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Arthroscopic meniscectomy surgery cost in India

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An arthroscopic meniscectomy is a procedure to remove some or all of a meniscus from the tibio-femoral joint of the knee using arthroscopic (keyhole) surgery. The procedure can be a complete meniscectomy where the meniscus and the meniscal rim is removed or partial where only a section of the meniscus is removed. This may vary from a minor trimming of a frayed edge to anything short of removing the rim. This procedure often carried out as an outpatient in a one-day clinic and is performed when a meniscal tear is too large to be corrected by a surgical repair of the meniscus. Where non-operative therapy provides some degree of symptom relief over the long-term, these benefits may become increasingly ineffective as the affected meniscus degenerates over time. In such cases, partial arthroscopic meniscectomy can be more effective in improving patient quality of life.

 Symptoms

• ✓Joint line tenderness and effusion.
• ✓Complaints of 'clicking', 'locking' and 'giving way' are common.
• ✓Functionally unstable knee^.
• ✓Symptoms are frequently more intense by flexing and loading the knee, with activities such as squatting and kneeling being poorly tolerated because of stiffness and pain

• ✓Joint line tenderness has been reported to be the best common test for meniscal injury.
• ✓Mcmurray's test is positive if an audible pop or a snap is heard at the joint line whilst flexing and rotating the patient's knee.
• ✓Appley's test is performed with the patient prone, then hyper-flexing the knee and rotating the tibial plateau on the femoral condyles.
• ✓Steinman's test is performed on a supine patient by bringing the knee into flexion and rotation.
• ✓Ege's Test is performed with the patient squatting. A positive result is an audible and palpable click heard/felt over the area of the meniscus tear. The patient's feet are turned outwards to detect a medial meniscus tear, and turned inwards to detect a lateral meniscus tear.
• ✓Thessaly test.
• ✓MRI: has a crucial role in patients with combined injuries and the assessment of the meniscal surfaces. Abnormal findings are graded I to IV.

Grade I: Discrete central degeneration - an intra-meniscal lesion of increased signal without connection to the articular surface.

Grade II: Extensive central degeneration – a larger intra-meniscal area of increased signal intensity, again without connection to the articular surface. May be horizontal or linear in orientation.

Grade III: Meniscal tear - increased intra-meniscal signal intensity with contour disruption of articular surface. May be associated with displacement of meniscal fragments or superficial step formation.

Grade IV: Complex meniscal tear - multiple disruptions of meniscal surfaces

The presence of tears in the red area versus the white areas of the meniscus is crucial as long term positive prognosis for the repair of tears is only good within the vascularised red areas.

This decision is based on several factors such as age, co-morbidities, compliance, tear characteristics (location of the tear, age and pattern of the tear) and whether the tear is stable or unstable. Where the tear is deemed to be unstable surgery is necessary. Degenerative or non-degenerative tears which are asymptomatic or stable are treated non-surgically, but treated surgically in symptomatic cases. It has then to be determined whether a meniscal repair or a meniscectomy is appropriate. Where none of the normal surgical treatments are appropriate total meniscectomy is the option. The factors taken in consideration are:

• ✓the clinical evaluation
• ✓related lesions
• ✓the exact type, location, and extent of the meniscal tear

Small, degenerative meniscal tears are often treated conservatively with rest, reducing load bearing on the joint through activity modification and treating with physical therapy. Where a non-surgical approach is taken it is essential that a good level of strength is achieved and maintained in the affected leg and activities requiring pivoting or sudden changes of direction are avoided. If the tear is large, in a low vascularised region or if conservative management fails to alleviate the associated pain and joint dysfunction then surgery is the next step.

Two small incisions are made in the anterior region of the knee below the patella. A camera is inserted through one of the incisions so that the surgeon can see the inside of the knee joint on a monitor. The other incision is used to place a tool into the joint that will clip and remove the torn piece of cartilage. While the camera is inside the joint the surgeon uses this opportunity to examine the rest of the knee to make sure it is otherwise healthy.

After meniscectomy rehabilitation protocol can be aggressive, because the knee joint anatomical structures should not be overly protected during the healing phase. The rehabilitative treatment consists of ice-ultrasound therapy, friction massage, joint mobilization, calf raises, steps-ups, extensor exercise and cycling.Treatment under water cannot begin until the wounds have properly closed in order to prevent increased risk of infection. In the first week after surgery rehabilitation treatment consists of a progressive loading with crutches. Early objectives after surgery are: control of pain and swelling, maximum knee range of motion (ROM) and a full weight bearing walking. There is no load limitation, with weight bearing being as tolerated by the patient. In the subsequent 3 weeks the goal is to normalize gait and to increase knee ROM, led by the patient’s tolerance. Intensive muscle strengthening, proprioceptive and balance exercises are carried out around the third week. Return to sport/activities is recommended only when the quadriceps’ muscle strength is at least 80% of the contralateral limb. Competitive level sport is, however, not recommended until muscle strength in the affected limb is at least 90%. Patients generally return to work after 1 to 2 weeks, to sporting activities after 3 to 6 week and to competition after 5 to 8 weeks.

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