And on my Swiss watch, this is 4pm. My name is Jacques Menetre from Geneva, Switzerland, and I'm the past president of ESCA, and I'm very pleased to welcome you this afternoon in our symposium. ESCA is the European Sports Medicine and Knee Surgery Society. It's the sister society of AOSSM in Europe. And on behalf of ESCA, I would like to congratulate AOSSM for the 50th anniversary of the society. Thank you for having us to celebrate this anniversary, and we wish you the same great success for the next 50 years. This afternoon we have been asked to talk about meniscus, cartilage, and I will speak about the European vision of the modern way we are treating our meniscal lesion. Then David Daujour will talk about the meniscal transplantation, and talk about the European and ESCA allograft initiative. Then Thomas Tischer will talk about the management of focal cartilage lesion, again a European perspective. And finally, Roland Becker, our current president of ESCA, will address the role of osteotomy in cartilage repair at the end of the talk. Well, without further ado, those are my disclosures. As you know, the meniscus is the best elastomer we have created so far. It's a load distributor, a shock absorber, a stabilizer. But not only, the meniscus plays a very important role by sharing the load with the cartilage, and on this very nice picture you can see that where meniscus is, the thickness of the cartilage is much less important than for the rest of the joint line. Meniscus has the capacity to heal by peripheral vascularization and the migration of synovial cells from the synovial tissue, although at the central part of the meniscus, this is in the vascular zone and there is no healing. Now, a modern way to address the meniscus injury today is to look at this figure of eight that we have implemented now two or three years ago. That means we have a forerunner evaluation of the meniscus structure, but not only, we probe the meniscus stability and the meniscus function in all the zones of the meniscus. And when we looked, we used this type of examination. We found that, for example, looking at a series of ACL tear, actually we had only 20% of isolated ACL and the rest of the lesions were associated meniscus lesion. You can see here that the medial side was involved as well as on the lateral side in this study, that the medial meniscus show about 15% of ramp lesion, for example, a couple of back tendril tear and longitudinal tear. On the lateral side, we had a couple of root tear, but we have a lot of posterolateral instability, and I will come back to that later. In this series, about 80% of the meniscus were repaired on the medial side and up to 90% were repaired on the lateral side. It means that when you start to look at the meniscus like that, we need to revise a little bit our classification to have the new meniscus lesion we have now in our knee. Well, I won't have time to discuss all of them, of course. A few words on the ramp lesion. Now anatomically, we start to better understand how this posterior aspect of the meniscus and how the ramp lesion works, and we partly know now the role as a dynamizer of the semimembranosus tendon. So how those lesions do occur? Well, if you look at there, we have a clear subluxation of the tibia below the femur, and obviously you will sort of uncap the posterior medial as well as the posterolateral compartment in those motions. And you may imagine easily that these knees will have not only an ACL tear, but other concomitant lesion in medial or lateral compartment. Well, we know that the prevalence of ramp lesion goes from 10 to 25 percent. It match our findings where we had 15 of them, and that those lesions can be found only if you go in the posterior medial compartment. So I really encourage you to go transnotch and to go into those posterior medial compartment to look and try to find the lesion right there. Well, you can also go into posterior medial aspect of the knee, where you will better identify the lesion that usually does about two centimeters long at the posterior aspect of the medial meniscus. Now, those ramp lesions, since we are looking carefully at them, has been shown to be very different from one to another. And therefore, we need to probably revise a bit the initial classification that has been described in order to better address the treatment. Well, this treatment can be various. You can do a classical one through the posterior medial portal using hood technique and PDS sutures. But nowadays, you can also address it by all-inside fixation, especially if you have a type 1, 4, or 5 lesion with a meniscal instability associated to it. Well, in this case, and this is a perfect illustration, if you look at it from the anterior view, you won't see many things. And if you pass, once again, the posterior medial compartment, you will find this lesion at the posterior aspect of the meniscus. If you do it all-inside, you need to place your sutures at the inferior aspect of the meniscus as well as the superior aspect of it. The superior one or the inferior one allows you for the reduction of the meniscus, as you can see it here. And then you always have to go back at the posterior medial to make sure that your meniscus is properly reduced and fixed. That was for the ramp. And we know that from this work coming from London, that you can fix it safely by all-inside repair devices, although to go below the meniscus, you need to have a needle that is relatively highly curved, at least over 20 degrees, to really fix the things correctly. A few words now on the posterior root tear. Well, if we place ourselves in the situation of ACL-associated lesion, on the medial side, you know that this is relatively rarely encountered. On the lateral side, though, this is a totally different story. Well, same thing. Why we do have those extensive lateral lesions? This is the same explanation that for the medial side. With this subluxation, you clearly have an end cap of this posterolateral structure, and usually the lesion occurs at two places, either at the root complex of the posterior horn of the lateral meniscus, or in this now so-called popliteal meniscal complex, which is around the iatus popliteus. Well, usually we address those by pull-out repair, using one or two tunnels in an anatomical attachment, and you will fix it this way. Well, there is also here a place for all-inside root repair, especially if you looked at this new category of lesion, that is the posterior horn tear insufficiency, or partial lesion, that has been described by the team of Romain Sale very recently. Well, you can help yourself with the classification that's been published by CRIS, that will orient also your type of treatment you may do here, once again by refixing this posterior horn of the lateral meniscus. Usually you have that type of presentation with a hypermobile posterior horn, you have a partial tear or insufficiency of the posterior lateral root, and you can fix it by doing horizontal and X-shaped sutures, in a way that you can re-tension the posterior horn, or I would say replace the proper hoop stress effect you may have in the posterior horn, as you can see illustrated in this video. Well, we know that from a biomarker standpoint, all the advantage and benefit to fix those root tear, and I would like to emphasize this paper just to pay a tribute, a special tribute, to Freddy Fu this afternoon. Now there is other problem, this is the posterolateral corner of the joint. You may have this posterior hypermobility of the posterior horn, that is very frequently due to the injury of the lateral meniscal tibial ligament. In this case you need to fix it, but you can also have this capsulomeniscal lesion, which is hypermobility of the lateral meniscus in front of the yatus popliteus. In this case you need to fix this back by posterior, superior, and inferior sutures, usually vertical sutures, in order to restore the proper stability of the lateral meniscus. Well, another formidable lesion is those radial tear in young patient here on the lateral compartment. I may have to say that today with the new devices we have, we are now able to address and try to re-fix as much as possible, and this repair should be done at all costs, because those lesions are extremely dangerous for, I would say, the function of this lateral compartment. Using crossing ashtag or ashtag type of sutures, you may have to re-fix this lateral meniscus and to fix these radial sutures. Well, we start to have, I would say, good evidence in literatures that all those repairs are beneficial for your knee and works well. Now, to make a long story short, I would say nowadays we really need to have a systematic examination of meniscus integrity, but not only. You have to look at all the stability of this menisci. You should repair as often as possible, especially on the lateral side. Obviously, preserve the meniscus tissue is something extremely important. Use the technique you're familiar with. And we start to have, I would say, a good body of evidence that it works well. Thank you very much. Please give the floor to David for the meniscus transplantation. Thank you. Thank you very much, Jacques. There are some places in the front. If you want to move, it will be much convenient for you. So state of the art in meniscus replacement. I have to acknowledge Tim Spaulding for his help for this presentation. This is something interesting that we launched in 2018. We did the European Allograft Initiative. As you should know, in Europe we are not so easy to use allograft, and we wanted to promote the use of allograft to the EU community. So we commissioned an initiative to look at the cost-effectiveness of technology appraisal to evaluate osteochondral allograft, meniscal allograft, and allograft used for ligament reconstruction. We ended up with a CESTA issue, a specific issue, with 23 papers, and 12 were coming from this allograft initiative. You can go on the website of ESCA and look at the full report of this huge work. If you have some time, you can read the 189 pages, but it's really interesting, and frankly, you have everything that you need about that. So the question was, when we started this European Allograft Initiative concerning the MAT, there are three issues. Does meniscectomy lead to early osteoarthritis? Does MAT prevent or delay osteoarthritis after meniscectomy? Is MAT an effective way of relieving continuous symptoms after meniscectomy? So we all know that when you remove the meniscus, you will increase the contact stresses on the tibiofemoral joint by 130%, and your impact load will be three times higher. So you can understand that you will destroy your meniscus. And we always say, save the meniscus. And you can save the meniscus when you have a radial tear like that, a traumatic tear, but sometimes the meniscus kills itself, and you have to remove it. And when you remove the meniscus, you will face some problem. And you will face what? You will face the post-meniscectomy syndrome, symptomatic unicompartmental pain, no significant articular cartilage wear. And this will occur in 20% of the full meniscectomies. And it starts about seven years after the meniscectomy. So this is what we have shown with this allograft initiative. And then you will end up with pain and with a problem with your knee. So the solution might be a meniscal allograft transplant. And the goal and the pre-surgery requirement, the goal is to reduce the pain and to improve the knee function, of course, and delay maybe the osteotomy or delay the partial knee arthroplasty or delay the total knee arthroplasty. Of course, you always have to start first with a conservative treatment, with injection, braces, physiotherapy, et cetera. Then you have to select the patient. And we use the International Meniscus Reconstruction Expert Forum. We state in 2015 that it concerns unicompartmental pain following the full meniscectomy. And it might be a concomitant solution to ACL repair or cartilage repair. But the math is definitely not indicated in patients with no symptoms. So what are the indications? Probably those meniscus deficiency, no arthritis or very low-grade arthritis, localized pain, patient under 50 years old. Maybe some studies will show that maybe we can go over 50. No big malalignment, no ligament pathology. And the contraindications are these ones, as you can imagine. The planning for good results is definitely to match perfectly the graft that you will use and the knee in which it will go. So you have to use X-rays, MRI, and the polar method is the way to match and to size your graft before surgery. Graft choice, you have many choices. And the one which is probably the most used is this one. And there is in the literature no absolute superiority of one method versus the others. But definitely the one which is good is this one, non-irradiated, frozen meniscus allograft. Then you can do open or orthoscopic surgery. And you have different techniques. You can use suture, you can use bone blocks, you can use bone bridges. No differences in the literature in terms of result comparing all those series. And then the complications are the one that you all know about knee surgery. Something is important is that if you ask for an MRI as a MRI control or if your knee is still painful, you might see an extrusion of your mat. But the extrusion is not related to the bad clinical results. So it's almost normal to have a graft extrusion. So Stefano Zaffanini from Italy did a very strange story, controversial story, because he pushed the mushroom or the indication very far. And he said that a mat could be a viable option in a patient who are over 50 years old. Thank you so much, Stefano. But we have a little bit more complication and a little bit higher failure rate. But it might be an option for that. If we go through this team-spelling study with a mid-term follow-up about the mat, you will see that the failure rate was about 10% at five years. So it means that it's pretty good. And then when we move to this Europe Allograft Initiative, which does a systematic review, it's a 30-case series, only one pilot RCT. And this is probably what is important to look at. There is no real control group in all those studies. So it maybe weakened a little bit the results of all those studies. But it's interesting, especially when you see the follow-up, 2.5 years and up to 17 years follow-up, which is a huge follow-up and very interesting follow-up. So what are the results? If you go over all those studies, you will see that the curve goes up to 90% of survival at five years, 70% at 10 years, and 60% at 15 years, which is finally not too bad and probably good. The latest review in KESTA in May 2020 shows also survivorship close to 90% at 10 years. So the results are good. So what can we say? We can say that if you look at the literature, that the procedure has very specific indications, symptomatic meniscus lost. All the fixation methods are about the same. The results for the lateral meniscus and the middle meniscus is a little bit different and it's also a little bit controversial if you look at the different studies. And for sure, it is not done to be a high-level spot guy, but it's like a salvage procedure. So the outcomes are really encouraging, for sure. Get the proper patient selection and the pre-surgical planning is very important, especially you have to match your size, your meniscus graft with the knee, mostly for young patients, of course, and look around and maybe sometimes you have to do an osteotomy, sometimes you have to do some ligament reconstruction, cartilage repair, and of course it might be an associated procedure. So this is something which is very important to understand. So if we go back to the questions that we asked in 2018, does meniscectomy lead to early arthritis? Of course, yes. Does MAT prevent or delay osteoarthritis after meniscectomy? There is a lack of good evidence, we have to say that, and the verdict will be not proven, but we may imagine that a little bit. Is MAT an effective way of relieving continuous symptoms after meniscectomy? I would say yes, it's effective. Effectiveness is a little bit different because we have no control group and this is the weakness of all those studies, and there is only one LCT providing good results, but with a very short-term evidence. So if we evaluate the cost effectiveness of the MAT, what could we say? We can say here again there is no control group actually to compare the methods, but interesting. In conclusion, what could we say? We will use this IMREF statement saying that a good indication would be the post-meniscectomy pain, pain on activities, stable or medistable, that you might add an ACL reconstruction, good alignment or corrected, might do an osteotomy, and of course, low-grade cartilage damages for sure. Merci beaucoup.

meniscus injuries

ramp lesions

posterior root tears

meniscus transplantation

meniscectomy

MAT