Description
Meniscal Cartilage Damage
Meniscal cartilage is an integral structural component of the human knee, functioning to absorb shocks and providing load sharing, joint stability, congruity, proprioception, and lubrication and nutrition of the cartilage surfaces. Total and partial meniscectomy frequently result in degenerative osteoarthritis. The integrity of the menisci is particularly important in knees in which the anterior cruciate ligament has been damaged. In these situations, the menisci act as secondary stabilizers of anteroposterior and varus-valgus translation.
Meniscal allograft transplantation (MAT) is considered a salvage procedure, reserved for individuals with disabling knee pain following meniscectomy who are considered too young to undergo total knee arthroplasty or in individuals who require a total or near total meniscectomy for irreparable tears. As a result, the population intended to receive these transplants is relatively limited.
Issues under study include techniques for processing and storing the grafts, proper sizing of the grafts, and appropriate surgical techniques. The four primary ways of processing and storing allografts are fresh viable, fresh frozen, cryopreserved, and lyophilized. Fresh viable implants, harvested under sterile conditions, are less frequently used because the grafts must be used within a couple of days to maintain viability. Alternatively, the harvested meniscus can be fresh frozen for storage until needed. Cryopreservation freezes the graft in glycerol, which aids in preserving the cell membrane integrity and donor fibrochondrocyte viability. CryoLife is a commercial supplier of such grafts. Donor tissues may also be dehydrated (freeze-dried or lyophilized), permitting storage at room temperature. Several secondary sterilization techniques may be used, with gamma irradiation the most common. The dose of radiation considered effective has been shown to change the mechanical structure of the allograft; therefore, nonirradiated grafts from screened donors are most frequently used.
Summary of Evidence
For individuals who are undergoing partial meniscectomy who receive meniscal allograft transplantation (MAT), the evidence includes systematic reviews of mostly case series and a randomized controlled trial (RCT). Relevant outcomes are symptoms, functional outcomes, and quality of life. The systematic reviews concluded that most studies have shown statistically significant improvements in pain and function following the procedure. The benefits have also been shown to have a long-term effect (greater than 10 years). Reviews have also reported acceptable complication and failure rates. There remains no evidence that MAT can delay or prevent the development of knee osteoarthritis. A limitation of the evidence is its reliance primarily on case series. The results of a single RCT, which enrolled a very small number of individuals and pooled data from randomized and nonrandomized groups, cannot be interpreted in a meaningful way. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who are undergoing partial meniscectomy and concomitant repair of malalignment, focal chondral defects, and/or ligamentous insufficiency who receive MAT, the evidence includes a systematic review of case series as well as case series published after the systematic review. Relevant outcomes are symptoms, functional outcomes, and quality of life. The systematic review concluded that pain and function improved following the procedure. One of the series published after the review showed that individuals with more severe cartilage damage experienced favorable outcomes similar to individuals with less cartilage damage. Another series published subsequently reported an overall 9.7 year survival of the implant. A limitation of the evidence is its reliance primarily on case series. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who are undergoing partial meniscectomy who receive collagen meniscal implants (CMIs), the evidence includes two (2) systematic reviews primarily of case series. Relevant outcomes are symptoms, functional outcomes, and quality of life. The reviews reported overall positive results with the CMI, but the quality of the selected studies (RCTs, observational studies) was low. Radiologic evaluations have shown reductions in the size of the implant in a large portion of individuals. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
