So, I'm just going to show a little bit about the way I do meniscal transplantation, mostly the lateral side. Again, we've evolved in the treatment of meniscus, and you can see we're evolving even more with newer type of implants. The indications for meniscal transplantation, I'm sure everybody's aware, this is from the IMREF, so basically symptoms from meniscectomy and concomitant surgery, I think, are the indications for meniscal transplantation. So if you have compartment overload and pain, and you have a stable knee, and you have good limb alignment, I think those are good indications for a meniscal transplant. I think if you don't have a stable knee or limb malalignment, you have to correct those, maybe at the same time or staged. The age has become more relative, I think more and more older patients in their 40s and 50s are undergoing meniscal transplantation, and obviously we have diffuse arthrosis. It's contraindicated. I use fresh, frozen, non-irradiated allografts, trying to get younger allografts from a recognized tissue bank, and the size matching is crucial. So their size on MRI, they send you the preoperative picture of the meniscus, the size of the meniscus, so you can check on your patient's x-rays. Generally small is not good. I think if it's going to be anything slightly larger than what you need is more acceptable. I probably should not be giving this talk. It should be Stefano Zaffagnini, who has done more meniscal transplants than anybody, probably, in the world. This is their latest paper, 324 consecutive meniscal transplants published in AJSM, and you can see it's very similar results. They're good in terms of symptom relief and function, and obviously it's not lifelong, and they only last a certain period of time. So this is the way I do the medial and lateral transplants. So the lateral side, I use a bone bridge, and because the roots are close together and very predictable where they're located. The medial meniscus, the anterior root is less predictable, so I do them separate with a posterior bone plug and a large press fit one centimeter by one centimeter plug. Why is that? Again, that's been well described that the anatomy of the medial meniscal root is variable, and I think to always do a trough on the medial side, I think you'll run into some trouble fitting the meniscus from the donor to the recipient. And so this is the ideal tepid knee for a meniscal transplant with obviously good articular cartilage and previous meniscectomy. On the medial side, basically do the preparation for the meniscus and remove the excess meniscus that's there. Leave a nice rim of meniscus that's bleeding and do the posterior root, then anterior incision, pass the meniscus in, and do basically inside-out suturing from the posterior root all the way to the front. And wherever the anterior root lies is where we put the anterior root. Now I just wanted to, you need to have a good team to do the surgery. So obviously you need good assistance and retrieval of the sutures doing inside-out suturing. So for the anterior root, basically you find where it fits and you create a one centimeter receptacle, and then it's press fit into the anterior root, and then basically close the incision and put some sutures through the meniscus in the anterior incision. For doing an osteotomy, perform the osteotomy on the tibial side first, and then the medial meniscus transplant. For the lateral side, here's an example of the osteotomy and medial meniscus transplant. For the lateral side, I do the meniscal transplant first and then perform the osteotomy after the meniscus transplant, usually a femoral osteotomy. So if they have valgus malalignment with valgus wear, do an osteotomy. So I use a trough for the lateral meniscus. And so you prepare the rim the same way on the lateral side, leave a nice bleeding rim of meniscus if you can. Here you see the popliteus and there's no rim of meniscus, which is fine. And prepare the meniscus transplant on the back table. So create the bone bridge, two drill holes from the anterior and posterior root, put sutures through the meniscus and through the bone. And that's how we're going to fix the meniscus into the trough. And you can see it there. It's prepared. It's generally a 7 to 8 millimeter deep and wide trough. And here I create the trough arthroscopically with a shaver and a bur. And you can see here you can measure and create that. Then put the guide wires in the posterior root, anterior root. And that's where the sutures from the meniscus transplant are going to come through. So here we're passing the sutures through the two tunnels that were made. So there you have the sutures for the anterior root, posterior root. And then I put a third suture through the corner of the meniscus coming out through the posterolateral incision. We're retrieving the needles and then basically bring the meniscus into the joint and fit it into the trough. So you can see here the meniscus is fitting. The trough has been pulled down and pulling down the bridge of bone and repairing the meniscus. And again, doing the suturing I think is inside out. You need a good assistant to do that. And you can get nice fixation with superior sutures, inferior sutures. And you get a nice fixed meniscus circumferentially. And then anteriorly put some sutures through the capsule and through the anterior part of the meniscus. And so this is what you end up with, with a nice healthy bleeding bed for the meniscus and likely going to heal without any problems. And again, this is a good surgery. I think it's a fun surgery to do. I don't use any special guides or instrumentation to do the trough or do the posterior tunnel for the medial meniscus. We published this series of 95 menisci that I did. And basically similar results and there is a significant re-operation rate as well. And there was a significant re-operation rate in other series that are published. And again, a systematic review done by some of my fellows looking at the indications for meniscus transplantation. So meniscus transplantation is indicated in young active patients who have stable well-aligned knees without advanced arthritis. I think it does provide symptomatic relief, but it does not necessarily prevent the progression of arthritis. And I don't think you can do it for that, but it probably does. So I think careful patient selection and post-operative activity modification that's been mentioned already are necessary to have good outcomes. Thanks for your attention. Thank you.

meniscal transplantation

lateral side

evolving treatment options

knee stability

allografts