Jonathan Bell FRCS (ORTH) – Meniscus Tears and other Complex Injuries of the Knee – Injury Rehab Network

The second Injury Rehab Network event of October 2023 with BASRaT featured Mr Jonathan Bell, Orthopaedic Consultant. The online event took place on the evening of 19th October with 500 sports rehabilitation professionals in attendance.

Jonathan’s presentation discussed the treatment and rehabilitation of sports knee injuries.

The recording of Mr Bell’s presentation is available to watch here

Mr Jonathan Bell FRCS (ORTH), Orthopaedic Consultant, Wimbledon Clinics

Jonathan is an orthopaedic consultant exclusively treating patients with knee problems. He has a wealth of experience in all aspects of knee surgery, including arthroplasty in the sportsman. Indeed, the vast majority of his surgery relates to a sports injury or a desire to return to sports or just remain active. Sports men and women, particularly skiers, travel from all over Europe to seek his opinion.

Jonathan set up Wimbledon Clinics over 20 years ago. He is passionate about multidisciplinary work and, as such, has built up a unique team of specialists. Despite being a busy surgeon, Jonathan believes in offering expert nonsurgical care within the clinic, and this encompasses all aspects of care, including sports medicine. He is an ideas person who is constantly looking for novel ways of working and collaborating with local practitioners, particularly through education. He has, for the last three years, run online MDT/ educational meetings. Jonathan treats from the once-a-week five-side footballer through to elite athletes, but his underpinning rationale is to keep the active active.

In addition, Jonathan advises a number of companies, including the insurance industry, pharma, Biotech, and imaging.

Jonathan is married to Claire Robertson (a consultant physiotherapist specialising in patella femoral and fat pad). They have two children, a dog and two alpacas. When not working, Jonathan likes being outdoors, hiking, fishing, and skiing.

Meniscus Tears and other complex injuries of the Knee

Jonathan’s presentation considered the treatment and rehabilitation of sports knee with a focus on meniscus tears and other complex injuries of the knee. Mr Bell discussed links with ACL injuries and controversy associated with meniscus tears.

Introduction

Mr Bell summarised the learning outcomes for the presentation whereby, at the end of the talk, practitioners should:

• Be clear on the impact of meniscal surgery
• Why do we like repair
• Techniques
• Special situations
• When it fails

What is the purpose of the meniscus?

Jonathan described how meniscus are important structures that provide a shock absorbing and stabilising function. When the meniscus is torn or removed, there is a very substantial decrease in contact area.

Jonathan compared the additional force on the knee when the meniscus is torn as being like the difference between treading on someone’s foot with a high heel compared to a flat shoe.

Studies show that patients who don’t have a torn meniscus repaired are four times more likely to develop osteoarthritis at long-term follow-up. Radiological signs of osteoarthritis are significant at ages 8-16 years.

What is the problem?

Mr Bell discussed how the medial meniscus (MM) deepens and widens the saucer around the knee joint. It improves stability and is more fixed to the tibia.  Removal leads to peak loading (high heel analogy), articular cartilage breakdown and then osteoarthritis.

Jonathan described how the lateral meniscus (LM) converts a dome to a dish and assists with rotational and dynamic stability. Loss increases rotational instability. The LM is less well-fixed than the MM.

Jonathan presented an image of the meniscus showing the blood supply. There are two zones: the red zone, which has a good peripheral capsular blood supply, and the white zone, with limited blood supply, which is metabolically much less active. Blood supply penetrates the white zone much more in teens. Mr Bell considered how a good blood supply is needed to heal.

Elite Sports

Jonathan discussed how meniscectomy affects elite sports with impacts on return to play and differences between LM and MM.

The problem with meniscus tears

Mr Bell considered the complexities of meniscus tears, including:

• The pattern of tear
• Location of tear
• Condition of the meniscus immediately before the tear
• Each pattern behaves differently
• LM is different to MM

Meniscus Repair Techniques

Jonathan described different techniques for meniscus repair, including:

• Outside in
• Inside/ out
• All inside

When comparing the results of different surgical techniques, Jonathan stated that healing times are similar, with failure rates at around 10% to 20%. Neurological injuries and operation time are higher with inside-to-out techniques.

Enhancement of Healing

Jonathan described that there is no magic wand to enhance healing. A fibrin clot can be placed into the tear before tightening sutures (Henning method). PRP is more anti-inflammatory rather than improving healing. Mr Bell stated that simultaneous ACL reconstruction improves healing due to the increase in blood around the joint. NSAIDs don’t affect healing. Stem cell research is still a work in progress.

Who/ What to Repair

Mr Bell discussed considerations for meniscus repair:

• Patients under 40
• Teenagers (all)
• No comorbidity (diabetes/ OA/ RA/ obesity)
• Likelihood of compliance
• Avoid in (horizontal tear), complex tear, parrot beak, extrusion unless young with root tear
• Repair has to be tension-free, meniscus-reducible and not stretched or misshapen.
• Blood supply
  • Peripheral simple vertical tear
  • Radial tear in a teenager
  • Root tear
  • Incomplete peripheral tear – trephine

Do they do well?

Jonathan discussed the success of meniscus repair, where failure is between 10-24%. There are, however, higher failure rates in adolescents with complex tears. Some studies on elite athletes show that return to play can be as long as 7-8 months.

Post-Op – Menisectomy vs Repair

Mr Bell considered the differences following meniscectomy and repair procedures:

Meniscectomy

• Full weight bearing
• 4-5 days take it easy
• Rehab 5-7 days
• 20 mins bike two weeks
• Earliest back to sport 6/7 weeks
• Eight weeks + for lateral meniscus

Meniscal repair

• Weight-bearing with crutches to slow them down
• No flex beyond 90 degrees for six weeks
• No brae unless concerns about compliance
• No squat for 3 to 4 months
• No run for 3 to 4 months

Failure

Jonathan considered some of the factors and signs associated with failure following meniscus surgery:

• Just don’t settle
• Persistent discomfort
• Low-grade effusion
• Creaky knee
• Tender joint line
• Mechanical symptoms
• MRI may not be that helpful
• 30% of failures occur after two years
• The majority of failures are apparent after six months

Esoteric Repairable Lesions

Jonathan described how these lesions are always associated with ACL rupture, and repair improves the stability of the knee. Not all lesions require repair, and trephination may be effective.

Radial tear in teens

Mr Bell described how he has only completed repairs of radial tears in teens. Some parts will be in the white/ white zone with limited blood supply, and Jonathan, therefore, recommends the use of a fibrin clot. The patient will need to non-weight bear for up to 6 weeks. A review showed that 60% healed, 30% part healed, and 8% failed (Milliron 2021).

Root Tears

Jonathan described how virtually every root tear will be degenerative. Any osteoarthritis is a contraindication. In the rare instance that root tears occur in teens/ young adults, Jonathan may consider a repair. The patient may need at least six weeks of non-weight bearing.

Degenerative Tears

Jonathan discussed how horizontal cleavage tears are degenerative tears and could almost be thought of as early osteoarthritis. Fragments in the medial recess don’t do well with non-operative treatment. Large fragments or tears may damage joint surfaces and cause mechanical problems.

Clunking knee in a teenager

Jonathan considered how a clunking knee in a teenager should be treated as a peripheral lateral meniscus tear until excluded by arthroscopy. Jonathan noted that the MRI would be normal and recommended that the patient be treated by a knee surgeon familiar with teens and meniscal repair.

Meniscus in the ACL injured knee

Mr Bell described how 1/3 of ACL ruptures have meniscal tears. He noted that there is debate about who should have surgery for the ACL rupture and whether reconstruction should take place immediately or delayed until after failed rehab.

What additional factors influence the outcome?

Jonathan discussed how the outcome may be influenced by stability, strength and psychological factors. Every month of delay increases the risk of a tear of the medial meniscus. The incidence of osteoarthritis can vary but is typically 40% – 80%. Jonathan noted that no studies show that osteoarthritis can be prevented completely.

Jonathan considered studies by Shelbourne, LouBoutin and Selmi into ACL surgery and osteoarthritis (OA). Over 17-20 years, the studies compared surgery vs non-operative approaches. In the surgery group, 50% had OA and 16% with severe OA. In the non-surgery group, everyone had OA, and 56% had severe OA.

Summary

Mr Bell summarised the key points covered in the presentation:

• Meniscii perform an important role in joint homeostasis
• Loss leads to instability, damage and osteoarthritis
• Preservation is key
• ACL literature illustrates these points very well

Q&A

Jonathan kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for the insights from Mr Bell to the questions.

Presentation Recording

The recording of Jonathan’s presentation is available to watch here

Follow Mr Jonathan Bell

• X: @bellkneesurgeon
• Wimbledon Clinics Website

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