关节镜下同种异体半月板移植的疗效分析

目的 探讨关节镜下同种异体半月板移植微创手术的临床疗效.方法 2006年1月至2008年7月,对21例(22侧)半月板损伤后切除半月板的患者行关节镜下同种异体半月板移植手术.在关节镜下用膝关节定位器制作容纳半月板前、后角骨栓(骨桥)的骨道(骨槽),将大小匹配的带有前、后角骨栓(骨桥)的同种异体半月板植入适当位置,并与关节囊缝合固定.全部患者于术前行MR检查,13例于术后1年复查MR.采用VAS疼痛评分、Lysholm评分和IKDC分级方法评价膝关节功能.3例分别于术后3、9及18个月行二次关节镜探奁.结果 全部病例无手术副损伤、感染或需摘除移植半月板者.随访6～28个月,平均16.3个月.患者手术前后膝关节均可伸直,屈曲活动度差异无统计学意义.VAS疼痛评分术前(7.0±2.3)分、术后(3.2±1.3)分,Lysholm评分术前(64.3±15.7)分、术后(80.1±19.4)分,差异均有统计学意义.术后IKDC分级较术前明显改善.术后3个月关节镜检查示移植半月板与关节囊基本愈合,形态完整;术后9个月移植半月板质地偏硬;术后18个月移植半月板与关节囊愈合牢固,质地接近正常半月板.术前与术后关节软骨分级差异无统计学意义.结论 同种异体半月板移植早期临床效果满意,移植半月板与周围组织愈合良好.但术后早期稳定性稍差,容易损伤.     

膝关节镜下同种异体半月板移植术(附2例初步报告)

[目的]通过对2例临床同种异体半月板移植中移植物取材、储存，手术操作技术、术后康复计划和不良反应等方面初步结果的总结，结合相关文献，讨论目前临床异体半月板移植的有关问题，为进一步开展此项临床技术提供参考。[方法]对2例外伤导致严重陈旧性半月板损伤、大部缺失的患者，在关节镜下实施同种异体半月板移植术，拟定术后康复计划，对其症状缓解、关节活动度恢复等近期随访结果作初步报告。[结果]患者无手术副损伤，术后伤口愈合良好，无明显伤口渗液，早期关节肿胀，6周左右肿胀消失。实验室检查未发现免疫排斥反应等征象。疼痛评分术前8分、6分，术后3分、2分。患者膝关节活动度恢复过程顺利。[结论]基于目前对半月板严重损伤者保留和修复半月板治疗中存在的困难，以及半月板属于免疫屏蔽器官的特点，异体半月板移植技术有可能成为治疗半月板严重损伤、缺失的一项重要技术。迄今已有的研究为其提供了充分的理论依据。但目前对其远期效果尚待进一步观察，关于移植物的消毒储存、手术操作技术、功能康复训练等临床问题也有待于进一步研究。     

关节镜下异体半月板移植微创手术初步报告

目的 总结关节镜下同种异体半月板移植微创手术中移植物制备、手术操作和术后康复过程等经验体会,为进一步开展此项技术提供参考. 方法 2006年11至12月对3例半月板严重损伤、大部缺损的患者,采用关节镜微创技术实施同种异体半月板移植手术,拟定术后康复计划,分别随访24、32和36周,对其结果做初步报告,并讨论异体半月板移植手术适应证和操作技术等问题.结果 患者无手术副损伤,术后伤口无渗液,6周左右关节肿胀基本消失.实验室检查未发现免疫排斥反应.患者疼痛评分(VAS)术后平均降低4.7分.膝关节Lysholm评分平均由术前59.0分增至术后81.7分.膝关节活动度接近正常. 结论 由于半月板缺损治疗中存在的困难及半月板属免疫屏蔽器官的特点,同种异体半月板移植术可能成为治疗半月板缺损的重要方法.异体半月板移植的手术适应证为:中青年患者,半月板已切除或无法保留,无软骨下骨明显病变,无严重股骨髁或胫骨平台畸形,无感染及其他外科手术禁忌证.     

关节镜下抽吸式半月板缝合术患者的康复护理

目的 探讨半月板损伤患者行关节镜下抽吸式半月板缝合术患者的康复训练方法和初步疗效.方法 对26例半月板损伤患者采用关节镜下抽吸式半月板缝合术,术前指导其进行增强股四头肌的肌力、增加膝关节活动度的训练,术后指导其行肌力训练、提高膝关节屈曲度的训练及负重训练、下楼梯训练.结果 术后住院6～8 d,平均7.5 d,伤口Ⅰ期愈合、关节活动度>90°出院;随访6～54周,25例症状消失,步态正常,恢复正常工作和生活;1例合并膝骨性关节炎,内侧副韧带损伤,术后关节肿痛,予以制动,手术后23周膝屈曲<100°.结论 关节镜下抽吸式半月板缝合术后,在康复训练时科学地掌握手术后关节的动静关系、时机和局部情况,对确保手术效果,促进半月板愈合,恢复膝关节的功能有重要的临床意义.     

关节镜下关节半月板损伤修复术围术期的护理

目的观察关节镜下关节半月板损伤修复术围术期的护理效果。方法对50例半月板损伤患者在关节镜下实施半月板修复术的同时,给予术前心理疏导、术后康复训练指导等围术期护理措施。结果本组均顺利完成手术。术后膝关节肿痛、关节绞锁及跛行等症状消失,关节功能明显改善。出院时调查对护理工作满意率100.00%。结论对在关节镜下实施半月板修复术的患者,实施围术期精心护理及康复训练,是取得满意疗效的重要措施。     

同种异体肋软骨膜移植半月板再生的实验研究

目的：探究同种异体肋软骨膜游离移植再生半月板的能力及其预防关节退变的意义。材料及方法：选用成年家犬10只，双膝关节内侧半月板切除后随机选取一侧膝关节内侧间隙植入同种异体肋软骨膜（同种异体移植组），对侧膝关节植入自体肋软骨膜（自体移植组），以全部切除的正常半月板及正常膝关节作为对照（对照组）。分别于术后4、8、12周切取标本，进行大体、光镜（HE染色及Alcian-blue,Safranin 0复杂）、透射电镜观察，并对正常半月板及术后12周的移植物进行生物力学测试。结果：12周时所有移植物都衍化再生出接近正常半月板大小及形态的纤维软骨板。在整个实验过程中未见明显的免疫排斥反应。生物力学测试结果显示两移植组再生半月板的抗拉伸性能无显著性差异，均低于正常半月板。结论：同种异体肋软骨膜游离移植于半月板缺失的犬的膝关节中可以存活，并可再生出接近正常形态、结构的半月板，无免疫排斥反应。     

关节镜联合关节外入路术式治疗半月板旁型囊肿

目的:探讨关节镜联合关节外入路术式治疗半月板旁型囊肿的疗效。方法:对13例半月板旁型囊肿患者采用膝关节镜探查,并根据半月板撕裂情况采取不同的缝合法修复,关节外入路手术切除囊壁。应用视觉模拟评分(VAS)评定膝关节疼痛程度,Lysholm膝关节评分评定膝关节功能。结果:13例伤口均I期愈合,无手术相关并发症。术后随访12～24个月,平均15.8个月,囊肿均无复发。术前膝关节VAS评分6.62±0.96,术后1.38±0.65(P0.01);Lysholm评分术前60.92±10.10,术后90.69±6.52(P0.01)。结论:关节镜联合关节外入路术式治疗半月板旁型囊肿,无复发,膝关节疼痛及膝关节功能改善明显,可获得较为理想的临床效果。     

关节镜下同种异体半月板移植的护理配合

目的 探讨全关节镜下同种异体半月板移植的手术护理配合.方法 对5例半月板损伤患者行关节镜下同种异体半月板移植术;术前访视,做好仪器、物品及同种异体半月板供体的准备;术中巡回、器械护士与术者密切配合;术后协助术者妥善包扎伤口,并送患者返回病房等.结果 5例患者平均手术时间3.7 h,术程顺利;术后均未出现排斥反应和其他并发症;随访1～5个月,均已完全负重,无疼痛、肿胀等临床症状.结论 关节镜下行同种异体半月板移植术,安全、患者恢复快;积极有效的护理配合是手术成功的重要保障.     

4例同种异体半月板移植术后中期随访报告

目的探讨同种异体半月板移植术后中期的临床效果。方法2005年6～7月,4例半月板切除术后患者接受关节镜辅助下的同种异体半月板移植。男3例,女1例。年龄分别21、27、35、38岁。3例内侧半月板移植,1例外侧半月板移植。随访内容包括症状及体征,术前及随访时的IKDC、Lysholm、Tegner评分。随访通过膝关节正侧位、双膝持重位及双下肢全长X线检查比较患侧及健侧关节间隙和力线改变,评估膝关节退变情况,通过MRI检查评估移植半月板位置及信号改变。其中1例接受二次关节镜探查。结果随访时间44～45个月。4例均无关节疼痛、肿胀等,关节活动度正常,IKDC、Lysholm及Tegner评分分别为84．75±2．63、91．50±4．43及7．00±0．82,术前为60．50±14．06、69．25±22．04及4．00±0．82。X线提示1例关节间隙较健侧狭窄2mm,其余正常,力线均正常。MRI提示3例内侧半月板体部均有轻度外凸,体部及后角有Ⅱ～Ⅲ度信号。1例二次关节镜探查提示移植半月板形态及张力正常。结论同种异体半月板移植术后中期临床效果良好,关节无明显退变,MRI对评估移植半月板具有重要价值。     

半月板损伤行关节镜手术治疗的康复护理

对27例膝关节半月板损伤的患者应用关节镜技术行镜下成形术，经过围术期的心理康复。股四头肌运动、踝泵运动、直腿抬高运动，膝关节屈曲运动及下地行走等训练，患者术后伤口Ⅰ期愈合，随访5～18个月，关节无疼痛，无顽固性积液，伸屈活动恢复正常，能从事日常活动。     

关节镜下前交叉韧带重建后内侧和外侧半月板同期移植术

目的 探讨全关节镜下前交叉韧带重建后内侧和外侧半月板同期移植的微创手术技术.方法 2008年8月对1例实施膝关节双束双通道前交叉韧带重建、内侧和外侧半月板切除的患者,在关节镜下实施内侧和外侧半月板同期移植微创手术.内侧半月板移植采用前后角骨栓固定方法,外侧半月板移植采用前后角骨桥固定方法.术后结果采用VAS疼痛评分、Cysholm评分和国际膝关节评分委员会(IKDC)分级评价.关节稳定性检查包括Lachman试验、抽屉试验和轴移试验.结果 术后随访26个月,患者膝关节屈曲、伸直和负重行走功能正常.VAS膝关节疼痛评分较术前降低2分,Lysholm评分较术前升高20分.IKDC分级由术前C级上升到B级.膝关节稳定性检查基本正常.术后1年MRI检查显示,重建前交叉韧带连续性完整,内侧和外侧移植异体半月板外形均较好,内侧半月板后角和外侧半月板前角有轻微萎缩.术后18个月关节镜复检观察到,外侧和内侧移植半月板均愈合良好,形态完整,但前角表面均有轻度磨损现象.结论 对膝前交叉韧带损伤和内、外侧半月板切除的患者,在前交叉韧带重建术后同期实施内侧和外侧半月板移植术可以尽量恢复膝关节的稳定性和力学平衡,对年轻患者是可供选择的治疗方式.术中建议采用同一供体的内侧和外侧异体半月板,制作各骨道时须注意其方向以避免骨道相互交通.

Abstract：

Objective To discuss the minimal invasive arthroscopic surgery technique and clinical results of both the medial and lateral meniscal transplantation following the anterior cruciate ligament reconstruction with double bundles and bone tunnels.Methods In August 2008 a minimal invasive surgery of both the medial and lateral meniscal allograft transplantation following anterior cruciate ligament reconstruction was preformed for 1 case with both the medial and lateral menicectomy by arthroscopic surgery.The method of two bone plugs attached on tibial plateau was employed for medial meniscal allograft transplantation and the technique the bridge in slot for lateral meniscal allograft transplantation.The VAS,Lysholm score and IKDC rating were recorded before and after operation.The stability of knee was assessed by Lachman test,drawer sign and pivot shift test.Results The patient was followed up 26 month after the operations.The degrees of knee flexion,extension and function of walk were normal.The Lachman test,drawer sign and pivot shift test were nearly normal.The VAS after operation was 2 points lower than that before operation.The Lysholm score post-operation was 20 points higher than pre-operation.The IKDC became B degree in late following-up from C degree before the operation.MRI revealed anterior cruciate ligament graft was continuous and the meniscal allograft was normal shape on year 1 after the operation.The posterior horn of medial meniscal allograft and anterior corner of lateral meniscal allograft showed slightly shrunk.The second-look arthroscopy showed that the healing occurring between meniscal allograft and the capsule and meniscal allograft was normal shape on month 18 after the operation.The anterior horn of medial and lateral meniscus was slightly worn.Conclusions Both the medial and lateral meniscal transplantation following the anterior cruciate ligament reconstruction in appropriately selected patients with the medial and lateral meniscus-deficient knee may recover the knee mechanic balance and stability,which is a option of treatment for that young and activity patients.It is proposed that the medial and lateral meniscal grafts harvested from a single donator.Attention should be paid to the direction of the bone tunnels fixing the horns of the meniscus in order to avoid communication with the tunnels of anterior cruciate ligament reconstruction.     

Meniscal allograft transplantation for symptomatic knee after meniscectomy of torn discoid medial meniscus: Report of three cases

In symptomatic discoid medial meniscus, partial meniscectomy is the principal treatment method and can yield promising short-term results. However, unlike the nondiscoid meniscus, discoid medial meniscus is frequently associated with horizontal cleavage tears, attributable to the presence of myxoid degeneration in the intrameniscal substance, in that it may potentially occur deteriorating long-term results because of re-tearing of remaining meniscus or secondary degeneration of cartilage of the medial compartment after meniscectomy. We experienced three rare cases of retear or secondary degeneration of cartilage of the medial compartment after meniscectomy for two patients with torn bilateral meniscus. Both patients were highly active young males. Meniscal allograft transplantation in complicated discoid medial meniscus was performed. At 2 years after meniscal allograft transplantation, clinical outcomes were improved with a normal range of motion. Orthopedic surgeons should recommend activity modification to prevent possible complicated injury of the discoid medial meniscus. Meniscal allograft transplantation may be an alternative option in highly active young patients undergoing complicated discoid medial meniscus to diminish pain, improve knee function, and prevent or delay degeneration.     

Allograft interference screw fixation in meniscus transplantation

Allograft meniscus transplantation is indicated to restore proper knee biomechanics and prevent subsequent articular degeneration in patients with a meniscus-deficient knee. A variety of techniques for fixation of meniscal transplants exist, with some techniques using soft-tissue fixation of the meniscal horns and others using bony fixation. The authors present a technique of meniscus transplantation using a tibial slot with allograft interference screw fixation. We have had excellent early results with this technique and believe that a cortical allograft interference screw reliably maintains the anatomic position of the meniscal attachments that are critical to the biomechanics and functional outcome of meniscus transplantation.     

Meniscus transplantation: current concepts

Treatment options are limited for young, meniscal-deficient patients with pain. This patient population is not age appropriate for total joint replacement, yet the loss of the meniscus leaves them at significant risk for the development of osteoarthritis. One increasingly popular option is the use of allograft meniscal transplantation. However, many questions, both clinical and biomechanical, still surround allograft meniscus transplantation. Clinical questions include risks of disease transmission, patient factors affecting ultimate outcome, optimal graft preservation methods, and surgical technique choice. Biomechanical questions include whether allograft meniscus transplantation can reproduce the functions of the meniscus, the effects of proper sizing and fixation methods on contact mechanics, and the effects of freezing on allograft strength. This article reviews these questions and more current concepts regarding allograft meniscus transplantation.     

Meniscal transplantation

The aims of a meniscal replacement are: 1) to reduce the pain experienced by some patients following meniscus resection; 2) to prevent the degenerative changes of cartilage and the changes in subchondral bone following meniscus resection; 3) to avoid or reduce the risk of osteoarthritis following meniscus resection; 4) to restore optimally the mechanical properties of the knee joint after meniscal resection. The results of meniscus transplantation have been studied in animals. There is no proof from these experiments that replacement of a meniscus can reduce the risk of arthritis, but there are indications that it can decrease the development of cartilage degeneration. In humans, the results of meniscus transplantation have been reported in several series of patients, operated with different techniques. There are no controlled studies of meniscus replacement in humans. In case of meniscal allograft implantation surgery should be minimally invasive, not sacrificing the original meniscal insertion points. It appears preferable to use an open technique in medial transplantation, whereas the arthroscopic approach appears to allow for easier lateral implantation.     

Stage-based treatment by partial meniscectomy, meniscal refixation and transplantation

Clinical and experimental studies have demonstrated that the meniscus is important for normal knee function. Loss of meniscus results in abnormal load transmission across the knee and may lead to degenerative joint disease. Preservation of meniscal tissue is therefore important. About 10 % of all meniscal tears are repairable. The most successful repairs occur in younger patients who have an acute, vertical tear in the vascular portion of the meniscus. Currently, arthroscopic meniscal repair procedures include the inside-out, the outside-in and the all-inside technique. Vertical suture techniques are superior to horizontally placed sutures. From a biomechanical point of view, 2-0 to 1 sutures are recommended for suture repair. Various meniscus implants are also available for meniscal repair. The initial fixation strength of the implants is lower compared to vertical sutures. A combination of suture techniques and implants might be a treatment option in posterior meniscal lesions. The collagen meniscus implant has been designed to support tissue ingrowth after segmental medial meniscectomy. Although fibrocartilage matrix formation has been shown, long-term clinical follow-ups are still required. Meniscal allograft transplantation may be indicated in limited situations. Younger patients with meniscal deficiency due to previous meniscectomy who have only early arthrosis, normal axial alignment, and a stable knee may currently considered appropriate candidates for meniscal transplantation.     

Editorial Commentary: Is the Capsulodesis the Solution to Reduce Graft Extrusion in Meniscal Allograft Transplantation?

The causes of graft extrusion after lateral meniscus allograft transplantation seem to be a multifactorial problem. A recent study shows that the lateral capsulodesis technique could result in better results relative to the degree of meniscal extrusion compared with the bone-bridge fixation technique. Long-term comparative clinical studies are needed to confirm the efficacy of this procedure.