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 --joint filler (incongruous condyles) -2.5 greater contact area when Medial Meniscus Lateral Meniscus mensicus present Secondary stabilizer to AP 200-300% increase in -prevent capsular/ translation in ACL deficient lateral compartment synovial impingement knee contact stresses when (more capsular attachment) removed (convex lateral -joint lubrication/ synovial plateau) distribution Follows tibia- 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
Palpation 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
Arthroscopy 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
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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%
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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 cartilage changes
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4. Meniscal 4. Meniscal Transplant Transplantation Outcomes Techniques
Meniscus +/- Bone 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
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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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