Combined Procedures to Repair and Restore Knee Meniscus and CartilageThe treatment of meniscus injuries has progressed and changed over the years. Meniscectomy (removing the meniscus) was the first procedure used. But long-term studies showed degeneration of the joint cartilage as a result. Meniscal repair is now performed whenever possible.
Repair procedures have also evolved over time. Meniscal autologous transplantation (MAT), osteochondral allograft(OA), andautologous chondrocyte implantation (ACI) are three of the newer repair methods. MAT repairs the meniscus. OA and ACI are used to repair damage that goes deeper into the cartilage layer underneath the meniscus.
To prevent complications, only one operation has been done at a time. In this study, patients had both the MAT and either the OA or the ACI at he same time. Follow-up for two years has shown good early results. Thirty (30) patients who had a meniscectomy with persistent painful symptoms were included. Symptoms were reported as knee swelling with activity, crepitus, and pain along the joint line. Crepitus is the snapping or crackling felt or heard in the joint.
Transplantation and cartilage restoration were done by one surgeon. The patients were divided into two groups: MAT with OA (group 1) and MAT with ACI (group 2). The authors describe the specific techniques used for each operation. In some studies, patients are randomly placed in one group or the other. In this study, the choice of treatment was made by the surgeon on an individual basis. Important factors were age and details of the lesion (size, location, depth).
There are also guidelines published to help surgeons make the best treatment decision. For example, younger patients with small defects can have the fresh-frozen ACI. Older patients with more bone loss and deeper defects are given fresh OA grafts.
After surgery, everyone followed the same six-to-12 week rehab program. Full motion and return to full activities was expected by the end of 12 months. Results were measured and reported in terms of symptoms, function, and level of sports activity. Joint range-of-motion and ligament stability were evaluated. Anyone who had to have revision surgery of the cartilage repair was considered a failure. Patient satisfaction was also used as a measure of success.
At the end of two years, 90 percent of the patients were satisfied with the results. Nearly half of the two groups had normal motion and function. X-rays showed good integration of the grafts. Most of the defects had filled in nicely with smooth edges. Complications after surgery included mild overgrowth of the ACI patch, softening of the graft, and one graft failure.
There were some differences between the two groups. The OA group all had repair of the medial compartment (side closest to the other knee). The ACI group had an equal number of repairs to the medial and lateral sides of the joint. Lateral refers to the outside half of the joint (away from the other knee). There were age and defect size differences between the two groups. As recommended, patients who had the ACI were younger and had better function before the surgery compared to the OA group.
The authors concluded that combining transplantation of meniscus and repair of the cartilage underneath can be done at the same time with a good result early on. This is good news for young, active adults with cartilage damage after meniscectomy that is causing pain and limiting function. Up until now, standard practice was to withhold the MAT from patients with defects of the cartilage because of the complications.
With continued study and improvements in surgical technique, surgeons expect to be able to use these procedures combined together with more and more patients. There will be fewer patients who can't have the procedures for various reasons. Long-term results of the combined implant procedures are unknown at this time. Future studies over five- and 10-year periods of time will help shape future treatment guidelines.
LCDR John-Paul H. Rue, MD, MC, USN, et al. Prospective Evaluation of Concurrent Meniscus Transplantation and Articular Cartilage Repair. In The American Journal of Sports Medicine. September 2008. Vol. 36. No. 9. Pp. 1770-1778.
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