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MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT G.C. COARI

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Page 1: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

MENISCAL SUBSTITUTES

SCAFFOLD AND TRANSPLANT

G.C. COARI

Page 2: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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.

Page 3: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 4: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 5: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

Pain and swelling in ADL

Under 50 years old

Limited chondral lesions

No ligament insufficency

No coronal malalignment

POST MENISCECTOMY SYNDROME

PRIMARY INDICATION

Page 6: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

ACL RECONSTRUCTION , OSTEOTOMY or

TREATMENT OF FOCAL CHONDRAL DEFECTS

CONCOMITANTLY WITH MAT

SECONDARY INDICATION

Page 7: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

INDICATION AS PREVENTION

THE RISKS OVERCOME THE

BENEFITS

Page 8: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 9: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

SEVERAL TECHNIQUES FOR MAT

SURGICAL PROCEDURE

BONY FIXATION

SUTURES FIXATION

Page 10: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

BONY FIXATION WITH “BONE BRIDGE” FOR LATERAL

Page 11: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 12: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

SEPARATE BONE PLUGS FOR MEDIAL

Page 13: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

2004 - 2016

OUR PREFERENCE

SUTURES FIXATION TECHNIQUE

Page 14: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 15: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 16: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 17: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 18: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 19: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 20: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

ALL - INSIDE

Page 21: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

IN - OUT

Page 22: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

OUT - IN

Page 23: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 24: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 25: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 26: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 27: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 28: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

IKDC SUBJECTIVE

Page 29: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

LYSHOLM

Page 30: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 31: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 32: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 33: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 34: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

- Intact anterior and posterior horn attachments

- Intact rim of the meniscus

SURGICAL INDICATIONS

Page 35: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 36: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 37: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 38: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

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

Page 39: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact
Page 40: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

Could it occupy the free space between

scaffold , meniscal allograft

transplantation and uni replacement ?

Page 41: MENISCAL SUBSTITUTES SCAFFOLD AND TRANSPLANT...CLINICAL EVIDENCE Correct indications : cronic pain for patients who has lost graeter than 50 % of the meniscus , but still has an intact

THANK YOU

“Je fait tous les journes des progrès ,

l’essential est la” P. Cèzanne


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