MENISCAL SUBSTITUTES
SCAFFOLD AND TRANSPLANT
G.C. COARI
SAVE THE MENISCUS
“ MENISCUS DEFICIENCY IS THE #1 PROBLEM IN ORTHOPAEDICS TODAY”.
F. Noyes, M.D.
-All clinics see many patients with irreparable meniscus lesions
-10 years later these patiens are candidates for HTOs,cartilage transfers and other
salvage procedures
-Finally, most of these patients ultimately require a knee replacement.
WHICH SOLUTION ?
Female , 20 years old
Two years before lateral total meniscectomy for complex discoid lesion
Pain and swelling in activity daily living
MENISCAL ALLOGRAFT
TRANSPLANTATION
RATIONALE OF THE MENISCUS
TRANSPLANT
Relieve pain and swelling
Restore normal anatomy
Improve knee stability
Prevent arthrosis progression ?
HIGH PERCENTAGE OF SYMPTOMS AND ARTICULAR
DEGENERATION AFTER MENISCECTOMY, ALSO
SELECTIVE
Pain and swelling in ADL
Under 50 years old
Limited chondral lesions
No ligament insufficency
No coronal malalignment
POST MENISCECTOMY SYNDROME
PRIMARY INDICATION
ACL RECONSTRUCTION , OSTEOTOMY or
TREATMENT OF FOCAL CHONDRAL DEFECTS
CONCOMITANTLY WITH MAT
SECONDARY INDICATION
INDICATION AS PREVENTION
THE RISKS OVERCOME THE
BENEFITS
GRAFT
Non irradiated fresh-frozen
Gender
Age
Weight
SIZING/MATCHING MAT is side , compartment and size specific
A consistent relationship exist between bony landmarks and meniscal size
SEVERAL TECHNIQUES FOR MAT
SURGICAL PROCEDURE
BONY FIXATION
SUTURES FIXATION
BONY FIXATION WITH “BONE BRIDGE” FOR LATERAL
SEPARATE BONE PLUGS FOR MEDIAL
2004 - 2016
OUR PREFERENCE
SUTURES FIXATION TECHNIQUE
ALL - INSIDE
IN - OUT
OUT - IN
62 MAT in 60 pt.
July 2003 – Setptember 2016
Clinical Evaluation on 55 pt.
Lysholm Knee Score
K.O.O.S.
IKDC
X ray , MRI
55 cases
- Lateral meniscus 44 , medial 13
- Men 20 Female 35
- average age 34 (range 21-48)
- Bone fixation 4 - Sutures fixation 51
FU 15 – 1.5 y.
FU mean 80 m. (18 – 138)
CLINICAL RESULTS
Concomitant procedures
ACL REC 4
ACL REVISION 1
A.C.I. 5
HTO 2
0%
5%
10%
15%
20%
25%
30%
35%
A normale B quasi
normale
C anormale D molto
anormale
0 0
37
18
25
20
3 7
Pre
Post
IKDC
IKDC SUBJECTIVE
LYSHOLM
K.O.O.S.
MEAN SCORE POST-OP PRE-OP
SYMPTOMS
PAIN
ACTIVITY DAILY
LIVING
SPORTS
QUALITY OF LIFE
56 75
57
35
70
83
38 59
91
53
It’s difficult to draw conclusions regarding MAT
- Different procedures
- Many studies with concomitant surgical procedures and different
chondral lesions
- 70-80 % good and excellent results with F.U. > 5- 10 y
SHELTON 95
GOBLE 98
CARTER 99
RATH 2000
WIRTH 2000
RATH 2001
NOYES 2005
HARNER 2006
COLE 2006 -2008
VERDONK 2006
LA PRADE 2011
KIM 2012
ZAFFAGNINI 2012
COARI –TRIPODO 2012
ROUMAZILLE 2013
MARCACCI 2014
YOON 2014
MC CORMICK 2014
LITERATURE
CLINICAL EVIDENCE
MAT IS becoming a shared surgery option
Pain and swelling relief is the main benefit
The overall failures can be estimated at 10 to 20% at 5 years
and 20 % at 10 y.
Clinical results are connected to chondral damage
No differences between bony or sutures fixation
No correlation between MRI extrusion and clinical results,
but extruded graft could be an indicator of failure
Bioresorbable collagen matrix
97,5% type -I collagen of bovine
2,5% glucosaminoglycans and ialuronic acid
MENISCAL SCAFFOLDS
Biodegradable , porous scaffold,
composed of polyuretane (20%) e
polycaprolactone(80%)
C.M.I. ACTIFIT
The scaffold is bioresorbable and created to serve as a
template for the in-growth of new meniscal tissue
- Pt. who has lost greater than > 50% of the meniscus
- Intact anterior and posterior horn attachments
- Intact rim of the meniscus
SURGICAL INDICATIONS
Most studies reported satisfactory clinical outcome at 10 y.
Second-look arthroscopy: evidence of new tissue ingrowth with
meniscus like cells and uniform fibrocartilage matrix
MRI studies showed increased signal intensity early that appared
to diminish with longer –term fu
STONE 1997
STEADMAN 2005
MONLIAU 2011
BULGHERONI 2010
ZAFFAGNINI 2011
RODKEY 2008
ZUIDEMA 2009
EFE 2012
DE CONINCK 2013
VERDONK 2012
ACTIFIT
C.M.I.
LITERATURE
CLINICAL EVIDENCE
Correct indications : cronic pain for patients who has lost
graeter than 50 % of the meniscus , but still has an intact
rim and anterior and posterior horn attachments
The primary goal is to restore a normal volume of meniscus
tissue
The scaffold prevent further degenerative changes
The scaffold provide long-term patient outcomes when
compared with partial meniscetomy
In acute cases no difference between meniscetomy and
scaffold
FUTURE DIRECTION A variety of different technologies are being studied for the purpose of replacing
lost meniscal tissue or entire meniscus
- Hydrogels , biphasic biocampatible materials
- Mesechymal stem cell – seeded scaffold
- Syntetic meniscus
PCU (polycarbonate-uretane matrix ) reinforced with high – modulus
UHMWPE fibers (ultrahigh molecular weight polietilene)
NUSURFACE
Could it occupy the free space between
scaffold , meniscal allograft
transplantation and uni replacement ?
THANK YOU
“Je fait tous les journes des progrès ,
l’essential est la” P. Cèzanne