Jean Ross, as of May 28, 2003, had surgery for a complete knee replacement.
If you have any interest in the details of that action, current as of May 28th, CLICK HERE.
Lets say that you have sore or aching knees, and you
eventually get an examination done by the MRI machine. You then get a copy
of the diagnostic report. This report is intended for a specialist doctor
who understands all the words on it, but you start reading it and find that you
don't understand any of the words. The MRI machine is fully described HERE. For
information about hip joint repair or replacement, click HERE.
This web section has many pages. Look at the Table Of Contents for more.
The report refers to a tear of the meniscus, but those
references must be evaluated in reference to the following. It is probably
better understood if you call this meniscus "cartilage" and consider it very
similar to the "gristle" you find in tough meat. Most likely in an older
person there was not a sudden "tear" of this cartilage, but a gradual wearing
and weakening. There are a couple surgical possibilities described here.
There is also a non-surgical, non-drug treatment that undoubtedly cannot be the
final answer, but can be a first response.
If you are considering getting an MRI? Check this
article out:
Physical therapist Diann
Inch knew she had injured her hip climbing a ladder, but an MRI scan didn't
find anything wrong.
As it turns out, it was the
scan that was wrong. (Source)
Left Knee
The report on the left knee includes this comment: There is no definite evidence of meniscal tear identified.
The patella appears to be unremarkable and shows normal relationship with the
distal femur. (source) At first
glance this comment seems to conflict with other details about the left knee --
something the doctor's explanation certainly should clear up.
The left knee official summary is as
follows:
1. moderate degenerative joint
disease with joint space narrowing and thinning of the articular cartilage, more
on the lateral compartment, with margin osteophyte formation.
2. There is mild joint effusion. No Baker's cyst.
3. Degenerative maceration and tear involving the lateral
meniscus.
4. Grade II signal change seen in the posterior horn of the
medial meniscus (source)
1. Moderate degenerative joint disease involving the
lateral compartment of the right knee joint with joint space narrowing, marginal
osteophyte formation and thinning of the articular cartilage. There is no
adjacent lateral femoral condyle and the lateral tibial plateau.
2. There is degenerative tear seen in the posterior
horn of the lateral meniscus and macerated appearance involving the mid zone and
anterior horn of the lateral meniscus.
3. Mild joint effusion No Baker's cyst.
4. Remainder of the exam of the right knee otherwise
appears unremarkable. Clinical correlation and follow-up recommended. (source)
You want to have your own informed opinion on what the
diagnosis means. So, you come to this page and find that many of the words
on YOUR MRI diagnosis are the same ones as shown here. No patient should
enter the meeting with the knee specialist without having read pages like the
ones on this web.
The term "tear" of a meniscus is probably one of the most
severe diagnoses for knee injury and pain. There is material about this BELOW, and also on THIS PAGE. Also
there is a simple and brief explanation on THIS page.
The treatment for torn meniscus is to reduce the swelling,
rest and ultimately, if necessary, surgery through use of an arthroscope device:
Initial treatment for a torn meniscus
usually is directed towards reducing the pain and swelling in the knee. Your
physician may recommend crutches for resting the knee for several days and
suggest ice to reduce the pain and swelling. If the knee is locked and cannot
be straightened out, surgery may be recommended as soon as reasonably possible
to remove the torn portion that is caught in the knee joint. Once a meniscus is
torn, it will most likely not heal on its own.
If
the symptoms continue, surgery will be required to either remove the torn
portion of the meniscus or to repair the tear. Most meniscus surgery today is
done using the arthroscope. Small incisions are made in the knee to allow the
insertion of a small TV camera into the joint. Through another small incision,
special instruments are used to remove the torn portion of meniscus while the arthroscope is used to see what is
happening. In some cases, the meniscus tear can be repaired. The arthroscope is used to view the torn
meniscus. Sutures are then placed into the torn meniscus until the tear is
repaired. Repair of the meniscus is not possible in all cases. Young people
with relatively recent meniscal tears are the most likely candidates for
repair. Degenerative type tears in older people are not usually repairable.
(source)
When the damage to the meniscus is related to a state of
degeneration, repair is usually not thought to be feasible. Replacement
was considered experimental in Denmark in 1998, but
seems to be accepted by at least one surgeon currently.
In the case of older,
degenerated (weakened and worn) menisci that typically split apart or break
down under routine, day-to-day or minimal stress conditions, the meniscus
itself has not been healthy for some time. A degenerative meniscal defect will
almost never bleed, and in fact may often occur gradually, without the patient
even being aware of it! When such gradual, degenerative meniscal cleavage or
fissuring develops and is discovered by MRI scanning or arthroscopy, while it
is still commonly said that the patient "tore" their meniscus, this is
actually a mischaracterization. To most people, "tearing" something implies a
sudden structural failure in response to a specific, applied force. While the
terms "torn" and "tear" are convenient for surgeons to use because they are
familiar to patients, it is misleading to use them in relation to a
degenerated meniscus that is simply worn, frayed, fissured, fragmented or just
plain broken down. When a patient hears a surgeon say "You have torn your
meniscus", they naturally infer that their meniscus was healthy and
functioning properly before it "tore", and that like freshly torn ligaments,
their "torn" meniscus can simply be repaired back together again or "fixed",
neither of which is the case with degenerated menisci. Within the confines of
currently available medical technology, degenerative meniscal defects are
almost never amenable to repair. Degenerate menisci break down either
spontaneously or under minimal stress because their intrinsic strength and
toughness have already been compromised by way of the aging process and/or
joint surface erosion caused by arthritis. Attempts at surgical repair are,
therefore, pointless and usually doomed to failure. There is little to be
gained by trying to stitch mushy, permanently weakened and improperly
functioning meniscal tissue back together again. For lack of a better
available treatment, surgical removal of the painful, defective meniscal
tissue is usually the most appropriate course of action. (source)
. . . .
Aside from good surgical
technique, the key to obtaining a high success rate with meniscal repair is
often as simple as using selective judgment when making the decision to repair
versus remove. All possible effort should be taken to repair otherwise healthy
menisci that have excellent healing potential, whereas effort should not be
wasted on thoroughly degenerated menisci that have no realistic chance of
healing well and/or functioning normally. The decision whether or not to
attempt repair in a "borderline" case (i.e., adequate healing is unlikely but
not impossible) can involve some input from the patient, as well as
consideration of the patient's specific circumstances. The younger the
patient, the more consideration should be given toward meniscal repair, as
loss of meniscal function sets in motion an accelerated aging process within
the joint that leads to at least some degree of future osteoarthritis in the
affected region of the knee. In an older individual (over 35 or 40) who is not
overweight and who has no leg malalignment ("bowleg" or "knock-knee"
deformity) a "borderline" meniscal tear with a sub-par chance for healing
after meniscal repair is often best treated by primary meniscectomy.
Karl Note: Complete removal of the
meniscus is an extreme procedure Do not miss THIS page to read about various forms of partial removal of a damaged meniscus.
This linked page disagrees with the minimal harm done by removal as indicated
just below.
"complete meniscectomy is a one-way ticket to arthritis!"
(source)
If complete removal is indicated, then "knee
replacement" is the next, serious, procedure to be understood.
On the "knee replacement page" are many links to separate pages with very
detailed images of the text material -- don't miss those!
This is because the
patient's knee has probably already been subjected to the majority of stresses
that it will see during the course of its lifespan, and it has no specific
risk factors (other than the meniscus injury) for premature osteoarthritis.
This makes the loss of meniscal cushioning less objectionable. One must also
consider the greater risk of surgical complications associated with meniscal
repair procedures (vs. simpler and quicker removal procedures) and the extra
surgical risks that the patient would be subjected to if a second procedure
were to be required because the repair of a "borderline" tear ultimately
failed. Even under ideal circumstances, a surgically "repaired" meniscus is
not guaranteed to heal!
HERE is a list of the types of things looked for in an MRI
of the knee, with the possible findings. This list shows not only the type
of things looked for, but the range of possible reports. It is a good list
to review to understand the MRI report as a whole.
Non-surgical and non-drug approaches to this diagnosis are
slim, but include
As a nutritional consultant to the
enlightened dental profession. In periodontal disease and surgery the soft
connective tissue (meniscus) is exposed and involved. The natural healing
protocols are: (see source for remainder)
and,
Joint swelling scores improved in 47.2% in
patients using cetyl myristoleate alone and 77.2% in patients using cetyl
myristoleate plus Glucosamine. Patients experiencing worsening or no reaction
totaled 1.0% both of the cetyl myristoleate groups, compared with improvement of
21.1% in placebo group. (more at source)
There is a medical treatment, short of surgery, called Viscosupplementation
with information here. This is a procedure where an
artificial fluid is injected into the knee area -- a fluid similar to the normal
human fluid in the knee. This is temporary, only, but can be useful
particularly when a person is not a candidate for knee surgery.
One of the common symptoms of knee pain is also a terrible
feeling of tiredness. That symptom may be caused by a problem of subnormal body
temperature. This is more widespread than thought and causes many other
health problems. Click HERE to read more about that.
DEPARTMENT OF IMAGING SERVICES
DATE OF PROCEDURZ:24-Jan-2003
EXAM#:35B-012403
REQUESTING PHYSICIAN: BENOWITZ, IRVIN S
Patient: 67 Year Old Female
DIAGNOSIS. SEVERE BILATERAL KNEE PAIN
INDICATIONS: SEVERE KNEE PAIN
MRI TECHNIQUE. Using a GE 1.5 Tesla magnet, the following pulse sequences were
obtained: Axial fat suppressed FSE T2, sagittal PSE proton density/T2 and
caronal Ti/fat suppressed proton density sequences.
MRI LEFT KNEE:
The knee appears to be in normal alignment. There is mild joint effusion seen in the suprapatellar bursa.
The visualized distal quadriceps tendon, patellae tendon,
ACL and PCL are well delineated and appear to be intact.
There is moderate degenerative joint disease with marginal osteophyte and joint space narrowing and articular cartilage thinning noted,
seen more at the lateral compartment.
At
the lateral compartment there is degenerative maceration of the mid zone and
anterior horn of the lateral meniscus. There is truncation appearance of the
posterior horn of the lateral meniscus, finding consistent with degenerative
tear.
At the medial compartment there is Grade II signal change
seen in the posterior horn of the medial meniscus.
There is no definite evidence of meniscal tear identified.
The patella appears to be unremarkable and shows normal relationship with the
distal femur.
On the coronal view projection the lateral and medial
collateral ligaments appear to be intact.
The visualized bone marrow around the left knee appears to
be unremarkable.
There are small subchondral bone marrow changes seen at the
inferior aspect of the tibial eminence most likely representing degenerative
changes.
There is joint space narrowing seen at the lateral
compartment with marginal osteophyte formation. This finding is consistent with
moderate degenerative joint disease.
There is subchondral mild bone marrow edema seen at the
lateral femoral condyle and lateral tibial plateau.
The lateral and medial collateral ligaments appear to be
intact. The patella shows normal relationship to the distal femur.
IMPRESSION: LEFT KNEE: :
1. Moderate degenerative joint
disease with joint space narrowing and thinning of the articular cartilage, more
on the lateral compartment, with margin osteophyte formation.
2. There is mild joint effusion. No Baker's cyst.
3. Degenerative maceration and tear involving the lateral
meniscus.
4. Grade II signal change seen in the posterior horn of the
medial meniscus
1. Moderate degenerative joint disease involving the
lateral compartment of the right knee joint with joint space narrowing, marginal
osteophyte formation and thinning of the articular cartilage. There is no
adjacent lateral femoral condyle and the lateral tibial plateau.
2. There is degenerative tear seen in the posterior
horn of the lateral meniscus and macerated appearance involving the mid zone and
anterior horn of the lateral meniscus.
3 . Mild joint effusion No Baker's cyst.
4. Remainder of the exam of the right knee otherwise
appears unremarkable. Clinical correlation and follow-up recommended.
The meniscus is a cartilage disc that cushions the point where the upper and
lower leg bones meet in the knee joint. The meniscus may tear as the result
of, for example, an accident, heavy load over a long period of time or
deterioration due to old age. The tear in the meniscus leads to "debris"
floating in the joint, which in turn leads to deterioration of the cartilage
surfaces of the leg bones. In acute cases, the pain can be very intense and
the joint may even lose most of its mobility, or even "lock". In the
long-term, arthritis may develop.
Treatment
There are two ways to treat a torn meniscus. Some tears can be repaired with
stitches that are similar to staples and dissolve after a few weeks - a
procedure which is performed arthroscopically (microsurgery). If the tear
cannot be repaired in this way, the loose "flap" and the resulting debris
are removed arthroscopically. The use of the surgical laser - a relatively
new development - has greatly reduced the recovery time necessary after such
an operation. Although removing a portion of the meniscus reduces its size
slightly, it alleviates the irritation in the joint, which is what
really causes damage. In addition, we remove as little of the meniscus as
possible.
For more detailed information on treatment of a torn meniscus, click here.
Further information can also be found in Dr. Toft's new
book: "Knee Arthritis? How to avoid an artificial knee", the summary of
which can be viewed
here.
How long will I be off work?
If the meniscus is stitched, you can expect to be off work for two to
three weeks, during which time you will need to use crutches: Patients who
do heavy manual work can expect to be off work for six to eight weeks. If a
part of the meniscus is removed, you can expect to be off sick for
one to two weeks if you work in an office - two to three weeks if you do
manual work. Depending on the extent of the damage to the leg bones, it may
take anywhere from one to six weeks before you are "back to normal".
Can I play sports again?
If the tear is detected early on, i.e. there is no major damage to the
surfaces of the leg bones, then you may play any sports you wish without
limitations - however, you must first observe a recovery period of between
four and six weeks. If there is major damage to the bone surfaces,
you may only be able to play sports again on a limited basis.
More detailed information on treatment of a torn meniscus
Some of the following information and graphics were
supplied courtesy of The Journal of Bone and Joint Surgery and Sulzer Medica.
New Devices for Repairing Tears
As you will have seen from the main torn meniscus
page, at Alpha Klinik we go to great lengths to preserve as much
healthy meniscal tissue as possible. In addition to the stitches and staples
discussed on the main page, a number of new devices for joining the torn
parts back together have been developed. One of these new devices is the
so-called double arrow, which re-connects the torn section by means
of a short suture or stitch (see figure A) and a special meniscal screw, the
thread of which allows for "interfragmental compression" (see figure B).
Meniscal Transplants
In younger patients, especially when there has been no arthritis-related
wear and tear damage to date, meniscal transplants from a special tissue
bank may also be an option. In the United States, the main supplier of such
grafts is the Cryolife Company, in Europe a sub-agency of Eurotransplant in the Netherlands is the main supplier. The (human)
graft tissues are known as "Allografts". They can be transplanted with a
minimal-invasive arthroscopic technique, and the results achieved so far are
very encouraging. The transplanted meniscus is fixed in place via cylinders
of transplanted bone set into cylindrical "receptors" surgically drilled
into the bone/cartilage surface of the upper surface of the lower leg bone
and sutures hold the outer edge of the grafted meniscus in place (see figure
C). The risk of disease transmission is minimal. As long as the grafted
meniscus is not rejected by the patient's body during the first couple of
years, the knee has a much-improved chance of not developing arthritis.
A new treatment for the regeneration of lost meniscal tissue
According to a recent press release from Sulzer Medica, the Collagen
Meniscus Implant (CMI) is the first product of its kind for the regeneration
of sections of the menisci that have been lost as a result of degeneration
or surgical removal following an injury.
Definition of a Meniscus
"The menisci are crescent-shaped cartilaginous structures located in the
knee joint. They distribute and transmit the compressive loads between the
thigh and the shinbone, provide shock absorption, lubricate the joint and
help to stabilise the knee. Sometimes fast twisting or rotational movements
of the loaded knee - which frequently occur during sport or daily activities
- can lead to meniscus injuries. It is often not possible to repair the
injured meniscal tissue, and in this case the damaged tissue has to be
partially or completely removed. Such treatment may lead to arthritis later
in life."
What is the Collagen Meniscus Implant (CMI)? The CMI is a
sponge-like structure that consists of highly purified collagen (see figure
D). It is implanted arthroscopically in order to replace damaged or
surgically removed meniscal tissue. The porous structure of the CMI serves
as a "scaffold" that supports ingrowth of new cells, which in turn leads to
the formation of new meniscal tissue. Patients are able to place full load
on the knee within seven to eight weeks after the surgery. To date, the CMI
has been implanted in about 200 patients world-wide. Thanks to good results
in the European clinical trial, the CMI received official approval (the "CE
mark") in February 2000.
Design Criteria of the CMI
The material used for the collagen meniscus implant has to conform to six
criteria: 1) it is biocompatible and bioresorbable; 2) it has a physical
shape similar to that of a normal human meniscus, or can be shaped
intra-operatively to the defect geometry; 3) it has a porous structure to
facilitate cellular ingrowth; 4) it has an initial mechanical strength
suitable for surgical implantation; 5) it is permeable to macromolecules for
nutrient supply; 6) it has an initial stability in order to function as a
template.
In an initial human feasibility study that began in 1993, the collagen
scaffold was found to be implantable and safe over a three-year period.
Histologically, it supported the regeneration of tissue for meniscal defects
of various sizes. No adverse immunological reactions were noted during
sequential serological testing. On a second look arthroscopy (performed
either three or six months after implantation), gross and histological
evaluation revealed newly formed tissue replacing the implant as it was
resorbed. At thirty-six months the patients reported a decrease in symptoms
and had returned to physical activity at a pre-injury level. Magnetic
resonance imaging demonstrated progressive maturation of the signal within
the newly developed meniscal tissue at three, six, twelve and thirty-six
months. These findings suggested that the collagen scaffold supported
regeneration of meniscus-like tissue. A second feasibility study was then
conducted before multi-center trials were started in Europe and the US in
1997. To date, the CMI appears to be safe over at least 7 years (based on
the available results) and no adverse effects attributable to the collagen
scaffold material have been reported.
CMI images courtesy of Sulzer Medica.
For more information on Sulzer Medica/the CMI, please click here to visit their web site.
New hope for patients with arthritis of the knee thanks to biological
cartilage replacement.
by Dr. med. Juergen Toft
Price: 22 Euro
First Edition (Hardback)
Publication Date: October 2000
Dimensions: 16 × 24 cm
Publisher: Alpha Klinik, Germany
ISBN: 3-00-006520-2
For the "man-on-the-street", there is virtually no literature on minimal
invasive arthroscopic joint surgery. The treatment possibilities described
in this book are especially interesting for patients who are too young for
an artificial knee joint and wish to pursue an active lifestyle after
treatment. Popular opinion says that the chances of healing a case of
arthritis are very slim. This book opens new horizons for patients who do
not wish to accept this diagnosis. In addition, readers will learn about
healthy nutrition habits that can further speed the healing process in
arthritis patients. The arthritis condition and treatment possibilities are
described in lay man's terms, which helps patients decipher other medical
reports that they may read or hear about. In addition, a huge array of
images makes the "medical jargon" understandable even for patients who are
informing themselves about this area for the first time.
Since it was published in English, French, German, Italian and Russian
in 2001, Dr. Toft's book has sold over 20,000 copies worldwide and has
been featured on well-known German and international television
programs, as well as in many mainstream and medical magazines (e.g. N24
and "World of Wonders" on German TV, plus a number of TV programs in the
U.S. and BBC News online).
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His personal philosophical articles are at PHILOSOPHY.
You want to have your own informed opinion on what the
diagnosis means. So, you come to this page and find that many of the words
on YOUR MRI diagnosis are the same ones as shown here. No patient should
enter the meeting with the knee specialist without having read pages like the
ones on this web.
If
the symptoms continue, surgery will be required to either remove the torn
portion of the meniscus or to repair the tear. Most meniscus surgery today is
done using the 
DEPARTMENT OF IMAGING SERVICES 
At
the lateral compartment there is degenerative maceration of the mid zone and
anterior horn of the lateral 
Treatment
Meniscal Transplants
The CMI is a
sponge-like structure that consists of highly purified collagen (see figure
D). It is implanted arthroscopically in order to replace damaged or
surgically removed meniscal tissue. The porous structure of the CMI serves
as a "scaffold" that supports ingrowth of new cells, which in turn leads to
the formation of new meniscal tissue. Patients are able to place full load
on the knee within seven to eight weeks after the surgery. To date, the CMI
has been implanted in about 200 patients world-wide. Thanks to good results
in the European clinical trial, the CMI received official approval (the "CE
mark") in February 2000.
Knee
Arthritis?