CARTILAGE TROUBLE?



cartilage trouble?

What is a cartilage?

The cartilage is a gristly, ring shaped structure that helps cushion and keep the two bones of the knee joint apart. There are two cartilages fixed on the top of the tibia which act as shock absorbers and stabilizers of the knee joint. They are thicker at their edge and thinner towards the middle, increasing the cup shape surface of the upper tibia.

How is the cartilage injured?

Although the cartilage is very strong a strip can be torn off it’s edge or it can develop a split. This can happen when the knee is twisted or bent right up, as in a full squat. Tears of the cartilage on the inner side of the knee are about five times more common than injuries to the outer cartilage. Some people will find that they have a torn cartilage even though they can’t remember any particular accident so it can seem to have come ‘out of the blue’.

What are the signs that the cartilage is torn?

There is pain over the edge of the cartilage along one side of the joint. The knee swells and can click or clonk. This is never a very loud noise and is usually felt rather than heard. It may be difficult to fully straighten the knee. The knee may give-way or collapse on twisting or bending.

What tests can be done to see if the cartilage is torn?

The diagnosis is usually made from the story and an examination of the knee. A plain x-ray is sometimes done if the person is older, where there might be a suspicion of the knee being arthritic. An x-ray also helps to exclude other problems such as a loose piece of bone floating in the joint, though the symptoms from this are usually more dramatic. The cartilage itself does not show on a plain x-ray. Sometimes a Magnetic Resonance Scan may be done (MRI). This uses magnetism, not x-rays. This can give good pictures of the cartilages and ligaments in the knee. It is an expensive test and is only used selectively. It is not helpful in assessing arthritis or ‘wear & tear’ and after middle age starts to show confusing, age-related changes.

Will physiotherapy help?

The knee muscles may get weak when the cartilage is torn and physiotherapy can help. If your muscles have remained in good condition and the knee has a full range of movement, then physiotherapy is unlikely to help.

Will my knee get better without an operation?

Many people with cartilage trouble find that their knee eventually settles down. In later life most people will have developed small tears in the cartilage, often without any symptoms. Cartilage trouble characteristically comes and goes. Even major problem can settle down. This is because small tears of the cartilage can heal up without treatment, and the symptoms can gradually disappear.

However, even if the knee has returned to normal, symptoms can reappear from time to time. It is advisable therefore to leave the knee for as long as possible before making any decisions to have an operation done.

Soon after an injury it can be difficult to tell just how badly torn the cartilage might be. After an acute injury it is often difficult to get the knee down straight, even after a simple sprain. It is therefore better to wait for as long as possible to see if the knee will get better without treatment. If the knee will still not come down straight, and if it will not fully bend, despite otherwise seeming to improve, then it is likely that a cartilage operation will be necessary.

Is it worth having an operation on the cartilage?

Cartilage operations are done using a small telescope (arthroscope). This is a type of so-called ‘microsurgery’. The arthroscope is put into the knee under a general anaesthetic and the inside of the joint examined. Simple tears of the cartilage are easily dealt with using the telescope so that the torn part of the cartilage can be removed as a daycase procedure. The procedure is done as a daycase and the recovery takes 2 - 4 weeks.

Only a small part of the cartilage is removed. The more that is left, the better the knee will be for the future with less risk of arthritis. Nevertheless, there is enough of the cartilage left that it can actually re-tear after another injury.

Small tears of the cartilage are the most difficult to deal with the arthroscope as they are usually right at the back of the knee where access with the telescope is difficult. As the tear in the cartilage gets worse the tear extends forward in the joint making it more accessible to the telescope. This means that small tears are difficult to deal with and the worse tears are easy. This reinforces the principle that it is best to leave the knee well alone if the symptoms are minor. If eventually the knee does get worse, an operation at that stage may well be easier.

The rate of the recovery after the operation depends on the type of the tear. Simple tears, particularly when the knee has been locked (i.e. cannot be fully straightened or fully bent) make for an easy operation and therefore a quick recovery. On other occasions the surgery can be more difficult and the knee will be slow to settle. For the first 1-2 weeks after the operation the knee feels quite uncomfortable and has a lot of fluid, but it may be possible to get back to a light or sedentary job within two weeks of the operation. It takes 2-4 weeks at least to get back to more vigorous activities, including sport. Physiotherapy is sometimes required after the operation, but not always. The 2-3 scars are quite heal quickly on the surface but as the tissues are deep they remain uncomfortable and lumpy for a month or two.

Can the cartilage be repaired?

Sometimes the cartilage will need to be repaired rather than removed. If the tear is right around the edge of the cartilage, which could mean total removal, then a repair might be preferable. This will only work if the rest of the cartilage is undamaged and there is a good blood supply to its edge. This is most likely in the younger patient who presents soon after injury with a knee which is very swollen due to blood in the joint, and when the knee cannot be fully straightened (“locked”). The repair is done at arthroscopy using small staples (“meniscal arrows”) which stick the cartilage back in place. The knee has to be braced and kept out of action for about 6 weeks while the cartilage heals. 10% may re-tear in the future. Repair is a much bigger job and so will only be recommended under special circumstances.

What are the long-term effects of having the cartilage removed?

If only a small part of the cartilage is removed then the knee can return to normal. For bigger tears, or where more complex surgery is concerned, then removal of a large part of the cartilage does leave the knee more vulnerable and some people may develop wear and tear many years later. It rather depends if there are any other problems in the knee such as a ruptured ligament, and whether the person returns to vigorous sport. Most people make a trouble free recovery.

Will arthroscopy help if my knee is arthritic?

Arthritis in the knee complicated by a torn cartilage may mean new symptoms such as clicking and catching, over and above the usual arthritis pain. A piece of bone moving around the knee will cause pain and locking. Trimming damaged parts of a worn-out cartilage in an arthritic knee and removing any floating bits of bone (‘loose bodies’) may help. The results of this treatment however are rather unpredictable and it is rarely curative. If you are unlucky, it may sometimes temporarily make the arthritis pain in the knee worse. If there is relief of pain from the arthroscopy, it may only be temporary. If the x-rays show that parts of the joint have worn down to bone, arthroscopy will be a waste of time.

Are there any possible complications after an arthroscopy?

Sometimes the knee will swell up very tightly 24-48 hours after the operation due to bleeding inside the joint. This might mean coming back into hospital to have the fluid drained. This happens after approximately 1% of operations. The knee can remain painful and swollen for several weeks after an arthroscopy, particularly if the surgery has been difficult or if the person is older with some wear and tear changes in the joint.

The most serious complication that can occur is infection of the knee. This is extremely rare (probably less than 1 in 1000 operations), but if it does happen, it can cause severe damage in the knee which often undergoes stiffening and may require major surgery to try and put it right. This is an extremely rare complication which usually only occurs if the surgery has been very difficult or in the older person where there is a lot of wear and tear in the joint. The risk of infection is increased if steroid or cortisone has been injected into the knee in the previous 6 months. Very rarely, the end result can be a knee which is permanently stiffened (arthrodesis).

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download