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meniscal repair enhancement techniques

meniscal repair enhancement techniques. 25 th Annual Meeting of the Iranian Orthopaedic Association Tehran – Olympic Hotel 20-24.Nov.2017. Mehran Soleymanha ( Ass. Prof. GUMS , Knee surgeon). Incidence of meniscal injury 66 to 70 per 100,000 people.

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meniscal repair enhancement techniques

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  1. meniscal repair enhancement techniques 25thAnnual Meeting of the Iranian Orthopaedic Association Tehran –Olympic Hotel 20-24.Nov.2017 Mehran Soleymanha (Ass. Prof. GUMS , Knee surgeon)

  2. Incidence of meniscal injury 66 to 70 per 100,000 people Traditional suture repair of the meniscus remain as a biological challenge reported rate of failed meniscal repair ranges from 5% to 43.5% Insall & Scott Surgery of the Knee. 2018

  3. Healing potential of meniscus tears • Smaller tears • Acute tears • Tears repaired in stable joints • Repairs performed with concomitant ACL reconstruction • Peripheral tears with adequate vascular supply • Young patient Albornoz, P, et al. The meniscal healing process. Muscles, ligaments and Tendons Journal. 2012

  4. Treatment algorithm of meniscus lesions Mordecai SC, et al. Treatment of meniscal tears: an evidence based approach. World J Orthop 2014

  5. Criteria for meniscal repair A completed vertical longitudinal tear longer than 10 mm in length A tear within the peripheral 10% to 30% of the meniscus or within 3 or 4 mm of meniscucapsular junction A peripheral tear that can be displaced toward the center of the plateau by probing, thus demonstrating instability The absence of secondary degeneration or deformity A tear in an active patient A tear associated with concurrent ligament stabilization Insall & Scott Surgery of the Knee. 2018

  6. Biologic augmentation strategies are designed to promote a healing environment around the relatively acellular meniscus Woodmass JM, et al. Meniscal Repair: Meniscal Repair Reconsidering Indications, Techniques, and Biologic Augmentation. JBJS. 2017

  7. Repair Enhancement and Biologic Augmentation • Current clinical applications include: • Mechanical Stimulation • marrow venting procedures • fibrin clots • platelet-rich plasma injections • stem cell-based therapies • gene therapy Woodmass JM, et al. Meniscal Repair: Meniscal Repair Reconsidering Indications, Techniques, and Biologic Augmentation. JBJS. 2017

  8. Mechanical Stimulation • Abrasion of the adjacent synovium (Synovial rasping) • neovascularization • IL -1 • TGF β1 • PDGF Taylor SA et al. Augmentation techniques for isolated meniscal tears. Curr Rev Musculoskelet Med. 2013 .

  9. Augmentation of Meniscus Repair through Trephination , Rasping , and Abrasion • Shelbourne KD, et al. Evaluation of peripheral vertical nondegenerativemedial meniscus tears treated with trephination alone at the time of anterior cruciate ligament reconstruction. Arthroscopy 2015 • Level III • Sample Size (% males) 881 • Mean FU times (mo) 45 Objective - 74 Subjective

  10. Trephination • 90% good result in symptomatic incomplete tear Mechanical Stimulation Taylor SA et al. Augmentation techniques for isolated meniscal tears. Curr Rev Musculoskelet Med. 2013 .

  11. marrow venting procedures • isolated meniscal tear repair with a marrow venting procedure • (intercondylar notch) • Meniscal repair in conjunction with an ACL reconstruction • release of growth factors and pluripotent cells after bone-tunnel drilling that results in biologic augmentation at the repair site Dean CS, et al. Outcomes after biologically augmented isolated meniscal repair with marrow venting are comparable with those after meniscal repair with concomitant anterior cruciate ligament reconstruction. Am J Sports Med. 2017

  12. fibrin clots Chahla J, et al. Meniscal Repair With Fibrin Clot Augmentation. Arthroscopy Techniques. 2017

  13. fibrin clots Chahla J, et al. Meniscal Repair With Fibrin Clot Augmentation. Arthroscopy Techniques. 2017

  14. fibrin clots Chahla J, et al. Meniscal Repair With Fibrin Clot Augmentation. Arthroscopy Techniques. 2017

  15. Augmentation of Meniscus Repair with Fibrin/Blood Clots • Biedert RM. Treatment of intrasubstance meniscal lesions: a randomized prospective study of four different methods. Knee Surg Sports TraumatolArthrosc2000 • Level II • Sample Size(% males) 40 (53) • Mean FU times (mo) 27 • Kamimura T, Kimura M. Meniscal repair of degenerative horizontal cleavage tears using fibrin clots: clinical and arthroscopic outcomes in 10 cases. Orthop J Sports Med 2014 • Level IV • Sample Size (% males) 9 (N/S) • Mean FU times (mo) 12

  16. Pearls for A Successful Fibrin Clot Augmentation • Sutures should be placed, but not tightened, before placement of the fibrin clot • Harvest, formation, and preparation of the clot should happen concomitantly with meniscal repair • Inside-out technique is the easiest for placement of the fibrin clot and also allows for placement of more sutures for increased stability when compared with the all-inside technique Chahla J, et al. Meniscal Repair With Fibrin Clot Augmentation. Arthroscopy Techniques. 2017

  17. platelet-rich plasma injections • PRP is defined as a platelet concentration of at least 1,000,000 platelets μ /L in 5 ml of plasma. • PDGF • TGF-β • EGF • IGF-I Griffin JW, et al. Platelet-rich Plasma in Meniscal Repair: Does Augmentation Improve Surgical Outcomes?. Clin Orthop Relat Res . 2015

  18. Augmentation of Meniscus Repair with Platelet-Rich Plasma • Pujol N, et al. Platelet-rich plasma for open meniscal repair in young patients: any benefit? Knee Surg Sports TraumatolArthrosc2015 • Level III • Sample Size(% males) 34 (71) (17 with PRP - 17 without) • PRPMean FU times (mo) 32 • Griffin JW, et al. Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes? Clin Orthop Relat Res 2015 • Level III • Sample Size(% males) 35 (80) (15 with PRP - 20 without) • PRPPRPMean FU times (mo) 48

  19. Augmentation of Meniscus Repair by Wrapping • Piontek T, et al. Complex meniscus tears treated with collagen matrix wrapping and • bone marrow blood injection: a 2-year clinical follow-up. Cartilage 2016 • Level IV • Sample Size(% males) 53 (75) • Mean FU times (mo) 24

  20. stem cell-based therapies • intra-articular injection of MSCs • easy to isolate • expand • capacity to differentiate into the chondrogeneic lineage • improve long-term outcomes of partial and total meniscectomy • allow for a broader indication of repair for both traumatic as well as degenerative meniscus tears Vangsness C T, al. Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study. J Bone Joint Surg Am. 2014 .

  21. Biomaterial Augmentation use of a fascia sheath to cover the repaired area use of a nanofibrous, woven biomaterial-based membrane for meniscal repair increase the opportunities to treat complex meniscal tears, without the risk of donor-site morbidity or disease transmission Shimomura K, et al. In vitro repair of meniscal radial tear using aligned electrospun nanofibrous scaffold. Tissue Eng Part A. 2015 .

  22. Take home message Woodmass JM, et al. Meniscal Repair: Meniscal Repair Reconsidering Indications, Techniques, and Biologic Augmentation. JBJS. 2017

  23. Thank you

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