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Jul 10, 2021

Orthobiologics and Stem Cells for the Treatment of Meniscal Tears: What is the Evidence?

What is the meniscus?

The meniscus is essential to a health knee joint, and acts as a shock absorber and helps stabilize the joint. An injury to the meniscus can impact the joint and increase load on the cartilage predisposing patients to developing osteoarthritis.

How are meniscus tears treated?

Knee meniscal injuries are common and symptomatic meniscal tears are often treated with activity modification, bracing, physical therapy and injections. In cases that do not respond to therapy, surgical repair or debridement is often the next step.

How are meniscus tears “fix” surgically?

Different meniscal repair techniques have also been described and typically fall into 2 categories: repair of the meniscus or meniscectomy.

Meniscus Repair Surgery

Most repair techniques involve suturing the meniscus. In these surgeries, the majority of cases the meniscus is fix or sutured to the joint capsule. This changes the normal anatomy and biomechanics of the joints, and limits the activity of the meniscus during motion (Wang et al. 2019).

Are there any limitations to “repairing” the meniscus?

Other complications include failure of these repairs or retearing of the meniscus. In a systematic review and meta-analysis found 23% of meniscal repairs fail (Nepple et al, 2012), and patients with degenerative tears may not even be candidates for this approach.

Partial Meniscectomy Surgery

Partial meniscectomy still remains the main treatment option in meniscus surgery, however, surgery for degenerative meniscus tears remains controversial. Several randomized controlled studies demonstrated no benefit of partial menisectomy over a pretend or “sham” surgery (Sihvonen et al, 2013).

In the majority of recent randomized controlled studies meniscus surgery was no better than nonoperative treatment (Beaufils et al, 2017). Despite this treatment options for degenerative meniscus tears are limited and these continue to be treated surgically. In fact, half of all of meniscus surgeries are performed on patients older than 45 years with degenerative meniscal lesions (Englund et al, 2008).

Are there any limitations to “repairing” the meniscus?

These surgeries are not without complications and may predispose the joint to early-onset arthritis (Longo et al. 2019). A partial menisectomy increases the risk of osteoarthritis at least ten to twentyfold (Vangsness et al. 2014). Other study that followed patients for 5 years after surgery, showed that patients were 2.5 times more likely to get a knee replacement than patient who did physical therapy (Katz et al 2019).


What is Driving the Shift in Management Strategy

  • There is an inability amongst surgeons to restore the anatomy and function when repairing the meniscus.
  • Due to these limitations in surgical management, there is a trend toward trying to maintain as much vital meniscal tissue as possible to avoid a rapid deterioration of cartilage.
  • This shift toward preservation and repair of the meniscus, includes an expanded role for orthobiological treatments that have the ability to facilitate healing and potentially regenerate the meniscus.

What is the evidence for orthobiologic injections for meniscal tears?

Orthobiologic injections, including platelet rich plasma (PRP) injections, bone marrow aspirate concentrates and mesenchymal stem cells or stromal cells (MSCs) have been proposed to improve pain and promote meniscal regeneration. The intraoperative use of biologic injections for meniscal tears is well established (Massey et al. 2019), but the use of biologics agents in nonsurgical meniscal treatments is limited.

MRI of knee showing meniscal tear before bone marrow concentrate aspirate derived stem cells (left) and MRI 6-months after bone marrow aspirate derived stem cells (Right) with increased meniscal volume and resolution of meniscal tear. .

What is the evidence for PRP injections?

Autologous platelet rich plasma (PRP) injections release multiple growth factors, cytokines and other signaling proteins that play an important role in healing. One double-blind RCT, compared PRP and trephination to trephination alone (puncturing the meniscus to stimulate bleeding and a healing response). In this study, the PRP group showed partial or full healing of the meniscus on MRI in 60% of patients. The authors concluded that the “[trephination] technique with PRP results in a significant improvement in the rate of meniscal” (Kaminski et al. 2019).

What is the evidence for Lipogems injections?

Micro-fragmented adipose tissue (MFAT) injections have been studied in a case report (Straino et al, 2017) and a larger case series pilot study using the Lipogems system (Malanga et al. 2021). Mesenchymal stem cells (MSCs) harvested from adipose tissue act as trophic mediators to stimulate differentiation of tissue intrinsic stem cells or reparative cells. MFAT has shown encouraging results and the Malanga et al study was previously reviewed by Journal Watch.

What is the evidence for bone marrow concentrate mesenchymal stem cell injections?

In an animal model using rabbits, bone marrow concentrate mesenchymal stem cells (MSCs) were able to enhance tissue regeneration (Zellner et al, 2013; Koch et al, 2019).

Adult mesenchymal stem cells derived from bone marrow aspirates were also tested in patients who previously underwent a partial menisectomy in a randomized, double blind, controlled study. The results showed that bone marrow derived stem cells were safe and a there was evidence of meniscus regeneration and improved pain after the injection of mesenchymal stem cells (Vangness et al. 2014).

Not all meniscus tears cause pain and dysfunction, but in cases where a meniscus tear is causing you pain we can precisely target the damaged or torn area of the meniscus using ultrasound. If you are looking for an alternative to a partial meniscectomy that would remove part of the meniscus has been found to be no better than physical therapy or a sham surgery for degenerative meniscus, contact us for a consultation. Surgery places patients at risk for early onset arthritis and a higher chance of needing a knee replacement. To learn more about nonoperative procedures for meniscus tear and a consultation with Dr. Sussman to see if you are a candidate contact us at:

(781) 591-7855

info@BSBortho.com

20 Walnut St

Suite 14

Wellesley MA 02481

References:

  1. Beaufils P, Pujol N. Management of traumatic meniscal tear and degenerative meniscal lesions. Save the meniscus. Orthop Traumatol Surg Res. 2017;103(8S):S237-S244.
  2. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N. Engl. J. Med. 2008, 359, 1108–1115.
  3. Kaminski R,Maksymowicz-Wleklik M, Kulinski K, Kozar-Kaminska K, Dabrowska-Thing A, Pomianowski S (2019) Short-term outcomes of percutaneous trephination with a platelet rich plasma intrameniscal injection for the repair of degenerative meniscal lesions. A prospective, randomized, double-blind, parallel-group, placebo-controlled study. Int J Mol Sci 20.
  4. Koch, M., Hammer, S., Fuellerer, J., Lang, S., Pfeifer, C. G., Pattappa, G., Weber, J., Loibl, M., Nerlich, M., Angele, P., & Zellner, J. (2019). Bone Marrow Aspirate Concentrate for the Treatment of Avascular Meniscus Tears in a One-Step Procedure-Evaluation of an In Vivo Model. International journal of molecular sciences, 20(5), 1120.
  5. Longo UG, Ciuffreda M, Candela V, Rizzello G, D'Andrea V, Mannering N, Berton A, Salvatore G, Denaro V. Knee Osteoarthritis after Arthroscopic Partial Meniscectomy: Prevalence and Progression of Radiographic Changes after 5 to 12 Years Compared with Contralateral Knee. J Knee Surg. 2019 May;32(5):407-413.
  6. Malanga GA, Chirichella PS, Hogaboom NS, Capella T. Clinical evaluation
    of micro-fragmented adipose tissue as a treatment option for patients
    with meniscus tears with osteoarthritis: a prospective pilot study. Int
    Orthop. 2021 Feb;45(2):473-480.
  7. Massey, P. A., Zhang, A., Stairs, C. B., Hoge, S., Carroll, T., & Hamby, A. M. (2019). Meniscus Repair Outcomes with and without Bone Marrow Aspiration Concentrate. Orthopaedic Journal of Sports Medicine, 7(7 suppl5), 2325967119S00283.
  8. Nepple JJ, Dunn WR, Wright RW. Meniscal repair outcomes at greater than five years: a systematic literature review and meta-analysis.
  9. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H,
    Kalske J, Järvinen TL; Finnish Degenerative Meniscal Lesion Study
    (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery
    for a degenerative meniscal tear. N Engl J Med. 2013 Dec
    26;369(26):2515-24.
  10. Striano RD, Battista V, Bilboo N (2017) Non-responding knee pain with
    osteoarthritis, meniscus and ligament tears treated with ultrasound
    guided autologous, micro-fragmented and minimally manipulated adipose
    tissue. Open J Regen Med 6:17–26.
  11. Vangsness CT, Farr J, Boyd J, Dellaero DT, Mills CR, LeRoux-Williams M (2014) Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study. J Bone Joint Surg Am 96:90–98.
  12. Wang, Z., Xiong, Y., Tang, X. et al. An arthroscopic repair technique for meniscal tear using a needle and suture: outside-in transfer all-inside repair. BMC Musculoskelet Disord 20, 614 (2019).
  13. Zellner J, Hierl K, Mueller M, Pfeifer C, Berner A, Dienstknecht T, Krutsch W, Geis S, Gehmert S, Kujat R, Dendorfer S, Prantl L, Nerlich M, Angele P. Stem cell-based tissue-engineering for treatment of meniscal tears in the avascular zone. J Biomed Mater Res B Appl Biomater. 2013 Oct;101(7):1133-42.

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