All right, so this is kind of like the ultimate endpoint, I guess, people that have meniscal deficiency and articular cartilage injury. So this is a 40-year-old male laborer. About two years ago, he injured his knee and had a medial meniscus tear. This is outside of me, was sent to me, but he previously went into arthroscopy and attempted meniscus repair. The repair eventually failed, or he retore it, went into arthroscopy, had a significant medial meniscectomy approximately a year later. He kind of went through the normal course of physical therapy for several months, continued to have pain, decreased function and swelling, tried NSAIDs, injections, and loading braces with middle improvement. These were the pictures that were provided to me of his post-meniscectomy knee. So you can see fairly significant meniscal tissue. You can see a little bit of one of the, looks like probably one of the anchors still in his meniscus through there. MRI studies showed deficiency of that medial meniscus. Maybe a little thinning of the articular cartilage there, but still fairly intact, no significant bone marrow edema. So the surgical plan was, he was referred for discussion of meniscus allograft transplantation. We obtained a match, we scheduled the surgery, but at the time of arthroscopy, we can see his meniscus, but over the course of about six months, he developed significant articular cartilage injury. So the question then becomes what to do, and I think the one significant point to make here is that some people, when they're doing the meniscus allograft transplants, have their assistant start preparing the meniscus, and they start looking inside the knee joint. Well, once you open that meniscus, it's yours. So I always tell people that you should scope the knee first to make sure they're going to be a candidate, and this was a perfect example. So what we ultimately had to do with this patient was, I scoped his knee, and I was not going to put a meniscus in that, discussed this with the patient afterwards, and the decision was to go ahead and do his meniscal transplant, but also repair his articular cartilage. People's thoughts, questions about that, I mean, this is kind of like the next stage of what Jim was talking about when you kind of get this meniscus problem, but you want to make sure the articular cartilage is okay. Be contraindicated to a meniscal transplant with that type of wear of that joint surface. Eric, you're not confident in your MR capability. I think MR these days allows patients to do a diagnostic or a cross-examination. I think you should know going in and deciding. Well, a good MR should answer the question. I think I need to scope the knee to assess the articular surface. The MRI that I showed was about five, six months prior to surgery. So that MRI didn't look as bad as his knee did, and obviously we could have repeated his MRI, but he really had no additional change in symptoms, any trauma or anything like that. So it was probably not worthwhile. Do you think he had progressed from the MR? What's that? So you think that patient, that compartment was progressing from your old MR? Yes. Yeah. So I think over the course of about five, six months, he developed more articular cartilage injury. If the patient, if they are progressing, they'll have either increasing pain, in particular I think if they're carrying a diffusion, if that knee's got a diffusion in it, that's the knee that worries me, that it probably is progressing, where, I don't know, the point is I guess with good MR these days, I think you can know going into the operation what you're going to do in general. Would you ever consider doing a needle scope on something you're not sure of? Certainly, you could. You know, at this point, you know, my major concern or my major thought was I scoped the knee before I did anything else at the same time, and that's when this was discovered. And so that's kind of why we would hold off on that. But certainly, you could consider doing a needle scope prior to embarking on any kind of procedure like this for sure. Yeah. You know, if you don't have good, there's some temp, I think Scott was also alluding to this, if the tempo of the pain is such that patient did well initially and then represents after some period of quiescence and return to sport, you're really suspicious that the problem now is cartilage, unlike the other one that we saw, which was sort of a short-term thing where they never got better to begin with. So oftentimes, it's because they're progressing, they're representing. So if you don't know and you don't have good index information and they come from the outside world into you, then I'll often say, look, we can do one of two things. We'll order a meniscus, but we may be calling an audible if we get in there and there's an articular cartilage thing, or we get enough confidence from the MRI, if it's possible, to say, we're going to do an OIGraft or whatever, or if you're a two-stage person, then you're going to be there anyway and you're going to biopsy them and come back. We'll be interested to hear what you did for the cartilage. So I think some of it depends upon what treatment you like to use for your articular cartilage in terms of the timing and tempo of, do you take a chance of scoping and not thawing the meniscus and so forth. So ultimately, we stopped at doing his arthroscopy, again, the importance of that initial arthroscopy. We decided to use an osteochondral allograft for this patient just because of the probably ease of getting it and the nature of his defect. So we ordered that and obtained, and we did the surgery for his meniscus allograft transplant and his osteochondral allograft. In doing this, I think there's a couple of different approaches, and it also depends upon what you utilize for your cartilage restoration. You could first prepare the knee for the meniscal transplant arthroscopically, and then do the arthrotomy and placement of the osteochondral allograft or placement of the autologous chondrocytes if you chose to do that, then introduce the meniscus and apply fixation. Or you could go ahead and perform the arthrotomy and place the osteochondral allograft, fix the cartilage defect with chondrocytes, then close and perform your meniscus allograft transplantation. So these were his pictures at the time of surgery, his new meniscus in place, and we placed an osteochondral allograft on his medial femoral condyle. Questions, thoughts? I thought that order of events is interesting, too. So I've had some success with, like, getting the meniscus graft in arthroscopically, but not fixing the front. And so you anchor the back, you can even get some stitches in the back, and then you do the arthrotomy so you flex the knee, get your graft, and then sometimes you can even just repair the anterior aspect and then close it up. There's a beautiful way to do it, but that seemed to be a workable option as well. Yeah. So, and then just, I mean, the thoughts, any thoughts? Obviously, you've got, we've probably seen situations where someone has done a carpentry surfacing procedure with some aspect of meniscal deficiency that wasn't addressed, and then that graft or that chondrocyte's failed. So that highlights the importance of adding that cushion there that you've got to have if you expect this stuff to work. And I'm assuming the alignment was... Yeah, he was in neutral alignment, standing, long leg x-rays, and so forth. And his was just a kind of compression of continued pain, discomfort, decreased function. Didn't have a lot of continuous joint effusions, but just kind of pain and disability. And I guess just following the audience real quick, like, if you've got a cartilage defect and not a complete meniscectomy, is there a threshold at which you would accept having some amount of meniscus loss and just doing cartilage? Like, say, you've got still 50% of your posterior horn, your meniscus. Is that enough to protect your cartilage? Or what's a rough cutoff that people use to say you've got to transplant that meniscus at the same time? Because I think that's crucial to these things. I see Matt Godman said he's got a comment. I think we don't know. I think the important point I would submit to the group to think about is some patients load cartilage to cartilage hematemia. Some patients load through the meniscus. And we need better ways to figure out who those are. So if you're going to load through the meniscus, you've got the rapid progressors where the meniscus loss there is, and they eat too much. We ought to do a transplant to another. Do they load hematema? Yeah, they can lose their whole meniscus and do fine. Sub-total menisectomy 20 years later, that needs fine. Other patients, a year later, they've got problems. There's really differences in the kinematics. We need better ways to figure that out. We're doing that with loaded MR. But just food for thought for the group, because that answers your question. We don't know what is the critical amount of meniscus loss that mandates replacement. Can you turn your mic on? Yeah, I don't think these mics work up here. But that brings up the question. These cartilage injuries, they don't just necessarily just come out of the blue. Something caused it. So is that amount of meniscus deficiency for that person showing that's not good for them? Right, does that define them as a meniscus loader because they've lost a certain amount and now they've got a cartilage defect? Does that define them as that group of people just because they got the cartilage defect that developed? So that's always a big question. And then it brings up the notion of as we move this into the future, segmental meniscus transplantations and different things like that, who knows if that's going to be workable or not. But, again, it's all... »» Is this a compartment that's not tolerating meniscus loss? Do we have to figure out? I don't have a good answer. We need better ways to figure out. It's a change in context. »» Whether 50% is enough or 60% or 80%? »» Look, you can have a radial tear that goes back to the periphery or a root and they function like they have no meniscus at all. So I think if you're faced with making a clinical decision, is it or it isn't, when it's clear, I think, is sort of I think what you're alluding to is if they are clean at index surgery, they do well, then they do poorly, you could maybe argue that the meniscectomy state led to secondary change, maybe. So if you're on the fence and you're saying maybe they have enough, maybe they don't, depending on how their meniscectomy was done, that is very helpful, I think, is when they get something down the road versus was that there at the time of surgery, the cartilage injury, you might make a different decision if you're hedging whether or not there is or there isn't enough. But it's less about the volume of the meniscus, in my opinion, and I think we know this from our root studies, than it is the way it's torn. So it's not what's missing. It's the configuration that probably leads you to at least contemplate do you or don't you. »» I always follow MRI scan, follow up with the MRI to see if there's bone marrow edema again. I keep stressing on the tibia, if you have a lesion on the femur, if they have a reaction on the tibia, then you know there's extra stress and be much more aggressive no matter how much you've excised. »» And we're up, it's 8.37, so we're seven minutes over. So we can keep the discussion going for a little bit, but we can kind of give a formal clap of conclusion here. And if there's any further questions, we can kind of mill around. But if anyone's got to get somewhere, we can get moving.

medial meniscus tear

meniscus repair

meniscectomy

meniscus allograft transplantation

articular cartilage injury