Cartilage Repair Center Brigham and Women s Hospital Harvard Medical School

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1 Brigham and Women s Hospital Harvard Medical School Safety, feasibility, and radiographic outcomes of the anterior meniscal takedown technique to approach chondral defects on the tibia and posterior femoral condyle: a matched control study Gergo Merkely MD 1, 2 Tom Minas MD, MS 1, 5 Takahiro Ogura MD 1, 3 Jakob Ackermann MD 1 Alexandre Barbieri Mestriner MD 1, 4 Andreas H. Gomoll, MD 1, 6 1, Brigham and Women s Hospital, Harvard Medical Center, Boston, MA, USA 2 Department of Traumatology, Semmelweis University, Budapest, Hungary 3 Sports Medicine Center Funabashi Orthopedic Hospital Funabashi, Chiba, Japan 4 Universidade Federal de São Paulo, São Paulo, Brazil 5 Paley Orthopedic and Spine Institute, West Palm Beach, Florida, USA 6 Hospital for Special Surgery, New York, New York, USA 850 Boylston Street Chestnut Hill, MA T: F:

2 Disclosures Gergo Merkely MD No financial conflicts to disclose.

3 Background Articular cartilage defect on the tibial plateau or posterior femoral condyle can be challenging to visualize and approach. To perform a thorough defect preparation and repair, hyperflexion of the knee and takedown of the anterior meniscal horn isoften necessary. After cartilage repair, transosseus sutures are used to reattach the anterior meniscal root to its insertion and the intermeniscal ligamentisrepaired. However, clinical evidence is lacking to support the safety of this technique.

4 Aim The aim of this study was to investigate whether meniscal extrusion develops after patients undergo meniscus takedown and transosseous refixation during autologous chondrocyte implantation (ACI). We hypothesized that anatomical repair using transosseous refixation of the anterior root of the meniscus in addition to repair of the intermeniscal ligament would provide secure fixation.

5 Methods We analyzed data from 124 patients with a mean follow-up of 6.8 ± 2.5 years. Sixty-two patients who underwent ACI with anterior meniscus takedown and refixation by the senior surgeon, [TM], were compared with a matched control group of patients (by age, gender, BMI, defect size, and affected compartment) who underwent ACI without meniscus takedown. Meniscal extrusion was investigated by measuring the absolute value and the relative percentage of extrusion (RPE) on 1.5-T magnetic resonance images (MRI) at finalfollow-up. The number of menisci with radial displacement greater or lesser than 3 mm was determined. In cases where a preoperative MRI was available, both pre- and postoperative meniscal extrusion was evaluated (n = 30) in those patients undergoing meniscaltakedown.

6 Methods Figure 1. Meniscal extrusion (meniscus is contoured by the dashed line) is defined as the greatest distance (a) from the most peripheral aspect of the meniscus to the border of the tibia, excluding any osteophytes on coronal images. PRE is defined as the percentage of the width of extruded menisci (a) compared with the entire meniscal width (b) (RPE = a/b x 100).

7 Surgical Procedure In patients with a tibial plateau and/or posterior femoral condyle defect, the anterior horn of the meniscus isreflected by incising the intermeniscal ligament and anterior root, and then mobilizing the meniscus together with the joint capsule by subperiosteal dissection off the tibia as a complete sleeve (Figures 2A and 2B). The knee is hyperflexed, and the tibia externally rotated for the medial compartment and internally rotated for the lateral compartment, providing excellent access to the defects. Following ACI, the meniscus was repaired with transosseous 1-0 Vicryl sutures (Ethibond) using a tapered needle and the intermeniscal ligamentwas reduced and repaired. (Figure 2C).

8 Surgical Procedure Figure 2. Perioperative images of a patient who underwent autologous chondrocyte implantation (ACI) for a lateral tibial plateau defect with meniscus takedown and reattachment. (A) Image showing the takedown of the intermeniscal ligament and the anterior horn of the meniscus. (B) Image showing the defect after ACI procedure. (C) Image showing transosseous refixation of the anterior meniscal horn with non-absorbable sutures and intermeniscal ligament (arrows) repair.

9 Results Baseline demographics showed no significant differences between groups. The time to failure after ACI averaged 3.3 ± 1.7 years. Mean follow-up period was 3.2 ± 1.5 years (revision to OCA: 3.5 ± 1.7; primary OCA: 2.7 ± 0.9). There were no significant differences in reoperation rates and survival rates between the groups.

10 Results Table 1. Patients Demographics

11 Results Table 2. Comparison of Radial Displacement between Patients with Meniscal Refixation after Meniscus Takedown and Control Patients withoutmeniscus Takedown. Table 4. Pre- versus postoperative comparison of displacement in patients withmeniscus takedown

12 Conclusion In conclusion, our matched cohort study identified overall low meniscus extrusion rates that were not different between patients with and without meniscal takedown during cartilage repair with ACI. Meniscal takedown and subsequent transosseous refixation is a safe and effective technique for exposure of the tibial plateau and posterior femoral condyle.

13 References 1. Ogura T, Mosier BA, Bryant T, Minas T. A 20-year follow-up after first-generation autologous chondrocyte implantation. Am J Sports Med. 2017;45(12): Minas T, Von Keudell A, Bryant T, Gomoll AH. The John Insall Award: a minimum 10- year outcome study of autologous chondrocyte implantation. Clin Orthop Relat Res. 2014; 472(1): Biant LC, Bentley G, Vijayan S, Skinner JA, Carrington RW. Long-term results of autologous chondrocyte implantation in the knee for chronic chondral and osteochondral defects. Am J Sports Med. 2014;42(9): Minas T. Autologous chondrocyte implantation. In: Minas T, editor. A primer in cartilage repair and joint preservation of the knee. Philadelphia, PA: Elsevier; p Lamblin CJ, Wahl CJ. Treatment of an articular lesion of the lateral tibial plateau utilizing a tibial drawer-exposure osteotomy and osteochondral allograft transplant: a case report. J Bone Joint Surg Am. 2011;93(12):e66(1-6). 6. Wajsfisz A, Makridis KG, Djian P. Arthroscopic retrograde osteochondral autograft transplantation for cartilage lesions of the tibial plateau: a prospective study. Am J Sports Med. 2013;41(2): Ueblacker P, Burkart A, Imhoff AB. Retrograde cartilage transplantation on the proximal and distal tibia. Arthroscopy. 2004;20(1):73-8.