Chicago 2010

911 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
911
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
27
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Chicago 2010

  1. 1. G.C. Coari – A. Tripodo – S. Cappato Casa di Cura “San Camillo” – Forte dei Marmi RELIVE: MENISCUS ALLOGRAFT
  2. 2. SORRY, MY ENGLISH IS NOT GOOD BUT MIGLIORERO’ AND SOMETIMES I AM “IMPULSIVE” BY GIOVANNI TRAPATTONI 02/05/2008 FIRST DAY AS IRELAND SOCCER COACH
  3. 3. SORRY, MY ENGLISH IS IMPROVING....IT ISN’T PERFECT YET.... BUT MIGLIORERO’... AND I HOPE TO BE GIVEN A 3 rd CHANCE IN TWO YEARS “GOOD-BYE TO 2012”
  4. 4. PEDERZINI - COARI - ARNALDI - ADRIANI - BERRUTO ZINI - PRIANO - ZORZI – NICEFORO - ADRAVANTI ITALIAN STUDY GROUP - SIA
  5. 5. SINCE OCTOBER 2002
  6. 6. A. TRIPODO TRAPIANTO MENISCALE: ESPERIENZA ITALIANA E RISULTATI S.I.A. FELLOWSHIP
  7. 7. <ul><li>...in the resection of the medial meniscus from 15 to 34%, a rise in the contact pressure on the cartilage of more than 350% has been observed.. </li></ul>BARATZ ME, FU FH “Meniscal tears: the effect of meniscectomy on articular contact areas and stresses in the human knee.” AM.J.SPORTS.MED 1986 “ Natural history after meniscectomy”……
  8. 8. “ Factors affecting late results after meniscectomy” JOHNSON e coll. JBJS 1974 99 Pz.; F.U. average 17,5 yy. ( 5-37) “ open meniscectomy” 57% unsatisfaction results Worse results in tardive meniscectomy, meniscal lateral tears, women, associated laxity 136 Pz.; F.U. average 8,5 yy. (7,9 – 11.6) “ Arthroscopy meniscectomy” Stable knee 53% had “Fairbank’s changes”(vs. 22% Check) 83% Lysholm > 90 22% severe symptomatic + arthrosys in valgus < 4° / in valgus > 10° “ Arthroscopy partial meniscectomy: a long term follow up” Fauno P. e coll. Arthroscopy 1992 “ Natural history after meniscectomy”……
  9. 9. “ Fifteen-years follow up of arthroscopy partial meniscectomy” BURKS RT e coll. Arthroscopy 1997 146 Pz.; F.U. average 14.7 yy. (13.8 – 16.4) “ Arthroscopy partial meniscectomy” 88% good-excellent (Lysholm & RX ) Worse results both in Rx in varus and women Worse results both in Rx and Functionality, if “ACL deficient” Not always links between Rx and functionality 75 Pz.; F.U. average 12.3 yy. (5 – 15) “ Arthroscopy partial lateral meniscectomy” 78% “Fairbank’s changes” Not always links between Rx and functionality “ Arthroscopic partial lateral meniscectomy in an otherwise normal knee” Scheller G e coll. Arthroscopy 2001 36 Pz.; F.U. average 14yy. (12 – 15) “ Arthroscopy partial and total meniscectomy” 33% “Fairbank’s changes” in partial meniscectomy 72% “Fairbank’s changes” in total meniscectomy 74% Lysholm > 94 “ Arthroscopic partial and total meniscectomy : a long term follow up study with matched controls” Andersson-Molina H. e coll. Arthroscopy 2002
  10. 10. <ul><li>“ MENISCUS DEFICIENCY IS THE 1 st PROBLEM IN ORTHOPAEDICS TODAY” </li></ul><ul><li>F. Noyes, M.D. </li></ul><ul><li>All clinics see many patients with irreparable meniscus lesions </li></ul><ul><li>10 years later these patients are candidates for HTOs, cartilage transfers and other salvage procedures </li></ul><ul><li>Finally, most of these patients require a knee replacement </li></ul>MENISCECTOMY IS NOT A BENIGN PROCEDURE
  11. 11. SAVE THE MENISCUS! SUTURE !!
  12. 12. AUTOLOGUS MENISCUS TRANSPLANTATION
  13. 13. RATIONALE FOR MENISCUS TRANSPLANTATION <ul><li>RELIEVE PAIN AND SWELLING </li></ul><ul><li>IMPROVE KNEE STABILITY </li></ul><ul><li>PREVENT PROGRESSION OF ARTHROSIS (?) </li></ul>
  14. 14. AN “ENCHANTING” HYPOTHESIS: CHANGING THE NATURAL HISTORY OF A MENISCUS DEFICIENT KNEE
  15. 15. <ul><li>PHYSIOLOGICALLY YOUNG, ACTIVE </li></ul><ul><li>NEUTRAL ALIGNMENT </li></ul><ul><li>NORMAL STABILITY </li></ul><ul><li>NO MORE THAN GRADE II-III CARTILAGE DAMAGE </li></ul><ul><li>UNDERSTANDS RISKS OF SURGERY, DISEASE TRANSMISSION </li></ul><ul><li>POST-OP COMPLIANCE AND REALISTIC EXPECTATIONS </li></ul><ul><li>NO KNEE ABUSER </li></ul>INDICATIONS “ PATIENT WITH PAIN IN THE AFFECTED MENISCAL-DEFICIENT COMPARTMENT”
  16. 16. <ul><li>No standard protocol </li></ul><ul><li>AP and ML bone size </li></ul><ul><li>RX, MRI and CT </li></ul><ul><li>46% mismatch 2-5 mm (Shaffer) </li></ul><ul><li>“ size does matter…” (Shaffer) </li></ul>GRAFT: “sizing/matching”
  17. 17. WHICH TYPE ? FRESH-FROZEN CRIOPRESERVED NOT IRRADIATED
  18. 18. THE SURGICAL TECHNIQUE HAS EVOLVED FROM ARTHROTOMY TO THE CURRENT ARTHROSCOPIC – ASSISTED TECHNIQUE 2002-03 OPEN TECHNIQUE 2004-10 SCOPE ASSISTED TECHNIQUE
  19. 19. SURGICAL PROCEDURE GENERAL CONCEPT <ul><li>BONE ANCORAGE </li></ul><ul><li>SINCE 2006 WITHOUT BONE </li></ul>
  20. 20. SURGICAL PROCEDURE GENERAL CONCEPT <ul><li>ANATOMICAL PLACEMENT OF MENISCAL HORNES </li></ul>
  21. 21. ACCURED FIXATION ALL - INSIDE IN - OUT OUT - IN
  22. 22. FEMALE 38 YY 25 YEARS AGO ARTHROTOMIC MENISCECTOMY LATERAL COMPARTMENT - PAIN - SWELLING BARMAID - STANDING ALL DAY NORMAL AXIS AND STABILITY KNEE
  23. 23. REHABILITATION <ul><li>Partial weightbearing 20% for 6 weeks </li></ul><ul><li>CPM (optional): 0-90° for 4 weeks </li></ul><ul><li>Brace 0°- 60° for 6 week </li></ul><ul><li>0°- 90° after 8 week </li></ul><ul><li>No jogging, twisting and squatting for 4 months </li></ul><ul><li>Total recover within 6 months </li></ul><ul><li> </li></ul>
  24. 24. Leisure sport activities, after 12 months after 12 months
  25. 25. <ul><li>AVERAGE AGE 37 YY </li></ul><ul><li>16 MALE - 20 FEMALE </li></ul><ul><li>24 LATERAL </li></ul><ul><li>- 14 MEDIAL </li></ul><ul><li>- 2 BICOMPARTIMENTAL </li></ul><ul><li>- 4 WITH BONE </li></ul><ul><li>- 34 WITHOUT BONE </li></ul>OUR EXPERIENCE SINCE JULY 2003 38 M.A.T. IN 36 PZ.
  26. 26. <ul><li>LATERAL MENISCUS 16 (1 BICOMPARTIMENTAL) </li></ul><ul><li>MEDIAL MENISCUS 4 </li></ul><ul><li>- BONE 4 - WITHOUT BONE 16 </li></ul><ul><li>- MEN 11 WOMEN 8 - AVERAGE AGE 34 </li></ul><ul><li>- TIMING 1 st TRAUMA AND SURGERY 2 yy–30 yy </li></ul><ul><li>- PREVIUS SURGERY 1-6 </li></ul><ul><li>- THE SAME SURGEON </li></ul><ul><li>- FOLLOW-UP: 6 MONTHS, 1 YEAR, EVERY YEAR </li></ul>OUR EXPERIENCE 19 PATIENTS - UP TO SEPTEMBER 2008 F.UP: 1 - 5 YY
  27. 27. <ul><li>I grade (0%) </li></ul><ul><li>II grade (30%) </li></ul><ul><li>III grade (50%) </li></ul><ul><li>IV grade (20%) </li></ul>ASSOCIATED PROCEDURES <ul><li>LCA 4 </li></ul><ul><li>M.A.C.I. 4 </li></ul><ul><li>HTO 1 </li></ul>CONDRAL LESIONS
  28. 28. <ul><li>CLINICAL </li></ul><ul><li>Lysholm Knee Score </li></ul><ul><li>K.O.O.S. </li></ul><ul><li>IKDC </li></ul><ul><li>X-RAY </li></ul><ul><li>MRI </li></ul>EVALUATION According to European Meniscal Transplantation Study Group
  29. 29. OUTCOMES IKDC <ul><li>A (normal) 4 (21%) </li></ul><ul><li>B (nearly normal) 11 (58%) </li></ul><ul><li>C (abnormal) 2 (10.5%) </li></ul><ul><li>D (severely abnormal) 2 (10.5%) </li></ul>
  30. 30. LYSHOLM K.O.O.S. PRE-OP POST-OP 89 (43-95) 45 (11-70) ADL ACTIVITIES OF DAILY LIFE 84.5 Sport/Rec SPORT ACTIVITIES SCALE 50.5
  31. 31. <ul><li>Initial F.U. studies - Generally good </li></ul><ul><li>Good results with longer f.u., but a note of caution </li></ul><ul><li>70-90 % good and excellent results </li></ul><ul><li>Very effective in pain relief </li></ul><ul><li>The grafts heal and look normal at second-look and MRI </li></ul><ul><li>Worse results in condral lesion III-IV grade </li></ul>DOES M.A.T. WORK? CLINICAL RESULTS FOR MENISCUS TRANSPLANT Garret 93 - Shelton 95 - Noyes 97- Del Pizzo 96 - Goble 98 - Carter 99- Verdonk 99 Rath 2000 - Wirth 2000 - Stollsteimer 2000 - Van Arkel 2002 - Cole 2006 - Harner 2005
  32. 32. 1 aa.MM / ML 4 aa. ML
  33. 33. 3 aa. MM
  34. 35. FALLIMENTI
  35. 37. <ul><li>No difference between bone / no-bone </li></ul><ul><li>Better results in isolated lateral transplantation </li></ul><ul><li>Better results in MM + HTO than in isolated medial </li></ul><ul><li>Pain relief is the most consistent benefit </li></ul><ul><li>Clinical results are not similar to M.R.I. </li></ul><ul><li>Clinical results connected with significant </li></ul><ul><li>chondral damage </li></ul><ul><li>90% satisfied and they would do it again </li></ul>CONSIDERATIONS
  36. 38. <ul><li>MENISCUS TRANSPLANTATION IS A VIABLE ALTERNATIVE IN TREATING THE MENISCUS DEFICENT SYMPTOMATIC KNEE </li></ul><ul><li>SUCCESS DEPENDS ON CAREFUL PATIENT SELECTION AND SURGICAL PRECISION </li></ul><ul><li>WE NEED LONGER F.U. TO DETERMINE BIOMECHANICAL FUNCTION AND EFFICACY </li></ul><ul><li>M.A.T. IS TECHNICALLY DEMANDING </li></ul>CONCLUSIONS
  37. 39. WHAT WE DON’T KNOW... <ul><li>DOES IT PROVIDE LONG-TERM BIOMECHANICAL FUNCTION? </li></ul><ul><li>WILL IT PROVE TO BE “CHONDROPROTECTIVE” AGAINST DEGENERATIVE PROGRESSION ? </li></ul>CONCLUSIONS
  38. 40. THANK YOU [email_address]

×