Torn meniscus: Is surgery necessary?

• One of the main questions asked by patients with a torn meniscus is whether it is necessary to have surgery or whether it can be solved conservatively.
• The choice of whether to treat a torn meniscus with surgery or conservative treatment must be made between the orthopaedic surgeon and the patient, depending on the patient's characteristics.
• If the severity of the torn meniscus is very high and does not allow the patient to lead a normal life, it is recommended to carry out a meniscus arthroscopy intervention.

When a torn meniscus is present, the symptoms are very characteristic, although they can be confused with the symptoms of cruciate ligament tears, so in order to differentiate a torn meniscus from a torn ligament, a physical examination by an orthopaedic specialist will be necessary to diagnose it.

This diagnosis of a torn meniscus is first made by the aforementioned physical examination, but is usually confirmed by other tests such as MRI or X-ray, including diagnostic arthroscopy.

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Below we will explain several points related to a torn meniscus, starting with the symptoms that the patient suffers from and that allow the doctor to suspect a meniscus tear during the medical interview.

At the time of the meniscus fracture, the patient feels a snapping sound in the knee, which is common to torn ligaments, which may have torn both the meniscus and the anterior cruciate ligament.

The main symptoms caused by a torn meniscus are:

• Pain: Pain due to a torn meniscus is usually moderate and increases with movements of the knee or leg support when standing, but one of the unmistakable signs that the meniscus may be torn is if pressure on the intra articular line of the knee (the imaginary line separating the top of the knee and the bottom) increases the pain. If the pain is generalised throughout the knee joint, it is possible that in addition to the torn meniscus there is damage to other structures such as the ligaments or the bone itself.
• Joint locking: Joint locking due to a torn meniscus is due to a portion of the torn meniscus being interposed between the femur and tibia preventing the knee from completing the flexion-extension movement.
• Joint effusion: This symptom, in addition to a torn meniscus, can also occur due to torn ligaments, preventing the knee from moving even moderately due to swelling.
• Reduced mobility: Because of all the above symptoms of a torn meniscus, the patient is unable to flex or extend the knee. In these cases, if the meniscus tear is not treated in time, atrophy of the muscles surrounding the knee due to inactivity is very common.

To determine whether a meniscus tear is present, it is vital that the diagnosis is made by a specialist in traumatology. 

To do this, the doctor performs an anamnesis of the patient, the technical name for what could commonly be called a medical interview, where the patient tells the doctor how the problem has occurred and what symptoms he or she perceives, as well as a physical examination to try to confirm the diagnostic suspicions he or she may have as a result of the anamnesis.

In addition to this initial diagnosis, if the doctor deems it appropriate, complementary tests will be carried out to determine the extent of the meniscus fracture and to ensure that there is no other structural damage to the joint (bone, ligaments, etc.). 

These types of complementary tests include an X-ray to determine if there is damage to the bone and an MRI scan that will allow the specialist to differentiate between a healthy meniscus and a torn meniscus.

In the anatomy of the knee, there are two menisci, one internal and one external. Depending on which of these meniscus is torn, we differentiate between an internal meniscus tear and an external meniscus tear:

• Internal meniscal tear: This is the most common meniscal injury, both in terms of traumatic and degenerative meniscal tears, the only difference being that traumatic meniscal tears are usually longitudinal while degenerative tears are usually horizontal.
• External meniscal tear: In these cases, the meniscal tear may be due to the development of a meniscal cyst (considered a degenerative tear) or one of the different types of tears such as a parrot's beak tear.

Once the diagnosis of the meniscus tear has been made and it has been determined whether or not there are associated injuries, the specialist and the patient will have a conversation to determine whether it is necessary to repair the torn meniscus or whether the patient could benefit from some type of conservative treatment.

This decision will be made based on the use of the joint (if you are an elite athlete or if sport is a very important part of your life), the pain and impairment this causes and of course the severity of the injury.

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The choice of conservative treatment of a torn meniscus is usually made in parameniscal injuries, which only affect the peripheral part of the meniscus. This area, being vascularised (it has veins and capillaries through which blood flows) is more likely to regenerate on its own in the same way that wounds regenerate.

For this treatment, the patient must undergo intensive rehabilitation to strengthen the muscles of the knee joint in order to distribute the strain between them and prevent it all falling on the damaged meniscus.

To cope with any pain, the doctor may prescribe painkillers and anti-inflammatory drugs. After each rehabilitation session, the patient should apply ice to the area of the torn meniscus to relax any swelling.

In time, the patient will be able to lead a normal life, although it is possible that the knee may occasionally swell after heavy physical exertion and ice should be used to reduce the swelling.

If surgery is chosen to repair the torn meniscus, the most commonly used approach today is knee arthroscopy. This surgery is one of the so-called minimally invasive surgeries as it allows the surgeon to repair the torn meniscus without the need for open surgery. 

This is done using an arthroscope, which is a tiny camera with a light connected to a monitor that allows the surgeon to repair the knee from the outside, viewing the inside of the joint on the monitor and repairing the problem with instruments inserted through two mini incisions.

In addition to the method of approach, there is a choice of two surgical techniques for repair of the torn meniscus, although a combination of the two is almost always performed. In all cases, the primary goal is to preserve as much meniscal tissue as possible:

• Meniscal suture: This surgical technique consists of suturing the meniscal tear to preserve all the meniscal tissue. This technique is usually used in young patients or athletes as it allows a large part of the meniscus to be preserved.
• Partial meniscectomy: On the other hand, this operation consists of removing the free edge detached as a result of the fracture. In these cases, an attempt is made to remove the minimum amount of tissue, as removing too much could lead to accelerated degeneration of the joint and the development of osteoarthritis. Nowadays, complete meniscectomy is no longer performed, as it used to consist of removing the entire meniscus, which resulted in a great deal of bone friction and early osteoarthritis.

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