The Long-term Chondroprotective Effect of Meniscal Allograft Transplant: A 10- to 14-Year Follow-up Study

Background: The long-term chondroprotective effect of meniscal allograft transplant (MAT) and its superiority over meniscectomy have rarely been reported. Hypothesis: MAT would reduce osteoarthritis (OA) progression when compared with the meniscus-deficient knee. Graft extrusion distance would strongly affect the chondroprotective effect of the MAT. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 17 knees receiving MAT were followed up as the MAT group. The MAT group was further divided into the nonextrusion subgroup (n = 9) and the extrusion subgroup (n = 8) according to 3-mm extrusion on the magnetic resonance imaging (MRI) coronal section. A further 26 consecutive patients receiving meniscectomy in the same period were followed up as the ME group. The healthy control group consisted of healthy contralateral legs chosen from the MAT and ME groups (n = 27). Joint space width (JSW) narrowing was measured on radiographs. Three-dimensional MRI with a T2 mapping sequence was used to quantitatively analyze cartilage degeneration and meniscal allograft extrusion in 5 directions (0°, 45°, 90°, 135°, and 180°). The cartilage degeneration index (CDI) was calculated according to the size and degree of the chondral lesions on MRI scans. The correlation between the CDI increase and the extrusion distance was analyzed. Results: The mean follow-up time was 11.3 years (range, 10-14 years). The MAT group had moderate superiority in chondral protection with less JSW narrowing (0.58 ± 0.66 mm) and CDI increase (1132 ± 1589) compared with the ME group (JSW narrowing: 1.26 ± 1.13 mm, P = .025; CDI increase: 2182 ± 1958, P = .079). The JSW narrowing (0.71 ± 0.80 mm; P = .186) and CDI increase (2004 ± 1965; P = .830) of the extrusion subgroup were close to those of the ME group, demonstrating that a 3-mm extrusion led to complete loss of the meniscal chondroprotective effect. The nonextrusion group had significantly less JSW narrowing (0.48 ± 0.48 mm; P = .042) and CDI increase (358 ± 249; P = .011) than the ME group. The JSW narrowing of the healthy control group was 0.22 ± 0.27 mm. The cartilage T2 values of the extrusion subgroup were similar to those of the ME group, with more OA features, whereas the T2 values of the nonextrusion subgroup were closer to those of the healthy control group. The extrusion distance in the 90° direction ( P = .002) and the follow-up time ( P = .019) significantly affected the CDI increase in the multivariate regression model. The average extrusion distance in the 45°, 90°, and 135° directions better predicted chondroprotection compared with the other individual directions. Conclusion: MAT had moderate advantages in chondroprotection compared with meniscectomy in the long term. Graft extrusion distance strongly affected the chondroprotective effect of MAT. The chondroprotective effect of the nonextruded meniscal allograft was close to that of the native meniscus, whereas the allografts with an extrusion >3 mm completely lost their function after meniscectomy.

Influence of peracetic acid-ethanol sterilisation on the biomechanical properties of human meniscus transplants

Purpose Meniscus allograft transplantation (MAT) is a possible treatment for patients suffering with pain after meniscectomy. Here, peracetic acid (PAA) sterilised meniscus transplants were investigated on whether they would provide an adequate alternative to fresh-frozen transplants in their viscoelastic and mechanical properties. Methods In this analysis, 31 menisci donors (26 male and 5 female) were included. The average donor age was 49.87 years, ranging from 32 to 65 years. Menisci of matched pairs of knees underwent chemical sterilisation while counterparts were left fresh-frozen. Stiffness and load to failure were determined via suture retention. Further menisci were analysed while attached to the tibial bone block using a novel test device to mimic physiological load distribution. Meniscus relaxation, stiffness and failure loads were determined. Histology and biphasic properties of the menisci were examined and results were analysed using paired t-tests. Results A novel custom built test device allowed the application of physiological loads for suture retention testing and revealed no significant differences between PAA sterilised (14.85 ± 4.46 N/mm, 50.49 ± 17.01 N) and fresh-frozen (18.26 ± 4.46 N/mm, 59.49 ± 21.07 N) regarding stiffness and failure load, respectively. Furthermore, initial 200 N loading showed significantly higher strain in sterilised menisci (18.87 ± 1.56) compared to fresh frozen (13.81 ± 1.04). Load relaxation experiments demonstrated significantly lower relaxation for sterilised menisci (77.71 ± 1.62) compared to fresh-frozen (89.11 ± 1.00, p-value < 0.0001). Conclusion Peracetic acid sterilised human menisci performed equally to fresh-frozen counterparts in a suture retention test and in physiological failure testing providing an adequate alternative. However, meniscus relaxation, biphasic properties and strain were shown to be significantly different between the groups. A common problem of MAT is graft extrusion or shrinkage, therefore the parameters measured here should be considered and may influence meniscus extrusion after transplantation. Level of evidence n/a (experimental study)

Postoperative Subchondral Bone Marrow Lesion Is Associated With Graft Extrusion After Lateral Meniscal Allograft Transplantation

Background: Adverse effects of graft extrusion after meniscal allograft transplantation (MAT) are difficult to assess and can be determined only in the long term using a simple radiograph. Recently, subchondral bone marrow lesions (BMLs) detected on magnetic resonance imaging (MRI) scans have been used to evaluate the outcomes or prognoses of various knee surgeries. However, whether subchondral BMLs on MRI scans reflect the effects of allograft extrusion remains unclear. Hypothesis: Subchondral BML in the lateral compartment of the knee joint on postoperative MRI scans would be associated with graft extrusion after lateral MAT. Study Design: Case-control study; Level of evidence, 3. Methods: Overall, 170 patients with lateral MAT between 2008 and 2013 were classified into extrusion (≥3 mm) and nonextrusion (<3 mm) groups based on findings on MRI scans obtained 3 to 6 months postoperatively. Subchondral BMLs in the lateral compartment were evaluated on the latest MRI scans. To exclude any bone marrow signal changes other than those caused by allograft extrusion, the latest MRI scans were compared with those obtained 3 to 6 months postoperatively. Only subchondral BMLs that occurred after that time point were counted. The association between allograft extrusion and subchondral BML was assessed using chi-square analysis. Logistic regression analysis was performed to control other related factors, including age, sex, body mass index, time from previous meniscectomy, alignment, and cartilage status at the time of MAT. Clinical outcomes according to subchondral BML were evaluated using the Lysholm score. Results: Of the 170 patients, 20 (11.8%) had subchondral BML on the latest MRI scans at a mean 53.6 ± 31.2 months postoperatively, with 14 and 6 patients in the extrusion and nonextrusion groups, respectively. Chi-square analysis showed a significant association between allograft extrusion and subchondral BMLs ( P = .025). Logistic regression analysis showed that extrusion and age were significant factors associated with subchondral BML ( P = .011 and .004, respectively). However, no differences were observed in the Lysholm scores in accordance with the subchondral BML ( P = .248). Conclusion: Subchondral BMLs on postoperative MRI scans were associated with graft extrusion after lateral MAT. However, there was no difference in clinical outcomes according to subchondral BML.

Surgical Outcome & Cost Analysis of Single Stage Anterior Decompression and Cage Fixation in Patients with Thoracic and Lumbar Tuberculous Spondylitis: A Single Centre Experience Over Six – Years with Comprehensive Literature Review

Objective: For Tuberculous spondylitis (TS) the optimal mode of management for extensive tuberculous spondylitis is still a subject of debate. We determined the outcome for single stage anterior decompression and cage fixation for dorso-lumbar TS. Material and Methods: This prospective study was conducted between 2012 and 2018. Worsening or new onset neurological deficit, increasing deformity, large paraspinal abscess and those not responding to anti-tuberculous drug therapy were included. Patients with severe comorbidities (> ASA class III) and recurrent cases were excluded. Demographics, clinical features, radiological characteristics, intraoperative details, postoperative complications and follow-up condition were recorded. Results: One patient with mean age of 45.6 ± 14.9 years with 17 (54.8%) males and 14 (45.2%) females. Mean symptoms duration was 71.9 ± 29.4 days. 41.9% had spasticity & 25.8% had sphincter dysfunction on presentation. Half (48%) of patients had a Frankel grade 3 or less bilaterally. Mean length of the procedure was 137.4 ± 19.9 minutes. 19.4% (n = 6) had postoperative pulmonary complications, 16.1% (n = 5) wound infection, 9.7% (n = 3) had worsening of neurologic deficit and one (3.2%) remained static. Graft extrusion and cage subsidence were noted in one (3.2%) patient each. Favorable outcome was observed in 83.9% (n = 26) while 16.1% (n = 5) had unfavorable outcome. Mean out-of-pocket cost was 164677.4 ± 11469.9 rupees (USD: 1187 approx). Conclusion: Timely spinal decompression with stabilization at the onset of the Pott’s disease in patients who fulfil the criteria as surgical candidates carries a promising outcome.

Use of Endoscopic Cartilage Graft Myringoplasty Without Tympanomeatal Flap Elevation to Repair Posterior Marginal Perforations

Objective: We evaluated the graft success rate and hearing outcomes of endoscopic cartilage graft myringoplasty without tympanomeatal flap elevation used to repair posterior marginal perforations. Study Design: A prospective case series. Materials and Methods: A total of 31 patients with posterior marginal perforations who underwent endoscopic cartilage graft myringoplasty were included. The outcomes were the hearing gain and graft success rate at 6 and 24 months. Results: The graft success rate was 96.7% (30/31) at 6 months and 90.3% (28/31) at 24 months; 1 patient exhibited composite graft extrusion and lateralization in the region of the anterior annulus; a residual perforation was apparent. Reperforation occurred in 2 patients. The mean preoperative air-bone gap (ABG; 28.61 ± 3.14 dB) was significantly greater than the mean postoperative ABG (12.15 ± 3.98 dB; P < .05) at 6 months; however, there was no statistically significant difference between the post-6 months and post-24 months with regard to ABG values ( P = .871), ABG gain ( P = 0.648), or functional success rate ( P = .472). No significant graft blunting or atelectasis was noted during follow-up. The free perichondrium became fully integrated with the skin of the external auditory canal; the perichondrium could not be clearly distinguished endoscopically 4 to 8 weeks postoperatively. Computed tomography revealed well-pneumatized middle ear and mastoid cavity at postoperative 24 months. Conclusion: Endoscopic cartilage graft myringoplasty without tympanomeatal flap elevation reliably repairs posterior marginal perforations. The short- and long-term graft success rate is high, and the hearing results are satisfactory; the technique is minimally invasive.

Delayed Rehabilitation After Lateral Meniscal Allograft Transplantation Can Reduce Graft Extrusion Compared With Standard Rehabilitation

Background: Meniscal extrusion prevention would be important for restoring normal knee kinematics, even though the effect of graft extrusion after meniscal allograft transplantation (MAT) has not been clearly identified. Hypothesis: When compared with standard rehabilitation protocols, delayed rehabilitation after lateral MAT could reduce graft extrusion. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 53 patients who underwent lateral MAT with the keyhole technique from June 2011 to March 2015 were included. Graft extrusion and lateral compartment articular cartilage loss on magnetic resonance imaging, joint space width (JSW) on weightbearing radiographs, and clinical outcomes (including subjective scores and functional tests) of 25 patients who underwent standard rehabilitation (group S) after lateral MAT were compared with those of 28 patients who underwent delayed rehabilitation (group D), which included immobilization during the first 3 weeks and use of unloading braces for 9 weeks. Results: Mean ± SD follow-up times for groups S and D were 25.7 ± 6.4 and 24.5 ± 7.1 months, respectively. Although the postoperative clinical outcomes did not differ between the groups, graft extrusion (3.2 ± 1.5 mm vs 1.8 ± 1.6 mm) and relative percentage of extrusion (32.2% ± 14.6% vs 17.3% ± 16.6%) were greater in group S than in group D ( P < .001 for both). The percentage of patients with graft extrusion (≥3 mm) was 52% in group S and 21.4% in group D. JSWs on Rosenberg view decreased by 0.1 mm in group S but increased by 0.3 mm in group D ( P = .035). Kellgren-Lawrence grade and modified Outerbridge grade progressed by 44% and 44% among patients in group S and by 17.9% and 21.4% among patients in group D, respectively. There were significant correlations between the coronal graft extrusion and postoperative JSWs on full extension (–0.452) and Rosenberg (–0.410) views, Kellgren-Lawrence grade (0.727), and modified Outerbridge grade (0.732) on magnetic resonance imaging ( P < .001 for all). Conclusion: Compared with standard rehabilitation, delayed rehabilitation showed less coronal graft extrusion and joint space narrowing on weightbearing and reduced the progression of arthrosis, although the rehabilitation protocols showed no differences in clinical outcomes.