meniscus substitutes for partial meniscectomised patients
TRANSCRIPT
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MENISCAL RECONSTRUCTION –
SUBSTITUTES
DR.RAJAT JANGIRLigament and Joints Clinic
JAIPUR
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• Human meniscus is a highly complex tissue with very specific biological and biomechanical properties, most of which are still not well understood
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REPLACE
• Natural tissues as meniscus allografts, quadriceps tendon, Hoffa fat pad
• Tissue engineering scaffolds, cells, growth factors, or combination
• Prosthetic devices
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Substitution
• By a meniscus allograft has been accepted as a viable therapeutic option for (sub)total meniscectomized knee
• For partial defects is an ongoing field of research and has attracted greater interest in recent years.
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APPROACHES
• Acellular scaffolds- scaffolds allow the human body to regrow tissue
• Accelerate healing, cells and/or growth factors or a combination of these could be added to the acellular scaffold (biomimetic properties)
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• Possible primary cell sources are bone marrow-derived mesenchymal stem cells (BMSC), local progenitor cells or differentiated meniscus and cartilage cells.
• Autologous growth factors in the form of a platelet-rich plasma
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• Isolated recombinant growth factors is still highly controversial and faced with regulatory constraints
• TGF-b1, PDGF bb, IGF-I, FGF2, BMP-6
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PROSTHETIC MENISCUS DEVICE
• Advantage it bypasses the intrinsic variability and time consumption of the biological approach, i.e., the patient does not need to heal but receives a prosthetic implant with specific biomechanical properties
• Difficulties in designing and manufacturing such implants is the biomechanical behaviour of the meniscus and its fixation to the capsule and bone.
• Fixation mode that ensures the stability of the meniscus.
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Menaflex (TM) Collagen Meniscus Implant
• Tissue engineering techniques and collagen matrix technology
• Supports ingrowth of new tissue and eventual regeneration of the lost meniscus
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Hypothesis
• Meniscus has the intrinsic ability to regenerate, provided that the biological environment is suitable for regeneration
• Tissue-engineered extracellular matrix scaffold can be used to support and guide meniscus regeneration
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7 Months-solid structure due to the new tissue formation
18 Months: new collagen fibrils are
smaller and more uniform than those in the
original implant
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5 years: Compact and Dense
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EVIDANCE
• Animal-Human Studies• Reconstruct irreparable or lost meniscus tissue
in patients with a meniscus injury and improve the functional outcomes of its recipients
• Rodkey WG, et al (2008)-Comparison of the collagen meniscus implant to partial meniscectomy: a prospective RCT. JBJS Am 90:1413–1426 LEVEL 1
• Steadman JR, Rodkey WG (2005) Tissue-engineered colla- gen meniscus implants: 5- to 6-year feasibility study results. Arthroscopy 21:515–525
• Zaffagnini S, Giordano G, Vascellari A et al (2007) Arthroscopic collagen meniscus implant results at 6 to 8 years follow up. Knee Surg Sports Traumatol Arthrosc 15:175–183
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Technique
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Fixation
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CMI
• Newly formed meniscus was observed in over two thirds of cases.
• Selecting the suitable candidate stable and well-alignedTechnically, a secure intraarticular attachment
is probably the most critical factor (FIXATION)
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ActifitPolyurethane Meniscus Implant
• Highly interconnected porous synthetic material enabling tissue ingrowth
• Aliphatic polyurethane,
• transformation into meniscus-like tissue takes place as the implant slowly degrades
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two configurations, medial and lateral
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• Two components, polyester (soft) and polyurethane (stiff)
• Soft segment 80% is a biodegradable polyester
• Semidegradable, stiff segments 20% are of uniform size and provide mechanical strength.
• Degradation of SOFT segments is expected to take 4–6 years.
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PREREQUISITES
• Intact meniscal rim and sufficient tissue present both in the anterior and the posterior horns to allow for secure fixation.
• Well-aligned stable knee, • BMI) below 35 • Free from systemic disease or infection • Cartilage damage (ICRS)<Grade 3
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• Importantly, no safety issues related to the scaffold, including cartilage damage or inflammatory reactions
• Performance data showed successful tissue ingrowth. • In conclusion, the 12-month clinical results are
comparable to those reported following partial meniscectomy; however, the ActifitTM scaffold has the added benefit of promoting meniscal tissue regeneration.
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EVIDANCE• Welsing RT, (2008) Effect on tissue dif- ferentiation and
articular cartilage degradation of a polymer meniscus implant: a 2-year follow-up study in dogs. AJSM 36:1978–1989
• Tienen TG, Heijkants RG, de Groot JH et al (2006) Replacement of the knee meniscus by a porous polymer implant: a study in dogs. AJSM 34:64–71
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CONCLUSION,
• Different approaches currently under investigation.
• The potential patient- specific variability and time consumption are a major challenge for the biological tissue engineer,
• While for the prosthetic approach the perfect material still has to be developed.
• Maybe a combination of a prosthetic core with a bioactive surface would be the ideal implant