Hi, this is Burt Mendelbaum, and welcome to this great, exciting ANNA course. My role now is to talk about lateral meniscus allograft transplantation for discoid meniscus issues in children and adolescents. I've done this in collaboration with Dr. Curtis Vandenberg between Cedars-Sinai, Colonel Jobe Institute, and Children's Hospital. At this point, we have no disclosures that are relevant to this study. What we're going to talk about today is basic science, surgical technique, outcomes. We'll ask the question, hopefully answer some of it, can we modify disease going forward? Know now that discoid meniscus on the lateral side is a significant problem. When you look at this study by Rodio et al., we've seen decline in clinical scores and long-term follow-up of those treated arthroscopically with discoid lateral meniscus in kids. They decline. They look like this, and they go to this on the right. We also know we see a pathogenic progression, discoid lateral meniscus tear, thinning of the articular cartilage of the lateral femoral condyle, and ultimately, they look like this in kids. This is the problem overall that we need to manage. Now we know that low distribution on the lateral side increases contact stress 200 to 300 percent greater, which is more than the medial side. We've seen some great consensus recommendations, and they recommend meniscus allograft on those younger patients and those prior to developing symptoms. As a consequence, we've developed indications, subtotal total meniscectomy, grade 3 or less chondromalacia, stable, no other comorbidities, including alignment. We also know that sizing should be specific on the lateral side. We use frozen lateral meniscus allograft. Also, we use an anatomic bone plug technique that is preferred, that we can do this anatomically for the posterior horns and the anterior horns. The importance of the lateral horns is really quite significant. There's some concerns about maintaining the appropriate configuration of meniscus. We avoid the tibial spine debridement. There is some fragility of the bone plugs, but we have to be careful, and we make these a very small size, 6 to 7 millimeters, and we do it all arthroscopically. Now remember that preparing the graft, we always put the P, the posterior side, and remember that the tiger sutures are always in the back. It's the way we remember that. When you're passing sutures, this will be helpful for you. Use a saw, leave a portion of the bone, put a web stitch, number two, fiber wire. Use a chia for PDS suture, and you size the bone plugs depending on the size of the child between 6 and 7 millimeters. Now meniscus transplant with open fices can be significant. We look at this closely. The first thing, you have to be distal enough, missing the fices, certainly in the lateral plane. In the coronal plane, you can see how we place the pin. We've looked at this very closely with computer modeling. When it comes to the fices, we only have 1.29% in terms of the medial meniscus and 1.12% the lateral side in terms of overall volume. In addition, from the distance to the fices in the periphery, you can see a significant for the roots, anteriorly and posteriorly, and the depth, which is really critical, is probably between 8 and 9 millimeters away from the fices. So we're safe. And we've checked that. We've looked at it. We understand it. Going forward. So let's start with the case. This is a case of a young discoid lateral meniscus deficiency, 12 years old. It's a healthy male with a bucket handle tear of the discoid lateral meniscus that had to be removed. It was irreparable. And in this situation, we had significant problems. The x-rays look like that, pretty unremarkable. And the alignment was just lateral to the tibial spine. In addition, skeletal age is the most accurate way of looking at growth remaining. And this child was 12. Let's look at another case. Case two. A discoid lateral meniscus deficiency, 16-year-old male, recent x-rays all normal, no comorbidities. You can see here the meniscus deficiency in the upper right corner and the meniscus allograft in place, which brings us to case three. A lateral meniscus deficiency, and this has already progressed to this osteocondyl defect. In this case, it's more significant, more of a challenge. And as you'll see, we do osteocondyl allograft first in conjunction with placing lateral meniscus allograft. Now, this is our approach to using intraarticular 7% angel PRP and for the osteocondyl allograft using BMAC, calcium chloride, and thrombin to facilitate healing, integration, and chondral protection. In three months MRI, we can see the osteocondyl allograft in place, well integrated, and the meniscus allograft in perfect place and very viable at this time with no significant extrusion. So what do we learn from outcomes? Here's from Minn-Coker, three patients. They conclude very helpful in this population. From Jason Rebeau and Brian Cole, 36 patients, 11 with open vices, show a significant improvement overall. And we looked at this from Tim Spaulding, 23 patients under the age of 18, five-year improvement in PROs. And lastly, in this systematic review, we try to find the ideal candidate, which appears to be a young male, normal weight, and the best case scenario is lateral meniscus allograft transplantation. How about complications? Arthrofibrosis, meniscus detachment, shrinkage, failure, extrusion are all possible, but we see in less than 5% to 10% range going forward. How about pitfalls and curls overall? Again, this is a complex procedure. And just as we learned from outliers, Malcolm Gladwell, 10,000 hours, practice, practice, practice. Don't compromise your exposure, it's an arthroscopic technique. Remember, you've got to have good fixation. We use a large passport, 1.2 centimeters. You have to know how to preserve the meniscus remnant, at least the edge, how to position the bone, how to miss the vices, and you have to be good at pulling through sutures and getting the graft in. So we conclude by saying that this is a good time. We've had an evolution of concepts, technique, and technologies. We learned the importance of meniscus for decreasing the contact area stresses. The old technique has evolved, preserving the vices going forward. But it's about practice, practice, practice. Developing an algorithm is key for telling us when to do the meniscus allograft. And we're learning that right now and further data will be forthcoming. And lastly, we're really focused on counter protection of these orthobiologic interventions, including PRP, hyaluronic acid, and perhaps mesenchymal stem cells going forward. It's an exciting time. And thank you very much for the opportunity of discussing lateral meniscus allograft transplantation in adolescents and children. Thank you.

lateral meniscus allograft

discoid meniscus

pediatric orthopedics

surgical technique

PRP healing