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Learning Curve For Lateral Meniscal Allograft Transplantation: Preventing Meniscal Extrusion

      Purpose

      This study analyzes the large number of lateral meniscal allograft transplantation (LMAT) procedures conducted by a single surgeon over 23 years to determine whether the absolute amount of graft subluxation and the incidence of extrusion are different at the present time compared to the early MAT era.

      Methods

      We reviewed 320 cases of LMAT performed by a single surgeon between 1996 and 2019. This cohort was chronologically divided into 8 groups (of 40 subjects). The absolute amount of subluxation was measured by the coronal sections of magnetic resonance images taken 1 year after operation. Subluxation by more than 3 mm was considered as extrusion. The graft extrusion learning curve was plotted in each series using the learning curve cumulative summation test (LC-CUSUM).

      Results

      Extrusion incidence was 41.6%, and the mean absolute amount of graft subluxation was 3.4 ± 2.2 mm for all subjects. There were significant between-group differences in extrusion incidence and absolute amount of graft subluxation (extrusion incidence, P < .001; absolute amount of graft subluxation, P < .001), and the extension incidence and graft subluxation decreased from Group I (72.5%, 4.6 ± 1.7) to Group VIII (27.5%, 2.5 ± 2.1). LC-CUSUM analysis signaled that the surgeon had achieved predefined acceptable outcomes in avoiding extrusion after 128 cases.

      Conclusion

      The incidence of extrusion and absolute amount of graft subluxation decreased significantly over a period of 23 years, and the surgeon achieved a certain level of proficiency after 128 cases.

      Level of Evidence

      Level IV, Case series.
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      References

        • Myers P.
        • Tudor F.
        Meniscal allograft transplantation: How should we be doing it? A systematic review.
        Arthroscopy. 2015; 31: 911-925
        • Samitier G.
        • Alentorn-Geli E.
        • Taylor D.C.
        • et al.
        Meniscal allograft transplantation. Part 2: Systematic review of transplant timing, outcomes, return to competition, associated procedures, and prevention of osteoarthritis.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 323-333
        • Kang D.G.
        • Park Y.J.
        • Yu J.H.
        • Oh J.B.
        • Lee D.Y.
        A systematic review and meta-analysis of arthroscopic meniscus repair in young patients: Comparison of all-inside and inside-out suture techniques.
        Knee Surg Relat Res. 2019; 31: 1-11
        • Kim Y.S.
        • Kang K.T.
        • Son J.
        • et al.
        Graft extrusion related to the position of allograft in lateral meniscal allograft transplantation: Biomechanical comparison between parapatellar and transpatellar approaches using finite element analysis.
        Arthroscopy. 2015; 31 (e2382): 2380-2391
        • Lee D.H.
        • Kim J.M.
        • Lee B.S.
        • Kim K.A.
        • Bin S.I.
        Greater axial trough obliquity increases the risk of graft extrusion in lateral meniscus allograft transplantation.
        Am J Sports Med. 2012; 40: 1597-1605
        • Lee S.M.
        • Bin S.I.
        • Kim J.M.
        • et al.
        Long-term outcomes of meniscal allograft transplantation with and without extrusion: Mean 12.3-year follow-up study.
        Am J Sports Med. 2019; 47: 815-821
        • Okazaki Y.
        • Furumatsu T.
        • Shimamura Y.
        • et al.
        Time-dependent increase in medial meniscus extrusion after medial meniscus posterior root tear analyzed by using magnetic resonance imaging.
        Knee Surg Relat Res. 2019; 31: 120-125
        • Lee B.S.
        • Chung J.W.
        • Kim J.M.
        • Kim K.A.
        • Bin S.I.
        Width is a more important predictor in graft extrusion than length using plain radiographic sizing in lateral meniscal transplantation.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 179-186
        • Dienst M.
        • Greis P.E.
        • Ellis B.J.
        • Bachus K.N.
        • Burks R.T.
        Effect of lateral meniscal allograft sizing on contact mechanics of the lateral tibial plateau: An experimental study in human cadaveric knee joints.
        Am J Sports Med. 2007; 35: 34-42
        • Jang S.H.
        • Kim J.G.
        • Ha J.G.
        • Shim J.C.
        Reducing the size of the meniscal allograft decreases the percentage of extrusion after meniscal allograft transplantation.
        Arthroscopy. 2011; 27: 914-922
        • Yoon J.R.
        • Kim T.S.
        • Lee Y.M.
        • Jang H.W.
        • Kim Y.C.
        • Yang J.H.
        Transpatellar approach in lateral meniscal allograft transplantation using the keyhole method: Can we prevent graft extrusion?.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 214-217
        • Lee B.S.
        • Kim J.M.
        • Kim J.M.
        • Kim K.A.
        • Bin S.I.
        Patient-related risk factors for the extrusion of lateral meniscal allograft transplants.
        Arthroscopy. 2015; 31: 699-706
        • Ahn J.H.
        • Kang H.W.
        • Yang T.Y.
        • Lee J.Y.
        Multivariate analysis of risk factors of graft extrusion after lateral meniscus allograft transplantation.
        Arthroscopy. 2016; 32: 1337-1345
        • Lee D.H.
        Incidence and extent of graft extrusion following meniscus allograft transplantation.
        Biomed Res Int. 2018; 2018: 5251910
        • Lee D.K.
        • Kim K.K.
        • Ham C.U.
        • Yun S.T.
        • Kim B.K.
        • Oh K.J.
        The learning curve for biplane medial open wedge high tibial osteotomy in 100 consecutive cases assessed using the cumulative summation method.
        Knee Surg Relat Res. 2018; 30: 303-310
        • Kordasiewicz B.
        • Kiciński M.
        • Małachowski K.
        • Boszczyk A.
        • Chaberek S.
        • Pomianowski S.
        Arthroscopic latarjet stabilization: Analysis of the learning curve in the first 90 primary cases: early clinical results and computed tomography evaluation.
        Arthroscopy. 2019; 35: 3221-3237
        • Schüttler K.F.
        • Schramm R.
        • El-Zayat B.F.
        • Schofer M.D.
        • Efe T.
        • Heyse T.J.
        The effect of surgeon's learning curve: complications and outcome after hip arthroscopy.
        Arch Orthop Trauma Surg. 2018; 138: 1415-1421
        • Smith K.M.
        • Duplantier N.L.
        • Crump K.H.
        • et al.
        Fluoroscopy learning curve in hip arthroscopy—A single surgeon's experience.
        Arthroscopy. 2017; 33: 1804-1809
        • Pollard M.E.
        • Kang Q.
        • Berg E.E.
        Radiographic sizing for meniscal transplantation.
        Arthroscopy. 1995; 11: 684-687
        • Lee D.H.
        • Kim T.H.
        • Lee S.H.
        • Kim C.W.
        • Kim J.M.
        • Bin S.I.
        Evaluation of meniscus allograft transplantation with serial magnetic resonance imaging during the first postoperative year: Focus on graft extrusion.
        Arthroscopy. 2008; 24: 1115-1121
        • Lee D.H.
        • Kim J.M.
        • Jeon J.H.
        • Cha E.J.
        • Bin S.I.
        Effect of sagittal allograft position on coronal extrusion in lateral meniscus allograft transplantation.
        Arthroscopy. 2015; 31: 266-274
        • Jeon B.
        • Kim J.M.
        • Kim J.M.
        • Lee C.R.
        • Kim K.A.
        • Bin S.I.
        An osteophyte in the tibial plateau is a risk factor for allograft extrusion after meniscus allograft transplantation.
        Am J Sports Med. 2015; 43: 1215-1221
        • Smith H.J.
        • Richardson J.B.
        • Tennant A.
        Modification and validation of the Lysholm Knee Scale to assess articular cartilage damage.
        Osteoarthritis Cartilage. 2009; 17: 53-58
        • Biau D.J.
        • Porcher R.
        A method for monitoring a process from an out of control to an in control state: Application to the learning curve.
        Stat Med. 2010; 29: 1900-1909
        • Biau D.J.
        • Williams S.M.
        • Schlup M.M.
        • Nizard R.S.
        • Porcher R.
        Quantitative and individualized assessment of the learning curve using LC-CUSUM.
        Br J Surg. 2008; 95: 925-929
        • Liu J.N.
        • Gowd A.K.
        • Redondo M.L.
        • et al.
        Establishing clinically significant outcomes after meniscal allograft transplantation.
        Orthop J Sports Med. 2019; 7 (2325967118818462)
        • Kim J.H.
        • Lee S.
        • Ha D.H.
        • Lee S.M.
        • Jung K.
        • Choi W.
        The effects of graft shrinkage and extrusion on early clinical outcomes after meniscal allograft transplantation.
        J Orthop Surg Res. 2018; 13: 181
        • Kim N.K.
        • Bin S.I.
        • Kim J.M.
        • Lee C.R.
        • Kim J.H.
        Meniscal extrusion does not progress during the midterm follow-up period after lateral meniscal transplantation.
        Am J Sports Med. 2017; 45: 900-908
        • Potter H.G.
        • Rodeo S.A.
        • Wickiewicz T.L.
        • Warren R.F.
        MR imaging of meniscal allografts: correlation with clinical and arthroscopic outcomes.
        Radiology. 1996; 198: 509-514
        • Verdonk P.
        • Depaepe Y.
        • Desmyter S.
        • et al.
        Normal and transplanted lateral knee menisci: Evaluation of extrusion using magnetic resonance imaging and ultrasound.
        Knee Surg Sports Traumatol Arthrosc. 2004; 12: 411-419
        • Verdonk P.C.
        • Verstraete K.L.
        • Almqvist K.F.
        • et al.
        Meniscal allograft transplantation: Long-term clinical results with radiological and magnetic resonance imaging correlations.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 694-706
        • Ha J.K.
        • Shim J.C.
        • Kim D.W.
        • Lee Y.S.
        • Ra H.J.
        • Kim J.G.
        Relationship between meniscal extrusion and various clinical findings after meniscus allograft transplantation.
        Am J Sports Med. 2010; 38: 2448-2455
        • Lee D.W.
        • Lee J.H.
        • Kim D.H.
        • Kim J.G.
        Delayed rehabilitation after lateral meniscal allograft transplantation can reduce graft extrusion compared with standard rehabilitation.
        Am J Sports Med. 2018; 46: 2432-2440
        • Park S.M.
        • Kim H.J.
        • Kim G.U.
        • et al.
        Learning curve for lumbar decompressive laminectomy in biportal endoscopic spinal surgery using the cumulative summation test for learning curve.
        World Neurosurg. 2019; 122: e1007-e1013