more difficult to repair because of the geographic area, because of the quality of the tissue. Do you agree with that?

Dr. Greg Portland:
Oh, a hundred percent. I mean, I think that as we age and not only age, but as we develop arthritis, the incidents of meniscus tears go up. So, if I see someone with arthritis on the inside part of the knee, for instance, the likelihood of them having a meniscus tear, there is about a hundred percent, right?

So, you know, to me, age and the presence of arthritis, both play a huge role in this.

Dr. Eric Chehab:
So when you’re making the decision to repair a meniscus, the factors include where the meniscus tear has occurred, the pattern of the tear, the blood flow to the tear, the quality of the tissue, the age of the patient.

And, quite frankly, the weight of the patient and some of the stress that we would anticipate on the repair site. When we do do a trimming procedure, what can our patients expect in terms of that outcome? They’re not doomed for arthritis for a trimming procedure. They certainly get an improvement in their symptoms.

You covered a ton of ground in that last answer. And I just want to ask you if you don’t mind listing, what are the factors in your mind that you go through when you’re making the decision to repair the meniscus?

Dr. Greg Portland:
So the factors that I use first and foremost is tear size and type. The second is geographic location of the tear.

The third is the status of the cartilage. The fourth is the age of their patient and the fifth is the size of that patient. All those are factors that to me, play a role as far as will I consider repairing this meniscus.

Dr. Eric Chehab:
If we go through those one by one, the size of the tear. If it’s a tiny, small tear, you’d be less inclined to sew and repair that compared to a larger tear where a large portion of the meniscus is displaced?

Dr. Greg Portland:
I agree wholeheartedly with that statement. So, if it’s a really small tear, if you clip a little bit of that, there’s still plenty of meniscus left to help protect that person’s knee. Conversely, if it’s an extremely large tear, then it’s a much better calculated gamble because if you get the meniscus to heal, then you’ve definitely changed the course of that knee’s life.

Dr. Eric Chehab:
And the younger the patient, the more likely you are to repair it.

Dr. Greg Portland:
Yeah. I think there are two factors at play. I think the first is, is that for a younger patient, it’s much easier to justify that because if you can get that to heal, there is so much more benefit on the backend.

The second thing is, is if I were to tell an 18 year old. ‘Hey, we got to stitch your meniscus, you’re going to go on crutches for five weeks, and we’re going to modify your life for six months in an effort to, to let you play 10 years of sport,’ that 18 year old and especially mom and dad are all in on that discussion.

If you tell a 50 year old, ‘Hey, you’re going to be on crutches for five weeks and you’re going to modify what you do for six months. Hopefully we’ll get a lot of years and by the way, the re-operation rate possibly could be 30%.’ No one buys that– like most people who are 50 and older are just like, ‘nah, just trim it, I don’t care if I get arthritis.’

So it’s a very different acceptance of what we’re trying to accomplish, both ways.

Dr. Eric Chehab:
Right. And the undertone of this is not every single meniscus repair heals. When we’re stitching it, it doesn’t always heal.

Dr. Greg Portland:
Yeah. So anyways, so if you look at different types of meniscus, one of the ones which historically we really didn’t repair, which is ones called horizontal tears–

They probably heal at only about a 50% clip. And then if you look at the best case scenario for the meniscus healing, which is something called a bucket handle tear, where there’s really good blood supply, and you do that at the same time of an ACL reconstruction, the healing rate for that, is probably about 90%.

So, the repair rate, while okay, is not perfect, you know–so a lot of our counseling stems from, ‘this is the expected healing rate, this is a potential likelihood of it keeping you from getting arthritis, and here’s a potential reoperation rate if you have pain from a failed repair.’ Those are all parts that I have with every patient that I discuss, in trying to, guesstimate from the MRI and the size and type of tear as far as to help patients make an educated decision. Do they want to proceed with surgery? And if so, do they want me to try and repair their meniscus?

Dr. Eric Chehab:
So let’s go to the surgical side. What a patient can expect the first week after, the first month, and the first six months. And we’ll start with the trim.

We get into the knee, it’s a small tear, not an area where blood supply is very good. Maybe it’s a 50 year old patient unwilling to go on the crutches and everything else. And just doesn’t have a tear that’s amenable to stitching and repairing, but more trimming and taking care of it.

What can they expect the first week, the first month, and the first six months?

Dr. Greg Portland:
If it’s okay with you, I’m going to divide that question into two categories. One is the patient with normal cartilage. And one is the patient with some early arthritis developing because that what they’re going to expect is very, very different. Okay?

So for the first week, both groups are pretty similar. Okay. They’re going to be a little sore. They’re going to, um, be able to put full weight on the knee. They can bend and straighten the knee when they’re laying down the, as, as comfortably as they can. And usually by about a week, their gait kind of normalizes.

And then what I tell patients is roughly at about one week, you can start doing light exercise bike, and at week two light elliptical and week three, a little bit more aggressive bike, an elliptical, but personally, I really don’t want the patients to pound for four or five weeks from surgery. And there’s two reasons for that.

One is, is when we have meniscus that we’ve kind of trimmed. You know, we rely on the interface where we kind of clipped it. We want that to seal up and heal up. So that’s not susceptible to re-tear. And probably that takes a few weeks for the body to do that. So part of why I don’t want people to go crazy right away, is to let that meniscus we left behind heal up.

The second, and just as critical thing is, the knee takes a hit from the surgery we do. So, when we do this surgery to either repair term of the meniscus, we use fluid to dilate the knee and that, that pressure of the fluid irritates the cartilage. And if we go too crazy and pounding the knee with activity right away, we can either have the cartilage deteriorate rapidly or develop stress breaks.

And unfortunately, I’ve seen both of them. And they’re not fun for patients to go through at all. So, at the five week mark, this is where there’s a clear difference between the two categories. The vast majority of people with normal cartilage usually are doing pretty well. They might have some soreness.

But on the whole, they’re doing pretty darn well, I would say the return to whatever activity you want to do is at least 80 to 90%.

Now the category where they’re developing some early arthritis, they’re all over the map. Um, there are some people are doing phenomenal who think that, you know what you’re doing as a surgeon, there are some other people who are doing pretty well, you know, a little sore, a little achey, but I’m, I’m getting there.

And then there’s another group that are really struggling. I’d probably say for people with some early arthritis and a meniscus tear that I clean up, I’d probably say about 20% are still struggling at five weeks, and it’s not uncommon to have to do a real strong anti-inflammatory called an oral steroid or consider a shot of steroid or consider a series of gel shots for some arthritis pain, because they are struggling so much.

And then at six months, usually that young individual with good cartilage has forgotten that they had anything done with their knee. Like almost universally they’re still doing extremely well. For the person with the trim, who’s got some early arthritis develop, they kind of continue along the same path that I described at five weeks.

There’s a lot of people who are doing great, who don’t have any pain. There are a lot of people who are on the whole are doing well, who need to take Advil. But other than that don’t have any symptoms– but then there are others where you’re continuing to help control their pain with injections and rarely, sometimes need a replacement sooner than they’d like.

Dr. Eric Chehab:
Right. So the articular cartilage plays a critical role in the expectations of the surgery. So if their articular cartilage is in good shape, in general, you can expect an excellent result from the trim procedure. If the articular cartilage is compromised, then all bets are off in terms of how predictable the results will be.

And if the patients know that upfront, it can help set expectations more realistically.

Dr. Greg Portland:
Oh, it absolutely can in, and you know, the hard part about it is, age isn’t always as critical as people think. Unfortunately, yesterday I operated on a person who is 40, who had terrible areas of no cartilage in her knee. Um, and unfortunately, you know, the likelihood of her doing well is worse than someone else I operate on who is in their sixties whose cartilage looked pretty good.

So, wholeheartedly, the cartilage is the number one determining factor of how someone does after any knee surgery, in general, in my opinion.

Dr. Eric Chehab:
And then was let’s switch gears a little bit to the repair.

And most of the time when we’re doing a repair of the meniscus, it is a younger person with reasonable articular cartilage. If their articular cartilage is already very compromised, the likelihood that we would subject them to a meniscus repair is certainly a lot less–

But with the repair, given it’s an extended recovery, take us through that first week, that first month, and that first six months of that meniscus that’s being sewn and repaired. And I, I hope I’m making that distinction up. We talked about trimming and we talked about repairing and the trimming is clipping out the small hangnail of tissue, and then the repair being stitching the meniscus.

So let’s stitch the meniscus. And let’s go through the first week, first month, first six months of their recovery.

Dr. Greg Portland:
So almost universally for that first week of stitching the meniscus, most surgeons will have people, either use crutches and put barely any or some weight on their foot. So they use crutches as load sharing.

And whenever we’re moving around, the knee will be in a brace, locked in extension. So if we walk like Frankenstein and don’t bend our knee at all at all, it actually will compress the meniscus. It will kind of squish it to the side and help it to heal. And then we will let people start to bend their knee, but often at a, at a limited clip.

So the further back we bend our knee, the more it wants to kind of displace or shift the meniscus. So for the first couple of weeks, each surgeon, depending on the tear size and the pattern and the tissue quality, we’ll have patients go at a little different clip as far as ‘when do I get off crutches? How quickly or rapidly can I bend the knee?’

And there is some debate in the orthopedic sports world for guys that you and I go to, where this person will limit bending the knee no more than a right angle for four weeks. And that person will let them bend a hundred percent. Personally, I change my rehab, every surgery, depending on all those factors I just mentioned:

Was it a good blood supply? How big was it? Was it with an ACL? How was the cartilage? You know, so a lot of factors go into play. And I think for every patient, I think for most surgeons is, is going to be kind of streamlined to what’s best for them and their surgeon’s opinion.

Dr. Eric Chehab:
So just to summarize a little bit, that first month patients can expect some restriction in their weight-bearing, some restriction in their range of motion.

But in general, that could be different from one person to the next, depending on the pattern of the tear and the repair type.

Dr. Greg Portland:
Correct. And then if we look at it, the hard part about meniscus healing, and this is one thing that I really stress to my patients, is it doesn’t heal a hundred percent. When we fix this, we’re only getting spot welds.

And so, as a result, you know, we have to go that much more conservatively before letting them get back to activity. So, in looking at soft tissue healing models, we think that probably the meniscus has healed roughly by about 16 weeks. Okay? And if you extrapolate 16 weeks on average, that’s about four months.

Most of the time we have to limit what our patients are able to do for 16 weeks. And then we have to get protective and functional movement and protection and activity for patients. And that usually takes another two months. So I don’t know about you, Eric, but I usually will say, I’m not going to let you pound on the knee for about four months in a straight line, but I’m not going to let you go back and play twisting, pivoting sports for six months. And then there are some sports which I actually recommend, ‘If I’m going to stitch this, you may want to, give up.’ And the number one sport for that, unfortunately is wrestling.

When people have seen wrestling at a high level, you look at the positions as knees, and there’s no way that meniscus is ever going to completely heal at one of the Big Ten meetings, when I used to take care of it, I actually asked that question ,because I just had this incredibly frustrating stint where I had fixed a wrestler’s knee, and he re-tore it.

And then I universally asked the other doctors, ‘Hey, has anyone had a successful repair in a wrestler long-term?’ And everyone said, ‘no, I just trim it out if they’re going to keep wrestling nowadays.’

So a lot of it is a function of the athlete and activity, but I think the biggest take home message of rehabilitating from a meniscus repair is you really need to let the spot welds get strong and be patient.

And even then you’re not guaranteed a hundred percent success.

Dr. Eric Chehab:
It’s amazing that this very small piece of tissue can have such a large impact on the trajectory of the health of someone’s knee. And obviously that impact is greater the younger the patient is, and you were mentioning these college wrestlers who are facing this choice of giving up wrestling or giving up their meniscus. That’s a tough choice for those kids.

Dr. Greg Portland:
Yeah, the hard part for me as a physician is you’re also an ex-athlete and you’re also a father. And I think you’re really sympathetic to the position of each person. Because everyone thinks there’s going to be like some easy conclusion where everyone’s going to walk away happy, and it just doesn’t exist.

Part of the challenge of a provider is everyone’s sports career ends at some point, and everyone thinks it’s going to be after being pro or a division one athlete, but yeah, a lot of people’s sports careers and at eighth grade, and when you and I grew up, we were much more accepting of that.

I have a lot of friends who tore their ACL in eighth grade, and guess what? They never played twisting, pivoting sports again. And that was just how it was. Hey doc said, you know, I can’t play this anymore. And everyone just said, okay, doc said it, and that’s what it is.

So I think the hard part for all of this is to, to kind of say, ‘How much risk, how much mentally and physically can my body tolerate and what’s best for my knee longterm?’ Because to your point, this meniscus is so critical, probably for most of these athletes, the best thing we could do for them would be to stitch them, and then have them just play recreational sports and not go back and compete and train at that uber high level that they’re used to.

Dr. Eric Chehab:
Let’s go through again, splitting between trimming, and sewing and repairing. For the trimming, what are some common complications and pitfalls that patients may experience?

In general, they don’t experience a lot of complications, but what are some of the things that you would consider complications for that type of trimming procedure?

Dr. Greg Portland:
Yeah, the number one complication from a trimming procedure is pain. And the length of that pain and intensity of that pain will vary. And fortunately for most people over time, that will go away as long as they have good cartilage.

The second complication, that is one of the more feared complications is a blood clot. Okay. And the risk of a blood clot for most individuals following a knee scope, it can range anywhere between one in 500 to one in 1500, depending on different studies that you read. So universally, I put people on a mild blood thinner, such as aspirin, in anyone who’s 21 years of age and older.

The third thing is, is there is a small risk of nerve damage. We have tiny little nerve branches, they kind of cross the knee. The typical presentation of this nerve damage is a little bit of numbness on the outside part of the knee, which really isn’t debilitating. It just feels funny, but rarely, some people sometimes can get something called a neuroma.

And those are the main complications of a trim that I see.

Dr. Eric Chehab:
And then likewise, let’s apply that to a repair. What are the most common complications of a stitched and sewn repaired meniscus?

Dr. Greg Portland:
The number one complication of a stitched meniscus is a re-tear. Depending on different tear types, there’s a different re-tear rate.

So I’ll give four common tear types that we see and just to show you how different this can be. So if we have what’s called a bucket handle tear, or a very large tear, we do at the same time as an ACL reconstruction, the re-tear risk of that is 10%.

If we have a traditional tear, where there’s good blood supply in what we call a vertical tear, kind of a straight across tear, the re-tear rate of that is 30%.

If we fix the attachment of the meniscus, something called the meniscus root repair, the failure rate of that is 40%.

And if we have kind of a split like cleaving the triangle and half something called a horizontal tear, the failure rate of that is 50%. So re-tear far and away is the number one complication.

Similar to what I just mentioned, the risk of a blood clot exists, the risk of nerve damage exists. And the other thing that we can see too is, we can see some loss of motion. It’s not uncommon to see a little bit of loss of motion, just because we have to protect the knee in order to let it heal.

And there is a much higher risk of nerve damage. Like for instance, if we stitch the inside meniscus, there is some risk to damaging some branches of the nerve, including a main part of the saphenous nerve that is clearly a risk factor. And then if we’re using little devices, we run the risk of damaging some structures in the back of the knee.

And unfortunately, all these risks are not high, but they’re real. And all those are the, are the biggest risks that I let my patients know about.

Dr. Eric Chehab:
Let’s talk about pain management. We’ll again divide it into the trim procedure and the repair procedures. With trim procedures and pain management, what do you find to be particularly helpful?

Dr. Greg Portland:
So for trimming the meniscus, typically people don’t even need to take much narcotic at all after surgery. They’re quite comfortable on an anti-inflammatory. So anti-inflammatory and ice are incredibly important. As well as appropriate activity. I think if people take it easy the first week and two weeks and not have that knee swell up, the likelihood of them flying through the recovery is excellent.

Dr. Eric Chehab:
Yeah, it really pays off that initial investment of taking it easy.

Dr. Greg Portland:
Yeah. I think a lot of people who are type A, who can’t sit down they’re up on the knee will swell, and they really struggle a lot. I think therapy is extremely helpful. I don’t think it’s as critical as for repair, but I usually recommend it for my patients and I think it helps them get from point A to B faster and more reliably.

And I think, you know, a lot of the tricks the therapists have at their disposal can really help patients’ pain.

Dr. Eric Chehab:
And what about the repair side?

Dr. Greg Portland:
The repair, therapy is a hundred percent necessary. As well as an anti-inflammatory. So for most heals or repairs, there is a little bit of a concern about doing too much anti-inflammatory because in the lab, the same part of our body that causes pain, which is an inflammatory response, also heals.

So, you know, for the repairs, I don’t know what your feeling is, but I bring this up and I don’t know how true it is or not, but I really push people more to, as quick as you can get to Tylenol as quick as you can ice, make those as much or more your friends than Advil.

And then therapy is such a critical part of the recovery from the repair that once again, the therapists really can help with that pain relief because part of the pain is just from the trauma of being stitched and the trauma of the surgery, but also getting stiff. So, stiffness can cause pain and as our knees get more functional and more flexion then often that pain will be much better.

Dr. Eric Chehab:
So finally, what are some things that you’d like patients to know about the meniscus and the treatment of the meniscus? Any, parting thoughts on the meniscus and the treatment for meniscus injuries?

Dr. Greg Portland:
Yeah, I think the first thing to know is, be honest with what you’re feeling, because you don’t want the treatment worse than the disease.

So I think sometimes people have a little bit of pain with paddle tennis and they’ve got a little mild arthritis and a little meniscus tear. Like, my first advice for that patient is, be appropriate with your treatment. Like, don’t rush to surgery immediately. Because oftentimes you can get better with simple means.

Alternatively, if you’re sensing that something’s not right in your knee, like it’s catching, it’s locking– please seek medical attention sooner than later. Okay? Because if you have a tear pattern that potentially is stitchable, there is a little bit of a race of time as far as the potential of being able to stitch that meniscus.

And then the third thing is if you do go through a repair, part of the soul searching, you have to decide on the backend is, ‘Well, what am I looking to get out of my knee?’

And what we’re looking for short-term may not always be the same as what we might be looking for long-term and, you know, a lot of life is kind of cross-training, in my opinion, you know, you kind of mix and match because hopefully by doing that, you’ll get as much wear out of every part of your body, as long as you can. And, while at the same time, still do a lot of the things that you love to do.

Dr. Eric Chehab:
It’s funny. I find that with a meniscus that this idea of we are thinking of your knee six weeks from now, six months from now, six years from now, and six decades from now–those four time periods seem to be most in conflict with the meniscus than with most other things that we treat.

If you’re thinking about the knee feeling the best it can six weeks from now, six months from now, six years from now, and six decades from now–the procedures don’t all line up. It doesn’t always go on the trim side, it doesn’t always go on the repair side.

Dr. Greg Portland:
No, I agree wholeheartedly. And that’s why there’s a lot of confusion.

I think there’s a lot of confusion for people I take care of, where often people will ask me to clarify things for another call or come in for another visit. And certainly, you know, it’s a source of multiple opinions that I see as far as ‘what should I do?’

I don’t know, I like to think I’m kind of the middle of the road person where, you know, you repair when it’s appropriate, you trim when it’s appropriate, and you operate when it’s appropriate. Because there’s a lot of people who come in with an MRI who say, ‘here’s my tear. I need surgery,’ where, you know, fortunately for a lot of those people, they can do just great without doing it and really not really changing the long-term outcome.

You know, one of the big things that I don’t know if this comes up with you is I have a lot of people who say, ‘well, I don’t want surgery because I don’t want to lose my meniscus because I have a tear and I still have symptoms.’ And what I tell that person as well, if your meniscus is torn, biomechanically, it’s not working. So you’re really not gaining anything functionally by living, by leaving it. And to me, that’s one of the things, if you truly want to change it biomechanically, then you need to stitch it. And going back to that study, I told you. it’s still not normal. And so, I think for a lot of this is, you and I want people to be happy and healthy and live the lives that they want.

And there are a lot of data points that we take into this that my feeling always is it’s always reasonable to go see a physician because part of their job is to just help you have a much better-informed decision, as far as your health. And to me, the meniscus is absolutely one of those things where there’s a lot of data points. And patients didn’t realize how many data points exist often when they come into your office.

Dr. Eric Chehab:
So I’d like to extend my thanks to Dr. Greg Portland for being here on the OrthoInform podcast and shedding a lot of light on this topic that is seemingly so simple but has a lot of data points and subtleties, and again, I appreciate your being here, Greg, and helping us out with this topic.

Dr. Greg Portland:
My pleasure, Eric, and listen best wishes with everything and good luck to everyone out there. And hopefully you never have to have a talk about your meniscus.