We rely on our knees for almost every movement we make. Whether we are walking, running or stretching – even when sitting, the knee joint, which is actually the largest joint in our body, plays a central role. If there is a problem with the knee, this has an immediate impact on our musculoskeletal system. This is particularly true, of course, if the meniscus tears or wears down. To shed more light on the specific characteristics of the meniscus, which consists of two crescent-shaped discs of cartilage, Leading Medicine spoke to Professor Dr Christoph Erggelet. The internationally renowned specialist in orthopedic surgery and traumatology (FMH) is Medical Director of the ADUS Specialist Clinic for Orthopedic Surgery in Dielsdorf near Zurich.
They lie between the lower and upper leg bones: our menisci, which stabilize the movements of the knee joint and, like a buffer, absorb all pressure and any sudden jolts in the knee. The cartilaginous connective tissue, which lies like a triangle within the knee joint, extends to the inner and outer sides of the knee joint and evenly transfers force from the thigh to the lower leg, enabling both legs to work together effectively. This enables rotational movements, extension and flexion. The medial meniscus is particularly stressed when the knee rotates outwards, while the lateral meniscus is stressed during inward rotation. The menisci also reduce the weight exerted on the knee joint and supply the joint with synovial fluid.
“If the meniscus is damaged, two aspects need to be considered. Firstly, the meniscus can be damaged as a result of an accident. For example, if you fall over, get up from a chair incorrectly, or make a wrong movement while playing sport. In such cases, a sudden and usually sharp pain sets in immediately, and the knee often swells up spontaneously. On the other hand, there is also degenerative meniscus damage, i.e. age-related wear and tear. In this case, the pain develops gradually. “Anyone who used to enjoy three- to four-hour hikes in their younger years will find, with a worn meniscus, that only a shorter walk of half an hour is possible without pain,” says Professor Dr Erggelet, describing the initial symptoms.
Patients also speak of a ‘knee lock’ when there is meniscus damage. This is because if the meniscus is pinched, the knee joint can no longer be fully extended. It is also important to know that the meniscus itself does not cause pain, as, like cartilage, it has no nerves. However, if the knee is twisted or bent incorrectly, it can irritate the joint capsule and thus trigger pain.
A thorough discussion with the patient plays a major role in the diagnosis
“As part of the diagnostic process, it is very important to let the patient describe exactly what happened. Did they slip? Did they make an awkward twisting movement, or were they exercising too intensely and lost their balance?” emphasises Professor Dr Erggelet. Only in this way can the doctor narrow down in advance the nature of the injury. This is naturally followed by a clinical examination, which always includes an MRI scan – an imaging technique that uses a strong magnetic field and radio waves to produce cross-sectional images of the body and provide further information on the size, type and location of the meniscus tear, as well as any further consequential damage, such as cartilage damage, in the knee joint. If the meniscus damage is identifiable and can be classified – for example, whether it is torn, partially torn or worn – then the appropriate treatment can be discussed.
Cross-section of the knee joint – menisci viewed from above (Photo: bilderzwerg/fotolia)
“Personally, I find it very important at this stage to also clarify what sort of person I am dealing with. Is it a young, active person who does a lot of sport and would like to continue doing so in the future? Is it someone who tends to have a sedentary job? Because it is only through this individual assessment that I can tailor a suitable treatment plan,” explains Professor Dr Erggelet, who always takes plenty of time for this.
Just a few years ago, surgery was performed much more frequently and at an earlier stage when it came to meniscus injuries – today, many cases can be treated conservatively
If, for example, the meniscus tear is stable and causes hardly any symptoms, a combination of medication and physiotherapy may be sufficient. “Meniscus damage isn’t life-threatening, after all,” says Prof. Dr Erggelet, adding: “As long as quality of life isn’t dramatically impaired and you can walk without pain, you can live without an intact meniscus. However, it’s important to bear in mind that a damaged meniscus causes long-term damage to the cartilage, which can lead to osteoarthritis in the long run. To illustrate this, imagine driving on a smooth tarmac road or a gravel track. In this case, the damaged meniscus would be the gravel track, so the cartilage gliding over it naturally wears down more quickly,” explains Prof. Dr Erggelet.
In younger people, damaged sections of the meniscus are usually removed and the meniscus is sutured. Here, the surgeon faces the particular challenge of weighing up which approach is best, taking into account the specific individual they are dealing with. Is the meniscus repairable? Is there still good blood supply? “The question of blood supply is a crucial one. The outer sides of the meniscus are supplied with blood, but the inner sides are not. However, if parts of the inner side are damaged, it makes no sense to try to suture them, as blood supply is essential for healing. The likelihood of a suture tearing again is extremely high. In such cases, I have to explain the situation clearly to the patient and make it clear that, if in doubt, we will meet again in six months’ time,” says Professor Dr Erggelet, describing the considerations that take place before an operation.
Footballers subject their knees to extremely high levels of stress. How often do you see nasty collisions and accidents during a football match? Here, too, we have to weigh up what makes the most sense. A 17-year-old footballer can certainly afford to be out of action for a year while recovering if a meniscus is reattached and requires that amount of time to heal. A 31-year-old footballer, on the other hand, is already past his prime and would likely be facing the end of his career with such a recovery period, which is why in this case one would tend to opt not for suturing but for the removal of the meniscus in order to replace it.
When the meniscus needs to be removed
As long as only small parts of the meniscus are damaged, these can be removed, and one can live well with what remains. However, if the entire meniscus is damaged, it should be completely removed and replaced. “Here we rely on donations from people who hold an organ donor card. The donated meniscus is adapted, inserted in the operating theater using special instruments, and must heal. The operation takes about an hour. I have been performing meniscus transplants for a good fifteen years and can say that the chances of recovery are excellent. The patient can usually walk again after two to three days. It can take up to six months before they can squat deeply. Unfortunately, the costs are not covered in Switzerland, and the willingness to donate organs is also rather problematic here, so we very often have to resort to prostheses. And artificial implants are, after all, merely an imitation of nature and, of course, cannot be compared in terms of quality,” laments Professor Dr Erggelet.
Of every hundred patients affected, around seventy have damage to the medial meniscus and thirty to the lateral meniscus. Of those thirty, four or five would in turn require a transplant.
Key features of the ADUS Clinic – motto “simply.well.cared for”
What makes the ADUS Clinic special is that it offers a wide range of orthopedic services. “There is no senior consultant here who has to be able to do everything, nor a team of junior doctors who are not as experienced. Here, there are experienced doctors for every speciality. We would not offer certain therapies or procedures if we were not capable of performing them. It is also the case that operations always follow the same procedure. This means it is always the same doctor who operates on shoulders and always the same one who operates on knees, using the same technique and following the same sequence. This results in far fewer complications and a more successful recovery for patients, as the procedures are consistent in terms of timing and are carried out with sound routine,” explains Professor Dr Erggelet regarding the hospital’s working methods.
“For the future, I would like to see less austerity in Switzerland. Often, we cannot offer patients what they are entitled to. I would like to cite the case-based flat rates as an example here. The flat-rate amount remains the same, but the associated costs are rising, so the value of the flat-rate payment inevitably falls; hospitals have to make savings here: on staff, on instruments, on implants, on services… This is, of course, in line with policy, but it is the insured who suffer as a result of these decisions. Fewer staff means, for example, a longer wait for a nurse if you are in pain in hospital or need to use the toilet. Fewer staff means longer waiting times for diagnoses and treatments. The situation in England and Canada clearly shows where this leads,” criticizes Professor Dr Erggelet, concluding our conversation with the remark: “It’s better to stay healthy!”
Many thanks, Professor Dr Erggelet, for this interesting and candid conversation!
You can contact our specialist directly via his profile page in the Leading Medicine Guide.
