Medial Meniscal Allograft Transplantation: The Bone Plug Technique

Abstract

The medial meniscus is crucial for knee homeostasis. Treating patients who have undergone a subtotal or total meniscectomy, or equivalent irreparable tear pattern, can be extremely challenging, especially in young, active patients. The importance of meniscal preservation has been reported by several authors. Meniscal repair is now widely accepted as the first surgical option for treating medial meniscal tears. Moreover, current guidelines recommend preserving as much meniscal tissue as possible. Treating a symptomatic medial meniscectomized knee is challenging because of limited surgical options. In this context, medial meniscal allograft transplantation arises as the preferred procedure. The purpose of this article was to detail the arthroscopic medial meniscal allograft transplantation technique with the use of 2 bone plugs.

Fig 1

Arthroscopic image of trimming the meniscal remnant tissue with a mechanical shaver while leaving a small rim of healthy tissue, as viewed through the anteromedial portal. (MFC, medial femoral condyle; MTP, medial tibial plateau.)

Fig 2

Intraoperative picture of a left knee showing the exposure of the anteromedial aspect of the tibia for tunnel placement.

Fig 3

Illustrations of a medial meniscal allograft transplantation for a right knee. (A) Placing the posterior meniscal horn passing sutures from the anteromedial incisions through the posteromedial capsule and out the posteromedial approach. These will later be matched up with the posterior horn sutures and used to pull the graft into place. (B) Illustration after the 2 tibial tunnels have been drilled and the allograft has been inserted. Both bone tunnels as well as the anterior and posterior horn sutures are in place.

Fig 4

Picture depicting a guide pin passing through the posterior root of the medial meniscal graft and a collared pin inserted through the bottom of the posterior root.

Fig 5

Picture depicting (A) a medial meniscal allograft with 3 anterior and 4 posterior meniscocapsular junction sutures, as well as 2 sutures through each bone plug. The periphery of the graft is marked with methylene blue to help distinguish it from the remnant native meniscal rim during arthroscopy. (B) Two nonabsorbable sutures are passed up through the bone plug, through the soft tissue, and back down the bone plug with a large straight needle.

Fig 6

Left knee picture showing (A) posterior passing sutures used to help with passage of the meniscal allograft, and (B) an arthroscopic view of the posterior horn sutures being used to properly position the graft. (MFC, medial femoral condyle.)

Fig 7

Right knee illustration showing the location of the anterior medial meniscal root tunnel and the anterior accessory tunnel. The anterior root tunnel is drilled in an anterograde fashion and the sutures will be passed through the accessory tunnel and tied down to a cortical fixation device over the anteromedial tibia.

Fig 8

Intraoperative image of a left knee after insertion of the medial meniscal allograft. The cortical fixation devices that secure the anterior and posterior bone plugs through the tibial tunnels can be seen. In addition, anterior horn sutures can be seen.

Fig 9

Arthroscopic image of a left knee showing placement of inside-out sutures to the middle portion of the allograft after the anterior and posterior roots and horns have been secured. (MFC, medial femoral condyle.)