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

10/28 - Meniscal Injury Surgery Rehab Flashcards

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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
how does the menisci function to maintain hoop stresses
convert compressive force to tensile force - multidirectional fibers allow response to force in all directions
26
what are 4 risk factors for a meniscal tear
older age (>60yo) male work related kneeling/squatting climbing >30 flights stairs/day
27
what population is it common to see acute meniscal tears in
cutting sports - soccer - rugby
28
what is the nature of the majority of meniscal tears
degenerative (aka older age)
29
what is a risk factor for future medial meniscal tears and why
delayed ACLR ACL damage allows more mobility in knee and creates more shear and torsion at meniscus
30
incidence of meniscal path in med vs lat menisci
40 in med 60 in lat
31
significance of ant vs post horn meniscal path
ant - more sx closer to full ext post - more contact as deeper into flex
32
significance of meniscal path in the body of the meniscus
limitations in blood supply - poor potential for healing
33
incidence of central vs peripheral meniscal path
central - dec peripheral - inc
34
what does a delay in ACLR inc the risk of
cartilage and med meniscus lesions
35
what is a frequent concomitant injury w meniscal path
ACL
36
what is the prevalence of meniscal path
2nd most common knee injury
37
why does the risk of meniscal path inc substantially w age
degenerative changes long term sustained load that led to degenerative changes
38
what are 3 zones used to describe the vascular region that meniscal path could be in
1. red on red 2. red on white - less blood supply 3. white on white - almost no blood supply - purely central portion
39
what types of tears are the most common
horizontal and longitudinal
40
what is a complex tear
multiple directions
41
what is a free-edge fraying tear
more degenerative changes
42
what is a bucket handle tear and what are indicators of this
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
what does an obstructive bucket handle tear an indication for
surgery - can develop flexion contractures
44
what are the types of meniscal tear (5)
horizontal longitudinal complex free-edge fraying bucket handle
45
what are 4 criteria of tears to be handled non-operatively
1. stable tear w <3mm displacement 2. small tear <1cm, longitudinal 3. partial thickness tear 4. degenerative tear
46
imaging and meniscal tears
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
ant partial meniscectomy (APM) vs PT outcomes w non-obstructive meniscal tears
no difference
48
what are the 4 main types of surgical treatments
total meniscectomy partial meniscectomy open meniscal repair arthroscopic meniscal repair
49
what is a consideration when deciding if a meniscal repair is appropriate and what may be a better option
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
what is the main reason that total meniscectomies are done today
presence of severe trauma
51
what does a total meniscectomy result in that makes this an avoided surgical option
degenerative changes in knee osteophyte formation
52
what are the concerns with doing a partial meniscectomy
inc articular load (65%) dec ability to distribute forces - dec contact area by 10%
53
outcomes from a partial meniscectomy?
outcomes decline over time - progressive radiologic degenerative changes (rate of which depends on patient)
54
rehab plan for partial meniscectomy (5)
control pain and swelling strength - maximize quads immediate ROM unrestricted amb FWB
55
what is the main limitation to rehab after a partial meniscectomy
discomfort swelling in quads
56
return to activity timeline after partial meniscectomy
work - 1-2wks full activity - 2-4wks sports - 4-6wks
57
what 3 factors contribute to a repair healing better than others
lateral > medial earlier/more acute > later younger patients
58
what concomitant procedure improves healing from a meniscal repair
ACL reconstruction
59
what is the nature an ACL reconstruction which improves healing of meniscal repairs
drilling tunnels into bone creating bleeding and healing environment for both aCL and meniscus repair
60
what are 3 surgical methods for a meniscal repair
outside in inside out all inside
61
what is an outside in technique and what is a pro and a con to this
needle pierces capsule from outside incision then pierces meniscus pro: less neurovascular injury con: less precise meniscal suture placement
62
what is an inside out technique and what is a pro and a con to this
needle pierces thru meniscus first, then out capsule pro: better meniscal suture placement con: inc risk of neurovascular injury (tho transient in nature)
63
what is an all inside technique and what is a pro and a con to this
done completely in the joint (similar to RC repair) pro: faster, no extra incision con: weaker fixation than suture
64
outcomes and surgical repair
no significant difference all work so doesn't matter much
65
what does Dr. Nolan attribute failure rates of meniscal repairs to (2)
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
why is the healing from meniscal repairs inc w concomitant injury (2)
synovial response enhanced vascular response - bleeding from bone
67
healing timeline after a meniscal repair
50% in 3-4wks 80% in 8-12wks 100% in 14-18wks
68
what ab the pathology of the injury impacts the treatment guidelines (7)
location of tear size of tear type of tear concomitant injury pt age (healing) pt activity level (goals) integrity of joint
69
what are 6 rehab considerations when prescribing interventions
WB progression knee flex AROM deep squats rotation activities pivoting activities impact loading
70
meniscal repair rehab goals per phase
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
ROM with rehab after a repair
immediate 0-90deg - concern w exercise: avoid rotation at end ranges, utilize midrange (25-85deg) full ROM by 4-6wks
72
active mobility with rehab after a repair
no resisted hamstrings for 8wks active knee flex - wk 5-6 in peripheral tears - min 6wks in complex tears
73
WB in peripheral vs complex tears
peripheral - less restricted d/t good vascularity complex - larger and more restricted WB progression
74
why is there limited hamstring activity early post op meniscal repair & when can we transition past this
semimem attachment to med meniscus popliteus to lat meniscus AROM 4-6wks resisted knee flex 6-8wks
75
what ms are targetted in strengthening after a meniscus repair
quad strength is critical glut med/hip ER key
76
what are the 3 main goals of early post-op phase of repairs
1. protect repair! 2. restore ext ROM / patellar mobility 3. minimize ms atrophy / restore quad control
77
what are 6 main goals of intermediate post-op phase of repairs
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
what are 4 main goals of late post-op phase of repairs
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
partial meniscectomy vs repair
no difference in functional tasks less OA changes and inc return to prior sports level of activity
80
what would be a good candidate for a meniscal transplant
young healthy lower level activity demand
81
what is an alternative to a meniscal transplant
joint replacement
82
outcomes from meniscal transplant
good outcomes w pain long term prevention of cartilage damage is unknown
83
what are 3 complications of meniscal transplants
failure infection inc extrusion of graft
84
what does rehab look like after a meniscal transplant (6)
immediate motion 0-90 immediate quad work control swelling gradual inc motion WBAT at 6-8wks running @6mo

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