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311 - Arthroscopic Meniscus Repair Indication and Technique

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					                                                                                   2011 Annual Meeting
                                                                                   Instructional Course
                                                                                     Lecture Handout




 Course Number: 311
 Course Title: Arthroscopic Meniscus Repair: Indication and Technique
 Location: San Diego Convention Center, Room 33
 Date & Start Time: 17-Feb-2011 08:00 AM
 INSTRUCTORS WHO CONTRIBUTED TO THIS HANDOUT:

 John D Kelly IV, MD - 7 (None; SLACK Incorporated); Submitted on: 10/17/2010.
 Nicholas A Sgaglione, MD - 1 (Biomet);3B (CONMED Linvatec; Smith & Nephew); Submitted on: 10/07/2010
 and last confirmed as accurate on 10/07/2010.
 Peter R Kurzweil, MD - 2 (Covidien);3C (Pierce Surgical Corporation);4 (Orteq); Submitted on: 04/07/2010 and
 last confirmed as accurate on 10/07/2010.


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DISCLAIMER
The material presented at this course has been made available by the AAOS for educational purposes only.

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course and for all claims, which may arise from the use of techniques and strategies demonstrated therein. The
material is not intended to represent the only methods, procedures or strategies for the situations discussed. Rather,
the course is intended to present an array of approaches, views, statements and opinions which the faculty believe
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                                     Meniscus Repair ICL 311

                                     San Diego February 2011



Moderator -- Peter R. Kurzweil, MD

Faculty – Nick Sgaglione, MD and John Kelly, MD



This course is divided into four sections, as follows:

   1. Dr. Kelly – appropriate selection of meniscus tears to repair concentrating on indications
      and contraindications.
   2. Dr. Kurzweil – Techniques for Meniscus repair. Methods to assess the reparability of
      meniscus tears intra-operatively as well as tips for using suture and fixators
   3. Dr. Sgaglione – The future of meniscus repair, including biologic augmentation such as
      blood clot and PRP and the use patches to fill meniscal defects
   4. Case Presentations
                 MENISCAL REPAIR TECHNIQUES AAOS 2011

                      Peter R. Kurzweil, MD, Fellowship Director
                    Southern California Center for Sports Medicine
                                   Long Beach, CA


In Surgery:

   •   General Anesthesia
          o Worried about using local anesthetics with recent chondrolysis cases
          o Allows opening of joint space to avoid scuffing articular
              cartilage
   •   Have instruments ready for several techniques
   •   Prophylactic antibiotics (?) – for routine scope + implants

Step 1: Assess bleeding at tear site
   • No tourniquet
   • No pump

Step 2: Can I instrument tear without scuffing articular cartilage?
   • Medial - may pie crust MCL & thigh post medial (valgus stress)
          o Pie-Crust MCL for tight knees
   • Lateral - Figure 4

Step 3: Prepare tear site for repair: RASP

Step 4: Plan on getting stable, anatomic reduction with compression at the repair site
   • Philosophy: like fixing a fracture
   • Which Repair technique is best? (Becker Arthroscopy 2009)
           o Suture repair provides superior biomechanical stability vs. Fixators
           o Clinical Success rate does not correlate with strength of repair
           o Biologic factors may be more important than choice of fixation

Step 5: Carrying out the plan (my preferred approach)
   • Posterior 1/3rd – Fixators
   • Anterior 2/3rd – Outside-In Sutures
NEURO-VASCULAR RISKS:
  • MEDIAL -- Know location of the saphenous nerve: trans-illuminate: nerve is just
    posterior to saphenous vein

   •   LATERAL --Beware fixators in the posterior horn lateral meniscus. Miller (J Knee
       Surg. July 2007)
          o Fixator within 3 mm of popliteal artery in 43% of the specimens.




                           •   2.1% Incidence of ABERRANT POPLITEAL ARTERY
                               (Minas AJSM 2008)
                               o Reason to get pre-op MRI scan
                               o Beware posterior horn lateral meniscus tear




2 SURGICAL OPTIONS – Sutures or Fixators

Sutures:                                           Fixators:
   1. Inside-Out                                      1. 1st Generation
   2. Outside-in                                      2. 2nd Generation
   3. All-inside

1. Sutures - Inside-out:
   • Most commonly done (worldwide) - the “gold standard” – but
     will skip because most no longer due or are not interested

2. Sutures - Outside-In
  • Indication: anterior 2/3rds of meniscus
  • Small incisions – “nick & spread” to capsule
        o To avoid saphenous nerve injury

   •   Advantages over inside-out:
          o No posterior incision
          o No rigid intra-articular cannulas
          o No needle-stick injuries to surgeon
          o Simple & inexpensive
  •   Technique
         o Meniscus Mender
         o Can do using only a spinal needle         (Kasemkijwattana. Arthroscopy 2004)


3. Sutures – All-Inside
   For posterior 1/3rd tears - 3 options to suture without using fixators:
     ♦ Needle from anterior portal (Espejo-Baena. Arthroscopy
         March 2008)
     ♦ Meniscus Viper (Arthrex)
          o Disposable suture passing instrument
          o Suture grasping needle – pierces tear & retrieves suture
     ♦ Flexpass (Pierce Instruments)

      •    All three are all-inside methods
            o Create vertical mattress suture
            o Require arthroscopic knot tying
            o No additional incisions – placed through
                existing portals
            o Difficult to access in tight posterior
                compartments

ALL SUTURE DEVICES

       •   Meniscal AS (All-Suture) (Covidien)
       •   CrossFix (Cayenne)
                o These deploy a suture with no anchors
                o Pre-tied sliding knot that sits on the meniscus
                o Each device delivers one suture
                o Covidien is Tennessee slider with two half – hitches
                o Cayenne


FIXATORS

First Generation - 1996

  •   Rigid, with threaded or barbed screw or nail
  •   High complication rate and failures
  •   Don’t use
SUTURE BASED FIXATORS – since 2001 – now 3rd Generation

   •   Can fix peripheral tears (to capsule) & adjust compression
                                   st
          o Not possible with 1 generation implants
   •   Omni-Span (Mitek)
   •   FasT-Fix 360 (S & N)
   •   Meniscal Cinch (Arthrex)
   •   Max-Fire (Biomet Sports Medicine)

Fixator Insertion Pearls
   • Avoid soft tissue entrapment when introducing device through portal
           o Shave fat pad around portal
           o Use metal skid in portal directed at meniscus and slide fixator along, keeping
               fixator “tip down” (pointing into cannula) as it slides in
   • For horizontal mattress configuration: insert most posterior implant first so that
       visualization of 2nd implant is not compromised by excess suture around 1st implant.
   • All Fixators deployed on rigid cannulas, which makes portal placement critical. Keep the
       portal low, and parallel to the tibial plateau
   • Try to insert fixators with horizontal orientation to minimize cutting radial tie fibers of
       meniscus


Omni-Span – (replaces Rapid-Loc)
  • Eliminates Top-Hot sitting on meniscus
  • Anchors (called “backstops”): PEEK
  • Insertion needle:
  • 0°, 12° & 27° needle angles
  • Suture: # 2-0 ORTHOCORD
  • Pre-tied sliding knot: proprietary self-locking modified bunt knot
  • Actively deploy each anchor after passing through tear
  • Technical Pearls:
        o 12° best angle, most versatile
        o Keep gun-trigger depressed when removing needle
        o Compensate for kick-back when deploying anchors to maintain needle depth
        o Don’t over-penetrate: 13-15mm is good depth
        o Use a probe in tensioning


FasT-Fix 360 – (replaces Ultra FasT-Fix)
   • Anchors: PEEK (or PLLA)
          o T1 1.0mm (W) x 1.0mm (H) x 5.1mm (L)
          o T2 0.76mm (W) x 1.5mm (H) x 4.8mm(L)
   • Insertion needle: 17 gauge
          o Straight (0°), +27°, & -12°
   • Suture: # 2-0 Ultra-Braid
   •   Pre-tied sliding knot: proprietary (no name)
   •   Major Advances
          o Needle and anchors smaller than prior model
          o Deploy anchor actively, so can insert and withdraw needle to reposition
   •   Technical Pearls
          o Push deployment trigger all the way forward to deploy each implant.
          o After T1 deploys let go of trigger and allow it to completely spring back
          o Then slowly retract needle & reinsert carefully for T2 deployment


Meniscal Cinch -
  • Anchors: PEEK
          o 0.75mm(W) x 1.5mm(H) x 5mm(L)
  • Insertion needle: .85mm
          o 15° curved up
  • Suture: # 2-0 Fiberwire
  • Pre-tied sliding knot: modified Weston
  • Major Advances
          o Knot sits behind meniscus
          o Deploy anchor actively, so can insert and withdraw needle to reposition
  • Technical Pearls
          o After 1st anchor deploys, excess suture in the joint
             can cause difficulty with visualization. Gently
             pulling external suture will remove the slack and
             facilitate insertion of 2nd anchor.
          o Knot follows 1st anchor
                 • For vertical stitch place 1st anchor through
                      body of meniscus and 2nd anchor superiorly
                      to prevent flouncing or curling up as knot
                      tightened

MaxFire
  • Anchors: “soft anchors” made of #5 polyester suture sleeves
  • Insertion needles: 18 gauge (1.3mm)
          o 5° and 15° curved
  • Suture: # 2-0 MaxBraid
  • Knotless: uses ziploop technology – creates two parallel sutures
  • Pearls: Grab the loop strands (leaving single strand free). Pull on
     each loop strand to determine which one tightens the inner loop.
     Alternately pulling ths loop strand and the single strand will tighten the
     first loop. Then simply pull the single strand until the second large loop
     is seated against the meniscus.
Summary of FIXATORS

Company Fixator           Needle     Needle         Suture Suture       Anchor         Anchor Size (mm)
                          Size       Curve          Size   Type         Material       LxHxW
S&N         FastFix 360   17 gauge   0°, 27°,-12°   2-0    UltraBraid   PEEK           T1 – 5.1 x 1.0 x 1.0
                          1.5 mm                                        or PLLA        T2 – 4.8 x 1.5 x 0.8
Mitek       Omni-Span     1.8mm      0°, 12°, 27°   2-0    OrthoCord    PEEK           B1 – 5.5 x 2.5 x 1.1
                          16 gauge
                                                                                       B2 – 4.5 x 2.3 x 1.1
Arthrex     Cinch         21 gauge   15°            2-0    Fiberwire    PEEK           A1 – 5.0 x 1.5 x 0.7
                          0.9 mm                                                       A2 – same
BioMet      MaxFire       18 gauge   5° & 15°       2-0    MaxBraid     #5 polyester
                          1.3 mm




In the future BIOLOGIC enhancement more important – Blood Clot & PRP




What do I do? – Final Points:
  • Outside-in anterior ½ - 2/3rd
  • Suture based fixators for posterior 1/3rd
  • Use both! hybrid fixation
  • Insert sutures & fixators perpendicular to the tear
          o May require accessory portals
  • Make sure the repair is stable
  • Blood clot or PRP to decrease 20% failure rate (?)




Postop – GO SLOW!
   • Knee brace 4-6 weeks
   • Crutches first 2 weeks
   • ROM > 90° when supine only
   • No squatting x 4 months
   • Unrestricted sports @ 6 months
                                      REFERENCES

FIXATORS:

  •   Haas AL, Schepsis AA, Hornstein J, Edgar CM. Meniscal repair using the FasT-Fix all-
      inside meniscal repair device. Arthroscopy February 2005 (Vol. 21, Issue 2, Pages 167-
      175) 42 knees with 14% failure of 2 years – no complications

  •   Reish MW, Kurzweil PR. FasT-Fix Meniscus Repair. Techniques in Knee Surgery.
      6(3):161-167, September 2007. Pearls for using FasT-Fix

  •   Kotsovolos ES, Hantes ME, Mastrokalos DS, Lorbach O, Paessler, HH. Results of All-
      Inside Meniscal Repair with the FasT-Fix Meniscal Repair System. Arthroscopy. January
      2006 (Vol. 22, Issue 1, Pages 3-9). 61 repairs with FasT-Fix. 10% failure at 1.5 years.

  •   Turman KA, Dicuch DR.  Meniscal Repair: Indications and Techniques.  J. Knee Surg. 
      2008:21:154‐162  good summary of latest techniques and rehabilitation 

  •   Miller MD, Kline AJ, Gonzales J, Beach WR. Pitfalls associated with FasT-Fix meniscal
      repair. Arthroscopy. October 2002 (Vol. 18, Issue 8, Pages 939-943)

  •   Mehta VM and Terry MA. Cyclic Testing of 3 All-Inside Meniscal Repair Devices: A
      Biomechanical Analysis AJSM, Vol. 37, No. 12 Meniscal Cinch and the Ultra FasT-
      Fix performed better than the MaxFire


SUTURES:

  •   Lambert EW, Bonner KF. Arthroscopic Meniscus Repair with Sutures: Outside-In
      Sports Med Arthrosc Rev. 2004;12:25-36.

  •   Wolf BR, Rodeo SR. Arthroscopic Meniscus Repair with Suture: Inside-Out with Fibrin
      Clot. Sports Med Arthrosc Rev. 2004;12:15-24.

  •   Bach BR, Jewell BF, Bush-Joseph C. Surgical Approaches for Medial and Lateral
      Meniscal Repairs. Techniques in Orthopedics 1993. 8(2): 120-128

  •   Laupattarakasem W, Sumanont S, Kesprayura S, Kasemkijwattana C. Arthroscopic
      Outside–In Meniscal Repair Through a Needle Hole (Technical Note) Arthroscopy, Vol.
      20, No 6 (July-August), 2004: pp 654-657 very clever technique

  •   Espejo‐Baena A, Figueroa‐Mata A,  Serrano‐Fernández J, Torre‐Solís F.  All‐Inside 
      Suture Technique Using Anterior Portals in Posterior Horn Tears of Lateral 
      Meniscus.   Arthroscopy, Vol 24, No 3 (March), 2008: pp 369.e1‐369.e4 
       
    •   Christian Stärke, M.D., Sebastian Kopf, M.D., Wolf Petersen, M.D., and Roland Becker,
        M.D. Current Concepts: Meniscal Repair. Arthroscopy: The Journal of Arthroscopic and
        Related Surgery, Vol 25, No 9 (September), 2009: pp 1033-1044
         


N-V RISKS:

    •   Cohen, SB, Boyd L, Miller MD. Vascular Risk Associated With Meniscal Repair Using
        RapidLoc Versus FasT-Fix: Comparison of Two All-Inside Meniscal Devices. J Knee
        Surg. 2007; 20:235 beware fixators in the posterior horn lateral meniscus with FasT-
        Fix – use penetration limiter

    •   Kelly M, McNichol MF. Identification of the saphenous nerve at arthroscopy.
        Arthroscopy. Vol 19, No 5 (May-June), 2003: pp E46

    •   Klecker RJ, Winalski CS, Aliabadi P, Minas T. The Aberrant Anterior Tibial Artery:
        Magnetic Resonance Appearance, Prevalence, and Surgical. AJSM Vol 36, No. 4. May
        2008 2.1% incidence aberrant popliteal artery get pre-op MRI




 
 
           Meniscal Repair:                                        Overview
   Indications, Pre-op Evaluation,
           Post-op Factors                         • What tears should we fix?
                                                   • How can we tell before surgery?
               John D. Kelly IV                    • Discuss post op care
          University of Pennsylvania




                                                           Menisci Heal with Scar
          Indications: an Art
                                                            (not meniscal tissue)
• Principles:
      Some repaired menisci will heal
      Some won’t
      A repaired meniscus is not NORMAL, (but it
      is better than no meniscus!)

     We can help some patients with repair
     We can harm some patients with repair




                                                                  Arnoczky et al




    Repaired Menisci are Smaller                     The Question You Must Ask:
             Pujol et al CT Arthrography

• the width of the repaired meniscus is            • In my hands, will a meniscus repair
  decreased by 10% to 15%                            HELP
•                                                    this patient?




                                                                                           1
      Meniscal Tear Classification                            Help Patients
                                                  • A successful repair may DELAY
       ‘Classic’ Indications
                                                    degenerative changes (Stein AJSM)
• Vascular areas                                  • A repaired meniscus may afford
  – Red on red - best
                                                    proprioception
  – White on red - good
  – White on white – no                           • A repaired medial (and lateral) meniscus
     • Noyes good results in                        will protect an ACL graft
       young patients




                                    Johnson




                                                              Meniscal Repair:
                    Help Patients                              Not ‘Perfect’
  • Lateral menisectomy more consequential        • Rockborn – Repair vs Meniscectomy:
    than medial menisectomy (DJD)                   Long Term Follow UP with XRAY
  • Repair will assist success of chondral
    biologic ‘resurfacing’ (microfracture, ACI,        7yrs. Repair had more joint space on
    OATS etc.)                                              xray
                                                       13yrs. No difference in joint space
                                                            between repaired vs. resected
                                                            meniscus




                Shelbourne 2003                                Majeski 2006
  • Repaired bucket handle medial tears at        • 64 patients with meniscus repair
    time of ACL Recon.                            • Followed 10 years
  • Clinical outcomes of repair not superior      • 46 developed DJD (vs 27 of contralateral
    to menisectomy                                  knee)
  • Repaired degenerative medial tears
    scored lower than repaired non
    degenerative tears




                                                                                               2
      Remember: Not All Tears are                       NOT ALL TEARS are CREATED
           Created Equal                                          EQUAL
 • Longitudinal tears preserve circumferential      • Irgang 2007
   fibers and maintain good measure of ‘hoop                patients with isolated medial
   stress’                                                  meniscal tears stratified into
                                                            tear types
                                                            longitudinal tears associated
                                                            with least chondral insult (root
                                                            avulsion worst!)




                                                           43 yo with ‘lateral knee pain’   Athroscopy 2004

                       Harm
 • Chondral injury
     cannula
                                                 Incidental partial tear
     prominent knots                             Medial meniscus
     prominent fixators
                                                 ‘Fixed’ with two
                                                 Mulberry Knots
                                                 of PDS




       ‘Second Look’
                                                                              Harm
                                                    •   Nerve injury                 •   DVT
                                                    •   Wound complications          •   RSD
                                                    •   Hemarthrosis                 •   Arthrofibrosis
                                                    •   Migration ‘fixators’         •   Meniscal cyst
                                                    •   Infection                    •   Chondrosis from
                                                    •   Synovitis                        absorbable implants?
‘Mulberry Knot’
Chondral Injury                                     •   Vascular injury
and Synovitis




                                                                                                                3
                                                             Minas 2008
                                             • 2.1% incidence of aberrant popliteal artery
                                             • Adherent to posterior cortex postero-
                                               lateral tibia
                                             • Anterior to popliteus
                                             • AT RISK for INSIDE OUT REPAIR




     Go for HIGH YIELD Repairs                          Think Twice for…
                  • Age < 45                                          Age > 45
• ‘High Yield’
                  • Tear ‘age’ less than 8
                    weeks
                                             • Low yield repair   }   Degenerative bucket
                                                                      Partial lateral tears
                  • Non degenerative                                  Presence of chondrosis
                    bucket
                                                                      Radial tear
                  • Tear within 3mm rim
                                                                      ‘Stable’, smaller tear
                  • Tear within 5mm rim
                    for medial tear + ACL                             Secondary tears
                  • Good alignment, min.
                    chondrosis




        Extruded Meniscus                            Extruded Meniscus
   Usually due to ‘Wear and Tear’                 Secondary to Root Avulsion




                                                                         =




                                                                                               4
     Lee at al
   Medial Root
     Repairs
Arthroscopy 2009
                                                                                           Lee at al
                                                                                           ‘no discernable degenerative
                                                                                           arthritic changes were found’




  Reduction of Sagittal Displacement                         Lateral Tears –
      Attained with Root Repair                             Classic Teaching
                                                              • Can ‘leave alone’ if…..

                                                                posterior horn flap

                                                                longitudinal tear
                                                                  posterior to popliteus


                                                                               BUT….




                   Ahn et al: Arthroscopy 2010
    Results of Arthroscopic All-Inside Repair for Lateral
   Meniscus Root Tear Patients Undergoing Concomitant
        Anterior Cruciate Ligament Reconstruction



                                                                                                   Or…use fixator




                                                                                                                           5
Double Attachment of Lateral Root
                                                             Alignment
 (Meniscofemoral Lig. and Direct)
                                           • Affects progression of
                                             arthritis post menisectomy
                                           • Mild varus ~ moderate
                                             varus in predicting DJD
                                           • More malalignment =
                                             greater dependence
                                             on meniscus!
                                           • If chondral surfaces OK,
                                             fix it despite alignment!




 Repair:Malalignment + Preserved
              Joint =                         Location, Location, Location
             Go for it!
                                           • Principles cont.
                                                 It is all about blood
                                                 supply (3-4mm from
                                                 rim)
                                                 If vascularity ‘marginal’ we
                                                 can enhance it (clot,
                                                 growth factors)
                                                 However, if tissue poor, it
                                                 is wise not to ‘be a
                                                 hero’




        Apples and Oranges                      MRI:Predict Reparability?
• Tears with ACL injuries are ‘different   • Nourissat 2008 MRI
  animals’                                   meniscal tears
• More peripheral                          • Lesions ‘reparable’ if
• Less degenerative                          rim < 4mm and
• More ‘blood’                               length > 10mm
                                           • MRI sensitivity for
                                             reparability 94%
                                           • Specificity 81%




                                                                                6
                  Bottom Line                         MOON ACL Study 2003
• In reality, most tears are NOT repairable      • 1014 ACL Reconstructions
      Poehling: only 26% tears ‘peripheral’ in   • Nine Fellowship Trained
            over 6,000 cases!                      Surgeons
                                                 • 69% medial meniscal tears
                                                   “not reparable …or left alone”
                                                 • 88% lateral meniscal tears “not
                                                   reparable…or left alone”




                Medial vs Lateral                        Lateral menisectomy
• Lateral compartment more ‘meniscus               More ‘consequential’ than medial
  dependent’                                      resection regarding symptoms/chondrosis
• Lateral meniscus covers more of lateral         ‘Lower the bar’ for most lateral meniscal
  tibial plateau and transmits more joint load    repairs
  than medial meniscus (70% vs 50%)


      Lateral                    Medial




                 Length of Tear                        Special Considerations:
• Length not as important as stability (hoop     • ‘scholarship athlete’
  stress)                                             ‘take it out doc’
• Generally, longer tears (>10mm) are less            ‘can’t miss this season’
  stable
• Some ‘smaller’ tears are unstable and
  require repair




                                                                                              7
      RX Scholarship Athlete                                  Rehab Issues
• Put the ‘ball in their court’                •   No two tears are alike
     ‘you wouldn’t want me to compromise       •   Some repairs need more ‘nurturing’
     your son’s daughter’s care?’              •   Other repairs need less attention
                                               •   Assess biology and stability of each repair
     affirm that probably better longer term
  results with repair




              Barber 2005                               Rehab Controversies
• Passive flexion and                          • Literature is not straight
  extension in porcine knees
  applied compressive force                      forward about rehab
  across lateral meniscal                        protocols with some
  tears
                                                 data suggesting limited
      BUT…..
            no weightbearing                     weightbearing is of
            applied                              some value, while
            no shear stress                      others refute this
            applied
            porcine tissue




     But….Experience Says…                                  Common Sense
• Flexion increases displacement of medial
  meniscal tear (femoral rollback)             • Weight bearing and
                                                 torsion = shear stress
                                               • Weight bearing increases
                                                 incidence of ‘falls’ and
                                                 twists




                                                                                                 8
                                                     JDK4 Rehab Protocol:
 JDK4 Rehab Protocol: All repairs
                                                    Promising/Stable Repairs
                         0
• Avoid flexion beyond 90 <
     4 weeks                                  • Weightbearing in
                                                extension x 6 weeks
• Avoid deep flexion with weightbearing < 4
  months                                      • Bike 4-6 weeks
• Running at 3.5 months (maybe)               • Closed chain
                                                strengthening 6 weeks
• ‘Cutting sports’ 5 months at (maybe)                               0
                                                (avoid leg press > 45 )
• ASA for DVT prophylaxis for 6 weeks




    JDK4 Rehab Protocol: Less
                                                  Remember Veritas (Truth)
    Promising Biology/Stability
                                              • In the best of hands, patients can expect
• Non weightbearing 6 weeks                     about a 20% failure rate!
• Consider immobilization in extension 1-2    • Counsel your patients that some repairs
  weeks                                         will need more TLC (crutches) than others
• Avoid passive hyperflexion 12 weeks         • Inform the patient that a repaired
                                                meniscus is by no means NORMAL




  Truthful Counseling Will Prepare
           You for Failure                             EXPECT the BEST
                                                 (But be prepared for the worst)




                                                                                            9
                            Summary                        Primum non Nocere
• Go for it if….. good biology:                 •   Poor tissue
    unstable                                    •   Avascular
    good tissue/vascular                        •   Inner rim radial tears
    longitudinal                                •   (Lateral, stable posterior longitudinal
    medial with ACL                                 tears)
    lateral




                            Summary                        CHOOSE WISELY
• If you can perform a ‘low morbidity’ repair
  in a ‘reasonable’ candidate….DO IT!
• Repaired menisci are not ‘normal’… but
  are better than no mensicus
• Be honest about healing potential
• Before you decide to fix…….




john.kelly@uphs.upenn.edu




                                                                                              10
             THE FUTURE of MENISCAL REPAIR: BIOLOGICAL UPDATE
                                  NICHOLAS A. SGAGLIONE, M.D.
                            North Shore Long Island Jewish Medical Center,
                                     Professor and Chairman
                     78th Annual Mtg of the American Academy of Orthopaedic Surgeons
                               ICL 311: San Diego, California, February 17, 2011


I.     INTRODUCTION
       A. Increasingly Active Patients with Great Expectations
       B. Clinical, Patient, Media Demands for Improving Joint Function
       C. Basic Science and Biomechanical Support for Meniscal Preservation
       D. Expanding Complex Knee Reconstructions are Being Carried Out
       E. Improving All – Arthroscopic Repair and Transplantation Techniques
       F. Meniscal Resection : Repair Remains < 9:1 / We Can Do Better
       G. Treatment Trends: Cost Concerns / Minimally Invasive Techniques / Recovery Issues
       H. Emphasis on Biological Solutions in Orthopaedics is Expanding

II.    MENISCUS REPAIR: "PUSHING THE ENVELOPE"
       A. "Best Shot is First Shot" to Preserve the Meniscus
       B. Versatile All – Arthroscopic Repair Techniques
       C. The Case for White – White Repairs (Noyes, Rubman, O'Shea, Okuda)
       D. The Case for Radial, Root Avulsion, Horizontal, Flap Tear Repairs (van Trommel)
       E. Challenges & Limitations: Repair Constructs / Healing – Biology / Recovery
       F. Technical Issues: "We Can Improve on Current Repair Devices"
       G. Healing Issues: " We Can Manipulate Meniscal Healing"
       H. Rehab & Recovery Time issues: " We Can Reduce Repair Recovery Times"

III.   BIOLOGICAL SOLUTIONS TO MANIPULATE HEALING
       A. Capturing the "ACL Advantage"
       B. Trephination & Vascular Access Channels / Bioabsorbable Conduits (Cook)
       B. Fibrin Clot vs. Platelet – Rich Plasma (PRP) Technologies (Henning, Arnoczky)
       C. Marrow Stimulation Techniques (Freedman)
       D. Growth Factors in your OR: Point of Care / Autologous / Cost – Effective Solution
       E. Cell – Based Targeting Therapies

IV.    EVOLVING DEVICE DEVELOPMENTS
       A. Versatile, easier and quicker arthroscopic insertion and delivery
       B. Rigid implant " straight pins " evolving to suture – based hybrid devices
       C. Strength improvements in load sharing devices allowing quicker recovery
       D. The case for complex red – white & white – white repairs
       E. Improved and more predictable bioabsorbable polymers
       F. Biological manipulation of meniscal healing: Bioactive sutures
       G. Bio - Adhesives: biologically derived vs. polymers / Photochemical Bonding
       H. Gene – enhanced tissue engineering applications
     MENISCAL SURGERY UPDATE 2011                                             N. Sgaglione, M.D.




V.      CURRENT PRP PROJECT: Platelet – Rich Fibrin Matrix (PRFM)
         A. Arthroscopic / Point of Index Intervention Autologous Method to Augment Repair
         B. 9cc Patient Sterile Blood Sample / 2 - Step Centrifugation and Matrix Preparation
         C. 1st (6 minute) Spin Step at 1100 rcf: Separation Step using NaCitrate as Anticoagulant
         D. Uses Gel Separator to Separate Cells from Plasma (with 97% platelet recovery)
         E. 2nd (15 minute) Spin Step at 1450 rcf: Concentrates Dense Fibrin Matrix
         F. Platelet yield and concentration is 4 – 5x over Baseline
         G. Platelet (Plt) pooled polypeptide growth factors are loaded in alpha granules
         H. Growth Factor Release is Based on Plt Activation during Clotting Cascade
         I. Concentrated Factors: PDGF – A & B, PD – EGF, TGF – b, VEGF, bFGF, ECGF
         J. Uses CaCl & Autologous Prothrombin to Initiate Fibrinogen to Fibrin clot conversion
         K. Avoids Bovine Thrombin - initiated Clotting & rbc contamination
         L. Result is Volume Stable Polymerized Dense Suturable Fibrin Matrix (Platelet trap)
         M. Mitogenic/ Chemotactic / Angiogenic / Upregulate Fibroblast & Collagen Proliferation
         N. Tear site Arthroscopic Delivery and Suture Technique
         O. Prospective Case Series: 38 pts with 4 yr FU: 85% Clinical Success

VI. POLYMER MENISCAL IMPLANT for PARTIAL MENISCECTOMIZED KNEE
     A. Aliphatic Polyurethane – Polycaprolactone (w butanediol moieties) copolymer
     B. Biodegradable (approx 6 yrs) w 80% porosity / isotropic interconnectivity
     C. Arthroscopic technique for medial & lateral delivery / CE Marked (2008)
     D. Basic Science (Canine) & Biomechanical Ovine Feasibility Data (Welsing, Tienen)
     E. Early Clinical European multicenter (9) Feasibility trial (52 pts: Verdonk, 2009)
     F. Medial 34 pts: Avg Age 33.4 and Lateral 18 pts Avg Age 25.8 years
     G. FU on consecutive series is 12 mon F/U w 2nd looks & biopsy
     H. Histology on 45 cases: 3 zones w viability & remodeling
      I. Clinical: VAS / KOOS / IKDC / Lysholm: Efficacy
      J. Safety: 13.7% incidence of adverse events & device removal
      K. MRI FU on 48 pts at intervals: tissue gain, healing, no AC wear

VII.     EMERGING NOVEL TECHNOLOGIES
         A. Allograft & Zenograft Transplantation Advances
         B. Gene – Enhanced Tissue Engineering Projects
         C. Drug - Coated (Bioactive Factor) and Eluting Repair Fixator Implants
         D. Angiogenic Suture Projects: Butyric Acid / GDF – 5 (TGF – b) / BMP - 14
         E. Bioadhesive Applications: Marine and Synthetic Polymers
         F. Cartilage Sensitive MRI as Postmeniscectomy Screening Tool

VIII.    PROBLEMS YET AHEAD
         A. Animal Model Limitations
         B. Safety AND Efficacy
         C. The Dilemma of Regulatory Hurdles: Devices vs. Biologicals
         D. Reality of Delivery of High Tech Gene – Enhanced Technologies
         E. Validation, Delivery, Dosing, Control and Patient Variability of Bioactive Proteins
         F. Perceptions: How Bad Can A Meniscectomy Be?
         G. Lack (Need) for RCT Evidenced – based Data
  MENISCAL SURGERY UPDATE 2011                                                          N. Sgaglione, M.D.




IX.    CONCLUSIONS
        A. Save the Meniscus!
        B. Improving Repair Methods
        C. Advancing Biological Methods and Technologies
        D. New Era of Molecular Biology, Biochemistry & Polymer Science
        E. Think Manipulation of Healing & Tissue Replacement
        F. More Research and Evidenced – Based Clinical Data is Needed
        G. Answer is Cost – Effective / Practical / Biological Solution to Preservation




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    MENISCAL SURGERY UPDATE 2011                                                          N. Sgaglione, M.D.




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MENISCAL SURGERY UPDATE 2011   N. Sgaglione, M.D.




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