meniscus transplant
TRANSCRIPT
Meniscus TransplantsKevin R. Stone, MD
Ann W. Walgenbach, RNNP Wendy S. Adelson, MS
Jonathan R. Pelsis, MHS
Stone Research FoundationSan Francisco
The Aging Knee
Pediatric Normal Adult OA Adult
The Knee Joint
Meniscus
• Key shock absorber in the knee
• Torn 1.5M times annually US
• Minimal healing– No spontaneous
regeneration template
• Loss of meniscus cartilage leads to:• Increased forces across the knee joint• Increased risk of articular cartilage damage• Pain and arthritis in many cases
• Painful arthritic joints:• Rough surfaces• Harsh, degradative environment
The Problem
• Reduce pain and improve function
• Preserve the biology of the knee
• Restore a biomechanically favorable environment
• Provide a buffer to prevent bone-on-bone contact and pain
The Goal
Meniscus Transplantation: Indications
Traditional thought: Meniscus Transplantation does not work in arthritic knees (Noyes & Barber-Westin 1995, Stollsteimer 2000, Rath 2001)
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)
Supporting Studies: Sizing
• 148 heights and weights compared to MRI meniscus size
Pearson’s Correlations (r):
Height vs Total Tibial Plateau (TTP) r = 0.7194
Weight vs TTP r = 0.5470
TTP vs Medial and Lateral Meniscal Width r = 0.7386, r = 0.7209
TTP vs Medial and Lateral Meniscal Length r = 0.7040, r = 0.7209
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
Meniscal Sizing Based on Gender, Height, and Weight
The Three-Tunnel TechniqueReplacing 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.
Articular Cartilage Paste Graft Procedure
Step 1
Step 5Step 4
Step 3Step 2
Meniscus Transplantation
• 225 performed since 1997
• Clinical Exam + Patient Reported Subjective Outcome (1, 2, 3, 5, 7, 10, 15+ yrs)
• IKDC
• WOMAC
• TEGNER
Current Study:
Long-Term Survival of Concurrent Meniscus Allograft Transplantation
and Articular Cartilage Repair: A Prospective 12-Year Follow-Up Evaluation
Pre-Allograft Transplant in placeTransplantation
OB IV
Study Design
Study Inclusion
• Irreparable injury of the meniscus
Or
• Loss of the meniscus
– More than 50%
• OB III/IV
• ROM ≥ 90°
Study Exclusion
• Rheumatoid Arthritis
• Tri-compartment arthritis
• Total loss of joint space
• Simultaneous med/lat meniscus allograft transplantation
Patient Selection
• Young patients with cartilage loss and pain
• Older patients with cartilage loss and focal pain who want to remain athletic and delay or avoid a knee arthroplasty.
• “Doc, isn’t there a shock absorber you can put in my knee?”
Surgical Technique• Medial Meniscus Allograft
Transplantation: Performed utilizing periosteum, but not bone blocks, at the meniscus horns.
• Lateral Meniscus Allograft Transplantation: Preformed by preserving the bony block between the horns and inserting it into a bone trough.
• 119 Meniscus Allograft Transplant Cases
• Mean age = 46.9 years (14.1 – 73.2 yrs)
• Mean follow-up = 5.8 years (2.1 mo – 12.3 yrs)
• 118 patients ≥ 3 months from injury to time of surgery (Mean = 14.2 years)
Patient Population of Study
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)
Results
• Procedure failure: Removal of allograft without revision (N = 7), or progression to knee arthroplasty [N = 18 (TKA or UNI)].
• 94/119 allograft cases successful (79%)– Of 25 failures, Mean time-to-failure:
4.65 ± 2.99 years
– Range: 2.1 months – 10.37 years
• Kaplan-Meier estimated mean survival time was 9.93 ± 0.40 years [95%CI: 9.14,10.72]
• 13 patients were lost to follow-up
Complications
• 4 Early Postoperative Infections– 3 Deep (1 Staphphylococcus Aures, 2 negative
serologies)– 1 Superficial (Staphylococcus Epidemis)
• All cases were treated arthroscopically with irrigation and debridement and IV antibiotics.
• All cases resolved, but one deep infection case ultimately failed, with the allograft being removed 12.5 months later.
Subsequent Surgeries
Primary Procedure
Subsequent Surgeries
1st
N = 62
2nd
N = 21
3rd
N = 10
4th
N = 2
Meniscus Allograft Revision 2 4 1 –Meniscus Allograft Repair 12 1 2 –Meniscectomy 22 9 1 –Microfracture /Articular Cartilage Paste Grafting 4 – 1 1
Chondroplasty / Debridement 20 6 4 1Other 2 1 1 –
Kaplan-Meier Survival AnalysisIn Patients OB III/IV
• Time-to-failure analysis with continuous enrollment over 12-yrs
• Takes into account remaining patients (still intact / lost to follow-up (N=13))
Intact/Lost To Follow-Up
94%92% 84% 79% 67%
Cox Proportional Hazards ModelWhat is it?
• A Cox model provides an estimate of a
variable’s effect on survival after
adjustment for other explanatory variables.
• In addition, it allows us to estimate the
hazard (or risk) of procedure failure, given
their prognostic variables.
What factors affect survival?• Cox Proportional Hazards Model was used
to explore the relationship between procedure failure and several covariates.
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 RELATEDRELATED
Cox Model - Related Hazards
• 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.
Effect of Age• 53 patients over 50 (Mean = 56 yrs)
– KM mean survival = 8.84 years [95% CI: 7.51,10.17]
– 71.7% (38/53) Success Rate1 allograft removed 2 mo. post-op
14 progressed to Joint Arthroplasty @ mean 5.1 years
• 66 patients under 50 (Mean = 39 yrs)– KM mean survival = 10.67 years [95% CI: 9.76,11.58]
– 84.8% (56/66) Success Rate6 allografts removed @ mean 4.0 years
4 Progressed to Joint Arthroplasty @ mean 5.2 years
Medial v. Lateral Transplants
Non Significant Hazard (p = 0.848)
Medial
(N = 85)
KM mean survival: 9.91 ± 0.46 years
Lateral
(N = 34)
KM mean survival:
10.17 ± 0.78 years
Malalignment
• Severity of Mal-Alignment (p = 0.535)
– Severe Malalignment (>7º) (N = 10)
– Moderate Malalignment (5 – 7º) (N = 39)
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
Patient Example: BK
• 27 year old male• Torn lateral meniscus in high school wrestling 1996• Partial lateral meniscectomy 2/96, 8/04
Pre-Operative X-Rays
BK: Pre-Op MRI
• MRI documents degenerative changes to LTP and loss of lateral meniscus
Patient Example: BK
• Lateral Meniscus Transplantation
Patient Example: BK 8 months post
• Arthroscopy for suprapatellar pouch and anterolateral swelling
• Lateral meniscus allograft transplant had healed
BK MRI 4 Years Post Op
•Lateral meniscus allograft appears normal and well positioned
•Patient reports no pain - “It feels really good”
Patient Example: JL
• 35 Year Old Female
Right Knee • 1984 - Lateral
Meniscectomy• 1988 - Lateral release• 2003 - Knee locked, total
meniscectomy• Valgus Alignment
Patient Example: JL
OB III/IV far-posterior aspect LFC, Microfracture LFC
JL: 4 months Post-Op
• Flexion contracture, debridement, closed manipulation, notchplasty
• No evidence of meniscal impingement
• Healed, intact lateral meniscus
JL: 6 years Post-Op
• Lateral Meniscus repair, chondroplasty, debridement, notchplasty
Patient Example: JA
• 37 Year old female
• Meniscectomy at age 20
• R-Lateral Meniscus missing
• OB III chondral defect
• Microfracture, Chondroplasty LFC
Long-Leg AP
JA: Preoperative X-ray
LateralAP
JA: Preoperative MRI
Lateral meniscus:• Absent posterior horn
Articular Cartilage:• Chondral damage
to LFC
JA Operative Images
A B CDeficient Lateral
MeniscusChondral Lesion of
LFCMicrofracture of
Lesion
JA Operative Images
A B CAbsent Meniscus Lateral Meniscus
TransplantTransplant Placement
JA: 5 Months Post-Op
Full Range of Motion with smooth articulation
JA: 2Yr Postoperative X-ray
PA Flexion AP
JA: 2yr Post-operative MRI
• Healed lateral meniscal allograft
JA: 5Yr Postoperative X-Ray
PA Flexion AP
JA: 5Yr Postoperative MRI
• Virtually unchanged meniscal allograft
Patient Example: GC
7o 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)
GC: Preoperative Images
Sagittal MRI
Loss of cartilage MFC
PA Flexion
Medial joint space narrowing
GC: Operative Images
A BBipolar lesions Morselization of MFC & MTP
Loss of medial meniscus
GC: Operative Images
A B CPlacement of medial
meniscal allograftImpaction ofpaste graft
Paste GraftedLesion
GC: Postoperative X-Ray
Long-leg AP
GC: 3yr Postoperative X-ray
APLong-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 DB
• 47 YO Male Skier
• R Knee: Chronic Pain
• Moderate to Severe Bilateral Pain
DB: Right Knee
Right Knee:
• 09/91: Medial Meniscectomy, Drilling MFC, Chondroplasty
• 12/97: (triple) Medial Meniscus Allograft, Osteotomy, Art Cart MFC, MFx LFC
• 05/98: Revision Osteotomy, Medial Meniscectomy, Debridement, MFx MTP
• 10/2000: Ilizarov, Meniscectomy, ChondroplastyPre-Op XRAY
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.
• 47 YO Female
• Beach volleyball injury (11/03)
• Failed debridement (11/03)
• Clinical exam:– Pain at rest = 8/10– Severe swelling – Giving way
• Meniscus Allograft, ACL reconstruction, Chondroplasty (3/05)
Patient Example: RT
RT: Pre-Operative MRI
Torn medial meniscus
MFC chondral lesion
LFC chondral lesion Torn ACL
Patient Example: RT
Medial meniscus Allograft Allograft Insertion
Allograft placement ACL BTB allograft
Patient Example: RT
• Intact meniscus transplant• ACL hardware removal due to prominence of fixation screw
RT: 3 Months Post
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
• Surgery for catching due to chondral flap at patellofemoral joint
• Intact meniscus allograft and ACL
RT: 18 Months Post
Conclusions
• Height and weight can be used to size meniscal allograft tissue.
• Three-tunnel Technique is necessary to fix meniscus allograft to tibial plateau, not the surrounding tissue, to avoid meniscus subluxation
• Improvements are maintained over the course of follow-up (2 – 12 yrs).