Table 1.

Pearls and Pitfalls of the Surgical Technique

Pearls

• Graft mismatch can be avoided through proper graft selection and sizing radiographs.

• A spinal needle can be used to localize the ideal placement of the transpatellar incision.

• Occasionally, the anterior horn attachment can be larger, up to 9 mm wide. If the anterior horn attachment site is wider than the intended width of the bone bridge, the attachment should be left intact, and the width of the bone bridge should be increased accordingly in the area of the anterior horn insertion only; the remainder of the bone bridge should be trimmed to 7 mm as intended. To accommodate the increased width, the corresponding area of the recipient slot should be widened accordingly.

• Undersize the bone bridge of the meniscal allograft by 1 mm to allow easy passage into the slot, which reduces the risk of bone bridge fracture during graft insertion.

• It can be helpful to elevate the iliotibial band tissue anteriorly to allow for easier suture tying beneath this structure after the meniscal sutures are passed.

• Varus stress can be helpful to open up the lateral compartment of the knee to facilitate graft entry.

• All-inside meniscus repair sutures may be helpful to secure the meniscal allograft posteriorly.

• Outside-in sutures can be helpful for securing the most anterior aspect of the meniscus.

• All instrumentation including sizing, guide pin placement, and reaming of the osteochondral defects must be done perpendicular to produce a graft that matches the recipient site.

Pitfalls

• Overaggressive reaming along the medial aspect of the tibial plateau can result in iatrogenic injury to the footprint of the anterior cruciate ligament and disruption of the posterior tibial cortex.

• Injury to neurovascular structures can occur through inside-out suture placement.

• Avoid undersizing the osteochondral allograft. It is better to marginally oversize the osteochondral allograft than leave a marginal quality tissue on the perimeter for the graft to integrate with.

• Inaccurate measurements at the 3, 6, 9, and 12 o'clock positions or failure to mark the 12 o'clock position can lead to the graft being recessed or sitting too proud.

• Avoid excessive force or a higher number of impactions when placing the osteochondral allograft as that may diminish chondrocyte viability.13, 14