Concomitant Arthroscopic Meniscal Allograft Transplantation and Anterior Cruciate Ligament Reconstruction

Abstract

In recent decades, arthroscopic meniscal allograft transplantation (MAT) has been refined as a robust option for the treatment of evolving unicompartmental tibiofemoral arthrosis in the setting of meniscal deficiency. It is imperative that the MAT be performed in a knee with anatomic stability and alignment to reduce aberrant biomechanical forces experienced by the allograft tissue to maintain its durability. Thus, in an anterior cruciate ligament (ACL)edeficient knee, ACL reconstruction (ACLR) must be performed to restore the stable knee environment for the MAT to succeed. Although these operations can be performed in staged fashion, a single-stage procedure with concomitant MAT and ACLR is an option. Its performance is technically demanding and requires careful consideration as to the intraoperative setup, incisions, graft options, surgical tools, and procedural order to properly secure the transplanted meniscal allograft and restore a functional, anatomic ACL. We present our preferred technique for concomitant arthroscopic MAT and ACLR, as well as some potential pitfalls and pearls to avoid pitfalls.

Acceptable clinical outcomes despite high reoperation rate at minimum 12-month follow-up after concomitant arthroscopically assisted anterior cruciate ligament reconstruction and medial meniscal allograft transplantation

“…This was followed by creation of a tibial tunnel for the ACLR, which was reamed with a 10 mm reamer. The position of the tibial tunnel was adjusted accordingly to provide space for the future tunnel drilled for the anterior meniscus bone plug; this was achieved by drilling obliquely or using a lateral entry point distally on the tibia to minimize potential overlap with the bone plug tunnel [ 4 ]. Passage of the meniscus allograft was performed using shuttling sutures through a medial safety incision where care was taken to preserve the saphenous vein.…”

“…While meniscus allografts are relatively durable with a 10-year survival rate of 73.5% and a 20-year survival rate of 56.2%, almost 32% require reoperation at some point [ 1 , 2 ]. In those patients presenting with knee instability in the setting of meniscus deficiency, a concomitant anterior cruciate ligament reconstruction (ACLR) may be performed to restore normal knee kinematics and reduce abnormal loading of the transplanted meniscus [ 3 , 4 ].…”

“…However, this subjects the patients to two procedures and two separate rehabilitations. While various techniques have been described in the literature for performing ACLR and MAT as a single-stage arthroscopic procedure, the combined procedure is technically demanding [ 4 , 5 ]. Over the past two decades, a few case series and retrospective cohort studies have been conducted to assess outcomes of concomitant ACLR and MAT, and most have reported substantial improvements in patient-reported outcome measures, as well as high rates of graft survival and return to sport at 3–5 year follow-up [ 6 – 10 ].…”

Minimum 10-Year Clinical Outcomes and Survivorship of Meniscal Allograft Transplantation With Fresh-Frozen Allografts Using the Bridge-in-Slot Technique

“…The senior author preferred the bridge-in-slot technique for medial and lateral MATs with fresh-frozen, nonirradiated meniscal grafts (JRF Ortho) and, if present, treated concomitant pathology such as malalignment, focal cartilage defects, or ligamentous insufficiency. 8,27,29 Before transplantation, the meniscus was assessed in addition to the anterior and posterior cruciate ligaments as well as the chondral surfaces of the medial, lateral, and patellofemoral compartments. The meniscus was debrided until a bleeding peripheral rim of 1 to 2 mm was left, and anterior and posterior horns were subsequently resected.…”

Five Key Points on Meniscal Allograft Transplantation

“…Limb misalignment may be corrected as indicated with either a high tibial osteotomy or a distal femoral osteotomy. In the ACL deficient knee, the preference of the senior author is to perform a modified bridge-in-slot technique as described previously 23 . In general, any concomitant cartilage procedures or osteotomies should be performed after MAT, as fixation of the meniscal allograft requires significant stress to the knee that may compromise these procedures.…”