chris o’grady, m 2-17_ogrady.pdf · knee (more capsular attachment) follows tibia- more likely to...

3/6/2017

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Chris O’Grady, M.D

Update on Treatment of Meniscal

Injuries Basic Science

• Anatomy• Biomechanics

Clinical

• Presentation• Diagnosis

• Treatment• Rehabilitation

Future

• Biologics• PRP

• Stem Cells

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Function

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--joint filler (incongruous condyles)

-2.5 greater contact area when mensicus present

-prevent capsular/ synovial impingement

-joint lubrication/ synovial distribution

-load (40-60% of standing load-stability (esp. rotatory)

Function

� Medial Meniscus

� Secondary stabilizer to AP

translation in ACL deficient knee

� (more capsular attachment)

� Follows tibia- more likely to be torn with rotatory force

� Lateral Meniscus

� 200-300% increase in

lateral compartment contact stresses when removed (convex lateral

plateau)

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Radin et al., CORR, 1984

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- Load transmission

increases in flexion vs ext

Fukubayashi et al. 1980

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Anatomy

� Histo: Fibrocartilage

� Composition

� Water 65%-75%

� Organic matter 25%-35%

� 75% Collagen

� Type I – 90%

� Types II, III,IV, V, VI, XVIII

� 25% Other

� Proteoglycans, DNA, Elastin

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Anatomy

� Triangular cross section

� Provide structural integrity

� � “concavity” of the

articulation

� Dissipates forces/friction across

medial/lateral compartments

� Axial Compression �Horizontal hoop stress

� Creates shear forces

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AnatomyStructure

� Mesh network:

� Arranged obliquely, radially, and vertically

� Prevents shear

� Bundles:

� Radial

� Located at surface and midsubtance

� Prevent longitudinal tears

� Circumferential

� Disperses compressive loads (hoops around wooden barrel)

Anatomy

Medial Meniscus

� C-Shaped structure

� Less mobile

� Firmly attached to capsule

� Deep MCL at mid body

� Posterior fibers of anterior horn merge with transverse ligament

� Periphery of meniscus attached to capsule through coronary ligaments

Medial Meniscus

� Wider in diameter

than the lateral

meniscus

� 9-10 mm wide

� 3-5 mm thick

� Covers 51-74% of condyle

Lateral Meniscus

� Semi-circular in shape

� More mobility

� Less peripheral attachments

� Popliteal Hiatus

� Anterior and posterior horns attach closer to each other than medial meniscus

� Anterior horn attaches adjacent to ACL

� Posterior horn attaches behind inter-condylar eminence

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Lateral Meniscus� Covers more tibia

� 75-93% of condyle

� 12-13 mm wide

� 3-5 mm thick

Meniscofemoral ligaments

� Humphrey & Wrisberg

� Run from posterior horn of lateral meniscus to medial femoral condyle

� Major Role

� Stabilize PH of Lateral Meniscus

� Minor role

� Stabilizing posterior tibialtranslation with compromised PCL

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Humphrey – Sag MRI

� Anterior to PCL

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Discoid Meniscus

� Incidence of 3.5-5%

� Usually lateral, but 20%

bilateral

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Discoid Meniscus

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

Watanabe Classification

Blood Supply

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PeriMeniscal Capillary Pleux

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Blood Supply

� 50-100% of meniscus vascular at birth

� 9 months: Inner 1/3rd 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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Arnoczky et al AJSM 1982

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Vascularity Zones

� Red-Red� Fully vascular

� Excellent healing potential

� Red-White� Border of vascular supply

� Good healing potential

� White-White� Relatively avascular

� Poor healing prognosis

Cannon et al,

Basic Science


Clinical



Future


• Stem Cells

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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

� Older � Degenerative (MMT)

� 1/3 occur with ACL tear� Acute: LMT

� Chronic: MMT

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Basic Science


Clinical



Future


• Stem Cells

24

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History

� Mechanism� Twisting, change in direction, or hyper-flexion

injury

� Feeling a “pop”� Acute pain or swelling� Slow-forming effusion� Locking/catching sensation� Degenerative tears(>40) often

more atraumatic with a chronic history

� Postmenisectomy syndrome –“toothache pain” after menisectomy

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Physical Exam

� Inspection

� Mild to moderate joint effusion

� Usually no ecchymosis

� Limb alignment

� ROM

� Typically normal� However, longitudinal bucket handle tears may block full

extension

� Stability

� Associated ligamentous injury

Physical Exam

� Palpation

� Joint line tenderness

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McMurray British Journal of Surgery 1942

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MMT: 90deg, valgus, ER, ext knee

+ click

Sen:59%

Spec: 93-97%

Apley Grind Test JBJS 1947

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Prone, 90deg

Stabilize thigh

Compress joint, ER

Sen: 41%

Spec: 86-93%

Thessaly Maneuver JBJS 2005

� 20 deg flex (IR, ER)

� Harrison, Clin J Sport

Med, 2009:

� 66 patients with +Thessaly, 65 had arthroscopic

findings of meniscal tear

� Sen 90%

� Spec 97.7%

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Ege’s Test

� Squat with full hip ER/ IR

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Imaging

� 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

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Widening

Squaring

Cupping

Hypoplastic

Imaging

� MRI:

� Diagnostic procedure of choice

� 95% accuracy

� High NPV

� Grading system 0, I, II, III

� Grade III consistent with complete tear

� Arthroscopy still gold standard

� Look for condylar edema

� (increased contact pressure on condyle when meniscus torn)

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MRI Grading

� 0: normal

� 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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Discoid Meniscus – Bow Tie Sign

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3 or more 5mm cuts with continuity of meniscus

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MRI

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Complex tear “Double PCL” – Bucket Handle

Arthrography

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Classification of Tears

Common Meniscal

Tears

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Radial Tear

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AANA Advanced Arthroscopy: The Knee

Horizontal Tear


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Bucket-Handle Tear

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Meniscal Root Tears

� Milder symptoms

� Joint line pain

� Less mechanical symptoms (only 9-14%)

� Posterior knee pain with deep flexion

� McMurray + 57%

� Effusion + 14%

Lee et al Arthroscopy 2009

LaPrade et al, AJSM March 2014

Ghost signExtruded meniscus

Root Tears

-3mm extrusion on mid coronal

-condylar edema

Basic Science


Clinical



Future


• Stem Cells

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Treatment Options

� Depends on

� Symptoms

� Affect on ADLs, Work, Sports

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Nonsurgical Options

� RICE

� Wt Loss

� Bracing (unloader)

� Injections

� Physical Therapy

� ROM

� Strengthening

� NSAIDs

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Surgical Options1. Leave alone

� Promote healing only

2. Meniscectomy� � surgical morbidity and

improves function

� Stable contoured rim

� Preserve as much tissue as possible

� Long-term risks?

3. Meniscal repair� Ideal treatment for the ideal

situation

� Vertical mattress sutures gold standard

4. Meniscal transplant� Symptomatic patient too young

for a TKA

1. Leave alone…

� Stable partial tears

� Stable longitudinal tears

� < 10 mm length

� < 3-5 mm displacement

� Do not displace into notch

� Do not touch femoral condyle

� Degenerative tears with significant OA

� Short radial tears: < 3 mm in length

� Leave tourniquet down to assess bleeding:

� Rasping

� Trephination

� Marrow stimulation, PRP, etc.� Enhance biologic healing response

� E.g. notch microfx

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2. Meniscectomy Indications

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2. Meniscectomy

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2. Meniscectomy Technique

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3. Repair Options

OpenInside-

Out

Outside-In

All-Inside

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Open Meniscal Repair

� Trans-capsular approach with capsule and synovium opened for visualization

� Indications:

� Tight compartments

� Peripheral tears in posterior horns

� Disadvantages:

� Larger approach

� Greater tissue trauma

Open Meniscal Repair

� Results� 80-90% survival rate after 13

years

� DeHaven Clin Sports Med1990

� Rockborn and Gillquist JBJS Br 2000

� Muellner AJSM 1999

� MRI data included, but unreliable method to assess healing

Arthroscopic Inside-Out

� Advantage:

� Consistent/More accurate suture placement

� Gold Standard

� Disadvantages:

� Risk of neurovascular injury

� 75-91% survival/healing

� Barrett et al Arthroscopy 1998

� Johnson et al AJSM 1999


� Advantage:


� Gold Standard

� Disadvantages:






� Advantage:


� Gold Standard

� Disadvantages:





Arthroscopic Outside In

� Advantage: � Less neurovascular risk

� Good for tears in anterior horn and body

� Disadvantage:� Less accurate suture

placement

� 65-78% survival/healing� Morgan et al AJSM 1991

� Rodeo et al AJSM 1999

� Plasschaert et al AJSM 199860

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Arthroscopic All-Inside

� Advantages:

� Decreased neurovascular

risk

� Minimally Invasive

� Decreased operative time

� Similar success rates

� New Gold Standard?

All-Inside Device Comparisons

Mehta, AJSM, 2009:� FastFix (S&N) vs. Meniscal Cinch

(Arthrex) vs. MaxFire (Biomet)

� Ultimate load to failure

� FastFix 86.1N, Meniscal Cinch 85.3N, MaxFire 64.5 N

� Gap formation (after 100 cylces)

� MaxFire: 6.7 mm

� Meniscal Cinch: 4.07mm

� 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

� All-Inside: Meniscal Cinch, MaxFire, FastFix, Sequent (ConMed), OmniSpan

� Gap Formation and Load to Failure

� Results

� No significant differences except MaxFire = bad

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• Isolated Bucket Handle Meniscus Tears (19 studies) 2012

• 2 Level II Studies, 1 Level III

• 17% failure inside out vs 19% all inside (No sig diff)

• Similar Patient reported outcome scores

• Complications

• Inside out- nerve injury/ irritation• All inside- local soft tissue irritation, swelling, implant migration

• Chondral injury issue in older model more rigid devices

Treatment Complications

� 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

Neurovascular Issues

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Caution with All-InsideCohen et al J Knee Surg 2007

-Fast Fix device within 3 mm of pop artery in half of specimens

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Complications of Suture

Meniscal Root Tears

� Non-op: � Co-morbidities preclude surgery

� Partial Meniscectomy:� Partial root avulsions

� Avoid completion of the tear� Root Repair

� Suture anchors, trans-osseous� Allaire et al JBJS 2008

� TF contact pressures as high as complete medial menisectomy

� Repair restores normal mechanics

Meniscal Root TearsTrans-osseous repair:

LaPrade et al, AJSM March 2014

Respecting the MeniscusTrends 2005-2011

� Abrams et al AJSM 2013

� Overall 11.4% increase in meniscal repairs

� Increase 48.3% meniscal repairs with

concomitant ACL recons

� Increased educational emphasis on meniscus preservation/repair

4. Meniscal Transplantation

� Candidates:

� Young, active, healthy individual (<40 yrs)

� Significant knee pain and limited function

� Too young for TKA

� Mechanical meniscal damage

� Absent or non-functioning

� Failed conservative tx

� Normal mechanical alignment and stable knee

� Outerbridge I or II cartilage changes

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4. Meniscal Transplantation

� Techniques

� Meniscus +/- Bone Plug

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4. Meniscal TransplantOutcomes

� 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

� 19% @ 15 yr

� - Concurrent Osteochondral autograft=

lower survival rate

� -Conclusion: MAT eventually fail and is

Example : 41 y.o male 14. 3 years s/p medial

MAT

4. Meniscal Transplant

� Complications:

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

� Technically difficult surgery

� Preservation techniques� Cell viability

� Biomechanical properties alteration

� Graft failure

� Disease transmission

Basic Science

• Anatomy

• Biomechanics

Clinical

• Presentation

• Diagnosis

• Treatment

• Rehabilitation

Future

• Biologics

• PRP

• Stem Cells

76

Rehab - Meniscal Repair

� Day 1-10:

� Brace locked at 0 for

ambulation and sleep

� 25-50% WB with crutches

� PROM 0-90

� SLR, Quad sets

Meniscal Repair Rehab

� Week 2-4

� Progress PROM to 0-135 by week 4

� 50% WB at week 2

� Full WB at week 3

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

� Continue to lock brace at night and for ambulation

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� Weeks 5-8

� Discontinue brace

� Strengthening:

� Wall squats 0-70

� Knee extensions 90-40

� Lateral step ups

� Balance

� Bike


� Week 9

� Initiate stair-stepper

� Progress to isotonic strengthening program

� Week 12

� Initiate pool running


� 4 months:

� Deep squats

� Inline running

� 5 months:

� Pivoting and cutting

� Agility drills

� 6 months:

� Return to activity

Basic Science


Clinical



Future


• Stem Cells

82

Biologic Enhancement

� Fibrin Clot� Jang 2011

� 95% Healing (41menisci)

� Synovial Abrasion� Ochi Arthroscopy 2001

� Activates chemotactic factors


� Trephination� Create vascular channels via

removal of core of tissue

� Connects avascular area to peripheral blood supply

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� Vascular channels� Cook AJSM 2007

� BioDuct™ (bioabsorbable porous implant)� Vascular access channels

� 71% healing of avascular tears in canine model


� Platelet-Rich Plasma

� Miller (2015):� Meniscus Repairs with (15) vs.

w/o PRP (20)

� No difference in clinical outcome scores, return to work/ sport or 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

chris o’grady, m 2-17_ogrady.pdf · knee (more capsular attachment) follows tibia- more likely to...

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