Indications and limits of meniscal allografts

doi:10.1016/S0020-1383(13)70006-8

Injury

Volume 44, Supplement 1, January 2013, Pages S21-S27

https://doi.org/10.1016/S0020-1383(13)70006-8 Get rights and content

Abstract

Meniscal allograft transplantation has emerged as a useful treatment for carefully selected patients. The aim of this review of meniscal allograft transplantation is to put this procedure into a clinical perspective. Since there still is a lack of consensus on how the success of meniscal transplantation should be evaluated it is difficult to compare study outcomes.

Nevertheless, almost all studies report an increase in patient satisfaction and improvement in pain and function. Clinical and functional outcome is improved in the majority of patients. Progression of cartilage degeneration according to MRI and radiological criteria was halted in a number of patients, indicating a chondroprotective effect. Joint space narrowing is only significantly progressive at long-term follow-up. On magnetic resonance imaging, shrinkage is seen after some years, but more in lyophilized allografts. Second-look arthroscopy usually shows good healing to the capsule. Overall, the clinical results of this type of surgery are encouraging and long-lasting in a well selected patient population who suffered a total meniscectomy. Meniscal allografting appears to becoming the golden standard therapy for these type of patients.

Introduction

The meniscus plays an important role in the complex biomechanics of the knee joint. It has function in load bearing, load transmission, shock absorption, joint stability, joint lubrication and joint congruity. Loss of this important anatomical structure results in higher peak stresses on the cartilage and eventually leads to cartilage degeneration.1, 2, 3, 4, 5, 6

The current indication for meniscal allograft transplantation is the young or middle-aged patient who presents with moderate to severe pain due to a previous total meniscectomy. Because of the usually mild degenerative cartilage disease, the relative young age of the patients and their desire to lead an active lifestyle, these patients are not candidates for a unicompartimental or total knee arthroplasty. Joint space narrowing should be limited to grade 2 lesions as measured on plain postero-anterior weight bearing radiographs according to the International Cartilage Repair Society (ICRS) classification system. Nevertheless, some studies1, 2, 7, 8, 9, 10 have shown that meniscal allografts can survive in an osteoarthritic joint (Outerbridge grade 3–4), with significant improvement in pain and function. In case of axial malalignment of the lower limb or instability of the knee joint, a corrective osteotomy or stabilization procedure at the time of transplantation is advised. It is the authors' conviction, that an ACL graft is significantly protected by the meniscus allograft as much as the meniscus is protected by an ACL graft. In case of focal cartilage defects, these lesions can be treated concomitantly.¹¹ Chondrocyte transplantation or osteochondral grafting procedures should be performed after completion of the meniscal transplantation in order to prevent accidental damage to the patch or graft during meniscal allograft insertion.¹²

In an effort to avert early joint degeneration, some also consider young, athletic patients who have had total meniscectomy, as candidates for meniscal transplantation prior to symptom onset.¹³ However, the results obtained so far still preclude a return to high-impact sports. As such, we do not recommend prophylactic meniscus allograft transplantation in the meniscectomized but asymptomatic patient.

Contraindication to meniscal allograft transplantation is the presence of advanced chondral degeneration, although some studies suggest that cartilage degeneration is not a significant risk factor for failure.¹⁴ In general, greater than grade 3 articular cartilage lesions according to the ICRS classification system should be of limited surface area and localized. Radiographic evidence of significant osteophyte formation or femoral condyle flattening is associated with inferior postoperative results because these structural modifications alter the morphology of the femoral condyle.¹⁵ Overall, it is believed that patients over age 50 have excessive cartilage lesions and are suboptimal candidates.

Axial malalignment tends to exert abnormal pressure on the allograft leading to loosening, degeneration, and failure of the graft.¹⁵ A corrective osteotomy should be considered in patients with more than two degrees of deviation toward the involved compartment, as compared with the mechanical axis of the contralateral limb. Varus or valgus deformity may be managed with either staged or concomitant high tibial or distal femoral osteotomy.¹² However, as in any situation in which procedures are combined, it is unclear which aspect of the procedure is implicated in symptom resolution, such as relief of pain.¹⁵

Other contraindications to meniscal transplantation are obesity, skeletal immaturity, instability of the knee joint (which may be addressed in conjunction with transplantation), synovial disease, inflammatory arthritis and previous joint infection.

In order to investigate the indications, limitations and results of meniscal allograft implantation we carried out a comprehensive review of the literature.

Section snippets

Materials and methods

In January 2011, we performed a literature search to identify all published and unpublished clinical studies of meniscal allograft transplantation using the following medical electronic databases: MEDLINE, MEDLINE preprints, EMBASE, CINAHL, Life Science Citations and British National Library of Health including the Cochrane

Central Register of Controlled Trials (CENTRAL). The medical databases were searched using the MeSH (Medical Subject heading) terms: meniscus, meniscal transplant,

Results

A total of 39 studies1, 2, 7, 9, 10, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 58 met the inclusion criteria and formed the basis of this review. Due to the small populations studied and the differences in indications, contraindications, preservation techniques, preoperative Outerbridge grade, fixation techniques, surgical techniques, concomitant procedures, evaluation tools and rehabilitation

Discussion

The comparison of published results is difficult due to the large differences in meniscal preservation techniques, types of surgical fixation, the concomitant procedures used, the clinical scoring systems and the follow-up time. Nonetheless, significant relief of pain and improvement in function have been been achieved in a high percentage of patients. These improvements appear to be long-lasting in 70% of patients. Based on plain radiology and MRI, a subset of patients does not show further

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Cited by (58)

A Comparison Between Polyurethane and Collagen Meniscal Scaffold for Partial Meniscal Defects: Similar Positive Clinical Results at a Mean of 10 Years of Follow-Up
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
To compare, at long-term follow-up, the clinical outcomes and failures of collagen and polyurethane meniscal scaffolds for the treatment of partial meniscal defects.
Patients affected by partial meniscal defect with intact anterior and posterior meniscal attachments and an intact rim at the circumference of the missing meniscus were included, treated with a collagen meniscal implant or with polyurethane scaffold, and clinically evaluated by analysis of the subjective International Knee Documentation Committee score, the visual analog scale score for the evaluation of knee function and symptoms, and the Tegner score to assess the activity level.
After 3 patients dropped out, a total of 47 patients, comprising 31 men and 16 women, with a mean age of 43 ± 14.1 years and mean body mass index of 25 ± 1.4, were clinically evaluated up to a mean of 10 years’ follow-up. The International Knee Documentation Committee score improved from 42.9 ± 15.9 to 67.4 ± 12.4 (P < .0005) in the polyurethane implant group and from 46.8 ± 16.7 to 62.1 ± 22.6 (P < .0005) in the collagen meniscal implant group. The visual analog scale score decreased significantly from baseline values of 5.4 ± 2.3 and 4.4 ± 1.7, to 3.4 ± 2.5 and 2.7 ± 2.4, respectively, at final follow-up in the polyurethane implant (P = .002) and collagen meniscal implant (P < .0005) groups. The Tegner score improved in both groups without reaching the preinjury activity level. No significant differences in the scores were found between the polyurethane and collagen scaffold groups. A total of 10 implants failed, 5 per group, for a cumulative failure rate of 21.3%, with no differences between the 2 scaffolds.
The long-term comparison showed positive and similar results for both polyurethane- and collagen-based meniscal scaffolds, with an implant survival rate of about 80% at 10 years of follow-up and no differences in terms of pain, function, and activity level.
Level IV, case-control comparative study.
An exploratory study of the histomorphogenesis and zonal vascular changes in the human fetal medial meniscus
2021, Translational Research in Anatomy
Citation Excerpt :
Thorough knowledge of the morphogenesis and zonal vascular changes of the menisci becomes imperative in the development of newer techniques for meniscal restoration. Some of the methods include meniscal allograft transplantation (MAT) [26], Growth factor-based strategies [27], mesenchymal stem cells (MSCs) augmented repair [28], and meniscal scaffolds [29]. Further, the present study may also support the process of developing a tissue-engineered meniscus [30].
Menisci plays an essential role in the functioning of the knee joint. It is mainly composed of water, collagen, and glycosaminoglycans. The cells seen in the menisci are fibrochondrocytes, mostly confined to the middle and inner zone of menisci. The morphogenesis of the developing menisci is not clearly understood. The present study intended to evaluate the morphological changes in the developing menisci by assessing the changes in the distribution of cells, fibers, and the extent of blood vessels within the medial menisci of fetuses of different developmental weeks.
ology: The present cross-sectional study was carried out on 48 fetuses divided into eight groups based on the week of development. The right knee was uniformly selected to procure the medial menisci which were further processed for microscopic observations. The cell density in the menisci was quantified at a fixed site in all the documented images. The arrangement of the blood vessels and collagen fibers was also observed.
Cell quantification showed that the menisci were highly populated with cells in the early stages of development which gradually decreased on development. The collagen fibers were orderly arranged in the later stages of development. The early menisci were entirely penetrated with blood vessels which were noted only in the periphery by the 29th week of gestation.
Histomorphogenesis of the medial menisci is important to surgeons, orthopedicians, and other interventionists while planning arthroscopic procedures and other advanced orthopedic surgeries. The present study helps us understand the morphological changes in the medial menisci at different developmental stages. Further, the study may also serve as a database to record the changes occurring in the number and arrangement of the cells, fibers, and vascularity in the developing medial menisci.
Surgical treatment of complex meniscus tear and disease: State of the art
2021, Journal of ISAKOS
Citation Excerpt :
Coronal malalignment tends to exert abnormal pressure on the allograft leading to graft failure. Verdonk et al reported that total meniscal replacement with allograft is one of the valuable alternatives with a satisfactory long outcome in total resection of the meniscus, and good healing of the peripheral rim to the joint capsule was observed in second-look arthroscopies.28 A systematic review showed that good early and midterm results of MAT could be achieved in a relatively young patient with only mild chondromalacia (lower than Outerbridge grade 3) at the time of transplantation, and radiological examination showed its chondroprotective effect.27
The meniscus is important for load distribution, shock absorption and stability of the knee joint. Meniscus injury or meniscectomy results in decreased function of the meniscus and increased risk of knee osteoarthritis. To preserve the meniscal functions, meniscal repair should be considered as the first option for meniscus injury. Although reoperation rates are higher after meniscal repair compared with arthroscopic partial meniscectomy, long-term follow-up of meniscal repair demonstrated better clinical outcomes and less severe degenerative changes of osteoarthritis compared with partial meniscectomy. In the past, the indication of a meniscal repair was limited both because of technical reasons and due to the localised vascularity of the meniscus. Meanwhile, it spreads today as the development of the concept to preserve the meniscus and the improvement of meniscal repair techniques. Longitudinal vertical tears in the peripheral third are considered the ‘gold standard’ indication in terms of meniscus healing. Techniques for meniscal repair include ‘inside-out’, ‘outside-in’ and ‘all-inside’ strategies. Surgical decision-making depends on the type, size and location of the meniscus injury. Meniscal root tears substantially affect meniscal hoop function and accelerate cartilage degeneration; therefore, meniscus root repair is necessary to prevent the progression of osteoarthritis change. For symptomatic meniscus defects after meniscectomy, transplantation of allograft or collagen meniscus implant may be indicated, and acceptable clinical results have been obtained. Recently, meniscus extrusion has attracted attention due to increased interest in early osteoarthritis. The centralisation techniques have been proposed to reduce the meniscus extrusion by suturing the meniscus-capsule complex to the edge of the tibial plateau. Long-term clinical outcomes of this procedure may change the strategy of treating meniscus extrusion. When malalignment of the lower leg is accompanied with meniscus pathologies, knee osteotomies are a reasonable option to protect the repaired meniscus by unloading the pathological compartment. Advancements in biological augmentation such as bone marrow stimulation, fibrin clot, platelet-rich plasma, stem cell therapy and scaffolds have also expanded the indications for meniscus surgery. In summary, improved repair techniques and biological augmentation have made meniscus repair more appealing to treat that had previously been considered irreparable. However, further research would be necessary to validate the efficacy of these specialised technique.
Meniscus Transplantation
2020, Complications in Orthopaedics: Sports Medicine
Meniscus allograft transplantation has been shown to be a successful treatment for prevention of early arthritis in patients with symptomatic meniscus deficiency. Although clinical outcomes are successful, complications may arise during any phase of the treatment process from preoperative planning to postoperative management. In this chapter, we outline potential adverse events and complications that can occur during each step of the treatment process, in addition to preventative measures that can be used and patient factors that should be considered to minimize their likelihood.
Meniscal Allograft Transplantation Is an Effective Treatment in Patients Older Than 50 Years but Yields Inferior Results Compared With Younger Patients: A Case-Control Study
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Thus, although concomitant cartilage lesions are being considered a contraindication less and less and although early MAT actually has recently been suggested in these cases even without marked pain to prevent further diffuse cartilage loss and to potentially yield a better long-term prognosis,19 the limited healing potential of older patients remains a concern. Actually, age has been poorly investigated among factors influencing the outcome of MAT, probably because of the commonly accepted cutoff of 50 years as an indication for MAT,9 and therefore, the evidence on older patients is limited in the literature. In our study, the analysis was focused, through a matched-pair comparative evaluation, on determining the opportunity to extend the indications for MAT to active adults older than 50 years.
To evaluate the influence of age on midterm clinical outcomes and failures of meniscal allograft transplantation (MAT), aiming at investigating the efficacy of MAT in patients older than 50 years.
In this case-control study, data on patients older than 50 years (older MAT [O-MAT] group) with at least 5 years of follow-up and a matched-pair group of patients younger than 30 years of age (younger MAT [Y-MAT] group) were extracted from a database of MAT procedures, performed with arthroscopic implantation of fresh-frozen meniscal allograft without bone plugs.
A matched-pair comparative analysis of midterm results and survival between 26 O-MAT patients and 26 Y-MAT patients was performed at a mean follow-up of 7.3 ± 2.2 years. All the clinical scores significantly improved from the baseline values in both the O-MAT and Y-MAT groups although with significantly lower scores in the O-MAT group. Two-thirds of O-MAT patients were able to return to a recreational level of sports activity. Only 2 patients in the O-MAT group underwent knee replacement, but the overall failure rate, also considering a clinical criterion, was 31% in the O-MAT group and 15% in the Y-MAT group (P = .3244). The mean survival time free from replacement or graft removal was 11.6 years in the O-MAT group and 12.3 years in the Y-MAT group (P = .691).
MAT is able to provide symptom relief and functional improvement at midterm follow-up in patients older than 50 years although with inferior results and a higher failure rate compared with those younger than 30 years. MAT can be considered a viable option to treat patients older than 50 years.
Level III, case-control study.
Evaluating meniscus allograft transplant using a cost-effectiveness threshold analysis
2018, Knee
Citation Excerpt :
Absolute indications for MAT do not exist; Rosso et al. identified relative agreement in the literature regarding indications for MAT, including: symptomatology related to previous total or subtotal meniscectomy, young age, stable or well aligned knee, and lack of Outerbridge grade III or IV changes [10]. It has also been suggested that candidates for MAT should have a body mass index (BMI) of less than 30 [11]. However, recent literature has suggested that these indications may be broadened, as authors have shown good outcome in active, middle-aged patients with moderate or severe pre-existing OA, as well as in patients with BMI over 30 [12,13].
It is unknown if meniscal allograft transplant (MAT) delays progression of osteoarthritis (OA). Cost-effectiveness threshold analysis can demonstrate the necessary delay in OA progression required by MAT to be considered cost-effective compared to non-operative management. The purpose of this study is to identify the efficacy MAT requires in delaying progression to OA in previously meniscectomized knees in order to be considered cost-effective compared to non-operative treatment. A secondary goal is to demonstrate the influence of age and BMI on the required efficacy of MAT for cost-effectiveness.
A Markov model was developed to evaluate the cost-effectiveness of MAT compared to non-operative management for patients with prior meniscectomy. Input parameters were identified in existing literature. Cost was derived from literature and The PearlDiver Patient Records Database. The required rate of OA progression was compared across treatment modalities to determine how effective MAT is required to be cost-effective.
MAT needs to be 31% more effective in delaying OA compared to non-operative interventions in order to be cost-effective. MAT is most cost-effective in 20–29 year-old patients, requiring a 25% greater efficacy in delaying OA. Obesity (BMI 30–35) makes MAT less cost-effective when compared to non-obese patients; however, the difference in required efficacy in delaying OA among obese patient when compared to non-operative management is approximately 10%.
MAT needs to be approximately one-third more effective in delaying OA in previously meniscectomized knees to be considered cost-effective. Younger, non-obese patients have the lowest required efficacy of MAT to be cost-effective.

View all citing articles on Scopus

: Conflict of Interest None of the authors have any conflicts of interest.

View full text

Indications and limits of meniscal allografts

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Transplantation of viable meniscal allograft: survivorship analysis and clinical outcome of one hundred cases

J Bone Joint Surg Am

Meniscus allograft survival in patients with moderate to severe unicompartmental arthritis: a 2- to 7-year follow-up

Arthroscopy

Meniscus replacement using Hoffa's infrapatellar fat bodies, initial clinical results

Unfallchirurgie

The current state of meniscal allograft transplantation and replacement

Knee

Autologous perichondral tissue for meniscal replacement

J Bone Joint Surg Br

Medial meniscus replacement by a tendon autograft. Experiments in sheep

J Bone Joint Surg Br

Meniscal allograft transplantation for unicompartmental arthritis of the knee

Clin Orthop

Irradiated meniscus allografts in the human knee: a two to five year follow-up study

Orthop Trans

Meniscal allograft replacement: a 1-year to 6-year experience

Arthroscopy

Combined autologous chondrocyte implantation and allogenic meniscus transplantation: a biological knee replacement

Knee

Meniscal allografts – where do we stand?

Am J Sports Med

Chondral injuries of the knee. A contermporary view of cartilage restoration

Orthop Spec Ed

Meniscal allograft trans-plantation

Clin Sports Med

Allograft meniscal transplantation: background, techniques, and results

Instr Course Lect

Meniscal allograft transplantation – part i: background, results, graft selection and preservation, and surgical considerations

Arthroscopy

Meniscal allografts: evaluation with magnetic resonance imaging and correlation with arthroscopy

Arthroscopy

Current status and imaging of allograft meniscal transplantation

Eur J Radiol

MR imaging of meniscal allografts: correlation with clinical and arthroscopic outcomes

Radiology

Meniscal transplantation: a review of 43 cases with 2- to 7-year follow-up

Sports Med Arthrosc Rev

Meniscal allograft transplantation: a 1- to 5-year follow-up of 22 patients

Arthroscopy

Meniscal transplantation in symptomatic patients less than fifty years old

J Bone Joint Surg Am

Human meniscus allografts' in vivo size and motion characteristics: magnetic resonance imaging assessment under weightbearing conditions

Am J Sports Med

Meniscus allograft transplantation: ten-year results of cryopreserved allografts

Arthroscopy

Meniscal allograft transplantation

Sports Med Arthrosc Rev

Clinical evaluation of arthroscopic-assisted allograft meniscal transplantation

Ann Acad Med Singapore

Prospective evaluation of allograft meniscus transplantation: a minimum 2-year follow-up

Am J Sports Med

Concomitant meniscal allograft transplantation and autologous chondrocyte implantation: minimum 2-year follow-up

Am J Sports Med

Current status of meniscal transplantation

Knee

Meniscus allograft transplantation using posterior peripheral suture technique: a preliminary follow-up study

J Orthop Sci