الذهب الابيض3

Document Sample
الذهب الابيض3 Powered By Docstoc
					IJPMR 15, April 2004; 1-6

     “Rehabilitation Following Arthroscopic Partial
          Meniscectomy –A Neglected Issue”
              Dr Ak. Joy Singh, Assistant Professor, Dr Nilachandra L, Registrar,
          Dr Y.Nandabir Singh, Assistant Professor, Dr Brogen Ak, Assistant Professor.
                      Department of Physical Medicine & Rehabilitation
                        Regional Institute of Medical Sciences, Imphal
Abstract
       Meniscus injury is common in sports. Arthroscopic partial meniscectomy has been the
gold standard treatment in symptomatic cases. This procedure is associated with minimal
morbidity, though early return to sport and performance are questionable issues. The Department
of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences had organised a
rehabilitation protocol and instituted of the same starting from the early postoperative period
with the aim to minimise early complications and help early return to sports. During early phase
of rehabilitation, knee effusions were noted in two, lower lateral scar adhesion in one and restricted
mobility of patello-femoral joint in another. Two cases of lateral compartment pain and another
case of infrapatellar tendinitis were recorded as late complications. The need of a supervised
rehabilitation programme is emphasised in this paper.
Key Words: meniscal injury, arthrosopic partial meniscectomy, rehabilitation
Introduction:                                                  Arthroscopic partial meniscetomy is the gold
                                                               standard procedure for the symptomatic cases.
Manipur is a leading sporting state in the
                                                               It gives less morbidity, lesser risk for major
country. Recent hosting and performance in the
                                                               complications, rapid return to sports and a better
5th National games and 58th Santosh trophy have
                                                               long-term result when compared with the open
proven the state’s credibility. Sport related
                                                               meniscectomy procedure. However importance
injuries are also very common. Proper and
                                                               of a defined rehabilitation programme
timely management of sport injury is critical.
                                                               following such an important procedure is often
Many promising sportspersons are disabled due
                                                               underestimated. This common procedure is
to improper management. One such problem is
                                                               associated with problems that may hamper early
management of meniscus injury.
                                                               return to sport. Common findings include a
Meniscus injury represents one third of all                    knee that is warm to touch, joint effusion,
athletic injury1. Treatment options for meniscal               muscle atrophy, decrease in muscle tone and
injuries include nonoperative management,                      strength especially quadriceps, adhesion and
meniscectomy, meniscal repair and meniscal                     scar tissue over the arthroscopic incisions, loss
replacement. For patient with frequently                       of range of mobility and tenderness of medial
symptomatic and irreparable tear, partial                      or lateral compartments of knee 2 . Such
meniscectomy removes unstable fragments that                   morbidity however minimal it may be will
may cause symptoms of locking and catching.                    surely affect performance of the athletes.
Address for Correspondence: Dr Ak Joy Singh, Department        Institution of a proper rehabilitation programme
of Physical Medicine and Rehabilitation, Regional Institute of
Medical Sciences, Imphal 795004, Manipur Email:
                                                               shall help in early detection of such problems
joyakoijam2@yahoo.com                                          and help smooth return to sport. The
                                                       1
Department of Physical Medicine has developed                  motion, patello-femoral joint mobilisation
a rehabilitation protocol and instituted the same              exercises started immediate post
starting from the early postoperative period with              operative
the aim to minimise early complications and               ·    Strengthening of quadriceps (from 2 nd
help smooth and early return to sports. The                    post operative day)and hamstring
results are analysed in this paper.                            muscles (from 5th post operative day)
                                                          ·    Strengthening of hip extensor and
Material and methods                                           abductor, ankle dorsiflexors
      Eighteen active sportspersons who                   ·    Ice, ultrasound therapy, electrical
underwent arthroscopic partial meniscectomy                    stimulation, interferrential therapy
for isolated meniscus injury by different                 ·    Stationary bike from 4th postoperative day
orthopaedic surgeons during the period of                 Second week
October 2001 to July 2003 were selected.                  ·    Isotonic and isokinetic (mild and faster
Sportspersons with both meniscus injury or                     speed) strengthening exercises for
associated chondromalacia patellae or cruciate                 quadriceps and hamstrings
ligament injury detected during arthroscopy,              ·    Closed kinetic chain exercises
instability of opposite knee joint or any other           ·    Balance or propioception training using
associated problem that will hamper the                        a rocker board
rehabilitation programme, more than six month             ·    Jogging or swimming from 10 th post
of injury before operation were excluded from                  operative days
the study. A rehabilitation protocol developed            ·    Strengthening of muscles around hip,
in the Department of Physical Medicine and                     ankle and other limb
Rehabilitation, Regional Institute of Medical             Third week
Sciences was instituted immediately following
                                                          ·    Continued strengthening exercises with
the arthroscopic procedure.                                    increase speed
Rehabilitation goals                                      ·    High speed isokinetic strengthening
1.    To control pain and swelling, 2. To regain               exercises for quadriceps and hamstrings
      a pain free active range of motion, 3.              ·    Sports specific drills – jump, hop, skip
      Graduated weight bearing, 4. Progressive            ·    Jogging on soft surface with progressive
      strengthening within the available range                 increase in speed and distance
      of motion, 5. Return to functional                  Fourth week
      activities/sport                                    ·    Progressive agility drills( backward and
                                                               lateral running, vertical jumping, cross
                                                               over, figure 8 running, etc.) with
Rehabilitation programme –                                     increasing speed and complexity
first week
                                                          ·    Progressive introduction of sprinting,
·      Compression bandage/knee sleeve                         acceleration and deceleration
       immediate and early post operative
                                                          ·    Return to sports
       period
·      Partial weight bearing as tolerated starting       Criteria for returning to sports
       from day of surgery
·      Full weight bearing from the third day             1. Absence of effusion, 2. Full range of motion
·      Active and active assistive range of               of knee joint, 3. Normal quadriceps/hamstrings

                                                      2
strength, 4. Normal hip external rotator                 absorption. They thus contribute to cartilage
function, 5. Good propioception, 6. Functional           preservation. Biomechanical testing has shown
exercises performed without difficulties, 7.             that the medial and lateral menisci transmit at
Simulated match situation (continuous cycling            least 50 to 70% of the weight bearing load when
for 30 minutes) without subsequent knee pain             knee is extended and upto 85 to 90% when knee
                                                         is flexed. This is why current treatment of
Results                                                  meniscal lesions is based on the notion of
All eighteen sportspersons were in the age group         maximum        preservation      of     menisci:
of 17 to 28 years. Fifteen were males and three          meniscectomy as partial as possible, but also
were females. Medial meniscus was involved               whenever possible, meniscal repair, or
in 14 and lateral in four cases. Highest numbers         abstention from surgery. In the case of meniscal
of sportspersons were from football (11),                lesion on an otherwise intact knee, the usual
followed by basketball (2), fencing (2), athletics       approach is very partial arthroscopic
(1), taekwondo (1), and hockey (1).                      meniscectomy. Arthroscopy has shortened
       Knee effusion lasting more than 10 days           postsurgical effect, but long-term results still
was noted in 2 patients. Lower lateral scar              show a certain percentage of narrowing of joint’s
adhesion and restricted mobility of patello-             space, in particular on the lateral meniscus3.
femoral joint was also noted in 1 patient each.                 Our common experience is that majority
Two patients reported continued tenderness of            of the patients who underwent partial
lateral compartment of knee even after the               meniscectomy do not undergo a supervised
completion of rehabilitation programme. One              rehabilitation programme. They are usually
patient with continued knee effusion during the          discharge following surgery with ROM and
rehabilitation programme was treated with                quadriceps        strengthening        exercises.
additional intra-articular injection of methly           Subsequently, we have come across patients
prednisolone. Another patient (fencer)                   developing reflex sympathetic dystrophy,
developed infra-patellar tendinitis within one           severely restricted mobility of patello-femoral
month of joining the main sport. All patients            joint following arthroscopic surgery. Such
returned to sports within 34+ 3.2 days. Follow           morbidity though minimal, frequently
up period ranged from 8 months to 2 years.               questioned the future of the sportsperson. A
Maximum performance of two patients was                  supervised rehabilitation programme can
inhibited, one due to continued lateral                  prevent these complications during the early
compartment pain and another due to infra-               postoperative period.
patellar tendinitis. MRI of the knee for the first
                                                                In the present study, males are more
patient showed osteonecrosis of the lateral
                                                         frequently involved (15:3) than females. Medial
femoral condyle. Ultrasonography of the
                                                         meniscus was more commonly injured than the
second case showed features suggestive of infra-
                                                         lateral meniscus (14:4). Footballers were most
patellar tendinitis, which was later co-related
                                                         commonly involved. Marc R. Safran 1 reported
with the training scheduled and found to be
                                                         male: female ratio of 2.5:1 and medial to lateral
overuse injury not related with the surgery.
                                                         meniscus tear ratio of 3:1. He identified football
Discussion                                               and basketball as main sports associated with
     The menisci of knee play an important               meniscal injury. Otherwise a meniscal tear is
role in joint congruence, stability and                  usually encountered in any sport which
                                                         necessitate twisting force with knee semi-flexed
                                                     3
or flexed. Lateral meniscus injuries are not                    Where there is persistent effusion some
common as this meniscus is more mobile and               causes should be sought and, where possible
therefore escapes injury.                                eliminated. Postoperative effusion is more
       Smillie4 reported 17% delayed recovery            easily prevented than cured. It is important that
in his own series and 34% from other series due          an efficient compression bandage be
to complications following open meniscectomy.            maintained in the early stages of weight
Complications are associated with long pre-              bearing 4 . Ogilvie- Harris 6 and Metcalf
operative history, rupture anterior cruciate             7
                                                           discussed persistent post operative effusion and
ligament, retained posterior segment,                    synovitis. If effusion persist for more than 3 to
osteochondritis dissicans, neuroma of                    4 weeks, NSAID therapy may be innitiated. If
infrapatellar branch of saphenous nerve,                 effusion is large, aspiration with installation of
congenital discoid meniscus, osteoarthrosis,             a corticosteroid may be carried out. If the
multiple meniscectomies, para-articular                  effusion continue for several months
ossification, postoperative infection. Presently         postoperatively, additional or subsequent
available literature mostly focus on late                intraarticular pathology should be considered.
complications like osteoarthritis and joint              If the athlete returns to play before the knee is
instability changes not on early postoperative           properly rehabilitated, he or she may not
complications. Moreover, a definite projection           experience difficulty during the first competition
on the need of a follow up rehabilitation                but may be prone to develop recurrent effusion
programme is lacking.                                    and persistent pain. Persistent effusion in two
       In 1988 Small 5 presented the largest             cases in the present study may be due to
prospective arthroscopy complication review.             overactivity with the aim to return to sport early
In this study, estimated complications of                during the early postoperative period or due to
arthroscopic meniscectomy ranged from 1.5%               inadequate surgery or failure to detect other
for lateral meniscus to 1.7% for medial meniscus         injuries during the procedure. Close monitoring
with an overall complication rate of 1.68%.              is essential during post meniscectomy
Thrombophlebitis, hemarthrosis, infection,               rehabilitation as the remaining meniscus and
persistent effusion, and synovitis dominates post        underlying articular cartilage slowly increase
operative complications.                                 their tolerance to weight bearing. The
       Arthroscopic partial meniscectomy is              development of increased pain and swelling
usually a straightforward procedure followed             should result in the programme being slowed
by a fairly rapid return to sport after four weeks       down or revised accordingly.
of rehabilitation. The rehabilitation process                   Infection has become a more frequent
usually takes longer if there has been a more            complication as arthroscopy becomes more
complicated tear of the meniscus, especially if          widely used. Scar adhesion may be seen when
the lateral meniscus is injured. The presence of         arthroscopic wounds are infected. This is
articular cartilage damage or ligament (MCL,             associated with poor aseptic and antiseptic
ACL) tears, will necessary slow down the                 techniques. It may lead to restricted mobility of
rehabilitation process1. Probably this explains          the patello-femoral joint and pain due to
why one patient continues to have pain in the            stretching of scar during knee movements. In
lateral compartment due to articular damage that         both situations, return to sport may be delayed
was not detected during the arthroscopic                 or patient return to sport with limitations.
procedure.
                                                     4
       Bonneus 8 evaluated thirty-one knees              highest impact on long-term results was
following arthroscopic partial meniscectomy of           damage to the articular cartilage, which did not
the lateral meniscus in athletes after an average        influence knee function for several years after
follow up of 8 years. 48.4% had excellent/good           surgery but become increasingly symptomatic
IKDC scores and 64.5% excellent/good                     over time after 5 years or more. Only 62% of
Lysholm score. The Tegner activity score                 patients with additional cartilage damage rated
dropped from 7.2 (competitive sports) to 5.7             excellent and good 12 years after surgery, in
(recreational sports). Fairbank changes were             contrast with 94.8% good and excellent results
noted in 92.9% of the radiographs. Deterioration         in patients with isolated meniscal tear.
of results after arthroscopic partial                           Return to sports following arthroscopic
meniscectomy is obvious. The extent of                   partial meniscectomy is considered when the
resection is a significant factor. Burks RT 9            quadriceps and hamstring muscles have
followed up 146 patients who had undergone               regained their strength, endurance and
arthroscopic partial meniscectomy about 14.7             synchrony, usually at approximately 6 to 8
years before. There were 88% good and                    weeks11. In the present series, return to sport
excellent results in the anterior cruciate stable        took around 34+ 3.2 days. Parry et al 12 in his
knees. The radiographic grade side-to-side               series of 1723 cases from Royal Air Force
difference showed the operative knee to be only          rehabilitation units reported that average time
a 0.23 grade worse than the nonoperative knee.           for return to duty after open meniscectomy was
Age at the time of meniscectomy was not found            62 days and no difference in the time of
to be a factor. Male patients had better                 recovery from medial as opposed to lateral
radiographic results than female patients, but           meniscus injury. In their series, 74% cases were
not better functional score. Medial and lateral          discharged to full duty; 21% discharged to
meniscus results were not significantly different.       modified duty and 3.9% returned to hospital.
Knees with a femoral-tibial anatomic alignment           Although knee arthroscopy and more
of more than 0 degree valgus compared with               specifically, meniscectomy have relatively low
less than or equal to 0 degree and that had              morbidity, complications do certainly occur.
undergone medial meniscectomy had                        Thorough patient evaluation, proper use of
significantly better radiographic results. In            arthroscopic equipments, gentle and correct
patients with anterior cruciate ligament tears,          surgical technique, meticulous intra- and post-
outcome after meniscectomy was significantly             operative monitoring, and patient education will
poorer than stable knee in regards to                    help in reducing the incidence of such
radiographic grade change, Lysholm, Tegner               complications. Above all, a supervised
and medial joint space narrowing. Schimmer               rehabilitation programme will certainly help in
RC10 reported results of the two steps evaluation        minimising morbidity due to such
following arthroscopic partial meniscectomy              complications.
with a 12 years follow up. He reported that
91.7% had an excellent or good result 4 years            Conclusion
after surgery and 78.1% rated excellent or good                Meniscus injury is a common sports
12 years after surgery. Early results therefore          related    injury.    Arthroscopic        partial
were mostly representative and did not change            meniscectomy has been a standard treatment
significantly during the long-term course for the        for the symptomatic cases. However this
isolated meniscal lesion. The factor with the            procedure is not the ultimate in their treatment,

                                                     5
rather it should be viewed as the beginning of a       7.    Metcalf RW. Arthrocopic meniscal
supervised rehabilitation programme for early                surgery. In: Shahriace J(editor).
and smooth return to sports without                          Arthroscopic surgery. Philadelphia; JB
complications.                                               Lipincott;1984.p93-97.
                                                       8.    Bonneux       I,   Vandekerchove       B.
References                                                   Arthroscopic lateral meniscectomy long
1.   Christopher D. Harner, Ronald A.                        term result in athletes. Acta orthop Belg
     Navarro. Knee cartilage. In: Marc R.                    2002;68(4):356-61.
     Safran, Douglas B. McKeag, Steven P. Van          9.    Burks RT, Metcaff MH, Metcalf RW.
     Camp (editors). Manual of Sports                        Fifteen years follow up of arthroscopic
     Medicine. Philadelphia: Lipincott-                      partial meniscectomy. Arthroscopy
     Raven;1998. p440-441.                                   1997;13(6):673-79.
2.   Norman F. Sprague III. Arthroscopic               10.   Schimmer RC, Brulhart KB, Duff C, Glinz
     Meniscal resection. In : W. Norman Scott                W. Arthroscopic partial meniscectomy: a
     (editor).The     Knee.      St.   Louis:                12 years follow up and two steps
     Mosby;1994.p 527-57.                                    evaluation of the long term course.
3.   Beaufils P. Meniscal lesions. Rev Trat                  Arthroscopy1998;14(2).136-42.
     1998;48(16):1773-79.                              11.   Michael GC, Clarence LS, Neal SEA.
4.   Smillie. Injuries of knee joint. Fifth                  Meniscectomy.         In    :     Freddie
     edition.     Edinburgh:         Churchill               HF,Christopher DH, Kelly GV (editors).
     Livingstone; 1978.                                      Knee Surgery. Baltimore:Williams and
5.   Small NC. Complications of arthroscopic                 Wilkins;1994.p591-63.
     surgery performed by experienced                  12.   Parry CBW, Nicols PJR, Lewis NR.
     arthroscopists.             Arthroscopy                 Meniscectomy: a review 1723 cases.
     1988;4(3):215-21.                                       Annals of Physical Medicine 1958;4: 201.
6.   Ogilvie-Harris DJ, Bauer M, Corey P.
     Prostaglandin inhibition and the rate of
     recovery        after       arthroscopic
     meniscectomy: a randomised double-
     blind control study. J Bone Joint Surg
     1985;67B: 567-71.




                                                   6

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:2
posted:1/20/2013
language:
pages:6
Description: الذهب الابيض