Yes, I'd like to thank the organizing committee and Dr. Kelly. I had to look up what luce liberi meant. It means free fight, and so with that, we'll get started. I have no disclosures. This is a problem that we often face in dealing with the unpreparable bucket-handled tear where you're left with a knee without a meniscus in it, and sometimes these patients will have pain going forward. Meniscus transplantation is used to address this problem, usually in the young patient with a near total meniscectomy and pain. It can also be used with cartilage restoration procedures and also in stabilizing to give secondary restraint for ACL reconstructions. What is the goal? The goal really overall with meniscus transplantation is reestablish anatomy. So we think of the anatomy, if we look at these two different pictures here, you can see there's a different attachment of the anterior and lateral meniscus on the top and the bottom. So we're trying to reestablish anatomy in the patient moving forward. We have to think about the structure of the meniscus. We have to think of its wedge shape. We have to think about the radial fibers as well as the longitudinal fibers. We need to think about that it acts as a load-bearing structure and that we're trying to get it into a position, and we need to think about the horn attachments being secure at that location. If we go to this study, it was a grouping of experts in the area of meniscus transplantation. It was the International Meniscus Reconstruction Experts Forum in 2015, and my debater, my free fighter, Dr. Carter, was part of this. Based on current evidence, the IMREF accepts there is no superiority of one surgical tech over another. So bone versus soft tissue, there's no difference as far as the clinical outcomes. So I like to think of the KISS property. Not to offend anyone, I was told it was keep it simple, Senate. And so we go forward. So if you think about how can we make this a procedure that is amenable to other people doing? Can you do a root repair, whether Dr. Shelborn thinks it should be done or not? Can you repair a simple meniscus? And can you do a labral repair? And if you can do these techniques, you can do a meniscus transplant. So here's obviously a patient that's had a root repair. And so if you can place a suture, put a hole through the tibia, curette its location where it came from, we can think about doing a meniscus transplant. We think about ease. It's easier to prepare a meniscus that you're not going to do with bone blocks than one with bone blocks. This is from Dr. Verdunck's paper here. Basically, you just take the meniscus off of the tibial plateau. When it comes to you, it comes on the tibial plateau, and you take the two horns off and place whip stitches in each of the two horns. You also usually place a traction device to help seat it as you pass the graft. When we're doing the meniscus transplant, it is important to resect the residual meniscus, but to leave a rim to help have some containment around that meniscus. In passing it, it's also easier to pass. You do not have any bone plugs to pass. So you're really passing a meniscus with sutures on each of the two horns, and then again a passing stitch. This can be passed through a cannula or a small incision the size of your index finger. This video will show a small video thing of the passing. This suture is going to the posterior horn, and this is going to the medial aspect. So the meniscus is pulled into the joint through the posterior horn suture, and then the second suture helps reduce the junction of the posterior horn and the body of the meniscus. And with relative ease, it can be brought into the joint relatively easily. The next step is to attach it. So just as if you were repairing a root tear of the posterior horn, you will tie it over the tibia anteriorly, either using a suture button or a fixation device. And we also prepare it anteriorly for receipt in this location. In repairing it anteriorly, we use a technique that is just very similar to repairing a labrum in the shoulder. A hole is drilled, and an implantable device to hold that suture in that position will allow you to successfully repair the anterior and the posterior horns. We then methodically go and essentially perform the largest meniscus repair. I use outside-in sutures anteriorly, and posteriorly use all-inside suturing techniques. And this results in the posterior half of the meniscus being repaired with all-inside technique, and the front half being repaired with an outside-in technique. People say, well, how common is this done, not using bone blocks? This was a meta-analysis that was done by Dr. Verdonck, and looking at a different amount of patients that underwent different techniques, they found in this group 37% actually did have bone blocks, 34.7% had soft tissue only. 19% had trans-osseous soft tissue only, 9% weren't defined. So actually, the majority in his paper were without bone blocks. If we look at another meta-analysis in this study, 15 of 36 studies looking at the medial meniscus were without suture only and no bone blocks, and the lateral meniscus, a very similar rate. And their conclusions were similar improvements in patient symptoms and good mid- to long-term grafted knee survival with both techniques, and there was no difference. And if you didn't catch this the first time around, the experts' forum said there was no superiority. So if my debating comes up and says there's superiority, he was a member and said no superiority. But what will they talk about? They'll talk about extrusion, and extrusion is measured by looking at the amount that is lateral to the aspect or medial to the aspect of the tibial plateau divided the whole width of the meniscus times 100. And what you find is that both meniscus actually typically extrude. In this study, which was probably the study that is the most quoted for the reason to consider doing a bone plug technique, suture only technique was slightly higher. But in their clinical study, there was no association between the extrusion and the dysfunctional outcome. This is looking at, so using bone bridges, if you just change where you put the bone plug or the slot in the tibia and the location of the horns, you're going to affect extrusion. This was work by Dr. Minus. He showed that if you actually did trans-osseous sutures with the tapered needle that you could actually, and again, this was with bone plugs and bone blocks, you could actually improve the extrusion. So it's probably not so much where you put it, but it's how well you actually fix it. This was work done by the group out of Pittsburgh at the scientific exhibit this year in 2019. And in this study, they did look at both bone blocks and they looked at sutures and they looked at medial lateral translation and they also looked at force across the joint. And what they found was there was no significant difference between bone block and suture fixation. So if you didn't catch it the second time, the third time is there is no superiority between the graphs. So I'd like to go back to a study that has not been repeated and is a fantastic study. It's looking at histology and allogenic response. This was Dr. Rodeo's work out of HSS looking at the allogenic response to meniscus transplants. As part of the study, they were all biopsied at later time intervals and they actually saw that there was an antigenic effect. While the graphs do not typically ever get rejected, there is an allogenic response. And they did stain looking at these antibodies against cytotoxic T lymphocytes. And they actually found overall that the histology scores, when they looked at them, were significantly better for meniscus transplants without attached bone plugs. And that's because there's less allogenic material without the bone plugs. The bone has more allogenic material than the meniscus itself. And so as another statement, there is no superiority. So if you're looking at which way to do it, and there's no superiority between the techniques, reestablish anatomy. What matters is getting the horn attachments right and getting a good repair of the periphery. The ease of the suture only technique is definitely easier than the bone block technique. And think about the viability of what you eventually put in there. So it's not a matter of just putting a piece of tissue in there. Will it continue to live? Thank you.

meniscus transplantation

knee pain

surgical techniques

meniscus graft

anatomy