Torn cartilages a.k.a. Meniscal tears.

This is probably one of the best-known and is indeed one of the commonest sports related injury within the knee.

Your “cartilages” are specialised pieces of tissue that helps separate the two bones which are connected to form the knee joint. They do much more however than simply act as passive spacers. They spread weight across a joint to reduce stress and damage to the other structures of the knee joint. In order to perform this complicated function, they are shaped in a special way that allows to move and adapt depending on the position of the joint, to spread weight as efficiently as possible. The cartilages or “menisci” are made of a substance called Hyaline cartilage which is both flexible and resilient. The high specialisation of this tissue however can put it at risk of damage and unfortunately renders it much less capable of healing itself like say, a cut on the back of the hand.

The classic mechanism of injury is of a severe twist of a knee on a leg which is weight-bearing, often with the foot unable to turn. This is not infrequently seen in footballers but can occur in all sorts of activities sporting or otherwise. More commonly however as clinicians we see many torn cartridges from day-to-day activities. They may occur in people who have had plenty of use out of their knees and there could be an element of accumulated injury. It is not uncommon therefore for a patient to express surprise after being told they have a torn cartilage when their own perception of the injury which provoked it was fairly minor.

The primary symptom of a torn cartilage is pain usually on the inside or outside of the joint. It is usually quite well localised and the patient can often described accurately the circumstances when they do get symptoms. Symptoms can be intermittent apparently settling down for a few days only to recur again. As well as pain, patients may complain of mechanical symptoms such as locking and occasionally giving away. This is thought to be due to the torn piece of cartilage getting stuck in the joint. The stuck piece can frequently free itself, and then he may return to normal for a short time.

Tears of the cartilage do not always result in symptoms, but they usually do particularly in active people.

We recognise several distinct types of tears with examples of the commonest three below:-

Radial Tear

Flap Tear

Bucket Handle tear

In certain circumstances, with certain patterns of care in favourable areas of the cartilage, surgical repair can be successful and is attempted whenever the prospect of success is reasonable. Unfortunately in many circumstances, surgical repair is not feasible and removing the damaged cartilage is the quickest and most effective way of relieving symptoms and getting the patient back to sport or other activities.

The modern surgical approach is to remove as little of the cartilage is possible. In effect, the bits that are removed are no longer functioning to protect the knee joint and if the surgery is performed appropriately, your knee is no worse off mechanically then had the torn cartilage being left, but you will of course reap the benefit significant improvement in your symptoms.

Will I get arthritis if I have my cartilage removed?

This is not a straightforward question, it depends on many factors for example:-

How old the patient is when the cartridges removed

Other associated injuries in particular damage to the joint surface

Damage to supporting ligaments of the knee

The family genetics and predisposition to arthritis.

In theory, removal of the damaged portion of the non-functioning cartilage will leave you at no greater risk than if you had been left untreated. Our understanding of the development of arthritis has improved substantially over the last two decades and we now realise that some patients 30 or 40 years ago clearly had other injuries to their knee which resulted in arthritis although from their own personal knowledge they were only aware of a torn cartilage.

The cartilage is obviously there for a purpose, and removing it must be of some detriment. There is definitely an increased risk of arthritis once you have torn your cartridge regardless of whether it is treated or not, and as a result we continue to research the best ways of preparing the cartilage, offsetting the effects of a torn cartilage or even replacing the cartilage. Later on in life this occurs the less likely you are to see any effects from it.

For most people simple removal of the torn portion is enough to restore function without significantly increasing the risk of arthritis later in life.

For the very young, teenagers and adolescents, the loss of the protection afforded by the cartridges is likely to have a more significant effect and surgical repair is much more likely to be attempted.

The results of repair do vary but they do have quite a high failure rate relative to other types of orthopaedic surgery. If the repair is combined with for example a cruciate ligament reconstruction, the success rate is much better. If the repair is attempted in a much older person where the tear is already in an unfavourable position, the success rate falls quite significantly.

Meniscal transplantation is still in its infancy. As yet we cannot be certain of the long-term results. It is quite invasive surgery and will only be considered in a tiny minority of patients.

Perhaps more encouraging is the development of artificial meniscal substitutes built on biological mesh,but again this kind of surgery is still at its early stages and is difficult to know whether will produce long-term protection.

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