Surgery of the Meniscus (eBook)

Christophe Hulet, MD, PhD, is Professor in Orthopedics and Traumatology at Caen University Hospital, Caen, France, where he is Head of the Orthopedics Department and Director of the Outpatient Surgical Unit. He has been Surgical College President of CAEN CHU since 2010. Dr. Hulet gained a Master’s Degree in Biological Sciences and Medical Anatomy from the University of Caen in 1991. In 1993 he presented his MD thesis on “cysts of the lateral meniscus” and in the same year he was awarded his Competence in General Surgery and Diploma of Specialized Studies in Orthopaedic Surgery and Traumatology. He subsequently gained his doctorate from the University of Caen and was appointed a University Professor in 2003. Dr. Hulet has held a variety of important positions, including as a member of the Basic Science Committee of ESSKA from 2010 to 2014, a member of the Knee Committee of ESSKA from 2012 to 2014, President of the Arthroscopy Committee of ESSKA from 2014 to 2016, and President of the French Society of Arthroscopy (Société Française d’Arthroscopie) from 2009 to 2011. He is the author of 140 articles in peer-reviewed JCR-listed journals.

Foreword 6
Foreword Surgery Meniscus Book 8
Preface 10
Contents 12
Part I: Meniscus Basic Science 17
1: Knee Meniscal Phylogeny and Ontogeny 18
1.1 Introduction 18
1.2 Knee and Meniscal Phylogeny 19
1.3 Meniscal Ontogeny 25
1.4 The Particular Case of Discoid Meniscus 27
Conclusion 28
References 28
2: Anatomy and Vascularisation 30
2.1 Medial Meniscus 30
2.1.1 Overview 30
2.1.2 Zone 1 31
2.1.3 Zone 2 31
2.1.4 Zone 3 32
2.1.5 Zone 4 32
2.1.6 Zone 5 32
2.2 Connections Between the Medial and the Lateral Meniscus 33
2.3 Lateral Meniscus 33
2.3.1 Anterior Root 33
2.3.2 Hiatus Popliteus 33
2.3.3 Menisco-femoral Ligaments 35
2.3.4 Posterior Root 35
2.4 Vascularisation 35
References 36
3: Histology-Ultrastructure-Biology 37
3.1 Introduction 37
3.2 Overview of the Anatomy and Biomechanics 38
3.3 Ultrastructure, Cells, and Extracellular Matrix 40
3.4 Vascularity and Innervation 43
3.5 From Biology to Repair and Replacement 44
Conclusion 45
References 45
4: Physiology: Biomechanics 48
4.1 Introduction 48
4.2 Morphology 48
4.3 Material Properties of Meniscal Tissue 51
4.3.1 Tensile Material Properties 51
4.3.2 Compressive Material Properties 51
4.4 Ligaments 52
4.4.1 Meniscotibial Ligaments 52
4.4.2 Meniscofemoral Ligaments 53
4.4.3 The Deep Medial Collateral Ligament (dMCL) 53
4.4.4 The Anterior Inter-meniscal Ligament 53
4.5 Functional Biomechanics of the Menisci 53
4.5.1 Load Distribution 53
4.5.2 Stability 55
4.5.3 Meniscal Motion During Knee Flexion 55
Conclusion 56
References 56
5: Physiopathology of the Meniscal Lesions 59
5.1 Introduction 59
5.2 Anatomy, Biology, and Biomechanics: Relevance on Meniscal Injuries 60
5.3 Traumatic Meniscus Injuries in Younger Population 63
5.4 Degenerative Meniscus Tears in Older Population 67
5.5 Meniscal Tears in Children 68
References 69
6: Meniscus Basic Science: Synthesis 74
Part II: Classification Meniscal Lesions 76
7: Traumatic Meniscal Lesions 77
7.1 Introduction: Traumatic Versus Degenerative Meniscal Tears 78
7.2 Classification of the Meniscal Tears 78
7.2.1 Radial Tears 78
7.2.2 Flap or Parrot-Beak Tears 79
7.2.3 Peripheral, Longitudinal Tears 79
7.2.4 Bucket-Handle Tears 79
7.2.5 Horizontal Cleavage Tears 79
7.2.6 Complex, Degenerative Tears 81
7.2.7 Meniscal Root Lesions (MRTs) 81
7.3 International Classification of Meniscal Tears 83
7.3.1 Tear Depth 83
7.3.2 Rim Width 83
7.3.3 Radial Location 83
7.3.4 Tear Pattern and Treatment 84
7.4 Traumatic Meniscal Lesion in ACL-Deficient Knee 84
7.4.1 Symptomatic Anterior Laxity of the Knee (Functional Instability) in a High-Demand Sports-Active Person 84
7.4.2 Anterior Laxity of the Knee Associated with Minor Symptoms in an Active Individual in Low-Demand Sports Activities 85
7.4.3 Meniscal Repair or Leave the Meniscal Tear Alone Without Treatment 85
References 87
8: Degenerative Meniscus Lesions, Cartilage Degeneration, and Osteoarthritis of the Knee 89
8.1 Etiology and Pathogenesis of Degenerative Meniscus Lesions 89
8.2 The Definition of a  Degenerative Meniscal Lesion at Arthroscopy or Magnetic Resonance Imaging 90
8.3 The Prevalence of Degenerative Meniscal Lesions 91
8.4 Degenerative Meniscal Lesions and Knee Symptoms 92
8.5 The Consequences in the Knee by a  Degenerative Meniscal Lesion 94
8.6 Knee Osteoarthritis 94
8.7 The Association Between Degenerative Meniscus Lesions and Osteoarthritis 95
8.8 Imaging Assessment of the Degenerate (Osteoarthritis) Knee: Role of Knee Radiographs 95
8.9 Imaging Assessment for the Degenerate Knee and Osteoarthritis: Role of Magnetic Resonance Imaging 96
References 97
9: Hidden Lesions and Root Tears 102
9.1 Arthroscopic All-Inside Suture Repair of Medial Meniscus Lesion in Anterior Cruciate Ligament-Deficient Knees 102
9.1.1 Introduction 102
9.1.2 Classification 103
9.1.3 Surgical Technique 103
9.1.4 Authors’ Clinical Outcomes 107
9.2 Arthroscopic All-Inside Repair for Lateral Meniscus Root Tear in Patients Undergoing Concomitant Anterior Cruciate Ligament Reconstruction 107
9.2.1 Introduction 107
9.2.2 Classification of the LMPH Root Tear 107
9.2.3 Surgical Technique 107
9.2.4 Authors’ Clinical Outcomes 108
9.3 Arthroscopic Meniscus Root Re-fixation Technique Using a Modified Mason-Allen Stitch 110
9.3.1 Introduction 110
9.3.2 Surgical Technique 110
References 113
10: Meniscal Lesions in Children: Classification, Discoid Meniscus, Traumatic Lesions 115
10.1 Introduction 115
10.2 Tears and Normal Meniscus 116
10.2.1 Generalities 116
10.2.2 Description of the Tears 116
10.2.2.1 According to the Vascularization of the Meniscus 116
10.2.2.2 According to the Type of Tear 116
10.2.2.3 According to the Stability of the Knee 118
10.3 Meniscal Tears and  Morphological Meniscal Anomaly 119
10.3.1 Discoid Meniscus 119
10.3.2 Lateral Hypermobile Meniscus 123
Conclusion 123
References 124
11: Discoid Meniscus: Histology 126
References 128
12: Classification of Meniscal Lesions: Synthesis 130
Part III: Preoperative Clinical Examination and Imaging 132
13: Clinical Examination, Standard X-Rays 133
13.1 Introduction 133
13.2 Clinical Examination 133
13.2.1 Anamnesis 133
13.2.2 General Clinical Examination of the Knee 134
13.2.3 Tests Commonly Used to Assess Meniscal Lesions 134
13.2.3.1 Joint Line Tenderness 134
13.2.3.2 McMurray’s Test 134
13.2.3.3 Apley’s Test 134
13.2.3.4 Thessaly’s Test 134
13.2.3.5 Steinmann I Test 139
13.2.3.6 Ege’s Test 140
13.2.3.7 Childress’ Sign (Squat Test) 140
13.2.3.8 Payr’s Test 140
13.2.3.9 Bohler’s Test 140
13.2.3.10 Combination of Different Tests 140
13.3 Standard X-Rays 142
References 142
14: Preoperative MR Imaging of the Meniscus 144
14.1 Introduction 144
14.2 Imaging Technique 144
14.3 Meniscal Tears 145
14.4 Imaging Pitfalls 145
14.5 Classification of Meniscal Tears 146
14.5.1 Longitudinal Tear 146
14.5.2 Radial Tear 146
14.5.3 Parrot-Beak Tear 147
14.5.4 Horizontal Tear 147
14.5.5 Bucket-Handle Tear 147
14.5.6 Flipped Meniscal Tear 148
14.5.7 Complex Tear 148
14.5.8 Root Tear 148
14.6 Meniscal Degeneration 150
References 150
15: Meniscus Ultrasound 152
15.1 Introduction 152
15.1.1 MRI Verses MSU 153
15.2 Imaging Assessment Meniscus 153
15.2.1 Radiographs 153
15.2.2 Ultrasound 153
15.2.3 Probes 153
15.3 Knee Ultrasound Equipment and Setup 154
15.3.1 Meniscus Scanning Positions 154
15.4 History of Meniscus Ultrasound 155
15.5 Normal Meniscus 155
15.5.1 Lateral Meniscus Vascularization 156
15.6 Conditions Suggesting Pathology 157
15.6.1 Lateral Posterior Popliteal Recessus 157
15.7 Meniscus Pathology 157
15.7.1 Meniscus Tear 157
15.7.2 Meniscus Flap Tear 157
15.7.3 Anterior Horn Dislocation of the Medial Meniscus 158
15.7.4 Meniscus Bucket Handle 158
15.7.5 Hidden Lesions 158
15.8 Meniscus Combined Lesions 158
15.8.1 Meniscus and Anterior Cruciate Ligament Instability 158
15.8.2 Meniscus Follow-Up in ACL-­Deficient Knees 159
15.9 Meniscus Repair 159
15.9.1 Ultrasound for Meniscal Repair 159
15.9.2 Meniscus Spontaneous Healing 160
15.9.3 Meniscus Reparability 162
15.9.4 Meniscus Repair 162
15.9.5 Acute Lesions 162
15.10 Specific Conditions 163
15.10.1 Meniscus Degeneration 163
15.10.2 Meniscus Chondrocalcinosis 163
15.10.3 Meniscus Extrusion 164
15.10.4 Meniscus Cyst 164
15.10.5 Discoid Meniscus 164
15.11 Complications or Prolonged Symptoms After Surgery 165
References 165
16: SPECT/CT Imaging of the Meniscus and Cartilage: What Does It Offer? 167
16.1 Introduction 167
16.2 Basics about SPECT/CT Imaging 167
16.3 Current and Potential Use of SPECT/CT 168
16.3.1 Meniscus 169
16.3.2 Cartilage 170
16.3.3 OA 170
Conclusion 170
References 171
17: Synthesis: Differences Between Traumatic and Degenerative Meniscal Lesions 173
17.1 Introduction 173
17.2 Clinical Examination 173
17.3 MRI 174
17.4 Relationship Between Clinical Symptoms and MRI 174
17.5 Radiographs 175
17.6 Histology 175
Conclusion 175
References 176
18: Synthesis 177
Part IV: Surgical Technique 178
19: Arthroscopy of the Normal Meniscus 179
19.1 Introduction 179
19.2 Medial Meniscus 180
19.2.1 Anterior Horn 180
19.2.2 Distal Insertion of the ACL 180
19.2.3 Body of the Meniscus 181
19.2.4 Deep MCL: Meniscotibial and Meniscofemoral Ligaments 181
19.2.5 Posterior Horn 182
19.3 Intermeniscal Ligament 183
19.4 Lateral Meniscus 183
19.4.1 Anterior Horn 183
19.4.2 Midbody of the Meniscus 184
19.4.3 Popliteus Tendon 184
19.4.4 Popliteomeniscal Fasciculi 184
19.4.5 Meniscofemoral Ligaments: Humphrey and Wrisberg Ligaments 184
19.5 Posterior Horn 185
Conclusion 187
References 187
20: Meniscectomy Medial: Lateral 189
20.1 Introduction 189
20.2 Indication for Surgery 190
20.3 Surgical Preparation and Patient Positioning 190
20.4 Diagnostic Arthroscopy and Portal Placement 190
20.5 Surgical Strategy During Medial Meniscectomy 192
20.6 Pitfalls During Meniscectomy 194
20.7 Specific Features to Lateral Meniscectomy 194
20.7.1 Approaches 195
20.7.2 Technical Features to Lateral Meniscectomies 195
20.7.3 Treatment of Vertical Radial Lesions 196
20.7.4 Treatment of a Lateral Meniscal Flap 196
20.7.5 Treatment of Horizontal Cleavage 196
20.7.6 Treatment of Meniscal Cyst 197
20.7.7 Treatment of Discoid Meniscus 198
20.7.8 Indications for Lateral Meniscectomy 198
20.8 Termination of the Procedure 199
20.9 Complications 199
20.10 Postoperative Regimen and Rehabilitation 200
Conclusion 200
References 200
21: Biomechanics of Meniscal Repair 202
21.1 Introduction 202
21.2 Meniscus Biomechanical Considerations 203
21.3 Meniscus Repair: Results 203
21.4 Sutures: Methods and Devices 205
21.5 Biomechanical Testing 206
21.6 Biomechanical Studies: Current Knowledge 207
21.7 Biomechanical Studies: Limitations 208
References 209
22: Meniscus Repair: Updated Techniques (Open and Arthroscopic) 211
22.1 Introduction 211
22.2 Arthroscopic Assessment 212
22.3 Debridement/Abrasion 213
22.4 Suture Placement 213
22.5 Fixation by All-Inside Devices 214
22.6 Inside-Out Technique 216
22.7 Outside-In Technique 216
22.8 Posteromedial Sutures for Meniscocapsular Lesions of the Medial Meniscus 216
22.8.1 General Principles 216
22.8.2 Surgical Technique 217
22.9 Open Meniscus Repair for Horizontal Cleavage in Young Patients 219
22.9.1 General Principles 219
22.9.2 Surgical Technique 219
Conclusion 221
References 222
23: Meniscal Repair: Enhancement of Healing Process 224
23.1 Introduction 224
23.2 Vascular Access Channel, Trephination, and Abrasion 225
23.3 Fibrin Glue and Fibrin Clot 226
23.4 Growth Factors and Platelet-­Rich Plasma 228
23.5 Synovial Flaps 230
23.6 Mesenchymal Stem Cells 230
Conclusion 231
References 232
24: Meniscal Cysts 235
24.1 Introduction 235
24.2 Etiology and Pathology of Meniscal Cysts 236
24.3 Incidence of Meniscal Cysts 237
24.4 Clinical Evaluation and Diagnostic 237
24.5 Treatment of Meniscal Cysts 240
24.5.1 Conservative Treatment 240
24.5.2 Surgical Treatment 240
24.6 Results 245
Conclusion 246
References 246
25: Discoid Meniscus and Meniscoplasty in Children 249
25.1 Introduction 249
25.2 Novel MRI Classification 251
25.3 Arthroscopic Partial Meniscectomy with Repair of the Peripheral Tear for Discoid Lateral Meniscus in Children 254
25.3.1 Diagnostic Arthroscopic Examination 254
25.3.2 Partial Central Meniscectomy 254
25.3.3 Meniscus Suture Repair for Peripheral Tears 255
25.3.4 The Modified Outside-In Technique for Tears from the Anterior Horn to the Posterolateral Corner 258
25.3.5 The Modified All-Inside Technique for Posterior Horn Tears 259
25.3.6 Postoperative Care 264
References 266
26: Repair in Children 268
26.1 Introduction 268
26.2 Diagnosis 269
26.3 Indications for Repair 269
26.3.1 Lesions Types 269
26.3.2 Rationale for Repair 269
26.3.2.1 Blood Supply 269
26.3.2.2 Age of the Lesion 270
26.4 Principles of Repair 270
26.4.1 Inside-Out Sutures 270
26.4.2 Outside-In Sutures 270
26.4.3 All-Inside Sutures 270
26.5 Repair Technique According to the Type of Lesion 271
26.5.1 Vertical Tears 271
26.5.2 Horizontal Tears and Meniscal Cysts 271
26.5.3 Meniscal Horn Avulsion 272
26.5.4 Radial Tears 272
26.5.5 Meniscal Substitution (Actifit®) 272
26.6 Postoperative Course 272
26.7 Results 272
Conclusion 274
References 274
27: Rehabilitation and Return to Sport 276
27.1 Introduction 276
27.2 Scientific Background (The State of Art in Meniscus Rehabilitation and Return to Sport) 277
27.2.1 Progressive Knee Motion 277
27.2.2 Progressive Weight-Bearing 278
27.2.3 Return to Activity 278
27.3 Rehabilitation Strategies 278
27.3.1 Organizational Principles 278
27.3.2 Clinical Principles 279
27.4 First Step: Walking Without Crutches 279
27.4.1 Criteria to Be Achieved 279
27.4.2 Specific Interventions 279
27.5 Second Step: When Running on a Treadmill 280
27.5.1 Criteria to Be Achieved 280
27.5.2 Specific Interventions 280
27.6 Third Step: When Starting On-Field Rehabilitation 280
27.6.1 Criteria to Be Achieved 280
27.6.2 Specific Interventions 280
27.7 Fourth Step: When Return to the Team 280
27.7.1 Criteria to Be Achieved 280
27.7.2 Specific Interventions 281
27.8 Considerations and Precautions According to the Type of Surgery 281
Conclusion 282
References 282
28: Partial Meniscectomy and Meniscal Suture: Graft Rehabilitation Guidelines 283
28.1 Guidelines for Partial Meniscectomy 284
28.2 Phase 1 285
28.2.1 1–2 Postoperative Weeks 285
28.2.1.1 Goals 285
28.2.1.2 Precautions/Contraindications 285
28.2.1.3 Exercise Program 285
At Home 285
Physiotherapy 285
28.2.2 3–4 Postoperative Weeks 285
28.2.2.1 Goals 285
28.2.2.2 Precautions/Contraindications 286
28.2.2.3 Exercise Program 286
At Home 286
Physiotherapy 286
28.3 Phase 2 287
28.3.1 5–6 Postoperative Weeks 287
28.3.1.1 Goals 287
28.3.1.2 Precautions/Contraindications 287
28.3.1.3 Exercise Program 287
At Home 287
Physiotherapy 288
28.3.2 7–8 Postoperative Weeks 288
28.3.2.1 Goals 288
28.3.2.2 Precautions/Contraindications 288
28.3.2.3 Exercise Program 288
At Home 288
Physiotherapy 288
28.4 Guideline for Meniscal Suture/Meniscal Graft 289
28.5 Phase 3 290
Conclusion 290
References 290
29: Synthesis 292
29.1 Introduction 292
29.2 Lesion Left In Situ 292
29.3 Meniscus Repair 293
29.4 Meniscectomy 293
29.5 Meniscal Lesions in Children (Repair, Discoid Meniscus) 293
29.6 Meniscal Cysts/Horizontal Cleavage of the Meniscus in the Young Athlete 294
29.7 Rehabilitation 294
Conclusion 294
References 294
Part V: Postoperative Evaluation 296
30: Functional and Objective Scores: Quality of Life 297
30.1 Chapter Structure 297
References 300
31: Postoperative Imaging of the Meniscus 301
31.1 Introduction 301
31.2 Partial Meniscectomy and Meniscal Repair 302
31.3 Meniscus Allograft Transplantation 302
References 304
32: Synthesis 306
Part VI: Results 308
33: Posterior Horn Plus Pars Intermedia Bucket-Handle Tear Resection: Long-Term Outcome and Complications 309
33.1 Introduction 309
33.2 Bucket-Handle Tear 310
33.3 Long-Term Outcome and Complications After Bucket-Handle Tear Resection (Posterior Horn Plus Pars Intermedia) 311
33.3.1 Bucket-Handle Tears Resection: Surgical Technique 311
33.3.2 Long-Term Outcome and Complications 312
Conclusion 314
References 314
34: Results of Lateral Meniscectomy 318
34.1 Introduction 318
34.2 Effects of Meniscectomy 319
34.3 Clinical and Radiographic Results of Arthroscopic Partial Lateral Meniscectomy 319
34.3.1 Short- to Mid-Term Follow-Up 319
34.3.2 Long-Term Follow-Up 320
34.4 Failures 321
Conclusion 321
References 321
35: Meniscal Repair: Intra- and Postoperative Complications 323
35.1 Introduction 323
35.2 Intraoperative Complications 324
35.2.1 Neurologic Complications 324
35.2.1.1 Saphenous Nerve Injuries 324
35.2.1.2 Peroneal Nerve Injuries 325
35.2.2 Vascular Complication 325
35.2.3 Medial Collateral Ligament Sprain and Cartilage Lesion 326
35.3 Postoperative Complications 326
35.3.1 Nonspecific Complications 326
35.3.1.1 Deep Venous Thrombosis (DVT) 326
35.3.1.2 Arthrofibrosis and Type 1 Complex Regional Pain Syndrome 327
35.3.1.3 Infection 327
35.3.2 Specific Complication Related to the Meniscal Repair 327
35.3.2.1 Mechanical Symptoms Related to the Fixation Devices 328
35.3.2.2 Meniscal Cyst Formation 328
35.3.2.3 Aseptic Synovitis 328
35.3.2.4 Cartilage Damage 328
35.4 Discussion 329
Conclusion 329
References 330
36: Meniscal Repair: Results 332
36.1 Meniscal Repair: Short-Term Results (Clinical Outcomes and Imaging) 332
36.1.1 Introduction 332
36.1.2 Meniscus Repair: Short-Term Clinical Outcomes 332
36.1.2.1 Difference Between Techniques 333
36.1.2.2 Medial Versus Lateral Meniscus 333
36.1.2.3 Time from Injury to Surgery 333
36.1.2.4 ACL Reconstruction 333
36.1.2.5 High-Level Sports 333
36.1.3 Failures 333
36.1.4 Trends in Meniscal Repair Practice 335
36.1.5 Short-Term Imaging 335
36.1.5.1 Short-Term Imaging Features 335
36.1.5.2 Short-Term Imaging Outcomes and Second-Look Arthroscopy 336
36.1.6 Outcomes of Meniscal Repair of Horizontal Cleavage Tears 337
36.1.7 Summary 338
36.2 Meniscal Repair: Long-Term Results (Clinical Outcomes and Imaging) 338
36.2.1 Introduction 338
36.2.2 Meniscus Repair Long-Term Results 338
36.2.3 Radiological Long-Term Results 339
36.2.4 Meniscus Repair in the Elite Athlete 339
36.2.5 Meniscus Repair and Concomitant ACL Reconstruction 340
36.2.6 Summary 341
References 341
37: Discoid Meniscus. Meniscus Lesions in Children: Indications and Results 345
37.1 Introduction 345
37.2 Origin and Ultrastructure 345
37.3 Diagnosis 346
37.4 Treatment 347
37.5 Results 348
37.6 Summary 352
References 352
38: Synthesis 355
Part VII: Indications: Adults 357
39: Traumatic Lesions in a Stable Knee: Masterly Neglect - Meniscectomy - Repair 358
39.1 Introduction 358
39.2 Basic Science 358
39.3 Patient History 359
39.4 Physical Examination 359
39.5 Imaging 360
39.6 Arthroscopy 360
39.7 Treatment Strategies 361
39.7.1 Conservative Treatment 361
39.7.2 Surgical Treatment 361
39.7.2.1 Meniscectomy 361
39.7.2.2 Repair 361
39.7.2.3 Evaluation of the Lesion and Decision Making 362
Conclusion 363
References 363
40: Meniscal Traumatic Lesions in ACL-Deficient Knee: Masterly Neglect, Repair, or Meniscectomy 365
40.1 Introduction 365
40.2 Masterly Neglect 366
40.3 Meniscal Repair 368
40.4 Meniscectomy 371
40.5 Meniscus Replacement 373
Conclusion 373
References 374
41: Degenerative Meniscal Lesions: Indications 378
41.1 Classification 379
41.2 Frequency 379
41.3 Assessing a DML 379
41.4 Treatment 380
41.4.1 Functional Treatment or Arthroscopic Meniscectomy? 380
41.4.2 Functional Treatment: What Does It Mean? 382
41.4.3 Partial or Subtotal Meniscectomy: Which Outcomes? 382
41.4.3.1 What Is the Risk of Osteoarthritis After APM? 382
41.5 Algorithm 383
Conclusion 385
References 386
42: Arthroscopic and Supplementation Therapy in Osteoarthritis of the Knee 388
42.1 Introduction 388
42.2 Arthroscopic Therapy 389
42.2.1 Lavage 389
42.2.2 Debridement 389
42.3 Supplementation 391
42.3.1 Intra-articular Viscosupplementation 392
42.3.2 Oral Supplements and Medication 394
Conclusion 395
References 395
43: Indications in Meniscus Surgery: Synthesis 398
43.1 Traumatic Lesions 399
43.2 Degenerative Meniscal Lesions 400
References 401
Part VIII: Post-meniscectomized Knee 403
44: Postoperative Osteonecrosis of the Knee: Incidence, Diagnosis, Management and Results 404
44.1 Introduction 404
44.2 Incidence and Epidemiology in ONPK 405
44.3 Physiopathology 406
44.4 Patient History, Physical Examination and Differential Diagnosis 408
44.5 Diagnosis of ONPK and Imaging Findings 409
44.5.1 Absence of Osteonecrosis on Preoperative Imaging 409
44.5.2 Timely Association Between MRI Signal Changes Following Arthroscopy 410
44.5.3 Imaging Findings and Classification 412
44.6 Histologic Findings 415
44.7 Blood Markers 415
44.8 Natural History and Prognostic Factors of ONPK 415
44.9 Treatment Options 416
Conclusion 416
References 417
45: Concepts in Managing the Patient with Post-meniscectomy Knee Pain 419
45.1 Introduction 419
45.2 Aim 420
45.3 Patient Assessment 420
45.4 Nonoperative Treatment 420
45.5 ‘A la carte’ Surgical Approach 420
45.5.1 Arthroscopy 421
45.5.2 Alignment 421
45.5.3 Stability 422
45.5.4 Meniscus Deficiency 423
45.5.5 Articular Cartilage Lesions 424
45.6 Rehabilitation 425
45.7 Decision Making: Putting It All Together 425
45.8 Summary 427
References 427
Part IX: Meniscal Reconstruction: Allograft 429
46: Basic Science on the Meniscus 430
46.1 Embryology 430
46.2 Chemical Composition and Organisation of Normal Meniscal Tissue 431
46.3 Cellular Composition of Meniscal Tissue 433
46.3.1 Fibrochondrocyte 434
46.3.2 Fibroblast-Like Cells 434
46.3.3 Cells of the Superficial Zone 434
46.4 Healing Response in the Injured Meniscus 434
46.4.1 Model I: Transection of the Anterior Cruciate 435
46.4.2 Model II: Plug Model 435
46.4.3 Model III: Tear Model 436
46.5 Rationale for Meniscal Replacement 436
46.6 Immunological Aspects of Meniscal Transplantation 438
Conclusion 438
References 439
47: Organization: Type of Grafts, Conservation, Regulation 442
47.1 Tissue Banks and Control 442
47.2 Donor and Recipient Protection 443
47.3 Harvesting 444
47.4 Risk and Recommendations 445
47.5 Regulation 445
47.5.1 Development 445
47.5.2 Ethics 446
47.6 Types of Grafts 447
47.6.1 Lyophilization 447
47.6.2 Freezing 447
47.6.3 Cryopreservation 448
47.6.4 Fresh Allograft 448
Conclusion 449
References 450
48: Meniscus Allograft: Organization and Regulation in Europe and USA 452
48.1 Organization in Europe 452
48.2 Organization in the USA 455
48.3 Tissue Procurement Overview 456
48.4 Comparison of Regulations, Standards, and Other Initiatives 457
48.4.1 Europe 458
48.4.2 USA 458
48.4.3 Overview 459
48.5 Activity 459
48.6 Consent/Authorization 460
48.7 Quality 462
48.7.1 Donor Suitability 462
48.7.1.1 Medical Records and Cause of Death 463
48.7.1.2 Malignancy 463
48.7.1.3 Age Criteria 464
48.7.1.4 Physical Evaluation 464
48.7.1.5 Donor Screening: Required Infectious Disease Testing 464
48.7.1.6 Procurement Site and Time Limits for Recovery 465
48.7.1.7 Testing the Tissue 465
48.7.1.8 Tissue Processing 465
Conclusion 466
References 466
49: Surgical Technique for Open Meniscal Allograft Transplantation 467
49.1 Indication 467
49.2 Clinical Examination and Preoperative Management 468
49.3 Surgical Technique (Lateral Meniscus Allograft Transplantation) 469
49.4 Postoperative Management 471
Conclusion 472
References 472
50: Meniscus Allograft Transplantation with Bony Fixation 473
50.1 Introduction 473
50.2 Clinical Evaluation 474
50.3 Surgical Indications 475
50.4 Procedure 476
50.5 Postoperative Course and Rehabilitation 481
50.6 Complications 481
50.7 Outcomes 481
References 481
51: Arthroscopic Meniscal Allograft Transplantation with Soft Tissue Fixation Through Bone Tunnels 483
51.1 Introduction 483
51.2 Soft Tissue Versus Bone Plug Fixation Techniques 483
51.3 Surgical Technique 484
51.3.1 Principles 484
51.3.2 The Key Stages 484
51.3.3 Technique Decision Options 484
Conclusion 492
References 492
52: Arthroscopic Technique with One Bone Plug: Meniscal Transplantion – How I Do It 493
52.1 Prerequisites 493
52.2 Preoperative Workup 495
52.3 Implantation of the Graft 495
52.4 Postoperative Rehabilitation 496
52.4.1 Week 0–3 496
52.4.2 Week 4–6 497
52.4.3 Week 7–9 497
52.4.4 Week 10–12 497
52.4.5 Week 13–18 497
52.4.6 Week 19–24 497
52.5 Follow-Up 497
Conclusion 497
References 498
53: Meniscal Allograft Transplantation: Results and Indications 499
53.1 Introduction 499
53.2 Indications 500
53.3 Patient-Reported Outcomes 500
53.4 Return to Sports 500
53.5 Radiological Outcomes 500
53.6 Complications and Failures 501
53.7 Discussion 501
Conclusion 502
References 502
54: Synthesis 505
54.1 Introduction 505
54.2 Procurement and Preservation of Meniscal Allograft 506
54.3 Surgical Technique 507
Conclusion 507
Part X: Meniscal Reconstruction: Substitutes 508
55: Collagen Meniscus Implant: Basic Science, Technique and Results 509
55.1 Introduction 509
55.2 Basic Science 510
55.2.1 Development of the Collagen Meniscus Implant (CMI) 510
55.2.2 CMI Animal Studies 511
55.3 CMI Surgical Technique 511
55.3.1 Medial CMI Technique 511
55.3.2 Lateral CMI Technique 513
55.3.3 Combined Surgeries 514
55.3.4 Rehabilitation Protocol 514
55.4 CMI Results 515
55.4.1 Medial CMI Clinical Results 515
55.4.2 Lateral CMI Clinical Results 516
55.4.3 Radiographic Results 516
55.4.4 MRI Results 517
55.4.5 Histological Results 517
55.5 Summary 518
References 518
56: Actifit Polyurethane Meniscus Scaffold: Basic Science, Techniques, and Results 521
56.1 Introduction 521
56.2 Basic Science 521
56.3 Indications/Requirements 522
56.4 Surgical Technique and Postoperative Rehabilitation 523
56.4.1 Surgical Technique 523
56.4.2 Postoperative Rehabilitation 525
56.5 Results 525
56.5.1 Clinical Results 525
56.5.2 MRI Results 525
56.5.3 Complications 527
Conclusion 528
References 528
57: Meniscal Substitutes Synthesis 530
57.1 Introduction 530
57.2 Scaffolds 530
57.3 New Approaches 531
Conclusion 531
References 531
Part XI: Substitutes and Future Technology 533
58: Gene Therapy, Growth Factors, Mesenchymal Cells, New Trends and Future Perspectives 534
58.1 Introduction 535
58.2 Gene Therapy for Meniscal Repair 535
58.2.1 Target Cells and Candidate Factors 535
58.2.2 Gene Transfer Vectors 535
58.2.3 Genetically Enhanced Tissue Engineering 536
58.2.4 Strategies and Applications of Gene Therapy 536
58.3 PRP and Future 538
58.3.1 PRP and Meniscus: Are In Vitro Evidences Correlated with Clinical Benefit? 538
58.3.2 PRP and Growth Factors: A Future in Meniscal Healing? 539
58.4 Mesenchymal Stem Cells in Meniscal Repair 540
58.4.1 Endogenous Mesenchymal Cell-Based Meniscal Repair 540
58.4.2 Mesenchymal Cells for Enhanced Meniscal Tear Repair 540
58.4.3 Mesenchymal Cells for Enhanced Meniscal Defect Repair 541
58.5 New Trends and Future Perspectives 542
58.5.1 Scaffolds: New Materials? New Methods? Patient Specific? 542
58.5.2 Controlling Growth Factors 544
58.5.3 Cell-Based Strategies and Bioreactors 545
Conclusion 545
References 547
Index 551