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PURPOSE: To evaluate the utility of meniscus allografts in combination with other procedures to delay knee arthroplasty in patients older than 50 years previously advised joint arthroplasty. METHODS: A total of 108 meniscus allograft transplants using the arthroscopic 3-tunnel technique between 1997 and 2019 in patients older than 50 years were retrospectively reviewed with a 2-year minimum follow-up period. Inclusion criteria were patients recommended for knee arthroplasty with pain and preservation of some joint space by standing flexion radiographs. Exclusion criteria were lack of joint space, failure to comply with rehabilitation protocol, and failure to complete research questionnaires. International Knee Documentation Committee composite and isolated pain scale were evaluated longitudinally. Time from meniscus allograft transplant to arthroplasty was measured, with failure defined as allograft excision or revision, progression to arthroplasty, or same or increased pain. RESULTS: Eighty-six of 108 (79.6%) patients met eligibility criteria. Over the follow-up mean 8.55 (range 0.68 to 25.2) years, 42 of 87 (48.2%) grafts progressed to arthroplasty with mean time of 8.64 (median 8.05) years. Concomitant procedures did not have significant impact on survival; however, survival medians were higher among paste graft and chondroplasty and lower among osteotomy groups. At the time of reporting, 41 of 84 (48.8%) patients had intact meniscus transplants, demonstrating significant improvements (P < .001) in pain and function as assessed by International Knee Documentation Committee Score. These improvements were sustained 10 years postoperatively, correlated to a mean of 65.8 years of age. At least 50% of patients achieved Minimal Clinically Important Difference through 10 years postoperatively. CONCLUSIONS: Meniscus allografts in combination with other arthroscopic interventions delay knee arthroplasty and improve knee symptoms of pain and function in a population of knee arthroplasty candidates older than 50 years. Influences of concomitant procedures cannot be defined. LEVEL OF EVIDENCE: Level IV, therapeutic case series, retrospective.
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This review describes the first studies on successful conversion of porcine soft-tissue bioprostheses into viable permanently functional tissue in humans. This process includes gradual degradation of the porcine tissue, with concomitant neo-vascularization and reconstruction of the implanted bioprosthesis with human cells and extracellular matrix. Such a reconstruction process is referred to in this review as "humanization". Humanization was achieved with porcine bone-patellar-tendon-bone (BTB), replacing torn anterior-cruciate-ligament (ACL) in patients. In addition to its possible use in orthopedic surgery, it is suggested that this humanization method should be studied as a possible mechanism for converting implanted porcine bioprosthetic heart-valves (BHV) into viable tissue valves in young patients. Presently, these patients are only implanted with mechanical heart-valves, which require constant anticoagulation therapy. The processing of porcine bioprostheses, which enables humanization, includes elimination of α-gal epitopes and partial (incomplete) crosslinking with glutaraldehyde. Studies on implantation of porcine BTB bioprostheses indicated that enzymatic elimination of α-gal epitopes prevents subsequent accelerated destruction of implanted tissues by the natural anti-Gal antibody, whereas the partial crosslinking by glutaraldehyde molecules results in their function as "speed bumps" that slow the infiltration of macrophages. Anti-non gal antibodies produced against porcine antigens in implanted bioprostheses recruit macrophages, which infiltrate at a pace that enables slow degradation of the porcine tissue, neo-vascularization, and infiltration of fibroblasts. These fibroblasts align with the porcine collagen-fibers scaffold, secrete their collagen-fibers and other extracellular-matrix (ECM) components, and gradually replace porcine tissues degraded by macrophages with autologous functional viable tissue. Porcine BTB implanted in patients completes humanization into autologous ACL within ~2 years. The similarities in cells and ECM comprising heart-valves and tendons, raises the possibility that porcine BHV undergoing a similar processing, may also undergo humanization, resulting in formation of an autologous, viable, permanently functional, non-calcifying heart-valves.
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Corrective lower limb osteotomies are innovative and efficient therapeutic procedures for restoring axial alignment and managing unicompartmental knee osteoarthritis. This review presents critical insights into the up-dated clinical knowledge on osteotomies for complex posttraumatic or congenital lower limb deformities with a focus on high tibial osteotomies, including a comprehensive overview of basic principles of osteotomy planning, biomechanical considerations of different implants for osteotomies and insights in specific bone deformity correction techniques. Emphasis is placed on complex cases of lower limb osteotomies associated with ligament and multiaxial instability including pediatric cases, computer-assisted navigation, external fixation for long bone deformity correction and return to sport after such osteotomies. Altogether, these advances in the experimental and clinical knowledge of complex lower limb osteotomies allow generating improved, adapted therapeutic regimens to treat congenital and acquired lower limb deformities.
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The C-shaped meniscus cartilages normally insert into bone around the tibial spines of the knee. As the knee joint rotates and flexes, circumferential hoop stresses are generated within the tissue, resisted by the collagen fibers that define both the insertion points and the ultrastructure of the meniscus tissue itself. For a transplanted meniscus to work normally, the biomechanical interface of the collagen fibers to the bone must be recreated.
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Articulação do Joelho , Meniscos Tibiais/cirurgia , Aloenxertos , Análise por Pareamento , Técnicas de SuturaRESUMO
PURPOSE: The purpose of this study is to evaluate the clinical outcomes of the articular cartilage paste graft procedure at a minimum of 10 years from surgery. It is hypothesized that articular cartilage paste grafting can provide patients with a durable repair of severe full-thickness osteochondral injuries, measured by persistence of procedure-induced benefit and subjective outcome scores at 10 or more years. METHODS: Seventy-four patients undergoing paste grafting at a mean age of 45.3 ± 10.8 years (range 13-69 years) were followed up at a mean of 16.8 ± 2.4 years (range 10.6-23.2 years) post-operatively using validated subjective outcome measures; Kaplan-Meier survival analysis was performed to estimate expected population benefit time. RESULTS: Kaplan-Meier estimated median benefit time of 19.1 years (mean: 16.6 ± 0.9 years) for all patients undergoing paste grafting. Thirty-one (41.9 %) patients had progressed to arthroplasty at a mean of 9.8 ± 5.6 years (range 0.4-20.6 years). Ninety percent of patients reported that the procedure provided good to excellent pain relief. Median IKDC subjective score increased significantly at most recent follow-up (70.1) compared to preoperative (55.7, p = 0.013). Median WOMAC scores decreased significantly from 26 to 14 (p = 0.001). Median Tegner score increase from 4 to 6 was not found to be significant (ns). VAS pain averaged 23/100 at most recent follow-up. CONCLUSIONS: Patients who underwent the paste grafting reported improved pain, function, and activity levels for an expected mean of 16.6 years, and for those who ultimately progressed to knee replacement, surgical treatment including the paste graft was able to delay arthroplasty until a mean age of 60.2 years, an age at which the procedure is commonly performed. Full-thickness articular cartilage loss can be successfully treated, reducing pain, and improving function, using this single-step, inexpensive arthroscopic procedure. LEVEL OF EVIDENCE: IV.
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Artroscopia , Cartilagem Articular/cirurgia , Articulação do Joelho/cirurgia , Transplantes , Resultado do Tratamento , Adolescente , Adulto , Idoso , Cartilagem/transplante , Feminino , Seguimentos , Humanos , Fraturas Intra-Articulares/patologia , Masculino , Pessoa de Meia-Idade , Osteoartrite/cirurgia , Manejo da Dor , Medição da Dor , Período Pós-Operatório , Transplante Autólogo , Adulto JovemRESUMO
PURPOSE: The purpose of this study was to evaluate the efficacy of meniscus allograft transplantation in an active patient population with moderate to severe cartilage damage and the procedure's ability to allow sports participation postoperatively. METHODS: Forty-nine patients with moderate to severe cartilage damage who underwent meniscus allograft transplantation were included in this study; those with symptoms related to articular cartilage damage also underwent articular cartilage repair. Kaplan-Meier (KM) survival estimate, potential hazards to survival, and subjective clinical outcomes were analyzed. For KM survival, failure was defined as progression to knee arthroplasty, surgical removal of the meniscus transplant without revision, a self-reported follow-up pain level that was more than preoperative level, or constant moderate pain with no relief from non-operative treatment. RESULTS: The mean follow-up time was 8.6 ± 4.2 years. The mean age at surgery was 45.3 ± 12.9 years. Meniscus transplantation was performed in 37 medial cases and 12 lateral cases. There were 41 patients with Outerbridge Grade IV and 8 with Grade III. Thirty-six (73.5%) patients were able to participate in sporting activities postoperatively. Eleven (22.4%) meniscus transplants failed at an average of 5.2 ± 4.4 years. The KM mean estimated survival time was 12.6 ± 0.7 years. No tested risks were found to affect sports participation or procedure success. CONCLUSIONS: Meniscus transplantation is a viable surgical option for patients with severe cartilage damage and missing or irreparable menisci to provide significant improvements in pain and function levels in the medium to long term with the majority of patients achieving their goal of participation in sporting activities. These results indicate that symptomatic patients may be able to participate in sports activities for an average of 12.6 years following meniscus transplantation. LEVEL OF EVIDENCE: Case series, Level IV.
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Doenças das Cartilagens/cirurgia , Cartilagem Articular/cirurgia , Traumatismos do Joelho/cirurgia , Meniscos Tibiais/transplante , Adulto , Cartilagem/transplante , Cartilagem Articular/lesões , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Esportes , Transplante HomólogoRESUMO
BACKGROUND: Revision of failed surgical treatments of osteochondritis dissecans (OCD) lesions remains a challenge without an obvious solution. The aim of this study was to evaluate seven consecutive patients undergoing osteochondral grafting of a failed OCD repair. METHODS: The mean time from surgery to the latest evaluation was 7.0 years. IKDC, WOMAC, Tegner, and MRI studies were collected both preoperatively and during follow-up. Evaluation of the graft was assessed using the magnetic resonance observation of cartilage repair tissue (MOCART) grading system. RESULTS: Over the course of the study period, five patients required additional surgery with a study median of one additional surgery (range, zero to 3). At most recent follow-up, there was significant improvement from preoperative values in median IKDC (p=0.004), WOMAC (p=0.030), and Tegner (p=0.012). Complete cartilage fill and adjacent tissue integration of the paste graft were observed by MRI evaluation in five of the seven (71.4%) patients. Definitive correlation between clinical outcomes and MRI scores was not observed. CONCLUSIONS: This study shows promising results of osteochondral grafting as a viable option for the revision of failed OCD lesion repairs; however, more patients are needed to fully support its efficacy in these challenging failed revision cases.
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Artroscopia , Cartilagem/transplante , Articulação do Joelho , Osteocondrite Dissecante/patologia , Osteocondrite Dissecante/cirurgia , Adolescente , Adulto , Estudos de Coortes , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Reoperação , Falha de Tratamento , Adulto JovemRESUMO
PURPOSE: Successful meniscus transplantation may depend on accurate sizing. Meniscal sizing is currently determined by measuring a combination of bony landmarks and soft-tissue insertion points through images obtained radiographically or by magnetic resonance imaging (MRI). The literature widely reports inaccuracy in sizing resulting from radiographic errors in magnification, erroneous identification of bony landmarks, and difficulty in differentiating between the soft-tissue and bone interface. In our meniscus transplantations we have observed that when the height and weight of the recipient matched those of the donor, the meniscal size appeared to be a match at surgical implantation; we designed this study to confirm this observation. METHODS: The MRI-based meniscal sizing of 111 patients (63 male and 38 female patients; mean age, 44 years [range, 15 to 76 years]), totaling 147 menisci (87 lateral and 60 medial), was compared with the height, weight, gender, and body mass index (BMI) of each patient. MRI scans were obtained with a 1.0-Tesla MRI system (ONI Medical Systems, Wilmington, MA). Sizing was performed by an independent musculoskeletal MRI radiologist as established by the literature. Statistical methods include nonparametric Pearson correlation (r) between MRI-based lateral meniscal width, lateral meniscal length, medial meniscal width, medial meniscal length, total tibial plateau width, and patient height, weight, gender, and BMI. Significance at the P = .05 level was used. RESULTS: Height was found to have a linear relationship to total tibial plateau, which has a good predictive correlation with meniscal dimensions of r > 0.7. Female patients generally present with smaller dimensions than male patients. High-BMI groups present with significantly larger meniscal dimensions than low-BMI groups at any given height. CONCLUSIONS: Height, weight, and gender are easily obtained variables and are proportional to meniscal tissue dimensions. These exploratory statistics establish correlations between height, weight, gender, total tibial plateau width, and meniscal size. CLINICAL RELEVANCE: Height, weight, and gender should be considered by both tissue banks and surgeons as fast and cost-effective variables by which to predict meniscal dimensions.
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Tamanho Corporal , Meniscos Tibiais/anatomia & histologia , Meniscos Tibiais/patologia , Adolescente , Adulto , Idoso , Estatura , Índice de Massa Corporal , Peso Corporal , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Meniscos Tibiais/transplante , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores Sexuais , Tíbia/patologiaRESUMO
PURPOSE: This study proposes treatment methods to provide a mechanically competent, immunocompatible, and sterile porcine graft for human knee ligament reconstruction. METHODS: The anterior cruciate ligament (ACL) was reconstructed by using treated porcine patellar tendon grafts or controls of untreated porcine grafts or allografts in 20 rhesus monkeys. Animals were stratified into 2-, 6-, and 12-month postreconstruction cohorts. Serologic and histologic assessments were performed to evaluate host immunological and cellular response. Healing and functional integrity of the ACL reconstructions were assessed by tensile biomechanical testing. RESULTS: Untreated porcine grafts were acutely resorbed and rejected, whereas treated porcine grafts and allografts were incorporated by the host as functional grafts. Temporal histologic assessment of treated porcine grafts and rhesus grafts revealed gradual host cellular infiltration and graft collagen remodeling through a similar mechanism of ligamentization. Biomechanical evaluations support graft functional integration with no difference between allograft and treated graft reconstructions. CONCLUSION: Rhesus allograft and treated porcine grafts presented with similar healing profiles in a long-term evaluation of ACL reconstruction. CLINICAL RELEVANCE: Immunochemical modification and sterilization of porcine patellar tendon grafts may improve initial biocompatibility and long-term functionality of xenografts in musculoskeletal applications.
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Ligamento Cruzado Anterior/cirurgia , Ligamento Patelar/patologia , Ligamento Patelar/transplante , Condicionamento Pré-Transplante/métodos , Animais , Ligamento Cruzado Anterior/patologia , Fenômenos Biomecânicos , Modelos Animais de Doenças , Ensaio de Imunoadsorção Enzimática , Rejeição de Enxerto , Sobrevivência de Enxerto , Haplorrinos , Ligamento Patelar/imunologia , Distribuição Aleatória , Procedimentos de Cirurgia Plástica/métodos , Valores de Referência , Fatores de Risco , Sensibilidade e Especificidade , Suínos , Resistência à Tração , Coleta de Tecidos e Órgãos , Transplante Heterólogo , Transplante HomólogoRESUMO
PURPOSE: We present meniscus allograft survival data at least 2 years from surgery for 45 patients (47 allografts) with significant arthrosis to determine if the meniscus can survive in an arthritic joint. TYPE OF STUDY: Prospective, longitudinal survival study. METHODS: Data were collected for 31 men and 14 women, mean age 48 years (range, 14 to 69 years), with preoperative evidence of significant arthrosis and an Outerbridge classification greater than II. Failure is established by previous studies as allograft removal. No patient was lost to follow-up. RESULTS: The success rate was 42 of 47 allografts (89.4%) with a mean failure time of 4.4 years as assessed by Kaplan-Meier survival analysis. Statistical power is greater than 0.9, with alpha = 0.05 and N = 47. There was significant mean improvement in preoperative versus postoperative self-reported measures of pain, activity, and functioning, with P = .001, P = .004, and P = .001, respectively, as assessed by a Wilcoxon rank-sum test with P = .05. CONCLUSIONS: Meniscus allografts can survive in a joint with arthrosis, challenging the contraindications of age and arthrosis severity. These results compare favorably with those in previous reports of meniscus allograft survival in patients without arthrosis. LEVEL OF EVIDENCE: Level IV.
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Artroplastia , Sobrevivência de Enxerto , Meniscos Tibiais/transplante , Osteoartrite do Joelho/cirurgia , Atividades Cotidianas , Adolescente , Adulto , Idoso , Cartilagem Articular/transplante , Exercício Físico , Feminino , Seguimentos , Humanos , Articulação do Joelho/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Medição da Dor , Complicações Pós-Operatórias , Radiografia , Reoperação , Análise de SobrevidaRESUMO
PURPOSE: To prospectively assess clinical outcomes and regeneration of osteoarthritic cartilage lesions treated with an articular cartilage paste grafting technique. TYPE OF STUDY: Prospective, longitudinal case series. METHODS: We treated 125 patients (136 procedures; 34% female, 66% male; mean age, 46 years; range, 17 to 73 years) with an Outerbridge classification of grade IV lesions with an articular cartilage paste graft. Clinical data were recorded 2 to 12 years from surgery, with 20 of 145 patients lost to follow-up over 12 years (13.7%). Clinical outcomes were captured annually with validated Western Ontario and McMaster Universities Arthritis Index (WOMAC), International Knee Documentation Committee (IKDC), and Tegner subjective questionnaires. Regenerated cartilage biopsy specimens were obtained at second-look arthroscopy from 66 patients and evaluated as to quality and quantity of defect fill by a blinded, independent histopathology reviewer. RESULTS: Preoperative versus postoperative validated pain, functioning, and activity measures improved significantly (P< .001). Clinically, 18 of the 125 patients were considered failures (14.4%), with 10 patients undergoing subsequent joint arthroplasty and 8 who reported worse pain after surgery. Regional histologic variation occurred. Forty-two of 66 biopsy specimens (63.6%) showed strong and consistent evidence of replacement of their articular surface, and 18 of 66 biopsy specimens (27.3%) showed development of areas of cartilage. CONCLUSIONS: Paste grafting is a low-cost, 1-stage arthroscopic treatment for patients with Outerbridge classification grade IV arthritic chondral lesions. The procedure offers excellent, long-lasting, pain relief, restored functioning, and possibility of tissue regeneration for patients with painful chondral lesions in both arthritic and traumatically injured knees. LEVEL OF EVIDENCE: Level IV, case series.
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Artroscopia/métodos , Cartilagem Articular/cirurgia , Osteoartrite do Joelho/cirurgia , Extratos de Tecidos/uso terapêutico , Adolescente , Adulto , Idoso , Medula Óssea , Cartilagem Articular/lesões , Cartilagem Articular/patologia , Condrócitos/transplante , Desbridamento , Feminino , Fêmur/cirurgia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/reabilitação , Dor/etiologia , Manejo da Dor , Recuperação de Função Fisiológica , Regeneração , Reoperação , Método Simples-Cego , Irrigação Terapêutica , Tíbia/cirurgia , Extratos de Tecidos/administração & dosagem , Transplante Autólogo , Resultado do Tratamento , CicatrizaçãoRESUMO
This technical note describes an improved arthroscopic technique of meniscal transplantation that simplifies the surgical procedure and secures the allograft to the tibia at 3 sites. The technique is useful for both medial and lateral meniscal transplantation and has been used in our clinic for over 60 meniscal transplantation procedures.