Twenty-year results of combined meniscal allograft transplantation, anterior cruciate ligament reconstruction and advancement of the medial collateral ligament

Abstract

The purpose of this study was to determine the objective and subjective long-term outcomes of the first free meniscal allograft transplantations in five patients with complete absence or non-repairable lesion of the medial meniscus after 20 years. Between 1984 and 1986 five patients underwent concomitant medial meniscal transplantation with a deep frozen meniscal allograft, ACL reconstruction and femoral advancement or temporary detachment of the MCL. The clinical outcome of the patients was evaluated 20 years postoperatively using clinical assessment, Lysholm-score, KOOS, IKDC-score, radiographs and magnetic resonance imaging. The Lysholm-score ranged between 21 and 97 points of 100 maximal available points. Corresponding to this the total KOOS ranged between 28.4 and 91.1%. The results of the IKDC-score were evaluated as nearly normal (B) (n = 2), abnormal (C) (n = 2) and severely abnormal (D) (n = 1). The radiological evaluation according to the Kellgren-Lawrence classification showed an increase of the degenerative changes between one and four grades. The radiological results revealed clear degenerative changes with long-term follow-up after meniscal allograft transplantation even though some patients did relatively well regarding the subjective and clinical results in the 20-year follow-up examination in comparison with the literature. Despite these relative clear results the question if medial meniscal transplantation can protect against development of arthritis cannot definitely be answered because in this first case series some aspects of meniscus transplantation that have not been considered which turned out to be of importance during the last 20 years. Furthermore, it has to be taken into account that all patients revealed a cartilage damage at the time of surgery and an ACL reconstruction was performed in addition. Nevertheless from biomechanical point of view it might be taken into consideration to combine the medial meniscus transplantation at least with a high tibial osteotomy. Level of evidence was (IV, case series).

O papel do adesivo de fibrina e da sutura na fixação do transplante de menisco preservado por ultracongelamento em coelhos

“…Além do mais, o quanto a restauração da dinâmica articular próxima da normal, proporcionada pelo transplante, possa prevenir a degeneração articular não está estabelecida. Trabalho (28) com seguimento de 20 anos de transplante de menisco mostrou que alguns pacientes isolados apresentaram resultados subjetivos satisfatórios, mas é preciso encarar o fato de que os resultados radiográficos mostram claramente que, em longo prazo, o transplante de menisco medial não protegeu a articulação do joelho das mudanças degenerativas. Contudo, os resultados são de difícil interpretação.…”

“…Contudo, os resultados são de difícil interpretação. Uma conclusão definitiva de que o transplante não protege contra artrite não pode ser embasada apenas em uma série de casos (28) . Assim, a experimentação animal é uma opção para se testar o transplante dentro de limitações estritas permitidas por um modelo experimental.…”

“…O ultracongelamento é referido como o que mantém os meniscos o mais próximo de sua estrutura a fresco e de menor custo operacional (9,13,14,20,27,28) . A preservação por 30 dias, em temperatura de -73ºC, usada nesta pesquisa, mostrou que o procedimento foi adequado e expresso pela manutenção do tamanho e textura macroscópica dos meniscos.…”

“…A cola de resorcina também se mostrou extremamente danosa para o joelho em coelhos na tentativa de fixação de defeitos osteocondrais da cartilagem articular (28) . A cola de fibrina é amplamente utilizada, com resultados favoráveis, em vários procedimentos operatórios e em diversas situações patológicas (23)(24)(25)(26)(27) .…”

Meniscal Allograft Transplantation: Where are we Standing?

“…Studies with the longest follow-up focus on progression of radiological changes in the affected knee. These studies found a range from progression observed in all treated cases when using lyophilized and deep-frozen grafts [79], to progression evidenced in 59% of the cases with use of cultured viable grafts [47]. Verdonk et al wrote that surgeons may expect a chondroprotective effect of MAT in about 30% of patients [9], but this has to be further investigated in the coming years.…”