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Robinson J, Murray IR, Moatshe G, Chahla J, Tollefson LV, Parker DA, Familiari F, LaPrade RF, DePhillipo NN. Current practice of biologic augmentation techniques to enhance the healing of meniscal repairs: A collaborative survey within the Meniscus International Network (MenIN) Study Group. Knee Surg Sports Traumatol Arthrosc 2025. [PMID: 40331602 DOI: 10.1002/ksa.12685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2025] [Revised: 03/22/2025] [Accepted: 03/23/2025] [Indexed: 05/08/2025]
Abstract
PURPOSE To evaluate practices and preferences among expert sports knee surgeons regarding biologic augmentation techniques in meniscal repair. METHODS A 12-question multiple-choice survey was distributed to the Meniscus International Network (MenIN) Study Group. It covered biologic augmentation techniques for various meniscal tear types, both in isolation and with anterior cruciate ligament reconstruction (ACLR). Eight options were assessed: no augmentation, trephination, rasping, marrow venting, fibrin clot, platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) and meniscal wrapping. Surgeons could select multiple techniques per scenario. RESULTS Forty-two surgeons participated: 42% from Europe, 18% from North America, 10% from Latin America, 21% from Asia and 9% from Africa/Oceania. For isolated meniscal tears (excluding meniscal root tears), 90% of surgeons used at least one biologic augmentation technique. For meniscal tears associated with ACLR, 66% of surgeons used at least one biologic augmentation technique. The most utilized techniques were rasping (19%-69%), trephination (7%-43%), and marrow venting (0%-74%). PRP (2%-19%), BMAC (0%-14%) and meniscal wrapping (0%-10%) were least used. Biologic augmentation was most frequent for isolated radial (93%), isolated bucket-handle (86%), isolated vertical (86%) and isolated horizontal tears (98% for younger patients, 86% for degenerative tears). ACLR-associated repairs had lower augmentation rates, and meniscal root tears showed the highest percentage of non-augmented repairs. Over 50% of surgeons use a single augmentation technique, while 20% use two techniques depending on tear type. Overall, 33.3% (n = 14) of surgeons reported utilizing PRP and/or BMAC for meniscal repair augmentation, with the highest use observed in South America (12%) based on geographic usage. CONCLUSIONS This survey provides insights into current meniscal repair practices among expert orthopaedic sports medicine surgeons. The findings reveal variability in approaches based on tear patterns and associated procedures, with a general preference for simpler mechanical augmentation techniques over more advanced biologics. For isolated meniscal tears (excluding meniscal root tears), 90% of surgeons in this cohort report using one or more biological augmentation techniques. LEVEL OF EVIDENCE Level V expert opinion.
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Affiliation(s)
| | - Iain R Murray
- Edinburgh Orthopaedics, University of Edinburgh, Edinburgh, UK
| | - Gilbert Moatshe
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
| | | | - David A Parker
- Sydney Orthopaedic Research Institute, Sydney, New South Wales, Australia
| | - Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, Catanzaro, Italy
- Research Center on Musculoskeletal Health (MusculoSkeletalHealth@UMG), Magna Graecia University, Catanzaro, Italy
| | | | - Nicholas N DePhillipo
- Department of Orthopedics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Za P, Ambrosio L, Vasta S, Russo F, Papalia GF, Vadalà G, Papalia R. How to Improve Meniscal Repair through Biological Augmentation: A Narrative Review. J Clin Med 2024; 13:4688. [PMID: 39200829 PMCID: PMC11355678 DOI: 10.3390/jcm13164688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/26/2024] [Accepted: 08/01/2024] [Indexed: 09/02/2024] Open
Abstract
Since the role of the menisci in knee stability, proprioception, and homeostasis has been well established, significant efforts have been made to repair meniscal tears, resulting in excellent clinical outcomes and a reduction in the progression of knee osteoarthritis (OA). However, varying failure rates have been reported, raising questions regarding the healing potential in cases of complex injuries, poorly vascularized and degenerated areas, and generally in the presence of unfavorable biological characteristics. Therefore, over the last few decades, different strategies have been described to increase the chances of meniscal healing. Biological augmentation of meniscal repair through various techniques represents a safe and effective strategy with proven clinical benefits. This approach could reduce the failure rate and expand the indications for meniscal repair. In the present study, we thoroughly reviewed the available evidence on meniscal repair surgery and summarized the main techniques that can be employed to enhance the biological healing potential of a meniscal lesion. Our aim was to provide an overview of the state of the art on meniscal repair and suggest the best techniques to reduce their failure rate.
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Affiliation(s)
- Pierangelo Za
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (P.Z.); (S.V.); (F.R.); (G.F.P.); (G.V.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Luca Ambrosio
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (P.Z.); (S.V.); (F.R.); (G.F.P.); (G.V.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Sebastiano Vasta
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (P.Z.); (S.V.); (F.R.); (G.F.P.); (G.V.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Fabrizio Russo
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (P.Z.); (S.V.); (F.R.); (G.F.P.); (G.V.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Giuseppe Francesco Papalia
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (P.Z.); (S.V.); (F.R.); (G.F.P.); (G.V.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Gianluca Vadalà
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (P.Z.); (S.V.); (F.R.); (G.F.P.); (G.V.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Rocco Papalia
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (P.Z.); (S.V.); (F.R.); (G.F.P.); (G.V.); (R.P.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
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Cong T, Reddy RP, Hall AJ, Ernazarov A, Gladstone J. Current Practices for Rehabilitation After Meniscus Repair: A Survey of Members of the American Orthopaedic Society for Sports Medicine. Orthop J Sports Med 2024; 12:23259671231226134. [PMID: 38639001 PMCID: PMC11025434 DOI: 10.1177/23259671231226134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/31/2023] [Indexed: 04/20/2024] Open
Abstract
Background There is no consensus among sports medicine surgeons in North America on postoperative rehabilitation strategy after meniscus repair. Various meniscal tear types may necessitate a unique range of motion (ROM) and weightbearing rehabilitation protocol. Purpose To assess the current landscape of how sports medicine practitioners in the American Orthopedic Society for Sports Medicine (AOSSM) rehabilitate patients after the repair of varying meniscal tears. Study Design Cross-sectional study. Methods A survey was distributed to 2973 AOSSM members by email. Participants reviewed arthroscopic images and brief patient history from 6 deidentified cases of meniscus repair-in cases 1 to 3, the tears retained hoop integrity (more stable repair), and in cases 4 to 6, the tear patterns represented a loss of hoop integrity. Cases were shuffled before the presentation. For each case, providers were asked at what postoperative time point they would permit (1) partial weightbearing (PWB), (2) full weightbearing (FWB), (3) full ROM, and (4) ROM allowed immediately after surgery. Results In total, 451 surveys were completed (15.2% response). The times to PWB and FWB in cases 1 to 3 (median, 0 and 4 weeks, respectively) were significantly lower than those in cases 4 to 6 (median, 4 and 6 weeks, respectively) (P < .001). In tears with retained hoop integrity, the median time to PWB was immediately after surgery, whereas in tears without hoop integrity, the median time to PWB was at 4 weeks postoperatively. Similarly, the median time to FWB in each tear with retained hoop integrity was 4 weeks after surgery, while it was 6 weeks in each tear without hoop integrity. However, regardless of tear type, most providers (67.1%) allowed 0° to 90° of ROM immediately after surgery and allowed full ROM at 6 weeks. Most providers (83.3%) braced the knee after repair regardless of hoop integrity and utilized synovial rasping/trephination with notch microfracture-a much lower proportion of providers utilized biologic augmentation (9%). Conclusion Sports medicine practitioners in the AOSSM rehabilitated meniscal tears differently based on hoop integrity, with loss of hoop stresses triggering a more conservative approach. A majority braced and utilized in situ adjuncts for biological healing, while a minority added extrinsic biologics.
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Affiliation(s)
- Ting Cong
- Mount Sinai Orthopaedic Surgery, Mount Sinai Hospital, New York, New York, USA
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rajiv P. Reddy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arielle J. Hall
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Akhmad Ernazarov
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - James Gladstone
- Mount Sinai Orthopaedic Surgery, Mount Sinai Hospital, New York, New York, USA
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Hutchinson ID, Rodeo SA. The Current Role of Biologics for Meniscus Injury and Treatment. Curr Rev Musculoskelet Med 2022; 15:456-464. [PMID: 35881326 PMCID: PMC9789233 DOI: 10.1007/s12178-022-09778-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW There is little doubt that the consensus has changed to favor preservation of meniscal function where possible. Accordingly, the indications for meniscal repair strategies have been refocused on the long-term interest of knee joint health. The development and refinements in surgical technique have been complemented by biological augmentation strategies to address intrinsic challenges in healing capacity of meniscal tissue, with variable effects. RECENT FINDINGS A contemporary approach to meniscal healing includes adequate surgical fixation, meniscal and synovial tissue stimulation, and management of the intraarticular milieu. Overall, evidence supporting the use of autogenous or allogeneic cell sources remains limited. The use of FDA-approved medications to effect biologically favorable mechanisms during meniscal healing holds promise. Development and characterization of biologics continue to advance with translational research focused on specific growth factors, cell and tissue behaviors in meniscal healing, and joint homeostasis. Although significant strides have been made in laboratory and pre-clinical studies, translation to clinical application remains challenging. Finally, expert consensus and standardization of nomenclature related to orthobiologics for meniscal preservation will be important for the advancement of this field.
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Affiliation(s)
- Ian D. Hutchinson
- grid.239915.50000 0001 2285 8823Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,grid.239915.50000 0001 2285 8823Laboratory for Tissue Engineering, Regeneration & Repair, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Scott A. Rodeo
- grid.239915.50000 0001 2285 8823Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,grid.239915.50000 0001 2285 8823Laboratory for Tissue Engineering, Regeneration & Repair, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Di Matteo B, Altomare D, Garibaldi R, La Porta A, Manca A, Kon E. Ultrasound-Guided Meniscal Injection of Autologous Growth Factors: A Brief Report. Cartilage 2021; 13:387S-391S. [PMID: 34515536 PMCID: PMC8808951 DOI: 10.1177/19476035211037390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Meniscal degeneration is a common finding even in young patients' knees, and it is regarded as a predictor for the onset of early osteoarthritis (OA). When symptomatic, it represents a challenge since arthroscopic surgery provides unpredictable results: recent evidence has shown that partial meniscectomy is not better than conservative management up to 2 years of follow-up, and the removal of meniscal tissue may accelerate OA progression toward OA. Intra-articular injection of corticosteroids or hyaluronic acid may help in providing temporary symptomatic relief, but no influence should be expected on the quality of the meniscal tissue. Biologic agents have been adopted to treat a variety of degenerative musculoskeletal pathologies, and the use of platelet-derived growth factors (GFs) has become routine. Preclinical studies have documented that platelet-derived GFs may play a beneficial role in stimulating meniscal repair and regeneration by triggering anabolic pathways and stimulating local mesenchymal stem cells from synovium. Furthermore, also mechanical stimulation (e.g., arthroscopic trephination or percutaneous needling) in the red-red or red-white zone may further promote tissue healing. The purpose of the present brief report is to describe the clinical outcomes at 18 months' follow-up in a cohort of patients affected by symptomatic medial meniscus degeneration and treated by percutaneous needling plus intra- and perimeniscal injection of autologous conditioned plasma (ACP). The procedure was shown to be safe and provided significant pain reduction and improvement in subjective scores. This treatment option deserves further investigation in a comparative setting, to establish whether it could offer advantage over isolated intra-articular injections.
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Affiliation(s)
- Berardo Di Matteo
- Department of Biomedical Sciences, Humanitas
University, Milan, Italy,Department of Traumatology, Orthopaedics and
Disaster Surgery, Sechenov First Moscow State Medical University (Sechenov University),
Moscow, Russia,Berardo Di Matteo, Istituto Clinico Humanitas, Via
Manzoni 113, Rozzano, Milano 20089, Italy.
| | - Daniele Altomare
- Department of Biomedical Sciences, Humanitas
University, Milan, Italy,IRCCS Humanitas Research Center, Rozzano
(MI), Italy
| | - Riccardo Garibaldi
- Hôpital du Valais, Service d’Orthopédie et
Traumatologie, Martigny, Switzerland
| | - Agostino La Porta
- Department of Biomedical Sciences, Humanitas
University, Milan, Italy,IRCCS Humanitas Research Center, Rozzano
(MI), Italy
| | - Angelo Manca
- Department of Biomedical Sciences, Humanitas
University, Milan, Italy,IRCCS Humanitas Research Center, Rozzano
(MI), Italy
| | - Elizaveta Kon
- Department of Biomedical Sciences, Humanitas
University, Milan, Italy,IRCCS Humanitas Research Center, Rozzano
(MI), Italy
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Rhim HC, Jeon OH, Han SB, Bae JH, Suh DW, Jang KM. Mesenchymal stem cells for enhancing biological healing after meniscal injuries. World J Stem Cells 2021; 13:1005-1029. [PMID: 34567422 PMCID: PMC8422933 DOI: 10.4252/wjsc.v13.i8.1005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/02/2021] [Accepted: 07/15/2021] [Indexed: 02/06/2023] Open
Abstract
The meniscus is a semilunar fibrocartilage structure that plays important roles in maintaining normal knee biomechanics and function. The roles of the meniscus, including load distribution, force transmission, shock absorption, joint stability, lubrication, and proprioception, have been well established. Injury to the meniscus can disrupt overall joint stability and cause various symptoms including pain, swelling, giving-way, and locking. Unless treated properly, it can lead to early degeneration of the knee joint. Because meniscal injuries remain a significant challenge due to its low intrinsic healing potential, most notably in avascular and aneural inner two-thirds of the area, more efficient repair methods are needed. Mesenchymal stem cells (MSCs) have been investigated for their therapeutic potential in vitro and in vivo. Thus far, the application of MSCs, including bone marrow-derived, synovium-derived, and adipose-derived MSCs, has shown promising results in preclinical studies in different animal models. These preclinical studies could be categorized into intra-articular injection and tissue-engineered construct application according to delivery method. Despite promising results in preclinical studies, there is still a lack of clinical evidence. This review describes the basic knowledge, current treatment, and recent studies regarding the application of MSCs in treating meniscal injuries. Future directions for MSC-based approaches to enhance meniscal healing are suggested.
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Affiliation(s)
- Hye Chang Rhim
- T.H. Chan School of Public Health, Harvard University, Boston, MA 02115, United States
| | - Ok Hee Jeon
- Department of Biomedical Sciences, Korea University College of Medicine, Seoul 02841, Seoul, South Korea
| | - Seung-Beom Han
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Seoul, South Korea
| | - Ji Hoon Bae
- Department of Orthopaedic Surgery, Guro Hospital, Korea University College of Medicine, Seoul 08308, Seoul, South Korea
| | - Dong Won Suh
- Department of Orthopaedic Surgery, Barunsesang Hospital, Seongnam 13497, South Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Seoul, South Korea
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Vint H, Quartley M, Robinson JR. All-inside versus inside-out meniscal repair: A systematic review and meta-analysis. Knee 2021; 28:326-337. [PMID: 33482623 DOI: 10.1016/j.knee.2020.12.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/25/2020] [Accepted: 12/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Meniscal repair using all-inside devices has garnered popularity compared to inside-out repair, yet few studies directly compare the two techniques in terms meniscal healing rates, surgical time, patient outcomes and incidence of complications. METHODS A systematic literature review was performed using the Medline, Cochrane and Embase databases. English-language studies comparing all-inside and inside-out arthroscopic meniscal repair techniques directly were included. Randomised controlled trials (RCTs) and observational studies with at least 10 patients in each treatment arm were included. Meta-analyses were performed using a fixed effect (when I2 < 50%) or random effects model (I2 ≥ 50%). RESULTS A total of 1042 studies were identified with seven being sui for inclusion (n = 505 patients). These comprised of one RCT two prospective and four retrospective, comparative, observational studies. Meta-analyses demonstrated that there was a significant reduction in operating time favouring all-inside repair (ratio of means [ROM] 0.62, 95% confidence interval [CI] 0.48-0.79; p = 0.0002) based on 3 studies (n = 208 patients). Based on 5 studies (n = 370 patients), there was no significant difference in meniscal healing rates between the groups (OR 1.26, 95% CI 0.52-3.10; p = 0.61). Nerve injury was more common after inside-out repair. There was a 85% reduction in the odds of nerve injury with the all-inside technique (OR 0.15, 95% CI 0.05-0.47; p = 0.0013). A qualitative data analysis suggested no difference in functional outcomes between the two techniques. CONCLUSIONS All-inside meniscal repair is associated with reduced operative time and a lower odds of nerve injury complications compared to inside-out repair, without compromising meniscal healing or functional results.
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Affiliation(s)
- Helen Vint
- Avon Orthopaedic Centre, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
| | - Megan Quartley
- Smith and Nephew, Department of Evidence Analysis, Smith and Nephew, Croxley Park Building 5, Hatters Lane, Watford, Hertfordshire WD18 8YE, UK
| | - James R Robinson
- Avon Orthopaedic Centre, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK.
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Van Genechten W, Verdonk P, Krych AJ, Saris DB. Biologic Adjuvants in Meniscus Repair: A Review of Current Translational and Clinical Evidence. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2020.150758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Treatment of Knee Meniscus Pathology: Rehabilitation, Surgery, and Orthobiologics. PM R 2019; 11:292-308. [DOI: 10.1016/j.pmrj.2018.08.384] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 08/11/2018] [Indexed: 01/13/2023]
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Vaquero-Picado A, Rodríguez-Merchán EC. Arthroscopic repair of the meniscus: Surgical management and clinical outcomes. EFORT Open Rev 2018; 3:584-594. [PMID: 30595844 PMCID: PMC6275851 DOI: 10.1302/2058-5241.3.170059] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
From the biomechanical and biological points of view, an arthroscopic meniscal repair (AMR) should always be considered as an option. However, AMR has a higher reoperation rate compared with arthroscopic partial meniscectomy, so it should be carefully indicated.Compared with meniscectomy, AMR outcomes are better and the incidence of osteoarthritis is lower when it is well indicated.Factors influencing healing and satisfactory results must be carefully evaluated before indicating an AMR.Tears in the peripheral third are more likely to heal than those in the inner thirds.Vertical peripheral longitudinal tears are the best scenario in terms of success when facing an AMR.'Inside-out' techniques were considered as the gold standard for large repairs on mid-body and posterior parts of the meniscus. However, recent studies do not demonstrate differences regarding failure rate, functional outcomes and complications, when compared with the 'all-inside' techniques.Some biological therapies try to enhance meniscal repair success but their efficacy needs further research. These are: mechanical stimulation, supplemental bone marrow stimulation, platelet rich plasma, stem cell therapy, and scaffolds and membranes.Meniscal root tear/avulsion dramatically compromises meniscal stability, accelerating cartilage degeneration. Several options for reattachment have been proposed, but no differences between them have been established. However, repair of these lesions is actually the reference of the treatment.Meniscal ramp lesions consist of disruption of the peripheral attachment of the meniscus. In contrast, with meniscal root tears, the treatment of reference has not yet been well established. Cite this article: EFORT Open Rev 2018;3:584-594. DOI: 10.1302/2058-5241.3.170059.
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Weber J, Koch M, Angele P, Zellner J. The role of meniscal repair for prevention of early onset of osteoarthritis. J Exp Orthop 2018; 5:10. [PMID: 29607459 PMCID: PMC5879034 DOI: 10.1186/s40634-018-0122-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/08/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The meniscus plays an important role in the integrity of the knee joint. Therefore, meniscus tissue preserving techniques for the therapy of meniscus injuries seem to be reasonable. One of the important questions is whether meniscal repair can prevent the knee joint from early onset of osteoarthritis. METHODS According to the review of the current literature, the principles of a successful meniscal repair are explained and the functional outcome and its impact on the prevention of osteoarthritis are analyzed in this article. RESULTS Current data show a positive impact of a successful meniscus repair on the functional outcome in long-term. By this a protective effect on the development of osteoarthritis via the repair of meniscus lesions to restore the meniscus integrity can be confirmed. However, higher rates of re-operations in context to meniscus suturing have to be considered. CONCLUSION Due to the improved functional outcomes as well as preventive effect on the development of osteoarthritis within the knee joint in long-term, it is of importance to preserve as much meniscus tissue as possible in meniscus therapy. Patients previously have to be informed about the higher revision rate in context to meniscus suturing.
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Affiliation(s)
- Johannes Weber
- Department of Trauma Surgery, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Matthias Koch
- Department of Trauma Surgery, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Peter Angele
- Department of Trauma Surgery, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.,sporthopaedicum Regensburg/Straubing, Hildegard von Bingen Strasse 1, 93053, Regensburg, Germany
| | - Johannes Zellner
- Department of Trauma Surgery, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
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Monibi FA, Bozynski CC, Kuroki K, Stoker AM, Pfeiffer FM, Sherman SL, Cook JL. Development of a Micronized Meniscus Extracellular Matrix Scaffold for Potential Augmentation of Meniscal Repair and Regeneration. Tissue Eng Part C Methods 2017; 22:1059-1070. [PMID: 27824291 DOI: 10.1089/ten.tec.2016.0276] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Decellularized scaffolds composed of extracellular matrix (ECM) hold promise for repair and regeneration of the meniscus, given the potential for ECM-based biomaterials to aid in stem cell recruitment, infiltration, and differentiation. The objectives of this study were to decellularize canine menisci to fabricate a micronized, ECM-derived scaffold and to determine the cytocompatibility and repair potential of the scaffold ex vivo. Menisci were decellularized with a combination of physical agitation and chemical treatments. For scaffold fabrication, decellularized menisci were cryoground into a powder and the size and morphology of the ECM particles were evaluated using scanning electron microscopy. Histologic and biochemical analyses of the scaffold confirmed effective decellularization with loss of proteoglycan from the tissue but no significant reduction in collagen content. When washed effectively, the decellularized scaffold was cytocompatible to meniscal fibrochondrocytes, synoviocytes, and whole meniscal tissue based on the resazurin reduction assay and histologic evaluation. In an ex vivo model for meniscal repair, radial tears were augmented with the scaffold delivered with platelet-rich plasma as a carrier, and compared to nonaugmented (standard-of-care) suture techniques. Histologically, there was no evidence of cellular migration or proliferation noted in any of the untreated or standard-of-care treatment groups after 40 days of culture. Conversely, cellular infiltration and proliferation were noted in scaffold-augmented repairs. These data suggest the potential for the scaffold to promote cellular survival, migration, and proliferation ex vivo. Further investigations are necessary to examine the potential for the scaffold to induce cellular differentiation and functional meniscal fibrochondrogenesis.
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Affiliation(s)
- Farrah A Monibi
- 1 Thompson Laboratory for Regenerative Orthopaedics (formerly Comparative Orthopaedic Laboratory), Missouri Orthopaedic Institute, University of Missouri , Columbia, Missouri.,2 Department of Orthopaedic Surgery, University of Missouri , Columbia, Missouri
| | - Chantelle C Bozynski
- 1 Thompson Laboratory for Regenerative Orthopaedics (formerly Comparative Orthopaedic Laboratory), Missouri Orthopaedic Institute, University of Missouri , Columbia, Missouri.,2 Department of Orthopaedic Surgery, University of Missouri , Columbia, Missouri
| | - Keiichi Kuroki
- 1 Thompson Laboratory for Regenerative Orthopaedics (formerly Comparative Orthopaedic Laboratory), Missouri Orthopaedic Institute, University of Missouri , Columbia, Missouri
| | - Aaron M Stoker
- 1 Thompson Laboratory for Regenerative Orthopaedics (formerly Comparative Orthopaedic Laboratory), Missouri Orthopaedic Institute, University of Missouri , Columbia, Missouri.,2 Department of Orthopaedic Surgery, University of Missouri , Columbia, Missouri
| | - Ferris M Pfeiffer
- 1 Thompson Laboratory for Regenerative Orthopaedics (formerly Comparative Orthopaedic Laboratory), Missouri Orthopaedic Institute, University of Missouri , Columbia, Missouri.,2 Department of Orthopaedic Surgery, University of Missouri , Columbia, Missouri.,3 Department of Bioengineering, University of Missouri , Columbia, Missouri
| | - Seth L Sherman
- 1 Thompson Laboratory for Regenerative Orthopaedics (formerly Comparative Orthopaedic Laboratory), Missouri Orthopaedic Institute, University of Missouri , Columbia, Missouri.,2 Department of Orthopaedic Surgery, University of Missouri , Columbia, Missouri
| | - James L Cook
- 1 Thompson Laboratory for Regenerative Orthopaedics (formerly Comparative Orthopaedic Laboratory), Missouri Orthopaedic Institute, University of Missouri , Columbia, Missouri.,2 Department of Orthopaedic Surgery, University of Missouri , Columbia, Missouri
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Monibi FA, Cook JL. Tissue-Derived Extracellular Matrix Bioscaffolds: Emerging Applications in Cartilage and Meniscus Repair. TISSUE ENGINEERING PART B-REVIEWS 2017; 23:386-398. [DOI: 10.1089/ten.teb.2016.0431] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Farrah A. Monibi
- Thompson Laboratory for Regenerative Orthopedics, Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, Missouri
| | - James L. Cook
- Thompson Laboratory for Regenerative Orthopedics, Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, Missouri
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Woodmass JM, LaPrade RF, Sgaglione NA, Nakamura N, Krych AJ. Meniscal Repair: Reconsidering Indications, Techniques, and Biologic Augmentation. J Bone Joint Surg Am 2017; 99:1222-1231. [PMID: 28719562 DOI: 10.2106/jbjs.17.00297] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jarret M Woodmass
- 1Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota 2The Steadman Clinic, Steadman Philippon Research Institute, Vail, Colorado 3Department of Orthopedics, Northwell Health System, Great Neck, New York 4Institute for Medical Science in Sports, Osaka Health Science University, Osaka, Japan
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Zellner J, Angele P. Rolle des Meniskuserhalts in der Arthroseprotektion. ARTHROSKOPIE 2017. [DOI: 10.1007/s00142-017-0134-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Pujol N, Salle De Chou E, Boisrenoult P, Beaufils P. Platelet-rich plasma for open meniscal repair in young patients: any benefit? Knee Surg Sports Traumatol Arthrosc 2015; 23:51-8. [PMID: 25377191 DOI: 10.1007/s00167-014-3417-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/30/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE Many studies have demonstrated that injection of various growth factors including platelet-derived growth factor could increase meniscal cell activity and stimulate repair. The purpose of this study was to augment repair and promote meniscal healing by the use of platelet-rich plasma (PRP) within horizontal cleavage meniscal tears repaired via an open approach. The hypothesis was that the clinical outcomes and healing process would be improved using this meniscal healing augmentation technique. METHODS In this case-control study, 34 consecutive young patients underwent an open meniscal repair to treat symptomatic Grade 2 or Grade 3 horizontal meniscal tears [median age 28 years (13-40)]. The median time between the onset of symptoms and surgery was 11.5 months (6-50). In the first group (17 consecutive patients, Group 1), a standard open meniscal repair was performed. In the second group (17 consecutive patients, Group 2), the same surgical repair was performed, but platelet-rich plasma was introduced into the lesion at the end of the procedure. Clinical outcomes were evaluated using KOOS and IKDC 2000 scores. MRI was performed at 1 year after surgery for objective evaluation. RESULTS At a minimum of 24 months postoperatively (mean 32.2 months, 24-40), three patients underwent subsequent meniscectomy (two in Group 1, one in Group 2). The mean KOOS distribution (pain, symptoms, daily activities, sports, quality of life) was 78.4, 86.1, 93.8, 74.4, 74.6 in Group 1, and 93.3, 90.7, 97.1, 88.8, 78.3 in Group 2 (p < 0.05 for pain and sports parameters). MRI revealed five cases with the complete disappearance of any hypersignal within the repaired meniscus in Group 2, and none in Group 1 (p < 0.01). CONCLUSIONS Open meniscal repair of horizontal tears extending into the avascular zone was effective at midterm follow-up in young patients. Clinical outcomes were slightly improved by the addition of PRP in this case-control study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nicolas Pujol
- Orthopedic Department, Centre Hospitalier de Versailles, Versailles-Saint Quentin University, 177, rue de Versailles, 78157, Le Chesnay, France,
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Mordecai SC, Al-Hadithy N, Ware HE, Gupte CM. Treatment of meniscal tears: An evidence based approach. World J Orthop 2014; 5:233-241. [PMID: 25035825 PMCID: PMC4095015 DOI: 10.5312/wjo.v5.i3.233] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 04/05/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
Treatment options for meniscal tears fall into three broad categories; non-operative, meniscectomy or meniscal repair. Selecting the most appropriate treatment for a given patient involves both patient factors (e.g., age, co-morbidities and compliance) and tear characteristics (e.g., location of tear/age/reducibility of tear). There is evidence suggesting that degenerative tears in older patients without mechanical symptoms can be effectively treated non-operatively with a structured physical therapy programme as a first line. Even if these patients later require meniscectomy they will still achieve similar functional outcomes than if they had initially been treated surgically. Partial meniscectomy is suitable for symptomatic tears not amenable to repair, and can still preserve meniscal function especially when the peripheral meniscal rim is intact. Meniscal repair shows 80% success at 2 years and is more suitable in younger patients with reducible tears that are peripheral (e.g., nearer the capsular attachment) and horizontal or longitudinal in nature. However, careful patient selection and repair technique is required with good compliance to post-operative rehabilitation, which often consists of bracing and non-weight bearing for 4-6 wk.
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Barber-Westin SD, Noyes FR. Clinical healing rates of meniscus repairs of tears in the central-third (red-white) zone. Arthroscopy 2014; 30:134-46. [PMID: 24384277 DOI: 10.1016/j.arthro.2013.10.003] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 09/30/2013] [Accepted: 10/04/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the clinical healing rate of repairs of meniscus tears that extend into the central one-third region and the factors that affect the outcome. METHODS A systematic search of PubMed was conducted to determine the outcome of meniscus repairs in the red-white (R/W) zone. Inclusion criteria were as follows: English language, clinical trials published from 1996 to 2013, R/W tears analyzed separately from tears in other zones, arthroscopic suture-based repairs, and all evidence levels. RESULTS Of 344 articles identified, 23 met the inclusion criteria. There were 1,232 patients who had 1,326 meniscus repairs, of which 767 were in the R/W zone. Concurrent anterior cruciate ligament reconstruction was performed in 955 patients (78%). The mean age was 25 years, and the mean follow-up was 4 years. Evaluation criteria included clinical examination in 22 studies, follow-up arthroscopy in 15, magnetic resonance imaging in 6, weight-bearing radiographs in 3, and the International Knee Documentation Committee subjective score in 1. Overall, 637 (83%) of the repairs were considered clinically healed because no additional surgery was required and no obvious clinical meniscus symptoms were detected. This included 382 of 470 inside-out suture repairs (81%) and 255 of 297 all-inside suture repairs (86%). Twenty-two factors were assessed in 13 studies to determine their influence on the outcome, with varying results. Authors generally found that patient age, chronicity of injury, involved tibiofemoral compartment, gender, and concurrent anterior cruciate ligament reconstruction did not adversely affect the results. Insufficient data existed to assess the healing rates according to the type of meniscus tear except for single longitudinal tears. Complications were reported in 3% of the patients in this review. Long-term assessment of a chondroprotective effect of the repairs was conducted in only 2 studies. CONCLUSIONS An acceptable midterm clinical healing rate was found for R/W meniscus repairs, supporting this procedure when appropriately indicated. Long-term studies assessing the chondroprotective effect in the involved tibiofemoral compartment using magnetic resonance imaging and radiographs are needed. LEVEL OF EVIDENCE Level IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Sue D Barber-Westin
- Cincinnati SportsMedicine and Orthopaedic Center, Noyes Knee Institute, and Jewish Hospital-Mercy Health, Cincinnati, Ohio, U.S.A..
| | - Frank R Noyes
- Cincinnati SportsMedicine and Orthopaedic Center, Noyes Knee Institute, and Jewish Hospital-Mercy Health, Cincinnati, Ohio, U.S.A
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Hasan J, Fisher J, Ingham E. Current strategies in meniscal regeneration. J Biomed Mater Res B Appl Biomater 2013; 102:619-34. [PMID: 24030973 DOI: 10.1002/jbm.b.33030] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/13/2013] [Accepted: 08/18/2013] [Indexed: 12/26/2022]
Abstract
The meniscus plays an important role in the biomechanics and tribology of the knee joint. Damage to or disease of the meniscus is now recognized to predispose to the development of osteoarthritis. Treatment of meniscal injury through arthroscopic surgery has become one of the most common orthopedic surgical procedures, and in the United States this can represent 10 to 20% of procedures related to the knee. The meniscus has a limited healing capacity constrained to the vascularized periphery and therefore, surgical repair of the avascular regions is not always feasible. Replacement and repair of the meniscus to treat injuries is being investigated using tissue engineering strategies. Promising as these approaches may be, there are, however, major barriers to overcome before translation to the clinic.
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Affiliation(s)
- Jahid Hasan
- Institute of Medical and Biological Engineering, Schools of Biomedical Sciences and Mechanical Engineering, University of Leeds, Leeds, LS2 9JT, UK
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Brucker P, Feucht M, Becker R, Hinterwimmer S, Holsten D, Imhoff A. Intraoperative biologische Augmentation am Meniskus. ARTHROSKOPIE 2013. [DOI: 10.1007/s00142-012-0736-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Driscoll MD, Robin BN, Horie M, Hubert ZT, Sampson HW, Jupiter DC, Tharakan B, Reeve RE. Marrow stimulation improves meniscal healing at early endpoints in a rabbit meniscal injury model. Arthroscopy 2013. [PMID: 23200846 DOI: 10.1016/j.arthro.2012.06.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To critically evaluate the effect of marrow stimulation (MS) on the extent of healing and the local biological environment after meniscal injury in ligamentously stable knees in a rabbit model. METHODS A reproducible 1.5-mm cylindrical defect was created in the avascular portion of the anterior horn of the medial meniscus bilaterally in 18 New Zealand White rabbits (36 knees). In right knees (MS knees), a 2.4-mm Steinman pin was drilled into the apex of the femoral intercondylar notch and marrow contents were observed spilling into the joint. Left knees served as controls. Rabbits were killed in 3 groups (n = 6 rabbits each) at 1, 4, and 12 weeks with meniscal harvest and blinded histomorphometric and histologic evaluation using an established 3-component tissue quality score (range, 0 to 6). One-week specimens were also evaluated for the presence of proregenerative cytokines using immunohistochemistry. RESULTS The mean proportion of the avascular zone defect bridged by reparative tissue was greater in MS knees than in controls at each endpoint (1 week, 55% v 30%, P = .02; 4 weeks, 71% v 53%, P = .047; 12 weeks, 96% v 77%, P = .16). Similarly, there was a consistent trend toward superior tissue quality scores in knees treated with MS compared with controls (1 week, 1.8 v 0.3, P = .03; 4 weeks, 4.3 v 2.8, P = .08; 12 weeks, 5.9 v 4.5, P = .21). No statistically significant differences, however, were observed at the 12-week endpoint. Increased staining for insulin-like growth factor I, transforming growth factor-β, and platelet-derived growth factor was observed in regenerated tissue, compared with native meniscal tissue, in all specimens at 1 week. Staining density for all growth factors was similar, however, in reparative tissue of MS and control knees. CONCLUSIONS The results of this study suggest that marrow stimulation leads to modest improvements in quality and quantity of reparative tissue bridging a meniscal defect, particularly during the early recovery period. CLINICAL RELEVANCE Clinical evaluation of marrow stimulation techniques designed to enhance healing in isolated meniscus repair surgery may be indicated.
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Affiliation(s)
- Matthew D Driscoll
- Department of Orthopaedic Surgery, Scott and White Memorial Hospital, Temple, Texas, USA.
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Affiliation(s)
- Don Johnson
- Carleton University Sports Medicine Clinic, Ottawa, ON, Canada.
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Abstract
BACKGROUND Avascular meniscal injuries are largely incapable of healing; the most common treatment remains partial meniscectomy despite the risk of subsequent osteoarthritis. Meniscal responses to injury are partially mediated through synovial activity and strategies have been investigated to encourage healing through stimulating or transplanting adjacent synovial lining. However, with their potential for chondrogenesis, synovial fibroblast-like stem cells hold promise for meniscal cartilage tissue engineering. QUESTIONS/PURPOSES Thus, specific purposes of this review were to (1) examine how the synovial intima and synoviomeniscal junction affect current meniscal treatment modalities; and (2) examine the components of tissue engineering (cells, scaffolds, bioactive agents, and bioreactors) in the specific context of how cells of synovial origin may be used for meniscal healing or regeneration. METHODS An online bibliographic search through PubMed was performed in March 2010. Studies were subjectively evaluated and reviewed if they addressed the question posed. Fifty-four resources were initially retrieved, which offered information on the chondrogenic potential of synovial-based cells that could prove valuable for meniscal fibrocartilage engineering. RESULTS Based on the positive effects of adjoining synovium on meniscal healing as used in some current treatment modalities, the chondrogenic potential of fibroblast-like stem cells of synovial origin make this cell source a promising candidate for cell-based tissue engineering strategies. CONCLUSIONS The abundance of autologous synovial lining, its ability to regenerate, and the potential of synovial-derived stem cells to produce a wide spectrum of chondral matrix components make it an ideal candidate for future meniscal engineering investigations.
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Affiliation(s)
- Derek B. Fox
- University of Missouri, Comparative Orthopaedic Laboratory, Columbia, MO USA ,University of Missouri, Veterinary Medical Teaching Hospital, 900 East Campus Drive, Columbia, MO USA
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Stärke C, Kopf S, Petersen W, Becker R. Meniscal repair. Arthroscopy 2009; 25:1033-44. [PMID: 19732643 DOI: 10.1016/j.arthro.2008.12.010] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 12/07/2008] [Accepted: 12/09/2008] [Indexed: 02/02/2023]
Abstract
The meniscus plays an important role in preventing osteoarthritis of the knee. Repair of a meniscal lesion should be strongly considered if the tear is peripheral and longitudinal, with concurrent anterior cruciate ligament reconstruction, and in younger patients. The probability of healing is decreased in complex or degenerative tears, central tears, and tears in unstable knees. Age or extension of the tear into the avascular area are not exclusion criteria. Numerous repair techniques are available, and suture repair seems to provide superior biomechanical stability. However, the clinical success rate does not correlate well with the mechanical strength of the repair technique. Biologic factors might be of greater importance to the success of meniscal repair than the surgical technique. Therefore, the decision on the most appropriate repair technique should not rely on biomechanical parameters alone. Contemporary all-inside repair systems have decreased the operating time and the level of surgical skill required. Despite the ease of use, there is a potential for complications because of the close proximity of vessels, nerves, and tendons, of which the surgeon should be aware. There is no clear consensus on postoperative rehabilitation. Weight bearing in extension would most likely not be crucial in typical longitudinal lesions. However, higher degrees of flexion, particularly with weight bearing, give rise to large excursions of the menisci and to shear motions, and should therefore be advised carefully. Long-term studies show a decline in success rates with time. Further studies are needed to clarify the factors relevant to the healing of the menisci. Tissue engineering techniques to enhance the healing in situ are promising but have not yet evolved to a practicable level.
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Affiliation(s)
- Christian Stärke
- Department of Orthopaedic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Abstract
BACKGROUND Injuries to the knee menisci are common and operations to treat them are among the most common procedures performed by orthopaedic surgeons. OBJECTIVES To evaluate the effects of common surgical interventions in the treatment of meniscal injuries of the knee. The four comparisons under test were: a) surgery versus conservative treatment, b) partial versus total meniscectomy, c) excision versus repair of meniscal tears, d) surgical access, in particular arthroscopic versus open. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (March 2001), MEDLINE (1966 -1998) and bibliographies of published papers. SELECTION CRITERIA All randomised and quasi-randomised trials which involved the above four comparisons or which compared other surgical interventions for the treatment of meniscal injury. DATA COLLECTION AND ANALYSIS Trial inclusion was agreed by both reviewers who independently assessed trial quality, by use of a 12 item scale, and extracted data. Where possible and appropriate, data were presented graphically. MAIN RESULTS Three trials, involving 260 patients, which addressed two (partial versus total meniscectomy; surgical access) comparisons were included.Partial meniscectomy may allow a slightly enhanced recovery rate as well as a potentially improved overall functional outcome including better knee stability in the long term. It is probably associated with a shorter operating time with no apparent difference in early complications or re-operation between partial and total meniscectomy. The long term advantage of partial meniscectomy indicated by the absence of symptoms (symptoms or further operation at six years or over: 14/98 versus 22/94; Peto odds ratio 0.55, 95% confidence interval 0.27 to 1.14) or radiographical outcome was not established.The results available from the only trial comparing arthroscopic with open meniscectomy were very limited in terms of patient numbers and length of follow-up. However it is likely that partial meniscectomy via arthroscopy is associated with shorter operating times and a quicker recovery. AUTHORS' CONCLUSIONS The lack of randomised trials means that no conclusions can be drawn on the issue of surgical versus non-surgical treatment of meniscal injuries, nor meniscal tear repair versus excision.In randomised trials so far reported, there is no evidence of difference in radiological or long term clinical outcomes between arthroscopic and open meniscal surgery, or between total and partial meniscectomy. Partial meniscectomy seems preferable to the total removal of the meniscus in terms of recovery and overall functional outcome in the short term.
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Affiliation(s)
- Jonathan R Howell
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, UK, EX2 5DW.
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An in vitro model to assess mechanisms and efficacy of a cellular conduit for treatment of avascular meniscal injuries. In Vitro Cell Dev Biol Anim 2008; 44:185-8. [PMID: 18528733 DOI: 10.1007/s11626-008-9111-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Accepted: 04/09/2008] [Indexed: 10/22/2022]
Abstract
Tears in the avascular portion of the knee meniscus are commonplace and are frequently incapable of healing spontaneously. Delivery of synovial cells from the meniscal periphery to avascular injuries can result in an effective healing response but is difficult to accomplish surgically. This report describes the development of a novel in vitro model comprised of three-dimensionally cultured cells in agarose used to assess the proof of concept that a cellular conduit device could be used to facilitate the delivery of synovial fibroblasts from a cell source to a remote acellular recipient site. The results indicate that synovial fibroblasts are capable of migrating through a cellular conduit more optimally than a created trephined channel over a clinically relevant distance in response to a chemotactic gradient. This model proved to be a reliable way to assess fibroblast-like synoviocyte migration in a clinically relevant fashion for application to avascular meniscal tear healing methodologies, and provided mechanistic information regarding the successful in vivo testing of this specific biomedical device.
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Abstract
BACKGROUND Avascular meniscal tears are a common and costly problem for which current treatment options are limited. HYPOTHESIS A bioabsorbable conduit will allow for vascular tissue ingrowth that is associated with histologic and biomechanical evidence for avascular meniscal tear healing superior to that associated with meniscal trephining in dogs. STUDY DESIGN Controlled laboratory study. METHODS Twenty-five dogs underwent medial arthrotomy with creation of anterior and posterior tears in the medial menisci (N = 50 tears). The dogs were assigned treatments for their menisci: conduit (n = 29 tears) or trephine (n = 21 tears). Dogs were assessed for lameness by subjective scoring after surgery and sacrificed at 6, 12, or 24 weeks and assessed for articular cartilage damage, gross and histologic appearance of the operated menisci, and maximal load-to-failure values using tensile testing of meniscal tears. Tears were considered to demonstrate biomechanical integrity when histologic partial to complete healing was noted in conjunction with a measured load to failure that was significantly greater than controls. RESULTS Based on histologic assessment, the conduit was associated with complete (n = 4) or partial (n = 5) healing in all avascular defects at 12 and 24 weeks after surgery in this study. No healing was seen in defects treated by trephination and repair. No lameness associated with surgery or meniscal treatment was noted after 4 weeks. No articular cartilage damage was noted in any joint. At both 12 and 24 weeks, mean load to failure for normal menisci (43.2 N and 28.6 N, respectively) was significantly (P < .017) higher than conduit-treated (22.3 N and 16.0 N, respectively) and trephine-treated (0.6 N and 2.1 N, respectively) menisci, and load to failure for conduit-treated menisci was significantly (P <or= .05) higher than trephine-treated menisci. Biomechanical integrity was noted in 10 of 14 conduit-treated menisci. CONCLUSION Conduit treatment resulted in functional healing with bridging tissue and biomechanical integrity in 71% of avascular meniscal defects for up to 6 months after surgery. No functional healing was noted in avascular meniscal tears treated by trephination and suture repair. CLINICAL RELEVANCE Clinical studies using the conduit in humans may be appropriate to determine the safety and efficacy of the device for cases of avascular and poorly vascularized meniscal tears, where the device can be successfully implanted from tear to meniscal rim, the tears can be surgically repaired, and patient compliance can be ensured.
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Affiliation(s)
- James L Cook
- Comparative Orthopaedic Laboratory, University of Missouri, 379 East Campus Drive, Columbia, MO 65211, USA.
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Shelbourne KD, Rask BP. The sequelae of salvaged nondegenerative peripheral vertical medial meniscus tears with anterior cruciate ligament reconstruction. Arthroscopy 2001; 17:270-274. [PMID: 11239347 DOI: 10.1053/jars.2001.19978] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE: To determine the clinical sequelae of nondegenerative peripheral vertical medial meniscus tears treated with abrasion and trephination alone (stable tears) or suture repair (unstable tears). Type of Study: Cohort follow-up. METHODS: At the time of anterior cruciate ligament reconstruction, 548 patients had nondegenerative peripheral vertical medial meniscus tears that were either left unsutured or repaired. Of 548 menisci, 233 were stable and were abraded and trephined (AT group), 139 were stable and left in situ (Situ group), and 176 were unstable and were repaired with sutures (Suture group). An unstable tear was defined as a torn meniscus that could be displaced into the intercondylar notch with a probe. Patients who had no medial or lateral meniscal tears at the time of ACL reconstruction served as a control population (No Tear group, n = 526). Subjective follow-up was obtained with a modified Noyes questionnaire. RESULTS: Objective follow-up was obtained at a mean of 4.8 +/- 1.7 years postoperatively. Subjective follow-up was obtained at a mean of 7.3 +/- 3.4 years postoperatively. At a mean of 3.7 years (range, 4 months to 10.7 years) after the reconstruction, a subsequent arthroscopy was required for 14 patients (6.0%) in the AT group, 15 patients (10.8%) in the Situ group, 24 patients (13.6%) in the Suture group, and 15 patients (2.9%) in the No Tear group; these numbers were not statistically significant. The mean total subjective score was not statistically significantly different between groups. CONCLUSIONS: Repaired unstable peripheral vertical medial meniscus tears have a failure rate of 13.6%, most retears occurring more than 2 years after repair. Of stable peripheral vertical medial meniscus tears treated with abrasion and trephination, most (94%) remain asymptomatic without stabilization.
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Affiliation(s)
- K. Donald Shelbourne
- Methodist Sports Medicine Center, Indianapolis, Indiana (K.D.S.); and the Hillsboro Orthopaedic Group, Hillsboro, Oregon (B.P.R.), U.S.A
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Abstract
Meniscal tears are very common sports injuries. Typical symptoms include pain, catching, and buckling. Signs on physical exam include joint-line tenderness, effusion, and, possibly, a click when the knee is taken through full range of motion. MRI is often needed to confirm tears and differentiate pain from that caused by other injuries such as articular cartilage damage. Treatment comprises physical therapy and rest, partial meniscectomy, or, in special instances, surgical repair. Therapeutic goals, which are often achieved, are to restore a high level of pain-free function and to prevent premature joint degeneration.
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Affiliation(s)
- J Bernstein
- University of Pennsylvania, Philadelphia, PA, 19104-6081, USA.
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Abstract
BACKGROUND Injuries to the knee menisci are common and operations to treat them are among the most common procedures performed by orthopaedic surgeons. OBJECTIVES To evaluate the effects of common surgical interventions in the treatment of meniscal injuries of the knee. The four comparisons under test were: a) surgery versus conservative treatment, b) partial versus total meniscectomy, c) excision versus repair of meniscal tears, d) surgical access, in particular arthroscopic versus open. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE and bibliographies of published papers. Date of the most recent search: August 1998. SELECTION CRITERIA All randomised and quasi-randomised trials which involved the above four comparisons or which compared other surgical interventions for the treatment of meniscal injury. DATA COLLECTION AND ANALYSIS Trial inclusion was agreed by both reviewers who independently assessed trial quality, by use of a 12 item scale, and extracted data. Where possible and appropriate, data were presented graphically. MAIN RESULTS Three trials, involving 260 patients, which addressed two (partial versus total meniscectomy; surgical access) comparisons were included. Partial meniscectomy may allow a slightly enhanced recovery rate as well as a potentially improved overall functional outcome including better knee stability in the long term. It is probably associated with a shorter operating time with no apparent difference in early complications or re-operation between partial and total meniscectomy. The long term advantage of partial meniscectomy indicated by the absence of symptoms (symptoms or further operation at six years or over: 14/98 versus 22/94; Peto odds ratio 0.55, 95% confidence interval 0.27 to 1.14) or radiographical outcome was not established. The results available from the only trial comparing arthroscopic with open meniscectomy were very limited in terms of patient numbers and length of follow-up. However it is likely that partial meniscectomy via arthroscopy is associated with shorter operating times and a quicker recovery. REVIEWER'S CONCLUSIONS The lack of randomised trials means that no conclusions can be drawn on the issue of surgical versus non-surgical treatment of meniscal injuries, nor meniscal tear repair versus excision. In randomised trials so far reported, there is no evidence of difference in radiological or long term clinical outcomes between arthroscopic and open meniscal surgery, or between total and partial meniscectomy. Partial meniscectomy seems preferable to the total removal of the meniscus in terms of recovery and overall functional outcome in the short term.
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Affiliation(s)
- J R Howell
- Orthopaedic Department, Royal Cornwall Hospital (Treliske), Truro, Cornwall, UK.
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