Clinical Outcomes Studies

"Long-term survival of concurrentmeniscus allograft transplantation and articular cartilage repair: A PROSPECTIVE TWO- TO 12-YEAR FOLLOW-UP REPORT."
J Bone Joint Surg Br 92-B(7): 941-948. Stone K.R., Adelson W.S., Pelsis J.R., Walgenbach A.W., Turek T.J. 2010.  
We describe 119 meniscal allograft transplantations performed concurrently with articular cartilage repair in 115 patients with severe articular cartilage damage. In all, 53 (46.1%) of the patients were over the age of 50 at the time of surgery. The mean follow-up was for 5.8 years (2 months to 12.3 years), with 25 procedures (20.1%) failing at a mean of 4.6 years (2 months to 10.4 years). Of these, 18 progressed to knee replacement at a mean of 5.1 years (1.3 to 10.4). The Kaplan-Meier estimated mean survival time for the whole series was 9.9 years (sd 0.4). Cox's proportional hazards model was used to assess the effect of covariates on survival, with age at the time of surgery (p = 0.026) and number of previous operations (p = 0.006) found to be significant. The survival of the transplant was not affected by gender, the severity of cartilage damage, axial alignment, the degree of narrowing of the joint space or medial versus lateral allograft transplantation. Patients experienced significant improvements at all periods of follow-up in subjective outcome measures of pain, activity and function (all p-values < 0.05), with the exception of the seven-year Tegner index score (p = 0.076).

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"Lessons Learned From Our First 100 Meniscus Allograft Transplants in Arthritic Knees." Musculoskeletal tissue regeneration : biological materials and methods.
Totowa, NJ: Humana Press. Stone K.R., A.W. Walgenbach, A. Freyer. 2008. 

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"Meniscus allograft survival in patients with moderate to severe unicompartmental arthritis: a 2- to 7-year follow-up."
Arthroscopy 22 (5): 469-478.  Stone, K.R., A.W. Walgenbach, T.J. Turek, A. Freyer, and M.D. Hill. 2006. 
PURPOSE: We present meniscus allograft survival data at least 2 years from surgery for 45 patients (47 allografts) with significant arthrosis to determine if the meniscus can survive in an arthritic joint. Type of Study: Prospective, longitudinal survival study. METHODS: Data were collected for 31 men and 14 women, mean age 48 years (range, 14 to 69 years), with preoperative evidence of significant arthrosis and an Outerbridge classification greater than II. Failure is established by previous studies as allograft removal. No patient was lost to follow-up. RESULTS: The success rate was 42 of 47 allografts (89.4%) with a mean failure time of 4.4 years as assessed by Kaplan-Meier survival analysis. Statistical power is greater than 0.9, with alpha = 0.05 and N = 47. There was significant mean improvement in preoperative versus postoperative self-reported measures of pain, activity, and functioning, with P = .001, P = .004, and P = .001, respectively, as assessed by a Wilcoxon rank-sum test with P = .05. CONCLUSIONS: Meniscus allografts can survive in a joint with arthrosis, challenging the contraindications of age and arthrosis severity. These results compare favorably with those in previous reports of meniscus allograft survival in patients without arthrosis. LEVEL OF EVIDENCE: Level IV.

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"Articular cartilage paste grafting to full-thickness articular cartilage knee joint lesions: a 2- to 12-year follow-up."
Arthroscopy 22 (3): 291-299.  Stone, K.R., A.W. Walgenbach, A. Freyer, T.J. Turek, and D.P. Speer. 2006. 
PURPOSE: To prospectively assess clinical outcomes and regeneration of osteoarthritic cartilage lesions treated with an articular cartilage paste grafting technique. TYPE OF STUDY: Prospective, longitudinal case series. METHODS: We treated 125 patients (136 procedures; 34% female, 66% male; mean age, 46 years; range, 17 to 73 years) with an Outerbridge classification of grade IV lesions with an articular cartilage paste graft. Clinical data were recorded 2 to 12 years from surgery, with 20 of 145 patients lost to follow-up over 12 years (13.7%). Clinical outcomes were captured annually with validated Western Ontario and McMaster Universities Arthritis Index (WOMAC), International Knee Documentation Committee (IKDC), and Tegner subjective questionnaires. Regenerated cartilage biopsy specimens were obtained at second-look arthroscopy from 66 patients and evaluated as to quality and quantity of defect fill by a blinded, independent histopathology reviewer. RESULTS: Preoperative versus postoperative validated pain, functioning, and activity measures improved significantly (P< .001). Clinically, 18 of the 125 patients were considered failures (14.4%), with 10 patients undergoing subsequent joint arthroplasty and 8 who reported worse pain after surgery. Regional histologic variation occurred. Forty-two of 66 biopsy specimens (63.6%) showed strong and consistent evidence of replacement of their articular surface, and 18 of 66 biopsy specimens (27.3%) showed development of areas of cartilage. CONCLUSIONS: Paste grafting is a low-cost, 1-stage arthroscopic treatment for patients with Outerbridge classification grade IV arthritic chondral lesions. The procedure offers excellent, long-lasting, pain relief, restored functioning, and possibility of tissue regeneration for patients with painful chondral lesions in both arthritic and traumatically injured knees. LEVEL OF EVIDENCE: Level IV, case series.

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Technique Papers

"Meniscus Reconstruction: the new field of rebuilding meniscus cartilage."
Knee Surgery, Arthroscopy, Sport Traumatology 7 (3): 9-18.  Stone, K.R., Pelsis J.R., Adelson W.S., Walgenbach, A.W. 2010.  
The collagen meniscus implant serves as a regeneration template for tissue repair and may expand the range of meniscus injuries that can be saved rather than resected. The objective of this monograph is to describe a new field of meniscus reconstruction in which regeneration templates are used to re-build missing segments of the meniscus and to expand the indications for meniscus repairs.

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"Meniscal sizing based on gender, height, and weight."
Arthroscopy 23 (5): 503-508.  Stone, K.R., A. Freyer, T. Turek, A.W. Walgenbach, S. Wadhwa, and J. Crues. 2007.  
PURPOSE: Successful meniscus transplantation may depend on accurate sizing. Meniscal sizing is currently determined by measuring a combination of bony landmarks and soft-tissue insertion points through images obtained radiographically or by magnetic resonance imaging (MRI). The literature widely reports inaccuracy in sizing resulting from radiographic errors in magnification, erroneous identification of bony landmarks, and difficulty in differentiating between the soft-tissue and bone interface. In our meniscus transplantations we have observed that when the height and weight of the recipient matched those of the donor, the meniscal size appeared to be a match at surgical implantation; we designed this study to confirm this observation. METHODS: The MRI-based meniscal sizing of 111 patients (63 male and 38 female patients; mean age, 44 years [range, 15 to 76 years]), totaling 147 menisci (87 lateral and 60 medial), was compared with the height, weight, gender, and body mass index (BMI) of each patient. MRI scans were obtained with a 1.0-Tesla MRI system (ONI Medical Systems, Wilmington, MA). Sizing was performed by an independent musculoskeletal MRI radiologist as established by the literature. Statistical methods include nonparametric Pearson correlation (r) between MRI-based lateral meniscal width, lateral meniscal length, medial meniscal width, medial meniscal length, total tibial plateau width, and patient height, weight, gender, and BMI. Significance at the P = .05 level was used. RESULTS: Height was found to have a linear relationship to total tibial plateau, which has a good predictive correlation with meniscal dimensions of r > 0.7. Female patients generally present with smaller dimensions than male patients. High-BMI groups present with significantly larger meniscal dimensions than low-BMI groups at any given height. CONCLUSIONS: Height, weight, and gender are easily obtained variables and are proportional to meniscal tissue dimensions. These exploratory statistics establish correlations between height, weight, gender, total tibial plateau width, and meniscal size. CLINICAL RELEVANCE: Height, weight, and gender should be considered by both tissue banks and surgeons as fast and cost-effective variables by which to predict meniscal dimensions.

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"Meniscal allografting: the three-tunnel technique."
Arthroscopy 19 (4): 426-30.  Stone K.R., A.W. Walgenbach. 2003. 
This technical note describes an improved arthroscopic technique of meniscal transplantation that simplifies the surgical procedure and secures the allograft to the tibia at 3 sites. The technique is useful for both medial and lateral meniscal transplantation and has been used in our clinic for over 60 meniscal transplantation procedures. 

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"Surgical technique for articular cartilage transplantation to full thickness cartilage defects in the knee joint."
Oper Tech Orthop (7):305-311.  Stone K.R., A.W. Walgenbach. 1997.  
Focal arthritic defects in the knee lead to pain, swelling, and dysfunction. Treatment of the defects has includeddrilling, abrasion, and grafting. This report describes our surgical technique of autogenous articular cartilage grafting of arthritic and traumatic articular cartilage lesions. Articular cartilage grafting can be performed as a single arthroscopic outpatient procedure. The mixture of articular cartilage and cancellous bone appears to provide a supportive matrix for cartilage formation. Pain relief is excellent if careful surgical technique and a defined rehabilitation program are followed. Further collagen typing data and additional biopsies will reveal more about the durability of the newly formed cartilage.

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Posters

"The use of articular cartilage paste graft in massive articular cartilage defects of the femoral condyle."
Stone, K.R., J.V. Crues III, D. Dang, J. Pelsis, W. Adelson, A. Freyer, T. Turek. 
Poster session presented at: 57th Annual Meeting of the Orthopaedic Research Society; 2011 January 13 - 16; Long Beach, CA.

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"Long-term survival of concurrent meniscus allograft transplantation and articular cartilage repair: A prospective 2 – 12 year follow-up evaluation."
Stone, K.R., W. Adelson, J. Pelsis, A. Walgenbach, T. Turek. 
Poster session presented at: International Symposium on Ligaments & Tendons - XI; 2011 January 12; Irvine, CA.

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"Long-term survival of concurrent meniscus allograft transplantation and articular cartilage repair: A prospective 2 – 12 year follow-up evaluation."
Stone, K.R., W. Adelson, J. Pelsis, A. Walgenbach, T. Turek. 
Poster session presented at: 56th Annual Meeting of the Orthopaedic Research Society; 2010 March 6 – 9; New Orleans, LA.

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