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Meniscal Injury
Ross Hauser, M.D.
The
menisci consist of semilunar fibrocartilage, partly filling the space between
the femoral and tibial bones. Four principal functions are ascribed to the
menisci:
1. To
spread a thin film of synovial fluid which provides nutrition to the
articular
cartilage
2. To act as shock absorbers
3. To increase the stability of the knee joint
4. To aid in the complex rotatory mechanics of the knee joint
Meniscus
injuries occur in most sports, but most commonly occur in contact sports. They
often occur in combination with
ligament injuries, particularly when the medial
meniscus is involved. This is partly because the medial meniscus is attached to
the
medial collateral ligament
and partly because tackles are often directed
towards the lateral side of the knee, causing external rotation of the tibia.
Injury to the medial meniscus is about five times more common than injury to the
lateral meniscus.
By knowing the function of the meniscus, it is possible to predict what will
happen when meniscal tissue is shaved or removed. Since it provides some of the
nutrition to the
articular cartilage, its removal will aid in the demise of the
cartilage. If the cartilage is damaged, then the pressures on the bone will be
too great and arthritis will soon follow. This is not the only reason why articular cartilage damage is sure to follow after
meniscectomy. The removal of
the menisci allows too much pressure to be put on the articular cartilage, thus
lessening the shock absorption. This is why cartilage damage and proliferative
arthritis must be the end result of meniscal removal. No other option is
available. If the surgeon removes the meniscus, arthritis is the end result. If
that were not enough, the menisci aid in the stability of the knee. If they are
removed, the knee is left with too much motion and becomes unstable. This also
increases the likelihood of articular cartilage damage and subsequent arthritis.
Arthroscopic shaving and removal of the meniscus would therefore be expected to
result in the progression of arthritis in the knee.
Prolotherapy, on the other
hand, would be expected to heal the meniscus, since Prolotherapy stimulates the
body to repair the injured tissue. Prolotherapy given to the injured menisci
stimulates
fibroblastic growth of new stronger meniscal tissue, thereby
repairing the area. This makes a lot more sense than its removal.
Study Shows Increased Contact Stress Pressure after Meniscectomy
There have been numerous studies showing that the contact stress pressure on the
articular cartilage significantly increases after meniscal removal. (Ahmed, A.
In vitro measurement of static pressure distribution in synovial joints. Part 1:
Tibial surface of the knees. Journal of Biomechanical Engineering. 1983;
105:216-225.; Brown, T. In vitro contact stress distributions on the femoral
condyles. Journal of Orthopedic Research. 1984; 2:190-199.)
One such study showed that after partial meniscectomy, the contact stress
pressures increased by 110 percent and after total meniscectomy they increased
200 percent. Their conclusion was expected. "The contact stresses increased in
proportion to the amount of meniscus removed.(Baratz, M. Meniscal tears: The
effect of meniscectomy and of repair on intra-articular contact areas and stress
in the human knee. American Journal of Sports Medicine. 1986; 14:270-274.)
Other studies have shown even greater increases in pressure, causing from a 450
to 600 percent (six times) increase in pressure on the tibia bone and articular
cartilage when the meniscus is removed. (Radin, E. Role of the menisci in the
distribution of stress in the knee. Clinical Orthopedics. 1984;
185:290-294.;Seedom, B. Transmission of the load in the knee joint with special
reference to the role of the menisci: Part 1. Eng Med. 1979; 8:220-228.)
Menisci are normally shaved or removed because they are believed to repair so
poorly. Menisci, like many of the soft tissues treated with Prolotherapy, have
poor blood supply. This is one of the reasons they heal poorly. The best
treatment option is to increase the circulation to the damaged menisci.
Studies Show Meniscal Surgery Actually Increases Injury
Repairing a meniscal tear with
arthroscopy makes conceptual sense, however, this
just does not occur often enough to warrant the procedure. In an animal study,
only 38 percent of the meniscal repairs actually healed. (Cabaud, H. Medial
meniscus repairs. American Journal of Sports Medicine. 1981; 9:129-134.)
To add insult to injury, another study showed that meniscal repair can actually
cause a further spreading of the injury to the non-injured meniscal tissue. The
authors noted, "It appears that in radial repairs, progressive spreading at the
repair site altered normal meniscal geometry and structure, adversely
influencing mechanical function." In common language, attempting to repair the
area with arthroscopy makes the normal meniscal tissue weaker and further
worsens the injury. The authors went on to say, "Meniscal tissue from repaired
radial lesions was significantly lower than controls in yield stress, maximum
stress, and elastic modulus. The repaired radial meniscal lesions demonstrated
abnormal force transmission and energy dissipation behavior qualitatively
similar to a complete meniscectomy." (Newman, A. Mechanics of the healed
meniscus in a canine model. American Journal of Sports Medicine. 1989;
17:164-175.) This is unbelievable! Repairing a meniscal tear makes the meniscal
tissue so weak that it is like having no menisci at all.
Incomplete Healing and Further Deterioration Result After Meniscal
Repair Surgery
In one large study, where 82 percent of the meniscal injuries were sustained
from sporting events, a full 75 percent of the meniscal repairs did not
completely heal.(Rubman, M. Arthroscopic repair of meniscal tears that extend
into the avascular zone. American Journal of Sports Medicine. 1998; 26:87-95.)
The follow-up arthroscopic examinations were done at a mean of 18 months and
clinical examinations at 42 months. This is one and a half and three and a half
years later, folks. These are not impressive statistics to encourage athletes to
undergo meniscal repairs. In this study, in only 18 months, 20 percent of the
patients had articular cartilage damage on the tibia and femur that was not
present on the initial arthroscopy, but was seen in follow-up arthroscopy. A
full 40 percent had deterioration of the articular cartilage under the knee cap.
This deterioration occurred over only 18 months! Yet the authors of the paper
state that 80 percent of the patients were asymptomatic. But 20 percent of the
patients needed further arthroscopic surgery! You see the difference between
pain-free and healed? Athletes are being coerced into these procedures that do
not repair or heal the injured the tissue. Eighty percent were pain-free while
their cartilage was rapidly deteriorating. What is being done to stop this
arthritic process? Unless the orthopedist plans to refer the athlete for
Prolotherapy, nothing is being done.
Prolotherapy and Torn
Meniscus
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