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

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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

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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

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SINCE OCTOBER 2002

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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

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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

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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

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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

THANK YOU

THANK YOU

alessandro@tripodo.net