Thank you, pleasure to present some of this data to you and opinions about it. No conflicts. So look, we all know that hundreds of thousands of meniscectomies are being done, 60% progress to arthritis, but only 20% progress if you repair the meniscus. So why aren't more menisci being repaired or replaced? We don't know, and only 2,000 are actually being replaced, and we don't know whether or not they progressed to arthritis or not. So since meniscus resection dooms the knee, why are so few replacements done? So the old thinking, and the reason why I believe, is that only young and healthy knees who failed conservative care could have a meniscus transplant. Well what's wrong with this view? Well failing conservative care means developing pain and arthritis, loss of sports activities during the critical years with knee depression syndrome setting in. What's the reason for limiting the indications? Well it's a belief that the outcomes of meniscus replacement are not good enough to delay pain or arthritis, and they fail when articular cartilage lesions are present. The new thinking, in my opinion, is that most knees can have a soft tissue reconstruction if the articular cartilage and ligaments are repaired or reconstructed. So in this study, 343 meniscus allograft procedures, 2 to 21 year follow-up, average age of 43, range 13 to 73, 71% of these patients had grade 3 and grade 4 lesions, and the outcomes will show that they had improved WOMAC, IKDC, and Tegner scores independent of cartilage status or age. It's crucial that you recognize that these are all done with a three-tunnel technique, which means that we anchored the meniscus to the tibia trying to reconstruct the meniscus skirt ligaments. The reason is, as you see from this wonderful video from Smigelski, that the meniscus is tied to the tibia through these skirt ligaments, not to the capsule primarily, and if you don't reconstruct them, the meniscus sublux is on the knee, which is what commonly happens with most meniscus transplantations. This is what meniscus transplantation looks like in many people's hands. It should not look like this. When you get the meniscus, it should look like this, with the meniscal attachments intact so that you can take them off the donor and reconstruct the tibial ligaments. We use height as our primary sizing technique since we demonstrated that height and weight correlates to tibial plateau, and it's just about as inaccurate as Pollard or any other X-ray and MRI method. The crucial part of the talk, though, is that if you're going to replace the meniscus in arthritic knees, you must repair the articular cartilage. Our preferred technique is an articular cartilage paste graft, which we've been talking about now for 30 years. We evolve from bone grafting. We morselize the defect, which is a super microfracture. We do not believe what you heard this morning, that little holes are good. Biology works by big fractures, and the bigger the fracture, the better the healing. When you harvest the articular cartilage and bone from the intercollar notch, reduce it to a paste, impact it into a lesion, which provides a preceded scaffold, apply motion, and 30% of these will be pure highland cartilage, 30% will be a mix, and 30% will be fibrous tissue. So then you ask, well, does meniscus transplantation delay joint arthroplasty? The mean graft survival time in our study is 17 years. Conversion to total knee, which is actually partial knee, is about 4%, and the average time is 6.5 years. So yes, the answer is yes. Adverse experiences from meniscus transplantation definitely occur. We got better over time, but we still had 13% clinical failures, 14% graft failures, 7% adverse events, as you see listed here. IKDC, Tegner, and WOMAC improved over the course of the study. The outcomes of combined biologic joint replacement is that there's no significant difference in patients comparing OA status or age. So listen, we think that the biologic knee replacement, where you're rebuilding the entire knee, is what you should think about, but if you're going to do it, you must repair the skirt ligaments to restore meniscus biomechanics, the ligaments and the articular cartilage must be repaired, severe malalignment, which means greater than 7 degrees, should be corrected. We do not correct alignment less than 7 degrees, because we believe that is normal alignment. People are born in varus, and rehab must be carefully controlled. So here's our indications, and these are ours. If they're missing a meniscus in a young person, replace it. Missing a meniscus in an older patient with pain, fix the associated lesions combined with a meniscus transplant replacement. How much alignment and variation is normal? We think it's debatable, but acceptable up to 7 degrees if the cartilage is replaced. Don't ever correct alignment alone. If the meniscus is missing, put a meniscus in when you do your osteotomy. Meniscus replacement can delay joint arthroplasty. Meniscus replacement can act as a soft tissue interpositional arthroplasty, even in arthritis in a 50- to 70-year-old age group. Soon-on-born patients face needs in arthroplasty, our preference. So our conclusions, combined meniscus transplantation, ligament reconstruction, and articular cartilage repair can provide sustained improvements in activity, pain, and function. Can we prevent driven athletes from destroying their knees? Not yet. But don't deny them a meniscus. Just do it. Thank you very much.

meniscus transplantation

cartilage status

age

ligament reconstruction

articular cartilage repair