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Author Topic: Chronic knee pain after medial meniscectomy  (Read 11967 times)

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Offline JuhaH

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Chronic knee pain after medial meniscectomy
« on: January 18, 2011, 02:55:39 PM »
Hi there,

I'm trying to find the reason for chronic knee pain after my medial meniscectomy, one year ago. 
Summary of my knee's injury: I tore my medial meniscus in January of 2010 while skiing telemark. I had a pretty big tears in my medial meniscus and after surgery I have only 20-30% meniscus left. I am having sharp stabbing pain, at the location of my medial meniscus used to be and knee never healed painless. I cant bear weight properly on that leg, after meniscectomy. Last 6 months pain has been increasing every month and I feel lot of nerve pain.

I believe that I have re-tear in meniscus and that isn't healing. It feels like a pinched nerve pain in my meniscal area and I can't walk because of the medial knee pain. I found many of articles that say the anterior and posterior horns of the menisci have a rich supply of both blood vessels and nerves. This, This and many other studies shows that some of the chronic pain in cases of meniscal tear could originate in the meniscus itself, especially with peripheral tears that may be accompanied by bleeding. I think that the pain might be caused by meniscus retear or/and there's too much body pressure on one small area on the surface of menisci after the meniscectomy and rest of meniscus crushed. Couple of articles in the Pubmed -> http://www.ncbi.nlm.nih.gov/pubmed/10738884 , http://www.ncbi.nlm.nih.gov/pubmed/10100118 and http://www.capetownorthopaedic.co.za/clinical-and-arthroscopic-diagnosis-of-meniscal-lesions.php

Meniscus showing increased vascularity of anterior and posterior horns and peripheral meniscus.



Degenerative tears are usually horizontal in the meniscus producing both an upper and lower segment of meniscus.



Microscopic Anatomy

Normal human meniscal tissue is composed of 72% water, 22% collagen, 0.8% glycosaminoglycans and 0.12% DNA. The posterior areas of meniscal tissue have higher water content. The meniscal body consists predominantly of a dense framework of circumferentially orientated coarse type I collagen fibres (fig 4). Radial fibres are found throughout but are less numerous. The radial fibres may act as a “tie” holding the circumferential fibres together, thereby resisting longitudinal splitting of the menisci and dissipating hoop. The collagens are extensively cross-linked by hydroxylpyridinium aldehydes. Type I collagen accounts for over 90% of meniscal tissue collagens while types II, III and V account for the remainder. This configuration provides the meniscus with greater elasticity and the ability to withstand compression forces.

Pattern of collagen fibres within meniscus. A, Radial fibres. B, Circumferential fibres. C, Perforating fibres. (From Shahriaree H: O'Connor's textbook of arthroscopic surgery, Philadelphia, 1984, JB Lippincott.)



Innervation

The nerve supply of the meniscus is, at present, debatable. Innervation arises mainly from the posterior articular nerve, but branches of the medial articular nerve provide part of the innervation of the medial meniscus. The menisci have a neural network of myelinated and unmyelinated nerves that extend from the perimeniscal connective tissue into the outer and middle thirds of the meniscus3. The perimeniscal connective tissue serves as a hilum for nerves entering the meniscus. The nerves enter along the outer edge of the meniscus and appear to funnel into the meniscus coming to a point at the boundary of the middle and inner thirds. Encapsulated end organs with a mechanoreceptor function predominate at the horns and attachment structures, while free nerve endings are found throughout, except for the inner third of the meniscal body. Three morphologically distinct mechanoreceptors namely, ruffini endings, golgi tendon organs and pacinian corpuscles have been identified.

No neural elements have been observed in the inner third of the meniscus. The horns and insertional ligaments have a sensory function that provides important proprioreceptive information related to the joint position. A greater concentration of nerves is found in the meniscal horns due to the need for afferent feedback at the extremes of flexion and extension. There is a greater concentration of nerves and receptors in the posterior horn of the meniscus, compared to the anterior horn; this may be related to the posterior location of collateral ligament attachment. During extension the collateral ligaments tighten because the greater curve of the anterior surface of the femoral condyles exerts leverage upon the ligament attachments. In turn, this may place the posterior horn of the meniscus under increasing pressure and tension, stimulating the mechanoreceptor system. The menisci could function as an “early warning” sensory device, coordinating the tension between the anterior meniscal horns, the posterior meniscal horns and/or posterior meniscofemoral ligament. It may be that the menisci aid in initiating protective muscular reflexes to compensate and adjust the tension in the different areas of the meniscus3.

In a study by Dye et al5 an attempted was made to correlate anatomical findings with actual physical findings. The researcher under went bilateral knee arthroscopy without anaesthesia and mapped out his neurosensory perceptions as each internal structure of the knee was stimulated. He experienced non- painful and poorly localized awareness at the inner rim, slight discomfort and poor localization at the capsular margins and moderate discomfort and poor localization at the anterior and posterior horns (fig 6). This observation may provide an explanation for the often poor localization that many patients experience with meniscal injury. The painful synovitis and capsular inflammation frequently associated with a meniscal injury may be a more important factor in the subjective localization of the site of possible cartilage damage rather than the sensation arising solely from the damaged meniscus.

Coronal and sagittal schematic representations of the conscious neurosensory findings of the intraarticular structures of the knee.



References:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155528

http://www.ncbi.nlm.nih.gov/pubmed/21081524

http://www.capetownorthopaedic.co.za/clinical-and-arthroscopic-diagnosis-of-meniscal-lesions.php

http://www.ncbi.nlm.nih.gov/pubmed/4091911
« Last Edit: March 27, 2012, 07:33:06 PM by JuhaH »
Skiing accident in january 2010. Left knee, medial joint space narrowing and constant pain following partial meniscectomy (30% medial meniscus left). Trying to prolong the knee replacement as long as I can.