| Part ? Anatomic study of the meniscal horns' insertionsObjective:1.To observe the attachment location on the tibia and anatomic characteristics of the anterior and posterior horn of medial and lateral meniscus.To measure the transverse and anteroposterior diameter of tibial attachment points of medial and lateral meniscus,as well as the distances among anterior and posterior horn insertion and their geometric center.2.To observe anatomic characteristics of medial and lateral intercondylar eminence,as well as anatomic relationships between medial and lateral intercondylar eminence and anterior and posterior horn of medial and lateral meniscus.To evaluate the possibility of operating the tibial tunnel in the process of simataniously medial and lateral meniscus transplantation together with anterior cruciate ligament(ACL)reconstruction.3.To discuss the meanings of these measurements in meniscal transplantation.Methods:The medial and lateral menisci of the 12 cadaver knees were anatomically evaluated.we studied the anatomical location and morphology of the bilateral meniscal anterior and posterior horns,the anterior cruciate ligament(ACL)and posterior cruciate ligament(PCL)also were anatomically evaluated.Then we observed the morphology of medial intercondylar eminence(MIE)and lateral intercondylar eminence(LIE)and measured the anteroposterior diameter;observed the positional relationship of the anterior horn bony insertion of the lateral meniscus(AHILM)with the LIE and the attachment to the tibia of the ACL,observed the positional relationship of the posterior horn bony insertion of the lateral meniscus(PHILM)with the LIE,measured the transverse diameter and longitudinal diameter of the PHILM and the AHILM,measured the distance from the center of the PHILM to the center of the AHILM.Observed the positional relationship of the anterior horn bony insertion of the medial meniscus(AHIMM)with the attachment to the tibia of the ACL,observed the positional relationship of the posterior horn bony insertion of the medial meniscus(PHIMM)with the MIE,measured the transverse diameter and longitudinal diameter of the AHIMM and the AHILM,measured the distance from the center of the PHIMM to the center of the PHILM,and measured the distance from the center of the medial meniscus(MM)to the center of the lateral meniscus(IM).Then we mimicked the arthroscopic fixation of the bone tunnel by bone lock-bolt in samples of the knee joint,using the campylodrome tibial locator to locate the anterior horn and the posterior horn,and drilled the bone tunnel from the cortex of the tibia to the attachment of the MM and IM,then estimated whether there was an comunication between the 2 bone tunnel.The joint capsule and the meniscotibial ligaments were removed,the knee were made extreme flexion,and the displacement of the anterior edge of the IM was measured.Results:The tibial insertion of ACL was irregularly located in the anterolateral direction of medial intercondylar eminence,including triangle(7 cases),oval(3 cases)and quadrangle shape(2 cases),with the maximal anteroposterior diameter of(15.51±1.04)mm and transverse diameter of(9.77±0.62)mm.There was a overlap covering relationship between the attachment location of anterior horn of the lateral meniscus and tibial insertion of ACL.In other words,the forebody of anterior horn of lateral meniscus was coordinated with the periphery of tibial insertion of ACL,with connective fibers between them.And the latter of anterior horn of lateral meniscus was attached to intercondylar eminence behind ACL.Finally,there was an angle between the axes of anterior horn of the lateral meniscus and lateral intercondylar eminence.The attachment of the anterior and posterior horn of lateral meniscus was separated by lateral intercondylar eminence,which was short and soaring,with anteroposterior diameter(8.69±1.03)mm.The attachment of anterior horn of lateral meniscus located in the groove in the front of intercondylar eminence.And an anterior horn of lateral meniscus could be divided into anterior and posterior part of the axis of lateral intercondylar eminence.The former section connected to tibial insertion of ACL by some parallel fibers,with an anteroposterior diameter of(7.95±0.96)mm and transverse diameters of(4.70±0.64)mm.The posterior edge of lateral part was inside the lateral intercondylar eminence,with the distance of(4.52±0.59)mm.The posterior horn of lateral meniscus was attached to the back of lateral intercondylar eminence,with anteroposterior diameter of(14.76±2.24)mm and transverse diameter of(4.42±0.66)mm,which was close to the width of lateral intercondylar eminence.The front side of posterior horn of lateral meniscus adjoined to the back of lateral intercondylar eminence;the lateral edge was near to the arc cartilage edge of the lateral tibial platform;the medial border located on the extension line of the peak axis of lateral intercondylar eminence,which was(17.68±1.42)mm away from the halfway point of the anterior and posterior horn of the lateral meniscus.The attachment location of the anterior and posterior horn of medial meniscus was separated by the tibial insertion of ACL and lateral intercondylar eminence,which was long and gentle,with an anteroposterior diameter(13.20±1.03)mm.The anterior horn of medial meniscus located on the slope in the front of the tibial insertion of ACL.The bevel of its attachment point and tibial platform were on an angle of(3 8.21±2.25)°.The anterior horn of medial meniscus was of the maximal anteroposterior diameter of(9.96±0.75)mm and maximal transverse diameter of(8.21±0.67)mm.The attachment location of posterior horn,which was in the front of posterior cruciate ligament(PCL)and behind the back edge of medial intercondylar eminence,located at the back intercondylar notch of tibia.The attachment location of posterior horn,with anteroposterior diameter of(9.77±0.96)mm and transverse diameter of(5.51±0.61)mm,was outside the axis of medial intercondylar eminence with the distance of(4.58±0.51)mm.The axis of medial intercondylar eminence was(35.90±2.30)mm away from the halfway point of anterior and posterior horn of lateral meniscus.The distance from anterior and posterior horn to their halfway point was(17.02±1.45)and(35.90±2.30)mm respectively.The distance from the midpoint of ACL to center of anterior horn of medial meniscus was(17.88±0.79)mm.With a 8mm osteotome which was close to tibial insertion of ACL and went through the attachment of anterior and posterior horn of lateral meniscus,a bone trough was produced.The trough passed and knocked off the lateral intercondylar eminence,but could not clear the latter half of anterior horn of lateral meniscus completely.While joint capsule and coronary ligament were cleared,the lateral meniscus went back significantly in the process from knee extension to extreme flexion,with the maximal translocation distance of(10.79±0.58)mm.Conclusions:(1)The posterior part of the AHILM located on the rear of the attachment of the ACL to the tibia,the bone bridge technique(adjoin the outer edge of the ACL)might lead to an out-shift when located the point of the anterior horn in the allograft lateral meniscal transplantation,but the bone lock-bolt technique would be more close to the anatomical attachment;(2)The distance from the anterior horn to the posterior horn of the IM and MM were long enough to perform the reconstruction of ACL combined with the allograft meniscal transplantation,in this study,we suggested to use small diameter drill;(3)The tension of anterior part of the IM were stronger when the knee joint undergo the flexion and the extension,so we suggested to reserve the adipose tissue ahead the IM,which might make the suture and the fixation convenient;(4)The anterior and posterior horn of the meniscus were not attached to the intercondylar eminence.There was an angle between the AHILM and the axis of the LIE.The inner edge of the PHILM located over the axis of the LIE and the AHIMM and the PHIMM located outside of the axis of the MIE,so if we use the data from the X-ray to match the meniscus,a smaller allogeneic meniscus might be choosed;CT could provide better vision of the intercondylar eminence and surrounding bony marks,through which the attachment of the meniscus could be more precisely evaluated,so the allograft matching using CT might had more advantages than X rays.(5)AHIMM located on the bevel of the anterior edge of the tibial plateau,when the bone lock-bolt technology was used to fix the allogeneic meniscus,the straight bone tunnel might lead to cortex fracture,so we suggested to use a V-shape bone tunnel.Part II Follow-up of meniscal allograft transplantationObjective:To investigate the midterm and long-term clinical results of arthroscopic meniscal allograft transplantation.To explore the issues about indication,operative tips and procedure,postoperative function,radiological appearance,complication and rehabilitation of meniscal allograft transplantation.To report our experience and provide for clinical reference.Method:From January 2007 to December 2013,73 consecutive patients underwent meniscus allograft transplantation(MAT)in the department of sports medicine,Peking University Shenzhen Hospital,and 61(36 men and 25 women)with a mean age of 32.3 years were followed up(F-U)for more than 6 months and were enrolled in this study.The F-U rate was 83.6%,the mean F-U was 31.0 months(6-80m);21 cases underwent lateral MAT of left knee,35 underwent lateral MAT of right knee,3 underwent medial MAT of left knee and 6 underwent medial MAT of right knee.26 cases combined lateral discoid meniscus,2 combined bucket-handle tear of the medial meniscus(MM),1 combined bucket-handle tear of the lateral meniscus(IM),and 13 combined ACL injury.4 cases combined I° cartilage injury,7 combined ?°cartilage injury,11 combined ?° cartilage injury,and 8 combined ?° cartilage injury.34 cases underwent meniscectomy combined MAT during the primary operation.MAT was performed during the second operation in 27 patients who had underwent subtotal meniscectomy and the mean time from the meniscectomy to the MAT was 36.6 weeks.There were 3 patients underwent the lateral MAT combined medial MAT at the same time.The mean hospitalization expenses were 58318.25 RMB.All patients were evaluated at follow-up by the range of the motion(ROM),IKDC score,Lysholm score,Tegner score,and VAS for pain scores.With regard to the patients combined ACL reconstruction,the physical examination included anterior drawer test and Lachman test.The joint space narrowing was evaluated on weight-bearing radiographs,and graft healing status,arthrosis changes in cartilage,and meniscal extrusion were investigated by MRI.Finally,we used SPSS program(version 19.0)for statistical analysis.The paired t test was used to compare preoperative and postoperative IKDC score,Lysholm score,Tegner score,and VAS;rank sum test was used for the ROM;and ?2 test used for the grade of the cartilage injury;correlations between meniscal extrusion and other parameters were analyzed by Pearson and Spearman p correlation tests.Results:61 patients were available for the follow-up including four patients who underwent second-look arthroscopy.The mean time of the operation was 2.05 hours.The mean times of the suture used outside-in technique for the anterior horn of the meniscus was 2.28,for the body of the meniscus using inside-out technique is 3.95,for the posterior horn of the meniscus used all-inside technique is 3.03.Forty-two(68.9%)patients prefered to take another MAT when there is a need.All the 61 patients had significant improvement in clinical symptoms at final follow-up.The mean results for VAS,IKDC score,Lysholm score were significant better than the data of preoperation(P<0.05),while there was no significant difference in the ROM and Teger score(P>0.05).Comparing the medial MAT and the lateral MAT,the postoperative ROM,VAS,IKDC score and Tegner score were not significantly different(P>0.05).With regard to the postoperative examination of the patients which underwent MAT combined ACL reconstruction,anterior drawer test and Lachman test were negative,with delined postoperative ROM.All the X-ray and MRI of the 61 patients showed no joint space narrowing.13 showed no hydrarthrosis,21 mild hydrarthrosis,20 moderate hydrarthrosis,7 severe hydrarthrosis.According to Stoller standard,with regard to reinjury of the transplanted meniscus,13 showed no reinjury,25?° reinjury,17 ?°reinjury and 6?°reinjury.All the meniscus grew union to the capsule.54(88.5%)transplanted meniscus showed extrusion and 2 extruded out of the tibial plateau.The mean distance of the maximum meniscal extrusion was(3.39±0.90)cm,and the relative percentage of extrusion was 33.73%.There was no significant difference between the lateral MAT and the medial MAT with regard to the extrusion(P>0.05).No significant correlations were found between meniscal extrusion and Lysholm score,IKDC score,ROM,VAS,Tegner score(P>0.05).No significant correlations were found between cartilage injury and ROM,Tegner score(P>0.05),there were significant correlations between cartilage injury and ROM,Lysholm score,and IKDC score(P<0.01).One incision was delayed union combined with fat liquefaction.Two patient occured synarthrophysis and both underwent the ACL reconstruction.One suffered postoperative joint infection.There were one failure of the operation and one meniscus allograft dislocation,which underwent second operation for the meniscal restoration.Conclusions:Meniscal allograft could grow union with capsule of the joint.Meniscal allograft transplantation resulted in significant symptomatic and functional improvement,was effective treatment for the patients who underwent meniscectomy. |
PDF Full Text Request