Clinical UM Guideline

 

Subject: Meniscal Allograft Transplantation of the Knee
Guideline #: CG-SURG-69 Publish Date:    12/27/2017
Status: New Last Review Date:    11/02/2017

Description

This document addresses meniscal allograft transplantation of the knee. Meniscal allograft transplantation of the knee is a surgical procedure used as a treatment option to restore normal meniscal function for selected individuals by replacing the damaged meniscus with donor cadaver allograft cartilage.

Note: Please see the following documents for additional information:

Clinical Indications

Medically Necessary:

Meniscal allograft transplantation of the knee is considered medically necessary as a treatment for individuals with significant partial (more than 50%) or complete loss of the meniscus* when all of the criteria listed below are met:

*Absence of meniscus must be firmly established by previous operative reports, magnetic resonance imaging (MRI), or diagnostic arthroscopy.

Not Medically Necessary:

Meniscal allograft transplantation of the knee is considered not medically necessary as a treatment for symptomatic individuals with partial or complete loss of the meniscus when criteria listed above are not met.

Meniscal allograft transplantation of the knee is considered not medically necessary as a treatment for asymptomatic individuals with partial or complete loss of the meniscus.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

29868

Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

 

 

ICD-10 Procedure

 

0SUC0KZ

Supplement right knee joint with nonautologous tissue substitute, open approach

0SUC4KZ

Supplement right knee joint with nonautologous tissue substitute, percutaneous endoscopic approach

0SUD0KZ

Supplement left knee joint with nonautologous tissue substitute, open approach

0SUD4KZ

Supplement left knee joint with nonautologous tissue substitute, percutaneous endoscopic approach

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Backgound

There are two types of cartilage within the knee. The surface or articular cartilage is teflon-like and facilitates the gliding and sliding of the bone ends upon each other. Articular cartilage is present in all of the joints of the body. The other type of cartilage in the knee is the meniscus, a c-shaped piece of fibrocartilage that lies between the weight bearing joint surfaces of the femur (thigh bone) and the tibia (shin bone). There are two menisci in the normal knee; the outside one is called the lateral meniscus, the inner one the medial meniscus. The meniscus cartilage acts as a cushion and absorbs force traveling up and down the leg and protects the surface cartilage of the knee. The menisci also cup the joint surfaces of the femur and therefore, provide some degree of stabilization to the knee.

Injuries to meniscal cartilage fall into two broad categories: traumatic tears which result from a sudden load being applied to the meniscal tissue, often from a twisting injury or blow to the side of the knee; and degenerative tears due to the natural drying out of the inner center of the meniscus that progress with age. As the meniscus becomes less elastic and compliant, a tear may occur with only minimal trauma. A torn meniscus will usually cause pain on the side of the knee that is localized to the meniscus. Typically, low-level swelling sets in the next day after the injury and is associated with stiffness. Any twisting, squatting or impact activities will pinch the tear and cause pain. Often the pain may improve with rest and anti-inflammatory medication after the initial injury but frequently recurs with any aggressive activity. With the exception of the outermost periphery where it joins to the vascular knee lining and has a blood supply, meniscal tissue does not heal and therefore presents a clinical problem which can over time lead to cartilage damage and osteoarthritis.

For isolated tears that are unresponsive to non-operative care, operative treatment may be indicated when disabling symptoms continue. Surgical treatment involves repairing or removing large unstable tears and is dependent on location, age and geometry of the tear, age of the individual and co-existing injury. In general, the principle is to save the meniscus whenever possible. Repair involves roughing up the injured surfaces of the tear and placing sutures or another fixation device across the tear to keep the edges opposed to facilitate healing. A partial meniscectomy is an operative procedure that involves trimming or removing the unstable torn portion of the cartilage, with the goal of eliminating or minimizing symptoms.

Significant meniscal damage can result in changes to meniscal structure and function and as a result, alteration in the alignment of the knee joint. Altered knee alignment results in re-distribution of the forces placed on the joint during normal activity, such as walking, which further damages the meniscus and articular surfaces of the femur or tibia. Over time this damage progresses leading to destruction of the joint.

After a complete loss of the meniscus from an extensive injury or repeated resections, rapid impairment of knee function most often occurs. Without therapy, osteoarthritis develops in most individuals in 5 to 10 years, faster than would occur as a consequence of aging. The treatment options available after meniscal depletion are limited. To find a therapeutic solution, meniscal allograft transplantation has been performed. Meniscal replacement seeks to: 1) reduce pain following removal of the meniscus; 2) prevent degenerative changes of the cartilage and subchondral bone after meniscus removal; 3) avoid or reduce the risk of osteoarthritis; 4) restore the mechanical properties to the joint after meniscal removal.

Proponents of meniscal allograft transplantation state that it can slow the onset of painful, disabling arthritis, avoid or delay the need for knee replacement at a very early age, and allow individuals to continue working and participating in sports or fitness activities.

Rationale

Loss of the meniscus either in part or whole, can have a poor prognosis in the long term, with the possibility of future arthritis thought to be proportional to the amount of tissue that is torn or removed. There is growing consensus that meniscal allograft transplantation may be indicated in a narrowly defined subset of individuals considered too young or active for arthroplasty and who meet specific criteria. Peer-reviewed research indicates the procedure is useful for carefully selected individuals with persistent pain, normal alignment, and a stable knee joint, and may offer the possibility of cartilage protection. Studies have demonstrated the effectiveness of this procedure in alleviating pain and swelling and in improving knee function in select individuals.

Verdonk and colleagues (2005, 2006) reported on the clinical outcomes of 100 meniscal allograft transplantations which had been completed on 96 individuals between 1989 and 2001. A total of 39 medial and 61 lateral allografts were transplanted into 70 men and 26 women with ages ranging from 16 to 50 years (mean age of 35 years). A survival analysis was performed with a mean duration of follow up of 7.2 years. At 10 years, 70% of those receiving transplants showed beneficial effects from the allograft. The authors concluded meniscal allograft can significantly relieve pain and improve function of the knee joint.

Von Lewinski and colleagues (2007) studied long-term outcomes of the first free meniscal allograft transplantations in 5 individuals. Between 1984 and 1986, 4 men and 1 woman with ages ranging from 24 to 26 years (mean age of 25 years) underwent simultaneous medial meniscal transplantation, anterior cruciate ligament (ACL) reconstruction and femoral advancement or temporary detachment of the medial collateral ligament (MCL). Clinical outcomes were evaluated at 20 years postoperatively by a variety of techniques including radiographs and magnetic resonance imaging (MRI). The radiological examinations revealed 2 persons with minimal, 2 persons with moderate and 1 person with severe degenerative changes. MRIs revealed shrinkage of the transplants and degenerative changes. Study limitations reported by the authors included that this was a case series done on those who first received the procedure, the meniscal allograft was always combined with other procedures, all individuals revealed cartilage damage at the time of surgery, control groups were not used, and evaluation criteria changed over time.

Rue and colleagues (2008) evaluated 30 individuals who underwent 31 combined meniscus transplantations and articular cartilage repairs between 1997 and 2004. The study group consisted of 18 males and 12 females with ages ranging from 13.9-47.9 years (mean age of 39.9). They were prospectively studied and completed standardized outcome surveys prior to surgery and annually after surgery for a minimum of 2 years. Two individuals were lost to follow-up, leaving 29 procedures to review. Significant improvements were observed. Of all study participants, 76% reported that they were completely (31%) or mostly (45%) satisfied with their results. Overall, 48% of participants were classified as normal or nearly normal at their most recent follow-up using the International Knee Documentation Committee examination score, and 90% of participants reported they would have the surgery again. The authors concluded that results of combined procedures were comparable with published reports of these procedures performed in isolation and long-term follow-up is needed.

Stone and colleagues (2010) investigated the long-term survival of concurrent meniscus allograft transplantation and repair of the articular cartilage. In a prospective 2–12 year follow-up report, 119 meniscal allograft transplantations were carried out in conjunction with articular cartilage repair in 115 individuals with severe articular cartilage damage. At the time of surgery, 53 (46.1%) of the study participants were over the age of 50. The mean follow-up period was 5.8 years (2 months to 12.3 years.). Twenty-five (20.1%) of the procedures failed at a mean of 4.6 years (2 months to 10.4 years). Of the failed procedures, 18 progressed to knee replacement at a mean of 5.1 (1.3-10.4) years. The researchers reported that the survival of the transplant was not affected by gender, axial alignment, the severity of cartilage damage, the degree of narrowing of the joint space or medial versus lateral allograft transplantation. With regards to the subjective outcome measures of the study (pain, activity and function), the researchers reported the study participants experienced significant improvements at all periods of follow-up, with the exception of the 7-year Tegner Index Score. The authors concluded that meniscal allograft transplantation carried out in conjunction with articular cartilage repair provides lasting pain relief and improved function in individuals with severe articular cartilage damage.

Several systematic reviews (Harris, 2010; Hergan, 2010) compared isolated meniscal allograft transplantations with meniscal allograft transplantation performed with a concomitant procedure (such as those for cartilage defects) and reported no significant difference in outcomes.

Verdonk and colleagues (2013) performed a literature review of 39 meniscal allograft studies. Included were 1145 individuals representing 1226 meniscus allografts (626 medial versus 446 lateral, 154 not specified). The mean age at the time of surgery was 34.4 years. The majority of individuals demonstrated improved clinical and functional outcomes. Progression of cartilage degeneration according to MRI and radiological criteria was halted in some individuals. Joint space narrowing was only significantly progressive at long-term follow-up. Second-look arthroscopy typically showed good healing to the capsule. Overall, a clinical success rate of 70% and higher has been reported at the final follow-up.

In a consecutive case series, McCormick and colleagues (2014) analyzed meniscal allograft transplants performed between 2003-2011 by a single surgeon. Among the 200 individuals (ages ranged from 16 to 56 years) who had a meniscal allograft transplant during the study time period, 172 (86%) were evaluated at a minimum 2-year follow-up (mean of 59 months). The authors reported a 32% reoperation rate for meniscal allograft transplant (the most common was simple arthroscopic debridement), and a 95% allograft survival rate at a mean of 5 years.

Recently, Kempshall and colleagues (2015) conducted a prospective study of 99 subjects who underwent meniscal allograft transplantation between May 2005 and Feb 2013. Major concomitant procedures performed included any combination of the following: osteotomy, ligament reconstruction, microfracture, MACI technique, or other chondral procedures. This study compared clinical outcomes of meniscal allograft transplantation in individuals with advanced chondral damage to those with minimal articular chondral damage. Mean follow-up was 2.9 years. Functional outcomes following allograft transplantation in knees with greater cartilage damage was reported as similar to knees with lesser cartilage damage when cartilage repair procedures had been used; however, implant survival was lower. The authors concluded that young individuals with advanced chondral damage should not be excluded from meniscal allograft transplantation; however, there are multiple study limitations including a small sample size, a large number of concomitant procedures that confounded outcome measures, a short follow-up period and the absence of a control arm for comparison. More study is needed before the author’s conclusions can be supported.

Although clinical experience has helped define indications for meniscal allograft transplantation, at this time there is still limited information on the long-term results of this procedure as well as other factors that impact outcomes. These include: the challenge in early detection of the onset of joint degeneration in those who are known to be meniscus-deficient; lack of information on the biology of the transplanted meniscus including the process of cell migration into the meniscus during cellular re-population and the effect of an immune response on graft remodeling; and lack of information to guide rehabilitation after meniscal transplantation.

Meniscal allograft transplantation of the knee is indicated, according to those who perform it, for those who have had a previous meniscectomy, persistent pain, normal alignment, and a stable joint. If the joint is unstable because of anterior or posterior cruciate ligament injury, these ligaments are reconstructed at the time of transplantation. The suggested ideal candidates are young, skeletally mature, physically active individuals with stable (or stabilizable) knees, and normal alignment. Severe articular damage (Outerbridge grade III or IV) may be repaired with chondral or osteochondral transplantation in conjunction with the meniscal transplant. The American Academy of Orthopedic Surgeons (2014) indicates that a meniscal transplant may be recommended for an active person younger than 55 years of age.

It is evident that meniscal allograft transplantation is a viable option for the treatment of symptomatic individuals provided rigid inclusion criteria are met. Those with appropriate indications should expect to do well postoperatively in terms of predictable reduction in pain and an ability to increase activity levels. Further study will clarify the long-term results of meniscal allografts as well as their role in preventing the progression of secondary osteoarthritis in the involved compartment.

Definitions

Allograft: A transplantation of tissue obtained from a donor of the same species; under most circumstances in knee surgery, the donor is a cadaver.

Arthroscopy: A procedure using a special instrument (arthroscope) that is inserted into the knee.

Articular: Of or relating to the skeletal joints.

Chondral: Of or pertaining to cartilage.

Meniscal: Pertaining to the meniscus, a crescent-shaped cartilage situated in the knee.

Meniscectomy: Removal of the meniscus.

Osteochondral: Pertaining to bone and the attached articular cartilage.

Outerbridge Classification System:

-grade 0:  normal cartilage
-grade I:  cartilage with softening and swelling
-grade II:  a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter
-grade III:  fissuring to the level of subchondral bone in an area with a diameter of more than 1.5 cm
-grade IV:  exposed subchondral bone

Skeletally mature: With respect to evaluation and treatment of the lower extremities, skeletal maturity implies radiographic closure of the epiphyseal growth plates and cessation of vertical growth.

Valgus: An abnormal position in which part of a limb is twisted outward away from the midline.

Varus: An abnormal position in which part of a limb is twisted inward toward the midline.

References

Peer Reviewed Publications:

  1. Cameron ML, Briggs KK, Steadman JR. Reproducibility and reliability of the outerbridge classification for grading chondral lesions of the knee arthroscopically. Am J Sports Med. 2003, 31(1):83-86.
  2. Cole B, Carter T, Rodeo S. Allograft meniscal transplantation: background, techniques and results. American Academy of Orthopaedic Surgeons. Instr Course Lect. 2003; 52:383-396.
  3. Crook TB, Ardolino A, Williams LA, Barlow IW. Meniscal allograft transplantation: a review of the current literature. Ann R Coll Surg Engl. 2009; 91(5):361-365.
  4. Felix NA, Paulos LE. Current status of meniscal transplantation. Knee. 2003; 10(1):13-17.
  5. Greis PE, Holmstrom MC, Bardana DD, Burks RT. Meniscal injury: II. Management. J Am Acad Orthop Surg. 2002; 10(3):177-187.
  6. Harris JD, Cavo M, Brophy R, et al. Biological knee reconstruction: a systematic review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy. 2011; 27(3):409-418.
  7. Hergan D, Thut D, Sherman O, Day MS. Meniscal allograft transplantation. Arthroscopy. 2011; 27(1):101-112. 
  8. Kempshall PJ, Parkinson B, Thomas M. Outcome of meniscal allograft transplantation related to articular cartilage status: advanced chondral damage should not be a contraindication. Knee Surg Sports Traumatol Arthrosc. 2015; 23(1):280-289.
  9. Lubowitz JH, Verdonk PC, Reid JB 3rd, Verdonk R. Meniscus allograft transplantation: a current concepts review. Knee Surg Sports Traumatol Arthrosc. 2007; 15(5):476-492.
  10. Matava MJ. Meniscal allograft transplantation: a systematic review. Clin Orthop Relat Res. 2007; 455:142-157.
  11. McCormick F, Harris JD, Abrams GD, et al. Survival and reoperation rates after meniscal allograft transplantation: analysis of failures for 172 consecutive transplants at a minimum 2-year follow-up. Am J Sports Med. 2014; 42(4):892-897.
  12. Packer JD, Rodeo SA. Meniscal allograft transplantation. Clin Sports Med. 2009; 28(2):259-283, viii.
  13. Peters G, Wirth CJ. The current state of meniscal allograft transplantation and replacement. Knee. 2003; 10(1):19-31.
  14. Rankin M, Noyes FR, Barber-Westin SD, et al. Human meniscus allografts' in vivo size and motion characteristics: magnetic resonance imaging assessment under weightbearing conditions. Am J Sports Med. 2006; 34(1):98-107.
  15. Rath E, Richmond JC, Yassir W, et al. Meniscal allograft transplantation: two- to eight-year results. Am J Sports Med. 2001; 29(4):410-414.
  16. Rodeo SA. Meniscal allografts--where do we stand? Am J Sports Med. 2001; 29(2):246-261.
  17. Rodeo SA, Seneviratne A, Suzuki K, et al. Histological analysis of human meniscal allografts. J Bone Joint Surg Am. 2000; 82-A(8):1071-1081.
  18. Rue JP, Yanke AB, Busam ML, et al. Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: minimum 2-year follow-up. Am J Sports Med. 2008; 36(9):1770-1778.
  19. Ryu RK, Dunbar V WH, Morse GC. Meniscal allograft replacement: a 1 year to 6 year experience. Arthroscopy. 2002; 18(9):989-994.
  20. Sekiya JK, Ellingson CI. Meniscal allograft transplantation. J Am Acad Orthop Surg. 2006; 14(3):164-174.
  21. Sohn DH, Toth AP. Meniscus transplantation: current concepts. J Knee Surg. 2008; 21(2):163-172.
  22. Stollsteimer GT, Shelton WR, Dukes A, Bomboy AL. Meniscal allograft transplantation: a 1- to-5 year follow-up of 22 patients. Arthroscopy. 2000; 16(4):343-347.
  23. Stone KR, Adelson WS, Pelsis JR, et al. Long-term survival of concurrent meniscus allograft transplantation and repair of the articular cartilage: a prospective two- to 12-year follow-up report. J Bone Joint Surg Br. 2010; 92(7):941-948.
  24. Verdonk PC, Demurie A, Almqvist KF, et al. Transplantation of viable meniscal allograft. Survivorship analysis and clinical outcome of one hundred cases. J Bone Joint Surg Am. 2005; 87(4):715-724.
  25. Verdonk PC, Demurie A, Almqvist KF, et al. Transplantation of viable meniscal allograft. Surgical technique. J Bone Joint Surg Am. 2006; 88 Suppl 1 Pt 1:109-118.
  26. Verdonk R, Almqvist KF, Huysse W, Verdonk PC. Meniscal allografts: indications and outcomes. Sports Med Arthrosc. 2007; 15(3):121-125.
  27. Verdonk R. Meniscal transplantation. Acta Orthop Belg. 2002; 68(2):118-127.
  28. Verdonk R, Volpi P, Verdonk P, et al. Indications and limits of meniscal allografts. Injury. 2013; 44 Suppl 1:S21-27.
  29. Von Lewinski G, Milachowski KA, Weismeier K, et al. Twenty-year results of combined meniscal allograft transplantation, anterior cruciate ligament reconstruction and advancement of the medial collateral ligament. Knee Surg Sports Traumatol Arthrosc. 2007; 15(9):1072-1082.
  30. Wirth CJ, Peters G, Milachowski KA, et al. Long-term results of meniscal allograft transplantation. Am J Sports Med. 2002; 30(2):174-181.
  31. Yoldas EA, Sekiya JK, Irrgang JJ, et al. Arthroscopically assisted meniscal allograft transplantation with and without combined anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2003; 11(3):173-182.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Orthopaedic Surgeons (AAOS). Meniscal transplant surgery. Last reviewed March 2014. For additional information visit the AAOS website at: http://orthoinfo.aaos.org/topic.cfm?topic=A00381. Accessed on October 20, 2017.
Index

Allograft Transplantation
Meniscal Allograft Transplantation

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

New

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development. Moved content of TRANS.00015 Meniscal Allograft Transplantation of the Knee to new clinical utilization management guideline document with the same title.