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.

DISCLOSURE
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The Academy does not view the existence of these disclosed interests or commitments implying bias or decreasing
the value of the author’s participation in the meeting.

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

The AAOS disclaims any and all liability for injury, loss or other damages resulting to any individual attending the
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
will be helpful to course participants.

Some drugs or medical devices demonstrated in Academy educational programs or materials have not been cleared
by the FDA or have been cleared by the FDA for specific uses only. The FDA has stated that it is the responsibility of
the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice.
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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NOTES