Post on 17-Aug-2020
2/13/2017
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Chris O’Grady, M.D
Update on Treatment of Meniscal
Injuries
Basic Science
• Anatomy• Biomechanics
Clinical
• Presentation• Diagnosis
• Treatment• Rehabilitation
Future
• Biologics• PRP
• Stem Cells
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Function
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--joint filler (incongruous condyles)
-2.5 greater contact area when mensicus present
-prevent capsular/ synovial impingement
-joint lubrication/ synovial distribution
-load (40-60% of standing load-stability (esp. rotatory)
Function
� Medial Meniscus
� Secondary stabilizer to AP
translation in ACL deficient knee
� (more capsular attachment)
� Follows tibia- more likely to be torn with rotatory force
� Lateral Meniscus
� 200-300% increase in
lateral compartment contact stresses when removed (convex lateral
plateau)
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Radin et al., CORR, 1984
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- Load transmission
increases in flexion vs ext
Fukubayashi et al. 1980
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Anatomy
� Histo: Fibrocartilage
� Composition
� Water 65%-75%
� Organic matter 25%-35%
� 75% Collagen
� Type I – 90%
� Types II, III,IV, V, VI, XVIII
� 25% Other
� Proteoglycans, DNA, Elastin
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Anatomy
� Triangular cross section
� Provide structural integrity
� � “concavity” of the
articulation
� Dissipates forces/friction across
medial/lateral compartments
� Axial Compression �Horizontal hoop stress
� Creates shear forces
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AnatomyStructure
� Mesh network:
� Arranged obliquely, radially, and vertically
� Prevents shear
� Bundles:
� Radial
� Located at surface and midsubtance
� Prevent longitudinal tears
� Circumferential
� Disperses compressive loads (hoops around wooden barrel)
Anatomy
Medial Meniscus
� C-Shaped structure
� Less mobile
� Firmly attached to capsule
� Deep MCL at mid body
� Posterior fibers of anterior horn merge with transverse ligament
� Periphery of meniscus attached to capsule through coronary ligaments
Medial Meniscus
� Wider in diameter
than the lateral
meniscus
� 9-10 mm wide
� 3-5 mm thick
� Covers 51-74% of condyle
Lateral Meniscus
� Semi-circular in shape
� More mobility
� Less peripheral attachments
� Popliteal Hiatus
� Anterior and posterior horns attach closer to each other than medial meniscus
� Anterior horn attaches adjacent to ACL
� Posterior horn attaches behind inter-condylar eminence
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Lateral Meniscus� Covers more tibia
� 75-93% of condyle
� 12-13 mm wide
� 3-5 mm thick
Meniscofemoral ligaments
� Humphrey & Wrisberg
� Run from posterior horn of lateral meniscus to medial femoral condyle
� Major Role
� Stabilize PH of Lateral Meniscus
� Minor role
� Stabilizing posterior tibialtranslation with compromised PCL
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Humphrey – Sag MRI
� Anterior to PCL
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Discoid Meniscus
� Incidence of 3.5-5%
� Usually lateral, but 20%
bilateral
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Discoid Meniscus
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Type I-Complete Type II-Incomplete Type III-Wrisberg subtype
Watanabe Classification
Blood Supply
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PeriMeniscal Capillary Pleux
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Blood Supply
� 50-100% of meniscus vascular at birth
� 9 months: Inner 1/3rd avascular
� By age 10: Mature
� Peripheral 10-25% of lateral vascular
� Peripheral 10-30% of medial vascular
� Inner 2/3rds by synovial fluid diffusion
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Arnoczky et al AJSM 1982
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Arnoczky et al AJSM 1982
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Vascularity Zones
� Red-Red� Fully vascular
� Excellent healing potential
� Red-White� Border of vascular supply
� Good healing potential
� White-White� Relatively avascular
� Poor healing prognosis
Cannon et al,
Basic Science
• Anatomy• Biomechanics
Clinical
• Presentation• Diagnosis
• Treatment• Rehabilitation
Future
• Biologics• PRP
• Stem Cells
23
Epidemiology
� Incidence (acute tears)� 60-70 cases/100,000 people per
year
� Male:Female � Ratios 2.5-4:1
� Younger � Acute
� Older � Degenerative (MMT)
� 1/3 occur with ACL tear� Acute: LMT
� Chronic: MMT
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Basic Science
• Anatomy• Biomechanics
Clinical
• Presentation• Diagnosis
• Treatment• Rehabilitation
Future
• Biologics• PRP
• Stem Cells
25
History
� Mechanism� Twisting, change in direction, or hyper-flexion
injury
� Feeling a “pop”� Acute pain or swelling� Slow-forming effusion� Locking/catching sensation� Degenerative tears(>40) often
more atraumatic with a chronic history
� Postmenisectomy syndrome –“toothache pain” after menisectomy
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Physical Exam
� Inspection
� Mild to moderate joint effusion
� Usually no ecchymosis
� Limb alignment
� ROM
� Typically normal� However, longitudinal bucket handle tears may block full
extension
� Stability
� Associated ligamentous injury
Physical Exam
� Palpation
� Joint line tenderness
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McMurray British Journal of Surgery 1942
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MMT: 90deg, valgus, ER, ext knee
+ click
Sen:59%
Spec: 93-97%
Apley Grind Test JBJS 1947
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Prone, 90deg
Stabilize thigh
Compress joint, ER
Sen: 41%
Spec: 86-93%
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Thessaly Maneuver JBJS 2005
� 20 deg flex (IR, ER)
� Harrison, Clin J Sport
Med, 2009:
� 66 patients with +Thessaly, 65 had arthroscopic
findings of meniscal tear
� Sen 90%
� Spec 97.7%
Ege’s Test
� Squat with full hip ER/ IR
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Imaging
� Weight bearing
� Don’t miss OA� X-rays:
� AP/Laterals
� Merchant/Sunrise
� 30-45 degree flexion views
� Calcifications � CPPD
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Discoid Meniscus
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Widening
Squaring
Cupping
Hypoplastic
Imaging
� MRI:
� Diagnostic procedure of choice
� 95% accuracy
� High NPV
� Grading system 0, I, II, III
� Grade III consistent with complete tear
� Arthroscopy still gold standard
� Look for condylar edema
� (increased contact pressure on condyle when meniscus torn)
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MRI Grading
� 0: normal
� I: globular increase in signal with no extension to surface
� II: near signal increase that does not extend to surface
� III: increased signal that abuts the freed edge of meniscus� Indicates tear
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Discoid Meniscus – Bow Tie Sign
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3 or more 5mm cuts with continuity of meniscus
MRI
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Complex tear “Double PCL” – Bucket Handle
Arthrography
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Classification of Tears
Common Meniscal
Tears
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Radial Tear
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AANA Advanced Arthroscopy: The Knee
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Horizontal Tear
AANA Advanced Arthroscopy: The Knee
Bucket-Handle Tear
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AANA Advanced Arthroscopy: The Knee
Meniscal Root Tears
� Milder symptoms
� Joint line pain
� Less mechanical symptoms (only 9-14%)
� Posterior knee pain with deep flexion
� McMurray + 57%
� Effusion + 14%
Lee et al Arthroscopy 2009 LaPrade et al, AJSM March 2014
Ghost signExtruded meniscus
Root Tears
-3mm extrusion on mid coronal
-condylar edema
Basic Science
• Anatomy• Biomechanics
Clinical
• Presentation• Diagnosis
• Treatment• Rehabilitation
Future
• Biologics• PRP
• Stem Cells
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Treatment Options
� Depends on
� Symptoms
� Affect on ADLs, Work, Sports
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Nonsurgical Options
� RICE
� Wt Loss
� Bracing (unloader)
� Injections
� Physical Therapy
� ROM
� Strengthening
� NSAIDs
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Surgical Options1. Leave alone
� Promote healing only
2. Meniscectomy� � surgical morbidity and
improves function
� Stable contoured rim
� Preserve as much tissue as possible
� Long-term risks?
3. Meniscal repair� Ideal treatment for the ideal
situation
� Vertical mattress sutures gold standard
4. Meniscal transplant� Symptomatic patient too young
for a TKA
1. Leave alone…
� Stable partial tears
� Stable longitudinal tears
� < 10 mm length
� < 3-5 mm displacement
� Do not displace into notch
� Do not touch femoral condyle
� Degenerative tears with significant OA
� Short radial tears: < 3 mm in length
� Leave tourniquet down to assess bleeding:
� Rasping
� Trephination
� Marrow stimulation, PRP, etc.� Enhance biologic healing response
� E.g. notch microfx
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2. Meniscectomy Indications
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2. Meniscectomy
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2. Meniscectomy Technique
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3. Repair Options
OpenInside-
Out
Outside-In
All-Inside
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Open Meniscal Repair
� Trans-capsular approach with capsule and synovium opened for visualization
� Indications:
� Tight compartments
� Peripheral tears in posterior horns
� Disadvantages:
� Larger approach
� Greater tissue trauma
Open Meniscal Repair
� Results� 80-90% survival rate after 13
years
� DeHaven Clin Sports Med1990
� Rockborn and Gillquist JBJS Br 2000
� Muellner AJSM 1999
� MRI data included, but unreliable method to assess healing
Arthroscopic Inside-Out
� Advantage:
� Consistent/More accurate suture placement
� Gold Standard
� Disadvantages:
� Risk of neurovascular injury
� 75-91% survival/healing
� Barrett et al Arthroscopy 1998
� Johnson et al AJSM 1999
Arthroscopic Inside-Out
� Advantage:
� Consistent/More accurate suture placement
� Gold Standard
� Disadvantages:
� Risk of neurovascular injury
� 75-91% survival/healing
� Barrett et al Arthroscopy 1998
� Johnson et al AJSM 1999
Arthroscopic Inside-Out
� Advantage:
� Consistent/More accurate suture placement
� Gold Standard
� Disadvantages:
� Risk of neurovascular injury
� 75-91% survival/healing
� Barrett et al Arthroscopy 1998
� Johnson et al AJSM 1999
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Arthroscopic Outside In
� Advantage: � Less neurovascular risk
� Good for tears in anterior horn and body
� Disadvantage:� Less accurate suture
placement
� 65-78% survival/healing� Morgan et al AJSM 1991
� Rodeo et al AJSM 1999
� Plasschaert et al AJSM 199861
Arthroscopic All-Inside
� Advantages:
� Decreased neurovascular
risk
� Minimally Invasive
� Decreased operative time
� Similar success rates
� New Gold Standard?
All-Inside Device Comparisons
Mehta, AJSM, 2009:� FastFix (S&N) vs. Meniscal Cinch
(Arthrex) vs. MaxFire (Biomet)
� Ultimate load to failure
� FastFix 86.1N, Meniscal Cinch 85.3N, MaxFire 64.5 N
� Gap formation (after 100 cylces)
� MaxFire: 6.7 mm
� Meniscal Cinch: 4.07mm
� FastFix: 3.59mm
� No significant difference after 500 cycles
More Comparisons…
Barber et al Arthroscopy 2011� Methods
� Outside-In Vertical Mattress with both Ethibond and Orthocord
� All-Inside: Meniscal Cinch, MaxFire, FastFix, Sequent (ConMed), OmniSpan
� Gap Formation and Load to Failure
� Results
� No significant differences except MaxFire = bad
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• Isolated Bucket Handle Meniscus Tears (19 studies) 2012
• 2 Level II Studies, 1 Level III
• 17% failure inside out vs 19% all inside (No sig diff)
• Similar Patient reported outcome scores
• Complications
• Inside out- nerve injury/ irritation• All inside- local soft tissue irritation, swelling, implant migration
• Chondral injury issue in older model more rigid devices
Treatment Complications
� Excessive meniscectomy
� Loss of hoop stress = chondrosis, early OA
� Failure to heal repair
� May require re-operation for meniscectomy
� Neurovascular injury with repair techniques
� Foreign material concerns
� Suture and Anchors
� Chondral injury from intra-articular devices
� Soft tissue penetration or entrapments
� Collateral ligaments, IT band, skin, etc.
� Beware posterior capsular pain with repairs
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Neurovascular Issues
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Caution with All-InsideCohen et al J Knee Surg 2007
-Fast Fix device within 3 mm of pop artery in half of specimens
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Complications of Suture
Meniscal Root Tears
� Non-op: � Co-morbidities preclude surgery
� Partial Meniscectomy:� Partial root avulsions
� Avoid completion of the tear� Root Repair
� Suture anchors, trans-osseous� Allaire et al JBJS 2008
� TF contact pressures as high as complete medial menisectomy
� Repair restores normal mechanics
Meniscal Root TearsTrans-osseous repair:
LaPrade et al, AJSM March 2014
Respecting the MeniscusTrends 2005-2011
� Abrams et al AJSM 2013
� Overall 11.4% increase in meniscal repairs
� Increase 48.3% meniscal repairs with
concomitant ACL recons
� Increased educational emphasis on meniscus preservation/repair
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4. Meniscal Transplantation
� Candidates:
� Young, active, healthy individual (<40 yrs)
� Significant knee pain and limited function
� Too young for TKA
� Mechanical meniscal damage
� Absent or non-functioning
� Failed conservative tx
� Normal mechanical alignment and stable knee
� Outerbridge I or II cartilage changes
4. Meniscal Transplantation
� Techniques
� Meniscus +/- Bone Plug
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4. Meniscal TransplantOutcomes
� Noyes et al AJSM 2016� 72 patients
� 96% follow-up
� Survivorship Analysis (xray, MRI, exam, reoperation)
� 85% @ 2 yr
� 77% @ 5 yr
� 69% @ 7 yr
� 45% @ 10 yr
� 19% @ 15 yr
� - Concurrent Osteochondral autograft=
lower survival rate
� -Conclusion: MAT eventually fail and is
Example : 41 y.o male 14. 3 years s/p medial
MAT
Meniscal Allograft Outcomes
� Retrospective, AJSM 2016
� 89pt, avg age 38
� Min F/U 2 yr (avg 4.9 yr)
� 79% Return to sport
� 88% were recreational
� 12% professional
� 49% at same level
� Avg 8.6 months return
� Age at MAT, highest
predictor of outcome 76
4. Meniscal Transplant
� Complications:
� Difficulty in locating, harvesting, and distributing size-matched specimens
� Technically difficult surgery
� Preservation techniques� Cell viability
� Biomechanical properties alteration
� Graft failure
� Disease transmission
Basic Science
• Anatomy
• Biomechanics
Clinical
• Presentation
• Diagnosis
• Treatment
• Rehabilitation
Future
• Biologics
• PRP
• Stem Cells
78
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Rehab - Meniscal Repair
� Day 1-10:
� Brace locked at 0 for
ambulation and sleep
� 25-50% WB with crutches
� PROM 0-90
� SLR, Quad sets
Meniscal Repair Rehab
� Week 2-4
� Progress PROM to 0-135 by week 4
� 50% WB at week 2
� Full WB at week 3
� SLR, mini-squats, knee extensions 90-0, balance
� Continue to lock brace at night and for ambulation
Meniscal Repair Rehab
� Weeks 5-8
� Discontinue brace
� Strengthening:
� Wall squats 0-70
� Knee extensions 90-40
� Lateral step ups
� Balance
� Bike
Meniscal Repair Rehab
� Week 9
� Initiate stair-stepper
� Progress to isotonic strengthening program
� Week 12
� Initiate pool running
Meniscal Repair Rehab
� 4 months:
� Deep squats
� Inline running
� 5 months:
� Pivoting and cutting
� Agility drills
� 6 months:
� Return to activity
Basic Science
• Anatomy• Biomechanics
Clinical
• Presentation• Diagnosis
• Treatment• Rehabilitation
Future
• Biologics• PRP
• Stem Cells
84
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Biologic Enhancement
� Fibrin Clot� Jang 2011
� 95% Healing (41menisci)
� Synovial Abrasion� Ochi Arthroscopy 2001
� Activates chemotactic factors
Biologic Enhancement
� Trephination� Create vascular channels via
removal of core of tissue
� Connects avascular area to peripheral blood supply
Biologic Enhancement
� Vascular channels� Cook AJSM 2007
� BioDuct™ (bioabsorbable porous implant)� Vascular access channels
� 71% healing of avascular tears in canine model
Biologic Enhancement
� Platelet-Rich Plasma
� Miller (2015):� Meniscus Repairs with (15) vs.
w/o PRP (20)
� No difference in clinical outcome scores, return to work/ sport or reoperation
Stem Cells
� 3 Groups (55 pt); Injection 1 wk after parital medial menisecotmy
� ex vivo cultured
� Ex vivo cultured adult human mesenchymal stem cells, hMSCs (Osiris Therapeutic)
� GroupA: Low concentraion (50x10-6) Allogenic MSC
� GroupB: High Concentraion (150) All MSC
� Group C: Control (Hyaluronic Acid)
� MRI @ 12 months to eval meniscal volume
� MSC group showed 24% of Group A and 6% of Group B reached 15% increase in meniscal volume
� None in group C showed increased meniscal volume (>15%)
� Decreased Pain (VAS) in MSC groups