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Combined meniscus allograft transplantation and articular cartilage paste grafting (a case study - part 3b of a course)

A 39-year-old male presented with right knee pain, swelling and instability. He had multiple knee injuries resulting from years of playing hockey and lacrosse. He had been symptomatic since he was 16 years old. He had a meniscectomy at age 38.

After four months, during which he undertook sixty days of skiing, he began experiencing pain again.

At his initial evaluation, he had positive Apley’s and McMurray’s tests for medial meniscus.

X-ray showing reduced joint space on one side

 

 

Review of x-rays (see left) revealed narrowing of the medial joint space of his right knee and a small amount of osteophyte formation.

 

 

Examination of his MRI revealed loss of his medial meniscus, articular cartilage damage to the medial femoral condyle and a large cyst on his tibia.

Meniscus allograft and paste grafting

In view of these findings, meniscus allografting and articular cartilage paste grafting [of the femoral condyle area] were performed.

tibial plateau with eburnated bonetibial plateau after microfracture

 

Microfracture was performed on an eburnated (lacking articular cartilage) area on the tibial plateau. The photo on the left shows the exposed bone where cartilage has been lost. The photo on the right shows the same area where microfracture is being performed by 'picking' through the surface to expose the bone marrow.

 

meniscal allograft in place

 

 

 

This photo on the left shows the meniscal allograft in place. The meniscal allograft is the structure to the right of the photo. Above it is the rounded end of the femur and below is the flattened top of the tibia - the tibial plateau.

 

Returning for his one year follow up, the patient was extremely pleased with his meniscal allograft. He had smooth, full range of motion of his knee and was able to hike, play ice hockey and walk with significantly less pain.

 

Arthroscopic meniscal trim, release of adhesion and articular cartilage biopsy

At 18 months postoperative, the patient returned for clinical examination of his knee. He had full range of motion, and a very prominent medial osteophyte.

X-ray showing improved joint spaceMRI from the side showing intact meniscus

 

Review of his knee x-ray (left - from the front) demonstrated varus deformity, however there was some preservation of the medial joint space (circled - compare with pre-op above).

Review of MRI (right) - this 'slice' of MRI scan from the side view of the knee revealed an intact medial meniscus (the two dark triangles within the red box are cross sections of the front and back parts of the meniscus), damage to the articular cartilage surface, and anterior arthrofibrosis.

In view of continued symptoms, he was brought into surgery for arthroscopic evaluation, during which time a small tear on the inner margin of the posterior horn was identified and gently resected. The remainder of the meniscus appeared stable throughout.

The previously paste grafted surface on the femoral condyle appeared white throughout, and there was no evidence of exposed bone. Two biopsies were obtained, one from the paste grafted region of the condyle, and another from the microfractured region on the tibial plateau. There was a marked anterior fibrotic band overlaying the ACL, which was released with an arthroscopic unit and a shaver.

At five years

At five years post meniscus allograft transplantation and articular cartilage paste grafting to the medial femoral condyle, and microfracture to the tibial plateau, the patient returned to us for clinical evaluation. He was very pleased with his knee and was skiing 40 days a year. The patient lacked the final 5 degrees of extension and the final 15 degrees of flexion, but this was adequate for him. Review of his x-rays revealed that his medial joint space was still open, although it appeared somewhat narrowed in his PA flexion view. His MRI documents that his meniscus is well positioned, however there were early degenerative changes in his medial compartment.

At seven years

At seven years postoperative, the patient was skiing three days a week in the winter, swimming laps in the summer, and reported no major problems with his knee.

Discussion

This case demonstrates a fairly typical patient who comes in to the doctor’s office and says ‘Hey Doc, I had my meniscus removed years ago when I was playing sports as a kid, or in high school or in college, and now 20 years later I have pain on the inside of my knee” - and the X-rays reveal medial joint space narrowing and there is some loss of motion.

So classically these patients were told either they could have an osteotomy in their mid forties or fifties, they could have a unicompartmental joint replacement or a total joint replacement. Or they were told “Go home, rest your knee, wait till you are older and then we will do your joint arthroplasty at that time”.

Today we give patients almost the opposite advice. We tell them it is quite important to exercise around their painful joint and that we can re-build the joint using biologic procedures that can keep them active and delay the time that joint arthroplasty might be required. In this patient we addressed the medial joint pain by treating the articular cartilage defect with a cartilage paste graft and treating the missing meniscus by replacing it with a medial meniscus allograft. By doing these biologic procedures we permitted him to return to a high level of skiing and sports.

We did not do an osteotomy for the following reasons –

  1. The patient was unwilling to take the amount of time off and risk the complication rate of the osteotomy
  2. The patient said, and we also believe that if the biologic treatments give him five to ten years of relief we could always do it again as an outpatient arthroscopic procedure.
  3. This was less of an impact on his life than moving on to an osteotomy.
  4. Our outcome data published this July in the British Journal of Bone and Joint Surgery showed that the alignment did not affect the outcome of meniscus allografting and articular cartilage paste grafting or cartilage treatment done with meniscus allografting in the first 119 patients that we performed these combined procedures for in a 2-12 year outcome study.

So based on the fact that the osteotomy would create more disability for the patient, a longer recovery time and appear to provide no significant benefit to the outcomes of the procedures performed, we performed just the outpatient meniscus allografting and articular cartilage treatment and returned the patient to sports.

It should be noted that doing these biologic procedures do not create a normal joint – so this patient did not recover his full range of motion – he still had some loss of extension and some loss of flexion. We think that’s unfortunate as our goal is to try to gain complete motion as we believe that the biologic procedures would last longer and the knee would feel more normal if we are able to obtain complete motion. However in biologic procedures there is still abnormal shapes, abnormal osteophytes, abnormal arthrofibrosis, not all of which can be treated when reconstructing the joint biologically.

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Updated: 10 Aug, 2013
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