Orthobiologics

Procedure

Product

A técnica de transplante segmentar de menisco aborda a falha no reparo do menisco, evitando a substituição total. Pacientes com defeitos irreparáveis podem se beneficiar de uma substituição parcial, completada com a técnica de transplante de menisco segmentar, que fornece a mesma biomecânica do compartimento da articulação tibiofemoral de um menisco intacto.1-3 Essa técnica ajuda a preservar os princípios de carga biomecânica nativa do joelho enquanto mantém fibras de aro nativas intactas.
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Referências
1. Strauss E, Caborn DNM, Nyland J, Horng S, Chagnon M, Wilke D. Tissue healing following segmental meniscal allograft transplantation: a pilot study. Knee Surg Sports Traumatol Arthrosc. 2019;27(6):1931-1938. doi:10.1007/s00167-019-05355-z
2. Seiter MN, Haber DB, Ruzbarsky JJ, Arner JW, Peebles AM, Provencher MT. Segmental meniscus allograft transplantation. Arthrosc Tech. 2021;10(3):e697-e703. doi:10.1016/j.eats.2020.10.059
3. Nyland J, Campbell K, Kalloub A, Strauss EJ, Kuban K, Caborn DNM. Medial meniscus grafting restores normal tibiofemoral contact pressures. Arch Orthop Trauma Surg. 2018;138(3):361-367. doi:10.1007/s00402-017-2849-x

Transplante segmentar de menisco

Human

Child (D)

Knee

A técnica dovetail simplifica o preparo do enxerto com uma série de cortes que poupam tempo, preparando o componente ósseo do enxerto para ser seguramente fixado no orifício semi-trapezoide do receptor na tíbia. O orifício em formato semi-trapezoide correspondente criado na tíbia com uma série de brocas, raspadores e dilatadores, é compatível com o preparo do bloco ósseo. 

 
A fixação periférica subsequente do enxerto na borda capsular com 2 FiberWire® Nº0 satisfaz o objetivo de criar um aloenxerto meniscal sólido. Preferencialmente utilizada na incompetência meniscal lateral, a técnica dovetail re-cria anatomicamente as relações meniscais laterais e normais no joelho.

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Meniscal Allograft Transplantation Featuring Dovetail Meniscal Allograft

Técnica de transplante de menisco Dovetail/Slot

A técnica de pino ósseo duplo para deficiências/rupturas de menisco usa pinos ósseos que podem ser preparados com as mãos livres ou usando uma trefina. A técnica de mãos livres é realizada usando um fórceps e broca de alta velocidade. Para obter informações mais detalhadas sobre esta técnica e/ou produtos da Arthrex utilizados nela, acesse a guia de recursos educacionais ou guia de produtos abaixo. A técnica de pino ósseo duplo para a reconstrução com aloenxerto meniscal oferece um método de implante de aloenxerto meniscal medial, com fixação rígida em ambos os pontos de fixação do corno. Foi mostrado que a fixação óssea e a cicatrização óssea no ponto de fixação permitem a manutenção da tensão da alça funcional pelo aloenxerto meniscal.

Double Bone Plug Meniscus Reconstruction

Transplante de menisco com pino ósseo duplo

ZoneNavigator System Cannula - Anterior

ZoneNavigator-System, Kanüle für Anterior, VE5

ZoneNavigator System Cannula - Anterior, VE5

CÂNULA DO SISTEMA ZONE NAVIGATOR - ANTERIOR

CÂNULA DO SISTEMA ZONE NAVIGATOR - ANTER

ZoneNavigator, Left Middle / Posterior Cannula

ZoneNavigator-System, Kanüle, links, für Mitte/Posterior, VE5

ZoneNavigator System Cannula - Left Mid/Posterior, VE5

Cánula angulación izquierda ZoneNavigator

CANULA DO SISTEMA ZONE NAVIGATOR - MEDIO ESQUERDO / POSTERIOR VE5

ZoneNavigator, Right Middle / Posterior Cannula

ZoneNavigator-System, Kanüle, rechts, für Mitte/Posterior, VE5

ZoneNavigator System Cannula - Right Mid/Posterior, VE5

Cánula angulación derecha ZoneNavigator

CANULA DO SISTEMA ZONE NAVIGATOR - MEIO / POSTERIOR DIREITO

As técnicas de aloenxerto de tecidos moles para meniscos continuam a evoluir com o avanço dos dispositivos de fixação. O uso de dispositivos comuns para reparo de meniscos permite maior flexibilidade, garantindo a colocação anatômica do enxerto. As técnicas cirúrgicas de aloenxerto de tecidos moles para meniscos e seus resultados clínicos estão bem documentados e têm boa eficácia clínica.1-4
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Referências
1. Kim SH, Lipinski L, Pujol N. Meniscal allograft transplantation with soft-tissue fixation including the anterior intermeniscal ligament. Arthrosc Tech. 2019;9(1):e137-e142. doi:10.1016/j.eats.2019.09.015
2. Spalding T, Parkinson B, Smith NA, Verdonk P. Arthroscopic meniscal allograft transplantation with soft-tissue fixation through bone tunnels. Arthrosc Tech. 2015;4(5):e559-e563. doi:10.1016/j.eats.2015.06.001
3. Elattar M, Dhollander A, Verdonk R, Almqvist KF, Verdonk P. Twenty-six years of meniscal allograft transplantation: is it still experimental? A meta-analysis of 44 trials. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):147-157. doi:10.1007/s00167-010-1351-6
4. Myers P, Tudor F. Meniscal allograft transplantation: how should we be doing it? A systematic review. Arthroscopy. 2015;31(5):911-925. doi:10.1016/j.arthro.2014.11.020

James L. Carey, MD, MPH (Philadelphia, PA), demonstrates a soft−tissue-only meniscal allograft transplantation and provides a full overview of the technique, from preparation of the recipient site and allograft through various fixation options for securing the graft.

video

Soft-Tissue Meniscal Allograft Transplantation Technique

Hello, I'm Jim Carrey and I'm going to present a meniscus allograft transplantation using a soft tissue technique. So here I've planned the incisions for a meniscus allograft transplantation in isolation. So I've outlined where I was planning to put these incisions. This is the lateral portal. This is the medial portal, slightly enlarged to allow both the passage of the allograft and also some fixation along the joint line. This incision is also to allow for some fixation along the joint line. I plan for it to be a little anterior to where the saphenous nerve would be, but I still think this is in that nick and spread zone where you have to take great care to make sure you're not injuring that sensory nerve. And then this incision is for the posterior root fixation. That suture be drawn through the small tunnel and tied over a button here. Now of course, if this meniscus allograft transplantation is not in isolation, and you're performing some concomitant procedures. You might actually have a more midline longitudinal incision, like for an ACL reconstruction that you're harvesting. Bone patellar tendon, bone autograft or for cartilage repair where you're doing an arthrotomy or a mini arthrotomy. This procedure could be performed through one midline incision if it was a bit longer, but this is my typical preference for meniscus allograft transplantation and isolation. So I've established arthroscopic portals, and I found that this compartment is indeed severely meniscal deficient. I've even worked to remove the central meniscal tissue that was grossly torn and nonfunctional, so that there's just a one millimeter rim to act as a buttress to keep the new meniscus in place and to facilitate healing. Now, in order to prepare the Posterior horn. I did it in a standard way for the medial aspect for the body. I switched portals and worked to come across like this to bite that tissue to the one millimeter rim. The anterior horn is a little bit more of a challenge. I will tend to try to use the straight biters to reach across there. I'll even use the 90 degree. I can use it in the direction that you would think like in this case, a 90 degree to the right will allow me to open up and bite this tissue. Oftentimes for working on the top surface, the 90 degree going the other way and holding it upside down will allow better visualization as you're removing that tissue. Of course, you can use back biters as well, and shavers and any way you can resect that central tissue. So you just have that one millimeter rim. The next step is to prepare the posterior root attachment site. Sometimes it can be challenging to get instruments in through this area. And so through the medial portal I'll sometimes come across and trephining some of the deep fibers of the MCL to allow it to open up enough to perform this part of the procedure. Now that I have great visualization of that area, there are a few ways that you can prepare this back region. One way is to use a Curette. This is a ring Curette. Sometimes using a burr will work on that area or a shaver, but I'm trying to remove the cartilage overlying this attachment site, so that's part of it prepared. The advantage is you don't have to worry about trying to pass the suture through the meniscus. Arthroscopically you can do that outside the body. Of course, now that we've prepared the knee to receive the meniscus allograft will prepare the meniscus allograft. The first step I'll do is I'll look at where the meniscus attaches. Here's the posterior root attachment site that I prepared in the knee. And I'll mark it with my pen. And then when the meniscus falls on that tissue let me know right where I want my sutures to go in. So they're going to go in the bottom around there and then the anterior horn. Sometimes it can be a little tricky to determine where does the meniscus end. Where does the inner meniscal ligament begin? I think we can see in this case it's somewhere right about there is that junction. I'll take the knife. And just like in the knee, we left a residual one millimeter rim of the native meniscus. So for outside the knee. Now for the transplant tissue I'm going to remove that one millimeter rim so that it fits in nicely. And the sharpest scissors you have that are heavy should be employed for this part because it can be tough tissue to work with. And you have to watch your fingers as well as you're working on this tough tissue. I use the scalpel to make an incision through this tissue, and then I put the scissors in it and fold just the curvature. And most of these fibers run longitudinally along the meniscus, and they kind of keep you on the right track. And I'll do the same thing about the posterior horn where I put my scalpel through the tissue. And then I'm just going to let the fibers pull me along that plane. They always. All right. So now I've removed that peripheral one millimeter rim. You can see the residual meniscal tissue there. I'm going to return to that area that I marked for the posterior horn. I want the sutures to come right out the inferior surface, because that's what's going to draw it right down into that small tunnel for the posterior horn. I do use the pen to mark a boundary there. I don't want any of my suture to go more medial than that boundary, because I fear that it could abrade against the articular surface, and especially in deep flexion. And sometimes we'll even cause a squeaky noise. Then I'm planning the attachment site. So again the sutures should come right in the bottom. I'm going to mark a boundary that I don't want any of my sutures to go more medial than that boundary. And then for the posterior horn and the anterior horn, that will be the FiberWire suture. The posterior horn suture will go through the tunnel, be tied over a button. And then the anterior horn suture will be secured in with a biocomposite anchor. I also need to plan for the absorbable monofilament suture to help draw in the meniscus in the body posterior aspect of the body, but also it can be tied over the capsule, whereas these sutures come out the inferior surface. This one comes right out the periphery. And then I do one locking loop of suture. That helps grasp the tissue, and then I pass the suture towards the front without a lock. This is one of those things. If you believe your meniscal root repairs can be secured and that they have capacity for healing. And essentially, if your meniscal root repairs work, then you should believe that this works because it's the same principles, but you're placing the suture even more carefully in the tissue and ensuring the quality of the tissue. And with these passages and again, the suture ultimately comes out the inferior surface to draw it right into the tunnel. And then I'll do the same thing for the anterior horn. I'm coming through the inferior surface. I'm doing one locking suture. I'm sharing. It's a nice simple loop. I'll pass the suture from the peripheral aspect to the central aspect. Then I'll do another locking, and then I'll pass the suture out the inferior surface, because again, it's going to be drawn directly into the bone there. Now we have that suture coming out the inferior surface of the anterior horn. Now I'll pass the absorbable monofilament from the periphery to the central aspect. And then from the superior surface back to the periphery. Now you can see we have the posterior route sutures passed which come out the inferior surface. We have the suture near the junction of the body and posterior horn passed, which comes out the periphery, and then the anterior route sutures pass, which come out again the inferior surface. Now I'm going to free the meniscus from the bone. So I'll look at where the sutures come out, and I'll go immediately lateral to that. I'll do the same thing about the anterior horn. So now you can see the meniscus allograft is now freed. Now there are a few ways with rigid targeting guides you can access this area. One way is with this kind of smooth guide from the medial portal to go underneath. And I think that would work quite well in this case. Another way to do it is to switch portals and use a targeting guide that you may have commonly used for ACL reconstruction to access that area. And you can put the tip right in the attachment site and drill right to that point. So I found that this targeting guide is lined up nicely. And then if you are doing an ACL reconstruction at the same time, I take care to make the tibial exterior starting point of the tunnel more inferior than the opening of the ACL tunnel, so that the whole tunnel is more inferior than the ACL tunnel. So now I'm holding the rigid targeting guide so that the aperture of this small 2.4mm tunnel should come out in the attachment site of the posterior root, and then on the tibial cortex, the tunnel is at least two fingerbreadths distal to the joint line. And in fact many of these are with ACL reconstructions. I'll even go distal to the ACL tunnel. So now with this rigid targeting guide, we'll drill to the aperture of the tunnel. And then we can take the bullet out and we can pop the guide off. And we can see where this will come out. It's within the footprint that we prepared. So there is the tip of the guidewire 2.4mm right in the anatomic attachment site of the meniscus. And then we're going to remove that guide pin. And we're going to place this. Micro SutureLasso up. That path is coming out right within the attachment site. I will grab it and then through here we'll place a suture shuttle, and we're going to pass the tails so that we leave the loop out through the medial portal. Now the next step is to plan the suture that will come in near the junction of the body and posterior horn to help draw it in. So I'll bring one in about here. And this will be probably for the anterior part. This is one area where you have to take care, and you have to plan so you don't get a suture bezoar and a big nest of suture is that I'm looking at where the suture for the posterior route shuttle comes out. And I'm going superior to that through the same portal. And then I'm going to pass another loop of suture. This one we can do the tiger stripe white, maybe, and I'll pass the tails and I'll leave the loop out of the medial portal. We'll draw in that suture that is TigerWire, and I try to keep the TigerWire anterior and then purple posterior just so I keep them straight. Now I've passed the second SutureLasso posterior to the one with the stripes. And I'm grabbing that. Then we'll do another loop of bluish or purplish suture there. Now we're ready to draw in the meniscal allograft. Double check to make sure that the portal is big enough to bring the allograft in. You can check if your little finger fits in. Then usually it's enough for the meniscal allograft. And now we're going to insert the meniscus. The first thing I did was I placed the sutures from the posterior root through the loop of sutures that goes through that posterior root tunnel, and we're going to shuttle that in place. After that's placed, I clamp that with a hemostat. And then everyone can relax a little bit because now the meniscal transplant is unlikely to fall out. The next step is to pass the sutures for the posterior and the anterior limbs that are passed through the body of the meniscus, the the posterior one. We kept track of posterior bluish in this case. And then we took care to try to minimize the risk of these getting tangled. And now we're passing the meniscus into the knee. So one of the important things that I check is to make sure that this is a simple connection right from the periphery of the transplant, right to that residual rim and capsule. Sometimes the sutures can get caught or soft tissue about the portal, or can even get looped around these posterior horn sutures. But in this case, you can see where the posterior root sutures go in, and we can pull tension about the body of the meniscus. Now I'll tie down the posterior horn over a button. So here is the metallic button that I have the suture pass through. I'm going to tie down the suture over the button. And then this will secure the posterior root. And then I secured it with about four throws of suture. If for some reason you notice later that it's loosened, it's easier to undo 3 or 4 throws than it is eight throws. And then you can retighten it again. So that's the only reason I didn't do more. Take a look at it. Arthroscopically. So now I'm checking the posterior root is secured and opposed to the bone there, as it should be. Next I'll tie down that suture medially that we use to shuttle the graft in place. And I'll take a look in. Just gives us a sense of what the meniscus will look like when it's secured. And now we'll use the all-inside repair devices to secure it to the posterior rim of residual meniscus. So for securing the posterior horn, I've placed this skid above the superior aspect of the meniscus. And then I'm going to use an all-inside repair device. So now we're going to secure the posterior horn with an all-inside technique. I'm going through about the center of the transplant tissue. And this tissue is very tough again. So I'll do little micro wiggles to get through it. Now I'll try to plan this so it's a diagonal. Not purely horizontal. Not purely vertical. And then. So now we get to see the the route again was tied over metallic button. This was the absorbable monofilament which is just tied on the other side of this tissue on the other side of the capsule. And this was an all inside meniscal repair. And I'll check make sure that all of those feel secure. You can see too, as you imagine these sutures being tightened, that some of the wrinkles come out. I don't treat this flounce at all along the way. I don't trim the meniscus, for example. Usually that just settles out. All right. Now we have one more hard part, which is passing this suture from outside to in. The first one can be hard because you're pushing through the capsule and you're pushing in. And then usually the second one, once the first one is pinned, is easier. For one loop through the other and pull it through. And we'll use that to shuttle in another one of these The absorbable monofilaments. That will pass that. And then this one I'm going to back out a little bit and then I'll pass that. All right. Well after doing that all inside repair of the posterior horn then we did an outside in repair in the body. You can see the meniscus is starting to line up. Well it's starting to feel like it's well secured. And the next step is going to be securing down the anterior horn. And for that we're going to use a biocomposite anchor. The first thing I'll do is I'll plan where I want this to attach. And it's usually right by the anatomic attachment site. I like to make the hole first with the awl, and then I use the curette to clear off some of the cartilage overlying the whole, especially on the medial side of the whole. All right. So there's the attachment site that I have planned for this anterior root. So here's the anchor for the anterior horn. And I'm looking at how the other tissues lining up. That will show back that out. And it shows there's the anchor well secured test and a tug. Usually these are carefully sized matched by uploading MRIs to a central database and finding the right size. This one was just was slightly larger than the recipient knee, but it still fits in quite nicely. After placing the anchor that secured the anterior root, I then went back and placed another suture in the anterior horn to help secure it using the ZoneNavigator system. And that is an inside out repair, which made it a little easier in this case, because when you're pushing from the outside in, you need to hold resistance, you need to hold to counter pressure. But when you go from inside out, of course it's a little easier because you're just pushing the meniscal tissue into the residual meniscal rim. So then at this point, I'll go back and evaluate the entire meniscus, all the fixation points, and make sure it's entirely stable. And then for the postoperative rehabilitation protocol For these meniscal transplants. I worry about the root healing, and so their weight bearing is protected for a period of six weeks. They use crutches, they have motion limits and a hinged knee brace that limits their flexion to 70 degrees for the first three weeks. During that time period, I worry about the rollback mechanism of the knee as the femur rolls back, could stress out the posterior horn and root repair too early. After six weeks, all of those precautions are lifted. There's no more motion limits. Weight bearing precautions, crutches or a brace. And then they start to increase their activities. They first ensure they get full motion and then strengthening. Then after that they resume normal function around 18 weeks. Post op would be the soonest we would clear someone for return to sporting activities.

Transplante de menisco

Transplante segmentar de menisco

Técnica de transplante de menisco Dovetail/Slot

Transplante de menisco com pino ósseo duplo

Técnica para transplante aloenxerto de tecidos moles para meniscos