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Meniscus Transplant

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Meniscus Transplant

  1. 1. Meniscus Transplants Kevin R. Stone, MD Ann W. Walgenbach, RNNP Wendy S. Adelson, MS Jonathan R. Pelsis, MHS 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. Meniscus 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>
  8. 8. 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
  9. 9. 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.
  10. 10. Articular Cartilage Paste Graft Procedure Step 1 Step 5 Step 4 Step 3 Step 2
  11. 11. Meniscus Transplantation <ul><li>225 performed 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>
  12. 12. 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 Transplant in place Transplantation OB IV
  13. 13. 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>
  14. 14. 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>
  15. 15. 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>
  16. 16. <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 of Study
  17. 17. 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)
  18. 18. 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>
  19. 19. 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>
  20. 20. 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
  21. 21. 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%
  22. 22. 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>
  23. 23. 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
  24. 24. 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>
  25. 25. 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>
  26. 26. Medial v. Lateral Transplants <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
  27. 27. Malalignment <ul><li>Severity of Mal-Alignment (p = 0.535) </li></ul><ul><ul><li>Severe Malalignment (>7º) (N = 10) </li></ul></ul><ul><ul><li>Moderate Malalignment (5 – 7º) (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
  28. 28. 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
  29. 29. BK: Pre-Op MRI <ul><li>MRI documents degenerative changes to LTP and loss of lateral meniscus </li></ul>
  30. 30. Patient Example: BK <ul><li>Lateral Meniscus Transplantation </li></ul>
  31. 31. 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>
  32. 32. 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>
  33. 33. 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>
  34. 34. Patient Example: JL OB III/IV far-posterior aspect LFC, Microfracture LFC
  35. 35. 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>
  36. 36. JL: 6 years Post-Op <ul><li>Lateral Meniscus repair, chondroplasty, debridement, notchplasty </li></ul>
  37. 37. 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
  38. 38. JA: Preoperative X-ray Lateral AP
  39. 39. 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>
  40. 40. JA Operative Images A B C Deficient Lateral Meniscus Chondral Lesion of LFC Microfracture of Lesion
  41. 41. JA Operative Images A B C Absent Meniscus Lateral Meniscus Transplant Transplant Placement
  42. 42. JA: 5 Months Post-Op <ul><li>Full Range of Motion with smooth articulation </li></ul>
  43. 43. JA: 2Yr Postoperative X-ray PA Flexion AP
  44. 44. JA: 2yr Post-operative MRI <ul><li>Healed lateral meniscal allograft </li></ul>
  45. 45. JA: 5Yr Postoperative X-Ray PA Flexion AP
  46. 46. JA: 5Yr Postoperative MRI <ul><li>Virtually unchanged meniscal allograft </li></ul>
  47. 47. 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)
  48. 48. GC: Preoperative Images Sagittal MRI Loss of cartilage MFC PA Flexion Medial joint space narrowing
  49. 49. GC: Operative Images A B Bipolar lesions Morselization of MFC & MTP Loss of medial meniscus
  50. 50. GC: Operative Images A B C Placement of medial meniscal allograft Impaction of paste graft Paste Grafted Lesion
  51. 51. GC: Postoperative X-Ray Long-leg AP
  52. 52. GC: 3yr Postoperative X-ray AP Long-leg
  53. 53. GC: 3Yr Postoperative Images 3 Years post-op L-medial allograft, osteotomy, & paste graft
  54. 54. GC: Comparison of healing 3-Years post-op allograft and paste graft to MFC Operative 3 yrs Post-op 3 yrs Post-op
  55. 55. 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>
  56. 56. 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
  57. 57. DB: Right Knee 10 Yr PostOp MRI
  58. 58. DB: 10 Yr Post Op XRAY
  59. 59. DB: 10 Yr PostOp 63 YO, Tegner = 6, Skis 30+ days/yr, Snow skis 50+ days/yr.
  60. 60. <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
  61. 61. RT: Pre-Operative MRI
  62. 62. <ul><li>Torn medial meniscus </li></ul>MFC chondral lesion LFC chondral lesion Torn ACL Patient Example: RT
  63. 63. <ul><li>Medial meniscus Allograft </li></ul>Allograft Insertion Allograft placement ACL BTB allograft Patient Example: RT
  64. 64. <ul><ul><li>Intact meniscus transplant </li></ul></ul><ul><ul><li>ACL hardware removal due to prominence of fixation screw </li></ul></ul>RT: 3 Months Post
  65. 65. Excellent joint space, intact meniscus allograft and ACL, but right knee clicking and catching RT: 18 Months Post
  66. 66. Intact meniscus allograft and ACL with diffuse thinning of patellofemoral cartilage RT: 18 Months Post
  67. 67. <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
  68. 68. 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><ul><li>Improvements are maintained over the course of follow-up (2 – 12 yrs). </li></ul>

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