London, September 18, 2000
Members | Abstracts | Future
Studies
Summary
Approximately 60 persons attended the meeting.
Henrik Aagaard welcomed on behalf of the Danish meniscal transplantation study group to this meeting. The basic idea is to establish a forum for cooporation in Europe on meniscal transplantation: exchange of ideas, sharing of experience, coordination of studies and research, and initiation for establishment of f. i. guidelines for rehabilitation. The form of organization was to be discussed later during the meeting.
The two chairmen were introduced: Klaus Milachowsky (Germany) and Carlo Fabbriciani (Italy). Five oral presentations followed (abstracts will be emailed to group members and should soon be available on the internet, see below).
Van Arkel presented the Dutch work on "Survival analysis of human meniscal transplantation".
Aagaard presented the Danish study "Dynamic compression properties of sheep meniscus allograft."
From Belgium Loorens reported on "DNA typing in meniscus allografting."
Peters from Germany shared "Long-term results of meniscal allograft transplantation from a critical point of view."
Michael Krogsgaard introduced the plans for a Danish study "The effect of meniscal allograft transplantation on pain and degenerative disease in the knee - an intended controlled, prospective, randomized study."
Following the abstracts there was a vigorous discussion.
Kevin Stone (San Francisco, USA) described in his lecture the status of meniscus transplantation in USA. Based on information from tissue banks, probably 4.000 replacements have been performed. The quality of the transplant varies from bank to bank, and donors may be up to 55 years old. Even though there are some guidelines for tissue banking, products are not uniform. In the USA there standards for Tissue Banking defined by FDA.
Sizing is a problem, as menisci are often a bit smaller than ordered, so 10% oversizing in ordering is advisable. Make sure to have a -80 degrees freezer in your clinic, so implants don't have to be returned.
Kevin Stone heavily emphazied the importance of forming an European study group. It will be valuable that efforts in Europe can be coordinated.
The American Meniscal Transplantation Study Group meets every year at AAOS. Everyone is welcome.
Kevin Stone has initiated a web-page on meniscus transplantation: www.meniscustransplantation.org, which has a doctors-site and a patients-site. This page is open for the European group to use as a means of communication.
Kevin Stone reported short term results on his own meniscus transplantations in grade IV arthritic knees. Generally pain decreased and activity increased.
Svend Erik Christiansen from Denmark discussed some possible ways to organize the study group. Other possible names were presented, f. i. European Meniscal Replacement Group, but everyone agreed to "European Meniscal Transplantation Group". Other means for meniscus replacements can of course be discussed in the group. Futher, it was concluded, that the group has a loose structure, bound together by an e-mailing system, which Henrik Aagaard will coordinate. The group is open and everyone interested in participating in the work can register with Aagaard. There is no fee.
The group will supply messages, abstracts etc. to a web site.
The group will meet in connection with ESSKA every second year. It was felt that a meeting earlier would be a good idea right now, and it was agreed to meet during ISAKOS in Switzerland in May 2001 and ask one or two Swiss members of the group to arrange the meeting there. It was discussed, if we shall try to work out standards for follow-up, but as the new IKDC score system has a special version for meniscus problems, we will wait for that. There is also a new cartilage classification system on it's way. It was suggested that a central European database for meniscus transplantation should be made, and it was agreed to.
Members who are interested in receiving a copy of the special issue of Scandinavian Journal of Medicine and Science in Sports on meniscal transplantation, can contact Henrik Aagaard.
The discussion was fruitful.
Next meeting: at ISAKOS in may 2001.
| Muellner, Thomas MD Univ. Clinic of Traumatology Waehriger Guertel 18-20 1019 Vienna AUSTRIA (tmuellner@csi.com) |
Winge, Søren MD Dept. Orthopaedics Hviovre Hospital Kettegårds Allé 30 2650 Hvidovre DENMARK (swinge@dadlnet.dk) |
| Torres, Marcelo MD Centro Goiano Ortopedia Rua 15 1340 Goiâosia BRAZIL (mrtorres@zaz.com.br) |
Aagaard, Henrik MD, PhD Strandstraede 10 2791 Dragoer DENMARK (h.aagaard@mai.ku.dk) |
| Verdonk, Peter MD Department of Orthopaedic Surgery Ghent University Hospital De Pintelaan 185 9000 Gent BELGIUM (pverdonk@yahoo.com) |
Bohnsach, Michael MD Orthopaedic Department Hannover Medical School Heimchenstrasse 1-7 30625 Hannover GERMANY (bohnsach@annastift.de) |
| Verdonk, René MD Department of Orthopaedic Surgery Ghent University Hospital De Pintelaan 185 9000 Gent BELGIUM (rene.verdonk@rug.ac.be) |
Kohn, Dieter MD, Dr. Med Orthopädische Universitäts Klinik Kirrberger Strasse 66421 Homburg Saar GERMANY (dieter.kohn@med-rz.uni-saarland.de) |
| Pasa, Libor MD Traumatological Hospital Ponavka 6 66250 Brno CZECH REPUBLIC (l.pasa@unbr.cz) |
Lazovic, Djordje MD Orthopaedic Department Hannover Medical School Heimchenstrasse 1-7 30625 Hannover GERMANY (lazovic@annastift.de) |
| Albrecht-Olsen, Peter MD Department of Orthopaedic Surgery Hilleroed Hospital Helsevej 2 3400 Hilleroed DENMARK (pealol@fa.dk) |
Lehrberger, Klaus MD Hauptstrasse 14 82008 München-Unterhaching GERMANY (lehrberger@t-online.de) |
| Christiansen, Sven E. MD Department of Orthopaedic Surgery Aarhus County University Hospital Tage Hansens Gade 2 8000 Aarhus C DENMARK (sechris@netscape.net) |
Mayr, Hermann MD Sana-Klinik-Sendling Friedastrasse 17 81479 München GERMANY (may.ju@t-online.de) |
| Krogsgaard, Michael MD, PhD Department of Orthopaedic Surgery H:S Bispebjerg University Hospital Bispebjerg Bakke 23 2400 Copenhagen NV DENMARK (mrk@dadlnet.dk) |
Metak, Gerhard MD Department of Surgery and Traumatology Krankenhauses München-Borgenhausen Englschalkinger Strasse 77 81925 München GERMANY (gerhard.metak@extern.lrz-muenchen.de) |
| Milachowski, Klaus A. MD, Dr. Med. Habil Gasterg Innere Wiener-Strasse 8 81667 München GERMANY (drdrmila@aol.com) |
de Boer, Herman H. MD, PhD Alrinne Medical Centre Box 4446 6401 CX Heerlen NEDERLANDS (a.tonino@inter.nl.net) |
| Muench, E. Otto MD Sana-Klinik-Sendling Friedastrasse 17 81479 Munich GERMANY (muench.gap@t-online.de) |
Engebretsen, Lars MD Department of Orthopaedic Surgery Ullevål Hospital 0407 Oslo NORWAY (lars.engebretsen@ikos.uio.no) |
| Peters, Gabriela MD Orthopaedic Department Hannover Medical School Heimchenstrasse 1-7 30625 Hannover GERMANY (peters@annastift.de) |
Cugat, Ramon Clinica del Pilar C/ Bajmes 271 08006 Barcelona SPAIN (ramon.cugat@tcn.servicom.es) |
| Wirth, Carl J. MD Orthopaedic Department Hannover Medical School Heimchenstrasse 1-7 30625 Hannover GERMANY (wirth@annastift.de) |
Mora, Gonzalo Instituto C.O.T. Clinica Quiron Avd. Blasco Ibanez 14 46010 Valencia SPAIN (gmorag@unav.es) |
| D'Anchise, Roberto MD Instituto Ortopedico Galeazzi Via Galeazzi 4 20100 Milan ITALY (r.danchise@flashnet.it) |
Renström, Per MD, PhD Section of Sports Medicine Dept. of Sports Orthopaedics Karolinska Hospital S-171 76 Stockholm SWEDEN (per.renstrom@kirurgi.ki.se) |
| Fabbriciani, Carlo MD Department of Orthopaedics University of Sassari Viale S. Pietro 43 07100 Sassari (SS) P.O. Box: 40 ITALY (clorto@ssmain.uniss.it) |
Miehlke, Wolfgang MD Schulthess-Klinik Lengghalde 2 8008 Zürich SWITZERLAND (miw@kws.ch) |
| Milano, Guiseppe MD Department of Orthopaedics University of Sassari Viale S. Pietro 43 07100 Sassari (SS) ITALY (milano@ssmain.uniss.it) |
Kaya, Ahmed MD Department of Orthopaedics SSK Tepecik Training Hospital 2023 Sokak No 8/7 Yali Apt. Bostanelli-Karsiyaka-Izmir TURKEY |
| van Arkel, Ewoud R.A. MD Department of Orthopaedics and Traumatology MCH Westinde Hospital Postbox 432 2501 CK Den Haag NEDERLANDS (arkmast@euronet.nl) |
Tan, Ismet MD Cukurova Universitesi Tip Fakultesi 01330 Adane TURKEY |
| Verlilok 1416 Sokak No 11 Kuhramemlar-Izmir TURKEY (verlilok@superonline.com) |
Turhan, Ahmet Ugur MD K.T.Ü. Tip Fakultesi Farabi Hastamesi ortopedi Bülümü 61080 Trabzon TURKEY |
| Brown, Jez Dept. Orthopaedics Northern General Hospital Herries Road Sheffield S5 7AU UK (jezbrown@doctors.co.uk) |
McDermott, Ian 30 Park Way Ruislip, Middelsex HA4 8NU UK (ian.mcdermott@doctors.org.uk) |
| Lokhande, Anil Royal Devon & Exeter Hospital 14A Russell Combes House Bovemoors Lane Exeter, EX2 5DS, Devon UK (avlokhande@hotmail.com) |
Strover, Angus E. 10 Henngrave Rd. Londión SE23 3NW UK (strovknee@aol.com) |
| Rao, Sudhir G. MD Queen Mary's Hospital Sidlup, Kent DA14 6LT UK (sudhir.rao@virgin.net) |
Seger, Bernard 601 Texan Trail Suite # 300 Corpus Christi Texas 79411 USA (cartilage1seger@aol.com) |
| Stone, Kevin R. MD The Stone Clinic 3727 Buchanan Street San Francisco, Ca. 94123 USA (kstonemd@stoneclinic.com) |
SURVIVAL ANALYSIS OF HUMAN MENISCAL TRANSPLANTATION
Ewoud RA van Arkel, MD1, Herman H de Boer, MD, PhD2 1Department of Orthopaedic
Surgery, MCH Westeinde Hospital, Den Haag, The Netherlands. 2Department
of Orthopaedic Surgery, Atrium Medical Centre, Heerlen, The Netherlands.
Material and Methods: We reviewed 63 consecutive meniscal allografts transplanted in 57 patients. There were 40 men and 17 women of average age 39 years (26 to 55). The lateral meniscus was transplanted in 34, the medial meniscus in 17, and both menisci in the same knee in 6. The average interval between total meniscectomy and transplantation was 16 years (3 to 33) and the average follow-up was 60 months (4 to 126). Survival analysis was performed using clinical criteria for failure, and allograft failure. Using the clinical criteria for failure, the worst case analysis, 13 were considered as failure.
Results: Lateral mensical transplantation failed in 5, medial in 7 and both lateral and medial in the same knee failed in one. Persistent pain was the cause of failure in 5 recipients ( 3 lateral and 2 medial), 8 were considered as allograft failure. A significant difference was found between the clinical results of lateral and medial meniscal transplants, Levene's test for equality of variances p = 0.001, and 2-tailed T-test p = 0.004 ( 95% confidence interval lower; 5.89, upper 29.88).
Conclusions: Because of different incidence in anterior cruciate ligament ruptures, differences in anatomy, and biomechanical functions between lateral and medial meniscus, lateral and medial meniscal allografts can not be compared. Survival for the lateral meniscal allograft was best, followed by both allografts in the same knee, and worst for the medial meniscal allografts. The results in recipients of medial meniscal allograft will improve when anterior cruciate ligament reconstruction is performed at time of meniscal allograft transplantation in a anterior cruciate ligament deficient knee.
DYNAMIC COMPRESSION PROPERTIES OF SHEEP MENISCUS ALLOGRAFT
Henrik Aagaard1,3, Uffe Jørgensen2, Finn Bojsen-Møller3. Dept.
Orthopaedic Surgery, Køge Roskilde County1. Dept. Orthopaedic Surgery,
Copenhagen County Hospital in Gentofte2. Dept. Medical Anatomy, Panum Institute3.
University of Copenha-gen, Denmark
Introduction: The compressive properties of the meniscus are important in its ability to function as shock absorber and load transmitter in the knee joint. The objective of this study was test the biomechanical properties of allograft menisci in dynamic compression.
Materials and methods: The medial menisci were harvested from sheep knees and tested biomechanically at the day of autopsy. Thirteen medial menisci were taken from knees 3 months after medial allograft transplantation. These 13 knees were implanted with a 3-month delay from meniscectomy (group D). Another 14 menisci were taken from knees 6 months after implantation, which was performed immediately following meniscectomy in a one-step procedure (group I). Sixteen menisci were from knees, which were sham operated 6 months prior to autopsy (group C). The meniscus cut out was placed in a hydraulic, uniaxial materials-testing machine (Instron® 8500+) for dynamic compression tests and loaded cyclically with 500 N at 1 and 3 Hz.
Results: At both 1 and 3 Hz stiffness in control group
C was less than in both transplant groups (I and D) (p<0.01). Hysteresis in C was less than
in both transplant groups (I and D) at 1 Hz (p<0.01). At 3 Hz creep in
C was greater than in I (p<0.05), and creep in I was greater than in C
(p<0.05).
Table 1. Biomechanical test data. C = controls, I = immediately transplanted,
D = delayed transplanted. Mean ± SD.
| GROUP (N) | C (16) controls |
I (14) immediately transplanted |
D (13) delayed transplanted |
|||
| Cycling frequency | 1 Hz | 3Hz | 1 Hz | 3 Hz | 1 Hz | 3 Hz |
| Stiffness N/mm | 1696 |
2443 |
3244 |
4722 |
3551 |
5326 |
| Hysteresis % | 17.0 |
20.0 |
22.2 |
23.6 |
23.7 |
27.2 |
| Creep mm | 167 |
95 |
196 |
84 |
162 |
66 |
Conclusion. The biomechanical properties of meniscus allografts were reduced both 3 and 6 months after implantation, but seamed to stabilize from 3 to 6 months. Experimental studies aimed at time-dependent changes to the biomechanical properties of the graft are encouraged.
DNA TYPING IN
MENISCAL ALLOGRAFTING
T. Lootens, R. Verdonk, L. Messiaen, E. Groessens, K. Van Den Abbeele University
Hospital Ghent, De Pintelaan 185, B-9000 GENT, Belgium
Introduction: Viable meniscal allografting is reported to allow for slow integration of recipient cells into the transplanted meniscal material.
Material and Methods: In 13 of 54 patients who received
a meniscal transplant and underwent a control arthroscopy, DNA fingerprinting
was used to evaluate possible ingrowth of meniscal allografts by acceptor
cells.
A small fragment of the meniscal allograft is retrieved via arthroscopy and
sent to the DNA laboratory together with a blood sample from the patient.
The biopsy fragment is cultured and the extracted DNA of the blood and tissue
samples is analysed after amplification using the PCR (Polymerase Chain Reaction)
technique.
Results: The compared DNA regions showed complete matching in six cases, incomplete matching (two cell populations together) in one case, and nonmatching in two cases. The remaining four cases could not be analysed due to culture failure.
Conclusions: These findings suggest partial or complete
ingrowth of the transplanted meniscus by acceptor cells. This ingrowth certainly
does not imply graft failure as proven in a simultaneous clinical examination
using the HSS (Hospital for Special Surgery) score. MRI performed prior to
arthroscopy and pathological examination of the retrieved fragment both show
a certain degree of mucoid degeneration in case of a matching DNA pattern.
A long-term follow-up is necessary to determine the consequence of this replacement
of donor cells by host cells.
LONG-TERM RESULTS OF MENISCAL ALLOGRAFT TRANSPLANTATION FROM A CRITICAL
POINT OF VIEW
Gabriela Peters, Carl J. Wirth
Orthopaedic Department, Hannover Medical School, Germany
Objective: To present the long-term clinical results meniscal allograft transplantation with concomitant ACL reconstruction evaluated by different scores.
Methods: Between 5/1984 and 12/1986 23 transplantation of the medial meniscus combined with reconstruction of the ACL had been performed in patients after medial meniscectomy and anterior knee instability. In 17 cases a lyophilized allograft and in 6 cases a deep frozen meniscal allograft was used. In a prospective study the clinical outcome of these patients was evaluated 14 years postoperatively by applying 7 different score systems. Control groups were used.
Results: Patients with deep frozen meniscus transplants obtained generally better results than patients with lyophilized meniscus transplants. Using the Lysholm-Score the differences to the control groups including patients with an intact meniscus or patients who had lost their meniscus were not significant. But by applying scores which consider more the cartilage situation in the knee joint we found a significant difference between the intact meniscus group and the lyophilized meniscus group. The differences intact versus deep frozen meniscus and lyophilized meniscus versus meniscectomized knees were not significant. This supported our impression that the deep frozen meniscus is more comparable with an intact meniscus and the lyophilized meniscus is more comparable with an meniscectomized knee.
Conclusion: It is difficult to find a suitable score for meniscal transplantation because the functions of the meniscus itself are multiple. Therefore it is important to use a specific score for the purpose of evaluation. Regarding the point of cartilage protection we can conclude that the deep frozen meniscus is more comparable with an intact meniscus and that the lyophilized meniscus is more comparable with meniscectomized knee joints after a follow-up of almost 15 years.
THE EFFECT OF MENISCAL ALLOGRAFT TRANSPLANTATION ON PAIN AND DEGENERATIVE
DISEASE IN THE KNEE - AN INTENDED CONTROL-LED, PROSPECTIVE, RANDOMIZED STUDY
Michael Krogsgaard, Henrik Aagaard, Svend E. Christensen,
Peter A. Olsen, Søren Winge, The Danish Meniscus Transplantation Group: Bispebjerg
(Copenhagen), Køge (Roskilde County), Århus (Århus County),
Hillerød (Frederiksborg County), Hvidovre (Copenhagen), Denmark.
Background: Allograft meniscus transplantation has been used for 15 years to relieve pain in patients who have had a total meniscectomy. The treatment series report of good short-term effect on pain, but the effect may be deteriorating long-term. Animal experiments indicate, that a meniscus allograft my protect the cartilage from degeneration and prevent osteoarthritis secondary to meniscectomy. In most human treatment series meniscus transplantation has been combined with a cruciate ligament reconstruction, articular cartilage repair or an osteotomy in a significant proportion of patients, which makes it difficult to separate the effect of the meniscus transplantation on pain.
Aim: To investigate the effect of a meniscus implant on pain and degenerative cartilage disease in meniscectomized patients.
Material and methods: Design: Prospective, randomized, controlled study.
Patients: In the 1960s, 70s and part of the 80s many patients had a total meniscectomy performed for meniscal lesion. These patients are identified in the patient files, and patients with no additional lesions to the knee and who have pain in the meniscectomized compartment, are invited for examination. 50 patients are required in each of the two treatment groups.
Inclusion criteriae: Age < 50, pain in the meniscectomized compartment only, the knee is stable and has no valgus or varus compared to the contralateral knee. If joint line narrowing is present on x-rays, it is in the meniscectomized compartment only. No general osteoarthritis of the knee, and no previous history of fracture in the same leg. No injury to meniscus, ligament or cartilage in the contralateral knee. Method: Patients who can be included and accept to participate in the study have a MRI performed. This must show that at least 80 % of the meniscus has been removed and that there is cartilage changes in the operated compartment only and no worse than Outerbridge III. Otherwise the patient is excluded. The patients are admitted to the department which has been chosen to perform the meniscus transplantations in Denmark. An arthroscopy is performed, and if the criteriae for inclusion are confirmed, the patient is randomized to either of two treatments: Meniscus transplantation, performed athroscopically assisted. Postoperatively ROM-splint with no motion for 3 weeks, followed by motion 0-60 degrees for 5 weeks. Full weight bearing from the operation. The other treatment is debridement of the knee (removal of loose cartilage flaps etc) and inforate ion of tibia under the meniscectomized compartment (six 2 mm drill holes). Postoperatively full ROM and full weight bearing for 4 weeks. Both groups receive muscle training from 8 weeks postoperatively.
Follow-up: Both groups are followed with identical procedures: Preoperatively and after 6 and 12 months and each following year for 5 years a clinical examination (including pain-score, Lysholm score and IKDC-score) is performed, in addition to standing x-rays in 45 degrees flexion, scitigraphy, dynamic MRI and functional testing. Pain is registered. These investigations are not performed by the operating surgeon, but at a different hospital. At 6 months arthroscopy is performed to test for healing and condition of the transplant. The results regarding pain and degenerative disease in the two groups are compared.
The list below includes potential future studies dealing meniscal transplantation, which are encouraged to be initiated. The list was inspired by the Meniscal Transplantation Symposium held in Copenhagen September 1998.
The studies is thought to be an inspiration to all who are interested. Every hospital, center, single person, or group are welcome to initiate one or more of the studies. If you do so, please inform the list administrator in order to mark this particular study on the list. The studies should optimally be coordinated by the European Meniscal transplantation Group and/or by the Meniscal Transplantation Study Group in the USA.
The studies on the list are mainly dealing with allografts, but also studies using other types of meniscal replacements should be encouraged.
The list is not complete and new suggestions are welcome. Please feel free to email your comments and suggestions to list administrator Henrik Aagaard, Denmark at h.aagaard@mai.ku.dk. The list is planned to be published on www.meniscustransplantation.org.
Animal experimental. There is a great need for longer termed studies with focus on the articular cartilage to document an effect of meniscal transplantation. Meniscal transplanted are compared to meniscectomized and normal controls. Systematic assessments of the articular cartilage.
Animal experimental. The first months after implantation the meniscal grafts seem to appear different from normal menisci and they present inferior biomechanical properties, but these changes also seem to diminish within the first year after implantation. From a large series of meniscal transplanted smaller the allograft is examined cross sectional series examined histologically and biomechanically in at different times from implantation.
Animal experimental. Knees implanted with fresh viable graft is compared to knees implanted with deep frozen or preserved non-viable grafts. Meniscectomized and control knees may be included. Short and long term studies of the graft and the articular cartilage.
Animal experimental and/or clinical. Animal experimental studies: Comparisons of pull-out strength. Clinical studies: Comparisons of clinical scores, second look arthroscopy and MRI scans.
Human cadaver and animal experimental. Five groups can be included in the studies: Horn detachment, bone (plug) fixation, suture anchors, meniscectomized, and controls. Human cadaver studies: Tibial contact area in and load distribution measured by pressure sensitive photographs. Animal experimental studies: Dynamic MRI investigation of allograft mobility and image analysis of allograft placement on the opened tibia plateau.
Human cadaver and animal experimental. The tensile and/or compressive biomechanical properties are tested in fresh harvested menisci. The tested menisci are then frozen or preserved and stored for different periods of time. After thawing the menisci are tested again.
Animal experimental. Meniscal allograft transplantation vs. tendon auto-/allograft vs. prosthesis vs. scaffold. Systematic assessments of the articular cartilage. One or more studies in which two or more different types of meniscal substitutions are compared.
Animal experimental and clinical. Presence of antibodies and antigens (HLA) in the synovium and in the synovial fluid investigated by immunohistochemical methods and HLA techniques. Animal experimental studies can be supplemented with an immunosuppressed group.
Animal experimental and clinical. Presence of specific immunological active cells such as T cells, giant cells, or plasma cells in the synovium adjacent to and far from the graft. Animal experimental studies can be supplemented with an immunosuppressed group.
Animal experimental. In vitro cultured recipient fibrochondrocytes are injected into the meniscal allograft. Graft appearance is investigated at different times (multiple cross sectional studies) and compared to control allografts without cell addition.
Animal experimental. Studies of growth factors added to in vitro cultured meniscal fibrochondrocytes and growth factors added to the meniscal allograft in the recipient knee.