JOÃO ESPREGUEIRA-MENDES MD, PhD

A. Monteiro, R. Rocha, N. Sevivas, JP. Araújo, N. Loureiro, I. Lopes, A. Sarmento, N. Ferreira

L. Silva, R. Pereira, R. Andrade, C. Saavedra, R. Bastos, B. Pereira, A. Costa, A.Neto,

M. Oliveira, RA Sousa, R.L. Reis and Niek van Dijk

Chairman of Clínica do Dragão - Espregueira-Mendes Sports Centre – FIFA Medical Centre of Excellence

Chairman and Professor of the Orthopaedic Department - Minho University

Treasurer and Chairman of the Publication Committee of ISAKOS

Board Member of the Patellofemoral Foundation

President of the European Society of Knee Surgery, Sports Trauma and Arthroscopy – ESSKA 2012-2014

PORTO, PORTUGAL

MENISCECTOMY

HOW MUCH IS TOO MUCH?

Clínica do Dragão – Espregueira-Mendes Sports Centre

FC Porto Stadium – Porto - Portugal

Official

Teaching Centre

PRESERVE THE FUTURE!

Malalignment, loss of meniscal tissue, cartilage defects and joint instability all seem to be strongly correlated to early OA

Meniscal lesion (ML) is one of the most common pathologies leading to Orthopaedic

Surgery throughout the world;

Over 450 000 arthroscopic procedures/year for ML in the USA

Garrett WE, Jr. et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II,

certification examination case mix. J Bone Joint Surg Am 2006;88:660-7.

COMPOSITION

1. Cells type

• Fibroblast-like

• Fibrochondrocytes

• Peripheric/multipotent cells?

2. ECM

• Water 70% total weight

• Collagen I, II, III, IV e VI (60-70%

dry weight)

• Proteoglycans (1-2% dry weight;

chondroitin-sulphate)

MENISCUS FUNCTIONS

1. Load transmission

2. Impact absorption – viscoelasticity:

“lower compressive stiffness and

permeability comparing to cartilage”

3. Lubrification and nutrition

4. Stability - increase joint surface

congruency

5. Proprioception

HUMAN FRESH MENISCUS TISSUE

CHARACTERIZATION

0,1 1 100,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

1,6

1,8

2,0

2,2

E' (

MP

a)

Frequência (Hz)

Menisco externo anterior

Menisco interno anterior

Menisco externo médio

Menisco interno médio

Menisco externo posterior

Menisco interno posterior

0,1 1 100,00

0,05

0,10

0,15

0,20

0,25

0,30

0,35

0,40

tan

Frequência (Hz)

Menisco externo anterior

Menisco interno anterior

Menisco externo médio

Menisco interno médio

Menisco externo posterior

Menisco interno posterior

Fresh medial meniscus is stiffer than lateral (higher values of E’).

Anterior segments present significantly lower cellularity & higher damping properties.

Cyclic loads influence the viscoelastic behaviour of menisci. By increasing the frequency leads to

an increase in stiffness.

• Conclusion: Menisci are not uniformed structures.

• Anterior segments have lower cellularity and higher damping.

• Cyclic loads influence viscoelastic characteristics. • Future TE therapies should consider segmental

architecture, cellularity and biomechanics of fresh tissue.

W-WR-WR-RW-WR-WR-R

100 µm100 µm100 µm

W-WR-WR-R

BIOMECHANICAL AND CELLULAR SEGMENTAL

CHARACTERIZATION OF HUMAN MENISCUS:

BUILDING THE BASIS FOR TISSUE ENGINEERING

THERAPIES

• Convex lateral tibial plateau vs concave medial plateau

• Lateral meniscus higher load transfer

• More mobile lateral meniscus

BIOMECHANICS

• The intact meniscus converts axial forces into radial strain

• The meniscus is subjected to compressive, tensile and shear stresses (A)

• When a load is applied, the meniscus is displaced away from the centre, resulting in tensile stress because of the anterior and posterior horn tibial attachments (B)

• Medial meniscus is a secondary restrictor of tibial anterior translation

BIOMECHANICS

• Menisci occupy 60% of the contact area between the tibial and femoral cartilage surfaces and transmit

> 50% of joint compression forces

• Meniscectomy – removal of 15% to 34% of a meniscus increases contact pressures by 350%

• Total lateral meniscectomy results in a 45/50% decrease in the total contact area and a 235% to 335%

increase in the peak local contact pressure

Removal of the medial meniscus can result in a 50% to 70% reduction in femoral condyle cartilage contact area.

BIOMECHANICS

• 3 Groups: 22%±9% in the first, 46%±11% in the second and 100% in the third

• Effect of meniscectomies on AP position and laxity of MFC

• 22% resection no difference with the intact knee

• 46% & 100% resection: sig. difference on stability comp. intact knees (P=.024) and

knees after resection (P=.037)

BIOMECHANICS

MRI evidence of a concomitant injury to the Mmeniscus

or Lmeniscus is associated with increased knee

rotatory laxity in patients with an ACL injury.

MENISCECTOMY & KNEE STABILITY

Partial meniscectomy in the ACL-deficient knee

significantly increased anterior tibial translation

(p = 0.01).

On the other hand, meniscal repair reduces knee

instability.

MENISCAL EXTRUSION IS EQUIVALENT TO LARGE MENISCECTOMY

• Mainly medial and lateral geniculate arteries

• Penetration 10-30% for medial meniscus and 10-25% for lateral

• Determines healing potential

• Different in children

• 3 zones: red-red; red-white and white-white

VASCULARIZATION

Hauger O et al. Radiology 2000;217:193-200Hauger O et al. Radiology 2000;217:193-200

W-W R-W R-R

Human meniscus structure Acelular silk-fibroin scaffold for meniscus

regeneration

(Blue zone) Silk scaff + meniscocytes + GG-MA

(Red zone) Silk scaff + MSCs + GG

ADVANCED TERM STRATEGY FOR MENISCUS

2012- Oliveira JM, Pereira H, Yan LP, Silva-Correia J, Oliveira AL, Espregueira-Mendes J, Reis RL,

Scaffold that enables segmental vascularization for the engineering of complex tissues and methods of making the same, pt provisional patent (number 20121000015781).

DIAGNOSTIC – CLINICS AND MRI

Cornerstone: careful history taking and assessment of subjective symptoms

1- History: common symptoms of meniscal injuries include pain along the joint line, swelling, effusions, stiffness,

cracking and locking or catching

2 - Physical examination: McMurray and Apley tests and joint line palpation

3 - Imaging gold standard: MRI (accuracy of 64-95%, sensitivity of 88% and specificity of 57%)

• Degenerative or non degenerative? X-Ray in weight-bearing

• Stable or unstable?

• ACL-stable or ACL-unstable knee?

Porto Knee Testing Device

PKTD show greater rotatory instability in knees with partial meniscectomy (up to 30%) – on going

PORTO KNEE TESTING DEVICE - PKTD

ROTATORY INSTABILITY MEASUREMENTS

ER IR

IN DAILY PRACTICE THERE IS A GAP BETWEEN: WHAT

SHOULD BE DONE... & WHAT IS ACTUALLY DONE...

ESSKA Instructional Course Lecture Book: Amsterdam 2014 Stefano Zaffagnini, Roland Becker, Gino M.M.J. Kerkhoffs, João Espregueira-Mendes, C. Niek van Dijk

We could repair but… price… high

level athletes… reinjury rate…

Meniscal repair gives better long-term

outcomes and higher reop rates than

partial meniscectomy

Lmeniscectomy has higher reop rates

than Mmeniscectomy

Mmeniscectomy has lower reop rates

than Mm repair

Lm repair better than Mm repair

“There has been an increased number of isolated meniscus repairs being performed in the US over

the past 7 years without a concomitant increase in meniscectomies over the same time frame. These

data suggest that meniscus repairs are increasing.”

387 845 meniscectomies (78%)

23 640 meniscus repairs (5%)

84 927 ACLR + repair or meniscectomy (17%)

There is still an ongoing debate in which concerns the best approach on meniscal surgery:

Traumatic

Meniscal repair

Meniscectomy

Degenerative

Meniscectomy

Conservative treatment

Large abuse of meniscectomy in degenerative tears

How much resect?

Large use of meniscectomy

Slow increase in meniscal repair

2012 French NHS only 12% repair

(20% possible to repair)

MENISCUS

RADIAL TEARS

Resection of the torned portion of the meniscus (avascular zone) – smooth meniscus

Repair (age, zone and quality of tissue)

“Leave it alone” (more lateral meniscus + ACLR)

HOW MUCH RESECT?

“LEAVE IT ALONE”

Meniscus tears left in situ at the time of ACLR, did not require reoperation at a minimum 6-year FU: 97.8%

for lateral and 94.4% for medial tears.

These findings re-emphasize the low reoperation rate after the non-treatment of small, peripheral lateral

meniscus tears while nothing less predictable results for medial meniscus tears left without treatment.

2015

Untreated meniscus lesions during ACLR demonstrated low rates of failures for LM (between 0% and

7% if posterior to the popliteus tendon), whereas 12–15% of untreated MM tears underwent

reoperation.

FLAP/PARROTS TEARS

Resection of the torned portion of the meniscus (avascular zone)

Repair (young age, zone and quality of tissue)

HOW MUCH RESECT?

HORIZONTAL TEARS AND CYSTS

Preserve as most meniscus as possible

Identify and resect the instable layer

Suture the two layers if possible

Horizontal tears very often associated with meniscal cysts

Debride and empty the cyst

Open cyst removal

HOW MUCH RESECT?

COMPLEX TEARS

Take time in planning

Preserve as most meniscus as possible

Identify and ressect the instable meniscus

Associate debridment and suture

HOW MUCH RESECT?

PERIPHERAL, LONGITUDINAL AND BUCKET-HANDLE

TEARS

Careful evaluation

Leave alone peripheral lesions with <1cm

Test reducibility of the bucket-handle tear

Suture whenever possible (RR & RW)

Increasing meniscal laxity without tear

may indicate root lesion (70º

arthroscope)

Lateral posterior root tears are often

associated with ACL injuries

Acute medial root tears are often

associated with cartilage and

multiligamentous knee injury (MCL)

ROOT TEARS

MENISCUS SYNOVIAL LESION – THE HIDDEN LESION

Often missed in MRI and through a standard anterior exploration (suspicion by medial

meniscus hypermobility)

Associated with ACL lesions (20%?)

Seen from the PM accessory portal or AL portal with the scope deep into the notch

Hidden under a membrane-like tissue and discover after minimal debridement

Type of tear is related with the type of discoid meniscus (Han et al., KSSTA, 2002)

Remove only the catching or impinging meniscus

Careful trimming and contouring of the remaining rim

Partial meniscectomy or partial meniscectomy + repair

Preserve and verify stability of the capsular rim (re-rupture)

DISCOID MENISCUS

HOW MUCH RESECT?

Conservative treatment should be the first option

Too many surgical indications

Favourable surgical indication: traumatic event and locking symptoms

In meniscal degenerative tears without knee OA, meniscectomy was no better than sham operation

DEGENERATIVE MENISCAL TEARS

HOW MUCH RESECT?

MENISCAL LESIONS IN CHILDREN

Good blood supply and better healing

Knee abusers!

Stress the indications for repair

Nevertheless: 293 patients and 324 menisci (129 primary repairs, 149 primary partial

meniscectomies and 46 discoid saucerizations)

87% success rate

At 40 months post-op, 13% of all menisci required revision

Bucket-handle tears had the highest re-tear rate

2016

• Neyret et al (1999) – at 10 Y FU after ACLR 20% incidence of OA in knees with partial

meniscectomy and 30% in knees with total meniscectomy;

• Dejour et al (1999) – at + than 10 Y FU only 7,6% in knees with ACLR and intact menisci

against 42% in ACLR+partial or total meniscectomy;

• Shelbourne et al (2000) – at 8 Y FU after ACLR 9% of OA in knees with partial lateral

meniscectomy, 23% after partial medial meniscectomy and 25% after both;

• Petty et al (2011) - Only meniscectomy – radiographic signs are significant 8 to 16 Y

FU after partial meniscectomy; Subtotal meniscectomy worse results.

• Niek van Dijk (2016) – 10-fold increase in OA compared to controls after meniscectomy.

MENISCAL REPAIR WITH CONCOMITANT ACLR

Association of ACLR to the meniscal repair may augment the repair success.

Concomitant meniscal repair with ACLR results in a 86% success rate at 6-year follow-up.

2014

ACLR + Meniscal repair = less 10% (24% vs 14%) on reop for both LM & and MM repairs than isolated meniscal repair.

• Partial medial meniscectomy

may lead to an increase in the

severity and size of cartilage

lesions;

• + cartilage wear in the medial

compartment.

• However, all compartments of

the knee were affected.

HOW MUCH?

After + 10 Y FU

After + 10 Y FU

HOW MUCH - € - ?

STATE OF THE ART ON MENISCUS TERM

HOW MUCH €?

TAILORED BIOPLOTTER TO PRODUCE 3D TE SCAFFOLDS

Ongoing Work:

•Patient-specific meniscus implant

• Image acquisition from CT/MRI

• Computer-assisted design

• 3D Bioplotter

• Printing of patient specific silk-based meniscus implant

• Preservation, repair and/or substitution are the general rules

• Treat the patient and not the scan

• Removal of 15 to 34% increases contact forces up to 350%

• More than 46% of resection generates PA instability (rotation?)

• Medial partial meniscectomy + ACLR can stand for up to 10-fold

higher risk of OA

• Within ACLR some meniscal tears (+lateral) can be left untreated

• Improve results of repairs

• TERM may give us a customized new meniscus

• Partial meniscectomy??? How much ???

CONCLUSION: PRESERVE THE MENISCUS!

How much is too much…?

Online transmission available

Thank you!