Meniscal Allografts, Cartilage Repair, and Concomitant Procedures

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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

Double Bone Plug Technique

Graft Preparation

1. The bone plugs can either be prepared freehand or by using a coring reamer.

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)

3. The freehand technique is performed using rongeurs and high-speed burr.

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)

5. Insert a collared pin into the bottom of the bone bridge.

6. Place a coring reamer of appropriate size over the collared pin and create a bone dowel. (Fig. 14-7)

7. Trim the dowels to the appropriate length.

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)

FIGURE 14-5

FIGURE 14-6

FIGURE 14-7

FIGURE 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)

3. Debride and smooth the intraarticular portions of the tunnel using rasps and a shaver.

FIGURE 14-9

FIGURE 14-10

Placement of the Meniscus Allograft

1. Create a limited or miniarthrotomy. (Fig. 14-11)

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)

4. Create a small posteromedial skin incision, and dissect the subcutaneous tissue to the capsule.

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.

FIGURE 14-11

FIGURE 14-12

FIGURE 14-13

FIGURE 14-14

FIGURE 14-15

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)

3. Place an 8-mm cannulated reamer over the guide wire, and create a bone tunnel 10 mm deep.

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)

FIGURE 14-16

FIGURE 14-17

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)

2. Create a miniarthrotomy corresponding to the side of implantation. (Fig. 14-21)

3. Place the alignment rod in the trough connecting the anterior and posterior horns. (Fig. 14-22)

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)

7. Attach the first drill guide to the osteotome handle. (Fig. 14-25)

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)

9. Remove all bone remnants and debris.

10. Secure the second drill guide to the osteotome blade. (Fig. 14-27)

11. Place a 7-mm drill into the guide and advance it to the posterior cortex. This hole, combined with the 6-mm hole, helps to create the trapezoidal shape of the recipient site.

12. Introduce the preshaped rasp into the now-created tunnel in the tibia. The rasp should be oriented such that the vertical side is toward the midline, and the top is flush with the tibial articular surface. (Fig. 14-28)

13. Advance the rasp slowly both by hand and by mallet until you contact the posterior cortex.

14. Insert the dovetail dilator into the trapezoidal slot until you contact the posterior cortex. (Fig. 14-29)

15. Correlate the precalibrated length markings on the rasp and dilator with the length of the meniscal allograft bone block. (Fig. 14-30)

16. Address any bone fragments or irregular surfaces before graft placement. (Fig. 14-31)

FIGURE 14-20

FIGURE 14-21

FIGURE 14-22

FIGURE 14-23

FIGURE 14-24

FIGURE 14-25

FIGURE 14-26

FIGURE 14-27

FIGURE 14-28

FIGURE 14-29

FIGURE 14-30

FIGURE 14-31

Graft Preparation

1. The initial large bone block can be trimmed to allow better placement in the graft holder. Anterior-posterior (AP) length should be cut in accordance with the premeasured length of the trapezoidal slot determined during tibial preparation.

2. Draw an outline of the dovetail bone block on the end of the bone block using the rasp as a guide. Align the vertical edge toward the midline and central to the anterior and posterior horn attachment sites (Fig 14-32).

3. Position the allograft in the workstation upside down. Align the midline edge of the dovetail outline with the vertical face of the holding posts. Align the soft tissue attachments with the lower face of the holding posts. The bone block is secure within the holding posts. (Fig. 14-33)

4. Position the first cutting guide so that the vertical cutting aligns face aligns with the vertical face of the holding posts. Use a sagittal saw to complete this cut. (Fig. 14-34)

5. Position the second cutting guide so it is flush to the bone block vertical cut. a horizontal or inferior side cut of the bone block complete using the sagittal saw. (Fig. 14-35)

6. Place the third and final cutting guide such that it is in contact with the medial bone surface and positioned to guide the angled cut of the bone. Again, use a sagittal saw to complete this cut. (Fig. 14-36)

7. Use the graft sizing block to determine appropriate sizing and easy passage. (Fig. 14-37 and 14-38)

FIGURE 14-32

FIGURE 14-33

FIGURE 14-34

FIGURE 14-35

FIGURE 14-36

FIGURE 14-37

FIGURE 14-38

Slot Technique

Tibial Preparation

1. Debride the meniscal remnant and identify the anterior and posterior horn attachment sites as previously described.

2. Create a marker using a thermal device connecting the anterior and posterior horn attachment sites. (Fig. 14-43)

3. Using a 4.0-mm round burr, create a reference slot going from the posterior to the anterior horn. The reference slot should be equal to the height of the burr and parallel to the sagittal slope of the tibia. (Fig. 14-44)

4. Remove tibial spine along this reference slot as needed.

5. Place the initial depth gauge guide into the knee such that the hook passes over the posterior cortex and the shaft of the guide lies flush with the tibial surface. (Fig. 14-45)

6. Keeping the depth gauge against the posterior cortex and flush with the articular surface, note the length and then place the drill guide over the guide wire. The drill guide should be seated firmly against the anterior tibia. (Fig. 14-46)

7. Drill the calibrated

^” guide pin through the drill guide hole. Advance the drill guide until the red marking on each instrument lines up. This will indicate that the end of the pin is 3 mm from the posterior wall. (Fig. 14-47)

8. Again confirm the length on the calibrated depth gauge and guide wire. (Fig. 14-48)

9. Preset this length on the drill before drilling the tibial plateau. (Fig. 14-49)

10. Remove the drill guide and depth gauge, leaving the guide pin in place. (Fig. 14-50)

11. Place the 8-mm cannulated drill, with depth set, over the guide wire and advance until the depth set chuck contacts the anterior tibia. The superior aspect of this tunnel may disrupt the tibial surface. (Fig. 14-51)

12. Insert the 8-mm box cutter over the guide pin and into the drilled hole. Advance slowly by gently tapping with a mallet. The markings on the box cutter correlate with the depth measurements and can be monitored to prevent overpenetration. (Fig. 14-52)

13. Create a slot that is 8 mm wide by 10 mm deep.

14. Use a 7-mm and 8-mm three-sided rasp sequentially to smooth the final slot. Remove any additional boney or soft tissue debris at this time as well. (Fig. 14-53)

FIGURE 14-43

FIGURE 14-44

FIGURE 14-45

FIGURE 14-46

FIGURE 14-47

FIGURE 14-48

FIGURE 14-49

FIGURE 14-50

FIGURE 14-51

FIGURE 14-52

FIGURE 14-53

Graft Preparation

1. Excess bone can be removed from the bone block to facilitate placement into the sizing block.

2. Place the meniscus onto the sizing block, making certain that the horns are flush with the markers of the inner surface of the sizing block. These marks assure a 10-mm height. (Fig. 14-54)

3. Once the graft is aligned appropriately, the U-pin will hold the meniscus in place in the block.

4. Measure the height using the anterior and posterior horns as reference marks. Remove excess bone using the bottom of the sizing block as a guide to achieve a 10-mm height. (Fig. 14-55)

5. The cartilage covering the tibial spine can be removed, but the cortex of the bone should not be violated. Violating the cortex may weaken the bone bridge and cause fracture during insertion.

6. The sizing block is designed with slots to allow for the creation of either a 7-mm or an 8-mm wide bone block. Select the desired width slot and, using a sagittal saw, cut to the appropriate width. (Fig. 14-56)

7. Excess bone extending beyond the posterior horn attachment can then be removed to adjust length. Leave any excess bone on the anterior horn until after bone block insertion so as not to compromise graft integrity. (Fig. 14-57)

8. Slide the bone bridge through the sizer to confirm height, width, length, and easy passage.

FIGURE 14-54

FIGURE 14-55

FIGURE 14-56

FIGURE 14-57

Graft Placement

1. Place either one or two pull-through sutures into the body of the meniscus at the posterior and middle third junction. If using two, they should be separated by 8 to 10 mm. The advantage of two pull-through sutures is that in a tight compartment they will give more leverage and puts less stress on the bone bridge. These two sutures can then be tied together over the capsule to provide additional fixation. (Fig. 14-58)

2. Introduce the bone bridge into the tibial bone slot and slowly advance using the pull-through sutures to help guide the meniscal body into position. (Fig. 14-59)

3. As needed, an assistant can apply either varus (lateral meniscus) or valgus (medial meniscus) stress to facilitate reduction of the meniscus.

4. Once reduced and in place, the knee is cycled through a range of motion to obtain final seating before suture fixation.

5. The bone bridge can be secured by either using a small interference screw or a suture anchor device acting as an interference screw. The preloaded sutures can then be utilized to secure the anterior horn and capsule. (Fig. 14-60)

6. Suture fixation is then achieved by using either the inside-out technique, all-inside technigue, or a combination of both.

FIGURE 14-58

FIGURE 14-59

FIGURE 14-60

Cartilage Repair and Meniscal Allograft Transplantation

Meniscal allograft transplantation can be performed concomitantly with articular cartilage restoration techniques.⁷^–⁹ It is imperative that appropriate preoperative planning is undertaken. The techniques of articular cartilage restoration are outlined in this text. The following is a general guideline for the combined procedures:

1. Perform an arthroscopic assessment of the knee joint, and prepare the meniscal remnant.

2. Proceed with all initial arthroscopic steps in the tibial preparation of the selected meniscal allograft transplantation (MAT) procedure.

3. Upon completion of the arthroscopic portions of the tibial preparation, proceed with creating an arthrotomy as will be required for the cartilage repair procedure. Most aspects of the tibial preparation in the MAT procedures can be done via an arthrotomy.

4. Identify the articular cartilage defect.

5. The meniscal allograft can be prepared by an assistant while the primary surgeon is preparing the articular cartilage defect. This will decrease operative time.

6. Prepare the articular cartilage defect in accordance with the selected articular cartilage repair technique as described elsewhere in this text.

7. Upon completion of the meniscal allograft preparation, place the appropriate pull-through sutures in the meniscal body and place aside in a moistened sponge.

8. After completion of the preparation of the articular cartilage defect it is recommended that the meniscal allograft be placed before completion of the articular cartilage repair. This will protect the repair site from being damaged during the reduction of the meniscus.

9. Create the posteromedial or posterolateral incision and dissect to the capsular layer. Pass the pull-through sutures into the joint, through the meniscus, and out the incisional area.

10. Proceed with the placement of the meniscal allograft. Pass the suture fixation mostly using inside-out sutures, but do not tie down. Again, this will prevent the risk of injury to the articular repair site while securing the meniscus. Leaving the suture untied allows for the extremes of motion of the knee during the articular cartilage repair without compromising meniscal fixation.

11. Meniscal allograft reduction can be challenging if the articular cartilage defect extends posteriorly. The meniscus can be caught on the rim of articular cartilage at the defect site.

12. The articular cartilage repair is then completed.

13. Final stabilization of the meniscal allograft is then achieved.

Cartilage Repair and ACL Reconstruction

1. Perform an arthroscopic preparation of the meniscal remnant and debridement of ACL remnant and intercondylar notch.

2. Proceed with the notchplasty as indicated.

3. It should be noted that any of the MAT techniques can be performed in combination with ACL reconstruction.

4. Proceed with arthroscopic portion of tibial preparation for the selected MAT procedure.

5. Proceed with arthroscopic creation of tibial and femoral tunnels for the selected ACL reconstruction procedure. There may be slight overlap of the tibial ACL tunnel and tibial tunnel if using a bone bridge technique for MAT.

6. Create a miniarthrotomy, and complete the tibial preparation for the MAT procedure.

7. Prepare the meniscal allograft tissue in accordance with the selected MAT technique. If an assistant is available to do this part of the procedure, it will reduce operative time.

8. If using autograft, the graft can be harvested and prepared simultaneously to the meniscal allograft preparation.

9. Pass pull-through suture into the knee as previously described.

10. Place separate pull-through sutures in the meniscal body.

11. Proceed with placement of the ACL graft, fixating only the femoral side.

12. Proceed with placement and reduction of the meniscal allograft. Allowing the knee to be lax will facilitate the reduction of the meniscal allograft into the appropriate position.

13. Two methods are recommended if using a bone bridge technique and there is overlap of the ACL tibial tunnel and bone bridge tibial tunnel. A burr or ronger can be used to gently remove some of an overlapping bone bridge. Take care not to injure the ACL graft. The graft can always be pushed up out of the tunnel during this procedure and then reduced once completed. If there is less overlap, then the ACL graft, which at this point will be soft tissue, can be gently compressed to the side allowing for passage of the bone bridge. (Fig. 14-61)

14. Once the meniscus is in place and the bone bridge reduced, complete the fixation of the meniscus. Again having the knee lax will facilitate fixation access.

15. After the completion of meniscal fixation, the ACL graft can be tensioned and fixed at the tibial tunnel site.

FIGURE 14-61

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2. Shaffer B., Kennedy S., Klimkiewicz J., et al. Preoperative sizing of meniscal allografts in meniscus transplantation. Am J Sports Med. 2000;28:524-533.

3. Shelton W.R., Dukes A.D. Meniscus replacement with bone anchors: a surgical technique. Arthroscopy. 1994;10:324-327.

4. Farr J., Gersoff W. Meniscal transplantation. In: Cole J.B., Malek M., editors. Articular Cartilage Lesions: a practical guide to assessment and treatment. New York: Springer; 2004:140-150.

5. Packer J.D., Rodeo S.A. Meniscal allograft transplantation. Clinics Sports Med. 2009;28:259-283.

6. Kohn D., Moreno B. Meniscus insertion anatomy as a basis for meniscal replacement: a morphological cadaveric study. Arthroscopy. 1995;11:96-103.

7. Farr J., Rawal A., Mayberry K.M. Concomitant meniscal allograft transplantation and autologous chondrocyte implantation: minimum 2-years follow-up. Am J Sports Med. 2007;35(9):1459-1466. Epub 2007 Apr 13

8. Gersoff W.K. Combined meniscal allograft transplantation and autologous chondrocyte implantation. Op Tech Sports Med. 2002;10(3):165-169.

9. Rue J.P., Yanke A.B., Busam M.L., et al. Prospective evaluation of concurrent meniscal transplantation and articular cartilage repair: minimum 2 year follow-up. Am J Sports Med. 2008;36:1770-1778.

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