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4. Rekonstruksi Meniscus dengan jahitan khusus

REKONTRUKSI MENISCUS DENGAN JAHITAN KHUSUS

Oleh Dr H Subagyo SpB - SpOT

 

ANATOMI MENISCUS

Ada satu meniscus pada setiap sisi sendi lutut.Meniscus berbentuk C - medial berada di bagian yang lebih dekat ke tengah / medial tubuh.Meniscus berbentuk U - lateral berada di bagian lebih jauh keluar dari pusat tubuh / lateral tubuh.

Meniscus melindungi tulang rawan artikular pada permukaan tulang femur dan tulang tibia.Artikular tulang rawan adalah materi halus, licin yang menutupi ujung tulang yang membentuk sendi lutut. Artikular tulang rawan sendi memungkinkan permukaan untuk saling bergesekkan terhadap satu sama lain tanpa merusak permukaan.

 

Gambar dari meniscus anatomi.

Sumber :http://www.mendmeshop.ca/_img/webmenisci.jpg

Sebagian besar, meniscus adalah avascular, yang artinya tidak ada aliran pembuluh darah.Hanya permukaan luar dari meniscus saja yang mendapat sedikit pasokan darah, dan daerah ini disebut zona merah.Bagian meniscus, paling dekat dengan pusat lutut, disebut juga zona putih, yang tidak memiliki aliran pembuluh darah sama sekali. Meskipun tepi luar meniscus ( zona merah ) memiliki peluang bagus penyembuhan, namun kerusakan lebih lanjut sehingga menuju ke bagian pusatmeniscus, tidak akan sembuh dengan sendirinya. Kerusakan zona putih meniscus sering membutuhkan pembedahan.

 

Gambar dari zona – zona meniscus.

Sumber :http://www.eorthopod.com/sites/default/files/images/knee_meniscus_surgery_anatomy03.jpg

Meniskus adalah bantalan tulang rawan / sendi lutut yang berbentuk seperti cincin yang berfungsi seperti shock absorber/penahan benturanuntuk melindungi lutut.Meniskus juga penting bagi stabilitas lutut.Ketika meniskus rusak, maka sendi lutut dapat menjadi longgar, atau tidak stabil.Tanpa perlindungan dan stabilitas meniscus yang sehat, maka permukaan lutut dapat mengarah ke suatu kondisi yang disebut osteoarthritis.

ETIOLOGI

Cedera pada struktur ini sangat sering terjadi dan sebagian besar dikarenakan olah raga antara lain sepakbola/ futsal, tenis, badminton  dan bola basket. Biasanya berupa cedera saat lutut terpuntir (twisted knee) mendadak dan satu atau kedua meniscus terperangkap diantara tulang femur dan tulang tibia.

Meniscus ini pun dapat robek ketika bagian dalam ligament dan sekitar lutut terobek. Pada usia lanjut meniscus dapat kehilangan konsistensi elastisitas dan kelunakannya. Dengan kelemahan struktur ini maka meniscus akan lebih mudah terobek.

 

Gambar meniscus yang robek.

Sumber :http://www.workoutmd.com/injuries/image-injuries/MeniscusInjury.jpg

 

Gambar dari jenis – jenis meniscus yang robek.

Sumber :http://www.jockdoc.ws/subs/pix/07bMeniscus.jpg

 

Gambar dari meniscus.

Sumber :http://www.regenexx.com/tag/meniscus/

 

Gambar dari normal meniscus.

Sumber :http://www.yorkshirekneeclinic.co.uk/images/C3.jpg

 

Gambar dari abnormal meniscus.

Sumber :http://www.orthopedie-genou.com/en/meniscus/images/lesione_complessa_menisco.jpg

GEJALA – GEJALALESI MENISCUS

Cedera meniscus, biasanya akan menimbulkan rasa nyeri tajam pada sisi lutut yang mengalami cedera. Nyeri awal dan bengkak akan hilang, akan tetapi akan terus mererus merasakan nyeri tajam ketika berputar mendadak. Lutut mungkin akan terkunci ketika bergerak fleksi atau ekstensi, atau anda mungkin tidak akan mampu bergerak fleksi atau ekstensi secara bebas.

DIAGNOSIS

Untuk mengetahui mekanisme cedera dan gejalanya adalah penting.Diagnosis lanjut untuk kerobekan lutut, adalah perlu untuk dilakukan tes atau manuver yang tepat. X - ray pada lutut biasanya dianjurkan untuk meyakinkan bahwa tidak ada degenerasi sendi, kelonggaran sendi, atau abnormalitas tulang yang lain. Bagaimanapun, meniscus merupakan jaringan lunak jadirobekan tidak terlihat pada X –ray, karena robekan meniscus hanya terlihat dengan MRI (magnetic resonance imaging), maka dari itu diagnosis hanya dapat ditegakkan dengan menggunakan MRI.

 

Gambar dari MRI meniscus yang robek.

Sumber :http://www.orthoassociates.com/SP11B39/MRI_Meniscal_tear.jpg

PENANGANAN

Tergantung dari tipe dan lokasi robekan dan berat-ringannya gejala, maka penanganan non - operasi dapat dicoba.Untuk cidera meniscus disini termasuk peranan fisioterapi untuk memelihara atau meningkatkan kekuatan otot dan lingkup gerak sendi, modifikasi aktifitas, pengobatan anti inflamasi, pemakaian penyangga lutut (deker).Umumnya, 1 sampai 3 bulan sebagai waktu yang diharapkan untuk kemajuan secara signifikan.

 

Gambar dari deker lutut.

Sumber :http://u.kaskus.us/2/auixeknv.jpg

PROSEDUR OPERASI

Pasien yang tidak mengalami kemajuan dengan penanganan non - operasi maka akan membutuhkan penanganan operasi. Kebanyakan robekan diambil atau diperbaiki, tetapi sekitar 10%robekan yang baru atau akut dapat dipulihkan dengan operasi.Robekan yang terjadi pada tepi paling luar dari meniscus mempunyai kesempatan yang lebih baik untuk penyembuhan ketika diperbaiki dari pada pada bagian yang lebih jauh dari sendi. Pada lingkaran yang paling luar terdapat pembuluh darah yang lebih banyak untuk membantu proses penyembuhan.

Cedera robek meniscus dapat menyebabkan gejala nyeri, bengkak, dan menimbulkan gerakan yang kaku.Tujuan pembedahan adalah untuk menghilangkan gejala ini, dan bertujuan untuk memperbaiki meniscus.Bagian yang cedera harus dihilangkan, dan hanya sejumlah kecil meniscus yang diambil keluar.Menjaga daerah sekitar meniscus sangatlah penting untuk menjaga lutut sehat. Jika meniscus masih mungkin untuk diperbaiki, maka hal ini akan lebih direkomendasikan.

 

Gambar dari arthroscopy lutut.

Sumber :http://www.eorthopod.com/images/ContentImages/knee/knee_meniscus_surgery/knee_meniscus_surgery01.jpg

Operasi meniscus dilakukan dengan menggunakan arthroscopy, dengan optik kamera TV yang kecil dan digunakan untuk melihat dan operasi di dalam sendi.Hanya potongan kecil diperlukan selama artroskopi.Ahli bedah tidak perlu membuka sendi lutut.Pembedahan dengan arthroscopy biasanya dapat dilakukan pada prosedur rawat jalan.

Dalam arthoscopy, maka akan dimasukkan instrument melalui dua atau empat pintu, dengan insisi kulit sepanjang 1cm. instrumen digunakan untuk melihat kerobekan pada meniscus. Untuk memperbaikirobekan meniscus, ahli bedah mungkin membutuhkan insisi yang lebih luas disekitar lutut. Pada lutut yang tidak stabil karena cidera ligament ( contohnya, kerobekan ligamentum cruciata anterior ), lebih diperhatikan untuk diperbaiki daripada kerusakan dari meniscus, hal ini dikarenakan ketidakstabilan lutut dapat menyebabkan robekan meniscus lebih jauh atau perubahan degeneratif.

Anestesi umum atau anestesi spinal akan dibutuhkan. Dua atau tiga insisi untuk membuat lubang kecil di lutut, yang disebut portal.Portal ini adalah adalah tempat dimana instrumen bedah arthroscope dimasukkan ke dalam lutut.Perlindungan pada saraf dan pembuluh darah tetap diperhatikan.

PARTIAL MENISECTOMI

Partial menisectomi merupakan prosedur untuk mengambil bagian yang rusak dari meniscus.Dimulai dengan memasukkan arthroscope ke salah satu portal. Sebuah probe dimasukkan ke portal lain. Semua bagian dari dalam sendi lutut akan diteliti melalui monitor. Ketika meniscus ditemukan, maka Instrumen bedah lainnya ditempatkan dalam portal lain dan digunakan untuk mengambil bagian meniscus yang robek.Alat pemotong digunakan untuk memotong dan membentuk potongan pada tepi meniskus.Larutan garam steril digunakan untuk membersihkan puing- puing dari cedera pembedahan, setelah itu portal ditutup dengan jahitan.

 

Gambar dari menisectomi.

Sumber :http://www.arthroskopi.com/admin/dinamik/resimekle/files/parsiyelmenisektomi.jpg

 

Gambar dari menisectomy.

Sumber :http://www.aclsolutions.com/images/Seif_meniscus%20blood%20supply.jpg

JAHITAN PERBAIKAN

Untuk memperbaiki meniscus, maka dilakukan jahitan perbaikan, yaitu dengan menggunakan arthroscope dan probe. Pembedahan digunakan untuk mendorong tepi meniscus yang robek secara bersama-sama. Kemudian tabung kanula dimasukkan melalui salah satu portal.Benang untuk melakukan jahitan meniscus dimasukkan melalui kanul dan masuk ke sendi lutut.Jahitan ke dua tepi meniscus dilakukan, untuk membuat robekan meniscus tersebut kearah yang berdekatan, sehingga bersatu.Jahitan tambahan dapat diletakkan berdampingan untuk meyakinkan posisi seluruh meniscus yang tetap.

 

Gambar dari operasi meniscus.

Sumber :http://www.jakarta-knee-center.com/images/penjahitan-meniscus-b.jpg

 

Gambar inside-out technique dengan vertical sutures

Sumber :http://www.rcsed.ac.uk/journal/svol1_6/10600002.html

 

Gambar dari outside-in technique dengan  horizontal sutures

Sumber :http://www.rcsed.ac.uk/journal/svol1_6/10600002.html

JAHITAN ANCHOR

Jahitan jangkar adalah perangkat khusus yang telah dirancang untuk melampirkan jaringan untuk tulang. Di masa lalu, banyak cara yang digunakan untuk melampirkan jaringan lunak (seperti ligamen dan tendon) untuk tulang. Metode yang biasa termasuk menempatkan jahitan melalui lubang bor di tulang, staples khusus dan sekrup dengan mesin cuci khusus.semuanya dirancang untuk menahan jaringan terhadap tulang sampai penyembuhan terjadi.

Jahitan jangkar telah menyederhanakan suatu proses dan menciptakan cara yang lebih kuat dari jaringan lunak yang melekat ke tulang. Alat ini cukup kecil yang dapat ditempatkan ke tempat yang layak dalam tulang melalui sayatan kecil menggunakan arthroscope. Sebagian besar perangkat ini baik terbuat dari logam atau plastik khusus sepertiimplant biodegradable, yaitu bahan yang dapat diserap oleh tubuh. Ini adalah jangkar.Jangkar ini dibor ditempat dimana ingin dipasang jaringan lunak.Jahitan yang melekat pada jangkar dapat melalui jaringan lunak dan terikat terhadap tulang.

Jangkar ini berbentuk seperti anak panah, ahli bedah menggunakan alat bedah untuk meletakkannya di bagian meniscus yang rusak.Biasanya hanya dua atau tiga panah yang diperlukan. Lesi yang lebih besar mungkin memerlukan sampai enam anak panah..Dibutuhkan sekitar enam bulan sebelum jangkar mulai diserap oleh tubuh.


 

Gambar dari meniscal arrow.

Sumber :http://sph.sagepub.com/content/1/5/438/F1/graphic-4.large.jpg

BIOSTRINGER INSERTION TECHNIQUE WITH BIO – ABSORBABLE DEVICE


FAST – FIX MENISCAL REPAIR SYSTEM

Fast – Fix meniscal repair system adalah implant yang berfungsi untuk fiksasi dari jahitan vertical mattress tanpa prosedur operasi invasive. Fast – Fix ini memungkinkan operator untuk memasang dua implant secara vertikal maupun horizontal, dapat mengencangkan jahitan. Perangkat ini dapat meminimalkan trauma artikular cartilage.

Gambar dari FastFix Meniscal Repair.

Sumber :http://global.smith-nephew.com/master/images/ProductImages-Endo-US/Techniq

TRANSPLANTASI MENISCAL

Digunakan untuk meniscus yang tidak dapat diperbaiki atau sebelumnya telah dihilangkan.Meniscal transplantasi menggunakan materi jaringan yang bersifat allograft.Sebuah allograft adalah jaringan yang berasal dari donor, biasanya diawetkan dari jaringan meniscus manusia.

Ahli bedah akan menggunakan arthroscope, kemudian akan menghilangkan sisa- sisa meniscus. Berikutnya, allograft disiapkan.Jahitan ditempatkan di sekitar tepi allograft.Allograft dijahit ke tulang tibia.Instrumen bedah, termasuk kanul atau jarum dapat digunakan untuk memberikan jahitan tambahan.Beberapa ahli bedah juga menggunakan jangkar khusus untuk meyakinkan agar allograft tetap ditempatnya. Sebuah probe digunakan untuk memastikan meniskus yang ditransplantasikan ke posisi tetap.

 

Gambar dari transplantasi meniscus.

Sumber :http://www.vangsnessmd.com/images/proc_img_menistrans.jpg

KOMPLIKASI

Seperti semua prosedur pembedahan besar, komplikasi dapat saja terjadi. Beberapa komplikasi yang paling umum adalah:

1. Komplikasi anestesi

Kebanyakan prosedur bedah menggunakan beberapa jenis anestesi.Masalah - masalah ini dapat diakibatkan karena reaksi terhadap obat yang digunakan, maka dari itu pastikan untuk mendiskusikan resiko dan perhatian khusus dengan anestesi.

 

Gambar anestesi umum.

Sumber :http://www.suaradokter.com/wp-content/uploads/2008/12/anest.jpg

2. Thrombophlebitis

Disebut trombosis vena dalam (DVT), dapat terjadi setelah operasi apapun, tetapi lebih mungkin terjadi setelah operasi di  panggul, atau lutut. DVT terjadi ketika gumpalan darah terbentuk di pembuluh darah besar di kaki.Hal ini dapat menyebabkan kaki nyeri, bengkak dan menjadi hangat saat disentuh. Jika gumpalan darah dalam pembuluh darah pecah, mereka dapat melakukan perjalananke paru – paru.di mana mereka akanmenyumbat  kapiler dan memotong suplai darah ke sebagian paru-paru.

Hal ini disebut emboli paru. Ada banyak cara untuk mengurangi risiko DVT, tapi mungkin yang paling efektif adalah edukasi pasien untuk bergerak secepat mungkin setelah operasi. Stoking khusus, obat mengencerkan darah pun dapat  mencegah pembentukkan gumpalan darah tersebut.

 

Gambar dari thrombophlebitis.

Sumber :http://4.bp.blogspot.com/_z9tidKPbZrg/R0-FXwivGQI/AAAAAAAABIk/5tnZoszKEik/s1600-R/Vein%2Btrouble%2Bday%2B3%2B-%2Bmarked%2Bred%2Barea.JPG

 1. Infeksi

Setelah operasi adalah mungkin bahwa portal kulit bisa menjadi terinfeksi. Ini akan membutuhkan antibiotik dan mungkin prosedur pembedahan lain untuk mengeringkan infeksi tersebut.

 2. Masalah pada jahitan anchor

Jahitan jangkar dapat menimbulkan masalah. Jika satu satu dalam posisi yang baik, namun sisi yang lain mengambang dan bisa melukai bagian-bagian lain di dalam sendi lutut, terutama tulang rawan artikular. Bagian ujung dari jangkar pun mungkin menyodok terlalu jauh melalui meniskus.Jika demikian, titik tersebut dapat menggosok dan mengiritasi jaringan terdekat.Pembedahan kedua mungkin diperlukan untuk memperbaiki masalah dengan jahitan jangkar.

3. Kegagalan cangkok

Operasi di mana jaringan yang dicangkokkan ke dalam tubuh, seperti sum – sum tulang atau transplantasi ginjal, memiliki resiko tinggi bahwa tubuh akan menolaknya. Hal ini tidak terlalu menjadi masalah bagi meniscal transplantasi.Cangkok yang diawetkan tidak mengandung sel hidup, sehingga tidak perlu dicocokkan dengan orang yang mendapatkan cangkok tersebut.

Alasan utama kegagalan dalam operasi transplantasi meniscal adalah ketika pasien terlalu banyak, terlalu cepat melakukan aktifitas setelah pembedahan.Melakukan olahraga dimana terdapatgerakan cepat memulai dan berhenti, berputar secara tajam, dan melompat, dapat menyebabkan kegagalan cangkok.

4. Lambat pemulihan

Tidak semua orang setelah operasi,akanmembuat meniscus cepat kembali seperti semula, yaitu kembali ke kegiatan rutin. Beberapa orang akanmerasa lebih baik, namun ada juga yang membuat lutut menjadi sedikit bengkak, masih sulit untuk melakukan aktivitas normal, dan hal ini terjadi bahkan beberapa bulan setelah operasi.

5. Sakit berkelanjutan

Operasi meniscus tidak selalu terjadi nyeri, namun beberapa orang bisa mengalami rasa sakit yang terus menerus, atau menjadi tak tertahankan, maka dari itu pengobatan pengontrol rasa sakit sangat dibutuhkan.

PASCA OPERASI

Perawatan operasi meniscus dapat dilakukan dengan rawat jalan. Pasien biasanya pulang pada hari yang sama dengan operasi. Portal ditutup, dan lutut dapat dibungkus dalam sebuah verban elastis.Kruk meniscal dapat digunakan setelah pembedahan.Mereka mungkin hanya diperlukan untuk satu atau dua hari setelah menisektomi sederhana.

 

Gambar dari walker.

Sumber :http://cdn-www.cracked.com/articleimages/ob/baddrivers/elderly%20man%20on%20walker.jpg

Penyembuhan dari pembedahan bervariasi untuk penderita yang berbeda dan untuk masalah klinik yang berbeda.Pasien dengan operasi perbaikan meniscal harus diberikan edukasi untuk tidak menempatkan beban di kaki selama empat sampai enam minggu setelah operasi, sehingga pasien dapat menggunakan kruk atau walker selama empat sampai tujuh hari.Mungkin terjadi pembengkakan selama tiga sampai enam minggu dan dapat kembali ke aktivitas normalnya sekitar empat sampai enam minggu.Hal ini berguna untuk memberi kesempatan meniscus agar sembuh.

Dibanding dengan operasi lutut secara terbuka, dengan insisi pembedahan yang luas, operasi arthroscopy menyebabkan terbatasnya jaringan sikatrik (scar), mempunyai waktu penyembuhan yang lebih cepat, dan mengijinkan untuk lebih cepat kembali bekerja atau olah raga.

Setelah prosedur transplantasi, kebanyakan pasien diperintahkan untuk hanya menyentuh ujung kaki yang dioperasikan di tanah selama empat sampai enam minggu.Pasien yang menjalani transplantasi meniscal biasanya memakai penyangga lutut selama setidaknya adalah empat minggu.Penjepit lutut tetap lurus.Hindari melakukan aktifitas yang terlalu banyak, dan terlalu cepat. Kompres dingin di lutut dan kaki pun dapat disarankan, selain itu dapat didukung dengan rehabilitasi.

REHABILITASI

Rehabilitasi tergantung dari jenis operasi yang dialami. Mungkin tidak akan membutuhkan terapi fisik formal setelah menisektomi parsial. Kebanyakan pasien dapat melakukan latihan mereka sebagai bagian dari program rumah.Jika memerlukan rawat jalan terapi fisik, maka perlu menghadiri sesi terapi selama dua hingga empat minggu, dan pemulihan penuh dapat memakan waktu hingga tiga bulan.

Perawatan pertama terapi fisik juga dirancang untuk membantu mengendalikan rasa sakit dan pembengkakan setelah operasi.Terapi fisik juga berguna untuk memastikan agar pasien menempatkan jumlah aman pada berat badan bagi kaki yang terluka.

Selama enam minggu pertama setelah operasi perbaikan meniscal, maka pasien harus menghindari menekuk lutut lebih dari 90 derajat, dinyatakan aman untuk secara bertahap menekuk lututnya.Namun, pasien harus menghindari aktifitas jongkok selama paling sedikit tiga sampai empat bulan.Selain itu tidak dianjurkan untuk lari, melompat, atau memelintir lutut setidaknya empat sampai enam bulan.Kadang-kadang pasien melanjutkan kegiatan olahraga dalam waktu empat sampai enam bulan setelah pembedahan untuk memperbaiki meniskus.

Dianjurkan latihan segera, setelah transplantasi meniscus.Tujuannya adalah agar lutut dapat beradaptasi untuk menekuk hingga 90 derajat dalam waktu empat minggu setelah operasi.Dengan berjalannya waktu, latihan yang lebih menantang dapat dipilih untuk memajukan kekuatan, fungsi, dan pergerakkan lutut.Idealnya, pasien akan dapat melanjutkan kegiatan mereka sebelumnya. Beberapa pasien mungkin akan didorong untuk memodifikasi pilihan aktivitas mereka, terutama jika allograft digunakan.

Ketika pasien dapat berjalan dengan baik, maka kunjungan rutin ke terapis dapat dihentikan. Namun pasienakan bertanggung jawab melakukan latihan sebagai bagian dari program yang sedang berlangsung di rumah.

 

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Mark Shapiro has been writing about, and promoting, consumer,
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This group had been performing for 30 years to capacity crowds.
I love the fact that you can adjust the white balance in real time
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exe to convert a one-hour long file to a generic WMV file.
bokep selingkuh | 27 Juni 2016 - 15:25:14 WIB
Videos allow you to show a more personal side of yourself and your business that just
isn't possible with print or any other media. Cam - Smartz
by design also provide real-time tracking data to Google Earth, which creates
animated behavior maps. More importantly, each one of
these benefits will ultimately enhance your profits and improve your bottom line.

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