meniscal substitutes scaffold and transplant...clinical evidence correct indications : cronic pain...

MENISCAL SUBSTITUTES

SCAFFOLD AND TRANSPLANT

G.C. COARI

SAVE THE MENISCUS

“ MENISCUS DEFICIENCY IS THE #1 PROBLEM IN ORTHOPAEDICS TODAY”.

F. Noyes, M.D.

-All clinics see many patients with irreparable meniscus lesions

-10 years later these patiens are candidates for HTOs,cartilage transfers and other

salvage procedures

-Finally, most of these patients ultimately require a knee replacement.

WHICH SOLUTION ?

Female , 20 years old

Two years before lateral total meniscectomy for complex discoid lesion

Pain and swelling in activity daily living

MENISCAL ALLOGRAFT

TRANSPLANTATION

RATIONALE OF THE MENISCUS

TRANSPLANT

Relieve pain and swelling

Restore normal anatomy

Improve knee stability

Prevent arthrosis progression ?

HIGH PERCENTAGE OF SYMPTOMS AND ARTICULAR

DEGENERATION AFTER MENISCECTOMY, ALSO

SELECTIVE

Pain and swelling in ADL

Under 50 years old

Limited chondral lesions

No ligament insufficency

No coronal malalignment

POST MENISCECTOMY SYNDROME

PRIMARY INDICATION

ACL RECONSTRUCTION , OSTEOTOMY or

TREATMENT OF FOCAL CHONDRAL DEFECTS

CONCOMITANTLY WITH MAT

SECONDARY INDICATION

INDICATION AS PREVENTION

THE RISKS OVERCOME THE

BENEFITS

GRAFT

Non irradiated fresh-frozen

Gender

Age

Weight

SIZING/MATCHING MAT is side , compartment and size specific

A consistent relationship exist between bony landmarks and meniscal size

SEVERAL TECHNIQUES FOR MAT

SURGICAL PROCEDURE

BONY FIXATION

SUTURES FIXATION

BONY FIXATION WITH “BONE BRIDGE” FOR LATERAL

SEPARATE BONE PLUGS FOR MEDIAL

2004 - 2016

OUR PREFERENCE

SUTURES FIXATION TECHNIQUE

ALL - INSIDE

IN - OUT

OUT - IN

62 MAT in 60 pt.

July 2003 – Setptember 2016

Clinical Evaluation on 55 pt.

Lysholm Knee Score

K.O.O.S.

IKDC

X ray , MRI

55 cases

- Lateral meniscus 44 , medial 13

- Men 20 Female 35

- average age 34 (range 21-48)

- Bone fixation 4 - Sutures fixation 51

FU 15 – 1.5 y.

FU mean 80 m. (18 – 138)

CLINICAL RESULTS

Concomitant procedures

ACL REC 4

ACL REVISION 1

A.C.I. 5

HTO 2

0%

5%

10%

15%

20%

25%

30%

35%

A normale B quasi

normale

C anormale D molto

anormale

0 0

37

18

25

20

3 7

Pre

Post

IKDC

IKDC SUBJECTIVE

LYSHOLM

K.O.O.S.

MEAN SCORE POST-OP PRE-OP

SYMPTOMS

PAIN

ACTIVITY DAILY

LIVING

SPORTS

QUALITY OF LIFE

56 75

57

35

70

83

38 59

91

53

It’s difficult to draw conclusions regarding MAT

- Different procedures

- Many studies with concomitant surgical procedures and different

chondral lesions

- 70-80 % good and excellent results with F.U. > 5- 10 y

SHELTON 95

GOBLE 98

CARTER 99

RATH 2000

WIRTH 2000

RATH 2001

NOYES 2005

HARNER 2006

COLE 2006 -2008

VERDONK 2006

LA PRADE 2011

KIM 2012

ZAFFAGNINI 2012

COARI –TRIPODO 2012

ROUMAZILLE 2013

MARCACCI 2014

YOON 2014

MC CORMICK 2014

LITERATURE

CLINICAL EVIDENCE

MAT IS becoming a shared surgery option

Pain and swelling relief is the main benefit

The overall failures can be estimated at 10 to 20% at 5 years

and 20 % at 10 y.

Clinical results are connected to chondral damage

No differences between bony or sutures fixation

No correlation between MRI extrusion and clinical results,

but extruded graft could be an indicator of failure

Bioresorbable collagen matrix

97,5% type -I collagen of bovine

2,5% glucosaminoglycans and ialuronic acid

MENISCAL SCAFFOLDS

Biodegradable , porous scaffold,

composed of polyuretane (20%) e

polycaprolactone(80%)

C.M.I. ACTIFIT

The scaffold is bioresorbable and created to serve as a

template for the in-growth of new meniscal tissue

- Pt. who has lost greater than > 50% of the meniscus

- Intact anterior and posterior horn attachments

- Intact rim of the meniscus

SURGICAL INDICATIONS

Most studies reported satisfactory clinical outcome at 10 y.

Second-look arthroscopy: evidence of new tissue ingrowth with

meniscus like cells and uniform fibrocartilage matrix

MRI studies showed increased signal intensity early that appared

to diminish with longer –term fu

STONE 1997

STEADMAN 2005

MONLIAU 2011

BULGHERONI 2010

ZAFFAGNINI 2011

RODKEY 2008

ZUIDEMA 2009

EFE 2012

DE CONINCK 2013

VERDONK 2012

ACTIFIT

C.M.I.

LITERATURE

CLINICAL EVIDENCE

Correct indications : cronic pain for patients who has lost

graeter than 50 % of the meniscus , but still has an intact

rim and anterior and posterior horn attachments

The primary goal is to restore a normal volume of meniscus

tissue

The scaffold prevent further degenerative changes

The scaffold provide long-term patient outcomes when

compared with partial meniscetomy

In acute cases no difference between meniscetomy and

scaffold

FUTURE DIRECTION A variety of different technologies are being studied for the purpose of replacing

lost meniscal tissue or entire meniscus

- Hydrogels , biphasic biocampatible materials

- Mesechymal stem cell – seeded scaffold

- Syntetic meniscus

PCU (polycarbonate-uretane matrix ) reinforced with high – modulus

UHMWPE fibers (ultrahigh molecular weight polietilene)

NUSURFACE

Could it occupy the free space between

scaffold , meniscal allograft

transplantation and uni replacement ?

THANK YOU

“Je fait tous les journes des progrès ,

l’essential est la” P. Cèzanne