Keywords: knee joint; Meniscus injury; Non-surgical therapy; surgical treatment
Physiological structure of meniscus: Meniscus is a "C"-shaped fibrocartilage "wedge" located between femoral condyle and tibial condyle, which is actually an extension of tibia and is used to deepen the articular surface of tibial plateau in order to better adapt to femoral condyle. The lateral meniscus is nearly annular, while the medial meniscus is semi-annular. Seen from the longitudinal axis, the meniscus periphery is thickest at the attachment of the joint capsule, gradually thinning, and thinnest at the free end of the joint. The main functions of meniscus include load transmission, shock absorption, improving joint stability and coordination, joint proprioception and so on.
The blood supply of meniscus largely determines the treatment of meniscus. In 1982, Amoczky et al. found that the vascular area of adult meniscus is about 0/0% ~ 25% of medial meniscus and 0/0% ~ 30% of lateral meniscus. It divides meniscus tissue into three areas: red area, white area and red and white area. The area with absolute blood vessels within 3mm of meniscus synovial junction is called red area; Absolute avascular areas with a distance greater than 5mm are called white areas; 3 ~ 5 mm apart is the relative vascular area called red and white area.
Li Jian's research on the blood supply of meniscus pointed out that the blood vessels in the meniscus are layered, and the blood vessels are divided into three layers: upper, middle and lower. There is little anastomosis between layers, and the meniscus angle is rich in vascular plexus nutrition supply. Blood vessels are distributed in the whole corner area, and even terminal capillaries are found on the free edge of meniscus corner. In addition to its own blood supply, the outer surface of meniscus body also has a synovial layer with the properties of vascular endothelial cells, which participates in the nutrition of meniscus synovial fluid.
Meniscal injuries are mostly caused by trauma, joint degeneration, inflammation and chronic strain, such as semilunar tear, meniscus delamination and rupture, meniscus incarceration and so on. Foreign literature reports that meniscus injuries are mostly medial, while domestic literature reports that meniscus injuries are mostly lateral. After meniscus injury, there may be degeneration, hyperplasia, hypertrophy and edema of muscle tissue around the edge to varying degrees, and the knee joint loses its stability and normal activity function, thus producing a series of clinical symptoms and signs. In the past, partial or total meniscectomy was often used, and the short-term effect was satisfactory. However, in recent years, with the in-depth study of the structure, function and injury mechanism of meniscus, most scholars advocate that the injured meniscus should be preserved or repaired by surgery as much as possible.
1 non-surgical therapy
1. 1 fixed therapy [1]
Some people argue that the knee joint should be fixed externally in a straight posture for several weeks until it heals on its own. After observation, it is found that the curative effect of this therapy is the same as that of meniscus suture repair, even better than that of suture repair. However, long-term fixation will lead to knee ankylosis and muscle atrophy, which will affect functional recovery. The fixing methods are also different. Some people advocate that the knee joint should be fixed in a straight position, while others advocate that the knee joint should be fixed with 160 ~ 170 splint or plaster support during acute injury and rest for 3 ~ 4 weeks. Some people think that external fixation with slight knee flexion of 20 can eliminate joint swelling, synovitis and muscle spasm, and promote the repair of injured meniscus.
1. 1.2 drug therapy
Early anti-inflammatory and analgesic drugs should be taken orally and anti-inflammatory and analgesic ointment should be used externally. In the later stage, you should take orally the drugs that warm the meridians and dredge the collaterals, and you can smoke and wash Chinese medicine.
1. 1.3 joint puncture, irrigation and intra-articular injection therapy
(1) Joint puncture and joint cavity lavage: When joint effusion and tension are too high, joint puncture can be performed, and joint cavity lavage can be performed after the effusion and hematocele are completely drained.
(2) Injecting drugs into the joint cavity: After joint puncture, cartilage protectants and drugs for supplementing the viscosity in the joint cavity are often injected into the joint cavity. The former can stimulate the synthesis of collagen and proteoglycan, inhibit or delay cartilage degeneration; The latter can increase the viscosity and elasticity of joint fluid, play a role in lubrication and shock absorption, thus protecting the diseased meniscus. Some scholars recommend that intra-articular injection of sodium hyaluronate can effectively relieve joint pain and swelling and improve joint function, which is a safe and effective method for the treatment of knee synovitis [1]. Growth factors such as platelet growth factor (PDGF), hepatocyte growth factor (HGF), bone morphogenetic protein (BMP 22) and insulin-like growth factor (IGI 2 1) can also be injected into the joint cavity to promote the healing of the injured meniscus.
1.4 manipulation
1.4. 1 lateral meniscus injury
(1) external rotation knee flexion: suitable for acute incarceration of lateral meniscus. The patient takes the supine position, and the operator stands on the affected side, holding the knee joint of the affected limb with one hand and the ankle joint with the other hand, overstretching the knee joint in a passive external rotation posture of the calf, overstretching the knee joint (there is obvious meniscus snapping or resetting feeling at this time), and then slowly straightening the knee joint.
(2) Rotating knee extension and pressing: it is suitable for mild tearing injury of lateral meniscus. The patient takes the supine position, and the operator stands on the affected side, holding the ankle of the affected limb with one hand, pressing the pain point of the lateral meniscus with the other thumb, and holding the inside of the knee with the other four fingers. Hands together, bend your knees 90 degrees, adduction and external rotation of your calves, and quickly abduct and straighten your knees. At this time, the pain point of the lateral meniscus is pressed, and the thumb takes the opportunity to press the anterior corner of the meniscus inward and press the edge of the meniscus along the joint space, and occasionally the closing sound of meniscus rupture can be heard.
1.4.2 medial meniscus injury
(1) pronation knee flexion: suitable for acute medial meniscus incarceration. The operation method is similar to the "external rotation over-extension knee flexion method", but it should be the over-extension knee flexion joint in the passive internal rotation posture of the calf.
(2) Rotating knee extension and pressing: it is suitable for mild tear of medial meniscus. Similar to the manipulation of lateral semilunar laceration, but in the knee flexion posture, the leg should be abduction, internal rotation and adduction, while the knee joint is straight, and the other hand (thumb against the anterior corner of the medial meniscus and the other four fingers are held outside the knee joint) is reset in the same way.
1. 1.5 physical therapy
Physical therapy can dilate blood vessels, promote blood circulation and reduce tissue edema. Liu Jincai et al [2] reported that micro-current stimulation can induce and accelerate chondrocyte differentiation and proliferation, accelerate collagen and matrix synthesis, and promote injury healing. The injured meniscus was also stimulated by 5~20uA DC, and the affected area healed 6 weeks earlier. Huang Feilong et al [3] used semiconductor laser to irradiate pain points or tender points, and compared with ultrashort wave. After five treatments, the effective rate in semiconductor laser group was 76.9%. The effective rate of patients in ultrashort wave group was 50. 0%. Physical therapy such as TDP, infrared ray, microwave, short wave and interference electricity can also be used.
1. 1.6 TCM therapy
(1) Oral administration of Chinese medicine: Chinese medicine can act on meniscus cartilage and perichondrium cells on the surface of meniscus, and promote the healing of injured meniscus through internal growth. Huang Xiaohan uses Jingutongxiao Pill (pharmaceutical composition: Radix Salviae Miltiorrhizae, Radix Aconiti Lateralis Preparata, Ramulus Cinnamomi, Radix Paeoniae Alba, Rhizoma Chuanxiong, etc. ) sanqi jiegu powder (drug composition: sanqi, frankincense, myrrh, angelica, peony, poria cocos, pyritum, etc. ) to treat this disease. Zheng Huaixian's TCM treatment has also achieved certain results.
(2) External application or fumigation of traditional Chinese medicine: 1No. External application prescription: 50 grams of Bletilla striata, 50 grams of Radix Paeoniae Alba, 50 grams of melon seeds, 50 grams of Cortex Albizziae, 50 grams of Radix Dipsaci, 50 grams of Rhizoma homalomenae, 65,438 06 grams of Eupolyphaga Seu Steleophaga, 65,438 06 grams of Radix Polygalae, and Rhizoma Dioscoreae Septemlobae.
1. 1.7 acupuncture
Whether for acute injury or postoperative rehabilitation, acupuncture has the functions of relieving pain, reducing swelling, improving metabolism and promoting blood circulation. Main acupoints: inner knee eye, calf nose, Yanglingquan and Ququan. Matching points: Hanging Bell, Xiaxi, Yinlingquan, Xue Hai, Liang Qiu, Zusanli, etc. Four main points were selected at a time, and 2~4 matched points were selected, with the eyes in the knee and the nose of the calf as a group, and Yanglingquan and Ququan as a group. The points were connected with an electro-acupuncture stimulator, and the waves were dispersed in the acute phase and in the chronic phase for 30min, and the matched points were not connected with an electric stimulator.
2 surgical treatment
Meniscus injury is a common disease of knee joint. Since Brodhurst first reported the combined open meniscectomy, it has been a common treatment for meniscus injury for more than 0/00 years. However, it is found that the removal of meniscus will lead to the disorder of load conduction of knee joint, thus accelerating the degenerative changes of articular cartilage. Some authors believe that the meniscus can regenerate after excision, but it has no normal meniscus shape.
The symptoms and signs are obvious, and the injured meniscus should be surgically removed as soon as possible, or the torn part should be removed or the stitched meniscus repaired to prevent traumatic arthritis. If the patient is young, the injury is located in the blood supply area, the ligament is intact, and the torn meniscus should be sutured as much as possible; If the patient is older and the injury is located in an area without blood supply, part of meniscus tear should be removed. Some scholars have followed up meniscectomy patients for an average of 4 ~ 18 years. The results showed that the highest satisfaction rate of curative effect after meniscectomy was 86%, and the lowest was 42%. 5%. The quadriceps femoris began to do static contraction exercise on the second day after operation, and began to do straight leg lifting exercise 2 ~ 3 days later to prevent quadriceps femoris muscle atrophy. After two weeks, he began to walk on the ground and generally returned to normal function 2 ~ 3 months after operation.
2. 1 arthroscopic surgery
Keelchi 1979 performed arthroscopic meniscus repair for the first time in Tokyo, Japan. Henning et al. took the lead in arthroscopic meniscus repair in the United States in 1980. Arthroscopic treatment of meniscus injury includes arthroscopic partial meniscectomy, meniscus plasty and meniscus suture. Arthroscopic meniscus suture is the most commonly used method, and there are three basic methods of arthroscopic meniscus suture: from inside to outside, from outside to inside, and total internal suture. Hotibe et al [4] reported that the complete cure rate was 73. The partial cure rate was 65438 09.0%. M ariani et al [5] reported that the excellent and good rate of suturing from outside to inside was 77.3%; Scott et al. [6] used the posterior incision of knee joint to repair meniscus under arthroscopy, and followed up 260 patients. The clinical manifestations of meniscus were 92% stable, 665438 0. 8% was cured. 16. 9% partial healing and 2 1. 2% did not heal. Tearing of meniscus edge can be repaired by suture, usually by partial meniscectomy, leaving an undamaged part. For those who are suspected of meniscus injury at an early stage, emergency arthroscopy is feasible, and meniscus injury can be treated at an early stage, which can shorten the course of treatment, improve the therapeutic effect and reduce the occurrence of traumatic arthritis. Arthroscopic surgery has the advantages of less trauma, quick recovery and high success rate. In addition, with the maturity of arthroscopic technology, laser and its adhesive have also been applied to arthroscopic surgery for meniscus suture and "welding".
In recent years, arthroscopic treatment of meniscus injury has made the following progress:
(1) In order to avoid and reduce the adverse consequences after total meniscectomy, arthroscopic total meniscectomy was changed to partial meniscectomy.
(2) Most scholars have come to the conclusion through the clinical and research of arthroscopic partial meniscectomy that the meniscectomy should not exceed the damaged or unstable part; At the same time, try to keep a concave and smooth meniscus edge and fibrous ring around the meniscus, especially near the popliteal hole of the lateral meniscus. Partial meniscectomy is superior to total meniscectomy. It is suggested that the degenerated meniscus should be preserved without affecting the biomechanics of normal joints.
(3) After partial meniscectomy, although some meniscal functions can be preserved, it is definitely not as good as complete meniscal. Even if a small part of meniscus is removed, it will cause abnormal pressure and lead to early degeneration of meniscus cartilage. The more meniscus should be preserved, the better. The best way is to sew up the rupture to make it heal. So repair the damaged meniscus as much as possible.
2.2 Allogeneic meniscus transplantation
In recent twenty years, more and more attention has been paid to the reconstruction of meniscus by allogeneic meniscus transplantation. The experiment of meniscus transplantation in sheep by szomor et al. proved that compared with total meniscectomy, autologous meniscus transplantation and allogeneic meniscus transplantation can reduce articular cartilage damage. There is no significant difference in articular cartilage injury score between autologous meniscus and allogenic meniscus transplantation, which proves that allogenic meniscus transplantation has a certain protective effect on articular cartilage. In the experiment of meniscus transplantation of dog knee joint, it was observed that the cartilage tissue of meniscus not only survived, but also had the function of synthesis and secretion, and the implanted allogenic meniscus could maintain its original basic tissue structure. No infiltration of monocytes and lymphocytes was found in the observation, which proved the possibility of meniscus allograft from immunology and histology. There is no clear clinical standard for the indications of meniscus transplantation.
Since 1984, Milachowski and others successfully applied allogeneic meniscus transplantation to treat severe meniscus injury for the first time, this surgical method has been gradually recognized in clinic, and the related surgical techniques and basic research have been enriched and improved accordingly. In order to avoid the adverse consequences of meniscectomy, allogenic meniscus transplantation has been carried out abroad, but it has not been widely carried out in China.
Zhang Yadong et al. performed minimally invasive arthroscopic meniscus transplantation on 12 patients with meniscus injury. All patients had no collateral injury, slight swelling of joints and no wound exudation in the early stage. Two weeks after operation, the wound healed well. Six weeks after operation, the joint swelling basically disappeared. Follow-up for 6- 17 months (average 10.3 months) showed that the patient's walking function was normal, and the average range of motion of knee joint was not significantly different from that before operation. Postoperative knee pain score was significantly lower than that before operation (P
The short-term and medium-term results of meniscus transplantation are satisfactory, and the long-term survival rate needs to be further improved. It is still in doubt when the biomechanical function of knee joint will return to normal or close to normal after meniscus transplantation. The long-term effect of meniscus transplantation is still controversial, especially the motor ability of young patients after transplantation is limited to some extent, which shows that the current meniscus allograft technology still needs further research and improvement.
Knee joint is the most complicated joint of human body, and meniscus, as a device to stabilize knee joint, has been paid more and more attention in recent decades. In the pursuit of high quality of life today, how to treat meniscus injury with the best method is still the key research direction of researchers. Arthroscopic suture and meniscus transplantation still have a lot of research space. I hope that through the efforts of all researchers, we will make greater achievements in the treatment of meniscus injury!
References:
[1] Pan Xianfeng, progress in clinical treatment and experimental research of meniscus injury [J], China Journal of Sports Medicine, 200 1, 20 (2): 194- 195.
[2] Liu Jincai, Huang Haiyang, Histological characteristics of anemic meniscus healing by electromagnetic stimulation [J], Chinese Journal of Orthopaedics, 1996, 16 (1): 47-49.
[3] Huang Feilong, Wang Huifang, Wang Yubin, observation on the treatment of meniscus injury of knee joint with traditional Chinese medicine [J], sports literature,1959,4 (2): 26.
Horiba, Lin Xiya, Nakata, et al. The Second Arthroscopic Meniscus Repair: 132 Summary of Arthroscopic Meniscus Repair [J ].j Bone, Joint Surgery,1995,77: 245-249.
Mariani P, Sant ori N, Adriani E, et al. Accelerated rehabilitation after artificial hip replacement: a clinical and MRI evaluation [J]. A total hip arthroscope, 1996, 12:680 -686.
[6] A.L. Brecht 2 Olsen P, Kristensen G, Burgaard P, et al. Comparison of arc suture and horizontal suture in arthroscopic meniscus repair: a prospective randomized study on arthroscopic evaluation [J]. Traumatic surgery of knee joint, 1999, 7:268-273.