John, thanks for the opportunity to present our findings. I've been in practice for 37 years now, and I'm trying to add some common sense to what otherwise is a surgical orientation to patients with knee problems. Taking care of meniscus tears many times is fun, and the most common person we see that we enjoy seeing is a 40-year-old male with a 6.5 millimeter joint space, the symptomatic degenerative medial meniscus tear, joint line pain. Take out the torn piece, and they're happy for now. You really can't repair it, but these patients are fairly fun to take care of. The most dramatic people we see, and that's what we're seeing more and more of, are the mid-50-year-old female, the acute onset of severe medial and posterior pain. Pain came out of nowhere. They felt a pop that seemed major at the time. They have a large effusion. They walk with a limp, and the radiographs may or may not show joint space narrowing, but if it does, we know they have an extruded medial meniscus. Need to take bilateral x-rays to evaluate joint space narrowing. There's no reason to do an MRI scan on somebody that has medial joint space narrowing, and I'll go over why. As orthopedic surgeons, when we see somebody that has a normal left knee and some narrowing on the right knee, and they have right knee pain, we as orthopedic surgeons think, what operation can I do with this person? Need to do an MRI scan, find a root tear, and then repair it, because that's what everybody does. If radiographs don't prove joint space narrowing, but the meniscus is extruded on the MRI scan, there has to be joint space narrowing. How did the meniscus get pushed out of the joint? Well, the joint space narrowing is putting extrusion pressure on the meniscus, and when the meniscus finally gives way, you sometimes hear and feel a painful pop, but the meniscus has to tear to get extruded. So an extruded meniscus means you have joint space narrowing, and the joint space narrowing causes the meniscus tear. Weight-bearing pushes the medial meniscus against the capsule, which is why I know that weight-bearing after a medial meniscus repair is critical to get it to heal. I don't know where the non-weight-bearing craziness of meniscus repairs comes about. We get such a skewed idea of what the inside of the knee looks like when we're doing a scope because the knee is distracted, and that's not the normal condition. When the posterior horn of the medial meniscus prevents extrusion in normal knees, so when the joint starts to narrow, there's huge pressure on the posterior horn, and either the meniscus tears silently at the posterior root or dramatically with a painful radial tear near the posterior horn. They have an acute onset, they feel a pop, we do an MRI scan, and the MRI scan shows the extrusion. The extrusion is because the joint has narrowed and pushed the meniscus out of the joint. The patient has difficulty walking, they come in, we do an MRI scan, the radiologist correctly says there's a medial meniscus tear, but they also say there's medial migration of the meniscus, slight extrusion of the meniscus. The darn meniscus has been pushed out of the joint by the joint space narrowing. Again, the positive MRI scan shows the meniscus extruded. How did the meniscus get there? It got pushed out of the knee because the joint space narrowing forced it out of the knee. Yes, these tears are associated with medial compartment narrowing, but they are not the cause of the narrowing. The narrowing causes the meniscus extrusion. Even if you can't see it on the plain x-rays, every time you do an arthroscopy on somebody with a medial meniscus root tear, they have articular surface damage of the medial femoral condyle. The joint space narrowing forces the meniscus out of the joint, and the extrusion is a result of the narrowing, not the cause. I was never sure how to treat these tears back in the day before I understood what was going on. I'd do a scope, and again, there's the articular surface damage. There's the posterior horn extrusion. The knee's wide open. I can grab this tear and pull it back into the knee because the joint's distracted. But as soon as I let go of the distraction of the joint, it's going to go back out again. Patients always have articular cartilage damage. The previous speaker spoke about lateral meniscus root tears that are totally different than medial tears. We're talking only about medial tears right now. We've talked about lateral tears in association with ACL tears totally separately. With the joint forced apart with the valgus pressure, I didn't know what to do. So my nurse said, well, take part of the back of the meniscus out there. See what happens. As soon as the meniscus or the scope was done and I let go of the valgus stress, the extrusion came back. I didn't feel good about doing a scope on these people. All people had articular cartilage damage. Many people, surprisingly, did well, even though I didn't do a darn thing at the time of the arthroscopy. Some patients had rapid degeneration, mostly in overweight female patients. Why is that? We looked at joint space width in patients with no history of previous injury, 897 patients. We did the PA x-rays. We evaluated the difference in the joint space based on sex. Equal joint space width in females is 5.4 and males 6.3. That's statistically significant, P less than .001. Less joint space in women indicates less articular cartilage. There is a huge difference between male and female knees. Equal narrowing in females is a larger percent of the articular surface in males. Females are more susceptible to joint stresses and can explain the higher rate of osteoarthritis in women than men. Trying to put a suture in the meniscus won't improve the outcomes and may make them worse. You notice I'm not calling this meniscus repair because that's a misnomer. What we're doing is putting a suture in an extruded meniscus. Yes, lab studies have shown increased joint mechanics with suturing the meniscus, but they have created this in a normal cadaver knee without joint space narrowing, without weight bearing. They cut it, find abnormal mechanics, put a stitch in it, and find it improves. Surgeons are trying to convince us that we can do this in humans. Lab studies are not in the clinical setting. Furthermore, clinical studies of placing a suture show extrusion is not reduced and progression of OA is not prevented. As surgeons, we try to feel like we have to do something. And again, there's the painful extruded meniscus. Although placing a suture sounds good, it won't help. The meniscus can't be pulled back into a narrow joint. The meniscus is extruded on this MRI scan even though the patient is non-weight bearing. So how can you pull that back into a narrowed knee? If you put a suture in the meniscus, then what rehab do you put on these people? You put them non-weight bearing for six weeks. It's difficult for patients to do. It's impossible to do for many middle-aged females. It causes range of motion and strength problems, and the extrusion is still there once the meniscus of the patient goes back to weight bearing. Any short-term symptomatic relief can't be maintained. We need to understand why the tear occurred. Joint space narrowing causes the medial meniscus root tear and the extrusion. Studies show that non-operative treatment can provide relief. Our non-operative treatment, and again, I don't operate on these. We get the patient through the initial painful period, use crutches if needed, cold compression. Injections can help. I have in-house therapists that work with our patients to get their range of motion back. Most important thing for these patients is to get full extension back. As they calm down, work on their extension, get their extension first, then work on their flexion. More than 80% of our patients get better with this treatment. Some patients, mainly females, have further joint space narrowing, but this cannot be changed with a scope or putting a suture in the meniscus. Medial meniscus root tears are caused by joint space narrowing, not the other way around. Putting a suture in the meniscus cannot pull the meniscus back into a narrow joint and be maintained. Putting a suture in the meniscus does not prevent extrusion, and surgery with restrictive post-op rehab may make patients worse in the end, and proper non-operative treatment can provide symptomatic relief in most cases. Thank you.

orthopedic surgeon

meniscus tears

knee problems

joint space narrowing

non-operative treatments