I have a few minutes just to talk about meniscus transplant and another plug on the centralization. You know, you all know why the Japanese came up with centralization, yes? They don't have meniscus transplants, it doesn't exist in Japan. So I think that's a very interesting concept, the centralization now adding it to root repairs and adding it to meniscus transplants. So no disclosures that are relevant here. I like this slide very much, don't want to talk too much about anatomy, but there's a beautiful dissection by Paugolano, the late Paugolano in Barcelona. And I just like studying this and when you get a meniscus transplant on the back table you kind of see the obvious differences between median and lateral. But it's a nice way to look at this and you see where the roots are, obviously you need to repair this in the most anatomic fashion you can. I'm just going to go through this a little bit more. So the reason to transplant menisci really is the partial meniscectomy will lead to overload of that joint. So if people come in and they have a meniscus deficient sort of pain in that compartment, that's where we're going after this. So the meniscectomy is unfortunately still the most common procedure in orthopedics. The contact forces are changed and so the meniscus transplant can really prevent that early OA. The ideal candidate for a meniscus transplant is somebody that has a neutral alignment or else you change it, as we just discussed. BMI I would handle for a meniscus transplant in the same fashion you would for a total knee. So you really have to watch the overweight with meniscus transplant, it's very difficult. The patient is usually under 30 years old, so isolated, sometimes a 50-year-old, I'm not sure. Have you fixed meniscus transplants in over 50, any of you three? Rarely though. Commonly? Rare. Yeah, rare. So my oldest was I think 45. The knee has to be stable, that's key, or else you stabilize it and there's no focal cartilage loss or you add it. So the isolated transplant is a rarity in my series. Now various alignment is protective for the lateral and vice versa, so this is another good paper from Korea. And then selection criteria, so really contraindications would be advanced OA, you know, Dr. Harner had taken this picture of my knee 25 years ago just to show this is where the pain is, so the one-finger sign would be the perfect patient, the patient that comes in and has pain all over the joint is maybe not the ideal candidate. Arthrofibrosis is a no-go, previous infection, inflammatory arthritis, these types of things are not good. But what do you do if you have a 17-year-old and they already have osteophytes? I think the osteophyte in that case isn't a deal-breaker because what else do you do in a 17-year-old? Unfortunately, we see that commonly. The techniques, the bone blocks on the roots is the most common technique, just for anchoring. We've used in Pittsburgh for many, many years, decades, just a soft tissue technique, which we recently modified to just include a little bit of a bony sliver. You can also do these troughs on the right, especially on the lateral side where the roots are very close together, if you remember that first slide I showed. This is not the whole history, it's just part of it, but it started in the late 80s, and then with the event of arthroscopy, it's a pretty slick procedure these days. Interesting I think is indications supported in the literature, this is from the International Meniscus Reconstruction Expert Group. These are your typical indications, so unicompartmental pain in the subtotal menisctomized knee, revision ACL with meniscus deficiency. If there's no pain in that compartment, but they have a revision ACL and no meniscus, it's a little bit tricky. There's not good consensus what to do there. You know that the lateral meniscus conveys more of the rotational stability, so if there's no meniscus in that compartment, you may think about it, and then the articular cartilage repair with meniscus loss is another good indication. There really isn't a role for prophylactic MAT, you probably see that a lot, I'm sure the panelists here, when people come to you and they just had the meniscus excised and they want a new one, that doesn't really make any sense, because most people will be fine with a meniscectomy for many years. The difference maker is obviously the discoid lateral meniscus in a 14-year-old, where eventually you'll do something for sure. Sizing is just the Pollard method, so I recommend to you that if you do meniscus transplant, you rather oversize by about 10% than undersize, because as David mentioned, you don't want any tension on your repair whatsoever. So this is one of the studies, I'm not exactly sure how they measured this, because when I go back at my series, I can't find out if they were undersized or not. I assume failures were undersized, but there's very little I can show to prove that. The harvesting is a fresh frozen, not irradiated graft, there are many other options too, cryopreservation, etc., but we use fresh frozen. I just want to show you these two cases, which are two of my most painful cases I have ever been part of, and sharing complications, relieve stress from your chest. So here we are. So if you look at the image on the left, this is a meniscus that I opened on the back table after I already had the patient on the table, the scope in, and the roots prepared to go. So then you're asking yourself, will you transplant that median meniscus in a 17-year-old child? And I made the decision not to do that, and that was a hard decision, with safety committees talking to you, with the parents flipping out on you, rightfully so. So my point here is, if you don't already do that, the meniscus tissue gets included in the surgical timeout, so in the preoperative timeout, there's no anesthesia block or intubation before you see this. And the same with this on the right. Would you transplant these tissues, guys? Hard to say, right? It's a really, really tough decision to make, but the problem obviously is there are such things as anatomic variants, nothing is torn on those menisci, they're just really tiny. So this is what it should look like, what the revision looked like, and the same here. It's the same size, except better tissue. This is a surgical technique just broken down by Leanne, who's sitting right there, who made this really nice chart. But essentially, as I mentioned, first is a graph check. You do a diagnostic arthroscopy. In some cases, I prefer a two-stage, if I just haven't met the patient at all and the MRI isn't all that great, I sometimes do a two-stage, especially if there's failed ACL-involved preferences to do one stage. Everything is done arthroscopically through enlarged portals, and in my hands, everything is done with all inside sutures, and then the roots get fixed in an isolated fashion. Here's just a little bit of video. So the benefit of leaving a little bit of bone on your roots is that the graft itself will not become too short. So if you take the graft off just the soft tissue, then you can sometimes make the graft a little shorter, and again, you must have a tension-free repair. So a little bony sliver is still attached. I'm just going to keep going to the next, and this is what the implant looks like. We mark out where all the sutures go. So I am going between six to maybe maximum nine sutures on a transplant. You guys go many more? I know Aaron just said 12, but... Not for transplants. Not for transplants. Yeah. So, I mean, you have a nice capsule junction there. So maybe I'm just going to show you one of these cases, because you probably want to talk about some questions. So this is one, I would two-stage. This is a football player sort of on track and field after, not completely after their career, but realizing there are a lot of issues. May you talk about, do you want to return back to sports, or do you want to have a knee that's going to last you for some time? So here's ACL rupture, BTB, failed again, and medial meniscectomy, some various alignment. Here you do a diagnostic scope to figure out what all needs to be done. You realize there's a medial condyle lesion and no medial meniscus, and so they receive the osteotomy. In my hands, I use over-the-top technique for ACL and revisions frequently, if the tunnel is half in and half out. It's a separate topic, obviously. With the medial opening wedge, you can also correct the slope a few degrees. Not as much as the anterior closing wedge, but you can do that. And then in a second stage, you can see here the compartments that we pull the, we make a posterior root tunnel first, and then pull the implant into the joint through the dilated portal, and then once it's in the correct position, start with these all-inside suture devices. Don't squeeze the meniscus too hard, obviously, with this Kelly clamp. But once it's in position, all the sutures go in. And then in this particular case, we didn't fix all the roots yet, then opened, then osteocondylalograft, then did the root fixation, because the osteocondylalograft, 120 degrees, your roots may be under quite some stress. Okay, I'm just going to run through this real quick and summarize. Go back one. So here's an outcome paper. This is just something just to keep in mind. This is not a procedure that is going to be perfect. This is not a procedure where you want to send people back into athletic competition. But our study here is on multiple surgeons and many, many years back, but on average 10 years follow-up, and you can see that over 50% had some sort of subsequent surgery. So that's not a great number, but it's a pretty honest number. And there are meniscus tears, oftentimes root tears, and if the meniscus is too small, you can have the anterior root pop off, et cetera. Some stiffness things, ACL and other related things. So here's a survivorship curve, obviously, for those that didn't have recurrent tears in their graft, a much better survival. And of course, your question is, will every meniscus transplant eventually fail, right? The answer is probably yes, because you do this on young people. And yes, eventually this may go to total knee. But to have that same conversation about what you tell the patient, you'd be open about it. Ideally, this last 20 plus years, will I need a total knee later? Who knows? I'm not going to tell them in so many years to get a total knee, because then they will. But these are just some sobering, but very honest numbers here. So in summary, carefully select your patients, not a prophylactic procedure. Talked about all the alignment and ligament issues. There is a high rate of secondary procedures, extrusion, we just started centralizing and making a third tunnel in the meniscus transplants, but that data is still to come. And there's some evidence that it's counter-protective. So I like this procedure. I recommend you put it into your armatory. Okay, thank you.

meniscus transplant

benefits

centralization

selection criteria

surgical techniques