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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 see also
Articular
Cartilage Growth
(see research
paper)
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
orthopedic plans to refer
the athlete for Prolotherapy, nothing is being done.
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