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RELIVE:
MENISCUS ALLOGRAFT
G.C. Coari – A. Tripodo – S. G.C. Coari – A. Tripodo – S. CappatoCappato
Casa di Cura “San Camillo” – Forte dei Casa di Cura “San Camillo” – Forte dei MarmiMarmi
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
SORRY, MY ENGLISH IS IMPROVING....IT ISN’T PERFECT YET.... BUT
MIGLIORERO’... AND I
HOPE TO BE GIVEN A 3rd CHANCE IN TWO YEARS “GOOD-BYE
TO 2012”
PEDERZINI - COARI - ARNALDI - ADRIANI - BERRUTO ZINI - PRIANO - ZORZI – NICEFORO -
ADRAVANTI
ITALIAN STUDY GROUP - SIAITALIAN STUDY GROUP - SIA
5
SINCE OCTOBER 2002
5
A. TRIPODO A. TRIPODO
TRAPIANTO MENISCALE: TRAPIANTO MENISCALE: ESPERIENZA ITALIANA ESPERIENZA ITALIANA
E RISULTATI E RISULTATI
S.I.A. FELLOWSHIPS.I.A. FELLOWSHIP
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...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..
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”……
“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”……
“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
“MENISCUS DEFICIENCY IS THE 1st PROBLEM IN ORTHOPAEDICS TODAY”F. Noyes, M.D.
- All clinics see many patients with irreparable meniscus lesions
- 10 years later these patients are candidates for HTOs, cartilage transfers and other salvage procedures
- Finally, most of these patients require a knee replacement
MENISCECTOMY IS NOT A BENIGN PROCEDUREMENISCECTOMY IS NOT A BENIGN PROCEDURE
SAVE THE MENISCUS!SAVE THE MENISCUS!
SUTURE !!
AUTOLOGUS MENISCUS AUTOLOGUS MENISCUS TRANSPLANTATIONTRANSPLANTATION
RATIONALE FOR MENISCUS TRANSPLANTATION
RELIEVE PAIN AND SWELLING
IMPROVE KNEE STABILITY
PREVENT PROGRESSION OF ARTHROSIS (?)
AN “ENCHANTING” HYPOTHESIS: CHANGING THE
NATURAL HISTORY OF A MENISCUS DEFICIENT KNEE
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PHYSIOLOGICALLY YOUNG, ACTIVE
NEUTRAL ALIGNMENT
NORMAL STABILITY
NO MORE THAN GRADE II-III CARTILAGE DAMAGE
UNDERSTANDS RISKS OF SURGERY, DISEASE TRANSMISSION
POST-OP COMPLIANCE AND REALISTIC EXPECTATIONS
NO KNEE ABUSER
INDICATIONS“PATIENT WITH PAIN IN THE AFFECTED MENISCAL-DEFICIENT COMPARTMENT”
No standard protocol
AP and ML bone size
RX, MRI and CT
46% mismatch 2-5 mm
(Shaffer)
“size does matter…”
(Shaffer)
GRAFT: “sizing/matching”
WHICH TYPE ?
FRESH-FROZEN CRIOPRESERVED
NOT IRRADIATED
THE SURGICAL TECHNIQUE HAS EVOLVED FROM ARTHROTOMY TO THE CURRENT ARTHROSCOPIC
– ASSISTED TECHNIQUE
2002-03
OPEN TECHNIQUE
2004-10
SCOPE ASSISTED
TECHNIQUE
SURGICAL PROCEDURE GENERAL CONCEPT
BONE ANCORAGE
SINCE 2006 WITHOUT BONE
SURGICAL PROCEDURE GENERAL CONCEPT
ANATOMICAL PLACEMENT OF MENISCAL HORNES
ACCURED FIXATION
ALL - INSIDE IN - OUT OUT - IN
22
FEMALE 38 YY
25 YEARS AGO ARTHROTOMIC MENISCECTOMY
LATERAL COMPARTMENT - PAIN - SWELLING
BARMAID - STANDING ALL DAY
NORMAL AXIS AND STABILITY KNEE
REHABILITATION
Partial weightbearing 20% for 6 weeks
CPM (optional): 0-90° for 4 weeks
Brace 0°- 60° for 6 week
0°- 90° after 8 week
No jogging, twisting and squatting for 4 months
Total recover within 6 months
Leisure sport activities, after 12 months
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- AVERAGE AGE 37 YY
-16 MALE - 20 FEMALE
- 24 LATERAL
- 14 MEDIAL
- 2 BICOMPARTIMENTAL
- 4 WITH BONE
- 34 WITHOUT BONE
OUR EXPERIENCE OUR EXPERIENCE
SINCE JULY 2003
38 M.A.T. IN 36 PZ.
- LATERAL MENISCUS 16 (1 BICOMPARTIMENTAL)
- MEDIAL MENISCUS 4
- BONE 4 - WITHOUT BONE 16
- MEN 11 WOMEN 8 - AVERAGE AGE 34
- TIMING 1st TRAUMA AND SURGERY 2 yy–30 yy
- PREVIUS SURGERY 1-6
- THE SAME SURGEON
- FOLLOW-UP: 6 MONTHS, 1 YEAR, EVERY YEAR26
OUR EXPERIENCE OUR EXPERIENCE
19 PATIENTS - UP TO SEPTEMBER 2008
F.UP: 1 - 5 YY
I grade (0%)
II grade (30%)
III grade (50%)
IV grade (20%) 27
ASSOCIATED PROCEDURESASSOCIATED PROCEDURES
LCA 4
M.A.C.I. 4
HTO 1
CONDRAL LESIONSCONDRAL LESIONS
CLINICAL
Lysholm Knee Score
K.O.O.S.
IKDC
X-RAY
MRI
28
EVALUATION According to European Meniscal
Transplantation Study Group
OUTCOMES
IKDC
• A (normal) 4
(21%)
• B (nearly normal) 11
(58%)
• C (abnormal) 2
(10.5%)
• D (severely abnormal) 2
(10.5%)
LYSHOLM K.O.O.S.
PRE-OP POST-OP
89 (43-95)
45(11-70)
ADLACTIVITIES OF DAILY LIFE
84.5
Sport/RecSPORT ACTIVITIES SCALE
50.5
31
DOES M.A.T. WORK?CLINICAL RESULTS FOR MENISCUS TRANSPLANT
• Initial F.U. studies - Generally good• Good results with longer f.u.,
but a note of caution• 70-90 % good and excellent results• Very effective in pain relief• The grafts heal and look normal
at second-look and MRI• Worse results in condral lesion III-IV
grade
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
1 aa.MM / ML
4 aa. ML
3 aa. MM
FALLIMENTI
No difference between bone / no-bone
Better results in isolated lateral transplantation
Better results in MM + HTO than in isolated medial
Pain relief is the most consistent benefit
Clinical results are not similar to M.R.I.
Clinical results connected with significant
chondral damage
90% satisfied and they would do it again
CONSIDERATIONS
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• MENISCUS TRANSPLANTATION IS A VIABLE ALTERNATIVE IN TREATING THE MENISCUS DEFICENT SYMPTOMATIC KNEE
• SUCCESS DEPENDS ON CAREFUL PATIENT SELECTION AND SURGICAL PRECISION
• WE NEED LONGER F.U. TO DETERMINE BIOMECHANICAL FUNCTION AND EFFICACY
• M.A.T. IS TECHNICALLY DEMANDING
CONCLUSIONS
WHAT WE DON’T KNOW...
• DOES IT PROVIDE LONG-TERM BIOMECHANICAL FUNCTION?
• WILL IT PROVE TO BE “CHONDROPROTECTIVE” AGAINST DEGENERATIVE PROGRESSION ?
CONCLUSIONS