Concomitant Arthroscopic Meniscal Allograft Transplantation and Anterior Cruciate Ligament Reconstruction

Optimizing Socket-Tunnel Position for Meniscal Allograft Transplantation Combined With ACL Reconstruction: A 3D Model Analysis

Background

Socket-tunnel overlap during meniscal allograft transplantation (MAT) combined with anterior cruciate ligament reconstruction (ACLR) may compromise graft integrity and lead to impaired fixation and treatment failure.

Purpose/Hypothesis

The purpose of this study was to determine optimal socket-tunnel drilling parameters for medial and lateral MAT with concurrent ACLR using artificial tibias and computed tomography (CT) scans for 3-dimensional (3D) modeling. It was hypothesized that clinically relevant socket tunnels could be created to allow for concurrent medial or lateral MAT and ACLR without significant risk for overlap at varying tunnel guide angles.

Study Design

Descriptive laboratory study.

Methods

A total of 27 artificial right tibias (3 per subgroup) were allocated to 9 experimental groups based on the inclination of the socket tunnels (55°, 60°, and 65°) created for simulating medial and lateral MAT and ACLR. Five standardized socket tunnels were created for each tibia using arthroscopic guides: one for the ACL tibial insertion and one for each meniscus root insertion. CT scans were performed for all specimens and sequentially processed using computer software to produce 3D models for quantitative assessment of socket-tunnel overlap risk. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests.

Results

No subgroup consistently presented significantly safer distances than other subgroups for all distances measured. Three cases (11%) and 24 cases (~90%) of tunnel overlap occurred between the ACL tunnel and tunnels for medial and lateral MAT, respectively. Most socket-tunnel overlap (25 of 27; 92.6%) occurred between sockets at depths ranging between 6.3 and 10 mm from the articular surface. For ACLR and posterior root of the lateral meniscus setting, the guide set at 65° increased socket-tunnel distances.

Conclusion

When combined ACLR and MAT using socket tunnels for graft fixation is performed, the highest risk for tibial socket-tunnel overlap involves the ACLR tibial socket and the lateral meniscus anterior root socket at a depth of 6 to 10 mm from the tibial articular surface.

Clinical Relevance

Setting tibial guides at 65° to the tibial articular surface with the tunnel entry point anteromedial and socket aperture location within the designated anatomic "footprint" will minimize the risk for socket-tunnel overlap.

Meniscal allograft transplantation (MAT) combined with revision ACL reconstruction and lateral extra-articular tenodesis results in significantly improved outcomes, but patient-reported knee function is inferior compared to an isolated MAT

PURPOSE

Meniscal allograft transplantation (MAT) is a valuable option for postmeniscectomy syndrome in young and active patients, which can successfully improve symptoms, function and quality of life. This study aimed to report outcomes and complications in patients treated with isolated MAT or MAT combined with revision anterior cruciate ligament reconstruction (ACLR) and lateral extra-articular tenodesis (LET).

METHODS

In total, 18 patients who were treated with MAT using a soft tissue fixation technique were retrospectively analysed. Patients were allocated into two groups, the isolated MAT group and the MAT plus revision ACLR + LET group (MAT+ group). Both groups were assessed using the following Patient-Reported Outcome Measures (PROMs): Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), Tegner Activity Scale, Lysholm score, EuroQol 5-Dimension 5-level (EQ-5D-5L) questionnaire and a patient acceptable symptom state (PASS) statement.

RESULTS

The mean follow-up was 3.2 years and the mean age of patients was 29 (±7.6) years. Ten patients were treated with isolated MAT and eight patients were treated with MAT combined with revision ACLR and LET. No complications and no reoperations were reported. In both groups, all PROMs significantly improved postoperatively (p < 0.05), except for the Tegner score in the MAT+ group, which did not reach statistical significance (not significant [n.s.]). No significant difference was found postoperatively in PROMs between the MAT and the MAT+ group; however, differences in the KOOS Symptoms, Sports and Quality-of-life subscales reached the minimal clinically important threshold. Mean values were: IKDC 61.2 (±13.9) versus 64.7 (±23.2), KOOS Total 72.8 (±14.9) versus 68.0 (±16.7), Lysholm score 83.2 (±11) versus 84.2 (±8.7) and EQ-5D-5L 71.8 (±14.9) versus 72.2 (±22.4). Median values for the Tegner Activity Scale were 4 versus 3. PASS statement was negative in 37.5% of the MAT+ group in comparison to 20% of the MAT group (n.s.).

CONCLUSION

In terms of patient-reported outcomes, MAT is an effective and safe procedure, even when combined with revision ACLR + LET. Compared to the preoperative assessment, a significant improvement of the postoperative PROMs can be expected either when MAT is performed isolated or in combination with ACLR + LET. However, clinically important differences between the two groups can be noted in favour of the isolated MAT procedure, especially regarding symptoms and sporting activity.

LEVEL OF EVIDENCE

Level III.

Minimum 10-Year Clinical Outcomes and Survivorship of Meniscal Allograft Transplantation With Fresh-Frozen Allografts Using the Bridge-in-Slot Technique

BACKGROUND

Meniscal allograft transplantation (MAT) has been shown to provide clinical benefits in patients with symptomatic meniscal deficiency in the short term and midterm. There is, however, a paucity of data regarding long-term outcomes after MAT using fresh-frozen allografts and the bridge-in-slot technique.

PURPOSE

To report clinical outcomes and revision rates after primary MAT with fresh-frozen allografts and the bridge-in-slot technique in a large case series of patients at a 10-year minimum follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of prospectively collected data was performed on patients undergoing primary MAT between 2001 and 2012. Lysholm, International Knee Documentation Committee subjective form, and Knee injury and Osteoarthritis Outcome Score subscales were collected preoperatively and at 1-, 2-, 5-, and minimum 10-year follow-ups. Cox proportional hazards modeling was used to identify variables associated with reoperation and failure, defined as revision MAT or conversion to arthroplasty. Reoperation was defined as a subsequent surgical intervention on the transplanted meniscus, including partial or total meniscectomy, meniscal repair, or failure as defined in the previous sentence.

RESULTS

A total of 174 patients undergoing MAT met the inclusion criteria and were followed for a mean of 12.7 ± 2.7 years (range, 10.0-21.0 years). The mean age at surgery was 28.3 ± 10.1 years. The patients were predominantly female (n = 92; 53%), and medial MAT was the most commonly performed procedure (n = 91; 52%). Concomitant procedures were performed in 115 patients (66%), with the most common procedure being osteochondral allograft transplantation (n = 59; 34%). Patients demonstrated statistically significant postoperative improvements at all time points for all patient-reported outcome measures (P≤ .0001). A total of 65 patients (37%) underwent a meniscal reoperation at a mean time of 6.6 ± 5.5 years (range, 0.3-16.7 years) postoperatively. A total of 40 patients (23%) met the criteria for failure at a mean time of 7.3 ± 5.0 years (range, 1.0-17.4 years) after MAT, with 22 of these patients having undergone a previous meniscal reoperation. At the final follow-up, 13 patients (7%) had undergone revision MAT and 27 (15%) had converted to arthroplasty. The MAT survival rates free of meniscal reoperation and failure were 73% and 85% at 10 years and 60% and 72% at 15 years, respectively. At the time of the final follow-up, 86% of patients reported that they were satisfied with their overall postoperative condition.

CONCLUSION

Primary MAT demonstrates efficacy and durability with high rates of patient satisfaction at a minimum 10-year follow-up. Patients should be counseled that although reoperation rates may approach 40% at 15 years, rates of overall revision MAT and conversion to arthroplasty remain low at long-term follow-up.

Acceptable clinical outcomes despite high reoperation rate at minimum 12-month follow-up after concomitant arthroscopically assisted anterior cruciate ligament reconstruction and medial meniscal allograft transplantation

BACKGROUND

Single-stage medial meniscus allograft transplantation (MAT) with concomitant anterior cruciate ligament reconstruction (ACLR) is a technically challenging procedure for management of knee pain and instability in younger patients, but clinical and functional outcomes data are sparse. The purpose of this study was to assess surgical and patient-reported outcomes following concomitant ACLR and medial MAT.

METHODS

We conducted a retrospective case series of patients who underwent medial MAT with concomitant primary or revision ACLR at our institution from 2010 to 2021 and had minimum 12-month follow-up. Complications, reoperations, visual analog scale (VAS) pain, satisfaction, Lysholm score, return to sport, and return to work outcomes were assessed. Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference, Pain Intensity, and Physical Function Scores were used to measure patients' functional status relative to the US population. P-values < 0.05 were considered significant.

RESULTS

The cohort consisted of 17 knees of 16 individual patients. The cohort was majority male (82.4%) with mean age of 31.9 years (range 19-49 years) and mean body mass index (BMI) of 27.9 kg/m² (range 22.5-53.3 kg/m²). Mean follow-up time was 56.8 months (range 13-106 months). Most patients underwent revision ACLR (64.7%). The 1-year reoperation rate was high (23.5%), with two patients (11.8%) tearing their meniscus graft. Patient-reported outcomes indicated low VAS pain (mean 2.2), high satisfaction (mean 77.9%), and fair Lysholm score (mean 81.1). Return to work rate was high (92.9%), while return to sport rate was low (42.9%). Postoperative PROMIS scores were comparable or superior to the national average and correlated significantly with patient satisfaction (p < 0.05).

CONCLUSIONS

The concomitant ACLR and MAT procedure is associated with excellent knee pain and functional outcomes and high rate of return to work after surgery, though the 1-year reoperation rate is high and rate of return to sport is low.

LEVEL OF EVIDENCE

IV.

TWO TO 14 YEAR OUTCOMES OF COMBINED MENISCAL ALLOGRAFT TRANSPLANTATION WITH ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A SYSTEMATIC REVIEW

PURPOSE

To evaluate the clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with meniscal allograft transplantation (MAT) through systematic review of current available evidence.

METHODS

A systematic database search of PubMed, Embase, Web of Science and CINAHL was performed from inception up to 7 December 2021 in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Follow-up studies (inception cohort studies/non-randomized controlled trials/retrospective cohort studies) and case series that had more than 10 people published in English, which involved patients who underwent a combination of ACLR and MAT were included. Quality of these studies were appraised using the Cochrane Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Systematic review of International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores were conducted.

RESULTS

Seven studies involving 363 patients were included. The average mean follow up time was 4.08 years, ranging from 1.75 to 14 years. All studies used the Lysholm Knee Scoring system to report clinical outcomes, while two studies and four studies used the IKDC Questionnaire and Tegner activity scale respectively to measure clinical outcomes post-operatively. Comparing postoperative to pre-operative scores, we found an improvement above the minimal clinically important difference (MCID) for the Lysholm (Mean Difference (MD) range= 16.00 to 26.10) and Tegner activity scores (MD range = 1.50 to 1.90). All but one study reported an increase above the MCID for IKDC scores post-op (MD range= 5.60 to 23.00).

CONCLUSIONS

Combined MAT and ACLR have good two to 14 year clinical outcomes post operatively and is an optimal procedure for patients with concurrent ACL injuries with irreparable meniscus injuries. More prospective studies and studies evaluating outcome differences between concurrent ACLR with MAT and staged ACLR with MAT should be conducted.

LEVEL OF EVIDENCE

IV, systematic review and/or meta-analysis of studies with Levels I to IV.

Staged meniscal allograft transplantation as a biologic treatment of the meniscal deficient knee: A prospective case series of 26 patients with maximum 88-month follow-up

INTRODUCTION

The meniscal deficient knee often exists within the setting of associated pathology including instability, malalignment and chondral injury. The aim of this study was to establish the role of meniscal allograft transplantation (MAT) as part of a staged approach to treatment of the previously menisectomised knee and report: (a) primary data endpoints (pre and post-operative Knee Injury and Osteoarthritis outcome scores (KOOS), Tegner scores, satisfaction scores and graft survival), and (b) secondary endpoints:(complication/reoperation rates, and meniscal extrusion measurements as determined by MRI).

MATERIAL AND METHODS

This prospective study included all patients that underwent arthroscopic fresh frozen allograft MAT at our institution (2010-2017) using a soft tissue fixation technique.

RESULTS

Twenty-seven MAT procedures were performed in 26 patients (16 lateral, 11 medial). Ten patients underwent ACL reconstruction, three ACI and two osteotomy in the pre-MAT phase. Seven patients underwent ACI within the post-operative phase. Post-operative mean KOOS scores improved significantly in all subscales (p < .002) as did Tegner scores (p < .05). Graft survival was 100%, satisfaction rate 92%, and mean meniscal extrusion 3.04 mm. Post operatively, three patients required meniscal repair and a single patient, partial menisectomy of graft. Two patients underwent arthroscopic arthrolysis following MAT.

CONCLUSIONS

This series highlights the multifactorial profile of the meniscal deficient knee and the role of MAT as a safe and reliable technique in the staged and comprehensive biologic treatment available to minimise symptoms and maximise outcomes.

LEVEL OF EVIDENCE

4.

Centralized anterior bone plug results in less graft extrusion in patients undergoing medial meniscus allograft transplantation following anterior cruciate ligament reconstruction

PURPOSE

This study was performed to analyze the effect of anterior bone plug positioning on clinical and radiological outcomes in patients undergoing medial meniscus allograft transplantation (M-MAT) following anterior cruciate ligament reconstruction (ACLR).

METHODS

Data from 24 patients who underwent M-MAT following meniscectomy and ACLR from November 2008 to June 2017 were retrospectively investigated. Patients were divided into either the centrally positioned group (group C) or the medially positioned group (group M) based on the location of the anterior bone plug for M-MAT. Clinical and radiographic follow-up was performed at two years postoperatively. International Cartilage Repair Society (ICRS) grades of chondral lesion, graft extrusion, and meniscus signal intensity were evaluated by magnetic resonance imaging (MRI) at one year postoperatively.

RESULTS

There were no significant differences in demographics including follow-up time of two years between the two groups. There were no significant differences in postoperative subjective International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores between groups. Furthermore, there were no significant differences in osteoarthritis progression or ICRS grade on MRI. However, group C showed significantly less absolute graft extrusion (P = .008) and relative graft extrusion (P < .0001) on one-year follow-up MRI, relative to group M. Meniscus signal intensity tended to be better in group C, although this difference was not statistically significant (P = .092).

CONCLUSION

The centrally positioned group showed significantly less graft extrusion on MRI compared to the medially positioned group; however, there were no statistically significant differences in clinical outcomes between the two groups.

[Mid-term effectiveness of arthroscopic anterior cruciate ligament reconstruction combined with meniscus allograft transplantation]

Objective

To summarize the mid-term effectiveness of arthroscopic anterior cruciate ligament (ACL) reconstruction combined with meniscus allograft transplantation.

Methods

A clinical data of 21 patients treated with arthroscopic ACL reconstruction and meniscus allograft transplantation and followed up more than 5 years between February 2007 and December 2014 was retrospectively analyzed. There were 12 males and 9 females, aged from 18 to 45 years, with an average age of 23.5 years. The cause of injury was sport sprain in 15 cases, falling in 4 cases, and traffic accident in 2 cases. The time from injury to operation ranged from 2 to 36 months, with an average of 12 months. Among them, 15 patients underwent previous meniscectomy, with an average interval of 1.6 years (range, 3 months to 6.5 years). All patients were primary ACL reconstruction. Preoperative anterior drawer test, Lachman test, and pivot shift test were positive. Lysholm score was 43.6±10.2. International Knee Documentation Committee (IKDC) score was 60.50±14.06. Of the 21 patients, 10 were gradeⅠ-Ⅱcartilage injuries and 11 were grade Ⅲ cartilage injuries according to MRI.

Results

All patients were followed up 5.1-7.8 years, with an average of 5.5 years. There were 2 cases of numbness of lower extremity, 3 cases of slight exudation of incision, 2 cases of articular movement bounce, 5 cases of mild joint swelling and pain after exercise. At last follow-up, Lachman tests were negative in 18 cases and positive in 3 cases; anterior drawer tests were negative in 19 cases and positive in 2 cases; pivot shift tests were negative in all cases. Lysholm score was 84.5±16.5 and IKDC score was 85.25±4.60, which were significantly higher than those before operation ( P<0.01). The flexion and extension of the affected knee joint were (128±13) and (3±7)°, respectively, which were smaller than those of the healthy knee joint [(133±15), (0±5)°] ( P<0.01). The results of KT-1000 test showed that when knee flexion was 30 and 90°, tibial anterior displacement of affected side [(2.35±1.20), (1.60±1.15) mm] were not significantly different from those of healthy side [(1.20±1.10), (1.10±1.03) mm] ( P>0.01). MRI showed that the ACL graft was in normal position and meniscus survived well. Cartilage injuries were gradeⅠ-Ⅱ in 18 cases and grade Ⅲ in 3 cases.

Conclusion

For patients with severe meniscus injury and ACL rupture, ACL reconstruction combined with meniscus allograft transplantation can restore the stability of the joint, recover the meniscus function which is conducive to the protection of articular cartilage and obtain satisfactory mid-term effectiveness.

The Influence of Full-Thickness Chondral Defects on Outcomes Following Meniscal Allograft Transplantation: A Comparative Study

PURPOSE

To compare a series of patients who underwent meniscus allograft transplantation (MAT) with full-thickness chondral defects (FTD) with those with no chondral defect (ND) with regard to the following: change in patient-reported outcomes (PROs) from baseline to 2-year follow-up and baseline to the final follow-up (including comparisons to minimal clinically important differences), complications and complication rates, reoperations and reoperation rates/timing, and failures and time to failure (revision MAT or conversion to total knee arthroplasty).

METHODS

Patients who underwent isolated medial or lateral MAT between September 1997 and March 2013 with a minimum of 2 years of follow-up were retrospectively identified and split into 2 groups based on the presence or absence of FTD (femoral condyle or tibial plateau) identified intraoperatively after debridement to allow for a better understanding of the lesion characteristics (when applicable): ND (Outerbridge grade 0/I) or FTD (Outerbridge grade IV). Patients with osteochondritis dissecans were eligible for inclusion, as were those with isolated single lesions, multiple lesions, or bipolar lesions. Those with a moderate Outerbridge grade (II and III)-whether treated or neglected-were excluded given the poorer reliability of grading intermediate lesions. Indications for MAT included those patients with subjective complaints (persistent joint-line pain) and objective findings (previous meniscectomy or nonviable meniscus state with pain localized to the affected compartment) of functional meniscal deficiency. All lateral MAT patients used a bridge-in-slot surgical technique, as did most medial MAT patients (few patients with earlier surgical dates received a keyhole technique). All FTD were treated concurrently at the time of index MAT with cartilage restoration procedures (microfracture, autologous chondrocyte implantation, DeNovo particulate cartilage grafting, or osteochondral auto/allografting). Reoperations, failures (revision MAT or conversion to arthroplasty), and PRO deltas were reported comparing baseline to 2-year follow-up and baseline to the final follow-up. Intergroup comparisons were made using Bonferroni-adjusted independent sample t-tests for continuous variables and χ-square for categorical variables.

RESULTS

A total of 91 patients (22 ND and 69 FTD) were identified and followed for a mean 4.48 ± 2.63 and 3.84 ± 2.47 years, respectively. There were no significant between-group differences in age, body mass index, or number of prior surgeries. The mean chondral lesion size in the FTD group was 4.43 ± 2.5 cm². Concomitant anterior cruciate ligament reconstruction was performed significantly more in ND-group patients than FTD-group patients (8 [38.1%] vs 8 [11.8%], P = .004). There were no differences between ND-group and FTD-group patients in concomitant realignment procedures performed (2 [9.1%] vs 7 [10.1%], P = .986), or prior ligament reconstruction (9 [40.9%] vs 18 [26.1%], P = .111) or realignment procedure (0 [0%] vs 0 [0%]). FTD-group patients underwent concomitant osteochondral allograft (69.6%), autologous chondrocyte implantation (18.8%), microfracture (13.0%), osteochondral autograft (4.3%), or DeNovo juvenile particulate cartilage implantation (1.4%). A comparison of the patient groups found no statistically significant differences in PROs preoperatively (P > .003 for all). Intergroup comparisons of both the 2-year and final follow-up delta PRO scores showed no statistically (P > .003 for all) or clinically (number of PROs meeting minimal clinically important differences) significant differences. One complication occurred (fractured hardware) in the FTD-group patients (1.3%). There were no differences in the number of subsequent surgeries (revision MAT: ND, 2 (10.0%) vs FTD, 8 (12.9%); P = .845) or failures (conversion to total knee arthroplasty: ND, 1 (5.0%) vs FTD, 2 (3.3%); P = .646).

CONCLUSIONS

When comparing a patient series with FTD who underwent MAT with a patient series with ND, there were no differences in the change in individual PROs from preoperative to the final follow-up. Similarly, there were no differences in complications or failure between those with ND or FTD diagnosed intraoperatively. The results of the current study suggest that chondral damage identified and treated by cartilage restoration means at the time of MAT may not affect the clinical outcomes of MAT.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.