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Particular care lumbar selective spinal nerve and transforaminal injection should be taken when performing transforaminal injec- (see Fig generic kamagra 100 mg on-line erectile dysfunction treatment bay area. Direct injection of particulate steroid into a tion on the left between T9 and L1 because the artery of spinal segmental artery supplying the spinal cord can lead Adamkiewicz buy kamagra visa outcome erectile dysfunction without treatment, the largest of the spinal segmental arteries order 100mg kamagra erectile dysfunction doctors in massachusetts, Chapter 6 Transforaminal and Selective Spinal Nerve Injection 79 lies between these levels in the majority of individuals order 100 mg kamagra visa erectile dysfunction age 16. Effectiveness of transforaminal The use of radiographic contrast injected during “live” or epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study. Periradicular means to accurately verify that injectate is not injected inﬁltration for sciatica: a randomized controlled trial. Fluoroscopic transforaminal lumbar cuff as it extends laterally onto the exiting nerve root. Selective nerve root blocks for the treatment of sciatica: evaluation of injection site Botwin K, Gruber R, Bouchlas C, et al. Outcome of cervical radiculopathy treated cohort of 56 patients with low back pain and sciatica. Systematic review of ther- apeutic lumbar transforaminal epidural steroid injections. Is it really possible to do a selective cervical spondylotic radicular pain: a retrospective analy- nerve root block? Their role in the evaluation of son with radiculography, computed tomography, and operative recurrent sciatica. Selective nerve root block in patient selection for lum- Vad V, Bhat A, Lutz G, et al. Paraplegia after lumbosacral nerve root thy: lateral approach periradicular corticosteroid injection. Complications of common selective vulnerable arteries and ischemic neurologic injuries after trans- spinal injections: prevention and management. Chapter 7 Facet Injection: Intra-articular Injection, Medial Branch Block, and Radiofrequency Treatment 81 C1 C1 C2 C2 C3 C3 C4 C4 C5 C5 C6 o 25 – 35 C7 C6 T1 C7 T1 T2 T2 T3 T3 T4 T4 T5 T5 T6 T6 T7 T7 T8 T8 T9 T9 o 60 – 70 T10 T10 T11 T11 T12 T12 L1 L1 L2 L2 L3 L3 o L4 25–35 L4 from o sagittal 0 L5 plane L5 Figure 7-1. The plane of orientation of the facet joints varies signiﬁcantly among cervical, thoracic, and lumbar levels. The axis of the joints and the plane of entry for intra-articular injection are shown for typical cervical, thoracic, and lumbar facet joints. The most important vertebra forming the superior portion of each thoracic facet historical feature is a predominance of axial spinal pain; joint lies directly posterior to the superior articular process, those patients who report that the predominance of their forming the inferior portion of each joint. This allows for pain is in the extremities are more likely to have acute or some degree of ﬂexion and extension, but limited rotation chronic radicular pain than facet-related pain. The steeply angled ceph- ity of the pain is typically deep and aching, and waxes and alad-to-caudad orientation of the thoracic facets also makes wanes with activity. Burning or stabbing qualities suggest intra-articular injection difﬁcult or impossible. Diagnos- facet joints are angled with a somewhat oblique orientation, tic studies are often unrevealing. Patients with signiﬁcant allowing for ﬂexion, extension, and rotation that is greater facet-related pain may have unremarkable plain radiographs than that in the thorax but less than in the cervical region. Patient selection for facet needle insertion for intra-articular facet injection are illus- injection or radiofrequency treatment is empiric and relies trated in Figure 7-1. The spinal nerve at facet joints has been established by injecting a mild irritant each level traverses the intervertebral foramen and divides (usually hypertonic saline) into speciﬁc facet joints in healthy into anterior and posterior primary rami. The posterior primary ramus, in vical, thoracic, and lumbar regions, respectively. The levels turn, divides into a lateral branch that provides innerva- to be treated are chosen by correlating the patient’s report of tion to the paraspinous musculature and a small, variable pain to these pain diagrams. Occasionally, a patient will pres- sensory branch to the skin overlying the spinous processes; ent with evidence of facet arthropathy and a pattern of pain the medial branch of the posterior primary ramus courses that corresponds to a single level, but this is uncommon. Treatment should be directed along the articular process to supply sensation to the joint. The speciﬁc course of C2/3 the medial branch nerves and cannula position for radiofre- quency treatment at speciﬁc spinal levels is discussed in the following sections. C3/4 C3/4 C5/6 Patient Selection Patients with facet-related pain are difﬁcult to distinguish from those with other causes of axial spinal pain. Some patients will present with sudden onset of pain follow- ing a signiﬁcant ﬂexion-extension (whiplash) injury, but more common is an insidious onset over months to years. Patients with myofascial or discogenic pain and, in the low back, those with sacroiliac dysfunction present with simi- lar symptoms. The pain caused by facet arthropathy is most pain patterns produced by speciﬁc cervical facet joints are illustrated. Data are derived from intra-articular injection in pronounced over the axis of the spine itself and is typically healthy volunteers. Typical pain patterns produced by speciﬁc thoracic facet joints are pain patterns produced by speciﬁc lumbar facet joints are illustrated. The overuse of How to select between intra-articular facet injection and facet injections, including intra-articular injections and diagnostic medial branch blocks followed by radiofre- radiofrequency treatment, has been singled out as a sig- quency treatment is still a question that is frequently posed niﬁcant area of concern. Limited outcome studies of intra-articular examined the scientiﬁc literature and made evidence- injection, particularly at the cervical level, have demon- based guidelines regarding the use of this treatment. In contrast, in those patients who obtain quency treatment are limited, and we will discuss each signiﬁcant pain relief from diagnostic blocks of the medial in turn. Based on this improved joint corticosteroid injection…[is] not recommended efﬁcacy and a long track record of safety, many practitioners (strong recommendation, moderate-quality evidence). Intra-articular injection remains of therapeutic medial branch block [and] radiofrequency of some value in those patients who have had recent onset denervation…for nonradicular low back pain. Intra-articular injection is also a because randomized trials consistently found them to be no reasonable alternative when the expertise or equipment for more effective than sham therapies. While A 2010 Practice Guideline, offering the following recom- observational studies have suggested that use of medial mendations: (1) “Intra-articular facet joint injections may branch blocks with local anesthetic alone can provide sus- be used for symptomatic relief of facet-mediated pain. Indeed randomized trials demonstrate C-arm is rotated 25 to 35 degrees caudally from the axial little beneﬁt for use of intra-articular injections, while well- plane without any oblique angulation. This brings the axis conducted observational studies suggest a more signiﬁcant of the x-rays in line with the axis of the facet joints and effect in treating chronic axial low back pain. Although trials of the use of medial branch blocks with local anesthetic the cervical facet joints can also be entered from a lateral alone, without subsequent radiofrequency treatment, have approach with the patient lying on his or her side, advanc- been encouraging, but randomized trials are lacking. Guidance on the optimal frequency for repeating these inter- The skin and subcutaneous tissues overlying the facet joint ventions as well as the efﬁcacy of using multiple repeated where the block is to be carried out are anesthetized with treatments over time is lacking entirely. The cervical level is easily Chapter 7 Facet Injection: Intra-articular Injection, Medial Branch Block, and Radiofrequency Treatment 85 Figure 7-5. The patient is placed prone with a small headrest under the forehead to allow for air ﬂow between the table and the patient’s nose and mouth. The needle is adjusted to remain coaxial and verse process that articulates with the ﬁrst rib (see Fig.
Investigations are limited by their lower sensitivity for mucosal pathology and inability to obtain tissue for histology or undertake therapeutic procedures cheap kamagra generic impotence cures. Therapeutic • Treatment of bleeding lesions (peptic ulceration buy kamagra 100 mg with mastercard erectile dysfunction 20, angiodysplasia order kamagra 50 mg with visa effexor xr impotence, varices kamagra 50 mg online blood pressure drugs erectile dysfunction, vascular malformations). Single- or double-balloon enteroscopy • allows views of the entire small bowel from an oral or rectal approach. For single- and double- balloon procedures, one is attached to a transparent overtube sliding over the endoscope, allowing movement forward by telescoping the small bowel by gripping and pleating it over the endoscope. For the double balloon, the second balloon is attached to the distal endoscope to act as an anchor. Alternative investigations to enteroscopy Barium investigations (follow-through or small bowel enema) are limited by a lower sensitivity for mucosal pathology. MrI small bowel studies are good for young patients, as these present no radiation risk, with contrast allowing clear serosal and mucosal images and views of the whole length of the small bowel. Single- or double-balloon enteroscopy allows visualization and treatment of lesions within the full length of the small bowel and may replace con- ventional enteroscopy, although procedure length and intensity will require deep sedation or Gan. Conventional enteroscopy will diagnose and treat lesions within the upper small bowel (to the jejunum) but is limited by patient tolerance as conscious sedation is used. Need to bear in mind both the patient’s ftness and willingness to undergo the purgative preparation, and also the risk of renal failure and electrolyte disturbance associated with administration of these agents (for advice, E Endoscopy, pp. Ideally, a low- residue diet should be followed for the 3 days pre-procedure to obtain the best views. For patients who are intolerant of such procedures, Gan may rarely be available with appropriate anaesthetic specialist support. Neither allows tissue or polypec- tomy to be taken for histology nor other therapeutic procedures to be per- formed. For these reasons, colonoscopy is considered the ‘gold standard’ for investigating likely colon cancer, diarrhoea, anaemia, and rectal bleed- ing. These alternative procedures all require the use of oral bowel-cleansing agents too. Indications Symptoms and signs • rectal bleeding (bright red = fexible sigmoidoscopy, and dark red = colonoscopy), but beware as some right-sided colonic lesions do present with bright red bleeding. Aim: to allow diagnosis and removal of polyps (adenomas) before development of carcinoma. Aim: to diagnose and remove polyps (adenomas) and reduce future bowel cancer risk. Full colonoscopy is ofered to those with >3 adenomas, those with a villous component to one or more polyps, and anyone with an adenoma of >1cm. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). ErCp is used for interventional procedures and to obtain biopsy and cytology specimens. Alternative investigations MrCp allows imaging of the biliary and pancreatic systems and is the best (and safest) option for diagnosis, although no therapeutic procedures are possible. Indications Diagnostic • Endoscopic diagnosis of periampullary polyps and tumours. Therapeutic • Biliary stenting: • palliation of pancreatic, ampullary, and cholangiocarcinomas. Indications • Staging of oesophageal, gastric, pancreatic, and distal biliary tumours. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Urea breath test • Expired air is collected after ingestion of 13C- labelled urea. Gastro-oesophageal refux disease and dys- pepsia in adults: investigation and management. General practitioners advised to ofer testing for adults without rectal bleeding if: • 50 years or over with unexplained abdominal pain or weight loss. Investigation • Simple and inexpensive, performed by the patient in their own home. Results • Sensitivity of the non-hydrated test is 70%; this i to 90% with rehydration, but at the loss of specifcity. False negatives ‘Old’ sample with bacterial degradation of hb, the presence of ascorbic acid, and reduced or absent bleeding at time of testing. Option appraisal of population- based colorectal cancer screening programme in England. Faecal lactoferrin • Neutrophil-derived protein; marker of intestinal infammation. Perinuclear antineutrophil cytoplasmic antibodies • Occur in the serum of 50–80% of patients with histologically confrmed ulcerative colitis, but only 10% of those with Crohn’s disease. Antibodies to Saccharomyces cerevisiae • Found in 60% of patients with Crohn’s disease, but only 5% of those with ulcerative colitis. Diagnostic precision of anti-Saccharomyces cerevisiae antibodies and perinuclear antineutrophil cytoplasmic antibodies in infammatory bowel disease. Carcinoembryonic antigen • i in 60% of those with localized colorectal carcinoma (CrC) and 80– 100% of those with metastatic disease. Radiology • MrI of the small bowel has mostly replaced barium radiology, particularly in younger patients, with a lack of radiation, greater sensitivity for mucosal detail by using contrast, and abilities to use cine views to determine motility. Nuclear medicine Radiolabelled white cell scintigraphy for infammation/infection • Uses 99mtechnetium– hexamethyl- propylene- amine- oxime (99mTc- hMpaO) to show intensity and extent of infammation or infection 1 and 3h after injection of autologous radiolabelled leucocytes. Lactose tolerance test Oral administration of 50g of lactose is followed by blood sampling every 30min for 2h. Lactose hydrogen test This is similar to the hydrogen breath test for bacterial overgrowth. Lactase- defcient individuals fail to metabolize lactose, which then undergoes lumi- nal metabolism by lactase-producing colonic bacteria to yield hydrogen. Glucose and fructose may be used as alternative short-chain carbohydrates to determine the presence of malabsorption. Tests of fat malabsorption (may occur in pancreatic malabsorption too) patients with fat malabsorption 2° to small bowel diseases, such as coeliac disease or tropical sprue, may malabsorb between 10 and 20g/day of fat, whilst patients with pancreatic insufciency may malabsorb 30–50g/24h. Hydrogen breath tests Rationale In mammals, the only source of breath hydrogen is bacterial fermentation of carbohydrates. In bacterial overgrowth, hydrogen production can occur in the small intestine, as well as in the colon. Method • a mouthwash is given beforehand to reduce contamination by oral bacteria.
Cutaneous lesions often are resistant to standard treatments such as topical steroids or tacrolimus and can be complicated by bacterial infections with the potential development of sepsis buy cheap kamagra 50mg on-line impotence kidney disease. Moreover generic kamagra 100 mg mastercard latest advances in erectile dysfunction treatment, other alterations may suggest ongoing autoimmune manifestations in other target organs purchase 50 mg kamagra with amex erectile dysfunction medication non prescription, such as hypothyroidism generic 50mg kamagra otc impotence your 20s, cytopenias, hepatitis, or nephropathy. Patients in the acute phase of disease can have normal or elevated white blood cell counts. Humoral immunity is normal with normal vaccination titers and normal immunoglobulin levels (IgG, IgM, and IgA). In fact, skin prick tests for immediate hypersensitivity are usually consistent with height- ened allergic response. In most cases, there is a marked discrep- ancy between macroscopic endoscopic and histological fndings. Macroscopically, the mucosa of the stomach, duodenum, jejunum, and ileum show only mild abnor- malities with a variable degree of enhanced mucosal granularity along with erythema. Colonic lesions can be more pronounced with loss of the normal vascular pattern due to edema, along with erythema, potentially involving the entire colonic mucosa. This infltrate consists predominantly of T lymphocytes and eosinophils, but is not specifc for the disease. In some patients, villous atrophy is associated with epithelial cell death and crypt abscess formation. Recent studies indicate that enterocyte cell death occurs through apoptosis probably induced by activated cytotoxic lympho- cytes. The number of goblet cells is also reduced, and in some cases, goblet cells are almost absent107 (Figure 11. These changes are often observed in small-bowel mucosa, but can also be seen in other parts of the digestive tract, such as the stom- ach or colon. In most cases, girls pres- ent with multiple extraintestinal autoimmune manifestations, such as thyroiditis or diabetes. Other mutations in regulatory genes controlling T-cell func- tions at the level of the intestinal mucosa are presumed to be the cause. Owing to the limited number of cases reported in the literature, it has been diffcult to compare different thera- peutic strategies and relative outcomes. Nutritional support and immunosuppressive therapy should be started promptly to counteract the initial acute manifestations. At onset, patients are hospitalized and receive supportive care such as fuids, antibiotics, and albumin. Remission can most often be induced by the combination of methylprednisolone and tacrolimus. Chronic immunosuppression increases the risk of viral, bacterial, or fungal infections. Pneumocystis jiroveci pneumonia is not uncommon so patients are rou- tinely placed on trimethoprim/sulfamethoxazole prophylaxis. In patients who sur- vive the frst years of life, immunosuppression may stabilize the existing symptoms; however, fares of the disease may occur and new symptoms may develop despite therapy. Early stem cell transplantation leads to the best out- come when the organs are yet to be damaged from autoimmunity and/or the adverse effects of therapy. This loss of lymph is responsible for a protein-losing enteropathy leading to lymphopenia, hypoalbuminemia, and hypo- gammaglobulinemia. Depending on the cause, it can be classifed into primary or secondary intestinal lymphangiectasia. The edema is pitting because the oncotic pressure is low due to hypoalbuminemia resulting from exudative enteropathy. Malabsorption may cause fat-soluble vitamin def- ciencies and hypocalcaemia leading to convulsions. Macroscopic abnormalities are usually obvious with the creamy yellow of jeju- nal villi corresponding to marked dilatation of the lymphatics within the intestinal mucosa. Histological examination of duodenal, jejunal, and ileal biopsies confrms the presence of lacteal juice, dilated mucosal and submucosal lymphatic vessels with polyclonal normal plasma cells. Elevated IgE levels without underlying allergic diathesis or disease has also been reported. The B-cell defects are characterized by low immunoglobulin levels (IgA, IgG, IgM) and poor antibody responses. However, severe and recurrent infections have been reported in case reports and case series. The absence of long-chain triglyceride in the diet may decrease the engorgement of the intestinal lymphatics with chyle, thereby preventing their rupture with ensuing protein and T-cell loss. After a few weeks, this treatment may lead to reversal of clinical and labora- tory measures such as hypoalbuminemia and lymphocytopenia. The disruption of the gastrointestinal tract by infammation and the associated symptoms of pain, nausea, and diarrhea lead to reduced food intake, reduced nutrient use, and ultimately to impaired nutrition status in these patients (Figure 11. Several studies have documented weight loss in 70%–80% of hospitalized patients and 20%–40% of outpatients with Crohn’s disease. Active disease within the small bowel can also lead to both macronutrient and micronutrient malab- sorption. Although nutrition intervention can ameliorate adverse effects on growth failure, permanent growth impairment can still occur in 19%–35% of children with Crohn’s disease. Dual-energy x-ray absorptiometry is widely accepted as a quantitative measurement technique for assessing skeletal status at all ages. Children should be assessed relative to age or body size and sex, with bone mineral density expressed as z-scores. Vitamin D supplementation and higher serum 25-hydroxyvitamin D levels have also been shown to be associated with quiescent disease activity. Ferric iron has been used as well with reportedly reduced side effects and good effcacy. Although a dose of 1 mg of folic acid is commonly used in pediatrics, the folic acid requirement of children with Crohn’s disease has not been determined. Stunting is usually seen in patients with long-standing uncontrolled disease or delayed diag- nosis. Well-nourished patients should try to achieve recommended caloric intakes and recommended daily allowances of vitamins and micronutrients. A more recent systematic review confrmed higher rates of remission in corticosteroid-treated patients. However, clinical studies, registries, and case reports warn of the increased risk of infections, particularly tuberculosis and fungal infections. The incidence of infections, however, increased in patients given infiximab more frequently. During the 36-month follow-up, the most prevalent adverse events were respiratory infec- tions.
The modifed Mason–Allen suture confguration demonstrated the highest maximum load and yield load on biomechanical cyclical testing porcine medial meniscal root tears cheap generic kamagra canada impotence cures natural, with superiority to hori- zontal mattress sutures or modifed loop stitches order kamagra 50 mg visa erectile dysfunction doctors in utah. However purchase kamagra 50mg on line erectile dysfunction drugs in development, two simple stitches may also represent an alternative given its similarly favorable stiffness and relative technical ease discount 100mg kamagra mastercard erectile dysfunction main causes. All tears were verti- cal tears and located within the red-red or red-white zones. At an average follow-up of 18 months (14–28 months), there were six failures, giving a success rate of 90. In a cadaveric study comparing three techniques for meniscal repair, inside out meniscal repair demonstrated higher gap formation than either suture-based or anchor-based all-inside meniscal repair with cyclical loading. There were no statistically signifcant differences in stiffness between the three repair techniques, whereas the all-inside suture-based and inside-out repair techniques demonstrated higher loads to failure than the anchor-based, all-inside repairs. Based on the available literature, the existing literature reveals that failure rates of all-inside menis- cal repair (24. Fifty-four meniscal tears in 46 patients who underwent all-inside meniscal repair with the Rapid- Loc device were retrospectively reviewed after at least 2 years of follow-up (mean 34. Symptomatic patients were evaluated by magnetic resonance arthrography and repeat arthroscopy. Predictive variables for failure included bucket-handle tears, multiplanar tears, tear length greater than 2 cm, and chronicity longer than 3 months. This laboratory analysis compares two all-inside repair devices with two different suture-based, inside-out repair techniques in a laboratory porcine model. The authors identifed that inside-out suture repair had similar biomechanical properties with cyclical loading and demonstrated no superiority relative to all-inside repair constructs. While there were no signifcant differences in failure rates between the groups, the follow-up was 3½ years shorter for the meniscal arrow repairs. All devices survived cyclic loading with no sig- nifcant difference in displacement. A limited arthrotomy may be performed • 3/8-inch osteotome early to facilitate preparation for bone trough/tunnels, or this may be deferred until • Battery-powered drill ready for graft passage. Anteromedial Tibial Approach • Percutaneous or small (2 cm to 3 cm) incision may be placed along the anteromedial tibia beginning at the level of the tibial tubercle for medial or lateral meniscus trans- plantation. Posterolateral Accessory Approach • A 3-cm to 4-cm incision is placed at the tibial joint line just posterior to the lateral collateral ligament with the knee in 90° of fexion, with one third of the incision above and two thirds below. Step 4: Allograft Meniscus Preparation • Lateral meniscus allograft • Peripheral meniscal tissue is exposed to provide a fresh surface for repair. Alternatively, 2-0 nonabsorbable sutures with attached needles may be passed directly through the meniscus and capsule in inside-out fashion. Alternatively, 2-0 nonabsorbable sutures with attached needles may be passed directly through the meniscus and capsule in inside-out fashion. Modern through zone-specifc cannulas placed through the anteromedial or anterolateral all-inside fxators may result in comparable portals, with alternating superior (Fig. Suture only fxation demonstrated a signifcantly higher rate of radiographic meniscal extrusion and secondary graft tear, although functional outcome measures did not correlate with the presence of meniscal extrusion. In a retrospective comparative study of patients undergoing inside-out versus all-inside repair of the posterior horn during meniscus allograft transplantation, there was no difference in mean Lysholm score, Tegner activity scale, degree of meniscal extrusion, or meniscal healing during sec- ond look arthroscopy. The mean operative time was signifcantly longer for inside-out repair than all-inside repair (169. Three patients (23%) required further surgery, including one patient each with revision meniscal allograft transplantation, partial meniscectomy, and secondary meniscal repair. The authors concluded that meniscus transplantation alone or in combination with other reconstructive procedures results in reliable improvements in knee pain and function at minimum 2-year follow-up; however, longer-term studies are necessary to determine if transplantation can prevent the articular degeneration associated with meniscectomy. The fnd- ings of this study agree with several other studies with shorter follow-up times that medial meniscal allograft transplantation can signifcantly improve knee function in symptomatic medial meniscus– defcient knees. The addition of a ligament-stabilizing procedure probably improved the results in this patient population. This paper provides current knowledge regarding the indications, operative techniques, rehabilita- tion programs, and clinical outcomes of meniscus repair and transplantation procedures. This paper provides a comprehensive review of the history of meniscal allograft transplantation, including background, indication, techniques, and outcomes. This paper describes the use of a femoral distractor during meniscus allograft transplantation. The improved visualization and access provided by the femoral distractor markedly simplifes the more challenging aspects of meniscus transplantation, helping to ensure precise tunnel placement, facili- tate graft passage, and aid in accurate suturing. The authors present a retrospective review of 172 patients undergoing meniscus allograft trans- plantation at a single institution over an 8-year time frame. During a mean 59-month follow-up, 32% of patients required a return to the operating room, (mostly commonly for meniscal débride- ment) at an average 21 months postoperatively (range, 2–107 months). This paper provides a biologic analysis of biopsied meniscal allograft and the adjacent synovial membrane in patients who had undergone meniscal allograft transplantation at a mean of 16 months earlier. The authors found that human meniscal allograft transplants are repopulated with cells that appear to be derived from the synovial membrane; these cells appear to actively remodel the matrix. Although there is histologic evidence of an immune response directed against the trans- plant, this response does not appear to affect the clinical outcome. The presence of histocompat- ibility antigens on the meniscal surface at the time of transplantation (even after freezing) indicates the potential for an immune response against the transplant. This paper provides a comprehensive review concerning meniscal allograft transplantation. It contains information on basic science and clinical results, surgical technique, and a discussion of several issues concerning the surgery, including patient selection, severity of degenerative changes, limb stability and alignment, graft sizing and processing methods, graft placement, and graft fxation. A retrospective study of 32 patients was conducted to determine the clinical outcomes following isolated lateral meniscal allograft transplantation. The fndings suggested that isolated meniscal allograft transplantation can be a benefcial procedure in properly selected symptomatic patients with a lateral meniscus–defcient knee. The data also suggested that earlier meniscal transplan- tation, before the onset of signifcant joint space narrowing, may result in improved outcomes. Finally, bony fxation may have a signifcant advantage over suture fxation, particularly with regard to knee range of motion. In a series of 227 military patients undergoing meniscal allograft transplantation, 22% of patients were unable to return to military duty at short-term follow-up due to persistent knee limitations. De- spite the high prevalence of prior (51%) and concomitant procedures (40%), the rates of secondary meniscal débridement and revision were 4. Tobacco use resulted in a higher risk of adverse outcomes, whereas higher-volume surgeons had reduced rates of failure postoperatively. Only 12% of patients required secondary surgery, and older age and inability to return to sporting activity were associated with worse clinical outcomes.