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Arthroscopic Meniscal Allograft Transplantation With Soft-Tissue Fixation Through Bone Tunnels

Open AccessPublished:October 12, 2015DOI:https://doi.org/10.1016/j.eats.2015.06.001

      Abstract

      Meniscal allograft transplantation improves clinical outcomes for patients with symptomatic meniscus-deficient knees. We describe an established arthroscopic technique for meniscal allograft transplantation without the need for bone fixation of the meniscal horns. After preparation of the meniscal bed, the meniscus is parachuted into the knee through a silicone cannula and the meniscal horns are fixed with sutures through bone tunnels. The body of the meniscus is then fixed with a combination of all-inside and inside-out sutures. This technique is reliable and reproducible and has clinical outcomes comparable with those of bone plug fixation techniques.

      Technique Video

      See video under supplementary data.

      The menisci of the knee act as load distributors as well as secondary stabilizers of the knee. Meniscal allograft transplantation is indicated for patients with a symptomatic meniscus-deficient compartment of the knee. Arthroscopic meniscal allograft transplantation with soft-tissue fixation is a less complicated and more minimally invasive procedure than bone plug techniques while still obtaining stable and secure graft fixation.

      Technique

      Our technique has been broken down into 10 key stages under the subheadings in this section and is shown in Video 1. The key messages of this technique are summarized in Table 1.
      Table 1Key Messages for Performing Meniscal Allograft Transplantation With All-Suture Technique
      This technique allows insertion of the meniscal allograft without bone plugs.
      Secure fixation of the meniscal horns is achieved through bone tunnels at the attachment sites.
      Peripheral fixation is achieved using a combination of all-inside and inside-out suture systems.
      This technique has several advantages over using bone blocks, with comparable results.

       Patient Positioning

      The procedure is performed with the patient under general or regional anesthesia with appropriate prophylactic antibiotics. The patient is positioned supine on the operating table with a thigh tourniquet, a single-thigh side support, and a footrest supporting the knee at 90°. For a lateral meniscal transplant, the knee will be moved to the figure-of-4 position. For a medial meniscal transplant, the leg will be abducted and rest against the outer hip of the operating surgeon.

       Graft Preparation

      The meniscal allografts are sourced from either NHS Blood and Transplant Tissue Services (Liverpool, England) or JRF Ortho (Centennial, Colorado) (imported by Fannin, Dublin, Ireland). The allograft is thawed to room temperature per the tissue bank's specific instructions (usually about 15 minutes in warm water or 1 hour at room temperature). The graft is dissected from the tibia, trimmed to its true margin, and freshened by the assistant at the start of surgery. The superior surface of the meniscus is marked to aid in orientation (Fig 1). In the case of the lateral meniscus, the most anterior margin of the popliteal hiatus is also marked and a No. 2 nonabsorbable suture is placed as an oblique vertical mattress suture. For the medial meniscus, a similar vertical mattress suture is inserted at a point at 40% of the circumference from posterior to anterior. This represents the middle traction suture (Fig 2A). No. 2 Ultrabraid sutures (Smith & Nephew, Andover, MA) are placed into the posterior and anterior horns using a modified whipstitch, with passage of the suture a minimum of 3 times along the meniscus and back again to ensure a good hold. It is important to ensure that the sutures emerge on the inferior aspect of the footprint of the meniscal horn. The prepared graft (Fig 1) is then wrapped in a vancomycin-soaked swab (500 mg in 100 mL of saline solution) and placed securely on the scrub table, awaiting implantation.
      Fig 1
      Fig 1The meniscal allograft has been dissected from the tibia and trimmed. It has then been labeled to aid orientation when inserting the graft into the knee. Whipstitches have been placed on the anterior and posterior horns to aid insertion and securing of the graft roots to the knee.
      Fig 2
      Fig 2(A) The lead sutures have been passed through the bone tunnels and out through the working portal. The middle traction suture has also been passed just anterior to the popliteus tendon and out through the working portal. The Arthrex PassPort silicone cannula is inserted through the working portal. (B) A lead suture is passed through the previously drilled posterior horn tunnel. This is then pulled through the working portal with a suture manipulator and clipped to the side. The same technique is used for the anterior horn tunnel.

       Knee Arthroscopic Evaluation

      The thigh tourniquet is inflated, and longitudinal (anteromedial and anterolateral) arthroscopy portals are made to allow for later extension. The treats the chondral lesions in the affected compartment, noting that the optimal indication for transplantation is chondral surfaces showing changes of International Cartilage Repair Society grade 3a or less.

       Recipient Bed Preparation

      The host meniscus is assessed and prepared by resecting the remaining meniscal tissue using a combination of arthroscopic punches and a shaver to leave, where possible, a 1- to 2-mm peripheral vascular rim of native meniscal tissue that will support the meniscal allograft. The recipient bed and synovium are rasped using a diamond-tipped rasp and fenestrated with a microfracture awl to stimulate healing and vascularization of the graft.

       Posterior and Anterior Horn Insertion-Site Preparation

      The tunnel positions for the meniscal horn attachment points are summarized in Table 2. The meniscal horn insertion sites are prepared using a combination of an angled punch to resect the remaining meniscus, a meniscal shaver, and a closed-cup curette, with exposure of subchondral bone over a 5- to 6-mm-diameter area.
      Table 2Optimal Meniscal Horn Insertion Points for Medial and Lateral Meniscal Horns
      Meniscus LocationOptimal Horn Insertion Point
      Medial meniscus
       Posterior hornJust posterior to medial tibial spine
       Anterior hornAnterior and medial to insertion of ACL on superior surface of tibial plateau
      Lateral meniscus
       Posterior hornJust posterior to ACL, between tibial spines
       Anterior hornAnterior to lateral tibial spine and just lateral to ACL
      ACL, anterior cruciate ligament.

       Posterior and Anterior Horn Tunnel Creation

      To prepare for the bone tunnels of the meniscal horn sutures, a 2-cm horizontal skin incision is made on the proximal tibia (opposite side to the transplanted meniscus). On the medial side, this is just above the hamstring tendon insertion on the bare area of the tibia, and on the lateral side, this is just under the flare of the anterolateral tibia. A 1-cm area of bare bone is exposed, elevating the tissue and periosteum. A contralateral working portal to the affected compartment is created by extending the relevant longitudinal arthroscopy portal to 2 cm, followed by insertion of a silicone cannula (PassPort; Arthrex, Naples, FL) (Fig 2A).
      A meniscal allograft transplantation drill aimer guide (Smith & Nephew) is inserted through the working portal and positioned in the posterior horn insertion point. The drill guide sleeve is then inserted into the handle and positioned onto the tibia through the prepared incision. The posterior horn suture tunnel is drilled with a long 2.4-mm-diameter Beath pin, with visualization of the tip emerging through the bone. The guidewire is overdrilled with a 4.5-mm cannulated EndoButton drill (Smith & Nephew), with the tip left carefully positioned just proud in relation to the tibial plateau surface. A closed-cup curette can be used to help protect against inadvertent damage to the articular surfaces and to help retract meniscal tissue, aiding visualization. The guidewire is removed, leaving the EndoButton drill bit in situ. A loop of No. 2-0 Prolene (Ethicon, Somerville, NJ) is passed through the 4.5-mm EndoButton drill bit on a suture passer and is retrieved through the working portal using a suture manipulator (Fig 2B). The free end of this lead suture is passed through the loop and clipped so that it hangs unsupported out of the way.
      The meniscal transplantation drill aimer guide is reintroduced through the working portal. The tunnel for the anterior horn is drilled in the center of the attachment footprint with the same sequence of steps. The suture ends are brought out through the working portal, clipped, and hung to the opposite side of the knee (Fig 2A). The suture manipulator is run along the sutures to ensure that there is no twisting or soft-tissue catching.

       Middle Traction Suture

      An 18-gauge needle is used to localize the correct insertion point. For the lateral meniscus, this point is just anterior to the popliteus tendon. For the medial meniscus, it is at 40% of the meniscal circumference from the posterior horn insertion. An Accupass suture device (Smith & Nephew) preloaded with a loop of No. 1 PDS (Ethicon) is then used, from outside in, to position 2 loops of sutures on the superior and inferior aspects of the meniscal bed directly above each other. Each loop is then gathered through the working portal and clipped to one side, with the surgeon once again checking for twisting with the other suture loops.

       Graft Passage

      The graft is “parachuted” through the working portal into the knee joint. The assistant holds the graft in the correct orientation adjacent to the working portal (Fig 3). Starting with the posterior horn sutures and then working anteriorly, all the meniscal sutures are pulled into position using the pre-placed shuttle sutures. The graft is now ready to be delivered into the knee through the working portal. Traction is first applied through the posterior sutures to pull the meniscus into the knee. The middle traction sutures are then used to complete the insertion of the meniscus into the knee. There is no traction applied to the anterior horn sutures until the meniscus is in place within the knee.
      Fig 3
      Fig 3The meniscal horn whipstitches have been passed through the working portal and out through the bone tunnels. The allograft is then pulled into the knee using the whipstitches and middle traction suture. The posterior horn is the lead suture for pulling the allograft into the knee.
      The anterior and posterior horn sutures are held temporarily over the bone bridge using a single knot throw and a clip. The graft is inspected arthroscopically to assess graft size and position, ensuring that it is snug against the meniscal bed.

       Graft Fixation

      The graft is fixed using a hybrid technique of all-inside, inside-out, and outside-in suture systems. With the arthroscope initially in the working portal, the first Fast-Fix 360 Meniscal Repair device (Smith & Nephew) is introduced through the ipsilateral compartment portal using a slotted cannula. With tension being held on the middle sutures, the posterior third is fixed to the prepared meniscal rim using the Fast-Fix 360 system, inserting sutures on the superior and inferior surfaces in a stacked vertical mattress pattern. Portals can be switched to ensure that an adequate fixation angle is achieved. A minimum of 4 suture devices are recommended, and by joysticking with the needle, the allograft can be optimally placed on the rim.
      The middle and anterior thirds of the meniscal graft are secured using an inside-out suture technique with No. 2-0 Ultrabraid. The sutures are inserted from the working portal in a stacked vertical mattress pattern (Fig 4 A and B). A curved inside-out cannula system is used, preferably achieving at least 6 to 8 loops in the body and anterior third, evenly spread on the superior and inferior surfaces of the meniscus. If there is inadequate suture hold on the anterior 1 to 2 cm, then an outside-in technique should be used.
      Fig 4
      Fig 4(A) The lateral meniscal allograft is in place (left knee), and vertical mattress sutures are placed at its superior surface. (B) The lateral meniscal allograft is in place (left knee), and vertical mattress sutures are placed at its inferior surface. (C) Final position of the lateral meniscal allograft transplant in the left knee. The meniscal horn sutures have been tied over the bone bridge, and sutures to the body have also been tied.

       Final Suture Fixation

      When the sutures are being tied, it is important to evaluate the position of the meniscus in the knee. The sutures should be tied so that the meniscus fits snuggly against the capsule (Fig 4C). In general, the capsule sutures are tied first, and the order is determined by visual assessment of the meniscus. Finally, the anterior and posterior horn sutures are tied under strong tension over the bone bridge, thereby minimizing radial displacement and extrusion.

      Discussion

      Meniscal allograft transplantation has been performed for over 30 years and has consistently been shown to improve clinical outcomes.
      • Smith N.A.
      • MacKay N.
      • Costa M.
      • Spalding T.
      Meniscal allograft transplantation in a symptomatic meniscal deficient knee: A systematic review.
      • Elattar M.
      • Dhollander A.
      • Verdonk R.
      • Almqvist K.
      • Verdonk P.
      Twenty-six years of meniscal allograft transplantation: Is it still experimental? A meta-analysis of 44 trials.
      It may also reduce the known high risk of osteoarthritis in these patients, although high-quality evidence for this is lacking.

      Smith NA, Parkinson B, Hutchinson CE, Costa ML, Spalding T. Is meniscal allograft transplantation chondroprotective? A systematic review of radiological outcomes. Knee Surg Sports Traumatol Arthrosc in press, available online 19 March, 2015. doi:10.1007/s00167-015-3573-0.

      The 2 most common types of meniscal horn fixation are soft-tissue fixation (described in this report) and bone fixation.
      • Smith N.A.
      • MacKay N.
      • Costa M.
      • Spalding T.
      Meniscal allograft transplantation in a symptomatic meniscal deficient knee: A systematic review.
      Recent studies have failed to show a significant biomechanical or clinical advantage of bone plug fixation over an all-suture technique.
      • Myers P.
      • Tudor F.
      Meniscal allograft transplantation: How should we be doing it? A systematic review.
      • McDermott I.
      • Lie D.
      • Edwards A.
      • Bull A.
      • Amis A.
      The effects of lateral meniscal allograft transplantation techniques on tibio-femoral contact pressures.
      Meniscal transplants secured by soft-tissue fixation have shown histologic advantages compared with bone plug fixation grafts. Significantly higher cellular viability and collagen organization were found on biopsy of the grafts secured by soft-tissue fixation only, which may be related to a higher immunologic host response caused by the addition of bone plugs.
      • Rodeo S.A.
      • Seneviratne A.
      • Suzuki K.
      • Felker K.
      • Wickiewicz T.L.
      • Warren R.F.
      Histological analysis of human meniscal allografts. A preliminary report.
      There is also a risk of increased articular cartilage damage if the bone plugs are malpositioned.
      • von Lewinski G.
      • Kohn D.
      • Wirth C.J.
      • Lazovic D.
      The influence of nonanatomical insertion and incongruence of meniscal transplants on the articular cartilage in an ovine model.
      A meta-analysis and clinical studies have shown comparable outcomes between the 2 different fixation techniques.
      • Elattar M.
      • Dhollander A.
      • Verdonk R.
      • Almqvist K.
      • Verdonk P.
      Twenty-six years of meniscal allograft transplantation: Is it still experimental? A meta-analysis of 44 trials.
      • Myers P.
      • Tudor F.
      Meniscal allograft transplantation: How should we be doing it? A systematic review.

      Alentorn-Geli E, Seijas Vazquez R, Garcia Balletbo M, et al. Arthroscopic meniscal allograft transplantation without bone plugs. Knee Surg Sports Traumatol Arthrosc in press, available online 14 April, 2010. doi:10.1007/s00167-010-1123-3.

      Although both techniques are viable options for meniscal allograft fixation, the technique described in this report provides a reliable method for surgeons to undertake meniscal transplantation.

      Supplementary Data

      References

        • Smith N.A.
        • MacKay N.
        • Costa M.
        • Spalding T.
        Meniscal allograft transplantation in a symptomatic meniscal deficient knee: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 270-279
        • Elattar M.
        • Dhollander A.
        • Verdonk R.
        • Almqvist K.
        • Verdonk P.
        Twenty-six years of meniscal allograft transplantation: Is it still experimental? A meta-analysis of 44 trials.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 147-157
      1. Smith NA, Parkinson B, Hutchinson CE, Costa ML, Spalding T. Is meniscal allograft transplantation chondroprotective? A systematic review of radiological outcomes. Knee Surg Sports Traumatol Arthrosc in press, available online 19 March, 2015. doi:10.1007/s00167-015-3573-0.

        • Myers P.
        • Tudor F.
        Meniscal allograft transplantation: How should we be doing it? A systematic review.
        Arthroscopy. 2015; 31: 911-925
        • McDermott I.
        • Lie D.
        • Edwards A.
        • Bull A.
        • Amis A.
        The effects of lateral meniscal allograft transplantation techniques on tibio-femoral contact pressures.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 553-560
        • Rodeo S.A.
        • Seneviratne A.
        • Suzuki K.
        • Felker K.
        • Wickiewicz T.L.
        • Warren R.F.
        Histological analysis of human meniscal allografts. A preliminary report.
        J Bone Joint Surg Am. 2000; 82: 1071-1082
        • von Lewinski G.
        • Kohn D.
        • Wirth C.J.
        • Lazovic D.
        The influence of nonanatomical insertion and incongruence of meniscal transplants on the articular cartilage in an ovine model.
        Am J Sports Med. 2008; 36: 841-850
      2. Alentorn-Geli E, Seijas Vazquez R, Garcia Balletbo M, et al. Arthroscopic meniscal allograft transplantation without bone plugs. Knee Surg Sports Traumatol Arthrosc in press, available online 14 April, 2010. doi:10.1007/s00167-010-1123-3.