Preservation Of Meniscal Tissue Research Articles

Improved Outcome With Knee Arthroscopy Relative to Physiotherapy for Symptomatic Unstable Meniscal Tears: 2-Year Prospective Cohort Study.

Although preservation of meniscal tissue is paramount, there are occasions when repair of a torn meniscus is not possible. The surgical option may be a partial meniscectomy, the objective being to alleviate the patient's symptoms with resection of only that portion of the meniscus that is no longer functioning but is the cause of symptoms. Previous studies have questioned the need to perform such surgery and have recommended nonoperative treatment instead. Our goal was to compare the outcome of partial meniscectomy with that of physiotherapy alone for irreparable meniscal tears. Clinical outcome following arthroscopic partial meniscectomy may differ from that following physiotherapy alone, for patients with symptomatic irreparable meniscal tears. Nonrandomized prospective cohort study. Level 2. Patients satisfying the inclusion criteria chose to undergo knee arthroscopy (group A) or physiotherapy (group B). The diagnosis of a meniscal tear was made on physical assessment and magnetic resonance imaging examination. The meniscal tear was preventing them from continuing with their regular weightbearing exercise. Outcomes of interest were the following patient-reported outcomes (PROs): the Knee Osteoarthritis Outcome Score (KOOS) and Tegner Activity Score (TAS), with minimal clinically important differences being 10 and 1, respectively. PROs were completed at baseline, and at 1-year and 2-year follow-up. Changes in scores within and between groups were compared using analysis of variance and Wilcoxon tests (P <0.05). A power analysis demanded 65 patients in each group to produce a power of 80% and a P value of 5%. Of 528 patients enrolled in the study, 10 were lost to follow-up and 8 were excluded. Data were complete for 269 in group A, and 228 in Group B. Group A and B were similar in terms of age (41.1 years, SD 7.8 vs 40 years, SD 13.3), body mass index (22.5 kg/m2, SD 3.1 vs 23.1 kg/m2, SD 2.3), radiographic grade of osteoarthritis (median grade 2, range 0-3 in both groups), gender (male:female = 134:135 vs 112:116), and duration of symptoms (44.4 days, SD 5.6 vs 46.6 days, SD 8.8), with P >0.05. At both 1-year and 2-year follow-up, Group A had higher scores in the mean total KOOS (88.8, SD 8.0 vs 72.4, SD 3.8), as well as in all subscales within the KOOS, and the TAS (median 7, range 5-9 vs median 5, range 3-6), with P <0.001 for each variable. Performing a knee arthroscopy with partial meniscectomy is associated with improved KOOS and TAS, relative to treatment with physiotherapy alone, at 2-year follow-up. Physically active patients with symptomatic irreparable meniscal tears may experience a better clinical outcome following knee arthroscopy, relative to to physiotherapy alone.

Distal Fixation of Meniscal Root Repair by Transtibial Pullout Technique via Transtibial Tubercle Fixation Without Hardware

The meniscal roots are critical in maintaining the normal shock-absorbing function of the meniscus. If a meniscal root tear is left untreated, meniscal extrusion can occur, rendering the meniscus nonfunctional, resulting in degenerative arthritis. Preservation of meniscal tissue with restoration of meniscal continuity is becoming the standard for meniscal root pathology. Not all patients are candidates for root repair; however, repair is indicated in active patients after acute or chronic injury with no significant osteoarthritis and malalignment. Two main repair techniques have been described: suture anchor (direct fixation) and transtibial pullout (indirect fixation). The most common root repair technique is a transtibial technique. In this technique, sutures are placed into the torn meniscal root and then shuttled down through the tunnel in the tibia to tie the repair distally. The option adopted in our technique is to fix the meniscal root distally by wrapping threads of FiberTape (Arthrex) around the tibial tubercle through a transverse tunnel posterior to the tibial tubercle with buried knots inside the transverse tunnel without the use of metal buttons or anchors. This technique provides secure tension for repair without loosening of knots and tension that occur when using metal buttons and avoiding irritation caused by metal buttons and knots in patients.

Arthroscopic Transosseous Repair of a Medial Meniscal Posterior-Root Tear.

(1) Preoperative evaluation, including patient history, examination, and imaging (i.e., radiographs and magnetic resonance imaging). (2) Preparation and positioning. The patient is placed in the supine position, and anteromedial and anterolateral portals are created. (3) Placement of sutures. Two simple cinch sutures are placed into the posterior horn, within approximately 5 mm of each other. (4) Footprint decortication. Remove articular cartilage from the native root insertion site. (5) Drilling of the transosseous tibial tunnel. Introduce a tibial tunnel guide over the decorticated base, set guide to 45° to 50°, place a 2-cm vertical incision over an anteromedial tibial guide footprint, advance a 2.4-mm guide pin through the guide, and overream to 5 mm. (6) Passing of the sutures with use of a looped suture passer introduced retrograde through the tibial tunnel to retrieve sutures. (7) Anchor placement and fixation. Apply maximum suture traction, drill a second aperture 0.5 to 1.0 cm distal to the original aperture on the anteromedial aspect of the tibia, pass the suture ends through the anchor, and fix the anchor into the aperture. (8) Repair evaluation and closure. Note the position and stability of the meniscal root relative to the native footprint. Standard closure in layers is performed. If the patient experiences no relief from nonoperative treatment, an MMPRT can be treated operatively via partial meniscectomy or repaired via direct suture-anchor repair or indirect transosseous (transtibial) repair. Direct repair utilizes a suture anchor inserted at the root site5. Variations of the present technique include different suture configurations or numbers of tunnels. Although several suture configurations have been described, the simple cinch stitch (utilized in the present procedure) has been shown to be better at resisting displacement than the locking loop stitch6. Moreover, it has been suggested that simple stitches are less technically difficult and more able to resist displacement because they require less tissue penetration than other stitches7. Lastly, procedures that utilize a single versus a second transtibial tunnel have been shown to be equivalent in cadaveric studies8. The desired results of MMPRT repair include anatomic reduction, preservation of meniscal tissue and knee biomechanics, and preservation of hoop stress, which improve activity, function, and symptoms and mitigate degenerative changes and the risk of progression to total knee arthroplasty. At a minimum of 2 years after transosseous repair, the Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form, and Tegner activity scale were significantly improved8,9. Previous studies have shown significant improvement in the Hospital for Special Surgery and Lysholm scores without radiographic osteoarthritis progression at the same minimum follow-up10. Lastly, in the longest-term follow-up study to date, transosseous repair survivorship was reported to be 99% at 5 years and 92% at 8 years, with failure defined as conversion to total knee arthroplasty11. Pearls○ Decorticate the native meniscal root down to bleeding bone.○ Consider fenestration or percutaneous release of the medial collateral ligament in order to further open a tight medial compartment.○ A self-retrieving suture passer allows the use of standard arthroscopy portals.○ A multiuse variable-angle tibial tunnel drill guide allows point-to-point placement over the native meniscal root insertion.○ A guide with a tip may be easier and more accurate to control.○ Consider different guides when drilling the tibial tunnel, according to the anatomy of the patient.○ A low-profile guide may provide better clearance along the condyles.○ Utilize a cannula when shuttling sutures through the tibial tunnel in order to prevent a soft-tissue bridge.○ With anchor fixation, consider drilling over a guide pin and tapping when the bone is hard.○ Study preoperative imaging to evaluate the amount of arthritis present. Evaluate all compartments on magnetic resonance imaging for additional pathology.Pitfalls○ Obliquity of the tibial tunnel can cause the guide pin and reamer to enter too anteriorly.○ Patient failure to adhere to postoperative rehabilitation and restrictions can lead to unfavorable outcomes.○ The use of lower-strength sutures may increase the risk of fixation failure.

Impianti e sostituti meniscali

When meniscal lesions occur, preservation of meniscal tissue and restoration of the normal meniscal biomechanics is imperative to avoid early knee osteoarthritis; however, current surgical treatments for meniscal tears suffer from subsequent cartilage degeneration and inconsistent post-treatment results. When meniscal replacement is indicated, the desired implant should be chondroprotective; nevertheless, long-term effects of meniscal transplantation in protecting the articular cartilage have not been fully elucidated as yet. To date, three clinical scaffolds that allow 3-dimensional reconstruction of the meniscal structure (Menaflex CMI, Actifit® scaffold and NUsurface® Meniscus Implant) are available on the market for use, but additional data are needed to properly evaluate their safety and effectiveness.

Inside-Out Meniscal Repair: Medial and Lateral Approach

Preservation of meniscal tissue has been proven to be the best approach in most cases of meniscal tears. Currently available techniques for treating a peripheral meniscal tear include inside-out, outside-in, and all-inside techniques. Each of these techniques present potential advantages and disadvantages. Despite technologic advances in all-inside devices, because of implant-related complications, cost concerns, and device availability, the inside-out technique is still the preferred method among many surgeons. Although the inside-out repair technique is considered more technically demanding and requires additional incisions, it has several advantages such as the possibility for an increased number of sutures, creating a stronger construct, and greater versatility in their placement. This article describes the inside-out meniscal repair technique with its corresponding posterolateral and posteromedial surgical approaches.

Efficacy of P188 on lapine meniscus preservation following blunt trauma

Traumatic injury to the knee leads to the development of post-traumatic osteoarthritis. The objective of this study was to characterize the effects of a single intra-articular injection of a non-ionic surfactant, Poloxamer 188 (P188), in preservation of meniscal tissue following trauma through maintenance of meniscal glycosaminoglycan (GAG) content and mechanical properties. Flemish Giant rabbits were subjected to a closed knee joint, traumatic compressive impact with the joint constrained to prevent anterior tibial translation. The contralateral limb served as an un-impacted control. Six animals (treated) received an injection of P188 in phosphate buffered saline (PBS) post trauma, and another six animals (sham) received a single injection of PBS to the impacted limb. Histological analyses for GAG was determined 6 weeks post trauma, and functional outcomes were assessed using stress relaxation micro-indentation. The impacted limbs of the sham group demonstrated a significant decrease in meniscal GAG coverage compared to non-impacted limbs (p<0.05). GAG coverage of the impacted P188 treated limbs was not significantly different than contralateral non-impacted limbs in all regions except the medial anterior (p<0.05). No significant changes were documented in mechanics for either the sham or treated groups compared to their respective control limbs. This suggests that a single intra-articular injection of P188 shows promise in prevention of trauma induced GAG loss.

Updates in biological therapies for knee injuries: menisci.

The preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following the repair of meniscus tears, including both simple longitudinal tears located in the periphery and complex multiplanar tears that extend into the central third avascular region. However, most types of meniscal lesions are managed with a partial meniscectomy. Options to restore the meniscus range from an allograft transplantation to the use of synthetic and biological technologies. Recent studies have demonstrated good long-term outcomes with meniscal allograft transplantation, although the indications and techniques continue to evolve, and the long-term chondroprotective potential of this approach has yet to be determined. Several synthetic implants, most of which are approved in the European market, have shown some promise for replacing part of or the entire meniscus, including collagen meniscal implants, hydrogels, and polymer scaffolds. Currently, there is no ideal implant generated by means of tissue engineering. However, meniscus tissue engineering is a fast developing field that promises to develop an implant that mimics the histologic and biomechanical properties of a native meniscus.

Meniscus Repair and Transplantation: A Comprehensive Update

Preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following repair of meniscus tears for both simple longitudinal tears located in the periphery and complex multiplanar tears that extend into the central third avascular region. This operation is usually indicated in active patients who have tibiofemoral joint line pain and are less than 50 years of age. However, not all meniscus tears are repairable, especially if considerable damage has occurred. In select patients, meniscus transplantation may restore partial load-bearing meniscus function, decrease symptoms, and provide chondroprotective effects. The initial postoperative goal after both meniscus repair and transplantation is to prevent excessive weight bearing, as high compressive and shear forces can disrupt healing meniscus repair sites and transplants. Immediate knee motion and muscle strengthening are initiated the day after surgery. Variations are built into the rehabilitation protocol according to the type, location, and size of the meniscus repair, if concomitant procedures are performed, and if articular cartilage damage is present. Meniscus repairs located in the periphery heal rapidly, whereas complex multiplanar repairs tend to heal more slowly and require greater caution. The authors have reported the efficacy of the rehabilitation programs and the results of meniscus repair and transplantation in many studies.

Meniscal Repair – Indications and Techniques

Meniscal tears are exceedingly common. Because the meniscus serves many vital functions to the knee joint, the preservation of meniscal tissue through meniscal repair is ideal. However, not all meniscal tears are amenable to repair, and each case must be critically assessed for repair suitability. It has been well documented that meniscal healing is enhanced in the setting of concurrent anterior cruciate ligament (ACL) reconstruction. This may influence the indications for repair, as well as the repair technique. Meniscal repair techniques have evolved over time from initial open repairs to inside-out and outside-in suture repairs to newer all-inside repair devices. The current gold standard remains inside-out vertical mattress suture repairs. All-inside repairs are best reserved for special circumstances, such as in the setting of concurrent ACL reconstruction.

The discoid meniscus

Discoid lateral meniscus is an intra-articular knee disorder typically presented in the young population and during adolescence. Different types of meniscal disorders and varied forms of presentation have been reported. The natural history depends on the type of anomaly and the presence of symptoms. Management of the disorder should be directed toward the resolution of the symptoms while preserving meniscal tissue and function. Modern surgical techniques enable suturing and preservation of meniscal tissue. The clinical manifestations, diagnostic modalities and criteria, accompanying conditions and practical management considerations are reviewed.

Stadiengerechte Therapie durch Meniskusresektion, -naht und -ersatz

Clinical and experimental studies have demonstrated that the meniscus is important for normal knee function. Loss of meniscus results in abnormal load transmission across the knee and may lead to degenerative joint disease. Preservation of meniscal tissue is therefore important. About 10 % of all meniscal tears are repairable. The most successful repairs occur in younger patients who have an acute, vertical tear in the vascular portion of the meniscus. Currently, arthroscopic meniscal repair procedures include the inside-out, the outside-in and the all-inside technique. Vertical suture techniques are superior to horizontally placed sutures. From a biomechanical point of view, 2-0 to 1 sutures are recommended for suture repair. Various meniscus implants are also available for meniscal repair. The initial fixation strength of the implants is lower compared to vertical sutures. A combination of suture techniques and implants might be a treatment option in posterior meniscal lesions. The collagen meniscus implant has been designed to support tissue ingrowth after segmental medial meniscectomy. Although fibrocartilage matrix formation has been shown, long-term clinical follow-ups are still required. Meniscal allograft transplantation may be indicated in limited situations. Younger patients with meniscal deficiency due to previous meniscectomy who have only early arthrosis, normal axial alignment, and a stable knee may currently considered appropriate candidates for meniscal transplantation.

Degenerative Lesions in the Articular Cartilage after Meniscectomy

Articular cartilage degeneration was studied in an experimental model including 68 knees of adult dogs on which five different types of medial meniscectomy had been performed with a followup period of 10 to 450 days. The results were assessed by macroscopic, radiologic, and histologic methods. The degenerative lesions increased proportionally to the amount of meniscal tissue resected and the duration of observation. These lesions proved to be more intense at the tibial plateau compared to the femoral condyle. For both joint surfaces the predominant location was the central zone. Considering the degenerative process by the articular cartilage after total meniscectomy, maximum preservation of meniscal tissue is recommended.