3/6/2017

Chris O’Grady, M.D

Update on Treatment of Meniscal Injuries Basic Clinical Future Science • Presentation • Biologics • Anatomy • Diagnosis • PRP • Biomechanics • Treatment • Stem Cells • Rehabilitation

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Function Function -- filler (incongruous condyles) -2.5 greater contact area when  Medial  Lateral Meniscus mensicus present  Secondary stabilizer to AP  200-300% increase in -prevent capsular/ translation in ACL deficient lateral compartment synovial impingement contact stresses when  (more capsular attachment) removed (convex lateral -joint lubrication/ synovial plateau) distribution  Follows - more likely to be torn with rotatory force -load (40-60% of standing load -stability (esp. rotatory)

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Radin et al., CORR, 1984

- Load transmission increases in flexion vs ext

5 Fukubayashi et al. 1980

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Anatomy Anatomy

 Histo: Fibrocartilage  Triangular cross section  Composition  Provide structural integrity  Water 65%-75%   “concavity” of the  Organic matter 25%-35% articulation  75% Collagen  Dissipates forces/friction across  Type I – 90% medial/lateral compartments  Types II, III,IV, V, VI, XVIII  Axial Compression   25% Other Horizontal hoop stress  Proteoglycans, DNA, Elastin  Creates shear forces

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Anatomy Anatomy

Structure Medial Meniscus  Mesh network:  C-Shaped structure  Arranged obliquely, radially, and  Less mobile vertically  Firmly attached to capsule  Prevents shear  Deep MCL at mid body  Bundles:  Posterior fibers of anterior horn merge with transverse  Radial ligament  Located at surface and midsubtance  Periphery of meniscus  Prevent longitudinal tears attached to capsule through  Circumferential coronary ligaments  Disperses compressive loads (hoops around wooden barrel)

Lateral Meniscus Medial Meniscus

 Wider in diameter  Semi-circular in shape than the lateral  More mobility meniscus  Less peripheral attachments  Popliteal Hiatus  9-10 mm wide  Anterior and posterior horns attach closer to each other than  3-5 mm thick medial meniscus  Covers 51-74% of  Anterior horn attaches adjacent to condyle ACL  Posterior horn attaches behind inter-condylar eminence

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Meniscofemoral ligaments Lateral Meniscus

 Covers more tibia  Humphrey & Wrisberg  75-93% of condyle  Run from posterior horn of  12-13 mm wide lateral meniscus to medial femoral condyle  3-5 mm thick  Major Role  Stabilize PH of Lateral Meniscus  Minor role  Stabilizing posterior tibial translation with compromised PCL

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Humphrey – Sag MRI Discoid Meniscus

 Anterior to PCL  Incidence of 3.5-5%  Usually lateral, but 20% bilateral

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Discoid Meniscus Blood Supply

PeriMeniscal Capillary Pleux

Type I-Complete Type II-Incomplete Type III-Wrisberg subtype

Watanabe Classification

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Blood Supply Arnoczky et al AJSM 1982

 50-100% of meniscus vascular at birth  9 months: Inner 1/3 rd avascular  By age 10: Mature  Peripheral 10-25% of lateral vascular  Peripheral 10-30% of medial vascular  Inner 2/3rds by synovial fluid diffusion

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Vascularity Zones

 Red-Red  Fully vascular  Excellent healing potential

 Red-White Basic Clinical Future  Border of vascular supply Science • Presentation • Biologics  Good healing potential • Anatomy • Diagnosis • PRP • Biomechanics • Treatment • Stem Cells  White-White • Rehabilitation  Relatively avascular  Poor healing prognosis

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Epidemiology

 Incidence (acute tears)  60-70 cases/100,000 people per year  Male:Female  Ratios 2.5-4:1  Younger  Acute Basic Clinical Future  Older  Degenerative (MMT) Science • Presentation • Biologics  1/3 occur with ACL tear • Anatomy • Diagnosis • PRP  Acute: LMT • Biomechanics • Treatment • Stem Cells  Chronic: MMT • Rehabilitation

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History Physical Exam

 Inspection  Mechanism  Twisting, change in direction, or hyper-flexion  injury Mild to moderate joint effusion  Feeling a “pop”  Usually no ecchymosis  Acute pain or swelling  Slow-forming effusion  Limb alignment  Locking/catching sensation  ROM  Degenerative tears(>40) often more atraumatic with a chronic  Typically normal history  However, longitudinal bucket handle tears may block full  Postmenisectomy syndrome – “toothache pain” after extension menisectomy  Stability  Associated ligamentous injury 25

Physical Exam McMurray British Journal of Surgery 1942

 MMT: 90deg, valgus, ER, ext knee  Joint line tenderness + click

Sen:59% Spec: 93-97%

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Apley Grind Test JBJS 1947 Thessaly Maneuver JBJS 2005

 20 deg flex (IR, ER) Prone, 90deg  Harrison, Clin J Sport

Stabilize thigh Med, 2009:  66 patients with +Thessaly, Compress joint, ER 65 had arthroscopic Sen: 41% findings of meniscal tear Spec: 86-93%  Sen 90%  Spec 97.7%

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Ege’s Test Imaging

 Squat with full hip ER/ IR  Weight bearing  Don’t miss OA  X-rays:  AP/Laterals  Merchant/Sunrise  30-45 degree flexion views

 Calcifications  CPPD

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Discoid Meniscus Imaging

 MRI: Widening  Diagnostic procedure of choice  95% accuracy  High NPV Squaring  Grading system 0, I, II, III  Grade III consistent with complete Cupping tear

 still gold standard Hypoplastic  Look for condylar edema  (increased contact pressure on condyle when meniscus torn)

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MRI Grading Discoid Meniscus – Bow Tie Sign

 0: normal 3 or more 5mm cuts with continuity of meniscus

 I: globular increase in signal with no extension to surface

 II: near signal increase that does not extend to surface

 III: increased signal that abuts the freed edge of meniscus  Indicates tear

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MRI Arthrography

Complex tear “Double PCL” – Bucket Handle

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Classification of Tears

Common Meniscal Tears

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Radial Tear Horizontal Tear

41 AANA Advanced Arthroscopy: The Knee AANA Advanced Arthroscopy: The Knee

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Bucket-Handle Tear Meniscal Root Tears

 Milder symptoms  Joint line pain  Less mechanical symptoms (only 9-14%)  Posterior knee pain with deep flexion  McMurray + 57%  Effusion + 14%

43 AANA Advanced Arthroscopy: The Knee Lee et al Arthroscopy 2009

Root Tears

-3mm extrusion on mid coronal -condylar edema

Extruded meniscus Ghost sign

Basic Clinical Future Science • Presentation • Biologics • Anatomy • Diagnosis • PRP • Biomechanics • Treatment • Stem Cells • Rehabilitation

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Treatment Options Nonsurgical Options

 Depends on  RICE  Symptoms  Wt Loss  Affect on ADLs, Work,  Bracing (unloader) Sports  Injections  Physical Therapy  ROM  Strengthening  NSAIDs

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1. Leave alone… Surgical Options

1. Leave alone 2. Meniscectomy  Stable partial tears  Leave tourniquet down to  Promote healing only   surgical morbidity and  assess bleeding: improves function Stable longitudinal tears   Rasping  Stable contoured rim < 10 mm length  Trephination  Preserve as much tissue as  < 3-5 mm displacement possible  Do not displace into notch  Marrow stimulation, PRP, etc.  Long-term risks?  Do not touch femoral condyle  Enhance biologic healing response  E.g. notch microfx 3. Meniscal repair 4. Meniscal transplant  Degenerative tears with  Ideal treatment for the ideal  Symptomatic patient too young significant OA situation for a TKA  Short radial tears: < 3 mm in  Vertical mattress sutures gold standard length

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2. Meniscectomy 2. Meniscectomy Indications

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2. Meniscectomy Technique 3. Repair Options

Inside- Open Out

Outside- All- In Inside

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Open Meniscal Repair Open Meniscal Repair

 Trans-capsular approach with  Results capsule and synovium opened  80-90% survival rate after 13 for visualization years  DeHaven Clin Sports Med  Indications: 1990  Rockborn and Gillquist JBJS  Tight compartments Br 2000  Peripheral tears in posterior horns  Muellner AJSM 1999  MRI data included, but unreliable method to  Disadvantages: assess healing  Larger approach  Greater tissue trauma

Arthroscopic Inside-Out Arthroscopic Inside-Out

 Advantage:  Advantage:  Consistent/More accurate suture  Consistent/More accurate suture placement placement  Gold Standard  Gold Standard

 Disadvantages:  Disadvantages:  Risk of neurovascular injury  Risk of neurovascular injury

 75-91% survival/healing  75-91% survival/healing  Barrett et al Arthroscopy  Barrett et al Arthroscopy 1998 1998  Johnson et al AJSM 1999  Johnson et al AJSM 1999

Arthroscopic Inside-Out Arthroscopic Outside In

 Advantage:  Advantage:  Consistent/More accurate suture  Less neurovascular risk placement  Good for tears in anterior horn  Gold Standard and body

 Disadvantages:  Disadvantage:  Risk of neurovascular injury  Less accurate suture placement

 75-91% survival/healing  65-78% survival/healing  Barrett et al Arthroscopy 1998  Morgan et al AJSM 1991  Rodeo et al AJSM 1999  Johnson et al AJSM 1999  Plasschaert et al AJSM 1998 60

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All-Inside Device Comparisons Arthroscopic All-Inside

 Advantages: Mehta, AJSM, 2009:  FastFix (S&N) vs. Meniscal Cinch  Decreased neurovascular (Arthrex) vs. MaxFire (Biomet) risk  Ultimate load to failure  Minimally Invasive  FastFix 86.1N, Meniscal Cinch  Decreased operative time 85.3N, MaxFire 64.5 N

 Similar success rates  Gap formation (after 100 cylces)  MaxFire: 6.7 mm  Meniscal Cinch: 4.07mm  New Gold Standard?  FastFix: 3.59mm  No significant difference after 500 cycles

More Comparisons…

Barber et al Arthroscopy 2011  Methods  Outside-In Vertical Mattress with both Ethibond and Orthocord • Isolated Bucket Handle Meniscus Tears (19 studies) 2012  All-Inside: Meniscal Cinch, MaxFire, FastFix, Sequent • 2 Level II Studies, 1 Level III (ConMed), OmniSpan • 17% failure inside out vs 19% all inside (No sig diff)  Gap Formation and Load to Failure • Similar Patient reported outcome scores  Results • Complications  No significant differences except MaxFire = bad • Inside out- nerve injury/ irritation • All inside- local soft tissue irritation, swelling, implant migration • Chondral injury issue in older model more rigid devices 64

Treatment Complications Neurovascular Issues

 Excessive meniscectomy  Loss of hoop stress = chondrosis, early OA  Failure to heal repair  May require re-operation for meniscectomy  Neurovascular injury with repair techniques  Foreign material concerns  Suture and Anchors  Chondral injury from intra-articular devices  Soft tissue penetration or entrapments  Collateral ligaments, IT band, skin, etc.  Beware posterior capsular pain with repairs 66

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Caution with All -Inside Cohen et al J Knee Surg 2007 Complications of -Fast Fix device within 3 mm of pop artery in half of specimens Suture

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Meniscal Root Tears Meniscal Root Tears Trans-osseous repair:  Non-op:  Co-morbidities preclude surgery  Partial Meniscectomy:  Partial root avulsions  Avoid completion of the tear LaPrade et al, AJSM March 2014  Root Repair  Suture anchors, trans-osseous  Allaire et al JBJS 2008  TF contact pressures as high as complete medial menisectomy  Repair restores normal mechanics

Respecting the Meniscus Trends 2005-2011 4. Meniscal Transplantation  Candidates:  Abrams et al AJSM 2013  Young, active, healthy individual (<40 yrs)  Overall 11.4% increase in meniscal  Significant knee pain and limited repairs function  Too young for TKA  Increase 48.3% meniscal repairs with  Mechanical meniscal damage  Absent or non-functioning concomitant ACL recons  Failed conservative tx  Normal mechanical alignment  Increased educational emphasis on and stable knee meniscus preservation/repair  Outerbridge I or II changes

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4. Meniscal 4. Meniscal Transplant Transplantation Outcomes  Techniques

 Meniscus +/- Plug  Noyes et al AJSM 2016  72 patients  96% follow-up  Survivorship Analysis (xray, MRI, exam, reoperation)  85% @ 2 yr  77% @ 5 yr  69% @ 7 yr  45% @ 10 yr Example : 41 y.o male 14. 3 years s/p medial  19% @ 15 yr MAT  - Concurrent Osteochondral autograft= lower survival rate

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4. Meniscal Transplant

 Complications:

 Difficulty in locating, harvesting, and distributing size-matched specimens

 Technically difficult surgery Basic Clinical Future  Preservation techniques Science • Presentation • Biologics  Cell viability • Anatomy • Diagnosis • PRP  Biomechanical properties • Biomechanics alteration • Treatment • Stem Cells • Rehabilitation  Graft failure

 Disease transmission

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Rehab - Meniscal Repair Meniscal Repair Rehab

 Day 1-10:  Week 2-4  Progress PROM to 0-135 by  Brace locked at 0 for week 4 ambulation and sleep

 50% WB at week 2  25-50% WB with crutches  Full WB at week 3

 PROM 0-90  SLR, mini-squats, knee extensions 90-0, balance

 SLR, Quad sets  Continue to lock brace at night and for ambulation

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Meniscal Repair Rehab Meniscal Repair Rehab

 Weeks 5-8  Week 9  Discontinue brace  Initiate stair-stepper  Progress to isotonic  Strengthening: strengthening program  Wall squats 0-70  Knee extensions 90-40  Week 12  Lateral step ups  Initiate pool running

 Balance  Bike

Meniscal Repair Rehab

 4 months:  Deep squats  Inline running

Basic Clinical Future  5 months: Science • Presentation • Biologics  Pivoting and cutting • Anatomy • Diagnosis • PRP  Agility drills • Biomechanics • Treatment • Stem Cells • Rehabilitation

 6 months:  Return to activity 82

Biologic Enhancement Biologic Enhancement

 Fibrin Clot  Trephination  Jang 2011  Create vascular channels via removal of core of tissue  95% Healing (41menisci)  Connects avascular area to  Synovial Abrasion peripheral blood supply  Ochi Arthroscopy 2001  Activates chemotactic factors

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Biologic Enhancement Biologic Enhancement

 Vascular channels  Platelet-Rich Plasma  Cook AJSM 2007  Miller (2015):  BioDuct™ (bioabsorbable  Meniscus Repairs with (15) vs. porous implant) w/o PRP (20)  Vascular access channels  No difference in clinical outcome  71% healing of avascular scores, return to work/ sport or tears in canine model reoperation

Stem Cells

 3 Groups (55 pt); Injection 1 wk after parital medial menisecotmy  ex vivo cultured  Ex vivo cultured adult human mesenchymal stem cells, hMSCs (Osiris Therapeutic)  GroupA: Low concentraion (50x10-6) Allogenic MSC  GroupB: High Concentraion (150) All MSC  Group C: Control (Hyaluronic Acid)

 MRI @ 12 months to eval meniscal volume

 MSC group showed 24% of Group A and 6% of Group B reached 15% increase in meniscal volume

 None in group C showed increased meniscal volume (>15%)

 Decreased Pain (VAS) in MSC groups

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