APROVECHAMIENTOS POR EL USO O APROVECHAMIENTO DE BIENES DEL DOMINIO PÚBLICO POR LA PRESTACIÓN DE SERVICIOS EN EL EJERCICIO DE FUNCIONES DE DERECHO

Figure 8 Arthroscopic photographs showing horizontal suture orientation (A) and vertical suture orientation (B) in meniscal repair.

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Only 13% of the identified studies were prospective in nature, and 75% of the studies defined failure as revi- sion.13

Meniscus Allografts

Both medial and lateral meniscus allograft transplanta- tion has been selectively performed for young to middle-aged patients with unicompartmental pain, lim- ited degenerative change after total meniscectomy, and normal alignment and stability. However, a systematic review of 15 studies reporting results emphasized sev- eral important unknown factors, including the method of preoperative assessment and criteria for transplanta- tion, the ideal method of graft preservation, graft sizing and the best method of fixation, and prospective out- comes data not confounded by concurrent procedures such as ACL reconstruction, high tibial osteotomy, and articular cartilage restoration.14 _{Because most patients}

who have had meniscal allograft transplantation report pain and swelling during activities of daily living, the goal is relief of pain and not return to vigorous sports involving cutting and pivoting. Additional prospective studies are needed to clarify the return to high-impact sports and longevity of outcomes.

Recommendations from the systematic review are (1) use of a fresh-frozen allograft size-matched within 5% of normal, (2) implantation by a method that has rigid fixation of both horns (to preserve hoop stresses), and (3) multiple suture fixation of the peripheral rim to the capsule. Patients should expect to return only to light sports activity until further evidence is forthcom- ing, and they should be monitored for infection and im- mune reaction.

Summary

The menisci provide important biomechanical function for articular cartilage health. Current randomized con- trolled trials and prospective longitudinal cohorts will define at the highest level of evidence their role in pa- tient outcomes, thus providing the clinically relevant goals for tissue engineers to improve repairs, develop functional scaffolds, and provide a living transplanted meniscus, all of which can improve a patient’s outcome. These are exciting times as evidence-based medicine and tissue engineering work collaboratively to improve the relevant meniscus predictors of patient outcomes.

Annotated References

1. Thompson WO, Thaete FL, Fu FH, Dye SF: Tibial me- niscal dynamics using three-dimensional reconstruction of magnetic resonance images. Am J Sports Med 1991; 19:210-215.

2. Arnoczky SP, McDevitt CA: The meniscus: Structure, function, repair, and replacement, in Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Sci-

ence: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Or-

thopaedic Surgeons, 2000, pp 531-545.

3. Baratz ME, Fu FH, Mengato R: Meniscal tears: The ef- fect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee: A prelimi- nary report. Am J Sports Med 1986;14:270-275. 4. Greis PE, Bardana DD, Holmstrom MC, Burks RT: Me-

niscal injury: I. Basic science and evaluation. J Am Acad

Orthop Surg 2002;10:168-176.

5. Abdon P, Lindstrand A, Thorngren KG: Statistical eval- uation of the diagnostic criteria for meniscal tears. Int

Orthop 1990;14:341-345.

6. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL: The diagnosis of meniscus tears: The role of MRI and clini- cal examination. Clin Orthop Relat Res 2007;455: 123-133.

This systematic review evaluated 32 prospective cohort studies comparing MRI and clinical examination to ar- throscopy in the diagnosis of meniscal pathology. The accuracy of an experienced examiner in diagnosing me- niscal tears approached that of MRI, and the authors concluded that MRI is best used clinically when the di- agnosis remains in doubt after history and physical ex- amination. Level of evidence: II.

7. Shelbourne KD, Martini DJ, McCarroll JR, Van- Meter CD: Correlation of joint line tenderness and me- niscal lesions in patients with acute anterior cruciate lig- ament tears. Am J Sports Med 1995;23:166-169. 8. Crawford R, Walley G, Bridgman S, Maffulli N: Mag-

netic resonance imaging versus arthroscopy in the diag- nosis of knee pathology, concentrating on meniscal le- sions and ACL tears: A systematic review. Br Med Bull 2007;84:5-23.

This systematic review scored the methodology of 59 ar- ticles comparing MRI and arthroscopy in the diagnosis of knee pathology, reporting on a total of 7,367 knee MRI scans and 5,416 arthroscopies. The authors con- cluded that MRI is the screening tool of choice for ther- apeutic arthroscopy with an accuracy of over 85% for meniscal tears, but the performance of MRI was differ- ent for diagnosing lateral versus medial meniscal pathol- ogy, with higher specificity for lateral meniscus tears and higher sensitivity for medial meniscus tears. Level of evidence: II.

9. Boden SD, Davis DO, Dina TS, et al: A prospective and blinded investigation of magnetic resonance imaging of the knee: Abnormal findings in asymptomatic subjects.

Clin Orthop Relat Res 1992;282:177-185.

10. Rangger C, Klestil T, Gloetzer W, Kemmler G, Bene- detto KP: Osteoarthritis after arthroscopic partial men- iscectomy. Am J Sports Med 1995;23:240-244.

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11. Schimmer RC, Brülhart KB, Duff C, Glinz W: Arthro- scopic partial meniscectomy: A 12-year follow-up and two-step evaluation of the long-term course. Arthros-

copy 1998;14:136-142.

12. McCarty EC, Marx RG, DeHaven KE: Meniscus repair: Considerations in treatment and update of clinical re- sults. Clin Orthop Relat Res 2002;402:122-134. 13. Lozano J, Ma CB, Cannon WD: All-inside meniscus re-

pair: A systematic review. Clin Orthop Relat Res 2007; 455:134-141.

This systematic review evaluated 31 articles that studied all-inside meniscal repair devices. Clinical failure rates ranged from 0% to 43.5%, and no notable differences were seen between the devices studied with regard to

failure rates. Definitive conclusions regarding outcomes could not be drawn because 77% of the studies were case series. Level of evidence: IV.

14. Matava MJ: Meniscal allograft transplantation: A sys- tematic review. Clin Orthop Relat Res 2007;455: 142-157.

This systematic review evaluated the clinical outcomes for meniscal allograft transplantation among 15 papers. The authors concluded that the ideal candidate is a lig- amentously stable young to middle-aged adult with joint line pain, normal knee alignment, and minimal arthritis. The allograft should be matched to within 5% of the normal meniscus size and firmly implanted. Patients should be limited postoperatively to light sports pending further outcomes research. Level of evidence: IV.

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