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Editorial Commentary: Meniscal Allograft Success—How Do We Get There?
Editorial Commentary: Meniscal Allograft SuccessdHow Do We Get There? Mark G. Siegel, M.D., Associate Editor
Abstract: Patients undergoing meniscal allograft transplantation show improvement at 10 years and even 15 years of follow-up. However, it is unclear what factors influence the results, including but not limited to bone plug versus allsuture repair, fresh versus cryopreserved grafts, proper sizing, and rehabilitation.
See related article on page 659
I
If you don’t know where you’re going, you’ll end up someplace else. eYogi Berra
was excited to read and review the article “LongTerm Survival Analysis and Outcomes of Meniscal Allograft Transplantation With Minimum 10-Year Follow-Up: A Systematic Review” by Novaretti, Patel, Lian, Vaswani, de Sa, Getgood, and Musahl.1 This article represents a large systematic review of meniscal allograft transplantations (MATs) with a minimum of 10 years’ follow-up. For the surgeon looking for guidance and direction, a meta-analysis of prior studies does give information that can be used to assist in determining treatment options. It is through the pooling of prior studies that large numbers are accumulated. This gives validity and significance to analysis and conclusions. This technique was used by Novaretti et al.,1 who have carefully pooled the data. They were able to find 658 patients with 688 meniscal allografts who met the inclusion criteria for the analysis. Novaretti et al.1 concluded that the long-term survivorship rate was 73.5% at 10 years and 60.3% at 15 years. The grafts were functional, and the results were fair compared with preoperative scores.
The authors report the following potential conflicts of interest or sources of funding: M.G.S. receives personal fees from Arthroscopy for serving as an associate editor. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/181356/$36.00 https://doi.org/10.1016/j.arthro.2018.11.027
668
What this article has achieved is to give hope and encouragement to the surgeons performing surgery and patients seeking intervention. In a large pooled data analysis, there is clearly evidence that the meniscal allograft has proven success and improvement of function. A concern is that we know the destination and goal, a functioning transplant, but have we been given the path to success? Without direction, success may not be achieved. And, like Yogi Berra tried to explain, the surgeon will end up someplace else, a failed allograft transplant. There are many aspects of this article that show the excellent approach of this meta-analysis.1 The articles chosen were screened through an exacting process. Data extraction was performed with specific critical factors analyzed. Each study was subject to quality assessment with the Methodological Index for Non-Randomized Studies (MINORS) criteria applied. This did allow for a very select number of articles. As the authors noted, only 11 of 3,826 studies were accepted for review.1 However, as noted by one of the reviewers of this article, “We really need better primary studies than another mash-up of low-quality studies." In addition, is there a perceived over-reach in the conclusions that should be accepted with caution? Novaretti et al.1 themselves noted that the follow-up period was not standardized to 10, 15, or 20 years. There were single studies that ranged from 2 to 16 years. In addition, they noted that there is no consistency in defining “failure.” The technique for the procedure is, at best, described as heterogeneous. Although bone fixation and sutureonly fixation are described as the most common surgical procedures, with a 75% preference for bone
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 2 (February), 2019: pp 668-669
669
EDITORIAL COMMENTARY
fixation, this review had a distribution of nearly 50%50%. The technique issue was explained by quoting a study showing that there is no observed difference regarding extrusion and MAT longevity when comparing both fixation techniques.2 Yet, the quoted study is a meta-review with a mean follow-up period of 5 years and includes 2-year evaluations. Using limited 5-year data and applying these to a 10- and 15-year follow-up study does not seem right. Also included in this study are 21 MATs that used a technique that has been abandoned, lyophilized allografts.3 One study with a follow-up period of 19 years found that 100% of the subjects had grade IV arthritis on radiographs.4 Despite this finding, the symptoms were noted to be improved. Another study found that among the lyophilized allografts evaluated at 14 years’ follow-up, there was improvement.5 A finding included in this study was that every graft was reduced in size on magnetic resonance imaging or arthroscopic evaluation. This indicated that all these grafts were nonfunctioning. To further confound the results, there is no evidence given showing that the use of MAT, regardless of type or fixation method, has been proved to reduce arthritis. Novaretti et al.1 quote a previous systematic review. Yet, that study states, “the quality of the included studies was low, with a high risk of selection and measurement bias. The limited number of studies using control groups also limits the value of results, especially when interpreting OA [osteoarthritis] progression. The studies included in this systematic review are also heterogeneous, with different inclusion criteria, techniques, graft type, associated procedures, rehabilitation and follow-up. . . . Given the lack of high-quality controlled trials, it is difficult to draw definitive conclusions. It appears that meniscal allograft
transplantation cannot universally reverse or prevent OA changes in patients with a symptomatic meniscaldeficient knee.”6 What is presented in the article by Novaretti et al.1 is a detailed meta-analysis and data review. It is encouraging to note that patients with MAT have improvement at 10 and even 15 years. However, it is not known what factors influence the results. The question of bone versus suture repair, fresh versus cryopreserved grafts, sizing, rehabilitation, and other factors is not answered. We all know the destination, a successful and functioning meniscal allograft. We know where to go and where we want to end the journey. What we need is someone who can give us the route.
References 1. Novaretti JV, Patel NK, Lian J, et al. Long-term survival analysis and outcomes of meniscal allograft transplantation with minimum 10-year follow-up: A systematic review. Arthroscopy 2019;35:659-667. 2. Jauregui JJ, Wu ZD, Meredith S, Griffith C, Packer JD, Henn RF III. How should we secure our transplanted meniscus? A meta-analysis. Am J Sports Med 2018;46: 2285-2290. 3. Binnet MS, Akan B, Kaya A. Lyophilised medial meniscus transplantations in ACL-deficient knees: A 19-year followup. Knee Surg Sports Traumatol Arthrosc 2012;20:109-113. 4. Wirth CJ, Peters G, Milachowski KA, Weismeier KG, Kohn D. Long-term results of meniscal allograft transplantation. Am J Sports Med 2002;30:174-181. 5. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-174. 6. Smith NA, Parkinson B, Hutchinson CE, Costa ML, Spalding T. Is meniscal allograft transplantation chondroprotective? A systematic review of radiological outcomes. Knee Surg Sports Traumatol Arthrosc 2016;24: 2923-2935.
Abstract: Patients undergoing meniscal allograft transplantation show improvement at 10 years and even 15 years of follow-up. However, it is unclear what factors influence the results, including but not limited to bone plug versus allsuture repair, fresh versus cryopreserved grafts, proper sizing, and rehabilitation.
See related article on page 659
I
If you don’t know where you’re going, you’ll end up someplace else. eYogi Berra
was excited to read and review the article “LongTerm Survival Analysis and Outcomes of Meniscal Allograft Transplantation With Minimum 10-Year Follow-Up: A Systematic Review” by Novaretti, Patel, Lian, Vaswani, de Sa, Getgood, and Musahl.1 This article represents a large systematic review of meniscal allograft transplantations (MATs) with a minimum of 10 years’ follow-up. For the surgeon looking for guidance and direction, a meta-analysis of prior studies does give information that can be used to assist in determining treatment options. It is through the pooling of prior studies that large numbers are accumulated. This gives validity and significance to analysis and conclusions. This technique was used by Novaretti et al.,1 who have carefully pooled the data. They were able to find 658 patients with 688 meniscal allografts who met the inclusion criteria for the analysis. Novaretti et al.1 concluded that the long-term survivorship rate was 73.5% at 10 years and 60.3% at 15 years. The grafts were functional, and the results were fair compared with preoperative scores.
The authors report the following potential conflicts of interest or sources of funding: M.G.S. receives personal fees from Arthroscopy for serving as an associate editor. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/181356/$36.00 https://doi.org/10.1016/j.arthro.2018.11.027
668
What this article has achieved is to give hope and encouragement to the surgeons performing surgery and patients seeking intervention. In a large pooled data analysis, there is clearly evidence that the meniscal allograft has proven success and improvement of function. A concern is that we know the destination and goal, a functioning transplant, but have we been given the path to success? Without direction, success may not be achieved. And, like Yogi Berra tried to explain, the surgeon will end up someplace else, a failed allograft transplant. There are many aspects of this article that show the excellent approach of this meta-analysis.1 The articles chosen were screened through an exacting process. Data extraction was performed with specific critical factors analyzed. Each study was subject to quality assessment with the Methodological Index for Non-Randomized Studies (MINORS) criteria applied. This did allow for a very select number of articles. As the authors noted, only 11 of 3,826 studies were accepted for review.1 However, as noted by one of the reviewers of this article, “We really need better primary studies than another mash-up of low-quality studies." In addition, is there a perceived over-reach in the conclusions that should be accepted with caution? Novaretti et al.1 themselves noted that the follow-up period was not standardized to 10, 15, or 20 years. There were single studies that ranged from 2 to 16 years. In addition, they noted that there is no consistency in defining “failure.” The technique for the procedure is, at best, described as heterogeneous. Although bone fixation and sutureonly fixation are described as the most common surgical procedures, with a 75% preference for bone
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 2 (February), 2019: pp 668-669
669
EDITORIAL COMMENTARY
fixation, this review had a distribution of nearly 50%50%. The technique issue was explained by quoting a study showing that there is no observed difference regarding extrusion and MAT longevity when comparing both fixation techniques.2 Yet, the quoted study is a meta-review with a mean follow-up period of 5 years and includes 2-year evaluations. Using limited 5-year data and applying these to a 10- and 15-year follow-up study does not seem right. Also included in this study are 21 MATs that used a technique that has been abandoned, lyophilized allografts.3 One study with a follow-up period of 19 years found that 100% of the subjects had grade IV arthritis on radiographs.4 Despite this finding, the symptoms were noted to be improved. Another study found that among the lyophilized allografts evaluated at 14 years’ follow-up, there was improvement.5 A finding included in this study was that every graft was reduced in size on magnetic resonance imaging or arthroscopic evaluation. This indicated that all these grafts were nonfunctioning. To further confound the results, there is no evidence given showing that the use of MAT, regardless of type or fixation method, has been proved to reduce arthritis. Novaretti et al.1 quote a previous systematic review. Yet, that study states, “the quality of the included studies was low, with a high risk of selection and measurement bias. The limited number of studies using control groups also limits the value of results, especially when interpreting OA [osteoarthritis] progression. The studies included in this systematic review are also heterogeneous, with different inclusion criteria, techniques, graft type, associated procedures, rehabilitation and follow-up. . . . Given the lack of high-quality controlled trials, it is difficult to draw definitive conclusions. It appears that meniscal allograft
transplantation cannot universally reverse or prevent OA changes in patients with a symptomatic meniscaldeficient knee.”6 What is presented in the article by Novaretti et al.1 is a detailed meta-analysis and data review. It is encouraging to note that patients with MAT have improvement at 10 and even 15 years. However, it is not known what factors influence the results. The question of bone versus suture repair, fresh versus cryopreserved grafts, sizing, rehabilitation, and other factors is not answered. We all know the destination, a successful and functioning meniscal allograft. We know where to go and where we want to end the journey. What we need is someone who can give us the route.
References 1. Novaretti JV, Patel NK, Lian J, et al. Long-term survival analysis and outcomes of meniscal allograft transplantation with minimum 10-year follow-up: A systematic review. Arthroscopy 2019;35:659-667. 2. Jauregui JJ, Wu ZD, Meredith S, Griffith C, Packer JD, Henn RF III. How should we secure our transplanted meniscus? A meta-analysis. Am J Sports Med 2018;46: 2285-2290. 3. Binnet MS, Akan B, Kaya A. Lyophilised medial meniscus transplantations in ACL-deficient knees: A 19-year followup. Knee Surg Sports Traumatol Arthrosc 2012;20:109-113. 4. Wirth CJ, Peters G, Milachowski KA, Weismeier KG, Kohn D. Long-term results of meniscal allograft transplantation. Am J Sports Med 2002;30:174-181. 5. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-174. 6. Smith NA, Parkinson B, Hutchinson CE, Costa ML, Spalding T. Is meniscal allograft transplantation chondroprotective? A systematic review of radiological outcomes. Knee Surg Sports Traumatol Arthrosc 2016;24: 2923-2935.