Cartilage is a thin,
elastic tissue that protects the bone and makes certain that the joint surfaces can slide easily over each other.
There are two types of
joint cartilage in the knees:
(meniscus), which has tensile strength and can resist pressure.
Hyaline cartilage: Which covers the surface along which the joints move.
Cartilage will wear over
the years, as it has a very limited capacity for self-restoration. The newly formed [healed Scar] tissue will generally consist of a large part of fibrous cartilage of lesser
quality than the original hyaline cartilage. As a result, new cracks and tears will form in the cartilage over time.
The Articular Cartilage, also known as the joint lining,( Hyaline cartilage) is a protective layer of tissue located on the ends of the bones which come together in the knee joint. These bones are the femur
(thigh bone), tibia (shin bone), and patella (kneecap).
Articular cartilage can be damaged by an injury or gradually deteriorate over time from a
variety of factors. When the articular cartilage is damaged or injured, it usually goes through a staged process of softening, flaking, fragmenting, and finally, complete loss where the underlying
subchondral bone is exposed. This process is commonly known as osteoarthritis.
Damaged or injured articular cartilage has a very limited
ability to heal itself. Therefore, once the process of osteoarthritis starts, there is little that the body can do to stop the deterioration.
Articular Cartilage surgery:
There are several procedures that can be done for damaged articular cartilage. The decision of which procedure to perform is based on the extent of
damage seen during arthroscopy and on MRI scans and x-rays. Important indications include the size of the damaged area - both in diameter and depth.
Small articular cartilage lesions (less than 1 cm2 in diameter and extending only partially down into the cartilage; not to the subchondral bone which lies beneath the articular cartilage) are
usually treated arthroscopically by debridement and drilling, abrasion, or microfracture.
The drilling/abrasion/microfracture procedures all work off of the concept that producing
very small holes in the subchondral bone will stimulate a healing response that forms tissue resembling articular cartilage (called fibrocartilage).
What are the symptoms of a damaged
- Damage to the menisci or cartilage can occur at any age.
Whilst one classically associates this injury with a young footballer sustaining a dramatic injury, in our experience, it is seen just as common in a slightly older population who can be doing no
more than simply going for an unusually long walk at a weekend.
- In short, the damage to the meniscus is an extremely common
condition that can occur during practically any form of activity.
- It is not unusual for patients to present with symptoms or
signs of a torn meniscus without being aware of any specific episode to which they can attribute the damage to the cartilage.
- Injury to the meniscus is associated with the classical
symptom of pain felt along the inside or outside aspect of the knee depending on which cartilage has been torn.
- Often this pain is slightly intermittent in nature and may
appear to get "better" only to come back and trouble the patient at a later stage.
- The pain is often associated with a
swelling which comes on gradually after the tear but in some cases does not occur at all.
- This twinging discomfort that patients often feel is often
exacerbated by any twisting activity of the knee and may occasionally be associated with more classical symptoms of a sense of giving way within the knee and very occasionally of
locking (inability to fully straighten the leg).
- All these symptoms are obviously troublesome to patients and
often prevent them from returning to any sporting activity.
- As a result of this, often a specialist opinion is sought
and further investigations can be undertaken to confirm the diagnosis.
Diagnosis of meniscus
- Whilst plain x-rays (radiographs) of the knee are not
particularly helpful in showing evidence of damage to soft tissue such as the cartilage within the knee, they can be useful in excluding the presence of a significant degenerative disease such as
- Once you have seen the specialist it is likely that the knee
will be examined particularly looking for signs of inflammation such as an effusion (swelling within the knee) or tenderness around the joint line surface.
- Whilst signs on examination point towards the possibility of
a torn cartilage, the best way of confirming this if surgery is to be considered is to undertake a Magnetic Resonance Imaging [MRI Scan].
- This investigation [MRI Scan] involves
placing the knee in a magnetic loop coil which produces very high-resolution pictures detailing the condition of the soft tissues associated with the knee.
- These scans are accurate (95%) enough to show whether a
meniscus is torn and thus a decision can be taken about the need for surgery.
- There is never an absolute need for surgery just because the
cartilage is torn, however, if the symptoms are annoying enough the patients often elect to press on with surgery.
Medial meniscus tear [MRI Scan]
Meniscus surgery & Arthroscopy:
There several types of arthroscopic meniscus procedures. The type of procedure used depends on what type of tear and where the tear is
- Simple tear. Tears in the outer one-third, or periphery, of the meniscus (which contains a
rich blood supply) can be repaired with a 70% chance of successful healing. There are no restrictions, such as age, other
injuries, or activity level for this procedure.
Complex tear. Tears extending into the central one-third portion of the meniscus, which has a limited blood supply, can also be repaired in some cases.
If the meniscus has multiple tears located in different regions, is shredded or severely
deteriorated due to multiple injuries, then it cannot be repaired. It may be possible to save some of the meniscus,
but if it must be removed it can be later replaced with a transplant.
Meniscectomy (or partial meniscectomy) refers
to the removal of all or part of a damaged cartilage within the knee called the meniscus.
This is probably one of the most common procedures now
performed by knee surgeons in the UK and is performed using a technique referred to as arthroscopy.
- The arthroscopy involves inserting a small telescope
attached to a camera into a small incision at the front of the knee (portal). This allows the whole of the knee to be inspected with water being used to inflate the knee.
- A fibre optic telescope instrument is used to view the internal cavity of the knee.
- The surgeon makes another incision through the other side of
the front of the knee to insert small instruments to cut away the loose or torn fragment of the damaged meniscus. Whenever possible the surgeon will remove only the damaged portion of the cartilage
leaving as much of the cushion function of the cartilage intact.
- This procedure takes place with the patient under either a
general or regional anaesthetic.
- This allows the knee to be fully examined and the suspected
damage to the cartilage (meniscus) to be confirmed and treated at the same time.
- The tear in the cartilage is often
found at the back portion of the knee and access to this area can be difficult which is why the experience of the surgeon is
- At the end of the procedure, which often lasts approximately
half an hour, the 2 small puncture mark incisions are closed either with a small stitch or a paper strip.
- The patient remains in hospital for an average 4 hours after
The surgeon will see the patient before they are discharged, hopefully having explained
what was found at the time of surgery.
1. Diagram : Bucket Handle Tear
1. Bucket Handle Tear
2. Diagram : Meniscal Flap Tear
2. Meniscal Flap Tear
- It is advisable in the immediate post-operative period to
decrease the amount of inflammation after the operation by providing the patient with a supply of anti-inflammatory medication.
- On discharge general advice is given that walking and
activity should be encouraged and guided by the pain.
- Whilst we encourage patients to get up and about after
surgery, they are discouraged from going back to work for approximately two weeks period. Sometimes due to work commitment patients have to return earlier than this and these cases they are urged to
be driven to the door of their work place or ideally work from home.
- In the three days following the operation, patients are
encouraged to keep a compression bandage on the knee to reduce the swelling and also to visit their physiotherapist if required to work on strengthening the muscles around the
- Patients will be given an outpatient follow up 2 weeks post
surgery in order to inspect the wounds and check that the movement of the knee and the pain is satisfactory.
- Despite the fact that the cartilages do not possess nerve
function, pain can be felt post-operatively as it was pre-operatively. It is not unusual to have experienced continued "twinges" of discomfort at the area of the meniscectomy as the cut and scars can
remain sensitive for several weeks [occasional 8weeks].
Each individual patient’s recovery time varies enormously but in
general between 2 weeks post surgery the patient should be returning to near normal activity with resuming sporting activity approximately at 6
Medial Meniscus flap tear: [before and after trimming]
Medial Meniscus tear: [before and after trimming]
Medial meniscus tear [MRI Scan]