**7.1 Post-meniscectomy knee and meniscus allograft transplantation (MAT)**

Primary functions of the meniscus include load transmission, shock absorption, and secondary joint stability. When the meniscus is anatomically (post-meniscectomy) or functionally (complete radial tears, root tears) lost, the ipsilateral articular cartilage now wholly bears the compartmental load. Thus, meniscal preservation is key to articular chondroprotection. In the young patient with meniscal deficiency, MAT is a viable treatment option. Key surgical tenets include proper sizing, graft bank source, bony rather than suture fixation, and recognition of associated chondral disease. Historically, ipsilateral full-thickness cartilage pathology was considered a contraindication to MAT due to the poor clinical outcomes seen after MAT in this patient group(Noyes and Barber-Westin 1995; van Arkel and de Boer 1995). Given the recent improvements in outcomes following cartilage surgery and MAT when considered in isolation, the combined procedure (either simultaneous or staged) has received much attention. In the presence of combined meniscal deficiency and advanced chondral pathology, cartilage surgery may be a necessary adjunct to MAT for optimal biological joint preservation.

### **7.1.1 Outcomes**

Outcomes following combined MAT and cartilage surgery (ACI, OAT, osteochondral allograft) have demonstrated equivalent subjective and objective clinical outcomes as either procedure performed in isolation(Harris, Cavo et al. 2011). In these studies, failure rate is low (12%), but the rate of re-operation is high (~50%). Most of the failures (86%) that occur following combined MAT and cartilage surgery were due to failure of the MAT. In addition to consideration of meniscal status, coronal plane alignment must also be accounted for so as to not overload the ipsilateral compartment that receives cartilage surgery and MAT.

anteromedialization (Fulkerson). The degree of medialization needed may be estimated with pre-operative measurement of the TT-TG (tibial tubercle-trochlear groove) distance. Nevertheless, the surgeon must be cognizant during the pre-operative workup and the operation itself to assure that no medial patellar or trochlear pathology exists if planning to unload the lateral patellofemoral compartments, as this will increase stress on degenerative cartilage(Kuroda, Kambic et al. 2001). Distal patellar cartilage pathology may warrant anteromedialization to allow the patella to enter the trochlea in earlier degrees of flexion and unload the distal cartilage pathology(Colvin and West 2008). In the presence of lateral patellar tilt, a lateral retinacular release may be indicated(Arendt 2009). Medial patellofemoral ligament (MPFL) insufficiency may warrant reconstruction(Arendt 2009).

The clinical outcomes following patellofemoral realignment osteotomy have demonstrated success with the proper indications. In patients with lateral and distal patellar defects, anteromedialization led to 100% patient satisfaction with 87% good to excellent results, while patients with medial, proximal, or diffuse defects had only 43% good to excellent results(Pidoriano, Weinstein et al. 1997). Excellent short- and mid-term outcomes have been demonstrated when distal patellofemoral realignment has been combined with ACI(Bentley, Biant et al. 2003; Minas and Bryant 2005; Henderson and Lavigne 2006; Farr 2007; Gigante,

**7.1 Post-meniscectomy knee and meniscus allograft transplantation (MAT)** 

Primary functions of the meniscus include load transmission, shock absorption, and secondary joint stability. When the meniscus is anatomically (post-meniscectomy) or functionally (complete radial tears, root tears) lost, the ipsilateral articular cartilage now wholly bears the compartmental load. Thus, meniscal preservation is key to articular chondroprotection. In the young patient with meniscal deficiency, MAT is a viable treatment option. Key surgical tenets include proper sizing, graft bank source, bony rather than suture fixation, and recognition of associated chondral disease. Historically, ipsilateral full-thickness cartilage pathology was considered a contraindication to MAT due to the poor clinical outcomes seen after MAT in this patient group(Noyes and Barber-Westin 1995; van Arkel and de Boer 1995). Given the recent improvements in outcomes following cartilage surgery and MAT when considered in isolation, the combined procedure (either simultaneous or staged) has received much attention. In the presence of combined meniscal deficiency and advanced chondral pathology, cartilage surgery may be a necessary adjunct

Outcomes following combined MAT and cartilage surgery (ACI, OAT, osteochondral allograft) have demonstrated equivalent subjective and objective clinical outcomes as either procedure performed in isolation(Harris, Cavo et al. 2011). In these studies, failure rate is low (12%), but the rate of re-operation is high (~50%). Most of the failures (86%) that occur following combined MAT and cartilage surgery were due to failure of the MAT. In addition to consideration of meniscal status, coronal plane alignment must also be accounted for so as to not overload the ipsilateral compartment that receives cartilage surgery and MAT.

**6.2.1 Outcomes** 

**7.1.1 Outcomes** 

Enea et al. 2009; Gobbi, Kon et al. 2009).

**7. Role of meniscus in cartilage surgery** 

to MAT for optimal biological joint preservation.

#### **8. Articular cartilage defect management algorithm**

Fig. 12. Management of symptomatic chondral defect of medial or lateral femoral condyle. Concurrent issues, such as meniscal deficiency and coronal plane malalignment, need to be addressed, either simultaneously or sequentially in a staged manner. The most important defect-specific parameter is size (area in cm2), dictating treatment choice. MAT (meniscus allograft transplantation), HTO (high tibial osteotomy), OWHTO (opening wedge HTO), CWHTO (closing wedge HTO), DFO (distal femoral osteotomy), OAT (osteochondral autograft), ACI (autologous chondrocyte implantation), OC (osteochondral) allograft. Yellow (cartilage restorative technique); Red (cartilage reparative technique); Purple (cartilage palliative technique).

Fig. 13. Management of symptomatic chondral defect of femoral trochlea or patella. Concurrent issues, such as patella alta, patella tilt, increased extensor mechanism lateral vector (tibial tubercle – trochlear groove [TT-TG] distance), and trochlear dysplasia, need to be addressed, either simultaneously or sequentially in a staged manner. Centrally or medially located defects warrant different unloading osteotomy techniques, pending normal alignment. Medial patellofemoral compartment articular cartilage pathology is a contraindication to medializing osteotomy. The most important defect-specific parameter is size (area in cm2), dictating treatment choice. OAT (osteochondral autograft), ACI (autologous chondrocyte implantation), OC (osteochondral) allograft. Yellow (cartilage restorative technique); Red (cartilage reparative technique); Purple (cartilage palliative technique).

Management of Knee Articular Cartilage Injuries 123

Articular cartilage defects of the knee are a common source of pain and disability. Their natural history progression to osteoarthrosis of the knee is not completely understood. The management of these lesions is clearly multifactorial, involving factors specifically related to the patient, the lower extremity, the knee and the defect. Several surgical procedures exist to treat these injuries when non-operative management has failed. These include palliative, reparative, and restorative techniques. Both subjective and objective outcomes demonstrate significant improvement following these procedures. The future of cartilage surgery will need high-quality randomized clinical trials, using minimally-invasive techniques with the goal of obtaining normal hyaline articular cartilage, in the hopes of delay or prevention of

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**9. Conclusions** 

**10. References** 

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### **9. Conclusions**

122 Modern Arthroscopy

Fig. 13. Management of symptomatic chondral defect of femoral trochlea or patella. Concurrent issues, such as patella alta, patella tilt, increased extensor mechanism lateral vector (tibial tubercle – trochlear groove [TT-TG] distance), and trochlear dysplasia, need to be addressed, either simultaneously or sequentially in a staged manner. Centrally or

alignment. Medial patellofemoral compartment articular cartilage pathology is a

size (area in cm2), dictating treatment choice. OAT (osteochondral autograft), ACI (autologous chondrocyte implantation), OC (osteochondral) allograft. Yellow (cartilage restorative technique); Red (cartilage reparative technique); Purple (cartilage palliative

technique).

medially located defects warrant different unloading osteotomy techniques, pending normal

contraindication to medializing osteotomy. The most important defect-specific parameter is

Articular cartilage defects of the knee are a common source of pain and disability. Their natural history progression to osteoarthrosis of the knee is not completely understood. The management of these lesions is clearly multifactorial, involving factors specifically related to the patient, the lower extremity, the knee and the defect. Several surgical procedures exist to treat these injuries when non-operative management has failed. These include palliative, reparative, and restorative techniques. Both subjective and objective outcomes demonstrate significant improvement following these procedures. The future of cartilage surgery will need high-quality randomized clinical trials, using minimally-invasive techniques with the goal of obtaining normal hyaline articular cartilage, in the hopes of delay or prevention of defect progression to osteoarthrosis of the knee.

#### **10. References**


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**7** 

**Articular Cartilage Regeneration with Stem Cells** 

Cartilage defects continue to be a clinical challenge as regards to articular cartilage regeneration. The structure and function of articular cartilage leads to non-healing lesions after injury occurs. Well-established arthroscopic methods utilize controlled healing with marrow stimulation or transferring of non-injured cartilage to areas of injury. These include: microfracture, chondral drilling, osteochondral autograft transfer system, ostechondral allograft transplant, and autologous chondrocyte implantation. However, more often than not the treatments result in the formation of fibrocartilage and similar results within all methods with no clear superior modality (Jakobsen et al, 2005; Lubowitz et al, 2007; Magnussen et al, 2008; Nakamura et al, 2009). Recent study has investigated synthetic and biologic adjuncts to current methodology, including the use of: hyaluronic acid (HA), platelet rich plasma, mesenchymal stem cells (MSC) and peripheral blood progenitor cells (PBPC). Cell therapy has produced exciting results in animal models and has been shown to regenerate hyaline cartilage clinically in the knee joint. Our current method utilizes arthroscopic subchondral drilling of cartilage lesions in combination with a postoperative adjunct treatment involving: stimulation of the release of PBPC with filgrastim, harvest of PBPC with apheresis, and postoperative intraarticular injection of PBPC in combination with HA. Our early results lead us to the conclusion that cell therapy will have an integral part in the future treatment of cartilage damage as well as other potential orthopedic,

Understanding the form and function of articular cartilage is the cornerstone to developing successful treatments for articular cartilage damage. Articular cartilage is a tissue that bears load and forms the articulating surfaces of diarthrodial joints. Articular cartilage dissipates

Articular cartilage is predominately composed of extracellular matrix (ECM) with a sparse population of chondrocytes that help to maintain the ECM. The major components of the

loads, has low friction, provides lubrication, and can last up to 8 decades.

**1. Introduction** 

surgical, and medical applications.

**2. Anatomy of articular cartilage** 

Khay-Yong Saw1, Adam Anz2, Kathryne Stabile2, Caroline SY Jee3, Shahrin Merican1, Yong-Guan Tay1 and Kunaseegaran Ragavanaidu4

*1Kuala Lumpur Sports Medicine Centre,* 

*4Clinipath, Klang 1,3,4Malaysia 2USA* 

*2Wake Forest University Baptist Medical Center, 3The University of Nottingham Malaysia Campus;* 

Scott, W. (2005). Insall & Scott Surgery of the Knee, Churchill Livingstone.

