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Medial Meniscus Transplant

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • evaluate for
  • knee pain
  • mechanical symptoms
  • pain or swelling with ADLs and sports
  • joint line tenderness
  • knee effusion
  • associated with decreased quadriceps strength
  • positive McMurrays, Apley grind and Thesaly tests

2

Interprets basic imaging studies

  • standing radiographs
  • 30 degree flexion lateral
  • AP weightbearing in extension
  • 45 degree PA flexion weightbearing views
  • identify fairbanks changes
  • discoid meniscus on radiograph
  • tibial spine hypoplasia, widening of the lateral joint line or flattening of the lateral femoral condyle on AP view.

3

Prescribes and manages non-operative treatment

  • Injects/aspirates knee
  • guides trial of medical managment
  • NSAIDS
  • attempts trial of physical therapy

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • continue hinged knee brace locked in extension for another 3-4 weeks
  • remove sutures
  • diagnose and management of early complications
  • postop: 4-6 week postoperative visit
  • increase range of motion at 6 weeks
  • start closed chain exercises, cycling and swimming at 6 weeks
  • diagnosis and management of late complications
  • start running at 4 to 6 months
  • squatting and pivoting sports are allowed at 6 to 9 months
  • postop: 1 year Postoperative Visit
B

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • MRI
  • 3-T gives excellent visualization on pathology.
  • useful in distinguishing tear, location and morphology

2

Provides complex nonoperative treatment

  • concomitant injuries
  • ligament
  • fractures

3

Modifies and adjusts post-operative treatment plan as needed

  • knee arthrofibrosis
  • continued pain
C

Preoperative H & P

1

Obtains history and performs basic physical exam

  • history
  • Age
  • Gender
  • HPI
  • PMHx
  • identify medical co-morbidities that might impact surgical treatment
  • Social History
  • physical exam
  • complete neurovascular exam of extremity.
  • ROM
  • Joint tenderness
  • Effusion
  • NV status

2

Order basic imaging studies

  • order triplanar standing radiographs of the knee

3

Perform operative consent

  • describe complications of surgery including
  • pain
  • infection
  • neurovascular injury
  • loss of motion
  • degenerative joint disease [DJD])

Operative Techniques

E

Preoperative Plan

1

Perform a thorough history and physical exam

  • history of previous surgeries
  • review imaging including standing full length xrays and MRI to determine other pathology
  • discuss the goals of surgery with the patient

2

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • standard knee arthroscopy instruments
  • meniscal transplant set

2

Room setup and equipment

  • standard OR table with choice of leg holder or post

3

Patient positioning

  • supine
  • contralateral leg is placed in a well leg holder
  • foot of the bed is dropped
G

Scope Insertion

1

Mark out the anatomy of the knee

  • draw out the patella, patellar tendon, and joint line
  • mark the medial joint line incision for open meniscal repair and the anterior portals

2

Place anterolateral portal

  • an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella
  • insert the blunt trocar at the same angle as incision

3

Place anteromedial portal

  • created under direct visualization once the medial compartment is entered
  • use a spinal needle to assess direction and appropriate superior/inferior direction.
  • visualizing the entrance from the lateral viewing portal
  • the medial portal should be located just superior to the medial meniscus
H

Diagnostic Arthroscopy

1

Visualize

  • suprapatellar pouch
  • undersurface of the patella and trochlear groove
  • lateral and medial gutters
  • medial compartment
  • visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment
  • the foot will be positioned on your opposite hip for control
  • medial meniscus, medial femoral condyle, and medial tibial plateau
  • once the anteromedial portal is created, a probe is used to assess the medial meniscus and cartilage
  • intercondylar notch – ACL/PCL
  • use probe to assess the ACL and PCL
  • lateral compartment
  • the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment
  • lateral meniscus, lateral femoral condyle, and lateral tibial plateau
  • a probe is used to assess the lateral meniscus and cartilage
I

Medial Meniscus Graft Preparation

1

Thaw out the medial meniscus tissue

  • thaw out a size matched medial meniscus

2

Remove the soft tissues

  • remove any capsular tissue from the meniscus

3

Prepare the graft

  • the graft may be fashioned with appropriate sized bone plug (usually 7 mm in width) running from the anterior to the posterior horn insertion sites
  • mark the superior portion of the graft with a marking pen for reference in the joint
  • place a suture in the posteromedial meniscus where the posterior and middle thirds of the meniscus meet
J

Tibial Preparation

1

Remove the remaining medial meniscus

  • remove the remaining meniscus until there is a 2mm rim of tissue to suture the meniscal allograft to

2

Prepare site for bone plug

  • may perform a small notchplasty of the medial wall of the notch inferior to the posterior cruciate ligament insertion if needed
  • use a spinal needed to localize a plane between the anterior and posterior horns of the native meniscus and make a skin incision that will allow access to this location
  • create a reference slot with the burr connecting the anterior and posterior horns
  • measure and create a bony trough that is 1 mm wider than the bone plug (usually 8 mm for a 7 mm bone plug)

3

Perform a posteromedial incision

  • create a posteromedial incision to pass sutures for an inside out fixation of the graft
  • the dissection is carried down to the capsule and a retractor is used to protect the neurovascular structures and to aid in retrieval of the long needles for a standard inside out repair
K

Delivery and Fixation of the Medial Meniscus

1

Deliver the meniscal allograft into the knee

  • a passing suture is placed through an inside out technique in the posteromedial knee mirroring the location of the suture that is placed in the meniscal allograft at the junction of the posterior and middle thirds.
  • pass the suture on the allograft though the knee from inside out using the passing suture
  • insert the meniscus and bone plug into the knee through the incision created in line with the anterior and posterior roots of the meniscus, while using the suture to help pull the meniscus into the joint
  • the meniscus will need to be reduced to the capsule which id usually done with a technique similar to reducing a bucket handle meniscus using a valgus force along with flexion and extension
  • cycle the knee to allow the meniscus allograft to site in the appropriate position.

2

Fix the graft into the knee

  • an interference screw can be used for fixation of the bone plug
  • use multiple vertical mattress inside out sutures on the superior and inferior articular surfaces of the allograft to fix the periphery of the tissue to the capsule
  • the sutures are passed out the posteromedial incision and will be tied over the capsule with the knee in extension
L

Wound Closure

1

Close the portals

  • use portal stitches

2

posteromedial incision

  • close the sartorial fascia deep
  • inverted interrupted sutures for subcuticular layer
  • absorbable or nonabsorbable suture for the skin

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • prescribe outpatient physical therapy
  • weightbearing as tolerated in knee brace locked in extension only
  • limit range of motion to 0 and 90 degrees for the first 6 weeks
  • schedule follow-up in 2 weeks
R

Complex Patient Care

1

Treat complex complications

 

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