Chapter 14 Meniscal Allografts, Cartilage Repair, and Concomitant Procedures
Introduction: Meniscal Allograft Transplantation
The preoperative planning for this procedure should include the identification of the meniscal pathology and obtaining sizing radiographs;1,2 confirming the sizing, site, and side of the tissue match from the tissue bank; and assessing ligamentous stability, alignment, and articular cartilage status. Any ligamentous abnormalities, malalignment, or articular cartilage pathology should be corrected either concomitantly or staged. At the time of surgery, before the initiation of anesthesia, confirm that the meniscus allograft is in the operating room (OR) and that it is the appropriate patient, size, side, and site. Three techniques will be reviewed: the double bone plug,3 the dovetail technique,4 and the slot technique.5
General Tibial Preparation
1. Under arthroscopic visualization identify the anterior and posterior horn attachments. (Fig. 14-1)6
2. Utilizing both arthroscopic instrumentation and a shaver, debride the remaining meniscal remnant leaving 1 to 2 mm of meniscal capsular rim and horn attachments. (Fig. 14-2)
3. Confirm the presence of punctuate bleeding in the remaining tissue. It is preferable not to use a tourniquet for this part of the procedure. (Fig. 14-3)
4. To facilitate visualization of the posterior horn attachment and body, a high-speed burr can be used to remove a portion of the tibial spine. In addition, a partial release of the medial collateral ligament (MCL) deep fibers can be carried out (Fig. 14-4)).
Double Bone Plug Technique
Graft Preparation
2. The anterior bone plug should be 8 mm in diameter and 10 mm long. The posterior plugs should be 6 to 7 mm in diameter and 8 mm in length. (Fig. 14-5)
4. If using a coring reamer, place a 2.4-mm guide pin through the center of the anterior and posterior horn attachment sites, extending through the bone block. (Fig. 14-6)
6. Place a coring reamer of appropriate size over the collared pin and create a bone dowel. (Fig. 14-7)
8. Pass a nonabsorbable size 0 or 1 suture up through the posterior plug. Place a horizontal mattress suture through the meniscal tissue at the attachment site. Pass the suture down through the bone plug. (Fig. 14-8)
Posterior Tibial Tunnel Preparation
1. Using an anterior cruciate ligament (ACL) tibial guide, place the tip of the guide on the posterior horn attachment such that the 2.4-mm guide wire will be centered. (Fig. 14-9)
2. Select a cannulated reamer 1 mm larger than the posterior plug diameter, and drill a tunnel from the anterior tibia exiting at the posterior horn attachment. (Fig. 14-10)
Placement of the Meniscus Allograft
2. Pass the suture attached to the posterior horn through the previously created posterior tunnel utilizing a suture retriever. (Fig. 14-12)
3. Place a pull-through suture guide into the body of the meniscus at the junction of the posterior and middle thirds. It is often helpful to use two separate pull-through sutures. (Fig. 14-13)
5. Pass the pull-through guide suture through the knee at the corresponding position in the remnant meniscus such that it exits the knee through the posteromedial incision.
6. Pass the posterior bone plug through the notch, guiding it into the posterior tunnel using the posterior tunnel suture and a blunt instrument to help position it. (Fig. 14-14)
7. Use the pull-through guide suture and blunt instrumentation to reduce the remainder of the body of the meniscus. (Fig. 14-15)
8. Secure the posterior bone plug by tying the sutures attached to the bone plug over a button on the anterior tibia.
Placement of Anterior Plug
1. After securing the posterior plug and reducing the body of the graft, seat the meniscus by placing it through a range of motion. This will also facilitate the selection of the attachment site for the anterior horn.
2. Utilizing a 2.4-mm guide pin, place it into the center of the area of anterior attachment, keeping it as perpendicular to the tibial joint surface as possible. (Fig. 14-16)
4. Reduce the anterior plug into the tunnel. Although this allows for press fit fixation, additional stabilization may be required with nonabsorbable size 0 or 1 sutures. (Fig. 14-17)
Securing the Meniscal Allograft
1. Secure the meniscus utilizing either an inside-out technique, an all-inside technique, or a combination of both.
2. If using the inside-out technique, use 2-0 absorbable sutures and pass them through the previously created posteromedial or posterolateral incision. (Fig. 14-18)
3. An all-inside technique is often used in the posterior body. This technique can be difficult if there isn’t adequate meniscal rim to pass the fixation device into.
Dovetail Technique
Tibial Preparation
1. After meniscal remnant preparation, under arthroscopic visualization use an arthroscopic burr to remove the tibial spine. Using the same burr, create a shallow trough into the cortical bone connecting the anterior and posterior horn attachment sites. (Fig. 14-20)
4. Place a precalibrated osteotome vertically in alignment with the alignment rod and advance it into the tibial plateau. It should be advanced to the posterior cortex of the tibia. (Fig. 14-23)
5. Remember that the anterior tibial plateau slopes inferiorly. Therefore the depth marker must be above the plateau anteriorly but flush more posteriorly.
6. Record the calibrated markings on the osteotome and use them to correlate with the bone block length during the remainder of the procedure. (Fig. 14-24)
8. Place a 6-mm drill into the guide and advance it until you reach the posterior cortex. The depth markings on the drill will correlate with the previously recorded depth from the osteotome. During the drill advancement, the overlying tibial surface will be disrupted. (Fig. 14-26)
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