. 2020 Sep 29;9(9):e1357–e1362. doi: 10.1016/j.eats.2020.05.015

Table 2.

Pearls and Pitfalls of the All-Arthroscopic Meniscal Allograft Transplantation Technique With Bone Plugs and Preloaded Sutures

Pearls	Pitfalls
• In medial meniscal allograft transplant, selective partial medial collateral ligament (MCL) release using the pie-crusting technique improves visibility, working area, and avoids iatrogenic chondral injuries. • The high-strength suture loop whipstitches should pass through a central hole of the bone block for correct pulling. • Use the suture passer device for the posterior horn fixation before inserting the meniscal allograft in the knee. • Enlarge the entry portal for the meniscus and be sure that there is not twisting in between the pulling sutures from the angle and the posterior horn. • The meniscal vertical preloaded sutures on the body of the meniscal allograft are very useful for a homogenous attachment to the meniscal rim and capsule. • The retrograde drill for meniscal roots fixation must be at least 1 cm deep and should have 0.5 mm more than the diameter of the bone plug. • Because of the swelling a knot pusher should be used for the peripheral fixation. • Be aware of keeping the balance of the meniscus inside the knee at all times during the knot tying. • Check the posterior meniscal horn fixation before root fixation and do not hesitate to reinforce it using all-inside meniscal sutures if needed. • Meniscal root fixation of the posterior root should be done in between 45° to 60° of knee flexion.	• Be cautious when drilling the anterior medial meniscus tunnel because it is much shorter and more anterior to avoid fractures. • During medial meniscal allograft transplantation, special care must be taken when doing the peripheral knot tying to not trap excessive subcutaneous fat tissue or any terminal branch of the saphenous nerve. • Problems in passing the bone plugs through the portal can be minimized using vegetal oil or bone wax for better sliding; obtain meticulous trimming of the bone irregularities and do not oversize the plug more than 8 mm in diameter. • Passing the posterior bone plug through the femorotibial space can be surpassed using the pie-crusting technique of the MCL release and better opening of the medial compartment; for lateral compartment, use a leg holder so varus can be forced for lateral posterior joint space opening. • Two assistants are ideal for better suture management during meniscal graft insertion to avoid inadvertent suture tangling.

Pearls

Pitfalls

•
In medial meniscal allograft transplant, selective partial medial collateral ligament (MCL) release using the pie-crusting technique improves visibility, working area, and avoids iatrogenic chondral injuries.
•
The high-strength suture loop whipstitches should pass through a central hole of the bone block for correct pulling.
•
Use the suture passer device for the posterior horn fixation before inserting the meniscal allograft in the knee.
•
Enlarge the entry portal for the meniscus and be sure that there is not twisting in between the pulling sutures from the angle and the posterior horn.
•
The meniscal vertical preloaded sutures on the body of the meniscal allograft are very useful for a homogenous attachment to the meniscal rim and capsule.
•
The retrograde drill for meniscal roots fixation must be at least 1 cm deep and should have 0.5 mm more than the diameter of the bone plug.
•
Because of the swelling a knot pusher should be used for the peripheral fixation.
•
Be aware of keeping the balance of the meniscus inside the knee at all times during the knot tying.
•
Check the posterior meniscal horn fixation before root fixation and do not hesitate to reinforce it using all-inside meniscal sutures if needed.
•
Meniscal root fixation of the posterior root should be done in between 45° to 60° of knee flexion.

•
Be cautious when drilling the anterior medial meniscus tunnel because it is much shorter and more anterior to avoid fractures.
•
During medial meniscal allograft transplantation, special care must be taken when doing the peripheral knot tying to not trap excessive subcutaneous fat tissue or any terminal branch of the saphenous nerve.
•
Problems in passing the bone plugs through the portal can be minimized using vegetal oil or bone wax for better sliding; obtain meticulous trimming of the bone irregularities and do not oversize the plug more than 8 mm in diameter.
•
Passing the posterior bone plug through the femorotibial space can be surpassed using the pie-crusting technique of the MCL release and better opening of the medial compartment; for lateral compartment, use a leg holder so varus can be forced for lateral posterior joint space opening.
•
Two assistants are ideal for better suture management during meniscal graft insertion to avoid inadvertent suture tangling.