Advanced Surgical and Conservative Treatments for Knee Ligament and Meniscus Injuries

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• Knee Stability Assessment
• Biological Ligament Repair
• Modern ACL Graft Techniques
• Meniscus Preservation & Suturing
• Meniscus Reconstruction & Transplantation
• Full Transcript

Knee Stability Assessment

Dr. Matthias Steinwachs, MD, emphasizes that the primary factor in treating a knee ligament injury is clinical stability. The decision between conservative and surgical treatment hinges on whether the knee is stable enough for the patient's activity level. Dr. Matthias Steinwachs, MD, explains that an MRI showing a partial ligament rupture does not automatically require surgery. If the knee remains stable, the injury is often best left alone. The key question is functional stability, not just the imaging results. This patient-centered approach helps avoid unnecessary surgical intervention.

Biological Ligament Repair

For partial ligament ruptures with excessive laxity, Dr. Matthias Steinwachs, MD, describes advanced biological repair techniques. One method is the "healing response" technique, founded by Dr. Richard Steadman. This arthroscopic procedure is similar to a microfracture. Surgeons create small drill holes near the ACL insertion point to recruit stem cells. These cells help partially reconstruct the damaged ligament. Dr. Matthias Steinwachs, MD, notes that collagen fibers naturally retract during healing, which can restore stability. Another technique involves re-fixing the ligament at its insertion point with strong sutures. A non-resorbable suture is run parallel to the protected ACL to restore its original integrity without a graft.

Modern ACL Graft Techniques

When a knee ligament is completely ruptured, reconstruction with a graft is necessary. Dr. Matthias Steinwachs, MD, outlines the evolution of graft choices. Historically, the patellar tendon-bone (PTB) technique was common. However, it often caused damage to the kneecap and patellar tendon. Dr. Steinwachs avoids the PTB technique for this reason. He also tends to avoid hamstring grafts in high-performance athletes. Studies show removing the hamstring can reduce knee stabilization function by up to 20%. His preferred graft for athletes is the quadriceps tendon. Dr. Matthias Steinwachs, MD, states this high-quality tendon material offers excellent stability and load-bearing capacity. It also avoids creating new symptoms at the graft harvest site.

Meniscus Preservation & Suturing

Meniscus injury treatment prioritizes preservation whenever possible. Dr. Matthias Steinwachs, MD, stresses that the main goal is to avoid resection of the injured meniscus. Suturing the torn meniscus is the preferred method. The success of a meniscus repair depends on good suture material and surgical skill. Dr. Matthias Steinwachs, MD, explains that saving the meniscus is crucial for long-term knee health. Removing even a part of it creates a missing area that can lead to joint degeneration. This approach was a key point in his discussion with Dr. Anton Titov, MD.

Meniscus Reconstruction & Transplantation

If a significant portion of the meniscus has been resected, reconstruction becomes necessary. Dr. Matthias Steinwachs, MD, discusses two main options. The first involves using scaffolds or matrices to fill the defect. These implants are placed in the missing area, and the body's cells grow over them to form new tissue. However, Dr. Matthias Steinwachs, MD, notes that the available materials are not yet ideal. For larger defects, he prefers a meniscus allograft transplantation. This procedure involves transplanting a whole donor meniscus. Dr. Matthias Steinwachs, MD, highlights that the results of full transplantation are better than partial scaffolds. He advises doing this surgery early to prevent osteoarthritic changes in the joint. Performing it too late may not fully avoid the development of arthritis.

Full Transcript

Dr. Anton Titov, MD: What are new technologies and surgical treatment methods of knee ligament injury and meniscus injury that are changing clinical practice today? What are the new treatment methods that patients with knee injury should be aware of?

Dr. Matthias Steinwachs, MD: The first point is, for example, the ligament. We learn that there is partially a biological background for conservative treatments if there is not a complete knee ligament rupture, so mostly a partial knee ligament rupture. The decision to work with the cartilage graft to insert into a damaged ligament is a more clinical decision.

Clinically, what we need is that we reconstruct a stable knee. Independent of what the MRI shows, if the damage is a little bit more or less, the key question is if the knee is stable enough. So if it’s a stable knee with some affection on the ligament, you do not touch that knee injury.

In the situation that a patient has an unstable knee and you have an athlete with sports activity, then you have to create a graft. You have to create a stable knee by inserting a new ligament. For that reason, at the end of your surgery, you’ll have, hopefully, a stable situation in the knee.

For that reason, we can use a technique called the healing response. This is an arthroscopic technique founded by Dr. Richard Steadman. The idea is that treatment suits a partial ligament rupture, which is not completely unstable, but the ligament has a little bit more laxity than is healthy for the sport.

In that situation, you can do something like a microfracture. We do something similar as we do it. To accomplish that, we make some drill holes to recruit cells near to the insertion point of the ACL, for example. The outrunning stem cells can partially reconstruct the damaged knee ligament.

All collagen under that treatment has the biology that the collagen fibers are retracting during the healing phase. For that reason, with the techniques, there is a chance to give the elongated ligament a little bit more stability and protect it a little bit. So it can be good enough to have a stable situation after treatment.

The other treatment we have on a ligament side is a technique where we re-fix the ligament at the insertion point with some sutures. We add a technique where a non-resorbable suture comes parallel to the protected sutured ACL. With that technique, we are restoring the initial ACL without using a graft for restoring the ligament.

This technique is more common and based on some good clinical studies, which show us that mostly the patient comes back to a stable knee. So for that reason, this is a ligament protection treatment.

In the situation that this is not working and the ligament is ruptured completely, with no chance for refixation, then you have to use the ligament graft. The grafts are quite different. In the history in the 60s and 70s, we used mostly a patellar tendon called PTB technique (patellar tendon-bone).

At the moment, we don’t use that because it creates a lot of damage to the kneecap. We see a lot of people who have problems with patellar tendon and with patella itself. For that reason, in athletes I don’t use patellar tendon-bone anymore at the moment.

So we use a quadriceps tendon. This is a high-quality tendon material which allows a high load and is very stable. The point is we see no symptoms in the area where we removed the graft. For that reason, it is a very good technique for that.

I mostly avoid using hamstring techniques because the hamstring has an active part for stabilization of the knee. If you remove that muscle and tendons, then this function is off. We see in some athletic analysis studies that up to 20% of the stabilization function can be off under that condition.

Whenever possible, I avoid that directly in cases where I have athletes with high performance demand, which means football players and high-performing athletes.

For the meniscus, the situation is quite difficult. We have mostly different parts of suturing. A good suture material and a good capacity to suture the meniscus is the main point to avoid the resection of the injured meniscus.

If the damaged part of the meniscus is resected, and you have a missing area of the meniscus, in that situation, you have to reconstruct the meniscus. There are some implants available in the market called matrices or scaffolds.

This is the idea that you can put the scaffold in the missing area from the meniscus, and the cells from the joint overgrow that scaffold and restore a so-called artificial cartilage of the meniscus. But the studies are a little bit good. We do not have the best material in place that we need for that.

In the situation that the majority of the meniscus is off because of resection, in that case, I do the transplantation of meniscus. I do allograft transplantation of the whole meniscus. These results are quite better than the partial filling of the defect of the meniscus.

I see here very good research. The idea is to do meniscus transplantation in an early stage, not in a final stage. So in the early stage of meniscus damage, you can a little bit prevent the osteoarthritic changes of the joint.

When you come in too late, you cannot completely avoid osteoarthritic joint in that situation.