Meniscal transplantation: still experimental surgery? A review

INTRODUCTION

The objective of this review is to give a state of affairs of meniscal transplantation, with the accent on preservation and surgical techniques.

MATERIALS AND METHODS

All articles were selected by performing a search on the literature by using relevant keywords. The most relevant articles were selected with close attention to the publication date.

RESULTS

When a meniscal tear is diagnosed, suture can be an option in the vascular zone, whereas the more frequently affected avascular zone heals poorly. A meniscectomy however is not without consequences, wherefore meniscal transplantation can be seen as a therapeutic option for pain reduction and improvement of function when the meniscus is lost. The meniscal scaffold, allograft and autograft can be currently withheld as possible grafts, where the meniscal scaffolds hold great promise as an alternative to the allograft. Various fixation techniques are therefore developed, where viable, deep frozen as well as cryopreservated allografts seem to give the most promising short term results. The transplantation can be performed using an open as well as an arthroscopic technique, using soft tissue fixation, bone plugs or blocks. De primacy of one technique can't be proven. In general meniscal transplantation can be considered as an acceptable procedure.

DISCUSSION

Since the outcomes of different studies are difficult to compare, an attempt should be made to limit new studies to the comparison of one aspect. We can conclude that larger, more comparative randomised controlled long-term studies are necessary to resolve which techniques can give the best long-term results.

Meniscal repair techniques required for the surgeon performing anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) tears are a common injury treated surgically by orthopedic specialists. There is a high incidence of concurrent meniscal injury that must be recognized and appropriately treated by the surgeon. The surgeon must be prepared to address the full spectrum of meniscal injuries with complex meniscal repair techniques when performing ACL reconstruction to decrease the likelihood of reoperation or postoperative symptoms for the patient.

Cruciate ligament reconstruction and risk of knee osteoarthritis: the association between cruciate ligament injury and post-traumatic osteoarthritis. a population based nationwide study in Sweden, 1987-2009

Objective

To study the association between Cruciate Ligament (CL) injury and development of post-traumatic osteoarthritis in the knee in patients treated operatively with CL reconstruction compared with patients treated non-operatively.

Design

Population based cohort study; level of evidence II-2.

Setting

Sweden, 1987–2009.

Participants

All patients aged between 15–60 years being diagnosed and registered with a CL injury in The National Swedish Patient Register between 1987 and 2009.

Main Outcome Measures

Knee osteoarthritis.

Results

A total of 64,614 patients diagnosed with CL injury during 1987 to 2009 in Sweden were included in the study. Seven percent of the patients were diagnosed with knee OA in specialized healthcare during the follow-up (mean 9 years). Stratified analysis by follow-up showed that while those with shorter follow-up had a non-significant difference in risk (0.99, 95%CI 0.90–1.09 for follow-up less than five years compared with the non-operated cohort), those with longer follow-up had an increased risk of knee OA after CL reconstruction (HR = 1.42, 95%CI 1.27–1.58 for follow-up more than ten years compared with non-operated cohort). The risk to develop OA was not affected by sex.

Conclusion

CL reconstructive surgery does not seem to have a protective effect on long term OA in either men or women.

[Arthroscopic repair of meniscus injury with Fast-fix under local anesthesia]

OBJECTIVE

To evaluate the clinical outcome of arthroscopic repair method of meniscus injury with Fast-fix under local anesthesia.

METHODS

From October 2005 to September 2012,106 patients with meniscus injuries admitted into our - hospital were studied, including 74 males and 32 females, ranging in age from 13 to 71 years old, averaged 27.6 years old. The duration of the disease ranged from 15 days to 5 years. The main clinical manifestations included knee joint pain after exercise, joint locking, pressing pain of knee joint and positive McMurray signs. The MRI showed meniscus tear or degeneration. Arthroscopic repairing surgeries were performed with Fast-fix under local anesthesia. Each patient was assessed with VAS pain evaluation and Lysholm knee-joint score system before and after operation. All the patients were followed up more than 1 year.

RESULTS

One hundred and 2 patients were followed up by recording subjective symptoms, clinical examinations and questions naires for an average of 2.6 years (ranged, 1.1 to 8 years), and 4 patients lost follow-up. All the 102 patients had no anesthetic complications. Ninety-six patients had normal subjective symptom and clinical examinations. Four patients had a mild ache with activities,2 patients had moderate pain after activities with joint space pressing pain. VAS pain evaluation and Lysholm knee-joint score after operation both were much better than that before operation.

CONCLUSION

onclusion: Local anesthesia can provide nice circumstances for surgeries. Arthroscopic repair using Fast-fix is an idea method for meniscus injury, especially for the posterior horn tear of medial meniscus, which is simple and convenient with less complications, and satisfactory results.

Accuracy of 3-Tesla MR and MR arthrography in diagnosis of meniscal retear in the post-operative knee

PURPOSE

This study assesses the accuracy of 3-Tesla (3-T) conventional MR imaging, 3-T MR arthrography, and the combined use of conventional MR and MR arthrography in the diagnosis of meniscal retears as compared with arthroscopy. The study also assess whether there are false-negative cases in which injected contrast does not extend into the meniscus despite a meniscal retear being seen on arthroscopy.

MATERIALS AND METHODS

One hundred consecutive knee MR arthrograms performed on patients with previous knee surgery were reviewed retrospectively. 3-T conventional MR imaging, 3-T MR arthrography, and the combined use of conventional MR and MR arthrography were assessed for meniscal retears as compared with arthroscopy. The criterion used to diagnose a meniscal retear on MR arthrogram was injected contrast tracking into the meniscus. All patients underwent second-look arthroscopy.

RESULTS

Seventy-four patients had conventional MR findings consistent with a meniscal retear. In 83 of the 100 patients, intraarticular contrast helped in demonstrating a retear. In ten patients, there were MR findings consistent with a meniscal retear despite intra-articular contrast not tracking into the meniscus. Ninety-four of the 100 patients had meniscal retears on second-look arthroscopy. Three-Tesla conventional MR examination was 78 % sensitive and 75 % specific, MR arthrogram examination was 88 % sensitive and 100 % specific, and the combined use of MR and MR arthrogram imaging was 98 % sensitive and 75 % specific in the diagnosis of a meniscal retear.

CONCLUSIONS

The combined use of 3-T MR and MR arthrography allows for high sensitivity and specificity in meniscal retear detection. In some patients, intraarticular contrast will not track into a meniscal retear. When MR findings are consistent with a meniscal retear but contrast does not extend into the meniscus, a meniscal retear is likely.

[Arthroscopic partial meniscectomy for medial meniscal tear in late middle-aged adults]

OBJECTIVE

To study the results of arthroscopic partial meniscectomy for medial meniscal tear in late middle-aged adults.

METHODS

From October 2010 to October 2012,49 patients meeting inclusion criteria were treated with arthroscopic partial meniscectomy for medial meniscal tear. There were 31 males and 18 females,with an average age of (55.3±2.8) years old. There were 22 left knees and 27 right knees. The average flexion angle was (116.01±12.03)°. The pre-operative HSS Knee Score was 48.73±8.43, and the Lysholm score was 63.95±5.45. The patients were followed up and evaluated. All the patients received a standard surgery, in which the torn tissue was removed, and the anterior part of the meniscus was left in situ.

RESULTS

All the surgeries were successful with no serious complications. All the patients were followed up,and the duration ranged from 12 to 36 months. All the patients had 5 degrees of muscle strength. The average flexion angle was (136.77±18.56)°. There was significant difference between the two angles before operation and after operation. The pre-operative HSS Knee Score was 90.17±4.10, and the Lysholm score was 87.84±5.16. Statistically, the difference between preoperative score and the postoperative score was significant.

CONCLUSION

Arthroscopic partial meniscectomy is a good option for medial meniscal tear in late middle-aged adults. Operative indication is crucial and the excellent surgical technique is also critical for the good clinical outcome. All the patients could get good clinical results, although there are some patients with motion restrictions in the early stage after operation.

Bony morphology of the knee and non-traumatic meniscal tears: is there a role for meniscal impingement?

OBJECTIVE

Meniscal tears are an important cause of morbidity. The aim of this study was to examine the relationship between non-traumatic meniscal tears and the intrinsic bony morphology of the knee.

METHODS

A retrospective analysis of 160 knee MRI scans in 150 patients was carried out who met the following criteria: (a) age between 20 and 45 years, (b) no history of knee trauma, surgery, infection, metabolic bone disease, and (c) no collateral or cruciate ligamentous injury. The medial tibial slope (MTS), lateral tibial slope (LTS), medial tibial plateau depth (MTPD), and medial and lateral femoral condylar offset ratios were calculated. The anterior horn, body, and posterior horn of the menisci were graded as 0 (no tear), 1 and 2 (degenerative changes), or 3 (definitive tear). One-way ANOVA and linear regression was used for statistical analysis.

RESULTS

In patients with grade 3 tears of the posterior horn of the medial meniscus, there was a significant association with shallower MTS (p < 0.05), smaller medial femoral offset ratio (p < 0.05) and smaller lateral femoral offset ratio (p < 0.05). Patients with grade 3 tears of anterior horn of the lateral meniscus had a significant association with shallower LTS (p < 0.05). No significant association was seen between MTPD and meniscal tears.

CONCLUSIONS

Our results suggest an association between bony morphology of the knee and non-traumatic meniscal tears. Shallower MTS and LTS may result in impingement of posterior horn of medial meniscus and anterior horn of lateral meniscus, respectively. Future kinematic studies will be needed to help confirm our findings.

Short- to mid-term results of arthroscopic meniscal repair of long vertical longitudinal tears using combined cruciate and horizontal suture techniques: a retrospective study

INTRODUCTION

The purpose was to evaluate the clinical results of arthroscopic meniscal repair of long vertical longitudinal tears using combined cruciate and horizontal suture techniques.

METHODS

Single surgeon retrospective case series study. A total of 38 patients having long vertical longitudinal tears were operated using combined cruciate and horizontal suture techniques. Two patients had to undergo a meniscectomy procedure within the 1st year postoperative and those were considered failure cases; 32 patients were available for follow-up evaluation (average 4.6 years) and six were lost including the two failures. Objective IKDC, modified Lysholm knee score, SF-36 score, VAS for patients' satisfaction and VAS for pain were used for follow-up evaluation. Kellgren and Lawrence (K/L) classification of osteoarthritis was also used.

RESULTS

Successful rate was 94.1% (32 patients), while failure was 5.9% (2 patients). Objective IKDC score revealed that 27 patients had grade "A" and 5 had grade "B," while no single patient had neither grade "C" nor "D." The average modified Lysholm score was 91.3. Average SF-36 score was 88.4. The average VAS for operation satisfaction was eight. Average VAS for pain was 1.5. Preoperatively, 30 patients were classified as normal K/L classification, while two patients were K/L classification grade "1." At the time of the follow-up, 24 patients were classified as normal K/L classification, six were grade "1," two were grade "2," and thus, six had osteoarthritis progression.

CONCLUSION

Arthroscopic meniscal repair of long vertical longitudinal tears using combined cruciate and horizontal suture techniques is a safe surgical procedure with good clinical outcome.

LEVEL OF EVIDENCE

Level IV.

The challenge of recruiting patients into a placebo-controlled surgical trial

BACKGROUND

Randomized placebo-controlled trials represent the gold standard in evaluating healthcare interventions but are rarely performed within orthopedics. Ethical concerns or well-known challenges in recruiting patients for surgical trials in general have been expressed and adding a placebo component only adds to this complexity. The purpose of this study was to report the challenges of recruiting patients into an orthopedic placebo-controlled surgical trial, to determine the number of patients needed to be screened and allocated in order to include one participant into the trial, and to identify reasons associated with participation in a placebo-controlled randomized surgical trial.

METHODS

Data were extracted from an ongoing placebo-controlled randomized controlled trial (RCT) on meniscectomy versus placebo surgery. We calculated the number of patients needed to be screened in order to include the required number of participants into the RCT. Participating patients were asked about their rationale for joining the study and which type of information was most useful for deciding upon participation.

RESULTS

A total of 476 patients entered the screening group, of which 190 patients fulfilled the inclusion and exclusion criteria. 102 patients declined to participate in the study due to various reasons and 46 were later excluded (no meniscus lesion on the magnetic resonance imaging scan or withdrawn consent). A total of 40 patients were finally included in the RCT. To include one patient into the RCT, 11.9 individuals needed to be screened. A total of 69% of participating patients considered the oral information to be the most important and the most common reason for participating was the contribution to research (90%).

CONCLUSIONS

Patients are willing to participate in an orthopedic placebo-controlled surgical trial. Oral information given by the surgeon to the patient and the contribution to research are important aspects to enhance patient recruitment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01264991, registered 21 December 2010.

Mesenchymal stem cells in synovial fluid increase after meniscus injury

BACKGROUND

Although relatively uncommon, spontaneous healing from a meniscus injury has been observed even within the avascular area. This may be the result of the existence of mesenchymal stem cells in synovial fluid.

QUESTIONS/PURPOSES

The purpose of this study was to investigate whether mesenchymal stem cells existed in the synovial fluid of the knee after meniscus injury.

METHODS

Synovial fluid was obtained from the knees of 22 patients with meniscus injury just before meniscus surgery and from 8 volunteers who had no history of knee injury. The cellular fraction of the synovial fluid was cultured for 14 days followed by analysis for multilineage potential and presentation of surface antigens characteristic of mesenchymal stem cells. Colony-forming efficiency and proliferation potential were also compared between the two groups.

RESULTS

Cells with characteristics of mesenchymal stem cells were observed in the synovial fluid of injured knees to a much greater degree than in uninjured knees. The colony-forming cells derived from the synovial fluid of the knee with meniscus injury had multipotentiality and surface epitopes identical to mesenchymal stem cells. The average number of colony formation, obtained from 1 mL of synovial fluid, in meniscus-injured knees was 250, higher than that from healthy volunteers, which was 0.5 (p < 0.001). Total colony number per synovial fluid volume was positively correlated with the postinjury period (r = 0.77, p < 0.001).

CONCLUSIONS

Mesenchymal stem cells were found to exist in synovial fluid from knees after meniscus injury. Mesenchymal stem cells were present in higher numbers in synovial fluid with meniscus injury than in normal knees. Total colony number per synovial fluid volume was positively correlated with the postinjury period.

CLINICAL RELEVANCE

Our current human study and previous animal studies suggest the possibility that mesenchymal stem cells in synovial fluid increase after meniscus injury contributing to spontaneous meniscus healing.

The prevalence of knee injuries ipsilateral to tibial shaft fractures and their impact on clinical outcome

OBJECTIVE

The purpose of this prospective study was to examine the prevalence of occult knee injuries in patients with ipsilateral tibial shaft fractures and determine their impact on clinical outcome.

MATERIALS AND METHODS

Preoperative knee MRI examination was performed in 41 patients (42 knees) with isolated tibial shaft fractures. Menisci, cruciate ligaments, collateral ligaments, extensor mechanism, osteochondral lesions, bone contusions and knee effusion were evaluated. All patients were treated with reamed and locked intra-medullary tibial nailing without an additional surgical procedure for knee injuries. All patients were followed to at least fracture union and were evaluated with knee examination and Lysholm knee score.

RESULTS

Of the 42 knees, 41 (97.6 %) showed at least one defined injury around the knee. There was only one patient who had totally normal knee MRI findings. One or more ligamentous injuries of the knee were identified in 35 (83.3 %) of the knees. Five patents (11.9 %) had medial meniscal tear in posterior horn. Extensor mechanism injuries were seen in two patients. Mild to marked joint effusion was observed in 35 (81 %) knees. Twenty-two knees demonstrated bone bruise; femoral condyle (n = 7), tibial plateau (n = 12), patella (n = 2) and fibular head (n = 1). No patients had osteochondral lesion. Patients were followed with a mean of 13.2 ± 3.6 (range 8-22) months. Clinical knee examination revealed Grade II (+) anterior drawer test in two patients. The mean Lysholm knee score was 99.1 ± 2.14 (range 91-100) at the final follow-up.

CONCLUSIONS

Ipsilateral intra-articular, extra-articular or combined knee injuries may occur at the time of injury with tibial shaft fractures. However, most of these injuries are not clinically relevant and heal without any sequel or remain asymptomatic late after fracture union. Routine use of preoperative knee MRI examination in patients with tibial shaft fractures is not necessary.

A multilayer tissue engineered meniscus substitute

Various methods have been tried to treat the main meniscus problem, meniscal tears, for which we believe tissue engineering could be a viable solution. In this study, a three dimensional, collagen-based meniscus substitute was prepared by tissue engineering using human fibrochondrocytes and a collagen based-scaffold. This construct was made with 3 different collagen-based foams interspaced with two electrospun nano/microfibrous mats. The top layer was made of collagen type I-chondroitin sulfate-hyaluronic acid (Coll-CS-HA), and the middle and the bottom layers were made of only collagen type I with different porosities and thus with different mechanical properties. The mats of aligned fibers were a blend of collagen type I and poly(L-lactic acid-co-glycolic acid) (PLGA). After seeding with human fibrochondrocytes, cell attachment, proliferation, and production of extracellular matrix and glucoseaminoglycan were studied. Cell seeding had a positive effect on the compressive properties of foams and the 3D construct. The 3D construct with all its 5 layers had better mechanical properties than the individual foams.

Localized form of pigmented villonodular synovitis of the knee: the meniscal mime

The localized form of pigmented villonodular synovitis of the knee is a rare condition with non-specific symptoms. This makes diagnosis especially difficult when the meniscus is affected. A full assessment with several imaging modalities can help support the preoperative diagnosis. But in the case reported here, the full clinical and paraclinical assessment (X-rays, CT arthrography and MRI) was wrong--the localized form of pigmented villonodular synovitis had mimicked a lateral meniscus injury and was only detected during arthroscopy. The lesion was excised surgically and the diagnosis was confirmed through postoperative histopathology.

An arthroscopic check valve release improves knee intrameniscal cyst symptoms in adolescent: a case report

Intrameniscal cysts begin with the flow of synovial fluid from a meniscal tear in one direction, enlarging probably as a result of an on-and-off valve mechanism of the tear flap. The current available literature focuses primarily on the necessity for surgery, however a large meniscus resection to remove cysts may place an additional burden on menisci, leading ultimately to knee joint degenerative changes. In this article, we present a rare case of intrameniscal cysts with an isolated horizontal meniscal tear in an adolescent, and describe a new arthroscopic procedure for treating this type of intrameniscal cyst. We performed arthroscopic partial release of the meniscal tear check-valve mechanism, preventing further intrameniscal cyst expansion. The patient's clinical symptoms improved, and this procedure may also be useful in treating intrameniscal cysts with an isolated horizontal meniscal tear and can be considered as an option to preserve meniscal function and minimize degenerative arthritis in young athletes.

Comparison between arthroscopic partial and total meniscectomy of medial meniscus in non-professional athletes

Large number of patients suffers from medial meniscus injury during athletic activities despite of not being involved in professional sports. Our goal was to compare clinical and functional outcome of arthroscopic partial meniscectomy with results of arthroscopic total meniscectomy of the medial meniscus in these non-professional athletes. The prospective interventional study was carried out in a five years period from January 2007 to December 2011. According to predefined inclusion and exclusion criteria 109 patients were selected and underwent surgery but 29 patients lost from follow-up. Results of 40 cases with Arthroscopic partial meniscectomy (Group-I) and 40 cases with arthroscopic total meniscectomy (Group-II) were analyzed. There were 75 male patients and the predominant age group was 21-30 years. Patients were followed up for a range of 36-60 months. Standard questionnaires of Visual Analogue Score (VAS), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner-Lysholm Knee Score (TLKS) and Tapper and Hoover criteria was used to assess and compare the outcomes. Radiological assessment was done to note any changes. Students were sufferers in majority cases and bucket handle tear had been the commonest type. Significant difference of clinical, functional and radiological outcome was observed at minimum 3 years follow up. One case needed revision in Group-II and the infection rates were insignificant. Arthroscopic partial meniscectomy is significantly better method for surgical management of medial meniscus injuries.

Popliteomeniscal fascicle tears

Isolated popliteomeniscal fascicle tears are often unrecognized and misdiagnosed. Patients typically have vague symptoms and often-normal magnetic resonance imaging and physical examination findings. Isolated injuries are often misdiagnosed and mistreated, leading to delayed surgical treatment. Unrecognized tears can lead to continued disability, lateral meniscus tears, and chondral lesions. Appropriate diagnosis and treatment with inside-out lateral meniscus repair will allow the athlete to return to activity.

Comparison of magnetic resonance imaging findings with arthroscopic findings in discoid meniscus

PURPOSE

It is widely accepted that although valuable in the diagnosis of the discoid meniscus and tears, magnetic resonance imaging (MRI) can be insufficient in determining the type of the tear. This study calculates the sensitivity and specificity of MRI in determining the presence and absence of tears and how these values differ for different types of tears.

METHODS

This study is a retrospective review of 10 years of our experience with arthroscopic discoid meniscus treatment between 1999 and 2009. MRI findings were compared with the intraoperative arthroscopic findings in 52 patients with 50 lateral and two medial discoid menisci of which 24 were complete and 28 were incomplete. Tears were classified into six groups: (1) no tear, (2) simple horizontal tear, (3) radial tear, (4) combined horizontal tear, (5) complex tear and (6) longitudinal tear. Sensitivity, specificity, positive and negative predictive values of MRI were calculated for each group separately and for the presence and absence of tears in general. In addition, the effect of age, type of discoid meniscus, and presence and absence of shift on the distribution of tear types were analysed.

RESULTS

MRI was found to be 100 % specific and 97.8 % sensitive for determining the presence or absence of a tear with a negative predictive value of 85.7 % and a positive predictive value of 100 %. The specificities were 80 % for simple horizontal, 50 % for radial, 66.7 % for combined horizontal, 55.6 % for complex and 14.3 % for longitudinal tears, whereas the sensitivities were 66.7 % for simple horizontal, 96.9 % for radial, 87.5 % for combined horizontal, 94.6 % for complex and 100 % for longitudinal tears. The presence and absence of shift and type of the discoid were found to affect the distribution of the tear type.

CONCLUSIONS

MRI is successful in determining the presence or absence of tears in discoid menisci; however, its ability to determine the tear type is questionable. Complete discoid menisci were found to have tendency towards having a simple horizontal or longitudinal tear, whereas incomplete discoid menisci tend to have radial or combined horizontal tears. Determination of the shift prior to surgery is important since it alters the surgical technique.

Clinical, radiological, and morphological evaluations of posterior horn tears of the lateral meniscus left in situ during anterior cruciate ligament reconstruction

BACKGROUND

Recent studies have shown that lateral menisci have a higher healing potential and that they can be treated successfully without symptoms by being left in situ during anterior cruciate ligament (ACL) reconstruction. However, few studies have reported morphological results.

HYPOTHESIS

Stable posterior horn tears of the lateral meniscus left in situ during ACL reconstruction could be healed spontaneously and would result in not only successful clinical outcomes but also morphological restoration.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among 367 patients who underwent primary ACL reconstruction between 2008 and 2010, 53 patients who had lateral meniscus tears that were left in situ were analyzed. These patients were evaluated subjectively and radiologically and compared with a matched control group that underwent ACL reconstruction without any other structural disorders. Of the 53 patients with stable posterior horn tears of the lateral meniscus left in situ, 28 patients were assessed by second-look arthroscopic surgery and magnetic resonance imaging (MRI).

RESULTS

The mean follow-up of the study group and the control group was 36.47 and 37.26 months, respectively. There were no statistical differences in postoperative clinical outcomes between the 2 groups. Clinical results of both groups including the Lysholm score, Tegner activity score, and International Knee Documentation Committee (IKDC) score significantly improved. In the subgroup composed of 28 patients, follow-up MRI showed 25 (89%) and 24 (86%) healed menisci in sagittal and coronal views, respectively. Twenty-one (75%) were considered to be completely healed, and 5 (18%) were incompletely healed on second-look arthroscopic surgery.

CONCLUSION

Stable posterior horn tears of the lateral meniscus left in situ at the time of ACL reconstruction revealed successful clinical outcomes compared with isolated ACL injuries and showed considerable healing and functional restoration of tears with repeat MRI and second-look arthroscopic surgery. Therefore, leaving stable posterior horn tears of the lateral meniscus in situ during ACL reconstruction should be considered.