Reoperation Rates Following Meniscus Transplantation Using the Truven Database

High failure rate but promising clinical performance after implantation of a flexible medial meniscus prosthesis at 1-year follow-up

PURPOSE

After unsatisfactory results in a first-in-human clinical investigation with an anatomically shaped medial meniscus prosthesis, the prosthesis and its fixation technique were altered. This interim analysis of a prospective single-arm clinical investigation aims to evaluate safety and clinical performance in a first-in-human study with the redesigned meniscus prosthesis system.

METHODS

Ten patients suffering from medial postmeniscectomy pain syndrome were treated with the meniscus prosthesis. Patient-reported outcome measures were obtained at baseline and at 6-week, 3-, 6-, and 12-month follow-up. Radiographs and magnetic resonance imaging scans were obtained to evaluate joint degeneration and prosthesis location.

RESULTS

The device alterations resolved the issues occurring with the previous design, but four prostheses were explanted after fixation failure or subluxation of the prosthesis. Five out of six patients who reached 1-year follow-up reported a clinically significant improvement of the knee injury and osteoarthritis outcome score pain subscale. Imaging revealed no adverse effects on joint degeneration.

CONCLUSION

The failure mechanisms that occurred with the previous design have been resolved, but the new fixation technique introduced new safety issues. Improvement of positioning and fixation techniques are considered essential future adaptations to reduce the risk of failure. The good clinical outcomes reported by the patients reaching 1-year follow-up indicate that the medial meniscus prosthesis is a potential solution for patients suffering from postmeniscectomy pain syndrome.

LEVEL OF EVIDENCE

Level II.

Editorial Commentary: Meniscus Allograft Transplantation With Concomitant High Tibial Osteotomy and Cartilage Restoration Risks Reoperations and Potential Worsening Outcomes Following Subsequent Total Knee Arthroplasty

The management of the 25- to 45-year-old patient with meniscal deficiency, chondral degeneration, and pain remains challenging. With the potential of a knee replacement in the future, the question I wrestle with is, "When is enough enough?" Meniscus allograft transplantation, when combined with osteotomy and/or cartilage restoration procedures, improves functional outcomes compared to preoperative levels but has not been demonstrated to delay progression of osteoarthritis and often leads to reoperations. Moreover, concomitant procedures do not show improved survivorship of the meniscal allograft. While many undergoing these procedures return to active lifestyles, many do not return to preinjury levels. Balanced clinical-patient discussions are needed about the benefits, limitations, and expectations of meniscus allograft transplantation and associated procedures on not only the current condition of the knee but also the future implications, including reoperations and potential worsening outcomes following total knee arthroplasty. Notably, meniscal allograft transplantation and concomitant procedures lead to additional surgeries, with up to a 59% reoperation rate at an average of 43 months. In some, more surgery does not necessarily lead to improved outcomes, and caution should be exercised; only 44% return to preinjury activity level after meniscus allograft transplantation and high tibial osteotomy. Forty percent are disappointed by level and type of sports participation following meniscus allograft transplantation, but only 14% of those patients would not undergo the procedure again.

Medial Meniscus Allograft Transplantation: Bone Plug Technique With Anatomic Anterior and Posterior Horn Fixation

Meniscus preservation is crucial for avoiding cartilage degeneration after symptomatic meniscal tears. Despite efforts, meniscal repair procedures may fail, which requires a partial or total meniscectomy. Meniscus allograft transplantation (MAT) presents a viable solution, offering symptom alleviation, enhanced knee function, and potential osteoarthritis progression delay. Although MAT can address both lateral and medial compartments, medial MAT poses greater challenges as the result of its intricate attachments and limited mobility. The medial meniscus's unique anatomy, including attachments to the intermeniscal ligament, deep medial collateral ligament, capsule, and the anterior cruciate ligament, demands meticulous transplantation techniques. Refinements in surgical techniques are ongoing, emphasizing the importance of anatomical precision, particularly in positioning the anterior and posterior horns of the medial meniscus. Here, we present a bone plug technique for medial MAT, prioritizing the accurate anatomical attachment of the anterior horns of the allograft to improve surgical outcomes.

Synthetic medial meniscus implant demonstrates high reoperation rates: Patients who retain implant or require implant exchange show improvement in post meniscectomy knee pain and clinical function

PURPOSE

To evaluate the clinical outcomes in the use of a synthetic medial meniscus implant in patients symptomatic after medial meniscectomy and not responsive to nonoperative treatment.

METHODS

This single-arm, multicenter, prospective study enrolled subjects between ages 30 and 75 with postmeniscectomy pain. Changes from baseline to 24 months were measured in the pain subscale of the knee injury and osteoarthritis outcome score (KOOS) and in KOOS overall (average of all 5 subscales) in patients that had received a medial meniscus implant. Success was a 20-point improvement at 24 months, and reoperation rates and implant failures were recorded. Visual Analog Scale, International Knee Documentation Committee, and Western Ontario Meniscal Evaluation Tool scores were also measured.

RESULTS

Of the 115 treated patients, 3 (2.6%) were either lost to follow-up or missed the 24-month visit, 48 (43%) patients had at least 1 subsequent surgery, and 12 (10.7%) had the implant permanently removed. Of the remaining 100 patients, the mean KOOS pain improved 28.4 points at 24 months (P < .001), and the mean KOOS overall improved 28.3 points (P < .001). Of the subjects, 76% had mean scores for KOOS pain above the minimal clinically important difference threshold, and 72% of subjects met or exceeded this threshold for KOOS overall. There were 29 patients (25.9%) who underwent implant exchange. The 24-month clinical outcomes were similar between subjects who had an implant exchange and patients who did not have any subsequent implant procedure (P < .2).

CONCLUSIONS

The synthetic medial meniscus implant shows high reoperation and failure rates. Patients who retained the implant or required implant exchange showed improved pain and function.

Patients With Depression and/or Anxiety Having Arthroscopic Rotator Cuff Repair Show Decreased Number of Prescriptions and Number of Psychotherapy Sessions in the Year After Surgery

PURPOSE

To determine whether the utilization of psychological treatments changes after arthroscopic rotator cuff repair (RCR) for patients with preoperative depression and/or anxiety.

METHODS

The Truven Healthcare Marketscan database was used to identify patients who underwent arthroscopic RCR between January 2009 and December 2016. We included all patients with diagnosis codes associated with either depression or anxiety before RCR. Patients were excluded if they did not have complete insurance coverage for 1 year before or after surgery, or if they had arthroscopic RCR in the year before the index surgical procedure. We compared the proportion of patients with preoperative depression or anxiety who filled a prescription and had psychotherapy procedural codes in the year before and the year after arthroscopic RCR.

RESULTS

A total of 170,406 patients who underwent RCR were identified, of which depression and/or anxiety was found in 46,737 patients (43.7% male). Of the 46,737 patients, 19.6% filled a prescription for a depression/anxiety medication at least once in the year before surgery. Of this subset of patients, 41.5% did not fill a prescription for depression or anxiety medication after surgery, whereas 32.6% continued medication use but demonstrated a median 30-day reduction in the number of days' worth of medication. Similarly, 13.1% of patients were attending psychotherapy sessions preoperatively, but 76.6% of those patients either stopped or reduced the amount of psychotherapy sessions in the year following RCR.

CONCLUSIONS

The number of prescriptions and psychotherapy sessions decreased in the year after RCR for patients with preoperative diagnoses of depression and/or anxiety.

LEVEL OF EVIDENCE

Level IV, case series.

Systematic Review of Clinical Results After Medial Meniscus Allograft Transplantation Reveals Improved Patient Reported Outcomes at Greater Than 5 Years Follow-Up

PURPOSE

To systematically summarize the medial meniscus allograft transplantation (MAT) reported outcomes and evaluate whether the surgical technique is associated with allograft extrusion and knee function.

METHODS

Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language clinical studies involving arthroscopically assisted medial MAT that reported the surgical technique and the presence of graft extrusion or functional outcomes after surgery. Studies in which outcomes for medial MAT could not be separated from lateral MAT were excluded. Surgical technique, allograft-related characteristics, and clinical outcomes were extracted.

RESULTS

Twenty-four studies with 328 medial MAT were included, 58.3% studies qualified as level 4 of evidence, 29.2% as level 3, and 12.5% as level 2. Allograft fixation techniques were bone plug (235/328 [71.6%]), bone bridge/trough (55/328 [16.8%]), and soft-tissue suture fixation only (38/328 [11.6%]). Relative percentage of extrusion after surgery ranged from 24.8% to 53.7%. Major extrusion (>3 mm) ranged from zero to 78%. Overall, functional scores improved after medial MAT. None of surgical techniques were associated with poor functional outcomes or extruded meniscus; however, nonanatomical placement of the anterior and posterior horns appeared to increase meniscus extrusion.

CONCLUSION

Medial MAT provides favorable outcomes, with acceptable rates of complication and failure regardless of surgical technique. Although allograft extrusion appears equivalent for both bone plug and soft-tissue fixation techniques, positioning allograft horns at the native meniscal footprint may be critical for preventing extrusion. However, the heterogeneity and low level of evidence of the studies included in this review prevent decisive conclusions regarding optimal MAT fixation techniques, clinical significance of allograft extrusion, or comparative clinical outcomes after medial MAT.

LEVEL OF EVIDENCE

Level IV - systematic review of Level II to IV studies.

High-grade preoperative osteoarthritis of the index compartment is a major predictor of meniscal allograft failure

INTRODUCTION

Preoperatively available predictors of meniscal allograft failure would help in patient counseling and surgical indication for meniscal allograft transplantation (MAT). It was hypothesized that young patient age, high posterior tibial slope (PTS), and high-grade osteoarthritis (OA) are predictors of meniscal allograft failure.

MATERIALS AND METHODS

Patients undergoing MAT with a minimum follow-up of 2 years were included in this retrospective study. Demographic and surgical data, and causes of meniscal allograft failure were collected. PTS and degree of OA (low-grade: Kellgren-Lawrence 0, 1, and 2; high-grade: Kellgren-Lawrence 3 and 4) of the index and opposite tibiofemoral compartments were determined on preoperative radiographs.

RESULTS

This study included 77 patients with a mean age of 25.7 ± 10.1 years at the time of MAT. After a mean follow-up of 7.6 ± 5.6 years, meniscal allograft failure was observed in 26 patients (34%). The median time from MAT to meniscal allograft failure was 1.3 years (inter-quartile range, 2.5 years). Meniscal allograft tears (88%) were the primary cause of graft failure, followed by high-grade OA (12%). Patients experiencing meniscal allograft failure were an average of 2.7 years (95% CI [2.2, 7.5], p = 0.202) older at the time of MAT than patients without failure. PTS was not found to be a predictor of meniscal allograft failure (odds ratio, 0.884 (95% CI [0.727, 1.073], p = 0.212)). Patients with high-grade preoperative OA of the index compartment had 28 times higher odds of experiencing meniscal allograft failure than patients with low-grade preoperative OA (p = 0.008).

CONCLUSIONS

High-grade preoperative OA of the index compartment was found to be a significant and clinically relevant predictor of meniscal allograft failure. Surgeons should be aware of the impact of OA on meniscal allograft survival, which needs to be considered in patient counseling and surgical indication for MAT in patients.

Younger Patients Are More Likely to Undergo Arthroscopic Meniscal Repair and Revision Meniscal Surgery in a Large Cross-Sectional Cohort

PURPOSE

To evaluate recent trends in the treatment of meniscal tears with arthroscopic repair and debridement and to assess revision surgery within 2 years using a large cross-sectional database.

METHODS

Patients with a diagnosis of meniscal tear from 2010 to 2017 were queried using the Mariner data set from PearlDiver. Patient demographic data were analyzed and tracked via International Classification of Diseases, Tenth Revision codes to investigate subsequent ipsilateral meniscal procedures and conversion to total knee arthroplasty within 2 years after index meniscal surgery.

RESULTS

Of the 1,383,161 patients with a diagnosis of meniscal tear, 53.0% underwent surgical treatment. Surgical treatment consisted of meniscal debridement in 96.6% of patients and meniscal repair in 3.4%. The percentage of meniscal repairs increased from 2.7% to 4.4% over the 8-year period evaluated, whereas the percentage of meniscal debridement decreased from 97.3% to 95.6% (P < .0001). Younger patients were more likely to undergo meniscal repair (23% of those aged 10-19 years) than older patients (<1% of those aged ≥60 years). Among the 191,729 patients with International Classification of Diseases, Tenth Revision coding and 2-year follow-up, 10.6% of patients with index meniscal repair required a revision meniscal operation and 1.2% underwent conversion to arthroplasty. Subsequent meniscal procedures within 2 years after index meniscal repair included meniscal debridement in 81.6% of patients and revision repair in 18.4%. Patients who initially underwent meniscal debridement were less likely to undergo revision meniscal surgery (5.1%), but 4.7% required conversion to arthroplasty. Patients aged 10 to 19 years were most likely to undergo revision meniscal procedures after both index meniscal repair (12.8%) and meniscal debridement (8.8%).

CONCLUSIONS

The rate of meniscal repair is increasing over time, with patients younger than 30 years most likely to undergo repair for a meniscal tear. Revision surgery for meniscal repair or debridement is more common in adolescents and patients who undergo an index meniscal repair.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Imageless Computer Navigation Reduces 5-Year All-Cause Revision Rates After Primary Total Knee Arthroplasty

BACKGROUND

The use of surgical navigation has been shown to reduce revision rates after total knee arthroplasty (TKA) in patients <65 years of age. It is unknown if this benefit extends to older patients. We hypothesized that the use of surgical navigation would reduce rates of all-cause revision in patients of all ages.

METHODS

In this cohort study, we queried the Truven MarketScan all-payer database to identify patients who underwent TKA from 2007 to 2015. Current Procedural Terminology codes were used to create 2 groups based on whether intraoperative navigation was used. Demographics, comorbidities, complications, and revision rates were determined. International Classification of Diseases codes were used to determine reasons for revision.

RESULTS

The conventional TKA cohort included 312,173 patients. The navigation cohort included 20,881 patients. There were not any clinically significant differences in demographics between the cohorts. All-cause revision rates were lower in the navigation cohort at 1 year (0.4% vs 0.5%, P = .04), 2 years (0.7% vs 0.9%, P = .003), and 5 years (0.9% vs 1.3%, P < .001) of follow-up. Revisions for mechanical loosening were more common in the conventional cohort (30.8% vs 21.9%, P = .009). Rates of revision for other causes, including infection, did not differ between groups, with the numbers available.

CONCLUSION

The use of surgical navigation yielded a 30.7% reduction in the all-cause revision rate at 5-year follow-up compared to conventional TKA. This benefit increased as follow-up duration increased. Increased usage of this inexpensive technology, from the current 6.3% in this US cohort, may reduce healthcare costs.

LEVEL OF EVIDENCE

III.

Association Between Meniscal Allograft Tears and Early Surgical Meniscal Allograft Failure

BACKGROUND

Meniscal allograft transplantation (MAT) has become a viable treatment option for patients with symptomatic meniscal deficiency. Some patients experience early surgical meniscal allograft failure attributed to causes that have not yet been sufficiently clarified.

PURPOSE

To evaluate the prevalence, types, and distribution of arthroscopically confirmed meniscal allograft tears and the associated effect on surgical meniscal allograft survival.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing MAT with a minimum 2-year follow-up were retrospectively reviewed. Descriptive and surgical data were collected. Type and location of arthroscopically confirmed meniscal allograft tears were recorded and compared between medial and lateral allografts and suture-only and bone block fixation. A survival analysis was conducted to evaluate the effect of meniscal allograft tears on surgical meniscal allograft survival.

RESULTS

This study included 142 patients (54% male; mean ± SD age, 29.6 ± 10.4 years) with a mean follow-up of 10.3 ± 7.5 years. The prevalence of meniscal allograft tears was 32%, observed at a median of 1.2 years (interquartile range, 2.8 years) after MAT. The posterior horns were most frequently affected, followed by the posterior roots, midbodies, anterior horns, and anterior roots. The most frequently observed tear types were root tears (43%), followed by longitudinal, horizontal, radial, complex, bucket-handle, and meniscocapsular separation tears. A statistically significant association was found between meniscal allograft tear types and fixation techniques (P = .027), with root tears predominant after suture-only as compared with bone block fixation (57% vs 22%). Patients with meniscal allograft root tears were a mean of 5.4 years (95% CI, 1.6-9.2 years; P = .007) younger than were patients without root tears. The 1-year surgical meniscal allograft survival rate was significantly lower for torn versus intact meniscal allografts (75% vs 99%; P < .001).

CONCLUSION

Meniscal allograft root tears were predominant, associated with younger patient age, and more often observed when using the suture-only fixation technique versus the bone block fixation technique. Torn meniscal allografts were associated with early surgical graft failure when compared with intact meniscal allografts, resulting in a significantly lower 1-year survival rate.

Arthroscopic-Assisted Lateral Meniscal Allograft Transplantation With Open Ligamentous Extra-Articular Tenodesis

Lateral meniscus allograft transplantation is performed in predominantly young, active patients and is an option to stabilize the joint in lateral meniscus-deficient patients after anterior cruciate ligament reconstruction. The lateral meniscus functions as an important restraint to anterior tibial translation, and meniscal transplant in such a patient may improve survivability of the graft in addition to preserving the patient's articular cartilage in the long term. A ligamentous extra-articular tenodesis procedure may be performed simultaneously to augment rotational stability of the joint, particularly in a patient with underlying ligamentous hyperlaxity.

Editorial Commentary: Meniscal Allograft Transplantation Results in Unacceptable Reoperation Rates According to a Large Claims Database-However, Reoperations Do Not Necessarily Equal Failure

The biomechanical and clinical importance of the meniscus is now well-accepted. In accordance with this understanding, recent focus has shifted toward techniques that preserve the meniscus, including repair and meniscal allograft transplantation (MAT). Although MAT is a technically challenging procedure, evidence has suggested that it restores knee kinematics and tibiofemoral contact pressures, which may subsequently delay or prevent cartilage degeneration. Recent literature has reported concerns as to the high rate of reoperations after MAT, bringing into question the clinical utility of this procedure and its place in the realm of knee preservation. However, reoperations do not necessarily equal failure. MAT is a temporizing procedure that, when aligned with patient expectations, is valuable.