Arthroscopic Partial Meniscectomy (Meniscus Removal) 微創半月板切除

Dr. Adrian Leung > Arthroscopic Partial Meniscectomy (Meniscus Removal) 微創半月板切除

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menisectomy

Background 背景

Meniscectomy is to remove the fragments of the torn meniscus which is not amendable for repair.

There are two menisci in knee, Medial (inner) and Lateral (outer). They are C-shaped and fit between the Femur (thigh), which has a curved surface for rotation and the Tibia (shin), which has a flat platform. Apart from allowing surface contact rather than point contact (a curve on a flat surface), the meniscus also provide stability. 

When the meniscus is torn, a common injury commonly happened when one sprains his knee, the stability of the knee will be compromised, and the knee will degenerate much quicker. There will be pain, and episodic swelling.

Repeated injury to the torn meniscus will ensure further propagation of the tear. This in turn will hasten the degeneration.

For patients who are young and active, arthroscopic repair is indicated. But for older patients, or if the torn is degenerative or complex, or fragments are too small to repair, removing these fragments and trimming the edge to smooth surface do benefit. Trimming the surface allows better conformity of the articulating surface, it also helps stopping tear propagation. And if there are fragments, they might cause scratching of the cartialge, called third body wear.

Meniscus can be shaved by minimal invasive technique, which is now standard procedure rather than open technique.

After partial removal, there is no requirement for protection, and patient can walk unaided right after.

The followings are additional surgical procedures, addressing different concomitant pathologies,

  1. Meniscal repair
  2. Chondroplasty
  3. Microfracture
  4. Loose body removal
  5. Platelet Rich Plasma injection

半月板修復就是把撕裂的半月板縫合。

膝關節有兩塊C形的半月板，內側（內側）和外側（外側）。它們在表面有弧面的股骨（大腿）和表面是平面的脛骨（脛骨）之間。有了半月板，弧面跟平面就不再是點接觸（曲線跟平面的接觸）而是整個表面的接觸之外。此外，半月板還增加了膝關節的穩定性。

半月板撕裂是一種膝關節扭傷時常見的結構受損。半月板撕裂會令膝關節的穩定性降低，所以膝關節會經常再扭傷，撕裂會越來越大，其他結構也會受影響，包括軟骨。而且，由於膝關節的接觸面積會不平滑，伴隨碎塊，會把軟骨刮傷，所以膝關節的退化速度會越來越快。期間會出現疼痛和水腫積液。

對於年輕或生活比較活躍的患者，一般會建議進行關節鏡下修復。但如果年紀比較大，或撕裂複雜甚至碎塊多，移除碎片及部份半月板以令表面平滑及貼服，不僅有助改善功能，減少疼痛和腫脹，而且也可能減緩退化過程。

通過微創技術切除半月板已是標準程序。開大刀在過去十年已經十分罕見。

切除部份半月板後，無需要保護及拐杖，可即時負重走路，亦不需要配戴支架。

以下是針對不同同時出現的傷患而附加的外科手術程序，

Indication 適應症

  • Medial Meniscus tear, peripheral and middle zone, anterior horn, body, and posterior horn 內側半月板撕裂，周邊和中部區域，前角，中位和後角
  • Lateral Meniscus tear, peripheral and middle zone, anterior horn, body, and posterior horn 外側半月板撕裂，周邊和中部區域，前角，中位和後角
  • Medial meniscus root avulsion, anterior and posterior 內側半月板撕脫
  • Lateral meniscus root avulsion, anterior and posterior 外側半月板撕脫

Preparation 預備

  • Pre-op workup 手術前身體檢查
  • Walking >10000 steps a day 堅持每天1萬步強化背及腿肌
  • Do more deep breath 多深呼吸
  • Continue usual medication on operative day 手術當天照常食藥
  • No food or drink for 6 hours 手術前6小時禁食及禁喝水
  • Admit to hospital 3 hours before surgery  手術前3小時到醫院
  • Inform your relative despite surgery takes less than 2 hours, you will return no earlier than 3 hours. 通知家人即使手術只需2小時，但回病房可能是3小時後
medial meniscus viewing from front 從前方看內側半月板
lateral meniscus viewing from front 從前方看外側半月板

Risk 風險

While all medical and nursing professionals endeavor to provide best and safest practice, complications still would occur.
General operative risks including heart attack, stroke, wound infection, wound hemorrhage, urinary tract infection, deep vein thrombosis, scar pain, unsightly scar, wound gapping and even failure to heal, etc, is possibly encountered.

Nerve and vascular injury are rarely occurred risk but can be catastrophic with paralysis, loss of sensation and even limb loss. Anatomical variants also carry more risk.

Persistence of symptom and recurrence is around 16%, but this is the natural course rather than complication.

儘管醫生和護士都會盡最大努力提供最佳和最安全的治療，但併發症仍會發生。

一般手術可能會遇到的風險，包括心臟病發作，中風，傷口感染，傷口出血，尿道感染，深層靜脈血栓形成，傷口疼痛，外觀不理想甚或傷口不癒等，這手術也不例外。

神經及血管損傷是很少遇上，但可導致災難性癱瘓，失去知覺甚至截肢。先天結構異常也會有更高的風險。

持續病癥不改善或復發大概為16%，但應屬這傷患的自然進程，不屬併發症。

Budget Estimation 預算費用 (Hong Kong 香港)

CPT code and RVU is as follows

  • 29881 partial menisectomy, RVU 7.03
  • 29877 chondroplasty, RVU 8.3
  • 29879 Microfracture, RVU 8.99

CPT碼和RVU如下

  • 29881　半月板切除術，RVU 7.03
  • 29877　軟骨打磨，RVU 8.3
  • 29879　微骨折，RVU 8.99

Estimation based on general ward as in Aug-2020,

  • Surgeon fee $28,120
  • Anaesthetist fee $9,373
  • Ward round $1,200/day
  • Hospital charge $25,000

Total around $64,893

根據普通房於2020年8月進行的估算，

  • 外科醫生費$28,120
  • 麻醉師費 $9,373
  • 巡房費$1,200
  • 醫院費$25,000
  • 總計 $64,893  左右
ATFL reconstruction 前距腓韌帶重建

Reference figures from private hospitals　醫院提供的參考數據

St Paul’s Hospital 聖保祿醫院

Median Charge 收費中位數　

  • Doctors’ fee 醫生費 $43,000
  • Hospital charge 醫院收費 $21,395
  • Total 總費 $64,395

Reference website

Cannosa Hospital 嘉諾撒醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 $31,003
  • Hospital charge 醫院收費 $23,715
  • Total 總費 $54,718

Reference website

Baptist Hospital 浸會醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 $36,600
  • Hospital charge 醫院收費 $22,261
  • Total 總費 $58,861

Reference website

Adventist Hospital 港安醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 $44,500
  • Hospital charge 醫院收費 $23,495
  • Total 總費 $67,995

Reference website

Post-op care 術後照顧

  • Control inflammation with regular usage of anti-inflammatory drug.
  • Apply cool pad (not ice pad) to the knee 30min 3 times a day.
  • If you have Cool-Pulse, use it as instructed.
  • Keep the knee above chest (sleep with 2 pillows supporting the calf, lie on floor and put calf on chair)
  • Tighten up your thigh and calf muscle 10 repetitions every 2 hours when you are awake.
  • Push the knee back against a flat and hard surface to straighten it, to prevent joint contracture.
  • You can walk without stick but using one might decrease the pain while you walk.
  • Stay home for first 3 days. Do not walk more than 3000 steps in first week, gradually increase to not more than 6000 steps a day in 2 weeks time.
  • The wound is covered by a waterproof dressing. After 2 weeks, you can shower after carefully remove the boot temporarily, but do not take bath or rub on it. Keep the dressing intact, there is no need to change it regularly.
Hamstring graft 將會用於重建的大腿後肌腱
Concommitant CFL tear 伴隨的跟腓韌帶撕裂
  • 定時服藥，控制發炎
  • 每天3次在膝蓋上敷涼墊（不是冰墊）30分鐘。
  • 如果您有Cool-Pulse，請按照指示使用它。
  • 將腳放高於胸部（躺下時用2個枕頭抬高小腿；平時躺在地上，將小腿放在椅子上）
  • 當不是睡覺時，每2小時收緊大腿和小腿肌肉10次。
  • 將膝蓋向後壓到平而堅硬的表面．例如窗台，避免關節萎縮。
  • 你不必使用拐杖，但以手仗步行可減少不適。
  • 手術後頭三天不要留家休息。第一周不要走超過3000步，在2週內逐漸增加到每天不超過6000步。
  • 傷口已用防水敷料覆蓋。所以2星期後，您可以脫下固定靴淋浴，但不要浸澡或捽這敷料。你只需保持敷料完整，無需定期更換它。

Early Post-op Complication　手術後早期併發症

Notify surgeon in case you have

  • Persistent fever of more than 37.5 Celcius
  • Chills and rigor
  • Wound pain despite rest
  • Wound redness and swelling
  • Purulent discharge from wound
  • Calf pain
  • Ankle swelling, progressive
  • Sudden onset of shortness of breath
  • Chest pain

如發現以下情況，要立即通知醫生

  • 持續高燒（口探高於攝氏37.5度）
  • 發冷打顫
  • 無論運動或休息時，傷口痛楚都持續增加
  • 傷口持續發紅腫脹
  • 傷口有膿液
  • 小腿愈見痛楚
  • 小腿、腳踝和腿部腫脹持續增加
  • 突發性的氣促
  • 胸口突然疼痛
Concomittant talar neck near fracture伴隨距骨受傷
Concomittant talar neck near fracture伴隨距骨受傷
Operative wound 手術刀口
Operative wound 手術刀口

Rehabilitation after Day 14 手術後2週復健

Exercise of calf and thigh muscles:

  1. Quadriceps contraction:
    Sit on chair, with your cast on, straighten the knee, count 15 seconds, and then relax. Rest for 10 seconds and repeat 10 times.
    When you have regained strength, lower your body with arm supporting with crutches or with a table, do light squat, hold 90 seconds, with interval rest, 10 repetitions, 4 times a day.
  2. Calf contraction:
    Sit on chair, tighten your calf muscle, count 15 seconds, and then relax. Rest for 10 seconds and repeat 10 times.
    When you have regained strength, do tip toe standing, hold 90 seconds, with interval rest, 10 repetitions, 4 times a day

Range of Motion exercise:

  • Put the foot on floor, slide the foot backward on floor, to increase knee bending angle.
  • Continue stretching exercise to ensure the knee is straight. You can compare to the normal side.

Further strengthening and return to sports:

  • You can sit in the office for a long hours in 2 weeks after the operation, and go running no earlier than 3 to 4 months.
  • Increase the amount of activity gradually and avoid strenuous exercise, especially running, kicking and jumping.
  • Sex life can start at 6 weeks after surgery.
  • Avoid excessive knee fatigue within one year.

小腿和大腿肌肉的運動:

  1. 大腿四頭肌收縮：
    坐在椅子上，全神貫注下伸直膝蓋，保持伸直並數15秒，然後放鬆。休息10秒鐘，重複10次。
    肌力漸恢復後，以上肢支撐慢慢到淺蹲，保持90秒，間隔休息，重複10次，每天4次。
  2. 小腿收縮：
    坐在椅子上，收緊小腿肌肉，數15秒鐘，然後放鬆。休息10秒鐘，重複10次。
    肌力漸恢復後，做趾尖企，保持90秒，間隔休息，重複10次，每天4次。
  1.  

運動範圍：

  1. 將腳放到地板上，慢慢拉回，以增加膝屈曲角度。
  2. 繼續壓膝，避免膝關節萎縮。

進一步加強肌力並重返正常運動：

  1. 您可以在手術後2週返回辦公室坐較長時間。需超過3個月才開始跑步。
  2. 逐漸增加運動量，避免劇烈運動，尤其是跑步，踢腿和跳躍。
  3. 性生活可以在手術後6週開始。
  4. 一年內避免膝關節過度疲勞。
Reference 參考文獻
  1. Ewa M Roos, Kristoffer Borbjerg Hare, Sabrina Mai Nielsen, et al. Better outcome from arthroscopic partial meniscectomy than skin incisions only? A sham-controlled randomised trial in patients aged 35–55 years with knee pain and an MRI-verified meniscal tear. BMJ Open. 2018; 8(2): e019461. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829931/
  2. Simon G F Abram, Andrew Judge, David J Beard, Andrew J Price. Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England. Lancet. 2018 Nov 17; 392(10160): 2194–2202.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238020/