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JOÃO ESPREGUEIRA-MENDES MD, PhD
A. Monteiro, R. Rocha, N. Sevivas, JP. Araújo, N. Loureiro, I. Lopes, A. Sarmento, N. Ferreira
L. Silva, R. Pereira, R. Andrade, C. Saavedra, R. Bastos, B. Pereira, A. Costa, A.Neto,
M. Oliveira, RA Sousa, R.L. Reis and Niek van Dijk
Chairman of Clínica do Dragão - Espregueira-Mendes Sports Centre – FIFA Medical Centre of Excellence
Chairman and Professor of the Orthopaedic Department - Minho University
Treasurer and Chairman of the Publication Committee of ISAKOS
Board Member of the Patellofemoral Foundation
President of the European Society of Knee Surgery, Sports Trauma and Arthroscopy – ESSKA 2012-2014
PORTO, PORTUGAL
MENISCECTOMY
HOW MUCH IS TOO MUCH?
Clínica do Dragão – Espregueira-Mendes Sports Centre
FC Porto Stadium – Porto - Portugal
Official
Teaching Centre
PRESERVE THE FUTURE!
Malalignment, loss of meniscal tissue, cartilage defects and joint instability all seem to be strongly correlated to early OA
Meniscal lesion (ML) is one of the most common pathologies leading to Orthopaedic
Surgery throughout the world;
Over 450 000 arthroscopic procedures/year for ML in the USA
Garrett WE, Jr. et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II,
certification examination case mix. J Bone Joint Surg Am 2006;88:660-7.
COMPOSITION
1. Cells type
• Fibroblast-like
• Fibrochondrocytes
• Peripheric/multipotent cells?
2. ECM
• Water 70% total weight
• Collagen I, II, III, IV e VI (60-70%
dry weight)
• Proteoglycans (1-2% dry weight;
chondroitin-sulphate)
MENISCUS FUNCTIONS
1. Load transmission
2. Impact absorption – viscoelasticity:
“lower compressive stiffness and
permeability comparing to cartilage”
3. Lubrification and nutrition
4. Stability - increase joint surface
congruency
5. Proprioception
HUMAN FRESH MENISCUS TISSUE
CHARACTERIZATION
0,1 1 100,0
0,2
0,4
0,6
0,8
1,0
1,2
1,4
1,6
1,8
2,0
2,2
E' (
MP
a)
Frequência (Hz)
Menisco externo anterior
Menisco interno anterior
Menisco externo médio
Menisco interno médio
Menisco externo posterior
Menisco interno posterior
0,1 1 100,00
0,05
0,10
0,15
0,20
0,25
0,30
0,35
0,40
tan
Frequência (Hz)
Menisco externo anterior
Menisco interno anterior
Menisco externo médio
Menisco interno médio
Menisco externo posterior
Menisco interno posterior
Fresh medial meniscus is stiffer than lateral (higher values of E’).
Anterior segments present significantly lower cellularity & higher damping properties.
Cyclic loads influence the viscoelastic behaviour of menisci. By increasing the frequency leads to
an increase in stiffness.
• Conclusion: Menisci are not uniformed structures.
• Anterior segments have lower cellularity and higher damping.
• Cyclic loads influence viscoelastic characteristics. • Future TE therapies should consider segmental
architecture, cellularity and biomechanics of fresh tissue.
W-WR-WR-RW-WR-WR-R
100 µm100 µm100 µm
W-WR-WR-R
BIOMECHANICAL AND CELLULAR SEGMENTAL
CHARACTERIZATION OF HUMAN MENISCUS:
BUILDING THE BASIS FOR TISSUE ENGINEERING
THERAPIES
• Convex lateral tibial plateau vs concave medial plateau
• Lateral meniscus higher load transfer
• More mobile lateral meniscus
BIOMECHANICS
• The intact meniscus converts axial forces into radial strain
• The meniscus is subjected to compressive, tensile and shear stresses (A)
• When a load is applied, the meniscus is displaced away from the centre, resulting in tensile stress because of the anterior and posterior horn tibial attachments (B)
• Medial meniscus is a secondary restrictor of tibial anterior translation
BIOMECHANICS
• Menisci occupy 60% of the contact area between the tibial and femoral cartilage surfaces and transmit
> 50% of joint compression forces
• Meniscectomy – removal of 15% to 34% of a meniscus increases contact pressures by 350%
• Total lateral meniscectomy results in a 45/50% decrease in the total contact area and a 235% to 335%
increase in the peak local contact pressure
Removal of the medial meniscus can result in a 50% to 70% reduction in femoral condyle cartilage contact area.
BIOMECHANICS
• 3 Groups: 22%±9% in the first, 46%±11% in the second and 100% in the third
• Effect of meniscectomies on AP position and laxity of MFC
• 22% resection no difference with the intact knee
• 46% & 100% resection: sig. difference on stability comp. intact knees (P=.024) and
knees after resection (P=.037)
BIOMECHANICS
MRI evidence of a concomitant injury to the Mmeniscus
or Lmeniscus is associated with increased knee
rotatory laxity in patients with an ACL injury.
MENISCECTOMY & KNEE STABILITY
Partial meniscectomy in the ACL-deficient knee
significantly increased anterior tibial translation
(p = 0.01).
On the other hand, meniscal repair reduces knee
instability.
MENISCAL EXTRUSION IS EQUIVALENT TO LARGE MENISCECTOMY
• Mainly medial and lateral geniculate arteries
• Penetration 10-30% for medial meniscus and 10-25% for lateral
• Determines healing potential
• Different in children
• 3 zones: red-red; red-white and white-white
VASCULARIZATION
Hauger O et al. Radiology 2000;217:193-200Hauger O et al. Radiology 2000;217:193-200
W-W R-W R-R
Human meniscus structure Acelular silk-fibroin scaffold for meniscus
regeneration
(Blue zone) Silk scaff + meniscocytes + GG-MA
(Red zone) Silk scaff + MSCs + GG
ADVANCED TERM STRATEGY FOR MENISCUS
2012- Oliveira JM, Pereira H, Yan LP, Silva-Correia J, Oliveira AL, Espregueira-Mendes J, Reis RL,
Scaffold that enables segmental vascularization for the engineering of complex tissues and methods of making the same, pt provisional patent (number 20121000015781).
DIAGNOSTIC – CLINICS AND MRI
Cornerstone: careful history taking and assessment of subjective symptoms
1- History: common symptoms of meniscal injuries include pain along the joint line, swelling, effusions, stiffness,
cracking and locking or catching
2 - Physical examination: McMurray and Apley tests and joint line palpation
3 - Imaging gold standard: MRI (accuracy of 64-95%, sensitivity of 88% and specificity of 57%)
• Degenerative or non degenerative? X-Ray in weight-bearing
• Stable or unstable?
• ACL-stable or ACL-unstable knee?
Porto Knee Testing Device
PKTD show greater rotatory instability in knees with partial meniscectomy (up to 30%) – on going
PORTO KNEE TESTING DEVICE - PKTD
ROTATORY INSTABILITY MEASUREMENTS
ER IR
IN DAILY PRACTICE THERE IS A GAP BETWEEN: WHAT
SHOULD BE DONE... & WHAT IS ACTUALLY DONE...
ESSKA Instructional Course Lecture Book: Amsterdam 2014 Stefano Zaffagnini, Roland Becker, Gino M.M.J. Kerkhoffs, João Espregueira-Mendes, C. Niek van Dijk
We could repair but… price… high
level athletes… reinjury rate…
Meniscal repair gives better long-term
outcomes and higher reop rates than
partial meniscectomy
Lmeniscectomy has higher reop rates
than Mmeniscectomy
Mmeniscectomy has lower reop rates
than Mm repair
Lm repair better than Mm repair
“There has been an increased number of isolated meniscus repairs being performed in the US over
the past 7 years without a concomitant increase in meniscectomies over the same time frame. These
data suggest that meniscus repairs are increasing.”
387 845 meniscectomies (78%)
23 640 meniscus repairs (5%)
84 927 ACLR + repair or meniscectomy (17%)
There is still an ongoing debate in which concerns the best approach on meniscal surgery:
Traumatic
Meniscal repair
Meniscectomy
Degenerative
Meniscectomy
Conservative treatment
Large abuse of meniscectomy in degenerative tears
How much resect?
Large use of meniscectomy
Slow increase in meniscal repair
2012 French NHS only 12% repair
(20% possible to repair)
MENISCUS
RADIAL TEARS
Resection of the torned portion of the meniscus (avascular zone) – smooth meniscus
Repair (age, zone and quality of tissue)
“Leave it alone” (more lateral meniscus + ACLR)
HOW MUCH RESECT?
“LEAVE IT ALONE”
Meniscus tears left in situ at the time of ACLR, did not require reoperation at a minimum 6-year FU: 97.8%
for lateral and 94.4% for medial tears.
These findings re-emphasize the low reoperation rate after the non-treatment of small, peripheral lateral
meniscus tears while nothing less predictable results for medial meniscus tears left without treatment.
2015
Untreated meniscus lesions during ACLR demonstrated low rates of failures for LM (between 0% and
7% if posterior to the popliteus tendon), whereas 12–15% of untreated MM tears underwent
reoperation.
FLAP/PARROTS TEARS
Resection of the torned portion of the meniscus (avascular zone)
Repair (young age, zone and quality of tissue)
HOW MUCH RESECT?
HORIZONTAL TEARS AND CYSTS
Preserve as most meniscus as possible
Identify and resect the instable layer
Suture the two layers if possible
Horizontal tears very often associated with meniscal cysts
Debride and empty the cyst
Open cyst removal
HOW MUCH RESECT?
COMPLEX TEARS
Take time in planning
Preserve as most meniscus as possible
Identify and ressect the instable meniscus
Associate debridment and suture
HOW MUCH RESECT?
PERIPHERAL, LONGITUDINAL AND BUCKET-HANDLE
TEARS
Careful evaluation
Leave alone peripheral lesions with <1cm
Test reducibility of the bucket-handle tear
Suture whenever possible (RR & RW)
Increasing meniscal laxity without tear
may indicate root lesion (70º
arthroscope)
Lateral posterior root tears are often
associated with ACL injuries
Acute medial root tears are often
associated with cartilage and
multiligamentous knee injury (MCL)
ROOT TEARS
MENISCUS SYNOVIAL LESION – THE HIDDEN LESION
Often missed in MRI and through a standard anterior exploration (suspicion by medial
meniscus hypermobility)
Associated with ACL lesions (20%?)
Seen from the PM accessory portal or AL portal with the scope deep into the notch
Hidden under a membrane-like tissue and discover after minimal debridement
Type of tear is related with the type of discoid meniscus (Han et al., KSSTA, 2002)
Remove only the catching or impinging meniscus
Careful trimming and contouring of the remaining rim
Partial meniscectomy or partial meniscectomy + repair
Preserve and verify stability of the capsular rim (re-rupture)
DISCOID MENISCUS
HOW MUCH RESECT?
Conservative treatment should be the first option
Too many surgical indications
Favourable surgical indication: traumatic event and locking symptoms
In meniscal degenerative tears without knee OA, meniscectomy was no better than sham operation
DEGENERATIVE MENISCAL TEARS
HOW MUCH RESECT?
MENISCAL LESIONS IN CHILDREN
Good blood supply and better healing
Knee abusers!
Stress the indications for repair
Nevertheless: 293 patients and 324 menisci (129 primary repairs, 149 primary partial
meniscectomies and 46 discoid saucerizations)
87% success rate
At 40 months post-op, 13% of all menisci required revision
Bucket-handle tears had the highest re-tear rate
2016
• Neyret et al (1999) – at 10 Y FU after ACLR 20% incidence of OA in knees with partial
meniscectomy and 30% in knees with total meniscectomy;
• Dejour et al (1999) – at + than 10 Y FU only 7,6% in knees with ACLR and intact menisci
against 42% in ACLR+partial or total meniscectomy;
• Shelbourne et al (2000) – at 8 Y FU after ACLR 9% of OA in knees with partial lateral
meniscectomy, 23% after partial medial meniscectomy and 25% after both;
• Petty et al (2011) - Only meniscectomy – radiographic signs are significant 8 to 16 Y
FU after partial meniscectomy; Subtotal meniscectomy worse results.
• Niek van Dijk (2016) – 10-fold increase in OA compared to controls after meniscectomy.
MENISCAL REPAIR WITH CONCOMITANT ACLR
Association of ACLR to the meniscal repair may augment the repair success.
Concomitant meniscal repair with ACLR results in a 86% success rate at 6-year follow-up.
2014
ACLR + Meniscal repair = less 10% (24% vs 14%) on reop for both LM & and MM repairs than isolated meniscal repair.
• Partial medial meniscectomy
may lead to an increase in the
severity and size of cartilage
lesions;
• + cartilage wear in the medial
compartment.
• However, all compartments of
the knee were affected.
HOW MUCH?
After + 10 Y FU
After + 10 Y FU
HOW MUCH - € - ?
STATE OF THE ART ON MENISCUS TERM
HOW MUCH €?
TAILORED BIOPLOTTER TO PRODUCE 3D TE SCAFFOLDS
Ongoing Work:
•Patient-specific meniscus implant
• Image acquisition from CT/MRI
• Computer-assisted design
• 3D Bioplotter
• Printing of patient specific silk-based meniscus implant
• Preservation, repair and/or substitution are the general rules
• Treat the patient and not the scan
• Removal of 15 to 34% increases contact forces up to 350%
• More than 46% of resection generates PA instability (rotation?)
• Medial partial meniscectomy + ACLR can stand for up to 10-fold
higher risk of OA
• Within ACLR some meniscal tears (+lateral) can be left untreated
• Improve results of repairs
• TERM may give us a customized new meniscus
• Partial meniscectomy??? How much ???
CONCLUSION: PRESERVE THE MENISCUS!
How much is too much…?
Online transmission available
Thank you!