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Transcript of Chicago 2010
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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
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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”
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PEDERZINI - COARI - ARNALDI - ADRIANI - BERRUTO ZINI - PRIANO - ZORZI – NICEFORO -
ADRAVANTI
ITALIAN STUDY GROUP - SIAITALIAN STUDY GROUP - SIA
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SINCE OCTOBER 2002
5
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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
QuickTime™ e undecompressore
sono necessari per visualizzare quest'immagine.
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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”……
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“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”……
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“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
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“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
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SAVE THE MENISCUS!SAVE THE MENISCUS!
SUTURE !!
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AUTOLOGUS MENISCUS AUTOLOGUS MENISCUS TRANSPLANTATIONTRANSPLANTATION
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RATIONALE FOR MENISCUS TRANSPLANTATION
RELIEVE PAIN AND SWELLING
IMPROVE KNEE STABILITY
PREVENT PROGRESSION OF ARTHROSIS (?)
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AN “ENCHANTING” HYPOTHESIS: CHANGING THE
NATURAL HISTORY OF A MENISCUS DEFICIENT KNEE
QuickTime™ e undecompressore Codec YUV420
sono necessari per visualizzare quest'immagine.
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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”
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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”
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WHICH TYPE ?
FRESH-FROZEN CRIOPRESERVED
NOT IRRADIATED
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THE SURGICAL TECHNIQUE HAS EVOLVED FROM ARTHROTOMY TO THE CURRENT ARTHROSCOPIC
– ASSISTED TECHNIQUE
2002-03
OPEN TECHNIQUE
2004-10
SCOPE ASSISTED
TECHNIQUE
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SURGICAL PROCEDURE GENERAL CONCEPT
BONE ANCORAGE
SINCE 2006 WITHOUT BONE
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SURGICAL PROCEDURE GENERAL CONCEPT
ANATOMICAL PLACEMENT OF MENISCAL HORNES
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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
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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
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Leisure sport activities, after 12 months
QuickTime™ e undecompressore
sono necessari per visualizzare quest'immagine.
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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.
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- 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
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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
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CLINICAL
Lysholm Knee Score
K.O.O.S.
IKDC
X-RAY
MRI
28
EVALUATION According to European Meniscal
Transplantation Study Group
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OUTCOMES
IKDC
• A (normal) 4
(21%)
• B (nearly normal) 11
(58%)
• C (abnormal) 2
(10.5%)
• D (severely abnormal) 2
(10.5%)
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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
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1 aa.MM / ML
4 aa. ML
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3 aa. MM
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FALLIMENTI
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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
QuickTime™ e undecompressore
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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
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WHAT WE DON’T KNOW...
• DOES IT PROVIDE LONG-TERM BIOMECHANICAL FUNCTION?
• WILL IT PROVE TO BE “CHONDROPROTECTIVE” AGAINST DEGENERATIVE PROGRESSION ?
CONCLUSIONS