Biologic Knee Replacement Kevin R. Stone, MD Ann W. Walgenbach, RNNP  Wendy S. Adelson, MS Jonathan R. Pelsis, MHS Menisku...
The Aging Knee Pediatric  Normal Adult  OA Adult
The Knee Joint
Meniscus  <ul><li>Key shock absorber in the knee </li></ul><ul><li>Torn 1.5M times annually US </li></ul><ul><li>Minimal h...
<ul><li>Loss of meniscus cartilage leads to: </li></ul><ul><ul><li>Increased forces across the knee joint </li></ul></ul><...
<ul><li>Reduce pain and improve function </li></ul><ul><li>Preserve the biology of the knee </li></ul><ul><li>Restore a bi...
The Alignment Controversy <ul><li>Is osteotomy a two plane crude correction of a multiplanar deformed geometry? </li></ul>...
A Solution ? Biologic Knee Replacement <ul><li>Smooth, repair, replace, or regenerate damaged articular cartilage </li></u...
Outerbridge Grading System  For Cartilaginous Degeneration   Outerbridge RE. The etiology of chondromalacia patellae.  J B...
Meniscus Allograft Transplantation:  Indications? <ul><li>Traditional thought:   Meniscus Transplantation does not work in...
Sizing: Surgeon Concerns <ul><li>“It takes me 6 months to get a properly sized meniscus.” </li></ul><ul><li>“My measuremen...
Meniscus Allograft: Sizing <ul><li>Success rate may be dependant on accurate sizing </li></ul><ul><li>Image-based sizing m...
Supporting Studies: Sizing <ul><ul><li>148 heights and weights compared to MRI meniscus size </li></ul></ul><ul><li>Pearso...
The Three-Tunnel Technique Replacing the Meniscus Stone KR, Walgenbach AW. “Meniscal Allografting: the Three-Tunnel Techni...
The Three-Tunnel Technique Movie
Articular Cartilage Paste Graft  Procedure Step 1 Step 5 Step 4 Step 3 Step 2
Meniscus Transplantation <ul><li>173 patients since 1997 </li></ul><ul><li>Clinical Exam + Patient Reported Subjective Out...
Current Study: <ul><li>Long-Term Survival of Concurrent  Meniscus Allograft Transplantation  and Articular Cartilage Repai...
Study Design <ul><li>Study Inclusion </li></ul><ul><li>Irreparable injury of the meniscus </li></ul><ul><ul><li>Or </li></...
Patient Selection <ul><li>Young patients with cartilage loss and pain </li></ul><ul><li>Older patients with cartilage loss...
Surgical Technique <ul><li>Medial Meniscus Allograft Transplantation:  Performed utilizing periosteum, but not bone blocks...
<ul><li>119 Meniscus Allograft Transplant Cases </li></ul><ul><li>Mean age = 46.9 years  (14.1 – 73.2 yrs) </li></ul><ul><...
Patient Population  (N = 119) Neutral / Varus / Valgus Moderate ( 5 – 7°) / Severe ( > 7°) Grade III / Grade IV Medial / L...
Review of Literature Mixed Patient Studies N = 119 N = 100 N = 29 N = 31 N = 44
Results <ul><li>Procedure failure: Removal of allograft without revision  (N = 7) , or progression to knee arthroplasty  [...
Complications <ul><li>4 Early Postoperative Infections </li></ul><ul><ul><li>3 Deep (1 Staphphylococcus Aures, 2 negative ...
Subsequent Surgeries – 1 4 2 Meniscus Allograft Revision – 2 1 12 Meniscus Allograft Repair – 1 9 22 Meniscectomy 1 1 – 4 ...
Kaplan-Meier Survival Analysis In Patients OB III/IV <ul><li>Time-to-failure analysis with continuous enrollment over 12-y...
Cox Proportional Hazards Model What is it? <ul><li>A Cox model provides an estimate of a variable’s effect on survival aft...
What factors affect survival? <ul><li>Cox Proportional Hazards Model was used to explore the relationship between procedur...
Cox Model - Related Hazards <ul><li>Independent of actual time-to-failure, increased number of previous surgeries (p = 0.0...
Effect of Age <ul><li>53 patients over 50 (Mean = 56 yrs) </li></ul><ul><ul><li>KM mean survival = 8.84 years  [95% CI: 7....
Medial v. Lateral Allografts <ul><li>Non Significant Hazard (p = 0.848) </li></ul>Medial (N = 85) KM mean survival: 9.91 ±...
Malalignment <ul><li>Severity of Mal-Alignment  (p = 0.535) </li></ul><ul><ul><li>Severe Malalignment (>7 º)  (N = 10) </l...
Subjective Outcome Scores <ul><li>IKDC, WOMAC, and TEGNER questionnaire follow-up schedule was preoperatively and at 2, 3,...
Subjective Outcome Scores 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Mean Tegner Index Score
Patient Example: BK <ul><li>27 year old male </li></ul><ul><li>Torn lateral meniscus in high school wrestling 1996 </li></...
BK: Pre-Op MRI <ul><li>MRI documents degenerative changes   to LTP and loss of lateral meniscus </li></ul>
Patient Example: BK <ul><li>Lateral Meniscus Allograft Transplantation </li></ul>
Patient Example: BK 8 months post  <ul><li>Arthroscopy for suprapatellar pouch and anterolateral swelling </li></ul><ul><l...
BK MRI 4 Years Post Op <ul><li>Lateral meniscus allograft appears normal and   well positioned </li></ul><ul><li>Patient r...
Patient Example: JL <ul><li>35 Year Old Female </li></ul><ul><li>Right Knee   </li></ul><ul><li>1984 - Lateral Meniscectom...
Patient Example: JL OB III/IV far-posterior aspect LFC, Microfracture LFC
JL: 4 months Post-Op <ul><li>Flexion contracture, debridement, closed manipulation, notchplasty </li></ul><ul><li>No evide...
JL: 6 years Post-Op <ul><li>Lateral Meniscus repair, chondroplasty, debridement, notchplasty </li></ul>
Patient Example: JA <ul><li>37 Year old female </li></ul><ul><li>Meniscectomy at age 20 </li></ul><ul><li>R-Lateral Menisc...
JA: Preoperative X-ray Lateral AP
JA: Preoperative MRI <ul><li>Lateral meniscus: </li></ul><ul><li>Absent posterior horn </li></ul><ul><li>Articular Cartila...
JA Operative Images A B C Deficient Lateral Meniscus Chondral Lesion of LFC Microfracture of Lesion
JA Operative Images A B C Absent Meniscus Lateral Meniscus Allograft Allograft Placement
JA: 5 Months Post-Op  <ul><li>Full ROM with smooth articulation </li></ul>
JA: 2Yr Postoperative X-ray PA Flexion AP
JA: 2yr Post-operative MRI <ul><li>Healed lateral meniscal allograft </li></ul>
JA: 5Yr Postoperative X-Ray PA Flexion AP
JA: 5Yr Postoperative MRI <ul><li>Virtually unchanged meniscal allograft </li></ul>
Patient Example: GC 7 o  varus L-knee Medial joint space narrowing Active 53 y.o. male. Meniscectomy: 1986, 1996 Medial me...
GC: Preoperative Images Sagittal MRI Loss of cartilage MFC PA Flexion Medial joint space narrowing
GC: Operative Images A B Bipolar lesions Morselization of MFC & MTP Loss of medial meniscus
GC: Operative Images A B C Placement of medial meniscal allograft Impaction of paste graft Paste Grafted Lesion
GC: Postoperative X-Ray Long-leg AP
GC: 3Yr Postoperative X-ray AP Long-leg
GC: 3Yr Postoperative Images 3 Years post-op L-medial allograft, osteotomy, & paste graft
GC: Comparison of healing 3-Years post-op allograft and paste graft to MFC Operative 3 yrs Post-op 3 yrs Post-op
Patient Example: SC <ul><li>39 y.o. male </li></ul><ul><li>Injury: 1970s playing hockey  </li></ul><ul><li>Meniscectomy (1...
SC: Preoperative MRI Bucket-handle tear with bipolar cartilage lesions on MFC & MTP Coronal Sagittal
SC: Operative Images Right knee bucket-handle tear displaced into intercondylar notch A B
SC: Operative Images Eburnated bone MFC Eburnated bone MTP Microfracture MTP Microfracture MTP
SC: Placement of Allograft Right Knee Placement of Medial Meniscal Allograft
SC: Comparison of healing   Return to full activity Intermittent catching and pain 17 Mo Post-op Pre-op Note improved join...
SC: 17 Mo Post Op MRI Coronal Sagittal
SC: 2nd Surgery Movie 17 mo. Post  Paste graft MFC +  Meniscus  Allograft Initial Surgery 17 mo. Post-op Meniscectomy
SC: 5 yr Post Op Images AP Allograft present with maturing degenerative changes Coronal
Patient Example DB <ul><li>47 YO Male Skier </li></ul><ul><li>R Knee:  Chronic Pain </li></ul><ul><li>Moderate to Severe B...
DB: Right Knee <ul><li>Right Knee:  </li></ul><ul><li>09/91:  Medial Meniscectomy, Drilling MFC, Chondroplasty </li></ul><...
DB: Right Knee 10 Yr PostOp MRI
DB: 10 Yr Post Op XRAY
DB: 10 Yr PostOp 63 YO, Tegner = 6, Skis 30+ days/yr, Snow skis 50+ days/yr.
<ul><li>47 YO Female </li></ul><ul><li>Beach volleyball injury (11/03) </li></ul><ul><li>Failed debridement (11/03) </li><...
RT: Pre-Operative MRI
<ul><li>Torn medial meniscus </li></ul>MFC chondral lesion LFC chondral lesion Torn ACL Patient Example: RT
<ul><li>Medial meniscus Allograft </li></ul>Allograft Insertion Allograft placement ACL BTB allograft Patient Example: RT
<ul><ul><li>Intact meniscus allograft </li></ul></ul><ul><ul><li>ACL hardware removal due to   prominence of fixation scre...
Excellent joint space, intact meniscus allograft and ACL, but right knee clicking and catching RT: 18 Months Post
Intact meniscus allograft and ACL with diffuse thinning of patellofemoral cartilage RT: 18 Months Post
<ul><li>Surgery for catching due to chondral flap at patellofemoral joint </li></ul><ul><li>Intact meniscus allograft and ...
Patient Example: RM 57 Male Long-leg MRI <ul><li>Injury: Football tackle 1978  </li></ul><ul><li>Previous Meniscectomy: 19...
RM: Operative Images Severe Articular Cartilage Damage
RM: Operative Images  Allograft insertion Articular Cartilage  Paste Grafting Repair
RM: Operative Images  High tibial opening wedge osteotomy
RM: 3.5 Years Post-Allograft  Movie  Primary Surgery Second Look, 3.5 years later
RM: Histology
RM: 3.5 Years Post Operative Long-leg
RM: 5 Years Post Operative MRI Sagittal Coronal
RM: 6 Year Post Operative X-Ray Long-leg Lateral
Patient Example: HM 5-7 o  varus L-knee <ul><li>18 Yrs Post meniscectomy  </li></ul><ul><li>2 Meniscectomies (‘86, ’96) </...
HM  4 Yrs 9 Mo Post Paste Graft Debrided lesion Healed paste graft
HM   4 Yrs 9 Mo Post Paste Graft Biopsy Histology
Biologic Knee Replacement  Revision Surgery
Patient Example: TA <ul><li>48 y.o. world-class female marathoner </li></ul><ul><ul><li>86 marathons,  </li></ul></ul><ul>...
TA: Preoperative MRI <ul><li>Tear at horn of medial meniscus </li></ul><ul><li>Osteoarthritis: medial compartment </li></u...
4/22/02: Right medial meniscus rim before allograft TA: Operative Images
TA: Meniscus Allograft Placement Preparation of medial meniscal allograft Placement of medial meniscal allograft Relations...
TA: Injury C <ul><li>Injury: 2 Mo. Post-op  </li></ul><ul><li>Swam in pool for 2 hours  </li></ul><ul><li>Developed immedi...
TA: Revision C A Movie Revision: 8 Months Post-allograft
TA: Revision: Operative Images Insertion of Meniscus Allograft with Articular Cartilage Paste Grafting Joint Arthroplasty ...
Patient Example: RT <ul><li>34 YO male </li></ul><ul><li>Partial meniscectomy for torn lateral meniscus (9/91), debridemen...
RT: Pre-Op Imaging <ul><li>X-rays: Collapse of lateral joint space. Mild patellar spurring. </li></ul>
RT: Pre-Op MRI <ul><li>Loss of articular cartilage on posterior aspect of LFC </li></ul><ul><li>Loss of posterior and cent...
RT:  Surgery 11/2009 <ul><li>Lateral Meniscus Allograft transplantation </li></ul><ul><li>Microfracture LFC and LTP (too f...
RT: MRI 2 days Post Op <ul><li>Allograft intact without evidence of tear </li></ul><ul><li>Anterior subluxation of the pos...
RT: Revision Surgery <ul><li>Interval repositioning of the lateral meniscus 5 days post index procedure. </li></ul><ul><li...
RT: MRI 1 Day Post Revision <ul><li>Repositioned Lateral Meniscus Allograft </li></ul>FSE T2 SAG FSE PD SAG
Conclusions <ul><li>Our research represents the largest and longest prospective study of meniscus replacement patients wit...
Conclusions <ul><li>Height and weight can be used to size meniscal allograft tissue. </li></ul><ul><li>Three-tunnel Techni...
Conclusions <ul><li>Repair of severe articular cartilage damage combined with meniscus replacement provides significant im...
Conclusions  <ul><li>The number of TKA surgeries is predicted to increase to 3.4 million by 2030 * , with increasing costs...
Conclusions <ul><li>Biologic joint reconstruction, rather than bionic (artificial) replacement, may be an appropriate firs...
Acknowledgements <ul><li>Thomas Turek </li></ul><ul><li>Mark Coleman </li></ul><ul><li>Abhi Freyer </li></ul><ul><li>Ann W...
2009 Team 2005 Team
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Biologic Knee Replacement Presentation

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Biologic Knee Replacement (BKR) is our approach to treating knee injuries, from trauma to arthritis, and is designed to help people delay, or even avoid, artificial knee replacement. BKR is a scientifically-proven collection of our out-patient surgical techniques and procedures and consists of any combination of meniscus transplantation, articular cartilage paste grafting, ligament replacement as explained in further detail below. Being "bone on bone" does not always mean that the joint needs to be artificially replaced, often the "bone on bone" is isolated to a portion of the knee joint and this can be repaired using Biologic Knee Replacement.

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  • Kevin R. Stone, MD
  • Kevin R. Stone, MD
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  • Kevin R. Stone, MD Rath = severe arthritis excluded
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  • Kevin R. Stone, MD The procedure step by step.
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  • Examine the coefficients for each explanatory variable. Positive Coefficient means that the hazard is higher WORSE PROGNOSIS Negative Coefficient implies a lower hazard BETTER PROGNOSIS
  • Kevin R. Stone, MD Bryan Kelly
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  • Kevin R. Stone, MD A= MRI confirming articular cartilage loss of the MFC B= Long leg x-ray demonstrating varus deformity of (L-knee??? I think it should be the Right knee: see x-rays and chart notes ) of about 5-7 degrees C= PA Flexion view demonstrating medial joint space narrowing bialterally L worse than R (nearly bone on bone on the Left). 51 yo ♂ real estate broker both knees w/ problems L worse than R. He has a long hx/o degenerative changes in the medial compartment, loss of the medial meniscus and previous efforts at surgical debridement in order to relieve his medial compartment pain. Pre-operative x-rays revealed medial joint space narrowing and loss of articular cartilage. Pre-operative MRI confirmed loss of the medial meniscus and loss of the artircular cartilage of the medial compartment. He stood in varus. In view of his young age and atheletic activities he requested an effort at biological reconstruction of the medial compartment.   03/10/1999 L-med-Allo/ ArtCart-MFC &amp; MTP/ Open high tib med wedge opening osteotomy using BionX implants and allograft bone/ chon-LFC/ debridement/   Sx: developed a “clicking soreness” on upper MFC thought to be scar tissue requested an effort at operative debridement   03/20/2002 L-knee arthros/ chon-troch/ partial (M)ectomy of Allo where at the posterior 1/3 there was a small flap tear
  • Kevin R. Stone, MD A= Kissing lesion, MFC, MTP w/ loss of medial meniscus B= Morcellation of the MFC &amp; MTP lesions and loss of medial meniscus
  • Kevin R. Stone, MD A= Placement of medial meniscal allograft B&amp;C= Articular cartilage paste grafting MFC.
  • Kevin R. Stone, MD
  • Kevin R. Stone, MD A= MRI (03/18/02) documenting site of medial meniscus allograft and cartilage paste graft B= Long-leg x-ray (03/14/02) demonstrating post-op alignment C= PA Flexion view (03/14/02) documenting previous osteotomy and preservation of some joint space.   03/14/02 Patient seen 3 years post-op. He noted that before surgery he was unable to do certain activities that he would like to do, and he noted that the knee just pops w/ squatting. He is otherwise quite happy. Px: He had 2 prominent bumps at the medial side of his femoral condyle that he is complaining about. He had patellofemoral crepitus. His pain level is minimal, and his activity level is high. Dx: Arthrofibrosis and bursitis of L-knee. Sx: developed a “clicking soreness” on upper MFC thought to be scar tissue requested an effort at operative debridement   03/20/2002 L-knee arthroscopy/ chond-troch/ partial (M)ectomy of Allo where at the posterior 1/3 there was a small flap tear
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  • Kevin R. Stone, MD A= Medial meniscus allograft 3 years S/P transplantation B= Medial meniscus allograft 3 years S/P transplantation C= Biopsy MFC 3 years S/P ArtCart
  • Kevin R. Stone, MD 11-06-2000 R-leg = 4 o varus L leg = 2 o varus Steve Cousins 04-23-2002 R-leg = 5 o varus L leg = 2.5 o varus 39 yo ♂ owner of a “Spicy Sports” company with a long history of injuries playing hockey and lacrosse. Symptoms since 1977 w/ knee locking on one occasion (1982) but spontaneously released without surgery. Eventually came to surgery 1999 but after skiing for 4 months pain recurred. Symptoms at time of xam: R-knee pain, swelling, instability.   11/07/2000 R-med-Allo/ ArtCart- MFC/ Mfx-MTP/ removal bucket-handle tear   Developed intermittent anterior knee catching and pain for which HE requested a repeat arthroscopic evaluation and again requested that osteotomy be delayed. Physical exam: lacked final few degrees of extension – excellent flexion and stability. MRI – intact meniscus, damage on the articular cartilage surface, and anterior arthrofibrosis. X-rays- well preserved joint space.   04/02/2002 R-partial med-meniscus/ chondroplasty – trochlea/ debridement
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  • Kevin R. Stone, MD A= Bucket-handle tear medial meniscus, displacing into the intercondylar notch. B= Bucket-handle tear medial meniscus, displacing into the intercondylar notch.
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  • Kevin R. Stone, MD Placement of the medial meniscal allograft in relation to ArtCart of MFC The only other picture of this meniscus is washed out and less distinct in demonstrating the implanted meniscus.
  • Kevin R. Stone, MD R-lat R-med L-med L-lat 11-6-2000 8.31 mm 0.70 mm 3.89 mm 6.91 mm 04-23-2002 7.28 mm 1.83 mm 4.85 mm 6.85 mm
  • Kevin R. Stone, MD A= Torn posterior medial meniscus B= S/P partial medial meniscectomy Slide “C” is a movie slide – demonstrating the allograft in relation to the healed MFC ArtCart 1.5 years post-op. Developed intermittent anterior knee catching and pain for which HE requested a repeat arthroscopic evaluation and again requested that osteotomy be delayed. Px: lacked final few degrees of extension – excellent flexion and stability. MRI – intact meniscus/ damage on the articular cartilage surface, and anterior arthrofibrosis. X-rays- well preserved joint space.   04/02/2002 R-partial medial meniscectomy/ chondroplasty – trochlea/ debride
  • Kevin R. Stone, MD A= Torn posterior medial meniscus B= S/P partial medial meniscectomy Slide “C” is a movie slide – demonstrating the allograft in relation to the healed MFC ArtCart 1.5 years post-op. Developed intermittent anterior knee catching and pain for which HE requested a repeat arthroscopic evaluation and again requested that osteotomy be delayed. Px: lacked final few degrees of extension – excellent flexion and stability. MRI – intact meniscus/ damage on the articular cartilage surface, and anterior arthrofibrosis. X-rays- well preserved joint space.   04/02/2002 R-partial medial meniscectomy/ chondroplasty – trochlea/ debride
  • Kevin R. Stone, MD A= Torn posterior medial meniscus B= S/P partial medial meniscectomy Slide “C” is a movie slide – demonstrating the allograft in relation to the healed MFC ArtCart 1.5 years post-op. Developed intermittent anterior knee catching and pain for which HE requested a repeat arthroscopic evaluation and again requested that osteotomy be delayed. Px: lacked final few degrees of extension – excellent flexion and stability. MRI – intact meniscus/ damage on the articular cartilage surface, and anterior arthrofibrosis. X-rays- well preserved joint space.   04/02/2002 R-partial medial meniscectomy/ chondroplasty – trochlea/ debride
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004
  • Kevin R. Stone, MD Rhonda Topple
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004 RT
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004 RT
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004 RT
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004 RT
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004 RT
  • Kevin R. Stone, MD Kevin R. Stone, Biological Knee Reconstruction Annual Joint Preserving Meeting, Johns Hopkins 2004 RT
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  • Kevin R. Stone, MD Tracy Achiles A= MRI demonstrating full-thickness MFC defect B= MRI demonstrating loss of medial meniscus C= MRI demonstrating loss of articular cartilage 48 yo ♀ fitness manager and triathlon/ iron-man competitor who tripped over her dog while walking it down the driveway landing on both knees. Subsequently saw local orthop surgeon who found a R-med meniscal tear and she underwent partial (M)ectomy Apr 27, 2001. Able to return to running but Sx pain/ swelling recurred. 2 nd Surgery Jan 2002   04/02/2002 – Right knee Surg: R-med-Allo/ R-MFC-ArtCart/ R-MFC|MTP|-Mfx/ Chon – troch   Two weeks post-op she swam in a pool for two hours with her legs kicking and developed immediate swelling. It was presumed that she most likely had re-torn her meniscus allograft. However, she was treated conservatively to see whether or not it would heal on its own. It failed to do so. She had recurrent swelling w/ activities and not responsive to a single effort of cortisone injection . 06/26/2002 - Right knee Surg: R- med-Allo repair/ Mfx-MFC /Chon -MTP
  • Kevin R. Stone, MD
  • Kevin R. Stone, MD A= Full thickness chondral defect MFC and loss of medial meniscus B= Full thickness chondral defect MFC and loss of medial meniscus
  • Kevin R. Stone, MD A= Preparation and placement of medial meniscal allograft B= Placement of medial meniscal allograft Slide “C” is a movie clip – demonstrates relationship of lesion to meniscus
  • Kevin R. Stone, MD A= Retained medial meniscal allograft. C= Refixation of medial meniscal allograft. Repair of the “unstable junction of meniscal capsule w/ medial meniscus allograft. Slide “B*” is a movie - demonstrates the instability of the junction of the junction of the capsule w/ the allograft
  • Kevin R. Stone, MD A= Retained medial meniscal allograft. C= Refixation of medial meniscal allograft. Repair of the “unstable junction of meniscal capsule w/ medial meniscus allograft. Slide “B*” is a movie - demonstrates the instability of the junction of the junction of the capsule w/ the allograft
  • Kevin R. Stone, MD A= Retained medial meniscal allograft. C= Refixation of medial meniscal allograft. Repair of the “unstable junction of meniscal capsule w/ medial meniscus allograft. Slide “B*” is a movie - demonstrates the instability of the junction of the junction of the capsule w/ the allograft
  • Kevin R. Stone, MD Ryan Timbrook
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  • Biologic Knee Replacement Presentation

    1. 1. Biologic Knee Replacement Kevin R. Stone, MD Ann W. Walgenbach, RNNP Wendy S. Adelson, MS Jonathan R. Pelsis, MHS Meniskus – Ersatz: Collagen Meniskus & Allograft 15. Janur 2010 Stone Research Foundation San Francisco
    2. 2. The Aging Knee Pediatric Normal Adult OA Adult
    3. 3. The Knee Joint
    4. 4. Meniscus <ul><li>Key shock absorber in the knee </li></ul><ul><li>Torn 1.5M times annually US </li></ul><ul><li>Minimal healing </li></ul><ul><ul><li>No spontaneous regeneration template </li></ul></ul>
    5. 5. <ul><li>Loss of meniscus cartilage leads to: </li></ul><ul><ul><li>Increased forces across the knee joint </li></ul></ul><ul><ul><li>Increased risk of articular cartilage damage </li></ul></ul><ul><ul><li>Pain and arthritis in many cases </li></ul></ul><ul><li>Painful arthritic joints: </li></ul><ul><ul><li>Rough surfaces </li></ul></ul><ul><ul><li>Harsh, degradative environment </li></ul></ul>The Problem
    6. 6. <ul><li>Reduce pain and improve function </li></ul><ul><li>Preserve the biology of the knee </li></ul><ul><li>Restore a biomechanically favorable environment </li></ul><ul><li>Provide a buffer to prevent bone-on-bone contact and pain </li></ul>The Goal
    7. 7. The Alignment Controversy <ul><li>Is osteotomy a two plane crude correction of a multiplanar deformed geometry? </li></ul><ul><li>Is osteotomy really a correction? </li></ul><ul><li>Are the complications worth it? </li></ul>“ Bad biomechanics ruins good biology any day of the week…” … However, biology lasts decades even in mechanically disadvantaged knees.
    8. 8. A Solution ? Biologic Knee Replacement <ul><li>Smooth, repair, replace, or regenerate damaged articular cartilage </li></ul><ul><li>Meniscus reconstruction </li></ul><ul><li>Meniscus allograft transplantation </li></ul><ul><li>Fibrous interpostional joint arthroplasty </li></ul><ul><ul><li>Reduce pain and improve function </li></ul></ul><ul><ul><li>Increase success of cartilage grafts </li></ul></ul>
    9. 9. Outerbridge Grading System For Cartilaginous Degeneration Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br, 1961;43: 752-7. Grade I Soft discolored superficial fibrillation Grade II Fragmentation < 1.3 cm 2 Grade III Fragmentation > 1.3 cm 2 Grade IV Erosion to subchondral bone (eburnation)
    10. 10. Meniscus Allograft Transplantation: Indications? <ul><li>Traditional thought: Meniscus Transplantation does not work in arthritic knees ( Noyes & Barber-Westin 1995, Stollsteimer 2000, Rath 2001) </li></ul><ul><li>Current thought: Meniscus Transplantation does work in arthritic knees if damaged articular cartilage is treated as well (van Arkel 2002, Noyes 2004, Verdonk 2005, Cole 2006, Stone 2006, Farr 2007, Rue 2008) </li></ul>
    11. 11. Sizing: Surgeon Concerns <ul><li>“It takes me 6 months to get a properly sized meniscus.” </li></ul><ul><li>“My measurements do not match the bank’s measurements.” </li></ul><ul><li>“Is there an easier, more accurate method for sizing?” </li></ul>
    12. 12. Meniscus Allograft: Sizing <ul><li>Success rate may be dependant on accurate sizing </li></ul><ul><li>Image-based sizing measures bony landmarks and insertion points however: </li></ul><ul><ul><li>Contrast limitations </li></ul></ul><ul><ul><li>Identification of soft versus mineralized tissue interface </li></ul></ul><ul><ul><li>Magnification errors </li></ul></ul><ul><li>Schaffer B, Kennedy S, Flimkiewicz J, Yao L. Preoperative Sizing of the Meniscal Allografts in Meniscal transplantation. Am Journal of Sports Med. Vol. 28, No. 4, 2000. </li></ul>
    13. 13. Supporting Studies: Sizing <ul><ul><li>148 heights and weights compared to MRI meniscus size </li></ul></ul><ul><li>Pearson’s Correlations (r): </li></ul><ul><li>Height vs Total Tibial Plateau (TTP) r = 0.7194 </li></ul><ul><li>Weight vs TTP r = 0.5470 </li></ul><ul><li>TTP vs Medial and Lateral Meniscal Width r = 0.7386, r = 0.7209 </li></ul><ul><li>TTP vs Medial and Lateral Meniscal Length r = 0.7040, r = 0.7209 </li></ul><ul><li>Stone KR, Freyer A, Turek T, Walgenbach AW, Wadhwa S, Crues J. Meniscal sizing based on gender, height, and weight. Arthroscopy 2007;23-5:503-8 </li></ul>Meniscal Sizing Based on Gender, Height, and Weight
    14. 14. The Three-Tunnel Technique Replacing the Meniscus Stone KR, Walgenbach AW. “Meniscal Allografting: the Three-Tunnel Technique.” Arthroscopy – The Journal of Arthroscopic and Related Surgery. 2003, 19(4):426-30.
    15. 15. The Three-Tunnel Technique Movie
    16. 16. Articular Cartilage Paste Graft Procedure Step 1 Step 5 Step 4 Step 3 Step 2
    17. 17. Meniscus Transplantation <ul><li>173 patients since 1997 </li></ul><ul><li>Clinical Exam + Patient Reported Subjective Outcome (1, 2, 3, 5, 7, 10, 15+ yrs) </li></ul><ul><ul><li>IKDC </li></ul></ul><ul><ul><li>WOMAC </li></ul></ul><ul><ul><li>TEGNER </li></ul></ul>The Stone Clinic Experience
    18. 18. Current Study: <ul><li>Long-Term Survival of Concurrent Meniscus Allograft Transplantation and Articular Cartilage Repair: A Prospective 12-Year Follow-Up Evaluation </li></ul>Pre-Allograft Allograft in place Transplantation OB IV
    19. 19. Study Design <ul><li>Study Inclusion </li></ul><ul><li>Irreparable injury of the meniscus </li></ul><ul><ul><li>Or </li></ul></ul><ul><li>Loss of the meniscus </li></ul><ul><ul><li>More than 50% </li></ul></ul><ul><li>OB III/IV </li></ul><ul><li>ROM ≥ 90° </li></ul><ul><li>Study Exclusion </li></ul><ul><li>Rheumatoid Arthritis </li></ul><ul><li>Tri-compartment arthritis </li></ul><ul><li>Total loss of joint space </li></ul><ul><li>Simultaneous med/lat meniscus allograft transplantation </li></ul>
    20. 20. Patient Selection <ul><li>Young patients with cartilage loss and pain </li></ul><ul><li>Older patients with cartilage loss and focal pain who want to remain athletic and delay or avoid a knee arthroplasty. </li></ul><ul><li>“Doc, isn’t there a shock absorber you can put in my knee?” </li></ul>
    21. 21. Surgical Technique <ul><li>Medial Meniscus Allograft Transplantation: Performed utilizing periosteum, but not bone blocks, at the meniscus horns. </li></ul><ul><li>Lateral Meniscus Allograft Transplantation: Preformed by preserving the bony block between the horns and inserting it into a bone trough. </li></ul>
    22. 22. <ul><li>119 Meniscus Allograft Transplant Cases </li></ul><ul><li>Mean age = 46.9 years (14.1 – 73.2 yrs) </li></ul><ul><li>Mean follow-up = 5.8 years (2.1 mo – 12.3 yrs) </li></ul><ul><li>118 patients ≥ 3 months from injury to time of surgery (Mean = 14.2 years) </li></ul>Patient Population
    23. 23. Patient Population (N = 119) Neutral / Varus / Valgus Moderate ( 5 – 7°) / Severe ( > 7°) Grade III / Grade IV Medial / Lateral Male / Female None / Mild–Moderate / Severe (Kellgren-Lawrence)
    24. 24. Review of Literature Mixed Patient Studies N = 119 N = 100 N = 29 N = 31 N = 44
    25. 25. Results <ul><li>Procedure failure: Removal of allograft without revision (N = 7) , or progression to knee arthroplasty [N = 18 (TKA or UNI)]. </li></ul><ul><li>94/119 allograft cases successful (79%) </li></ul><ul><ul><li>Of 25 failures, Mean time-to-failure: 4.65 ± 2.99 years </li></ul></ul><ul><ul><li>Range: 2.1 months – 10.37 years </li></ul></ul><ul><li>Kaplan-Meier estimated mean survival time was 9.93 ± 0.40 years [95%CI: 9.14,10.72] </li></ul><ul><li>13 patients were lost to follow-up </li></ul>
    26. 26. Complications <ul><li>4 Early Postoperative Infections </li></ul><ul><ul><li>3 Deep (1 Staphphylococcus Aures, 2 negative serologies) </li></ul></ul><ul><ul><li>1 Superficial (Staphylococcus Epidemis) </li></ul></ul><ul><li>All cases were treated arthroscopically with irrigation and debridement and IV antibiotics. </li></ul><ul><li>All cases resolved, but one deep infection case ultimately failed, with the allograft being removed 12.5 months later. </li></ul>
    27. 27. Subsequent Surgeries – 1 4 2 Meniscus Allograft Revision – 2 1 12 Meniscus Allograft Repair – 1 9 22 Meniscectomy 1 1 – 4 Microfracture / Articular Cartilage Paste Grafting 1 4 6 20 Chondroplasty / Debridement – 1 1 2 Other 4 th N = 2 3 rd N = 10 2 nd N = 21 1 st N = 62 Subsequent Surgeries Primary Procedure
    28. 28. Kaplan-Meier Survival Analysis In Patients OB III/IV <ul><li>Time-to-failure analysis with continuous enrollment over 12-yrs </li></ul><ul><li>Takes into account remaining patients (still intact / lost to follow-up (N=13) ) </li></ul>Intact/Lost To Follow-Up 94% 92% 84% 79% 67%
    29. 29. Cox Proportional Hazards Model What is it? <ul><li>A Cox model provides an estimate of a variable’s effect on survival after adjustment for other explanatory variables. </li></ul><ul><li>In addition, it allows us to estimate the hazard (or risk) of procedure failure, given their prognostic variables. </li></ul>
    30. 30. What factors affect survival? <ul><li>Cox Proportional Hazards Model was used to explore the relationship between procedure failure and several covariates. </li></ul>Age (p = 0.026) Number of Previous Surgeries (p = 0.006) Number of Additional Surgeries Osteotomy performed concomitantly Number of concomitant procedures Outerbridge Grade (III or IV) Medial v. Lateral Allograft Joint Space Narrowing Malalignment Severity Alignment Type Sex NOT RELATED RELATED
    31. 31. Cox Model - Related Hazards <ul><li>Independent of actual time-to-failure, increased number of previous surgeries (p = 0.026) and increased age at time of surgery (p = 0.006) increases the risk of meniscus allograft transplantation failure. </li></ul>
    32. 32. Effect of Age <ul><li>53 patients over 50 (Mean = 56 yrs) </li></ul><ul><ul><li>KM mean survival = 8.84 years [95% CI: 7.51,10.17] </li></ul></ul><ul><ul><li>71.7% (38/53) Success Rate </li></ul></ul><ul><ul><ul><li>1 allograft removed 2 mo. post-op </li></ul></ul></ul><ul><ul><ul><li>14 progressed to Joint Arthroplasty @ mean 5.1 years </li></ul></ul></ul><ul><li>66 patients under 50 (Mean = 39 yrs) </li></ul><ul><ul><li>KM mean survival = 10.67 years [95% CI: 9.76,11.58] </li></ul></ul><ul><ul><li>84.8% (56/66) Success Rate </li></ul></ul><ul><ul><ul><li>6 allografts removed @ mean 4.0 years </li></ul></ul></ul><ul><ul><ul><li>4 Progressed to Joint Arthroplasty @ mean 5.2 years </li></ul></ul></ul>
    33. 33. Medial v. Lateral Allografts <ul><li>Non Significant Hazard (p = 0.848) </li></ul>Medial (N = 85) KM mean survival: 9.91 ± 0.46 years Lateral (N = 34) KM mean survival: 10.17 ± 0.78 years
    34. 34. Malalignment <ul><li>Severity of Mal-Alignment (p = 0.535) </li></ul><ul><ul><li>Severe Malalignment (>7 º) (N = 10) </li></ul></ul><ul><ul><li>Moderate Malalignment (5 – 7 º) (N = 39) </li></ul></ul>7 Osteotomies – 71.4% Success Rate (5/7) – 2 UNI 3 NO Osteotomy – 66.7% Success Rate (2/3) – 1 UNI – 50% Success Rate (4/8) – 2 TKA, 1 UNI, 1 Removed 8 Osteotomies – 80.6% Success Rate (25/31) – 2 TKA, 2 UNI, 2 Removed 31 NO Osteotomy
    35. 35. Subjective Outcome Scores <ul><li>IKDC, WOMAC, and TEGNER questionnaire follow-up schedule was preoperatively and at 2, 3, 5, 7, 10, 15 year post-op. </li></ul><ul><li>Tegner Index was used to normalize return to activity across a diverse population * </li></ul>* Rodkey et al. Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial. J Bone Joint Surg Am 2008;90-7:1413-26. Current Tegner activity score Highest reported pre-injury score = Tegner Index Score
    36. 36. Subjective Outcome Scores 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Mean Tegner Index Score
    37. 37. Patient Example: BK <ul><li>27 year old male </li></ul><ul><li>Torn lateral meniscus in high school wrestling 1996 </li></ul><ul><li>Partial lateral meniscectomy 2/96, 8/04 </li></ul>Pre-Operative X-Rays
    38. 38. BK: Pre-Op MRI <ul><li>MRI documents degenerative changes to LTP and loss of lateral meniscus </li></ul>
    39. 39. Patient Example: BK <ul><li>Lateral Meniscus Allograft Transplantation </li></ul>
    40. 40. Patient Example: BK 8 months post <ul><li>Arthroscopy for suprapatellar pouch and anterolateral swelling </li></ul><ul><li>Lateral meniscus allograft transplant had healed </li></ul>
    41. 41. BK MRI 4 Years Post Op <ul><li>Lateral meniscus allograft appears normal and well positioned </li></ul><ul><li>Patient reports no pain - “It feels really good” </li></ul>
    42. 42. Patient Example: JL <ul><li>35 Year Old Female </li></ul><ul><li>Right Knee </li></ul><ul><li>1984 - Lateral Meniscectomy </li></ul><ul><li>1988 - Lateral release </li></ul><ul><li>2003 - Knee locked, total meniscectomy </li></ul><ul><li>Valgus Alignment </li></ul>
    43. 43. Patient Example: JL OB III/IV far-posterior aspect LFC, Microfracture LFC
    44. 44. JL: 4 months Post-Op <ul><li>Flexion contracture, debridement, closed manipulation, notchplasty </li></ul><ul><li>No evidence of meniscal impingement </li></ul><ul><li>Healed, intact lateral meniscus </li></ul>
    45. 45. JL: 6 years Post-Op <ul><li>Lateral Meniscus repair, chondroplasty, debridement, notchplasty </li></ul>
    46. 46. Patient Example: JA <ul><li>37 Year old female </li></ul><ul><li>Meniscectomy at age 20 </li></ul><ul><li>R-Lateral Meniscus missing </li></ul><ul><li>OB III chondral defect </li></ul><ul><li>Microfracture, Chondroplasty LFC </li></ul>Long-Leg AP
    47. 47. JA: Preoperative X-ray Lateral AP
    48. 48. JA: Preoperative MRI <ul><li>Lateral meniscus: </li></ul><ul><li>Absent posterior horn </li></ul><ul><li>Articular Cartilage: </li></ul><ul><li>Chondral damage to LFC </li></ul>
    49. 49. JA Operative Images A B C Deficient Lateral Meniscus Chondral Lesion of LFC Microfracture of Lesion
    50. 50. JA Operative Images A B C Absent Meniscus Lateral Meniscus Allograft Allograft Placement
    51. 51. JA: 5 Months Post-Op <ul><li>Full ROM with smooth articulation </li></ul>
    52. 52. JA: 2Yr Postoperative X-ray PA Flexion AP
    53. 53. JA: 2yr Post-operative MRI <ul><li>Healed lateral meniscal allograft </li></ul>
    54. 54. JA: 5Yr Postoperative X-Ray PA Flexion AP
    55. 55. JA: 5Yr Postoperative MRI <ul><li>Virtually unchanged meniscal allograft </li></ul>
    56. 56. Patient Example: GC 7 o varus L-knee Medial joint space narrowing Active 53 y.o. male. Meniscectomy: 1986, 1996 Medial meniscus-allograft 3/99 Paste Graft MFC & MTP High medial tibial osteotomy (Bionx wedge and allograft bone)
    57. 57. GC: Preoperative Images Sagittal MRI Loss of cartilage MFC PA Flexion Medial joint space narrowing
    58. 58. GC: Operative Images A B Bipolar lesions Morselization of MFC & MTP Loss of medial meniscus
    59. 59. GC: Operative Images A B C Placement of medial meniscal allograft Impaction of paste graft Paste Grafted Lesion
    60. 60. GC: Postoperative X-Ray Long-leg AP
    61. 61. GC: 3Yr Postoperative X-ray AP Long-leg
    62. 62. GC: 3Yr Postoperative Images 3 Years post-op L-medial allograft, osteotomy, & paste graft
    63. 63. GC: Comparison of healing 3-Years post-op allograft and paste graft to MFC Operative 3 yrs Post-op 3 yrs Post-op
    64. 64. Patient Example: SC <ul><li>39 y.o. male </li></ul><ul><li>Injury: 1970s playing hockey </li></ul><ul><li>Meniscectomy (1999) </li></ul><ul><li>Pre-op: </li></ul><ul><ul><li>Varus </li></ul></ul><ul><ul><li>Joint space narrowing </li></ul></ul><ul><li>Right Medial Meniscus Allograft (2000) </li></ul>
    65. 65. SC: Preoperative MRI Bucket-handle tear with bipolar cartilage lesions on MFC & MTP Coronal Sagittal
    66. 66. SC: Operative Images Right knee bucket-handle tear displaced into intercondylar notch A B
    67. 67. SC: Operative Images Eburnated bone MFC Eburnated bone MTP Microfracture MTP Microfracture MTP
    68. 68. SC: Placement of Allograft Right Knee Placement of Medial Meniscal Allograft
    69. 69. SC: Comparison of healing Return to full activity Intermittent catching and pain 17 Mo Post-op Pre-op Note improved joint space compared to pre-op
    70. 70. SC: 17 Mo Post Op MRI Coronal Sagittal
    71. 71. SC: 2nd Surgery Movie 17 mo. Post Paste graft MFC + Meniscus Allograft Initial Surgery 17 mo. Post-op Meniscectomy
    72. 72. SC: 5 yr Post Op Images AP Allograft present with maturing degenerative changes Coronal
    73. 73. Patient Example DB <ul><li>47 YO Male Skier </li></ul><ul><li>R Knee: Chronic Pain </li></ul><ul><li>Moderate to Severe Bilateral Pain </li></ul>
    74. 74. DB: Right Knee <ul><li>Right Knee: </li></ul><ul><li>09/91: Medial Meniscectomy, Drilling MFC, Chondroplasty </li></ul><ul><li>12/97: (triple) Medial Meniscus Allograft, Osteotomy, Art Cart MFC, MFx LFC </li></ul><ul><li>05/98: Revision Osteotomy, Medial Meniscectomy, Debridement, MFx MTP </li></ul><ul><li>10/2000: Ilizarov, Meniscectomy, Chondroplasty </li></ul>Pre-Op XRAY
    75. 75. DB: Right Knee 10 Yr PostOp MRI
    76. 76. DB: 10 Yr Post Op XRAY
    77. 77. DB: 10 Yr PostOp 63 YO, Tegner = 6, Skis 30+ days/yr, Snow skis 50+ days/yr.
    78. 78. <ul><li>47 YO Female </li></ul><ul><li>Beach volleyball injury (11/03) </li></ul><ul><li>Failed debridement (11/03) </li></ul><ul><li>Clinical exam: </li></ul><ul><ul><li>Pain at rest = 8/10 </li></ul></ul><ul><ul><li>Severe swelling </li></ul></ul><ul><ul><li>Giving way </li></ul></ul><ul><li>Meniscus Allograft, ACL reconstruction, Chondroplasty (3/05) </li></ul>Patient Example: RT
    79. 79. RT: Pre-Operative MRI
    80. 80. <ul><li>Torn medial meniscus </li></ul>MFC chondral lesion LFC chondral lesion Torn ACL Patient Example: RT
    81. 81. <ul><li>Medial meniscus Allograft </li></ul>Allograft Insertion Allograft placement ACL BTB allograft Patient Example: RT
    82. 82. <ul><ul><li>Intact meniscus allograft </li></ul></ul><ul><ul><li>ACL hardware removal due to prominence of fixation screw </li></ul></ul>RT: 3 Months Post
    83. 83. Excellent joint space, intact meniscus allograft and ACL, but right knee clicking and catching RT: 18 Months Post
    84. 84. Intact meniscus allograft and ACL with diffuse thinning of patellofemoral cartilage RT: 18 Months Post
    85. 85. <ul><li>Surgery for catching due to chondral flap at patellofemoral joint </li></ul><ul><li>Intact meniscus allograft and ACL </li></ul>RT: 18 Months Post
    86. 86. Patient Example: RM 57 Male Long-leg MRI <ul><li>Injury: Football tackle 1978 </li></ul><ul><li>Previous Meniscectomy: 1978, 1993 </li></ul><ul><li>Moderate varus mal alignment ( ≤ 7°) </li></ul><ul><li>MFC OCD lesion </li></ul>
    87. 87. RM: Operative Images Severe Articular Cartilage Damage
    88. 88. RM: Operative Images Allograft insertion Articular Cartilage Paste Grafting Repair
    89. 89. RM: Operative Images High tibial opening wedge osteotomy
    90. 90. RM: 3.5 Years Post-Allograft Movie Primary Surgery Second Look, 3.5 years later
    91. 91. RM: Histology
    92. 92. RM: 3.5 Years Post Operative Long-leg
    93. 93. RM: 5 Years Post Operative MRI Sagittal Coronal
    94. 94. RM: 6 Year Post Operative X-Ray Long-leg Lateral
    95. 95. Patient Example: HM 5-7 o varus L-knee <ul><li>18 Yrs Post meniscectomy </li></ul><ul><li>2 Meniscectomies (‘86, ’96) </li></ul><ul><li>Pain >1 year </li></ul><ul><li>Varus deformity </li></ul><ul><li>Medial joint space narrowing </li></ul><ul><li>L-medial meniscus-allograft (3/1999) </li></ul><ul><li>Paste graft MFC & MTP </li></ul><ul><li>High medial tibial osteotomy (Bionx wedge and allograft bone) </li></ul><ul><li>Chondroplasty LFC </li></ul><ul><li>Partial lateral meniscectomy </li></ul><ul><li>Notchplasty </li></ul>
    96. 96. HM 4 Yrs 9 Mo Post Paste Graft Debrided lesion Healed paste graft
    97. 97. HM 4 Yrs 9 Mo Post Paste Graft Biopsy Histology
    98. 98. Biologic Knee Replacement Revision Surgery
    99. 99. Patient Example: TA <ul><li>48 y.o. world-class female marathoner </li></ul><ul><ul><li>86 marathons, </li></ul></ul><ul><ul><li>12 Ironmans </li></ul></ul><ul><ul><li>3 Double Ironman Triathalons </li></ul></ul><ul><li>Neutral alignment / mild medial joint space narrowing </li></ul><ul><li>Meniscectomy: 4/2001 and 1/2002 </li></ul>AP X-ray <ul><li>R Medial Meniscus Allograft + Microfracture (bipolar lesions) </li></ul>
    100. 100. TA: Preoperative MRI <ul><li>Tear at horn of medial meniscus </li></ul><ul><li>Osteoarthritis: medial compartment </li></ul>Saggital Coronal
    101. 101. 4/22/02: Right medial meniscus rim before allograft TA: Operative Images
    102. 102. TA: Meniscus Allograft Placement Preparation of medial meniscal allograft Placement of medial meniscal allograft Relationship of lesion to meniscus A B Movie
    103. 103. TA: Injury C <ul><li>Injury: 2 Mo. Post-op </li></ul><ul><li>Swam in pool for 2 hours </li></ul><ul><li>Developed immediate swelling </li></ul>A Movie
    104. 104. TA: Revision C A Movie Revision: 8 Months Post-allograft
    105. 105. TA: Revision: Operative Images Insertion of Meniscus Allograft with Articular Cartilage Paste Grafting Joint Arthroplasty 3/2006 (38 Mo. Post Op) A B C D
    106. 106. Patient Example: RT <ul><li>34 YO male </li></ul><ul><li>Partial meniscectomy for torn lateral meniscus (9/91), debridement 2006 </li></ul><ul><li>Lateral joint line pain </li></ul><ul><li>Severe pain and swelling with activities </li></ul><ul><li>Positive Apley’s, McMurray’s, and hyperextension tests </li></ul>
    107. 107. RT: Pre-Op Imaging <ul><li>X-rays: Collapse of lateral joint space. Mild patellar spurring. </li></ul>
    108. 108. RT: Pre-Op MRI <ul><li>Loss of articular cartilage on posterior aspect of LFC </li></ul><ul><li>Loss of posterior and central aspects of lateral meniscus </li></ul>PD SAG PD COR
    109. 109. RT: Surgery 11/2009 <ul><li>Lateral Meniscus Allograft transplantation </li></ul><ul><li>Microfracture LFC and LTP (too far posterior for Articular Cartilage Paste Grafting) </li></ul><ul><li>Removal of anvil osteophyte </li></ul>
    110. 110. RT: MRI 2 days Post Op <ul><li>Allograft intact without evidence of tear </li></ul><ul><li>Anterior subluxation of the posterior aspect of the lateral meniscus with anterior displacement of the bone block (12 mm). </li></ul>FSE T2 SAG FSE PD SAG
    111. 111. RT: Revision Surgery <ul><li>Interval repositioning of the lateral meniscus 5 days post index procedure. </li></ul><ul><li>Re-microfracture of distal femoral condyle to ensure good blood clot. </li></ul>
    112. 112. RT: MRI 1 Day Post Revision <ul><li>Repositioned Lateral Meniscus Allograft </li></ul>FSE T2 SAG FSE PD SAG
    113. 113. Conclusions <ul><li>Our research represents the largest and longest prospective study of meniscus replacement patients with severe chondral damage. </li></ul><ul><li>Meniscus replacement can improve symptoms, even in severe OA . </li></ul><ul><li>Meniscus replacement should not be limited to young patients without articular cartilage damage. </li></ul><ul><li>Axial malalignment does not affect outcome. </li></ul>
    114. 114. Conclusions <ul><li>Height and weight can be used to size meniscal allograft tissue. </li></ul><ul><li>Three-tunnel Technique is necessary to fix meniscus allograft to tibial plateau, not the surrounding tissue, to avoid meniscus subluxation </li></ul>
    115. 115. Conclusions <ul><li>Repair of severe articular cartilage damage combined with meniscus replacement provides significant improvements in activity, pain, and function. </li></ul><ul><li>Improvements are maintained over the course of follow-up (2 – 12 yrs). </li></ul>
    116. 116. Conclusions <ul><li>The number of TKA surgeries is predicted to increase to 3.4 million by 2030 * , with increasing costs † . </li></ul><ul><li>18/119(15%) cases in our study progressed to knee arthroplasty 4.8 years after meniscus replacement (range: 1.3 – 10.4 yrs) . </li></ul><ul><li>Average age at time of knee arthroplasty was 61 years (range: 52 – 72 yrs) . </li></ul>* Kurtz, AAOS Chicago, 2006 † Kurtz, JBJS, 2007
    117. 117. Conclusions <ul><li>Biologic joint reconstruction, rather than bionic (artificial) replacement, may be an appropriate first step for many people with knee joint arthritis. </li></ul>
    118. 118. Acknowledgements <ul><li>Thomas Turek </li></ul><ul><li>Mark Coleman </li></ul><ul><li>Abhi Freyer </li></ul><ul><li>Ann Walgenbach </li></ul><ul><li>Jonathan Pelsis </li></ul><ul><li>Wendy Adelson </li></ul><ul><li>Sharon Bobrow </li></ul>Meniscus Allograft Transplantation: 1997 – 2010 Articular Cartilage Paste Grafting: 1991 – 2010
    119. 119. 2009 Team 2005 Team

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