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MSK 1 > 10/28 - Meniscal Injury Surgery Rehab > Flashcards

10/28 - Meniscal Injury Surgery Rehab Flashcards

1
Q

why were there poor outcomes w complete meniscectomies

A

osteophyte formation
joint space narrowing
OA changes

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2
Q

what is the shape of the meniscus and how is this integral to its function

A

wedge shaped

deepens joint
helps the articulation of the femur and tibia

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3
Q

what characteristic gives the meniscus its strength and ability to resist load and tension in various directions

A

orientation of all fibers
- oriented differently depending on the layer

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4
Q

what is the compensation of the extracellular matrix

A

mostly water (72%)
collagen (22%)
- type 1 - 90% dry weight

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5
Q

describe the blood supply to the menisci

A

periphery from capsular lining
lat and med geniculate a.
peripheral vascularity

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6
Q

how does vascularity change throughout the meniscus and why is this significant

A

peripheral most vascularized
- best at A-P horns
limited on medial side

affects healing potential if there is less blood supply

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7
Q

why do the A-P horns have the best vascularity

A

where the menisci attach to the bone
- why you get better blood supply

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8
Q

describe innervation of the menisci

A

free nerve endings greatest density in outer 1/3 & A/P horns

mechano receptors

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9
Q

how does the innervation contribute to the menisci functions

A

meniscus plays a role in proprioception, mechanoreception, joint position sense, and balance

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10
Q

what are the 3 mechanoreceptors found in the menisci and how do they specifically contribute to meniscus function

A

type 1 - Ruffini
type 2 - pacinian
type 3 - golgi

type 2 = joint motion
type 1 and 3 = joint position

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11
Q

what type of mechanoreceptor(s) detects joint position

A

type 1 and 3

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12
Q

what type of mechanoreceptor(s) detect joint motion

A

type 2

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13
Q

what are type 1 mechanoreceptors and what does it detect specifically

A

ruffini
pressure

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14
Q

what are type 2 mechanoreceptors and what does it detect specifically

A

pacinian
tension

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15
Q

what are type 3 mechanoreceptors and what does it detect specifically

A

golgi
terminal ROM

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16
Q

what is often a precaution after a medial meniscus repair and why

A

limit hamstring activity
- semimem attaches to med meniscus

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17
Q

med vs lat meniscus: shape, area, attachments, mobility

A

SHAPE:
- med = “c” or crescent shape
- lat = “o” or circular shape

AREA:
- med = cover 60% of articular cartilage
- lat = cover 80% of articular cartilage

ATTACHMENTS:
- med = semimem, deep MCL
- lat = popliteus

MOBILITY:
- med = firmly fixed
- lat = very mobile

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18
Q

meniscal excursion: med vs lat

A

med: 5mm
lat: 11mm

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19
Q

what creates meniscal excursion in NWB vs WB

A

NWB - ms move menisci
WB - condyles move menisci

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20
Q

what are the menisci functions (7)

A

joint stability
shock absorption
joint lub and nutrition
proprioception
load bearing
maintain joint height
maintain hoop stresses

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21
Q

how does the menisci function to create joint stability

A

makes femorotibial articulation more congruent
- facilitates articulation

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22
Q

how is shock absorption impacted after a meniscectomy

A

dec by 20%

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23
Q

describe the load bearing function of the meniscus

A

load during activity
- 70% lat compartment load
- 50& med compartment load

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24
Q

how is load bearing affected by a meniscectomy

A

contact area reduced by at least 1/2
contact pressure inc 2-3x

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25
Q

how does the menisci function to maintain hoop stresses

A

convert compressive force to tensile force
- multidirectional fibers allow response to force in all directions

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26
Q

what are 4 risk factors for a meniscal tear

A

older age (>60yo)
male
work related kneeling/squatting
climbing >30 flights stairs/day

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27
Q

what population is it common to see acute meniscal tears in

A

cutting sports
- soccer
- rugby

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28
Q

what is the nature of the majority of meniscal tears

A

degenerative (aka older age)

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29
Q

what is a risk factor for future medial meniscal tears and why

A

delayed ACLR

ACL damage allows more mobility in knee and creates more shear and torsion at meniscus

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30
Q

incidence of meniscal path in med vs lat menisci

A

40 in med
60 in lat

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31
Q

significance of ant vs post horn meniscal path

A

ant - more sx closer to full ext
post - more contact as deeper into flex

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32
Q

significance of meniscal path in the body of the meniscus

A

limitations in blood supply
- poor potential for healing

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33
Q

incidence of central vs peripheral meniscal path

A

central - dec
peripheral - inc

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34
Q

what does a delay in ACLR inc the risk of

A

cartilage and med meniscus lesions

35
Q

what is a frequent concomitant injury w meniscal path

A

ACL

36
Q

what is the prevalence of meniscal path

A

2nd most common knee injury

37
Q

why does the risk of meniscal path inc substantially w age

A

degenerative changes
long term sustained load that led to degenerative changes

38
Q

what are 3 zones used to describe the vascular region that meniscal path could be in

A
  1. red on red
  2. red on white
    - less blood supply
  3. white on white
    - almost no blood supply
    - purely central portion
39
Q

what types of tears are the most common

A

horizontal and longitudinal

40
Q

what is a complex tear

A

multiple directions

41
Q

what is a free-edge fraying tear

A

more degenerative changes

42
Q

what is a bucket handle tear and what are indicators of this

A

sizable tear that flops over
- can act as a chockblock and be obstructive

sx: clicking, locking, catching
- sometimes knee can get stuck in position

43
Q

what does an obstructive bucket handle tear an indication for

A

surgery
- can develop flexion contractures

44
Q

what are the types of meniscal tear (5)

A

horizontal
longitudinal
complex
free-edge fraying
bucket handle

45
Q

what are 4 criteria of tears to be handled non-operatively

A
  1. stable tear w <3mm displacement
  2. small tear <1cm, longitudinal
  3. partial thickness tear
  4. degenerative tear
46
Q

imaging and meniscal tears

A

MRI might not tell you details of tear
- or might not even get one

usually send to PT anyway, even if don’t do well (and they usually do) then better surgical outcomes

47
Q

ant partial meniscectomy (APM) vs PT outcomes w non-obstructive meniscal tears

A

no difference

48
Q

what are the 4 main types of surgical treatments

A

total meniscectomy
partial meniscectomy
open meniscal repair
arthroscopic meniscal repair

49
Q

what is a consideration when deciding if a meniscal repair is appropriate and what may be a better option

A

what is the ability to heal
- what is the blood supply
- if no blood supply, repair will fail

best option in that case would be partial meniscectomy

50
Q

what is the main reason that total meniscectomies are done today

A

presence of severe trauma

51
Q

what does a total meniscectomy result in that makes this an avoided surgical option

A

degenerative changes in knee
osteophyte formation

52
Q

what are the concerns with doing a partial meniscectomy

A

inc articular load (65%)
dec ability to distribute forces
- dec contact area by 10%

53
Q

outcomes from a partial meniscectomy?

A

outcomes decline over time
- progressive radiologic degenerative changes (rate of which depends on patient)

54
Q

rehab plan for partial meniscectomy (5)

A

control pain and swelling
strength - maximize quads
immediate ROM
unrestricted amb
FWB

55
Q

what is the main limitation to rehab after a partial meniscectomy

A

discomfort
swelling in quads

56
Q

return to activity timeline after partial meniscectomy

A

work - 1-2wks
full activity - 2-4wks
sports - 4-6wks

57
Q

what 3 factors contribute to a repair healing better than others

A

lateral > medial
earlier/more acute > later
younger patients

58
Q

what concomitant procedure improves healing from a meniscal repair

A

ACL reconstruction

59
Q

what is the nature an ACL reconstruction which improves healing of meniscal repairs

A

drilling tunnels into bone
creating bleeding and healing environment for both aCL and meniscus repair

60
Q

what are 3 surgical methods for a meniscal repair

A

outside in
inside out
all inside

61
Q

what is an outside in technique and what is a pro and a con to this

A

needle pierces capsule from outside incision then pierces meniscus

pro: less neurovascular injury
con: less precise meniscal suture placement

62
Q

what is an inside out technique and what is a pro and a con to this

A

needle pierces thru meniscus first, then out capsule

pro: better meniscal suture placement
con: inc risk of neurovascular injury (tho transient in nature)

63
Q

what is an all inside technique and what is a pro and a con to this

A

done completely in the joint (similar to RC repair)

pro: faster, no extra incision
con: weaker fixation than suture

64
Q

outcomes and surgical repair

A

no significant difference

all work so doesn’t matter much

65
Q

what does Dr. Nolan attribute failure rates of meniscal repairs to (2)

A
  1. d/t new injury during return to sport
  2. in attempt to preserve as much meniscus as possible, repairing some areas that don’t have good blood supply -> leads to poor healing
66
Q

why is the healing from meniscal repairs inc w concomitant injury (2)

A

synovial response
enhanced vascular response
- bleeding from bone

67
Q

healing timeline after a meniscal repair

A

50% in 3-4wks
80% in 8-12wks
100% in 14-18wks

68
Q

what ab the pathology of the injury impacts the treatment guidelines (7)

A

location of tear
size of tear
type of tear
concomitant injury
pt age (healing)
pt activity level (goals)
integrity of joint

69
Q

what are 6 rehab considerations when prescribing interventions

A

WB progression
knee flex AROM
deep squats
rotation activities
pivoting activities
impact loading

70
Q

meniscal repair rehab goals per phase

A

weeks 0-4
- protected WBing vs NWB
- avoid re-tear (no squats, hammies)
- ROM 0-90deg
- no resistive work

weeks 4-16
- full ROM by wk 6
- improve strength/endurance
- normalize gait

weeks 17-24
- improve total limb function
- return to sport

71
Q

ROM with rehab after a repair

A

immediate 0-90deg
- concern w exercise: avoid rotation at end ranges, utilize midrange (25-85deg)

full ROM by 4-6wks

72
Q

active mobility with rehab after a repair

A

no resisted hamstrings for 8wks

active knee flex
- wk 5-6 in peripheral tears
- min 6wks in complex tears

73
Q

WB in peripheral vs complex tears

A

peripheral - less restricted d/t good vascularity

complex - larger and more restricted WB progression

74
Q

why is there limited hamstring activity early post op meniscal repair & when can we transition past this

A

semimem attachment to med meniscus

popliteus to lat meniscus

AROM 4-6wks
resisted knee flex 6-8wks

75
Q

what ms are targetted in strengthening after a meniscus repair

A

quad strength is critical
glut med/hip ER key

76
Q

what are the 3 main goals of early post-op phase of repairs

A
  1. protect repair!
  2. restore ext ROM / patellar mobility
  3. minimize ms atrophy / restore quad control
77
Q

what are 6 main goals of intermediate post-op phase of repairs

A
  1. normalize gait
  2. progress to full pain-free ROM
  3. gradually introduce load
  4. develop ms control /endurance
    - focus on form!
    - high rep, low load
  5. initiate hamstring strengthening
  6. enhance balance/proprioception
78
Q

what are 4 main goals of late post-op phase of repairs

A
  1. ms hypertrophy
    - high load, low reps
  2. progress balance/proprioception
  3. introduce plyometrics
  4. interval jogging progression

3 and 4 are more milestone based

79
Q

partial meniscectomy vs repair

A

no difference in functional tasks

less OA changes and inc return to prior sports level of activity

80
Q

what would be a good candidate for a meniscal transplant

A

young healthy
lower level activity demand

81
Q

what is an alternative to a meniscal transplant

A

joint replacement

82
Q

outcomes from meniscal transplant

A

good outcomes w pain
long term prevention of cartilage damage is unknown

83
Q

what are 3 complications of meniscal transplants

A

failure
infection
inc extrusion of graft

84
Q

what does rehab look like after a meniscal transplant (6)

A

immediate motion 0-90
immediate quad work
control swelling
gradual inc motion
WBAT at 6-8wks
running @6mo

MSK 1 (31 decks)

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