Meniscal Allograft Transplantation

By: Thomas M. DeBeradino, M.D.

Member, AANA Communications and Technology Committee

 

Meniscal allograft transplantation (MAT) has been repeatedly shown to be a valid option for improving pain and function in normal compartments and even in mild to moderate osteoarthritic (OA) joints (Kellgren-Lawrence grades 2 or 3). Therefore, Orthopaedic Surgeons may now consider recommending MAT as a salvage procedure even in knees affected by early to moderate OA.

 

Knee joint preservation has taken steps forward in the past decade with a reaffirmation that the biologic and biomechanical importance of the intact or replaced meniscus is critical to preserving the knee joint (both medially and laterally). It is often needfully combined with cartilage restoration surgery, offloading the affected compartment with appropriate osteotomies and biologic adjuvant therapy.

 

Techniques for MAT have evolved with new evidence suggesting clinical equivalence with bony bridges/bone troughs, bone plugs/sockets and all soft tissue graft construct preparations. My preferred technique for the past 27 years has been isolated small bone plug constructs for both medial and lateral MAT preparations. My personal reasons to continue utilizing bone plugs is to allow maximal personalization of MAT sized-matched grafts and more exact recapitulation of anatomically correct posterior horn socket positioning. The allograft bone does allow for bone-to-bone healing, and the plugs minimize the total volume of allograft bone and bone exposed to synovial fluid to maximize early healing. All soft tissue grafts have also grown in popularity with advantages suggested as easier graft passage and solid healing to bone with appropriate suture repair techniques.

 

The issue of meniscal extrusion has worked its way into the discussion of both posterior horn root tears and now meniscal allograft transplantation, especially when considering soft tissue only MAT configurations. Biomechanical studies suggest that root repair with centralization is effective at reducing extrusion and the mechanical sequelae that accompany it. Meniscal centralization using various sutures/anchors has grown in popularity to help augment the soft tissue to bone healing of the posterior horn root tear attachment site. This also offloads the tension and tendency for meniscal body extrusion in the early and later phases of MAT healing and incorporation when a soft tissue only construct is utilized. No data yet exists demonstrating significantly improved results by adding centralization stitches with bone plug or bone bridge MAT constructs. I do not use centralization sutures routinely with my bone plug graft preparation technique. Centralization stabilizing suture techniques are mostly used with medial MAT and not the lateral MAT graft since there is markedly more functional anterior-posterior translation of the lateral meniscus throughout knee motion.

 

The concept of doing a staging or concomitant-appropriate osteotomy to unload the involved compartment has been reinforced as a significant way to help negate meniscal extrusion. In my practice, a concomitant HTO is the default plan and indicated until proven otherwise with longstanding weightbearing films as the objective measure for the degree of required angular correction.

 

Fresh frozen MAT grafts are routinely fixed to the capsule using inside-out sutures tied over the capsule trying to push the capsule to the meniscus as opposed to pulling the meniscus to the capsule, especially if the capsule is capacious as in more chronic cases. Fixing both horns first recreates the normal hoops stresses. These two technique tips help prevent iatrogenic time-zero meniscal extrusion.

 

References:

Arthroscopy Journal

  1. Gilat, R., Cole, B.J. Meniscal Allograft Transplantation: Indications, Techniques, Outcomes. Arthroscopy. 2020 Apr;36(4):938-939. doi: 10.1016/j.arthro.2020.01.025. PMID: 32006568.

  2. Wagner, K.R., Kaiser, J.T., Quigley, R.A., Hevesi, M., Damodar, D., Meeker, Z.D., Cotter, E.J., Yanke, A.B., Cole, B.J. Revision and Conversion to Arthroplasty Are Low Among Adolescents Undergoing Meniscal Allograft Transplantation Using the Bridge-In-Slot Technique at Midterm Follow-Up. Arthroscopy. 2024 Apr;40(4):1186-1194.e1. doi: 10.1016/j.arthro.2023.07.059. Epub 2023 Aug 18. PMID: 37597703. Graft Extrusion of 3

  3. Song, J.H., Bin, S.I., Kim, J.M., Lee, B.S., Choe, J.S., Cho, H.K. Graft Extrusion of 3 Millimeters Is Acceptable at a Minimum of 5-Year Outcomes for Lateral Meniscal Allograft Transplantation. Arthroscopy. 2023 Aug;39(8):1841-1847. doi: 10.1016/j.arthro.2023.01.103. Epub 2023 Feb 10. PMID: 36774970.

  4. Wang, Z., Credille, K., Swindell, H., McCormick, J.R., Darbandi, A., Alzein, M., Dandu, N., Cole, B.J., Yanke, A.B. Concomitant Treatment of High-Grade Cartilage Lesions Mitigates Risk of Meniscal Allograft Transplant Failure. Arthroscopy. 2024 May;40(5):1703-1713.e2. doi: 10.1016/j.arthro.2023.11.011. Epub 2023 Nov 25. PMID: 38008388.

 

ATech Video Club

  1. Floyd, E.R., Carlson, G.B., LaPrade, R.F. Arthroscopic-Assisted Lateral Meniscal Allograft Transplantation With Open Ligamentous Extra-Articular Tenodesis. Arthroscopy Techniques. 2021 Feb 22;10(3):e903-e908. doi: 10.1016/j.eats.2020.11.011. PMID: 33738231; PMCID: PMC7953422.

  2. Morgan, C., Bell, R., Burland, J.P., Edgar, C.M. Meniscus Allograft Transplantation Augmented With Autologous Bone Marrow Aspirate Concentrate. Arthroscopy Techniques. 2023 Jun 5;12(7):e1021-e1026. doi: 10.1016/j.eats.2023.02.043. PMID: 37533910; PMCID: PMC10390746.

  3. Richards, J.A., Williamson, J.T., Woodard, D.R., Caborn, D.N.M. All-Soft-Tissue Meniscus Allograft Transplantation With Circumferential Suture Tape Augmentation to Mitigate Hoop Stress and Promote Centralization. Arthroscopy Techniques. 2024 Mar 27;13(5):102954. doi: 10.1016/j.eats.2024.102954. PMID: 38835470; PMCID: PMC11144943.

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