Update on Treatment of Meniscal Injuries Function Function Radin et al., CORR, 1984

Transcription

1 Chris O Grady, M.D Update on Treatment of Meniscal Injuries Basic Science Anatomy Biomechanics Clinical Presentation Diagnosis Treatment Rehabilitation Future Biologics PRP Stem Cells 2 Function --joint filler (incongruous condyles) -2.5 greater contact area when mensicus present -prevent capsular/ synovial impingement -joint lubrication/ synovial distribution -load (40-60% of standing load -stability (esp. rotatory) Medial Meniscus Secondary stabilizer to AP translation in ACL deficient knee (more capsular attachment) Follows tibia- more likely to be torn with rotatory force Function Lateral Meniscus % increase in lateral compartment contact stresses when removed (convex lateral plateau) 3 4 Radin et al., CORR, Load transmission increases in flexion vs ext 5 Fukubayashi et al

2 Anatomy Histo: Fibrocartilage Composition Water 65%-75% Organic matter 25%-35% 75% Collagen Type I 90% Types II, III,IV, V, VI, XVIII 25% Other Proteoglycans, DNA, Elastin Triangular cross section Provide structural integrity concavity of the articulation Anatomy Dissipates forces/friction across medial/lateral compartments Axial Compression Horizontal hoop stress Creates shear forces 7 8 Structure Anatomy Mesh network: Arranged obliquely, radially, and vertically Prevents shear Bundles: Radial Located at surface and midsubtance Prevent longitudinal tears Circumferential Disperses compressive loads (hoops around wooden barrel) Anatomy Medial Meniscus C-Shaped structure Less mobile Firmly attached to capsule Deep MCL at mid body Posterior fibers of anterior horn merge with transverse ligament Periphery of meniscus attached to capsule through coronary ligaments Medial Meniscus Wider in diameter than the lateral meniscus 9-10 mm wide 3-5 mm thick Covers 51-74% of condyle Lateral Meniscus Semi-circular in shape More mobility Less peripheral attachments Popliteal Hiatus Anterior and posterior horns attach closer to each other than medial meniscus Anterior horn attaches adjacent to ACL Posterior horn attaches behind inter-condylar eminence 2

3 Lateral Meniscus Covers more tibia 75-93% of condyle mm wide 3-5 mm thick Meniscofemoral ligaments Humphrey & Wrisberg Run from posterior horn of lateral meniscus to medial femoral condyle Major Role Stabilize PH of Lateral Meniscus Minor role Stabilizing posterior tibial translation with compromised PCL 14 Humphrey Sag MRI Discoid Meniscus Anterior to PCL Incidence of 3.5-5% Usually lateral, but 20% bilateral Discoid Meniscus Blood Supply PeriMeniscal Capillary Pleux Type I-Complete Type II-Incomplete Type III-Wrisberg subtype Watanabe Classification

4 Blood Supply % of meniscus vascular at birth 9 months: Inner 1/3 rd avascular By age 10: Mature Peripheral 10-25% of lateral vascular Peripheral 10-30% of medial vascular Inner 2/3rds by synovial fluid diffusion Arnoczky et al AJSM Arnoczky et al AJSM 1982 Vascularity Zones Red-Red Fully vascular Excellent healing potential Red-White Border of vascular supply Good healing potential White-White Relatively avascular Poor healing prognosis 21 Cannon et al, Epidemiology Basic Science Anatomy Biomechanics Clinical Presentation Diagnosis Treatment Rehabilitation Future Biologics PRP Stem Cells Incidence (acute tears) cases/100,000 people per year Male:Female Ratios 2.5-4:1 Younger Acute Older Degenerative (MMT) 1/3 occur with ACL tear Acute: LMT Chronic: MMT

5 History Basic Science Anatomy Biomechanics Clinical Presentation Diagnosis Treatment Rehabilitation Future Biologics PRP Stem Cells Mechanism Twisting, change in direction, or hyper-flexion injury Feeling a pop Acute pain or swelling Slow-forming effusion Locking/catching sensation Degenerative tears(>40) often more atraumatic with a chronic history Postmenisectomy syndrome toothache pain after menisectomy Inspection Physical Exam Mild to moderate joint effusion Usually no ecchymosis Limb alignment ROM Typically normal However, longitudinal bucket handle tears may block full extension Stability Associated ligamentous injury Physical Exam Palpation Joint line tenderness 28 McMurray British Journal of Surgery 1942 Apley Grind Test JBJS 1947 MMT: 90deg, valgus, ER, ext knee + click Sen:59% Spec: 93-97% Prone, 90deg Stabilize thigh Compress joint, ER Sen: 41% Spec: 86-93%

6 Thessaly Maneuver JBJS 2005 Ege s Test 20 deg flex (IR, ER) Harrison, Clin J Sport Med, 2009: 66 patients with +Thessaly, 65 had arthroscopic findings of meniscal tear Sen 90% Spec 97.7% Squat with full hip ER/ IR 32 Imaging Discoid Meniscus Weight bearing Don t miss OA X-rays: AP/Laterals Merchant/Sunrise degree flexion views Calcifications CPPD Widening Squaring Cupping Hypoplastic Imaging MRI Grading MRI: Diagnostic procedure of choice 95% accuracy High NPV Grading system 0, I, II, III Grade III consistent with complete tear 0: normal I: globular increase in signal with no extension to surface II: near signal increase that does not extend to surface Arthroscopy still gold standard Look for condylar edema (increased contact pressure on condyle when meniscus torn) III: increased signal that abuts the freed edge of meniscus Indicates tear

7 Discoid Meniscus Bow Tie Sign MRI 3 or more 5mm cuts with continuity of meniscus Complex tear Double PCL Bucket Handle Arthrography Classification of Tears 39 Radial Tear Common Meniscal Tears 41 AANA Advanced Arthroscopy: The Knee 42 7

8 Horizontal Tear Bucket-Handle Tear AANA Advanced Arthroscopy: The Knee AANA Advanced Arthroscopy: The Knee 44 Meniscal Root Tears Root Tears Milder symptoms Joint line pain Less mechanical symptoms (only 9-14%) Posterior knee pain with deep flexion McMurray + 57% Effusion + 14% -3mm extrusion on mid coronal -condylar edema Extruded meniscus Ghost sign Lee et al Arthroscopy 2009 LaPrade et al, AJSM March 2014 Treatment Options Depends on Symptoms Basic Science Anatomy Biomechanics Clinical Presentation Diagnosis Treatment Rehabilitation Future Biologics PRP Stem Cells Affect on ADLs, Work, Sports

9 RICE Wt Loss Bracing (unloader) Injections Physical Therapy ROM Strengthening NSAIDs Nonsurgical Options Surgical Options 1. Leave alone Promote healing only 3. Meniscal repair Ideal treatment for the ideal situation Vertical mattress sutures gold standard 2. Meniscectomy surgical morbidity and improves function Stable contoured rim Preserve as much tissue as possible Long-term risks? 4. Meniscal transplant Symptomatic patient too young for a TKA 49 Stable partial tears Stable longitudinal tears < 10 mm length < 3-5 mm displacement Do not displace into notch Do not touch femoral condyle Degenerative tears with significant OA Short radial tears: < 3 mm in length 1. Leave alone Leave tourniquet down to assess bleeding: Rasping Trephination Marrow stimulation, PRP, etc. Enhance biologic healing response E.g. notch microfx 2. Meniscectomy Indications Meniscectomy 2. Meniscectomy Technique

10 3. Repair Options Open Meniscal Repair Trans-capsular approach with capsule and synovium opened for visualization Open Inside- Out Indications: Tight compartments Peripheral tears in posterior horns Disadvantages: Outside- In All- Inside Larger approach Greater tissue trauma 55 Open Meniscal Repair Arthroscopic Inside-Out Results 80-90% survival rate after 13 years DeHaven Clin Sports Med 1990 Rockborn and Gillquist JBJS Br 2000 Muellner AJSM 1999 MRI data included, but unreliable method to assess healing Advantage: Consistent/More accurate suture placement Gold Standard Disadvantages: Risk of neurovascular injury 75-91% survival/healing Barrett et al Arthroscopy 1998 Johnson et al AJSM 1999 Arthroscopic Inside-Out Arthroscopic Inside-Out Advantage: Consistent/More accurate suture placement Gold Standard Disadvantages: Risk of neurovascular injury 75-91% survival/healing Barrett et al Arthroscopy 1998 Johnson et al AJSM 1999 Advantage: Consistent/More accurate suture placement Gold Standard Disadvantages: Risk of neurovascular injury 75-91% survival/healing Barrett et al Arthroscopy 1998 Johnson et al AJSM

11 Arthroscopic Outside In Advantage: Less neurovascular risk Good for tears in anterior horn and body Disadvantage: Less accurate suture placement Arthroscopic All-Inside Advantages: Decreased neurovascular risk Minimally Invasive Decreased operative time Similar success rates 65-78% survival/healing Morgan et al AJSM 1991 Rodeo et al AJSM 1999 Plasschaert et al AJSM New Gold Standard? All-Inside Device Comparisons Mehta, AJSM, 2009: FastFix (S&N) vs. Meniscal Cinch (Arthrex) vs. MaxFire (Biomet) Ultimate load to failure FastFix 86.1N, Meniscal Cinch 85.3N, MaxFire 64.5 N Gap formation (after 100 cylces) MaxFire: 6.7 mm Meniscal Cinch: 4.07mm FastFix: 3.59mm No significant difference after 500 cycles More Comparisons Barber et al Arthroscopy 2011 Methods Outside-In Vertical Mattress with both Ethibond and Orthocord All-Inside: Meniscal Cinch, MaxFire, FastFix, Sequent (ConMed), OmniSpan Gap Formation and Load to Failure Results No significant differences except MaxFire = bad Treatment Complications Isolated Bucket Handle Meniscus Tears (19 studies) Level II Studies, 1 Level III 17% failure inside out vs 19% all inside (No sig diff) Similar Patient reported outcome scores Complications Inside out- nerve injury/ irritation All inside- local soft tissue irritation, swelling, implant migration Chondral injury issue in older model more rigid devices 65 Excessive meniscectomy Loss of hoop stress = chondrosis, early OA Failure to heal repair May require re-operation for meniscectomy Neurovascular injury with repair techniques Foreign material concerns Suture and Anchors Chondral injury from intra-articular devices Soft tissue penetration or entrapments Collateral ligaments, IT band, skin, etc. Beware posterior capsular pain with repairs 11

12 Neurovascular Issues Caution with All-Inside Cohen et al J Knee Surg Fast Fix device within 3 mm of pop artery in half of specimens Complications of Suture Meniscal Root Tears Non-op: Co-morbidities preclude surgery Partial Meniscectomy: Partial root avulsions Avoid completion of the tear Root Repair Suture anchors, trans-osseous Allaire et al JBJS 2008 TF contact pressures as high as complete medial menisectomy Repair restores normal mechanics Meniscal Root Tears Trans-osseous repair: Respecting the Meniscus Trends LaPrade et al, AJSM March 2014 Abrams et al AJSM 2013 Overall 11.4% increase in meniscal repairs Increase 48.3% meniscal repairs with concomitant ACL recons Increased educational emphasis on meniscus preservation/repair 12

13 Candidates: 4. Meniscal Transplantation Young, active, healthy individual (<40 yrs) Significant knee pain and limited function Too young for TKA Mechanical meniscal damage Absent or non-functioning Failed conservative tx Normal mechanical alignment and stable knee Outerbridge I or II cartilage changes 4. Meniscal Transplantation Techniques Meniscus +/- Bone Plug 74 Outcomes 4. Meniscal Transplant Noyes et al AJSM patients 96% follow-up Survivorship Analysis (xray, MRI, exam, reoperation) 2 yr 5 yr 7 yr 10 yr 15 yr - Concurrent Osteochondral autograft= lower survival rate -Conclusion: MAT eventually fail and is Example : 41 y.o male years s/p medial MAT Meniscal Allograft Outcomes Retrospective, AJSM pt, avg age 38 Min F/U 2 yr (avg 4.9 yr) 79% Return to sport 88% were recreational 12% professional 49% at same level Avg 8.6 months return Age at MAT, highest predictor of outcome Meniscal Transplant Complications: Difficulty in locating, harvesting, and distributing size-matched specimens Technically difficult surgery Preservation techniques Cell viability Biomechanical properties alteration Graft failure Basic Science Anatomy Biomechanics Clinical Presentation Diagnosis Treatment Rehabilitation Future Biologics PRP Stem Cells Disease transmission 78 13

14 Rehab - Meniscal Repair Meniscal Repair Rehab Day 1-10: Brace locked at 0 for ambulation and sleep 25-50% WB with crutches PROM 0-90 SLR, Quad sets Week 2-4 Progress PROM to by week 4 50% WB at week 2 Full WB at week 3 SLR, mini-squats, knee extensions 90-0, balance Continue to lock brace at night and for ambulation Meniscal Repair Rehab Meniscal Repair Rehab Weeks 5-8 Discontinue brace Strengthening: Wall squats 0-70 Knee extensions Lateral step ups Week 9 Initiate stair-stepper Progress to isotonic strengthening program Week 12 Initiate pool running Balance Bike Meniscal Repair Rehab 4 months: Deep squats Inline running 5 months: Pivoting and cutting Agility drills Basic Science Anatomy Biomechanics Clinical Presentation Diagnosis Treatment Rehabilitation Future Biologics PRP Stem Cells 6 months: Return to activity 84 14

15 Biologic Enhancement Biologic Enhancement Fibrin Clot Jang % Healing (41menisci) Synovial Abrasion Ochi Arthroscopy 2001 Activates chemotactic factors Trephination Create vascular channels via removal of core of tissue Connects avascular area to peripheral blood supply Biologic Enhancement Biologic Enhancement Vascular channels Cook AJSM 2007 BioDuct (bioabsorbable porous implant) Vascular access channels 71% healing of avascular tears in canine model Platelet-Rich Plasma Miller (2015): Meniscus Repairs with (15) vs. w/o PRP (20) No difference in clinical outcome scores, return to work/ sport or reoperation Stem Cells 3 Groups (55 pt); Injection 1 wk after parital medial menisecotmy ex vivo cultured Ex vivo cultured adult human mesenchymal stem cells, hmscs (Osiris Therapeutic) GroupA: Low concentraion (50x10-6) Allogenic MSC GroupB: High Concentraion (150) All MSC Group C: Control (Hyaluronic Acid) 12 months to eval meniscal volume MSC group showed 24% of Group A and 6% of Group B reached 15% increase in meniscal volume None in group C showed increased meniscal volume (>15%) Decreased Pain (VAS) in MSC groups 15