If conservative therapies do not provide concrete results or are not conclusive, the doctor may decide to proceed to repair the torn meniscus/menisci via arthroscopy. Under anaesthesia, the knee is examined to check ligament stability and the surgeon evaluates whether to repair with specific sutures or selectively remove the lesion. During the surgery, a saline solution is injected to extend the knee and an arthroscope is introduced. The images are projected on a screen, guiding the surgeon during the surgery. Once the problem has been identified and surgically corrected, the saline solution is drained, and the surgical incisions are irrigated with a local anaesthetic. The incisions are closed with sutures, Steri-strips adhesive (wound closure strips), premedicated plasters and bandages. If the patient is young, it is preferable for them to go have the meniscus sewn arthroscopically. The injured portion of the meniscus is repaired rather than removed, to preserve the entire surface. This type of operation protects the cartilage from wear and arthrosis better than selective meniscectomy (removing the injured portion of the meniscus). This surgical procedure’s advantages are the reduction of postoperative pain, a lower risk of infections and complications and a more rapid recovery time. The operation takes place under local anaesthesia (localized to the knee), regional anaesthesia(from the waist down), or general anaesthesia (the patient is completely asleep).
What to do after surgery – postoperative care
The patient is usually hospitalized for one night. For isolated meniscal tears — where no other anatomical structures are involved — recovery times are between 20 and 30 days. The recovery times are longer for meniscal suture and it is necessary to block the knee with a brace and the use of crutches is necessary for up to 14 days after surgery. The patient is re-evaluated about 30 days after surgery to verify the rehabilitation therapy’s effectiveness in terms of recovery of the knee joint and the tropism (growth) of the quadriceps muscle (thigh muscles). Before returning to everyday activities, it is necessary to gradually recover muscle tone because the knee is weak, and there is a risk of causing a new injury. Recovery times vary according to the patient’s characteristics (age, state of health, type of work performed). Meanwhile, proprioceptive exercises (leaps, balance on one foot) are recommended, which are useful to resume pre-injury knee functionality and skills.
The anterior cruciate ligament (ACL) can be repaired or reconstructed through arthroscopic surgery. It is a rare procedure performed only in a few selected cases. Two small incisions are made on the front of the knee and a third incision for removing the tendons. A saline solution is injected to clean and expand the part to allow easy inspection. It is performed under either spinal or general anaesthesia.
In arthroscopic reconstruction, the tendons of the Gracilis and Semitendinosus muscles are used, and a small incision is made in the anterior medial part of the tibia (shinbone), a few centimetres from the joint line. If, on the other hand, the patellar tendon or quadriceps tendon is used, the incision is made centrally, between the patella and the tibial tuberosity. Tunnels are drilled at the femur (thighbone) and tibia in the optimal position, then the neo-ligament is inserted and fixed with a button on the femur whereas on the tibia, a screw and a metal staple are used. During the surgery, other problems affecting the menisci or cartilage, if any, are also treated arthroscopically. At the end of the procedure, the saline solution is drained and the surgical incisions are irrigated with a local anaesthetic. The incisions are then closed with a suture, Steri-strips adhesives, premedicated water resistant plasters, and a bandage. The surgeon will evaluate the use of a brace.
Minimally invasive
Once the surgery is finished, the patient is taken back to the ward and the postoperative physiotherapy treatment begins. Pain is controlled through personalized drug therapy. Discharge can take place within the day but patients generally stay overnight in the hospital. The day following the surgery, some physiotherapy exercises are performed in accordance with the orthopedist’s instructions. In the first two weeks, crutches are needed but will gradually be abandoned. Driving can resume after a few weeks. A suggestion: since the neo-ligament must be protected for up to 4-6 months after surgery, therefore, open kinetic chain exercises (i.e., the foot does not rest on a rigid surface or the ground) should be avoided. Playing sports should be possible 9 months after surgery following an adequate rehabilitation program. There is scientific evidence that a full return to normal activities just 6 months after surgery increases the risk of new ligament rupture.
Surgical procedure for patella (kneecap) instability occurs through arthroscopic surgery and open surgery with spinal or general anaesthesia. Surgery is planned according to clinical data, radiography, MRI, and CT Lionese evaluations. The first step is the arthroscopic evaluation of the knee, with the eventual treatment of cartilage, meniscal, or internal ligament lesions. The next step is surgical correction with open surgery technique.
The treatment consists of reconstructing the medial patellar femoral ligament, which is the patellar’s primary retention system. A tendon is taken from the patient with a small incision and the ligament is reconstructed with a minimally invasive technique, centring the patellar.
It consists of performing an osteotomy, or a cut in the tibia (shinbone) that allows the insertion of the patellar tendon on the tibia. This procedure is aimed at improving the alignment of the patellar on the femur (thigh bone). This results in a centred patella, decreasing the pressure between the worn cartilage areas and decreasing patellar luxation risk.
The surgery involves the reconstruction of the trochlear groove (part of the femur in which the patellar sits and moves). It is performed in only very selected cases when there is a high risk of patellar instability, pain, and wear of the cartilage. The surgery consists of remodeling the bony part under the femoral trochlea’s articular cartilage with special instruments, which is corrected and then repositioned with absorbable sutures.
These procedures are performed to restore stability to the patellar, give the correct gliding (patellar-tracking), treat pain and prevent further dislocations.
Moderately invasive
If necessary, a brace is used to keep the knee stable after the surgery. Physiotherapy begins immediately with a weighted load and a range of motion that varies depending on the treatment performed. Playing sports is possible approximately 6-12 months after surgery.
The cartilage reconstruction surgery takes place under either spinal or general anaesthesia. After the preparation of the area for operation, the knee is examined under anaesthesia to check for ligament stability. The tourniquet (a cuff-like device to prevent severe bleeding) is then placed at the bottom end of the thigh and two small incisions are made on the sides of the patellar tendon. Once the arthroscopy instruments are introduced, the joint is watered with a saline solution, and the image is projected on the screen. A diagnostic arthroscopy is then performed and once identified, the lesion can be treated.
In the case of superficial and small lesions, the fragments are removed. On the other hand, if the lesions are broader and more profound, different treatments will be performed to reach the bone plane. These plans are established based on the X-ray and MRI findings before the operation is performed. Autologous cartilage transplants can be performed at the same time as arthroscopy (Mosaicoplasty). It is possible to culture cartilage tissues in a laboratory to create a cartilage membrane which is then inserted during the second operation (ACI and MACI techniques). On the market, there are also synthetic structures (the Scaffolds) that help the tissues regenerate and recreate a structure similar to cartilage tissues. At the end of the procedure, the saline solution is drained, and the surgical incisions are watered with a local anaesthetic. The incisions are then closed with adhesive steri-strips, premedicated plasters and a bandage.
Moderately invasive
What to do after surgery – postoperative care
After surgery, the joint surface must be protected while the cartilage heals. To protect the knee, a knee brace is used and the patient must utilize crutches and not apply any load to the knee for a period of time. This period will vary and is necessary to restore the mobility of the joint. During the first few weeks after surgery, the patient may start to move the operated joint. As the healing progresses, physical therapy will be focused on strengthening the muscles. Periodic checks will help to determine recovery time and physiotherapy duration. After approximately 12 months, depending on the recovery of joint functions, the patient will be able to resume sports or running.
This surgery consists of managing multi-ligament injuries and injuries to the cartilage and menisci if they are damaged. It is performed under spinal or general anaesthesia. The injured cruciate ligaments (ACL and PCL) are reconstructed using tendons taken from the patient, such as the tendons of the Gracilis and Semitendinosus muscles and the patellar. The choice depends on the patient’s age, functional demands, and eventual injuries to other knee ligaments.
The operative treatment of collateral ligament injuries is related to the extent of the damage and the injury’s location. The medial collateral ligament (MCL) injury can be treated conservatively (without intervention) in some specific cases, the surgeon proceeds according to the characteristics of the injury to perform repair or reconstruction. The lateral collateral ligament (LCL) is usually treated surgically by reconstructing the tendons of the Gracilis or Semitendinosus muscle. In multiple ligament injury scenarios, ligaments from a deceased donor (allografts) may be needed. These tissues are donated and made available to the bone bank. Transmission of viral infections or infections using these materials is not currently described in the literature.
Invasive
The patient is discharged to the ward after surgery. In the following months, crutches and a brace must be used. A few days after the operation, the pain will start to decrease and the rehabilitation process that consists of recovering the range of motion and muscle tone commences. After about 6 weeks, the patient can run on a gym bike; after 5-6 months, they can run normally. Sports activities can be resumed 8-9 months after surgery. Checkups are periodically performed to assess the progress of function recovery.
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