Editorial Commentary: Collagen Meniscal Scaffolds
Abstract: Small collagen meniscal scaffolds are a treatment for partial meniscectomy, which is clinically much more common than subtotal or total meniscectomy. The scaffold alone shows promising results, but readers must be mindful of risk of bias in the literature. Addition of stem cells and growth factors is the next step in meniscal tissue engineering.
See related article on page 927
C
ollagen meniscal scaffolds, as systematically reviewed in this issue by Warth and Rodkey from Vail, Colorado,1 are a solution for partial meniscectomy. To our knowledge, the results of partial meniscectomy are good,2 but according to Warth and Rodkey, “There is evidence that collagen meniscus scaffold implantation provides superior clinical outcomes when compared with partial meniscectomy alone. Level of Evidence: Level IV.”1 As readers, we must distinguish the small scaffolds described for partial meniscectomy from total meniscus replacement, but since total (or “subtotal”) meniscectomy is rare, and partial meniscectomy is extremely common, the potential significance of a collagen meniscal scaffold is enormous. Readers will note that the “multicenter, prospective randomized clinical trial, which confirmed the safety and efficacy of the implant”3,4 represents research published by the same Dr. Rodkey who is coauthor of this review. Readers will also note that this review was performed according to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) Guidelines, which mitigate against bias. However, the authors state that “although risk of bias assessments are standard practice for systematic reviews, we chose to exclude this assessment since our institution is connected with several of the included studies.” Readers should draw their own conclusions, but our assessment is that Warth and Rodkey are mindful in their effort to minimize bias. The scaffold investigated does not provide cells or growth factors, so here, we rely on the host. In the future, we anticipate that cells and/or growth factors
Ó 2015 by the Arthroscopy Association of North America 0749-8063/15191/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.02.043
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could be added.5-12 MRI and second-look arthroscopy suggest that meniscal scaffolds decrease in volume over time, yet histology “most often reveals good tissue integration and.meniscus fibrochondrocyte maturation as the follow-up period was increased.” Collagen meniscus scaffolds represent a large step in the direction of meniscal tissue engineering, to be considered in articles that follow in this month’s ISAKOS Knee Biologics Supplement Part II13,14 Finally, we very much admire all seven Tables published in “Resorbable Collagen Scaffolds for the Treatment of Meniscus Defects.”1 While sometimes, unfortunately, Tables can appear boring or overwhelming, Warth and Rodkey’s Tables are exemplary, educational, and worthy of careful review. James H. Lubowitz, M.D. Editor-in-Chief
References 1. Warth RJ, Rodkey WG. Resorbable collagen scaffolds for the treatment of meniscus defects: A systematic review. Arthroscopy 2015;31:927-941. 2. Petty C, Lubowitz J. Does arthroscopic partial meniscectomy result in knee osteoarthritis? A systematic review with a minimum of 8 years’ follow-up. Arthroscopy 2011;27:419-424. 3. Rodkey WG, Steadman JR, Li ST. A clinical study of collagen meniscus implants to restore the injured meniscus. Clin Orthop Relat Res 1999;367:S281-S292 (suppl). 4. Stone KR, Steadman JR, Rodkey WG, Li ST. Regeneration of meniscal cartilage with use of a collagen scaffold. Analysis of preliminary data. J Bone Joint Surg Am 1997;79:1770-1777. 5. Lubowitz JH. Editorial commentary: Meniscal allograft yields acceptable outcomes (for a salvage procedure). Arthroscopy 2015;31:926. 6. Kon E, Roffi A, Filardo G, Tesei G, Marcacci M. Scaffoldbased cartilage treatments: With or without cells? A
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 5 (May), 2015: pp 942-943
EDITORIAL COMMENTARY
7. 8.
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systematic review of preclinical and clinical evidence. Arthroscopy 2015;31:767-775. Lubowitz JH. Editorial commentary. Scaffold-based cartilage treatments. Arthroscopy 2015;31:776. Cugat R, Cuscó X, Seijas R, et al. Biologic enhancement of cartilage repair: The role of platelet-rich plasma and other commercially available growth factors. Arthroscopy 2015;31:777-783. Lubowitz JH, Provencher MT, Poehling GG. Cartilage treatment and biologics current research. Arthroscopy 2013;29:1597-1598. Lubowitz JH, Provencher MT, Poehling GG. Stem cells in the knee. Arthroscopy 2013;29:609-610.
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11. Lubowitz JH, Provencher MT, Poehling GG. Stem cells in arthroscopy. Arthroscopy 2012;28:891-892. 12. Lubowitz JH, Poehling GG. Saving our cells: Advances in tissue engineering for focal cartilage defects. Arthroscopy 2009;25:115-116. 13. Moran CJ, Busilacchi A, Lee CA, Athanasiou KA, Verdonk PC. Biological augmentation and tissue engineering approaches in meniscus surgery. Arthroscopy 2015;31:944-955. 14. Hogan MV, Walker GN, Cui LR, Fu FH, Huard J. The role of stem cells and tissue engineering in orthopaedic sports medicine: Current evidence and future directions. Arthroscopy 2015;31:1017-1021.
Abstract: Small collagen meniscal scaffolds are a treatment for partial meniscectomy, which is clinically much more common than subtotal or total meniscectomy. The scaffold alone shows promising results, but readers must be mindful of risk of bias in the literature. Addition of stem cells and growth factors is the next step in meniscal tissue engineering.
See related article on page 927
C
ollagen meniscal scaffolds, as systematically reviewed in this issue by Warth and Rodkey from Vail, Colorado,1 are a solution for partial meniscectomy. To our knowledge, the results of partial meniscectomy are good,2 but according to Warth and Rodkey, “There is evidence that collagen meniscus scaffold implantation provides superior clinical outcomes when compared with partial meniscectomy alone. Level of Evidence: Level IV.”1 As readers, we must distinguish the small scaffolds described for partial meniscectomy from total meniscus replacement, but since total (or “subtotal”) meniscectomy is rare, and partial meniscectomy is extremely common, the potential significance of a collagen meniscal scaffold is enormous. Readers will note that the “multicenter, prospective randomized clinical trial, which confirmed the safety and efficacy of the implant”3,4 represents research published by the same Dr. Rodkey who is coauthor of this review. Readers will also note that this review was performed according to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) Guidelines, which mitigate against bias. However, the authors state that “although risk of bias assessments are standard practice for systematic reviews, we chose to exclude this assessment since our institution is connected with several of the included studies.” Readers should draw their own conclusions, but our assessment is that Warth and Rodkey are mindful in their effort to minimize bias. The scaffold investigated does not provide cells or growth factors, so here, we rely on the host. In the future, we anticipate that cells and/or growth factors
Ó 2015 by the Arthroscopy Association of North America 0749-8063/15191/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.02.043
942
could be added.5-12 MRI and second-look arthroscopy suggest that meniscal scaffolds decrease in volume over time, yet histology “most often reveals good tissue integration and.meniscus fibrochondrocyte maturation as the follow-up period was increased.” Collagen meniscus scaffolds represent a large step in the direction of meniscal tissue engineering, to be considered in articles that follow in this month’s ISAKOS Knee Biologics Supplement Part II13,14 Finally, we very much admire all seven Tables published in “Resorbable Collagen Scaffolds for the Treatment of Meniscus Defects.”1 While sometimes, unfortunately, Tables can appear boring or overwhelming, Warth and Rodkey’s Tables are exemplary, educational, and worthy of careful review. James H. Lubowitz, M.D. Editor-in-Chief
References 1. Warth RJ, Rodkey WG. Resorbable collagen scaffolds for the treatment of meniscus defects: A systematic review. Arthroscopy 2015;31:927-941. 2. Petty C, Lubowitz J. Does arthroscopic partial meniscectomy result in knee osteoarthritis? A systematic review with a minimum of 8 years’ follow-up. Arthroscopy 2011;27:419-424. 3. Rodkey WG, Steadman JR, Li ST. A clinical study of collagen meniscus implants to restore the injured meniscus. Clin Orthop Relat Res 1999;367:S281-S292 (suppl). 4. Stone KR, Steadman JR, Rodkey WG, Li ST. Regeneration of meniscal cartilage with use of a collagen scaffold. Analysis of preliminary data. J Bone Joint Surg Am 1997;79:1770-1777. 5. Lubowitz JH. Editorial commentary: Meniscal allograft yields acceptable outcomes (for a salvage procedure). Arthroscopy 2015;31:926. 6. Kon E, Roffi A, Filardo G, Tesei G, Marcacci M. Scaffoldbased cartilage treatments: With or without cells? A
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 5 (May), 2015: pp 942-943
EDITORIAL COMMENTARY
7. 8.
9.
10.
systematic review of preclinical and clinical evidence. Arthroscopy 2015;31:767-775. Lubowitz JH. Editorial commentary. Scaffold-based cartilage treatments. Arthroscopy 2015;31:776. Cugat R, Cuscó X, Seijas R, et al. Biologic enhancement of cartilage repair: The role of platelet-rich plasma and other commercially available growth factors. Arthroscopy 2015;31:777-783. Lubowitz JH, Provencher MT, Poehling GG. Cartilage treatment and biologics current research. Arthroscopy 2013;29:1597-1598. Lubowitz JH, Provencher MT, Poehling GG. Stem cells in the knee. Arthroscopy 2013;29:609-610.
943
11. Lubowitz JH, Provencher MT, Poehling GG. Stem cells in arthroscopy. Arthroscopy 2012;28:891-892. 12. Lubowitz JH, Poehling GG. Saving our cells: Advances in tissue engineering for focal cartilage defects. Arthroscopy 2009;25:115-116. 13. Moran CJ, Busilacchi A, Lee CA, Athanasiou KA, Verdonk PC. Biological augmentation and tissue engineering approaches in meniscus surgery. Arthroscopy 2015;31:944-955. 14. Hogan MV, Walker GN, Cui LR, Fu FH, Huard J. The role of stem cells and tissue engineering in orthopaedic sports medicine: Current evidence and future directions. Arthroscopy 2015;31:1017-1021.
